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REVIEW LECTURES

for LU 6

Basic Eye Exam


Common OPD Complaints
Common ER Cases
Pharmacology
INTRODUCTION

• This is a REVIEW:
• Repeat of some of your lectures last year.
• Aim: give you guidelines regarding what to
study; from now on you need to do a lot of
self study
• The pace of the lecture will therefore be a
little faster than first-timers: about 40
sec/slide
• This entire lecture is in your handout
• Just a guideline of topics to study
• YOU MUST STUDY ON YOUR OWN
• Ophtha is “another world”
• New terms, new skills, a lot of procedures
• The general rules of the Medical Profession hold
true
– TREAT THE PATIENT
– TAKE A CONCISE YET GOOOOOD HISTORY
– IF YOU ARE IN DOUBT: ASK! This is the importance
of the hierarchy in the Medical World
– THINK OF NOTHING- BUT TO GIVE PERFECT
SERVICE AND EVERYTHING, EVERYTHING ELSE
WILL FOLLOW
BASIC EYE EXAM
Visual Acuity Testing

• Check vision first before touching


patients’ eyes or shining light onto
patients’ eyes
Distance Visual Acuity
• VA = 6/30 + 1 
• 6/21 -2
• If the patient is not
able to read all the
letters in a given line
– Record this as a (+) or
a (-) the number of
letters read or not read
Distance Visual Acuity

• VA = 6/15 +3
• 6/12 - 2 
Visual Acuity Testing
• If patient is unable to read the 6/60 line at
6 meters.
– Move the patient closer to a distance JUST
ENOUGH for the patient to be able to read
JUST THE FIRST LINE
• VA measurement = numerator is replaced by the
new distance where the patient was able to read
the first line e.g. 3/60
Visual Acuity Testing
• Finger Counting is never done at a
distance of 6 meters or more
• If VA improves with PH, likely that poor
vision is due to an EOR
Vision in Infants
• When testing VA in infants
– Make sure that the only stimulus being used
is visual (no auditory stimuli e.g. bells)
– Observe if infant becomes irritable when one
eye is covered compared to the other
– Record VA as
• (+) dazzle/
• Centered, steady, maintained, able to fixate,
follows object
Near Vision
• Near vision : NV
– If patient is able to read only figures larger
than those corresponding to the J16 line,
Near Vision is recorded as >J16
Gross Examination
• Check eyelids and eyelash, check position
of lids
• Check for proptosis, exophthalmos
• Check corneal clarity and corneal light
reflex
• Check sclera
• Check pupil size and pupillary light
reaction
• Check extraocular muscle movement
INTRAOCULAR PRESURE
• Normal IOP 8-21 mmHg (Goldmann
applanation tonometer)
• IOP difference greater than 2 mmHg in
both eyes: glaucoma screening is
recommended
• Palpation tonometry: hypotonic, soft, firm
or hard
• Do not palpate if you suspect an open eye
injury !
FUNDUSCOPY
• Check media
• Check disc (difference of O.2 in CD ratio
between eyes is suspicious)
• Check retinal vessels
• Check for presence of hemorrhages,
exudates or other lesions
• Check macular area and foveal reflex
Common OPD
Complaints and Conditions
COMMON EYE COMPLAINTS
• Decreased visual acuity
• Photophobia
• Colored Haloes
• Red eye
• Painful eye
• Protrusion
• Squint
• Inability to move eye
• Exudation
• Itching
Decreased Visual Acuity:
Error of Refraction
• Distance vision
– All children by age 3 should have v.a. checked
– Errors of Refraction
• Myopia
• Hyperopia
• Near or Reading vision
– Errors of Refraction
• Myopia
• Hyperopia
• Presbyopia
Decreased Visual Acuity: Cataracts
Note: check ROR, Dilated Pupil Exam
Decreased Visual Acuity: Corneal Leukoma
Decreased Visual Acuity: Glaucoma
Potentially blinding: check C/D ratio
Decreased VA: Retinal Diseases:

