Ophthalmic review for GP
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Ophthalmic reviewOphthalmic reviewforfor
General PractitionersGeneral Practitioners
Dr. Riyad G. BanayotDr. Riyad G. Banayot
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EyelidsEyelids
Applied anatomyStye and chalazionBlepharitisMadarosis & PoliosisDiffuse eyelid diseaseBenign eyelid lesionsMalignant eyelid tumors
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Applied anatomyApplied anatomy
Cross section of lower eye lid
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Eye Lid RednessEye Lid Redness
External Hordeolum - Stye
Infection of lid gland Local pain redness and
swelling No need to refer Treatment: compresses,
topical antibiotic
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Eye Lid RednessEye Lid Redness
Chalazion Granulomatous inflammation
of Meibomian gland Slow course - months Compresses at onset;
antibiotics no benefit If non-resolving refer
electively for transconjunctival incision & curettage
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Treatment of chalazion
Injection of local anaesthetic Insertion of clamp Incision and curettage
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Eye Lid RednessEye Lid Redness
Blepharitis - staphylococcal Chronic infection with
periodic flare-ups Staphylococcal or
seborrheic Irritation, burning and
itching Scales or crusting on
lashes Treatment: lid hygiene &
topical antibiotics
Staphylococcal
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Eye Lid RednessEye Lid Redness
Blepharitis - seborrheic
Chronic infection with periodic flare-ups
Staphylococcal or seborrheic Irritation, burning and itching Greasy scales or lashes
stuck together Treatment: lid hygiene &
topical antibiotics
seborrheic
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Madarosis
Local causes• Chronic anterior lid margin disease
• Infiltrating tumours
• Burns, radiotherapy or cryotherapy
Systemic causes• Generalized alopecia
• Myxoedema
• SLE
• Syphilis• Leprosy
Following removal
Decrease in number or complete loss of lashes
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Poliosis Premature localized whitening of hair
Ocular associations
• Chronic anterior blepharitis• Sympathetic ophthalmitis
• Vogt-Koyanagi-Harada syndrome
• Waardenburg syndrome
Systemic associations
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Diffuse eyelid diseaseDiffuse eyelid disease
Acute allergic edemaContact dermatitisAtopic dermatitisSystemic causes of lid edema
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Acute allergic oedemaAcute allergic oedema
• Causes - insect bites, urticaria and angioedema• Unilateral or bilateral• Painless, red, pitting oedema• Chemosis may be present• Self-limiting
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Contact dermatitisContact dermatitis
• Sensitivity to topical medication• Unilateral or bilateral• Painless oedema and erythema• Vesiculation and crusting• Thickening if chronic
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Atopic dermatitisAtopic dermatitis• Associated with asthma and hay fever• Chronic itching and scratching
Facial - in young children Flexural - knees, elbows, wrists and ankles
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Ocular associations of atopic dermatitisOcular associations of atopic dermatitis
Angular blepharitis Vernal disease
Thickening, crusting and fissuring
Staph. blepharitis
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Ocular associations of atopic dermatitisOcular associations of atopic dermatitis
Keratoconus Keratoconjunctivitis
Shield-like cataract Retinal detachment
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Systemic causes of lid oedemaSystemic causes of lid oedema
• Myxoedema
• Renal disease
• Congestive heart failure
• Obstruction of superior vena cava
• Fabry's disease
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Benign eyelid lesionsBenign eyelid lesions
XanthelasmaCapillary hemangiomaNaevus flammeusNaevus flammeus
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XanthelasmaXanthelasma
• Usually bilateral and located medially
• Common in elderly or those with hypercholesterolemia• Yellowish, subcutaneous plaques containing cholesterol and lipid
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Capillary haemangiomaCapillary haemangioma
• Rare tumour which presents soon after birth• Starts as small, red lesion, most frequently on upper lid
• Blanches with pressure and swells on crying
