1. Opthalmology Revision Dr Nikesh Vallabh

2. Contents • Anatomy • Examination of the eye • Diabetic eye • Hypertensive eye • Red eye • Visual loss • Systemic disease – eye signs

4. Examination • Visual acuity • Test each eye separately • Wearing glasses (pinhole) • Snellen acuity expressed as fraction • Upper value ‘’CAN’’ • Lower value ‘’SHOULD’’ • Counting fingers • Hand movements • Perception of light

6. Pupils • Inspection • Response to light • Direct • Consensual • RAPD • Incomplete retinal arterial occlusion • Optic neuritis

9. Eye position and movement • Look at corneal reflexes • Squint test • Eye movements - diplopia

11. IO IO SR SR MR LR MR LR SO IR SO IR Note: Upgaze and downgaze must also be tested but are composite movements involving multiple muscles.

12. {S04 LR6} 3

14. Third nerve palsy. • Surgical • Likely if painful and pupil involved • Intercranial anuerysm • Medical • Likely if painless and pupil not involved • Diabetes • HTN • Giant cell arteritis • Idiopathic

16. Fourth nerve palsy. • Oblique diplopia often with tilt. • Very subtle on examination – affected eye slightly up, weak on looking down and in. • Isolated IV is usually “idiopathic”.

17. Internuclear Opthalmoplegia • Medical sign • Indicative of Extraocular muscle weakness • One or both eyes • It is a disorder of conjugate lateral gaze in which the affected eye shows impairment of adduction • The partner eye diverges from the affected eye during abduction, producing horizontal diplopia • During extreme abduction, compensatory nystagmus can be seen in the partner eye

18. Internuclear Opthalmoplegia • If right eye is affected the patient will "see double" when looking to the left and the images will be side by side • Causes • MS esp if bi lateral • Vascular

19. Nystagmus Eyelids Ectropion Entropion Trichiasis Ptosis Evert Opthalmoscopy 1% tropicamide Set to 0 Fixate distant object RE RH RE Red reflex Optic disc 4 quadrants Macula Examination

20. Diabetic eye • Background retinopathy • Pre- proliferative retinopathy • Proliferative retinopathy • Macular retinopathy

22. Background • Dots • Weakend vessels • Micro aneurysms • Blots • Damaged vessels • Haemorrhages • Hard exudates • Proteins + lipids from blood leak into retina • No damage to vision • Warning sign

24. Pre-prolferative • BDR + …… • Cotton wool spots • Pale white • Blocked blood vessels • Localised areas of nerves damaged • Flame haemorrhages

26. Proliferative • Neovascularisation • Proliferative growth of NEW, ABNORMAL blood vessels • Prone to bleed • Esp. with sudden movements or HTN • Treat with laser therapy

27. Panretinal photocoagulation

28. Diabetic maculopathy

29. History • Vision • mode of onset, extent, pattern, mode of recovery. • Pain • nature, severity, radiation, associated symptoms • Discharge • watery, purulent, bloody • Injury • what caused it, how was the eye hit, how hard, did it bleed, was vision lost?

30. RED EYE

32. Bacterial Conjunctivitis • Sx • Grittiness/ FB sensationDiffuse • Redness greatest in fornicies • D • Yes – purulent • Lashes stick together • V • No • Tx • Self resolving • Chloramphenicol ointment QDS or drops hourly • 7 day course

34. Acute allergic conjunctivitis • Sx • Itching +++ • Bilateral • Diffuse red • FH Atopy, asthma, eczema • Papillae oedema- cobblestones • D • Stringy watery • V • No • Tx • Antihistamine drops Levocabastine QDS

38. Adenovirus conjunctivitis • Sx • Diffuse redness worse inner canthus • Ass. with cold/URTI • Swelling of eyelids • D • Watery discharge • V • No • Tx • Self resolving • Highly contagious

40. Hazards of local steroids • Induction of cataract • 1 drop predsol once daily for 1 year gives a cataract • Steroid responders • 1/3 population get pressure rise after 6/52 drop Rx • Allows herpes simplex to run riot

43. Acute Iritis/ Ant uveitis • Sx • Pain and Photophobia • Ciliary flush • Irregular pupil –adhesion iris to lens • Hypopyon – inflammatory cells in ant. Chamber • Ass. with Ank. spond • D • No • V • Possible - blurred vision due to inflamed iris • Tx • Steroids, Atropine

45. Episcleritis • Sx • Mild discomfort • Segmental redness • D • No • V • No • Tx • Self resolving

46. Episcleritis

47. Scleritis • Sx • More serious than episcleritis • Boring pain • Ass. Systemic disease RA, vasculitis, sarcoid • D • No • V • No • Treat • urgent – steroid, NSAIDS

48. Scleritis

49. Staining the cornea. • Reveals epithelial defects. • Instil one drop of fluorescein from a minim. • Examine in blue light for best visibility. • Epithelial defects fluoresce green. Corneal abrasion Dendritic ulcer

50. Corneal Ulcer • Sx • Pain and photophobia -sensitive cornea • Diffuse red • Hx of Trauma or FB • D • Possible • V • Yes • Tx • Check if c.lens wearer – culture lens • Fluoroscein Dye • Cultures – viral, bacterial, fungal • Evert eyelid – sub tarsal FB • Antibiotics • Ciprofloxacin and chloramphenicol drops