Common eye disorders

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COMMON EYE DISORDERS:

COMMON EYE DISORDERS Presented By: Kiran deep Randhawa M.Sc Final Year

Introduction::

Introduction : Diseases of the eye may be related to a variety of systemic disorders. Isolated problems like infections, congenital anamolies, trauma and Vitamin deficency are also common. Detailed history related to eye problems, opthalmological examination including test for visual acuity and color vision , opthalmoscopic examination, tonometry, refraction test should be performed.

Categorization of common opthalmic problems::

Categorization of common opthalmic problems: Orbital diseases and disorders: Hypertelorism/ hypotelorism Exophthalmos Micropthalmia Orbital cellulitis Periorbital cellulitis Orbital benign and malignant tumours Orbital injury

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2.Diseases of eyelids: Ptosis Lid retraction Lagophthalmos Entropion Ectropion Stye Tumors Vascular anamolies 3.Diseases of lacrimal system: Congenital nasolacrimal duct obstruction Alacrima

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4. Diseases of conjuctivitis : Conjuctivitis Opthalmia neonatorum Non inflammmatory conditions like subconjuctival hemmorrhage Dermoid cyst Dermolipoma Conjuctivital xerosis Bitot’s spot Conjuctival discoloration Neurofibromas

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5. Corneal diseases : Interstitial keratitis Corneal ulcers Sclerocornea Microcornea Corneal pigmentation Keratomalacia

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6. Abnormalities of sclera: Blue sclera in Marfan’s syndrome Episcleritis Scleritis Pupillary and uveal tract abnormalities: Iris coloboma Congenital microcoria Dyscoria Persistent pupillary membrane Heterochronia

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7. Diseases of lens: Cataract Ectopia lenitis 8. Diseases of eye movement and alignment : Strabismus (squint) Nystagmus 9. Refractive errors Hypermetropia Myopia Astigmatism Visual disorders Night blindness Diplopia

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10.Diseases of retina and vitreous Retinopathy of prematurity Retinopathy due to systemic disorders Retinal detachment Retinoblastoma Retinitis pigmentosa 11. Optic nerve diseases Papilledema Optic neuritis Optic atrophy Increased intraocular pressure Congenital increased intraocular pressure Glucoma

Retinopathy of Prematurity (ROP):

Retinopathy of Prematurity (ROP) Retinopathy of prematurity ( ROP ), previously known as retrolental fibroplasia ( RLF ), is an eye disease that affects prematurely-born babies. It is  caused by disorganized growth of retinal blood vessels leading to hyperoxia resulting from high concentration of oxygen therapy which may result in scarring and retinal detachment.

Incidence ::

Incidence : About 14,000 are affected by ROP and 90% of those affected have only mild disease. About 1,100- 1,500 develop disease severe enough to require medical treatment 400-600 infants each year become legally blind from ROP

Causes and risk factors::

Causes and risk factors: The infants are then exposed to elements, such as medication and light and temperature changes. These factors may interfere with the normal development of blood vessels in the eye and cause ROP.

Risk factors:

Risk factors Birth before 32 weeks' gestation, especially before 30 weeks Birth weight of less than 1500 g, especially less than 1250 g Possible risk factors include supplemental oxygen, hypoxemia, hypercarbia, concurrent illness.

Pathophysiology ::

Pathophysiology : Excessive oxygen therapy causes hyperoxic , causes retinal vasoconstriction and irreversible capillary endothelial cell destruction. As the area becomes ischemic, angiogenic factors, such as vascular endothelial growth factor (VEGF), is made by the mesenchymal spindle cells and ischemic retina to provide new vascular channels. These new vascular channels are not mature and do not respond to proper regulation.

Sign and symptoms::

Sign and symptoms : Symptoms of severe ROP include: Abnormal eye movements Crossed eyes Severe nearsightedness White-looking pupils (leukocoria)

Stages of ROP::

Stages of ROP : The International Classification of Retinopathy of Prematurity (ICROP) has describe the stages according to different zones:

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The zones are centered on the optic nerve. Zone 1 is the posterior zone of the retina, defined as the circle with a radius extending from the optic nerve to double the distance to the macula. Zone 2 has inner border defined by zone 1 and the outer Zone 3 is the residual temporal crescent of the retina

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Stage 1 is a faint demarcation line.  There is mildly abnormal blood vessel growth Stage 2 is an elevated ridge. Blood vessel growth is moderately abnormal. Stage 3 is extraretinal fibrovascular tissue. Blood vessel growth is severely abnormal. Stage 4 is sub-total retinal detachment. Blood vessel growth is severely abnormal and there is a partially detached retina. Stage 5 is total retinal detachment.

Diagnosis :  :

Diagnosis : Physical exam History taking An indirect ophthalmoscope Retinal examination with scleral depression

Treatment ::

Treatment : Peripheral retinal ablation is the mainstay of ROP treatment. The destruction of the avascular retina is performed with a solid state laser photocoagulation device, as these are easily portable to the operating room or neonatal ICU.

Cryotherapy:

Cryotherapy A n earlier technique in which regional retinal destruction was done using a probe to freeze the desired areas, has also been evaluated in multi-center clinical trials as an effective modality for prevention and treatment of ROP. However, when laser treatment is available, cryotherapy is no longer preferred for routine avascular retinal ablation in premature babies, due to the side effects of inflammation and lid swelling.

