Hukm Ophthal Guideline-Latest Edited PDF

REPORT OF THE UKM CLINICAL PATHWAYS
AND ALGORITHMS FOR OPHTHALMOLOGY

CLINICIANS WORKSHOP 2018
1st Edition
HOSPITAL CANSELOR TUANKU MUHRIZ, UKMMC
1
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The contents of this report are not to be quoted without the expressed and
written permission of the HCTM, UKMMC.
Please direct all enquiries regarding this report to:
UKMMC, Quality Department

2nd Floor, Nursing Hostel Block,
UKM Medical Centre
Jalan Yaacob Latif, Bandar Tun Razak,
56000, Cheras, KL
Contact Number : 03 - 91455072 / 5052
1st Edition
First printing 2018
Second printing 2019
2
CONTENTS PAGE
General Abbreviations 5
Editorial Board 6
Introduction to the UKM Clinical Care Pathways and Algorithms for Ophthalmology 7
Clinicians Workshop 2018

Clinical Practice Guideline Algorithms 11
Acute Angle Closure 12
AAC Management Flow Chart 13
o Contraindications for mannitol

o Contraindications for acetazolamide
o Contraindications for -blocker
Laser Peripheral Iridotomy
15
Argon Laser Peripheral Iridoplasty 16
Age Related Macular Degeneration (AMD)

Diagnosis of Wet AMD (Algorithm 1) 17
18
Treatment of AMD-CNV (Algorithm 2)
19
Treatment of PCV (Algorithm 3)
20
Treatment of RAP (Algorithm 4)
o Detailed Abbreviations
o Contraindications for Fundus Fluorescein Angiography
o Contraindications for Indocyanine Green Angiography
o Contraindications for Photodynamic Therapy
General Caution for Anti-Vascular Endothelial Growth Factor (VEGF) Therapy
Blunt Trauma 23
Central Retinal Vein Occlusion 24
Chemical Injury 25
Management
Roper Hall Classification
Corneal ulcer
Approach to new case
27
Bacterial keratitis
30
Fungal keratitis
35
Acanthamoeba keratitis
42
Viral keratitis 44
3
Diabetic Macula Oedema 55
Anti VEGF Therapy Guidelines 56
Endophthalmitis
Diagnosis (Algorithm 1) 57
Acute Post-Op Endophthalmitis (Algorithm 2) 58
Chronic Post-Op Endophthalmitis (Algorithm 3) 59
Endogenous Endophthalmitis (Algorithm 4) 60
Anterior Chamber Tap 61
Vitreous Chamber Tap 61
Intravitreal Antibiotic Injection 62
Preparation of Intravitreal Antibiotic 62

Hyphaema 63
Orbital Fracture 64
Management
Primary Open Angle Glaucoma (POAG) Suspect 65
Classification of POAG/Ocular Hypertension (OHT)/ POAG Suspect

Rhegmatogenous Retinal Detachment (RRD)
Algorithm 1 67
68
Treatment Options for RRD (Algorithm 2)
Sarcoid Uveitis 72
Syphilitic Uveitis 73
Tuberculous Uveitis 74
Thyroid Eye Disease 76
Retinopathy of Prematurity -
Uveitis 79
Anterior Uveitis 80
81
Intermediate Uveitis
82
Posterior Uveitis/ Panuveitis
Clinical Care Pathways (CCP) 83
CCP for Cataract Surgery (Pre-Operative Assessment) 84
CCP for Uncomplicated Cataract Surgery (Post-Op Assessment) 87
CCP for DMO 89
CCP for Post-Op Endophthalmitis 96
CCP for ROP 100
References 103
Acknowledgements 106
4
General Abbreviations
Acute Angle Closure AAC
Acute Angle Closure Glaucoma AACG
Age related macular degeneration AMD
Argon Laser Peripheral Iridoplasty ALPI
Branch Retinal Vein Occlusion BRVO
Central Retinal Vein Occlusion CRVO
Choroidal Neovascularisation CNV
Clinical Care Pathways CCP
Diabetic Macular Oedema DMO
Fundus Fluorescein Angiography FFA
Indocyanine Green Angiography ICGA
Polypoidal Choroidal Vascularisation PCV
Primary Open Angle Glaucoma POAG
Proliferative Diabetic Retinopathy PDR
Retinal Angiomatous Proliferation RAP
Retinopathy of Prematurity ROP
Rhegmatogenous Retinal Detachment RRD
Tuberculosis/ Tuberculous TB
Verteporphyin Photodynamic Therapy vPDT
Vascular endothelial growth factor VEGF
(Note: Detailed abbreviations follow the Algorithms)
5
Editorial Board
Editor: Professor Dr Mae-Lynn Catherine Bastion1
Assistant Editor: Dr Ainal Adlin Naffi1
Chief Registrar for Clinics: Dr Oh Kah Lay2
Secretary: Dr Tan Wen Hsia2
Members:
1. Dr Aimy Mastura Zurairah Yusof2
2. Dr Alvernia M Samy2
3. Dr Christina Ng Wei Khee2
4. Dr Lam Chen Shen2
5. Dr Logeswary Kandasamy2
6. Dr Mohd Najmi Khairudin2
7. Dr Raja Farahiyah Raja Othman2
8. Dr Siuw Chin Pei2
Advisors:
Associate Professor Dr Jemaima Che Hamzah1
Associate Professor Dr Norshamsiah Md Din1
Associate Professor Dr Aniza Ismail3,4
Dr Mushawiahti Mustapha1
Dr Aida Zairani Zahidin1
Dr Wan Haslina Wan Abdul Halim1
Dr Othmaliza Othman1
Dr Safinaz Mohd Khialdin1
Dr Malisa Ami1
Dr Rona Asnida Nasaruddin1

1
Lecturers and Ophthalmologists, Department of Ophthalmology, Faculty of Medicine, Universiti
Kebangsaan Malaysia (UKM)
2
Medical officers in Registrar year training, Department of Ophthalmology, Faculty of Medicine,
Universiti Kebangsaan Malaysia (UKM)
3
Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia (UKM)
4
Head of Quality Department, Hospital Canselor Tuanku Muhriz, Pusat Perubatan UKM
6
Introduction to the UKM Clinical Care Pathways and Algorithms for Ophthalmology Clinicians
Workshop 2018
Department of Ophthalmology, Hospital Canselor Tuanku Muhriz, Pusat Perubatan UKM has been
offering the range of full clinical services for Ophthalmology since 1983. The number of outpatients
seen by this department often is the highest of all the departments in the hospital, averaging 1000
patients per year. In addition to this service, the department also trains undergraduate and
postgraduate students in Ophthalmology.
There is a need for effective, efficient and evidence based treatment algorithms as well as clinical
care pathways for specialists and trainee specialists to be able to refer to when managing patients
with various ophthalmic conditions.
The local ophthalmology fraternity already has a number of clinical practice guidelines which are
available online. However these are limited to the following conditions:
Retinopathy of Prematurity, 2005 (1)
Management of Postoperative Infectious Endophthalmitis, 2006 (2)
Screening of Diabetic Retinopathy, 2011 (3)
Management of Glaucoma (2nd Ed) , 2017 (4)
Management of diabetic Macula Oedema (5)
This report aims to provide a comprehensive compilation of evidence based clinical algorithms for
common ophthalmology conditions. Ophthalmology trainees and specialist practitioners in UKM and
Malaysia will be able to refer to this publication as a quick reference and management standard. This
publication will be revised every 5 years to ensure that the most up to date evidence is contained
within.
Background to the UKM CLINICAL PATHWAYS AND ALGORITHMS FOR OPHTHALMOLOGY

CLINICIANS Workshop 2018
Planning for this workshop occurred under the auspices of the Quality Committee of the Department
of Ophthalmology, UKM for which the Editor was the Chairperson from 2015 to date. The Quality
Committee recommended a workshop be organized in order to standardize treatment plans for
common ophthalmology conditions in the form of clinical practice guidelines to ensure quality care
could be given to all patients attending UKM Medical Centre Ophthalmology Clinic.
The organizing committee for the workshop comprised the following members:
Advisor and Head of Department: Associate Professor Dr Jemaima Che Hamzah
Invited expert: Associate Professor Dr Aniza Ismail
Chairperson: Professor Dr Mae-Lynn Catherine Bastion
Project Leader: Dr Ainal Adlin Naffi
Registrar representative: Dr Oh Kah Lay
Secretary: Dr Tan Wen Hsia
Committee members:
1. Dr Aimy Mastura Zurairah Yusof
2. Dr Alvernia M Samy
7
3. Dr Christina Ng Wei Khee
4. Dr Lam Chen Shen
5. Dr Logeswary Kandasamy
6. Dr Mohd Najmi Khairudin
7. Dr Raja Farahiyah Raja Othman
8. Dr Siuw Chin Pei
The committee first met on 29 January 2018. Associate Professor Dr Aniza, who was the invited
expert on CPG shared her experience and the committee referred to her publication on CPG in their
subsequent writings (6). Given the long timeframe required to prepare a complete clinical care
pathway (CCP) for all diseases, the committee decided to focus on 5 conditions of importance in
Ophthalmology from various subspecialties and to prepare the CCP for clinicians. These were:
Cataract Pre and Post Operation
Diabetic Macula Oedema
Endophthalmitis
Glaucoma
Retinopathy of Prematurity
In addition, the committee prepared treatment algorithms for various other common
ophthalmology diseases as listed in the Table of Contents which would be based on the latest
treatment guidelines and evidence in the literature.
The committee worked in teams as shown below. The teams were selected generally based on
registrar pairing in subspecialty teams in the Ophthalmology Clinic, UKMMC and members were the
main authors on the algorithms and CCPs:
Team Title of Algorithm/ CCP Authors/ Members Consultants
1 1. Rhegmatogenous retinal Najmi Logeswary Mae-Lynn/

detachment Mushawiahti/
Ainal
2. Endophthalmitis post op/
traumatic/ endogenous/
vitreous tapping and
intravitreal antibiotics
2 1. Trauma: Tan Oh Mae-Lynn/

Mushawiahti/
i. Chemical injury
Ainal
ii. Orbital fracture
iii. Hyphaema
iv. Blunt trauma
2. Age related macular

degeneration (AMD) / Polypoidal
8
choroidal vasculopathy (PCV) / Retinal
angiomatous proliferation (RAP) / Anti-
Vascular Endothelial Growth Factor
therapy (VEGF) guidelines
3. Diabetic macula oedema

(DMO)
4. Retinal Vein Occlusion (RVO)
3 1. Retinopathy of Prematurity Alvernia Raja Safinaz

Farahiyah
2. Acute angle closure Laser Rona/
Peripheral Iridotomy Jemaima
Aida/ Wan
3. Corneal ulcer
4 1. Glaucoma suspect Christina Lam Norshamsiah
2. Thyroid Eye Disease (TED)
3. Cataract Surgery Pre-operative and

Post-operative Assessment
5 1. Uveitis anterior/ Siuw Aimy Norshamsiah

intermediate/ posterior
2. TB uveitis and management of

patient on TB medications
3. Syphilitic uveitis
4. Sarcoid uveitis
The workshop to present the drafted CCP and treatment algorithms was conducted on 13 April 2018
at Hotel Bangi Putrajaya. The programme commenced with an informative lecture on Clinical
Practice Guidelines by the invited faculty, Associate Professor Dr Aniza. This was followed by
presentation of the drafts followed by small group sessions with UKM Ophthalmology Department
lecturers and subspecialists. Following this, committee members performed the required
amendments which were compiled by the Secretary.
This report represents a compilation of the CCP and treatment algorithms made by this Committee
and is current as of April 2018.
(1) Health Technology Assessment Unit Ministry of Health Malaysia. Dec 2005. Clinical Practice
Guidelines. Retinopathy of Prematurity. MOH/P/PAK/ 103.05(GU)
(2) CPG Secretariate Ministry of Health Malaysia. Aug 2006. Management of Postoperative Infectious
Endophthalmitis. MOH/P/PAK/116.06 (GU)
(3) CPG Secretariate Ministry of Health Malaysia. June 2011. Screening of Diabetic Retinopathy.
MOH/P/PAK/216.11 (GU)
9
(4)Malaysian Health Technology Assessment Section Ministry of Health Malaysia. June 2017.
Management of Glaucoma (2nd Ed). MOH/P/PAK/346.17 (GU)
(5) DME Steering Committee of Ministry of Health Malaysia. Management of Diabetic Macula
Edema. Sept 2015.
(6) Aniza I, Saperi S, Syed Mohamed A. Carta Alir Klinikal Penjagaan Kesihatan dan Kawalan Kos
Rawatan. Penerbit UKM Press 2015.
10
Clinical Practice Guideline
Algorithms for Clinicians
11
ACUTE ANGLE CLOSURE (AAC)
Acute angle closure (AAC) is diagnosed when IOP >21 mmHg with occludable angle in the presence of:
1. Any two of the following symptoms:

Ocular and periocular pain
Nausea and/or vomiting
istory of blurring of vision and haloes
AND
2. Any three of the following signs:

Conjunctival injection
Corneal epithelial oedema
Mid-dilated unreactive pupil
Shallow anterior chamber
Aim of treatment: to lower the IOP urgently and relieve the acute symptoms
12
AAC MANAGEMENT FLOW CHART
Symptoms
Eye pain, redness, blurring of vision,
headache, nausea, vomiting
Clinical features
Affected eye: red eye, raised IOP (usually 50 80mmHg),
corneal oedema, shallow AC, closed angles, fixed semi-dilated pupil,
iris bombe, glaucomflecken
Contralateral eye: shallow AC, narrow angles
Differential diagnosis
DO NOT DILATE (BOTH EYES) 2° angle-closure
(e.g. phacomorphic,
inflammatory, neovascular)
Management
(Medical therapy to break attack and prepare patient for LPI)
Systemic:
First line: IVI mannitol 20% (0.5 - 2g/kg or 5ml/kg) x 30 - 45 minutes*
(1 pint or 500ml of mannitol 20% contains 100g mannitol)
If mannitol is contraindicated, give IV acetazolamide 500mg stat**
Followed by oral acetazolamide 250mg QID + oral potassium chloride 1200mg BD
Affected eye:
Prostaglandin analogue (e.g. latanoprost 0.005% stat, then ON)
-blocker (e.g. timolol 0.5% stat, then BD)***
Alpha-2 agonist (e.g. brimonidine 0.2% stat, then TDS)
Steroid (e.g. topical dexamethasone 1% stat, then 2-hourly)
Pilocarpine 2% stat and every 15 minutes x 1 hour, then QID (off after LPI)
Consider corneal indentation with a 4-mirror goniolens (may help relieve pupil block)
Consider ALPI as the initial treatment in acute angle closure attack or when there is persistent
occludable angle following laser iridotomy (ALPI is contraindicated in area with PAS)
Contralateral eye:
Pilocarpine 2% stat, then QID is often given while awaiting Nd:YAG LPI
(in either case, the priority is for prompt bilateral LPIs)
Analgesics
Lying the patient supine may allow the lens to fall back away from the iris
Follow Malaysian CPG Management of Glaucoma (Second Edition) (Copy available

on)http://www.moh.gov.my
http://www.acadmed.org.my
13
http://www.mso.org.my
* Contraindications of mannitol
1. Cardiac failure
2. Renal failure
** Contraindications of acetazolamide
1. Sulphur allergy
2. Patients who are susceptible to ketoacidosis or hepatic insufficiency
3. Renal impairment
*** Contraindications of -blocker
1. Bradycardia
2. Heart block
3. Bronchospasm
1
ALPI Argon Laser Peripheral Iridoplasty
2
LPI Laser Peripheral Iridotomy
14
LASER PERIPHERAL IRIDOTOMY
from Malaysian CPG Management of Glaucoma (Second Edition)
Pre-Laser Management
i. Get informed consent

ii. Instil pilocarpine 2%
iii. Consider brimonidine 0.15 - 0.2%, and/or -blocker, and/or oral CAI, and/or steroid eye drops before
the procedure to reduce post-treatment IOP spike/inflammation
iv. Instil topical anaesthesia
v. Use iridotomy lens e.g. Abraham lens (+66 dioptres) or equivalent
vi. Choose superior quadrant of the iris which is well covered by the upper eyelid, in a thin-looking area
or an iris crypt and placed as peripheral as possible
vii. Post-PI: topical steroid 4-hourly to reduce inflammation
Argon followed by Nd:YAG Laser
Preparatory burns Argon laser

Spot size : 200 -
Exposure time : 0.2 - 0.5 sec
Power : 200 - 600 mW (depends on iris pigmentation; lower power for
darker irides to avoid charring)
Penetrating burns Argon laser (chipping technique)

Spot size
Exposure time : 0.05 - 0.1 sec
Power : 600 - 1,000 mW (modify parameters depending on response)
End point : Presence of gush of aqueous and pigments
Penetration laser burns Nd:YAG laser

Power : 3 - 8 mJ
Number of shots : Usually 2 - 5 shots
Adequate iridotomy size : 200 -
Modified from Asia-Pacific Glaucoma Guidelines (Third Edition).

