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NURHAIDA DJAMIL

DEPARTEMEN ILMU KESEHATAN MATA FAKULTAS KEDOKTERAN UNIVERSITAS ISLAM SUMATERA UTARA MEDAN 2012

March 2, 2013

NURHAIDA DJAMIL, MD EXTERNAL EYE DISEASES

Orbicularis oculi muscle anatomy. (A) Frontalis, (B) corrugator superciliaris, (C) procerus, (D) orbital orbicularis, (E) preseptal orbicularis, (F) pretarsal orbicularis.

Hordeoulum internum
Ini adalah peradangan supuratif pada kelenjar meibom yang berhubungan dengan penyumbatan saluran. Etiology Ini dapat terjadi sebagai infeksi staphylococcal utama kelenjar meibom atau akibat infeksi sekunder dalam sebuah chalazion (chalazion terinfeksi). Treatment -Hot compresses 2-3 times -Antibiotic eyedrops (3-4 times a day) and eye ointment (at bed time) should be applied to control infection. -Anti-inflammatory and analgesics relieve pain and reduce oedema

Hordeoulum eksternum Ini adalah peradangan akut supuratif kelenjar dari Zeis atau Moll. Treatment -Hot compresses 2-3 times -Antibiotic eyedrops (3-4 times a day) and eye ointment (at bed time) should be applied to control infection. -Anti-inflammatory and analgesics relieve pain and reduce oedema.

Chalazion

Granulomatosa kronis peradangan kelenjar meibom. Eksisi bedah dilakukan melalui sayatan vertikal ke dalam kelenjar tarsal

Blefaritis anterior -By chronic inflammation of bilateral palpebral -Staphylococcus aureus, Staphylococcus epidermidis -Symptoms: irritation, burning, itching Blefaritis posterior palpebral inflammation due meibom gland dysfunction.

Entropion Palpebral folding inward. Caused senile, or Congenital ,cicatrical.

Ektropion

-palpebral folding outwards


-Caused relaxation of musculus orbicularis oculi (senile) or due to by paralysis N.Facialis

Radang konjungtiva (konjungtivitis) secara klasik didefinisikan sebagai hiperemi konjungtiva terkait dengan pelepasan yang mungkin berair, berlendir, mukopurulen atau purulen. Etiological classification 1. Infective conjunctivitis: bacterial, chlamydial, viral,fungal, rickettsial, spirochaetal, protozoal, parasitic 2. Allergic conjunctivitis. 3. Irritative conjunctivitis. 4. Keratoconjunctivitis associated with diseases of skin and mucous membrane. 5. Traumatic conjunctivitis. 6. Keratoconjunctivitis of unknown etiology.

Clinical classification Depending upon clinical presentation, conjunctivitis can be classified as follows: 1. Acute catarrhal or mucopurulent conjunctivitis. 2. Acute purulent conjunctivitis 3. Serous conjunctivitis 4. Chronic simple conjunctivitis 5. Angular conjunctivitis 6. Membranous conjunctivitis 7. Pseudomembranous conjunctivitis 8. Papillary conjunctivitis 9. Follicular conjunctivitis 10. Ophthalmia neonatorum 11. Granulomatous conjunctivitis 12. Ulcerative conjunctivitis 13. Cicatrising conjunctivitis

ACUTE MUCOPURULENT CONJUNCTIVITIS Acute mucopurulent conjunctivitis is the most common type of acute bacterial conjunctivitis. It is characterised by marked conjunctival hyperaemia and mucopurulent discharge from the eye.

Common causative bacteria are: Staphylococcus aureus, Koch-Weeks bacillus, Pneumococcus and Streptococcus. Clinical course. Mucopurulent conjunctivitis reaches its height in three to four days Treatment Topical antibiotics Irrigation of conjunctival sac with sterile warm saline once or twice a day Dark goggles

ACUTE PURULENT CONJUNCTIVITIS The disease affects adults, predominantly males.Commonest causative organism is Gonococcus; but rarely it may be Staphylococcus aureus or Pneumococcus. Treatment 1. Systemic therapy is far more critical than the topical therapy for the infections caused by N. gonorrhoeae and N. meningitidis. Because of the resistant strains penicillin and tetracyline are no longer adequate as first-line treatment. Any of the following regimes can be adopted : Norfloxacin 1.2 gm orally qid for 5 days Cefoxitim 1.0 gm or cefotaxime 500 mg. IV qid or ceftriaxone 1.0 gm IM qid, all for 5 days;

