11/19/2020

1

Inflammatory and infectious conditions of the eye

Content by Stephanie Stokes‐Buzzelli, MD

Presentation by Nikhil Goyal, MD representing 🚁

November 19, 2020

Objectives

• Cover topics in the Model of EM not previously covered under the Trauma and Red Eye didactics

• External eye

• Posterior pole

• Orbit

• Win Friends and Impress Ophtho People

1

2

11/19/2020

2

External eye

Blepharitis

• Chronic inflammation of the eyelids

3

4

11/19/2020

3

• Anterior Blepharitis: inflammation at base of eyelash follicles (less common)

• Posterior Blepharitis: meibomiangland dysfunction, leads to inflammation

• Conditions associated• Acne rosacea• Parkinson's disease• Seborrheic dermatitis

Blepharitis ‐ presentation

• Chronic eyelid irritation with intermittent exacerbations

• Red, swollen, itchy eyelids• Crusting/matting of eyelashes in the morning

• Flaking and scaling of eyelid skin• Excessive tearing• Photophobia and burning eye pain• Blurred vision: occurs with corneal involvement (infiltrates; punctate erosions)

• Chronic inflammation progresses to ectropion, entropion, madarosis (loss of eyelashes), poliosis (whitening of lashes), trichiasis (misdirected lashes)

5

6

11/19/2020

4

Blepharitis ‐ Treatment

• Frequent warm compresses• Gentle eyelid scrubs

• warm water/baby shampoo/hand towel to remove debris (lid hygiene)• avoid vigorous scrubbing

• Topical Erythromycin ointment QID x 7‐14 days or Bacitracin

• Ophthalmology referral for further management• Severe inflammation ‐ combine with steroids Sulfacetamide ointment QID (gradually discontinue after 7 day course)

• Oral antibiotics for severe, recurrent cases• Tetracycline 1‐2g divided BID‐QID for 1‐2 months• Doxycyline 100‐200mg divided BID for 1‐2 months

Dacryostenosis

• Narrowing of the nasolacrimal duct which drains tears away leading to excessive tearing (epiphoria) or infections of the lacrimal sac (dacryocystitis) 

• Congenital • 3‐12‐week‐old infants• Causes tearing and persistent crusting of eyes• Gentle massage, warm compresses• Typically spontaneously resolves by 9 months

• Acquired• Age related narrowing• Trauma (scarring), inflammatory conditions (sarcoid)• May require probing or surgery

8

9

11/19/2020

5

Dacryocystitis

• Inflammation and infection of the nasolacrimal sac as a result of obstruction

• Located in the medial canthal region

http://medical‐dictionary.thefreedictionary.com/lacrimal+apparatus

DacryocystitisSymptoms: Acute onset of pain, redness, and edema of lacrimal sac (innermost aspect of lower eyelid)

• Purulent discharge from puncta• Excessive tearing due to obstruction of outflow of tears

Etiology: S. aureus, S. pneumoniae

Complications:• Conjunctivitis, preseptal cellulitis, lacrimal sac abscess• Extension into orbit causing orbital cellulitis, meningitis

or cavernous sinus thrombosis• Check eye movements and for proptosis

10

11

11/19/2020

6

Dacryocystitis 

• Consult ophthalmology

• Treatment• Amoxicillin/clavulanate 500mg TID x 7‐10 days

• Ampicillin/sulbactam 1.5g IV q6 for severe infections

• Warm Compresses +/‐ topical antibiotics (polytrim, erythromycin) in addition too, but never alone

Chronic Dacryocystitis

• Chronic nasolacrimal duct obstruction

• Etiology: • Recurrent infection, foreign body, structural

abnormality, mucocele development

• Symptoms• Slow onset of epiphora, medial canthal

fullness and tenderness• Intermittent, milky discharge from puncta

12

13

11/19/2020

7

Dacryocystitis

• Dacryocystocele• enlargement of non-inflamed larcimal sac in infant

• Gray-blue in color

• May progress to...

• Congenital Dacryocystitis (inflamed larcimal sac)• Highest morbidity/mortality due to poor formation of

orbital septum• Progression to orbital cellulitis, brain abscess,

meningitis, sepsis, death

Lacrimal system disorders

• Canaliculitis: • Inflammation of the canaliculi secondary to obstruction

• Symptoms: tearing, red eye (primarily nasal aspect of lower or upper eyelid)

• Treatment• Obstruction needs to be cultured and removed (ophthalmology) and topical antibiotic drops (polytrim, moxifloxacin)

https://www.studyblue.com/notes/note/n/2‐eyelid/deck/8400451

14

15

11/19/2020

8

Chalazion vs Hordeolum (stye)

