Extraocular and Intraocular inflammations of the eye are a very wide-ranging topic. Some of the important diseases based on their anatomical locations and their management have been enumerated here. Diabetics are more prone to inflammation and infection due to their reduced immunity.
Eyelids and Lacrimal System
The most common inflammations of the eyelids are those involving the lashes, lid margins and those arising within the meibomian glands.
Blepharitis: Usually involves the lid margins and may be associated with conjunctivitis. It is most commonly due to a staphylococcal infection.
Hordeolum: is a focal acute infection of the meibomian glands, most commonly due to a staphylococcal infection. These are more common in poorly controlled diabetics.
Chalazion: is a focal chronic inflammation of the meibomian gland.
Blepharochalasis: results from repeated idiopathic episodes of eyelid oedema and inflammation resulting in wrinkling of the skin, atrophy of fat and ptosis.
Treatment: Warm, moist compresses and topical antibiotics usually produces resolution of the inflammation. Incision and curettage may be required for the treatment of chalazions. Steroids may be required for blepharochalasis. Proper control of diabetes is also required for early resolution of infection.
Dacryocystitis: usually results from and obstructioin of the nasolacrimal duct. It is characterized by localized pain, discharge, oedema and erythema over the lacrimal area.
Treatment: Acute infections usually respond to moist, warm compresses with topical and systemic antibiotics. Chronic infections often need to be treated with lacrimal surgery. Diabetes must be properly controlled before taking the patient for surgery.
The orbit is the common site of inflammatory disorders related to infections, trauma and systemis disease.
Graves disease - It is a multisystem disease of unknown etiology. Some of the clinical signs are lid retraction, lid lag, lid pigmentation, extraocular muscle palsy, poor convergence, unequal pupillary dilatation and ao audible bruit over the closed eye.
Investigations - include T3, T4, TSH levels. Orbital ultrasound B scan and CT scan show enlarged extraocular muscles and inflammation of the orbital fat.
Treatment - includes topical lubricants to prevent corneal drying. The palpebral fissure may be narrowed by a lateral torsorraphy. Surgical decompression or local radiation may be considered if the vision progressively declines.
Pseudotumors - Orbital inflammations of unknown etiology are collectively described as pseudotumors.
Treatment - Oral steroids usually produce a rapid resolution of the pseudotumor symptoms. Diabetes must be properly monitored when the patient is on systemic steroids.
Cellulitis - It is usually the result of extension of infection from the ethmoidal sinuses. The common organisms are Staphylococcus aureus, Streptococcus and Haemophilus Influenzae. The clinical signs include fever, pain, soft tissue oedema and restricted eye movement.
Treatment - Consists of systemic antibiotics. Orbital surgery is not necessary unless an abscess cavity is present.
Phycomycosis - Caused by organisms Phycomycetes. These fungii usually extend from the sinuses or nasal cavity and are seen in patients with disabling systemic illness. This is an opportunistic infection and is seen in poorly controlled diabetics.
- includes administering Injection Amphoterecin B intravenously and surgical
excision of the involved tissue.
Conjunctivitis - It is most commonly bacterial but may also occur due to virus, allergy or toxic factors. The clinical feature are vascular engorgment, irritation, discharge and foreign body sensation.
includes topical and in some cases systemic antibiotics and warm moist compresses
to remove the meibomian secretions.
Trachoma: Chlamydia trachomatis infections are usually seen as neonatal inclusion conjunctivitis in neonates, adult inclusion conjunctivitis or Trachoma. Trachoma manifests as scarring of the tarsal conjunctiva, epithelial keratitis, corneal vascularisation and sharply defined (Herbert's) pits at the limbus.
Treatment: Oral tetracycline or Erythromycin 250mg 3 times a day.
Bacterial corneal ulcers: These are most commonly caused by S. aureus, S. pneumococcus, Pseudomonas and Moraxella infections. These ulcers show stromal infiltration, corneal oedema and folds, endothelial fibrin plaques and anterior chamber reaction.
Investigation: corneal scrapping from the areas of ulceration are taken for staining, culture and antibiotic sensitivity testing.
Treatment: 1) Topical fortified antibiotics along with systemic antibiotics. 2) Cycloplegics like Atropine 1% eye drops. 3) Collagen shields: soaking the lens in antibiotics helps as a high dose drug delivery system.
Herpes Simplex Keratoconjunctivitis: This is a self-limited condition in which the keratitis occurs as a course punctate or a diffuse branching epithelial dindritic keratitis. Recurrent disease may occur as epithelial infectious ulcers, stromal interstitial keratitis, stromal immune disciform keratitis and iridocyclitis.
Mechanical debridement using a cotton tipped applicator.
Antiviral chemotherapy with topical vidaraline 3% or Idoxuridine 0.5% ointment 5 times a day.
