Dr.

Masitha Dewi Sari,SpM

Anatomi segmen anterior

CONJUNCTIVITIS
Definisi: peradangan conjunctiva ditandai dengan discharge (sekret) dapat berair, mucoid, mucopurulent atau purulent

KLASIFIKASI BERDASARKAN ETIOLOGI 1. Infective conjunctivitis : bacterial, chlamydial, viral, fungi, spirochaetal, protozoal, paracitic,etc, 2. Allergic conjunctivitis 3. Irritative conjunctivitis 4. Keratocinjunctivitis associated with diseases of skin and mucous membrane 5. Traumatic conjunctivitis 6. Keratoconjunctivitis of unknown etiology

gatal

Viral Bacteri Chlamydial Allergic minimal minimal minimal hebat Menye luruh sedang Menye luruh sedang hebat Sering pd inclusion Menyeluruh (merah muda) Sedang Hebat Tidak ada

hyperemia Menye luruh lakrimasi sekret nodule Scraping, pewarnaa n demam hebat

minimal Paling Hebat sering jarang

monosit Bacteri PMN kadang kadang

PMN < Eosinofil plasma sel Tidak ada Tidak ada

Gejala-gejala umum Conjunctivitis

1. Merasa seperti ada benda asing 2. Merasa panas (burning/scratching sensation) 3. Perasaan mata bengkak (fullness around the eye) 4. Gatal 5. Fotofobia (jika terkena kornea)

Tanda-tanda umum Conjunctivitis

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Hyperemi Banyak air mata Chemosis (oedem conjunctiva bulbi ) Exudation/discharge ( kotoran mata ) Pseudoptosis Hypertrophy papil Folicle Pseudomembran Granuloma Preauriculer adenopathy (pembesaran kelenjar preauriculer)

Bacterial conjunctivitis

Viral conjunctivitis

Allergic conjunctivitis

Chlamydial conjunctivitis

PENANGANAN
Tergantung kausa Hindari faktor iritasi atau alergen Antibiotik tetes / salep tergantung jenis konjungtivitis 3-4x/hari selama 5- 7 hari

Bacterial Conjunctivitis

Infections
Conjunctivitis
Bacterial
If severe purulent discharge and hyperacute onset (12-24 hours), need prompt ophtho eval for workup of Gonococcal conjunctivitis

Gonococcal Conjunctivitis

Infections
Conjunctivitis
Viral
Monocular/Binocular watery discharge, chemosis, conjunctival inflammation Associated with
Viral respiratory symptoms Palpable preauricular node

Fluorescein stain may reveal superficial keratitis Treatment:

Cool compresses Naphazoline/pheniramine for conjunctival congestion Ophthalmology follow up in 7-14 days

Infections
Conjunctivitis
Allergic
Monocular/binocular pruritis, watery discharge, chemosis History of allergies No lesions seen with fluorescein staining, no preauricular nodes, Conjunctival papillae Treatment:
Eliminate inciting agent Cool compresses Artificial tears Naphazoline/pheniramine

Infections
Conjunctivitis
Allergic
Monocular/binocular pruritis, watery discharge, chemosis History of allergies No lesions seen with fluorescein staining, no preauricular nodes, Conjunctival papillae Treatment:
Eliminate inciting agent Cool compresses Artificial tears Naphazoline/pheniramine

Infections
Herpes Simplex Virus
Classic: Dendritic epithelial defect ED care depends on the site of infection
Eyelid and conjunctiva
Topical antivirals (trifluorothymidine drops/vidarabine ointment) 5 times/day Topical erythromycin ointment Warm soaks

Cornea
Topical antivirals 9 times/day

Anterior chamber
Cycloplegic agent may be used

First 3 days of infection: Acyclovir/famcyclovir

Infections
Herpes Zoster Ophthalmicus
Shingles with trigeminal distribution, ocular involvement, concurrent iritis Pseudodentrite
Mucous corneal plaque with epithelial erosion

Treatment:
Acyclovir Topical antivirals Warm compresses Oral analgesics or cycloplegics for pain relief

Ophthalmology consult mandatory

Infections
Herpes Zoster Ophthalmicus
Shingles with trigeminal distribution, ocular involvement, concurrent iritis Pseudodentrite
Mucous corneal plaque with epithelial erosion

Treatment:
Acyclovir Topical antivirals Warm compresses Oral analgesics or cycloplegics for pain relief

