Anterior eye structures disorders
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EYE ANTERIOR STRUCTURES PATHLOGIES
AND DISORDERS
FielmannOptometristIrina Jagiloviche-mail: [email protected]
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DISORDERS OF LASHES
1. Trichiasis
2. Metaplastic lashes
3. Distichiasis
4. Phthiriasis palpebrarum
6. Poliosis
5. Madarosis
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MadarosisDecrease in number or complete loss of lashes
Local causes
• Chronic anterior lid margin disease
• Infiltrating tumours
• Burns, radiotherapy or cryotherapy
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PoliosisPremature localized whitening of hair
Ocular associations
Chronic anterior blepharitis
Sympathetic ophthalmitis
Systemic associations
Vogt-Koyanagi-Harada syndrome
Waardenburg syndrome
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Distichiasis
•Second row of lashes arising from meibomian gland orifices
•Congenital
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Trichiasis
Most frequently affects lower lidof normal lashes
Most frequently affects lower lid
Inferior punctate epitheliopathy
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Phthiriasis palpebrarum
Infestation of lashes by pubic crab louse and its ova (nits)
Typically affects children in poor hygenic conditions
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Staphylococcal blepharitis
Chronic irritation worse in morningsScales around base of lashes (collarettes)
Hyperaemia and telangiectasia of anterior lid marginScarring and hypertrophy if longstanding
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Complications of staphylococcal blepharitis
poliosis madarosis trichiasis Recurrent styes
Marginal keratitis Tear film instability
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Seborrhoeic blepharitis
Shiny anterior lid margin
Hyperaemia of lid margin
Greasy scales
Lashes stuck together
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Meibomianitis
Meibomian cyst formation
Inflamed and blocked meibomian gland orifices
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Meibomian seborrhoea
Oil globules over meibomian gland orifices Oily and foamy tear film
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Herpes simplex
Signs• Crops of small vesicles• Rupture and crust• Heal without scarring after 7 days
Complications • Follicular conjunctivitis • Keratitis
Treatment - topical antivirals
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BENIGN EYELID LESIONS1. Nodules
• Chalazion • Acute hordeola
2. Cysts
•
• Cyst of Moll• Cyst of Zeiss• Sebaceous cyst• Hidrocystoma
3. Tumours
Xanthelasma
• Viral wart• Keratoacanthoma• Naevi• Capillary haemangioma• Port-wine stain• Pyogenic granuloma• Cutaneous horn
Molluscum contagiosum•
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Signs of chalazion (meibomian cyst)
Painless, roundish, firm lesion within tarsal plate
May rupture through conjunctiva and cause granuloma
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Molluscum contagiosum
Painless, waxy, umbilicated nodule
May be multiple in AIDS patients
Chronic follicular conjunctivitis
Occasionally superficial keratitis
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Xanthelasma
Common in elderly or those with hypercholesterolaemia
Yellowish, subcutaneous plaques containing cholesterol and lipid
Usually bilateral and located medially
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Eyelid cystsCyst of Moll
Cyst of Zeis
Translucent
On anterior lid margin
On anterior lid margin
Opaque
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Viral wart (squamous cell papilloma)
Most common benign lid tumour
Raspberry-like surface
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KeratosesSeborrhoeic Actinic
Common in elderly
Discrete, greasy, brown lesion
Flat ‘stuck-on’ appearance
Affects elderly, fair-skinned individuals
Most common pre-malignant skin lesion
Rare on eyelids
Flat, scaly, hyperkeratotic lesion
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Keratoacanthoma
Uncommon, fast growing nodule
Acquires rolled edges and keratin-filled crater
Involutes spontaneously within 1 year
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Naevi
Elevated
May be non-pigmented
No malignant potential
Flat, well-circumscribed
Pigmented
Low malignant potential
Has both intradermal and junctional components
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MALIGNANT EYELID TUMOURS
