Transcript Раптова втрата зору. Гострий приступ гла

Lecture 2
«RED EYE» DISEASES
Lecture is delivered by
Ph. D., assistant of professor Tabalyuk T.A.
TYPES of INJECTION of EYEBALL:
1. Superficial or conjunctival;
2. Deep or ciliary or pericorneal;
3. Mixt
TYPICAL FOR ALL TYPES OF CONJUNCTIVITIS
ARE THE NEXT SIGNS:
1. RED EYE (superficial injection);
2. CORNEAL SYNDROME
(photophobia, profuse tearing, blepharospasmus);
3. DISCHARGE from the eye
KEY SIGNS of
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BACTERIAL CONJUNCTIVITIS:
purulent & sticky discharge from the eye;
bilateral, but frequently asymmetrical
ACUTE EPIDEMIC CONJUNCTIVITIS KOHA-UYIXA:
oedematous & thicken bulbar conjunctiva form two triangules arround
cornea;
haemorrhages under bulbar conjunctiva
GONOCCOCAL CONJUNCTIVITIS:
usually bilateral in infants & monolateral in adults;
first 3-4 days discharge with blood remainder, then profuse purulent
discharge (gonoblennoreia);
easy bleeding conjunctiva
PNEUMOCOCCAL CONJUNCTIVITIS:
membranes on palpebral conjunctiva, which are easy removed;
conjunctiva does not bleed after membranes removing
DIPHTERITIC CONJUNCTIVITIS:
membranes on palpebral conjunctiva and eyelids edges, which are removed
with difficulty;
conjunctiva bleeds after membranes removing;
on the places of membranes location star scars appears soon;
combimation with diphteria of nose, throat, laryngs etc.
KEY SIGNS of
VIRAL CONJUNCTIVITIS:
serous watery discharge;
pink folliculae on lower eyelid conjunctiva;
palpable prearicular lymph nodes;
 subconjunctival haemorrhages;
infectuion usually begins in one eye & in 2-3 days spreads into the fellow
eye
general reaction of the organism (fever, sore throat etc.) or upper
respiratory infection in anamnesis
ALLERGIC CONJUNCTIVITIS:
itching subjectivelly;
papillae on upper eyelid conjunctiva;
allergic anamnesis
TRAHOMA
(caused by Chlamydia trahomatis)
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chronic duration;
four phases (infiltration, progression, regression, scaring);
large yellow-gray folliculae on thicked conjunctiva of upper eyelid;
typical corneal damage – pannus tracomatosus in upper part with
superficial neovascularization;
 formation of large star scars
Complications & outcome:
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trichiasis;
madarosis;
stricturae of lacrimal exretory system;
symblepharon;
xerosis etc.
LOCAL ANTIBACTERIAL TREATMENT:
drops - S.Sulfacili Na 30 %,
S.Dimexidi 10 %,
S.Gentamycini 0,3 %,
S.Laevomycetini 0,25 %,
S.Polymixini B 0,25 %,
S.Tobramycini 0,3 %,
S.Chlorhexidini 0,02 %,
S. Ciprophloxacini 0,3 %,
Сiloxani etc.
ointments – Ung. Tetracyclini 1 %,
Ung. Tobramycini 0,3 %,
Ung. Erythromycini 1 % etc.
LOCAL ANTIVIRAL TREATMENT:
drops -Interferoni,
Reaferoni,
Laferoni,
Viaferoni,
Interlok
IDU,
S. Florenali 0,1 %,
S. Oxolini 0,1 %,
S. tebrofeni 0,1 % etc.
ointments – Ung. Florenali 0,5 %,
Ung. Oxolini 0,25 %,
Ung. Tebrofeni 0,5 %,
Ung. Acycloviri 5 % (or Zovirax or Verolex) etc.
LOCAL ANTIALLERGIC TREATMENT:
drops – S. Ca Chloridi 3 %,
S. Dexamethasoni 0,1 %,
«Lecrolyn» (Santen),
«Alomid» (Alcon),
«Emadin» (Alcon) etc.
ointments –Ung. Maxidex & other corticosteroids.
TYPICAL FOR ALL TYPES OF KERATITIS
ARE THE NEXT SIGNS:
1. Red eye (deep injection, in severe cases mixt injection);
2. Corneal syndrome (photophobia, profuse tearing, blepharospasmus);
3. Reducing of visual acuity;
4. Lasting pain, more severe in daytime, when eye is open;
5. Inflammatory infiltrate in the cornea
BACTERIAL ULSER
caused by pneumococcus, pseudomonas, diplococcus, strepthococcus,
staphylococcus etc. It is exogenis keratitis and always is a result of cornea
microtrauma.
