Ординатура / Офтальмология / Учебные материалы / Color Atlas of Ophthalmology The Quick-Reference Manual for Diagnosis and Treatment
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4 External Diseases 121
Fig . 4.14 Cornea conjunctival lipoid degeneration.
Management
Treat th e u n derlying con dit ion to redu ce th e risk of progression (reduce fat serum levels). At tem pt closing th e feeder vessels w ith argon laser ph otocoagu lat ion . Severe cases w ith affected pu pillar y area m ay requ ire pen et rat ing keratoplast y, alth ough th is degen erat ion m ay recur in th e graft .
Conjunctival Retention Cysts
Conjun ct ival lym ph at ic cysts are soft , t ran slu cen t , an d m obile. Large cyst s m ay give dr y eye or foreign body sen sat ion (eye discom for t or tearing). A conju n ct ival cyst m ay reveal differen t possible origin s an d can be due to parasit ic in festat ion (e.g., cist icercosis), w h ich h as to be ruled ou t w h en th e p at ien t h as t raveled to en - dem ic region s, or it m ay be an accessor y lacrim al glan d, a post t raum at ic in clusion cyst (of conjun ct ival epith eliu m ), or sim ply a lym ph at ic cyst (th e m ost com m on ).
Presentation
Soft , t ran slucen t , an d m obile flu id -filled m ass w ith in th e conjun ct iva, alon e or in groups, fou n d at slit-lam p exam in at ion . More frequ en t in th e bu lbar conju n ct iva an d in th e in ferior tarsu s or in ferior cul-de-sac (Fig. 4.15).
Fig . 4.15 Conjunctival lymphatic retention cyst.
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Differential Diagnosis
Cyst of m align an t origin (ru le out parasit ic in festat ion an d h em at ic dyscrasia)
Management
Th ese cysts n eed n o t reat m en t u n less th ey cau se persisten t dr y eye or foreign body sen sat ion . Topical lubrican t s provide relief. Th eir w all can be easily broken in feriorly w ith a few sh ot s of n eodym ium :yt t rium -alu m in um -garn et laser app lied in feriorly on th e cyst w alls, w ith care to avoid conju n ct ival vessels. Postsu rgical cyst can be excised .
Superior Limbic Keratoconjunctivitis
Th is con dit ion is of un kn ow n et iology an d associated w ith thyroid disease. In su - perior lim bic keratoconjun ct ivit is, conju n ct ival laxit y m igh t in du ce in flam m ator y ch anges from m ech an ical t raum a of hyper t roph ic pap illae of th e u pper t arsal con - jun ct iva. It affects m ain ly adu lt w om en . A sim ilar con dit ion is foun d in soft con tact len s w earers using th im erosal-preser ved solut ion s.
Presentation
Sym ptom s in clu de tearing, bu rn ing, superior hyp erem ia, an d foreign body sen - sat ion . Pat ien ts w ith filam en ts are ext rem ely sym ptom at ic. In flam m at ion of th e su perior bu lbar conjun ct iva result s in edem a w ith redun dan t conjun ct iva. Th ere is predom in an t involvem en t of th e superior lim bu s, adjacen t epith elial kerat it is, an d papillar y hyper t rophy of th e u pper t arsal conjun ct iva. Th e in ferior conjun ct iva an d corn ea appear n orm al. Th e age range is 20 to 70 years. Occu rren ce is predom i- n an tly in fem ales, is usu ally bilateral, an d m ay be asym m et rical, w ith rem ission s an d exacerbat ion s. Dr y eye is often presen t (Fig. 4.16).
Fig . 4.16 Superior limbal keratoconjunctivitis.
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Differential Diagnosis
Clin ical fin dings are diagn ost ic (in flam m at ion of th e su perior bu lbar conju n ct iva w ith absolutely n orm al appearan ce of th e in ferior conjun ct iva an d corn ea).
