Dr. G ita lis a Andayani, S pMDepartment of Opthalmology

FKUI/RS CM1

SUMMARY OF EYE

PROBLEMS

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

- Congestion of conjunctival blood vessels- If clarity of media disturbedvision decreased

- In developing countries accounts for 40% eye problems

RED EYES

Red Eyes, normal vision

Conjunctivitis (bacterial/viral/chlamidyal/allergic)

Pterygium Subconjunctival hemorrhage Episcleritis and scleritis

CONJUNCTIVITISClinical presentation Nonspecific:

watery eyes, irritation, stinging, foreign body sensation, photophobia or itchiness

Discharge: watery, mucoid, purulent or mucopurulent

Conjunctival injection Eyelid swelling Tarsal conjunctiva:

papillae/follicles/membrane Cornea and pupils usually normal

CONJUNCTIVITIS

CONJUNCTIVITIS

CONJUNCTIVITIS

Conjunctivitis Bacterial Conjunctivitis

Chlamidial conjunctivitis (trachoma) Allergic/vernal conjunctivitis

CONJUNCTIVITISManagement

- Can be done by GP

- Eye hygiene

- Eyedrops:

viral self-limiting, antibiotics

bacterial antibiotics

allergic/vernal antiallergy, steroids(!)

- 3 days w/o improvement: refer

PTERYGIUM

• growth of triangular fibrovaskular tissue invading the cornea

• patients in hot climate, chronic dryness and high sunlight exposure

• difference from pinguekula: yellow-white deposit at nasal/temporal from limbus (collagen degeneration, calcification)

• apex always in the cornea side, often with Fe deposits

PTERIGIUM

PTERYGIUM

Management:

• Excision with conjuctical graft

• Lamellar keratoplasty

SUBCONJUNCTIVAL HEMORRHAGE

• No pain, no discharge

• Well-demarcated

• Self-limiting within 2 weeks

EPISCLERITIS AND SCLERITIS

• Sclera covered by 3 vascular layers:

- Conjungtival blood vessels

- Superfisial episcleral vessels

(in Tenon layer);

with phenilephrin: blanching

- Deep vascular plexus

EPISCLERITIS AND SCLERITIS

Episcleritis:

• common, benign, self-limiting

• young adult

• related to systemic disease

• types: - simple (sectoral,diffuse)

- nodular

EPISCLERITIS AND SCLERITIS

Scleritis:

• granulomatous inflammation

• rheumatoid arthritis, connective tissue disorder

• less common

• severity: mild-severe (necrotizing)• types: - anterior scleritis (non-necrotizing / necrotizing)

- scleritis posterior

EPISCLERITIS AND SCLERITIS

Simple, sectoral episcleritis non-necrotizing, diffuse scleritis

early necrotizing scleritis Scleral necrosis

Episcleritis and Scleritis

Management:Episcleritis - Steroids/NSAID eyedrops

- Systemic ibuprofen/flurbiprofen

Scleritis- Oral NSAID

- Oral Steroid

- Combination

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Red Eyes, Decreased Vision

Keratitis

Cornea Ulcer

Anterior Uveitis (iritis, iridocyclitis)

Acute Glaucoma

Endophthalmitis

KERATITISC ornea: Frontmost part of eye Main component in refraction (70% ) Tear film

KERATITIS

Keratitis: Inflammatory cells infiltration Corneal opacity Superficial / deep Cause: Infection (Viral/bacterial/fungal) Also: Dry eyes, trauma, drug toxicity, UV exposure,

contact lens irritation, allergy, immunogenic states, chronic conjunctivitis

May progress to cornea ulcer

KERATITIS-CORNEAL ULCER

Clinical presentation

- photophobia

- periocular pain

- foreign body sensation

- ciliary flush

- corneal opacity

Diagnosis : - reduced cornea sensibility

- fluorescein test

- assessment of corneal regularity

KERATITIS – CORNEAL ULCER

Keratitis with fluorescein staining

Corneal ulcer (fungal) Perforating corneal ulcer

Photo-s courtesy of dr Lukman Edwar

Corneal Ulcer

Cause Pseudomonas Strepcococcus pneumonia

Virus Fungi Allergy

Location central central central central central

Excavation + + - - -

Color greenish yellow yellow abcess satelites infiltrates

Hypopion + + -/+ + -

Appearence purulent discharge purulent discharge

quiet abcess Diffuse

Sensibility normal normal decreased increased normal

Perforation frequent frequent rare frequent none

KERATITIS – CORNEAL ULCER

Management:

- Refer to ophthalmologist

- Medication based on causative microorganism

virus antiviral

bacteria antibiotics

fungi antifungal

- Corneal scar

ANTERIOR UVEITIS

• Inflammation of iris and ciliary body• Usually auto-immune• Isolated or part of systemic condition:

- ankylosing spondilitis- juvenile rheumatoid arthritis- Reiter Syndrome- sarcoidosis- herpes simpleks- herpes zoster- Behçet Syndrome (with stomatitis aftosa)

ANTERIOR UVEITIS

Clinical presentation:- periocular pain- photophobia- usually mild decrease of vision- ciliary flush- small, irregular pupil, due to adhesion to

lens surface permukaan lensa

ANTERIOR UVEITIS

Clinical presentation:- indistinct iris crypts- cornea opacity- cells and flare in AC keratic precipitates, hypopion- IOP changes

Posterior synechia

Iris nodules

Hypopion

ANTERIOR UVEITISPhoto-s courtesy of dr Lukman Edwar

Normal iris

ANTERIOR UVEITIS

Keratic precipitates

ANTERIOR UVEITIS

Management:- Refer to Ophthalmologist- Work-up- Medication: - cycloplegics eyedrops - corticosteroids eyedrops - oral corticosteroids oral (prn) - Glaucoma drugs

ACUTE GLAUCOMA

• ocular emergency• sudden IOP elevation• block of aqueous humor outflow• elder patients• Asians >>

Acute Glaucoma

Clinical presentation:• mostly unllateral• occipital pain• nausea, vomitting• extremely red eye• conjunctival chemosis• cloudy cornea• midilated pupil• pupillary reflex none/poor• shallow AC• hard eyes

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Acute Glaucoma

Management:- Refer to ophthalmologist- Immediately lower IOP: Pilocarpine 2% Timolol 0.5% Asetazolamid Oral glycerin /IV manitol surgery / laser iridotomy

ENDOPHTHALMITIS

• Purulent intraocular infection• Caused by infection through the cornea, trauma post-surgery (mainly: cataract surgery), or endogenous• Bacterial/fungal• Most common: staphylococcus aureus, proteus and pseudomonas• If with extraocular infection: panophtalmitis

Endophthalmitis

Clinical presentation:- periocular pain - chemosis - eyelid swelling- corneal opacity- anterior uveitis- hypopion

Endophthalmitis

Management:- Refer to ophthalmologist- Aqueos / vitreous tap- intravitreal antibiotic/antifungal- systemic antibiotic - Panoftalmitis: evisceration

Chronic visual loss

cataract

glaucoma (chronic: open and closed angle)

Retinopathies (mainly: diabetic retinopathy)

Macular Degeneration

(AMD=age-related macular degeneration) Others: e.g. retinitis pigmentosa

Cataract

Lens opacity Penyebab:

- degeneration: senile/age-related- complication of ocular disease / metabolic / drug-induced(komplikata)- congenital- traumatic

cataract

Cataract

Symptoms Early

- no symptoms- fog- glare- difficulty in reading

Late- blur of vision- leucocoria

CataractManagement Depend on patient’s demand; if interfering

with daily activity: Cataract surgery

Technique:- Intracapsular Cataract Extraction(ICCE) now rarely done- Extracapsular Cataract Extraction(ECCE)- Phacoemulsification- Small-incision

Phacoemulsification

Glaucoma

• Optic neuropathy, mainly caused by chronic IOP elevation due to increased outflow resistance• visual field defects• 2 types: - open angle glaucoma

- closed angle glaucoma

Opt i c di s c changes i n gl aucoma

Normal Optic Disc Glaucomatous disc Advanced glaumatous disc

Glaucoma

Symptoms • IOP > 21 mmHg (normal 10-21)• Open angle: asymptomatic; if there is indicating late stages (frequently bumping, rainbow halo, periocular pain)• Closed angle: predisposition to acute glaucoma• Constricted visual field

Glaucoma

Management• Observation• Glaucoma drugs: - beta-blocker

- acetazolamid - pilocarpine

• Laser (iridotomy, trabeculotomy, trabeculoplasty)• Surgery (iridectomy, trabeculektomy, implant)

RETINOPATHIES

N on-inflammatory retina dis orders

2 mos t c ommon:

- hypertensive retinopathy

- diabetic retinopathy

Retina anatomy

Sklera

Koroid

Membran Bruch

RPE=epitel

pigmen retina

Fotoreseptor

Lapisan serabut saraf

Hypertensive retinopathy

• caused by chronic hypertension• depend on onset• - Grade I: narrowing of vessels - Grade II: + narrowing of veins at crossing - Grade III: + intraretinal hemorrhages, exudates - Grade IV: optic disc edema, star figured

macular exudates

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Hypertensive retinopathy

Cotton-wool spots and macular star

Disc oedema

Focal Generalized

Arteriolar constriction

Extravascular signs

Flame-shaped retinal haemorrhages

Arteriolosclerosis (A-V changes)

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Grading of arteriolosclerosis

