ACUTE RED EYE

PREPARED BY :-
ARAVENDGANESH A/L RAMAKRISHANAN - 012021100120
JULIAN NATANIELL PARAMAKURU - 012021100164
LADY ANNIE ARUNA KIANE MANEKA HENDRICKS - 012021100174
SREE VAASNI A/P NARASIMMAN - 012021100012
THIVYAN A/L KANNAN - 012021100121
YASMIN NABILAH BINTI BUSERAH - 012020100020
 CONJUNCTIVITIS
SREE VAASNI NARASIMMAN - 012021100012
JULIAN NATANIELL PARAMAKURU - 012021100164
 CONJUNCTIVITIS

● inflammation or infection of the transparent

membrane ( conjunctiva ) that lines the
eyelid and covers the white part of the
eyeball

● ‘PINK EYE’
 CLASSIFICATION

INFECTIOUS NON- INFECTIOUS

VIRAL BACTERIAL
● ALLERGIC
● SUBACUTE ● TOXINS/ CHEMICAL
● ACUTE ● FOREIGN BODY
● CHRONIC ● TRAUMA
● NEOPLASM
 VIRAL CONJUNCTIVITIS

● Causative organism : adenovirus ( enterovirus ,

HSV)
● Occurs in community epidemies such as school,
workplace, physician office
● Mode of transmission : contaminated fingers,
medical instruments , swimming pool water , sharing
towels
 Non specific acute
Pharyngoconjunctival fever
follicular conjunctivitis

Chronic/ relapsing adenoviral Herpes simplex virus

conjunctivitis

Types of viral conjunctivitis

Mollucum systemic viral infection Acute hemorrhagic
contagiosum conjunctivitis

Epidemic
keratoconjunctivitis
 SYMPTOMS

Redness
Discharge

Sore throat / cold

Itchiness
Photophobia
SIGNS
SIGNS
 INVESTIGATION

● Giemsa stain
● Nucleic acid amplification —> PCR
● Viral culture
● ‘Point care’ immunochromatography
● Serology - IgM or IgG
 MANAGEMENT
● Spontaneous resolution
● Reduction of transmission risk
● Molluscum contagiosum - removal
● Topical steroids - severe membranous or
pseudomembranous adenoviral conjunctivitis (monitor IOP
)
● Treat the risk factors such as discontinuation of contact
lens
● Others : artificial tears, cold or warm compress,
antihistamine
 ACUTE BACTERIAL CONJUNCTIVITIS

● Common causes in neonates: Chlamydia

trachomatis, Neisseria gonorrhoeae
● In children: Haemophilus influenzae (80%),
Streptococcus pneumoniae (20%), and Moraxella
catarrhalis.
● In adults: Staphylococcus aureus
 HYPERACUTE BACTERIAL CONJUNCTIVITIS
● Etiology: Neisseria species, most commonly N.
gonorrhoeae
● Presentation: profuse, purulent discharge with rapidly
progressive symptoms of marked conjunctival
injection, irritation, tenderness to palpation, chemosis,
lid swelling and tender preauricular adenopathy
 HYPERACUTE BACTERIAL
CONJUNCTIVITIS
● Ophthalmia neonatorum: gonococcal ocular
infection with bilateral discharge 3-5d after birth
from vaginal transmission
● Sexually active teens: transmitted from genitalia to
hand to eyes, commonly see concurrent urethritis
● Sight-threatening
 CHRONIC CONJUNCTIVITIS
● Most common etiology: Staphylococcus species
● More common in adults and patients with acne rosacea
or facial seborrhea
● Presentation varies: redness, itching, burning,
foreign-body sensation, flaky debris, blepharitis
(common), eyelash loss
● Concurrently see styes and chalazia of the lid margin
from chronic inflammation of the meibomian glands
 SYMPTOMS

Redness
Discharge

Burning
Bilateral & eyelids stuck together
 SIGNS

Lid edema
Mucopurulent Discharge

Blepharitis
Conjunctival hyperaemia
INVESTIGATION
● binocular conjunctival swabs and scrapping
● Culture should include enriched media such as
chocolate agar or Thayer–Martin for N. gonorrhoeae
● Polymerase chain reaction (PCR
TREATMENT
● Topical antibiotics
● Systemic antibiotics
● Topical steroid
● Irrigation
● Reduce the t risk of transmission
● Review
● Statutory notification of public health authorities
 - Acute Allergic Conjunctivitis
- Seasonal & Perennial Allergic
Conjunctivitis
- Vernal Keratoconjunctivitis (VKC)
Allergic - Atopic Keratoconjunctivitis (AKC)

