Dr. Chamath FernandoMBBS (Sri Jayewardenepura)

LecturerDepartment of Family Medicine

FMSUSJP

Common Symptoms Blurring of vision Redness Pain Loss of vision Photophobia Discharge

Refractive Errors Disorders of the lids Conjunctivitis Corneal disorders Episcleristis / Scleritis Sub Conjunctival Haemorrhages Dry eye syndrome Cataracts Glaucoma Uveitis Disorders of the retina Loss of vision Amarausis Fugax Temporal arteritis Hypertensive changes in the retina Diabetic eye disease Strabismus

Eye Condition Treatment (spectacles, contact lenses or excimer laser)

Emmetropia Normal refraction of the cornea and lens

Myopia Short sightedness Corrective– Concave lenses

Hypermetropia Long sightedness Convex lenses

Presbyopia The ability of the lens to change the convexity is lost after the fourth decade of life – causing difficulties with near vision

Bifocals

Astigmatism The eye is not the same curvature of radius for refraction. (e.g. myopic in one plane and emmetropic in the other)

Cylindrical lenses corrected according to the axis

Bifocals

Conditions TreatmentEntropion Inward rolling of the lid

marginsRubbing of the eye lashes against the globeIrritationMimics conjunctivitis

Surgical Correction

Ectropion The eyelid margins are not apposed to the globe Lacrimal puncta cannot drain tearsCauses a watery eye

Surgical treatment

Dacrocystitis Inflammation of the lacrimal sacPresents as a painful lump by the side of the nose

Broad spectrum antibioticsOphthalmologist referral for surgical treatment

Blepharitis Inflammation of the eyelid marginStye- Inflammation of the eyelashes and lash folliclesChalazion -Inflammation and blockage of the Meibomian glands

Lid toilet Topical antibiotics – Chloramphenicol or Fusidic acidIf orbital cellulitis – Broad spectrum antibioticsIf residual lump – Incision and curettage

Commonest cause of Red eye Causes: Viral, Bacterial, Chlamydial, Allergic Clinical features:

◦ Redness◦ Soreness (sandy gritty sensation)◦ Discharge◦ Vision not impaired◦ Usually bilateral involvement

Aetiology Discharge

Preauricular node

Corneal Involvement

Comment Treatment

Bacterial (5%)(Gonococcus - copiousH. InfluenzaeS. PneumoniaeStaphylococcusMoraxella)

Mucopurulent

-ve except gonococci

+ve Gonococcus

Rapid onsetGonococcal infection in the neonate – symptoms occur within 2 days of birth

Gonococcal – Conjunctival swab shows diplococciTreated with Oral and Topical PenicillinChloramphenicol

ViralAdenovirusHSV 1 commonly Molluscum Contagiosum

Watery +ve +ve Adenovirus

50% UnilateralCold and / or sorethroatAss. With chemosis, lid oedemaMay cause blurring of vision due to corneal involvementAdenoviral – Very contagiousDendritic corneal ulcer

HSV – Vesicles around the eye

Molluscum – umbilicated lesions on eyelids

Adenoviral – Self limitingLubricantsCold compressPrevent cross infectionIf intense – may require steroidsHSV – Self limitingSome may use Aciclovir topicallyMolluscum- Ophthalmologist referral for surgical treatment If severe - Steroids

Aetiology Discharge Preauricular node

Corneal Involvement

Comment Treatment

Chlamydial(Chlamydia trachomatis)

Watery + ve +ve GU dischargeSlow onset of symptomsSexually transmitted (in active individuals)Neonatal – with maternal reproductive tract secretions (2 weeks)Trachoma –blindness

Topical erythromycin bdAdolescents and adults to GU surgeonNeonates to paediatrician to exclude associated pneumonitis or otitis

AllergicSeasonalPerinnial

Stringy/ sticky -ve +ve Itchy Avoidence of allergensTopical anti-histamines like azelastineTopical mast cell stabilizer like Na ChromoglicateSteroids avoided generally

1. Trauma 2. Keratitis

Condition Features TreatmentCorneal Abrasions – a focal area of the epithelium gets rubbed away

Intense painInability to open the eye (blepharospasm)LacrimationVisual acuity reducedEx: may require topical anaesthetic (Tetracaine)Use Florescin (orange) dye with a blue lamp examination to identify the abrasion (in green colour)

G. Chloramphenicol qds X 5 daysPad the eye X 24 hours

Corneal Foreign bodye.g. flies

LacrimationPhotophobia

Remove gently with copious amounts of salineTopical antibiotics(Choramphenicol and Fusidic acid)

Direct Trauma FB may be visibleFlat anterior chamberHyphaemia (Blood in anterior chamber) SCHBrusing if associated blunt trauma

Instill no dropsRefer to an ophthalmologist urgently

Corneal inflammation Causes: HSV infection, Contact lens,

blepharitis Cilnical features: Redness, Pain, Lacrimation,

Sensation of a foreign body, photophobia

HSV- Dendritic ulcer◦ The Virus remains dorment in the CN V◦ Gets activated in immunosuppression◦ Can lead to a geographical ulcer

