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Head and Eyes
Dr. Megan Gonzales ND, EAMP
SIOM Western Clinical Sciences Fall 2012
External Eye Anatomy
Internal Eye Anatomy
Eyelid and Lacrimal
Ducts
Blepharitis
Exopthalmos
Ptosis
Orbital Cellulitis
Dacrocystitis
Chalazion
Stye
Blepharitis
Blepharitis is from an overgrowth of bacteria
and may be linked to repeated styes and
chalazia. You are more likely to develop this
condition if you have seborrheic dermatitis of
the face or scalp, rosacea, lice, and allergies.
Exophthalmos
Exophthalmos
Exophthalmos (also called exophthalmia or
proptosis) is a bulging of the eye anteriorly out
of the orbit. Exophthalmos can be either
bilateral (as is often seen in Graves' disease)
or unilateral (as is often seen in an orbital
tumor).
other causes - infection, parasitic cysts, pseudoexophthalmos
related to paralysis of the extraocular muscles
Signs and symptoms: bulging eyeballs, with diplopia,
extraocular muscle edema causes malallignment of the eyes.
Other symptoms are related to systemic cause of
exophthalmos (hyperthyroidism, tumor, cavernous sinus
thrombosis)
Diagnosis: usually based on obvious sign of bulging eyes, CT
or MRI, culture of any discharge, Bx of orbital tissue
Treatment: depends on underlying cause of dysfunction. Cold
compress for trauma, treatment with antimicrobials, surgery,
partial or total thyroidectomy
Ptosis
Ptosis
PTOSIS: is also called "drooping eyelid." It is
caused by weakness of the muscle
responsible for raising the eyelid, damage to
the nerves that control those muscles, or
looseness of the skin of the upper eyelids.
can be congenital either genetic or through a trait where the levator palpebrae
muscles fail to fully develop
aquired: advanced age - from cataract surgery, eyelid edema or other mechanisms
leading to a heavy eyelid
muscular dystrophy or myasthenia gravis where muscles are malfunctional
paralysis
nutritional factors such as thiamine deficiency in chronic alcoholism and other states
of malnutrition
can lead to lazy eye in children
diagnosis is based on physical exam and finding the underlying condition causing
ptosis
may not require treatment but will be surgically correct if it interferes with vision. Can
also be prescribed special glasses that contain and eyelid “crutch”
Orbital Cellulitis
Orbital Cellulitis
Orbital cellulitis is an acute infection of the
tissues immediately surrounding the eye,
including the eyelids, eyebrow, and cheek.
related to any type of infection from direct inoculation via the blood
stream or near-by structures eg. sinuses. Also surgery, insect or
animal bites, and foreign body trauma
can cause cavernous sinus thromosis, hearing loss, septicemia,
meningitis, optic nerve damage
usually unilateral eyelid edema, reddened eyelids, hyperemic
orbital tissue, extreme orbital pain, impaired eye movement,
purulent discharge. Associated: fever, chills, malaise according to
the cause of cellulitis.
Diagnosis is based on clinical picture, CT and MRI of sinuses and
brain, culture and sensitivity of discharge or wounds.
Treatment: antimicrobials both systemic and topical, moist
compresses, bed rest and fluids, I & D if abscess is present
Dacrocystitis
Dacryocystitis is an infection of the
nasolacrimal sac, frequently caused by
nasolacrimal duct obstruction. The term
derives from the Greek dákryon (tear),[1] cyst
(sac), and -itis (inflammation). It causes pain,
redness, and swelling over the inner aspect of
the lower eyelid. It is most commonly caused
by Staphylococcus aureus and Streptococcus
pneumoniae. The most common complication
is corneal ulceration, frequently in association
with S. pneumoniae.
can lead to orbital cellulitis
it is extremely painful and presents with constant tearing,
there can be a sensation of pain or pressure over the
nasolacrimal sac and applied pressure may or may not
cause discharge from the punctum
clinical picture, CBC and culture and sensitivity of any
discharge is used to determine type of infection, in infants
if it is due to duct atresia and x-ray after radiopaque
injection shows the location
treatment: warm compresses with topical and systemic
antimicrobials, surgery can also be performed.
