Ординатура / Офтальмология / Учебные материалы / Color Atlas of Ophthalmology The Quick-Reference Manual for Diagnosis and Treatment

4 External Diseases 101

Differential Diagnosis

Oth er kin ds of conju n ct ivit is (in fect ious, allergic, or toxic), an d dr y eye. Ru le ou t sebaceou s glan d carcin om a in u n ilateral cases.

Management

Lid hygiene: Com m ercially available ready-for-use lid scru bs or w arm -w ater

soaks w ith dilu ted n eu t ral baby sh am poo in th e m orn ing an d at n igh t , tear su pplem en t s, an t ibiot ic gels (e.g., fu sidic acid) or oin t m en t (e.g., er yth rom ycin or bacit racin )

Diet: Vitam in an d om ega-3 su pplem en tat ion , salm on in t ake, olive oil in t ake

Flax oil: Th e best source is grou n d flax seeds so ligin an d fiber are in clu ded

Tapered topical steroids: For severe in flam m at ion or corn eal in filt rates or ph lycten u les. Dual-act ion topical an t iallergic m edicat ion provides relief (e.g., ketot i- fen fu m arate 0.025%, azelast in e hydroch loride 0.05%, olopatadin e hydroch loride 0.1%.)

Oral system ic tet racyclines: For acn e rosacea in adu lts (oral doxycyclin e, 500 m g

1g/ever y 6 h ours for 1 m on th of t reat m en t)

Abundant art ificial tears and topical lubricants: For dr y-eye sym ptom s (e.g., topical sodium hyalu ron ate 0.18%)

Treat m en t is t apered according to sym ptom s

Conjunctivitis

Any in flam m at ion of th e conju n ct iva is referred to as conjun ct ivit is.

Adenoviral Conjunctivitis (Epidemic Keratoconjunctivitis,

Pharyngoconjunctival Fever)

Adenoviral infections predom inate in sum m er m onths. Most textbooks refer to viral conjunctivitis as infections produced by adenoviruses (epidem ic conjunctivitis, adenoviral conjunctivitis). But different viruses are responsible for different t ypes of conjunctivitis. Picornavirus (m ainly enterovirus 70 and Coxsackievirus A24) are responsible for acute hem orrhagic conjunctivitis, w hich is clinically sim ilar to adenoviral conjunctivitis but m ore severe. It is highly contagious and occurs in epidem ics.

Epidem ic keratoconjunct ivit is: Cau sed by aden oviru ses 8 an d 19 w ith ch aracterist ic preauricu lar lym ph n ode, p h ar yngit is, an d subepith elial in filt rates 5 to 10 days after th e in it ial sym ptom s

Pharyngoconjunct ival fever: Cau sed by aden oviru ses 3 an d 7, w ith fever an d ph ar yngit is; associated w ith pu blic sw im m ing pools in sum m er

Presentation

Classic sign s in clu de red eye (u n ilateral or bilateral), ciliar y inject ion (m ild irit is), an d epip h ora. In cases of aden oviral conjun ct ivit is, th e p at ien t refers to recen t exposure to an in dividual w ith red eyes at h om e, sch ool, or w ork or h as a h istor y of recen t sym ptom s of an upper resp irator y t ract in fect ion . Th e in cu bat ion period is 5 to 12 days. Acute follicu lar conju n ct ival react ion m ain ly in th e in ferior tarsal conju n ct iva, ch em osis, preauricu lar aden opathy, su bconjun ct ival petech iae (ver y sm all h em orrh ages), an d som et im es early, n on specific m ild pu n ctate keratopathy

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m ay be seen . Su bepith elial in filt rates develop 5 to 12 days after th e in it ial sym p - tom s (suggest aden oviru s serot ypes 8 an d 19). Corn eal opacit ies can persist for a few w eeks to m on th s (w e h ave seen u p to 2 years). Th ey can decrease visu al acuit y an d cau se glare sym ptom s. Epith elial ulcerat ion (par t ial or total) m ay occu r. Eyelid edem a an d su b-conju n ct ival h em orrh age suggest s acute h em orrh agic conju n ct i- vit is. In severe cases, m em bran es an d pseu dom em bran es can lead to conju n ct ival scarring an d sym bleph aron .

