Category Archives: Opthalmology

Opthalmology

REACTIVE ARTHRITIS

Reactive Arthritis was also called Reiter’s Arthritis is RF-negative and HLA-B27 Linked Imflamatory oligoarthritis typical with Enthesitis, accompanied with Inflamatory occular and/or inflamatory genitourinary and other systemic manifestation usually post gastrointestinal or genitourinary infection.

During world war one and two many cases emerged with the Triad of Symptoms viz. Inflamation of Joints, Inflamation of eyes and Inflamation of Uretha. Which drew attention of medical community due to common presentation in many giving it some syndrome like picture. On further investigations it was found out that most of them were exposed to urogenital or Gastro-intestinal infection 1-4 weeks prior to onset of this Triad of Symptoms. This was initially termed as “Fessenger-Leroy-Reiter’s Syndrome” or simply  “Reiter’s Syndrome”. But as the physician Hans Conard Julius Reiter  was involved in attrocities and war crimes with Hitler, so his name was removed and later renamed and termed as “Reactive Arthritis”.

EPIDEMIOLOGY OF REACTIVE ARTHRITIS

  • AGE – It more frequently affects age group of 20-40 years.
  • SEX – It is more common in Males then in Females.
  • ETHNICITY – Due to its association with HLA-B27 it is frequently found in white race compared to dark race as comparatively HLA-B27 occurs more commonly in white population.
  • RISK FACTOR – Person with HIV positive status are more prone to develop reactive arthritis.

SIGNS AND SYMPTOMS OF REACTIVE ARTHRITIS

The onset of symptoms of Reactive Arthritis typically starts 4-35 days after an initial infection of gastro-intestinal system or genito-urinary system.

TRIAD OF REACTIVE ARTHRITIS

Reactive arthritis in most of the cases presents where patient cant – SEE, PEE, climb the TREE! due to following Classical Triad of Symptoms of reactive arthritis

i) OLIGOARTHRITIS

Oligoarthritis involving less than five joints. It may frequently involve knee and sacroilliac joint as well. May present itself in additive pattern where it starts with one joint and add another joints subsequently or it may be migratory in pattern where the set of inflamed joints keep changing by addition and simultaneous substraction of joints involved.

ii) NON-GONOCOCCAL GENITOURINARY INFLAMATION

Inflamation of genitourinary system classically presents itself at the onset of the disease. Not always but in many its typically after initial sexual exposure. It presents as frequent burning micturation, uritheritis, prostatitis, balanitis in men and salpingitis, vulvitis and vaginitis in women.

iii) OCCULAR INFLAMATION

Occular Inflamation may present itself as mild conjunctivitis or uveitis in 75% of cases with gastrointestinal origin and 50% of cases with urogenital  involvement. patients have intermittent irritation in eyes with blurred vision typically commences at onset of disease.

OTHER SYMPTOMS

  • Few patients also presents with peculiar symptom which is specific to reactive arthritis, its Keratoderma Blenorrhagica which are small hard nodule commonly appear on soles occasionally on palms and rarely on other parts of body subcutaneous nodules are not incluced. Even in absence of above mentioned triad of symptom the presence of Keratoderma Blenorrhagica is diagnostic for reactive arthritis.
  • In reactive arthritis; typical to HLA B27 related immunological reactions; involves Entheses that is where skeletal muscles attaches with bones through tendons, where it causes Enthesitis and tendon inflamation especially the tendo-achilles and also fascia in particular Plantar Tendinitis.
  • Occasionally patients also suffer from dactilitis giving finger sausage-like apperance “sausage finger” due to inflamation.
  • Mucocutaneous involvement presents as ulcerative or non ulcerative stomatitis, apthous ulcers and geographic tongue are also seen as presentation of this disease
  • Cardiac involvement causing pericarditis and aortic regurgitation in cases which do no recover soon or if its recurring or progressive.
  • Gastrointestinal manifestation like pain and cramps with frequent semiformed stools with mucous and insome cases blood due to  inflamation and ulcceration in gastrointestinal tract.

