Causes of Conjunctivitis

There are a number of different causes of conjunctivitis which are as follows:

1. Bacterial: The commonest organisms causing bacterial conjunctivitis are Streptococcus, Staphylococcus, Hemophilus and less commonly Clamydia Trachomatis. The bacterial conjunctivitis symptoms are redness and swelling of the eye with a typical yellowish green sticky mucopurulent discharge . It begins in one eye but since the discharge is contagious it spreads to the other eye very fast. There is a gritty and irritating feeling in the eye and also some amount of photophobia.
2. Viral: Viral conjunctivitis causes are most often associated with upper respiratory tract infections like common cold. The symptoms are watering and itching in the eyes with scanty discharge. It is associated with a pinkinsh discoloration of the eye and associated iritis.
3. Allergic: Allergic conjunctivitis pink eye is the inflammation of the conjunctiva due to an allergic reaction. It is associated with redness of the conjunctiva with profuse lacrymation and rhinitis. The symptoms are part of the allergic response due to the effect of release of histamine on the mast cells. The histamine causes dilatation of blood vessels, irritation of the nerve ends and secretion of tears.
4. Chemical: Entry of any acidic or alkaline substance into the eye can give rise to conjunctivitis. Strong chemicals can lead to necrosis of the conjunctiva.

Other causes of conjunctivitis are those associated with reactive arthritis and the presence of gene HLA-B27.

Symptoms of Conjunctivitis

1. Redness in the white portion of the eye is one of the first signs of conjunctivitis.
2. Increased lacrymation (tears)
3. Thick, yellow discharge from the eyes
4. Sticking of the eyelids in the morning.
5. Itching and burning in the eyes
6. Blurring of the vision
7. Photophobia-increased sensitivity to light.

Diagnosis of Conjunctivitis

The diagnosis is mainly done on the basis of symptoms and clinical examination. In some cases a swab test or a conjunctival patch may be need investigation in a laboratory.

Treatment of Conjunctivitis

The conjunctive eye treatment usually depends on the causative factor. If the conjunctivitis is bacterial in origin, or related to STDs then the treatment is mainly antibiotic eye drops which are the best prescription drops for pink eye, ointments or pills. The eye drops are medicated and they need to be instilled into both the eyes 3-4 times a day as per the dosage. Oral antibiotics are not usually needed for conjunctivitis, but if there is an associated disease then they might be given.

Viral conjunctivitis is mostly associated with a cold or rhinitis and it clears up on its own within seven days. But viral conjunctivitis is highly contagious and spreads very fast. So you need to take care by washing the hands frequently, using a separate napkin to clean the eye and washing it separately. Also if you are using contact lenses when you got the infection, you should throw away those lenses and get a new pair. Do not use make up when you have conjunctivitis.

Allergic conjunctivitis treatment is very easy. The problem tends to resolve once the irritant is taken care of. In contact lenses conjunctivitis, the lenses are the cause of the irritation of the conjunctiva, and removing the lenses can cure the inflammation.

If the conjunctivitis is caused by any foreign body or smoke, then the best solution is to irrigate the eye and to wash it with lots of cold water. Once the irritant is out, gradually the redness will go away and the eye will get back to normal.

There are popular eye drops available by the name of artificial tears. They help to clear out the irritants in the eye and also take care of the dryness of the conjunctiva.

Prevention of Conjunctivitis

1. Do not touch or rub the affected eye
2. Wash your hands very nicely so that the infection does not spread to the other eye or to other members of the family.
3. Wash the napkins and pillow covers separately in hot water so as to disinfect them.
4. Do not use eye make up
5. Avoid using contact lenses. Never share your lenses with anyone.
6. Do not use the eye drops used in the infected eye for the normal eye.

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Scleritis literally means the inflammation of the sclera, which is the outer white area of the eye. The sclera is responsible  for providing the white color of the eye and maintaining the shape of the eye. This  requires prompt diagnosis and treatment because it is a serious eye condition that may lead to possible vision loss.

