The Eyes

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Group of diseases a/w vision loss, optic nerve, +/- intraocular pressure

GLAUCOMA
 Classification Clinical diagnosis
• Open vs Closed • Initially peripheral loss
• Primary open angle glaucoma (visual field)
• Ocular hypertension • Visual acuity affected late disease
• Low tension glaucoma
• Secondary glaucoma
• Chronic closed angle closure
glaucoma
 Disease monitoring Treatment
• IOP • Medical
- Topical
• Optic disc appearance - Beta blocker
- Alpha agonists
• Visual fields - PG analogues,
(Humphrey visual fields) - Carbonic anhydrase inhibitors

• Surgical (trabeculectomy)

• Laser treatment
Overproduction of aqueous humour + lack of drainage

ACUTE CLOSED ANGLE GLAUCOMA

Pathophysiology
• Overproduction of aqueous humour + lack of drainage
• Produced in ciliary body and drains into canal of sneel
• Iris dilates  becomes thicker  obstructs drainage
• Increase pressure in anterior chamber
• Cup/disk ratio increases(N 0.3): damage to optic n.
 Risk Factors Presentation:
• Elderly • Extremely painful
• Female • Sudden Onset
• Small eyes • Headache
• Loss of vision
• Vomiting
• Walking into dark room
precipitates pain (due pupillary
dilation)
 Diagnosis Treatments:
• Red eye • Emergency Referral
(dilated conjunctival vessels at • Constrict pupil: IV acetazolamide
corneal edge) • IV Mannitol: osmotic diuretic
• Hard on palpation • PG analogues: stop production
• Hazy, cloudy cornea • Topical beta-blocker: close pupil
• Fixed midpoint pupil • Pilocarpine: ↑ Ach to open canal
• Tonometry • Steroid drops
• Cup:Disc >0.3 • Cut a hole into iris: LASER
IRIDOTOMY
1o Open Angle Glaucoma
Risk Factors: Diagnosis
• Increasing age • Intraocular pressure
• African more severe Goldmann tonometry
• Family history • Visual field appearance
• Myopia Humphrey visual field test
• Diabetes • Optic disc appearance
Cupping
• Raised IOP
• Visual acuity
• Pupil reactions
RAPD
• Gonioscopy
Slit lamp: open vs closed
Chronic Glaucoma
Facts Treatment:
• Usually asymptomatic • PG analogue (travoprost)

• Diagnosed by screening • Topical beta-blockers (timolol)

• Confirmation via tonometry • Topical carbonic anhydrase

↑ intraocular pressure inhibitors (dorzolamide)

• Pilpcarpine
Lens become opacificied, usually bilateral (unilateral in trauma)

CATARACTS- ADULTS
 Causes: Presentation
• Age • Blurred vision
• Diabetes
• Uveitis • Colors seem to fade
• Steroid use
• Trauma • Glare
• Radiation At night- difficulty driving
• Poor nutrition
• Wilson’s (sunflower cataract) • Poor night vision
• High intensity light
• No pain / red (uveitis)
 Diagnosis Management
• ↓ visual acuity • Refraction: to improve vision

• Develop over many months • Surgery:

• Early cataracts
Opthalmoscope + sit-lamp exam
• Difficult visualization of optic disk
- Phacoemulsification of lens
- Outpatient clinic
- 10-20 minutes
- Topical / Intraocular anaesthesia
- -ive: infection, bleed

N.B nuclear most common: starts centrally (nucleus),

expands to periphery
Nuclear sclerosis: emulsification
CATARACTS- CHILDREN
 Causes Diagnosis / Complication
• Inherited • Don’t see red reflex
• Autosomal Dominant • Ambylopia (lazy eye)
• Birth trauma
• Maternal infection
(rubella, toxoplasmosis)
• Metabolic disease
(galactosaemia)
LEUKOCORIA
Facts
• White red reflex

