Patient

GP/55/M
A case of
Endophthal
mitis
 CHIEF COMPLAINT:
t eye pain and swelling of 5 days duration.

HISTORY OF PRESENT ILLNESS

55-year old male married, Roman Catholic,

Electrician
Hypertensive
Polycystic kidney disease
S/P pars plana vitrectomy in 2015
1-week PTA, sudden persistent, heavy left
eye pain (5/10).
Recurring every 2 hours
associated with hyperemia
self-medicated with Paracetamol
500mg/tab, every 4 hours , temporary
 the patient lifted
3 Days heavy objects
PTA eye pain 10/10
associated with fronto-
parietal headache.

Sought consult at
the UERM-ER
worsening hyperemia,
and immediately
discharge, matting,
seen by Dr. De
with slightly
Grano
edematous
conjunctiva on the
left.
Prescribed with Acetazolamide 250mg
thrice a day; and Timolol eye drops twice
a day, partial relief of symptoms.
 Few
Hours symptoms persisted
unable to tolerate left
PTA eye pain. (10/10).

Consult and associated with

subsequent frontoparietal
admission. headache, peri-
orbital swelling,
nausea and vomiting,
sweating, and
edematous
conjunctiva
(+) Headache (-) Bowel movement changes (-) Decrease
urinary frequency
 Past
Medical
History
2006 Diagnosed with HTN and CVD stroke; with
highest SBP of 200mmHg. Admitted at PGH and was
given Losartan 50mg, OD, and Amlodipine 500mg,
BID; UERM

2009-Polycystic kidney disease , UERM

2010 Had a tricycle accident, patient was seen in

Community Paranaque Hospital, needed sutures near
the right eye brow line.

2015-Started Hemodialysis due to Polycystic kidney

disease
 Family
History
(+) HTN and CVD Patients mother and
maternal grandmother
(+) Epilepsy Patients second grandson

Social
History
Frequent smoker and alcoholic drinker
stopped since 2006 when he was diagnosed
with HTN and CVD stroke
Non-alcoholic drinker
Functional Class 2: (+) chest pain in walking
long distances
 Differentia
ls
Sinusitis Glaucoma
Blepharitis Optic Neuritis
Conjunctivitis Uveitis
Corneal Iritis
Infection/Keratiti Preseptal
s Cellulitis
Episcleritis Orbital Cellulitis
Scleritis Endophthalmitis
BLEPHARITIS

BLEPHARITIS: inflammation of the lid margin

If the cause is viral, there is tearing but may or
may not present with discharge
If bacterial, there is copious, mucopurulent
discharge presenting with mattering of the eye.
Usual etiologic agent is Staphylococcus

R/O because it cannot explain the severity of the

illness, only explains the discharge and redness
CONJUNCTIVITIS

start out as hyperemia with tearing

copious purulent discharge.
pre-auricular node
HYPEREMIA: clinical sign of acute conjunctivitis
CONJUNCTIVAL CONGESTION : Redness in the
periphery: infectious
WATCH OUT FOR:
Petechial hemorrhages: Consider Strep Pneumoniae,
H.Aegyptius (Koch-weeks conjunctivitis)
Subconjunctival hemorrhage: suspect adenovirus
Acute hemorrhagic conjunctivitis: picornavirus
Pale whitish discharge: consider allergy
CHEMOSIS: patient feels that there is plastic enclosed on
his eye
Common: Gonococcus
CORNEAL INFECTIONS/KERATITIS
Rapid onset pain
Conjunctival injection
Photophobia
Decreased vision

Risk Factors:
Corticosteroid use
Contact lens wearers
Previous corneal surgery

This explains the acute onset of the illness and the

start of the infection of the patient however
cannot fully explain other manifestations
MAIN SIGNS OF CORNEAL DISEASE
Corneal opacification due to hereditary defects,
trauma, infections or degeneration
Neovascularization commonly seen in infections
and trauma; leads to decreased visual acuity
(decrease in vision)
Edema build-up of fluid or swelling due to damage
to the endothelial and epithelial layer
Ulceration infective condition disrupting the
epithelial layer
Pigmentation ferritin deposited in the widened
intracellular spaces