Management
Con ser vat ive t reat m en t offers on ly tem porar y relief of sym ptom s (pressu re patch - ing, Plan o T ban dage con tact len s, Baush & Lom b In c., St . Lou is, MO). Silver n i- t rate (0.5 to 1.0% solut ion ) is applied w ith a sat urated cot ton sw ab. It u su ally relieves sym ptom s for 1 m on th an d can be repeated safely. Topical an t ih istam in es an d m ast cell st abilizers (e.g., olopat adin e hydroch loride 0.1%, ketot ifen fu m arate 0.025%, azelast in e hydroch loride 0.05%) are h elpfu l. Moist urizing drop s an d oin t- m en ts provide on ly m in im al relief. Cr yoth erapy an d a su rgical approach can be taken in recalcit ran t cases involving resect ion or recession of th e su perior bu lbar conju n ct iva or in -office th erm ocau terizat ion of th e su perior bulbar conju n ct iva w ith a disposable oph th alm ic cauter y u n der topical an esth esia. Th e u se of topical steroids is usually in effect ive.
Episcleritis
Episclerit is is a t ran sien t , self-lim ited in flam m ator y process of th e episclera. Most episclerit is is idiopath ic, but it can also be associated w ith system ic disorders su ch as rh eu m atoid ar th rit is, acn e rosacea, an d atopy.
Presentation
Th ere is an acute on set an d diffuse or n odu lar ocu lar redn ess w ith out irrit a- t ion or pain . In flam ed ep iscleral vessels radiate posteriorly from th e lim bus (Fig. 4.17A,B).
Fig . 4.17 (A) Episcleritis. (Continued on page 124)
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Fig . 4.17 (Continued) (B) Nodular episcleritis.
Differential Diagnosis
Sclerit is, uveit is, conjun ct ivit is
Management
Th e con dit ion is self-lim ited; n o t reat m en t is n eeded . Topical steroids or n on steroidal an t iin flam m ator y drugs (NSAIDs) or a com bin at ion of th ese can accelerate recover y. Vasocon st rictors an d refrigerated art ificial tears p rovide relief.
Scleritis
Sclerit is is a gran u lom atous in flam m at ion of th e sclera th at m ay presen t in associat ion w ith system ic diseases such as rh eu m atoid ar th rit is, system ic lu pu s er yth em atosu s, polyarterit is n odosa, or Wegen er gran ulom atosis. Sclerit is can be self-lim it ing or can progress to a p oten t ially blin ding n ecrot izing process. Possible com plicat ion s in clude scleral th in n ing (especially in recurren t sclerit is), sclerom a- lacia perforan s, sclerosing kerat it is, perip h eral corn eal m elt ing, uveit is, cat aract , m acu la edem a, ch oroidal gran ulom as, an d ret in al det ach m en t . Posterior sclerit is occurs m u ch less frequen tly th an an terior sclerit is an d m ay exten d in to th e an terior segm en t of th e eye. In cases of n ecrot izing sclerit is, in fect ion h as to be ruled out .
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Fig . 4.18 Scleritis table.
Presentation
Th ere is severe ocu lar pain w ith or w ith ou t decreased vision (suspect posterior involvem en t if vision is com prom ised). On set of sclerit is is m ore gradu al th an is seen in episclerit is an d is accom pan ied by u n i- or bilateral red eye, lacrim at ion , an d ph otoph obia (Fig. 4.18).
Differential Diagnosis
Conju n ct ivit is, uveit is, episclerit is
Management
Man agem en t in cludes system ic NSAIDs (e.g., in dom eth acin , ibuprofen , n aproxen ), topical steroids (e.g., bet am eth ason e, dexam eth ason e) an d system ic oral steroids (oral steroids preferred over topical), an d im m u n osup pressan t th erapies (e.g., m eth ot rexate, cycloph osph am ide, cyclosporin e, azath ioprin e). System ic t reat m en t w orks bet ter th an topical, w h ich h as to be con sidered accessor y to a system ic an - t iin flam m ator y regim en .