Chalazion
A chalazion (a more intense stye) is a small
lump in the eyelid caused by obstruction of an
oil producing or meibomian gland. Chalazia
may occur in the upper or lower lids, causing
redness, swelling and soreness in some
cases.
can lead to astigmatism
diagnosis: visual exam and palpation of the
eyelid. A Bx should be performed if the
chalazion is persistent or recurring to rule out
meibomian cancer.
Treatment: warm compresses for 10-15
minutes up to 4 times a day. Incision and
curettage may be necessary. After surgery
antibiotic topicals may be prescribed but
otherwise are not useful.
Stye
Hordeolum AKA Stye
Stye (hordeolum) A stye is caused by bacteria from the
skin that get into the oil glands in the eyelids that provide
lubrication to the tear film. Styes are similar to common
acne pimples that occur elsewhere on the skin. You may
have more than one stye at the same time.
Styes usually develop over a few days and may drain and
heal on their own. A stye can become a chalazion -- this is
when an inflamed oil gland becomes fully blocked. If a
chalazion gets large enough, it can cause trouble with
your vision.
Conjunctival Disorders
inclusion conjunctivitis
conjunctivitis
trachoma
Inclusion Conjunctivitis
Inclusion Conjunctivitis
caused by Chlamydia trachomatis an obligate intracellular
organism, can be a cause of “ophthalmia neonatorum” due to
infection while passing through the birth canal.
usually occurs in adults 18-30 years of age
can cause otitis media and blindness.
in neonates the first signs are reddened eyelids and slight
discharge. A psuedomembrane can form which causes conjunctival
scarring.
In adults follicles appear inside the lower eyelids. It can persist for
weeks or months with superficial corneal involvement.
Inclusion Conjunctivitis
Diagnosis is based on clinical features and
history of sexual behavior including contact
with an infected individual, a conjunctival
scraping will be performed to check for the
specific organism.
A systemic anti-microbial is prescribed
generally erythromycin and neonates are
treated with anti-microbial ointment to the
eyelids at 1 hour post birth.
Conjunctivitis
Conjunctivitis, commonly known as pink eye, is an
infection of the conjunctiva (the outer-most layer of
the eye that covers the sclera). The three most
common types of conjunctivitis are: viral, allergic,
and bacterial. Each requires different treatments.
With the exception of the allergic type, conjunctivitis
is typically contagious and self-limiting.
Common bacterial causes: Staph aureus, Neisseria
gonorrhoeae
Common viral causes: adenoviruses, herpes
simplex type 1
complications include: corneal infiltrates, reinfection and eye loss
hyperemia of the conjunctiva with tearing and sometimes discharge, pain
and photophobia. It often begins in one eye but spreads quickly to the
other. Acute bacterial conjunctivitis lasts about 2 weeks, viral
conjunctivitis has little to no exudate and can produce a severe disabling
disease or be 2-3 weeks in course.
Diagnosis -symptoms, stained conjunctival scrapings revealing
lymphocytes due to viruses, neutrophils with a bacterial infection and
eosinophils when allergens are the culprit.
Treatment: application of broad-spectrum anti-biotics, prevention of a
secondary infection with viral infections. The most important thing is to
prevent spread of the disease.
As Neisseria gonorrhoeae can be an infective agent diagnosis is
important and the health care provider must report the infection!
Trachoma
Trachoma
the most common cause of preventable blindness in less
developed nations
a form of chronic keratoconjunctivitis, may have a systemic
symptomatic picture
it is self limiting but permanently damages the cornea and
conjunctiva due to scarring, the resulting secondary infections
can cause blindness it is therefore important to diagnose and
treat the condition early
this is a result of an infection from Chlamydia trachomatis gram negative obligate intracellular bacterium. Transmitted
eye-to-eye by flies and gnats or hand-to-eye contact.
it is prevalent in Africa, Latin America and Asia primarily in children.