1. Basal cell carcinoma
2. Squamous cell carcinoma
3. Meibomian gland carcinoma
4. Melanoma
5. Kaposi sarcoma
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Basal Cell Carcinoma - Important Facts
1. Most common human malignancy
2. Usually affects the elderly
3. Slow-growing, locally invasive
5. 90% occur on head and neck
6. Of these 10% involve eyelids
7. Accounts for 90% of eyelid malignancies
4. Does not metastasize
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Nodular basal cell carcinoma
Shiny, indurated nodule
Surface vascularization
Slow progression
May destroy large portion of eyelid
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Ulcerative basal cell carcinoma(rodent ulcer)
Chronic ulceration
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Sclerosing basal cell carcinoma
Indurated plaque with loss of lashes
May mimic chronic blepharitis
Spreads radially beneath normal epidermis
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Squamous cell carcinoma
Nodular Ulcerative
Less common but more aggressive than BCC
No surface vascularization
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Meibomian gland carcinoma
Hard nodule; maymimic chalazion
Diffuse thickening of lid margin and loss of lashes
Very large tumour
Conjunctival invasion; maymimic chronic conjunctivitis
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Melanoma
Blue-black nodule withnormal surrounding skin
May be non-pigmented
Plaque with irregular outline
Variable pigmentation
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Kaposi sarcoma
Vascular tumour occurring in patients with AIDS
Usually associated with advanced disease
Very sensitive to radiotherapy
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Entropion & ectropion
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Horner syndrome
Caused by oculosympathetic palsy
Usually unilateral mild ptosis and miosis, anisocoria
Normal pupillary reactions
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Important causes of Horner syndromeCentral(first order neurone)
• Brainstem disease (vascular, demyelination)• Spinal cord disease (syringomyelia, tumours)
Pre-ganglionic (second order neurone)
• Intrathoracic lesions (Pancoast tumour, aneurysm)
• Neck lesions (glands, trauma)
Post-ganglionic (third order neurone)
• Internal carotid artery disease• Cavernous sinus mass
Posterior hypothalamus
Ciliospinal centre of Budge( C8 - T2 )
Superior cervicalganglion
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Simple bacterial conjunctivitis
Crusted eyelids and conjunctival injection
Subacute onset of mucopurulent discharge
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Signs of conjunctivitis
Usually bilateral, acute waterydischarge and follicles
Subconjunctival haemorrhages andpseudomembranes if severe
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Signs of keratitis
Focal, epithelial keratitis Focal, subepithelial keratitis
May persist for months Transient
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Progression of vernal conjunctivitis
Diffuse papillary hypertrophy, most marked on superior tarsus
Formation of cobblestone papillae
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Limbal vernal
Trantas dotsMucoid nodule
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1. Benign• Naevus• Papilloma• Epibulbar dermoid• Lipodermoid
2. Pre-malignant• Primary acquired melanosis ( PAM )• Intraepithelial neoplasia (carcinoma in situ)
3. Malignant• Melanoma• Squamous cell carcinoma• Kaposi sarcoma• Lymphoma
CONJUNCTIVAL TUMOURS
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Naevus
30% are almost non-pigmented
Most frequently juxtalimbalSharply demarcated and slightly elevated•
Presents in first two decades
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Melanoma
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PapillomaPedunculated Sessile
• Presents in middle age• Not caused by infection• Single and unilateral
• Presents in childhood or early adulthood• Infection with papilloma virus • May be multiple and bilateral
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• Presents in childhood• Smooth, soft mass• Usually juxtalimbal
• Occasionally Goldenhar syndrome
Epibulbar dermoidSigns Association
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Lipodermoid
• Presents in adulthood• Soft, movable, subconjunctival mass• Most frequently at outer canthus
