RED EYE (HIGH RISK)EXTERN AKECHANOK WATCHARAPUNJAMART

RED EYE (HIGH RISK)

• Infectious Keratitis/ Corneal Ulcer

•Anterior Uveitis

•Acute angle closure glaucoma

Infectious Keratitis/Corneal Ulcer

Infectious Keratitis/Corneal Ulcer• Infection

• Bacterial: Adnexal infection, lid malposition, dry eye, CL• Pseudomonas aeruginosa

• Staphylococcus aureus

• Streptococci.

• Viral: HSV, HZO• Fungal: Candida,Fusarium,Aspergillus,Penicillium• Protozoan: Acanthamoeba in CL wearer

• Mechanical or trauma

• Chemical: Alkali injuries are worse than acid

Clinical features• Blurred vision

• Ocular pain

• Photophobia

• Epiphora

• Purulent discharge

• Eye lid swelling

• Ciliary injection

• corneal infiltration, ulcer

• Hypopyon

รปแสดงกระจกตาตดเชอเหนเปนวงเลกสขาว (Focal corneal ulcer) (ขอบคณภาพถายผปวย จากคลนกกระจกตา รพ.ธรรมศาสตร เฉลมพระเกยรต)

Investigation• Corneal scraping

• May not be required for a small infiltrate,particularly without an epithelial defect and away from the visual axis.

• Conjunctival swabs• Particularly in severe case, may be culture when corneal

scape is negative

• Contact lens cases• Bottles of solution and lens for culture

• Gram strain,Giemsa stain ,KOH ,Culture

• Sensitivity reports

REFERENCE:

Treatment• Fortify broad spectrum

antibiotic

• Antifungus : Amphotericin B eye drop,Natamycineye drop

• Acyclovir eye ointment

• Cycloplegic drug ( 1% Atropine eye drop)

Anterior Uveitis

Anatomical Classification• Uveitis : an inflammation of uveal tract

• Anterior uveitis

• Iritis : inflammation primarily involves the iris

• Iridocyclitis : in which both iris and pars plicata of the ciliary body

• Intermediate : Inflammation predominantly involving the pars plana,the peripheral retina and the vitreous

• Posterior uveitis : involves the fundus posterior to the vitreous base

• Retinitis : Primary focus in the retina

• Choroiditis : Primary focus in the choroid

• Vasculitis : which may involve veins, arteries or both

• Panuveitis

• Endophthalmitis : implies inflammation, often pururent, involving all intraocular tissue except the sclera

• Pandophthalmitis : involves the entire globe,often orbital extension

Definition : Acute : Sudden onset and limited duration

Chronic : Persistent inflammation,Prompt relapse

(in less than 3 months)

Recurrent : repeat episodes separated by period of

inactive without treatment lasting at least 3 months

Anterior uveitis • Most common form of uveitis (75%)

• Acute anterior uveitis is the most common form of anterior uveitis ,accounting for three-quarters of cases

Main symptoms

• Sudden onset of unilateral pain

• Photophobia

• Redness

• Decrease vision

• Lacrimation

Signs• Ciliary injection (circumcorneal

flush)

• Fine white keratic precipitaes (KP)

• Aqueous flare and cell in anterior chamber

• Iris nodules (Koeppe & Busaccanodule )

• Iris atrophy

• Rubeosis iridis

• Miosis

• Posterior synechiae

Causes • Autoimmune

- Juvenile rheumatoid arthritis

- Ankylosing spondylitis - Reiter’s syndrome

• Infections- Syphilis

- TB- Herpes Zoster

• Malignancy- Leukemia

- Lymphoma- Retinoblastoma

• Other- Traumatic uveitis- Retinal detachment- Ideopathic

Type of Anterior Uveitis1. Suppurative

2. Non supurative

2.1 Granulomatous uveitis

- chronic, posterior uveitis

- infection Toxoplasma, TB

- injury : sympathetic ophthalmia

2.2 Non granulomatous uveitis

- more common

- Anterior uveitis

- Hypersensitvity phenomenon —» Steroid

Differentiation of Granulomatous & nongranulomatous uveitis

Feature Granulomatous Nongranulomatous

Onset

Course

Pain

Photophobia

Blurred vision

Anterior segment

Injection

Iris nodule

(Koeppe,Busacca

nodules

KP

Fundus

Recurrence

Insidious

Long

None or minimal

Slight

Marked

+

+++

Mutton fat

Nodular lesion

Sometimes

Acute

Short

Marked

Marked

Marked,moderate

+++

+

Small fine

Diffuse involvement

Common

Complication• Anterior, posterior synechiae

• Rubeosis iridis

• Band keratopathy

• Cataract

• Secondary glaucoma

• Retinal detachment

• Cystoid macular edema

• Hypotony – phthisis bulbi

Aim of Treatment

1. Relief of pain

2. Improve vision

3. Prevent complication

Treatment1. Medical therapy

- specific Rx.

- Non specific Rx.

1.1 Corticosteroid- Topical

-Systemic

1.2 Cycloplegic

1.3 Cytotoxic agent

Treatment

2. Surgical therapy

2.1 Cataract —» cataract extraction

2.2 Glaucoma —» Trabeculectomy

2.3 Vitreous opacification

—» Parplana vitrectomy

2.4 Retinal detachment—» Laser, SBP ( sclera

bucking procedure)

Acute angle closure glaucoma

What is glaucoma?

• A disease of progressive optic neuropathy

with loss of retinal neurons and their axons (nerve fiber layer) resulting in blindness if left untreated.

Robert N. Weinreb, MD1; Tin Aung, MD, PhD2,3; Felipe A. Medeiros, MD, PhD1

JAMA. 2014;311(18):1901-1911. doi:10.1001/jama.2014.3192.

Clinical picture of glaucoma

1. High intraocular pressure

2. Optic disc change

cupping & degeneration

3. Visual field defect

GLAUCOMACup-to-disk ratio

GLAUCOMA

Normal

DISK CUPPING

Glaucoma

GLAUCOMA

Glaucomatous cupping

Cardinal signs

•ปวดตา•ปวดหว•ตามว (มองเหนสรง)•ตาแดง•คลนไสอาเจยน

How to maintain Intraocular pressure ?

Normal

c - Iris outflow

a - Conventional outflow-90%

b - Uveoscleral outflow

Aqueous outflow

Open angle glaucoma

Angle closure glaucoma

Sign- ciliary injection

- corneal edema

- shallow anterior

chamber

- semidilated pupil

- increase IOPCorneal oedema

Ciliary hyperaemia

Dilated pupil

Management1. Medical treatment

1.1 Osmotic treatment- 20% Mannitol intravenous drip ( 250 ml)- 50% glycerine (1-2 ml/kg.)

1.2 Carbonic anhydrase inhibitor- Acetazolamide (Diamox) oral

- Topical : Brinzolamide : Dorsolamide

Management1.3 Cholinergic agent

- 2% Pilocarpine ed. —» Miotic —» decrease

papillary block

1.4 B-Blocker

- 0.5% Timolol maleate ed.

1.5 Selective Sympathominetic- Alphagan ed. (Brimonidine)

1.6 Prestaglandin deviation

- Lagtonoprost

- Travanoprost

- Bimatoprost

2. Surgical treatment- Laser iridotomy

- Peripheral

iridectomy

- Trabeculectomy

THANKS YOU