Opthalmology Revision

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					Opthalmology Revision

    Dr Nikesh Vallabh
                 Contents
•   Anatomy
•   Examination of the eye
•   Diabetic eye
•   Hypertensive eye
•   Red eye
•   Visual loss
•   Systemic disease – eye signs
                 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
                    Pupils
• Inspection
• Response to light
  – Direct
  – Consensual
• RAPD
  – Incomplete retinal arterial occlusion
  – Optic neuritis
  Eye position and movement
• Look at corneal reflexes
• Squint test
• Eye movements - diplopia
                              IO       IO
     SR                                                           SR


                              MR MR                                    LR
LR

 IR                        SO        SO
                                                                  IR

          Note: Upgaze and downgaze must also be tested but are
          composite movements involving multiple muscles.
•{S04 LR6} 3
            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
          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”.
    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
   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
                   Examination
• Nystagmus          • Opthalmoscopy
• Eyelids              –   1% tropicamide
  –   Ectropion        –   Set to 0
  –   Entropion        –   Fixate distant object
  –   Trichiasis       –   RE RH RE
  –   Ptosis           –   Red reflex
  –   Evert            –   Optic disc
                       –   4 quadrants
                       –   Macula
                Diabetic eye
•   Background retinopathy
•   Pre- proliferative retinopathy
•   Proliferative retinopathy
•   Macular retinopathy
                  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
           Pre-prolferative
• BDR + ……
• Cotton wool spots
  – Pale white
  – Blocked blood vessels
  – Localised areas of nerves damaged
• Flame haemorrhages
              Proliferative
• Neovascularisation
  – Proliferative growth of NEW, ABNORMAL
    blood vessels
  – Prone to bleed
  – Esp. with sudden movements or HTN
• Treat with laser therapy
Panretinal photocoagulation
Diabetic maculopathy
                   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?
• RED EYE
         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
      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
       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
     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
           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
                Episcleritis
• Sx
  – Mild discomfort
  – Segmental redness
• D
  – No
• V
  – No
• Tx
  – Self resolving
Episcleritis
                    Scleritis
• Sx
  – More serious than episcleritis
  – Boring pain
  – Ass. Systemic disease RA, vasculitis, sarcoid
• D
  – No
• V
  – No
• Treat
  – urgent – steroid, NSAIDS
Scleritis
         Staining the cornea.
• Reveals epithelial
  defects.
• Instil one drop of
  fluorescein from a
  minim.
• Examine in blue light   Corneal abrasion

  for best visibility.
• Epithelial defects
  fluoresce green.


                            Dendritic ulcer
                    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
Everting the eyelid.




               Subtarsal FB
              Management
• Never give steroid for undiagnosed red
  eye!
• Aciclovir ointment 5 x a day for 2 wks
  – await resolution
With severe scarring
  – Rehabilitiate eye
  – contact lens or corneal transplant
Sunconjunctival haemorrhage

                  Check BP

                  Discharge
                Acute Glaucoma
• Sx
  –    Severe headache/ Eye pain
  –    N+V
  –    Consider all pt. >50
  –    Permanent damage
  –    Semi dilated pupil
  –    Eye stony hard
• D
  – No
• V–
  – Profound
  – Blurred vision due to corneal oedema
  – Pupils less reactive to light
            Acute glaucoma
Treatment
  – break the attack
    • Diamox IV, Pilocarpine 2% 20m later pupil
      constriction
    • Oral glycerol, Mannitol
  – prevent further attacks
    • Iridotomies
    • Hole in iris to allow drainage
  – deal with residual glaucoma
    • drop treatment, drainage surgery
 Causes of acute visual loss
– TIA and stroke
– Migraine
– Retinal and optic nerve vascular occlusions
– Optic neuritis
– Haemorrhage (retinal or vitreous)
– Cataracts
– Acute glaucoma
– Retinal detachment
– Macular degeneration
        Central artery occlusion
• Sx
  – Sudden
  – Painless loss of vision
  – Temporary or permenant
• O/E
  –   Profound visual loss
  –   Loss of direct light response – complete
  –   RAPD – incomplete
  –   Cherry red spot
  –   Thready arteries
              Management
• Exclude temporal arteritis
• Ocular massage
• Re-breathe into bag to increase CO2
  – no good after 4 hours
• Prevent further episodes
  – Assess risk factors
  – aspirin
  – Carotid dopplers
            Venous occlusion
• Sx
  – Gradual onset
  – Vision not always impaired
  – Commonly occurs in the sheath where artery and vein
    cross over
• O/E
  – Oedema – cotton wool spots
  – Haemorrhages
  – Swelling of disc
• Tx
  – Check BP and for hyperviscosity
  – Laser therapy to ablate the ischaemic retina
Branch Retinal Vein Occlusion
        Vitreous haemorrhage
Symptoms
  – cobwebs and floaters
  – loss of vision
Signs
  – mild - hazy retinal details
  – moderate - dull red reflex
  – severe - no red reflex
              Management
• Investigate for diabetes
• Chair rest
  – watching TV
• Ultrasound scan
  – to check for underlying detached retina
• Vitrectomy if not settling
         Retinal Detachment
Symptoms
  – early: flashes and floaters
  – later: curtain coming up/down over vision
  – later still: loss of vision
Signs
  – early: retinal tear, mild vitreous bleed
  – later: grey wrinkly detached retina
Summary - Causes of sudden visual loss.
condition         typical VA      Fundus              Associations        management
                                  appearance
retinal artery    CF or worse     pale with thin      Carotid bruit or    <6 hrs ocular
occlusion                         arteries, cherry    cardiac valve       massage,
                                  red spot                                rebreathing.
                                                                           >6 hrs nil.
retinal vein      6/12 to HM      Haemorrhages in     BP, DM,            Bloods. Observe
occlusion                         affected sector     glaucoma            or laser.
ischaemic optic   6/60 or worse   pale swollen disc   Giant cell          ESR; if GCA
neuropathy                        with splinters      arteritis; PMR.     likely, high dose
                                                                          steroids.
optic neuritis    6/12 to NPL     Swollen disc (but   MS                  Pain relief only;
                                  may be normal)                          recovery is the
                                                                          rule.
retinal           6/6 to HM       Dull grey mobile    Myopia;             Surgical repair.
detachment                        shadow              previous eye
                                                      surgery
macular           6/60 or worse   Dark red to black   Macular             Usually nil.
haemorrhage                       patch in central    degeneration
                                  fundus
vitreous          6/6 to HM       blobs, streaks &    diabetes; retinal   Ultrasound.
haemorrhage                       clouds obscuring    detachment          Laser or surgery.
                                  view
END

				
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posted:6/26/2011
language:English
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