NOTES

NOTES
EYE INFECTIONS

GENERALLY, WHAT ARE THEY?

PATHOLOGY & CAUSES DIAGNOSIS
▪ Ocular disorders with infectious, DIAGNOSTIC IMAGING
noninfectious etiologies → inflammation, ▪ Fundoscopy
damage to eye structures
CT scan/MRI
▪ Orbits, sinuses
RISK FACTORS
▪ Immunocompromised state, contact with
infectious agent, ocular trauma, certain LAB RESULTS
systemic diseases ▪ Giemsa/Gram stains; cultures

COMPLICATIONS OTHER DIAGNOSTICS

▪ Range from benign, self-limiting to vision- ▪ Snellen chart
threatening infections

TREATMENT
SIGNS & SYMPTOMS
MEDICATIONS
▪ Structural damage, functional impairment ▪ Antimicrobials

OTHER INTERVENTIONS
▪ Address comorbidities

OSMOSIS.ORG 585
 CHALAZION
osms.it/chalazion
may demonstrate diffuse inspissation of
PATHOLOGY & CAUSES yellowish contents from eyelid margin
orifices
▪ Firm, painless lipogranulomatous
inflammatory lump in eyelid; caused by
blockage of ocular sebaceous glands
▫ Deep chalazion: inflammation of
meibomian sebaceous glands
▫ Superficial chalazion: inflammation of
Zeis sebaceous glands
▪ Gland obstruction → impissation
(decreased flow of secretions) →
granulomatous inflammatory response →
lipogranuloma inflammation → lesion forms
on upper (most common)/lower eyelid
▪ Slow growing; may persist for weeks/
months; deeper within eyelid than
hordeolum (stye)

RISK FACTORS Figure 76.1 A chalazion of the left upper

▪ Rosacea, seborrhea, blepharitis, inflamed eyelid.
hordeolum

COMPLICATIONS
▪ If large chalazion presses on cornea →
visual changes
▪ Recurring chalazion: may signal carcinoma
(rare)

SIGNS & SYMPTOMS

▪ Eyelid erythema; swelling; firm, nodular,
rubbery consistency
Figure 76.2 The histological appearance
DIAGNOSIS of a chalazion. There is granulomatous
inflammation with giant cells, numerous
macrophages as well as neutrophils and
OTHER DIAGNOSTICS eosinophils surrounding a nidus of lipid.
▪ Clinical history, physical examination
▪ Histological examination: chalazia may
indicate eyelid carcinoma

Slit-lamp
▪ Determine status of meibomian glands;

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OTHER INTERVENTIONS
TREATMENT ▪ Warm, wet compresses encourage
drainage
MEDICATIONS
▪ Ocular cleansing pads applied to eyelid
▪ Recalcitrant chalazia: intralesional steroid
margin
injection
▪ Treat comorbidities (e.g. blepharitis,
rosacea)
SURGERY ▪ Small chalazion may resolve on own
▪ Recalcitrant chalazia: incision, curettage

CHORIORETINITIS
osms.it/chorioretinitis

PATHOLOGY & CAUSES SIGNS & SYMPTOMS

▪ Inflammation of choroid, retina; AKA ▪ Floaters (vitritis), blurred vision, impaired
posterior uveitis color/night vision, ocular pain, photophobia,
excessive lacrimation
CAUSES
Infectious DIAGNOSIS
▪ Bacterial: tuberculosis, syphilis
DIAGNOSTIC IMAGING
▪ Viral: cytomegalovirus, West Nile virus,
herpes simplex virus (HSV) 1 Fluorescein angiography
▪ Parasitic: toxoplasmosis, onchocerciasis ▪ Irregularities
▪ Fungal: Candida albicans
Fundoscopy
Noninfectious ▪ Creamy white/yellow/gray lesions; keratic
▪ Sarcoidosis, Behçet’s disease, traumatic precipitates; retinal edema, necrosis;
chorioretinitis chorioretinal atrophy, neovascularization;
cotton-wool infiltrates (Candida-associated
chorioretinitis); polymorphic retinochoroidal
RISK FACTORS
scars (toxoplasmosis-associated
▪ Immunodeficiency, contact with infectious chorioretinitis)
agent, traumatic eye injury, systemic
disease associated with chorioretinitis
OTHER DIAGNOSTICS
▪ Clinical history, physical examination
COMPLICATIONS
▪ Retinal hemorrhage/detachment, visual
impairment with macular involvement TREATMENT
MEDICATIONS
▪ Corticosteroids/antimicrobials

OSMOSIS.ORG 587
 Figure 76.3 A retinal photograph displaying
the features of chorioretinitis. There are
numerous, patchy, cream-colored lesions and
retinal edema.