Conjunctivitis - Contact Allergic

Blepharoconjunctivitis
Julian Nataniell Paramakuru (012021100164)
- Mechanically Induced (Giant)
Papillary Conjunctivitis
 Acute Allergic Conjunctivitis
- Signs & Symptoms
- Investigations
- Redness
- Conjunctival
(Conjunctival
scrapings (raised
hyperaemia)
eosinophils)
- Watering
- Itching - Treatment
- Chemosis - Usually not
needed
- Can use cold
compression
 Seasonal Allergic Perennial Allergic
Conjunctivitis Conjunctivitis
Timing of Exacerbation Spring & Summer Throughout the year

Allergens Dust mites

Grass & Pollens Animal dander
Fungal spores

Clinical Features - Redness

- Chemosis
- Itching & watering
- Sneezing & nasal discharge

Treatment - Treatment
- Artificial tears
- Mast cell stabilisers
- Antihistamines
- Topical steroids
 Signs & Symptoms
● Thick mucus
● Discharge
Vernal ● Pain

Keratoconjunctivitis ●
●
Lacrimation
Photophobia
(VKC) ● Blurred vision
● Foreign body sensation
Vernal Keratoconjunctivitis (VKC)
Palpebral
- Vernal means ‘spring’
- Usually affects people in warm, dry
weather
- Usually seen in prepubescent males
- Classification
- Palpebral
- Limbal
- Keratopathy
A. Macropapillae resembling cobblestone
(Focal)
B. Diffuse inflammatory infiltrate
C. Progresses to giant papillae
D. Mucus deposition in between papillae

A/B -> C -> D

Vernal Keratoconjunctivitis (VKC)
Keratopathy

Kerato = horn = cornea

A. Superior punctate epithelial erosions

B. & C. Plaque & Shield ulcer

D. Pseudogerontoxon (can resemble arcus

senilis) - usually seen in patients with
recurrent Limbal VKC
Vernal Keratoconjunctivitis (VKC)
Limbal

Limbus = Border between the cornea and the

sclera of the eye

A - C = Gelatinous limbal conjunctival papillae

D = Severe limbal VKC

 Signs & Symptoms
● Pain
● Blurry vision
Atopic ● Photophobia

Keratoconjunctivitis ● Foreign body sensation

(AKC)
Atopic Keratoconjunctivitis (AKC)
Is a rare disease that typically develops in adulthood
following a long history of atopy (dermatitis & asthma)

Does not favor either gender

A. Eczematoid skin changs

B. Diffuse conjunctival infiltration

C.& D. Forniceal shortening due to chronic scarring of

conjunctiva

E. Peripheral vascularisation

F. Persistent epithelial defects

Atopic Keratoconjunctivitis (AKC)

Diagnostic signs of AKC

- Hertoghe sign:
- Absence of the lateral portion of the
eyebrows

- Dennie-Morgan folds:
- Lid skin folds caused by persistent
rubbing
 Treatment of VKC & AKC
General Local Systemic Surgical

- Allergen - Mast cell - Oral - Superficial

avoidance stabillisers antihistamine keratectomy
- Cold (Sodium (Loratidine) - Remove
compression gromoglicate) - Antibiotics plaques
- Topical (Doxycycline) - Debride
- Maintain lid
antihistamine - Immuno ulcers
hygiene - Allow
(Bepotastine) suppresive
- Bandage epithelializ
- Combination agents
contact lens ation
of mast cell (Cyclosporin) - Surface
wear
stabilisers & maintenance/
antihistamine restoration
(Olopatadine)
surgery
- Topical
steroids
(Prednisolone)
 Contact Allergic Blepharoconjunctivitis
Definition Causes S&S Treatment

Contact dermatitis of - Reaction to eye - Erythema and - Discontinuation of

the eye drop thickening of precipitant
- Mediated by constituents eyelids - Topical steroids
T-cell mediated - Reaction to (Blepharo-)
hypersensitivity contact lens
solutions
- Mascara
 Mechanically Induced (Giant) Papillary Conjunctivitis
Definition Causes S&S Treatment

