24.05.23 - OCULAR INFECTIONS - Presentation.pptx

This presentation gives a brief overview of most common ocular infections in India

1. OCULAR INFECTIONS Presented By: Dr. Shreyan Dani Guided By: Dr. Dharanidharan (AP)

2. History Taking: Chief Complains: Pain Fatigue Redness Itching Watering Discharge Matting of Eye Lashes Vision Headache Asthenopic Symptoms

3. History Taking: HOPI: Trauma/Surgery How it started? Progression Use of Spectacles/Contact Lens Hygiene Past History: Diabetes Immunosuppresants Medications & Compliance to medications

4. Right Ocular Examination Left Orbit Lids & Lacrimal Apparatus Conjunctiva Sclera Cornea Anterior Chamber Iris Pupil Lens Anterior Vitreous Fundus: Media Disc Vessels Macula Periphery

5. Important Ocular Infections : Orbit : Pre-Septal Cellulitis Orbital Cellulitis Lids & Lacrimal Apparatus: Blepharitis Chalazion External Hordeolum (Stye) Internal Hordeolum Dacryocystitis

6. Important Ocular Infections : Conjunctiva : Conjunctivitis (Bacterial, Viral, Allergic) Trachomatis (involves both Cornea & Conjunctiva) Sclera : Episcleritis , Scleritis Cornea : Keratitis Iris : Iritis Uvea : Anterior & Posterior Uveitis Endophthalmitis & Panophthalmitis

7. Conjunctivitis

8. SIGNS & SYMTPOMS OF CONJUNCTIVITIS: Symptoms : Redness, Irritation, Photophobia, Discharge Signs : Viral : Watery/Serous Discharge Allergic : Mucoid Discharge Trachoma : Stringy/Ropy Mucoid Discharge Bacterial/Chlamydial : Mucopurulent Discharge Gonococcal : Purulent / Sanguinous (Blood mixed)

9. CONJUNCTIVAL CONGESTION CIRCUMCILIARY / CIRCUMCORNEAL CONGESTION Bright Red Greyish Red, ill defined Marked in Fornix Especially around Limbus Vessels involved: Anterior & Posterior Conjunctival Vessels (superficial vessels) Vessels involved: Anterior Ciliary Vessels (Deep Vessels) Branch Dichotomously Branch Parallelly or Radially Fill from Fornix Fill from Limbus Significance: Conjunctivitis Significance: Keratitis, Acute Iridocyclitis, Acute Congestive Glaucoma etc …

10. m/c/c : Staphylococcus Aureus m/c/c of Hyperacute Cases : Gonococcal Conjunctivitis Treatment of Bacterial Conjunctivitis : CIPROFLOXACIN Eye Drops: 0.3% BACTERIAL CONJUNCTIVITIS:

11. VIRAL CONJUNCTIVITIS: ALLERGIC CONJUNCTIVITIS: m/c/c : Adenovirus Symptomatic Treatment LUBREX Eye Drops 1-1-1-1 OLOPATADINE Eye Drops 1-1-1-1 X 1 Wk Tab. CETIRIZINE 5 MG : 3 DAYS

12. ANGULAR / DIPLOBACILLARY CONJUNCTIVITIS: Caused by: Moraxella lacunata (produce proteolytic enzymes) Moraxella – Axenfeld Diplobacillus thus, also known as Diplobacillary Conjunctivitis C/F: 1) Redness of Canthi 2) Macerration of Lid Margins T/t: 1) OXYTETRACYCLINE EYE OINTMENT 2) 2% ZINC OXIDE SKIN LOTION

13. GONOCOCCAL CONJUNCTIVITIS: Must be treated appropriately as it can penetrate intact corneal epithelium and cause Corneal Matting & Perforation Rx: 1) T . CIPROFLOXACIN : 500 MG Single Dose 2) T. RIFAMPICIN : 600 MG X BD X 5 Days 3) If Systemic Signs : CEFTRIAXONE iv or im