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Intraepithelial neoplasia(carcinoma in situ)
• Juxtalimbal fleshy avascular mass
• May become vascular and extend onto cornea• Presents in late adulthood• Malignant transformation is uncommon
Signs Progression
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Primary acquired melanosis (PAM)
PAM without atypia is benign
PAM with atypia is pre-malignant Unilateral, irregular areas of flat, brown pigmentation
May involve any part of conjunctiva
Presents in late adulthood
Signs Types
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Conjunctival melanoma
From PAM with atypia
Sudden appearance of nodules in PAM
From naevus
Sudden increase in size or pigmentation
Primary
Solitary nodule
Frequently juxtalimbal but may be anywhere•
Very rareMost common type
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Squamous cell carcinoma
• Rarely metastasizes
• Arises from intraepithelial neoplasia or de novo
• Frequently juxtalimbal
• Slow-growing
• Presents in late adulthood• May spread extensively
Signs Progression
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Kaposi sarcoma
• Most frequently in inferior fornix
• Affects patients with AIDS• Vascular, slow-growing tumour of low malignancy• Very sensitive to radiotherapy
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Lymphoma
• Salmon-coloured, subconjunctival infiltrate
• Usually presents in adulthood• Benign or malignant
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PERIPHERAL CORNEAL INFLAMMATION
1. Marginal keratitis
2. Rosacea keratitis
3. Phlyctenulosis
4. Acute stromal keratitis
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Marginal keratitis
Subepithelial infiltrate separated by clear zone
Circumferential spread Vascularization followed by resolution
Progression
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Rosacea keratitis
Peripheral inferiorvascularization
Subepithelial infiltration Thinning and perforation if severe
• Affects 5% of patients with acne rosaeca• Bilateral and chronic
Progression
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Phlyctenulosis
• Small pinkish-white nodule near limbus• Usually transient and resolves spontaneously
• Starts astride limbus• Resolves spontaneously or extends onto cornea
• Uncommon, unilateral - typically affects children• Severe photophobia, lacrimation and blepharospasm
Conjunctival phlycten Corneal phlycten
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Acute stromal keratitis
Superficial or mid-stromal infiltration Opacification and vascularization
• Uncommon, usually unilateral• Associated with non-necrotizing scleritis
Progression
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CORNEAL INFECTIONS
1. Bacterial keratitis
2. Fungal keratitis
3. Acanthamoeba keratitis
4. Infectious crystalline keratitis
5. Herpes simplex keratitis-Epithelial-Disciform
6. Herpes zoster keratitis
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Bacterial keratitis• Contact lens wear• Chronic ocular surface disease• Corneal hypoaesthesia
Expanding oval, yellow-white, dense stromal infiltrate
Stromal suppuration and hypopyon
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Fungal keratitis
Frequently preceded by ocular trauma with organic matter
Greyish-white ulcer which may be surrounded by feathery infiltrates
Slow progression and occasionally hypopyon
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Acanthamoeba keratitis• Contact lens wearers at particular risk• Symptoms worse than signs
Small, patchy Anterior stromal infiltrates
Perineural infiltrates (radial keratoneuritis)
Ulceration, ring abscess& small, satellite lesions
Stromal opacification
Treatment
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Infectious crystalline keratitis• Very rare, indolent infection (Strep. viridans)
• Particularly following penetrating keratoplasty
White, branching, anterior stromal crystalline deposits
• Usually associated with long-term topical steroid use
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Herpes simplex epithelial keratitis
• Dendritic ulcer with terminal bulbs
• Stains with fluorescein
• May enlarge to become geographic
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Herpes simplex disciform keratitis
Central epithelial and stromal oedema
Folds in Descemet membrane
Small keratic precipitates
Occasionally surrounded by Wessely ring
Signs Associations
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Herpes zoster keratitis