CONJUNCTIVITIS
osms.it/conjunctivitis
▪ Common causes: Staphylococcus aureus,
PATHOLOGY & CAUSES Streptococcus pneumoniae, Haemophilus
influenzae
▪ Inflammation of conjunctiva, transparent
▪ Hyperacute bacterial conjunctivitis
mucous membrane covering inside of
eyelids (tarsal conjunctiva), globe (bulbar ▫ Causes: Neisseria gonorrhoeae (most
conjunctiva) common)/Neisseria meningitidis
▫ Non-keratinized epithelium containing ▫ Oculogenital disease: usually
goblet cells, highly vascularized transmitted from genitals to eyes via
substantia propria hands
▫ Turns pink/red when inflamed: diffuse ▫ Vision-threatening
conjunctival injection ▪ Chlamydial
▪ Infection, inflammation → dilatation ▫ Caused by Chlamydia trachomatis
of conjunctival vessels → conjunctival ▫ Adult inclusion conjunctivitis: chronic,
hyperemia, edema → inflammatory indolent
discharge ▫ Trachoma: infectious blindness cause
worldwide; active trachoma caused
TYPES by serotypes A, B, Ba, C (low-income
country-endemic, mostly in children);
Infectious (bacterial) initial follicular inflammation progresses
▪ Highly contagious; spread by direct contact in severity → cicatricial disease, vision
loss

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Infectious (viral) ▪ Infected eye “stuck” shut from morning

▪ Highly contagious; spread by direct contact crusting; gritty, burning sensation (viral);
▪ Causes: adenovirus (most common), HSV itching (allergic); photophobia (corneal
(in children), varicella zoster virus (VZV) involvement); transient visual impairment
▫ Ocular manifestation of systemic ▪ Preauricular lymphadenopathy
infection
▫ Epidemic keratoconjunctivitis (EKC):
caused by adenovirus 8, 19, 37;
fulminant conjunctivitis, keratitis
(epithelium of conjunctiva, cornea);
corneal inclusions degrade visual acuity

Noninfectious (allergic)
▪ Caused by airborne allergens (seasonal,
perennial)
▪ Immunoglobulin E (IgE)-mediated → local
mast cell degranulation
Figure 76.4 The clinical appearance of
Noninfectious (nonallergic) conjunctivitis.
▪ Caused by mechanical/chemical insult

RISK FACTORS DIAGNOSIS

▪ Exposure to causative agent,
immunocompromised state, atopy (allergic LAB RESULTS
conjunctivitis) ▪ Adenoviral conjunctivitis: rapid point-of-
▪ Contact lens wear: common source of care adenovirus antigen test
mechanical injury, nonallergic, infectious ▪ Recalcitrant conjunctivitis: conjunctival
conjunctivitis biopsy (rule out neoplasm)

Giemsa/gram stains
COMPLICATIONS ▪ Confirm identity of organism in suspected
▪ Cornea: keratitis (inflammation), ulcer, infectious cause
perforation, scarring
▪ Dacryocystitis (bacterial infection of lacrimal
sac) OTHER DIAGNOSTICS
▪ Vision loss ▪ Clinical history, physical examination

SIGNS & SYMPTOMS TREATMENT

▪ Appearance: unilateral/bilateral
MEDICATIONS
inflammation; pinkish-red eye; eyelid ▪ Ocular lubricant drops/ophthalmic ointment
edema; chemosis (conjunctival edema); ▪ Allergic conjunctivitis: antihistamine drops
excessive lacrimation ▪ Adult inclusion conjunctivitis: systemic
▪ Discharge therapy to eradicate Chlamydia infection
▫ Bacterial: purulent/mucopurulent; white/ (antibiotics)
yellow/green ▪ Bacterial conjunctivitis: Topical antibiotic
▫ Gonococcal: hyper-purulent, profuse drops/ointment
▫ Viral: watery; stringy ▪ Epidemic keratoconjunctivitis (EKC): topical
glucocorticoids
▫ Allergic: watery, mucoid
▫ Nonallergic: mucoid