Inflammation of the - Ocular - Foreign body - Removal of offending

conjunctiva +
prosthesis sensation stimulus
formation of very
large papillae - Contact lens - Redness - Ensure effective
(CL) wear (hyperaemia) cleaning of
- Exposed suture - Itchiness prosthesis/ CL
- Increased - Topical:
mucus - Mast cell
production stabilisers
- Blurry vision - Antihistamines
- Presence of - Steroids
large papillae - NSAIDs
 ACUTE UVEITIS
ARAVENDGANESH A/L RAMAKRISHANAN - 012021100120
● Uveitis is inflammation of uveal tract with/without inflammation of
adjacent structure
Classification based on Anatomical
Uveal Tract = 1. Anterior Uveitis

+ Iris -
-
Iritis
Anterior cyclitis
+ Ciliary Body - Iridocyclitis

+ Choroid 2. Intermediate Uveitis

- Posterior cyclitis
- Pars Planitis
3. Posterior Uveitis
- Choroiditis
- Chorioretinitis
- Neuro-uveitis
Classification based on Clinical Classification based on Pathological

Granulomatous Non-granulomatous
(Exudative)

- Due to microbial - Due to allergic or

infection autoimmune
- TB, Syphilis, disease
toxoplasmosis,
herpes
 Etiology
It occurs due to a perforating wound or corneal ulcer. It causes acute purulent iridocyclitis and
Exogenous infection
panophthalmitis.

Organisms lodged in some other organ of the body reach the eye through the bloodstream.

Bacterial

- Septicaemia due to Streptococcus, Staphylococcus Meningococcus, Pneumococcus

Endogenous infection
- Tuberculosis, syphilis, gonorrhoea

Viral - Mumps, measles, influenza, herpes

Protozoa - Toxoplasma, toxocara, cysticercosis

Secondary infection Adjacent infection structure spreaded to uveal tract

It occurs due to hypersensitivity reaction to autologous tissue components (autoimmune reaction).

Allergic-inflammation / Hypersensitivity reaction - Therefore uveitis occurs commonly in association with: rheumatoid arthritis, systemic lupus
erythematosus, sarcoidosis, ankylosing spondylitis, Reiter’s disease, Behcet’s syndrome.
- Patient with HLA-B27 allele
 Signs
Anterior Uveitis 1. Ciliary flush - Active hyperemia of
Symptoms anterior ciliary blood vessels
1. Painful Red eye congestion due to inflammation
- Inflammation of iris and ciliary body
2. Photophobia
- Iris very sensitive to stimulation due
to many nerve fibers
- Excessive pupillary constriction and 2. Keratic precipitate - Inflammation
ciliary spasm causing Irritation causing nutrition deficit of the corneal
3. Blurry vision endothelium causing desquamation
- Present of hazy plasmoid aqueous and sticky. Inflammatory cells form in
and keratic precipitate triangle pattern with apex in superior
4. Increase tear production / watery (arlt triangle) due to aqueous
discharge convection current and gravity.
 Signs Cont.
● Aqueous Flare
- Aqueous become haziness due to inflammatory exudate that contain
leucocyte, coagulated protein and in severe form fibrin

● Hyphema
- When blood collects between the clear front part of the eye (cornea)
and the colored part of the eye (iris)

● Hypopyon
- The accumulation of white blood cells that form a whitish layer of fluid
in the lower portion of the eye anterior chamber (front part)
 Signs Cont.
● Miosis
- Inflammation of iris causing dilation of blood vessel lead to plasma
leakage causing excessive mechanical constriction
- Inflammation also cause overstimulation lead to muscle spasm

● Koeppe nodule
- Inflammatory cell precipitates which lie at the pupillary margin and could
be found in non-granulomatous as well as granulomatous uveitis

● Busacca nodule
- Modules that lies on the iris surface which are pathognomonic for
granulomatous uveitis
Posterior Uveitis
- Inflammation of the posterior uveal tract (choroid).
- Lesion can primary to adjacent structure like retina and blood vessel
- Location of lesion may be:
● Focal
● Multifocal
● Diffuse
- Symptoms (Impaired vision)
● Positive scotoma
Floaters Scotoma
● Negative scotoma
● Floaters
- Signs
● Retinitis
● Choroiditis
Retinitis Choroiditis
Investigations
Hematological Tests Sampling
- HLA Tissue Typing (HLA-B27) - Aqueous Tap
- CBC, ESR, CRP - Iris Biopsy
- Serology: Syphilis, HIV, Lyme disease - Vitreous Biopsy
- Serum ACE, Lysozyme - Conjunctival Biopsy
- ANA, ANCA, IGRA

