Kuliah Blok Mata

Halida Wibawaty
Infection Immunology subdivision
Department of Ophthalmology
RSUD Dr Moewardi
Surakarta
CONJUNGTIVAL INFECTION
 CONJUNCTIVAL INFECTIONS
1. Bacterial
• Simple bacterial conjunctivitis
• Gonococcal keratoconjunctivitis

2. Viral
• Adenoviral keratoconjunctivitis
• Molluscum contagiosum conjunctivitis
• Herpes simplex conjunctivitis
3. Chlamydial
• Adult chlamydial keratoconjunctivitis
• Neonatal chlamydial conjunctivitis
• Trachoma
 Simple bacterial conjunctivitis

Signs

Crusted eyelids and conjunctival Subacute onset of mucopurulent

injection discharge

Treatment - broad-spectrum topical antibiotics

 Gonococcal keratoconjunctivitis
Signs Complications

Acute, profuse, purulent discharge, Corneal ulceration, perforation

hyperaemia and chemosis and endophthalmitis if severe

Treatment

• Topical cyprofloxacin/levofloxacin
• Intravenous cefoxitin or cefotaxime
 Adenoviral Keratoconjunctivitis
1. Pharyngoconjunctival fever
• Adenovirus types 3 and 7
• Typically affects children
• Upper respiratory tract infection
• Keratitis in 30% - usually mild

2. Epidemic keratoconjunctivitis
• Adenovirus types 8 and 19
• Very contageous
• No systemic symptoms
• Keratitis in 80% of cases - may be severe
 Signs of conjunctivitis

Usually bilateral, acute watery Subconjunctival haemorrhages and

discharge and follicles pseudomembranes if severe

Treatment - symptomatic
 Molluscum contagiosum conjunctivitis
Signs

• Waxy, umbilicated eyelid nodule • Ispilateral, chronic, mucoid

discharge
• May be multiple • Follicular conjuntivitis

Treatment - destruction of eyelid lesion

 Herpes simplex conjunctivitis
Signs

Unilateral eyelid vesicles Acute follicular conjunctivitis

Treatment - topical antivirals to prevent keratitis

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

Subacute, mucopurulent follicular Variable peripheral keratitis

conjunctivitis

Treatment - topical tetracycline and oral tetracycline

or erythromycin
Neonatal chlamydial conjunctivitis
• Presents between 5 and 19 days after birth

• May be associated with otitis, rhinitis and pneumonitis

Mucopurulent papillary conjunctivitis

Treatment - topical ofloxacin or cyprofloxacin
 Trachoma
• Infection with serotypes A, B, Ba and C of Chlamydia
trachomatis
• Fly is major vector in infection-reinfection cycle
Progression

Acute follicular Conjunctival Herbert pits

conjunctivis scarring (Arlt line)

Pannus formation Trichiasis Cicatricial entropion

Treatment - systemic azithromycin and topical levofloxacin
Conjungtivitis, Allergy
ALLERGIC CONJUNCTIVITIS

1. Allergic rhinoconjunctivitis

2. Vernal keratoconjunctivitis

3. Atopic keratoconjunctivitis
 Allergic rhinoconjunctivitis
• Hypersensitivity reaction to specific airborn antigens
• Frequently associated nasal symptoms
• May be seasonal or perennial

Transient eyelid oedema Transient conjunctival oedema

 Vernal keratoconjunctivitis
Frequently associated with atopy: asthma, hay fever and dermatitis

•Recurrent, bilateral
• Affects children and young
adults
• More common in males
and in warm climates
• Itching, mucoid discharge
and lacrimation
Types
• Palpebral
• Limbal
• Mixed

Treatment
• Topical mast cell stabilizers
• Topical steroids
 Progression of vernal conjunctivitis
Diffuse papillary hypertrophy, most marked on superior tarsus

Formation of cobblestone papillae Rupture of septae - giant papillae

Limbal vernal

Mucoid nodule Trantas dots

 Progression of vernal keratopathy

Punctate epitheliopathy Epithelial macroerosions

Subepithelial scarring
Plaque formation (shield ulcer)
 Atopic keratoconjunctivitis

Typically affects young patients with Eyelids are red, thickened, macerated
atopic dermatitis and fissured
 Progression of atopic conjunctivitis

Infiltration of tarsal conjunctiva causing featureless appearance

Inferior forniceal papillae Mild symblepharon formation

 Progression of atopic keratopathy

Punctate epitheliopathy Persistent epithelial defects

Subepithelial scarring Peripheral vascularization

Eyelids
Blefaritis
CHRONIC MARGINAL BLEPHARITIS
1. Anterior
• Staphylococcal
• Seborrhoeic

2. Posterior
• Meibomianitis
• Meibomian seborrhoea

3. Treatment
 Staphylococcal blepharitis

• Chronic irritation worse in mornings • Hyperaemia and telangiectasia of anterior

lid margin
• Scales around base of lashes
(collarettes) • Scarring and hypertrophy if longstanding
Complications of staphylococcal blepharitis

