CENTRAL COAST DAY HOSPITAL OPTOMETRIST CONFERENCE - 26 FEBRUARY 2012

Anterior Segment - Common Clinical Presentations in Optometry

DR VIVEK CHOWDHURY

Fuchs endothelial dystrophy

Eventually bullous keratopathy - EPI

Later central stromal oedema - STROMA

Gradual increase in cornea guttata with peripheral spread

Progression

Pseudophakic Bullous Keratopathy

Fuchs endothelial dystrophy

Pseudophakic Bullous Keratopathy

SYMPTOMS:Acuity. Haloes/Glare.Diurnal Variation.Discomfort/Pain

SIGNSGuttae and Endothelial Opacity.Stromal OedemaEpithelial Oedema/Erosions.Corneal Thickness/Pachymetry

Fuchs endothelial dystrophy

Pseudophakic Bullous Keratopathy

1. In Patients with Corneal Endothelial Decompensation, all of the following may indicate progression of the disease except:a. Increased Corneal Thickness.b. Epithelial Defectsc. Deteriorating Visual Acuityd. Symptoms Worse in the Afternoon

ANTERIOR CHAMBER IOLS

Primary Cataract Surgery – Problems with Capsular Bag/Zonular Support – PXF Patients/Hx Trauma.

Secondary IOL - Aphakic Patient

Problems Related to:ACIOL ItselfComplications of the Primary Surgery

ANTERIOR CHAMBER IOLS

Look out For:

Cornea: Corneal Endothelial Decompensation/Bullous Keratopathy. Corneal Wounds.AC: Inflammation/Uveitis, AC Vitreous, Hyphaema.Iris: Irregular Pupil, Iris Tuck, Angle Closure, PI.Angle: Trauma from Haptics, Glaucoma.Capsule: Residual Capsule in Pupillary Axis, Lens MaterialRetina: CME, Breaks, Detachment, Lens remnants

2. In a patient with an anterior chamber intraocular lens – It is usually important to check for all of the following except:

a. Raised Intraocular Pressureb. Corneal Decompensation.c. Uveitis.d. Iris Naevus

TRAUMA

1. Eyelid

2. Orbital blow-out fractures• Floor• Medial wall

• Haematoma• Margin laceration• Canalicular laceration

3. Globe Injuries• Anterior segment• Posterior segment

Anterior segment complications of blunt trauma

Sphincter tear

Cataract Angle recession

Hyphaema

Lens subluxation

Iridodialysis Vossius ring

Rupture of globe

Macular hole Optic neuropathyEquatorial tears

Posterior segment complications of blunt trauma

Choroidal rupture and haemorrhageCommotio retinae Avulsion of vitreous base

and retinal dialysis

Complications of penetrating trauma

Flat anterior chamber

Vitreous haemorrhage

Damage to lens and iris

EndophthalmitisTractional retinal detachment

Uveal prolapse

3. In a patient with a past history of blunt trauma to the eye - which of the following is incorrect:a.A deep AC means there is a low risk of glaucomab.cataract may be associated with zonule laxity/phacodonesisc.there is an increased risk of retinal breaksd.the patient may have a dilated pupil

Adenoviral - Signs of keratitis

Treatment

• Focal, epithelial keratitis • Focal, subepithelial keratitis • May persist for months

- topical steroids if visual acuity diminished by subepithelial keratitis

• Transient

Progression of vernal conjunctivitis Diffuse papillary hypertrophy, most marked on superior tarsus

Formation of cobblestone papillae Rupture of septae - giant papillae

Limbal vernal

Trantas dotsMucoid nodule

Progression of vernal keratopathy

Punctate epitheliopathy Epithelial macroerosions

Plaque formation (shield ulcer) Subepithelial scarring

Progression of ocular cicatricial pemphigoid

Diffuse hyperaemia

Subepithelial fibrosis and shrinkage

Symblepharon

Pseudomembrane formation

Naevus

• 30% are almost non-pigmented

• Most frequently juxtalimbal• Sharply demarcated and slightly elevated

• Presents in first two decades

Lipodermoid

• Presents in adulthood• Soft, movable, subconjunctival mass• Most frequently at outer canthus

Intraepithelial neoplasia(carcinoma in situ)

• Juxtalimbal fleshy avascular mass

• May become vascular and extend onto cornea

• Presents in late adulthood

• Malignant transformation is uncommon

Signs Progression

Primary acquired melanosis (PAM)