This condition is usually associated with autoimmune disorders such as:  Wegener’s granulomatosis, systemic lupus erythematosus and rheumatoid arthritis.  Women are often affected with scleritis in association with some menstruation problems.  There are other cases in which the cause of the condition is unknown. This is not a common disease, though it may be an early sign of some connective tissue diseases. [3]

Types of Scleritis

1. Diffuse Scleritis. This involves the anterior portion of the sclera and is usually the most common type.
2. Nodular Scleritis. This type involves the formation of nodules in the sclera.
3. Necrotizing Scleritis. This type is usually the most severe of its kind and is most likely to result in the loss of vision. It  is also known as scleromalacia perforans.
4. Posterior Scleritis. This is considered the rarest type and involves the posterior area of the eye. Retinal detachment, closed angle glaucoma and muscular eye problems are the most common complications associated with this type.

Causes Of Scleritis

• Scleritis is often associated with an underlying disease that usually affects the body as a systemic condition. Generalized vascular disorders, connective tissue diseases and autoimmune disorders have been linked to half of the cases, especially those cases that have both eyes affected with the condition.
• Some cases have been linked to the presence of microorganisms like fungi, parasites, pseudomonas and viruses.
• Exposure to chemicals and trauma.
• About 30% of the cases of scleritis have unknown cause.

Signs and Symptoms of Scleritis

• The sclera may become red and swollen. In some cases, the sclera would turn into a purple hue.
• A severe, penetrating and ocular pain may be felt in the head and facial regions. The pain may radiate to the temple areas and jaw. Pain would usually result from the over stretching and stimulation of the nerve endings during inflammation.
• Photophobia or intolerance to light may also be felt. Pain is experienced when exposed to light.
• Tearing without purulent discharge usually occurs.
• Decreased visual acuity which may possibly lead to vision loss.

Scleritis Pictures

Picture 1 : Scleritis image

Picture 2 : Scleritis

Picture 3 : Scleritis photo

Diagnosis and Work Up

• Physical examination of the eye under broad daylight is important in determining scleritis. This can be done by retracting the eyelids to determine the involvement of the surrounding areas of the sclera.
• Visual acuity testing is done through the Snellen eye chart or the metric acuity test.
• Slit lamp examination is done to examine the internal structures of the eyes like the eyelids, sclera, conjunctiva and the iris. No special preparation is required prior to the procedure. [5]
• Eye drops, however, may be used to dilate the pupils 15 to 20 minutes prior to the actual examination of the eyes. In addition, the eye drops should also be used with caution because it may cause an increase in the intraocular pressure.
• Phenylephrine or neosynephrine eye drops may be used to differentiate episcleritis from scleritis. The blood vessels may appear blanched in episcleritis and not in scleritis. Episcleritis is the inflammation of the outer layer of the sclera.
• Computed tomography (CT) scan, ultrasonographies and magnetic resonance imaging (MRI) may also be used in examining the eye structure.

Treatment for Scleritis

• Scleritis is best managed by treating the underlying cause. Different causes of the underlying condition require specific therapy.
• Eye surgery is necessary in cases of necrotizing scleritis. Damaged corneal tissue would need to be repaired to preserve eye function and prevent further eye deterioration, which may lead to vision loss. Scleral grafts may be used and can be obtained through eye banks.
• Oral medication like corticosteroids may be indicated to suppress inflammation especially if the case is associated with an autoimmune disorder.[6]
• In less severe cases, non-steroidal anti-inflammatory drugs like ibuprofen may be used to relieve pain.
• Oral antibiotics may be prescribed if it is thought to be infectious.
• Chemotherapy may be used for more aggressive cases.  Methotrexate (MTX) is usually the first drug of choice for chemotherapy. Cyclophosphamide or azathioprine may also be used.
• Subconjunctival steroid injections may also be used if systemic side effects of certain drugs are causes of concerns.

Complications Associated with Scleritis

• Severe vision loss or blindness is probably the worst complication. This can happen if scleritis is left untreated.
• Keratitis and uveitis are also possible. Keratitis is the inflammation of the cornea of the eye while uveitis refers to the inflammation of the uveal tract of the eye. The uveal tract includes the iris, choroid and ciliary body.
• Cataract, glaucoma, retinal swelling may also develop as complications.
• Cataract and glaucoma  may occur as a result of long term use of corticosteroid eye drops.

Prognosis for Scleritis

Scleritis is a serious eye condition that needs prompt and aggressive diagnosis and treatment to prevent worsening and deterioration of the condition, which may eventually lead to blindness. It has the tendency to be recurrent. Therefore strict compliance with the medications is necessary. In addition, the underlying condition needs to be diagnosed and treated properly to eliminate the chances of recurrence and to prevent further complications.