Dilated Vessels
Dilated Vessels and Ocular Vein Varicosities
Dilated vessels are com m on ly seen in h ealthy pat ien t s, especially w om en w ith ve- n ou s in su fficien cy. Th ey m ay be a sign of ven ous congest ion or raised episcleral pressure, eith er due to carot id cavern ous fist u la or to any orbit expan sive process or in flam m ator y disease of th e eye. Dilated episcleral sen t in el vessels can be presen t in cases of m align an t m elan om a of th e ch oroid or ciliar y body.
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Fig . 4.19 Dilated vessels.
Presentation
Presen t at ion is asym ptom at ic. Foreign body sen sat ion occurs in th e case of varicosit ies. Oth er sign s an d sym ptom s of red eye or orbit expan sive process m ay also be seen . Thyroid disease presen t s w ith dilated vessels, m ain ly over th e extern al rect us m u scles (Fig. 4.19).
Differential Diagnosis
Any cau se of red eye (conjun ct ivit is, idiopath ic raised ep iscleral pressure, ven ous in sufficien cy, carot id cavern ou s sin us fist u la, episclerit is, sclerit is, ch ron ic irrita- t ion , glau com a su rger y)
Management
No t reat m en t is n eeded if th e con dit ion is idiopath ic. Varicosit ies can be successfully redu ced using argon laser ph otocoagulat ion . Th e occasion al u se of vasocon - st rictors im proves cosm et ics but th ere is n o defin it ive t reat m en t . Treat th e con - com it an t illn ess.
Dilated Episcleral Vessels in Sturge -Weber Syndrome
St u rge-Weber syn drom e is a rare n eu rological disorder presen t at birth , ch aracterized by a birth m ark (u sually on th e face) kn ow n as a port-w in e st ain cau sed by an overabun dan ce of capillaries arou n d th e t rigem in al n er ve ben eath th e surface of th e face. Neu rological problem s arise du e to a loss of n er ve cells an d calcificat ion of t issu e in th e cerebral cortex of th e brain on th e sam e side of th e body as th e bir th m ark (angiom atosis of th e cen t ral n er vous system ). Neu rological sym ptom s in clu de seizu res th at begin in in fan cy an d m ay w orsen w ith age. Convulsion s usu - ally h appen on th e side of th e body opposite th e birth m ark an d var y in severit y. Th ere m ay be m u scle w eakn ess on th e sam e side. Som e ch ildren w ill h ave developm en t al delays an d m en tal retardat ion . St u rge-Weber syn drom e rarely affects oth er body organ s.
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Fig . 4.20 Sturge -Weber syndrom e table.
Presentation
Ch aracterist ic facial bir th m ark (can var y in color from ligh t pin k to deep purple). Most pat ien t s w ith angiom a th at affect s th e su perior lid h ave glaucom a at bir th or w ill develop it later. Dilated episcleral vessels are seen , along w ith bup h th alm os, seizu res, convulsion s, m uscle w eakn ess, m en tal ret ardat ion or learn ing disabili- t ies, an d possible developm en t al delay (Fig. 4.20).
Differential Diagnosis
Facial angiom a w ith ou t n eu rological m an ifestat ion s, oth er cau ses of elevated episcleral pressu re (e.g., thyroid oph th alm opathy, th rom bosis of th e cavern ous sin u s, carot id -cavern ou s fist ula)
Management
Treat th e sym ptom s. Treat in creased in t raocu lar pressu re w ith eyedrops (avoid m iot ics). Su rger y can be perform ed on serious cases of glaucom a. Laser t reat m en t can ligh ten or rem ove th e facial bir th m ark. An t iconvu lsan t m edicin es are u sed to con t rol seizu res. Physical th erapy is h elpfu l in ch ildren w ith m u scle w eakn ess.
Carotid Cavernous Sinus Fistula
Carot id cavern ous fist u las are un i- or bilateral abn orm al com m u n icat ion s (sh u n t s) of th e carot id ar teries directly or in directly in to th e vein s of th e cavern ous sin u s. Th ey are frequ en tly cau sed by t raum a, alth ough th ey can be spon t an eou s in m en o- pau sal w om en . Depen ding on th e am ou n t of blood injected in to th e sin u ses, th ey can produce differen t am ou n t s of n eu ro-oph th alm ological m an ifest at ion s.
