 |  | Clinical Guidelines and Treatment Manual (MSF, 1993, 319 p.) | ||
 |  | Chapter 5 - Eye conditions | ||
|  | Conjunctivitis | ||
| | Trachoma | ||
| | Vitamin A deficiency | ||
| | Pterygium | ||
| | Cataract | ||
| | Onchocerciasis | ||
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- Acute inflammation of the conjunctivae which may be infectious (viral or bacterial), allergic or irritative.
- Infectious conjunctivitis is often endemic and may become epidemic in conditions of poor hygiene. Secondary infection may lead to keratitis and subsequent blindness.
- Viral conjunctivitis is often preceded by a cold.
Clinical features
- "Red eye" (injected conjunctivae), either unilateral or bilateral. May be purulent discharge. Visual acuity intact.
- Pain and photophobia are signs of comeal involvement. Look for pericorneal injection and examine after fluoroscein staining if available. Examine carefully to exclude foreign body (corneal or conjunctival).
- Chronic pruritis is usually the allergic form.
Treatment
(dispensary)
- Usual picture
· Wash a several times a day to remove any discharge. Use cooled boiled water or normal saline.
· Then, apply:
tetracycline eye ointment 1 %: 4 times/day x 5 days
or
sulphacetamide 10 %.
· Always look for foreign bodies (sub-conjuctival or comeal) and remove.
· Never use topical steroids.
(hospital)
- Ophthalmia neonatorum (gonococcal)
It is bilateral and appears immediately after birth. If only after 3 days, it is likely to be chlamydia.
· Prevention
Formerly, a 1% solution of silver nitrate was used for all neonates. This product is effective but may be dangerous if poorly prepared or stored; evaporation in hot climates may greatly increase the solution's concentration and thus toxicity. The current WHO recommendation is to use: tetracycline 1% eye ointment: apply in each eye at birth.
· Treatment
Clean with normal saline or ringer´s lactate at least 4
times/day (danger of sticking).
+ tetracycline 1 % eye ointment applied 2
hourly initially.
+ penicllin G (IM): 100,000 IU/kg divided in 3-4 injections
x 7 days.
Treat the mother.
- Allergic conjunctivitis
Treat as for simple
conjunctivitis.
+ promethazine (PO): 75 mg/d divided in 3 doses
or
chlorphenamine(PO): 12 mg/d divided in 3 doses
- Keratoconjunctivitis (corneal ulcers)
Same treament as for simple conjunctivitis: tetracyclin ointment. Never use ointments or drops containing corticosteroids.
Give vitamin A in therapeutic doses and cover with an eye pad to relieve pain and photophobia. Oral analgesia as needed.
Consult ophthalmologist whenever one is available.
If too
painful, adrenaline (epinephrine) can be given (dilution of 1 mg ampoule in 10
ml normal saline or ringer's lactate): apply several drops 4 times/day.
- Prophylaxis against the ocular complications of systemic conditions (e.g. measles and other febrile illnesses):
vitamin A in prophylactic doses.
Prophylactic eye toilet with
0.9 % ringer´s lactate
solution.
- Keratoconjunctivitis due to Chlamydia trachomatis. It is the world's major cause of blindness.
- Endemic and contagious, its occurrence is associated with poor hygiene, lack of water and over crowding.
Clinical features
Trachoma evolves through four stages. Early forms (stages I and II) can be completely cured with appropriate therapy. Patients in endemic areas should be examined by everting the upper eyelid (have the patient look down and draw the eyelashes up while "tripping" the tarsal plate over a matchstick).
Follicles are the basic lesions; there are whitish granulations on an inflammatory base. Staging is discussed below.
Treatment
Treatment is always local. WHO does not recommend systemic antibiotics, though these were formerly used. The regimen alters according to the staging of the illness.
STAGE I (dispensary)
- Bilateral follicular conjunctivitis, first present in the upper palpebral conjunctive (thus the need always to evert the upper lid).
- tetracycline 1% eye ointment 3 times/day x 4-6 weeks.
STAGE II (dispensary)
- Frank trachoma: as in stage I, plus vascular pannus across cornea.
- Same treatment as above, for 2 to 3 months.
STAGE III (dispensary)
- Scarring and infiltration of the palpebral and bulbar conjunctivae and of the cornea. Complete cure is no longer possible.
- Local disinfection and tetracycline ointment.
STAGE IV (dispensary)
- Scarring and contractures invert the edge of the lids producing an entropion.
- Irritation by eyelashes (trichiasis) causes more severe ulceration and scarring of the cornea. Blindness results.
- Only surgical treatment is effective in correcting the entropion. Surgery should be offered even if the patient is already blind, so as to reduce continuing irritation and pain.
- If infection remains active, administer tetracycline ointment.
Prevention
- Adequate quantities of soap and water
- Personal hygiene (hand washing, eye toilet)
- Health education
Nutritional deficiency of vitamin A principally affecting infants and young children. Clinical manifestations are often precipitated by an acute febrile illness (measles, diarrhea etc) and signs may evolve very quickly (in hours).
Clinical features
STAGE I
Night blindness
Difficult to observe in infants and young children, but at nightfall they may stop playing or become fearful.
STAGE II
Xerophthalmia
Dryness (xerosis) affecting first the conjunctivae then the cornea.
Bitot's spots: foamy white patches on bulbar conjunctive.
STAGE III
Keratomalacia
Comeal opacities, quickly leading to blindness.
Treatment (dispensary)
Only stages I and II are completely reversible.
Give vitamin A at all stages of active xerophtalmia. Also give vitamin A to all children with measles. Corneal changes require urgent treatment.
- 100,000 IU stat PO for infants < 1 year on day 1, day 2 and day 8.
- 200,000 IU stat PO for older children and adults on day 1, day 2 and day 8.
Prevention
- Vitamin A
· Mother: 200,000 IU at the time of delivery or in the two months which follow. Fertile women must not receive more than 10,000 IU/d, except in the two months following a delivery.
· Children from 6 to 11 months of age: 100,000 IU by mouth every 3 to 6 months.
· Children from 1 to 5 years of age: 200,000 IU by mouth every 3 to 6 months.
- Nutritional education: instruct mothers on locally available foods that are rich in vitamin A (e.g. yellow fruits, vegetables - especially papaya and carrots - red palm oil, green leafy vegetables, liver, eggs...).
Note: doses of vitamin A given should be marked on the health card. It is toxic so do not exceed the recommended dose.
- Whitish triangular membrane on the nasal aspect of the bulbar conjunctive progressing slowly towards the cornea.
- Associated with dry climates, dust and wind. Does not regress spontaneously.
Treatment (dispensary)
- Uncomplicated pterygium Symptomless, not encroaching across the pupil. No treatment.
- Progressive pterygium Vascular, encroaching across the pupil, causing discomfort, lacrimation and sometimes secondary infection:
· Disinfection: wash eye with normale saline, apply tetracycline ointment.
· Surgical excision: if skills and facilities are available locally.
Bilateral opacities of the lens that cause a progressive loss of visual acuity
Cataract is common in tropical regions and occurs at a younger age than in Western countries. It is possibly associated with repeated episodes of dehydration.
Apart from surgery there is no treatment.
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