• Causes
- Cataract
- Retinoblastoma
- Toxocariasis
- Retionpathy of prematurity
- Corneal opacity
RETINOBLASTOMA
Facts
• Malignant embryonal retinal tumour
• RB gene mutation
• 13q14 in 40%

• Presentation
- Usually <2yr
- Squint
- Leukocoria
Affects keratin of cornea

KERATITIS
 Presentation
• Onset 1-2 dys
• Red, swollen, painful eye
• Photophobia
• Reduced vision
Diagnosis / Treatment
• Fluorescein stain
- Binds areas: no epithelium
- Dendritic pattern
- Corneal opacity

• Trauma: remove all  regrow

Risk Factors: - Topical idoxuridine
- Contact lens - Foscarnet: if resistant
- Trauma
- Herpes simplex • Emergency referral:
- Microbiology confirmation
If mistaken for uveitis  put steroids  herpes grow fast blindness

HERPES SIMPLEX KERATITIS

• Presentation
- Pain + swollen
- Watering
- Photophobia
- Reduced vision
- Previous episodes

• Diagnosis
- Fluorescein staining

• Management
- Urgent REFERRAL
- Ontiment acyclovir 3% 5/dy for 2-3 wks
INFECTIVE KERATITIS
• Diagnosis
- Corneal scrape for C&S
- HSV PCR

• Management
- Bacterial
- Intensive board spectrum drops
- Ofloxacin
- Vancomycin + ceftazidime
Peripheral corneal ulcer

MARGINAL KERATITIS
 Presentation Management
• Onset over days • Stains with fluorescein
• Redness in adjacent • Responds well to
conjunctiva • Steroid/antibiotic drop
• Gritty eye, FB sensation • Refer

Red eye & FB sensation

- Trichiasis
- Corneal FB
- Blepharitis
- Marginal keratitis
CONJUNCTIVITIS
Viral- adenovirus
Presentation
• Bilateral • Conjunctival follicles
• Red eyes (a/w chlamydia)
• Watery discharge
• +/- pain • Easily transmissible
• Itch
• Lid swelling • Normal vision
• Preauricular adenopathy
• No photophobia
Bacterial- staph. aureus
Presentation Management
• Staph. aureus • Topical antibiotics
• Unilateral • Chronic: blepharoconjunctivitis
• Purulent, thick discharge • Risk of orbital cellulitis
• Conjunctival papillae (IV antibiotics to prevent)
• Not itchy
• No adenopathy

Poorly transmissible
Normal vision: normal pupils
Allergic
Presentation
• Itch • Conjunctival papillae
• Watery discharge • Subtarsal cobblestones
• a/w atopy appearance
• Lid swelling
• Periocular eczematous skin
• Chronic
Chemical
Risk Factors / Presentation Management
• Itraogenic: glaucoma drops • Chloramphenicol drops QDS for 1-
• Acids / alkalis 2wk

• Irritation
• No pain
• Diffuse conjunctival odema
• Conjunctival hyperaemia
• Always involves lid + eye
• Allergic:
- add olapatadine BD
- mild topical steroids
Summary
UVEITIS
• Autoimmune disease
• Photophobia
• Slit lamp examination
• Topical steroids
ACUTE IRITIS
 Causes
• HLA B27
• Ankylosying spondylitis
• Reiter
• Reactive arthritis
• Inflammatory bowel
• Psoriatic arthritis
• Idiopathic
Presentation
• Increasing pain (1-3dys)
• Photophobia
• Blurring later
• Previous episodes
 Previous episodes Management
• Constricted pupil • Urgent referral
• Circumcorneal redness
• Intensive topical steroids