Amsterdam: Kugler Publication
15
ARGON LASER PERIPHERAL IRIDOPLASTY (ALPI)
from European Glaucoma Society Guidelines
Use Abraham lens +66D (PI lens)
Spot size: 200 - 500µm
Duration: 0.1 - 0.5 sec
Power : 200 - 400mW
Shots : 20 - 24 shots over 360 degree (180 degree may be effective) or
2 shots per clock hour (leave 2 shots diameter apart) avoiding radial vessels
Location : extreme iris periphery
16
DIAGNOSIS OF WET AGE-RELATED MACULAR DEGENERATION (AMD) (ALGORITHM 1)
Wet AMD
AMD-CNV PCV RAP
Clinical Diagnosis
-Serous neurosensory retinal Sero- sanguineous maculopathy - Single intra-retinal
detachment with 1 of the characteristic haemorrhage or FSH at peri-
features: macular area
-RPE detachment
-Serous/ sero- - Extensive small drusen
sanguineous/notched PED
-Sub-RPE, sub/intra/pre-
retinal haemorrhages - Massive sub-macular bleed
-Hard exudates - Breakthrough bleeding
- Sub-retinal orange nodule

-Epi/intra/sub-retinal or sub-RPE
scar or glial tissue - CSCR-like features
OCT Diagnosis
-Increased retinal thickness -Large notched PED -PED with intra-retinal cystoid
expansion
-Intra and /or SRF -SRF
-Intra-retinal fluid with hyper-
-Small PEDs -Moderate hyper-reflectivity
reflectivity of inner retinal
beneath PED with double hump
-Suspicion of CNV layers
features
-Sub-RPE/sub-retinal hyper- -Increased hyper-reflectivity of
-Polypoidal structure attached to
reflectivity inner retinal layer where
back surface of detached RPE
anastomosis is occurring
-EDI normal / thinner choroidal
-EDI normal or increased
thickness
choroidal thickness
17
Angiographic Diagnosis
*Highly recommended to perform both FFA & ICGA at least for the initial diagnosis if no contra-indications
FFA *ICGA mandatory if PCV is FFA

suspected
A)Classic -Intra retinal anastomosis
Single /multiple focal nodular within the macula
-Lacy pattern of /well delineated
area of hyper-fluorescence from
hyperfluorescence -PED
choroidal circulation within 1st
-Aggressive leakage 6min of ICGA injection together -Diffuse leakage
with one / more of the following
B)Occult features: -Cystoid spaces
-Stippled hyper-fluorescence -Nodular appearance -On viewing images, the vessels

occurring early at the level of the are seen to turn sharply from
RPE.RPE layer elevation & -Hypoflourescence halo the inner retina towards the
increasing hyper-fluorescence and surrounding the focal hyper- choroidal interface
pooling of dye at sub-RPE space fluorescence
during later phases.
-BVN
ICGA
-Diffuse hyper-fluorescence with
-Pulsatile filling
poorly demarcated boundaries. -Identification of retino-
Late leakage of indeterminate -Polyp corresponding to orange choroidal anastomosis
origin nodule on fundus examination
- Massive sub-macular bleed
Treatment, Algorithm 2 Treatment, Algorithm 3 Treatment, Algorithm 4
18
TREATMENT OF AMD-CNV (ALGORITHM 2)
Suspected AMD-CNV from clinical diagnosis
OCT
No Activity
Activity Present
No CNV FFA/ICGA Confirmed CNV
Follow up within 4
months with Amsler Extra-Macular Macular
Chart
-Treat with thermal Treat with Deterioration

No CNV Suspected
laser antiVEGF x 3 after 3rd
AMD-CNV
photocoagulation then PRN injection, ICGA
should be
-Treat with anti-VEGF
performed
Follow up within 6
months to 1 year Follow up 4-8
Disease
stable weeks for 1 year
-Continuously re-evaluate for leakage
-Instruct patient to promptly report any Follow up 3 Disease unstable

vision changes between visits monthly x 1 year
then 6 monthly
Retreatment criteria
-any loss of vision with OCT

evidence of fluid in the macula
-increase in OCT sub/intra

retinal fluid
-New macular haemorrhage
-Persistent fluid on OCT
-Residual or new CNV activity
Refer Retinal Specialist
19
TREATMENT OF PCV (ALGORITHM 3)
Suspected PCV Subretinal haemorrhage >4DD and

within 10-14 days
No Activity OCT
Pneumatic displacement
with/without rTPA
Activity Present
No PCV FFA/ICGA Confirmed PCV
Review diagnosis and treat

Extra-Macular Macular
underlying pathology
-Treat with thermal laser Initial:

photocoagulation to polyp
ICGA guided vPDT & antiVEGF
or feeder vessels
monthly x3
Or
AntiVEGF monotherapy
Disease stable
Complete regression of
OCT & VA monthly or each visit
polyp (no leakage on
FFA) ( FFA /ICGA 3 month after treatment )
-Instruct patient to promptly report any Disease Repeat Anti-VEGF

Repeat vPDT monotherapy
vision changes between visits unstable
monotherapy / vPDT +
antiVEGF
Repeat ICGA shows Repeat ICGA shows

incomplete regression complete
Follow up monthly x 6 months then of polyps regression of
3 monthly x 1 year polyps but leakage
on FFA with clinical
or OCT signs of
activity
20
TREATMENT OF RAP(ALGORITHM 4)
Suspected RAP
No Activity OCT
Activity Present
No RAP FFA/ICGA Confirmed RAP
Review diagnosis and treat

underlying pathology
AntiVEGF Deterioration after
monotherapy x 3 3rd injection, ICGA
then PRN should be
performed
Disease unstable
Follow up 4-8
Disease stable
weeks for 1 year

Follow up 3
-Instruct patient to promptly report any monthly x 1 year
vision changes between visits then 6 monthly
Refer Retinal Specialist
21
Detailed Abbreviations:
AMD: age-related macular degeneration
CNV: choroidal neo-vascularization
PCV: polypoidal choroidal vasculopathy
RAP: retinal angiomatous proliferation
CSCR: central serous chorio-retinopathy
PED: pigment epithelial detachment
RPE: retinal pigment epithelium
OCT: optical coherence tomography
FFA: fundus fluorescein angiography
ICGA: indocyanine green angiography
FSH: flame shaped haemorrhage
VEGF: vascular endothelial growth factor
BVN: branching vascular network
SRF: sub-retinal fluid
vPDT: verteporfin photodynamic therapy
rTPA: recombinant tissue plasminogen activator
22
Contraindications for FFA
- Severe fluorescein allergy at previous exposure

- Advanced renal failure
- History of drug allergy
Contraindications for ICGA
- Severe ICG allergy at previous exposure

- Known iodine allergy
- Uremia
- Liver disease
Contraindications for vPDT
- Lesion size >5400 micron

- Polyps obscured by blood on ICGA
General caution for anti-VEGF therapy:
- Permanent structural damage in the fovea

- Evidence or suspicion of hypersentivity to antiVEGF agent
- Thrombo-embolic phenomena, including MI or CVA in the preceding 3 months , or recurrent
thrombo-embolic phenomena
23
BLUNT TRAUMA
History:
Mechanism of injury
Eye pain
Diplopia
Blurring of vision
Flashes / floaters
Other visual symptoms
Examination:
VA
RAPD
EOM
External globe injury
Orbital wall fracture
Conjunctiva / sclera: perforation, laceration
Cornea: Foreign body, epithelial defect, laceration
AC: hyphaema, uveitis
Iris: miosis, mydriasis, sphincteric rupture,
iridodialysis, angle recession (late)
Lens: Vossius ring, cataract, subluxation, dislocation
Fundus: VH, PVD, commotio retinae, Berlin edema,
macula hole, retinal breaks/dialysis, choroidal
rupture, TON, optic nerve avulsion
Investigation:
Orbital X ray OM view

CT orbit
Hess chart / BSV
OCT macula
Management of Orbital Fracture
Management of globe rupture Management of TON Refer to Flow Chart

Orbital Fracture
Admit Admit ward
NBM CXR, FBC, FBS, ECG,
IM Tetanus UFEME
Shield the eye Start IV
Start IV antibiotics methylprednisolone 1g
Ciprofloxacin 400mg bd OD x 3/7 followed by oral
For emergency op prednisolone 1mg/kg for
(primary repair) 11 days (based on ONTT)
IV Ranitidine 50mg tds
24
CENTRAL RETINAL VEIN OCCLUSION
Clinical Assessment:
-Duration of symptoms
-History of DM, hypertension, hyperlipidaemia
-Initial VA an important indicator of final visual prognosis and NV risk
-RAPD
-Any rubeosis iridis, gonioscopy, IOP
-Fundus examination- Dilated tortuous retinal veins, retinal haemorrhages in all four
quadrants, cotton wool spot (CWS), mild optic disc oedema, new vessels at disc/
elsewhere (NVD/ NVE), macula oedema
- BP, DXT
Systemic Investigations:
Elderly patient: FBC,ESR,FBS, FLP
Young patient: FBC,ESR,FBS, FLP ANA, Anti-ds DNA, Anti
Phospholipid screening,
Coagulation profile.
Status of ischaemia Status of macula
Clinically ischaemic Clinically non-ischaemic Macular oedema No macula

FFA-to look for capillary non OCT- to look for macula oedema. oedema
perfusion, neovascularisation (NV)
(as soon as the haemorrhagesclear)
- Anti-VEGFs Ranibizumab,
Aflibercept, Bevacizumab
- Steroids- Dexamethasone
implant, Triamcinolone
Non-ischemic. Ischaemic
Monthly follow up and OCT to

look for resolution of macula
oedema
No NV Presence of NV
No treatment
needed. Full PRP/ Anti-
VEGF Monitoring to watch for
Good visual
macula oedema
prognosis.
Close Monitoring
Note: RCOphth: FFA to

Presence of NV assess macular ischaemia
Watch for ischaemic conversion Early if no masking or at
Close monitoring 3 months: Severe macular
Follow up monthly for 3/12, then ischaemia
2 monthly until 6/12, AntiVEGF not
Then 2 monthly for another 1
recommended, monitor for
year(or longer if evidence of
NV
ongoing ischaemia is still present
or severe ischaemia noted at
baseline)
25
MANAGEMENT OF CHEMICAL INJURY
Patient with
chemical injury
Irrigate with 2-3L of normal saline

immediately
Double evert eyelids
Remove any debris / foreign body
(especially in fornices)
pH normal Assess pH pH abnormal

*Alkaline has
worse injury
Assess extend of
injury based on
Roper Hall
classification
Immediate: Long term:

Topical steroids Treat
Cycloplegia persistent
Topical epithelial
antibiotics defect
+/-IOP lowering AMT
drops Refer cornea
Analgesia team for
Oral doxycyclin transplant
Oral Vitamin C
26
ROPER HALL CLASSIFICATION
Grade Prognosis Limbal ischaemia Cornea involvement

1 Good None Epithelial defect
2 Good <1/3 Hazy cornea, iris details
visible
3 Guarded 1/3 to ½ Hazy cornea, iris details
obscured
4 Poor >1/2 Cornea opaque with iris
and pupil obscured
27
Approach to Corneal Ulcer
1. History 4. Signs
2. Risk Factors 5. Complication
a. General 6. Investigation
b. Specific Risk Factor 7. Treatment
3. Symptoms 8. References
1. History:
Trauma
CL wear
o Type of contact lens (soft, hard, RGP),
o Wear time (daily disposable/monthly disposable/any extended wear/wear during sleep/wear
with bathing or swimming)
o Solutions (special solutions/normal saline/pipe water),
o Expiry date of both solutions and contact lens,
o Refractive/cosmetic wear
Hot tub/lake/river/swimming pool exposure
Previous corneal abnormalities, previous corneal ulcer
Systemic diseases (SLE, RA, chronic dermatitis, eczema)
Comorbidity (is DM well controlled?)
Topical steroid used or immunosuppressive therapy
2. Risk Factors
a. General
Ocular Systemic
Trauma Nutrition
Corneal abrasion (trauma with insect, Vitamin A deficiency
vegetative material)
CL Immunosuppression
Extended wear > soft > daily disposable > rigid Drugs
gas permeable (RGP); poor hygiene Immunodeficiency syndromes
Diabetes
RA
SLE
Iatrogenic
Corneal surgery (e.g. LASIK)
Removal of suture
Loose suture
Long-term topical steroids/antibiotics
Ocular surface disease
Dry eyes
Bullous keratopathy
Immune-mediated ocular surface disease
Progressive conjunctival scarring disorders
Chronic blepharokeratoconjunctivitis
Chronic keratitis (e.g. HSV)
Neurotrophic keratitis (e.g. HSV, VZV,
tumours of the cerebellopontine angle)
Lid disease
Entropion
Lagophthalmos
Trichiasis
Nasolacrimal disease
Chronic dacryocystitis
b. Specific Risk Factors (to refer specific flow chart)
28
3. Symptoms
Pain
o if Acanthamoeba: severe pain disproportionate to lesion
o Disciform keratitis (endotheliitis): may be painless
o If VZV keratitis: preherpetic neuralgia (mild intermittent tingling to severe constant
electric pain),
Foreign body sensation
redness
reduce vision
photophobia
tearing
discharge (may be purulent)
4. Signs (to refer specific flow chart)
5. Investigations
Perform early and adequate corneal scrapes. (If small < 1mm periphery, may not need scraping)
Check corneal sensation (decreased sensation can suggest herpetic keratitis).
If patient wears CL, send lenses, solutions, and cases for culture.
Liaise with microbiologists.
If no fundus view: B scan TRO exogenous endophthalmitis
Specific investigations: (to refer specific flow chart)
How to Perform a Corneal Scraping