14. NEONATAL CONJUNCTIVITIS / OPHTHALMIA NEONATORUM:

15. Causes of Neonatal Conjunctivitis : Chemical Conjunctivitis : on Day of Birth Gonococcal Conjunctivitis : 1 – 2 Days Other Bacterial Conjunctivitis : 3 – 5 Days Chlamydial Conjunctivitis : 5 – 15 Days Viral Conjunctivitis : 7 – 12 Days – by HSV type 2 Note: Mcc of Neonatal Conjunctivitis : Chlamydia Mcc of Neonatal Blindness : Gonococcal

16. Treatment of Neonatal Conjunctivitis : Gonococcal Conjunctivitis: Aqueous PENICILLIN Eye Drops : 10,000 – 20,000 IU per ml Loading Dose: every 1 min for ½ hour f/b Every 5 Mins for ½ hour f/b Every Hour Treatment of Parents

17. Treatment of Neonatal Conjunctivitis : Chlamydial Conjunctivitis: ERYTHROMYCIN Eye Ointment + Syp . ERYTHROMYCIN 50 mg/kg/day divided in 4 doses Treatment of Parents

18. Follicles : with Boiled Sagu Grain Appearance Centre contains “LEBER CELLS”

19. ARLT’s LINE

20. HEBERT’S FOLLICLES & PITS

21. TRACHOMA

22. TRACHOMA: Chronic Keratoconjunctivitis : characterized by Mixed Follicular Response of Conjunctiva Papillary Response of Conjunctiva Etiology : CHLAMYDIA TRACHOMATIS Epitheliotropic Organism – produces intracytoplasmic inclusion bodies k/a HALBERSTAEDTER PROWAZEK BODIES Source of Infection: Conjunctival Discharge

23. Clinical Features of Trachoma: Two Phases : Phase of Active Trachoma Phase of Cicatricial Trachoma

24. Clinical Features of Trachoma: Phase of Active Trachoma: Symptoms: Foreign Body Sensation, Lacrimation, Stickness of Lids, Discharge etc ... Conjunctival Signs: Follicles, Leber , Papillae Corneal Signs: Superficial Keratitis, Heberts Follicles, Progressive Pannus

25. Clinical Features of Trachoma: II. Phase of Cicatricial Trachoma: Occurs d/t Delayed/Cell Mediated/Type IV HSR Conjunctival Signs: Conjunctival Scarring & Arlt’s Line, Concretions, Mucus deposition in Glands of Henle Corneal Signs: Regressive Pannus, Heberts Pits, Corneal Opacity , Other Complications (Ectasia, Xerosis , Total Corneal Pannus)

26. Grading of Trachoma:

27. Grading of Trachoma:

28. Treatment of Trachoma: TETRACYCLINE / ERYTHROMYCIN 1% Eye.Oint . : 4 times/day x 6 weeks Or SULFACETAMIDE 20% Eye Drops : 3 times/day x 6 weeks + TETRACYCLINE 1% Eye.Oint . : at night x 6 weeks DOC : Systemic: AZITHROMYCIN 500 MG X 5 DAYS

29. Treatment of Trachoma: SAFE Strategy : by WHO S: Surgery : Tertiary Prevention A: Antibiotics : Secondary Prevention F: Facial Hygiene : Primary Prevention E: Environmental Changes : Primordial Prevention

30. HYPOPYON CORNEAL ULCER (aka Serpiginous Corneal Ulcer/ Creeping Corneal Ulcer / Ulcer Serpens): Causes: Streptococcus pneumoniae (mcc) Pseudomonas aeruginosa (very aggressive) Biofilm formation – esp in Contact Lens Use Staphylococcus aureus (peripherally located) Staphylococcus epidermidis following Corneal Transplant

31. HYPOPYON CORNEAL ULCER (aka Serpiginous Corneal Ulcer/ Creeping Corneal Ulcer / Ulcer Serpens): Treatment: (Fortified Topical Antibiotics) – Intensive Rx Moxifloxacin / 4 th Gen. Fluoroquinolones Vancomycin + Cephalosporins Vancomycin + Aminoglycosides