• Mydriatic drop
(cyclopentolate)
DIABETIC RETINOPATHY
 Pathogenesis Risk Factors
• Microvascular + Macrovascular • Hyperglycaemia
• Pericyte loss • Hypertension
• Endothelial cell damage • Hyperlipidaemia
• Hallmarks: occlusion & leakage • Smoking
• Pregnancy
• Renal failure
Classification
Background Pre-proliferative
• Microaneurysms • Extensive ischemia
• Dot haemorrhages • Deep retinal hemorrhage
• Hard exudates • Venous changes- beading &
looping
• Cotton wool spots- nerve fiber
layer infarcts
• Intra-retinal microvascular
abnormalities (IRMA)
Classification
Proliferative
• New vessels
disc NVD; elsewhere NVE)
• Vitreous haemorrhage
• Vitreous traction
(tractional retinal detachment)
+/- Maculopathy
• main cause of sight loss
• macular odema
• macular ischaemia
severely damaging; ineffective tx
Classification
Presentation Management
• Early • Optismise RF control
- Asymptomatic
• Stop smoking

• Late
• Laser photocoagulation
- Reduced VA
- Macula: ↓ leakage + oedema
- Macular odema - Peripheral retina: ↓neovascular drive
- Vitreous haemorrhage
- Tractional retinal detachment • Intravitreal anti-VEGF therapy
• Vitrectomy
SEVERE DIABETIC DISEASE
• Rubeotic glaucoma
- Severe
- Refractory glaucoma
- High intraocular pressure

• Persistent vitreous haemorrhage

- Requires vitrectomy

• Tractional retinal detachment

- Vitrectomy if macula threatened
LASER TREATMENT
Facts
• Retinal pigment epithelium absorbs high energy
• Thermal burn
• RPE pump reduces odema
• Closure of leaking vessels
• Destroys ISCHAEMIC RETINA
• Decreases angiogenic growth factors
Classification

Focal Panretinal photocoagulation

• Central field defects • Loss of peripheral field
• Burn spread • Impaired night vision
• Inadvertent foveal burn • Implications for driving license
• Pain during procedure
ABRASIONS
• Trauma (contacts)
• Feels like sand in eye
• Fluorescein stain
• No specific therapy
• Patch not clearly beneficial (contraindicated if
had contacts)
EPISCLERITIS
 What / Presentation Management
• Localized, diffuse redness • Oral steroids
• Palpebral conjunctiva spared • If no response  refer
• Spontaneously resolves

• Mild discomfort
• Tenderness
Noninfectious lid margin inflammation (Chronic)

BLEPHARITIS
 Risk Factors / Presentation Treatment
• Seborrhea • Warm compresses
• Ecaema
• Lid scrubs
• Rosacea
• Chloramphenicol ointment BD
• Crusting along lid margins • Doxycycline 50-100mg OD x 3 mo
• Irritation
• Chronic redness • Artificial tears
(Facial/lid rosacea)
• Antibiotic ointment
(bacitracin if suprainfection)
Ingrowth of the eyelashes

TRICHIASIS
 Causes Management
• Idiopathic • Pull out
• Blepharitis (but regrow)
• Trachoma
• Cryotherapy

• Chloramphenicol
(x corneal damage)
leading cause of blindness + destroys macula

AGE RELATED MACULAR

DEGENERATION
 Pathology Risk Factors
• Retinal pigment epithelial cell loss • Age
• Caucasian
• Drusen • Smoking
deposits b/t RPE+photoreceptors • Diet

• Photoreceptor loss
Classification
Dry Wet
• slow progress • Fast Progression
• Drusen atrophy
• Bleeding under retina:
submacular haemorrhage

• Macular edema / exudate:

indicate choroidal neovascular
membrane
Classification
Wet Wet
• End-stage • Peripheral vision maintained
• Submacular fibrosis
Classification
Symptoms Diagnosis
• Blurring of central vision (central • Amsler grid
scotoma)
• Fluorescein angiography
• Distortion of vision • Leakage
• Hyperfluorescence
• Reading difficulties • OCT
• Difficulty
• 3D imaging
* recognizing faces • Retinal thickness
* drive a car • Fluid
* read, print
* sewing
Management
• Early
- Stop smoking
- Vitamins
anti-oxidant: C, E, zinc ; Macular pigments: lutein selenium