Instil preservative-free topical anaesthesia (and perform scrape prior to use of fluorescein).
Use a Kimura spatula, No. 15 scalpel blade or 23G needle.
Remove any necrotic tissue/debris first.
edge to the base
Scrape both the base and leading edge of the ulcer (from uninvolved to involved cornea).
Place material onto glass slide for microscopy and staining (Gram stain, KOH)
Plate onto
-blood agar (aerobes)
-chocolate agar (Neisseria, Haemophilus)
-Sabouraud agar (fungi)
-McConkey Agar (gram ve bacteria)
-consider non-nutrient E. coli-enriched agar (for Acanthamoeba)
-consider Lowenstein Jensen Medium for Nocardia and mycobacteria)
the traditional technique; use separate

needles for each agar dish.
Do not penetrate into the agar (do on the surface only)
4. Complications
limbal and scleral extension

corneal perforation
endophthalmitis
panophthalmitis
secondary high intraocular pressure (IOP)
secondary fungal infection
29
5. Treatment
Stop CL wear if any
Treat accordingly ((to refer specific flow chart)) - Infection is assumed to be bacterial until
proven otherwise.
+/- cycloplegics
Indications for admission

o Severe infection: >1.5mm diameter infiltrate, centrally located (vision threatening),
hypopyon, purulent exudate, or complicated ocular and systemic problem
o Poor compliance: either with administering drops or returning for daily review.
o Other concern: only eye, paeds patient, failing to improve, etc.
If limbal lesion or corneal perforation: KIV add systemic prophylaxis T. ciprofloxacin 500mg BD
If stromal necrosis or threatened perforation:

o consider oral doxycyclines 100mg BD (inhibit matrix metalloproteinase (MMPs)
and pro-inflammatory cytokines)
o oral vitamin C 500mg to 1g OD
o accelerate the proliferation of corneal epithelial cells and the healing of

epithelial defects,
o modulator of collagen production,
o suppress angiogenic factors, including vascular endothelial growth
factor and MMPs thereby inhibiting corneal neovascularization,
o also act as a cofactor of extracellular matrix synthesis
o help damaged corneal stromal tissues recover in a normal manner,
o also neutralizes oxygen-free radicals)4
o
If dry eye: add lubrication (occ lacrilube tds) and punctal occlusion/tarsorraphy (depending on
cases)
Correct lid deformities and trichiasis
Consider topical steroids (gutt dexamethasone 1% BD to OD dose)

Use carefully following re-epithelialization
Indication:
o in the presence of sterile culture

o to reduce inflammation
o to reduce stromal scarring
o to improve visual outcome.
Initiation requires frequent follow-up.
Contraindication:
o acanthamoeba and fungal infection
If initial scrape results are no growth and current regimen proves clinically ineffective,
consider withholding treatment for 6 - 12h before rescraping or performing a formal corneal
biopsy.
Refer Cornea Team if 30

- large, central
- no/poor response
- fungal keratitis (please refer early)
- cornea biopsy
Bacterial Keratitis
Signs of Bacterial Keratitis
Circumcorneal/diffuse injection,
single or multiple foci of white opacity within stroma +oedema,
usually associated epithelial defect
anterior uveitis
hypopyon
ground glass appearance (Pseudomonas)
Investigations for Bacteria
Gram stains
Culture
o blood agar (aerobes)
o chocolate agar (Neisseria, Haemophilus)
o McConkey agar (gram ve bacteria)
Organism Suggested Treatment Comments

Preferred Alternative
Bacterial Keratitis
No Growth/ Mixed
Growth
Non severe Ciprofloxacin 0.3% Commence a
keratitis (small eye drop q1- 2h loading dose of
peripheral one drop every
keratitis) may OR 15 minutes for 3
consider hours followed
monotherapy Moxifloxacin 0.5% by hourly drops
eye drop q1- 2h around the
clock.2
OR Taper based on
clinical
Levofloxacin 0.5% response.
eye drop q1- 2h
Severe bacterial Cefuroxime 5%

keratitis dual eye drop q1-2h
therapy is
advocated PLUS
Gentamicin 0.9%
eye drop q1-2h
Bacterial Keratitis Gram-Positive Cefuroxime 5% Moxifloxacin

Cocci eye drop q1-2h 0.5% eye drop
q1- 2h
31
Streptococcus Fortified
pneumonia Benzylpenicillin G
10,000 IU/ml (6
mg) eye drop q1-
2h
Methicillin- Vancomycin 5%
resistant eye dropq1-2h
Staphylococcus
aureus (MRSA)
Gram-Negative Gentamicin 0.9% Moxifloxacin

Rods eye drop q1-2h 0.5% eye drop
q1- 2h
PLUS
OR
Ceftazidime 5%
eye drop q1-2h Levofloxacin
0.5% eye drop
q1- 2h
Gram-Negative Gentamicin 0.9% Ceftazidime 5%

Cocci eye drop q1-2h eye drop q1-2h
OR
Moxifloxacin
0.5% eye drop
q1- 2h
OR
Levofloxacin
0.5%eye drop
q1- 2h
Contact Lens No Growth Ciprofloxacin 0.3%

Related Bacterial Non severe eye drop q1- 2h
Keratitis keratitis (small
peripheral OR
keratitis) may
consider Levofloxacin 0.5%
monotherapy eye drop q1- 2h
Severe bacterial Gentamicin 0.9%

keratitis dual or 1.4% eye drop
therapy is q1-2h
advocated
PLUS
Ceftazidime 5%
eye drop q1-2h
32
Simplified Flow Chart for the Management of Bacterial Keratitis
Suspect Bacterial Keratitis
Take a detailed history
Clinical signs suggestive of Circumcorneal/diffuse injection

bacterial keratitis single or multiple foci of white opacity within
stroma +oedema,
usually associated epithelial defect
anterior uveitis
hypopyon
ground glass appearance (pseudomonas)
Perform early and adequate corneal

Gram stain
scraping
Culture
o Blood agar (aerobes)
o Chocolate agar (Neisseria,
Haemophilus)
o McConkey agar (gram ve bacteria)
KIV admission (Indication)

Severe infection: >1.5mm diameter infiltrate,
centrally located (vision threatening),
hypopyon, purulent exudate, or complicated
ocular and systemic problem
Poor compliance: either with administering
drops or returning for daily review.
Other concern: only eye, paediatric, failing to
improve, etc.
Consider systemic work-up Check for diabetes

FBC, U&E, LFT
Topical antibacterial therapy

Initial treatment
Non severe keratitis (small peripheral keratitis)
Ciprofloxacin 0.3% eye drop q1- 2h OR Moxifloxacin

0.5% eye drop q1- 2h OR Levofloxacin
33 0.5% eye drop
q1- 2h
Severe bacterial keratitis, dual therapy is advocated
Cefuroxime 5% eye drop q1-2h PLUS

Gentamicin 0.9% eye drop q1-2h
Trace culture and sensitivity
Culture Gram-Positive Streptococcus Methicillin- Gram-Negative Gram-

Cocci pneumonia resistant Rods Negative Cocci
Staphylococcus
aureus (MRSA)
Preferred Cefuroxime 5% Fortified Vancomycin 5% Gentamicin Gentamicin

Treatment eye drop q1-2h Benzylpenicillin G eye dropq1-2h 0.9% eye drop 0.9% eye drop
10,000 IU/ml q1-2h q1-2h
(6mg)eye drop
q1-2h PLUS
Ceftazidime 5%
eye drop q1-2h
- -
Alternative Moxifloxacin Moxifloxacin Ceftazidime
Treatment 0.5% eye drop 0.5% eye drop 5% eye drop
q1- 2h q1- 2h q1-2h
OR OR
Levofloxacin Moxifloxacin
0.5% eye drop 0.5% eye drop
q1- 2h q1- 2h
OR
Levofloxacin
0.5% eye drop
q1- 2h
Commence a loading dose of one drop every 15 minutes for 3 hours followed by hourly drops around the
clock.2 Taper based on clinical response.
34
Fungal Keratitis
Fungal Risk Factors
contamination with organic matter (e.g. agricultural work, gardening)

trauma (including LASIK)
immunosuppression (e.g.topical corticosteroids, alcoholism, diabetes, systemic immunosuppressive
disease)
ocular surface disease (e.g. dry eye, neurotrophic cornea)
hot humid climate
Signs of Fungal
Yeast infection
infiltrate, and a relatively small epithelial ulceration.
Filamentary fungal infection: usually insidious.

o Early: may be asymptomatic, intact epithelium, minimal corneal stromal infiltrate, and mild
AC inflammation.
o Later: satellite lesions, feathery branching infiltrate, and immune ring.
o In severe infection: ulceration, involvement of deeper corneal layers and Desce
membrane, white plaque on the endothelium, and severe AC inflammation (e.g. hypopyon).
In late infection, these distinctive patterns may be lost, and the clinical appearance may resemble an advanced
bacterial keratitis.
Fungal Investigations
Stains: Gram (stains fungal walls), Giemsa (stains walls and cytoplasm), Grocotts methenamine silver
(GMS) stain, Periodic Acid Schiff (PAS) stain, and Calcofluor white may also be used.
KOH
Culture: Sabouraud Dextrose Agar (for most fungi) and Blood Agar (for Fusarium); may require up to
14d; taken from cornea scraping or tissue biopsy.
Confocal microscopy if available

Histopathology: from corneal biopsy.
PCR for fungal DNA to send to IMR (03-26162665)
35
Fungal Yeast Topical: Topical therapy tapered

Keratitis There are with response.
Amphotericin B 0.15%-0.2% eye however
drop q1-2h contraindications Relapse is common
to the use of and may signify
+Fluconazole 0.2% eye drop q1- 2h systemic incomplete sterilization
antifungal therapy or reactivation.
PLUS in pregnancy and Treatment is
lactation. prolonged (>12wk).
Systemic:
Systemic antifungals are
Fluconazole 200-400mg PO q24h x 7 associated with
to 14 days significant side effects,
including
(if immunosuppressed: Fluconazole renal dysfunction
PO 100mg OD) (voriconazole),
hepatotoxicity
If Invasive yeast infections: (fluconazole,
Intravenous Flucytosine voriconazole),
200 mg/kg daily in 4 divided doses x blood disorders
1/52 (require monitoring of plasma (flucytosine,
concentration) voriconazole).
Monitoring should
If poor treatment response, give include FBC, RP, and LFT
prior to starting
Intraocular: treatment and at least
Ketoconazole
weekly during
200mg PO q24h
+Subconjunctival Fluconazole treatment.
(100-400mg BD)5
2mg/ml (0.2%)
In addition, dosing may
OR
+Subconjunctival Voriconazole 1-2% need to be reduced in
the presence
Voriconazole
+Intracameral of renal dysfunction,
(also indicated for
Amphotericin B 10ug/0.1 ml4 and plasma level
fluconazole-
(can be given 5-10ug/0.1ml)5
resistant Candida
(Should be performed with AC* Monitoring is required
spp)
washout) for flucytosine.
+Intravitreal Amphotericin B (5 Topical administration

10ug in 0.1 ml)4 of amphotericin B and
(can be given 1-10ug/0.1ml)5 voriconazole is not
(esp in secondary endophthalmitis) considered to be
harmful in pregnant
+ Intrastromal Amphotericin 5-10 and lactating women.
ug/0.1ml5
(in resistant/partial response to
treatment)
36
Intraocular:
Intracameral or
Intravitreal
Voriconazole
50 ug/0.1ml
(in resistant cases)
Filamentous Topical:
Natamycin 5% eye drop q1-2h
OR
Fluconazole 0.2% eye drop q 1- 2h
OR
Voriconazole 1-2% eye drop q1- 2h
PLUS
Systemic:
For patients > 40 kg body weight

this may be given
Oral Voriconazole (400mg BD for 2

doses then 200mg BD, increasing if
required to 300 mg BD)
OR
Intravenously (6 mg/kg BD for

2doses then 4 mg/kg BD).
Children 2 12 years,
Oral Suspension Voriconazole 200
mg BD;
intravenous 7 mg/kg BD (can reduce
to 4 mg/kg BD if not tolerated).
37
If poor treatment response,give
Intraocular:
+Subconjunctival Fluconazole
2mg/ml (0.2%)
+Subconjunctival Voriconazole 1-2%
+Intracameral Voriconazole
50 ug/0.1ml
+Intravitreal Voriconazole
50 ug/0.1ml
+ Intrastromal Voriconazole
50 ug/0.1ml
(in resistant/partial response to
treatment)
*AC Anterior Chamber
38
Simplified Flow Chart for the Management of Fungal Keratitis
Suspect Fungal Keratitis if risk factors

Contamination with organic matter (e.g.
Agricultural work, gardening)
Trauma (including LASIK)
Immunosuppression (e.g.topical corticosteroids,
alcoholism, diabetes, systemic
immunosuppressive disease)
Ocular surface disease (e.g. Dry eye,
neurotrophic cornea)
Hot humid climate
Check for systemic disease

Immunosuppression (topical steroid use)
Other opportunistic infections
Clinical signs suggestive of

fungal keratitis Yeast infection: insidious or rapid, often localized
infiltrate, and a relatively small epithelial

ulceration.
Filamentary fungal infection: usually insidious.

