Ординатура / Офтальмология / Английские материалы / Oculoplasty and Reconstructive Surgery Made Easy_Garg,Touky, Nasralla_2009

Miscellaneous Disorders 399

•In old age the lacrimal papilla and the puncta become more prominent and rotate out, due to the laxity of tissues due to senile changes (Figures 6 and 7).

•As the puncta do not dip into the lacus lacrimalis, this pool of the tears is not siphoned by the lacrimal passages and overflows onto the cheeks.

Differential Diagnosis

•Senile ectropion of the lower eyelids.

•Chronic conjunctivitis.

•Chronic blepharitis.

Treatment

•Three–snip operation to open up the lower lacrimal canaliculus onto the tarsal conjunctival surface.

•Conjunctivodacryocystorhinostomy may have to be resorted to in unrelenting cases.

Prognosis

• Fair to good chances of recovery of functions.

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EYELASH IN THE CANALICULUS

Introduction

•Foreign bodies in the conjunctival ‘cul-de-sac’ are common, and cause great discomfort and irritation, till the time these are removed.

•Foreign bodies in the canaliculi are rare and not of much significance if these do not produce a blockage.

•Eyelash in the canaliculus is both, conspicuous to the examiner and irritating to the patient, as it protrudes out through the punctum and wipes over the conjunctiva with each movement of the eyelid (Figures 8 to 10).

Figure 8: Eyelash in the canaliculus protruding through the punctum

Figures 9 and 10: Eyelash in the upper canaliculus protruding through the punctum.

Miscellaneous Disorders 401

Etiology

•11 to 13 eyelashes are shed daily, from each eye, and go into the conjunctival sac only if the patient happens to rub the eye. The flow of the tears takes these to the punctum, where once engaged, the siphon created and further rubbing of the eye, draws it into the canaliculus.

•The proximal end of the eyelash is the first to go through the punctum, because of its rigid nature in contrast to the limp distal end.

Treatment

Removal with an epilation forceps.

FOREIGN BODY IN SULCUS SUBTARSALIS

Introduction

No examination of the eye is complete, without everting the upper eyelid, for, the sulcus subtarsalis is an ideal place to stick to, for all foreign bodies in the conjunctival sac

(Figure 11).

Figure 11: Foreign body in the sulcus subtarsalis

402 Oculoplasty and Reconstructive Surgery

Etiology

•Unprotected driving of two wheelers, especially at dusk, when the insects fly towards the vehicular lights.

•Unprotected harvesting and threshing of crops.

•Unprotected working in front of lathes and grinders.

Clinical Features

Pain, lacrimation, photophobia and conjunctival discharge.

Treatment

Removal with a sterile 26 G hypodermic needle after anesthetizing the conjunctival sac with a local anesthetic and instilling a broad spectrum antibiotic ointment into the sac.

GRAVES’ OPHTHALMOPATHY (THYROTOXICOSIS)

Clinical Features (Figures 12 to 14)

Symptoms

•Exophthalmos

•Dry eyes.

Signs

1.Lid signs

•Retraction of upper lid (Dalrymple’s sign) (Figure 12)

•Lid lag (Von Graefe’s sign)

•Lid oedema (Enroth sign)

•Infrequent blinking (Stellwag’s sign)

•Difficulty in everting the upper lid (Gifford’s sign)

2.Ocular motility defects

•Weakness of convergence (Mobius sign)

3.Conjunctival chemosis.

4.Proptosis.

Miscellaneous Disorders 403

Figure 14: Exophthalmos: Left eye

5.Exposure keratitis.

6.Optic neuropathy.

Differential Diagnosis

1.Thyroid disorders.

2.Chronic nongranulomatous intraorbital lesions (pseudotumor).

3.Primary intraorbital tumors.

4.Secondary intraorbital tumours, etc. should be looked for.

Investigations

1. Positional tonometry.

Miscellaneous Disorders 405

Etiology

•Causative organism

–Chlamydia trachomatis, a Bedsonian organism belonging to the psittacosis—lymphogranuloma—trachoma (PLT) group.

•Predisposing factors

–Contracted in early childhood, though can effect at any age

–Female patients out number males.

–No race is immune to this disease.

–Areas having dry and dusty climate are more prone.

–Poor and outdoor workers are affected more commonly.

•Source of infection

–Main source is the conjunctival discharge of the patient.

•Mode of spread

–Direct

–Vector transmission or

–Contaminated materials in clinics and homes.

Clinical Features

Symptoms

In the absence of secondary infection:

•Mild foreign body sensation is felt in the eyes

•Watering

•Stickiness of the eyelids and

•Very little mucoid discharge.

Signs

•Congestion of upper tarsal and fornicial conjunctiva.

•Chronic follicular conjunctivitis, classically more marked on the upper tarsal plate, though these may be present on the conjunctiva at other sites also.

406 Oculoplasty and Reconstructive Surgery

Figure 15: White line of Arlt

•Follicles lead to progressive scarring of the upper conjunctiva, producing a few linear scars or often a transverse band in the sulcus subtarsalis called white line of Arlt (Figure 15).

•When marked scarring occurs, it leads to entropion, trichiasis, and secondary ocular surface breakdown, including corneal ulceration.

•Primary corneal involvement, which occurs along with the conjunctivitis, includes:

–Epithelial keratitis

–Marginal and central corneal infiltrates and

–Superficial vascularization, which is more pronounced in the upper half of the cornea – as a fibrovascular pannus.

•Follicle formation at the limbus regresses to sharply defined depressions called Herbert’s pits, at the base of the pannus

(Figure 16).

•Concretions may be formed due to accumulation of dead epithelial cells and inspissated mucus in the ducts of Henle.

Miscellaneous Disorders 407

Figure 16: Herbert’s pits

Grading of Trachoma

MacCallan classified the conjunctival changes occurring in trachoma, as follows:

1.Trachoma I

•Immature follicles on the upper tarsal conjunctiva, including the central area, but there is no scarring.

2.Trachoma II

•Mature (necrotic or soft) follicles on the upper tarsal conjunctiva, obscuring the tarsal vessels, but there is still no scarring.

3.Trachoma III

•Follicles are present on the tarsus and definite scarring of conjunctiva is present.

4.Trachoma IV

•There are no follicles on the tarsal plate, but definite scarring of the conjunctiva is present.

Differential Diagnosis

•Acute adenoviral follicular conjunctivitis (Epidemic keratoconjunctivitis).

•Palpebral spring catarrh.

408 Oculoplasty and Reconstructive Surgery

Figure 17: Surgery for entropion (a sequel to trachoma)

Treatment

1.Oral tetracycline or erythromycin, 250 mg thrice a day. Clinical response is slow and prolonged treatment is required. Tetracycline and erythromycin is preferred over oral sulphonamides, as they have lesser side effects as compared to the later.

2.Topical tetracycline or erythromycin ointments, twice a day for over to months.

3.Concretions are removed with a hypodermic needle under topical anesthesia.

4.Trichiasis is treated by epilation, electrolysis or cryolysis.

5.Entropion is surgically corrected (Figure 17).

6.Xerosis is alleviated by artificial tear drops.

Prognosis

•Bad, unless prophylactic measures are taken and once it has started, unless it is treated aggressively.

HERPES ZOSTER OPHTHALMICUS

Introduction

•People over age 70 have a much greater chance of HZO infection.