OUR INSTITUTION

The Manila Doctors

Hospital
Department of
Ophthalmology

With the founding of Manila

Doctors Hospital in 1956,
the Department of Eye, Ear,
Nose and Throat (EENT)
was established with Dr.
Carlos Sevilla as its
founding Chair. The hospital
then was a non-training
institution. In 1979, a distinct
and separate Department of
Ophthalmology was formed
with Dr. Romeo B. Espiritu
as the first Chair. The
following year a residency
training program was
established. The program
started as a 3-year,
preceptorship type
residency, accepting one
Resident per year. At that
time, the Manila Doctors

Hospital (MDH)
Ophthalmology training
program was hailed as the
model for preceptorship type
residency training.
As a result of the
Department's desire to
provide continuing medical
education in the specialty,
the Department held its first
postgraduate course in
1992. This activity became
an annual affair, and to this
date the Department has
organized a total of 21
postgraduate courses.
The establishment of a fullyequipped Charity OutPatient Eye Clinic by 1993
facilitated the transition from
the preceptorship type
residency training to the
standard program we have
now.

HIAN HO KUA, MD
HOSPITAL DIRECTOR
A Message from our Hospital
Director

Welcome to the participants of
the 23rd Post-Graduate Course
of the Department of
Ophthalmology titled 2 Fast, 2
Infectious, a series of lectures
which focuses on various eye
infections and the newest
innovations and trends in
treatment.

Over the years, participants in
this annual event have learned
lessons, but, of course, in the
field of medicine, especially in
ophthalmology, there is always
an open spot for learning new
things.

We hope that the lives

demonstrations, lectures, open
forum and interaction among
participants will bring about a
wealth of knowledge among
participants in the practice of
their chosen discipline.

In addition, it is always a delight
to be able to hold an event such
as this annual lecture series,
because it allows us to open our
doors to participants from
outside the Manila Doctors
Hospital. This way, we not only
teach our own residents up-to-
date innovations and
technology in their field, but we
also enable them to exchange
ideas and interact with
residents from other
participating hospitals.

Finally, to the lecturers, our
sincerest gratitude to your
willingness to share your
knowledge and expertise; and
to the people behind this event,
congratulations and we look
forward to another successful
one this year.

We wish everyone a fruitful and
productive day!

MARIO JOSELITO JUCO, MD

MEDICAL DIRECTOR
A Message from our Medical
Director

On the occasion of the 23rd
Postgraduate Course of the
Department of
Ophthalmology, I congratulate
the Chairman, Dr. Cesar
Ramon Espiritu, and the Post-
graduate Course Working
Committee, for this years
course and its theme 2 Fast, 2
Infectious focusing on the
latest updates and trends in
the management of the
different types of eye
procedures and surgeries.

With the topnotch faculty of
experts to share their

expertise and experience in

this one-day continuing
medical education event, we
are confident that the lectures,
open forum, and the
interactions among
participants will bring about
fresh perspectives and wealth
o knowledge and education,
necessary to keep up with the
advances in the delivery of
healthcare services in the field
of ophthalmology.

Welcome to all the
participants and my sincerest
thanks and appreciation to the
Faculty of Experts for sharing
both time and expertise for
the greater benefit of the
Filipino patient whom we

serve.

May God Bless you all!

CESAR RAMN ESPRITU, MD

CHAIRMAN

A Message from our

Department Chair

In behalf of the faculty and staff
of the department of
Ophthalmology and the
administration of the Manila
Doctors Hospital, I would like to
welcome the speakers,
participants, and our industry
partners to our 23rd post-
graduate course.
Our organization has
always strove to be unique but
at the same time relevant in
offering learning opportunities
through our post-graduate
programs. For example, in just
the recent past, we had such
themes as Aesthetic
Ophthalmology, Evidence-
Based Ophthalmology,
Occupational and Recreational
Injuries and Hazards to the

Eye, and Sneak Peek:

Emerging Technologies. In
keeping with this concept, this
years course on 2 Fast, 2
Infectious gives emphasis on
the different infectious agents
and their proper and up-to-date
management. We hope that at
days end, all of us will leave
with a clearer understanding of
the various eye infections, that
will aid us in arriving with the
accurate diagnosis and proper
treatment in a fast and efficient
manner.
I would also like to take
this opportunity to thank all
those who worked hard to make
this activity a success. Our vice-
chairman, Dr. Manuel Manolet
Delfin, Jr., the chief resident, Dr.
Criselda Chavez and the rest of
the resident staff who all
deserve our praise for a job well

done. Likewise, the continuing

support from and
encouragement by the
administration of the Manila
Doctors Hospital, particularly
its medical director, Dr. Mario
Juco, has assured the
departments growth over the
years. Lastly, this expression of
gratitude will not be complete
without recognizing the
invaluable support of our
industry partners. I and the
entire staff of the MDH
department of ophthalmology
look forward to a lasting,
mutually-
productiverelationship.

Have a great day,
everyone!

PRESEPTAL AND ORBITAL

CELLULITIS
June 14, 2014
Cellulitis is an inflammation of the soft
connective tissue from an infection. The orbital
septum is a fibrous membrane that separates
the eyelid skin from the deeper structures of
the orbit. Preseptal cellulitis is an infection or
inflammation of the eyelid skin that does not
extend beyond the orbital septum into the
orbit. Orbital cellulitis is an infection or
inflammation of the orbit. Since the orbit has
direct communications with the sinuses,
infection can spread into the orbit in a patient
with a sinus infection. Orbital cellulitis is
usually more serious than preseptal cellulitis.

Orbital cellulitis if untreated can be potentially

sight and life threatening. Both adults and
children are affected but it is more frequent
in the pediatric age group. In children, history
of upper respiratory tract infection prior to
the onset is very common.
Signs of orbital infection are characterized by

eyelid edema, erythema, chemosis, proptosis,

blurred vision, fever, headache, and double
vision.

Imaging studies for detection of orbital
abcess and the use of antibiotics and early
drainage have significantly decreased visual
morbidity. The infectious organisms are best
identified by microbiologic culture.

Treating upper respiratory or sinus
infections before leading into orbital cellulitis
is an important part in preventing preseptal
cellulitis from progressing to orbital cellulitis.
Equally important in preventing orbital
cellulitis is prompt and appropriate
treatment of preseptal skin infections or even
odentogenic infections before they spread
into the orbit.

BLEBITIS
In glaucoma surgery, the creation of an
auxillary drain between the anterior chamber
and the outside of the eyeball is a potential
route for infectious agents that may cause
blebitis and in the long run bleb-associated
endophthalmitis.

Blebitis was defined by Dr. R.H. Brown as an
infection around the bleb that could be
associated with mild to moderate anterior
chamber
reaction
without
vitreous
involvement. The description of blebitis as
white on red appearance of the bleb
surrounded by hyperemic conjunctiva with or
without hypopyon was observed in post-
trabeculectomy patients.

Eye symptoms present with blebitis have
sudden onset pain, photophobia, mucopurulent
discharge, hyperemic and injected conjunctiva.

Blebitis and bleb associated endophthalmitis

was thought and debated as part of a spectrum.

Infectious agents most commonly associated
with blebitis are less virulent than
endophthalmitis and are usually from the
normal lid and lacrimal flora. With a good
combination of antibiotic treatment the visual
prognosis is good. But some glaucoma
specialists treat blebitis as bleb associated
endophthalmitis and admit and prescribe
aggressive antibiotics to control its progression.