The hallmark signs are:
acute beginning,
severe corneal syndrome,
corneal ulcer with one progressive edge
The lysis of cornea till Descemet’s membrane is called descemethocele. It is
threat for corneal perforation. Bacterial ulser often is associated with pus in
anterior chamber – a hypopion.
The complications of bacterial ulser:
corneal perforation,
panuveitis,
endophthalmitis,
orbital cellulitis
Bacretiological and bacteriscopical researching are necessary. The treatment is
performing in clinic
CLINICAL FEATURES of ADENOVIRAL KERATITIS:
many punctate subepithelial solitary round infiltrates (like a coin)
not juting out;
decreasing of corneal sensitivity on the hole surface not only
above the infiltrate;
folliculular conjunctivitis;
palpable prearicular lymph nodes;
general reaction of the organism (fever, sore throat etc.) or upper
respiratory infection in anamnesis
CLINICAL FEATURES of
HERPES KERATITIS:
unilateral,
less corneal syndrome,
bilateral decreasing of corneal sensitivity,
prolongated duration,
recidivation
Imunodiagnostic is necessary.
It may be primary (in age 5 month-5years) in first virus
penetration and postprimary in inficated person.
The clinical forms of secondary herpes keratitis:
superficial (vesiculous and dendritic) &
deep (like disc, methaherpetic and deep stromal).
SYPHILITIC PARENCHYMATOUS KERATITIS –
the late (often in 6-20 years old) appearence of congenital syphilis.
The diagnosis is confirmed by positive serological reaction (RW).
The three cardinal symptoms of congenital syphilis are the next:
keratitis,
deafing,
special teeth
The cyclic duration is typical for this keratitis:
phase of infiltration (3-4 weeks) – less corneal syndrome, the dissemination of
punctate infiltrates in corneal stroma from periphery (limbus area) to the
center;
phase of vascularusation (6-8 weeks) – intensive infiltration and deep
vascularization, express corneal syndrome;
regressive phase (1-2 years) – the regression of infiltrates from the center to
the periphery.
For syphilitic parenchymatous keratitis is not typical ephithelium defect
(fluorescein test is negative). The disease is bilateral. The inflammation of
second eye usually occurs in two or more years.
The specific treatment: Extencillini (Penicillini G) 2.4 mln. OD for injection. The
injection is repeated in 7 days.
HAEMATOGENIC TUBERCULOTIC KERATITIS
caused by mycobacterium tuberculosis
Clinical peculierities:
large isolate yellow infiltrates in deep layers at any part of
cornea;
mixt (superficial and deep) vascularization;
torpid recurrent duration, without acute inflammation;
scleritis may occur;
unilateral;
positive tuberculine tests
Imunodiagnostic is necessary.
The treatment includes general and topical usage of
antituberculotic drugs (isoniazidi, streptomycini);
imunomodulators; vitamins.
TUBERCULOTIC ALLERGIC KERATITIS
is a local reaction of sensilization. It is usually occurs in children
with nonactive primary lung tuberculosis and peripheral lymph
nodes tuberculosis.
Permanent symptoms:
flictena (gray small focus in superficial corneal layers)
superficial vessels are companions of flictena
corneal syndrom is extensive
Mantoux’s test is positive
X-ray examination and blood analysis are necessary.
The treatment includes corticosteroids and desensilization
drugs, not antituberculotic.
MANAGEMENT PRINCIPLES in KERATITIS
• Specific treatment: antibacterial, antiviral, antifungal etc.
medicines generally (intravenous, intramuscular injections,
per os) and locally (in drops, ointments, subconjunctival
and parabulbar injections).
• Mydriatics to prevent uveitis.
• Stimulators of corneal regenerations (1 % chinini
hydrochloridi, 4 % taufoni, emoxipini, solcoserili,
actovegini, corneregel, dexpanthenol, methyluracili,
vitasik).
• Proteolytic ferments locally for infiltrate lysis (fybrinolysini,
lidasae, collalysini).
• Desensilization therapy (Diazolini, Tavegili, Klaritini).
• Imunocorrection (Decaris, Timalini, Taktivini, Chigaini)
• Vitamins (B1, B2, C etc.).