Presentation
Patients present w ith arterialized dilated vessels of the conjunctiva and orbit, unilateral or bilateral, proptosis, lid edem a, papilledem a, retinal edem a w ith hem orrhages, uveitis, secondary glaucom a associated w ith elevated venous pressure, anterior seg- m ent ischem ia, and iris atrophy. There can also be visual loss and dysfunction of the extraocular m uscles. Pulsating exophthalm ia occurs in advanced (i.e., high -flow )
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cases. Patient refers to an audible sound that follow s the heart rate. Cavernous sinus syndrom e (cranial ner ve II, IV, and VI palsy) and Tolosa-Hunt syndrom e m ay also present (Fig. 4.21A,B).
Differential Diagnosis
Cavern ous sin u s th rom bosis, du ral sin u s ar terioven ou s fist u la, cavern ou s sin us ar terioven ou s m alform at ion s, orbital pseudot um or, thyroid orbitopathy, orbital am yloidosis, orbital t u m or, orbit al cellu lit is, m ucorm ycosis
A
B
Fig . 4.21 (A) Carotid cavernous fistula. (B) Carotid cavernous fistula.
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Management
Neu rosu rger y by a n eu roradiologist (det ach able balloon or m etallic coil em bolizat ion ) accom plish es reversal of ocu lar m an ifest at ion s in p at ien ts w ith vision at risk or pat ien ts w ith in tolerable sym ptom s (h igh -flow sh un ts). Low -flow sh u n t s (m ain ly t raum at ic) spon t an eou sly occlude w ith t im e. Th e gam m a kn ife can be used w h ere available.
Pigmented Conjunctival Lesions
Ocular or Oculodermal Melanocytosis (Congenital Melanosis Oculi)
Ocular Melanocytosis
Th is n on h eritable congen it al hyperpigm en tat ion of th e eye h as in creased frequ en cy in w h ites. Path ology sh ow s an in creased n um ber of m elan ocytes in th e affected t issu es. Th e con dit ion can progress w ith th e u se of topical prostaglan din an alogues (e.g., latan oprost) u sed to t reat glau com a.
Presentation
Presen tat ion in clu des in creased gray or bluish pigm en tat ion of th e globe (sclera an d episclera) th at is u su ally un ilateral (Fig. 4.22).
Differential Diagnosis
Prim ar y acqu ired m elan osis (affect s th e conju n ct iva on ly an d oth er m u coses), ocu - loderm al m elan ocytosis (n evus of Ot a), n evu s, m elan om as, pigm en ted dep osits, foreign body iron deposit s
Fig . 4.22 Ocular melanocytosis.
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Management
No t reat m en t is n eeded . Carefu l periodic ocular exam in at ion s are required becau se of th e in creased risk of uveal m elan om as in affected in dividuals.
Oculodermal Melanocytosis
Th is con dit ion is caused by diffuse dist ribut ion of proliferated m elan ocytes an d is m ore com m on in Asian s an d blacks. It is associated w ith ip silateral glau com a.
Presentation
Asym ptom at ic. Un ilateral facial an d/or blue-gray pigm en t at ion of th e globe, usu - ally follow ing th e ipsilateral dist ribu t ion of th e t rigem in al n er ve (V1 an d V2) (Fig. 4.23).
Differential Diagnosis
Prim ar y acqu ired m elan osis, n evu s, m elan om as, pigm en ted dep osits, foreign body iron dep osits, facial angiom a
Management
No t reat m en t is n eeded . Ru le out glaucom a, ret in it is pigm en tosa, an d congen it al cataract . Ocu loderm al m elan ocytosis rarely u n dergoes m align an t t ran sform at ion .
Fig . 4.23 Oculoderm al melanocytosis. Heterochromia.