Disorders of the Eyes Additional Reading: Article posted: Vision Loss in Older Adults The Patient History: Chapter 16 - Red Eye Special exams ●Fluorescein ●stain for object in eye or damage to cornea ●more superficial exam of the eye ●Tonometry ●Determines intraocular pressure (15.5mmHg is normal) ●Used to dx glaucoma ●Slit lamp exam ●10-20X magnification ●Used to dx various eye conditions 3 Eye Pain Usually indicates inflammation of one of 3 structures ➢ Keratitis ➢ Iritis ➢ Uveitis ➢ Acute angle closure glaucoma What are common causes of pain? Infx, trauma & increased intraocular pressure Examination: ➢ Careful examination of cornea, anterior chamber, iris and retina is mandatory ➢ Assess visual acuity VINDICATING IT ●Idiopathic ● Cluster headache (plus intense, unilateral, tearing and rhinitis, shorter, frequently re-occuring, restless) ●Inflammatory ● Hordeolum infx, chalazion, interstitial keratitis, iritis, scleritis, dacryoadenitis, optic neuritis (MS can have this) ●Infectious ● Herpes simplex and zoster ● Sinusitis, dental abscesses ●Mechanical/trauma ● Foreign body, corneal abrasion, glaucoma, eyestrain RED EYE ●Anatomical Differential ● Eyelids and Lacrimal Sac Dacrocystitis(inflammed lacrimal sac – obstructs flow of tears), Blepharitis, Hordeolum, Entropion/Ectropion ● Conjuctiva ● Bacterial, Viral, Allergic, N. gonorrhea, Chemical, Subconjunctival hemorrhage ● Anterior Chamber ● Hypemia (increased superficial vascularization) ● Sclera ● Epi/Scleritis, Keratitis, Corneal abrasion, Herpetic keratitis ● Orbit ● Periorbital cellulitis, Orbital cellulitis ● Uveal Tract ● Iritis ● Glaucoma - Acute closed angle glaucoma ● 6 Red Flags Causes of Red Eye 7 Red Flag Causes of Red Eye 8 Conjunctivitis Infectious ➢ Bacterial, viral*m/c adenovirus specifically, chlamydial, fungal parasitic Non-infectious ➢ Allergic asthma, dermatitis, irritant ➢ Toxic ➢ Secondary to another disorder: dacryocystitis, dacryoadenitis, cellulitis, Kawasaki disease Allergic conjunctivitis ●Atopic ●Giant papillary conjunctivitis(mechanical irritation, often contacts, of conjunctiva) ●Vernal – end up with cobblestone appearance of conjunctiva. Can have corneal ulcers and keratitis ● occurs in children lasts 5-10 days then resolves ● Seasonal Iatrogenic: ● Topical antibiotics gentomyosin, sulphonamides ect Sx/Sn: eye itching b/l, tearing with stringy discharge, eye fullness sensation, conjunctival hyperemia, marked chemosis swelling of the conjunctiva Viral Conjunctivitis Most common cause of conjunctivitis (80%) Common cause of swimming pool conjunctivitis Signs and symptoms: ●Serous discharge, lid edema ●Associated with URI ●Palpable and tender preauricular nodes ●Severe pharyngitis ●Mild to no pain, mild itching ●Fever ●Initially unilateral may progress to opposite eye w/in 24-48 hrs ●Highly contagious for up to 12 days ● Associated with which virus? Adenovirus (M/C), varicella zoster, herpes simples, ebstein barr virus, influenza ● Why should you care? Complications? Dif consequences depending on the virus type. Ensure it is viral. 14 Herpetic Infection ● HSV or HVZ ● Immediate referral to Opthamologist ● S&Sx ● pain, photophobia diffuse or ciliary injection ● dendrites seen on fluorecein staining ● may cause inflammation and scarring of the cornea and in some cases the retina and optic nerve are involved ● chronic outbreaks may cause glaucoma, cataract formation, double vision and scarring of the cornea 15 es-pictures 16 Cornea.html 17 Bacterial conjunctivitis ●Newborns ● What are common causes?chemical prophylaxis (M/C of conjunctivitis erythromycin drops at birth to prevent gonorrhoea) ● Gonorrheal infx: bilateral mucopurulent discharge that comes back even if you wipe it away. ●Children ● Streptococcus pneumoniae ● H influenza ● Staphylococcus species ● Moraxella species ●Adults ● Staph, Strep, E. coli, Pseudomonas, Moraxella, Chlamydia, Gonorrheal Bacterial Conjunctivitis ●Usually occurs suddenly ● Unilateral → to opposite eye within 2-5 days ●Mucopurulent discharge ●Matting of lashes in the a.m ●Significant irritation with stinging sensation or foreign body sensation ●Eyelid edema ●Variable conjunctival injection ●Visual acuity not affected ●Complications: Blepharitis, External hordeolum, conjunctival scarring and blindness (clap) Blepharitis ●Most common Inflammation of the eyelids ●Anterior (outside of eyelid) ● Affects base of eyelashes ● Associated with Staph or seborrhea ●Posterior (inner eyelids) ● Affects meibomian gland openings ● Associated with rosacea and seborrheic dermatitis Blepharitis ●Signs and symptoms ● Bilateral ● Pruritus ● Local irritation and burning/ not painful ● Inflammation of eyelid margin ● Moderate lid swelling ● Lower eyelid more affected ● Soft oily yellow skin scaling Keratitis ●Corneal inflammation or Infection ●Etiology ● Eye trauma ● Infection ● Secondary to scleritis Keratitis ●Signs and symptoms ● Moderate to severe eye pain** know differences b/w conditions ● Moderate to severe to foreign body sensation ● Blurred vision ● Watery to mucopurulent eye discharge ● Photophobia ● Eye tearing ● Painful red eye, with ciliary flush ● Pupils are equal, cornea appears cloudy Staphylococcal Keratitis Uveitis ●Inflammation of the choroid layer: ● Iris (iriditis) ● Iris+ciliary body (iridocyclitis) ● Posterior compartment (posterior uveitis) ● Endophlalmitis – really bad, rare, often bacterial infection of entire eye ●In general, divided into anterior and posterior uveitis ● Often anterior divided into granulomatous and nongranulomatous inflammation… ● Even though “granulomatous” refers to etiologies that cause granulomas and classical granulomas sometimes aren’t found in the eye Uveitis - history ●Anterior uveitis: ● Acute – Pain, redness, photophobia, excessive tearing, and decreased vision; pain generally develops over a few hours or days except in cases of trauma ● Chronic - Primarily blurred vision, mild redness; little pain or photophobia except when having an acute episode ●Posterior uveitis: ● Blurred vision, floaters ● Symptoms of anterior uveitis (pain, redness, and photophobia) absent ● Symptoms of posterior uveitis and pain suggest anterior chamber involvement, bacterial endophthalmitis, or posterior scleritis Uveitis ●Etiology: ● for anterior (about 90%): idiopathic, seronegative spondyloarthropathies/IBD, sarcoidosis, JIA, lupus, AIDS, herpes, tubular interstitial nephritis ● Most common are idiopathic, and autoimmune ● For posterior: a lot of infections: ● Toxoplasmosis and CMV infections are common ● Cat scratch disease ● Autoimmune/sarcoidosis causes can also cause posterior Uveitis ●Not very common – about 17-52 cases/100,000/year… 90% are an anterior uveitis ●It’s not common, so why do we care? ● Can cause a lot of different complications: ● Macular edema and destruction ● Glaucoma ● Corneal damage ● cataracts Uveitis Labs • • • • • CBC Urinalysis ESR CRP Basic Metabolic panel • 2nd line labs • TB Skin test • HLA-B27 • Rapid Plasma Reagin (RPR) • Which imaging is indicated? Chest x ray Orbital Inflammation ●Orbital cellulitis ● Inflammation + infection of tissues posterior to the orbital septum ● Bacterial in origin – common causes are Staph aureus, Strep pneumo, and H. influenza ● Bacteria seeded from skin or from sinuses, or from a pre-existing peri-orbital cellulitis ● Nasty complications ● 11% rate of vision loss ● Small minority of cases (1%) with cavernous sinus thrombosis (which has a 50% mortality) ● Small minority will result in intracranial abscesses or meningitis Orbital inflammation ●Orbital cellulitis: ● Signs/symptoms ● ● ● ● ● ● Proptosis (exopthalmos) Pain on eye movement Elevated intraocular pressure Fever, headache Edema of the eyelid Conjunctivitis ● Treated with antibiotics Glaucoma ● In open angle glaucoma, the aqueous humor has complete physical access to the trabecular meshwork, and the elevation in intraocular pressure results from an increased resistance to aqueous outflow in the open angle. ● In angle closure glaucoma, the peripheral zone of the iris adheres to the trabecular meshwork and physically impedes the egress of aqueous from the eye. Acute angle-closure glaucoma ●Glaucoma ● Increased intraocular pressure with optic nerve injury ●Risk factors ● Increasing age ● Far sightedness ● Family hx ● Angle closure glaucoma in contralateral eye ● Pupillary dilation Acute angle closure glaucoma ●Etiologies ● Opthalmic anticholinergic agents ● Systemic medications – antidepressants, sulfa based medications, topiramate ●Acute Symptoms (Usual presentation) ● Decreased visual acuity, severe vision loss in hours to days ● Photophobia ● Headache ● Extreme deep eye pain ● Nausea and vomiting ● Halos ● Usually unilateral Acute angle-closure glaucoma ●Signs ● Decreased visual acuity ● Mildly dilated pupil ● Increased IOP – 25-50 mmHg ● Eye redness; Ciliary injection ● Conjunctival edema ● Corneal edema (cloudy, “steamy” hazy) ● Optic disc cupping 39 Open Angle Glaucoma ●Most common type of glaucoma ● Seen mostly in older patients (rarely in people under 40 yrs of age) ●Risk Factors ● Black race – 4 fold increase ● First Degree relative with glaucoma ● DM ● Severe Nearsightedness ● Eye injury ● Eye trauma, uveitis, steroids Pterygium ●Growth on the surface of the conjunctiva ●Starts at the inner canthus and enlarges laterally to cover portion of cornea ●Etiology: UV light exposure, low humidity, dust, wind ●Pinguecula ● Only involves conjunctiva, no cornea involement ●Symptoms: foreign body sensation, tearing, dry and itchy eyes, persistent redness. 