Ординатура / Офтальмология / Английские материалы / Common Eye Diseases and Their Management 3rd edition_Galloway, Amoaku, Galloway_2006

Figure 15.2. Retinoblastoma: leucocoria.

with a survival rate of at least 95% at five years. Treatment is usually in the form of a sector or total iridectomy.

The Eyelids

Benign Tumours

Meibomian Cysts (Chalazion)

This is the commonest eyelid lump in all ages. It is caused by blockage of the meibomian gland orifice such that the secretions accumulate. A granulomatous inflammation is set up, which results in a painless, round, firm, slowly growing lump in the tarsal plate (Figure 15.3).The cyst can become infected, when it becomes red hot and painful. Treatment is by incision and curettage.

Molluscum Contagiosum

This is caused by a viral infection and is most commonly seen in children. The lesions consist of several pale,waxy,umbilicated nodules on the eyelids and face. Similar lesions can be located on the trunk. The eyelid lesions shed viral particles, which produce a chronic conjunctivitis and less often superficial keratitis. The lesions might disappear in about six months, but can need curettage or cautery.

Papilloma

This is the name used to describe a rather common virus-induced nodule or filiform wart often seen on the lid margin.

Seborrhoeic Keratosis

This is common in the elderly and consists of slow-growing, sessile, greasy lesions of the eyelid. They are usually brown and friable.

Senile Keratosis

Senile keratosis consists of multiple, flat, scaly lesions, which can occasionally undergo transformation into a squamous cell carcinoma.

Xanthelasma

These are slightly elevated lesions consisting of lipid deposits usually on the medial aspect of the eyelids. They can be associated with hyperlipidaemia, especially in the younger patient.

Figure 15.4. Keratoacanthoma (with acknowledgement to Mr A. Sadiq).

Kaposi Sarcoma

This is a well-known association with acquired immune deficiency syndrome (AIDS). The lesions consist of purple nodules on the eyelid and similar lesions in the lower conjunctival fornix composed of proliferating endothelial and spindle-shaped cells. Inflammatory cells might also be present with vascular channels without endothelial cell lining. Human herpes virus 8 is thought to be important in the pathogenesis of these lesions.

Benign Vascular Tumours of

the Eyelids

These fall into three types: capillary haemangioma of the newborn (strawberry naevus), cavernous haemangioma and telangiectatic haemangioma.

Capillary Haemangioma of the Newborn

(Strawberry Naevus)

This is usually seen before the age of six months, and nearly all examples regress spontaneously, usually in few months and by the age of five years. Tumours appear as red, slightly raised marks on the skin.Even extensive tumours of this kind can show a dramatic improvement over several years and conservative management is usually indicated unless the tumour is associated with a fold of skin that occludes the eye, causing amblyopia. Larger tumours can produce orbital enlargement. If treatment is required, intralesional steroid injections have proved beneficial.

Cavernous Haemangioma

These tumours lie more deeply in the skin and appear as a bluish swelling in the lid, which expands when the child cries. These lesions can also disappear spontaneously or, if persistent, they can be treated by freezing.

Telangiectatic Haemangioma

Also known as the port wine stain or naevus flammeus, this tumour tends to be distributed over the area supplied by one or more of the branches of the fifth cranial nerve and usually remains throughout life as a dark red discolouration in the skin (Figure 15.5). The importance of this particular appearance is its association with secondary glaucoma and haemangioma of the meninges. The latter produces calcification and a characteristic X-ray appearance. The combination of lesions is known as the Sturge–Weber syndrome. There can be hypertrophy of the affected area of the face, leading to asymmetry.