Can lead to conjunctival scarring and corneal scarring, eyelid deformities
and loss of vision
it begins with a mild-looking bacterial conjunctivitis. After 1 month
untreated the conjunctival follicles become enlarged and yellow and gray.
At this time small blood vessels invade the cornea and upper lid.
Contracture of the eyelid leads to entropion (the eyelids turn in and
eyelashes scratch the cornea)
Diagnosis is made based on symptoms and signs confirmed with a
special stain detecting chlamydia
Treatment requires topical and systemic antibiotic medications with
erythromycin, doxycycline or sulfonamides and surgery for the entropion.
Entropion
Corneal Disorders
Keratitis
Corneal Abrasion
Corneal ulcer
Keratitis
Keratitis
inflammation of the cornea it may result from bacterial, fungal
or viral infections and can lead to blindness
commonly caused by the herpes simplex virus type 1.
Bacterial infections can result due to infection of a corneal
abrasion.
can cause blindness and corneal scarring and perforation
it is usually unilateral, presenting with decreased vision and
discomfort to acute pain and tearing with photophobia.
the corneal light reflexes may be distorted when examined
with a penlight.
it is diagnosed by patient history - a recent
URI with cold sores and eye irritation after
wearing contacts.
Treatment - if due to herpes antiviral drops ,
ointment or oral acyclovir is prescribed.
Bacterial infections require antibacterial drops
given every half hour for the first 48 hours.
Corneal Abrasion
Corneal Abrasions
a scratch on the epithelium of the cornea, usually
due to foreign body under the eyelid. They happen
in people who don’t wear protective eye coverings
in high risk fields or when people fall asleep with
contacts in. Can also be due to accidental dust,
dirt or grit. The most common cause of
ophthalmologic EMERGENT hospital visits in the
US.
Can cause corneal erosion, ulceration or
permanent vision loss
causes erythema, increased tearing, discomfort on
blinking, feeling of “something in the eye”, pain
disproportionate to the size of injury secondary to
high innervation from the trigeminal nerve.
Diagnosis is made based on history of eye trauma or
prolonged use of contacts and symptoms of an
abrasion. An ophthamologist will use a stain and
special light to discern scratches.
Treatment: topical anesthetics, removal of foreign
body, antibiotic eye drops, a pressure patch to
relieve pain on blinking, discontinued use of
contacts while healing.
Corneal Ulcer
Corneal Ulcers
a major cause of blindness worldwide. They produce
scarring or perforation. Ulcers may occur anywhere but
are most commonly found marginally. They require
treatment within hours to prevent visual impairment.
Usually due to a variety of infective agents. Commonly:
Staph aureus, Pseudomonas aeruginosa, Herpes
simplex type 1, varicella-zoster, Candida and
Cephalosporium (bacterial, viral and fungal).
Can cause corneal scarring, loss of the eye, loss of
vision
begins with pain that is worse on blinking, photophobia
and increased tearing. Eventually a central ulceration will
cause blurred vision. The eye may be injected and
purulent discharge may be present.
Diagnosis is based on history of trauma or over use of
contact lenses. Use of a dye to show the ulcer confirms
diagnosis.
Treatment: PROMPT is NECESSARY TO SAVE VISION.
Broad spectrum antimicrobial drops are used. If due to
bacterial infection a patch SHOULD NOT be used
because it generates an even better growth environment.
Analgesics and observation for possible development of
secondary glaucoma.
Uveal tract, Retinal, Lens
Disorders
uveitis
retinal detachment
vascular retinopathies
age-related macular degeneraton
cataract
retinitis pigmentosa
Uveitis
Uveitis is swelling and irritation of the uvea,
the middle layer of the eye. The uvea provides
most of the blood supply to the retina.
Uveal Tract
Uveitis
usually idiopathic but can be the result of allergies, bacteria,
viruses, fungi, chemicals, trauma and even surgery.
can cause cataracts, glaucoma, retinal detachment, blindness
moderate to severe unilateral eye pain, severe injection,
tearing, small pupil non-reactive to light, blurred vision and
sometimes produces deposits left on the back of the cornea.
Onset is acute or insidious.
Diagnosis is made with slit lamp examination.