o Early: may be asymptomatic, intact
epithelium, minimal corneal stromal
infiltrate, and mild AC inflammation.
o Later: satellite lesions, feathery
branching infiltrate, and immune ring.
o In severe infection: ulceration,
involvement of deeper corneal layers
white
plaque on the endothelium, and severe
AC inflammation (e.g. hypopyon).
In late infection, these distinctive patterns may be lost,

and the clinical appearance may resemble an advanced
bacterial keratitis.
Perform early and adequate

corneal scrapes Stains: Gram, Giemsa, Grocotts methenamine
silver (GMS) stain, Periodic Acid Schiff (PAS)
stain, and Calcofluor white
KOH
Culture: Sabouraud Dextrose Agar (for most

fungi) and Blood Agar (for Fusarium);
PCR for fungal DNA to send to IMR (03-26162665)
39
KIV admission (Indication) Severe infection: >1.5mm diameter infiltrate,
centrally located (vision threatening), hypopyon,
purulent exudate, or complicated ocular and
systemic problem
Poor compliance: either with administering drops
or returning for daily review.
Other concern: only eye, paediatric, failing to
improve, etc.
Consider systemic work-up
Check for diabetes
FBC, U&E, LFT
Topical antifungal therapy
Initial treatment
Amphotericin B 0.15%-0.2% eye drop q1-2h If filamentous is suspected,
+Fluconozole 0.2% eye drop q 1- 2h
Natamycin 5% eye drop q1-2h OR Fluconozole 0.2% eye
PLUS drop q 1- 2hORVoriconazole 1-2% eye drop q1- 2h
Fluconozole 200-400mg PO q24h x 7 to 14 days (if PLUS

immunosuppressed: Fluconozole PO 100mg OD)
Oral Voriconazole (400mg BD for 2 doses then 200mg BD,
increasing if required, up to 300 mg BD)#
OR
If invasive yeast infections:
Intravenous voriconazole (6 mg/kg BD for 2doses then 4
Intravenous Flucytosine 200 mg/kg daily in 4 divided mg/kg BD)#
doses x 1/52 (require monitoring of plasma
concentration)
40
Trace culture and sensitivity
If poor response to treatment
+Subconjunctival Fluconazole 2mg/ml (0.2%)
+Intracameral Amphotericin B 10ug/0.1ml4 (can be given 5-10 ug/0.1ml)5(Should be performed

with AC* washout)
+ Intravitreal Amphotericin B (5 10ug in 0.1ml)4 (can be given 1-10ug/0.1ml)5 (especially in

secondary endophthalmitis)
+ Intrastromal Amphotericin B 5-10 ug/0.1ml5 (in resistant/partial response to treatment)
+Subconjunctival Fluconazole 2mg/ml (0.2%)
+Intracameral Voriconazole 50 ug/0.1ml
+Intravitreal Voriconazole 50 ug/0.1ml
+Intrastromal Voriconazole 50 ug/0.1ml (in resistant/partial response to treatment)
Commence a loading dose of one drop every 15 minutes for 3 hours followed by hourly drops around the
clock.2 Taper based on clinical response.
#
For patients > 40kg weight only.
In children 2 to 12 years:
Oral voriconazole (suspension): (200 mg twice daily)
Intravenous voriconazole: (7 mg/kg every 12 hours, reduced to 4 mg/kgevery 12 hours if not tolerated)
*AC Anterior Chamber
41
Acanthamoeba Keratitis
Acanthamoeba Risk Factors
CL wear: especially with extended wear, poor CL hygiene (e.g. rinsing in tap water), or after swimming
with CL in situ (ponds, hot tubs, swimming pools).
Corneal trauma: notably in a rural or agricultural setting.
Signs of Acanthamoeba
Epitheliopathy, pseudo- and true dendrites

stromal infiltrates (may progress circumferentially to form a ring infiltrate) late sign
perineural infiltrates (pathognomonic)
reduce corneal sensation.
(commonly misdiagnosed as herpes simplex keratitis)
Specific Investigations for Acanthamoeba
Stains: Gram (stains organisms), Giemsa (stains the organism and cysts), Calcofluor white (stains cysts
visualized under UV light), PAS stain.
Culture: non-nutrient agar with E. coli overlay, at 25 and 37°C, may require up to 14d. (send in
transport media (page saline) -to obtain from Parasitology Lab, Pra-Clinical Block, HUKM, ext no: lab
8434 / office 9525.
If not available, to keep in normal saline can be kept x 48hr, but result can be negative if not send on
the same day)
Send for histology (fixed in 10% formalin) (not available in HUKM)
Acanthamoeba PCR to IMR (03-26162683).
If in vivo confocal microscopy available, direct visualization of cysts are diagnostic (double cyst wall)
Light and electron microscopy of acanthamoebal cysts.
42
Acanthamoeba Keratitis Chlorhexidine 0.02% eye drop Propamidine Taper treatment,

Acanthamoeba sp. q1-2h isethionate 0.1% q1- according to
2h clinical
PLUS improvement.
Biguanide Relapse is
(polyhexamethylenebiguanide common
(PHMB)) 0.02% eye drop q1-2h and may signify
incomplete
+ gentamicin 0.9% eye drop q1- sterilization of
2h active
Acanthamoeba
trophozoites or
reactivation of
resistant
intrastromal cysts.
Topical therapy
tapered with
response over a
duration of 6-12
month
43
Viral Keratitis
Viral Risk Factors
Local
Topical medication : Prostaglandin analogue,4 topical steroid
Local trauma and inflammation: Laser surgery eg LASIK, PK, Lamellar keratoplasty, PRK
Periorbital vesicular rash (or other area)
Follicular conjunctivitis
Systemic
Immunosuppressed patient (organ transplant patients, DM, Measles, HIV, children)
Atopy (hay fever, asthma, atopy eczema)
(associated with severe HSV keratitis, tend to be bilateral, and severe atopy disease has 2 4.8 fold
of risk having ocular HSV)4
Risk of Future Recurrences in HSV Keratitis4

History of HSV stromal keratitis
(only 3% of epithelial and endothelial HSV keratitis recur, while 28% of HSV stromal keratitis recur)
High number of previous episodes of recurrences

short interval between attacks tend to be associated with short interval during future attacks
Classification of HSV Keratitis
Corneal Layer Nomenclature Alternate Term

Epithelium HSV Epithelial Keratitis Dendritic Corneal Ulcer
Geographic Corneal Ulcer
Stroma HSV Stromal Keratitis without Ulceration Non-necrotising Keratitis

Interstitial Keratitis
Immune Stromal Keratitis
HSV Stromal Keratitis with Ulceration Necrotising Keratitis
Endothelium HSV Endothelial Keratitis Disciform Keratitis
Adopted from AAO Guidelines of Herpes Simplex Keratitis Treatment4
44
Signs of Herpes Simplex Virus
Epithelial
Superficial punctate keratitis stellate erosion dendritic ulcer (branching morphology with terminal
bulbs, cf. pseudodendrites) if untreated, becomes geographic ulcer (large amoeboid ulcer with dendritic
advancing edges; also more common presented inimmunocompromised/topical steroids).The dichotomous
branching and terminal bulbs of the geographic ulcer, which are seen peripherally, often distinguish it from
a metaherpetic ulcer.
Ulcer base stains with fluorescein (de-epithelialized); ulcer margins stain with Rose Bengal (devitalized viral-
infected epithelial cells); reduce corneal sensation.
Metaherpetic (Trophic) Ulcer5

-is the only form of epithelial ulceration that does not have any live virus.
-The ulcer is called trophic if it arises de novo and metaherpetic if it follows a dendritic or
geographic ulcer, although the terms are frequently used interchangeably.
-Metaherpetic ulcers result from the inability of the epithelium to heal.
-The causes are multifactorial and include toxicity from antiviral medications, loss of innervation
and neural-derived growth factors, poor tear surfacing, and underlying, low-grade stromal
inflammation.
-Metaherpetic ulcers are difficult to differentiate from geographic ulcers.
-They can be distinguished by their smooth, gray, elevated borders that do not stain with Rose
Bengal.
-The Rose Bengal dye stains the unhealthy epithelial cells attempting to migrate across the base
of the ulcer, whereas fluorescein leaks through these poorly adherent cells into the stroma and
stains the periphery so-called reverse staining.
Systemic: history of orofacial or genital ulceration.
Stromal keratitis (may occur with or without epithelial ulceration)

Multiple or diffuse opacities corneal vascularization
lipid exudation
scarring or may lead to thinning
AC activity
Endothelial Keratitis (endotheliitis/disciform) - probably results from viral antigen hypersensitivity,

rather than reactivation.
Central/paracentral disc of corneal oedema
Mild AC activity
fine KPs
Wessely ring (stromal halo of precipitated viral antigen/host antibody) immune ring of deep
stroma signify deposition antigen antibody complex
High IOP
Chronic Anterior Uveitis
45
Signs of Varicella Zoster Virus
Systemic and cutaneous disease
Viral prodrome, rash (papules vesicles pustules scabs)

Predominantly within the one dermatome (Va)
Hutchinsons sign (cutaneous involvement of the tip of the nose, indicating nasociliary nerve
involvement and likelihood of ocular complications)
may be disseminated in the immunocompromised
Additionally, the resultant neurotrophic cornea is vulnerable to bacterial and fungal keratitis.
Epithelial Keratitis
Common
acute (onset 2 3d after rash; resolve in few week)
superficial punctate keratitis + pseudodendrites
often with anterior stromal infiltrates
Stromal
nummular keratitis with anterior stromal granular deposits is uncommon and occurs early (10d)
necrotizing interstitial keratitis with stromal infiltrates
thinning
and even perforation (cf. HSV) is rare and occurs late (3mo years).
Disciform
Endotheliitis with disc of corneal oedema
mild AC activity
fine KPs
late onset (3mo years)
chronic
uncommon
Neurotrophic
corneal nerve damage causes persistent epithelial defect
thinning, and even perforation
late onset
chronic
uncommon
46
Investigations for HSV
This is usually a clinical diagnosis
Stain: Giemsa stain (multinuclear giant cells)
Viral Culture : transport via Viral Transport Media - contact Lab Unit Tissue Culture, HUKM (ext no: ext
5483 or IMR (03-26162677)
Viral PCR : Conjunctival and corneal swabs or AC paracentesis of aqueous in keratouveitis (diagnostic)
- not available in HUKM/IMR/MKA Sg. Buloh.
- Available at DNA Laboratory SDN Bangi (03-89252700)
Beware false negatives, as long-term aciclovir will reduce HSV DNA copy number.
Investigations for VZV
Viral PCR : Conjunctival and corneal swabs or AC paracentesis of aqueous in keratouveitis

(diagnostic)
- Not available in HUKM/IMR/MKA Sg. Buloh.
Complications associated with HZO
Ocular:
Conjunctivitis
2° Microbial Keratitis
Glaucoma
Anterior Uveitis
Necrotizing Retinitis (Acute Retinal Necrosis (Arn), Progressive Outer
Retinal Necrosis (Porn))
Episcleritis
Scleritis
Optic Neuritis
Cranial Nerve Palsies
Systemic:
Strokes (Cerebral Vasculitis)
Neuralgia
47
Infection/Condition & Likely Suggested Treatment Comments
Organism Preferred Alternative
Herpes Simplex Epithelial Acyclovir 400mg PO 5

Keratitis Keratitis times/day Use
Herpes Simplex Type preservative-
1&2 OR free treatment
if coexistent
Acyclovir 3% eye ocular
ointment 5 times/day surface
(if available) disease.
(Both for 10-14 days, Not to use

continued for at least steroid if
3days after complete epithelial
healing) breakdown.
PLUS Monitor IOP

and treat, as
Gentle Debridement necessary.
HSV Stromal Topical corticosteroid Topical Alternative to

Keratitis (e.g. Dexamethasone Cyclosporine0.05% Acyclovir PO:
without 0.1% or Prednisolone to 0.4% QID4
0.5-1% 1-4×/d for (as adjunctive Valaciclovir PO
Ulceration
greater than 10 weeks therapy to replace 1g 3×/d for 7d,
(tapering dose)4 / reduce the need
(Non- of topical steroids) or
necrotizing PLUS
Stromal Famciclovir PO
Keratitis) Acyclovir 400mg PO 5 750mg OD for
times/day for greater 7d;
(epithelium than 10 weeks (tapering
intact) dose)4
HSV Stromal Acyclovir 400mg PO 5

Keratitis with times/day x for greater
Ulceration than 10 weeks(tapering
dose)4
(Necrotizing
Stromal Keratitis)
+Acyclovir 3% eye
ointment 5 times/day
(if available)
To add topical
corticosteroid once
epithelium heal.
Recurrent Herpes Prophylaxis:

Simplex Epithelial Acyclovir 400mg PO
/ Stromal q12h x 1 year or longer
Keratitis (depending on cases)
48
Endotheliitis Topical
corticosteroid(e.g.
Dexamethasone 0.1% or
Prednisolone
0.5-1% 4×/d, titrating
down in not less than 4
weeks minimum.
(aim for
minimum effective dose)
Some patients
may require low dose
(e.g. prednisolone 0.1%
alt 1×/d) for months or
even maintenance.
PLUS
Oral aciclovir400mg 5x
/d not less than 4 weeks
minimum
Infection/Condition & Likely Suggested Treatment Comments

Organism Preferred Alternative
Herpes Zoster
Ophthalmicus1 Epithelial Topical lubricants,
Herpes Zoster Virus usually preservative-free
Systemic antiviral:
start as soon as rash Post-herpetic
appears (up to 72 hrs neuralgia may
of rash onset or when cause
vesicles still active) Stromal and Topical depression
disciform corticosteroid(e.g. (even suicide);
either Dexamethasone 0.1% or treatments
Prednisolone include
Aciclovir PO 800mg 0.5-1%1 4×/d, for amitriptyline,
5×/d for 7-10 days 4-6 weeks gabapentin,
(only when epithelium and topical
OR intact) capsaicin
cream.
Valaciclovir PO 1g Some patients may
3×/d for 7d require low dose (e.g. Monitor IOP:
Prednisolone 0.1% assess whether
OR OD/EOD) for months or due to
even maintenance. inflammation
Famciclovir PO or steroids, and
750mg OD for 7d Threatened perforation treat
may require accordingly.
If immunosuppress- gluing, BCL, or tectonic
ed, then Aciclovir IV grafting.
10mg/kg 3×/d.
Neurotrophic Preservative-free topical

lubricants + Lacri-Lube
ON
Consider tarsorrhaphy
49
(surgical or medical with
botulinum toxin-induced
ptosis), AMG, or
conjunctival flap.
Anterior uveitis Topical steroid

treatment (e.g.
Dexamethasone 0.1% or
Prednisolone
0.5-1%) and
cycloplegia for
comfort/AC activity.
Detailed abbreviations:
PK Penetrating Keratoplasty
PRK Photorefractive Keratectomy
cf compare with
mo month
BCL Bandage Contact Lens
AC Anterior Chamber
50
Simplified Flow Chart for the Management of Viral Keratitis
Suspect Viral Keratitis if risk factors
Local
Topical medication : Prostaglandin analogue,4
topical steroid
Local trauma and inflammation: Laser surgery eg
LASIK, PK, Lamellar keratoplasty, PRK
Periorbital vesicular rash (or other area)
Follicular conjunctivitis
History of HSV Keratitis
Systemic
Immunosuppressed patient (organ transplant
patients, DM, Measles, HIV, children)
Atopy (hay fever, asthma, atopy eczema)
Systemic: history of orofacial or genital ulceration.
Clinical signs
Epithelial : Systemic and cutaneous disease:

Dendritic ulcer (branching morphology with Viral rash (papules, vesicles, pustules)
terminal bulbs) Predominantly within the one dermatome (Va)
If untreated, dendritic geographic ulcer (large
amoeboid ulcer with dendritic advancing edges may be disseminated in the immunocompromised
Metaherpetic (trophic) ulcer5 chronic or chronic Additionally, the resultant neurotrophic cornea is
recurrent superficial postherpetic disease without vulnerable to bacterial and fungal keratitis.
any detectable hsv-activity, neurotrophicity occurs
and corneal healing is problematic. Epithelial Keratitis:
Superficial punctate keratitis + pseudodendrites
Stromal : (+ epithelial ulceration) Often with anterior stromal infiltrates
Multiple or diffuse opacities Corneal
vascularization Neurotrophic:
Lipid exudation Corneal nerve damage causes persistent epithelial
Scarring or may lead to thinning defect
AC activity Thinning, and even perforation
Late onset
Endothelial Keratitis (endotheliitis/disciform) : Chronic
Central/paracentral disc of corneal oedema Stromal:
Nummular keratitis with anterior stromal granular
Mild AC activity deposits (uncommon)
Fine kps Necrotizing interstitial keratitis with stromal
Wessely ring infiltrates
High IOP Thinning
Chronic anterior uveitis Perforation is rare and occurs late (3months
years).
Disciform:
Endotheliitis with disc of corneal oedema
Mild AC activity
Fine kps
Chronic
51
Perform early and adequate corneal scrapes
Investigations for HSV