Develops in about 50% within 2 days of rash
Small, dendritic or stellate epithelial lesions
Tapered ends without bulbs
Resolves within a few days
Develops in about 30% within 10 days of rash
Multiple, fine, granular deposits just beneath Bowman membrane
Halo of stromal haze
Nummular keratitisAcute epithelial keratitis
May become chronic
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CORNEAL DEGENERATIONS
1. Age-related• Arcus senilis• Vogt white limbal girdle
2. Lipid keratopathy
• Crocodile shagreen • Cornea guttata
• Primary• Secondary
3. Band keratopathy
4. Spheroidal degeneration5. Salzmann nodular degeneration
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Arcus senilis• Innocuous and extremely common in elderly
• Occasionally associated with hyperlipoproteinaemia
• Bilateral, circumferential bands of lipid deposits
• Diffuse central and sharp peripheral border
• Peripheral border separated from limbus by clear zone
• Clear zone may be thinned ( senile furrow)
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Vogt white limbal girdle
Innocuous and very common in elderly
Bilateral
White, crescentic line along nasal and temporal limbus
Type 1 - separated from limbus by clear zone
Type 2 - not separated by clear zone
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Crocodile shagreen
• Uncommon and innocuous
• Usually bilateral
Polygonal stromal opacities separated by clear space Most frequently involve anterior stroma (anterior crocodile shagreen)Occasionally involve posterior stroma (posterior crocodile shagreen)
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Cornea guttata• Common, bilateral and usually innocuous• Rarely progression to Fuchs dystrophy
Tiny dark spots on central endothelium
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Lipid keratopathy
Usually unilateral stromal deposits without vascularization
Rare, occurs spontaneously in avascular cornea
Unilateral stromal deposits with vascularization
Common, secondary to previous disciform keratitis
Primary Secondary
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Band keratopathy
Interpalpebral limbal opacification
• Common, unilateral or bilateral depending on cause
• Subepithelial calcification
Central spread of calcification
Small holes within calcified area Separated by clear zone
Progression
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CORNEAL DYSTROPHIES1. Anterior
• Cogan microcystic• Reis-Bucklers• Meesmann• Schnyder
2. Stromal• Lattice I, II, III• Granular I, II, III (Avellino)• Macular
3. Posterior• Fuchs endothelial• Posterior polymorphous
..
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Cogan microcystic dystrophy• Most common of all dystrophies• Neither familial nor progressive• Recurrent corneal erosions in about 10% of cases
Dots
Fingerprints
Cysts
Maps
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MicrocystsDots
Maps Fingerprints
Signs of Cogan dystrophy
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Onset - early childhood with recurrent corneal erosions
Superficial polygonal opacities Honeycomb appearance
keratoplasty if severe
Reis-Bucklers dystrophy..
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Meesmann dystrophy
Onset - first decade with mild visual symptoms
Treatment - not required
• Clear in retroillumination• Grey in direct illumination
• Tiny, epithelial cysts, maximal centrally
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Onset - second decade with visual impairment
Treatment - excimer laser keratectomy
Schnyder dystrophy
Subepithelial ‘crystalline’ opacities
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Onset - late first decade with recurrent corneal erosions
Treatment - penetrating keratoplasty if severe
Lattice dystrophy type I
Fine, spidery, branching lines within stroma
Later general haze may submerge lesions
Progression
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Onset - first decade with recurrent corneal erosions
Treatment - penetrating keratoplasty if severe
Granular dystrophy type I
Eventual confluenceInitial superficial andcentral crumb-like opacities
Later deeper and peripheral spread but limbus spared
Progression
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Onset - old age
Treatment - penetrating keratoplasty if advanced
Fuchs endothelial dystrophy
Eventually bullous keratopathy
Later central stromal oedema
Gradual increase in cornea guttata with peripheral spread