Chalazion

• Chronic granulomatous inflammation• Due to blockage of meibomian gland

• Nontender, nodular lesion

• Often present for weeks-months• Less likely to be at lid margin• Larger lesions - cause visual disturbances

by pressing on the cornea

• Acute infection of eyelid gland• Often Staphylococcus aureus infection

• Tender lump at lid margin, which may become red over the course of a few days-week

• External Hordeolum ("Stye")• Involvement of zeis glands

• Internal Hordeolum• Involvement of meibomian glands

Hordeolum (stye)

16

17

11/19/2020

9

Treatment

• Hot (not burning) compresses• 10-15 min, QID (self-limiting)

• Treat underlying blepharoconjunctivitis / persistent infection

• Symptomatic patient or lesion unresponsive to initial treatment arrange ophthalmology follow-up

• Incision and drainage if large or refractory to conservative management

• Antibiotics indicated if infection spreads (preseptal infection)

Preseptal vs Postseptal(Orbital) Cellulitis

• Determined by relation of infection to orbital septum

• Thin tissue that divides eyelid from eye socket

18

20

11/19/2020

10

Preseptal cellulitis

• Infection/inflammation anterior to orbital septum

• Often < 5yo

• Etiology:• Direct inoculation (trauma, insect bite)

• Hematogenous (URI, middle ear infection) ‐ less common if immunized

• Micro: s. aureus, s. epidermidis and strep pyogenes, H. flu• Immunocompromised: fungi

Orbital cellulitis

• Infection/inflammation of soft tissue behind the orbital septum

• Average age 8 • Etiology

• URI's• Sinusitis (ethmoid sinus medially through lamina papyracea)• Extension of preseptal infection or bacteremia

• Micro: often based on age• < 9yo – 1 organism• > 9yo – polymicrobial (aerobic and anaerobic bacteria)• Examples: s. aureus (MRSA), step anginosus/pyogenes/pneumoniae, h influenzae B (less common with vaccine)

• Immunocompromised/diabetes: fungus (Mucor or aspergillus)

21

22

11/19/2020

11

Orbital Cellulitis• OPHTHALMOLOGIC EMERGENCY• Signs/symptoms

• Erythema and edema to eyelids, fever, leukocytosis,• Proptosis (bulging of eyes), pain with eye movements, ophthalmoplegia (lack of eye movement)

• Optic nerve compromised = decreased vision, RAPD

• Exam: check vision, eye movements and IOP, look in mouth/nares for black eschar

• CBC, blood cultures• ICT orbit if concerned for orbital involvement• Consult ophthalmology

• Admit for IV antibiotics• ~10% may require surgery to drain abscess

https://radiopaedia.org/articles/subperiosteal‐abscess‐of‐the‐orbit

POCUS for Orbital Cellulitis

• Not well‐studied

• Findings: • Nonspecific thickening of orbital wall

• Edema of the orbit

23

24

11/19/2020

12

Sign Preseptal Cellulitis Orbital Cellulitis

Fever + +

Lid edema and chemosis Moderate‐severe Severe

Proptosis ‐ +

Eye motility Normal Decreased

Pain with eye movement ‐ +

Vision Normal Diminished/diplopia

RAPD ‐ Possible

Leukocytosis Min‐moderate Yes

Additional findings Skin infection Sinusitis, dental abscess

https://pedclerk.bsd.uchicago.edu/page/periorbital‐and‐orbital‐cellulitis

Posterior Segment

25

26

11/19/2020

13

Endophthalmitis

• EMERGENCY!!!!

• Most often caused by bacterial or fungal infection that enter the eye during surgery or a penetrating trauma

• May have hematogenous spread in immunocompromised

• Symptoms• increasing redness

• swelling around the eye

• light sensitivity

• severe pain

• loss of vision

Endophthalmitis• Exam findings:

• Hypopyon (layered white in AC)• Injection (redness to conjunctiva)• Swollen eyelids and conjunctiva• Corneal haze (edema)

• Call ophthalmology immediately• Treatment: culture vitreous/aqueous fluid (vitreous tap) and inject antibiotics into vitreous cavity + possible surgery (vitrectomy)

• If no source known, systemic work‐up indicated• Blood cultures, possible imaging

https://www.eyeworld.org/article‐ascrs‐cataract‐clinical‐committee‐publishes‐endophthalmitis‐white‐paper

27

28

11/19/2020

14

Uveitis• Anterior Uveitis

• Anterior uveitis occurs in the front of the eye. It is the most common form of uveitis, predominantly occurring in young and middle‐aged people. Many cases occur in healthy people and may only affect one eye but some are associated with rheumatologic, skin, gastrointestinal, lung and infectious diseases.

• Intermediate Uveitis • Intermediate uveitis is commonly seen in young adults. The center of the inflammation often appears in the vitreous. It has been linked to several disorders including, sarcoidosis and multiple sclerosis.

