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Ophthalmology for Finals -Revision Lecture

Ophthalmology for Finals -Revision Lecture. Dania Al-Nuaimi. Lecture Outline. Anatomy Approach to the Ophthalmic Patient The Red Eye Loss of Vision Sudden Gradual Quiz. Surface Anatomy. Approach to the ophthalmic patient. Ophthalmic History. Presenting Complaint

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Ophthalmology for Finals -Revision Lecture

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  1. Ophthalmology for Finals-Revision Lecture Dania Al-Nuaimi

  2. Lecture Outline • Anatomy • Approach to the Ophthalmic Patient • The Red Eye • Loss of Vision • Sudden • Gradual • Quiz

  3. Surface Anatomy

  4. Approach to the ophthalmic patient

  5. Ophthalmic History • Presenting Complaint • History of Presenting Complaint • Past Ophthalmic History • Previous surgery, trauma, refractive error • Past Medical History • Diabetes, hypertension, atopy • Family History • genetic/congenital conditions, glaucoma,cataract • Social History • Smoking, alcohol, can they put eye drops in themselves? • Drug History and allergies

  6. History of Presenting Complaint • Onset – gradual/sudden • Duration – transient/persistent • Is visual acuity affected? • Is there loss of vision? • Total/sectoral/field loss • One or both eyes? • Is the eye red? – distribution and intensity of redness • Pain/discomfort/photophobia • Discharge? • Floaters/flashing lights • Glare? • Trauma/chemical injury/foreign body

  7. Examination • Visual Acuity • Pupils • External Eye Examination • Lids • Conjunctiva • Episclera • Sclera • Cornea • Anterior Chamber • Lens • Fundoscopy • Visual Fields to Confrontation • Ocular Motility • Slit lamp examination

  8. THEREDEYE

  9. Systematic Approach • Lids • Conjunctiva • Episclera • Sclera • Cornea • Anterior Chamber

  10. Lids • Blepharitis • itching, burning, FB sensation • tearing • crusting • swollen lids • conjunctival injection • Blocked Meibomian glands • Chalazion • Rx - lid hygiene, topical antibiotic, oral doxycycline

  11. Conjunctiva • Subconjunctival Haemorrhage • Conjunctivitis • Bacterial • Viral • Allergic • Conjuntivitis in infants • Other conjunctival lesions

  12. Subconjunctival Haemorrhage • No pain/mild discomfort • Vision normal • ? trauma – exclude foreign body • Well demarcated area • No discharge • Check • For areas of other bruising • history of anticoagulants • BP • (?Anticoagulant status, FBC)

  13. Conjunctivits - Bacterial • Acute • Mild gritty discomfort • Mucopurulent discharge • Normal Vision • No Staining of cornea • No Systemic symptoms • Commonest pathogens: • Staph epidermidis • Staph aureus • Strep pneumoniae • H. influenzae • Rx – antibiotics • Chloramphenicol QDS 1/52

  14. Conjuncitivis - Viral • Acute (7-10/7) • Mild Gritty discomfort • Slight/moderate photophobia • Watery Secretion or discharge • Visual acuity – normal or sl reduced • Lids – follicles • Corneal opacities – subepithelial • Systemic symptoms- eg. sore throat or flu like symptoms • Pre-auricular lymph node may be swollen • Rx – conservative • Cool compress • Artificial tears

  15. Conjunctivitis - Chlamydial • Subacute onset (2-3/52) • Discomfort - gritty • Photophobia -Variable • Discharge -Watery ± pus • Visual acuity – Normal/Slightly Reduced • Lid oedema • Diffuse conjunctival hyperaemia • Cornea • Clear • Late: pannus and/or diffuse fibrosis, also of conjunctiva • Systemic symptoms: • None • related to STI • Rx • Topical – Chloramphenicol • Systemic – Doxycycline (Refer to GUM clinic)

  16. Conjunctivitis - Allergic • Bilateral • Discomfort – itching • Discharge – clear • Seasonal • Chemosis • Papillae/cobblestones • Rx – avoidance of stimulus, mast cells stabilisers, antihistamines, steroids