Trichiasis, madarosis poliosis Recurrent styes

,

Marginal keratitis Tear film instability

 Seborrhoeic blepharitis

• Shiny anterior lid margin • Greasy scales

• Hyperaemia of lid margin • Lashes stuck together
 Meibomianitis

Inflamed and blocked Toothpaste-like plaques

meibomian gland orifices from meibomian glands

Thickened posterior lid margin Meibomian cyst formation

 Treatment of Chronic Blepharitis

1. Lid hygiene - with 25% baby shampoo

2. Tear substitutes - for associated tear film instability

3. Systemic antibiotic - for severe posterior blepharitis

4. Warm compresses - to melt solidified sebum

in posterior blepharitis
Hordeolum
Signs of chalazion (meibomian cyst)

Painless, roundish, firm lesion May rupture through conjunctiva

within tarsal plate and cause granuloma
 Treatment of chalazion

Injection of local anaesthetic Insertion of clamp Incision and curettage

 Acute hordeola
Internal hordeolum External hordeolum (stye)
( acute chalazion )

• Staph. abscess of meibomian • Staph. abscess of lash follicle and

glands associated gland of Zeis or Moll
• Tender swelling at lid margin
• Tender swelling within tarsal plate
• May discharge through skin • May discharge through skin
or conjunctiva
 Xanthelasma

• Common in elderly or those with

hypercholesterolaemia
• Yellowish, subcutaneous plaques
containing cholesterol and lipid
• Usually bilateral and located medially
ECTROPION AND ENTROPION
1. Ectropion
• Involutional
• Cicatricial
• Paralytic
• Mechanical

2. Entropion
• Involutional
• Cicatricial
• Congenital
• Epiblepharon
 Involutional

• Affects lower lid of elderly patients

• May cause chronic conjunctival inflammation

and thickening
 Causes of cicatricial ectropion
• Contracture of skin pulling lid away from globe
• Unilateral or bilateral, depending on cause

Unilateral ectropion due to Bilateral ectropion due to severe

traumatic scarring dermatitis
Paralytic ectropion and lagophthalmos
Caused by facial nerve palsy which,
if severe, may give rise to the following:

Exposure keratopathy caused by Epiphora caused by combination of:

lagophthalmos • Failure of lacrimal pump
mechanism
• Increase in tear production
resulting from corneal exposure
 Mechanical ectropion
Mechanical lid eversion by tumour

Treatment
• Removal of the cause, if possible
• Correction of significant horizontal lid laxity
 Involutional entropion and trichiasis

Affects lower lid because upper lid If longstanding may result in corneal
has wider tarsus and is more stable ulceration
 Cicatricial entropion

• Severe scarring of palpebral conjunctiva

which pulls lid margin towards globe
• May affect lower or upper eyelid
• Causes include cicatrizing conjunctivitis,
trachoma and chemical burns
 Congenital entropion

• Very rare - not to be confused with epiblepharon

• Inturning of entire lower eyelid and lashes
• Absence of lower lid crease
• When skin is pulled down lid also pulls away from
globe
• Does not resolve spontaneously
EPISCLERITIS AND SCLERITIS

1. Episcleritis
• Simple
• Nodular
2. Anterior scleritis
• Non-necrotizing diffuse
• Non-necrotizing nodular
• Necrotizing with inflammation
• Necrotizing without inflammation
( scleromalacia perforans )

3. Posterior scleritis
 Simple episcleritis
• Common, benign, self-limiting but frequently recurrent
• Typically affects young adults
• Seldom associated with a systemic disorder

Simple sectorial episcleritis Simple diffuse episcleritis

Treatment
• Topical steroids
• Systemic flurbiprofen ( 00 mg tid if unresponsive
 Nodular episcleritis
• Less common than simple episcleritis
• May take longer to resolve
• Treatment - similar to simple episcleritis

Localized nodule which can be moved over Deep scleral part of slit-beam
sclera not displaced
Causes and Systemic Associations of Scleritis

1. Rheumatoid arthritis
2. Connective tissue disorders
• Wegener granulomatosis
• Polyteritis nodosa
• Systemic lupus erythematosus

3. Miscellaneous
• Relapsing polychondritis
• Herpes zoster ophthalmicus
• Surgically induced
Diffuse anterior non-necrotizing scleritis
• Relatively benign - does not progress to necrosis
• Widespread scleral and episcleral injection

Treatment

• Oral NSAIDs
• Oral steroids if unresponsive
 Nodular anterior non-necrotizing scleritis
More serious than diffuse scleritis

On cursory examination resembles Scleral nodule cannot be moved over

nodular episcleritis underlying tissue

Treatment - similar to diffuse non-necrotizing scleritis

Anterior necrotizing scleritis with inflammation
• Painful and most severe type
• Complications - uveitis, keratitis, cataract and glaucoma
Progression

Avascular patches Scleral necrosis and Spread and coalescence

visibility of uvea of necrosis

Treatment
• Oral steroids
• Immunosuppressive agents (cyclophosphamide, azathioprine, cyclosporin)
• Combined intravenous steroids and cyclophosphamide if unresponsive
Anterior necrotizing scleritis with inflammation
(scleromalacia perforans)
• Associated with rheumatoid arthritis
• Asymptomatic and untreatable

Progressive scleral thinning with exposure of underlying uvea