Treatment: is vigorous and prompt. One must ascertain the
cause. For severe cases oral corticosteroids are prescribed.
Retinal Detachment
A retinal detachment occurs when the retina’s
sensory and pigment layers separate.
Because it can cause devastating damage to
the vision if left untreated, retinal detachment
is considered an ocular emergency that
requires immediate medical attention and
surgery. It is a problem that occurs most
frequently in middle-aged and elderly
populations.
predisposing factors include myopia, intraocular
surgery, trauma. Spontaneous retinal holes may
develop as a normal part of aging. Rare in children.
can lead to severe vision impairment, blindness
initially there may be floating spots in the vision or
recurrent flashes of light. It is a painless and gradual
progression that can be described as a veil or curtain
obscuring part of the visual field.
An ophthalmologist will diagnose
it will need to be surgically repaired.
Vascular Retinopathy
result from interference of eye blood supply often related
to chronic medical conditions. There are 5 types: central
retinal artery occlusion, central retinal veinous occlusion,
diabetic retinopathy, hypertensive retinopathy, diabetic
retinopathy, sickle-cell retinopathy.
the diminished blood supply causes visual deficiencies.
the cause can be idiopathic. More frequently it is due to atherosclerosis, embolism, carotid occlusion, temporal
arteritis, heart failure, infection, hypercoagulation
problems like sickle cell disease.
can lead to blindness and secondary glaucoma
central retinal artery occlusion causes sudden painless unilateral blindness. It
typically causes permanent blindness.
Central retinal venous occlusion is painless and results in partial loss of visual acuity
- one can still see movement and light. Most patients develop secondary glaucoma
shortly after onset.
diabetic retinopathy can cause hemorrhages, microaneurysms and leakage of fluid
into the macular area causing decreased visual acuity - reading and driving, night
vision
proliferative diabetic neuropathy shows neovascularization in the fundus. The new
vessels are fragile and rupture causing sudden loss of vision. Scar tissue can form
which pulls the retina and can lead to retinal detachment.
hypertensive retinopathy - blurred vision and headache. Vascular changes reflect
high blood pressure - like tortuous veins and swelling of the head of the optic nerve.
Eventual leads to visual defects and blindness.
Sickle cell retinopathy - shows peripheral arteriolar occlusions with anastomoses,
neovascularization, hemorrhage and leads to retinal detachment.
diagnosis is made with a visual acuity exam
and vital sign check. An ophthalmologist will
examine the fundus (posterior eye) for obvious
changes.
therapies directed at correcting the underlying
condition and controlling the intraocular
pressure are used to treat, surgery to
decrease neovascularization may be used
Age Related Macular
Degeneration
Age-related macular degeneration (ARMD)
is a degenerative condition of the macula (the
central retina). It is the most common cause
of vision loss in the United States in those 50
or older, and its prevalence increases with
age. AMD is caused by hardening of the
arteries that nourish the retina. This deprives
the sensitive retinal tissue of oxygen and
nutrients that it needs to function and thrive.
As a result, the central vision deteriorates.
this is the most common cause of legal blindness in adults and a
predominant cause of severe loss of central vision in the elderly.
can cause blindness and nystagmus
there is a change in central vision where straight lines become
distorted and blank areas appear in the center of vision.
Diagnosis is based on examination of the fundus after dilation
Treatment: laser photocoagulation is used to reduce the
possibility of severe vision loss if related to serous macular
degeneration. Laser treatments can also be used with wet
macular degeneration to destroy abnormal blood vessels.
Cataract
A cataract is a clouding of the natural lens,
the part of the eye responsible for focusing
light and producing clear, sharp images. The
lens is contained in a sealed bag or capsule.
As old cells die they become trapped within
the capsule. Over time, the cells accumulate
causing the lens to cloud, making images look
blurred or fuzzy. For most people, cataracts
are a natural result of aging.
patients will generally experience painless
blurring and obscuring of vision over time. The
black pupil begins to appear hazy and there
can be blinding glare from lights at night.
Diagnosis: visual acuity is decreased though
opacity is unnoticed until advanced stage.