32. F UNGAL CORNEAL ULCER

33. FUNGAL CORNEAL ULCER: Organisms: Aspergillus fumigatus (mcc) Candida albicans (in immunocompromised) Cf: h/o vegetable matter trauma Long History dt less pain SIGNS ARE OUT OF PROPORTION TO SYMPTOMS

34. FUNGAL CORNEAL ULCER: Cf: Leathery Appearance – Dry Look with Feathery Margins Satellite Lesions + Immune Ring of Wesseley (stromal ring d/t HSR III) Immobile Fungal Hypopyon (d/t fibrin) Rx: - NATAMYCIN 5% E/DROPS - DOC - AMPHOTERICIN B 0.15% (In Candida) Note: Steroids are CONTRAINDICATED

35. VIRAL KERATITIS

36. VIRAL KERATITIS: True Dendrites (with Terminal Knob) : in HSV Pseudodendrites : in Vericella zoster virus Geographic / Ameboid Ulcer Rx: ACYCLOVIR 3% E/ Oint . - 5 times/day

37. VIRAL KERATITIS: Stromal Keratitis: - HSR to Viral Antigens can present as Nummular Keratitis or Disciform Keratitis Rx: Topical STEROIDS + decrease IOP

38. HERPES ZOSTER OPHTHALMICUS

39. HERPES ZOSTER OPHTHALMICUS: Reactivation of Vericella zoster which is latent at GASSERIAN GANGLION (of Trigeminal Nerve) HUTCHINSON’S SIGN/RULE RX: ACYCLOVIR – Oral 800 mg – 5 times/day x 10-14 D Sys. Steroids - may prevent Trigeminal Neuralgia In Immunocompromised : iv ACYCLOVIR

40. EXTERNAL HORDEOLUM (STYE)

41. EXTERNAL HORDEOLUM : Cause : infected & inflammed GLAND OF ZEIS Cf : Painful Swelling at the lid margin Pus Point present at the base of eye lash Treatment: Epilation Incision & Drainage – may be required Topical Antibiotics : CIPROFLOXACIN 0.3% E/DROPS 1-1-1-1 X 7 Days Hot Fomentation & Lid Hygiene

42. INTERNAL HORDEOLUM

43. INTERNAL HORDEOLUM : Cause : infected & inflammed MEIBOMIAN GLAND Cf : Painful Swelling behind the lid margin Pus Point present away from the lid margin Treatment: Incision & Drainage – may be required Vertical Incisions after everting the eyelid Topical Antibiotics : CIPROFLOXACIN 0.3% E/DROPS 1-1-1-1 X 7 Days Hot Fomentation & Lid Hygiene

44. CHALAZION

45. CHALAZION : Cause : chronic lipogranulomatous inflammation of MEIBOMIAN GLAND Cf: Painless swelling away from lid margin Treatment: Incision & Drainage – may be required Vertical Incisions after everting the eyelid – with Chalazion Clamp Topical Antibiotics : CIPROFLOXACIN 0.3% E/DROPS 1-1-1-1 X 7 Days TRIAMCINOLONE ACETONIDE – Intralesion steroid injection Hot Fomentation & Lid Hygiene,

46. PRESEPTAL CELLULITIS

47. PRESEPTAL CELLULITIS: Infection of the subcutaneous tissues anterior to the orbital septum. Organisms: Staphylococcus aureus & Streptococcus pyogenes Causes: Trauma/ Sx , Insect Bites, other foci of infection, hematogenous spread from URT or Middle Ear. Cf : Swollen, Firm, Tender Red Eyelid Note: Vision, Pupillary Reactions & Ocular Motility are unimpaired

48. PRESEPTAL CELLULITIS: Treatment: Oral Antibiotics: CO-AMOXICLAV 250-500/125 mg : 2-3 times/day In Severe Cases: Intravenous Antibiotics - Ceftazidime Complications: Abscess, Meningitis, Cavernous Sinus Thrombosis, Orbital Cellulitis