Subretinal hge: AMD, trauma DM Retinopathy

Macular scar RRD with Proliferative


Vitreoretinopathy
Retinal Manifestation of Systemic Dse

Hypertensive Ret: AV
crossing changes Macular edema / star

Branch Retinal Vein Occlusion Central Retinal Vein Occlusion


Decreased VA: r/o Systemic Dis
r/o Carotid/Cardiac Valve Plaques, Abnormal Lipid Profile, HPN, Drugs,
Contraception, Behcet’s Dis

Cotton Wool Spot: (Large) / Branch Central Retinal Arteriole


Retinal Arteriole Occlusion Occlusion : CRAO

Branch Retinal Arteriole CRAO: Aratiles/Cherry Red


Occlusion: BRAO Spot
Decreased VA: Blinding Eye Diseases:
Potentially Life Threatening
Retinoblastoma

Note: mid dilated pupil: OS


Red Eye Differentials
Acute Angle Glaucoma
• Hazy cornea: edema,
mid-dilated, shallow
anterior chamber
– Haloes
– Photophobia
– pain

• Ciliary flush: dilated deep


conjunctival and
episcleral vessels around
limbus
Red Eye Differentials
Herpes Simplex Keratitis

Dendritic corneal ulcer


Red Eye Differentials: Conjunctivitis

• Discharge: bacterial
– Purulent: creamy white
– Mucopurulent:
yellowish

• Discharge: allergic
– Serous: white stringy
Bacterial Conjunctivitis

• Discharge

– Purulent: creamy white

– Mucopurulent:
yellowish
Bacterial Conjunctivitis

• Exudation: “mattering”
– Conjunctival or eyelid
inflammation
– Not in acute glaucoma
Allergic Conjunctivitis
• Hyperemia/dilation of
the conjunctival blood
vessels
• Can have white
stringy discharge
Stringy discharge
Red Eye Differentials
Scleritis
• Potentially serious
• Inflammation: focal or
diffuse
• Usually painful
• Usually chronic
• r/o collagen vascular
disease
• r/o rheumatoid
diseases
Red Eye Differentials
Subconjunctival Hemorrhage
• blood between conjunctiva and sclera with
areas of intact white sclera
Red Eye Differentials
Blunt trauma
• Hyphema vs Hypopyon
Red Eye Differentials
Pterygium
• Triangular fold of vascular conjunctiva
creeping into cornea
Red Eye Differentials
Corneal Foreign Body
• Surrounded by a rust ring and edema
• Pain, foreign body sensation, tearing
Red Eye Differentials
Tarsal Conjunctival FB
Adnexal Eye Disease
Staph blepharitis: chronic
• Inflamed eye lids
• Swollen eye lids
• Oily discharge
• Eyelashes clump
together
• Forms COLARETTE
around eyelash
Adnexal Eye Disease
Seborrheic Blepharitis
• Dry, flaky lashes
• Red lid margins
Adnexal Disease
External Hordeolum
• Focal Staph infection
• Red and painful
• Acute swelling of
glands of zeiss and
moll also meibomian
glands
• Points towards skin
• May be quite large
Adnexal Disease
Internal Hordeolum
• Meibomian gland
• Points towards
conjunctiva
ADNEXAL DISEASE:
Chalazion

• Eyelids

– Chalazion: focal,
chronic,
granulomatous
infection of meibomian
gland
• Large non tender lid
mass
• May be chronic result of
hordeolum
• r/o sebaceous cell
carcinoma
Adnexal Eye Disease: Potentially
Life Threatening
ADNEXAL DISEASE
• Lacrimal system
– Dacryocystitis
• Results from
obstruction of
nasolacrimal duct
• Pain, edema, erythema
over lacrimal sac
• Discharge from puncta
is sign of infection
Adnexal Disease
Nasolacrimal Duct Obstruction
• Most common
congenital
abnormality
• May be transient
• May open in 3 weeks
• Tears and mucus
may accumulate
which may result into
dacryocystitis
Protrusions
• Exophthalmos
– Forward protrusion of
globe
– Retraction of lids
– r/o leukemia in kids
• Orbital mass
– Chemosis
– Hyperemia of conj
– Prolapse over lid
– Fixed eye: no EOM
Protrusion: Life Threatening
• Tumors
– Melanoma
– Retinoblastoma
STRABISMUS
• Phoria
– Latent tendency for misalignment
– May elicit problem by covering eyes alternately
• TROPIA
– manifest when both eyes open
• ESOphoria/tropia: eyes directed inwards
• EXOphoria/tropia: eyes directed outwards
• Vertical
– hyper and hypo
Strabismus
3rd Cranial Nerve Paresis
• Ptotic lid
• Failure to adduct
• Failure to elevate