Sym ptom s in clude ph otoph obia an d eye pain if th ere is corn eal involvem en t (aden oviru s), in ten se w ater y disch arge (serou s), an d itchy eye(s). It is usu ally be- n ign an d self-lim ited an d gen erally h as a longer cou rse th an acute bacterial con - jun ct ivit is, last ing for ~2 to 4 w eeks (Fig. 4.2A,B).

Differential Diagnosis

Oth er epidem ic keratoconjun ct ivit is, h erpes sim plex in fect ion , h erpes zoster in - fect ion , in fect iou s m on on u cleosis (w ith eye involvem en t), Epstein -Barr virus in - fect ion , Dim m er kerat it is, bru cellosis

Management

Most cases are self-lim ited, w ith n o m orbidit y, an d requ ire n o specific t reat m en t . High ly con tagious cases requ ire st rict hygien e m easu res. In st ru ct you r pat ien t th at

A

B

Fig. 4.2 (A, B) Adenoviral conjunctivitis.

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Management

No t reat m en t is usu ally n ecessar y. Bed rest , dark glasses, cold com presses, an d an algesics (e.g., paracetam ol 500 m g ever y 8 h ou rs) are h elpfu l. Given th at th is is h igh ly con t agious, st rict hygien e m easures sh ould be obser ved . Provide relief of flu like sym ptom s w ith oral an t ih ist am in es an d decongest an ts. Low -dose top i- cal steroids com bin ed w ith vasocon st rictors an d du al-act ion topical an t iallergic m edicat ion provide com for t (e.g., ketot ifen fum arate 0.025%, azelast in e hydroch loride 0.05%, olopat adin e hydroch loride 0.1%.). Topical gel of gan ciclovir h as proven efficacy in sh or ten ing disease course. Topical broad -spect ru m an t ibiot ics m ay h elp to preven t secon dar y bacterial in fect ion .

Herpes Simplex Keratoconjunctivitis

Most textbooks refer to viral conjun ct ivit is as th at produced by aden oviruses (epidem ic conjun ct ivit is, aden oviral conjun ct ivit is), bu t differen t viruses are respon - sible for differen t t ypes of conju n ct ivit is or keratoconju n ct ivit is. Herpes sim plex virus (HSV) is th e m ost dangerous cause, especially HSV t ype 1 (m ou th , gen it al). HSV t ype 2 m ay also be a cau se, esp ecially in ch ildren an d n eon ates. HSV affects a variet y of ocular t issu es an d m ay cau se ocular derm at it is, epith elial an d st rom al kerat it is, an d even iridocyclit is (Fig. 4.4A,B).

Presentation

Red pain fu l eye (un ilateral or bilateral, usually u n ilateral), ph otoph obia-epiph ora, acute follicular conjun ct ival react ion m ain ly in th e in ferior tarsal conju n ct iva,

A

4 External Diseases 105

ch em osis, som et im es early n on specific m ild pu n ct ate keratopathy, classic den - drite-like corn eal u lcerat ion w ith term in al bulbs. Flu orescein stain s th e u lcer base, w h ereas rose bengal st ain s th e u lcer edges. Usually occu rs in sexu ally act ive adu lt s. In cases left u n t reated or in late diagn osis or in m u n ocom prom ised pat ien t s it can lead to disciform kerat it is, in terst it ial kerat it is, an d iridocyclit is.

Differential Diagnosis

Epidem ic keratoconjunctivitis, varicella-zoster herpetic infection, corneal abrasion

Management

Ophthalm ic ganciclovir gel (preferred) or acyclovir ointm ent (five tim es daily, 7 to 10

days is usually enough). Ganciclovir gel is m uch less toxic for the corneal epithelium than acyclovir. Use in children m ay not be approved for herpes sim plex in som e countries. Alternatives include 3%vidarabine ointm ent (five tim es daily, until reepithelialization or 7 days), 1%trifluridine drops (1 drop every 2 hours, m axim um 9 drops), or 0.5%idoxuridine drops (one drop, five tim es per day, 7 days).

