Ophthalmic review for GP

Ophthalmic reviewOphthalmic reviewforfor

General PractitionersGeneral Practitioners

Dr. Riyad G. BanayotDr. Riyad G. Banayot

EyelidsEyelids

Applied anatomyStye and chalazionBlepharitisMadarosis & PoliosisDiffuse eyelid diseaseBenign eyelid lesionsMalignant eyelid tumors

Applied anatomyApplied anatomy

Cross section of lower eye lid

Eye Lid RednessEye Lid Redness

External Hordeolum - Stye

Infection of lid gland Local pain redness and

swelling No need to refer Treatment: compresses,

topical antibiotic


Chalazion Granulomatous inflammation

of Meibomian gland Slow course - months Compresses at onset;

antibiotics no benefit If non-resolving refer

electively for transconjunctival incision & curettage

Treatment of chalazion

Injection of local anaesthetic Insertion of clamp Incision and curettage


Blepharitis - staphylococcal Chronic infection with

periodic flare-ups Staphylococcal or

seborrheic Irritation, burning and

itching Scales or crusting on

lashes Treatment: lid hygiene &

topical antibiotics

Staphylococcal


Blepharitis - seborrheic

Chronic infection with periodic flare-ups

Staphylococcal or seborrheic Irritation, burning and itching Greasy scales or lashes

stuck together Treatment: lid hygiene &

topical antibiotics

seborrheic

Madarosis

Local causes• Chronic anterior lid margin disease

• Infiltrating tumours

• Burns, radiotherapy or cryotherapy

Systemic causes• Generalized alopecia

• Myxoedema

• SLE

• Syphilis• Leprosy

Following removal

Decrease in number or complete loss of lashes

Poliosis Premature localized whitening of hair

Ocular associations

• Chronic anterior blepharitis• Sympathetic ophthalmitis

• Vogt-Koyanagi-Harada syndrome

• Waardenburg syndrome

Systemic associations

Diffuse eyelid diseaseDiffuse eyelid disease

Acute allergic edemaContact dermatitisAtopic dermatitisSystemic causes of lid edema

Acute allergic oedemaAcute allergic oedema

• Causes - insect bites, urticaria and angioedema• Unilateral or bilateral• Painless, red, pitting oedema• Chemosis may be present• Self-limiting

Contact dermatitisContact dermatitis

• Sensitivity to topical medication• Unilateral or bilateral• Painless oedema and erythema• Vesiculation and crusting• Thickening if chronic

Atopic dermatitisAtopic dermatitis• Associated with asthma and hay fever• Chronic itching and scratching

Facial - in young children Flexural - knees, elbows, wrists and ankles

Ocular associations of atopic dermatitisOcular associations of atopic dermatitis

Angular blepharitis Vernal disease

Thickening, crusting and fissuring

Staph. blepharitis

Ocular associations of atopic dermatitisOcular associations of atopic dermatitis

Keratoconus Keratoconjunctivitis

Shield-like cataract Retinal detachment

Systemic causes of lid oedemaSystemic causes of lid oedema

• Myxoedema

• Renal disease

• Congestive heart failure

• Obstruction of superior vena cava

• Fabry's disease

Benign eyelid lesionsBenign eyelid lesions

XanthelasmaCapillary hemangiomaNaevus flammeusNaevus flammeus

XanthelasmaXanthelasma

• Usually bilateral and located medially

• Common in elderly or those with hypercholesterolemia• Yellowish, subcutaneous plaques containing cholesterol and lipid

Capillary haemangiomaCapillary haemangioma

• Rare tumour which presents soon after birth• Starts as small, red lesion, most frequently on upper lid

• Blanches with pressure and swells on crying

• Grows quickly during first year

• May be associated with intraorbital extension

• Begins to involute spontaneously during second year

Periocular haemangiomaPeriocular haemangioma

• Steroid injection in most cases• Surgical resection in selected cases

• High-out heart failure

Treatment options

Occasional systemic associations

• Kasabach-Merritt syndrome - thrombocytopenia, anemia and reduced coagulant factors

• Maffuci syndrome - skin haemangiomas, endrochondromas and bowing of long bones

Port-wine stain (naevus flammeus)Port-wine stain (naevus flammeus)

• Rare, congenital subcutaneous lesion• Segmental and usually unilateral

• Does not blanch with pressure

• Ipsilateral glaucoma in 30%

• Sturge-Weber or Klippel-Trenaunay-Weber syndrome in 5%

Associations

Malignant eyelid tumorsMalignant eyelid tumors

Basal cell carcinomaSquamous cell carcinomaMeibomian gland carcinomaMelanomaKaposi sarcoma