  17. Conjunctivitis - Neonatal • Ophthalmianeonatorum • < 1 month old • notifiable disease • Causative organisms • Neisseria gonorrhoea • Chlamydia Trachomatis • Commonly acquired from birth canal • Immature local immunity • Potentially sight threatening • May result in serious systemic disease • Rx • Gonococcal – systemic ceftriaxone • Chlamydial – systemic erythromycin • After counselling refer mother (and partner) to GUM clinic

  18. Episclera Pingueculum Pterygium Triangular sheet of fibrovascular tissue Dry climate/UV light exposure Invades the cornea May become inflamed • Degenerative yellow-white deposit • adjacent to the limbus • Reassurance/lubricants • May become inflamed

  19. Scleritis • Uncommon • Sight-threatening inflammation • Bilateral (50% cases) • Moderate/severe pain – classically wakes the patient at night • Purplish hue - involvement of the deep episcleral vessels • Systemic diseases are present in 50% of patients • Connective tissue diseases • Eg. RA, Wegener’s. SLE etc. • Rx – NSAIDs or Steroids

  20. Cornea • Abrasion • Ulcers • Bacterial • Viral • Herpes Simplex • Acanthamoeba

  21. Corneal Abrasion • FB/Trauma • Blurred vision • Pain • Photophobia • Watering • Usually heals within 48hrs • Rx – chloramphenicol QDS 1/52

  22. Corneal Ulcers - Bacterial • May be associated with Contact Lenses (CL) • Pain+++ • Reduced Vision • Photophobia • Watery or mucopurulent discharge • Corneal opacification • Staining with Fluourescein • Anterior chamber inflammation +/- hypopyon • Common Causes: • Staph aureus • Staph epidermidis • Strep pneumonia • Pseudomonas aeruginosa(CL) • H. Influenzae(children) • Rx – antibiotics following scrape

  23. Cornea Ulcer– Viral • Herpes simplex • Primary episode associated with vesicular rash • Recurrent • Blurred vision • Pain++ • Photophobia • Watery discharge • Reduced corneal sensation • Dendritic ulcer – highlighted by fluourescein • Rx • Topical antiviral –zovirax 5x/day then taper • If recurrent consider systemic antiviral • Do not prescribe topical steroid as can cause geographic ulcer

  24. Cornea - Acanthamoeba • Acanthamoeba = free-living protozoa • Soil, dust, sea, fresh and chlorinated water • History of CL wear • Foreign body sensation • Blurred vision • Photophobia • Discharge watery++ • Ring infiltrates • Symptoms worse and disproportionate to signs • Rx – topical anti-amoebic agents

  25. Anterior Chamber - Uveitis • Onset over 1-2 days • Previous history • Visual acuity - Poor • Pain- moderate • Photophobia - Moderate / Severe • Watering • Unilateral or bilateral • Systemic associations: • Eg. HLA B27, connective tissue disorders

  26. Uveitis • Circumcorneal purple + diffuse conjunctival injection • Cornea –Keratic precipitates • Anterior chamber -flare, cells +/- hypopyon • Iris - Often hyperaemic • Pupil -Contracted +/- Synechiae • May have activity in posterior chamber and signs in fundus

  27. Anterior chamber - AACG

  28. Acute angle closure Glaucoma • Age Usually 50 + • Usually Unilateral • Severe pain • radiating to forehead • Nausea and vomiting • Visual acuity –reduced usually onset 2-3 hours • Slight photophobia • Watery secretion or discharge • Hypermetropia (shallow anterior chamber) • Preceded by episodes of blurring pain or haloes for an hour or two in some early evenings for a few weeks

  29. Acute Angle Closure Glaucoma • Circumcorneal purple + diffuse, conjunctival injection • Hazy Cornea (oedema) • Anterior chamber shallow • (N.B. see fellow eye) • Iris - Oedematous and hyperaemic • Pupil - Dilated, oval • Pupil light reflex - Absent or reduced • IOP- Very high • Tenderness - Marked • Rx – urgent referral to ophthalmologist for acute treatment of pressure