Malignant Tumours of the Eyelids

Basal Cell Carcinoma

This is the most common malignant tumour of the eyelid in adults (80–90% of cases). Patho-

Figure 15.5. Port wine stain (naevus flammeus).

genesis is related to exposure to ultraviolet light, hence it most frequently involves the lower lid and medial canthus. The tumour begins as a small insignificant nodule, which turns into a small crater-like lesion with a slightly raised, pearly-coloured edge with fine dilated blood vessels on its surface (Figure 15.6). Although the tumour rarely metastasises, it is locally invasive, and, therefore, early diagnosis and treatment is important. In the early stages, it is a simple matter to remove the lesion and confirm the diagnosis by biopsy, but if left the tumour tends to spread into surrounding structures and into the underlying bone and orbit (Figure 15.7). Treatment depends on the size, extent and location of the tumour. Usually, surgical excision with wide margins is the technique of choice, either by a simple excisional biopsy or by the more complex Mohs’ procedure. The more extensive, neglected basal cell carcinomata are treated by radical surgery, cryotherapy or palliative radiotherapy.

Squamous Cell Carcinoma

Squamous cell carcinoma is the second most common malignant eyelid lesion and constitutes 5–10% of cases. It occurs most commonly in the elderly and is related to sunlight exposure. The tumour can initially resemble a basal cell carcinoma, although the edges are usually not rolled. Spread tends to occur to the local lymph nodes (preauricular for the upper lid and submandibular for the lower lid). Treatment is similar to a basal cell carcinoma.

Figure 15.6. Early basal cell carcinoma of medial canthus.

a

b

Figure 15.7. Extensive basal cell carcinoma involving the orbit and extending across the nose to the opposite side. a Clinical photograph; b computerised tomography scan.

Sebaceous Gland Carcinoma

This uncommon tumour constitutes 1–3% of malignant eyelid tumours (higher in Asians). It arises from the meibomian glands in the tarsal plate. It appears as a discrete, firm nodule, which often presents as a “recurrent chalazion”, thereby delaying diagnosis. Treatment involves wide excision with or without radiotherapy. Mortality ranges from 6% to 30%, depending on site, size, symptom duration and histological classification.

Melanoma of the Eyelid

Malignant melanoma of the eyelids is similar to malignant melanoma elsewhere, appearing as a raised, often shiny, black lump. It metastasises at an early stage and the prognosis does not seem to be altered by excision.

The Conjunctiva

Benign Lesions

Benign Pigmented Lesions of

the Conjunctiva

Conjunctival epithelial melanosis occurs in approximately 90% of black people and 10% of white people, and is noticeable in early life. The lesions are flat, brownish patches scattered throughout the conjunctiva, but might be more noticeable at the limbus (Figure 15.8). Usually, they do not grow. Other pigmented lesions, for example the benign naevus, require closer attention and specialist evaluation.

Nonpigmented Lesions

Pingueculum is a common mass lesion of the conjunctiva. It is seen as a yellowish nodule usually on the medial interpalpebral fissure. It is a fibrovascular degeneration and is seen in all climates.

Pterygium is a growth of abnormal fibrovascular tissue extending from the conjunctiva over the cornea (Figure 15.9). It is thought to result from to chronic irritation from dust and solar radiation. It is more common in hot climates and individuals who work out of doors. Recurrent inflammation of the pterygium is often self-limiting but responds to a short course of topical steroids. If it extends over the visual axis of the cornea it can cause visual impairment and, therefore, surgical excision might be required, although regrowth occurs in a large proportion of patients.

Figure 15.9. Pterygium.

Malignant Lesions

Melanoma of the Conjunctiva

Malignant melanomata can occur on the conjunctiva (Figure 15.10) but they should not be confused with the relatively common benign conjunctival naevus. The latter is a slightly raised pigment-stippled lesion often seen at the limbus on the temporal side. Closer examination with the hand lens or microscope reveals one or two minute cysts. It is generally accepted that these benign lesions should be excised and biopsied if they become irritable or sometimes simply on cosmetic grounds, but they rarely become malignant. The treatment of conjunctival malignant melanoma involves wide surgical excision with adjuvant cryotherapy or radiotherapy. The five-year survival rate is approximately 85%.

