psss - red eyes with visual loss

8/12/2019 PSSS - Red Eyes With Visual Loss

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Red Eyes with Visual Loss

Krisnald M. N.

I11109027


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Acute Angle-Closure Glaucoma

Acute angle closure ("acute glaucoma") occurs

when sufficient iris bomb develops to cause

occlusion of the anterior chamber angle by

the peripheral iris.


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Classification from Natural History

PRIMARY ANGLE-CLOSURE SUSPECT (PACS)

An eye in which appositional contact between the peripheral irisand posterior trabecular meshwork is presentor consideredpossible, in the absenceof elevatedIOP, PAS, disc, or VFchanges.

Epidemiologically, this has been defined as an angle in which 180-

270 of the posterior trabecular meshwork cannot be seengonioscopically

PRIMARY ANGLE CLOSURE (PAC)

PACSwith statistically raised IOP and/or primary PAS, without disc

or VF changes

PRIMARY ANGLE CLOSURE GLAUCOMA (PACG)

PACwith glaucomatous optic neuropathyand corresponding VFloss

IOP, intraocular pressure; PAS, peripheral anterior synechiae; VF, visual field.


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Risk Factors

Demographic factors:

a. Age (> 60 years old)

b. Female sex

c. Chinese ethnic origin

d. Family history

(especially first-degree

relatives, becauseocular anatomic

features are inherited)

Precipitating factors:

a. Dim illumination (including extremes of

temperature causing people to stay

indoors)

b. Drugs

Anticholinergic agents [topical, e.g.,atropine, cyclopentolate, and tropicamide,

or systemic, e.g., antihistamine,

antipsychotic (especially antidepressants),

anti-parkinsonian, atropine, and

gastrointestinal spasmolytic drugs]

Adrenergic agents (topical, e.g.,

epinephrine and phenylephrine, or

systemic, e.g., vasoconstrictors, central

nervous system stimulants,

bronchodilators, appetite depressants,

and hallucinogenic agents)

c. Emotional stress (possibly due to mydriasis

secondary to increased sympathetic tone)


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Clinical Findings

Pain (usually sudden in

onset)

blurred vision

Photophobia

colored haloes around

lights

Headache

nausea and vomiting.

markedly increased

intraocular pressure

(IOP > 40 mmHg)

shallow anteriorchamber

a steamy cornea

a fixed, moderatelydilated pupil

ciliary injection.


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Differential Diagnosis

Secondary ACG

Other causes of headache (e.g., migraine or

cluster headache).


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Treatment

Goal: Decreasing IOP immediately, relievingpain, and preparing patient to surgery

Pilocarpine 2% every one minute in 5 minutes,

then every one hour in a day Asetazolamide 500 mg IV, then 250 tablet

every 4 hour when nausea is gone

Retrobulbar xylocain 2%decreasesaqueous humour production + anesthesy

Morphine 50 mg scpatient in extreme pain


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Treatment (2)

After IOP decreased, eye pain and injection

gone, and preparation for surgery is ready:

SurgeryPeripheral Iridectomy

Alternative: trabeculetomy


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Uveitis

The term "uveitis" denotes inflammation of

the iris (iritis, iridocyclitis), ciliary body

(intermediate uveitis, cyclitis, peripheral

uveitis, or pars planitis), or choroid

(choroiditis).

Uveitis usually affects people 2050 years of

age and accounts for 10

20% of cases of legalblindness in developed countries.


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Anterior Uveitis

Anterior uveitis is most common and is usually

unilateral and acute in onset

Clinical findings: typical symptoms include

pain, photophobia, and blurred vision.

Examination usually reveals circumcorneal

redness with minimal palpebral conjunctival

injection or discharge.