OSMOSIS.ORG 589
 OTHER INTERVENTIONS
▪ Warm, wet compresses encourages
drainage
▪ Hyperacute conjunctivitis, EKC: immediate
specialized ophthalmologist referral
▪ Viral conjunctivitis: self-limiting; usually
resolves in 2–3 weeks

KERATITIS
osms.it/keratitis
▪ Immunocompromised state
PATHOLOGY & CAUSES ▪ Topical (ocular) corticosteroid use
▪ Cornea inflammation → corneal tissue ▪ Contributing disorders: rosacea;
destruction keratoconjunctivitis sicca (dry eye
syndrome); neurotrophic keratitis (lesion on
▪ Inflammatory response → stromal damage
cranial nerve V); autoimmune diseases (e.g.
from infection, host response → edema,
rheumatoid arthritis, cicatricial pemphigoid)
infiltrates, necrotic ulceration, focal thinning,
perforation
COMPLICATIONS
CAUSES ▪ Endophthalmitis (interior eye inflammation),
intraocular damage, vision loss, keratolysis
Infectious (corneal melting)
▪ Bacteria: Staphylococcus aureus,
Pseudomonas aeruginosa, coagulase-
negative Staphylococcus, diphtheroids, SIGNS & SYMPTOMS
Streptococcus pneumoniae
▪ Viruses: HSV, herpes zoster ▪ Erythema
▪ Fungi: Candida supp., Aspergillus supp., ▪ Preauricular lymphadenopathy
Fusarium supp. ▪ Discharge: mucopurulent (bacterial), watery
▪ Parasites: Acanthamoeba (viral)
▪ Corneal opacity, stromal infiltrate (immune
Noninfectious complex deposits), ulcer
▪ Corneal inflammation with no known ▫ Bacterial keratitis: yellow infiltrates
infectious etiology ▫ Fungal keratitis: white infiltrates,
feathery borders
RISK FACTORS ▫ Acanthamoeba: Wessely ring infiltrate
▪ Corneal epithelium disruption ▪ Hypopyon (layer of white cells in anterior
▫ Contact lenses (contact lens-related chamber): fulminant bacteria
keratitis); esp. improper use (e.g. ▪ Foreign body sensation; difficulty keeping
overnight wear, poor hygiene) eye open; photophobia; pain; decreased
▫ Recent keratoplasty, trauma, corneal visual acuity, blurred vision; blepharospasm
exposure (e.g. Graves’ ophthalmopathy,
Bell’s palsy)

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Penlight
▪ Visualizes infiltrate/ulcer (> 0.5mm); round,
white spot (bacterial keratitis)

Fluorescein dye
▪ Corneal uptake of dye
▫ Visualize loss of epithelial cells,
ulceration
▫ Green glow under cobalt blue light
Figure 76.5 An individual with sterile keratitis
▫ Diffuse white opacity/dull corneal light
of the left eye.
reflex
▫ Seidel sign (leaking aqueous humor
→ fluorescein streaming): penetrating
DIAGNOSIS trauma

DIAGNOSTIC IMAGING Snellen chart

▪ ↓ visual acuity
Fundoscopy
▪ Slit beam; examine contour abnormalities of
cornea, lens, retina; small corneal infiltrates; TREATMENT
faint branching grey opacity (viral keratitis)
MEDICATIONS
LAB RESULTS ▪ Topical antimicrobials for infectious etiology
▪ Corneal scrapings, cultures: suspected
infectious etiology OTHER INTERVENTIONS
▪ Control of associated comorbidities
OTHER DIAGNOSTICS ▪ Temporary discontinuation of wearing
▪ Clinical history, physical examination contact lenses

