dr. M. Yusran, M.Sc.

, SpM
Department of Ophthalmology
Faculty of Medicine Universitas Lampung
 Isinflammation of the eyelid
 Blepharitis can be classified according to
anatomic location:
• anterior blepharitis affects the eyelid skin, base
of the eyelashes and the eyelash follicles
• posterior blepharitis affects the meibomian
glands and gland orifices.
 Risk Factors
• Dry eyes
• Dermatologic condition
• Demodicosis
• Rosasea
• Isotretinoin
• Giant papilary conjunctivitis
 Blepharitis has traditionally been
clinically subcategorized
• Staphylococcal
• Seborrheic
• meibomian gland dysfunction (MGD)
• or a combination thereof
 Symptoms and signs (e.g., redness, irritation, burning, tearing,
itching, crusting of eyelashes, loss of eyelashes, eyelid sticking,
blurring or fluctuating vision, contact lens intolerance,
photophobia, increased frequency of blinking)
 Time of day when symptoms are worse (worsening of the
symptoms in the morning is typical of blepharitis, whereas
symptoms that worsen later in the day are typical of aqueous
deficient dry eye)
 Duration of symptoms
 Exacerbating conditions (e.g., smoke, allergens, wind, contact
lenses, low humidity, retinoids, diet and alcohol consumption, eye
makeup)
 Symptoms and signs related to systemic diseases (e.g., rosacea,
allergy)
 Current and previous systemic and topical medications (e.g.,
antihistamines or drugs with anticholinergic effects, or drugs used
in the past such as isotretinoin that might have an effect on the
ocular surface)
 Recent exposure to an infected individual (e.g., pediculosis
palpebrarum [Phthirus pubis])
 Staphylococcus Blepharitis
Staphylococcal blepharitis

• Chronic irritation worse in mornings • Hyperaemia and telangiectasia of

anterior lid margin
• Scales around base of lashes
• Scarring and hypertrophy if longstanding
(collarettes)
 Parasitic blepharitis

Phthiris pubis Demodex folliculorum

 Culture if recurrent disease or
unresponsive to treatment
 Microscopic evaluation in demodex mite
 Biopsi to rule out carcinoma
 Warm compresses
 Eyelid cleansing, including eyelid massage
in cases of MGD to express the meibomian
glands
 Antibiotics (topical and/or systemic)
• Tetracycline eye ointment
• Doxycycline 100 mg or tetracycline 1000 mg in
divided doses
 Topicalanti-inflammatory agents (e.g.,
corticosteroids, cyclosporine) in severe
inflamation
Eyelid
Hordeolum
chalazion
 Tratment
• Warm compress
• Topical antibiotic
• Incision and drainage if needed
 Education
• Eye lid hygiene
 Conjunctivitis, or inflammation of the
conjunctiva, is a general term that refers
to a diverse group of diseases/disorders
that affect the conjunctiva primarily.
 Conjunctivitis can be classified as
• Infectious or noninfectious
• Acute, chronic, or recurrent.
 The causes of infectious conjunctivitis
include
• viruses
• bacteria.
 The types of noninfectious conjunctivitis
are
• Allergic
• mechanical/irritative/toxic
• immune-mediated
• neoplastic.
 Itching
• Main symptom in allergic conjungtivitis
 Discharge
• discharge may range from serous (watery)to
mucopurulent and grossly purulent.
 Unilateral Versus Bilateral Conjunctivitis
• The majority of cases present unilaterally with the
second eye becoming involved within a few days
• Unilateral follicular involvement accompanied by a
nontender, palpable preauricular lymph node is
suggestive of adult inclusion disease.
• Chronic unilateral conjunctivitis :lacrimal duct
obstruction, a retained foreign body, drug-induced
disease, molluscum contagiosum, dural sinus fistula,
and a masquerade syndrome
 Appearance of Conjunctiva
• A velvety, beefy-red conjunctiva suggests a
bacterial
• “Milky” appearance – is characteristic of allergy
• Subconjunctival hemorrhages are more
frequently seen with viral infections
• An inflammatory membrane can be seen with
any severe bacterial infection, including
Neisseriu and Streptococcus pyogenes, but today
is more characteristic of adenovirus, herpes
simplex and Stevens-Johnson syndrome
 Lymphadenopathy
• a small tender preauricular or submandibular
lymph node is present in viral and inclusion
conjunctivitis.
• A palpable node rarely occurs in acute bacterial
infections but may be seen with a hyperacute
conjunctivitis due to neisseria or a chronic
moraxella or chlamydial infection.
SEASONAL CONJUNCTIVITIS ATOPIC CONJUNCTIVITIS
 GIANT PAPILARY
VERNAL COJUNCTIVITIS CONJUNCTIVITIS
SEVERE CASE OF HERPES SIMPLEX VIRUS
CONJUNCTIVITIS VIRAL CONJUNGTIVITIS
HERPES ZOSTER
GONOCOCCAL NONGONOCOCCAL
CONJUNCTIVITIS CONJUNCTIVITIS
 AN EARLY KAPOSI SARCOMA
“MASQUERADE” CAUSE (E.G.,
SEBACEOUS CARCINOMA) OF LESION OF THE EYELID SKIN IN A
CHRONIC CONJUNCTIVITIS PATIENT WITH AIDS
 Allergic conjunctivitis
• Allergen avoidance
• Anti Histamine
• Mast cell stabilizer
• Corticosteroid
 Superior Limbic Keratoconjunctivitis
• lubricants, mast-cell stabilizers, cyclosporine,62
soft contact lenses, and/or punctal occlusion
 Contact
Lens-Related
Keratoconjunctivitis
• topical corticosteroid
 Floppy Eyelid Syndrome
• taping the patient’s eyelids shut or by having the
patient wear a protective shield while sleeping
 Adenoviral Conjunctivitis
• artificial tears, topical antihistamines, or cold
compresses may be used to mitigate symptoms.
• Available antiviral agents are not effective in treating
adenoviral conjunctivitis
 Herpes Simplex Virus Conjunctivitis
• oral acyclovir 200 to 400 mg five times per day
 Varicella (Herpes) Zoster Virus
Conjunctivitis
• oral antivirals are recommended at a dose of 800 mg
five times daily for 7 days for acyclovir
 Bacterial Conjunctivitis
• Use of topical antibacterial therapy is associated
with earlier clinical and microbiological
remission compared with placebo in days 2 to 5
of treatment
Corneal Ulcers
 Microbial Corneal Ulcers