Basal Cell Carcinoma (BCC)Basal Cell Carcinoma (BCC)

1. Most common human malignancy

2. Usually affects the elderly

3. Slow-growing, locally invasive

5. 90% occur on head and neck

6. Of these 10% involve eyelids

7. Accounts for 90% of eyelid malignancies

4. Does not metastasize

Frequency of location of BCCFrequency of location of BCC

Lower lid - 70% Medial canthus - 15%

Upper lid - 10% Lateral canthus - 5%

Nodular BCCNodular BCCEarly

• Shiny, indurated nodule

• Surface vascularization

• Slow progression

Advanced

• May destroy large portion of eyelid

Ulcerative BCCUlcerative BCC(rodent ulcer)(rodent ulcer)

Early

Chronic ulceration

Advanced

Raised rolled edges and bleeding

Sclerosing BCCSclerosing BCC

• Indurated plaque with loss of lashes

Advanced

• Spreads radially beneath normal epidermis

Early

• May mimic chronic blepharitis • Margins impossible to delineate

Squamous cell carcinomaSquamous cell carcinoma

• Predilection for lower lid

• Hard, hyperkeratotic nodule

• Less common but more aggressive than BCC

• May develop crusting fissures

• May arise de novo or from actinic keratosis

Ulcerative

• No surface vascularization

• Red base• Borders sharply defined, indurated and elevated

Nodular

Meibomian gland carcinoma

Spreading

Nodular

• Very rare aggressive tumour with 10% mortality• Predilection for upper lid

Hard nodule; maymimic a chalazion

Very large tumour

Diffuse thickening of lid margin and loss of lashes

Conjunctival invasion; maymimic chronic conjunctivitis

MelanomaMelanoma

From lentigo maligna (Hutchinson freckle)

Nodular

• Blue-black nodule with normal surrounding skin

• Plaque with irregular outline• Variable pigmentation

• Affects elderly• Slowly expanding pigmented macule• May be non-pigmented

Superficial spreading

Kaposi sarcomaKaposi sarcoma

Advanced Early

Pink, red-violet lesion

• Vascular tumour occurring in patients with AIDS• Usually associated with advanced disease• Very sensitive to radiotherapy

May ulcerate and bleed

Treatment OptionsTreatment Options

3. Cryotherapy

2. Radiotherapy• Small BCC not involving medial canthus

1. Surgical excision• Method of choice

• Small and superficial BCC irrespective of location

• Adjunct to surgery in selected cases

• Kaposi sarcoma


Orbital septum which separates the anterior structures from the orbit

Eye RednessEye Redness

Cellulitis Preseptal cellulitis

– Same as cellulitis anywhere else

– No orbital signs– No need to refer


Cellulitis Orbital cellulitis

– Proptosis, restricted extraocular movements, pain

– Urgent referral for IV antibiotics

– CT helps differentiate preseptal form

Congenital nasolacrimal duct obstructionCongenital nasolacrimal duct obstruction

Acute dacryocystitis Epiphora and matting

Congenital nasolacrimal duct Congenital nasolacrimal duct obstructionobstruction


Nasolacrimal Duct Obstruction

Dacryocystitis (acute/chronic) if infected

Swelling or abscess in lower inner canthus – Depending on severity,

may need hospitalization– Referral is required– Initial treatment: IV or PO

Antibiotics +/- external drainage


Laceration– Usually requires referral– Assume all lacerations

medial to punctum involve lacrimal drainage system

– Canalicular lacerations should be repaired within 24 hours

Intubation of the lacrimal system following repair of torn upper and lower canaliculi

ConjunctivitisConjunctivitis

Bacterial Chlamydial

Adult Neonatal Trachoma

Viral VKC Atopic Keratoconjunctivitis Allergic Ophthalmia neonatorum

ConjunctivitisConjunctivitis

IrritationFB sensationPhotophobiaDiffuse rednessTearing

Bacterial ConjunctivitisBacterial Conjunctivitis

Exudate: Pus

Scraping: PMNs

Preauricular Lymph

nodes: Not palpable

Adult chlamydial keratoconjunctivitisAdult chlamydial keratoconjunctivitis

Treatment

• Infection with Chlamydia trachomatis serotypes D to K• Concomitant genital infection is common