Imaging Ocular:
- B-scan
- OCT
- FAF
- FA
- ICGA
- UBM

General:
- Chest X-Ray & Sacroiliac Joint X-Ray
Complications

1. Complicated Cataract

- Opacification of the natural lens of the eye

due to inflammatory conditions of the eye
or uveitis

2. Secondary Glaucoma - Also known as uveitic glaucoma

- A common complication of Herpetic
Uveitis (HSV)

3. Cyclitic Membrane
- Fibrovascular proliferations that extend
from the inner side of the ciliary body to
the vitreous base and the peripheral retina
Complications

4. Cystoid Macular Edema

- Retinal thickening of the macula due to a

disruption of the normal blood-retinal
barrier

5. Phthisis bulbi

- An clinical condition representing an

end-stage ocular response to severe
eye injury
- Caused by Uveitis
Treatment
Treatment Medications

Corticosteroids/Steroids Topical (Ointments/Eye drops):

- Prednisolone 1% or Dexamethasone 0.1%
- 1 drop/hour x3 days → 2 hourly x3 days → 4x/day x1 week → 3x/day x1
week → 2x/day x1 week → 1x/day x1 week → Stop
- Ointment is instilled at bedtime to supplement the drops.

Subconjunctival:
- Indications: Severe cases, Poor compliance.
Betamethasone Sodium Phosphate solution (4 mg in 1 ml).

Regional (Periocular):
- Indications: Severe cases, Poor compliance, Adjunct of therapy in
resistant CAU.
Methylprednisolone/Triamcinolone at sub-tenon space (40–80 mg).

Intraocular:
- Indications: AU for CMO unresponsive to other forms of therapy.
Intravitreal Triamcinolone Acetonide (4 mg in 0.1 ml).

Systemic:
- Indications: Severe cases, Stagnant on max topical & periocular.
Prednisolone 1–1.5 mg/kg 4x/day x1–2 weeks → Taper over 5–6 weeks.
Treatment Cont.
Cycloplegic Agent/MyDriatic Eye Drops Cycloplegic Agents:
- Indications: AAU, Exacerbation of CAU.
- Cyclopentolate (12–24 hours), Homatropine (3
days), Atropine (7–10 days), Phenylephrine 2.5% or
10%.

Mydriatic Eye Drops:

- Adrenaline + Atropine + Procaine. Acts as a local
anesthetic to improve comfort.

NSAIDs To reduce inflammation & pain:

- Ibuprofen, Aspirin, Naproxen, Tolmetin.

Immunosuppressive Therapy Last resort: Methotrexate, Azathioprine,

Mycophenolate mofetil, Cyclosporine.
Treatment Cont.
Antimicrobials Used in cases of infections.

Tissue Plasminogen Activator (TPA) For severe fibrinous anterior uveitis: 12.5–25 μg in
0.1 ml injected into AC.
References
- Yang, P. (2021). Complications and Their Management. In: Atlas of Uveitis. Springer, Singapore.
https://doi.org/10.1007/978-981-15-3726-4_11
- Weinberg RS. Anterior uveitis. Ophthalmol Clin North Am 1993; 6(1):23-8
- Salmon, John F. Kanski's Clinical Ophthalmology: A Systematic Approach. Elsevier, 2020.
SUBCONJUNCTIVAL
HEMORRHAGE
YASMIN NABILAH - 012020100020
 SUBCONJUNCTIVAL HEMORRHAGE
What is subconjunctival hemorrhage?

DEFINITION

A condition where blood leaks from small blood vessels beneath the
conjunctiva.