Epithelial debridem ent and patching: Use gan ciclovir an d an t ibiot ic oin t m en t .

Add topical antibiotic drops, gel, or ointm ent to avoid superinfection: Dark glasses, antihistam ines (e.g., levocabastine every 8 to 12 hours) and vasoconstricting drops provide relief. Oral fam ciclovir reduces duration and the risk of recurrence.

Concom itant use of topical ganciclovir, steroids, and oral fam ciclovir: Required for disciform kerat it is, in terst it ial kerat it is, an d iridocyclit is. In th e case of iridocyclit is, prescribe cycloplegia.

Acute Bacterial Conjunctivitis

Becau se of th e excellen t defen se system s of th e eye, acute bacterial conju n ct ivit is is un com m on , bu t it is st ill th e m ost com m on eye disease. In m ost cases self-lim - ited an d ben ign , it is ch aracterized by th e presen ce of abun dan t m ucopu rulen t disch arge in a pat ien t w ith red eye. Th ere is con siderable overlap in th e presen t ing fin dings from differen t bacteria. On ly exper t clin ician s m ay be able to recogn ize th e probable in fect ive agen t at a clin ical level.

Epidem iology/t ransm ission: In fect ious for th e first 48 h ours of t reat m en t

Presentation

Signs: Redn ess w ith variable conju n ct ival inject ion (hyperem ia), palpebral conju n ct iva being m ore affected th an bu lbar, lid sw elling (m arked lid edem a ch aracterist ic of Haem ophilus influenzae an d Corynebacterium diphtheriae), m em bran es th at are com m on ly seen w ith St reptococcus pyogenes an d Corynebacterium diphtheriae, an d ch em osis (bulbar conju n ct iva an d forn iceal). Th ere is u su ally n o preauricu lar aden opathy or skin involvem en t , th e corn ea is usu ally clear (possible corn eal ulcerat ion if un t reated), an d th e pupil reacts n orm ally.

Sym ptom s: Unilateral, sudden onset of red eye w ith significant irritation and foreign body or grit t y sensation (no outstanding pain), w hich progresses to the

other eye in 2 to 5 days. It is usual for sym ptom s to be present for several days or w eeks at the tim e of presentation . An uncom m only long duration or frequent recurrences suggest that other factors or conditions m ay be present (e.g., chronic dacryocystitis, urethritis). The patient has sticky lids or m at ting of eyelashes, especially in the m orning, w ith serom ucoid (at the beginning) or m ucopurulent copious grayish, yellow, or green discharge (later). W hite discharge is due to abun - dant m ucus and suggests allergic reaction . Visual acuit y is preser ved except for the expected m ild blur due to the discharge and debris in the tear film . Consider gonococcal conjunctivitis if there is excessive purulent discharge.

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A B

Differential Diagnosis

Any cause of red eye (e.g., viral conju n ct ivit is, allergic conju n ct ivit is, any kerat it is, uveit is, acu te angle closure glau com a)

Management

Lid cleansing: It is im por tan t to keep th e lids clean an d rem ove all disch arge.

Broad-spect rum topical ant ibiot ic: Most cases of bacterial conju n ct ivit is clear

in 48 to 72 h ou rs w ith a low dose of any broad -spect rum an t ibiot ic applied topically. Con t in ue t reat m en t for at least 7 days. High ly respon sive to em pirical t reat m en t (e.g., tobram ycin , n orfloxacin , levofloxacin ). Tw o drops in affected eyes, ever y 3 to 4 h ours, for 1 w eek.