Subacute, mucopurulent follicular conjunctivitis

Variable peripheral keratitis

- topical tetracycline and oral tetracycline or erythromycin

Neonatal chlamydial conjunctivitisNeonatal chlamydial conjunctivitis

Treatment

• May be associated with otitis, rhinitis and pneumonitis

• Presents between 5 and 19 days after birth

Mucopurulent papillary conjunctivitis

- topical tetracycline and oral erythromycin

Trachoma

Treatment - systemic azithromycin

• Infection with serotypes A, B, Ba and C of Chlamydia trachomatis• Fly is major vector in infection & re-infection cycle

Acute follicular conjunctivitis

Conjunctival scarring (Arlt’s line)

Herbert pits

Pannus formation Trichiasis Entropion

Progression

Viral ConjunctivitisViral Conjunctivitis

Usually bilateral, acute waterydischarge and follicles

Subconjunctival haemorrhages &pseudomembranes if severe

Exudate: Profuse wateryScraping: MononuclearPreauricular Lymph nodes: Palpable

Vernal KeratoconjunctivitisVernal Keratoconjunctivitis(VKC) - (spring catarrh)(VKC) - (spring catarrh)

Main symptoms: Intense ocular

Itching

Exudate: Profuse watery

Scraping: Mononuclear

Preauricular Lymph nodes: Palpable

Atopic keratoconjunctivitisAtopic keratoconjunctivitis

• Typically affects young patients with atopic dermatitis• Eyelids are red, thickened, macerated and fissured• Infiltration of tarsal conjunctiva causing featureless appearance

Allergic ConjunctivitisAllergic Conjunctivitis

Exudate: Watery +/- mucoid

Scraping: Eosinophil

Preauricular Lymph

nodes: Not palpable

Ophthalmia NeonatorumOphthalmia NeonatorumNeonatal conjunctivitisNeonatal conjunctivitis

Contamination of infant’s eyes when passing through vagina and cervix

Gonococcus: – Rapid blindness, 2ry corneal

ulceration– Onset 2-3 days after birth– Broad spectrum topical

antibiotics Chlamydia:

– Less destructive, may last months

– Onset 5-12 days– topical tetracycline and oral

erythromycin

Subconjunctival HemorrhageSubconjunctival Hemorrhage

Common Causes: trauma,

operation, uncontrolled HTN, valsalva, cough, vomiting, straining maneuvers

No treatment; reassurance

Pingueculum / PterygiumPingueculum / Pterygium Pingueculum:

– On conjunctiva only

Pterygium:– Invading cornea

Chronic diseases / degeneration Refer if symptomatic Treatment: surgical excision –

high recurrence rate

Immuno-bullous diseasesImmuno-bullous diseases

Cicatricial pemphigoidStevens-Johnson syndrome

Cicatricial pemphigoidCicatricial pemphigoid• Chronic and progressive• Typically affects elderly women• Increased prevalence of HLA-B12

Oral mucosal lesions in most cases Skin lesions are less common

Progression of ocular cicatricial pemphigoidProgression of ocular cicatricial pemphigoid

Diffuse hyperemia

Subepithelial fibrosis and shrinkage

Symblepharon

Pseudomembranes

Complications of ocular cicatricial pemphigoidComplications of ocular cicatricial pemphigoid

Ankyloblepharon

Corneal keratinization

Metaplastic lashes Cicatricial entropion

Obliteration of fornices 2ry bacterial keratitis

Stevens-Johnson syndromeStevens-Johnson syndrome• Acute, and self-limiting• Hypersensitivity to drugs or infection• Typically affects young men

Lesions of oral mucosa and lips

Maculopapules which may develop into target lesions

Vesiculobullous,hemorrhagicand necrotic lesions

Ocular complications of Stevens-Johnson syndrome

Transient conjunctivitis and lid crusting without sequelae

membranous or pseudo-membranous conjunctivitis

Focal fibrotic patches andoccasionally symblepharon

Metaplastic lashes


layers of precorneal tear film

Dry EyesDry Eyes

Chronic redness Burning No need to refer Treatment: artificial tear

drops


The cornea consists of the five layers:

1- epithelium

2- Bowman's layer

3- stroma

4- Descemet's membrane

5- endothelium

KeratitisKeratitis

Bacterial– Contact lens wearers– White infiltrate in

cornea – Pain, reduced vision – Should be referred – Treatment: topical

antibiotics

KeratitisKeratitis

Fungal– Frequently preceded by

ocular trauma with organic matter

– Grayish white infiltrate surrounded by feathery infiltrate in cornea

– Pain, reduced vision – Should be referred – Treatment: topical

antifungal agents & systemic therapy if severe

KeratitisKeratitis

Acanthamoeba– Contact lens wearers at

particular risk– Anterior stromal infiltrates,

ulceration, ring abscess & stromal opacification

– Pain, reduced vision – Should be referred – Treatment: chlorhexidine or

polyhexamethylenebiguanide

KeratitisKeratitis Viral

Herpes Simplex

– Recurrent dendrites, corneal edema, iritis

– Refer– Treatment: Acyclovir

ointment

KeratitisKeratitis

ViralHerpes Zoster

– V1 Dermatome– Dendrites, iritis, other

ocular inflammation– Treatment: Oral

Acyclovir; start and

then refer

keratoconuskeratoconusNipple cone Oval cone Globus cone

Small and steep curve Larger and ellipsoidal Largest cone

Signs of keratoconusSigns of keratoconusBilateral in 85% but asymmetrical

Oil droplet reflex Prominent corneal nervesVogt striae

Acute hydrops Munson sign Fleischer ring & scarring

Bulging of lower lids on downgaze

Systemic associations of keratoconusSystemic associations of keratoconus

Crouzon syndromeMarfan's syndrome Osteogenesis imperfecta

Atopic dermatitis Down syndrome Ehlers-Danlos syndrome

Vortex keratopathyVortex keratopathy

Toxic maculopathyToxic maculopathy

Peripheral corneal involvement in Peripheral corneal involvement in rheumatoid arthritisrheumatoid arthritis

• Chronic and asymptomatic• Circumferential thinning with intact epithelium (‘contact lens cornea’)

• Acute and painful• Circumferential ulceration and infiltration

Treatment - systemic steroids and/or cytotoxic drugs

Without inflammation With inflammation

Rosacea keratitisRosacea keratitis

Peripheral inferiorvascularization

Subepithelial infiltration Thinning and perforation if severe

• Affects 5% of patients with acne rosacea• Bilateral and chronic

Progression

Treatment - topical steroids and systemic tetracycline or doxycycline

Metabolic KeratopathyMetabolic Keratopathy

Corneal Foreign BodyCorneal Foreign Body

If metal striking-metal is the mechanism of injury always get an X-Ray/CT scan of skull (This is mandatory if there is an open globe injury or suspicion of entry wound)

Superficial corneal FB can be removed with Q-tip or needle tip, otherwise refer

Rust rings develop after initial removal

UV burnUV burn


The scleral stroma is composed of collagen bundles of varying size and shape that are not

uniformly oriented

There three vascular layers that cover the anterior sclera: conjunctival, superficial episcleral and deep vascular plexus

Applied anatomy of vascular coatsApplied anatomy of vascular coats

Scleritis

• Maximal congestion of deep vascular plexus

• Slight congestion of episcleral vessels

• Maximal congestion of episcleral vessels

EpiscleritisNormal

• Radial superficial episcleral vessels• Deep vascular plexus adjacent to sclera

Episcleritis / ScleritisEpiscleritis / Scleritis Episcleritis:

– Common– Localized inflammation,

lasts 2 wks.– Treatment with topical

steroids or oral NSAIDs Scleritis:

– Rare– Granulomatous or

necrotizing, Vision threatening.

– Treatment with immunosuppression

UveitisUveitis

Pain, reduced vision, ciliary flush

Systemic association: Sarcoid, HLA B-27, inflammatory bowel disease, TB, syphilis

Refer Treatment: topical

steroids, dilating drops

Acute Angle Closure Acute Angle Closure GlaucomaGlaucoma Sudden severe pain,

loss vision, N & V Red eye with ciliary

flush, pupil fixed & mid dilated, cornea steamy, increased IOP

Emergency referral Treatment: drops to

lower IOP, constrict pupil, diuretics, laser iridotomy

Eye chemical injuriesEye chemical injuries

Chemical burns – irrigate immediately– NEVER give acid for alkali or vice versa

For all but least severe trauma – referAlways protect the eye from further

injury during transfer

Acquired cataractAcquired cataractAge relatedDiabetesMyotonic dystrophyAtopic dermatitisTraumaDrugsComplicated (secondary)

Age related cataractAge related cataract

Nuclear Cortical

Subcapsular Christmas

Diabetic cataractDiabetic cataractJuvenile

• White punctate or snowflake posterior or anterior opacities

• May mature within few days

Adult

• Cortical and subcapsular opacities• May progress more quickly than in non-diabetics