Ophthalmology consult mandatory

Infections
Herpes Zoster Ophthalmicus
Shingles with trigeminal distribution, ocular involvement, concurrent iritis Pseudodentrite
Mucous corneal plaque with epithelial erosion

Treatment:
Acyclovir Topical antivirals Warm compresses Oral analgesics or cycloplegics for pain relief

Ophthalmology consult mandatory

Traumatic Eye Injuries

Conjunctival Foreign Bodies
Lid eversion Remove with a moistened sterile swab

PENGUICULA
Definisi Penebalan conjunctiva mata berbentuk segitiga yang puncaknya menghadap kornea yang terdapat di conjunctiva bulbi pada celah mata. Bisa terjadi pada nasal dan temporal sit Patologinya sama dengan pterygeum Etiologi : Iritasi Matahari Debu Angin

Klinis : Penonjolan warna kuning seperti lemak PA : hyalin (+) dan suatu elastic degeneration dari lapisan submucosa Penimbunan kalsium pada penguicula tsb Pengobatan : Tidak perlu Bila terjadi inflamasi Artificial tears

beri steroid topical

PTERYGEUM
Definisi : Penebalan conjunctiva berbentuki segitiga puncaknya dekat ke kornea/mencapai ke kornea Klinis : - Pembuluh darah membesar - visus menurun oleh karena astigmatisma irruguler pembiasan tidak pada satu tempat - stroma proliferasi - sering pada bagian nasal, dalam pertumbuhannya bisa sampai pada pupil Gejala : - panas - merasa seperti ada benda asing

 Pengobatan : tidak spesifik, bila ada tanda-tanda inflamasi beri steroid topikal Indikasi Operasi - pertumbuhannya progressif 2 cm - Gangguan visus - gangguan gerakan bola mata - iritasi berulang merah - keluhan kosmetik - apabila recidif, beri sinar beta atau extirpasi, lakukan transplantasi dari mukosa mulut, kantung amnion atau conjunctiva lain Patologi : - epitel kornea - membrana bowmen hilang/rusak - stroma prokiferasi seperti jaringan granulasi

INFLAMASI PADA KORNEA

Peradangan pada kornea (keratitis) dengan karakteristik oedem kornea, infiltrasi seluler, dan kongesti siliar

Klasifikasi topographical (morphological)

A. Ulcerative keratitis (corneal ulcer) 1. Berdasarkan lokasi (a) ulkus kornea sentral (b) ulkus kornea perifer 2. Berdasarkan purulen (a) ulkus kornea purulenta / suppurative (b) ulkus kornea non purulen

3. Berdasarkan hypopion (a) ulkus kornea simple (tanpa hypopion) (b) ulkus kornea hypopion 4. Berdasarkan kedalaman ulkus (a) superfisial (b) deep (c) ulkus kornea dengan impending perforation (d) ulkus kornea perforasi

B. Non ulcerative Keratitis 1. Superficial keratitis (a) diffuse superficial keratitis (b) superficial punctate keratitis 2. Deep keratitis (a) non suppurative (b) suppurative deep keratitis

GEJALA
Mata merah Nyeri Fotofobia Pandangan kabur berair

Pemeriksaan
Tajam penglihatan menurun tes fluorescein (+) defek Pada infeksi berat hypopion

KERATITIS SUPERFICIAL PURULENTA (ULCUS CORNEAL)

Defenisi - infeksi cornea dengan adanya infiltrasi dan hilangnya substansi cornea - hampir slamanya expgenous oleh organisme pyogenik - penyebab ulcus cornea tanpa lesi epithel : * gonorrhea * diphterioe Bakteri lain harus ada lesi epithel ulcus cornea stophylococcus menyebabkan superficial punctate erotion

PENYEBAB 1. Bakteri a. Pneumococcus b. Staphylococcus aureus, Staphylococcus epidermidis c. Alpha Haemolyticus Streptococcus d. Nocardia e. Mycobacterium f. Streptococcus viridans g. Klebsiella pneumonia 2. Virus a. Herpes simplex b. varicella zoster c. Variola d. Adenovirus 3. Fungal a. Aspergillus b. Candida c. Cephalosorium d. Fusarium e. Penicillium 4. Autoimmune 5. Amuba

