PSSS - Red Eyes With Visual Loss
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Transcript of PSSS - Red Eyes With Visual Loss
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Red Eyes with Visual Loss
Krisnald M. N.
I11109027
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Acute Angle-Closure Glaucoma
Acute angle closure ("acute glaucoma") occurs
when sufficient iris bomb develops to cause
occlusion of the anterior chamber angle by
the peripheral iris.
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Classification from Natural History
PRIMARY ANGLE-CLOSURE SUSPECT (PACS)
An eye in which appositional contact between the peripheral irisand posterior trabecular meshwork is presentor consideredpossible, in the absenceof elevatedIOP, PAS, disc, or VFchanges.
Epidemiologically, this has been defined as an angle in which 180-
270 of the posterior trabecular meshwork cannot be seengonioscopically
PRIMARY ANGLE CLOSURE (PAC)
PACSwith statistically raised IOP and/or primary PAS, without disc
or VF changes
PRIMARY ANGLE CLOSURE GLAUCOMA (PACG)
PACwith glaucomatous optic neuropathyand corresponding VFloss
IOP, intraocular pressure; PAS, peripheral anterior synechiae; VF, visual field.
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Risk Factors
Demographic factors:
a. Age (> 60 years old)
b. Female sex
c. Chinese ethnic origin
d. Family history
(especially first-degree
relatives, becauseocular anatomic
features are inherited)
Precipitating factors:
a. Dim illumination (including extremes of
temperature causing people to stay
indoors)
b. Drugs
Anticholinergic agents [topical, e.g.,atropine, cyclopentolate, and tropicamide,
or systemic, e.g., antihistamine,
antipsychotic (especially antidepressants),
anti-parkinsonian, atropine, and
gastrointestinal spasmolytic drugs]
Adrenergic agents (topical, e.g.,
epinephrine and phenylephrine, or
systemic, e.g., vasoconstrictors, central
nervous system stimulants,
bronchodilators, appetite depressants,
and hallucinogenic agents)
c. Emotional stress (possibly due to mydriasis
secondary to increased sympathetic tone)
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Clinical Findings
Pain (usually sudden in
onset)
blurred vision
Photophobia
colored haloes around
lights
Headache
nausea and vomiting.
markedly increased
intraocular pressure
(IOP > 40 mmHg)
shallow anteriorchamber
a steamy cornea
a fixed, moderatelydilated pupil
ciliary injection.
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Differential Diagnosis
Secondary ACG
Other causes of headache (e.g., migraine or
cluster headache).
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Treatment
Goal: Decreasing IOP immediately, relievingpain, and preparing patient to surgery
Pilocarpine 2% every one minute in 5 minutes,
then every one hour in a day Asetazolamide 500 mg IV, then 250 tablet
every 4 hour when nausea is gone
Retrobulbar xylocain 2%decreasesaqueous humour production + anesthesy
Morphine 50 mg scpatient in extreme pain
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Treatment (2)
After IOP decreased, eye pain and injection
gone, and preparation for surgery is ready:
SurgeryPeripheral Iridectomy
Alternative: trabeculetomy
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Uveitis
The term "uveitis" denotes inflammation of
the iris (iritis, iridocyclitis), ciliary body
(intermediate uveitis, cyclitis, peripheral
uveitis, or pars planitis), or choroid
(choroiditis).
Uveitis usually affects people 2050 years of
age and accounts for 10
20% of cases of legalblindness in developed countries.
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Anterior Uveitis
Anterior uveitis is most common and is usually
unilateral and acute in onset
Clinical findings: typical symptoms include
pain, photophobia, and blurred vision.
Examination usually reveals circumcorneal
redness with minimal palpebral conjunctival
injection or discharge.