Progression
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1. Keratoconus
2. Keratoglobus
3. Pellucid marginal degeneration
CORNEAL ECTASIAS
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Morphological classification of keratoconus
Nipple cone Oval cone Globus cone
Small and steep curvature Larger and ellipsoidal Largest
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Signs of keratoconusBilateral in 85% but asymmetrical
Oil droplet reflex Prominent corneal nervesVogt striae
Acute hydrops Munson sign Fleischer ring & scarring
Bulging of lower lids on downgaze
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Keratoglobus
Bilateral protrusion and thinning of entire cornea Associations - Leber congenital amaurosis and blue sclera
Onset usually at birth
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Pellucid marginal degeneration
• Bilateral crescent-shaped inferior corneal thinning
• Onset between 20 and 40 years
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EPISCLERITIS AND SCLERITIS
1. Episcleritis• Simple• Nodular
2. Anterior scleritis• Non-necrotizing diffuse • Non-necrotizing nodular• Necrotizing with inflammation• Necrotizing without inflammation ( scleromalacia perforans )
3. Posterior scleritis
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Applied anatomy of vascular coats
Scleritis
• Maximal congestion of deep vascular plexus
• Slight congestion of episcleral vessels
• Maximal congestion of episcleral vessels
EpiscleritisNormal
• Radial superficial episcleral vessels• Deep vascular plexus adjacent to sclera
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Simple episcleritis• Common, benign, self-limiting but frequently recurrent
• Typically affects young adults
• Seldom associated with a systemic disorder
Simple sectorial episcleritis Simple diffuse episcleritis
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Nodular episcleritis• Less common than simple episcleritis
• May take longer to resolve
• Treatment - similar to simple episcleritis
Localized nodule which can be moved over sclera
Deep scleral part of slit-beam not displaced
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Diffuse anterior non-necrotizing scleritis
• Widespread scleral and episcleral injection
• Relatively benign - does not progress to necrosis
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Complications of uveitis
Posterior synechiae - 30% Cataract -20%
Glaucoma due to PAS - 15% Band keratopathy - 10%
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UVEAL TUMOURS 1. Iris melanoma
2. Iris naevus
6. Choroidal haemangioma
7. Choroidal metastatic carcinoma
8. Choroidal osseous choristoma
• Circumscribed• Diffuse
9. Melanocytoma
3. Ciliary boy melanoma
4. Choroidal melanoma
5. Choroidal naevus
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Iris Melanoma
1. Very rare - 8% of uveal melanomas
2. Presentation - fifth to sixth decades
3. Very slow growth
4. Low malignancy
5. Excellent prognosis
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Iris melanoma
Usually pigmented nodule at least 3 mm in diameter Invariably in inferior half of iris
Occasionally non-pigmented Surface vascularization
Angle involvement may cause glaucoma
Pupillary distortion, ectropion uveae and cataract
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Differential diagnosis of iris melanoma
Large iris naevus distorting pupil Leiomyoma
Adenoma of pigment epithelium
Primary iris cyst Ciliary body melanoma eroding iris root
Metastasis to iris
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Iris naevusTypical Diffuse
• Diameter usually less than 3 mm• Occasionally mild distortion of pupil an ectropion uvea
• May cause ipsilateral hyperchromic heterochromia
• May be associated with Cogan-Reese syndrome
• Pigmented, flat or slightly elevated
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Ciliary body melanoma
• Rare - 12% of uveal melanomas
• Presentation - 6th decade
• May be discovered by chance
• Prognosis - guarded
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Anterior uveitis
Symptoms: acute iritis causes a sudden onset of unilateral photophobia, redness, pain and blurred vision. In chronic anterior uveitis symptoms may initially be absent or mild. Signs: Circumcorneal injection and a small pupil in acute iritis. Keratic precipitates may be small in acute iritis or large and mutton fat in granulomatous inflammation. Hypopyon and a fibrinous exudate.