Stain: Giemsa stain
Viral Culture : transport via Viral Transport Media - contact Lab Unit Tissue Culture, HUKM (ext
no: ext 5483 or IMR (03-26162677)
Viral PCR : Conjunctival and corneal swabs or AC paracentesis of aqueous in keratouveitis

(diagnostic)
- not available in HUKM/IMR/MKA Sg. Buloh.
KIV admission (Indication)
Severe infection: >1.5mm diameter infiltrate, centrally located (vision threatening), hypopyon,
purulent exudate, or complicated ocular and systemic problem
Poor compliance: either with administering drops or returning for daily review.
Other concern: only eye, paediatric, failing to improve, etc.
Consider systemic work-up

Check for diabetes
FBC, U&E, LFT
52
Topical antiviral therapy
Initial treatment
Herpes Simplex Keratitis
Epithelial HSV Stromal HSV Stromal Recurrent Herpes Endotheliitis

Keratitis Keratitis without Keratitis with Simplex
Ulceration Ulceration Epithelial /
(Epithelium intact) Stromal Keratitis
Acyclovir 400mg Topical Acyclovir 400mg PO Prophylaxis: *Topical

PO 5 times/day corticosteroid (e.g. 5 times/day x for Acyclovir 400mg corticosteroid(e.g.
Dexamethasone greater than 10 PO q12h x 1 year or Dexamethasone
OR 0.1% or weeks (tapering longer (depending 0.1% or
Prednisolone dose)4 on cases) Prednisolone
0.5-1% 1-4×/d for 0.5-1% 4×/d,
Acyclovir 3% eye
greater than 10 + Acyclovir 3% eye titrating down in
ointment 5
weeks (tapering ointment 5 not less than 4
times/day
dose)4 times/day weeks minimum.
(if available)
(if available)
PLUS PLUS
(Both for 10-14
days, continued for
at least 3days after Acyclovir 400mg PO To add topical Oral aciclovir400mg
complete healing) 5 times/day for corticosteroid once 5x /d not less than 4
greater than 10 epithelium heal. weeks minimum
weeks (tapering
PLUS dose)4
Gentle
Debridement *(Aim for
minimum effective
dose.
PLUS
Some patients
may require low
Preservative free
dose (e.g.
artificial tears (esp
prednisolone 0.1%
coexistent ocular
alt 1×/d) for
surface disease).
months or
even maintenance)1
53
Topical antiviral therapy
Initial treatment
Herpes Zoster Ophthalmicus
Systemic antiviral:
Start as soon as rash appears (up to 72 hrs of rash onset or when vesicles still active) either
Aciclovir PO 800mg 5×/d for 7-10 days OR Valaciclovir PO 1g 3×/d for 7days OR Famciclovir PO750mg OD for
7days
If immunosuppressed, then IV Aciclovir 10mg/kg 3×/d.
Detailed abbreviations:
PK Penetrating Keratoplasty
PRK Photorefractive Keratectomy
cf compare with
mo month
BCL Bandage Contact Lens
AC Anterior Chamber
54
DIABETIC MACULA OEDEMA (DMO)
History:
- Diabetic history duration, control
- Hyperlipidaemia, Hypertension
- End organ damage
Examination:
-VA, RAPD, IOP, Rubeosis iridis, Lens
-Diabetic retinopathy
-CSME
Ix:
OCT macula
Central involved DMO with Central involved DMO with very Non-central involved DMO
vision impairment good vision
-Ideally, licensed anti-VEGF with Observation until vision Observation until central- involved
proven efficacy & safety is impairment, then either focal/ DMO.
administered. grid laser or anti-VEGF if DMO
-If anti-VEGF not available, then persists.
focal/grid laser.
55
ANTI-VEGF THERAPY GUIDELINES for DMO
Improving Stable Worsening
- - OCT central subfield Not improving or worsening on OCT or VA: After withholding injection,
when stable, if worsening on
10% or VA letter score Sometimes inject, sometimes withhold injection. OCT of VA, resume
- If only stable since last injection inject at least one more injections.
line time to be confident that both OCT and VA are stable and
not improving. Worsening = OCT central
- - Inject again. subfield thickness increase
- If stable for at least 2 consecutive injections: by >10% or VA letter score
If OCT CSF <250um and VA 20/20 or better decreased by >5 letters or -1
defer injection, return in 4 weeks; if stable or line.
improve, double follow up to 8 weeks; if still
stable or improve, double follow up to 16 weeks;
if worsen, inject.
If OC
o If less than 6 months of injections inject
o defer
injection
- consider focal/ grid laser of OCT CSF
>250um
o Return in 4 weeks
If stable or improve, double
follow up to 8 weeks; if still
stable, double follow up to 16
weeks.
If worsen, inject
56
ENDOPHTHALMITIS DIAGNOSIS (ALGORITHM 1)
Endophthalmitis
Exogenous Endogenous
Endophthalmitis Endophthalmitis
Acute Post-op Chronic Post-op

Endophthalmitis Endophthalmitis
Risk factors Risk factors
Ocular Background
Blepharitis, conjunctivitis, dacryocystitis, lacrimal duct obstruction Diabetes/HIV/IV drug abuse/ESRF on
dialysis/indwelling catheter/
Systemic immunosuppression/abdominal surgery
Immunosuppression, diabetes mellitus, atopic dermatitis, dry eyes
Active foci of infection
Surgery Liver abscess/pneumonia/ endocarditis/soft
Longer duration, complications, vitreous loss, surgical instruments, tissue infection
Mitomycin C
Presentation (acute) Presentation (chronic) Presentation
Pain Can be similar like acute Foci of on-going infection

Redness endophthalmitis Ill-patient
Reduced vision White eyes (possible)
Swollen lids Additionally: Pain
Discharge Redness
Corneal oedema Gradual reduced vision Reduced vision
AC cells, fibrin, hypopyon Persistent low grade uveitis AC cells
Vitritis Hypopyon Chorioretinitis
Retinitis Vitritis
Vasculitis Plaque on PC or IOL Bilateral ocular involvement
OD swelling Vitritis
Clinical Practice Guidelines, Management of Post-Operative Endophthalmitis. Ministry of Health Malaysia, August 2006
57
ACUTE POST-OP ENDOPHTHALMITIS (ALGORITHM 2)
Acute Post-op Endophthalmitis
Refer Algorithm 1 Diagnosis

IVT tap within 1 hour
Send for gram stain/KOH/C&S
IVT vancomycin 2mg/0.1 ml Ant chamber tap (optional)
IVT ceftazidime 2mg/0.1ml Investigation
Trace KOH/gram stain within 24 hours
Gutt vancomycin 5% hourly (Possible delay due to laboratory
Gutt ceftazidime 5% hourly constraints since 2017)
Gutt dexamethasone 2hourly
Oral ciprofloxacin 750mg BD x 2/52 Treatment
(Alternatively oral moxifloxacin)
Oral Clarithromycin 500mg BD x 2/52 if
culture negative
Cycloplegic/Analgesia/IOP lowering if VA PL or worse
needed Re-assessment criteria:
Symptoms
Visual acuity
RAPD
AC activity/hypopyon
Vitritis
Responding Not responding
Trace C&S after

48 hours
Continue treatment Re-inject IVT antibiotic

(culture-adjusted)
Responding -24 hours (post-vitrectomised)
- 48 hours (non-vitrectomised)
Continue topical/oral antibiotic
May consider oral steroid
Prednisolone 1mg/kg/day tapering
dosage for 3/52 duration if fungal not Worsening uncontrolled
likely infection with poor visual Not responding
potential
VR referral
Evisceration
Haimann MH, Weiss H, Miller JA. Endophthalmitis Vitrectomy Study.ArchOphthalmol. 1991;109(8):1060 1061
58
CHRONIC POST-OP ENDOPHTHALMITIS (ALGORITHM 3)
Chronic Post-op Endophthalmitis

IVT tap within 1 hour
IVT vancomycin 2mg/0.1 ml
Ant chamber tap (optional)
IVT ceftazidime 2mg/0.1ml
Investigation Trace KOH/gram stain within 24
Gutt vancomycin 5% hourly
hours
Gutt ceftazidime 5% hourly
(Possible delay due to laboratory
Gutt dexamethasone 2hourly
constraints since 2017)
Oral ciprofloxacin 750mg BD x 2/52
Oral Clarithromycin 500mg BD x 2/52 if Treatment
culture negative
Cycloplegic/Analgesia/IOP lowering if needed
Suspected fungal (add):
IVT amphoB 5mcg/0.1ml Re-assessment criteria:
Systemic antifungal Symptoms
Visual acuity
RAPD
AC activity/hypopyon
Vitritis
Responding Not responding

Trace C&S after
48 hours
Re-inject IVT antibiotic

Continue treatment Responding (culture-adjusted)
-24 hours (post-vitrectomised)
- 48 hours (non-vitrectomised)
Continue topical/oral antibiotic

Oral steroid contraindicated in fungal Not responding Worsening uncontrolled
Prednisolone 1mg/kg/day tapering infection with poor visual
dosage for 3/52 duration if fungal ruled potential
out
VR referral Evisceration
Consider surgery
Removal of IOL and capsule
Haimann MH, Weiss H, Miller JA. Endophthalmitis Vitrectomy Study.ArchOphthalmol. 1991;109(8):1060 1061
59
ENDOGENOUS ENDOPHTHALMITIS (ALGORITHM 4)
Endogenous Endophthalmitis
IVT tap
Ant chamber tap (optional)
Trace KOH/gram stain within 24 hours
(Possible delay due to laboratory
constraints since 2017)
Investigation FBC
Blood C&S (include fungal)
Urine C&S
CXR
USG Abdomen
Echocardiogram
Treatment
Mainstay treatment is systemic

intravenous antibiotics/antifungal Moderate and severe ocular disease
Need medical consultation to assist in (significant vitreous involvement)
treatment and planning
Mild vitritis Systemic antibiotic

Mild ocular disease
Focal chorioretinitis Intravitreal antibiotic
Vitrectomy for selected cases
Systemic antibiotic alone

Close monitoring
Mohammad Ali Sadiq, Muhammad Hassan, Aniruddha Agarwal, Salman Sarwar, et al. Endogenous endophthalmitis:
diagnosis, management, and prognosis.. J Ophthalmic Inflamm Infect. 2015;5:32
60
Anterior Chamber Tap
1. Obtain consent from patient.

2. Instil topical anaesthetic drops.
3. Perform limbal paracentesis at the slit lamp, using a 1 ml syringe (not an insulin syringe) with a half inch 25
gauge needle. A larger bore needle, e.g. 23 gauge needle, may be used if there is hypopyon. Loosen the
plunger first before entering the eye to ease the aspiration of aqueous.
4. Aspirate 0.1 to 0.2 ml of aqueous.
5. Inoculate aqueous specimen onto culture plates and smear it on glass slide.
6. Label the syringe, culture plates, glass slide or culture bottle before sending them to the laboratory.
Vitreous Tap
1. Obtain consent from patient.

2. Prepare vitreous tap set consisting of eyelid retractor, caliper, conjunctival forceps, 5ml syringes, 23G
needle, cotton buds, eye pad, and povidone iodine 5% solution.
3. Perform procedure using aseptic technique in a quiet and clean place, either at the outpatient clinic, ward or
operating theatre.
4. Clean the periorbital skin and conjunctival sac with povidone iodine 5%.
5. Drape the eye.
6. Instil topical anaesthetic drops and subconjunctival injection of 2% lignocaine.
7. Perform vitreous tap using a 5ml syringe with 23G needle. Enter the eye about 4 mm posterior to the limbus
for phakic eyes or 3.5 mm for aphakic or pseudophakic eyes.
8. Aspirate about 0.2ml to 0.4 ml of vitreous.
9. Inoculate vitreous specimen onto culture plates and smear it on a glass slide.
10. Label the syringe, culture plates, glass slide or culture bottle before sending them to the laboratory
61
Intravitreal Antibiotic Injection
1. Prepare and dilute intravitreal antibiotics using an aseptic technique.

2. Prepare different antibiotics in separate syringes.
3. Use 26G or 30G needle and inject 4 mm (phakic eyes) or 3.5 mm (pseudophakic/ aphakic eyes) posterior to
the limbus into the mid vitreous cavity, with the bevel of the needle pointing anteriorly
Preparation on Intravitreal Antibiotic
Vancomycin Hydrochloride (2mg in 0.1ml)

1. The vial contains 500 mg vancomycin powder
2. Reconstitute the vial with 10 ml of 0.9% normal saline (NS). Mix well
3. Withdraw 4ml (200mg) and add 6ml of 0.9% NS
4. Take 0.1 ml (=2 mg)
Ceftazidime sodium (2mg in 0.1ml)

1. The vial contains 1000 mg ceftazidime powder.
2. Reconstitute the vial with 10 ml of 0.9% NS/water for injection. Mix well
3. Withdraw 1 ml (100mg) and add 4ml of 0.9% NS/water for injection
4. Take 0.1 ml ( = 2 mg)
Amphotericin B (0.005mg in 0.1ml)

1. The vial contains 50-mg of amphotericin B powder
2. Reconstitute the vial with 10ml sterile water for injection
3. Withdraw 1ml (5mg) and add 9ml of sterile water for injection. Mix well
4. Withdraw 1ml (0.5mg) and add 9ml of sterile water for injection. Mix well
5. Take 0.1 ml (= 0.005mg)
62
HYPHAEMA
Chief Complaints: Clinical assessment:

Recent ocular trauma/ surgery - VA, Pupillary exam, IOP, slit-lamp exam
- Height of hyphaema from inferior limbus
Risk Factors: - Gentle B scan if no view
Bleeding diathesis sickle
haemoglobinopathy*,
Clotting disorder
Anticoagulant therapy Medical management:
- Admit high risk cases (Paediatrics, Bleeding
diathesis,
Grade III and above, IOP>21)
- Topical steroids, Cycloplegics**, Antiglaucoma
- Strict bed rest and head elevation at 45 degrees
- Globe protection (Eye shield)
- Avoid aspirin/ antiplatelets/ NSAIDS/ warfarin
Daily Review:
- IOP check
- Rule out rebleeding
- Corneal blood staining
- Gonioscopy angle recession of >180 degrees
require
Indication for surgical intervention:

-Large hyphaema causing complete visual obstruction in a paediatric patient-risk of
amblyopia
-Corneal blood staining
-IOP >25 for 1/7 in pt with sickle haemoglobinopathy
-IOP >50 for 5/7 to prevent optic nerve damage
-Unresolved hyphema initially total and not resolving <50% at 6days with IOP >25
-Unresolved hyphema for 9/7 to prevent PAS
Follow up:
- IOP check
- Gonioscopy angle recession of >180 degrees
require
Annual checks lifelong
63
MANAGEMENT OF ORBITAL FRACTURE
Patient with
orbital fracture
History:
Mechanism of injury
Any diplopia
Any BOV
Other associated injuries
Thorough orbital and ocular examination
Ocular investigations: Systemic investigations:
Hess/BSV CT orbit(2mm cut)

