Tenonite

Tenon's capsule is a dense fibrous barrier that separates the fat pad of the orbit from the eyeball. Inflammation of this capsule is called "tenonitis": such a disease is polyetiological and, as a rule, secondary - that is, caused by an inflammatory or allergic process in other tissues and organs.

Epidemiology

Inflammatory processes affecting the visual organs are considered one of the most serious problems in clinical ophthalmology, since the inflammatory reaction can cause dangerous and often irreversible damage to the eye tissues.

According to medical statistics, inflammation of various eye tissues is the most common ophthalmopathology. According to some data, 80% of patients experience temporary disability, and in 10% of cases the disease leads to complete loss of vision.

Tenonitis does not occupy a leading position among frequent infectious lesions of the visual organs: the leading places belong to conjunctivitis (about 67%), blepharitis (about 22%), keratitis (5%), iridocyclitis, choroiditis. Therefore, the disease can be safely classified as a relatively rare eye pathology, since tenonitis occurs less often than 1% of cases.

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Causes tenonite

One of the most common causes of tenonitis is the presence of an inflammatory reaction in other areas of the visual organ. Thus, tenonitis becomes a secondary disease. Inflammation can move from the following pathological foci:

• corneal ulcers;
• anterior uveitis (iridocyclitis);
• inflammation of the inner membranes of the eyeball (endophthalmitis);
• inflammation of all membranes of the eyeball (panophthalmitis).

Not so often, but still possible, development of tenonitis due to acute respiratory viral infection, scarlet fever, erysipelas, mumps. The infectious agent is β-hemolytic streptococcus group A, influenza virus.

Serous tenonitis can develop as a consequence of syphilis or chickenpox.

Purulent tenonitis develops with hematogenous or lymphogenous bacterial metastases.

Medicine describes cases of development of pathology in patients who are in the active phase of the rheumatic process or suffering from collagenoses.

Tenonitis may be a complication following surgery in patients with cataracts, strabismus, phacoemulsification, and after penetrating injuries to the visual organs.

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Risk factors

Risk factors that accelerate the development of tenonitis may include:

• conditions accompanied by decreased immunity;
• constant use of contact lenses;
• dry eye syndrome;
• craniocerebral and eye injuries;
• states of vitamin deficiency in the body;
• allergic processes (spring catarrh, hay fever, etc.);
• metabolic disorders, endocrine pathologies (obesity, diabetes, etc.);
• chronic systemic pathologies (rheumatoid arthritis, gout, etc.).

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Pathogenesis

The eyeball is placed in a specific structure called Tenon's capsule. This structure allows the eyeball to move and is fixed in the center. In the area where the cornea attaches to the sclera, the capsule is adjacent to the conjunctival stroma. The sclera and capsule are connected by Tenon's space, which allows the eyeball to rotate freely. On the back surface, the capsule is attached to the sclera by connective tissue fibers.

Tenon's capsule has its own system of ligamentous apparatus, which consists of fascial sheets and processes. Lockwood's ligaments, which are as if woven into the capsule, are responsible for the equilibrium function of the oblique eye muscles. The eyeball rotates at a certain amplitude: if this amplitude increases, then both the eyeball and the capsule shift simultaneously.

Tenon's bursa forms the so-called episcleral (supravaginal) space - a system of cavities in the loose episcleral tissue.

The optic nerves and muscle fibers pass through the capsule to the eyeball. Its anterior segment is attached to the eyeball, and the posterior segment is fused with fatty tissue. Tenon's capsule is tightly connected to the optic nerve by a network of ciliary nerve fibers and arterial vessels.

In the anterior part, the bursa is pierced by the rectus oculi muscles, giving the muscular sheath a sleeve-like appearance.

Due to the peculiarities of the structural organization, any inflammatory or allergic process affecting nearby tissues can become one of the causes of tenonitis development – be it a bacterial or viral infection, trauma. Against the background of weakened immunity, inflammation spreads to nearby structures.

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Symptoms tenonite

According to the nature of the clinical course, serous and purulent forms of tenonitis are distinguished. If the lesion is extensive, the inflammatory reaction can spread throughout the entire Tenon space: if a small area is affected, local tenonitis is called.

The disease is acute or subacute. Acute onset is accompanied by patient complaints of a feeling of squeezing of the eyeball, severe pain in the affected eye, which intensifies with movement. The pain radiates to the frontal and superciliary area. As a rule, only one of the visual organs is affected.

On the second or third day after the first signs of tenonitis appear, the stage of pronounced clinical symptoms begins. The feeling of squeezing is replaced by exophthalmos. The motor ability of the eyeball is sharply limited, diplopia may occur. Edema appears in the area of the orbital conjunctiva and eyelids, while no pathological discharge or lacrimation is observed.