HSV KERATITIS
Herpes simplex virus (HSV) keratitis is a
diagnostic and therapeutic dilemma to the
ophthalmologist.
Virus
isolation
is
considered a standard procedure for
diagnosis of viral infections; however, it is a
relatively time consuming, expensive
procedure. It will also depend on viable
infectious material that usually needs to be
transferred to a special virology laboratory
for processing. Rapid diagnostic tests that
allow results within hours, have been
utilized and reported for decades now.
These rapid tests, enzyme or fluorescence
based immunological detection of HSV-1
antigen or polymerase chain reaction (PCR)
based detection of viral DNA, have not been
evaluated simultaneously in a clinically well
defined group of patients.
For the past 5 years we have been routinely
employing a triad of tests on corneal

scrapings for the diagnosis of HSV-1

keratitis in patients seen at our clinics,
namely Giemsa stain, immunofluorescence
assay (IFA), and PCR.
It is also vital to note of HSV keratitis
treatment, that recurrences may lead to
corneal stromal scarring and decreased
visual acuity. Consequently, herpetic
stromal keratitis is a common indication for
corneal transplantation. There is a relatively
high risk of graft failure.
Approaching a patient presenting with HSV
keratitis is no simple case, it poses a myriad
of threats and difficulties for us eye doctors.

FUNGAL KERATITIS
Fungal keratitis is a serious ocular infection with
potentially catastrophic visual results. Caused
by any of the many species of fungi capable of
colonizing human tissue, it occurs worldwide
and its incidence is increasing in frequency.

The list covers many fungi including but not
limited to yeasts of Candida spp., filamentous
with septae such as Aspergillus spp.,Fusarium
spp., Cladosporium,spp., Curvularia, and non
septated such as Rhizopus. Risk factors include
trauma, ocular surface disease, and topical
steroid use.

The early stage of fungal keratitis remains a
diagnostic and therapeutic challenge to the
ophthalmologist. There is difficulty in
establishing the clinical diagnosis, isolating the
etiologic fungal organism in the laboratory, and
treating the keratitis effectively with topical

antifungal agents. Unfortunately, delayed

diagnosis is common, primarily because of lack
of suspicion. When a diagnosis has been made,
management remains a challenge because of
the poor corneal penetration of antifungal
agents.
The incidence of fungal keratitis has increased
over the past 30 years. This increased
occurrence of fungal keratitis is a result of the
frequent use of topical corticosteroids along
with antibacterial agents in treating patients
with keratitis. With better laboratory facilities,
the awareness about fungal keratitis has
increased.

BACTERIAL
ENDOPHTHALMITIS
Rare but serious. Fatal to the eye and to an
ophthalmologists practice as this can make
or break ones medical prowess. We see a lot
of patients with diabetes mellitus, systemic
malignancy, sickle cell anemia, systemic
lupus
erythematosus,
and
human
immunodeficiency virus (HIV) infection, plus
patients
who
have
had
extensive
gastrointestinal surgery, endoscopy, and
dental procedures, yes all of them may
increase risk of endogenous endophthalmitis.
Systemic immunomodulatory therapy and
chemotherapy may also put patients at risk.
Although the eye may be the only location
where the infection can be found, there is an
extraocular focus in 90% of cases. One must
consider the possibility of pneumonia, urinary
tract infection, bacterial meningitis, or a liver
abscess as possible sources of infection. A
wide variety of bacteria can cause
endogenous
endophthalmitis.
In
Asia,

infection from Klebsiella species in liver

abscesses is the most common cause of
endogenous endophthalmitis. It is important
to also consider endogenous endophthalmitis
in newborns and infants, especially those
younger than 6 months. The complications of
endogenous endophthalmitis can be serious.
If the diagnosis of systemic infection is
missed, the patient may develop sepsis and
even die. In severe cases, recurrent or
persistent intraocular infection may require
multiple surgeries and multiple injections of
intravitreal antibiotics.
In addition, complications such as cataract
development,
retinal
detachment,
suprachoroidal
hemorrhage,
vitreous
hemorrhage, hypotony, and phthisis bulbi can
occur in the most severe cases. The
prognosis is directly related to the offending
organism and the systemic status of the
patient. Bacterial endophthalmitis is not only
blinding but deadly.