Diabetic retinopathy

Complication of diabetesComplication of diabetes Chronic hyperglycemiaChronic hyperglycemia damage to microvasculars Chronic visual lossChronic visual loss Main cause of blindness in DM 50% of diabetics within 10 yrs will have retinopathy

Mekanisme kebutaan pada diabetic retinopathy

leakage of exudates, lipid and blood to the retina

Macular edeme

Decreased blood flow to the retina

iskemia

neovascularization PDR

-vitreous hemorrhage- Fibrovascular scar

- retinal traction retinal detachment

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Diabetic retinopathy

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Normal retina

PDR vitreuous hemorrhage Fibrovascular scar in PDR

Early PDR FFA

NPDR

AMD=age-related macular degeneration

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• Chronic visual loss caused by changes of the macula

• bilateral

AMD=age-related macular degeneration

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• Problem world wide

• 4 th in global cause blindness

• Treatment:

- Photodynamic therapy

- Anti-VEGF

- others

Acute (persistent) visual loss

retinal detachment

vitreous hemorrhage

retinal vein occlusion

Retinal artery occlusion

Optic neuritis

Retinal detachment

• detachment of neurosensory retina from RPE

• mainly caused by retinal breaks

• floaters, photopsia, shadow curtain

retinal detachmentManagement• pneumatic retinopexy• vitreoretina surgery

- Scleral buckling- Vitrectomy

Scleral buckling (SB) Vitrectomy

Vitreous hemorrhage

• Blood in the vitreous

• Rupture of blood vessels

• Cause: trauma, retinal breaks, DM, hypertension

• On examination: fundus reflex absent

• Vitrectomy maybe needed

Oklusi (sumbatan) arteri retina

• Sumbatan arteri retina akibat radang / spasme / trombus / melambatnya aliran darah

• Mengenai satu mata

• Tidak sakit

• Berhubungan erat dengan kelainan jantung

• Tanda: retina pucat, cherry-red spot

Retinal vein occlusion

• Central/branch

• Unilateral

• Painless

• Systemic risk factors

• flame-shaped hemorrhages, cotton wool spots

Optic neuritis• inflammation/intoxication/demyelination of the optic nerve

• may be accompanied by pain

• unilateral

• sluggish pupil reflex, RAPD +

OCULAR TRAUMA

• Chemical/thermal burn• Corneal erosion• Corneal and conjunctival foreign body• Blunt trauma• Penetrating/perforating trauma• Hyphema• Intraocular foreign body• Orbital wall fracture

Chemical burn

• Alkali:- pestisides- household products (cleaners, etc)

• Asam (acid):- batteries

→ damage to cornea• Thermal:

- flame- hot water- metal liquid, etc

→ usually milder

Chemical burn

Penatalaksanaan:

• immediate

• topical anesthetics

• Corneal edema/chemosis? Opacity?

• Irigate eyeball with 1-2 liter water/ NaCl

Chemical burn

Managenment

• Clean the eyelid sac from debris

• Topical medications (steroid+antibiotics,

EDTA, tetracycline)

• Bandage lens if necessary

Corneal erosion

• Superficial (epithelial)• Common causes: fingernail, comb/brush contact lens• Risk for infection• Pain, photophobia, watery, irritation, foreign body sensation

Corneal erosion

Management:• Topical anesthetics• Fluorescein test• Check tarsal conjunctiva of upper eyelid

→ retained foreign body? • Antibiotics eyedrop• Bandage lens/patching• Re-epithelisation) within 24-48 jam

Conjunctival/corneal foreign body

Conjunctival foreign body Corneal foreign body

• Dust, occupational, etc• Photophobia, watery, foreign body sensation• Management: foreign body extraction

Blunt trauma

• Eyelid hematoma

• Hyphema

• Subconjunctival hemorrhage

• Vitreous/Retinal hemorrhage

• Orbital fracture

• Retinal commotion

Blunt trauma

Hematoma + subconjunctival subhemorrhage RE

(good eye movement)

Hyphema

Hyphema(clotting) Hyphema occupying ½ AC

Full hyphema

Hyphema

Management:

• hospitalization (risk: visual loss, IOP

elevation, re-bleeding in 30% cases)

• bed-rest, semi-fowler position

• tranexamic acid (e.g Transamin)

Lens subluxation

Iridodialisis

Kommosio retina

Penetrating/perforating injury

Penetrating/perforating injury

Management:

• refer to ophthalmologist

• antibiotics eyedrop

• oral antibiotics

• ATS, TT

• patch eyes

• primary repair

Laceration/ruptur of eyelid and face

- ATS, TT

- NaCl / Betadine compress

- Immediate repair

Or bi t al wal l f r act ur e

Enophthalmus, restriction of eye movement

I nt r aocul ar f or ei gn bi dy

Management:

-Immediate extraction for foreign body

-Oral and intravitreal foreign body

-Corticosteroids