PATOLOGI Terjadi nekrose setempat pada lapangan pandang cornea (sampai stroma) sequestrum lepas danjatuh pada saccus conjunctiva (sel mati dan mikroorganisme, sel-sel radang). Sebagian sequestrum menempel pada permukaan ulcus epitel yang rusak lebih luas dari ulcusnya sendiri, begitu juga pada lapisan bowman Epitel dengan cepat tumbuh ke arah ulcus, tumbuh pada pinggir bahkan diatas infiltrat. Dasar ulcus menonjol karena adanya inhibisi cairan sekret ulcus. Batas antara ulcus dengan jaringan sehat, sama seperti bagian tubuh yang lain, yaitu ada dinding PMN leukosit membentuk lapisan kedua pertahanan sehingga lekosit berfungsi sebagai : - digestive : mencerna - macerating : menghancurkan - dissolving : melarutkan jaringan nekrose Jaringan terlepas ulkus tambah lebar dan kekeruhan berkurang

 Dasar dan pinggiran transparan Perbaikan mulai terjadi, terbentuk pembuluh darah halus dari limbus dekat ulcus untuk mensuplai bahan-bahan yang rusak Antibodi untuk mengatasi infeksi (pannus) Meresap ke cornea di COA) merangsang pembuluh darah iris dan corpus ciliare sehingga terjadi hiperemi iris tanpa ciliary infection Iritasi/peradangan bisa terlalu hebat sehingga leukosit dan PMN keluar dari pembuluh darah masuk ke COA dan mengendap di bagian COA disebut hypopion SIMPTOM Ulcus cornea pada stadium akut/progresive ulcus - blepharospasme - lacrimation - fotophobia dan pain

SIGN Visus menurun ulcus central Infiltrat dengan lesi epitel di atasnya Ciliary infection Iridocyclitis keratitis precipitate (bentuk segitiga di epitel cornea), hypopion Pannus (pembuluh darah yang masuk ke cornea) DD MATA MERAH 1. conjunctivitis akut 2. Glaukoma akut 3. Keratitis 4. Uveitis

PENYEMBUHAN ULCUS Pannus (+) ada cicatrix pada bekas ulcus Serabut yang baru terbentuk tidak tersusun teratur sebagaimana normalnya bias cahaya tidak teratur Parut luas pembuluh darah besar /menetap Membran bowman tidak tumbuh lagi Cornal focets cicatrix tidak keruh / transparan dan permukaannya datar (mata serangga) Nb : tidak terbentuk jaringan ikat, tapi cornea masuk ke dalam.

BERDASARKAN KETEBALAN CICATRIX DIBAGI :

1. Nebula : kekeruhan ringan, dapat dilihat dengan lup 2. Macula : kekeruhan lebih jelas dapat dilihat dengan mata telanjang 3. Leucoma : kekeruhan jelas sekali jika kekeruhan sangat menebal (leukoma adherent) pelengketan ke depan ke belakang cornea dengan permukaan iris

KOMPLIKASI Cicatrix Penyembuhan cicatrix yang tidak sempurna, cornea di bekas ulcus menonjol/bulging disebut : ECTATIC CICATRIX = KERAECTASIS Descematocele Ulcus dalam seluruh stroma dikenai kecuali descement membrane menonjol oleh karena tekanan intra oculi sehingga terlihat gelembung yang transparant Hypopion sebelum perforasi : steril (Ag-Ab reaction) Perforation Synechia Anterior Kalau perforasi kecil, iris akan menutupnya sehingga ada perlengketan iris ke kornea atau organisasi Leucoma Adherent pada bagian cornea yang perforasi terbentuk parut tebal dimana iris tetap melekat dibawahnya. Intra Oculer Haemorrhage Perforasi tiba-tiba dilatasi tiba-tiba pada pembuluh darah intra ocular ruptur pembuluh darah

KOMPLIKASI Cicatrix Penyembuhan cicatrix yang tidak sempurna, cornea di bekas ulcus menonjol/bulging disebut : ECTATIC CICATRIX = KERAECTASIS Descematocele Ulcus dalam seluruh stroma dikenai kecuali descement membrane menonjol oleh karena tekanan intra oculi sehingga terlihat gelembung yang transparant Hypopion sebelum perforasi : steril (Ag-Ab reaction) Perforation Synechia Anterior Kalau perforasi kecil, iris akan menutupnya sehingga ada perlengketan iris ke kornea atau organisasi Leucoma Adherent pada bagian cornea yang perforasi terbentuk parut tebal dimana iris tetap melekat dibawahnya. Intra Oculer Haemorrhage Perforasi tiba-tiba dilatasi tiba-tiba pada pembuluh darah intra ocular ruptur pembuluh darah