43 Differential Diagnosis of Red Eye Conjunctivitis Acute Iritis Acute AngleClosure Glaucoma Keratitis Discharge Bacteria Virus Allergic No No Profuse tearing Pain No ++ (tender globe) +++ (nausea) ++ (on blinking) Photophobia No +++ + ++ Blurred vision No ++ +++ Varies Pupil Normal Smaller Fixed in middilation Same or smaller Injection Conjunctiva Ciliary flush Diffuse Diffuse Cornea Normal Keratic precipitates Cloudy Infliltrate, edema, epithelial defects IOP Normal Varies Increased Normal or increased Anterior chamber Normal +++ cells and flare Shallow Other Large, tender pre- Posterior Colored halos Cells and flare or normal Transient or sudden visual loss ●Optic neuritis ●Anterior ischemic optic neuropathy ●Posterior ischemic optic neuropathy ●Toxic optic neuropathy ●Retinal detachment ●Transient Ischemic Attack ●Classic migraine ●Stroke ●Vitreous degeneration Chronic Visual loss ●Cataract ●Glaucoma ●Maculardegeneration ●Diabetic retinopathy ●Melanoma RETINAL DETACHMENT Separation of the neurosensory retina from the retinal pigment epithelium ●Rhegmatogenous retinal detachment is associated with a fullthickness retinal defect ● develop after the vitreous collapses structurally, and the posterior hyaloid exerts traction on points of abnormally strong adhesion to the retinal internal limiting membrane. ● Liquefied vitreous humor seeps through the tear and gains access to the potential space between the neurosensory retina and the retinal pigment epithelium ● Most common type ● Causes: ● ● ● Age Cataract surgery Inflammation in posterior chamberie uveitis RETINAL DETACHMENT ●Non-rhegmatogenous retinal detachment, exudative type = retinal detachment without retinal break ● may complicate retinal vascular disorders associated with significant exudation and any condition that damages and permits fluid to leak from the choroidal circulation beneath the retina ● Causes: ● Trauma, hypertension, tumors, autoimmune disease… many causes RETINAL DETACHMENT ●Non-rhegmatogenous retinal detachment, tractional type = contractile membranes in and around the retina pull the neurosensory retina away from the RPE ● Can be viewed as scar formation that separates the retina from the pigment epithelium ● Second most common type after rhegmatogenous ● Causes: diabetes, retinal ischemia, eye trauma Retinal Detachment 51 Retinal Detachment – Clinical features ●Initial symptoms commonly include the sensation of a flashing light (photopsia) related to retinal traction and often accompanied by a shower of floaters and vision loss ●Over time, the patient may report a shadow in the peripheral visual field ● may spread to involve the entire visual field in a matter of days ● described as cloudy, irregular, or curtainlike. 54 RETINAL VASCULAR DISEASE Diabetes Mellitus ●Review the effects of hyperglycemia on the lens and iris: ● Cataracts ● Neovascular membranes that can cause glaucoma ● The retinal vasculopathy of diabetes mellitus may be classified into ● background (preproliferative) diabetic retinopathy ● proliferative diabetic retinopathy ●Prognosis & Epidemiology ● 65,000 per year contract proliferative DR in US ● 8000 people in the US become blind per year from DR; leading cause of new cases of blindness Background (preproliferative) diabetic retinopathy Pathology ●The basement membrane of retinal blood vessels is thickened. ●Microaneurysms are an important manifestation of diabetic microangiopathy ●Macular edema ●Hemorrhagic exudates Diabetic retinopathy – clinical features ●In the initial stages patients are generally asymptomatic; in the more advanced stages of the disease, however, patients may experience: ● floaters, blurred vision, distortion, and progressive visual acuity loss ●Signs, from early to late, include microaneurysms (quite early), hemorrhages (dot and flame), retinal edema, hard exudates, cotton-wool spots, macular edema (common cause of vision impairment) ●Proliferative is late – characterized by new vessels, hemorrhages, fibrovascular membranes, retinal detachment, and macular edema 58 59 Optic Neuritis – retrobulbar optic neuropathy ●Inflammation of the optic nerve ●Etiologies ● Posterior uveitis ● Optic nerve vascular lesions ● Encephalomyelitis ● Tumor – optic nerve glioma, neurofibromatosis, meningioma ● Fungal infections ● Medications Optic Neuritis ● Usually presents in young individuals ● Symptoms ● Pain behind affected eye ● Impaired vision – one or both eyes ● Signs ● Abnormal pupil light reflex ● Extra ocular movements painful ● Pressure on globe pressure A 55 year old woman presented with acute onset of redness in her left eye which she noted upon awakening in the morning. She had no pain, ocular discharge photophobia, blurry vision, or history of blunt trauma. On examination, she was normotensive. Her pupils were equal and reactive and her corrected vision was 20/20 62 63