Professional Documents
Culture Documents
By Dr Brenda Tam
Case Study 1
History
23 years old young lady
Good past health
c/o : floaters in both eyes for 2 months
What would you do ?
Flashes and Floaters
• Ophthalmoscopic examination
− red reflex
− optic disc
Papillary Light Reflex
Swinging light test
Afferent Papillary Defect
Afferent Papillary Defect
Examination
• Test ocular tension:
- Tonometry by Schiotz or electronic tonometer
- Finger palpation and ballotment is not a
reliable method
• Slit lamp is a useful instrument for detail
examination of the anterior segment of the
eye
e.g. corneal erosion, anterior hypopyon
• NB: contact lens should be removed to
facilitate examination
Acute Visual Loss
Anatomical approach
– Optical : ciliary spasm
– Tear film : Dry eye
– Cornea : Ulcer
– Lens : Cataract
– Uvea : Uveitis
– Vitreoretinal : Retinal detachment
– Optic nerve : Optic neuritis
Acute Visual Loss
Transient visual loss
(vision returns to normal within 24 hrs, usually within
1 hr)
- Few seconds : Dry eyes
- Few mins : amaurosis fugax (unilateral)
vertebrobasilar artery insufficiency
(bilateral)
- 10-60 mins : Migraine
Acute Visual Loss
Visual loss lasting longer than 24 hrs
Painful
- Acute glaucoma
- Optic neuritis
- Uveitis
- Corneal disease
Acute Visual Loss
Visual loss lasting longer than 24 hrs
Painless
- Retinal artery or vein occlusion
- Ischaemic optic neuropathy e.g. Giant cell
arteritis
- Vitreous hemorrhage
- Retinal detachment
- Other retinal or CNS disease
Chronic Visual Loss
Anatomical approach
– Optical : refractive error
– Tear film : Dry eyes
– Cornea : dystrophies, pterygium
– Lens : Cataract
– Uvea : Uveitis
– Vitreoretinal : Retinal detachment, diabetic
retinopathy
– Optic nerve : glaucoma, chronic papilloedema
– Cortical and functional blindness
– Amblyopia
Cataract
It is the opacity of the lens of the eye causing
partial or total blindness
The lens is made mostly of water and protein
- The protein is arranged to let light pass
through and focus on the retina
- Sometimes some of the protein clumps
together and cloud small areas of the lens,
blocking some light from reaching the retina
and interfering with vision
Anatomy
Cataract - Natural Course
In its early stages, a cataract may not cause a
problem
The cloudiness may affect only a small part of
the lens. However, over time, the cataract
may grow larger and cloud more of the lens,
making it harder to see
Because less light reaches the retina, your
vision become dull and blurry
Some people may find their close-up vision
suddenly improves, but this is temporary.
Vision gets worse again as the cataract grows
Cataract - Symptoms
1. Blur vision
2. Glare
3. Monocular diplopia – with ghost image
4. Myopia shift
Cataract - Symptoms
• Cortical type
Many DM patient develop this type of cataract
Types of Cataract
IOP measurement
(eg. By Schiotz tonometer)
+
Optic disc evaluation
(increase in cup disc ratio, >0.9 – Highly suspicious
0.6-0.8 - moderately suspicious)
+
Visual field testing
Treatment for Glaucoma
Because damage to the optic nerve cannot
be reversed, treatment is aimed at
preventing or slowing further damage.
The pressure is lowered to a level regarded
as safe for a particular patient. This level is
generally between 15-20 mmHg. In more
severe glaucoma a lower pressure is required
to prevent further damage.
Patients need to be followed up regularly
while on treatment because overtime
treatment changes may be required.
Treatment for Glaucoma
Eye Drops
Eye drops lower the intraocular pressure by
either decreasing fluid production or
increasing fluid outflow through the
drainage angle.
They must be used regularly and
continuously.
The effect of a medication only lasts a certain
number of hours after which time the eye
pressure may again rise, resulting in damage
to the optic nerve.
Treatment for Glaucoma
Eye Drops
The effectiveness of drops may be increased
by blocking the lacrimal ducts after putting the
drop in. This is done by applying gentle
pressure over the inside corner of the eyes,
next to the nose, while closing your eyes for
five minutes after each drop.
