Opthalmology

Diabetes

• Refractive changes due to glucose, correct when glucose stable

• Extraocular muscle paralysis CnIII and CnVI• Retinopathy– Background – microaneurysms, dot haemorrhage,

hard exudates– Pre-Proliferative – cotton wool spot, blot

haemorrhage, venous loops– Proliferative – neovascularisation, traction retinal

detachment, glaucoma.

Investigation / Management Retinopathy

• Ix – Digital photographic screening and Fundal Fluorescien angiography.

• BP/Lipid/Glycaemic control• Photocoagulation – retinal/macular, argon

laser or xenon.• Vitrectomy – clear vitreous haemorrhage,

allows laser, relieve traction

Background retinopathy

Background

Pre Proliferative Retinopathy

Pre Proliferative

Proliferative

Proliferative Retinopathy

Laser Photocoagulation

Hypertension• Keith Wagner Classification• Grade I – minimal constriction and irregularity of

arterioles• Grade II – AV nipping• Grade III – Flame haemorrhages and soft

exudates• Grade IV – papilloedema, collection of hard

exudates radiating in a star shaped formation• Fundal changes reflect severity of HTN, reversal

shows control

Hypertensive Retinopathy

Grade IV Malignant Phase

Red Eyes

Conjunctivitis• Conjunctivitis– Grittiness sensation– Normal Vision– Purulent discharge– Crusting of lid margins– History of contact– Redness of conjunctiva– Mx Hygiene, swab, prescribe topical Abx

chloramphenicol or fusidic acid– Bilateral consider chlamydia– Opthalmia neonatorum – newborns under 1 month,

reportable disease

Corneal Ulcer/Keratitis/Abscess

• Painful red eye• Contact lenses, FB, facial cold sores???• Photophobia• Purulent discharge in bacterial cases• Fluorescein staining reveals area of epithelial

defect under cobalt blue light• Immediate opth opinion, corneal scrape,– antivirals for herpes simplex dendritic ulcer– Intense Abx for bacterial ulcer

Corneal Ulcer

Keratitis

Uveitis• Inflammation of the Uveal tract – iris, ciliary body and choroid• Painful red eye• Photophobia• Blurred vision or floaters• Cilicary circumcorneal injection• Reduced acuity• Sluggish or irregular pupil• Iris details may be hazy• Inflam cells on corneal endothelium• Raised intraocular pressure• Cataract in recurrent or chronic uveitis• Rx reducing regimen of topical steroid (dexamethasone 0.1%)• Cycloplegic and dilating drop (cyclopentolate 1%) for pain

relief and prevention of synechiae

Uveitis

Acute Angle Closure Glaucoma• Older hypermetropic people• Sudden onset severly painful red eye• Blurred vision• Halos around lights• Headache• Nausea and vomiting

• Reduced visual acuity• Brick red eye• Hazy cornea• Vertically mid dilated fixed pupil• V high IOP

Acute Angle Closure Glaucoma

• URGENT• IV carbonic anhydrase inhibitor –

acetazolamide 500mg• Oral acetazolamide for 24h• Pilocarpine• Timolol or Iodipine to reduce IOP• Laser Iridotomies as permanent prevention• Trabeculectomy

AcuteGlaucoma

Sudden Painless Loss of Vision

Retinal Detchment

• Sudden Painless Loss of vision• Usually preceeded by symps of flashing lights• Floaters and visual field defects may occur• Visual acuity may be normal if the macula is

not involved• Once macula involved central vision is lost• Manage – laser to retinal hole or retinal

surgery with or without vitrectomy

Central Retinal Vein Occlusion• Aetiology– Systemic Hypertension– Raised intraocular pressure– Hyperviscosity syndromes– Vessel Wall disease (diabetes, sarcoidosis)

• Check– IOP– BP– Viscosity

• Flame shaped Haemorrhages• Tortuous vessels

Central Retinal Artery Occlusion• Aetiology– V high IOP ? Glaucoma– Arterial Embolus– Atheroma or inflammation (Giant cell arteritis)

• Check– BP– Pulse ?AF– Carotids ?bruit– Heart ?murmur– Refer to Cardiology

• Cherry red spot at origin of artery

Central Retinal Artery occlusion

Gradual Loss of Vision

Cataract

• Blurred vision• Glare• RF: DM, steroids, chronic uveitis, FH,

Congenital• Congenital risk amblyopia• Rx Phacoemulsification and Lens implantation

Age Related Macular Degeneration• Commonest cause of blindness in the elderly• Causes loss of central vision• Macula has fine pigmentory clumps and patches of

atrophy• White round spots – drusen, usually large and

confluent• Neovascularisation may occur• Manage – urgent fundal fluorescein andgiographic

tests to treat neovasc with photocoagulation• Peripheral vision is not affected

Some Randoms

Papilloedema

Scleromalacia

Chalazion

Exopthalmos

Stevens Johnson Syndrome

Pterygium

Pinguecula

Corneal Dystrophy

Iridocyclitis (deformed pupil)

Chorioretinitis

Toxoplasma Chorioretinitis

Histoplasma infection

Macula Dystrophy

Sickle cell Retinopathy

Optic Atrophy

Retinoblastoma

Retinopathy of prematurityDragging of the optic disc

Tuberous sclerosis

Siderosis Bulbi – retained Fe Particle

IridodialysisIris torn at root

Hyphaema – blood in anterior chamber

Lens Dislocation