• Grows quickly during first year
• May be associated with intraorbital extension
• Begins to involute spontaneously during second year
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Periocular haemangiomaPeriocular haemangioma
• Steroid injection in most cases• Surgical resection in selected cases
• High-out heart failure
Treatment options
Occasional systemic associations
• Kasabach-Merritt syndrome - thrombocytopenia, anemia and reduced coagulant factors
• Maffuci syndrome - skin haemangiomas, endrochondromas and bowing of long bones
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Port-wine stain (naevus flammeus)Port-wine stain (naevus flammeus)
• Rare, congenital subcutaneous lesion• Segmental and usually unilateral
• Does not blanch with pressure
• Ipsilateral glaucoma in 30%
• Sturge-Weber or Klippel-Trenaunay-Weber syndrome in 5%
Associations
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Malignant eyelid tumorsMalignant eyelid tumors
Basal cell carcinomaSquamous cell carcinomaMeibomian gland carcinomaMelanomaKaposi sarcoma
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Basal Cell Carcinoma (BCC)Basal Cell Carcinoma (BCC)
1. Most common human malignancy
2. Usually affects the elderly
3. Slow-growing, locally invasive
5. 90% occur on head and neck
6. Of these 10% involve eyelids
7. Accounts for 90% of eyelid malignancies
4. Does not metastasize
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Frequency of location of BCCFrequency of location of BCC
Lower lid - 70% Medial canthus - 15%
Upper lid - 10% Lateral canthus - 5%
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Nodular BCCNodular BCCEarly
• Shiny, indurated nodule
• Surface vascularization
• Slow progression
Advanced
• May destroy large portion of eyelid
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Ulcerative BCCUlcerative BCC(rodent ulcer)(rodent ulcer)
Early
Chronic ulceration
Advanced
Raised rolled edges and bleeding
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Sclerosing BCCSclerosing BCC
• Indurated plaque with loss of lashes
Advanced
• Spreads radially beneath normal epidermis
Early
• May mimic chronic blepharitis • Margins impossible to delineate
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Squamous cell carcinomaSquamous cell carcinoma
• Predilection for lower lid
• Hard, hyperkeratotic nodule
• Less common but more aggressive than BCC
• May develop crusting fissures
• May arise de novo or from actinic keratosis
Ulcerative
• No surface vascularization
• Red base• Borders sharply defined, indurated and elevated
Nodular
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Meibomian gland carcinoma
Spreading
Nodular
• Very rare aggressive tumour with 10% mortality• Predilection for upper lid
Hard nodule; maymimic a chalazion
Very large tumour
Diffuse thickening of lid margin and loss of lashes
Conjunctival invasion; maymimic chronic conjunctivitis
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MelanomaMelanoma
From lentigo maligna (Hutchinson freckle)
Nodular
• Blue-black nodule with normal surrounding skin
• Plaque with irregular outline• Variable pigmentation
• Affects elderly• Slowly expanding pigmented macule• May be non-pigmented
Superficial spreading
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Kaposi sarcomaKaposi sarcoma
Advanced Early
Pink, red-violet lesion
• Vascular tumour occurring in patients with AIDS• Usually associated with advanced disease• Very sensitive to radiotherapy
May ulcerate and bleed
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Treatment OptionsTreatment Options
3. Cryotherapy
2. Radiotherapy• Small BCC not involving medial canthus
1. Surgical excision• Method of choice
• Small and superficial BCC irrespective of location
• Adjunct to surgery in selected cases
• Kaposi sarcoma
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Applied anatomyApplied anatomy
Orbital septum which separates the anterior structures from the orbit
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Eye RednessEye Redness
Cellulitis Preseptal cellulitis
– Same as cellulitis anywhere else
– No orbital signs– No need to refer
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Eye RednessEye Redness
Cellulitis Orbital cellulitis
– Proptosis, restricted extraocular movements, pain
– Urgent referral for IV antibiotics
– CT helps differentiate preseptal form
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Applied anatomyApplied anatomy