49. ORBITAL CELLULITIS: Infection of the soft tissues behind the orbital septum. Organisms: Streptococcus pneumoniae , Staphylococcus aureus, Streptococcus pyogenes & Haemophilus influenzae Causes: Paranasal Sinusitis (esp. Ethmoid), Preseptal Cellulitis, Dacryocystitis , Midfacial Skin or Dental Infection, Trauma/ Sx Cf : Rapid onset of Pain, exacerbated by Eye Movement, Proptosis & Swelling, Malaise, Visual Impairment, Double Vision Note: Vision, Pupillary Reactions & Ocular Motility are Impaired

50. ORBITAL CELLULITIS: Signs: Pyrexia Optic Nerve Compression : RAPD, Vision, Colour Vision Tenderness, Warmth, Chemosis , SCH, Proptosis Fundus: Choroidal Folds & Optic Disc Swelling Complications: Optic Neuropathy, Exposure Keratitis, raised IOP, Endophthalmitis , CRAO, CRVO Subperiosteal Abscess (most in Medial Orbital Wall) Intracranial Complications : uncommon, but serious

51. ORBITAL CELLULITIS: Investigations: Routines, High Resolution CT Orbit, Sinuses & Brain Treatment: Hospital Admission with Urgent ENT & frequent Ophthalmic Rv. IV Antibiotics: DOC – CEFTAZIDIME + Oral METRONIDAZOLE (for Anaerobes) IV Antibiotics continued till patient is apyrexial for 4 days, f/b 1-3 weeks of Oral Treatment Note: Vision, Colour Vision & EOM are affected in these cases.

52. ENDOPHTHALMITIS

53. ENDOPHTHALMITIS : Ophthalmic Emergency Suppurative Inflammation of inner coats of eyeball Causes: Ocular Penetrating Trauma / Ocular Surgery Mc organisms: Staphylococcus aureus & epidermidis Symptoms: Acute onset of Pain, Redness, Photophobia & Diminution of Vn Rapid Progression of vision loss d/t Retinal Toxicity

54. ENDOPHTHALMITIS : Signs: Poor Visual Acquity – 6/60 to PL+ (BUT NEVER PL –VE) Hazy Cornea Hypopyon Yellow Reflex in Pupil Fundus – not visible Management: Vitreous Tab + Intravitreal Antibiotics Vitrectomy (if no improvement with antibiotics/severe cases)

55. ENDOPHTHALMITIS : Intravitreal Antibiotics: VANCOMYCIN : 1 mg/0.1 ml CEFAZOLIN : 2.25 mg/0.1 ml AMIKACIN : 400 gm/0.1 ml CEFTAZIDIME : 2 mg/0.1 ml Topical Drugs: Corticosteroids : PREDNISOLONE 0.1% X 2nd Hourly Fortified Vancomycin 25mg/ml Cycloplegics : HOMATROPIN 2% x 1-1-1

56. PANOPHTHALMITIS

57. PANOPHTHALMITIS : Suppurative inflammation of all coats of eyeball. VISUAL ACQUITY IS PERCEPTION OF LIGHT –VE Complications: Orbital Cellulitis, Septic focus can spread to brain – cause Meningitis, Encephalitis, Brain Abscess Treatment: EVISCERATION No way to salvage vision

58. EMERGENT INTERVENTIONS BY OPHTHALMOLOGISTS

59. WHEN TO CALL AN OPHTHALMOLOGIST : Post-operative complications Endophthalmitis & Panophthalmitis Severe Bacterial Conjunctivitis Pre-septal Cellulitis & Orbital Cellulitis Corneal Ulcers Impending Perforations Intraocular Penetrating Trauma

60. REFERENCES: Parson’s Diseases of the Eye (by Ramanjit Sihota & Radhika Tandon) Kanski’s Clinical Ophthalmology (by John F. Salmon) AAO’s Part 2: Fundamentals & Principles of Ophthalmology The Will’s Eye Manual (by Wolters Kluwer) Tintinalli’s Emergency Medicine (Judith E. Tintinalli , Editor in Chief)

61. THANK YOU