Oint m ents and gels: Ver y usefu l w ith ch ildren (day an d n igh t) or for overn igh t use in adult s

Cult ures: Con sider for cases refractor y to topical t reat m en t

Chlamydia Trachoma

Ch lam ydial organ ism s are respon sible for n eon at al conju n ct ivit is, adu lt in clu sion conju n ct ivit is, t rach om a, an d lym ph ogran ulom a ven ereu m (Nicolas-Favre disease, in t ropical region s, rarely affects th e eye). Ch lam ydial (in clusion ) conju n ct ivit is t ypically affects sexu ally act ive teen s an d you ng adult s, an d Chlam ydia is th e m ost frequ en t in fect iou s cause of n eon atal conju n ct ivit is in th e Un ited States. Adult in - clusion conju n ct ivit is, also called parat rach om a, is du e to Chlam ydia t rachom at is serot ypes D to K, w h ereas t ru e t rach om a is du e to Chlam ydia t rachom at is sero- t ypes A to C (Fig. 4.6A,B).

Presentation (Table 4.1)

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A B

Fig. 4.6 (A) Trachom a, cicatricial ptosis, lid everted following trachoma. (B) Trachom a corneal ulceration.

Table 4.1 Presentation of Chlam ydia Trachom a

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Table 4.1 (Con t in u ed)

Management

Salin e rin sing clears th e m u copur ulen t debris from th e lids an d conjun ct iva.

Azithromycin (Zithrom ax) 1 g by m outh is the drug of choice. One dose has been

docum ented as being as effective as doxycycline for the treatm ent of genital chlamydial infection. For greater safety we prescribe 500 m g, once every day for 3 days.

Altern at ives:

Oral am oxicillin or er yth rom ycin 250 to 500 m g, orally, fou r t im es daily, for 3 or 4 w eeks

Oral doxycyclin e 100 m g, orally, t w ice daily, for 1 w eek (be aler t for p reg- n an cy or lactat ion )

Oral tet racyclin e 250 to 500 m g, orally, fou r t im es daily, for 1 w eek (con t rain - dicated in pregn an t or lact at ing w om en an d ch ildren u n der age 8)

Topical antibiotics are relatively ineffective (but useful). Topical therapy is adjunctive but not essential: rifam picin (drops or ointm ent), or erythromycin oint- m ent (drug of choice for pregnant wom en), or tetracycline drops or ointm ent, three tim es daily, for 7 days. We always prescribe adjunctive topical therapy.

In ch ildren u se oral er yth rom ycin su spen sion , 40 m g/kg/day, in fou r divided doses for 2 w eeks.

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In pregn an t w om en use er yth rom ycin 250 to 500 m g, orally, fou r t im es daily, for 3 w eeks.

Topical flu oroquin olon e (ofloxacin or ciprofloxacin ) if th ere is a corn eal in - fect ion

Topical steroids can give tem porar y relief (st art a few days after topical an t i- biot ics).

Treat sexual partners. A condom does not protect against chlamydial conjunctivitis.

Chlamydia/Adult Inclusion Conjunctivitis

Th is con dit ion is sexually t ran sm it ted an d t ypically foun d in young adu lts. It presen ts as ch ron ic follicular conju n ct ivit is cau sed by Chlam ydia t rachom at is serot ypes D to K. A h istor y of vagin it is, cer vicit is, or u reth rit is m ay or m ay n ot be presen t .

Presentation

Presen tat ion in clu des ch ron ic, bilateral, red, an d irrit ated eye. In ferior tarsal or bulbar conjun ct ival follicles, su perior corn eal pan n us, palpable p reau ricu lar n ode, or t iny, gray-w h ite periph eral subepith elial in filt rates m ay be presen t . A st ringlike, m u cous disch arge is t ypical.

Differential Diagnosis

All oth er form s of ch ron ic conjun ct ivit is

Management

Diagn ost ic test s in clu de slit-lam p exam in at ion , direct ch lam ydial im m u n o-

flourescen ce test , or Chlam ydia cu lt ure of th e conju n ct iva. Conju n ct ival scrap - ing w ith Giem sa st ain sh ow s basoph ilic in t racytop lasm ic in clusion bodies in epith elial cells, polym orph on u clear leukocytes, an d lym ph ocytes in n ew born s.