Myotonic dystrophy cataractMyotonic dystrophy cataract

• Myotonic facies• Frontal balding • 90% of patients after age 20 years

• Stellate posterior subcapsular opacity

• No visual problem until age 40 years

Atopic dermatitis cataractAtopic dermatitis cataract

• Cataract develops in 10% of cases between 15-30 years

• Bilateral in 70% • Frequently becomes mature

• Anterior subcapsular plaque (shield cataract)• Wrinkles in anterior capsule

Traumatic cataractTraumatic cataract

Penetration

Concussion

‘Vossius’ ring from imprinting of iris pigment Flower-shaped

• Ionizing radiation

• Electric shock

• Lightning

Other causes

DrugsDrugsChlorpromazine

• Long-acting mioticsOther drugs

• Amiodarone• Busulphan

- initially posterior subcapsularSystemic or topical steroids

- central, anterior capsular granules

Complicated cataractComplicated cataract

• Chronic anterior uveitis• High myopia

Posterior subcapsular

• Hereditary fundus dystrophies• Central, anterior subcapsular opacities

Glaukomflecken

• Follows acute angle closure glaucoma

Congenital cataractCongenital cataract

• 33% - idiopathic - may be unilateral or bilateral• 33% - inherited - usually bilateral• 33% - associated with systemic disease - usually bilateral• Other ocular anomalies present in 50%

Classification of congenital cataractClassification of congenital cataract

Anterior polar Posterior polar Coronary Cortical spoke-like

Lamellar Central pulverulent Sutural Focal dots

Causes of cataract in healthy neonateCauses of cataract in healthy neonate

Hereditary (usually dominant)

Idiopathic

With ocular anomalies• PHPV• Aniridia• Coloboma• Microphthalmos• Buphthalmos

Causes of cataract in unwell neonateCauses of cataract in unwell neonate

Intrauterine infections

• Rubella

• Toxoplasmosis

• Cytomegalovirus

• Varicella

Metabolic disorders

• Galactosaemia

• Hypoglycaemia

• Hypocalcaemia

• Lowe syndrome

Ectopia lentis - AcquiredEctopia lentis - AcquiredTrauma

• Buphthalmos• Megalocornea

Anterior uveal tumours Degenerate eye

Stretched zonules

Ectopia lentis - ADEctopia lentis - ADSystemic features of Marfan's syndrome

• Limb-trunk disproportion • Arachnodactyly

• Pectus excavatum

• High-arched palate

• Aortic dilatation, dissection and regurgitation• Mitral valve prolapse

Ocular features of Marfan syndromeOcular features of Marfan syndromeLens

• Upward subluxation • Zonule usually intact

Retinal detachment

• Axial myopia

Blue scleraCornea planaAngle anomaly and glaucoma

• Lattice degeneration

Ectopia lentis - AREctopia lentis - ARWeill-Marchesani syndrome

Systemic features

• Short stature

Ocular features

• Short stubby fingers (brachydactyly)

• Mental handicap

• Microspherophakia

• Angle anomaly and glaucoma

• Anterior lens subluxation

Ectopia lentis - AREctopia lentis - ARHomocystinuria (Defect in cystathionine synthetase)

Systemic features

• Malar flush and fine, fair hair• Marfanoid habaitus• Increased platelet stickiness• Mental handicap

Ocular features

• Downward lens subluxation

• Disintegration of zonule

Congenital glaucomaCongenital glaucoma

Corneal edema associated with lacrimation and photophobia

Buphthalmos

Dysthyroid OphthalmopathyDysthyroid Ophthalmopathy

Bilateral autoimmune swelling of extraocular muscles +/- orbital inflammation

Findings:– Proptosis (exophthalmos)– Restricted EOM– Inflammation– Optic nerve compression– Corneal exposure

Treatment: steroids / radiotherapy when active surgery when “burnt out”

Diabetic RetinopathyDiabetic Retinopathy

Background / Non-proliferative– Leaking vessels cause edema

& exudates– Treatment: referral for laser if

VA less than 6/9

Proliferative– Ischemic retina secretes

vascular growth factor – fragile new vessels rupture & bleeding may lead to scar and retinal damage / detachment

– Treatment: referral for PRP

Exposure keratopathyExposure keratopathy

Rosacea keratitis Rosacea keratitis

Keratitis in systemic collagen Keratitis in systemic collagen vascular disordersvascular disorders

Pituitary adenomaPituitary adenoma

Visual field defects caused by compression of chiasm from below

by pituitary adenoma

Axial CT scan of right pituitary adenoma invading right cavernous sinus

Optic NeuritisOptic Neuritis Mostly unilateral sudden loss

of vision, disturbance in color vision and pain with EOM

50% go on to develop MS Findings: poor vision, poor

color vision, afferent pupillary defect, optic nerve usually normal, visual field defect

Treatment: usually refer to neurologist, IV not oral steroids

Axial MRI scan showing periventricular plaques of demyelination (left: T1; right: T2)

Ophthalmic review for GP

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