The Orbit (see Table 15.1)

Lacrimal Gland and Sac Tumours

Lacrimal gland tumours can either be inflammatory, mixed cell tumours or adenocarcinomas. They present with proptosis or a mass in the outer part of the eyelid superotemporal orbit. Lacrimal sac tumours are less common and present with sac swelling. Benign lesions and infections need to be excluded.

Dermoid Cyst

This cystic swelling is usually seen at the level of the eyebrow in the upper outer part of the orbit. It is smooth and fluctuant and often fixed to bone. Sometimes a deeper part of the cyst can occupy a cavity in the bone and a computed tomography (CT) scan is advisable when this is suspected. Rupture of the cyst can lead to profound orbital inflammation. Excision on cosmetic grounds and for diagnosis is usually indicated.

Cavernous Haemangioma

This is the commonest primary neoplasm of the orbit in adults. It is benign. It is unusual for surgery to be necessary in such cases. It is usually located within the muscle cone, and gives rise to axial proptosis.

surgical resection and/or radiotherapy is indicated if intracranial spread is documented.

Rhabdomyosarcoma

This rare but highly malignant orbital tumour is seen in children. Its growth is so rapid that it may be misdiagnosed as orbital cellulitis. If a correct diagnosis is made at an early stage, there is some hope of reaching a cure by combining radiotherapy and chemotherapy. The tumour is thought to arise from striated muscle and the histological diagnosis is confirmed by finding striation in the tumour cells. It is usually located in the superonasal orbit.

Metastatic Tumours and Tumours from Neighbouring Sites

A wide variety of tumours can invade the orbit and produce proptosis and often diplopia. Lymphoma is one example. It can present as an isolated lesion or in association with Hodgkin’s disease or leukaemia. Examples of local spread from adjacent structures include carcinoma of the nasopharynx, carcinoma of the lacrimal gland and meningioma. In children, orbital metastases arise most commonly from neuroblastoma and Ewing’s sarcoma. In the adult, the commonest primary sites are bronchus, breast, prostate and kidneys.

Glioma of the Optic Nerve

This rare tumour causes progressive proptosis and optic atrophy but it can be slow growing. There is an association with Von Recklinghausen’s disease (neurofibromatosis type 1) and the presence of pigmented patches in the skin should make one suspect this. Treatment by

Table 15.1. Primary orbital tumours.

“Pseudotumour” (Idiopathic Orbital

Inflammatory Disease)

This is an inflammatory swelling in the orbit of unknown cause, which can present with pain, proptosis and diplopia. A mass might be palpable in the orbit and biopsy reveals nonspecific inflammatory tissue consisting mainly of lymphocytes. Diagnosis can eventually be made by exclusion of other causes of proptosis. In severe cases, a course of systemic steroids and/or radiotherapy is usually effective.

Exophthalmos and Proptosis

Both these terms mean forward protrusion of the eyes but traditionally exophthalmos refers to the bilateral globe protrusion in thyroid disease. Proptosis refers to unilateral forward

displacement of the globe from whatever cause. In practice, the terms tend to be used rather loosely and are now almost synonymous.

Causes of Proptosis (see Table 15.2)

When one eye seems to bulge forward, the doctor might have a serious problem on his hands and the following likely causes should be considered:

•Pseudoproptosis. An apparent bulging forward of the eye occurs if the eye is too big, as in unilateral high myopia, or if the other eye is sunken following a blow-out fracture of the maxilla (orbital floor). These need to be distinguished from a true proptosis.

•Thyrotoxicosis. This is the commonest cause of unilateral or bilateral proptosis; diagnosis is achieved from the history, examination and tests of thyroid function (Figure 15.11).

•Infection. Orbital cellulitis, usually from neighbouring sinuses, requires urgent otorhinological opinion.

•Trauma. Proptosis can occur as a result of retro-orbital haemorrhage. Diagnosis should be possible from the patient’s history.

