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Introduction to Eye Problems in Indonesia
Gitalisa Andayani
G
Department of Ophthalmology, FKUIJakarta 2008
The EYE Most vital sensory organ
(80% of information obtained from vision) Delicate Eye problems:
- encountered in everyday clinical practice- may cause visual impairment- worldwide health problem
Visual impairment Definitions (WHO): Visual impairment: low vision and blindness - Low vision: best corrected visual acuity of 6/18 to 3 m counting fingers (CF) - Blindness: best corrected visual acuity of 3 m CF or less
Mostly: avoidable (preventable and/or curable)
Global blindness
WHO, 1990: prevalence of blindness ranged from 0.08% in children to 4.4% adults over 60 years; overall global prevalence of 0.7% at least 7 million people become blind each year the number of blind people worldwide was increasing by 1–2 million per year
Source: Global Initiative for the Elimination of Avoidable Blindness : action plan 2006-2011, WHO, 2007
Source: Global Initiative for the Elimination of Avoidable Blindness : action plan 2006-2011, WHO, 2007
Source: Global Initiative for the Elimination of Avoidable Blindness : action plan 2006-2011, WHO, 2007
Global causes of blindness
Impact of blindness
Social burden: Becoming other people’s responsibility Immobilition of otherwise healthy
individuals Financial loss:
Cost of surgery / treatment / rehabilitation Mental impact:
patients feel disabled, leads to depression
Blindness in Indonesia Blindness prevalence in Indonesia: 1.5%
(high, compared to other South East Asian countries)
Major causes of blindness in Indonesia: - cataract- glaucoma- refractive errors- retinal diseases- corneal diseases(Survei Kesehatan Rumah Tangga, Depkes, 1993)
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Problem
Indonesia: sporadic, local data in several regions
Most recent national data >10 years ago: Survei Kesehatan Rumah Tangga 1996 (1.5%)
No data on Childhood Blindness
SKRT: Survei Kesehatan Rumah Tangga (1993, 1996)
Prevalence of Blindness in Indonesia: increase from 1.2% to 1.5%
Prevalence of main causes of blindness:- Cataract: est. 52% (backlog 1.5 million) - Glaukoma from 0.1% in 1983, to 0.2% in 1996
Hospital-based (RS Cipto Mangunkusumo, 1982) incidence of Glaucoma 1.8% among new patients aged ≥ 40 yo, 65% of them blind
- Refractive Errors: 0,14%. Jakarta: prevalence of school myopia 21 – 52%
- Diabetic Retinopathy: included in ”other cause of blindness”, 28%, but estimated to be 0.13% (SKRT 1996)
- AMD: Universitas Gajah Mada, Yogyakarta: study on a population ≥ 40 yo of 3000 in 2004, found prevalence of 1.1%
-Childhood Blindness-Blindness from cataract est. 1-4 per 10.000. -ROP caused blindness in 1.1% in Blind
Schools in Java Island
Prevention of blindness
‘VISION 2020: the Right to Sight’ : an established partnership between the World
Health Organization (WHO) and the International Agency for the Prevention of Blindness (IAPB)
launched in 1999 with the 2 aims:- eliminating avoidable blindness by 2020- preventing the projected doubling of avoidable visual impairment between 1990 and 2020.
Prevention of Blindness
Involves: Facilities Human resources Funds Awareness
Prevention of blindness and eyecare Health care personnels:
GPs, opthalmologists, nurses, optometrists
Organizations Government NGOs Profession
(Indonesia: PERDAMI) Collaborative groups
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Ophthalmology for GP Knowing the anatomy and physiology of
the eye, and the pathogenesis of eye diseases
Basic eye examination Diagnosis of eye problems Treatment planning: complete, initial, or
referral
Anatomy of the eye
Lateral Canthus
Punctum lacrimalis
CorneaLimbus
Conjunctiva
PupilIris
Karunkula
Upper eyelid
Lower eyelid
Medial Canthus
Anatomy of the eyeCiliary body
Vitreous(‘glass jelly’)
Cornea
Optic nerve
Macula
Pupil
Iris
Lens
Limbus {
Anterior Chamber
Posterior Chamber
Lens zonulesExtraocular
Muscles
Retina
ChoroidSclera
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Classification of Eye Problems
Red eyes (normal and decreased vision) Chronic visual (progressive) loss Acute visual (persistent) loss Trauma Abnormalities in ocular alignment and
motility Refractive disorders
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Red eyes
Clear refractive media: normal vision Opacity of refractive media: decreased vision Vasodilation of vessels of the conjunctiva
/episclera / sclera / cornea Inflammatory (infection and non-infection) Normal vision: conjunctivitis, scleritis, episcleritis,
pterygium, pinguecula Decreased vision: acute glaucoma, keratitis, uveitis,
endophthalmitis
Conjunctivitis
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Chronic visual decrease Caused by chronic changes in the clarity of
refractive media or function Abnormality of neural pathway (from
retina tovisual cortex) Mostly: degenerative process E.g: cataract, chronic glaucoma, diabetic
retinopathy, age-related macular degeration (AMD)