Most of the cases of Reactive Arthritis recover within six months, in many cases it keeps comming back time and again and in few it becomes chronic and progressive which may increase risk of severe complications.

COMPLICATIONS OF REACTIVE ARTHRITIS

In chronic progressive and recurring cases the patient may develop following complications

  • Ankylosing Spondylosis
  • Disabling Arthritis
  • Aortitis
  • Aortic Regugitation
  • Conduction defects of Heart
  • Pericarditis
  • Amyloid deposits
  • Immunoglobulin A Nephropathy

CAUSE OF REACTIVE ARTHRITIS

Reactive Arthritis is is HLA B27 linked inflamatory arthritis and enthesitis preceeded by a spell of infection either of genito-urinary system  or gastro-intestinal system by following commonly involved organisms

GENITO-URINARY INFECTIONS ASSOCIATED WITH REACTIVE ARTHRITIS

  • Chlamydia Trachomatis
  • Ureaplasma Urealyticum

GASTRO-INTESTINAL INFECTIONS ASSOCIATED WITH REACTIVE ARTHRITIS

  • Salmonella Spp.
  • Shigella Spp.
  • Campylobacter Spp.
  • Yersinia Spp.

4-35 days after the spell of urethritis or food poisoning by above mentioned organisms the symptoms of reactive arthritis sets in, where the synovial fluid has negative culture ans is free from infection and but the HLA B27 linked  inflamation is thought to be triggered due to

  • Autoimmune reaction due to cross reactivity of micro-organism antigen with joint tissue  or
  • Micro-organism antigenic components that may have settled in joint tissue.

DIAGNOSIS OF REACTIVE ARTHRITIS

Clinically the Reactive Arthritis can be diagnosed with help of Sensitivity and Specificity Guidlines laid down by American College of Rheumatology, for clinical diagnosis with given set of presenting symptom, its as follows

  1. Arthritis > 1 month with Urethritis and/or cervicitis has  sensitivity of 84.3% and specificity of 98.2%.
  2. Arthritis > 1 month with Urethritis or Cervicitis or bilateral Conjunctivitis has Sensitivity of 85.5% Specificity of 96.4%.
  3. Arthritis, Urethritis and Conjunctivitis has Sensitivity of 50.8% and sensitivity of 98.8%.
  4. Arthritis > 1 month, Conjunctivitis and Urethritis has Sensitivity 48.2% and Specificity of 98.2%.

Patients falling in above criteria or those showing just Keratoderma Blenorrhagica without any other symptoms and other suspected cases can be sent for following test for further evaluation.

  • HLA B27 testing
  • Urine routine and culture
  • STOOL Routine and culture
  • Throat swab culture
  • Cervix and Urethral swab culture
  • Erythrocytes Sedimentation Rate
  • C-Reactive Protein Test

HOMEOPATHIC TREATMENT FOR REACTIVE ARTHRITIS

Being an immune mediated systemic reaction that too the one that is triggered with different causative agents and even to same agents different individuals will respond differently.

Though they may have same set of general symptoms like the classical triad of reactive arthritis but intensity of each of the symptom of triad will differ in each individual,

Now this is where the homeopathic individualisation process starts. In Homeopathy we believe that though majority of human genome is the same but the minor variations in gene and the epigenome make the whole lot of difference in various characteristerics of each individual, similarly their immune reaction also varies, so every person should have individualised medicine.

Homeopathic Treatment is based on symptom similarity and individualisation of case based on peculiar symptoms based on which the case is individualised and medicine is selected.

Alternatively as per Homeopathic principle of Genus Epidemicus or pathology based symptomatology there can be disease specific homeopathic medicine derived from common symptomatic representation of a disease condition in a group of population.

Now this can not be the most similimum homeopathic prescription but roughly it can hit the disease condition within an indivudual though not accurate but will yeild some results in most of the cases.

To yield best homeopathic results there can be no generalised common approach for all cases.

But still if we have to attempt common standardised pathology based approach then to give some guidelines on homeopathic approach towards cases of reactive arthritis I have attempted following rough guidelines which may help to give some vision in approach towards such cases.