Treatment: surgical extraction of lens opacity
with correction of visual deficits. Common
complication is infection.
Retinitis Pigmentosa
Retinitis pigmentosa (RP) is a rare, hereditary
disease that causes the rod photoreceptors in
the retina to gradually degenerate. The rods
are located in the periphery of the retina and
are responsible for peripheral and night
vision. Cones, another type of photoreceptor,
are densely concentrated in the macula. The
cones are responsible for central visual acuity
and color vision.
no cure is known for this rare hereditary
condition but vitamins A and E might help slow
progression.
Other Random Disorders
optic atrophy
extraocular motor nerve palsies
glaucoma
Optic Atrophy
Optic Atrophy
can develop spontaneously or secondary to inflammation or edema of
the optic nerve head, it may subside without treatment but, if the optic
nerve degenerates it is irreversible.
usually results from central nervous system disorders like tumors,
syphilis, retinal vascular disease. Can also be related to chronic
papilledema, central retinal artery or venous occlusion, exposure to
methanol and quinine or vitamin B12, amino acid or zinc deficiency.
can cause abrupt or gradual painless loss of vision or acuity of vision.
an ophthalmologist will examine visual acuity and the fundus to diagnose.
Treatment: corrects underlying cause to prevent irreversible changes.
Extraocular Motor Nerve Palsies
Extraocular muscles and movement
including CN innervations
Extraocular Motor Nerve
Palsies
dysfunctions of the III, IV and VI cranial nerves associated
with trauma, diabetes and intracranial aneurysm
most commonly due to trauma
Signs and Symptoms: usually diplopia varying in different
visual fields related to which nerve is involved.
CT or MRI are used to rule out tumors and to help find the
cause of palsy.
Treatment: identification and appropriate cure for underlying
cause
Glaucoma
Glaucoma
Glaucoma is a disease caused by increased
intraocular pressure (IOP) resulting either from
a malformation or malfunction of the eye’s
drainage structures. Left untreated, an
elevated IOP causes irreversible damage the
optic nerve and retinal fibers resulting in a
progressive, permanent loss of
vision. However, early detection and
treatment can slow, or even halt the
progression of the disease.
Open Angle
•
Open angle (also called chronic open angle or primary
open angle) is the most common type of glaucoma. With this
type, even though the anterior structures of the eye appear
normal, aqueous fluid builds within the anterior chamber,
causing the IOP to become elevated. Left untreated, this may
result in permanent damage of the optic nerve and
retina. Eye drops are generally prescribed to lower the eye
pressure. In some cases, surgery is performed if the IOP
cannot be adequately controlled with medical therapy.
Acute Angle Closure
•
Only about 10% of the population with glaucoma
has this type. Acute angle closure occurs because
of an abnormality of the structures in the front of
the eye. In most of these cases, the space
between the iris and cornea is more narrow than
normal, leaving a smaller channel for the aqueous
to pass through. If the flow of aqueous becomes
completely blocked, the IOP rises sharply, causing
a sudden angle closure attack.
Acute angle-closure glaucoma is an ocular
emergency to treat IOP with agents like
pilocarpine to constrict the pupil and allow fluid
to escape
Refractive Disorders
Myopia
Nearsightedness or myopia, occurs when
light entering the eye focuses in front of the
retina instead of directly on it. This is
caused by a cornea that is steeper, or an
eye that is longer, than a normal eye.
Nearsighted people typically see well up
close, but have difficulty seeing far away.
Hyperopia
Farsightedness or hyperopic, occurs when
light entering the eye focuses behind the
retina, instead of directly on it. This is caused
by a cornea that is flatter, or an eye that is
shorter, than a normal eye. Farsighted people
usually have trouble seeing up close, but may
also have difficulty seeing far away as well.
Astigmatism
Astigmatism means that the cornea is oval
like a football instead of spherical like a
basketball. Most astigmatic corneas have two
curves – a steeper curve and a flatter curve.
This causes light to focus on more than one
point in the eye, resulting in blurred vision at
distance or near. Astigmatism often occurs
along with nearsightedness or farsightedness