•Haemangioma. This can expand after bending down or crying.Ultrasound and CT scanning can confirm the diagnosis. Occasionally, angiography might be required.

•Pseudotumour. Biopsy should be carried out if possible, and other causes excluded.

•Mucocele of sinuses. Diagnose by X-ray or CT scan.

•Lymphoproliferative disease. A biopsy, full blood count and sternal marrow puncture should be carried out.

Table 15.2. Causes of proptosis.

•Endocrine

•Vascular abnormalities

•Inflammatory disorders

•Primary orbital tumours

•Metastases

Figure 15.11. Proptosis: dysthyroid disease.

•Others. There are a large number of possible but rare causes of proptosis.

Assessment of Proptosis

In the clinic, proptosis is best assessed by standing behind the seated patient and asking him to look down. The position of each globe in relation to the lids and face can be best seen by this means. Proptosis can be measured by means of an exophthalmometer. A number of such instruments are on the market and they depend on measuring the distance from the rim of the outer margin of the orbit to the level of the anterior part of the cornea. These measurements are not always accurate (especially for the novice) but best results are achieved by ensuring that they are made by the same person, using the same instrument on each occasion for a given patient.

Once thyroid disease and trauma have been excluded, the patient would require further investigations including systemic examination, full blood picture, orbital ultrasound, CT scan, magnetic resonance imaging (MRI) scan, possibly carotid angiography and sometimes orbital biopsy.

The fact that injuries to the eye and its surrounding region demand special attention and create great concern for patient and doctor is self-evident when the eye alone is involved, but when other life-threatening injuries are present, the eye injury, seeming slight at the time, might be overlooked. Sometimes, the eyelids might be so swollen that it is difficult to examine the eyes and a serious perforating injury could be obscured. When other injuries are present and an anaesthetic is needed, it is essential that the eyes are examined carefully, if possible under the same anaesthetic. As in the case of injuries elsewhere, those to the eye demand urgent and immediate treatment, and neglect can result in tragedy even though the problem might have at first seemed slight.

Injuries to the Globe

Contusion

The eye casualty officer comes to recognise a familiar pattern of contusion, the effect of squash ball injuries and blows from flying objects in industry or after criminal assault. Injuries from industrial causes have now become quite uncommon thanks to better control by means of protective clothing and proper guarding of machinery.As a result,sporting injuries have become more evident,although here increasing public concern has also led to some improvement. Notable instances of good

control are the use of protective guards in ice hockey and cricket. The surrounding orbital margin provides good protection to the eyes from footballs and even tennis and cricket balls, but the rare golf ball contusion injury usually leads to loss of the sight of the eye. Squash balls and especially shuttle cocks have earned a bad reputation for inflicting contusion injuries and, from the economic point of view, leading to loss of time at work and hospital expenses.

The extent of damage to the eye from contusion depends on whether it has been possible to close the eyelids in time before the moment of impact. If the lids have been closed, bruising and swelling of the eyelids is marked and the injury to the eye might be minimal. It must be remembered though that this is not an infallible rule and the eyes themselves must always be carefully examined, even when there is extreme swelling of the lids. It is always possible to examine an eye, if necessary using an eye speculum under general anaesthesia. In the primary care situation, one must be very careful not to apply more than gentle pressure to the eyelids in case the globe of the eye has been perforated and when there is doubt, referral to the eye department is advisable. The important clinical features of contusion injury are best considered by looking at the anatomical parts of the eye.

Cornea

The most common injury to the cornea is from the corneal foreign body and this has already

been described in Chapter 5.Almost as common is the corneal abrasion. It is odd how this is so often caused by the edge of a newspaper, a comb or a child’s fingernail. Abrasions from the leaves of plants or twigs need special attention because of the type of infection that can occur (fungal), but any abrasion can lead to the condition known as recurrent abrasion. Here, the patient experiences a sharp pain in the eye in the early morning usually on waking, sometimes many months after the initial injury. It is thought that the lid margin adheres to the area of weakened healed corneal epithelium during sleep. The diagnosis is easily missed if the patient has forgotten about the original injury and if the cornea is not examined carefully with the slitlamp biomicroscope.This problem of recurrence is a reason to treat these abrasions with some care and to provide the patient with a lubricating ointment to be used at night for some time after the original injury has healed. Sometimes, recurrent abrasion results from a rare inherited disorder of the corneal epithelium.