2. Midriaticum Sulfasatropin tetes mata 1% 3 guttae/hari untuk : Mengistirahatkan iris dan corpus ciliare Mencegah synechia Mencegah iridocyclitis 3. Kebersihan Ulcus Bersihkan saccus conjunctiva 3 kali atau lebih dengan antiseptik lotion hango Fungsi : Antiseptik Menghilangkan sekret dan jaringan mati Menghilangkan mikroorganisme Antiseptik : Acidum boricum 3% (2%) Amonium totrat normal 10% Mercuryl axicyanide 0.01%

4. Pemanasan (Heat) Moist heat kompres hangat dengan acidum boricum hangat beri 3 kali atau lebih Dry heat penyembuhan lebih cepat 5. Perbaiki Keadaan Umum 6. Benda asing (corpus alineum) - diangkat / ekstersi 7. Scrapping dan Cautherization Scrapping mengatasi meluasnya ulcus, dinding dan dasar ulcus Cautherization - panas : electrocautery actual cautery - Chemical : yodium tinctur puroliqueel carbonic acid 2 sampai 3 kali interval 1-2 hari 8. Tarsorrhapy Menjahit kelopak mata atas dan bawah (agar obat dapat mencapai ulcus melalui conjunctiva) 9. Conjunctival Flap Ulcus ditutup dengan conjunctiva bulbi brigde ataupun total 10. Parasintesis Tujuan - mencegah erosi - menghilangkan rasa sakit - Nutrisi pada cornea yang sakit - penambahan antibodi yang baru

Superficial punctate keratitis

Ulkus kornea

Ulkus kornea dgn hypopion

penangananan
Antibiotika tetes / salep dapat diberi setiap 30 menit 1 jam, tergantung keparahan infeksinya Hindari pemakaian steroid Antibiotika fortified pd kasus ulkus kornea berat (dgn hypopion) Cycloplegic (atropin tetes) Injeksi antibiotika subconjunctiva Antibiotika oral gol.fluoroquinolone (mis. Ciprofloxacin 2 x 500mg),penetrasi ke kornea baik

Injeksi subconjunctiva

Complicated Corneal Ulcer

Perforated Corneal Ulcer

Healed Keratocele

Hypopyon Ulcer
Types Corneal Ulcer (Superficial Purulent Keratitis) with Hypopyon Ulcer Serpen

Hypopyon Ulcer
There is always an associated iritis in all cases of Corneal Ulcer due to diffusion of toxins of infecting bacteria into the eye. Sometimes iridocyclitis is so severe that it is accompanied by outpouring of leucocytes from uveal blood vessels and these cells gravitate to bottom of the anterior chamber to form hypopyon (pus in anterior chamber)

Introduction
The hypopyon which forms in bacterial keratitis is sterile as the leucocyte secretion is due to irritation by toxins and not by the bacteria Hypopyon may develop in hours and it may change in quantity and may also rapidly disappear. Hypopyon in bacterial keratitis is fluid and changes its position with change in head posture

Etiology

Predisposing Factors
1. High Virulence of infecting organism 2. Resistance of the tissues, which is low 3. Dacryocystitis 4. Ocular trauma 5. Old, debilitated or alcoholic 6. Measles or scarlet fever

Organisms
Pyogenic organisms like Staphylococci, Streptococci, Gonococci, Moraxella, Pseudomonas and Pneumococci

Hypopyon Ulcer

Ulcus Serpen
Ulcus Serpen is hypopyon ulcer caused by Pneumococci in adults and has tendency to creep over the cornea in serpiginous fashion

Symptoms
Sever pain, photophobia, marked diminution of vision, watering, foreign body sensation (grittiness)

Signs
Grayish white or yellowish disc like lesion near centre of cornea. Opacity is marked at edges than at the centre and more marked in one direction (where it is progressive). In the direction of progression there is cloudiness (grey coloured) and fine line ahead of disc Cornea may be lusterless. There is severe iritis and aqueous is hazy or there may be rank hypopyon amount which varies

Signs
Untreated ulcer increases in depth and spread towards the side of dense infiltration, while on the other side simultaneously healing (cicatrization) takes place. There is infiltration just anterior to Descemets membrane underneath the floor of ulcer with normal intervening lamellae, due to which there is tendency for perforation of cornea. Intra-ocular tension is usually raised in these cases.