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Anterior uveitis
Posterior synechiae Hypopyon
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Acute anterior uveitis in young adults
Fibrinous exudate Residual pigment on lens
• Majority are men
• Initially no systemic disease
• Minority subsequently develop ankylosing spondylitis
• 45% are positive for HLA-B27
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IMPORTANT SYSTEMIC ASSOCIATIONS OF UVEITIS1. Spondylarthropathies
• Systemic features• Ocular features
2. Juvenile idiopathic arthritis
3. Sarcoidosis
4. Behçet disease5
5. Vogt-Koyanagi-Harada syndrome5
7. Tubulointerstitial nephritis
6. Inflammatory bowel disease• Ulcerative colitis• Crohn disease
• Systemic features
• Ocular features
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ACQUIRED CATARACT
• Morphological1. Classification of age-related cataract
• According to maturity
• Diabetes• Myotonic dystrophy• Atopic dermatitis• Trauma
2. Other causes of cataracts
3. Surgery
• Secondary (complicated)
• Large incision extracapsular extraction• Phacoemulsification
• Drugs
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Classification of Age-related Cataract According to Morphology
1. Subcapsular• Anterior• Posterior
2. Nuclear
3. Cortical
4. Christmas tree
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Subcapsular cataract
Anterior Posterior
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Nuclear cataract
• Exaggeration of normal nuclear ageing change• Causes increasing myopia
• Increasing nuclear opacification
• Initially yellow then brown
Progression
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Cortical cataract
Initially vacuoles and clefts Progressive radial spoke-like opacities
Progression
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Christmas tree cataract
Polychromatic, needle-like opacities May co-exist with other opacities
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Classification according to maturity
Immature Mature
Hypermature Morgagnian
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Other causes of cataract - diabetesJuvenile
• White punctate or snowflake posterior or anterior opacities
• May mature within few days
Adult
• Cortical and subcapsular opacities• May progress more quickly than in non-diabetics
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Other causes of cataract - atopic dermatitis
• Cataract develops in 10% of cases between 15-30 years
• Bilateral in 70% • Frequently becomes mature
• Anterior subcapsular plaque (shield cataract)
• Wrinkles in anterior capsule
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Causes of traumatic cataract
Penetration
Concussion
‘Vossius’ ring from imprinting of iris pigment Flower-shaped
• Ionizing radiation
• Electric shock
• Lightning
Other causes
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DrugsChlorpromazine
• Long-acting mioticsOther drugs
• Amiodarone
• Busulphan
- initially posterior subcapsularSystemic or topical steroids
- central, anterior capsular granules
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Secondary (complicated) cataract
• Chronic anterior uveitis
• High myopia
Posterior subcapsular
• Hereditary fundus dystrophies• Central, anterior subcapsular opacities
Glaukomflecken
• Follows acute angle- closure glaucoma
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LenticonusPosterior
• Posterior axial bulge• Unilateral - usually sporadic• Bilateral - familial or in Lowe syndrome
Anterior
• Anterior axial bulge
• Associated with Alport syndrome
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ECTOPIA LENTIS
1. Acquired
2. Isolated familial ectopia lentis
3. Associated with systemic syndromes• Marfan syndrome
• Weill-Marchesani syndrome
• Homocystinuria
4. Treatment options
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Acquired ectopia lentisTrauma
• Buphthalmos• Megalocornea
Anterior uveal tumours Degenerate eye
Stretched zonules
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Ocular features of Marfan syndrome
Upward subluxation
Zonule usually intact Axial myopia
Blue scleraCornea planaAngle anomaly and glaucoma
Lattice degeneration
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Weill-Marchesani syndromeSystemic features
Short stature
Ocular features
Short stubby fingers (brachydactyly)
Mental handicap
Microspherophakia
Angle anomaly and glaucoma
Usually anterior lens subluxation
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Homocystinuria• Defect in cystathio beta-synthase
Systemic features
Malar flush and fine, fair hair
Marfanoid habaitus
Increased platelet stickiness
Mental handicap
Ocular features
Downward lens subluxation
Disintegration of zonule
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Treatment Options for Ectopia Lentis
• For induced astigmatism
1. Spectacle correction
• For aphakic portion
• Associated cataract
3. Surgical removal
• Lens-induced glaucoma
2. Nd:YAG laser zonulysis to displace lens out of visual axis
• Endothelial touch
• When other methods are inappropriate
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Refrerencfes
Jack J Kanski. Clinical Ophtalmology. A Systemic approach
Jack J Kanski. Illustrated Tutorials