OS: Abnormal eye


Strabismus
6th Cranial Nerve Paresis

• Failure to abduct

OS: Abnormal eye

• Eyes are straight in


adduct gaze and
directly ahead
OD: Abnormal eye: fails to abduct
COMMON ER CASES
• TAKE VISUAL ACUITY
before examining the eye
Chemical burn:
can lead to blindness
• Differentiate between acid and alkali
ALKALI
• Ammonia (NH2): fertilizers, cleaning
agents
• Lye (NaOH): drain cleaners
• Potassium hydroxide
• Magnesium hydroxide: sparklers, flares,
firecrackers
• Lime: plaster, cement, whitewash, mortar
CHEMICAL BURN:
TRUE OCULAR EMERGENCY
Alkali
• Alkali more serious than acid burn
• The whiter the eye the poorer the prognosis
Acid
• Sulfuric acid: car battery, industrial acid
• Hydrochloric acid/muriatic acid: bathroom
cleanser, household acid
• Nitrous acid
• Hydrofluoric acid
• Acetic acid (>10%)
Chemical Burn: Acid
• Chemical burn: IRRIGATE, IRRIGATE,
IRRIGATE, IRRIGATE
– Even before reaching the ER
– Pour continuous flowing water over the eye
• Tap water
• Bottled drinking water
• BEST is Balanced Salt Solution
Chemical Burn:
Initial ER Management
• Topical anesthetic
• Copious irrigation with balanced saline solution
• Check for retained foreign bodies, chemical
precipitates. Flip lids and swab fornices.
• Topical cycloplegics (atropine sulfate 1%), TID
• Topical antibiotics (broad spectrum such as
fluoroquinolones), q4 hours
• Patch eye
• Prompt referral to ophthalmologist
Sudden, painless, profound
loss of vision!
Always consider vascular
etiologies.
The other true eye emergency!
CRAO:
Central Retinal Arteriole Occlusion
1. Afferent pupillary
defect is profound or
total
2. Extensive retinal edema
(pale retina)
3. Cherry-red/aratiles spot
CRAO: ER MANAGEMENT
• Ocular massage (digital or 3-mirror lens): 10
seconds ON, 5 seconds OFF
• Induce hypercarbia: re-breath CO2
• Sublingual isosorbide dinitrate 10 mg
• Lower eye pressure: acetazolamide 500 mg,
mannitol 20%, oral glycerol 50% (1 g/kg)
• Anterior chamber paracentesis
• IV streptokinase
• Prompt referral to ophthalmologist
Corneal Foreign Bodies
and
Abrasion
CORNEAL FB AND ABRASION
• Common complaint at the ER
• Usually work related (grinding,
hammering, chipping, etc.)
• Accidental trauma (blast, insect, fingernail,
etc.)
• Pain, tearing, redness, FB sensation,
photophobia, lid swelling
CORNEAL FB: METAL
CONJUNCTIVAL FB

This is how you flip upper lid. Foreign body has been removed.
CORNEAL FB & ABRASION
ER MANAGEMENT
• Put topical anesthetic for exam purpose only
• Examine under strong light and magnification
• Remove FB with forceps or cotton swabs if
possible
• May irrigate with sterile saline solution
• Cover with broad spectrum topical antibiotics
(every 1 hour)
• Place semi-pressure eye patch
• Prompt referral to ophthalmologist
Perforating Injuries of the Eye
PERFORATING INJURIES
• One of the most common reason for admission
to eye ward at PGH
• Majority of patients are male and children (30%)
are common
• Work or play related, assault and accidental
trauma
• Corneal, limbal, corneo-scleral, scleral etc.
• Intraocular structures are usually involved
• Common cause of endophthalmitis and
blindness
Perforating Injuries
• Sharp objects: wire, walis ting-ting, BBQ
stick, needles, knives, scissors etc.
• Projectiles: metal fragment, nail, glass
fragment, dart etc.
• Blasts: firecrackers explosion, gun blast,
dynamite, pillbox etc.
Intraocular FB: IOFB