OUTCOME of KERATITIS
is corneal opacity, which includes:
nubecula – it can be seen only by special examination
macula – it can be seen without special examination by our
eye, but the iris and pupil are seen through it
leucoma - it can be seen without special examination, but the
iris and pupil can’t be seen through it
We try to treat corneal opacity during one year with the help of
proteolytic ferments (fibrinolysini, lidasa, kolallisini) in drops,
subconjunctival injections and physiotheraputic procedures.
If the scarring is axial in the cornea, the vision of the eye may
be permanently impaired. In these circumstances, some
improvement may be obtained with spectacles, but a contact
lens may give better vision.
In severe cases, a corneal graft will be required in order to
improve the sight.
DIFFERENTIAL DIAGNOSIS of
CORNEAL INFILTRATE & OPACITY
Sign
Red eye
Corneal infiltrare
Corneal opacity
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Limits
irregular
regular
Cornea
not glassy
glassy
fluorescein
test
positive
negative
Corneal
syndrome
The anterior uveitis is inflammation of iris and ciliary body. Thus its
another name is “iridocyclitis”. The mixt injection, corneal syndrome, pain,
which increases at the night, and decreasing of visual acuity are typical.
Aethiology: commonly idiopathic but numerous systemic causes – HLA-B27associated (ankylosing spondylitis, Reiter’s syndrome, psoriatic arthritis);
juvenile idiopathic arthtritis (especially high risk if pauciarticular-onset and ANApositive); inflammatory bowel diseases (ulcerative colitis,Crohn’s disease); noninfectious systemic diseases (sarcoidosis, Behchet’s disease, Vogt-KoyanagiHarada syndrome); infections (herpes zoster and simplex, syphilis.
tuberculosis).
Clinical features of iritis:
pain increases in lighting;
changing of iris picture (another colour, oedema, vessels are seen);
small pupil (miosis) and its weak reaction on light;
posterior synechiae (iris-lens adhesions)
Clinical features of cyclitis:
pain increases in palpation (ciliary pain) and accommodation;
keratic precipitates;
vitreous opacities;
changes of intraocular pressure (usual first increasing then decreasing)
Сomplications of anterior uveitis:
panuveitis,
endophthalmitis,
panophthalmitis
Outcome of anterior uveitis:
secondary glaucoma,
complicated cataract,
vitreous opacity,
hypotonia,
eye atrophy
Management:
Topical steroids and mydriatics are the mainstay of treatment
Periocular steroid injection
Systemic steroids, immunosuppressive agents and antibiotics for the
infections (e.g. tuberculosis, syphilis)
First aid in iridocyclitis:
Mydriatics
Steroids
Diuretics
In posterior uveitis or choroiditis the eye is quiet
(not red), pain doesn’t disturb, corneal syndrome is not
typical. The visual functions are decreased. Patches are
seen in ophthalmoscopy.
Aethiology: toxoplasmosis, toxocariasis, cytomegalovirus,
histoplasmosis, tuberculosis, syphilis etc.
For central choroiditis metamorphopsia, photopsia, central
scotoma and loss of visual acuity are typical.
For peripheral choroiditis peripheral scotoma and
narrowing of visual field are typical.
Management: antimicrobial or antiviral agents
administered systemically and topical.
DIFFERENTIAL DIAGNOSIS between
NEW & OLD FUNDUS PATCH
Sign
colour
new patch
old patch
pink
white or yellow
limits
irregular
regular
pigmentum
in the center
on periphery
oedema
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-
CLINICAL FEATURES of ENDOPHTHALMITIS:
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red eye (mixt injection);
corneal syndrome;
reducing of visual acuity;
pain
hypopion (pus in the anterior chamber);
abscess of vitreous (yellow fundus reflex)
CLINICAL FEATURES of PANOPHTHALMITIS:
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red eye (mixt injection);
corneal syndrome;
reducing of visual acuity;
pain;
hypopion;
abscess of vitreous
imbibition of cornea by pus
purulent choroidoretinitis (with visual field defects & fundus patches if
seen)
DIFFERENTIAL DIAGNOSIS of
INFLAMMATORY DISEASES OF EYE ANTERIOR SEGMENT
Sign
red eye
conjunctivitis
+
(superficial
injection)
keratitis
+
(deep or mixt
injection)
iridocyclitis
+
(deep or mixt
injection)
corneal
syndrome
+
+
+
pain
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+
+
(in daytime)
(at night, incresing in
lighting & palpation)
decreased
visual acuity
-
+
+
peculierities
discharge
corneal infiltrate
keratic precipitates,
posterior synechiae,
miosis, vitreous
opacities
THANK YOU FOR
ATTENTION!