ORBITAL CELLULITIS
osms.it/orbital-cellulitis
RISK FACTORS
PATHOLOGY & CAUSES ▪ More common in children
▪ Migration from other infections
▪ Serious infection involving contents of orbit
(ocular muscles, surrounding fat; not globe) ▫ Bacterial rhinosinusitis: Staphylococcus
aureus, streptococci (common); fungal
rhinosinusitis (rare)
CAUSES ▫ Dacryocystitis: lacrimal sac infection
▪ Entry of microorganisms into orbital space ▫ Infected mucocele: mucus-containing
▫ Via anatomical perforations of nerves, cystic lesion of salivary gland
blood vessels in paranasal sinuses (e.g. ▫ Infections involving teeth, middle ear,
ethmoid) face
▫ Migration from surrounding tissues (e.g. ▪ Direct inoculation: ophthalmic surgical
face, eyelids) after local trauma/surgery procedures; orbital trauma with fracture/
▫ Inflammatory response → tissue foreign body
destruction

OSMOSIS.ORG 591
 COMPLICATIONS LAB RESULTS
▪ Extraorbital extension: epidural/subdural
Complete blood count (CBC)
empyema; brain abscess; meningitis;
cavernous sinus thrombosis; dural sinus ▪ Leukocytosis; ↑ absolute neutrophil count
thrombosis; involvement of cranial nerves (ANC)
III, IV, V, VI; optic neuritis
Blood/orbital/subperiosteal aspirates cul-
▪ Endophthalmitis: interior eye inflammation tures
▪ Vision loss ▪ Identify causative organism
▪ Potentially fatal if sepsis develops

OTHER DIAGNOSTICS
SIGNS & SYMPTOMS ▪ Clinical history, physical examination
▪ Ocular motility: pain with movement
Systemic ▪ Pupillary light reflex: sluggish/absent reflex
▪ Fever; severe headache, vomiting, mental → optic nerve involvement
status changes (intracranial complications) ▪ Exophthalmometry: measures degree of
proptosis
Ocular
▪ Asses color vision acuity: determines optic
▪ Red, swollen eyelids; chemosis nerve involvement
(conjunctival edema); pain (esp. with eye
▪ Intraocular pressure measurement (↑)
movement); ophthalmoplegia (paralysis
of eye muscles); proptosis (abnormal
displacement of eye); impaired visual acuity,
color vision; abnormal pupillary light reflex
TREATMENT
MEDICATIONS
DIAGNOSIS ▪ Antimicrobials

DIAGNOSTIC IMAGING SURGERY

CT scan/MRI ▪ External (through orbit)/endoscopic
transcaruncular approach
▪ Orbits, sinuses; detects abscess,
intracranial changes

Dilated fundoscopy
▪ Determines optic neuropathy/retinal
vascular occlusion

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OSMOSIS.ORG 593
 PERIORBITAL (PRESEPTAL)
CELLULITIS
osms.it/periorbital-cellulitis

PATHOLOGY & CAUSES SIGNS & SYMPTOMS

▪ Mild infection of superficial tissues of ▪ Ocular pain, eyelid swelling, erythema,
anterior eyelid (tissues anterior to orbital fever, lymphadenopathy
septum); more common than orbital
cellulitis
DIAGNOSIS
CAUSES
DIAGNOSTIC IMAGING
▪ Introduction/migration of microorganisms
into preseptal space: Staphylococcus Contrast-enhanced CT scan (orbits, sinus-
aureus, Streptococcus pneumoniae, other es)
streptococci, anaerobes ▪ Distinguishes between preseptal, orbital
cellulitis; associated sinusitis
RISK FACTORS
▪ More common in children LAB RESULTS
▪ Migration from other infections: sinusitis;
upper respiratory tract infection; CBC
dacryocystitis; bacteremia (rare) ▪ Leukocytosis
▪ Direct inoculation: trauma (e.g. insect bites,
Cultures (abscess contents, paranasal sinus
animal bites, introduction of foreign bodies);
secretions)
ophthalmic surgical procedures
▪ Identify causative agent

COMPLICATIONS
OTHER DIAGNOSTICS
▪ Orbital cellulitis
▪ Clinical history, physical examination

TREATMENT
MEDICATIONS
▪ Oral antibiotics

Figure 76.6 An individual with left-sided

periorbital cellulitis.

