see also: [[Red eye]] #infectious_diseases > skip to [[#Periorbital and orbital cellulitis]] section # infections of the lid and border ## Blepharitis ![[Pasted image 20240328133704.png]] - inflammation of eyelid - rims are red, eylashes may stick - "dandruff of the eyelid" - RF: seborrheic dermatitis, chronic strep/staph infection - Tx: gentle lid scrubs with baby shampoo - topical abx ## Hordeolum - acute *painful* nodule from blocked glands (abscess of lid margin) - external ("stye") or internal - "horders live in a pig stye" ; HORDelum = style - usually staph aureus - Tx: warm compress → abx ointment → I&D if severe (send to opthal) ![[Pasted image 20240328133854.png]] ![[Pasted image 20240328133905.png]] ## Chalazion - *chronic* stye - painless - chronic internal granulomatous rxn of meibomian gland - Tx: warm compress → refer to opthal for excision ## Dacrocystitis ![[Pasted image 20240328140022.png]] ![[Pasted image 20240328140036.png]] - infection of lacrimal system - usually staph aureus - tears that don't drain, purulent discharge - adjacent cellulitis from obstruction - Tx: warm compresses, abx # Red eye See also: [[Red eye]] ## Conjunctivitis - bacterial or viral ("pink eye") - also allergic, chemical - Can be presenting symptom of [[SJS and TENs|SJS]]! | | General | clinical features | treatment | | --------- | -------------------------------------------------------------------------------------------------------------------------------------------------------------- | --------------------------------------------------------------------------------------------------------- | ---------------------------------------------- | | Viral | - usually adenovirus<br>- highly contageous<br>- epidemic keratoconjunctivitis -- severe form | - unilateral or bilateral red eye<br>- thin, watery discharge<br>- pre-auricular adenopathy<br>- a/w URTI | - eye washes<br>- cold compress<br>- no school | | Bacterial | - strep or staph<br>- pseudomonas in contact lens<br>- usually self limited<br>- rare: chlamydia/gonorrhoea (copious discharge from gonococcal conjunctivitis) | - copious purulent discharge<br>- eyes glued shut in morning | topical abx (systemic if STI) | ## Iritis / uveitis / choroiditis ==anterior uveitis = iritis== (see [Eye and Ear anterior uveitis guideline](x-devonthink-item://FE49069D-E78A-4F23-B2C0-EE2697EA5DA9)) > Not usually an infection; can be autoimmune eg HLA-B27 or sarcoidosis or trauma, see below Inflammation of iris, ciliary body, or choroid — all continuous with one another and collectively called the *uvea*. > [!pearl]- Uvea anatomy brief > ![[65229B07-97F2-4E62-90A7-59436590C7BE.png]] > Uvea is between outer sclera and cornea and inner retina. > > **Iris** - controls amt of light hitting retina. Sympathetic dilates, parasympathetic constricts > > **Ciliary body** - secretes aqueous fluid into posterior chamber and controls shape of lens. Contains sphincter muscles that relax zonular fibers. > > **Choroid** - a bed of blood vessels under the retina. Supplies nutrition to outer 1/3 of retina (rods and cones receptors). Retinal detachments can separate from this source of nutrition, causing photoreceptors to die! ***Causes:*** - traumatic iritis - hit in eye - pupil usually constricted - hurts b/c of spasm from ciliary body - dilate pupil can help pain - infective - [[Syphilis]] - [[Tuberculosis]] - HSV / CMV / VZV - Toxoplasmosis - Post-infectious - systemic (eg rheumatologicla cause) - HLA-B27 - Psoriatic arthritis - Reactive arthritis - Sarcoidosis (consider if also restrictive lung issues, skin findings in a female) - Behcet syndrome (young adult with recurrent, painful oral apthous ulcers, genital ulcers, eye lesions (eg uveitis), skin lesions, thrombosis) - 50% of cases are idiopathic ***Findings:*** - decreased visual acuity, pain, *consensual photophobia* (pain in symptomatic eye when unaffected eye is exposed to light), no discharge - slit lamp: cell and flare (WBCs in anterior chamber) ![[Pasted image 20240328135407.png|ciliary flush: limbus around