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Scleral buckling and/or vitrectomy surgery may be considered for severe ROP (stage 4 and 5) for eyes that progress to retinal detachment. Intravitreal injection of bevacizumab (Avastin) has been reported as a supportive measure in aggressive posterior retinopathy of prematurity

Prognosis ::

Prognosis : Most premature infants with ROP recover with no lasting visual problems. Many premature infants with slight problems in retinal blood vessel growth have the vessels return to normal without treatment. Most infants with mild ROP can be expected to recover completely. About 1 out of 10 infants with early changes will develop more severe retinal disease. Severe ROP may lead to significant vision problems or blindness. The most important factor in the outcome is early detection and treatment.

Complications:

Complications Complications may include severe nearsightedness and blindness. Most infants with severe vision loss related to ROP have other complications of prematurity and require a multidisciplinary approach to rehabilitation.

Conjuctivitis :

Conjuctivitis Definition :Inflammation of the conjunctiva and conjunctival erythema caused by injection and hyperemia of tortuous superficial vessels. This is one of the most common causes of red eye in children.

Potential causes ::

Potential causes : Conjunctivitis is usually viral or bacterial The allergic form is more common in adolescents Wearing contact lenses Other causes include preseptal or orbital cellulitis, corneal injury, uveitis and glaucoma all of which are referred to an physician or nurse practitioner

Bacterial Pathogens:

Bacterial Pathogens Chlamydia Haemophilus influenza (non-typable) Neisseria gonorrhoea Staphylococcus aureus (more common in adults) Streptococcus pneumonia

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Viral Pathogens Adenovirus Enterovirus Epstein-Barr virus and herpes zoster virus (less common) Measles and rubella viruses Allergic Seasonal pollens Environmental exposure

Clinical manifestation::

Clinical manifestation: Children with mild viral or superficial bacterial conjunctivitis do not usually have significant systemic symptoms . Eye(s) red Burning, gritty sensation or foreign body sensation in eyes Thick, purulent discharge with crusting in morning Complicating bacterial infections, such as otitis media Recent contact with others with similar symptoms Recent sexual activity and possible STI Often unilateral initially

Allergies – seasonal or environmental:

Allergies – seasonal or environmental Visual acuity normal Papillary reaction normal Pre-auricular nodes palpable in Neisseria gonorrhoea and Chlamydia Conjunctiva erythematous (unilateral or bilateral) Purulent discharge

Viral:

Viral Commonly , a viral URTI has preceded the eye infection Acute onset of redness Mild to no pain, possibly gritty sensation or mild itching Tearing or mucoid discharge Recent contact with others with similar symptoms Systemic symptoms may be present (e.g., sneezing, runny nose, sore throat, preauricular lymphadenopathy) May begin unilateral, but often bilateral within 24 hours

Diagnostic Tests:

Diagnostic Tests May require a culture and sensitivity (C&S) if no response to treatment or if an STI is suspected.

Management and intervention:

Management and intervention Goals of Treatment: Relieve symptoms and resolution of infection Rule out more serious infections (e.g., uveitis) Prevent complications Prevent spread of infection to others

Non-pharmacologic Interventions:

Non-pharmacologic Interventions Apply warm or cool compresses to eyes, lids and lashes qid for 15 minutes Public health measures that support good hygiene (i.e., frequent hand-washing, use of separate clean face cloth and towels).

Pharmacological Interventions :

Pharmacological Interventions Bacterial : Topical antibiotic eye drop or ointment: P olymyxin B gramicidin eye drops, 2 or 3 drops qid for 5-7 days, or S ulfacetamide 10% eye drops, 2 or 3 drops q3-4 hrs. for 5-7 days, or B acitracin-polymyxin eye ointment qid for 5-7 days, or E rythromycin 0.5% eye ointment qid for 5-7 days

Viral :

Viral Artificial tears or saline washes often provide excellent symptomatic relief (antibiotics are not indicated)

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Allergic Oral antihistamines may be tried if symptoms are severe. Most common side effects are drowsiness, dry mouth, and fatigue: C etirizine : 2-6 yrs. – 5 mg po qd or divided bid; greater than 6 yrs. – 5-10 mg po qd or divided bid , or L oratidine : 2-5 yrs. – 5 mg po daily; 6 yrs. or older – 5-10 mg po daily For children 4 years and older, topical antihistamine eye drops are recommended if symptoms are not controlled by oral antihistamines or oral antihistamines cannot be tolerated:

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Cromolyn Na 4% eye drops, 1-2 drops every 4-6 hours Pregnant and Breastfeeding Women (dosing as above) Erythromycin eye ointment, polymyxin B gramicidin eye drops, bacitracin-polymyxin eye ointment, Artificial tears, cromolyn Na, and loratidine Sulfacetamide should only be used if clearly needed.

Client/caregiver education and discharge information:

Client/caregiver education and discharge information Advise on condition, timeline of treatment and expected course of disease process. Counsel parents or caregiver about appropriate use of medications (dose, frequency, and instillation). Advise parents or caregiver to avoid contamination of the tube or bottle of medication with the infecting organisms Advise parents or caregiver to never share or use another person’s eye drops or ointments.

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Recommend avoidance of cosmetics during acute phase (current eye cosmetics should be discarded because they may harbor bacteria and cause recurrent infection). Avoid sharing eye cosmetics. Suggest ways to prevent spread of infection to other household members (do not share towels or face clothes, use different areas of the face cloth for each eye).

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Instruct parents or caregiver (and child, if of a suitable age) about proper hygiene, especially of hands and eyes. Wash hands often. Do not wear contact lenses until healed and clean lenses thoroughly. For infectious forms, recommend school or day care restrictions for 24-48 hours.. For allergic form: recommend that child avoid going outside when pollen count is high and that protective glasses be worn to prevent pollen from entering the eyes.

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