When a patient presents with a corneal abrasion, the eyelids are often swollen perhaps from rubbing and the distress and agitation can be considerable. Examination may be impossible without first instilling a drop of local anaesthetic. These drops should never be continued as treatment because they could seriously delay the healing of the cornea.

Anterior Chamber

A small bleed into the anterior chamber of the eye is seen as a fluid level of blood inferiorly (“hyphaema”) (Figure 16.1). This is a sign of potential problems because of the risk of secondary bleeding after two or three days. This risk is especially serious in children and the complication can lead to secondary glaucoma and at worst,the loss of the eye.The parents need to be warned about this if there is a hyphaema. Treatment is by strict rest with little or no head movement to avoid further bleeding and regular measurement of the intraocular pressure.

Iris

When confronted by a flying missile, the normal reaction is to attempt to close the eyelids and to rotate the eyes upward. This is the reason why the commonest point of impact is the lower

Figure 16.1. Hyphaema showing anterior chamber half filled with blood.

temporal part of the eye and it is in this region of the iris that one is most likely to see peripheral iris tears (“iridodialysis”).

When the eye is compressed the iris periphery is torn at its root, leaving a crescentic gap, which looks black, but through which the fundus and red reflex can be observed. Such an injury also provides an excellent view of the peripheral part of the lens and the zonular ligament (Figure 16.2).

Contusion can result not in a tear of the iris root, but in a tangential splitting of the iris and ciliary body from the sclera producing recession of the angle of the anterior chamber; the appearance is often associated with secondary glaucoma, sometimes many years after the injury and is identified using the special contact lens known as the gonioscope.

A sudden impact on the eye can also produce microscopic radial tears in the pupillary

Figure 16.2. Iridodialysis or splitting of the iris root in lower temporal quadrant. A sure sign of previous contusion.

sphincter of the iris. This could be a subtle microscopic sign of previous injury when no other signs are present, or the damage might be more severe, resulting in persistent dilatation of the pupil (traumatic mydriasis). Unless the eye is examined, this widening of the pupil after injury can be mistaken for a third cranial nerve palsy.

Choroid

Tears in the choroid following contusion have a characteristic appearance. They are concentric with the disc and are seen as white crescents where the sclera is exposed. When near the macula, there is usually permanent damage to the central vision (Figure 16.3). They are also potential sites for choroidal neovascularisation.

Lens

Any severe contusion of the eye is liable to cause cataract, but the lens might not become opaque for many years after the injury. The lens can also become subluxated (slightly displaced because of partial rupture of the zonular ligament) or even dislocated either anteriorly into the anterior chamber or posteriorly into the vitreous.

Vitreous

The vitreous can become displaced from its attachments around the processes of the ciliary body or around the optic disc after a contusion injury if it has not already undergone this change as part of the normal ageing process. The patient might be aware of something floating in front of the vision. More extensive floating black spots can indicate a vitreous haemorrhage caused by excessive vitreous traction on a retinal blood vessel. Although such haemorrhages usually clear completely in time, they tend to accompany more serious damage to the retina, which can only be fully revealed once clearing has taken place.

Retina

Bruising and oedema of the retina are seen as grey areas with scattered haemorrhages. The macular region is susceptible to oedema after contusion injuries, causing permanent damage to the reading vision. Just as tears can occur to the peripheral iris, so a similar problem is seen in the peripheral retina. These crescent-shaped retinal dialyses are also most common in the lower temporal quadrant and their importance lies in the fact that they may lead to a detachment of the retina unless the tear is sealed by laser treatment. Any significant contusion injury of the eye requires a careful inspection of the peripheral retina.