2. Topical antibiotic therapy presently recommended includes ofloxacin, ciprofloxacin or tobramycin eye drops
3. Irrigation of the eyes

ACUTE MEMBRANOUS CONJUNCTIVITIS It is an acute inflammation of the conjunctiva, characterized by formation of a true membrane on the conjunctiva. Now-a-days it is of very-very rare occurrence, because of markedly decreased incidence of diphtheria Etiology The disease is typically caused by Corynebacteriumdiphtheriae and occasionally by virulent type of Streptococcus haemolyticus. Treatment A. Topical therapy 1. Penicillin eye drops (1:10000 units per ml) 2. Antidiphtheric serum (ADS) should be instilled every one hour. 3. Atropine sulfate 4. Broad spectrum antibiotic ointment B. Systemic therapy 1. Crystalline penicillin 5 lac units 2. Antidiphtheric serum (ADS) (50 thousand units) should be given intramuscularly stat

VIRAL CONJUNCTIVITIS Most of the viral infections tend to affect the epithelium, both of the conjunctiva and corne. ACUTE SEROUS CONJUNCTIVITIS Etiology. It is typically caused by a mild grade viral infection which does not give rise to follicular response. Clinical features. Acute serous conjunctivitis is characterised by a minimal degree of congestion, a watery discharge and a boggy swelling of the conjunctival mucosa. Treatment. Usually it is self-limiting and does not need any treatment. But to avoid secondary bacterial infection, broad spectrum antibiotic eye drops may be used three times a day for about 7 days.

Acute herpetic conjunctivitis Acute herpetic follicular conjunctivitis is always an accompaniment of the 'primary herpetic infection', which mainly occurs in small children and in adolescents. Etiology. The disease is commonly caused by herpes simplex virus type 1 and spreads by kissing or other close personal contacts. HSV type 2 associated with genital infections, may also involve the eyes in adults as well as children, though rarely.

VERNAL KERATOCONJUNCTIVITIS (VKC) It is a recurrent, bilateral, interstitial, self-limiting, allergic inflammation of the conjunctiva having a periodic seasonal incidence. Etiology It is considered a hypersensitivity reaction to some exogenous allergen, such as grass pollens Treatment 1. Topical steroids 2. Mast cell stabilizers such as sodium cromoglycate (2%) drops 4-5 times 3.Topical antihistaminics are also effective.

GIANT PAPILLARY CONJUNCTIVITIS (GPC) It is the inflammation of conjunctiva with formation of very large sized papillae. Etiology. It is a localised allergic response to a physically rough or deposited surface (contact lens, prosthesis, left out nylon sutures). Probably it is a sensitivity reaction to components of the plastic leached out by the action of tears. Symptoms. Itching, stringy discharge and reduced wearing time of contact lens or prosthetic shell. Signs. Papillary hypertrophy (1 mm in diameter) of the upper tarsal conjunctiva, similar to that seen in palpebral form of VKC with hyperaemia Treatment 1. The offending cause should be removed. After discontinuation of contact lens or artificial eye or removal of nylon sutures 2.Steroids are not of much use in this condition

PHLYCTENULAR KERATOCONJUNCTIVITIS Phlyctenular keratoconjunctivitis is a characteristic nodular affection occurring as an allergic response of the conjunctival and corneal epithelium to some endogenous allergens to which they have become sensitized. Etiology It is believed to be a delayed hypersensitivity (Type IV-cell mediated) response to endogenous microbial proteins. Causative allergens Tuberculous proteins ,Staphylococcus proteins ,Other allergens may be proteins of Moraxella Axenfeld bacillius and certain parasites (worm infestation). Management 1. Local therapy. i. Topical steroids ii. Antibiotic drops and ointment 2. Specific therapy. i. Tuberculous infection should be excluded by Xrays chest, Mantoux test. Ii.Septic focus, in the form of tonsillitis, adenoiditis, or caries teeth

PTERYGIUM Pterygium (L. Pterygion = a wing) is a wing-shaped fold of conjunctiva encroaching upon the cornea from either side within the interpalpebral fissure. Etiology. Etiology of pterygium is not definitely known. But the disease is more common in people living in hot climates Pathology. Pathologically pterygium is a degenerative and hyperplastic condition of conjunctiva. The subconjunctival tissue undergoes elastotic degeneration and proliferates as vascularised granulation tissue under the epithelium, which ultimately encroaches the cornea. The corneal epithelium, Bowman's layer and superficial stroma are destroyed Treatment. Surgical excision is the only satisfactory treatment