CAUSES

● Trauma
● Surgery
● Severe eye infections
● Mechanical straining (e.g violent coughing, sneezing, vomiting, lifting
heavy weights)
● Eye rubbing
SUBCONJUNCTIVAL HEMORRHAGE
ETIOLOGY & RISK FACTORS

Age-related association
● Younger individual
Use of contact lens.
● Older individual
Systemic vascular disease (e.g hypertension, diabetes mellitus).
Other risk factors
● Use of Aspirin or platelet-affecting medications.
● Rare association
➔ Bleeding diathesis
➔ Vitamin C deficiency
➔ Abusive trauma
SUBCONJUNCTIVAL HEMORRHAGE
CLINICAL PRESENTATION

Symptoms Signs

Usually asymptomatic but Unilateral

may present with
● Momentary sharp
pain Localised or diffuse
● Snapping or popping hemorrhage
sensation
Fresh bright red blood
under the conjunctiva
Red eye

Unaffected vision
SUBCONJUNCTIVAL HEMORRHAGE
DIFFERENTIAL DIAGNOSIS

Differential diagnosis of subconjunctival hemorrhage:

● Acute hemorrhagic conjunctivitis

● Periocular hematoma

● Retrobulbar hemorrhage
 SUBCONJUNCTIVAL HEMORRHAGE
Acute hemorrhagic conjunctivitis

A highly contagious viral eye infection that usually occurs in tropical area, typically caused by enterovirus
and coxsackievirus. It usually benign and may resolves within 1 to 2 weeks.
Symptoms
● Rapid onset of severe conjunctivitis
● Subconjunctival hemorrhage
Management
● Prevent undue alarm and discourage home remedies
● Control the spread
Complications (rare)
● Polio-like paralysis (about 1 in 10,000 cases)
 SUBCONJUNCTIVAL HEMORRHAGE
Periocular hematoma

Also known as “black eye” and is involves localized hematoma and/ or periocular ecchymosis (diffuse
bruising) due to blunt trauma.

Causes and association

1. Trauma to the globe or orbit
Leading to oedema and bruising, and the blood from the trauma may extend to subconjunctival space,
leading to subconjunctival hemorrhage.
2. Orbital roof fracture
SCH without a visible posterior limit suggests anterior extension of a posterior bleed.
3. Basal skull fracture
Characterized by bilateral ring hematoma “panda eyes”, including subconjunctival hemorrhage.
 SUBCONJUNCTIVAL HEMORRHAGE
Retrobulbar hemorrhage

A rare complication of retrobulbar anaesthesia in cataract surgery, where bleeding occurs in retrobulbar
space and caused subconjunctival hemorrhage as blood spreads under the conjunctiva.

Retrobulbar hemorrhage can cause increased in orbital pressure.

Criteria to perform cataract surgery

● Soft globe with easy retropulsion after digital massage
● Loose and mobile eyelids
● Surgery is cancelled in case of firm globe in a tense orbit with proptosis and tight lids

So, small incision cataract surgery can be safely performed following limited retrobulbar hemorrhage.
 SUBCONJUNCTIVAL HEMORRHAGE
INVESTIGATIONS

Clinical examinations Blood tests

● Visual Acuity ● Complete blood count

● Slit Lamp Examination ● Coagulation profile
● Intraocular pressure (IOP) Investigations

Imaging studies Systemic assessment

● CT scan of orbit ● Blood pressure monitoring

● MRI Additional tests ● Diabetes screening

● Autoimmune workup
SUBCONJUNCTIVAL HEMORRHAGE
MANAGEMENT

1. Reassurance and observation

2. Treat the underlying causes
➔ HPT - Antihypertensive medications
➔ Trauma
➔ Coagulopathy or anticoagulant use - monitor INR level, adjust the dosage
3. Symptomatic relief
➔ Artificial tears
➔ Avoid rubbing eyes
4. Lifestyle and preventive measures
➔ Avoid heavy lifting, strenuous activities
➔ Smoking cessation
5. Referral to specialist (ophthalmology, hematology, neurosurgery)
References
● Cionni RJ, Osher RH. Retrobulbar hemorrhage. Ophthalmology. 1991 Aug;98(8):1153-5. doi:

10.1016/s0161-6420(91)32158-4. PMID: 1923350.

● Kanski, J. J., Bowling, B., Nischal, K. K., & Pearson, A. (2020). Clinical ophthalmology: A

systematic approach (9th ed.). Elsevier. (Pg 178, 200-201, 892)

● Wright PW, Strauss GH, Langford MP. Acute hemorrhagic conjunctivitis. Am Fam Physician. 1992

Jan;45(1):173-8. PMID: 1309404.