Optic Nerve

A variable degree of optic atrophy can become apparent a few weeks after a contusion injury. Blunt injuries to the eye can cause bleeding into the optic nerve sheath or tearing of the tiny pial blood vessels that supply the nerve, both resulting in complete, irreversible loss of vision on the affected side. Attempts have been made to relieve the situation by emergency decompression of the optic nerve, nerve sheath fenestration, use of hyperbaric oxygen and highdose steroids. No treatment has shown a clear benefit except optic nerve decompression in specific circumstances.

Perforation

As soon as the globe of the eye is penetrated there is a serious risk of infection. The vitreous is an excellent culture medium and in the

Figure 16.3. Healed choroidal tear. Another sign of previous injury.

pre-antibiotic era, eyes were totally lost within two or three days as a result of this. A perforating wound of the eye must, therefore, be considered a surgical emergency. Perforating injuries are seen in children from scissor blades, screwdrivers, darts and other more bizarre objects. In adults, there has been a dramatic fall in the incidence of such injuries since the introduction of compulsory seat belts but “do-it-yourself” accidents and assaults still take their toll. Following such an injury it is important to consider the possibility of an intraocular foreign body, especially when there is a history of using a hammer and chisel.

The outcome of a perforating injury is dependent on the depth of penetration and the care with which the wound is cleaned and sutured. If the cornea alone is damaged, excellent results can be obtained by careful suturing under general anaesthesia using the operating microscope. If the lens has been damaged, early cataract surgery might be needed and deeper penetration can result in the need for retinal detachment surgery.

On admission or in the casualty department, the patient is given tetanus prophylaxis and both systemic and local antibiotics. If early surgery under general anaesthesia is likely to be needed, it is better for the patient not to eat or drink to avoid delays in hospital. If it becomes clear that the injury is a serious one, it is better to warn the patient at an early stage about the possible risk of losing the sight of the eye or even the need to replace it with an artificial one.

Intraocular Foreign Body

Metallic foreign bodies tend to enter the eyes of those who operate high-speed grinders without goggles or those using a hammer and chisel on metal without eye protection. These injuries might seem slight at first and sometimes patients do not attach much importance to them. Any such eye injury with this occupational history warrants an X-ray of the eye. When ferrous metals remain in the eye they can cause immediate infection, or at a later date the deposition of ferrous salts, in a process known as siderosis. This can eventually lead to blindness of the eye. Other metals also tend to give reactions, particularly copper and for this reason the metallic fragment should be removed (Figure 16.4). This is achieved either by using intravit-

Figure 16.4. A small metallic foreign body lying on the retina.

reous forceps under microscopic control or using a magnet. The exact surgical technique is planned beforehand once the foreign body has been accurately localised in the eye. Airgun pellets cause particularly severe eye injuries and the eye is often lost because of the extensive disruption at the time of the injury. Some intraocular foreign bodies, such as glass particles or some alloys, might be tolerated quite well and a decision could have to be made as to whether observation is preferable in the first instance. This especially applies when the sight of the eye remains good. When a foreign body is not to be removed immediately, many ophthalmologists would insert intravitreal antibiotics as a prophylactic measure against endophthalmitis. When a foreign body is found lying deeply in the cornea, its removal can result in loss of aqueous and collapse of the anterior chamber. It is prudent to arrange that removal should be done under full sterile conditions in the operating theatre, where the corneal wound can be sutured if necessary.

Sympathetic Ophthalmia

This rare complication of perforation is more common in children. The injured eye remains markedly inflamed and the wound might have been cleaned inadequately or too late. Over a period of two weeks to several months or even years a particular type of inflammatory response begins in the uvea and subsequently a similar reaction occurs in the other eye. The inflammation in both eyes can be so severe as to cause blindness. The condition does, however,