Etiological classification
1. Infective keratitis (a) Bacterial (b) Viral (c) Fungal (d) Chlamydial (e) Protozoal (f) Spirochaetal 2. Allergic keratitis (a) Phlyctenular keratitis (b) Vernal keratitis (c) Atopic keratitis 3. Trophic keratitis (a) Exposure keratitis (b) Neuroparalytic keratitis (c) Keratomalacia (d) Atheromatous ulcer

4. Keratitis associated with diseases of skin and mucous membrane. 5. Keratitis associated with systemic collagen vascular disorders. 6. Traumatic keratitis, which may be due to mechanical trauma, chemical trauma, thermal burns, radiations 7. Idiopathic keratitis e.g., (a) Mooren's corneal ulcer (b) Superior limbic keratoconjunctivitis (c) Superficial punctate keratitis of Thygeson

BACTERIAL CORNEAL ULCER There are two main factors in the production of purulent corneal ulcer: Damage to corneal epithelium; and Infection of the eroded area. However, following three pathogens can invade the intact corneal epithelium and produce ulceration: Neisseria gonorrhoeae, Corynebacterium diphtheriae and Neisseria meningitidis Symptoms 1. Pain and foreign body sensation 2. Watering 3. Photophobia 4. Blurred vision results from corneal haze. 5. Redness of eyes Signs 1. Lids are swollen. 2. Marked blepharospasm may be there. 3. Conjunctiva is chemosed and shows conjunctival hyperaemia and ciliary congestion. 4. Corneal ulcer usually starts as an epithelial defect

Treatment Ciprofloxacin (0.3%) eye drops, or Ofloxacin (0.3%) eye drops, or Gatifloxacin (0.3%) eye drops

HERPES SIMPLEX KERATITIS Mode of Infection HSV-1 infection. It is acquired by kissing or coming in close contact with a patient suffering from herpes labialis. HSV-II infection. It is transmitted to eyes of neonates through infected genitalia of the mother.

HERPES ZOSTER OPHTHALMICUS Herpes zoster ophthalmicus is an acute infection of Gasserian ganglion of the fifth cranial nerve by the varicella-zoster virus (VZV). It constitutes approximately 10 percent of all cases of herpes zoster. Etiology Varicella -zoster virus
I. Systemic therapy for herpes zoster 1. Oral antiviral drugs, Acyclovir in a dose of 800 mg 5 times a day for 10 days 2.Analgesics 3.Systemic steroids. They appear to inhibit development of post-herpetic neuralgia when given in high doses.

ALLERGIC KERATITIS 1. Phlyctenular keratitis

2. Vernal keratitis

3. Atopic keratitis

MYCOTIC CORNEAL ULCER The incidence of suppurative corneal ulcers caused by fungi has increased in the recent years due to injudicious use of antibiotics and steroids. Etiology corneal infections are : i. Filamentous fungi e.g., Aspergillus, Fusarium, Alternaria, Cephalosporium, Curvularia and Penicillium. ii. Yeasts e.g., Candida and Cryptococcus. (The fungi more commonly responsible for mycotic corneal ulcers are Aspergillus (most common), Candida and Fusarium).

Clinical features Symptoms are similar to the central bacterial corneal ulcer (see page 95), but in general they are less marked than the equal-sized bacterial ulcer and the overall course is slow and torpid. Signs : Corneal ulcer is dry-looking, greyish white, with elevated rolled out margins. Delicate feathery finger-like extensions are present into the surrounding stroma under the intact epithelium. A sterile immune ring (yellow line of demarcation) may be present where fungal antigen and host antibodies meet. Multiple, small satellite lesions may be present around the ulcer.

Treatment I. Specific treatment includes antifungal drugs: 1. Topical antifungal Natamycin (5%) eye drops,Fluconazol (0.2%) eye drops,Nystatin (3.5%) eye ointment. 2. Systemic antifungal drugs may be required for severe cases of fungal keratitis. Tablet fluconazole or ketoconazole may be given for 2-3 weeks. II. Non specific treatment. Non-specific treatment and general measures are similar to that of bacterial corneal ulcer (see page 98). III. Therapeutic penetrating keratoplasty may be required for unresponsive cases

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