Patients complain of severe photophobia. The general condition is disturbed with tenonitis, but insignificantly - this is an important diagnostic sign indicating the absence of general intoxication of the body.

Stages

Tenonitis can have several inflammatory stages:

1. Alternate stage, in which initial tissue damage occurs.
2. Exudative stage, accompanied by accumulation of fluid in Tenon's space.
3. Proliferative stage (or reparative).

Acute tenonitis usually lasts from several hours to several days.

Subacute tenonitis can last for several weeks.

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Forms

Tenonitis of allergic etiology (serous inflammation) and metastatic (purulent) tenonitis are distinguished. The process can be acute or subacute, which is determined by the corresponding clinical picture.

• Serous tenonitis is accompanied by conjunctival chemosis and minor exophthalmos. This type of disease is more favorable; clinical symptoms are observed for several days, after which the patient's condition improves. The quality of visual function, as a rule, does not suffer.
• Purulent tenonitis is the most unfavorable form of the disease, which is often accompanied by perforation of the conjunctiva in the area of attachment of the eye muscles. Purulent lesions can be complicated by cyclitis, iridocyclitis, and damage to the optic nerve.

Autoimmune tenonitis

Human organs of vision are reliably protected by immunity from infectious damage. However, sometimes the components of immunity themselves are capable of stimulating the development of an inflammatory reaction. Its cellular memory is present in the eye for a long time and causes a relapse of the inflammatory process upon the next contact with the pathogen.

In addition, immunity is also activated during molecular mimicry, when certain bacteria disguise themselves as the body's own structures. Chlamydia, for example, may have this feature.

The influence of external factors sometimes triggers painful autoimmune reactions that cause damage to organs and systems.

Inflammatory eye diseases often accompany autoimmune pathologies in the human body. Sometimes tenonitis can be the first sign of the disease. However, more often it appears after other systemic manifestations.

Autoimmune tenonitis has its own characteristics:

1. the disease has a predominantly acute course;
2. bilateral damage is observed, unlike bacterial inflammation (the eyes may not be affected simultaneously, but after some time).

Most often, autoimmune tenonitis is combined with damage to the skin, joints, and lungs.

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Complications and consequences

Timely treatment, which is prescribed at the initial stage of tenonitis development, allows preventing an unfavorable outcome of the disease. In some cases, remote consequences may develop in the form of limited motor ability of the eyeball, atrophy of the optic nerve, amblyopia.

Against the background of a progressive and widespread purulent inflammatory process, panophthalmitis, meningitis, brain abscess, and generalized sepsis may occur, threatening the death of the patient.

Almost all negative consequences and complications can be avoided, provided that you seek medical help in a timely manner and follow all medical recommendations.

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Diagnostics tenonite

Any, even the most experienced medical specialist can prescribe the correct and effective treatment only after receiving the results of a comprehensive diagnosis. In order for the diagnosis to be correct - in particular, tenonitis, the doctor will definitely examine the affected eye using ophthalmoscopy and a slit lamp, check the visual function, measure the intraocular pressure. To identify the infectious agent, several appropriate laboratory tests must be carried out.

If tenonitis is suspected, the following diagnostic measures may be most in demand:

• Laboratory tests:

1. PCR analysis of scrapings taken from the conjunctiva and cornea;
2. PCR blood test to determine the quality and quantity of the tenonitis pathogen;
3. bacterial culture of eye discharge to determine the sensitivity of the pathogen to antibiotic therapy;
4. allergy tests;
5. microscopic examination to rule out fungal disease or demodicosis.

• Instrumental diagnostics:

1. computed tomography (CT scan of the orbits is performed, which is a layer-by-layer image of the orbital cavity in three projections);
2. ultrasound examination in B-mode (involves obtaining echo signals reflected from eye structures);
3. visometry (checking the quality of visual function);
4. tonometry (measurement of intraocular pressure).

During external examination, slight exophthalmos, eyelid edema and conjunctival redness are detected. The degree of exophthalmos is first or second.

If the difference in the height of the eyeballs is more than 2 mm, we speak of a unilateral process.

When palpating the projection zone of the pathological focus, aggravation of pain sensations is observed. The image obtained during computed tomography indicates the presence of fluid in the Tenon space.

Ultrasound examination helps to determine the nature of the exudate:

• serous fluid tends to spontaneous resorption;
• The purulent contents gradually increase in volume, after which they break through into the conjunctival cavity.

The quality of visual function in vasimetry usually corresponds to reference values. Intraocular pressure may increase in purulent tenonitis.