Complications
Untreated cases progresses to increase in hypopyon which becomes fibrinous leading to perforation Iris prolapse through large opening whole cornea may slough leaving peripheral cornea which is nourished by limbal vascular loops. Eventually panophthalmitis develops which destroys the eye

Treatment
Routine treatment of Corneal Ulcer Tab Acetazolamide Local Betablocker Therapeutic keratoplasty Control of infection results in absorption of hypopyon

Fungal Keratitis

Fungal Keratitis
Fungal keratitis is challenging corneal disease and presents as very difficult form bacterial keratitis. Difficulty arise in making correct clinical and laboratory diagnosis. The treatment of fungal keratitis is also difficult due to poor availability of antifungal drugs and delay in starting treatment. Treatment is required on long term basis, intensively and often cases require therapeutic keratoplasty.

Fungal Keratitis
Fungi enter into corneal stroma through epithelial defect, which may be due to trauma, contact lens wear, bad ocular surface or previous corneal surgery. In stroma fungi multiply and causes tissue necrosis and inflammatory reaction. Organisms enter deep into the stroma and through an intact Descemets membrane into the anterior chamber and iris. They can also involve Sclera.

Fungal Keratitis
The spread is due to the fact that the blood borne growth inhibiting factors may not reach the avascular tissue like cornea and sclera.

Risk Factors
1. Trauma outdoor/ or the one which involves plant matter (including contact lenses) 2. Topical medications: corticosteroids, anaesthetic drug abuse and topical broad spectrum antibiotics use for long time (resulting in non-competitive environment for growth)

Risk Factors
3. Systemic use of steroids 4. Corneal surgeries (Penetrating keratoplasty, refractive surgery) 5. Chronic keratitis (herpes simplex, herpes zoster, Vernal or allergic keratoconjunctivitis, and neurotrophic ulcer) 6. Diabetes , Chronically ill / hospitalised patients, AIDS and leprosy

Causative fungi
I. II. Yeast: Candida species (albicans), Cryptococcus Filamentous septated A. Non-pigmented hyphae: Fusarium species (solani), Aspergillus species (fumigatus, flavus, niger) B. Pigmented hyphae (dematiaceous): Alternaria, Curularia , Cladosporium species

Causative fungi
III. Filamentous non-septated : Mucor and Rhizopus species IV. Diphasic forms: Histoplasma, Coccidiodes, Blastomyces

Clinical Features

Symptoms

Onset is slow Symptoms are less compared to signs Diminution of vision, pain, foreign body sensation

Signs
Diminution of vision, depending on location of ulcer Conjunctival and ciliary congestion Epithelial defect Stromal infiltrates Elevated areas, hypate (branching) ulcers, irregular feathery margins Dry and rough texture

Fungal Keratitis with Hypopyon

Signs
Satellite lesions Brown pigmentation due to dematiaceous fungus (Curvularia lunata) Intact epithelium with stromal infiltrates Anterior chamber reaction

Fungal Keratitis

Fungal Keratitis Pigmented Lesion

Case of Fungal+ Bacterial Keratitis

Laboratory Diagnosis
The Gram and Giemsa stains are used as initial stains Potassium Hydroxide (10-20 %) wet mounts Culture Media: Sheep blood agar, Chocolate agar, Sabouraud dextrose agar, Thioglycollate broth Anterior chamber tap under aseptic conditions to aspirate hypopyon and or endothelial plaque

Treatment
Natamycin 5% suspension: frequency will depend on severity of condition Candida species respond better to Amphotericin B 0.15% Fluconazole 2% Miconazole 1% Scrapping every 24 to 48 hours Treatment is required for 4 6 weeks

Treatment
Sub-conjunctival injection of Miconazole 5 10 mgm of 10 mgm/ml suspension (indicated in severe form of keratitis, scleritis and endophthalmitis) Systemic: Fluconazole or Ketoconazole is indicated in severe form of keratitis, scleritis and endophthalmitis

Surgical Treatment
1. Daily debridement with spatula/ blade every 24 48 hours 2. Surgical treatment is required in approximately 1/3rd cases of fungal keratitis due to failure of medical treatment or perforation 3. Surgical treatment in the form of : therapeutic keratoplasty, conjunctival flap or lamellar keratoplasty