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Congenital nasolacrimal duct obstructionCongenital nasolacrimal duct obstruction
Acute dacryocystitis Epiphora and matting
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Congenital nasolacrimal duct Congenital nasolacrimal duct obstructionobstruction
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Eye RednessEye Redness
Nasolacrimal Duct Obstruction
Dacryocystitis (acute/chronic) if infected
Swelling or abscess in lower inner canthus – Depending on severity,
may need hospitalization– Referral is required– Initial treatment: IV or PO
Antibiotics +/- external drainage
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Eye RednessEye Redness
Laceration– Usually requires referral– Assume all lacerations
medial to punctum involve lacrimal drainage system
– Canalicular lacerations should be repaired within 24 hours
Intubation of the lacrimal system following repair of torn upper and lower canaliculi
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ConjunctivitisConjunctivitis
Bacterial Chlamydial
Adult Neonatal Trachoma
Viral VKC Atopic Keratoconjunctivitis Allergic Ophthalmia neonatorum
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ConjunctivitisConjunctivitis
IrritationFB sensationPhotophobiaDiffuse rednessTearing
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Bacterial ConjunctivitisBacterial Conjunctivitis
Exudate: Pus
Scraping: PMNs
Preauricular Lymph
nodes: Not palpable
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Adult chlamydial keratoconjunctivitisAdult chlamydial keratoconjunctivitis
Treatment
• Infection with Chlamydia trachomatis serotypes D to K• Concomitant genital infection is common
Subacute, mucopurulent follicular conjunctivitis
Variable peripheral keratitis
- topical tetracycline and oral tetracycline or erythromycin
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Neonatal chlamydial conjunctivitisNeonatal chlamydial conjunctivitis
Treatment
• May be associated with otitis, rhinitis and pneumonitis
• Presents between 5 and 19 days after birth
Mucopurulent papillary conjunctivitis
- topical tetracycline and oral erythromycin
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Trachoma
Treatment - systemic azithromycin
• Infection with serotypes A, B, Ba and C of Chlamydia trachomatis• Fly is major vector in infection & re-infection cycle
Acute follicular conjunctivitis
Conjunctival scarring (Arlt’s line)
Herbert pits
Pannus formation Trichiasis Entropion
Progression
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Viral ConjunctivitisViral Conjunctivitis
Usually bilateral, acute waterydischarge and follicles
Subconjunctival haemorrhages &pseudomembranes if severe
Exudate: Profuse wateryScraping: MononuclearPreauricular Lymph nodes: Palpable
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Vernal KeratoconjunctivitisVernal Keratoconjunctivitis(VKC) - (spring catarrh)(VKC) - (spring catarrh)
Main symptoms: Intense ocular
Itching
Exudate: Profuse watery
Scraping: Mononuclear
Preauricular Lymph nodes: Palpable
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Atopic keratoconjunctivitisAtopic keratoconjunctivitis
• Typically affects young patients with atopic dermatitis• Eyelids are red, thickened, macerated and fissured• Infiltration of tarsal conjunctiva causing featureless appearance
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Allergic ConjunctivitisAllergic Conjunctivitis
Exudate: Watery +/- mucoid
Scraping: Eosinophil
Preauricular Lymph
nodes: Not palpable
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Ophthalmia NeonatorumOphthalmia NeonatorumNeonatal conjunctivitisNeonatal conjunctivitis
Contamination of infant’s eyes when passing through vagina and cervix
Gonococcus: – Rapid blindness, 2ry corneal
ulceration– Onset 2-3 days after birth– Broad spectrum topical
antibiotics Chlamydia:
– Less destructive, may last months
– Onset 5-12 days– topical tetracycline and oral
erythromycin
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Subconjunctival HemorrhageSubconjunctival Hemorrhage
Common Causes: trauma,
operation, uncontrolled HTN, valsalva, cough, vomiting, straining maneuvers
No treatment; reassurance
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Pingueculum / PterygiumPingueculum / Pterygium Pingueculum:
– On conjunctiva only
Pterygium:– Invading cornea
Chronic diseases / degeneration Refer if symptomatic Treatment: surgical excision –
high recurrence rate
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Immuno-bullous diseasesImmuno-bullous diseases
