Dr. Masitha Dewi Sari,SpM CONJUNGTIVITIS 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 Infective conjunctivitis : bacterial, chlamydial, viral, fungi, spirochaetal, protozoal, paracitic,etc, Allergic conjunctivitis Irritative conjunctivitis Keratocinjunctivitis associated with diseases of skin and mucous membrane Traumatic conjunctivitis Keratoconjunctivitis of unknown etiology
Viral Bacteri Chlamydial Allergic gatal minimal hebat hyperemia Menye luruh Menyeluruh (merah muda) lakrimasi sedang Sedang sekret Paling Hebat nodule sering jarang Sering pd inclusion Tidak ada Scraping,pewarnaan monosit Bacteri PMN PMN < plasma sel Eosinofil demam kadang
Gejala-gejala umum Conjunctivitis Merasa seperti ada benda asing Merasa panas (burning/scratching sensation) Perasaan mata bengkak (fullness around the eye) Gatal Fotofobia (jika terkena kornea)
Tanda-tanda umum Conjunctivitis 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 work-up 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 beri steroid topical Artificial tears
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
KERATITIS
INFLAMASI PADA KORNEA Peradangan pada kornea (keratitis) dengan karakteristik oedem kornea, infiltrasi seluler, dan kongesti siliar
Klasifikasi topographical (morphological) Ulcerative keratitis (corneal ulcer) 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 Superficial keratitis (a) diffuse superficial keratitis (b) superficial punctate keratitis 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 conjunctivitis akut Glaukoma akut Keratitis 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 focet’s cicatrix tidak keruh / transparan dan permukaannya datar (mata serangga) Nb : tidak terbentuk jaringan ikat, tapi cornea masuk ke dalam.
BERDASARKAN KETEBALAN CICATRIX DIBAGI : Nebula : kekeruhan ringan, dapat dilihat dengan lup Macula : kekeruhan lebih jelas dapat dilihat dengan mata telanjang 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 High Virulence of infecting organism Resistance of the tissues, which is low Dacryocystitis Ocular trauma Old, debilitated or alcoholic 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 Trauma outdoor/ or the one which involves plant matter (including contact lenses) 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 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 Daily debridement with spatula/ blade every 24 – 48 hours Surgical treatment is required in approximately 1/3rd cases of fungal keratitis due to failure of medical treatment or perforation 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: Primary 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 Cell body in transport along enters nucleus trigeminal ganglion nerve axon at neuron (Persists indefinitely in a latent state) 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 & Asbury’s 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 patients. Vaughan & Asbury’s General Ophthalmology 16th Edition, 136
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 & Asbury’s 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 & Asbury’s 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 & Asbury’s General Ophthalmology 16th Edition, 136-137
Treatment TREATMENT : DRUGS 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 & Asbury’s 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 & Asbury’s 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. Vaughan & Asbury’s General Ophthalmology 16th Edition, 136-137
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 & Asbury’s 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 & Asbury’s General Ophthalmology 16th Edition, 136-137
Distinguishing features of dendrites associated with HSV versus VZV Overall Fine, lacy Thick ropy Epithelium Linear defect with bared stroma, surrounded by edematous epithelial cells Elevated, painted-on appearance Staining Base stains with fluorescein. Diseased border epithelial cells stain with rose bengal Minimal fluoroescein staining Terminal bulbs Frequent 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 & Asbury’s 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 Crohn’s disease Reiter’s syndrome Lens induced
UVEITIS Infections Syphilis Tuberculosis Herpes zoster Herpes simplex Adenovirus
UVEITIS Malignancy Retinoblastoma Leukemia Lymphoma Malignant melanoma
UVEITIS Others Idiopathic Traumatic RD Fuch’s iridocyclitis Gout
UVEITIS Posterior CMV Toxoplasmosis Aids Herpes simplex Herpes zoster Candida
UVEITIS Autoimmune Behcet’s syndrome VKH syndrome Polyarteritis nodosa Sympathetic ophthalmia
UVEITIS Malignancy Malignant melanoma Leukemia Metastatic lesions Unknown Sarcoidosis
UVEITIS TREATMENT Steroids Cycloplegics Antimetabolites Analgesics 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
TERIMA KASIH