Note: no protective eye goggles


Metallic Intraocular FB with vitreous hemorrhage
Globe Perforating Injury

Do not extract: Will need xrays to determine extent of penetration


Corneal Perforating Injury: CPI

Peaked pupil, r/o incarcerted iris Prolapsed iris, peaked pupil,


Scleral Perforating Injury
Perforating Injury:
ER Management
• Determine nature of trauma and extent of injury
• Give anti-tetanus regimen
• Start broad spectrum topical and systemic
antibiotic therapy
• Eye shield
• Avoid manipulation or pressure on the eye
• Prompt referral to ophthalmologist
Contusion Injuries of the Eye
(blunt trauma)
Closed Globe Injury
Open Globe Injury
Blunt Closed Globe Injury

Subconjunctival Hemorrhage Contusion Hematoma


Subconjunctival Hemorrhage
r/o blunt closed injury r/o valsalva related r/o HPN
Subconjunctival Hemorrhage,
Contusion Hematoma:
ER Management
• Closed globe injury
• Vision may be affected with “Berlin’s
Edema” / “Commotio Retinae”
• Conservative management
• Cold compress for the first 24 hours
• Warm compress on succeeding days
• Resolution in 7 to 14 days
Blunt Globe Injury: Hyphema
r/o Occult Ruptured (open) globe

Grade 3 Hyphema 8-Ball Hyphema


Hyphema: ER Management
• High back rest
• Limit activity
• Eye shield
• Topical cycloplegic (atropine sulfate)
• Monitor eye pressure
• Prompt referral to ophthalmologist
Ruptured Eyeball: Occult

HISTORY!, BOV, Severe conjunctival hyperemia, Eccentric pupil , Very


deep anterior chamber, hyphema, hypotonia
Ruptured Eyeball
Ruptured Eyeball
Blunt Globe Injury: Ruptured
eyeball/ Open globe injury
• Determine nature of trauma and extent of
injury
• Eye shield
• Broad spectrum topical and systemic
antibiotics
• Avoid any pressure on the eye
• Prompt referral to ophthalmologist
Urgent Red Eye Conditions

Acute red eye problems seen at


the emergency room
URGENT because it may be
possible to save vision
ACUTE ANGLE CLOSURE
GLAUCOMA: AACG
• Severe eye pain and BOV
• Redness, congestion,
injection
• Headache, nausea, vomiting
• mid-dilated, non-reactive
pupil
• firm to hard eyeball
AACG
Ciliary conj congestion,Mid-dilated
NORMAL EYE
pupil, corneal edema, pain,
haloes, photophobia
AACG: ER Management
• Acetazolamide 500 mg, IV Mannitol 20%
(1 g/kg), oral glycerol 50% (1 g/kg)
• Topical beta-blocker
• Prompt referral to ophthalmologist
Gonorrheal Conjunctivitis
Gonorrheal Conj: ER Mgt
• Irrigate with sterile normal saline solution
• Take precautionary measures to avoid spread
• Ceftriaxzone 250 mg IM (neonate); 500 mg to 1
gm IM (adult); single dose
• Ciprofloxacin: 250 mg single dose; 100 mg BID
• Azithromycin: 1 gm single dose
• Prompt referral to ophthalmologist
RETINOBLASTOMA

0-2 y.o. cat’s eye reflex, squint, glaucoma, dilated pupil, extruding eyeball
REFER IMMEDIATELY TO A TERTIARY CENTER
OCULAR PHARMACOLOGY

