CENTRAL COAST DAY HOSPITAL OPTOMETRIST CONFERENCE - 26 FEBRUARY 2012

1. CENTRAL COAST DAY HOSPITAL OPTOMETRIST CONFERENCE - 26 FEBRUARY 2012 DR VIVEK CHOWDHURY Anterior Segment - Common Clinical Presentations in Optometry

2. Fuchs endothelial dystrophy Pseudophakic Bullous Keratopathy Progression Gradual increase in cornea guttata with peripheral spread Later central stromal oedema - STROMA Eventually bullous keratopathy - EPI

3. Fuchs endothelial dystrophy Pseudophakic Bullous Keratopathy SYMPTOMS: Acuity. Haloes/Glare. Diurnal Variation. Discomfort/Pain SIGNS Guttae and Endothelial Opacity. Stromal Oedema Epithelial Oedema/Erosions. Corneal Thickness/Pachymetry

4. Fuchs endothelial dystrophy Pseudophakic Bullous Keratopathy • In Patients with Corneal Endothelial Decompensation, all of the following may indicate progression of the disease except: • Increased Corneal Thickness. • Epithelial Defects • Deteriorating Visual Acuity • Symptoms Worse in the Afternoon

6. ANTERIOR CHAMBER IOLS Primary Cataract Surgery – Problems with Capsular Bag/Zonular Support – PXF Patients/Hx Trauma. Secondary IOL - Aphakic Patient Problems Related to: ACIOL Itself Complications of the Primary Surgery

7. ANTERIOR CHAMBER IOLS Look out For: Cornea: Corneal Endothelial Decompensation/Bullous Keratopathy. Corneal Wounds. AC: Inflammation/Uveitis, AC Vitreous, Hyphaema. Iris: Irregular Pupil, Iris Tuck, Angle Closure, PI. Angle: Trauma from Haptics, Glaucoma. Capsule: Residual Capsule in Pupillary Axis, Lens Material Retina: CME, Breaks, Detachment, Lens remnants

8. 2. In a patient with an anterior chamber intraocular lens – It is usually important to check for all of the following except: • Raised Intraocular Pressure • Corneal Decompensation. • Uveitis. • Iris Naevus

9. TRAUMA 1. Eyelid • Haematoma • Margin laceration • Canalicular laceration 2. Orbital blow-out fractures • Floor • Medial wall 3. Globe Injuries • Anterior segment • Posterior segment

10. Anterior segment complications of blunt trauma Vossius ring Hyphaema Iridodialysis Sphincter tear Cataract Lens subluxation Angle recession Rupture of globe

11. Posterior segment complications of blunt trauma Choroidal rupture and haemorrhage Avulsion of vitreous base and retinal dialysis Commotio retinae Macular hole Optic neuropathy Equatorial tears

12. Complications of penetrating trauma Uveal prolapse Damage to lens and iris Flat anterior chamber Vitreous haemorrhage Tractional retinal detachment Endophthalmitis

13. 3. In a patient with a past history of blunt trauma to the eye - which of the following is incorrect: A deep AC means there is a low risk of glaucoma cataract may be associated with zonule laxity/phacodonesis there is an increased risk of retinal breaks the patient may have a dilated pupil

14. Adenoviral - Signs of keratitis • Focal, subepithelial keratitis • Focal, epithelial keratitis • Transient • May persist for months Treatment - topical steroids if visual acuity diminished by subepithelial keratitis

15. Progression of vernal conjunctivitis Diffuse papillary hypertrophy, most marked on superior tarsus Formation of cobblestone papillae Rupture of septae - giant papillae

16. Limbal vernal Trantas dots Mucoid nodule

17. Progression of vernal keratopathy Punctate epitheliopathy Epithelial macroerosions Plaque formation (shield ulcer) Subepithelial scarring

18. Progression of ocular cicatricial pemphigoid Diffuse hyperaemia Pseudomembrane formation Symblepharon Subepithelial fibrosis and shrinkage

19. Naevus • Most frequently juxtalimbal • Presents in first two decades • Sharply demarcated and slightly • elevated • 30% are almost non-pigmented

20. Lipodermoid • Presents in adulthood • Soft, movable, subconjunctival mass • Most frequently at outer canthus

21. Intraepithelial neoplasia (carcinoma in situ) Signs Progression • May become vascular and extend onto • cornea • Presents in late adulthood • Malignant transformation is uncommon • Juxtalimbal fleshy avascular mass