Its seen that in few case it begins after gastro-intestinal infection and in some case post genito-urinary infection. So this will further guide determining “morbid cause” behind the disease directing us in homoeopathic similimum medicine selection.

Now reactive Arthritis shows a triad of symptom in most of the cases. So this triad helps us to reach to group of medicines with such combination of symptoms.

Intensity, occurance of symptoms and its sequence in triad differs in each individuals. For example

  • In some person urogenital symptoms may be more severe compared to occular symptoms or arthritis symptoms, where as in others arthritis and ocular symptoms would be more severe than urogenital symptoms.
  • Some may not have occurence of  conjunctivitis
  • In some all three triad occur at a time where as in some patients it may occur gradually one after another in different sequence.

All this helps us find out the “seat of disease” in an individual and its degree of affinity towards various organs which can be related to homeopathic medicines during selection process.

Further arthritis may show different pattern like

  • progressive
  • migratory
  • additive
  • symetry
  • predominantly involved joint
  • sequence of joint involvement
  • number of joints involved
  • severity
  • intensity
  • type of sensation and other symptoms

Also similarly symptoms of occular involvement and urogenital involvement should be take in to account in absolute detail. This further helps refine and classify the patient and the respective medicines to be repertorised.

Which other systems and organs are involved like mucous membranes, skin, heart, kidney etc and what type of pathology they are showing like tissue destruction or just inflamation and functional disturbance or tissue lysis with regenerated and degenerative changes this will help to decide what “type of miasm” is underlying wether its psoric, syphillitic or psychotic type pathology.

Certain symptom are very “peculiar” for the  disease and occurs in few individuals like Keratoderma Blenorrhagica eruption, now location of this eruption will further help individualise the case.

Enthesitis – Inflamation of tendo-achilles and plantar fascitis is  “very specific” to the disease but does not occur in all individuals, so if plantar fascitis or inflamation of tendo-achilles if occurs in someine with this disease then it helps further in individualisation of during homeopathic medicine selection.

Other than this the general health and family background should be noted to derive  constitutional types and association of HLA B27 in 75% of this individual further helps in individualisation and homeopathic medicine selection.

COMMONLY USED HOMEOPATHIC MEDICINES FOR REACTIVE ARTHRITIS

  • PHOSPHORUS
  • ARSENICUM ALBUM
  • RHUS TOXICODENDRON
  • BRYONIA ALBA
  • LEDUM PALUSTURE
  • THUJA OCCIDENTALIS
  • ANTIMONIUM CRUDUM
  • ARGENTUM NITRICUM
  • BORAX
  • MERCURIOUS SOLUBILIS
  • PULSATILLA NIGRICANS

CHALAZION

WHAT IS CHALAZION?

Chalazion is a small, usually painless lump or swelling that appears on eyelids as a result of cyst formation due to blockage of duct of Meibomian gland or rarely of Glands of Zeis. It can appear on upper and lower eyelids. It can be single or multiple and can affect both the eyelids of both the eyes at same time.

CAUSES AND RISK FACTOR

CHALAZION is caused by a blockage in duct of one of the tiny Meibomian Gland of upper and lower eyelid or due to infection or inflammation of Meibomian Gland and rarely of Gland of Zeis in which it is usually secondary to Stye.

Meibomian Glands are responsible for secretion on Meibum which is oily in nature that traps tear within eye by forming thin layer above surface of secreted tear, thus retaining it in eye by not letting it spill out and also reduces evaporation of tears thus playing a major role in keeping eye moist. There are around 50 mebomian glands in upper eyelids and 25 mebomian glands in kower eyelids they are situated on the rim of eyelids on Tarsal plate

Glands of Zeis are sebaceous glands that open up in hair follicle of eyelash they secrete sebum to keep eyelids and eyelash soft and supple, it also plays part in providing lubrication. In this gland the chalazion formed is usually secondary to stye and is not too frequent.

It is more common in people with following risk factors

  • Chronic Blepharitis
  • Seborrhea
  • Rosacea
  • Long term inflammation of eyelids.
  • Infective conjunctivitis.
  • Person wearing contact lenses.
  • Those who have frequent exposure to pollution, smoke, dust etc.
  • Those using Kajal or Surma.