MAIN SYMPTOMS OF CORNEAL DISEASE

Iridescent vision there will be halos or glare due
to epithelial and endothelial edema
Reduced visual acuity interference with
EPISCLERITIS
Benign inflammatory condition affecting deep
subconjunctival connective tissue and superficial
scleral lamellae
localized to the episclera and Tenons capsule
Mostly unilateral (2/3 of cases)
Dense lymphocytic infiltration

Acute redness , Mild pain , No discharge

Redness is usually localized, but may be diffuse or nodular
Dilated episcleral vessels
Mild tenderness and irritation
Straight radial inflamed vessels
Salmon pink and movable vessels
Blanches with adrenergic agents as opposed to scleral
vessels
SCLERITIS
immune-mediated vasculitis that frequently leads
to destruction of the sclera
Symptoms are usually gradual, extending over
several days
Boring or piercing ocular pain, which worsen at
night and awaken them from sleep
Pain may be referred to other regions of the head
and and face
Globe is tender on tonometry
Sclera with violaceous hue
inflammed scleral vessels, cannot be moved with
cotton-tipped applicator
Scleral edema often with overlying episceleral
edema
UVEITIS
Inflammation associated with uveitis may affect
only the front of your eye (anterior uveitis) or
the back of your eye (posterior uveitis). Uveitis
can also affect all three layers of the uvea
(panuveitis).
Uveitis is most common in people ages 20 to 50.
The most common type of uveitis is anterior
uveitis. Inflammation of the iris is called iritis or,
if it also involves the ciliary body, iridocyclitis.

SYMPTOMS OF UVEITIS:
Eye pain
Light sensitivity (photophobia)
Decreased/blurred vision
Dark, floating spots in your field of vision
CAUSES OF UVEITIS
Autoimmune disorders, such as rheumatoid arthritis or
ankylosing spondylitis
Inflammatory disorders, such as Crohn's disease or
ulcerative colitis
Infections such as syphilis, toxoplasmosis or tuberculosis
Eye injury
Certain cancers, such as lymphoma, that masquerade as
uveitis (called masquerade syndromes)
nterior Uveitis
nilateral, acute
ain, photophobia, blurred vision
ircumcorneal redness with minimal injection of the conjunctiva or discha
iosis
ecreased corneal sensation (Herpetic uveitis due to HSV or VZV or lepros
creased IOP (HSV, VZV, CMV, toxoplasmosis, syphilis, sarcoidosis)
eratic precipitates
is nodules
ypopyon
is atrophy or transillumination
nterior or posterior synechiae
Intermediate
Uveitis
Bilateral
Vitreous inflammation (hallmark)
Floaters
Blurred vision
Vitritis
Vitreous condensates
Panuveitis
Posterior Uveitis
Retinitis, choroiditis, retinal
vasculits, papillitis
Floaters
Loss of visual field or scotoma
Decreased vision
Retinal detachment
Ocular injection , Pain , Hypopyon
Granuloma formation
Glaucoma
Vitritis
GLAUCOMA

A change in the IOP may be high, low or

normal; as long as it is not tolerated by the
eye.

Arcuate field defect first starts superiorly, then

inferiorly, producing tunnel vision; due to pressure
on nerve; lose ability to detect light in certain
areas; leave thumbmark image

Tunnel vision/Central Island vision in

glaucoma: if undetected, can lead to total
blindness and is already irreversible.
Requires at least 2 of the 3 criteria to be
classified as glaucoma:
1. Abnormal eye pressure (structural damage) Normal:
10-21 mmHg. 95% who have glaucoma have IOP greater than
the normal values.

2. Optic nerve damage (functional damage) Since the

optic nerve is the weakest part of the eye, this part shows
cupping upon fundoscopy. However,
technology is not accurate enough to detect minimal changes in
optic nerve damage. A definite impairment on the activities is
necessary, a video diagnosis which requires several visits to
determine the problem.