Surgical Treatment
Surgery is usually indicated within 4 weeks due to failure of medical treatment or recurrence of infection Unfavorable outcome is due to scleritis, endophthalmitis and recurrence Cryotherapy with topical antifungal treatment or corneoscleral graft in cases of fungal scleritis and keratoscleritis

VIRAL KERATITIS

Introduction
Viruses are obligate intracellular parasites that contain only one type of nucleic acid within he infectious unit and are unable to replicate by binary fission. Viruses that cause corneal disease are Herpes simplex ( HSV) Varicella zoster ( VZV) Epstein Barr ( EBV) Adenovirus Cytomegalovirus (CMV) can also cause keratitis and is more commonly associated with AIDS

Epidemiology and pathogenesis

HSV, VZV, EBV, and CMV are all members of the family Herpesviridae. DNA viruses There are two types of HSV HSV-1 is more commonly associated with labial and ocular infection. HSV-2 is associated with genital infection.
Ophthalmology 2004, (2), 475-481

Epidemiology and pathogenesis

Herpes simplex keratitis is a leading cause of corneal blindness in the developing world. Estimated prevalence is approx 150 per 100,000 population. Ocular HSV tends to be a unilateral disease with only one eye affected by primary disease in approx 80-90% of cases. Atopy appears to be risk factor for bilateral disease, & is associated with gastric cancer, lumbar zoster, malaria and pulmonary tuberculosis

HERPES SIMPLEX KERATITIS

Herpes Simplex Keratitis occurs in two forms: 1. Primary 2. Recurrent

Primary HSV-1 (HSV type 1) infections

Occurs most commonly in the mucocutaneous distribution of the trigeminal nerve. spread of Primary virus Infected Nearby Infection epithelial cells sensory nerve endings Viral genome along enters nucleus nerve axon at neuron (Persists indefinitely in a latent state) Cell body in transport

trigeminal ganglion

www.emedicine.com

PRIMARY HSV-1
Primary infection of any of the 3 branches (ophthalmic, maxillary, mandibular) of cranial nerve V leads to latent infection of nerve cells in trigeminal ganglion. Interneuronal spread of HSV within ganglion allows patients to develop ocular disease without ever having had primary ocular HSV infection.
www.emedicine.com

RECURRENT HSV INFECTION

Has been thought of as reactivation of virus in the sensory ganglion. Virus migrates down nerve axon to produce lytic infection in ocular disease. Recent evidence suggests, virus may subsist latently within corneal tissue, serving as a potential source of recurrent disease.
www.emedicine.com

CLINICAL FINDINGS
Primary Herpes Simplex Keratitis Infrequently seen Manifested as vesicular blepharoconjunctivitis occasionally with corneal involvement Usually occurs in young children Topical antiviral therapy may be used as prophylaxis and as therapy
Vaughan & Asburys General Ophthalmology 16th Edition, 136

CLINICAL FINDINGS
Recurrent type herpetic keratitis Attacks triggered by Fever Overexposure to UV light Trauma Onset of menstruation Local/ systemic source of immunosuppression Bilateral lesions develop in 4-6% of patients and seen mostly in atopic Vaughan & Asburys General Ophthalmology 16th Edition, 136 patients.

SYMPTOMS
Irritation Photophobia Tearing Reduction in vision (when central cornea is affected) Corneal anesthesia usually occurs early in the course of infection and thus symptoms may be minimal.

SYMPTOMS
Corneal ulceration can occasionally be the only sign of recurrent herpetic infections

Recurrent herpes simplex virus dendritic ulcer with an adjacent stromal scar

LESIONS: Dendritic ulcer

Most characteristic lesion, occurs in corneal epithelium Typical branching, linear pattern with feathery edges and terminal bulbs at ends. Visualized by fluorescein staining
HSV dendritic ulcer stained with fluorescein

Dendritic keratitis

This patient suffers from herpetic keratitis. Fluorescein staining reveals dendritic ulcer typical of herpes keratitis. This is treated with topical 3% acyclovir
www.eyecasualty.co.uk/.../ cornealinfections.html

Geographic ulceration

Form of chronic dendritic disease. Delicate dendritic lesions take a broader form. Corneal sensation is diminished

HSV geographic ulcer

Other corneal lesions

Other corneal epithelial lesions caused by HSV are Blotchy epithelial keratitis Stellate epithelial keratitis Filamentary keratitis Usually transitory, often become typical dendrites within a day or two.