Optic nerve function test Plain x-ray if CT unavailable
General Management Surgical management

Refrain from nose
blowing
Nasal decongestion
Oral/systemic
antibiotics
Co manage with Patient factors: Ocular factors:
Maxillofacial
Symptomatic diplopia Enophthalmos> 2mm
Observe if:
Young patient Hypoesthesia
1. Small fracture
Oculocardiac reflex Hypoglobus
2. Minimal diplopia /
Trapdoor fracture Large fracture
restriction /
enophthalmos involving > half of
orbital floor
Monitor with serial
Hess chart Significant diplopia
64
PRIMARY OPEN ANGLE GLAUCOMA SUSPECT
Classification of Primary Open Angle Glaucoma (POAG)/ Ocular Hypertension (OHT)/ Primary
Open Angle Glaucoma Suspect
Assessment
IOP >21mmHg Any Any
ONH/RNFL Normal Suspicious* Damage
Normal Normal/ Defects%

VF
Suspicious#
OHT POAG Suspect POAG
IOP = Intraocular pressure High IOP Normal IOP

ONH = Optic nerve head
RNFL = Retinal nerve fiber layer
VF = Visual Field
OD = Optic disc OHT POAG Suspect POAG
#
*Suspicious ONH/RNFL changes Suspicious or early defects on VF
Increase vertical CDR Glaucoma hemi field test (GHT) graded as outside
Inferior superior nasal temporal normal limits
(ISNT) rule A minimum of three clustered points (non-edge
Neuroretinal rim notching or points) with significantly depressed sensitivity, of
acquired pit in OD which one should have a significance of p<1% on the
Asymmetry CDR between OD >0.2 pattern deviation plot
OD haemorrhage p-value of PSD<5%
Nasalization/ bayonetting of vessels
Peripapillary beta zone atrophy %
RNFL thinning/ loss
classical defects
Paracentral scotoma, nasal step and arcuate

scotoma; temporal wedge is an uncommon feature
65
POAG Suspect with normal IOP
No treatment
Monitoring
IOP Measurement
ONH/RNFL
o Enlargement of CDR
During visit
o ONH changes
o RNFL defect
Should be examine properly with dilated pupils
Serial optic disc imaging if available (every visit)
Visual field (VF)
Risk Factor Assessment *If there is no change

in the parameters after
Ocular: 3-5 years, the patient
can be transferred
CCT<555µm from active glaucoma
ONH changes: disc hemorrhage, beta zone peripapillary atrophy care to general
Wide diurnal IOP fluctuation (>10mmHg, need to be confirmed ophthalmologist or
with phasing) primary care
Myopia optometrist for annual
assessment
Non-ocular:
Advancing age
Positive family history
Hypoperfusion conditions: OSA syndrome, Raynauds
phenomenon, low blood pressure, nocturnal hypotension, low
ocular perfusion pressure, low intracranial pressure
Initially follow-up every 4 months to look for progression and reproducibility on HVF
6 HVF in 2 years, >-2dB means fast progression
Subsequent follow-up
IOP Remain Normal >21mmHg Any
ONH/RNFL No Changes No Changes Damage
Remain Normal Not Progressing Not Progressing Defects
Monitor* OHT NTG/POAG
66
RHEGMATOGENOUS RETINAL DETACHMENT, RRD (ALGORITHM 1)
Risk factor History Examination

Myopia Sudden loss of vision (Curtain IOP low/high
Cataract surgery /other ocular effect) Tobacco dusting
surgery Progressive loss of visual field Retinal breaks
Family history of RD Floaters & flashes Macula on or off
Trauma
Previous retinal tear
Marfan syndrome
Stickler syndrome
RRD
Specific assessments
- 3 mirror examination of bilateral
eyes
- BIO examination with indentation
Investigation
B scan if there is no view
Pre-op Ix : FBC/RP/CXR/ECG
Acute management
Rest in bed
Prepare for operation (NBM, counselling and
consent)
Posture depending on location of the
detachment
VR Referral & treatment options according to
Algorithm 2
(** Urgent referral if macula on)
67
TREATMENT OPTIONS FOR RRD (ALGORITHM 2)
Treatment Option for RRD
Vitreous attached Vitreous detached
Superior break
Breaks within 1 clock hour Breaks treatable by indentation
Posture compliance
Yes No Yes No
Pneumatic Scleral Buckle

Retinopexy
Breaks which are multiple, too posterior or large

Obscured by media opacity
RRD too bullous
Proliferative vitreoretinopathy, PVR
{
Posterior vitrectomy, PPV
68
RETINOPATHY OF PREMATURITY
Risk Factor
Low birth weight (<1500 grams)
Gestational age (<32 weeks)
Extended supplemental O2
Others e.g: Intraventricular hemorrhage, Respiratory
distress syndrome, sepsis
Whom to screen
Birth weight <1500 g or
Gestational age <32 weeks or
Infants with an unstable clinical course who are at high risk
(determined - neonatologist/ paediatrician)
When to screen
4 to 6 weeks after birth or at 30 weeks postconception age (whichever is later)
Termination of ROP screening

Without ROP - ion age.
50 weeks postconception age and no prethreshold disease (defined as stage 3 ROP in zone II, any ROP in zone I) or
worse ROP is present; or
Regression of ROP. Characteristics of regression are seen on at least 2 successive examinations:
o Lack of increase in severity
o Partial resolution progressing towards complete resolution
o Change in colour in the ridge from salmon pink to white.
o Transgression of vessels through the demarcation line.
o Commencement of the process of replacement of active ROP lesions by scar tissue.
When to treat (Ablative treatment of avascular retina)
Threshold disease of ROP, defined as having all the following features:

Stage 3 ROP in zone 1, or zone 2
Involving 5 or more contiguous clock hours; or 8 or more cumulative clock hours and
the presence of plus disease
High risk pre-threshold disease of ROP, defined as any of the following:

Zone I, any stage ROP with plus disease
Zone I, stage 3 ROP without plus disease or
Zone II, stage 2 or 3 ROP with plus disease
69
CLASSIFICATION OF RETINOPATHY OF PREMATURITY
(The International Classification of Retinopathy of Prematurity)
Zone 1: Superior
Twice radius from optic nerve Optic nerve
to the fovea (macular involvement)
Zone III
Zone 2:
Nasal involvement to temporal Zone II
equator
Temporal
Nasal
Zone 3: Zone I
Residual crescent anterior to Zone II
Fovea
Inferior Ora Serrata
Stages Plus disease

Stage 0 - Immature retina Venous dilatation and arteriolar tortuosity of the
Stage 1 - Demarcation line
Stage 2 - Ridge Iris vascular engorgement
Stage 3 - Ridge + extraretinal fibrovascular proliferation Poor pupillary dilatation
Stage 4 - Sub-total retinal detachment Vitreous haze
4A - Extrafoveal
4B - Foveal
Stage 5 - Total retinal detachment The extent of ROP- Developing vasculature that is
5A - Open funnel involved quantified from 1-12 clock hours
5B - Closed funnel
70
SCREENING AND TREATMENT FOR
RETINOPATHY OF PREMATURITY
First ophthalmic examination: 4-6 weeks or at 30 weeks
No ROP, Zone 1 ROP stage 1, Zone 2 ROP

Immature retina or 2 or 3 (i.e. any
Zone 3 ROP stage)
Stage 1 Stage 2 Stage 3
Screen 2-3 weekly Screen at least Screen 2 weekly Screen 1-2 weekly Screen at least
weekly weekly
Regressing ROP and/or Threshold ROP with plus disease

Maturation of retinal vessels or High risk pre-threshold ROP
Mature eye Laser therapy or

Cryotherapy
Post treatment- Screen Disease not

No ROP - 1 year post term weekly regressed
With ROP 3 months post term
Comprehensive eye Stage 4 or 5 ROP Cicatricial ROP

examination
tagmus Scleral buckling Lens aspiration

Or
Fundus Lens sparing
vitrectomy
Follow up
Till the child reaches pre school years
assess the development of:
11
71
SARCOID UVEITIS
HISTORY
Ocular: Ocular pain / photophobia / floaters / reduce vision
Systemic: SOB / Fever / Arthralgia / Skin nodules
SIGNS
Anterior uveitis OD nodule / granuloma and/or choroidal

Mutton-fat KPs / iris nodules nodules
(Koeppe/Busacca) Conjunctival nodules
TM nodules / tent-shaped PAS Lacrimal gland enlargement dry eye
Vitreous opacities snowballs / string of Proptosis orbital involvement with a mass
pearls lesion
Multiple chorioretinal peripheral lesion Diplopia CN involvement / orbital mass
(active / atrophic) lesion
Nodular / segmental periphlebitis (candle
wax drippings) / retinal macroaneurysm in
inflamed eye
INVESTIGATIONS
Baseline:
systemic:
FBC / ESR / VDRL / RF
CXR abnormal >90% ocular sarcoid (Symmetric bihilar enlargement +- parenchymal disease)
Mantoux test 50% anergy
Ocular: OCT Macula, FFA / ICG
Diagnostic:
found in 60 90% with active sarcoid
useful in children when ACE is less reliable
Purified Protein Derivative (PPD) anergy help distinguish with TB (50% sarcoid are anergic)
Biopsy transbronchial, endobronchial, conjunctival, lacrimal gland
MANAGEMENT
COMPLICATIONS st
1 line: Topical, periocular, systemic corticosteroid
Chronic uveitis, CMO,
cycloplegics
Cataract, Secondary
2nd line: Steroid-sparing agent
glaucoma
Referphysician / rheumatologist for other systemic involvement
Proposed Diagnostic criteria for intraocular sarcoidosis
Definite Biopsy supported diagnosis with a compatible uveitis

Presumed Biopsy not done, presence of BHL with a compatible uveitis
Probable Biopsy not done and BHL negative, presence of 3 of suggestive intraocular signs,
and 2 positive investigational tests
Possible Biopsy negative, 4 of suggestive intraocular signs, and 2 positive investigational tests
72
SYPHILITIC UVEITIS
Syphilitic uveitis
Potential blinding condition
History of high risk behaviours, immunocompromised
Physical examination of skin rash, palms and sole maculopapular rash, genital and perianal
chancres, lymph node swelling, oral cavity gummata
Uveitic findings: Granulomatous anterior uveitis , intermediate or posterior uveitis, iritis,

iridocyclitis, iris nodules, multifocal choroiditis, vasculitis, RPE mottling, necrotising retinitis,
serous retinal detachment, CMO, choroiditis, inflammatory disc oedema
Ocular findings: episcleritis, scleritis, stromal keratitis, marginal corneal infiltrate, keratic
precipitates, cataract, Argyll Robertson pupil, extraocular motility deficit
Testing for suspected syphilis:

1. Nontreponemal tests: RPR, VDRL
2. Treponemal test: EIA, FTA-ABS, TPPA, TPHA, CIA
Management :
Co-management with infectious disease physician

Treat as neurosyphilis: 10-14 day course of systemic antibiotics
Test forHIV, Hep B, Hep C
Patient should undergo lumbar puncture and CSF analysis
Medical therapy
IV Penicillin G 24million units daily for 10-14 day or IM Procaine Penicillin 2.4million units daily and Probenicid
2g daily for 10-14days (watch out for Jarisch Herxheimer reaction)
Adjunctive therapy:- topical steroids, oral steroids to be used with caution in RVD positive patients
Repeat lumbar puncture at 6 months post-treatment if initial CSF VDRL is positive

Persistent ocular inflammation despite treatment: may need to repeat systemic antibiotics
73
TB UVEITIS
TB uveitis is intraocular inflammation secondary to mycobacterium

tuberculosis
Risks: immunocompromised, TB contact, health care provider
Spread: primary ocular infection or secondary spread
Sub-category of uveitis Ocular Features

Anterior uveitis Granulomatous, non-granulomatous, iris nodules,
ciliary body tuberculoma
Intermediate uveitis Granulomatous, non-granulomatous with organizing
exudates in pars plana/ peripheral uvea
Posterior and panuveitis Choroidal tubercle
Choroidal tuberculoma
Subretinal abscess
Serpiginous-like choroiditis
Retinitis and retinal vasculitis Occlusive vasculitis and retinal haemorrhages
Vitreous haemorrhage
Neuroretinitis and optic neuropathy Optic disc swelling
Macular exudates
Choroidal granuloma/ optic disc granuloma
Endophthalmitis and panophthalmitis
Investigation:
Sputum AFB, CXR, Tuberculin skin test
Quantiferon-Gold test: when skin test inconsistent with clinical findings. However, a negative result
does not rule out TB. Repeat test may be necessary
Ocular fluid PCR, ocular fluid culture/AFB

FBC, RP, LFT, ESR, Hep B, Hep C, HIV
Definite diagnosis: Presumed:
1. One or more signs suggestive of TB and 1. Findings consistent with TB, no other cause
2. One of following is positive: identified and
a) AFB on microscope or culture of M. 2. Tuberculin test 15mm or more, evidence of

Tuberculosis from ocular fluid pulmonary (positive CXR) or extrapulmonary
TB and
b) Positive PCR from ocular fluid
3. Responds to anti-TB without recurrence and
4. Exclusion of other uveitis entities
74
Treatment Treat underlying infection. Multidrug antimicrobial therapy in combination with
topical and oral corticosteroids when necessary.
Initial 2 months of rifampicin, isoniazid, pyrazinamide, and ethambutol. Continuation

of 7 months of rifampicin and isoniazid only
Monitor possible ocular complications secondary to anti-TB-
i) visual acuity, RAPD, light brightness, red desaturation, colour vision, HVF
ii) assess before starting anti-TB and then monitor at 2 months and every 3 months
subsequently
For ocular complication: CMO, retinal vasculitis, persistent vitritis, consider

immunosuppressant dose of oral corticosteroid but only if on effective anti-TB
NOTIFICATION at PPUKM
Notify online at e-notifikasi:
Manual notification:
TBIS 10A form x1 copy: to submit to Respiratory clinic
TBIS 10F form x3 copies : 1 in BHT, 1 to respiratory clinic, 1 for DOT
DOT book to be filled up and for DOT at nearest KK for 2weeks