Contact Lens Keratitis ◦ Can be life threatening◦ Urgent referral to an ophthalmologist

Blepharitis◦ Staphelococcus aureus is responbible for most of

the cases◦ Rx: with Chloramphenicol

Episcleritis (between the conjunctiva and the sclera)

Localized, deep redness Tender area +/- Not painful No discharge Normal vision No photophobia Normal pupils and cornea Rx: topical/oral steroids

Scleritis Symptoms are intense Painful loss of vision Severe form associated with Rheumatoid arthritis causes

Scleromalacia perforans Urgent referral

Symptoms – A bright red eye due to a bleed beneath the conjunctiva caused by rupture of a small blood vessel

Causes – ◦ Raised intracranial pressure (Coughing, sneezing)◦ Trauma◦ Violent rubbing◦ Bleeding disorders or anticoagulants (recurrent)◦ Hypertension

Management◦ Control of the cause◦ Mild analgesics◦ Eye lubricants◦ Reassurance of resolution within weeks◦ Make sure the line doesn't extend beyond the visible sclera

(may be associated with orbital fracture)

Loss of vision?

SymptomsSevere PainPhotophobiaReduced visionColoured halos around the point of light in patient’s visionProptosisSmaller pupilOn Examination Raised IOP Shallow anterior chamber depth Corneal Epithelial disruption

Cause Conjunctiva Injection

Unilateral/Bilateral

Pain Photophobia

Vision Pupil Intraocular pressure

Conjunctivitis

Diffuse Bilateral (in Bacterial)

Gritty Occasionally with Adenovirus

Normal Normal Normal

Anterior Uveitis

Circum-corneal

Unilateral

Painful Yes Reduced Constricted

Normal or raised

Acute Glaucoma

Diffuse Unilateral

Severe Mild Reduced Mild dilated

Raised

Associated with Keratoconjunctivitis Sicca / Sjogren’s syndrome

Clinical Features: ◦ FB sensation/ gritty feeling in the eye◦ Mucoid discharge◦ Photophobia◦ Blurred vision

Management◦ Artificial tears◦ Eye lubricants◦ Moisture chambers glasses at night◦ Secretogogues e.g rebamipide ◦ Punctal plugs◦ Ophthalmologist referral

Moisture chamber

Commonest cause of reversible blindness The commenest surgical procedure so far

Aetiology◦ Senile (legal blindness <6/12)◦ Congenital – Maternal infection, Familial◦ Metabolic – Diabetes, galactosaemia, Wilson’s

disease, hypocalcaemia◦ Drug induced – Corticosteroids, amiodarone◦ Traumatic◦ Inflammatory – Uveitis◦ Disease associated – Down’s, Dystrophia myotonica

Clinical features –◦ Gradual painless deterioration of vision is the

commonest symptom◦ Problems with night vision◦ Glare – Common with posterior subcapsular cataract

Investigations◦ Diabetes◦ Hypocalcaemia

Management◦ Early detection and ophthalmologist referral is

essential in the infants to prevent development of amblyopia later on in life

◦ Correction of the aetiological factor◦ Mild cases – spectacles◦ If opacified – Extraction of cataracts and intra ocular

lens insertion Most popular – Phacoemulsification

Elevation of the internal pressure of the eye >21mmHg◦ (Normal : 10-21mmHg)

Second commonest cause of blindness – via optic nerve damage◦ Mainly visual field defects

Primary open angle Glaucoma

Acute angle closure glaucoma

Commonest Ophthalmic emergency – Acute rise of pressure >50mmHg

Aetiology Due to blockage of the trabecular meshwork, drainage of aqueous humor is impeded

Pushing of the lens anteriorly pressing against the meshworkCommonly when the pupil is maxiamaly dilated

Risk factors

ElderlyBlack raceFamily historyMyopia

Elderly – Shallow anterior chambers in Women and Hypermetropics

Clinical features

Gradual painless loss of peripheral visual field

Red painful eyeHeadacheNausea, VomitingEye is injected, hard and tenderHaziness of cornea

Diagnosis Ophthalmoscopy – Cupping of the fundusIOP measurement is the definitive

IOP measurement or clinically

Treatment Reduction of AH production – Topical Timolol and Acetozolamide (Topical and Oral)Increasing the drainage of AH - Prostaglandin analogues (Travoprost)

Emergency referral to an ophthalmologistAnalgesicAntiemetics

(IV AcetozolamidePilocarpine to constrict pupilsProstaglandin analogues, Beta blockersIV Mannitol if resistantSurgical – Hole in the peripheral iris

Uveal Tract – ◦ Iris – Iritis/ Anterior Uveitis◦ Cilliary body – Intermediate Uveitis ◦ Choroid – Posterior uveitis◦ Entirely – Pan uveitis

Symptoms ◦ Blurred vision◦ Redness◦ Photophobia◦ Pain – Mainly anterior symptom◦ Floaters – Mainly posterior symptom