In most cases, preventive treatment is not available. However, patients with underlying conditions which have scleritis as one of its complications should be informed regarding the risks and possible development of the condition.

Successive consultation with the ophthalmologist and other specialists involved in treating the systemic condition should also be done regularly. This is to monitor and evaluate the recurrence of scleritis as well as the autoimmune disorder. In addition, the patient should be properly educated regarding the facts associated with scleritis and the underlying condition.

References:

1. http://emedicine.medscape.com/article/1228324-followup#a2645
2. http://www.nlm.nih.gov/medlineplus/ency/article/001003.htm
3. http://en.wikipedia.org/wiki/Scleritis
4. http://www.medicinenet.com/scleritis/article.htm
5. http://www.medicinenet.com/scleritis/page3.htm#how_is_scleritis_diagnosed
6. http://www.rightdiagnosis.com/s/scleritis/treatments.htm
7. http://vision.about.com/od/sportsvision/p/Scleritis.htm
8. http://emedicine.medscape.com/article/809166-overview

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Metamorphopsia is a defect in vision in which lines appear wavy, parts of the line appear blank and flat surface bend. A patient with metamorphopsia, for instance, sees a tree bending despite the fact that it is perfectly straight. Patients with this disorder must see an ophthalmologist right away to check their condition. In some cases, metamorphopsia is underlying symptom of more serious cases that can further damage the sense of vision of an individual.

Anatomy of the Eye

The human eye is very important because it gives us the sense of sight, which is one of the five senses of a typical human being. Vision is the sense that has been studied most. The tracts inside the eye carry information that we see to our brain, in which the image is being processed.

The adult eye is a sphere that measures about 1 inch (2.5 cm) in diameter. Its wall is made up of three tunics or coats and its inside is occupied with fluids known as humors that help to maintain its shape. The lens, the main focusing apparatus of the eye, is supported upright inside the eye and is composed of two chambers.
The remotest tunic, the protective sclera is thick, whitish connective tissue. Also called the fibrous tunic, the sclera is seen as the whitish part of the eye. Its middle frontalportion is modified so that it is crystal clear. The cornea, a transparent window, where the light passes through, is composed of thousands of nerve endings especially pain receptors which is it hurts when an inanimate objects touches the cornea.

In the middle portion of the eyeball is the choroid, atunic thatis well-supplied with blood andholds a darkish pigment. In the anterior portion, the choroid accommodates two structures, which are the ciliary body and the iris. The lens is located in the ciliary body. In the center of the iris, the pupil is located, where the light passes.

The deepest tunic of the eye is the fragile whitish retina, which extends anteriorly only to the ciliary body. The retina is composed of many receptor cells, the rods and cones. Rods and cones, which are commonly known as photoreceptors, react to light.

Lens

Light that enters the eye is focused on the retina by the lens, a flexible biconvex crystal-like structure. The lens is held upright in the eye by suspensory ligaments attached to the ciliary body.

How the Light Passes Through the Eye

When light passes from one matter to another that has a different thickness, its speed changes and its rays bent, or refracted. Light rays are bent in the eye as they encounter the cornea, aqueous humor, lens and vitreous humor.

Light waves the eye through the cornea and then passes to the pupil. At first, the light waves are twisted in the cornea then it progress to the crystalline lens then to the nodal point, which is located behind the lens. The image produce at the back of the lens is upside-down. Afterwards, the light continues to the vitreous humor then back to retina which is at the back of the vitreous. The macula, which is located in the center of the retina, provides the best vision in any location of the retina. Inside the retina, the light waves are transformed into electrical signals then transported to the occipital cortex through the optic nerve. Here, the electrical signals are interpreted by the brain as an image.

Causes of Metamorphopsia

1. Macular Degeneration

Most of the people who develop metamorphopsia, acquire this as a symptom of macular degeneration particularly age-related macular degeneration usually accompanies bychoroidal neovascularization. Macular degeneration is a condition in which it affects old people particularly 50 years old in which there is a loss of vision in the center of visual field of the eye due to the damage to the retina.