A patient on more than one drop should wait
five minutes between drops to allow time for
their absorption.
Treatment for Glaucoma
Eye Drops
1. Topical cholinergic agonists
- increase aqueous outflow
- duration of action from 6 hrs to 1 wk
- Short-acting : Pilocarpine, Carbachol
- Long-acting : phospholine iodide
S.E. : increase bronchial secretion, diarrhoea,
nausea vomiting, increase myopia, brow pain
and pupillary constriction (cause decreased
vision)
Treatment for Glaucoma
Eye Drops
2. Topical beta-blockers
- decrease aqueous production
- Duration of action is 12-36 hrs
- Treated with once daily or twice-a-day
dosing
- commonly used are :
Timolol (Timoptic), levobunolol (Betagan),
carteolol (Ocupress), metipranolol
(OptiPranolol)
S.E. : bronchospasm, bradycardia, CHF,
impotence
Treatment for Glaucoma
Eye Drops
3. Topical adrenergic agonists
- decrease resistance to outflow and may
decrease aqueous production
- Duration of action 8-12 hrs
- Treated with twice- or thrice-a-day dosing
- commonly used are :
epinephrine, Dipivefrin (Propine),
Apraclonidine (Iopidine)
S.E. : tachycardia, tremor, anxiety, headache
pupillary dilation, conjunctival injection
Treatment for Glaucoma
Eye Drops
4. Carbonic anhydrase inhibitor
- decrease aqueous production by inhibiting
ion transport associated with aqueous
secretion
- Currently available oral form are:
acetazolamide
(Diamox), methazolamide (Neptazane)
S.E. : malaise, anorexia, electrolyte
disturbance, blood disorder :
thrombocytopenia, agranulocytosis,
neutropenia, aplastic anemia
Treatment for Glaucoma
Surgery
If medical therapy fails, consider the
surgical procedures :
Laser surgery
Filtering surgery
Cyclodestructive surgery
Drainage device surgery
Acute angle closure Glaucoma
Accounts for about 10% of glaucoma cases
High risk groups :
3. Elderly
4. Female
5. Family history
6. Hyperopia
7. Asians/Eskimos
Acute angle closure Glaucoma
Predisposing factors
Lens size : growth of the crystalline
lens causes a shallow anterior
chamber
Short eye
Small corneal diameter
Acute angle closure Glaucoma
There is an excessive area of iris apposition
to the lens, which impedes the flow of
aqueous from the posterior chamber to the
anterior chamber.
The iris bows forward because of the higher
pressure in the posterior chamber, and the
iris occludes the anterior chamber angle
the drainage angle of the eye becomes
blocked. The blockage may be sudden and
complete, raising eye pressure to a very high
level quickly
Acute angle closure Glaucoma
Acute angle closure Glaucoma –
Symptoms
Medical emergency
Eye pain and redness
Haloes around lights
Rapidly progressive impairment of
vision
Headache
Nausea and vomiting
Acute angle closure Glaucoma –
Signs
Pupil fixed and dilated
Shallow anterior chamber
Corneal edema
Optic disc : edematous and hyperemic
Cup:disc ratio >= 0.5
IOP may range from 40-80 mmHg or
above
Acute angle closure Glaucoma –
Treatment
Urgent eye consultation
Diamox (acetazolamide)
– 500mg IV stat, then 250mg QID P.O.
Pilocarpine 4% eyedrops
– Q 30 mins x 4, then 1% Q4H
Timolol eyedrops if not C.I.
Miotic eyedrops to constrict pupil & facilitate
outflow
Analgesics and anti-emetics
Acute angle closure Glaucoma –
Treatment
After IOP under control, consider
- Laser iridotomy – with a hole in the iris, it provides an
alternative channel for aqueous to reach the anterior chamber
- Drainage surgery
Case Study 2
67 years old man
c/o : sudden onset of visual loss in Lt eye for
3 hrs
PE :
- profound loss of vision in Lt eye – only finger
counting
- Rt pupil responds to light directly but not
consensually, and Lt pupil responds to light
consensually but not directly
Case Study 2
Fundi exam :
Case Study 2
The Lt eye shows a cherry-red spot in the
macula, and the whole retina is infarcted and
edematous, with narrowing of retinal
arterioles and venules
PE:
- Marcus Gunn pupil
- optic disc edema, hyperaemia, marked
venous dilatation and tortuosity, flamed-
shaped retinal haemorrhage, cotton wool
spots
Central Retinal Vein Occlusion
(CRVO)
History :
- Unilateral / bilateral
- Any pain?