Filamentary keratitis

Subepithelial lesions
Caused by HSV infection Ghost like image, larger than original epithelial defect seen in the area immediately underlying epithelial lesion. Does not persist for more than a year

Disciform keratitis
Most common form of stromal disease in HSV infection. Edematous stroma without significant infiltration and usually without vascularization. Edema is most prominent sign. Keratic precipitates may lie directly under disciform lesion but may also involve the endothelial lesion.

Vaughan & Asburys General Ophthalmology 16th Edition, 136

Peripheral lesions of the cornea

Caused by HSV Usually linear lesions, show loss of epithelium Testing for corneal sensation is unreliable. Patient is far less photophobic than patients with nonherpetic corneal infiltrates.

Treatment
Should be directed at eliminating viral replication within the cornea, while minimizing damaging effects of inflammatory response.

Vaughan & Asburys General Ophthalmology 16th Edition, 136-137

Treatment
DEBRIDEMENT Epithelial debridement is an effective way to treat dendritic keratitis Infected epithelium is easy to remove with tightly wound cotton tip applicator. Adjunctive therapy with topical antiviral accelerates epithelial healing.
Vaughan & Asburys General Ophthalmology 16th Edition, 136-137

TREATMENT : DRUGS Antiviral medicines used in treatment of Herpes Simplex Virus

Treatment
Route Topical

Ocular Disease
Form 0.1% solution Frequency Action Hourly while Inhibits viral thymidine awake kinase, thymidylate kinase and DNA polymerase 5 times daily Every 2 hours while awake Inhibits viral DNA polymerase Inhibits viral thymidylate synthetase

Antiviral Idoxuridine

Vidarabine Trifluridine

Topical Topical

3% ointment 1% solution

Acyclovir

Topical Oral

3% 5 times daily Activated by viral ointment thymidine kinase to inhibit DNA polymerase 200/400/ 400 mg 5 Ophthalmology 2004, (2), 475-482 800 DT times daily
Ophthalmology 2004, 2; 475-482

Treatment
Trifluridine and acyclovir are much more effective in stromal disease than others. Idoxuridine and trifluridine are frequently associated with toxic reactions. Oral acyclovir may be useful in treatment of severe herpetic eye disease particularly in atopic individuals.

Vaughan & Asburys General Ophthalmology 16th Edition, 136-137

Treatment
Oral acyclovir : DOSAGE: For active treatment 400 mg five times daily in nonimmunocompromised patients. 800 mg five times daily in compromised and atopic patients. Prophylactic dosage in recurrent disease is 400 mg twice daily. Famciclovir or valacyclovir may also be used. Topical corticosteroids accelerate corneal thinning, increasing risk of corneal perforation.
Vaughan & Asburys General Ophthalmology 16th Edition, 136-137

Surgical treatment
Penetrating keratoplasty indicated for visual rehabilitation in patients with sever corneal scarring. Should not be undertaken until herpetic disease has been inactive for many months. Systemic antiviral agents should be used for several months after keratoplasty to cover use of topical steroids. Lamellar keratoplasty has advantage over penetrating keratoplasty of reduced potential for corneal graft rejection. General Ophthalmology 16th Edition, 136-137 Vaughan & Asburys

Varicella zoster viral keratitis (VZV)

Occurs in two forms: Primary ( varicella) Recurrent ( herpes zoster) Ocular manifestations are uncommon in varicella but common in ophthalmic zoster.
Vaughan & Asburys General Ophthalmology 16th Edition, 136-137

Varicella zoster viral keratitis (VZV)

Ocular manifestations Usual eye lesions are pocks on lids and lid margins. Keratitis occurs rarely. Epithelial keratitis with or without pseudodendrites occurs more rarely. Disciform keratitis with uveitis of varying duration has been reported.