Baseline investigations before starting anti-TB: HIV, FBS, LFT
At 2 weeks post anti-TB: LFT
Case must be referred to respiratory team TRO pulmonary involvement
75
THYROID EYE DISEASE (TED)
IOP = Intraocular pressure
EOM = Extraocular muscle
GC = Glucocorticoid
76
1. Symptomatic treatment includes lubricant eye drops and ointment for dry eye, prism for symptomatic
diplopia, botulinum toxin injection for upper lid retraction
2. Diclofenac 50mg BD
3. Selenium 100µg BD
4. Pulses of IV Methylprednisolone 500mg weekly for 6 weeks then 250mg weekly for another 6 weeks
(total cumulative dose should not exceed 8g in one course)
Screen for liver dysfunction, hypertension, diabetes, urine infections, glaucoma and history of peptic
ulcer prior to steroid treatment, and monitor for side effects
5. Orbital radiotherapy is a COMBINATION therapy to steroid, should not be given alone
Must be avoided in patients with diabetic retinopathy or sever hypertension, caution in patients
younger than 35 years
6. IV Methylprednisolone 1g/day for 3 days followed by 1mg/kg/day of oral prednisolone
7. Rehabilitative surgery should only be performed in patients who had inactive TED for at least 6
months
77
*Activity
EUGOGO CAS VISA NO SPECS
and severity Mild Spontaneous retrobulbar pain Vision Class 0: No physical signs or symptoms
Pain on attempted up or down gaze
U <2mm eyelid retraction Redness of the eyelids Score Class 1: Only signs (eyelids retraction or lid
G Mild soft tissue Redness of conjunctiva lag)
G involvement Swelling of the eyelids Yes
O <3mm exophthalmos Inflammation of caruncle/ plica No Class 2: Soft tissue involvement (0: absent; a:
G Transient or no diplopia Conjunctival oedema minimal; b: moderate; c: marked)
O Corneal exposure Inflammation
responsive to lubricants A CAS > 3/7 indicates active disease Score Class 3: Proptosis (0: absent; a: minimal; b:
= Orbital pain (none, with
moderate; c: marked)
Increasing proptosis (>2mm in 1-3 gaze, at rest): 0-2
E Moderate-to-severe months) Chemosis: 0-2 Class 4: Extraocular muscle signs (0: absent;
u >2mm eyelid retraction Decrease in eye movements in any Eyelid edema: 0-2
a: limitation in extreme gaze; b: evident
r Moderate or severe soft direction of >5° in 1-3 months Conjunctival injection: 0-2
o tissue involvement Decrease in visual acuity (>1 lines on Eyelid injection: 0-1 restrictions; c: fixation of globe)
p >3mm exophthalmos Snellen chart using pinhole) in 1-3
e Inconstant or constant months Strabismus Class 5: Corneal involvement (0: absent; a:
a diplopia Score stippling; b: ulceration; c: clouding, necrosis,
n Strabismus: 0-3 perforation)
Sight-threatening Restrictions: 0-2
G Dysthyroid optic Class 6: Sight loss (0: absent; a: vision 0.63-
r neuropathy Appearance 0.5; b: vision 0.4-0.1; c: vision >0.1, no light
o Corneal breakdown Score perception)
u Mild
p
Moderate
Severe
o
f
G
Gra
CAS = Clinical Activity Score
78
UVEITIS
CLASSIFICATION
ANATOMICAL AETIOLOGY
Type 1 site Involvement Group Subgroup
Anterior AC Iritis Infectious Bacterial

Uveitis Iridocyclitis Viral
Fungal
Intermediate Vitreous Pars planitis Parasitic
Uveitis Posterior cyclitis Others
Posterior Retina/Choroid Choroiditis Non- Known systemic association
Uveitis Chorioreinitis infectious Not known systemic association
Retinochoroiditis Masquerade Neoplastic
Neuroretinitis Non-neoplastic
Panuveitis AC, Vitreous
and Retina, or
Choroid
PATHOLOGICAL COURSE OF DISEASE

Granulomatous Non- Acute Sudden onset, limited duration
granulomatous
Recurrent Repeated episodes, inactive
Nutton-fat KPs Fine KPs periods =/> 3 months of
Dense PS Filiform PS treatment
Iris nodule No or few iris Chronic Persistent, relapse in <3 months

(Koeppe/Busacca nodules (Koeppe) of treatment
)
Insidious onset, Acute onset,

chronic course short duration
79
ANTERIOR UVEITIS
Symptoms:
Acute:- Pain, redness, photophobia, tearing, decreased vision
Chronic:- Decreased vision (cataract, CMO, ERM), floaters, Hx of exacerbations / remissions
Systemic:- Joint pain, facial rashes, oral ulcer, genital ulcer, prolonged cough, sexual promiscuity, LOA,LOW
Signs:
Circumlimbal injections, AC flare/cells, PS, KPs (especially inferior), anterior vitreous cells (spill-over)
Keratic Precipitates:-
Fine/Stellate (covers whole endothelium):
e.g. HSV, HZV, CMV, Fuchs heterochromia iridocyclitis (FHIC)
Small nongranulomatous:
e.g. HLA-B27-associated, trauma, masquerade syndromes, JIA, Possner-Schlossman syndrome (PSS) etc.
Granulomatous / Mutton-fat:
e.g. Sarcoisosis, TB, syphilis, sympathetic ophthalmia, VKH syndrome etc.
Other signs:
Low IOP (ciliary body shutdown)
High IOP (herpetic, lens-induced, FHIC, PSS)
Hypopyon (HLA-B27, Behcet [shifting], endophthalmitis)
Iris nodules (sarcoidosis, TB, syphilis)
Iris atrophy (sectoral herpetic, diffuse FHIC)
Band Keratopathy (JIA, chronic uveitis)
Baseline Investigations
For severe or recurrent AAU:-
FBC, ESR, VDRL, CXR, Mantoux test
(1st episode of mild to moderate AAU no need investigation)
Investigate other possible causes accordingly
Management
Frequent potent topical steroid (Dexamethasone 0.1% or Prednisolone acetate 1%)
Mydriatic agents (cyclopentolate 1%, Tropicamide 1% etc)
Subconjunctival mydriacaine if PS
Treat the underlying cause if any
80
INTERMEDIATE UVEITIS
Symptoms:
Floaters, decreased vision, minimal photophobia, minimal external inflammation, often bilateral
Signs:
Ant. Vitreous cells, vitritis or snowballs (cellular aggregates floating predominantly at inferior vitreous)
Snowbanking (white exudative material over inferior ora serrata and pars plana- s/w BIO with indentation)
Peripheral vascular sheathing, mild AC reaction, PS in uncommon
Look for complications: CMO, cataract, secondary glaucoma, ERM, exudative RD, retinal neovascularization.
Differential Diagnosis:
Pars planitis (idiopathic, >70%), sarcoidosis, Multiple sclerosis, Syphilis, Toxocariasis
Others: IBD, Bartonella, Whipple syndrome, primary Sjogren syndrome, Lymphoma etc.
Investigations:
FBC, ESR, VDRL, CXR, Mantoux test
Additional: Serum ACE (adult), Serum lysozyme (children)
OCT macula (CMO)
FFA /ICG
MRI brain +/- orbit with gadolinium (TRO demyelinating disease)
Management
Topical:
if significant AC activity steroids, mydriatic agents
Topical antiglaucoma for secondary glaucoma or steroid-induced high IOP
Periocular (orbital floor/ subtenon): corticosteroid (triamcinolone 40mg or methylprednisolone)
Intravitreal: corticosteroid (eg Ozurdex [0.7mg dexamethasone])
Systemic:
Oral Prednisolone 1mg/kg/day, IV pulsed methylprednisolone 500-1000mg daily for 3 days
Other immunosuppressives: methotrexate, azathioprine, ciclosporin, mycophenolate (cellcept)
Biologics / anti-TNF (C/I in multiple sclerosis): Infliximab, Rituximab, Adalimumab
Surgery:
Cataract surgery
Glaucoma surgery: failed medical therapy
Vitrectomy: vitreous opacities, VMT, ERM, RD
Treat the underlying infection if any
*Periocular/intravitreal/systemic therapy is required if CMO or visually disabling floaters

**Pericoular/intravitreal for very asymmetric or unilateral or if unable to tolerate systemic corticosteroids
Co-manage with neurological team if suspicious of demyelinating disease
81
POSTERIOR UVEITIS / PANUVEITIS
Symptoms:
Floaters, Blurred vision
(Pain, redness, photophobia usually absent unless AC inflammation present)
Signs:
Cells in posterior vitreous, vitreous haze, retinal or choroidal inflammatory lesions (retinitis, choroiditis), retinal
vasculitis (sheathing and exudates around vessels)
Anterior and intermediate uveitis (indicative of panuveitis), retinal neovascularisation, CMO, ERM, CNV
Differential Diagnosis:
Posterior uveitis:
Retinitis:-
Focal: Idiopathic, Toxoplasma, Cysticercosis, Masquerade
Multifocal: Idiopathic, Syphilis, HSV, VZV, CMV, Sarcoidosis, Masquerade, Candidiasis, Bartonella
(neuroretinitis, macula star)
Choroiditis:-
Focal: Idiopathic, Toxocariasis, TB, Masquerade
Multifocal: Idiopathic, POHS, SO, VKH, Sarcoidosis, Serpiginous, Masquerade, Birdshot, MEWDS
Panuveitis:
Investigations:
Baseline:-
FBC, ESR, VDRL, RF, CXR, Mantoux test
Others:
FFA: denotes activity of choroiditis/retinitis, neovascularization, Capillary fallout areas, vasculitis,
CMO, CNV
ICGA: For deeper choroidal lesion such as white dot syndrome
OCT: CMO, ERM, CNV membrane
B scan: for hazy fundus view
Additional (as necessary):-
Toxoplasma (IgG/IgM/PCR), Serum ACE level, VDRL, ANA, CMV (IgG/IgM/PCR), HSV & HZV (viral
culture/PCR)
Management
Posterior uveitis: Systemic corticosteroids
Panuveitis: Topical and systemic corticosteroids, mydriatic agents
*Treat the underlying infection if present

In cases of infective uveitis, systemic corticosteroid need to be initiated at least 48-72 hours after starting of specific anti-
infective therapy and stopped at least 1 week prior to stoppage of specific treatment
82
Clinical Care Pathways for
Clinicians
83
CLINICAL CARE PATHWAY FOR CATARACT SURGERY
(PRE-OPERATIVE ASSESSMENT)
Name:
NRP: Date: ______________
Ocular diagnosis:
Medical History
Cataract Surgery
Date of first eye surgery: ________
Intra-
Past Ocular Surgery (Eye

to be operated)
Cause of Cataract Secondary

If primary: If secondary:
Congenital
Ocular Comorbidity (Eye

to be operated) Anterior Segment Posterior Segment
-Proliferative diabetic retinopathy
city
ype)
Lens Related Complication
Miscellaneous Others:
-existing non glaucoma field defect

(eg. CVA)
Systemic Comorbidity
Allergies
84
Ocular Examination
Right eye Left eye
Vision Unaided
With pinhole
Refracted
Refraction
(State if not applicable)
Diagram
Anterior segment:
Lens:
RAPD
Lids
Conjunctiva
Cornea
Anterior Depth
chamber shallow shallow
Activity
Iris
Pupil
mm
IOP (mmHg)
Lens status ar
85
Diagram
Fundus:
Vitreous
Optic Disc CDR: CDR:
Macula mal
Retina
B scan finding (state if N/A)
Physical Examination Investigation Results Medications

BP: _____________ FBC: WBC: __________ Topical:
PR: _____________ Hb: __________
CVS: _____________ Plt: __________
Lung: _____________ RP: Urea: __________
Abdomen _____________ Na: __________
Able to lie K: __________ Systemic:
flat: Creat: __________
Spine/neck FBS: __________
problem: RBS: __________
Others: HbA1c: __________
ECG __________
Input from CXR: __________
cardio: Others:
Biometry Plan
Eye to be operated
Technique Eye Refer to:
Surgery Clinic:
For:
Axial length: _________________
Keratometry K1: _________________
K2: _________________
Cornea astig: _________________ Anaesthesia ECG
ACD: _________________ Date of
operation
Date of
IOL power with target refraction:
admission
TCA:
- Primary: Admission
- 3-piece: Withhold
- ACIOL: medication:
Payment / sponsor: -pay Form
(BDU / implant
etc)
86
CLINICAL PATHWAY FOR UNCOMPLICATED CATARACT SURGERY
(POST OP ASSESSMENT)
Name:
NRP:
Operation:
Date of Operation:
Day of operation 1 week post-op 4-6 weeks post-op
Date: Date: Date:
Consultation
&
assessment
________________________________
-hourly vital signs Cornea:
(on admission and upon OT

call)
Suture: Cor
-paying patients to pay at

UKM K-Health) Siedels:
Social welfare (approval AC depth: ______________

letter)
AC depth: ______________ AC activity: _____________
AC activity: _____________
IOP: ___________ mmHg

Activity -op review IOP: ___________ mmHg
Cornea: IOL: s:
Siedels: Fundus (If applicable):
Fundus (If applicable):
AC depth: ______________
AC activity: ______________
87
IOP: ___________ mmHg
Education
-op care
Medications -op drops to QID
Frequency:
______________until TCA
ox /
cravit
Frequency:
______________until TCA
maxitrol
Frequency:
______________until TCA
Discharge -op
plans refraction
88
CLINICAL CARE PATHWAY FOR DIABETIC MACULA OEDEMA (DMO)
Patient Details:
Name: MRN:
Age: Gender: M/ F
Assessment
History of Diabetes:
Diabetes Type 1 Duration:__________

Diabetes Type 2 Duration:__________
Medications:
Oral Agents Name:______________ Dose:__________ Frequency:__________
Name:______________ Dose:__________ Frequency:__________
Insulin Name:______________ Dose:__________ Frequency:__________

Latest HbA1c:________% Date:________
Complications:
Chronic Kidney Disease Stage:________
Cardiovascular Disease
Neuropathy
Other co-morbid:
Hypertension
Medication:
Hyperlipidaemia
Medication:
89
Ocular History Complaints:
Blurring of vision Duration:__________

Metamorphopsia Duration:__________
Others:__________
Ocular Examination Right Eye Left Eye
Visual Acuity (VA)
Relative afferent pupillary defect (RAPD)
Anterior Segment:
Conjunctiva
Cornea
Anterior chamber
Presence of Rubeosis Iridis
Intraocular Pressure
Fundus:
Clinically significant macular oedema Clinically significant macular oedema
Retinal thickening within 500 µm of the macular Optic disc Retinal thickening within 500 µm of the macular
centre. CDR centre.
Hard exudates within 500 µm of the macular centre Diabetic Retinopathy Hard exudates within 500 µm of the macular centre
with adjacent retinal thickening. Macula with adjacent retinal thickening.
One or more disc diameters of retinal thickening, part One or more disc diameters of retinal thickening, part
of which is within one disc diameter of the macular of which is within one disc diameter of the macular
centre. centre.
Investigations Retinal swelling Optical Coherent Tomography (OCT) Retinal swelling

Central Retinal Thickness (CRT):__um CRT:___um
Cystoid macular oedema (CMO) Cystoid macular oedema (CMO)
Subretinal fluid (SRF)
Subretinal fluid (SRF)
Follow Up & Treatment
90
Activities \ Visit Visit 1 Visit 2 Visit 3
Date:
RE LE RE LE RE LE
Visual Acuity
OCT: Retinal swelling Retinal swelling Retinal swelling Retinal swelling Retinal swelling Retinal swelling
CRT:___um CRT:___um CRT:___um CRT:___um CRT:___um CRT:___um
CMO CMO CMO CMO CMO CMO
SRF SRF SRF SRF SRF SRF
Treatment:
Laser: Grid laser Grid laser Grid laser Grid laser Grid laser Grid laser
Focal laser Focal laser Focal laser Focal laser Focal laser Focal laser
Eyedrop: Ketorolac (Acular) Ketorolac (Acular) Ketorolac (Acular) Ketorolac (Acular) Ketorolac (Acular) Ketorolac (Acular)
Nepafenac(Nevanac) Nepafenac(Nevanac) Nepafenac(Nevanac) Nepafenac(Nevanac) Nepafenac(Nevanac) Nepafenac(Nevanac)
91
Intravitreal Anti-VEGF Anti-VEGF Anti-VEGF Anti-VEGF Anti-VEGF Anti-VEGF
Injection:
Ranibizumab Ranibizumab Ranibizumab Ranibizumab Ranibizumab Ranibizumab
Aflibercept Aflibercept Aflibercept Aflibercept Aflibercept Aflibercept
Steroid Steroid Steroid Steroid Steroid Steroid
Dexamethasone Dexamethasone Dexamethasone Dexamethasone Dexamethasone Dexamethasone
(Ozurdex) (Ozurdex) (Ozurdex)