2. Retinal Detachment

This is a condition in which the retina separate from its supporting layers. When this happens, the eye is unable to see things clearly and metamorphopsia happens. Retinal detachment can be caused by head trauma or injury to the infected eye, diabetes, complication in surgery, family history of retinal detachment and a bad case of nearsightedness.

3. Migraine

This happen when blood vessels in the brain dilate and stimulate the release of hormones in the brain. These hormones activate pain receptors thus causing pain. The pain that a person experience when he is having a migraine causes visual problems that can attribute to the symptoms of metamorphopsia. The symptoms are temporary but there are others who frequently experience migraines.

4. Macular Hole

Can result to symptoms of metamorphopsia, blurring of vision, and difficulty in reading. This usually happens to people who are over the age of 60. There are many causes for the progress of hole in the macula such as retinal detachment, underlying diseases, eye injuries, and many more.

Signs and Symptoms of Metamorphopsia

• Straight lines appear wavy or curly
• Flat surfaces are seen as curved
• A grid of straight lines may appear blank

Treatment of Metamorphopsia

The treatments available for this condition depend on the underlying causes. To properly get a treatment, a patient will need to see an ophthalmologist first and undergo an ophthalmologic examination.

If the cause of distorted vision or metamorphopsia is bleeding which is usually seen in patients with macular degeneration, laser photocoagulation can be an option to prevent further hemorrhage. Furthermore, if retinal detachment is the culprit for causing symptoms of metamorphopsia then surgery must be considered as a priority treatment. Scleral buckling, pneumatic retinoplexy and vitrectomy are the surgeries that can treat retinal detachment. However, if the cause of metamorphopsia is only macular hole, it can be treated using cryotherapy to prevent a full-scale retinal detachment.

Lastly, migraines can be cured using pain medications such as acetaminophen and NSAIDs or other non-medication alternatives such as relaxation techniques, getting enough sleep, avoiding smoking, and avoiding foods high in tyramine.

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The retina is the light-sensitive tissue found at the posterior portion of the inner eye. It focuses the images that comes through the lens and converts them into electrical impulses which are sent to the brain via the optic nerve. It contains photoreceptor cells (cones and rods) contained in its most sensitive part, the macula. The retina has around seven million cones for detailed daytime vision and color perception; and about 75 – 150 million rods for the dim light (black and white) and peripheral visions. A light-sensitive ganglion cell helps in the reflexive responses to bright light.

The retina occupies around 65 percent of the eye’s inner surface. It has a thickness of about 0.2 mm and an area roughly the dimension of a silver dollar (1100mm²). Each retina contains approximately two hundred million neurons. It has a highly vascular layer (choroid) that supplies its oxygen and nutrients. The “red eye” sometimes noted in flash photos is attributable to the light reflected from this layer. It is red since the light’s shorter wavelengths are absorbed by the oxygenated blood.

Retinal Detachment

Retinal detachment occurs when the retina is separated from its supporting tissues. Early detachment is usually localized however if it is not treated immediately, the whole retina may break free and this could lead to blindness and loss of vision. A detached retina is considered a medical emergency.

There are three recognized types of retinal detachment

1. Rhegmatogenous retinal detachment happens as a result of a break in the retina allowing fluids in the vitreous space to enter the sub-retinal space causing the retina to be detached from the retinal pigment epithelium. This is the most widespread type of retinal detachment.
2. Exudative or Secondary retinal detachment is due to any vascular abnormalities, injury or inflammation beneath the retina. The fluid would still leak into the sub-retinal space even without any tear, break or hole.
3. Tractional retinal detachment happens when the sensory retina is pulled away by the fibrovascular tissue from the retinal pigment epithelium due to inflammation, neo-vascularization or injury.

A normal retina is transparent. An opaque or gray retina seen through slit-lamp examination with complete pupil dilation or opthalmoscopy would indicate retinal detachment.

The risk for retinal detachment to occur in a normal eye is approximately five in a hundred thousand per year. This eye condition is more common in middle age or elderly individuals (20,000 in 100,000 a year). This is also common in people with severe myopia since the retina is stretched out too thin. It would also occur more often in post-cataract surgery. Patients with proliferative retinopathy either due to diabetes or sickle cell anemia will most likely have tractional retinal detachment due to neo-vascularization.

Partially Detached Retina

In this condition, only a portion of the retina is detached from the retinal pigment epithelium. A special laser treatment, photocoagulation, is used to form a scar around the retinal hole border. This would fuse the retina with the supporting layer and prevent fluids from leaking in.

