CHAPTER 12: OPTHALMOLOGY
Points to be covered in this topic
➤ CONJUNCTIVITIS
➤ GLAUCOMA
➤ Definition
➤ Etiopathogenesis
➤ Clinical Manifestation
➤ Non-pharmacological Management
➤ Pharmacological Management
12.1 CONJUNCTIVITIS
12.1.1 Definition
• Conjunctivitis, commonly known as "pink eye".
• It is an inflammation of the conjunctiva, which is the thin, clear tissue that lines
the inner surface of the eyelid and covers the white part of the eye (sclera).
• This inflammation can be caused by various factors, including infections (viral or
bacterial), allergies, or irritants.
✓ Types Of Conjunctivitis
○ Bacterial Conjunctivitis
○ Viral Conjunctivitis
○ Allergic Conjunctivitis
○ Toxic Conjunctivitis
Etiopathogenesis
• Infectious conjunctivitis can be caused
by bacteria, viruses, fungi, and parasites,
with adenovirus being the most common
pathogen.
• Bacterial conjunctivitis is more
common in children and is caused by a
variety of pathogens, including
staphylococcal species, Streptococcus
pneumoniae, Haemophilus influenza,
chlamydia trachomatis, and
Corynebacterium diphtheria.
• Allergens, toxins, and local irritants are responsible for non-infectious
conjunctivitis.
Pathogenesis of Conjunctivitis (Bacterial and Viral)
12.1.3 Clinical manifestation of Conjunctivitis
➤ Bacterial conjunctivitis
• Acute redness of eye
• Grittiness of eyes
• Purulent (Yellow or green colour) discharge
• Conjunctival congestion
• Inflamed conjunctiva
• Swollen eyelids
➤ Viral conjunctivitis
• Serous discharge
• Redness and itchiness of eye
• Photophobia
• Follicular hypertrophy
• Pain
• Sore throat and runny nose
• Eye crustiness while waking
• Swollen eyelids
12.1.4. Non pharmacological Management
• Clean eyes at regular interval with water.
• Perform frequent hand washing.
• Do not share handkerchiefs or towels.
• Wear dark coloured goggles to avoid contamination.
• Towels and pillows should not be shared.
• Swimming in pools should be avoided.
• Use cold compress and artificial tears for reliving dryness and inflammation.
• Patients should clean eyelids with a damp cloth.
• Avoid using contact lenses during infection period.
12.1.5. Pharmacological Management
Bacterial conjunctivitis
✓ Topical antibiotics
• Older-generation antibiotics are recommended for mild, non-vision-threatening
bacterial conjunctivitis.
• While later-generation and fluoroquinolones are reserved for serious infections to
minimize microbial resistance risk.
Older generation Antibiotics:
○ Trimethoprim with polymyxin B
○ Gentamicin
○ Tobramycin
○ Neomycin
○ Ciprofloxacin
✓ NSAIDS can also be used for pain and inflammation.
Viral conjunctivitis
• Generally self-treatable.
• Topical antiviral drugs (ganciclovir gel, Idoxuridine solution and ointment,
vidarabine ointment, and trifluridine solution).
• Corticosteroids can be used in serious case.
12.2 GLAUCOMA
12.2.1 Definition
• Glaucoma is a progressive optic nerve damage disease linked to raise intraocular
tension (I.O.T.), with the main therapeutic measure being to lower I.O.T which can
retard the progression of optic nerve damage.
• Normal intra ocular pressure of our eye is 10–21 mm of Hg which may increase
up to 70 mm of Hg in case of glaucoma.
• The rise in ocular hypertension may be due to increased formation or impaired
drainage of aqueous humors.
• Untreated glaucoma leads to permanent damage of the optic nerve and resultant
visual field loss, which can lead to blindness.
Cause of glaucoma:
✓ Primary glaucoma: The cause is unknown
✓ Secondary glaucoma: Conditions like tumor, diabetes, advanced cataract or
inflammation
(Fig.12.2: Comparison of normal vs. glaucoma vision)
12.2.2 Types of glaucoma
A. Open angle glaucoma (Wide angle, chronic simple)
B. Closed angle glaucoma (Narrow angle, acute congestive)
(Fig.12.2: Types of glaucoma)
A. Open angle glaucoma (Wide angle, chronic simple)
• It is most likely a genetically predisposed degenerative illness that affects the
trabecular meshwork's patency, which eventually disappears beyond middle age.
The I.O.T. grows gradually and insidiously.
• In most situations, ocular hypotensive medications are the only option left and are
taken over the long term.
B. Closed angle glaucoma (Narrow angle, acute congestive)
• It occurs in individuals with a narrow iridocorneal angle and shallow anterior
chamber.
• The I.O.T. remains normal until an attack is precipitated, usually by mydriasis.
• The I.O.T. rises rapidly to very high values (40–60 mmHg). It is an emergent
condition with marked congestion of eyes and severe headache.