Azith rom ycin 1 g by m ou th single dose, doxycyclin e 100 m g by m outh t w ice a day, or er yth rom ycin 500 m g by m outh four t im es a day for 7 days is given to th e pat ien t an d sexual part n ers.

Topical er yth rom ycin an d tet racyclin e t w o to th ree t im es a day for 2 to 3 w eeks are oth er t reat m en t opt ion s.

Chronic Conjunctivitis and Recurrent Corneal Abrasions

Ch ron ic conju n ct ivit is an d recurren t corn eal abrasion s m ay h ave th eir origin s in a lid disease (e.g., bleph arit is), a lid m alp osit ion (e.g., en t ropion ), or a lacrim al w ay dysfu n ct ion (e.g., dacr yocyst it is). Left un t reated, th ese con dit ion s can resu lt in severe dam age to th e ocu lar su rface as a resu lt of differen t corn eal an d con - jun ct ival com plicat ion s. Determ in ing th e cause is essen t ial to in dicate adequ ate t reat m en t .

Presentation

Sym ptom s in clu de recu rren t or ch ron ic conjun ct ivit is (red eye, disch arge, etc.), spasm odic inversion of th e eyelid m argin (spasm odic en t ropion ), foreign body sen sat ion , ocu lar su rface irrit at ion , corn eal abrasion s, an d scars. In advan ced cases th ere can be vision problem s (ast igm at ism , leu kom as in th e visu al axis), rest ric-

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Fig . 4.7 Spasmodic entropion with corneal ulceration sequelae.

t ion of ocu lar m ot ilit y (pseudopter ygiu m , sym bleph aron ), an d blin dn ess (in un - derdeveloped coun t ries w h ere su rger y is un available) (Fig. 4.7).

Differential Diagnosis

Trich iasis, dist ich iasis, dacr yocyst it is, t rach om a, ch em ical bu rn s, au toim m u n e disorders (e.g., pem ph igoid)

Management

Treat m en t varies w ith th e cause of recu rren t conju n ct ivit is. Un t il su rger y can be perform ed, bot u lin u m toxin inject ion s provide im m ediate tem porar y relief of spast ic en t ropion by w eaken ing th e pretarsal orbicularis oculi m u scle. Dacr yocystorrh in ostom y is perform ed in com plete obst ru ct ion of lacrim al p ath w ays. Treat com plicat ion s w h en n ecessar y (e.g., topical an t ibiot ic drops an d oin t m en t s for in - fect ious conjun ct ivit is). Provide ext raocular lubricat ion w ith gels an d oin t m en t s to reduce th e risk of abrasion s.

Giant Papillary Conjunctivitis

Papillae m ay be presen t in an oth er w ise h ealthy person . Papillae are gen erally presen t in th e sup erior lid t arsal conju n ct iva, m ost often papillae are due to an in - ten se allergic respon se, eith er con t act (con t act len s u sers, as part of a GellCoom bs t ype 1 im m u n oglobulin E–m ediated hypersen sit ivit y react ion ) or spring allergy (vern al keratoconju n ct ivit is). Gian t pap illar y conju n ct ivit is is a ch ron ic reversible in flam m ator y con dit ion . In th e presen ce of gian t papillae con sider th e follow ing:

Vern al conjun ct ivit is

Atopic keratoconju n ct ivit is

Gian t papillar y conjun ct ivit is of con tact len ses

Gian t papillae of prosth eses, corn eal scleral sh ields

En ds of nylon sut ures, cyan oacr ylate glue, ext ruded scleral buckles

Presentation

Pat ien ts presen t w ith itch ing, red eyes, foreign body sen sat ion , m ucou s disch arge, an d th e presen ce of gian t papillae at slit-lam p exam in at ion (cobbleston e aspect), usually in prosth eses or con tact len ses w earers (associated w ith u se of all t ypes