• Posterior Uveitis• Pan‐Uveitis

• Pan‐uveitis is a term used when all three major parts of the eye are affected by inflammation. Behcet’s disease is one of the most well‐known forms of pan‐uveitis and it greatly damages the retina.

• Intermediate, posterior, and pan‐uveitis are the most severe and highly recurrent forms of uveitis. They often cause blindness if left untreated

Uveitis

• The signs and symptoms of uveitis depend on the type of inflammation. 

• Acute anterior uveitis may occur in one or both eyes and in adults is characterized by eye pain, blurred vision, sensitivity to light, a small pupil, and redness. 

• Intermediate uveitis causes blurred vision and floaters. Usually it is not associated with pain.

• Posterior uveitis can produce vision loss. This type of uveitis can only be detected during an eye examination

29

30

11/19/2020

15

Posterior Uveitis

• Inflammation to posterior segment (choroid, retina)• Causes

• An attack from the body’s own immune system (autoimmunity).• Infections or tumors occurring within the eye or in other parts of the body. • Bruises to the eye. • Toxins that may penetrate the eye• In many cases the cause is unknown

• Diseases associated (HIV, MS, Sarcoid, Colitis, RA, TB, and more)• Symptoms: blurred vision and floaters

• Pain, redness and photophobia (light sensitivity) are usually absent unless anterior inflammation is also present

• Treatment can include oral and intraocular injections of antibiotics and steroids, immunosuppressants

Optic neuritis

• Inflammation that damages the optic nerve, a bundle of nerve fibers that transmits visual information from your eye to your brain

• Epidemiology• Age 18‐40 yr. Mean age 30‐35 yr

• Incidence:  6.4/ 100,000• Female (66%)

• Highest in higher latitudes; lower near equator

32

33

11/19/2020

16

Optic neuritis Possible Etiology

• Viral • Autoimmune mediated

• Multiple Sclerosis (MS)• Neuromyelitis Optica

• Chronic diseases• Sarcoid• SLE• IBD

• Infectious• Syphilis, Lyme disease, cat-scratch fever• Herpes, measles, mumps, West Nile Virus

• Drug induced • Chloramphenicol• Ethambutol• Quinine

Optic NeuritisSymptoms:

• Pain:• worsened by eye movement. 

• dull ache behind the eye.

• Vision loss in one eye:• temporary reduction in vision, but the extent of loss varies, can be permanent

• develops over hours or days and improves over several weeks to months.

• Visual field loss: any pattern.

• Loss of color vision: colors appear less vivid than normal.

• Flashing lights. flickering lights with eye movements.

• Signs: RAPD, decreased visual acuity and color vision• 33% will have optic nerve swelling

• 66% no optic nerve swelling = retrobulbar optic neuritis

http://www.nanosweb.org/files/Patient%20Brochures/English/OpticNeuritis_English.pdf

34

35

11/19/2020

17

Optic Neuritis

• Diagnosis• Consult neurology and ophthalmology• MRI of brain and orbits with gadolinium and fat suppression

• Confirms of the diagnosis of acute demyelinating optic neuritis • Prognosticates the risk of developing MS

• Lumbar puncture• Not an essential test• 60 ‐ 80 % of patients with acute optic neuritis have nonspecific abnormalities (CSF) including lymphocytes (10 to 100) and elevated protein

• Treatment: Typically improves spontaneously• IV solumedrol – May speed vision recovery and decrease risk of MS• Plasma Exchange for steroid failure• Risk of recurrent optic neuritis generally associated w MS

https://doi.org/10.14253/kjcn.2013.15.1.13

Papilledema

• Optic disc swelling due to increased intracranial pressure

• Usually bilateral and can occur over a period of hours to weeks

• Etiologies include tumors, hydrocephalus, idiopathic intracranial hypertension, subdural/epidural hematoma, subarachnoid hemorrhage, AVM, brain abscess, meningitis, encephalitis, cerebral venous sinus thrombosis

https://en.wikipedia.org/wiki/Papilledema

36

38

11/19/2020

18

Papilledema• Symptoms

• Headache – positional (worse when laying, waking, straining, bending)• +/‐ nausea and vomiting

• Transient blurred/loss of vision (seconds)• Often precipitated by change in position

• Double vision• Pulsatile tinnitus – rhythmic/pulsating whoosh

• Signs• Disc swelling • Venous engorgement (typically the first sign in papilledema)• Absent venous pulsation • Hemorrhages adjacent to the optic disc• Blurring of optic margins

Treatment

Depends largely on the underlying cause• Consults to ophthalmology and neurology• Diagnostics of MRI w/ gadolinium + MRV, CT/CTV, Lumbar puncture w/ CSF analysis and opening pressure

• Medications may include diuretics (acetozolamide), steroids

• Surgical procedures• Lifestyle modifications

39

40

11/19/2020

19

Questions?

41