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Differential diagnosis

Differential diagnostics allows us to distinguish tenonitis from myositis of the external muscles of the eyeball, as well as from episcleritis and scleritis.

With myositis, pronounced exophthalmos is observed, with clear photophobia and tracer flow.

Episcleritis, scleritis, tenonitis - these diseases require a special diagnostic approach due to the common clinical picture. The distinctive features are:

• severe redness of the orbital conjunctiva;
• the presence of symptoms of inflammation in the outer connective tissue membrane of the eye;
• photophobia.

If there is ocular phlegmon, then there are also signs of general intoxication: fever, headache, general deterioration of condition.

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Treatment tenonite

Treatment of the disease may vary depending on the type of tenonitis, as well as the individual characteristics of the patient. If serous tenonitis has developed as a result of an active form of rheumatism, then the introduction of glucocorticosteroid drugs is mandatory. The method of administration is usually subconjunctival or retrobulbar.

If the infectious origin of tenonitis is proven, injection antibiotic therapy with broad-spectrum drugs is mandatory.

Surgical treatment is used for purulent tenonitis. The operation involves general anesthesia, opening and subsequent installation of drainage in the Tenon space. After the operation, systemic antibiotic therapy is prescribed.

Subacute course responds well to treatment with physiotherapeutic procedures. UHF therapy, diathermy, dry heating are used as standard. Electrophoresis with glucocorticosteroid drugs is indicated for rheumatic tenonitis.

In addition to general treatment, immunostimulants may be prescribed.

Drug treatment

First of all, treatment is aimed at eliminating the underlying disease that led to the development of tenonitis. Then, the pathology is treated directly, depending on its form.

• Serous tenonitis:

1. instillation of corticosteroids (0.5-2.5% Hydrocortisone suspension, 0.3% Prednisolone solution, 0.1% Dexamethasone solution);
2. Sofradex - eye drops.

• Suppurative tenonitis:

1. intramuscular injection of Benzylpenicillin at a dosage of 300 thousand IU up to 4 times a day;
2. orally Sulfapyridazine 500 mg up to 4 times a day with a further reduction in the frequency of administration to 2 times a day;
3. orally Ampiox 250 mg, Oxacillin 250 mg, Metacycline hydrochloride 300 mg, or Ampicillin 250 mg;
4. orally Indomethacin 0.025 g, or Butadion 0.15 g three times a day.

To avoid side effects when treating with corticosteroids, the drugs are discontinued gradually over several days.

Antibiotic therapy usually lasts 7-10 days, after which tests should be repeated to clarify the dynamics of the infectious process. Long-term use of antibiotics is not recommended.

Taking nonsteroidal anti-inflammatory drugs can be accompanied by digestive system disorders, so such treatment is often supplemented with drugs that protect the gastric mucosa from damage.

Vitamins

The best way to get all the necessary vitamins is a varied and complete diet, with a predominance of plant foods. If for some reason you cannot diversify your diet (for example, with diseases of the digestive system), then the doctor can prescribe tablet multivitamin preparations that will help, in particular, with tenonitis. If you trust the reviews, then the following vitamin complexes have the greatest effectiveness:

• Complivit oftalmo is a special combination of vitamins and minerals to support the function of the visual organs. The composition of the drug includes 8 vitamin and 6 mineral components.
• Doppelherz with lutein – contains a number of vitamins, as well as lutein and zeaxanthin. This drug can only be taken by adult patients.
• Super Optic is an effective combination of B-group vitamins, minerals and microelements, polyunsaturated and monounsaturated fatty acids and amino acids. This complex is designed to improve vision in people over 40 years of age.
• Vitrum Vision is a complex of vitamins and minerals with plant components: the drug is represented by zeaxanthin, lutein and blueberry anthocyanosides.

One of the listed drugs is taken according to the instructions. There is no need to take two or more multivitamin complexes at once, as this approach can lead to an overdose of vitamins.

Physiotherapy treatment

The treatment plan often includes the prescription of physiotherapy. Local thermal effects significantly improve the condition.

• Diathermy is a method that involves exposure to alternating current with parameters of 1 MHz, up to 3 A. The procedure helps to increase blood circulation in tissues, improve trophism and reduce pain. Diathermy is not used for purulent tenonitis.
• UHF therapy involves the action of an alternating electric field of ultra-high frequency, deeply penetrating into tissues. The method has anti-inflammatory, vasodilatory, analgesic, anti-edematous and bacteriostatic effects.

Heat therapy, electrophoresis, diadynamic therapy, ultrasound and massage are indicated. In accordance with the doctor's prescription, treatment begins with heat procedures followed by electrophoresis sessions.