3. Visual field damage (functional damage) arcuate vision

field defect, tunnel vision
OPTIC NEURITIS
Main signs and symptoms:
Acute blurring of vision, within 1-5 days of the
swelling (unlike Papilledema)
Loss of vision is the cardinal symptom of optic neuritis
and is particularly useful in differentiating papillitis
from papilledema.
Dull headache on the same side
Eye pain with movement of eyes .
Relative Afferent Pupillary Defect (RAPD) or
Marcus Gunn Pupillary escape phenomenon (only
if UNILATERAL)
Red color desaturation on Isihara test chart which
is a sign of optic nerve disease
Patient presenting with acute visual loss with RAPD
and Red color desaturation= Optic nerve problem
RESEPTAL VS ORBITAL CELLULITIS
 PERI-ORBIITAL CELLULITIS ORBIITAL CELLULITIS
ANATOMY Infection anterior to the Infection posterior to the orbital
orbital septum including septum
eyelids and surrounding
tissues
EPIDEMIOL Usually patients <5y/o ; Average 6.8 years (1 week to
OGY more common than orbital 16 years), 2:1 (male: female)
cellulitis
PATHOGENE Extension of the external Extension of rhinosinusitis, URI,
SIS ocular infection or superficial dental abscess, hematogenous
break in skin (hematogenous spread
spread)
MICROBIOL Hib, Staph aureus, Staph Hib, Staph aureus, Staph
OGY epidermidis, S. pyogenes epidermidis, S. pyogenes, Strep
species
PRESENTATI Unilateral erythema, Same, along with blurred
ON swelling, warmth and vision, ophthalmoplegia,
tenderness of the eyelid proptosis, chemosis
MAJOR Painful, swollen lid extending Painful, swollen lid that stops at
MANIFESTA beyond orbital rim, normal orbital rim, decreased vision,
TIONS/DIFF vision, full EOMs, white restricted ocular motilities,
ERENTIATIN
conjunctiva, no proptosis, no proptosis, malaise ad=nd fever
G FACTORS
fever
DIAGNOSIS Clinical, wound and blood Clinical, wound and blood
GS/CS GS/CS, CT: diffuse fat
ENDOPHTHALMITIS
When intraocular inflammation involving both the
posterior and anterior chambers is attributable to
bacterial and fungal infection. The retina and the
choroid may be involved and occasionally there is
concomitant infective scleritis or keratitis.
Chronic post-operative endophthalmitis has multiple
recurrences of chronic indolent inflammation of the
eye. The recurrent indolent inflammation may occur
at any point during the post-operative course, as
early as 1-2 weeks after surgery, but it is often
delayed by many weeks to months and sometimes
years.

Chronic post-operative bacterial endophthalmitis is

 Endogenous
Endophthalmitis
This is caused by hematogenous dissemination of
bacterial organisms resulting in intraocular infection.
This is an uncommon entity and accounts for less
than 10% of all forms of endophthalmitis
Predisposing conditions include diabetes mellitus,
systemic malignancy, sickle clee anemia, SLE and HIV
The most common gram (+) organisms are
Streptococcus species, Staph aureus, and Bacillus
species. While for gram (-) are Neisseria meningitidis,
Haemophilus influenzae, and Escherichia coli and
Klebsiella species
In Asia, infection from Klebsiella species in liver
abscess is the common cause of endogenous
Postoperative endophthalmitis
is an inflammatory condition of the eye, presumed to be due to
an infectious process from bacteria, fungi or, on rare occasions,
parasites that enter the eye during the perioperative period.

Clinical symptoms
Acute Onset of pain
Photophobia
Blurred vision
Reduced visual acuity
Periorbital and eyelid edema
Fibrin in the Anterior chamber
Hypopyon
Vitreous inflammation and vitreous
cells
Small microabscess in the retina or
subretinal space and white
centeredretinal hemorrhages (Roth
 DIAGNOSTICS
Anterior chamber paracentesis and
vitrectomy with vitreous and aqueous cultures
Gram stain and Giemsa stain
Blood and other body fluid cultures

TREATMENT
Intraviteal antibiotics for several weeks
Systemic antibiotics for >6 weeks
Surgery if the infections