  30. Red Eye Questions • An 81 year old man is admitted to hospital with nausea and vomiting. On examination the right eye looks red and the pupil is dilated fixed and oval in shape. He complains of severe pain around the eye and sees rings of light around bright objects. • Acute Anterior Uveitis • Acute Glaucoma • Blepharitis • Conjunctivitis • Episcleritis

  31. Red Eye Questions 2. A 30 year old man with ankylosingspondylitis complains of a painful eye with reduced vision. On examination the patient dislikes bright light and the eye is red, especially around the cornea. The pupil is small and fixed. • Acute Anterior Uveitis • Acute Glaucoma • Blepharitis • Conjunctivitis • Episcleritis

  32. Red Eye Questions 3. An 18 year old man presents with a gritty red eye. On examination the conjunctiva is red and swollen and he has a sticky yellow discharge. • Acute Anterior Uveitis • Bacterial Conjunctivitis • Blepharitis • Viral Conjunctivitis • Allergic Conjunctivitis

  33. Red Eye Questions 4. A 28 year old contact lens wearer presents with a painful red eye. On examination she has a corneal defect that stains with fluorescein and there is a hypopyon. • Acute Anterior Uveitis • Bacterial Conjunctivitis • Bacterial Corneal ulcer • Viral Conjunctivitis • Allergic Conjunctivitis

  34. Red Eye Questions 5. A 25 year old lady presents with a gritty red eye. She has had a cough for the past week. On examination she has a watery discharge and on everting the lid there are follicles present. • Acute Anterior Uveitis • Bacterial Conjunctivitis • Blepharitis • Viral Conjunctivitis • Allergic Conjunctivitis

  35. Sudden Painless Loss of Vision • AmaurosisFugax • Giant Cell Arteritis • Papilloedema • Vitreous haemorrhage (DR) • Central Retinal Artery Occlusion • Central Retinal Vein Occlusion • Retinal Detachment • Optic neuropathy

  36. Central Retinal Artery Occlusion White swollen retina with cherry red spot at macula Afferent pupillary defect Causes: GCA, atherosclerosis/carotid artery disease Associations:

  37. Central Retinal Vein Occlusion Commoner than arterial occlusion Most occur in age >65 Dilated, tortuous veins, retinal haemorrhages all 4 quadrants, mild optic disc oedema Associations: Diabetes, hypertension, smoking, inflammatory disorders

  38. Retinal Detachment Floaters Flashing lights Field loss Falling Acuity

  39. Gradual Loss of Vision • Cataract • Chronic Glaucoma • Diabetic Retinopathy • Hypertensive Retinopathy • Age Related Macular Degeneration • Optic Atrophy

  40. Cataract

  41. Cataract • Cataract = lens opacity • Account for 40% global blindness • Can be congenital or acquired • Main risk factor = AGE • Cataracts are present in : • 16% age 65-69 • 71% age >85 • Other Risk factors: • Sunlight • Smoking • Alcohol • Dehydration • Radiation • Corticosteroids • Diabetes Mellitus • Trauma

  42. Signs and Symptoms • Reduced vision • near / distance / both (what daily activities?) • Glare • oncoming headlights • Myopic shift • ‘second sight’ • monocular diplopia • when lens changes occur differentially within lens

  43. Nuclear Sclerotic Cataract

  44. Cortical Cataract

  45. Clinical Evaluation • What is the cause of the cataract? • Does the amount of lens opacity correspond to the degree of visual impairment? • Is the patients ability to function sufficiently educed to warrant surgery? • What is the prognosis for improvement of vision? • Are there any ocular/systemic considerations? • Does the patient want surgery

  46. Functional Considerations • Legal or corporate requirements for vision • Driving • car • bus • HGV • Flying • Other mechanical equipment • Personal

  47. Glaucoma

  48. Glaucoma • Group of diseases • Primary open angle is the commonest in the UK • POAG asymptomatic • Often picked up by routine optometric examination • May or may not have raised IOP • Characterised by optic nerve and visual field changes

  49. Glaucomatous disc • Enlarged cup:disc ratio • asymmetry in cup size • loss of neuroretinal rim • loss of ISNT rule • laminar dots • bayonetting of vessels • Disc margin Haems • Peripapillary atrophy

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