ENDOPHTHALMITIS
LADY ANNIE - 012021100174
 Definition
It can be defined as an intraocular infection (e.g. bacterial or fungal) that affects the
inner coats of the eye associated with significant, progressive vitreous inflammation.

Classification
(based on route of infection)

Exogenous Endophthalmitis Endogenous Endophthalmitis

● Post-operative ● Hematogenous
● Trauma dissemination and spread
● Post-intravitreal injection from a distant infective
● Bleb-related source in the body.
 Risk factors

Systemic Local
● Diabetes mellitus ● Blepharitis, conjunctivitis,
● Host Immunosuppression dacryocystitis, lacrimal duct
● Use of immunosuppressive obstruction etc.
drugs (e.g. corticosteroids) ● Contact lens wearer
● Ocular prosthesis
● Trauma: Delay in primary
repair, retained IOFB , the
position and extent of
wounds.
 Risk factors
Operative risk factors
Intraoperative Postoperative

● Inadequate eyelid & ● Wound leak and dehiscence

conjunctival disinfection ● Inadequately buried sutures
● Inadequate draping of lid & ● Suture removal
lashes ● Vitreous incarceration in the
● Prolonged duration of surgical wound
surgery ● Occurrence of filtering bleb
● Presence of intraoperative
complications
● Contaminated surgical
instruments
 Risk factors
Operative risk factors

● Cataract surgery - the most commonly performed

intraocular surgery & most common surgery preceding
endophthalmitis.
● Intracapsular cataract extraction (ICCE) has a higher risk
compared to extracapsular cataract extraction (ECC) and
phacoemulsification.
● Clear corneal incision has a higher risk for postoperative
endophthalmitis.
 Aetiological agent
Postoperative endophthalmitis Acute (Onset is usually 1– 7d post-op)
● Coagulase negative staphylococcus e.g. Staphylococcus epidermidis
● Staphylococcus aureus

Chronic (Onset is usually several weeks to months post-op)

● Propionibacterium acnes
● Corynebacterium spp.

Post-traumatic endophthalmitis ● Bacillus cereus

● Staphylococcus spp.

Post-intravitreal injection ● Coagulase-negative staphylococcus

● Viridans streptococci

Bleb-related endophthalmitis (associated ● Haemophilus influenzae

with glaucoma filtering surgery) ● Streptococcus spp.

Endogenous endophthalmitis Bacterial

● Staphylococcus aureus
● Streptococcus spp.
● Gram-negative bacilli

Fungal
● Candida spp.
● Aspergillus spp.
Symptoms

● Blurring of vision
● Ocular pain
● Ocular redness
● Eye discharge
● Eyelid swelling
● Photophobia
Signs
● Visual acuity: decreased
● Eyelids swelling
● Conjunctival injection, chemosis and
discharge
● Corneal oedema
● Anterior chamber: Fibrinous exudate &
hypopyon
● Vitreous clouding (vitritis) - impaired
view of fundus
● Loss of red reflex
 Signs

Signs that may be seen in chronic postoperative

endophthalmitis:
● Low-grade anterior uveitis
● Keratic precipitates
● Vitritis
● Capsular plaques
Signs

Signs that may be seen in fungal

endophthalmitis:
● Fluffy, white infiltrate with
‘string-of-pearls’ appearance in
anterior chamber and vitreous humor
(Candidal endophthalmitis)
 Differential Diagnosis

Ddx for Acute Postoperative Endophthalmitis:

● Retained lens material (in the AC or vitreous) causing severe uveitis
● Vitreous haemorrhage
● Postoperative uveitis
● Toxic anterior segment syndrome (TASS)

Ddx for Chronic Postoperative Endophthalmitis:

● Other causes of anterior uveitis (e.g. idiopathic, sterile post-surgical
and chronic/recurrent viral infection)
 Investigations
Laboratory investigations
Imaging
● B-scan ultrasound ● Aqueous and vitreous
specimens: C&S, microscopy,
PCR
● C&S of conjunctival or corneal
swabs
● Systemic investigation e.g. blood
and urine culture (especially for
endogenous endophthalmitis)

Presence of dense, hyper-reflective echoes in the

vitreous cavity suggestive of exudates.
Membrane-like echo in the scan suggests
presence of a total retinal detachment.
 Management
Intravitreal antibiotics Topical antibiotics &
● Administered immediately Subconjunctival antibiotics
after culture specimens are injections
obtained (empirical)
● E.g. Vancomycin or ceftazidime
● Antibiotic combinations e.g.
● To treat possible ocular surface and
ceftazidime + vancomycin
anterior segment infection.