12.2.3 Etiopathogenesis
• Anyone can develop glaucoma. However, some people are at higher risk than
others.
Risk factors for glaucoma include:
• Race: Glaucoma is the leading cause of blindness for people of African descent.
• Age: People age 60 and older are more at risk for developing glaucoma.
• Family history: People with a family history of glaucoma are more likely to
develop the disease, especially those with a sibling who has the condition.
• High fluid pressure inside the eyes: People with high fluid ocular pressure inside
the eyes are at an increased risk.
• Decreased corneal thickness: People with a thinner cornea are at greater risk of
glaucoma.
• Certain medical conditions: diabetes, migraines, high blood pressure extreme
nearsightedness or farsightedness.
• Eye injury or certain types of eye surgery.
Pathogenesis
(Fig.12.2: Pathogenesis of glaucoma)
12.2.4 Clinical manifestation
• The clinical manifestations of glaucoma can vary depending on the type of
glaucoma and the stage of the disease.
• Clinical manifestations associated with these two major types are:
➤ Open-Angle Glaucoma
• Asymptomatic in Early Stages
• Gradual Peripheral Vision Loss
• Optic Nerve Head Changes
• Elevated Intraocular Pressure (IOP)
• Visual Field Defects
• Halos and Blurred Vision
➤ Angle-Closure Glaucoma
• Sudden Onset Symptoms
• Severe Eye Pain
• Blurred Vision
• Halos or Rainbow coloured circles Around Lights:
• Nausea and Vomiting
• Red Eye
12.2.5 Non-pharmacological Management
1. Healthy Lifestyle
✓ Exercise and Meditation
• Exercise regularly to reduce pressure on eyes in open angle glaucoma patients.
Consult a doctor for an appropriate routine, avoid head tilts, and avoid intense
workouts to avoid eye pressure buildup.
• High eye pressure, worsened by stress, is a major cause of glaucoma. Yoga and
meditation, including yoga nidra, can help manage stress and anxiety, strengthen
eye health, and reduce glaucoma.
✓ Diet
• A healthy, nutritious diet, rich in antioxidants,
essential vitamins (A,C,E), and minerals, is crucial for
eye health.
• Green leafy vegetables, fruits, dry fruits, nuts and plenty of water daily can help in
glaucoma management.
2. Laser Therapy
• Laser Trabeculoplasty: This procedure helps improve the
drainage of aqueous humor by using a laser to modify the
trabecular meshwork.
• Laser Peripheral Iridotomy: Used in angle-closure glaucoma, this laser procedure
creates a small hole in the peripheral iris to improve fluid drainage.
3. Surgery
• Trabeculectomy: A surgical procedure that creates a new drainage channel for
aqueous humor, reducing IOP.
• Minimally Invasive Glaucoma Surgery (MIGS): Various
minimally invasive procedures aim to improve aqueous
outflow with fewer complications compared to traditional
surgeries.
12.2.6 Pharmacological Management
Classification of drugs used in glaucoma
There are various drugs used in glaucoma given below-
1. Timolol
• Ophthalmic timolol is used to treat increased intraocular pressure in patients with
ocular hypertension or open-angle glaucoma, with its oral form used to manage
high blood pressure.
• It is the prototype of ocular β-blockers, is nonselective (β1 + β2). First ocular beta
blocker to be used topically.
✓ Mechanism of action
• The blockade of β2-receptors by timolol in the blood vessels leads to a decrease in
peripheral vascular resistance, reducing blood pressure.
2. Dipivefrine
• It is a prodrug of Adrenaline
• Is indicated as initial therapy for the control of intraocular pressure in chronic
open-angle glaucoma.
✓ Mechanism of action
• The released Adrenaline (from Dipivefrine) lowers I.O.T. by augmenting
uveoscleral outflow, β2 receptor mediated increase in hydraulic conductivity of
trabecular filtering cells, as well as by reducing aqueous formation (α1 + α2
receptor mediated).
3. Latanoprost
• Latanoprost is an isopropyl ester prodrug used to treat increased intraocular
pressure
✓ Mechanism of action
• Latanoprost selectively stimulates the prostaglandin F2 alpha receptor and this
results in a decreased intraocular pressure (IOP)
4. Dorzolamide
• Dorzolamide is a carbonic anhydrase inhibitor used to treat high intraocular
pressure in ocular hypertension and open angle glaucoma.
✓ Mechanism of action
• Carbonic anhydrase inhibitor that lowers intraocular pressure (IOP) by reducing
aqueous humor formation.
5. Pilocarpine
• Pilocarpine stimulates cholinergic receptors on M3 muscarinic receptor on iris
sphincter muscle, causing muscle contraction and miosis, crucial for short-term
management of angle-closure glaucoma’s.
✓ Mechanism of action
• Stimulation of muscarinic receptor.