iris of inflammation. means inflammation is past conjunctivae, helpful to differentiate from conjunctivitis]] ![[Pasted image 20240328153351.png| more dramatic ciliary flush]] **Treatment** - dilate pupil - +/- steroids (consult with opthal before giving steroids) # less scary conditions ## Episcleritis - benign, self-limiting inflammatory disease affecting the episclera (thin layer of tissue between conjunctiva and sclera (white of eye) - abrupt onset painless [[Red eye]] - distinct from [[#Iritis / uveitis / choroiditis|uveitis]] because uveitis is in the *anterior chamber* whereas episcleritis is superficial - redness in eye due ot engorgement of the large episcleral blood vessels, which run in a radial direction from the limbus (pigmented zone between cornea, conjunctiva, and sclera - most cases resolve in 7-10 days - smoking tobacco delays response - *nodular type* more aggressive and takes longer to resolve - some cases can rarely progress to scleritis ***causes:*** - idiopathic (most common) - vasculitis (polyarteritis nodosa, behcet disease, granulomatosis with polyangiitis) - [[Systemic rheumatic diseases]] (rheumatoid arthritis, SLE, psoriatic arthritis, ankylosing spondylitis, [[Inflammatory Bowel Disease]] - rare: lyme disease, TB, syphilis, herpes zoster ***DDx:*** - [[#Iritis / uveitis / choroiditis]] → patients often have similar risk factors and uveitis is more significant because it affects the anterior chamber - [[#pinguecula]] - [[#pterygium]] - exclude evidence of [[#hypopyon]] ***Treatment:*** - lubricating eye drops - d/w opthal if considering steroids ![[Pasted image 20250516120610.png]] > [!caption] Eye with episcleritis ![[Pasted image 20250516120448.png]] ![[Pasted image 20250516120530.png]] The corneal limbus manifests as a dark ring around the iris ## subconjunctival haemorrhage - painless - no vision loss - sharp demarcation at limbus - from trauma, valsalva, etc - Tx: cold compresses, reassurance, resolves in weeks ## pinguecula a chronic exposure to dry windy conditions. buildup of protein, fat, calcium. like a callus of the skin on the eye. can get inflamed. but no need for treatment. ![[Pasted image 20240328185859.png]] ## pterygium similar to pinguecula but is a vascular triangular mass that grows from the nasal side towards the centre of eye, sometimes creeps in on cornea and into visual axis ![[Pasted image 20240328190018.png]] # Cornea infection ## corneal abrasion Doesn’t usually cause infection; often discharge with chlorsig eye drops and protection See [[eye trauma#corneal foreign body]] ![[Pasted image 20250516120448.png]] ## keratitis - diffuse, superficial, punctate keratitis - pain, photophobia, redness, foreign body sensation - causes: - UV keratitis - topical eye drug toxicity - dry eye - mild chemical injury - Tx: artificial tears, topical abx to preventinfection , +/- cycloplegics for analgesia ![[Pasted image 20240328175854.png]] > Do not keratitis confuse with *cataracts* which are painless. can happen after electrical injury. painless ## Corneal ulcers - focal, white opacity - +/- corneal epithelial defect - pain, red, photophobia, vision defect - ==pseudomonas in contact lens wearers can blind an eye in 1 day== → needs local abx therapy - causes: - bacterial - fungal - viral (HSV) - refer to opthal (eg often treated with steroids) - if branching/dendritic pattern, may be *herpetic* ![[Pasted image 20240328175931.png]] # anterior chamber infections ## hypopyon - purulence in the *anterior chamber* of eye - can see white cells in anterior chamber - need opthal referral - ==not to be confused with== **[[eye trauma#hyphema]]** -- blood in the anterior chamber ![[Pasted image 20240328171949.png]] ## endophthalmitis see guideline [here](x-devonthink-item://BD6E1E69-3E55-4455-8D0E-C46002590C65) ![[Pasted image 20240328172509.png]] - extreme version of hypopyon - infection of the **deep eye structures** - pain and vision loss - infected chambers hazy and opaque - often caused by *ocular surgery* ; other causes include globe