KATARAK Kekeruhan lensa Penyebab:
- degenerasi (senilis): usia tua- penyakit mata lain/metabolik/obat
(komplikata)- bawaan (kongenital)- trauma (traumatik)
kekeruhan lensa (katarak)
KATARAKTanda dan gejala Dini:
- terkadang belum ada keluhan- melihat kabut/asap- silau- sulit membaca
Lanjut:- buram- bercak putih pada pupil (lekokoria)
KATARAKPenatalaksanaan Bergantung kebutuhan penderita; bila sudah mengganggu: OPERASI KATARAK
Teknik:- Intracapsular Cataract Extraction(ICCE) sudah ditinggalkan- Extracapsular Cataract Extraction(ICCE)
mulai ditinggalkan- Phacoemulsification- Small-incision
Phacoemulsification
GLAUKOMA• kerusakan saraf optik, umumnya akibat peningkatan tekanan intra okular (karena hambatan outflow)• gangguan lapang pandang• 2 tipe: - glaukoma sudut terbuka
- glaukoma sudut tertutup
Saraf optik normal Saraf Glaukoma Saraf Glaukoma Lanjut
GLAUKOMATanda dan gejala • Tekanan bola tinggi > 21 mmHg (normal 10-21)• Sudut terbuka: tanpa gejala; bila ada sudah lanjut (sering menabrak2, halo pelangi, nyeri sekitar mata)• Sudut terbuka: bisa terjadi glaukoma akut
tanda sisa serangan akut (katarak, pupil lebar, iris atrofi)• Lapang pandang menyempit
GLAUKOMA
Penatalaksanaan • Observasi• Obat-obat glaukoma: - beta-blocker
- asetazolamid- pilokarpin
• Laser (iridotomi, trabekulotomi, trabekuloplasti)• Operasi (iridektomi, trabekulektomi, implant)
Retinopati diabetik
Gangguan retina akibat komplikasi diabetesGangguan retina akibat komplikasi diabetes GGlukosa darah meninggi lama-lama pembuluh darah organ-organ (terutama ginjal, saraf, mata) rusak Penurunan penglihatanPenurunan penglihatan Penyebab kebutaan terbesar pada penderita diabetes 50% penderita diabetes setelah 10 tahun akan menderita retinopati
Mekanisme kebutaan pada retinopati diabetik
kebocoran cairan, lemak dan darah di retina
dari pembuluh darah yg rusak Edema makula
aliran darah ke retina menurun iskemia
neovaskularisasi PDR
-perdarahan vitreus- Jar fibrovaskular- retinal traction ablasi retina
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Retinopati diabetik
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Retina normal
Retinopati diabetik proliferatif Retinopati diabetik proliferatif dengan traksi
Retnopati diabetik non-proliferatif FFA
Retnopati diabetik non-proliferatif
AMD=age-related macular degeneration
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• Penurunan visus sentral perlahan akibat
degenerasi makula pada usia lanjut
• mengenai kedua mata
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Acute visual loss Caused by acute changes in
refractive media or function, or acute disturbances in visual pathway
May be associated with systemic disease
E.g: retinal detachment, retinal vascular occlusive diseases, vitreous hemorrhage, optic neuritis, optic neuropathies
Retinal detachment
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Trauma Penetrating/perforating injury Blunt injury Chemical injury
Chemical injury
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Abnormalities of ocular alignment and motility
Strabismus (squint) Nystagmus Diplopia Paresis of external ocular muscles Orbital tumors
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Refractive problems Myopia Hypermetropia Astigmatism Presbyopia
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Learning ObjectivesKnowledge:
- pathology- epidemiology, clinical features, pathogenesis- scientific basis- management, referral- promotion and prevention
Skills:- communication with patients- integration of history and examination- investigation
Attitudes:- ethical behaviour- confidentiality- respect social, cultural backgrounds
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Core clinical problems and conditions
Acute decreased visionChronic decreased visionRed eye, normal vision
Red eye, decreased visionOcular injury
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Physical examination skills
-Eye examination-Visual acuity test
-Funduscopy-Tonometry
Medical imaging knowledge and skills
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Learning activities
-PKK: Bedside teaching tutorials
-PKK: Outpatient department
-PSSS
-Diskusi pagi: topic sessions
-Case presentations
-Night shift: 4 – 8 PM
-Ujian: written & portfolio
Ophthalmology Department, FKUI/RSCM
Sub-specialty Clinics Cornea & Refractive Surgery Vitreo-Retina Neuro-Ophthalmology Tumor (Oncology) Oculoplastic – Reconstructive Pediatric Ophthalmology Strabismus Glaucoma Infection dan Immunology Refraction
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Ophthalmology Department
Operating Rooms Ward: Public Wing (7th floor) Emergency clinic
Ophthalmology examination
Refraction
Snellen Chart
Pinhole test
Ophthalmology examination
Funduscopy
Ophthalmology examination
Digital palpation
Schiotz Tonometry
Slitlamp biomicroscopy+ applanation tonometer
Confrontation test
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Welcome to Eye Department….
Use your time well
advice:- do your best……….!
Thank you