Detached Retina Causes

Retinal detachment frequently occurs with no underlying cause. But the following conditions could also cause the retina to be detached:

• Trauma
• Hemorrhage
• Diabetes
• exudates behind or in front of the retina
• Inflammatory disorders
• Sudden, extreme physical exertion
• Posterior vitreous detachment
• Myopic degeneration
• Aphakia (lack of crystalline lens)
• Congenital malformations
• Choroidal tumors

Detached Retina Symptoms

One of the most common symptoms of detached retina is a spreading “black curtain” or shadow across the vision field. As the minute blood vessels bleed in the vitreous layer, blurring of vision may occur.

Other retinal detachment symptoms that might be experienced are:

• Bright flashes of light most especially at the peripheral vision due to the pulling action of the vitreous field
• Floaters that might appear as strings, dark spots or specks across vision field due to condensations in the vitreous layer
• Partial blindness
• Loss of central vision

Since the retina does not have sensory nerves that could relay pain sensations, pain is not considered as one of the symptoms of detached retina.

Detached Retina Treatment

A detached retina can be treated in several ways. The type of treatment would depend on the severity, location and type of detachment.

Retinal tears or holes are sometimes treated to avoid their progression to a complete detachment by cryotherapy or laser therapy. Cryotherapy freezes the surrounding area of the tear to reattach the retina back while laser therapy would include the burning of tiny holes around the tear to solder the retina back to its place.

Pneumatic retinopexy is another way of reattaching the retina. The eye is anesthetized locally and the doctor would inject a tiny gas bubble inside the vitreous cavity. This bubble would press the retina against the posterior section of the eye. This treatment is most useful for detachments at the upper segment of the eye since gas would rise up. The bubble would be gradually absorbed after two to six weeks.

If partial retinal detachment is not treated it would be completely detached inside six months. The longer the retina is detached the more difficult it would be to reattach it since the vitreous layer would start to shrink and fibrous growths would start forming on the retina. Once this happens, the eye would continue to lose its visual capacity and eventually the person becomes blind.

Detached Retina Surgery

Retinal detachments are ophthalmologic emergencies and need to be treated immediately with surgery. Surgical procedure for this condition is done under general or local anesthesia, depending on the severity of the detachment. NPO is maintained at least 6 hours before the scheduled operation. Mydriatics are given prior to the surgical procedure to dilate the pupil.

• Scleral buckle surgery is the conventional treatment for a detached retina. In this procedure, the doctor will stitch silicone bands to the sclera. This would push the wall of the eye against the hole to seal it thus reducing or stopping the flow of fluid into the sub-retinal space and reattaching the retina. Laser or freezing is then done to close the hole. Oftentimes, the fluid is also drained from the space.
• Vitrectomy entails the removal of the vitreous layer then the eye is filled with silicon oil (more common) or C₃F₈ or SF6 gas. The advantages of this procedure are that the gas will be absorbed after two to eight weeks and the absence of a myopic shift but unfortunately, it would also lead to a development of cataract in the affected eye.

Detached Retina Surgery Recovery

Over 85-90% of the retinal detachment cases are successfully treated with just one operation while the remaining cases would require over two operations. The patients would slowly recover their vision within a few weeks but visual acuity might not be as fine before the detachment. The visual acuity would actually depend on the location of the detachment. If the macula is not involved then the vision might be quite good. Involvement of the macula for less than a week would improve the vision but not 20/20. If the macula was separated for a longer period then vision is restored but might be impaired, most of the time at 20/200 – the cutoff point for legal blindness. The patient may need to wear an eye patch after the operation to prevent strain on the operated eye.

Detached Retina Surgery Complications

Possible complications of the surgery would include:

• New holes formed
• Bruises around the eye
• Hemorrhage inside of the eye
• Glaucoma
• Cataract
• Diplopia
• Medication allergy
• Ptosis
• Itching and swelling
• Sympathetic opthalmia
• Infection
• Immune reaction that would affect the unoperated eye (extremely rare)

Detached Retina Surgery Time and Cost

The need to stay in the hospital would depend on the type of surgery that will be done. Usually, a patient stays a day or two. Total cost of operation would be little bit costly depending on the area you belong.