Ophthalmic herpes zoster

Is accompanied by keratouveitis that varies in severity according to immune status of the patient. Children with zoster keratouveitis usually have benign disease, aged have severe and sometimes blinding disease. Corneal complications in ophthalmic zoster often occur if there is skin eruption in areas supplied by branches of the nasociliary nerve. Vaughan & Asburys General Ophthalmology 16th Edition, 136-137

Distinguishing features of dendrites associated with HSV versus VZV

Feature Overall Epithelium HSV Fine, lacy Linear defect with bared stroma, surrounded by edematous epithelial cells Base stains with fluorescein. Diseased border epithelial cells stain with rose bengal Frequent VZV Thick ropy Elevated, painted-on appearance

Staining

Minimal fluoroescein staining

Terminal bulbs

None

Treatment
Intravenous and oral acyclovir have been used successfully for treatment of herpes zoster ophthalmicus, particularly in immunocompromised patients. Oral dosage is 800 mg five times daily for 10-14 days. Therapy needs to be started within 72 hours after appearance of the rash.
Vaughan & Asburys General Ophthalmology 16th Edition, 136-137

Traumatic Eye Injuries

Corneal Foreign Bodies
May be removed with fine needle tip, eye spud, or eye burr after topical anesthetic applied Then treat as a corneal abrasion Deep corneal stoma FB or those in central visual axis require ophtho consult for removal Rust rings can be removed with eye burr, but not urgent Optho follow up in 24 hours for residual rust or deep stromal involvement

UVEITIS
ANTERIOR Autoimmune Infections Malignancy Others
POSTERIOR Viruses Bacteria Fungi Autoimmune Malignancy Unknown

UVEITIS
Inflammation of the uveal tract Symptoms blurred vision Photophobia Pain

UVEITIS
Inflammation of the uveal tract Signs Injection Flare Keratic precipitates Posterior synechias iris nodules

UVEITIS
Complications Anterior synechias Posterior synechias Cataract Glaucoma Macular edema

UVEITIS
Autoimmune
JRA Ankylosing spondylitis Ulcerative colitis Crohns disease Reiters syndrome Lens induced

UVEITIS
Infections
Syphilis Tuberculosis Herpes zoster Herpes simplex Adenovirus

UVEITIS
Malignancy
Retinoblastoma Leukemia Lymphoma Malignant melanoma

UVEITIS
Others
Idiopathic Traumatic RD Fuchs iridocyclitis Gout

UVEITIS
Posterior
CMV Toxoplasmosis Aids Herpes simplex Herpes zoster Candida

UVEITIS
Autoimmune
Behcets syndrome VKH syndrome Polyarteritis nodosa Sympathetic ophthalmia

UVEITIS
Malignancy
Malignant melanoma Leukemia Metastatic lesions Unknown Sarcoidosis

UVEITIS
TREATMENT
Steroids
topical local systemic

Cycloplegics Antimetabolites Analgesics

ENDOPHTHALMITIS
Peradangan bola mata yg melibatkan uvea dan retina, disertai dgn eksudat di vitreous, camera okuli anterior dan camera okuli posterior

Gejala
Nyeri yg hebat Pandangan kabur Mata merah

Pemeriksaan
Penurunan tajam penglihatan Injeksi konjungtiva Peradangan COA dan hypopion Funduskopi : nervus opticus dan retina tidak dapat dilihat dgn jelas krn adanya inflamasi vitreous

endophthalmitis

USG

Penanganan
Antibiotik fortified topikal tiap jam : cefazolin atau vancomycin, gentamycin atau tobramycin Antibiotika injeksi subconjunctiva Vitrectomy dan antibiotika injeksi intravitreal

 Vitrectomy diindikasikan pada pasien yang tidak menunjukkan kemajuan terapi dlm 48 72 jam atau pd pasien dgn infeksi berat dmn tajam penglihatan hanya persepsi cahaya. Vitrectomy bermanfaat utk mengeluarkan organisme,toksin dan enzim pada vitreous

PANOPHTHALMITIS
Inflamasi purulenta pada seluruh struktur bola mata termasuk kapsula Tenon

Gejala
Nyeri mata yg sgt berat dan nyeri kepala Hilangnya penglihatan Sangat berair Sekret purulen Mata sangat merah dan bengkak Demam malaise

Tanda
Kelopak mata oedem dan hiperemis Bola mata sedikit proptosis, pergerakan bola mata terbatas & nyeri Chemosis konjungtiva Kornea keruh COA berisi pus seluruhnya Tajam penglihatan hilang (NLP) TIO menigkat perforasi

panophthalmitis

Penanganan
Anti-inflamasi dan analgetik Antibiotika spektrum luas eviscerasi

eviscerasi