Etiology: granuloma or non-granuloma
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Etiology
Granulomatous
Sarcoiditis
Syphillis
Tuberculosis
Virus
Fungal (Histoplasmosis)
Parasite (Toxoplasmosis)
Nongranulomatous
Acute Trauma
Chronic Diarrhea
Reiter disease
Herpes simplex
Bechet Syndrome
Posner Schlosman Syndrome
After surgery
Adenovirus infection
Parotitis
Influenza Chlamidia
Chronic Rheumatoid arthritis
Fuchs heterochromic iridocyclitis
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Symptoms
Granulomatous
No pain
Slight photophobia
Blurred vision
Big keratic precipitate (mutton
fat)
Koeppe nodules (cell
accumulation on the iris
margin)
Busacca nodules (cell
accumulation on iris surface)
Nongranulomatous
Pain
Marked photophobia
Blurred vision
Small keratic precipitate
Miosis
Relaps usually occur
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Differential Diagnosis
Posterior uveitis with spillover into the
anterior chamber
Conjunctivitis
Keratitis
Acute angle closure glaucoma
Posner
Schlossman syndrome Drug-induced uveitis (e.g., rifabutin, cidofovir,
sulfonamides, pamidronate).
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Vogh-Koyanagi-Harada Syndrome
This disease damaged uvea, retina, and
meningen
Unknown cause; usually affect people in
second decade of life
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Treatment
Systemic and topical steroid
Cycloplegic
Consult to neurologist for neurologicalproblems
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Endoftalmitis
Severe inflammation of the inner eye
Supurative inflammation in eye cavity and the
structure of the eye
Exogenous endoftalmitis: caused by eye
trauma or secondary infection after surgery
Endogenous endoftalmitis: caused by
hematogenous spreading of microorganism
from other site of infection in the body
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Treatment
Bacterial causes: periocular or subconjunctiva
antibiotics
Fungal causes: amphotericin B (150
microgram subconjunctiva)
Cycloplegic 3 times a day
Corticosteroid can be chosen
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Sympathetic Ophthalmia
Sympathetic ophthalmia is a rare but devastating
bilateral granulomatous uveitis that comes on 10
days to many years following a perforating eye
injury. Ninety percent of cases occur within 1 year after
injury.
The cause is not known, but the disease isprobably related to hypersensitivity to some
element of the pigment-bearing cells in the uvea.
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Treatment
Enucleation within 10 days after injury.
The sympathizing eye should be treated
aggressively with local or systemic
corticosteroids.
Other immunosuppressive agents, such as
cyclosporine, cyclophosphamide, and
chlorambucil, may be required as well
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Glaucomatocyclitic Crisis
(Posner-Schlossman Syndrome)
Glaucomatocyclitic crisis is a self-limited
relapsing disease, marked by high IOP and
slight anterior chamber inflammation
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Clinical Findings
noninjected eye with a slightly dilated pupil,
minimal anterior chamber cells
occasional, small, nonpigmented keratic precipitates
inferiorly on the corneal endothelium. Intraocular pressures range from 40 to 60 mmHg
despite a lack of angle closure or other morphologicalchanges of the anterior chamber angle.
The ocular hypertensive phase is often associated withthe episodes of inflammation and is easily managed.
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Etiology
Unknown
Suspected causes are immunological and
infectious etiologies. Such as CMV and herpes
virus
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Treatment
Prednisolone acetate 1% 1-4 times a day
(topical)
Timolol topical 0,25-0,5% 1-2 times a day or
dorzolamide 2% 1-3 times a day
Oral acetazolamide 250 mg 2-3 times a day.
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Clinical Findings
Decreased visual acuity
Pain
Exophtalmos
Lid edema
Chemotic conjunctiva
Steamy cornea
Hypopion
Leukocoria
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Treatment
High-dose antibiotics
Very severe symptoms: evisceration
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What is the treatment of bacterial keratitis for
positive Gram bacteria and negative Gram
bacteria
Gentamicin (negative)
Bacitrasin, cepalosporin (positive)
Lagophtalmos (kelopak mata tidak menutup
sempurna: N III (occulomotorius)