• PAM without atypia is benign• PAM with atypia is pre-malignant • Unilateral, irregular areas of flat,

brown pigmentation• May involve any part of conjunctiva

• Presents in late adulthood

Signs Types

Conjunctival melanoma

From PAM with atypia

• Sudden appearance of nodules in PAM

From naevus

• Sudden increase in size or pigmentation

Primary

• Solitary nodule• Frequently juxtalimbal but may be anywhere

• Very rare• Most common type

Squamous cell carcinoma

• Rarely metastasizes

• Arises from intraepithelial neoplasia or de novo

• Frequently juxtalimbal

• Slow-growing

• Presents in late adulthood• May spread extensively

Signs Progression

Marginal keratitis

Subepithelial infiltrate separated by clear zone

Circumferential spread Bridging vascularization followed by resolution

• Hypersensitivity reaction to Staph. exotoxins• May be associated with Staph. blepharitis• Unilateral, transient but recurrent

Progression

Treatment - short course of topical steroids

Phlyctenulosis

• Small pinkish-white nodule near limbus• Usually transient and resolves spontaneously

• Starts astride limbus• Resolves spontaneously or extends onto cornea

• Uncommon, unilateral - typically affects children• Severe photophobia, lacrimation and blepharospasm

Conjunctival phlycten

Treatment - topical steroids

Corneal phlycten

Herpes simplex epithelial keratitis

• Dendritic ulcer with terminal bulbs

• Stains with fluorescein• May enlarge to become geographic

• Aciclovir 3% ointment x 5 daily

• Debridement if non-compliant

Treatment

Herpes simplex disciform keratitis

• Central epithelial and stromal oedema

• Folds in Descemet membrane

• Small keratic precipitates

- topical steroids with antiviral cover

• Occasionally surrounded by Wessely ring

Treatment

Signs Associations

Herpes zoster keratitis

• Develops in about 50% within 2 days of rash• Small, fine, dendritic or stellate epithelial lesions• Tapered ends without bulbs• Resolves within a few days

• Develops in about 30% within 10 days of rash• Multiple, fine, granular deposits just beneath Bowman membrane• Halo of stromal haze

Nummular keratitisAcute epithelial keratitis

• May become chronic

Treatment - topical steroids, if appropriate

4. A patient is complaining of blurry vision after cataract surgery, but the visual acuity is 6/6 unaided, It is important to check all of the following except.

a. The tear film.b. The posterior capsule and IOL

position.c. The macula.d. The eyebrows.

Simple episcleritis• Common, benign, self-limiting but frequently recurrent• Typically affects young adults

Treatment

• Seldom associated with a systemic disorder

Simple sectorial episcleritis Simple diffuse episcleritis

• Topical steroids

Nodular episcleritis• Less common than simple episcleritis• May take longer to resolve• Treatment - similar to simple episcleritis

Localized nodule which can be moved over scleraDeep scleral part of slit-beam not displaced

Grading of severity of chemical injuries

• Clear cornea

Grade I (excellent prognosis)

• Limbal ischaemia - nil

• Cornea hazy but visible iris details

Grade II (good prognosis)

• Limbal ischaemia < 1/3

• No iris details

Grade III (guarded prognosis)

• Limbal ischaemia - 1/3 to 1/2

• Opaque cornea

Grade IV (very poor prognosis)

• Limbal ischaemia > 1/2

Medical Treatment of Severe Injuries

1. Copious irrigation ( 15-30 min ) - to restore normal pH

2. Topical steroids ( first 7-10 days ) - to reduce inflammation

3. Topical and systemic ascorbic acid - to enhance collagen production

4. Topical citric acid - to inhibit neutrophil activity

5. Topical and systemic tetracycline - to inhibit collagenase and neutrophil activity

5. My patient with blepharitis is back again asking me to look for the sand that’s in his eye, I am going to do all the following except:

A. Change to a preservative free artificial tear supplement and/or a more viscous artificial tear supplement, and/or a thick artificial tear gel just before sleep.

B. Prescribe Chloramphenicol ointment to the lid margins.

C. Trial Steroid ointment to the lid margins, and/or a short, tapering course of a mild topical steroid.

D. Get my receptionist to tell them that I’ve gone on holiday.

THE END