References:

http://www.nlm.nih.gov/medlineplus/ency/article/001027.htm

http://emedicine.medscape.com/article/798501-overview

http://www.nhs.uk/conditions/retinal-detachment/Pages/Introduction.aspx

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Trachoma is said to have originated particularly in Egypt and Middle East and therefore it is also known as Egyptian Ophthalmia along with other alternative names like Granular Conjunctivitis, War Ophthalmia and Military Ophthalmia. Sometimes it is also generally referred as just Conjunctivitis.

As old as the history itself, Trachoma is prone to every race and community with even disastrous epidemic forms reported. Though, the number of cases has considerably reduced in most of the developed countries, it is not so in major part of developing nations as it is related to poverty and overcrowded conditions.

According to recent reports, trachoma has left nearly 8 million people blind whereas approximately 84 million need treatment. Compared to men, it is more common in children and women (especially in their 40s).

Causes of Trachoma

Trachoma is triggered due to the bacteria known as Chlamydia Trachomatis resulting in irritating eyes and discharge of mucous from the eyes at repeated times. Though it clears up in about a month’s time, it can spread rapidly due to poor hygiene. Other factors that spread the infection from person to person include direct eye contact, nose & throat secretions and using common objects like towel and washcloths.

At times, even insects (like flies) carry the discharge from infected person to a healthy human.

Trachoma Symptoms

Symptoms of trachoma are usually noticed in 5-12 days after exposure to the bacteria starting with the eyelid lining tissue turning red/pink and swollen. Its symptoms are quite similar to ‘pink eye’. If untreated, it can even lead to developments of scars.

Itching and drainage of pus or mucus from the eye are among the first signs of trachoma. After a few days of disease progression, the patient turns sensitive to light or develops photophobia. Individuals also experience blurry vision and pain in the eye.

Some other trachoma symptoms include cloudy cornea, corneal scarring, swollen eyelids and turned-in eyelashes (a condition of trichiasis). Further complications related to ear, throat and nose are also observed.

The symptoms of trachoma in children include white lumps under the upper eye lid’s surface and appearance of follicles at the junction of sclera and cornea. The scars developed on the eyelid result in deformation of the lid such that the lashes rub against the eye. This rubbing gives way to more scars and corneal opacities which can lead to blindness.

The symptoms in children are usually not painful until the adulthood is reached as the disease progresses at a sluggishly.

Trachoma Treatment

An eye examination and laboratory tests are considered necessary to recognize the presence of Chlamydia trachomatis bacteria and thus diagnose the condition trachoma.

Once diagnosed, the various treatment options for trachoma depend on the stage and severity of the condition. For the initial stages, medications are used whereas a surgery becomes mandatory in the advanced stages.

There are no vaccines available for trachoma. However, an early detection treated with antibiotics like erythromycin and doxycycline as these have proved to be effective in the initial stages. These antibiotics work when experiencing symptoms like inflamed cornea and eyelids, light sensitivity and tearing. However, these antibiotics are not effective once the scars develop.

Some other medications for treating trachoma include tetracycline eye ointment and azithromycin (oral). Though, oral azithromycin is more effective, the price too is very high and therefore remains unaffordable to most not-so-rich communities.

When trachoma reaches the later stages an eyelid rotation surgery is required. Also known as bilamellar tarsal rotation surgery, it involves the rotation of eyelashes away from cornea by a small incision made in the scarred lid. This improves the eyesight by limiting the advancement of corneal scars. This simple surgery, lasting for hardly 15 minutes, has high enduring success rates.

If the cornea turns cloudy to the level that can result in blindness then corneal transplantation is needed. Corneal transplantation or Cornea grafting involves the replacement of infected corneas with healthy donor corneas. However, the success rate of corneal transplantation is reportedly low as the corneas can be rejected by the body.

The best way to avoid first time trachoma infection and re-infection is to maintain good sanitary conditions. Hygienic habits like regularly washing the face, reducing fly population, effective sanitation ways and cleaner water not only reduces the risk transmission of trachoma but also keeps it at bay forever.

References:

http://www.mayoclinic.com/health/trachoma/DS00776/DSECTION=treatments%2Dand%2Ddrugs

http://en.wikipedia.org/wiki/Trachoma

Journal of Neuro-Ophthalmology by North American Neuro-Ophthalmology Society

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