22. Primary acquired melanosis (PAM) Signs Types • Presents in late adulthood • PAM without atypia is benign • PAM with atypia is pre-malignant • Unilateral, irregular areas of flat, • brown pigmentation • May involve any part of conjunctiva

23. Conjunctival melanoma From naevus Primary From PAM with atypia • Very rare • Most common type • Solitary nodule • Sudden appearance of • nodules in PAM • Frequently juxtalimbal • but may be anywhere • Sudden increase in size • or pigmentation

24. Squamous cell carcinoma Signs Progression • Arises from intraepithelial • neoplasia or de novo • Slow-growing • May spread extensively • Presents in late adulthood • Rarely metastasizes • Frequently juxtalimbal

25. Marginal keratitis • Hypersensitivity reaction to Staph. exotoxins • May be associated with Staph. blepharitis • Unilateral, transient but recurrent Progression Subepithelial infiltrate separated by clear zone Bridging vascularization followed by resolution Circumferential spread Treatment- short course of topical steroids

26. Phlyctenulosis • Uncommon, unilateral - typically affects children • Severe photophobia, lacrimation and blepharospasm Conjunctival phlycten Corneal phlycten • Small pinkish-white nodule • near limbus • Usually transient and resolves • spontaneously • Starts astride limbus • Resolves spontaneously or extends • onto cornea Treatment- topical steroids

27. Herpes simplex epithelial keratitis • Dendritic ulcer with terminal bulbs • May enlarge to become geographic • Stains with fluorescein Treatment • Aciclovir 3% ointment x 5 daily • Debridement if non-compliant

28. Herpes simplex disciform keratitis Signs Associations • Central epithelial and stromal oedema • Occasionally surrounded by • Wessely ring • Folds in Descemet membrane • Small keratic precipitates - topical steroids with antiviral cover Treatment

29. Herpes zoster keratitis Acute epithelial keratitis Nummular keratitis • Develops in about 50% within • 2 days of rash • Develops in about 30% within • 10 days of rash • Small, fine, dendritic or stellate • epithelial lesions • Multiple, fine, granular deposits • just beneath Bowman membrane • Tapered ends without bulbs • Halo of stromal haze • Resolves within a few days • May become chronic Treatment - topical steroids, if appropriate

30. 4. A patient is complaining of blurry vision after cataract surgery, but the visual acuity is 6/6 unaided, It is important to check all of the following except. • The tear film. • The posterior capsule and IOL position. • The macula. • The eyebrows.

31. Simple episcleritis • Common, benign, self-limiting but frequently recurrent • Typically affects young adults • Seldom associated with a systemic disorder Simple sectorial episcleritis Simple diffuse episcleritis Treatment • Topical steroids

32. Nodular episcleritis • Less common than simple episcleritis • May take longer to resolve • Treatment - similar to simple episcleritis Localized nodule which can be moved over sclera Deep scleral part of slit-beam not displaced

33. Grading of severity of chemical injuries Grade I (excellent prognosis) • Clear cornea • Limbal ischaemia - nil Grade III (guarded prognosis) Grade IV (very poor prognosis) Grade II (good prognosis) • No iris details • Opaque cornea • Cornea hazy but visible • iris details • Limbal ischaemia > 1/2 • Limbal ischaemia - 1/3 to 1/2 • Limbal ischaemia < 1/3

34. Medical Treatment of Severe Injuries 1. Copious irrigation ( 15-30 min ) - to restore normal pH 2. Topical steroids ( first 7-10 days ) - to reduce inflammation 3. Topical and systemic ascorbic acid - to enhance collagen production 4. Topical citric acid - to inhibit neutrophil activity 5. Topical and systemic tetracycline - to inhibit collagenase and neutrophil activity

35. 5. My patient with blepharitis is back again asking me to look for the sand that’s in his eye, I am going to do all the following except: • Change to a preservative free artificial tear supplement and/or a more viscous artificial tear supplement, and/or a thick artificial tear gel just before sleep. • Prescribe Chloramphenicol ointment to the lid margins. • Trial Steroid ointment to the lid margins, and/or a short, tapering course of a mild topical steroid. • Get my receptionist to tell them that I’ve gone on holiday.

36. THE END