- Severity of pain
- Any discharge?
- Any change of visual acuity?
Red Eyes
Examination
- Visual acuity – if significantly reduced, it
suggests corneal damage
- Eyelids – any discharge
- Conjunctiva – look for any follicles in the
inferior fornix
- Corneal sensation – if markedly decreased, it
suggests a dendritic ulcer
- Cornea – to exclude corneal ulcers
- Pupil – to exclude acute glucoma
Case study 3
42 years old man presents with unilateral Lt
eye redness and with marked pain, blur vision
photophobia, no response after taken topical
antibiotic from GP for few days
No discharge, no headache, no vomiting
PE : VA 20/60 on Lt eye, anterior chamber
depth not shallow,
IOP 20mmHg
Case Study 3
Ans : The photo shows ciliary flush
- dilated deep conjunctival and episcleral
vessels circumferential to corneal lumbus
- signify inflammation of iris and ciliary body
(anterior uveitis)
- management : patient should be referred to
eye immediately for topical corticosteroid
drops
- most cases respond rapidly and settle after
4-6 wks of treatment
Conjunctivitis
The hyperemia is produced by diffuse dilation
of the conjunctival blood vessels, and tends
to be less intense in the perilimbal region
Subconjunctival haemorrhage
3.
Photo 1 : Pterygium
– Most case occur in tropical climates
– Sugical exicion is indicated if it starts to encroach on the
visual axis or for cosmetic reason
Photo 2 : Stye
– Acute inflammation of the glands or hair follicles in
the eyelid, which cause pain and redness
– Tx : hot compresses, for topical A/B if infected
Photo 3: Chalazion
– Chronic inflammation of a meibomian gland in the
eyelid, which is usually non-tender
For stye and chalazion, most cases are sterile
inflammatory reactions, and will resolve
spontaneously. Incision and drainage is indicated
only when lesions become persistent.
Eye Injuries
Chemical burns
• Check pH with pH paper
• Damage : alkaline > acid
• Deeper penetration; coagulative necrosis
• Treatment : no place for chemical
neutralization.
• immediate copious irrigation with NS (IV drip
set) until pH back to normal, neutral range
(around 7.4)
Eye Injuries
Chemical burn
• remove chemical particles, esp. upper &
lower fornices.
• eyedrops
− local anaesthetics (stat only)
− cycloplegic (eg gutt Mydriaticum) : for relief
of ciliary spasm.
− antibotic eyedrops / ointment
• eye padding
• consult ophthalmologist immediately
Eye Injuries
Corneal abrasion/ulcer
− Positive staining with Fluorescein strip.
Eye Injuries
Corneal abrasion/ulcer
• Treatment
− Short-acting cycloplegic (stat only)
− Antibiotics eyedrops / ointment
− +/- eye padding, not proven to improve healing
• Note
− Local anaesthetics eye drops delay re-
epithelization.
− Steroid eyedrops - complication of penetrating
ulcer
− Refer to ophthalmologist for follow up (risk of
scarring)
Eye Injuries
Foreign bodies
• Irrigation with NS.
• After LA eyedrops, remove with moist cotton tips, If
adherent, carefully scrape with hypodermic needle
• Central FB (along visual axis) should better be
removed by the ophthalmologist
• Note
− Excessive scraping can cause more damage to
cornea & subsequent scarring.
• Refer to ophthalmologist e.g. Corneal abrasion,
rust ring
Eye Injuries
Hyphema
• Blood in anterior chamber
• Hyphema should be regarded as a severe
injury.
• Increase in IOP & glaucoma is a great risk
with total hyphaemia
• Management :
- pad eye
- consult eye urgently
- admit for bed rest & assessment.
The End