• Wet
- Intravitreal anti-VEGF therapy (loading 3mnths)
- Vitamin supplements

• Dry
- Low vision magnifying aids
- Social services
RED EYE
Differentials
• Conjunctivitis
• Subconjunctival haemorrhage
• Episcleritis
• Trauma (foreign body / corneal abrasion)
• Allergy
• Uveitis*
• Acute angle glaucoma*
• Corneal ulcers*
• Endophthalmitis*
• Scleritis*
• Penetrating injury*
• Chemical injury*
Painful with photophobia

• Normal vision:
- Iritis
- Bacterial / herpetic keratitis
- Scleritis
Summary
AMAUROSIS FUGAX
 RF / Etiology Presentation

• Middle aged • Fleeting vision loss

• Cardiovascular disease • Usually one eye
• Seconds to minutes
• Arterial embolism (TIA) • Painless
• Giant cell arteritis
 Diagnosis Management
• Cardiovascular examination • Aspirin 75mg
• Blood Pressure • Refer for medical
• ESR, CRP, FBC assessment
• Carotid ultrasound
RF <40yrs

OCULAR MIGRAINE
 Presentation Management
• Missing patches of vision • Lifestyle advice
• Hemianopic defects
• Scintillating colours • No work up
• Zig-Zag lines
• 20-30 minutes
• Reassure
• Followed by headache
(full resolution)
• Episodic
GIANT CELL ARTERITIS
 Facts / RF Presentation
• Vasculitis • Sudden permanent / Transient
• Small to medium arteries • Loss of vision in 1 eye
• Headache
• Age >60yrs • Jaw claudication
• Temporal tenderness
• Non-specific constitutional symp.
• Neck / Shoulder aches
 Diagnosis Investigations
• RAPD • ESR, CRP, FBC
• Pale swollen disc • Temporal artery biopsy
• Scalp tenderness
• Tender, nodular, non
pulsatile superficial
temporal artery
 Management Complications
• IV methylprednisolone • Ischaemic neuropathy
(swollen disc)
• Prednisolone
• 60-80mg
• Taper slowly to 5-10mg
(maintenance: 1-2yrs)

• Aspirin
NON-ARTERITIC ANTERIOR
ISCHAEMIC OPTIC NEUROPATHY
 RF / Presentation Diagnosis
• 45-65 yrs • Optic disc swelling
• Hypertension • Disc haemorrhages
• RAPD
• Sudden, painless • Altitude field loss
• Loss of vision • Normal ESR
• Mild to Moderate
RETINAL VEIN OCCLUSION
 Facts Risk Factors
• Central or branch of retinal vein • >50yrs
• Macular oedema + ischaemia • Diabetes
• Hypertension
• Atherosclerosis
• Glaucoma
 Presentation Management
• Sudden, painless • Retinal laser photocoagulation

• Hemorrhage in 4 quadrants • Intravitreal anti VEGF injection

• Haemorrhagic swollen optic disc • Ranibizumab

RETINAL ARTERY OCCLUSION
 RF / Presentation Diagnosis / Treatment
• Embolus • RAPD
• Giant cell arteritis • Pale posterior pole
• Cherry red macula
• Sudden, painless
• Unilateral vision loss • 100% Oxygen
• Ocular massage
• Acetazolamide
• Thrombolytics
VITREOUS HEMORRHAGE
• Risk Factors
- Diabetes (proliferative)

• Presentation
- Sudden, painless
- Unilateral vision loss
- Floaters

• Diagnosis
- Loss of red reflex
- No view of retina
OPTIC NEURITIS
 Risk Factors Presentation
• Young + middle aged • Sudden
• Idiopathic • Unilateral vision loss
• Viral • Pain, ache on eye
• Multiple sclerosis movement
 Diagnosis Management
• RAPD • Reassure

• Loss of colour vision

• Recovery over 3 months
• +/- swollen disc
(+: papillitis ; -: retrobulbar)

• MRI: demyelination