Therapeutic soft contact lens to protect the damaged basement membrane. Proper control of diabetes is also required.
Herpes Zoster Ophthalmicus: The ophthalmic form of the disease usually presents as conjunctivitis, episcleritis, scleritis, keratitis, iridocyclitis, glaucoma, chorioretinitis and optic neuritis. The keratitis may occur as a punctate epithelial keratitis or a dendritic ulceration.
Oral Acyclovir tablets.
Antiviral treatment with Vidaraline 3% ointment.
Lateral tarsoraphy if the cornea is anaesthetic.
Fungal keratitis: Fungal ulcers usually have a plaque-like surface, stromal infiltrates and smaller satellite lesions or a gray or dirty white, rough, textured surface.
Investigations: Scraping for staining and culture.
Natamycin 5% topical drops.
Injection Amphotericin B or oral Ketoconazole tablets.
Uveitis refers to inflammation of the uveal tract. It may be divided into iritis, cyclitis, iridocyclitis and choroiditis.
Clinical features of uveitis are as follows -
Anterior Uveitis: The typical symptoms are ocular pain, hyperemia, photophobia and blurred vision. The signs are prilimbal flush, fine white keratic precipitates, cells and flare, fibrin exudation and posterior synaechiae.
Intermediate Uveitis: This is usually bilateral and presents with blurred vision, floaters and a snow bank appearance at the ora serrata.
Posterior Uveitis: It is usually insidious in onset with blurring of vision but no pain. The lesions tend to be patchy yellow-white areas of infiltrate with overlying vitritis. Diseases of the choroids like Vogt-Koyanagi-Harada (VKH) Syndrome can cause an exudative retinal detachment.
Panuveitis: involves the entire uveal tract. It presents with large greasy keratic precipitates, posterior synaechiae, iris nodules and vitreous haze. The course is chronic and has a fair to poor prognosis.
The anatomic locations of some of the major types of uveitis are-
Anterior: Ankylosing spondylitis, Sarcoid, Tuberculosis, Herpes Simplex or Zoster, Reiter's disease.
Both anterior and posterior: AIDS, Rubella, Toxoplasmosis, Sarcoid, Tuberculosis, Sympathetic Ophthalmia, Syphilis.
Posterior: Aspergillosis, Candidiasis, Cytomegalovirus, Histoplasmosis, Periarterits Nodosa, Cysticercosis.'
Investigations for Uveitis:
Skin Testing: eg Tuberculin Test, Kveim Test
Blood Tests: CBC, ESR, Antibody titres, ACE, HLA, ANA etc
Radiological: Xray of skull, chest, joints and sinuses
Fluorescein Angiography: for systoid macular oedema, capillary non-perfusion, neovascularization.
Anterior chamber aspiration
Treatment of Uveitis:
Specific: Treatment of the disease
Corticosteroids: Topical and systemic steroids are very effective. Periocular steroid injection are useful in certain conditions. Diabetes must be properly monitored when the patient is on steroids.
Cyclopegics: Atropine 1% drops are used prevent ciliary spasm and posterior synaechiae.
Immunosuppresive Agents: may be used in patients who fail to respond to conventional steroid treatment or to augment steroid treatment. These must be prescribed in concert with a physician especially in diabetics.
Complications of Uveitis:
Corneal band-shaped keratopathy
Macular oedema and cellophane maculopathy
Exudative retinal detachment
A variety of diseases cause inflammation primarily of the sensory retina, the RPE or the retina and choroids.
Retinitis: may be bacterial or fungal and is carried to the retina as a septic emboli.
Infectious disease of the RPE:
Rubella retinitis: seen in children born of mothers who contracted rubella in the first trimester of pregnancy. It presents as salt-and-pepper mottling of the RPE.
Acute posterior multifocal placoid pigment epitheliopathy (APMPPE): It presents as one or more flat, gray-white, subretinal lesions in the posterior pole.
Retinochoroiditis: It is associated with conditions involving the cornea.
Optic Nerve Head
Optic Neuritis: results from inflammation or demyelination of the optic nerve. Neurosyphilis and multiple sclerosis are some of the causes.
Clinical Features: Optic neuritis usually present with a dull retro orbital pain, transient blurring of vision or visual loss, a centrocecal scotoma and an afferent pupillary defect.
The fundus findings are blurring of the disc margins and mild hyperaemia in the early stages. A fully developed papillitis shows marked swelling, hyperaemia, obliteration of the physiologic cup and splinter haemorrhages. The late changes include temporal disc pallor and glial tissue formation on the disc.
Visual evoked potential
MRI for multiple sclerosis
Steroid treatment is controversial since there is no evidence that it influences the ultimate level of visual recovery or prevents a second attack. Mild or moderate conditions often show a spontaneous recovery of vision.