Systemic antibiotics
● Intravenous antibiotics of the same choice as
intravitreal antibiotics can be used in severe
virulent endophthalmitis.
● Alternatively, oral fluoroquinolones (penetrate
the eye well) and moxifloxacin is also
recommended.
● Oral clarithromycin - for culture negative
infections
 Management
Corticosteroids Topical Cycloplegics
● Limit destructive complications of the inflammatory ● E.g. atropine 1% - relieve
process. ciliary body spasms
● Topical (dexamethasone 0.1%), intravitreal
(dexamethasone), or systemic (Prednisolone
1mg/kg).
● Fungal infection to be excluded before Anti-glaucoma agents
administering prednisolone.
● E.g. timolol - reduce
intraocular pressure

Vitrectomy
● Immediate pars plana vitrectomy for patient with perception of light (not
hand movements vision or better) at presentation.
● It should also be considered if the clinical signs are worsening.
 Postoperative Endophthalmitis
Prophylaxis
5%
Treatment of pre-existing
povidone-iodine
infections
For the preparation of
skin and conjunctival
sac Early resuturing of
Scrupulous leaking wounds
preparation of the
surgical site Reviewing
personal surgical
practice
Antibiotic prophylaxis
e.g. Intracameral cefuroxime (1 mg
in 0.1 ml) injected into the
AC at the end of surgery.
 Management

Chronic postoperative
endophthalmitis
Intravitreal antibiotics
● Vancomycin is the antibiotic of choice.
● P. acnes is also sensitive to methicillin,
cefazolin and clindamycin.

Vitrectomy
● Often requires pars plana vitrectomy
and removal of the capsular bag and/or
IOL.
● Secondary IOL implantation may be
considered at a later date.
 Management
Fungal Traumatic
endophthalmitis endophthalmitis
Antifungal ● Open globe injuries: Give
● Intravenous amphotericin-B in prophylactic antibiotics (e.g.
combination with oral flucytosine ciprofloxacin 750 mg twice daily or
(resistance is a concern). moxifloxacin 400 mg once daily)
● Voriconazole (orally or intravenously) - together with topical antibiotic,
broad spectrum antifungal with low steroid and cycloplegia.
reported resistance and high ocular ● High-risk cases (e.g. agricultural
penetration. injuries): Give prophylactic
● Adjunctive intravitreal treatment may be intravitreal antibiotics
given(100 µg in 0.1 ml). ● Prompt removal of a retained IOFB.
● Treatment for established cases is
Pars plana vitrectomy the same as for acute postoperative
● Consider vitrectomy at an early stage, bacterial endophthalmitis.
especially for severe or unresponsive
disease.
 Complications

● Panophthalmitis
● Phthisis bulbi
● Retinal necrosis
● Retinal detachment
● Secondary glaucoma
 References
● Salmon, J. F. (2020). Kanski’s Clinical Ophthalmology (9th ed.). Elsevier.
● Clinical Practice Guidelines: Management of Post-operative Infectious
Endophthalmitis (2006)
● Durand, M. L. (2013). Endophthalmitis. Clinical Microbiology and Infection, 19(3),
227-234.
● Kernt, M., & Kampik, A. (2010). Endophthalmitis: pathogenesis, clinical presentation,
management, and perspectives. Clinical Ophthalmology, 121-135.
● Sadiq, M. A., Hassan, M., Agarwal, A., Sarwar, S., Toufeeq, S., Soliman, M. K., ... &
Nguyen, Q. D. (2015). Endogenous endophthalmitis: diagnosis, management, and
prognosis. Journal of ophthalmic inflammation and infection, 5, 1-11.
 Pterygium
THIVYAN KANNAN - 012021100121
 Background
● A pterygium is a triangular fibrovascular sub-epithelial ingrowth of degenerative bulbar conjunctival tissue
that grows over the limbus onto the cornea.
● Nasal part of bulbar conjunctiva more commonly affected than temporal par