Associated diseases◦ Ankylosing spondilitis◦ Arthritis◦ Inflammatory Bowel disease◦ Sarcoidosis◦ TB◦ Syphilis◦ Toxoplasmosis◦ Behcets syndrome◦ Lymphoma◦ Viruses – CMV, HSV, HIV◦ Idiopathic

Classical Triad◦ Redness (genaralized)◦ Pain◦ Photophobia

Signs◦ Cells with keratic precipitates in the anterior chamber, pus◦ IOP may be raised due to the cells clogging up the There

may be posterior synechiae◦ trabecular meshwork

Treatment◦ Ophthalmologist referral◦ Dexamethasone 0.1% topically◦ Cyclopentolone to prevent posterior synechiae also

allowing fundoscopy◦ Mx of raised IOP

Central Retinal Vein Occlusion

Central Retinal Artery Occlusion

Retinal detachment

Age related macular degeneration

Symptoms Sudden profound painless loss of vision of one eye

Sudden profound painless loss of vision of one eye

Painless progressive visual field lossFloaters and flashes prior to detachment

Progressive loss of central vision

Pathogenesis Obstruction of venous outflow and increased intravascular pressure leading to dilated veins, retinal haemorrhages, retinal oedema and cotton wool spots

Results in infarction of the inner 2/3 of the retina90 minutesOedema of the retina thinningCherry red spot

The area of visual field loss corresponds to the area of detachment of the retina

Lipofucin deposits can be seen deposited under the retina

Risk Factors DM, HT, Cardiovascular disease, Glaucoma, Vasculitis and Blood dyscrasias

DM, HT, Cardiovascular disease, Glaucoma, Vasculitis and Blood dyscrasias

ElderlySmokingHTHypercholesteraemiaUV exposure are suggested

Treatment Rx underlying conditionRefer to ophthalmologist

Emergency referralOcular massageBreathing into a bag CO2 VasodilatationDislodging of Emboli

Iv AcetazolamideParacentesis

Urgent referral to the ophthalmologist

Referral to the ophthalmologistModification of risk factors

Sudden Transient Loss of Vision in one eye. Due to thromboembolism Embolus may be visible at ophthalmoscopy

during an attack

Implications:◦ May be the first evidence of internal carotid artery

stenosis◦ Hamiparesis may follow

◦ DD: Migraine, GCA

Common in elderly Presentation: Sudden painless loss of unilateral

vision (May have preceded by Amaurosis fugax)◦ May proceed to bilateral disease

Associations: ◦ Severe unilateral temporal headache (along the

distribution of the artery with features of inflammation). The artery is thickened and pulseless

◦ Severe facial pain in chewing◦ IHD, microangiopathic neuropathy

Management◦ Ix: ESR elevated◦ Diagnosis confimed by : Bx◦ Rx: High dose steroids

Painless PainfulCataract Acute angle closure glaucomaOpen angle glaucoma Giant cell arteritisRetinal detachment Optic neuritisCentral retinal vein occlusion UveitisCentral retinal artery occlusion ScleritisDiabetic retinopathy KeratitisVitreous Haemorrhage ShinglesAge related macular degeneration Orbital cellulitisOptic nerve compression TraumaCerebrovascular disease

Keith Wagener Classification of Hypertensive Retinopathy◦ Grade 1 – Tortuosity of the retinal arteries with

increased reflectiveness “Silver wiring”◦ Grade 2- Grade 1+ “Arteriovenous nipping”

◦ Grade 3 – Grade 2 + Flame shaped haemorrhages and Cotton wool spots

◦ Grade 4 - Grade 3 + Papilloedema (blurring of the optic disc margin

The significance of Grade 3 and 4?◦ Malignant Hypertension

Diabetic retinopathy – A microvascular complication

Cataract External Ocular palsies Sixth and third cranial nerve palsies

◦ CN III palsies recover within a period of 3-6 months

Progression of the disease is rapid in type 1 >type 2 diabetics

TypesI. Background retinopathyII. Preproliferative and proliferative retinopathyIII. MaculopathyIV. Mixed retinopathy

◦ Dot haemorrhages - Microaneurysms◦ Blot hamemorrhages - Intra retinal haemorrhages◦ Cotton wool spots – Micro infarcts (lasts longer

than those due to HT)

Retinal ischaemia Neovascularization fibrous tissue forming around the new vessels

Exudates around the macula within one optic disc’s width

Many features mentioned above present together

Rx:◦ Aggressive control of glycaemia◦ Ophthalmologist referral (surgical procedures e.g

laser photocoagulation)

Mal alignment of the two eyes/ visual axi Cause : Poor coordination of the extra ocular

muscles groups Due to: e.g. CP, syndromes like Noonan, stroke,

botulism, diabetes Implications:

◦ Cosmesis◦ Diplopia◦ Amblyopia (Lazy eye)

Tests: Corneal light reflex, Cover-uncover test (read) Treatment:

◦ Spectacles◦ Cover the better eye to improve the amblyopic eye◦ Ophthalmologist (Muscle surgery)

Kumar and Clark – Clinical Medicine Medscape

Download the presentation: e-learning◦ http://lms.sjp.ac.lk/med/blog/index.php?

userid=1268