Cicatricial pemphigoidStevens-Johnson syndrome
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Cicatricial pemphigoidCicatricial pemphigoid• Chronic and progressive• Typically affects elderly women• Increased prevalence of HLA-B12
Oral mucosal lesions in most cases Skin lesions are less common
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Progression of ocular cicatricial pemphigoidProgression of ocular cicatricial pemphigoid
Diffuse hyperemia
Subepithelial fibrosis and shrinkage
Symblepharon
Pseudomembranes
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Complications of ocular cicatricial pemphigoidComplications of ocular cicatricial pemphigoid
Ankyloblepharon
Corneal keratinization
Metaplastic lashes Cicatricial entropion
Obliteration of fornices 2ry bacterial keratitis
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Stevens-Johnson syndromeStevens-Johnson syndrome• Acute, and self-limiting• Hypersensitivity to drugs or infection• Typically affects young men
Lesions of oral mucosa and lips
Maculopapules which may develop into target lesions
Vesiculobullous,hemorrhagicand necrotic lesions
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Ocular complications of Stevens-Johnson syndrome
Transient conjunctivitis and lid crusting without sequelae
membranous or pseudo-membranous conjunctivitis
Focal fibrotic patches andoccasionally symblepharon
Metaplastic lashes
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Applied anatomyApplied anatomy
layers of precorneal tear film
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Dry EyesDry Eyes
Chronic redness Burning No need to refer Treatment: artificial tear
drops
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Applied anatomyApplied anatomy
The cornea consists of the five layers:
1- epithelium
2- Bowman's layer
3- stroma
4- Descemet's membrane
5- endothelium
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KeratitisKeratitis
Bacterial– Contact lens wearers– White infiltrate in
cornea – Pain, reduced vision – Should be referred – Treatment: topical
antibiotics
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KeratitisKeratitis
Fungal– Frequently preceded by
ocular trauma with organic matter
– Grayish white infiltrate surrounded by feathery infiltrate in cornea
– Pain, reduced vision – Should be referred – Treatment: topical
antifungal agents & systemic therapy if severe
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KeratitisKeratitis
Acanthamoeba– Contact lens wearers at
particular risk– Anterior stromal infiltrates,
ulceration, ring abscess & stromal opacification
– Pain, reduced vision – Should be referred – Treatment: chlorhexidine or
polyhexamethylenebiguanide
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KeratitisKeratitis Viral
Herpes Simplex
– Recurrent dendrites, corneal edema, iritis
– Refer– Treatment: Acyclovir
ointment
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KeratitisKeratitis
ViralHerpes Zoster
– V1 Dermatome– Dendrites, iritis, other
ocular inflammation– Treatment: Oral
Acyclovir; start and
then refer
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keratoconuskeratoconusNipple cone Oval cone Globus cone
Small and steep curve Larger and ellipsoidal Largest cone
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Signs of keratoconusSigns of keratoconusBilateral in 85% but asymmetrical
Oil droplet reflex Prominent corneal nervesVogt striae
Acute hydrops Munson sign Fleischer ring & scarring
Bulging of lower lids on downgaze
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Systemic associations of keratoconusSystemic associations of keratoconus
Crouzon syndromeMarfan's syndrome Osteogenesis imperfecta
Atopic dermatitis Down syndrome Ehlers-Danlos syndrome
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Vortex keratopathyVortex keratopathy
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Toxic maculopathyToxic maculopathy
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Peripheral corneal involvement in Peripheral corneal involvement in rheumatoid arthritisrheumatoid arthritis
• Chronic and asymptomatic• Circumferential thinning with intact epithelium (‘contact lens cornea’)
• Acute and painful• Circumferential ulceration and infiltration
Treatment - systemic steroids and/or cytotoxic drugs
Without inflammation With inflammation
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Rosacea keratitisRosacea keratitis
Peripheral inferiorvascularization