Etiology: granuloma or non-granuloma


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Etiology

Granulomatous

Sarcoiditis

Syphillis

Tuberculosis

Virus

Fungal (Histoplasmosis)

Parasite (Toxoplasmosis)

Nongranulomatous

Acute Trauma

Chronic Diarrhea

Reiter disease

Herpes simplex

Bechet Syndrome

Posner Schlosman Syndrome

After surgery

Adenovirus infection

Parotitis

Influenza Chlamidia

Chronic Rheumatoid arthritis

Fuchs heterochromic iridocyclitis


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Symptoms

Granulomatous

No pain

Slight photophobia

Blurred vision

Big keratic precipitate (mutton

fat)

Koeppe nodules (cell

accumulation on the iris

margin)

Busacca nodules (cell

accumulation on iris surface)

Nongranulomatous

Pain

Marked photophobia

Blurred vision

Small keratic precipitate

Miosis

Relaps usually occur


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Differential Diagnosis

Posterior uveitis with spillover into the

anterior chamber

Conjunctivitis

Keratitis

Acute angle closure glaucoma

Posner

Schlossman syndrome Drug-induced uveitis (e.g., rifabutin, cidofovir,

sulfonamides, pamidronate).


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Vogh-Koyanagi-Harada Syndrome

This disease damaged uvea, retina, and

meningen

Unknown cause; usually affect people in

second decade of life


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Treatment

Systemic and topical steroid

Cycloplegic

Consult to neurologist for neurologicalproblems


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Endoftalmitis

Severe inflammation of the inner eye

Supurative inflammation in eye cavity and the

structure of the eye

Exogenous endoftalmitis: caused by eye

trauma or secondary infection after surgery

Endogenous endoftalmitis: caused by

hematogenous spreading of microorganism

from other site of infection in the body


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Treatment

Bacterial causes: periocular or subconjunctiva

antibiotics

Fungal causes: amphotericin B (150

microgram subconjunctiva)

Cycloplegic 3 times a day

Corticosteroid can be chosen


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Sympathetic Ophthalmia

Sympathetic ophthalmia is a rare but devastating

bilateral granulomatous uveitis that comes on 10

days to many years following a perforating eye

injury. Ninety percent of cases occur within 1 year after

injury.

The cause is not known, but the disease isprobably related to hypersensitivity to some

element of the pigment-bearing cells in the uvea.


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Treatment

Enucleation within 10 days after injury.

The sympathizing eye should be treated

aggressively with local or systemic

corticosteroids.

Other immunosuppressive agents, such as

cyclosporine, cyclophosphamide, and

chlorambucil, may be required as well


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Glaucomatocyclitic Crisis

(Posner-Schlossman Syndrome)

Glaucomatocyclitic crisis is a self-limited

relapsing disease, marked by high IOP and

slight anterior chamber inflammation


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Clinical Findings

noninjected eye with a slightly dilated pupil,

minimal anterior chamber cells

occasional, small, nonpigmented keratic precipitates

inferiorly on the corneal endothelium. Intraocular pressures range from 40 to 60 mmHg

despite a lack of angle closure or other morphologicalchanges of the anterior chamber angle.

The ocular hypertensive phase is often associated withthe episodes of inflammation and is easily managed.


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Etiology

Unknown

Suspected causes are immunological and

infectious etiologies. Such as CMV and herpes

virus


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Treatment

Prednisolone acetate 1% 1-4 times a day

(topical)

Timolol topical 0,25-0,5% 1-2 times a day or

dorzolamide 2% 1-3 times a day

Oral acetazolamide 250 mg 2-3 times a day.


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Clinical Findings

Decreased visual acuity

Pain

Exophtalmos

Lid edema

Chemotic conjunctiva

Steamy cornea

Hypopion

Leukocoria


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Treatment

High-dose antibiotics

Very severe symptoms: evisceration


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What is the treatment of bacterial keratitis for

positive Gram bacteria and negative Gram

bacteria

Gentamicin (negative)

Bacitrasin, cepalosporin (positive)

Lagophtalmos (kelopak mata tidak menutup

sempurna: N III (occulomotorius)

psss - red eyes with visual loss

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