(Ozurdex) (Ozurdex) (Ozurdex)
Triamcinolone Triamcinolone Triamcinolone
Triamcinolone Triamcinolone Triamcinolone
Status: Improving Improving Improving Improving Improving Improving
Status quo Status quo Status quo Status quo Status quo Status quo
Worsening Worsening Worsening Worsening Worsening Worsening
Activities \ Visit Visit 4 Visit 5 Visit 6
Date:
RE LE RE LE RE LE
Visual Acuity
92
Treatment:
Intravitreal Injection: Anti-VEGF Anti-VEGF Anti-VEGF Anti-VEGF Anti-VEGF Anti-VEGF

Ranibizumab
Ranibizumab Ranibizumab Ranibizumab Ranibizumab Ranibizumab
Aflibercept
Aflibercept Aflibercept Aflibercept Aflibercept Aflibercept
Steroid
Steroid Steroid Steroid Steroid Steroid
Dexamethasone
Dexamethasone Dexamethasone Dexamethasone Dexamethasone Dexamethasone
(Ozurdex)
(Ozurdex) (Ozurdex) (Ozurdex) (Ozurdex) (Ozurdex)
Triamcinolone
Triamcinolone Triamcinolone Triamcinolone Triamcinolone Triamcinolone
93
Activities \ Visit Visit Visit Visit
Date:
RE LE RE LE RE LE
Visual Acuity
Treatment:
94
Intravitreal Injection: Anti-VEGF Anti-VEGF Anti-VEGF Anti-VEGF Anti-VEGF Anti-VEGF
Ranibizumab Ranibizumab Ranibizumab Ranibizumab Ranibizumab Ranibizumab
Aflibercept Aflibercept Aflibercept Aflibercept Aflibercept Aflibercept
Steroid Steroid Steroid Steroid Steroid Steroid
Dexamethasone Dexamethasone Dexamethasone Dexamethasone Dexamethasone Dexamethasone
(Ozurdex) (Ozurdex) (Ozurdex) (Ozurdex) (Ozurdex) (Ozurdex)
Triamcinolone Triamcinolone Triamcinolone Triamcinolone Triamcinolone Triamcinolone
95
CLINICAL CARE PATHWAY FOR POST-OP ENDOPHTHALMITIS
Patient particulars
Name : Age : Date :

IC number : Ethnicity :
RN : Gender :
Symptoms Risk Factors Signs
Ocular
Systemic
oedema
ids
________________
-going infection
Please specify ________________________
Surgery
is
Date __________
_____________ __ Date __________
tions
-C usage __________________
96
Investigations Done Treatment Diagnosis
Date :
Time : Date :
Colour : Time :
Date :
Time : Date : -op (Refer Table 1)
Time :
_______________ cin B 5 mcg/0.1mls -op (Refer Table 1)
Date :
Time :
_____________________
1) __________________________
2) __________________________
Please specify _______________
97
TABLE 1 FOR POST-OP ENDOPHTHALMITIS
Day 1 Day 2 Day 3 Day 4 Day 5

Symptoms
Improvement
Visual Acuity
Re-assessment RAPD
Parameters Hypopyon
Level (mm)
Vitritis/B-
scan
Improvement
oving
Status
Investigations _______________ _______________
_______________
antibiotics antibiotics antibiotics antibiotics antibiotics

Management
regime regime regime regime regime
Evisceration
Referral Refer medical
Day 6 Day 7 Visit 1 (D8 - D14) Visit 2 (3 - 6 weeks) Visit 3 (2 - 3 months)

Symptoms
Improvement
Visual Acuity
98
Re-assessment RAPD
Parameters
Hypopyon
Ievel
Vitritis/B-
scan
Improvement
Status
Investigations
antibiotics antibiotics
Management regime regime
Referral al
99
Clinical Care Pathway for Retinopathy of Prematurity
Name : _________________________
Details MRN : _________________________
DOB : _________________________
Sex : Male Female
Mo : ____________________
Reason for Birth weight <1500g

screening Gestational age <32 weeks
Infants with an unstable clinical course who are at high risk (determined
by neonatologist/paediatrician)
Other: _____________________________________________
Gestational age:
History ____________ weeks ______________ days
Birthweight:
____________ g
Number of Current Birth:

Single Twin Triplets
Other: ___________________
Antenatal History/Complications:
1._____________________________________
2._____________________________________
3._____________________________________
4._____________________________________
Mode of Delivery:
SVD Assisted LSCS
Other: ____________________
Postnatal Complications:
1._____________________________________
2._____________________________________
3._____________________________________
4._____________________________________
Ventilation Requirement:
IPPV Duration : __________ days __________ hours
CPAP Duration : __________ days __________ hours
Maximum Fi02 (%): __________ Maximum Pa02 (mmHg): _________
100
Examination Examined by:
Dr ________________________
Place of examination:
NICU
Eye clinic
Other: ______________________
Visit number:
1 4
2 5
3 Other: ______________
Chronological Age: (time elapsed after birth)

___________ weeks ____________ days
Postconception Age: (gestational age + chronological age)

____________ weeks ______________ days
Prior Treatment:
None Photocoagulation Cryotherapy
Other:______________
Eye Right Eye Left eye

Examination
Clear Cornea Clear
Hazy Hazy
Other: ______________ Other: ______________
Pupil
Inadequate dilation <6mm Inadequate dilation <6mm
Other: ______________ Other: ______________
Normal Optic Normal

Other: ______________ disc/ Other: ______________
Macula
No ROP Fundus No ROP
ROP present ROP present
Uncertain Uncertain
Other: ______________ Other: ______________
R L
101
ROP staging Right Eye Left Eye
Stage 1 Stage 1
Stage 2 Stage 2
Stage 3 Stage 3
Stage 4 : 4A 4B Stage 4 : 4A 4B
Stage 5 5A 5B Stage 5 5A 5B
Zone I Zone I
Zone II Zone II
Zone III Zone III
Extent: _____________ clock hour Extent: _____________ clock hour
Plus disease None None

Venous dilatation at post pole Venous dilatation at post pole
Arteriolar tortuosity at post pole Arteriolar tortuosity at post pole
Dilated iris vessels Dilated iris vessels
Poor pupil dilatation Poor pupil dilatation
Vitreous haze Vitreous haze
Other: ___________________ Other: ___________________
Comments on ocular examination:
Diagnosis Right Eye Left Eye

No ROP No ROP
Immature retina Immature retina
Mature retina Mature retina
ROP: ROP:
Stage 1, Zone 1 2 3 Stage 1, Zone 1 2 3
Prethreshold Prethreshold
Threshold ROP Threshold ROP
Cicatricial ROP Cicatricial ROP
Other: Other: ___________________________-
_____________________________ __
Management Follow up review:

( Date: ________________ )
1 week
2 week
3 week
Other: ___________________
Cycloplegic refraction appointment

Discharge
102
Treatment:
Cryotherapy Photocoagulation
Surgery: Scleral buckle Vitrectomy Lens aspiration
Other: __________________
103
REFERENCES
General
1. Aniza I, Saperi S, Syed Mohamed A. Carta Alir Klinikal Penjagaan Kesihatan dan Kawalan Kos Rawatan. Penerbit UKM
Press 2015.
Acute angle closure

1. Denniston A & Murray P (Eds.). Oxford Handbook of Ophthalmology. 2014. OUP Oxford.
2. Cioffi GA (2014). 2014-2015 Basic and Clinical Science Course, Section 10: Glaucoma.
3. Malaysian Health Technology Assessment Section Ministry of Health Malaysia. June 2017. Management of
Glaucoma (2nd Ed). MOH/P/PAK/346.17 (GU)
4. European Glaucoma Society. Terminology and Guidelines for Glaucoma. 2014. Dogma.
Blunt Trauma
1. Oxford Handbook of Ophthalmology, 3rd Edition. 2014. Oxford University Press.

2. Kanski J J & Bowling B. Clinical ophthalmology: a systematic approach. 2016. 8th Ed. Elsevier Health Sciences.
3. AAO Orbit, Eyelids, and Lacrimal System Book 7 BCSC Edition 2014-2015
CRVO
1. Clinical Care Pathways, Tan Tock Seng Hospital Singapore, 2007 (unpublished)
2. The Central Vein Occlusion Study. Baseline and early natural history report. Arch Ophthalmol 1993;
111:1087-95
3. The Central Vein Occlusion Study. Natural history and clinical management of Central Retinal Vein Occlusion.
Arch Ophthalmol 1997; 115: 486-491
4. The Central Vein Occlusion Study Group N report. A randomized clinical trial of early PRP for ischemic
Central Vein Occlusion. Ophthalmology 1995 Vol 102; 10: 1434-1444
5. Wong TY. The Ophthalmology Examinations Review. 2nd Edition. World Scientific. New Jersey.
Chemical Injury
1. Oxford Handbook of Ophthalmology. Ocular Trauma; Chemical Injury, 3rd Edition. 2014. Oxford University
Press.
2. AAO External Diseases and Cornea, Book 8 BCSC Edition 2014-2015.
3. Kanski JJ & Bowling B. (2016). Clinical ophthalmology: a systematic approach. Elsevier Health Sciences.
Corneal ulcer
1. Denniston, A., & Murray, P. (Eds.). (2014). Oxford handbook of ophthalmology. OUP Oxford.
2. Pharmaceutical Services Division Ministry of Health Malaysia. 2014. National Antibiotic Guidelines.
4. Cho YW, et al. Efficacy of systemic vitamin C supplementation in reducing corneal opacity resulting from
infectious keratitis. 2014. Medicine 93.23
104
5. Guidelines for Management of Fungal Keratitis. Birmingham and Midland Eye Centre / Ophthalmology, NHS
Trust, 2011.
6. Müller GG, Kara-José N, Castro RS. Antifungals in eye infections: drugs and routes of administration. Revista
Brasileira de Oftalmologia. 2013 Apr;72(2):132-41.
7. White ML and Chodosh J. Herpes simplex virus keratitis: a treatment guideline. 2014. The American Academy
of Ophthalmology Clinical Guidelines
8. https://www.aao.org/focalpointssnippetdetail.aspx?id=356f0d13-8853-410f-ac6b-7ff5e0257800.
Diabetic Macula Oedema
1. DME Steering Committee of Ministry of Health Malaysia. Management of Diabetic Macula Edema. Sept
2015.
2. CPG Secretariate Ministry of Health Malaysia. June 2011. Screening of Diabetic Retinopathy.
MOH/P/PAK/216.11 (GU)
Endophthalmitis
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4. Babar TF, Hussain M, Zaman M. Clinical Indications for Evisceration and Orbital Implant Trends. Pak J
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2. Denniston AKO, Murray PI. Oxford Handbook of Ophthalmology. 3rd edition. Oxford Medical Publications.
2014. 422-450.
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uveitis. Indian Journal of Ophthalmology. 2010;58(1):29-43. doi:10.4103/0301-4738.58470.
ACKNOWLEDGEMENTS
Dr Shelina Oli Mohamed, MD, MSc.Oph (UKM)

Medical Retina and Uveitis Services, Hospital Shah Alam
Our hardworking Research Assistants, Dr Nurfarahin Md Nasir (MD), Dr Natijah Syuhada Zubir (MD) and Dr Intan Hafizah
Hamzah (MD)
Pn Analiza Abu Bakar, Pn Juliana Sarman & Cik. Norlin Abd Rani from Quality Department, HCTM
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REPORT OF THE UKM CLINICAL PATHWAYS

AND ALGORITHMS FOR OPHTHALMOLOGY

HOSPITAL CANSELOR TUANKU MUHRIZ, UKMMC

Please direct all enquiries regarding this report to:

UKMMC, Quality Department

Contact Number : 03 - 91455072 / 5052

First printing 2018

Second printing 2019

Clinicians Workshop 2018

Acute Angle Closure 12

AAC Management Flow Chart 13

o Contraindications for mannitol

Age Related Macular Degeneration (AMD)

Central Retinal Vein Occlusion 24

Anti VEGF Therapy Guidelines 56

Acute Post-Op Endophthalmitis (Algorithm 2) 58

Chronic Post-Op Endophthalmitis (Algorithm 3) 59

Endogenous Endophthalmitis (Algorithm 4) 60

Anterior Chamber Tap 61

Vitreous Chamber Tap 61

Intravitreal Antibiotic Injection 62

Preparation of Intravitreal Antibiotic 62

Classification of POAG/Ocular Hypertension (OHT)/ POAG Suspect

Thyroid Eye Disease 76

CCP for Cataract Surgery (Pre-Operative Assessment) 84

CCP for Uncomplicated Cataract Surgery (Post-Op Assessment) 87

CCP for DMO 89

CCP for Post-Op Endophthalmitis 96

CCP for ROP 100

Acute Angle Closure AAC

Acute Angle Closure Glaucoma AACG

Age related macular degeneration AMD

Argon Laser Peripheral Iridoplasty ALPI

Branch Retinal Vein Occlusion BRVO

Central Retinal Vein Occlusion CRVO

Choroidal Neovascularisation CNV

Clinical Care Pathways CCP

Diabetic Macular Oedema DMO

Fundus Fluorescein Angiography FFA

Indocyanine Green Angiography ICGA

Polypoidal Choroidal Vascularisation PCV

Primary Open Angle Glaucoma POAG

Proliferative Diabetic Retinopathy PDR

Retinal Angiomatous Proliferation RAP

Retinopathy of Prematurity ROP

Rhegmatogenous Retinal Detachment RRD

Verteporphyin Photodynamic Therapy vPDT

Vascular endothelial growth factor VEGF

(Note: Detailed abbreviations follow the Algorithms)

Editor: Professor Dr Mae-Lynn Catherine Bastion1

Assistant Editor: Dr Ainal Adlin Naffi1

Chief Registrar for Clinics: Dr Oh Kah Lay2

Secretary: Dr Tan Wen Hsia2

1. Dr Aimy Mastura Zurairah Yusof2

3. Dr Christina Ng Wei Khee2

4. Dr Lam Chen Shen2

6. Dr Mohd Najmi Khairudin2

7. Dr Raja Farahiyah Raja Othman2

8. Dr Siuw Chin Pei2

Associate Professor Dr Jemaima Che Hamzah1

Associate Professor Dr Norshamsiah Md Din1

Associate Professor Dr Aniza Ismail3,4

Dr Aida Zairani Zahidin1