Etiology
● Primarily driven by ultraviolet (UV) radiation exposure, which damages limbal stem cells,
alters fibroblast behavior, and induces inflammatory responses, leading to tissue remodeling
and progression of the condition.
● Hereditary, with different inheritance patterns suggested, including genes like MMP-1 and
factors related to blood vessel growth; microRNAs may also play a role, but the exact
genetic causes are still not fully understood.
● Viral agents, particularly human papillomavirus (HPV) and herpes simplex virus (HSV), may
play a role in the development of pterygium in genetically susceptible individuals
 Risk factors
● Ultraviolet (UV) Exposure:
● Environmental Factors:
● Lifestyle/ Occupational Factors
● Genetic Predisposition
● Sex : Male:Female = 2:1

Histology showing collagenous

degenerative changes in vascularized
subepithelial stroma
Stocker’s line
Clinical Features

Symptoms Signs
● Mostly small lesions are ● Triangular pinkish growth
asymptomatic ○ Base: lies within the interpalpebral
● Irritation and a gritty sensation, conjunctiva
● Foreign body sensation ○ Apex: encroaches upon the cornea
● Congestion, dryness ● Diplopia on Lateral Gaze
● Visual disturbance ● Acquired Astigmatism
● Impaired vision
 Types of pterygium
Progressive Atrophic
● Thick, fleshy with prominent ● Thin, Attenuated, with poor
vascularity vascularity
● Gradually increasing in size and
encroaching towards the centre of ● No opaque spot (cap) is seen
the cornea ● Stationary
● Opaque infiltrative spot (cap) seen ● Ultimately it becomes
just in front of the apex of the membranous but never
pterygium
disappears
● Deposition of iron as a line
(Stocker's line) is seen in corneal
epithelium infrage 16 of the apex.
Progressive Atropic
Clinical Classification
 Tan’s Classification of pterygium

Mild Pterygium Moderate Pterygium Severe pterygium

Clearly visible episcleral blood Partially visible episcleral blood Totally obscured episcleral blood
vessels under the body of the vessels under the body of the vessels under the body of the
pterygium pterygium. pterygium
 True Pterygium Pseudopterygium

Typically grows horizontally, often nasally Can occur anywhere along the corneal
Site
periphery

Progressive, can invade Bowman’s layer Non-progressive, does not invade deeper
Growth pattern
layers

Adherence Firmly adherent to the limbus May have free edges,can pass a probe underneath

Degenerative condition, often due to UV Inflammatory condition, often due to trauma

Etiology exposure or ulcers

Age Common in adults Any age group

 Differential Diagnosis
Complications ● Pinguecula
● Visual Impairment ● Nodular Episcleritis,
● Corneal Astigmatism ● Phlycten
● Subconjunctival Fibrosis ● Conjunctival carcinoma in situ (Bowen's
● Ocular surface squamous Disease)
neoplasia ● Limbal tumors like
○ Limbal Dermoid.
Medical Management
● Symptomatic Treatment: Similar to pinguecula, patients are advised to wear sunglasses to minimize UV
exposure. Topical NSAIDS for short term comfort. Vasoconstrictive agents to minimize redness

Surgical Management
1. Simple Excision (Bare Sclera Technique):
● High recurrence rate (~80%).
● Leaves bare sclera after removal.
2. Conjunctival Autografting:
● Uses a graft from the superior or upper-temporal conjunctiva.
● Can be secured with sutures or tissue glue, reducing irritation and recovery time.
● Lower recurrence rates compared to simple excision.
3. Adjunctive Treatments:
● Mitomycin C (MMC): Reduces recurrence risk.
● Beta-irradiation: Alternative adjunctive therapy.
4. Peripheral Lamellar Keratoplasty:
● Indicated for deeper lesions.
References
● Kanski, J. J., Bowling, B., Nischal, K. K., & Pearson, A. (2020). Clinical ophthalmology: A
systematic approach (9th ed.).
● Shahraki, T., Arabi, A., & Feizi, S. (2021, May 31). Pterygium: An update on
pathophysiology, clinical features, and Management. Therapeutic advances in
ophthalmology.
https://pmc.ncbi.nlm.nih.gov/articles/PMC8170279/#section11-25158414211020152
● Shahraki, T., Arabi, A., & Feizi, S. (2021b, May 31). Pterygium: An update on
pathophysiology, clinical features, and Management. Therapeutic advances in
ophthalmology.
https://pmc.ncbi.nlm.nih.gov/articles/PMC8170279/#section11-25158414211020152