Subepithelial infiltration Thinning and perforation if severe
• Affects 5% of patients with acne rosacea• Bilateral and chronic
Progression
Treatment - topical steroids and systemic tetracycline or doxycycline
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Metabolic KeratopathyMetabolic Keratopathy
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Corneal Foreign BodyCorneal Foreign Body
If metal striking-metal is the mechanism of injury always get an X-Ray/CT scan of skull (This is mandatory if there is an open globe injury or suspicion of entry wound)
Superficial corneal FB can be removed with Q-tip or needle tip, otherwise refer
Rust rings develop after initial removal
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UV burnUV burn
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Applied anatomyApplied anatomy
The scleral stroma is composed of collagen bundles of varying size and shape that are not
uniformly oriented
There three vascular layers that cover the anterior sclera: conjunctival, superficial episcleral and deep vascular plexus
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Applied anatomy of vascular coatsApplied anatomy of vascular coats
Scleritis
• Maximal congestion of deep vascular plexus
• Slight congestion of episcleral vessels
• Maximal congestion of episcleral vessels
EpiscleritisNormal
• Radial superficial episcleral vessels• Deep vascular plexus adjacent to sclera
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Episcleritis / ScleritisEpiscleritis / Scleritis Episcleritis:
– Common– Localized inflammation,
lasts 2 wks.– Treatment with topical
steroids or oral NSAIDs Scleritis:
– Rare– Granulomatous or
necrotizing, Vision threatening.
– Treatment with immunosuppression
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UveitisUveitis
Pain, reduced vision, ciliary flush
Systemic association: Sarcoid, HLA B-27, inflammatory bowel disease, TB, syphilis
Refer Treatment: topical
steroids, dilating drops
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Applied anatomyApplied anatomy
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Acute Angle Closure Acute Angle Closure GlaucomaGlaucoma Sudden severe pain,
loss vision, N & V Red eye with ciliary
flush, pupil fixed & mid dilated, cornea steamy, increased IOP
Emergency referral Treatment: drops to
lower IOP, constrict pupil, diuretics, laser iridotomy
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Eye chemical injuriesEye chemical injuries
Chemical burns – irrigate immediately– NEVER give acid for alkali or vice versa
For all but least severe trauma – referAlways protect the eye from further
injury during transfer
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Acquired cataractAcquired cataractAge relatedDiabetesMyotonic dystrophyAtopic dermatitisTraumaDrugsComplicated (secondary)
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Age related cataractAge related cataract
Nuclear Cortical
Subcapsular Christmas
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Diabetic cataractDiabetic cataractJuvenile
• White punctate or snowflake posterior or anterior opacities
• May mature within few days
Adult
• Cortical and subcapsular opacities• May progress more quickly than in non-diabetics
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Myotonic dystrophy cataractMyotonic dystrophy cataract
• Myotonic facies• Frontal balding • 90% of patients after age 20 years
• Stellate posterior subcapsular opacity
• No visual problem until age 40 years
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Atopic dermatitis cataractAtopic dermatitis cataract
• Cataract develops in 10% of cases between 15-30 years
• Bilateral in 70% • Frequently becomes mature
• Anterior subcapsular plaque (shield cataract)• Wrinkles in anterior capsule
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Traumatic cataractTraumatic cataract
Penetration
Concussion
‘Vossius’ ring from imprinting of iris pigment Flower-shaped
• Ionizing radiation
• Electric shock
• Lightning
Other causes
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DrugsDrugsChlorpromazine
• Long-acting mioticsOther drugs
• Amiodarone• Busulphan
- initially posterior subcapsularSystemic or topical steroids
- central, anterior capsular granules
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Complicated cataractComplicated cataract
• Chronic anterior uveitis• High myopia
Posterior subcapsular
• Hereditary fundus dystrophies• Central, anterior subcapsular opacities
Glaukomflecken