At the regression stage, careful massage of the affected eye with medicinal ointments is practiced.

Folk remedies

Tenonitis is a rather specific disease, and not every folk healer knows how to fight it correctly. However, folk recipes for getting rid of tenonitis do exist. However, it is recommended to use them only against the background of general drug treatment prescribed by a doctor.

• For tenonitis, lotions with a decoction of celandine and honey are effective. To prepare the decoction, pour 1 tbsp of the plant with 200 ml of hot water and keep on low heat for about five minutes. Then filter the product and add 1 tsp of honey. Soak a cotton pad in the medicine and apply to the affected eye for 10 minutes.
• Make compresses based on fresh cucumber juice, boiled water and baking soda, in equal proportions. Keep the compresses on the affected eye for 10 minutes.
• Grind 10 g of marshmallow root, pour 1 liter of boiling water and leave in a thermos for an hour. Filter the infusion through several layers of gauze and use to wash the eye three times a day.

Please note: if the condition worsens during treatment, you must consult a doctor.

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Herbal treatment

• In case of severe symptoms of tenonitis, cotton pads soaked in warm dill seed decoction are applied to the affected eye before going to bed. The procedure lasts about ten minutes, and the total duration of treatment is two weeks.
• Take the leaves of common burdock, wash them with running water, put them through a meat grinder and squeeze out the juice. The juice is cleaned through several layers of gauze and dripped into the affected eye one drop in the morning and evening. The duration of treatment is one week.
• Select sprouted potatoes, remove sprouts from them - one tablespoon of such sprouts is needed. Raw materials are poured with 200 ml of vodka, infused for a week. Drink 1 teaspoon three times a day after meals.
• Take equal amounts of blueberries and rose hips. Pour 3 tablespoons of raw material into a thermos, add 600 ml of boiling water, close and leave overnight. Strain in the morning and drink 150 ml 4 times a day half an hour before meals.
• Take 3 tablespoons of chamomile, pour 200 ml of boiling water, leave for about an hour, filter. Use the infusion to wash the affected eye, several times a day.

Homeopathy

The undoubted advantage of homeopathic preparations is the impossibility of causing harm to the patient: due to small dilutions, such remedies practically do not cause side effects and overdoses.

The following preparations are used for tenonitis in dilutions C3, C6.

• Aconite - in the acute period of tenonitis, take 5-8 granules (or drops) every half hour.
• Belladonna - in the acute period it is used similarly to Aconite.
• Mercury is prescribed 6-8 granules (or drops) up to 4 times a day. The drug is allowed to be combined with Belladonna.
• Hepar sulfur is prescribed 4-5 drops twice a day (the drug is especially recommended for purulent tenonitis).
• Arsenic is taken 6-8 drops in the morning and evening. It can be alternated with Hepar sulfur every other day.

Before choosing any of the listed drugs, you should first consult a homeopathic specialist: dosage adjustments may be necessary depending on the constitutional characteristics of the patient suffering from tenonitis.

Prevention

The basis of any prevention is hygiene, which also applies to the organs of vision. If you do not follow the rules of hygiene that are accessible to everyone, then the infection will have a much greater chance of penetrating the tissues and giving rise to the development of the inflammatory process. Therefore, it is essential to monitor the cleanliness of the face and eyes - especially for those who use contact lenses.

Those who work at the computer for a long time need to periodically do special and simple visual gymnastics. It consists of such exercises as eyeball rotation, shifting the gaze into the distance and close, up and down. To improve local blood circulation, you can also rub your ears, temples and neck.

Lifestyle and nutrition greatly affect overall health. When these factors are disrupted, immunity is weakened, so when conditions favorable for infection are created, tenonitis will develop faster.

• It is necessary to eat well and nutritiously.
• You should forget about smoking, drinking alcohol and other bad habits.
• It is advisable to move more and spend more time outdoors.

And another important point of prevention is the prevention of eye injuries. When working with various mechanisms, dust, paints, you need to wear protective glasses to avoid foreign substances getting into the organs of vision.

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Forecast

The quality of the prognosis depends on the timeliness of tenonitis diagnosis, as well as the completeness of the treatment. Patients who have been diagnosed with this condition should visit an ophthalmologist twice a year for follow-up examinations.

If the patient experiences frequent relapses, he is prescribed therapeutic correction – a repeated course of treatment.

The form of the pathology also affects the quality of the prognosis. Subacute serous tenonitis usually has the most favorable outcome: it is even possible to eliminate the disease without subsequent organic disorders. As for purulent tenonitis, the outcome depends on how timely the diagnosis was. With early detection and adequate treatment of the disease, the prognosis is positive.

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