rupture, penetrating eye injury, foreign body - Tx: ophthal referral, intraocular abx and systemic abx # Periorbital and orbital cellulitis > anatomical difference: is the infection past the orbital septum or not? see: [RCH - periorbital and orbital cellulitis](https://www.rch.org.au/clinicalguide/guideline_index/Periorbital_and_orbital_cellulitis/) ![[Pasted image 20241108153511.png|orbital septum is tissue continuous w/ periosteum of the orbital rim and fuses with upper and lower eyelids]] **periorbital (pre-septal) cellulitis** - minimal pain, lid oedema (give abx). no pain on EOMs - kids > adults - may be from another infection (eg *dental spread* or *sinusitis* - ==strep, staph, H flu, gram negative, sinus organisms, MRSA, anaerobes== - *cefalexin 33mg/kg* (max 1g) oral TDS or cefuroxime if mild periorbital cellulitis in kids **orbital cellulitis** - looks sick, ==pain with eye movement== - ptosis, oedema, proptosis, exopthalmosis +/- purulent discharge - no conjunctivitis - may have chemosis (oedema of conjunctiva) - decreased, painful eye movements - mgmt: - CT orbits + contrast, inpatient IV abx - *ceftriaxone* 50mg/kg (2g IV) od + *fluclox* 50mg/kg (2g) IV QID or Vanc if suspected MRSA - swab for mcs, culture, and viral PCR if any discharge - consider [[Lateral canthotomy]] and cantholysis if evidence of orbital compartment syndrome > consider *H influenzae* in non-immunised children. otherwise S pneumo, S aureus, gram negatives common **complications** - meningitis - sepsis - orbital/subperiosteal abscess - [[Cerebral venous thrombosis#Cavernous sinus venous thrombosis|cavernous sinus venous thrombosis]] - [[Cranial nerve palsies]] in CN III-VI - vision loss from elevated IOP - retinal detachment | | Preseptal cellulitis | Orbital cellulitis | | -------------------- | --------------------------------------------------------------------------------------------------------------- | --------------------------------------------------------------------------------------------------------------------------------------------------------------- | | cause | - local trauma<br>- infected chalazion<br>- dacrocystitis<br>- URTI<br>- severe conjunctivitis<br>- recent surg | - acute sinusitis<br>- posterior extension of preseptal cellulitis<br>- orbital trauma, surg, foreing body<br>- dental or facial infection<br>- dacrocystitis | | appearance | systemically well | may be unwell | | fever | variable | often febrile | | eyelids | - inflamed and swollen<br>- fluctance ?lid abscess | same as preseptal | | conjunctiva | usually normal | chemosis (conjunctival oedema) | | orbital signs | normal | - restricted/painful eye movements → **early** sign<br>- proptosis (late finding)<br>- [[Diplopia]] | | optic nerve | normal | - [[Relative afferent pupillary defect\|RAPD]] (late / **red flag** finding)<br>- ↓ visual acuity (later finding)<br>- may have change in colour, visual fields | | posterior<br>chamber | normal | - +/- optic disc swelling | ![[Pasted image 20240915191514.png]] CT showing inflammation of right orbit involving pre- and post-septal regions, gas in right orbit, and right ethmoid sinusitis, supporting *orbital cellulitis* ![[Pasted image 20241108154021.png]] ![[Pasted image 20241108154552.png|Orbital anatomy on CT]] RCH decision schema for periorbital and orbital cellulitis: ![[Pasted image 20241108152714.png]] **Chandler classification of orbital infections** ![[Pasted image 20250108123633.png]] - **stage I**: preseptal orbital cellulitis with inflammation and edema anterior to the orbital septum. - **stage II**: orbital cellulitis with extension of the inflammation and edema beyond the orbital septum.  - **stage III**: [subperiosteal abscess](https://radiopaedia.org/articles/subperiosteal-abscess-of-the-orbit?lang=us)beneath the periosteum of lamina papyracea. - **stage IV**: orbital abscess and purulent collection within orbit.  - **stage V**: [[Cerebral venous thrombosis|cavernous sinus thrombosis]] after posterior extension of the infection through the superior ophthalmic veins.