The succeeding slides are all


included in the handouts. If
preferred, lecture of this section
may be deferred.
Drug Administration Routes
• Topical: Anterior
– Drops, Suspensions, gels, ointments
– Low concentration in Posterior Chamber
• Local Injection: Anterior & Posterior
– Injections, delivery devices
– Subconjunctival, Subtenons, Retrobulbar
– Intracameral, (anterior chamber) Intravitreal (vitreous
cavity)
– Used for drugs with poor corneal penetration
– Higher risk and more apprehension
• Systemic: Anterior & Posterior
– Oral, intravenous
– Has to penetrate blood ocular barrier
Commonly Used Ocular
Therapeutic Drugs
• Glaucoma or IOP lowering drugs
• Antibiotics
• Anti-inflammatory
• Anti-allergy
• Decongestants/Lubricants
IOP Lowering Drugs
• Beta blockers
• Cholinergic stimulators
• Adrenergic stimulators
• Carbonic Anhydrase Inhibitors
• Prostaglandin analogs
• Hyperosmotics
Beta-Adrenergic Blockers
• Block ß2 receptors in • Timolol
ciliary processes • Betaxolol
• Reduce aqueous • Levobunolol
secretion • Metripranolol
• May protect optic
nerve
• Side effects:
– Bradycardia
– asthma
Cholinergic Agonists
• Increase outflow of • Pilocarpine
aqueous • Carbachol
• Open trabecular
meshwork
• Side effects
– Pupil constriction
– Decreased vision
– Myopia
Adrenergic Agonists
• Apraclonidine
– Decrease aqueous production
– Increase trabecular outflow
– Increase uveoscleral outflow
• Brimonidine
– Decrease aqueous production
– No effect on tracular meshwork
– Increase uveoscleral outflow
Adrenergic Agonists:
Adverse Effects
• Apraclonidine • Brimonidine
– Frequent ocular – Headaches
allergy – Fatigue
– Arrythmias – Hypotension
– Restricted use
– Eye redness
– Hypotension
Carbonic Anhydrase Inhibitors
• Block CAI enzyme • Oral
needed to produce – Acetazolamide
aqueous
– Dichlorphenamide
• SE: paresthesias,
– Methazolamide
tiredness, constipation or
diarrhea • Topical
• Renal stones, acidosis – Dorzolamide
• Aplastic anemia – Brinzolamide
• Stinging for drops
Prostaglandin Analogs
• Novel drug • Latanoprost
• Increase uveoscleral • Travoprost
outflow • Bimatoprost
• SE: hyperemia, Iris
hyperpigmentation,
ocular inflammation
• No systemic effects
• Have become #1 Rx
• Additive with other Rx
Antimicrobials
• Antibacterials
• Antifungals
• Antivirals
• Antiparasitics
Antibacterials
• Aminoglygosides • Fluoroquinolones =
– Tobramycin broad spectrum
– Gentamycin – Ciprofloxacin
– Vancomycin – Ofloxacin
– Neomycin
– Levofloxacin
• Erythromycin – Gatifloxacin
• Polymyxin B – Moxifloxacin
• Chloramphenicol
• Sulfacetamide
• Fusidic acid
Anti-inflammatory: Steroids
• Highly potent • Ocular SE
• Affect several areas – Cataract
of inflammation – IOP elevation
– Decrease – Infections
prostaglandins – Delayed Wound
– Decrease leucocyte Healing
activity
– Preserve membrane
permeability
– Anti-angiogenic
– Inhibit wound healing
Steroids
• Topical • Local Injection
– Prednisolone acetate – Anecortave Acetate
– Dexamethasone – Triamcinolone
– Fluoromethalone – Methylprednisolone
– Rimexalone • Systemic
– Loteprednolone – Prednisone
• Soft steroid, less risk of
– Methylprednisolone
increased IOP
– Dexamethasone
NSAID
• Decrease • Ocular preparation
Prostaglandins – Diclofenac
• Decrease – Ketorolac
leukotrienes – Indomethacin
• Fewer ocular side – Ketotifen
effects than steroids
• Cause GI discomfort
Acknowledgement
• Dr. Teresita Castillo
• Dr. Alex Tan
• Dr. Harvey Uy
• Dr. Milagros Arroyo
• Dr. Ma. Florentina Gomez
Thank you!

Good Luck!

STUDY!
Enjoy!

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