CMV RETINITIS
Cytomegalovirus (CMV) retinitis is a full
thickness retinal infection that can lead to
necrosis and retinal breaks and detachments
caused by human cytomegalovirus. In the
immunocompetent host, infection is
generally asymptomatic or limited to a
mononucleosis-like syndrome with signs and
symptoms including fever, myalgia, cervical
lymphadenopathy, and mild hepatitis. CMV
remains latent in the host and may reactivate
if host immunity is compromised. HIV-
positive people are most at risk, especially
when the CD4 cell count is low.

In the eye, CMV most commonly presents as a
viral necrotizing retinitis which typically
starts in the midperiphery and can progress
in a "brush fire" pattern. Severe visual loss
primarily occurs from the direct spread of
retinitis into the posterior pole, affecting
central vision, or from retinal detachment

(RD) secondary to multiple retinal breaks in

the peripheral, necrotic retina. Early and
aggressive
treatment
with
antiviral
medication for both CMV and HIV, combined
with improved surgical techniques for RD
repair, has helped to improve the visual
outcomes in patients with CMV retinitis.

The advent of highly active antiretroviral
therapy (HAART), with consequent recovery
of immune function allows individuals to
discontinue their CMV therapy if the retinitis
has resolved adequately with antiviral
treatment. Careful monitoring of both
immune status and ophthalmic findings are
necessary to prevent retinal damage from an
asymptomatic recurrence.

TOXOPLASMA AND
TOXOCARA INFECTIONS
Toxoplasma
gondii and Toxocara spp.
infections, which can cause disease, share soil
ingestion as a common mode of exposure.

Toxoplasma gondii, a protozoan parasite, is
shed as environmentally resistant oocysts in cat
feces and becomes infectious after 15 days
when the oocysts sporulate. Toxoplasma gondii
has great importance in public health. Women
in initial stages of gestation may undergo
miscarriage, premature birth, neonatal death
and even the classical Sabin's Triad,
characterized by retinochoroiditis, cerebral
calcifications, hydrocephaly or microcephaly.

Toxocariasis caused by infection with larvae of
Toxocara canis, and to a lesser extent by
Toxocara cati and other ascaridoid species,
manifests in humans in a range of clinical
syndromes. These include visceral and ocular

larva migrans, neurotoxocariasis and covert or

common toxocariasis. Toxocara canis is one of
the most widespread public health and
economically important zoonotic parasitic
infections humans share with dogs, cats and
wild canids. This neglected disease has been
shown through seroprevalence studies to be
especially prevalent among children from socio-
economically disadvantaged populations both
in the tropics and sub-tropics and in
industrialized nations.

This lecture discusses the transmission,
diagnosis, management and clinical syndromes
of Toxoplasmosis and Toxocariasis, their public
health importance, epidemiology, control and
current research needs.

NEONATAL
CONJUNCTIVITIS
Neonatal conjunctivitis refers to chemical
irritation or pathogenic organism which causes
purulent ocular drainage. Diagnosis is more
often based on clinical knowledge and usually
confirmed by laboratory testing. Common
causes include the following:
1) Bacterial Infection
2) Chemical Inflammation
3) Viral infection.

With Chlamydia trachomatis being the
most common bacterial cause; which
accounts to 40% of conjunctivitis in
neonates < 4 wk of age. The prevalence of
maternal chlamydial infection ranges from
2 to 20%. About 30 to 50% of neonates
born to acutely infected women acquire
infection, and 25 to 50% of those develop
conjunctivitis (and 5 to 20% develop
pneumonia). Other bacteria, including

Streptococcus pneumoniae and non-

typeable Haemophilus influenzae, account
for another 30 to 50% of cases, whereas
gonococcal ophthalmia (conjunctivitis due
to Neisseria gonorrhoeae) accounts for <
1% of cases.1

Chemical conjunctivitis is usually secondary to
the instillation of topical therapy for ocular
prophylaxis.

Treatment should ideally be organism-specific
antimicrobials.

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