• Follows acute angle closure glaucoma
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Congenital cataractCongenital cataract
• 33% - idiopathic - may be unilateral or bilateral• 33% - inherited - usually bilateral• 33% - associated with systemic disease - usually bilateral• Other ocular anomalies present in 50%
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Classification of congenital cataractClassification of congenital cataract
Anterior polar Posterior polar Coronary Cortical spoke-like
Lamellar Central pulverulent Sutural Focal dots
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Causes of cataract in healthy neonateCauses of cataract in healthy neonate
Hereditary (usually dominant)
Idiopathic
With ocular anomalies• PHPV• Aniridia• Coloboma• Microphthalmos• Buphthalmos
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Causes of cataract in unwell neonateCauses of cataract in unwell neonate
Intrauterine infections
• Rubella
• Toxoplasmosis
• Cytomegalovirus
• Varicella
Metabolic disorders
• Galactosaemia
• Hypoglycaemia
• Hypocalcaemia
• Lowe syndrome
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Ectopia lentis - AcquiredEctopia lentis - AcquiredTrauma
• Buphthalmos• Megalocornea
Anterior uveal tumours Degenerate eye
Stretched zonules
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Ectopia lentis - ADEctopia lentis - ADSystemic features of Marfan's syndrome
• Limb-trunk disproportion • Arachnodactyly
• Pectus excavatum
• High-arched palate
• Aortic dilatation, dissection and regurgitation• Mitral valve prolapse
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Ocular features of Marfan syndromeOcular features of Marfan syndromeLens
• Upward subluxation • Zonule usually intact
Retinal detachment
• Axial myopia
Blue scleraCornea planaAngle anomaly and glaucoma
• Lattice degeneration
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Ectopia lentis - AREctopia lentis - ARWeill-Marchesani syndrome
Systemic features
• Short stature
Ocular features
• Short stubby fingers (brachydactyly)
• Mental handicap
• Microspherophakia
• Angle anomaly and glaucoma
• Anterior lens subluxation
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Ectopia lentis - AREctopia lentis - ARHomocystinuria (Defect in cystathionine synthetase)
Systemic features
• Malar flush and fine, fair hair• Marfanoid habaitus• Increased platelet stickiness• Mental handicap
Ocular features
• Downward lens subluxation
• Disintegration of zonule
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Congenital glaucomaCongenital glaucoma
Corneal edema associated with lacrimation and photophobia
Buphthalmos
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Dysthyroid OphthalmopathyDysthyroid Ophthalmopathy
Bilateral autoimmune swelling of extraocular muscles +/- orbital inflammation
Findings:– Proptosis (exophthalmos)– Restricted EOM– Inflammation– Optic nerve compression– Corneal exposure
Treatment: steroids / radiotherapy when active surgery when “burnt out”
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Diabetic RetinopathyDiabetic Retinopathy
Background / Non-proliferative– Leaking vessels cause edema
& exudates– Treatment: referral for laser if
VA less than 6/9
Proliferative– Ischemic retina secretes
vascular growth factor – fragile new vessels rupture & bleeding may lead to scar and retinal damage / detachment
– Treatment: referral for PRP
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Exposure keratopathyExposure keratopathy
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Rosacea keratitis Rosacea keratitis
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Keratitis in systemic collagen Keratitis in systemic collagen vascular disordersvascular disorders
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Applied anatomyApplied anatomy
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Pituitary adenomaPituitary adenoma
Visual field defects caused by compression of chiasm from below
by pituitary adenoma
Axial CT scan of right pituitary adenoma invading right cavernous sinus
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Optic NeuritisOptic Neuritis Mostly unilateral sudden loss
of vision, disturbance in color vision and pain with EOM
50% go on to develop MS Findings: poor vision, poor
color vision, afferent pupillary defect, optic nerve usually normal, visual field defect
Treatment: usually refer to neurologist, IV not oral steroids
Axial MRI scan showing periventricular plaques of demyelination (left: T1; right: T2)