SYMPTOM OF CHALAZION

  • Painless lump or swelling in upper and lower eyelid usually visible or palpable.
  • It can affect both eyes at the same time.
  • Usually they are well defined round with sharp margin and whole surface of sphere is easily palpable if held netween fingers with eyelids gliding over it.
  • There can be one or multiple chalazia.
  • Sometimes in cases of multiple the chalazia, due to frequent secondary infections, they may mate and overlap adjecent chalazia.
  • In mated and overlaping multiple chalazia it becomes necessary to rule out malignancy.
  • Symptoms depend on its size larger chalazia may cause disturbance in vision due to obstruction of viewing fleid.
  • In some cases it may cause nystagmus.
  • If there is secondary infection then it  might be red and inflammed in appearance and may also occasionally be painful.
  • May complicate and show blepheritis as well.

DIAGNOSIS

Sometimes Chalazion may be confused with external or internal Stye.

DIFFERENCE BETWEEN STYE AND CHALAZION.

EXTERNAL STYE

Is caused due to infection in the area of eyelash follicle or sweat gland.

INTERNAL STYE

It is caused due to infection of a meibomian gland.

Difference between chalazia and stye is that stye are painful but chalazia usually aren’t and chalazia may develop after stye.

By physical examination or by asking the patient if there is pain so that it can be differentiated whether it is stye or chalazion. Although chalazion with secondary infection may be painful, so proper evaluation is required in all doubted cases, by checking the location and palaption helps to diagnose properly.

Chalazia those are abnormally large or has abnormal texture of skin over it or is fixed and skin over it is not freely gliding or they are recurring or multiple or overlaping or suspicious with other unusual characteristics should be investigated for malignancy.

Differential diagnosis includes

  • Stye
  • Mebomian adenoma
  • Carcinoma of sebaceous gland
  • Sarcoid Granuloma
  • Foreign Body Granuloma.

TREATMENT

Chalazion may disappear by its own just use a warm compression to your eyelid it can reduce the swelling. If it does not reduce then necesary treatment is essential.

ROLE OF HOMEOPATHY:

Under conventional mode of treatment, surgical removal of chalazion is the only option. which has its own comolications like dryness of eyes and irritation of eyes due to scar formation at site of excision and also it damages and makes mebomein glands non functional forever.

However, In homeopathy chalazion is treated in a non invasive manner with gentle and effective approach.

Few indicated homeopathic remedies in Chalazion are

APIS MELLFICA

Presents with swollen eyelids, redness, intolerance of heat and touch especially right sided with burning and stinging sensation.

PULSATILLA NIGRICANS

Patient presents with itching and thick profuse discharge, Worse in warm room better in open air. There is dimness of vision swelling of eyelid and patient wishes to rub or wipe eye constantly.

STAPHYSAGRIA

Indicated in Recurrent chalazion, better by warmth application. Sunken eyes , heat in eyeball, feel dry despite lachrymation.

THUJA OCCIDENTALIS

Indicated in case of Chalazion. Eyelids stick together, usually left sided, eye lid feel heavy as lead and may be dry and scaly. Bluring of vision.

GRAPHITES

Indicated in case of chalazion, recurrent stye, conjunctivitis, red and swollen eyelid with much dryness it is good for blepharitis too. Indicated remedy for eruption on lids that become hard over a period of time.

CALCAREA FLOURICA

Indicated in case of chalazion. Gland enlarged and become stony hard useful in patient has had chalazion for a very long time. Swelling of eyeild with pain.

CONIUM MACULATUM

Indicated in case of chalazion. Frequently used remedy for stye and chalazion which have a tendency to become stony hard over a period of time for chronic and long standing complaints.

HEPAR SULPHURIS

I have found this remedy effective in almost allthe cases of chalazion when given in 30 potency with frequent repetition 2-3 times a day for a prolonged period of time and then chalazion starts showing signs of inflamation after which the medicines should be stopped and soon we see the chalazion gradually is resoved in few weeks after the medicines were stopped.