Bacteria Fungi Viral Parasite

• Staphylococcus • Fusarium • Herpes • Acanthamoeb

• Streptoccocus • Aspergillus simplex a
• Pseudomonas • Candida • Herpes zoster
• Enterobacteriaceae
Incidence of Bacterial Corneal Ulcers

• More than 500,000 patients of bacterial

corneal ulcers develop annually
worldwide
• Trauma the most common of risk factor
• Contact lens wear noted in 19-42%,
extended wear lenses increase the risk
 Diagnosis of Corneal Ulcers

• History
• Clinical appearance
• Microbiologic work-up
 Bacterial Corneal Ulcers

Most Common Organisms :

• Staphylococcus (29%)
• Pseudomonas (22%)
• Acinettobacter (15%)
• Streptococcus (12%)
• Enterobacteriaceae
• Klesiella (9%)
• Enterobacter (7%)
• Proteus (6%)

Clusters: Staphylococcus Chain: Streptococcus

aureus pneumoniae
 History

• Corneal epithelial trauma

• Contact lens wear
• Bacterial conjunctivitis/blepharitis
• Keratoconjunctivitis sicca
• Misdirected lashes/entropion
• Decreased immunologic defenses
• Foreign body
• History of previous corneal disease/
steroid use
 Examination

• Epithelial defect,stromal tissue loss,

infiltration, edema (descemet`s
folds)
• Anterior chamber reaction
• Conjunctival hyperemia
• Upper lid edema
• Mucopurulent exudate,
 Culture

• Slides for Gram and Giemsa stain

• Culture by direct inoculation of
plates
• Blood/thioglycollate/Saboraud
agar plates
• Kimura spatula
• If deep infiltrate, consider
superficial keratectomy/corneal
biopsy
 Management

Initial therapy :
• Broad-spectrum antibiotics

Modified therapy based on :

• Organism identify
• In vitro sensitivities
• Clinical response
Fungal Corneal ulcers

• Filamentous
• Septae
• Non-septae
• Yeasts
• Diphasic (rare)
Principal Causes of Fungal Corneal ulcers

Virulent
• Fusarium
• Aspergillus
• C.albicans

Less virulent
• Curvularia
• Alternaria
• Phialophora
• Other Candida
 Fungal Corneal Ulcers

Risk Factors :

• Corneal injury, frequently by tree branches or

vegetative material
• Topical corticosteroid therapy, after corneal
transplantation with steroid usage
• Soft contact lens wear (15%)
• Systemic immunosuppression : diabetes,
alcoholism
• Connective tissue diseases : Sjogren`s syndrome
 Therapeutic Advances in Fungal
Ulcers
Imidazoles :
• Synthetic, broad spectrum, fungistatic
• Potency less than Amphotericin B
• Lower toxicity than Amphotericin B
• Ketoconazole, miconazole, Itraconazole, fluconazole,
voriconazole.
• Fluconazole and voriconazole has much greater
corneal penetration than Amphotericin B and
Natamycin
 Therapeutic Advances in Fungal
Ulcers Fusarium corneal ulcers
Natamycin (Pimaricin) :

• Topical 5% suspension
• Poor penetration
• Less efective in deeper keratomycosis
• Topical : hourly for initial 24 hours.
• Maintenance therapy for 5-7 days, and taper
based on clinical response.
 Therapeutic Advances in Fungal
Ulcers

Amphotericin B :

• Polyene antibiotic
• Highly toxic to ocular surface
• Topical : 15-30 minutes for 24 hours, then
every hour.
• Maintenance therapy for 5-7 days, and
taper based on clinical response.
 HSV
 Dendriticlesion
 Treatment:
• Topical antivirus
 Corneal ulcer can occur due to various
protozoa, of which Acanthamoeba is the
most notorious.
 Other protozoa: Microsporidia
 Risk factors for Acanthamoeba keratitis:
- Contact lens wearers
- Contaminated water/solutions
- Corneal trauma
 Severe pain, radial keratoneuritis
• Stromal infiltrates: pseudodendritic
• Stromal haze: intense immune ring
 Diamidines: propamidine, hexamidine

 Biguanides: polyhexamethylene biguanide

(polyhexanide), chlorhexidine
 Aminoglycosides: neomycin, paromomycin

 Imidazoles/triazoles: miconazole,

ketoconazole, itraconazole