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STYE (HORDEOLUM)
osms.it/stye

PATHOLOGY & CAUSES SIGNS & SYMPTOMS

▪ Blockage, purulent inflammation of upper/ ▪ Tenderness; fluctuant pustule; localized
lower eyelid swelling, erythema; excessive lacrimation;
photophobia
CAUSES
▪ Sterile/bacterial (e.g. Staphylococcus DIAGNOSIS
aureus, Staphylococcus epidermidis)

Internal DIAGNOSTIC IMAGING

▪ Meibomian sebaceous gland; points toward Slit lamp, fundoscopy
conjunctival side of lid → conjunctival ▪ Determine infection extension to other
inflammation tissues
External
▪ Zeiss/Moll sebaceous glands; points toward OTHER DIAGNOSTICS
skin surface of eyelid ▪ Clinical history, physical examination
▪ Visual acuity assessment
RISK FACTORS
▪ Touching eyes with contaminated hands,
chronic blepharitis, seborrhea, improper TREATMENT
contact lens hygiene, sleeping with eye
makeup, immunocompromised state MEDICATIONS
▪ Topical antibiotic ointment

COMPLICATIONS
▪ Hardens → chalazion SURGERY
▪ Incision, curettage: if progresses to
chalazion

OTHER INTERVENTIONS
▪ Warm compresses encourage drainage
▪ Usually self-limiting with spontaneous
resolution

Figure 76.7 A stye on the right lower eye

lid.

OSMOSIS.ORG 595
 UVEITIS
osms.it/uveitis
TYPES
PATHOLOGY & CAUSES
Anterior (most common)
▪ Inflammation of uveal tract (choroid, ciliary ▪ Anterior uveal tract; iritis, iridocyclitis
body, iris); unilateral/bilateral (inflammation of ciliary body)
▪ Onset: rapid/insidious
Panuveitis
▪ Course: acute/recurrent/chronic
▪ Anterior chamber, vitreous body, retina/
▪ Duration: persistent (> three months)/
choroid
limited (≤ three months)
Posterior uveitis
▪ Retina/choroid

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Intermediate uveitis LAB RESULTS

▪ Vitreous body; chorioretinal inflammation
Microscopy, cytology, culture, polymerase
chain reaction (PCR)
CAUSES ▪ Fluid sampling/biopsy; identify presence of
▪ Bacterial: tuberculosis, syphilis infectious agent
▪ Viral: cytomegalovirus, HSV
▪ Fungal: candidiasis, Pneumocystis jirovecii OTHER DIAGNOSTICS
▪ Parasitic: Acanthamoeba, toxoplasmosis ▪ Clinical history, physical examination
▪ Noninfectious systemic: Crohn’s disease,
ankylosing spondylitis Snellen chart
▪ Conditions confined to eye: trauma, acute ▪ ↓ visual acuity
retinal necrosis
Pupillary light reflex
▪ Sluggish pupillary reaction to light →
RISK FACTORS synechiae
▪ Systemic infectious, inflammatory
conditions Intraocular pressure
▪ No change if uncomplicated uveitis; ↑ in
acute uveitis-induced glaucoma
COMPLICATIONS
▪ Intraocular hypertension, glaucoma;
increased intraocular pressure; posterior TREATMENT
synechiae (iris adheres to lens); band
keratopathy (corneal calcium deposits); MEDICATIONS
cataract; vision loss
▪ Corticosteroids: topical, local injection,
implantable, systemic
SIGNS & SYMPTOMS ▪ Recalcitrant uveitis: immunomodulatory
agents (if corticosteroid response
inadequate)
▪ Ocular erythema
▪ Recalcitrant uveitis: tumor necrosis factor
▪ Impaired vision
(TNF) inhibitor (if resistant to treatment)
▪ Pain, photophobia, vision distortion, floaters
▪ Posterior synechiae prevention: mydriatic/
(vitritis), photopsia (flashing lights)
cycloplegic medications
▪ Viral-associated uveitis: antivirals
DIAGNOSIS
DIAGNOSTIC IMAGING
Fluorescein/indocyanine green angiography
(posterior uveitis)
▪ Evaluate status of retinal vascular
circulation; identify choroidal disease

Fundoscopy
▪ Ciliary flush: perilimbal redness
▪ Keratic precipitates: inflammatory deposits
on cornea
▪ Hypopyon: white blood cells settle on
bottom of anterior chamber
Figure 76.8 An individual with a hypopyon
▪ Haziness of aqueous humor: protein
of the left eye as a result of severe anterior
accumulation
uveitis.

OSMOSIS.ORG 597