Geriatric Ophthalmology

Dr Arvind ChouhanProf. & Head

Deptt Of Ophthalmology

‘Senior citizen’ or ‘Elderly’ as a person who is of age 60 years or above.

Geriatrics or Geriatric Medicine:◦ specialty that focuses on health care of elderly

people◦ aims to promote health by preventing and treating

diseases and disabilities in older adults

The elderly population (aged 60 years or above) account for 7.4% of total population in 2001.

Geriatrics…..

About 64 per thousand elderly persons in rural areas and 55 per thousand in urban areas suffer from one or more disabilities.

Most common-loco motor disability 3% hearing disability 1.5%

Blindness (1.7% in rural areas, and 1% in urban areas)

Health Problems in Old persons

Loss of transparency of Optical Media like : Cornea-Ulcer / Scar / Opacity / Degeneration

/Dystrophy/ Dry EYE Lens- Cataract / Dislocation/ Subluxation Vitreous-Degeneration/Haemorrhage Retinal Layers-DR / ARMD / HTN Loss of Normal Architecture- DR /

Glaucoma / ARMD High Refractive Errors-Myopia /Hyperopia Presbiopia

Visual Impairment is due any of the following causes:

common in the elderly population The m/c causes:

◦ Age-related Cataract 52%◦ ARMD NonExudative -25% Exudative -5% ◦ Glaucoma 2-10%◦ Diabetic Retinopathy.

incidence rates increase with increasing age.

Visual impairment <6/18-6/60 Severe visual Impairment <6/60-3/60 WHO Blind <3/60-1/60

Visual impairment

Other than Blindness Presbyopia Ocular Surface Diseases: Blepharitis Enteropion /Ectropion Pterygium Dry Eye Corneal Ulcer or Keratiits Corneal Degeneration Corneal Dystrophy

Ophthalmological Problems in Elderly

With age, visual impairment and blinding disorders occur with increasing frequency.

Poor visual function affects other quality-of-life parameters:◦ Disability, ◦ Falls and fractures, ◦ Activities of daily living (ADLs) ◦ Independence, ◦ Use of community support services, ◦ Sense of well-being◦ Depression and ◦ Mortality

Nuclear Cortical Christmas tree Subcapsular Anterior & Posterior

Classification of Age-related Cataract According to Morphology

Cataract….

Nuclear Cortical

Posterior SubCapsular

Anterior SubCapsular

Cataract….

Snow Flakes (Diabetic)

Christmas Tree

Due to PenetratingTrauma

Due toBluntTrauma

Drugs Causing Cataract Steroid-induced

cataracts Phenothiazine Antipsychotics Busulfan Amiodarone Chlorpromazine

Secondary cataract

uveitic Anterior plaque opacities

Extensive posterior synechiae and anterior lens opacity

Classification according to maturity

Immature Mature

Hypermature Morgagnian

Nuclear Cataract…

Cataracta nigra Cataracta brunescens

Dark nucleus floating in liquefied, “milky” cortex has settled inferiorly

For Visual improvement-M/C Medical indications :

Surgery for Cataract..When & Why

I. Lenticular opacification (cataract)

IV. Lens-induced inflammation

II. Lenticular malposition A. Phacotoxic uveitis (phacoanaphylaxis) A. Subluxation B. Phacolytic glaucoma B. Dislocation C. Phacomorphic glaucoma III. Lenticular malformation V. Lenticular tumor A. Coloboma A. Epithelioma B. Lenticonus B. Epitheliocarcinoma C. Lentiglobus VI. Facilitatory (surgical access) D. Spherophakia A. Vitreous base,Ciliary Body,Ora Serrata

History & Attention of Medical Conditions: Diabetes mellitus, HTN, Actual or suspected myocardial infarction (MI) in the

past 6 Months, Angina, Rheumatic fever, transplanted or Prosthetic Heart Valve, previous

Endocarditis , Jaundice in the past, HIV infection, Epilepsy

Preop. Assesment .to.Lens Extaction

Pupillary responses. Visual acuity & Cuurent Refractive Status Ocular adnexa. Cornea & Previous Refractive Surgeries Anterior chamber. Lens. Fundus examination if possible other wise B-

Scan. Cover test. A heterotropia may indicate

amblyopia,

Preop. Assesment .to.Lens Extaction…

Net corneal power (K) Axial length (AL) IOL power (IOLP)

IOL Power calculation…

Peribulbar block:-Xylocaine 2%& Bupivacaine-outside Musclecone Topical anaesthesia:- drops or gel-Xylocaine 4% or Proparacaine, tetracaine 1% drops, GA if Pt. Mentally ill or Epileptic or Sensitive to LA drugsclass

Anaesthesia..

Small incision Cataract Surgery..

Diseases affecting the cornea second only to cataract in overall importance.

Infection and Trauma , that cause corneal Ulcer Or Scarring,

leading causes in many developing countries

Corneal ……

Keratiits

Degenerative Keratoconus Iridocorneal Endothelial (ICE) syndrome Inherited Corneal stromal dystophies Fuch’s endothelial dystrophy Doctor-caused (iatrogenic) Bullous keratopathy (sometimes)

Gel Drop Dys Keratoconus

Actions to restore function or reduce existing disability from disease complications ie.

Corneal transplantation or Optical keratoplasty Diseased cornea is replaced by Healthy

Donor Cornea to restore the Transparency.

Managemment of corneal blindness...

Penetrating keratoplasty (Optical)

Age-related maculopathy (ARM) drusen and RPE changes as early features Dry (non-exudative) AMD most common form, 90% of diagnosed disease; geographic atrophy (GA)-

Age-related macular degeneration (AMD)

Hard Drusen

Soft Drusen

less common, more rapid progression- advanced sight loss. CNV) and Pigment epithelial detachment (PED). Dry form can develop into the wet.

Wet (exudative) AMD

Wet AMD is associated with CNV Abnormal growth of a blood vessel complex through Bruch membrane from the choriocapillaris. Localized hypoxia and the accumulation of metabolic products.

Choroidal neovascularization

potentially progressive characteristic Optic neuropathy associated with Visual field loss as damage

progresses, and Intraocular pressure is usually a key

modifying factor.

The distribution of IOP- a range of 11–21 mmHg.

Glaucoma….

Optic Cup:Optic Disc

Normal Disc & Cup Large Cup

Congenital (developmental) or Acquired

Subclassification: Open-Angle Angle-Closure

Primary and Secondary Glaucoma Ocular Non-Ocular

Classification..

Angle-closure glaucoma…

Relative PupillaryBlock

anterior Iris bowing;

Iridocorneal contact

The distribution of IOP- a range of 11–21 mmHg.

some patients glaucomatous damage occurs with IOPs less than 21 mmHg (Normal Tension or Normal-Pressure Glaucoma)

Some unaffected with IOPs up to 30 mmHg (Ocular Hypertension).

IOP..

IOP measurement -Shiontz tonometry,Goldmann Appalanation tonometry,Non-Contact Tonometry

Primetry - Visual field defect Optical coherence tomography (OCT) Glaucoma Hemifield test Short-wave automated perimetry (SWAP)-Blue

stimulus & Yellow Background Frequency-doubling contrast test Ultrasound Biomicroscopy Anterior Segment OCT Pachymetry for CCT

Diagnosis of Glaucoma..

Target Pressure -30% reduction

Although there is no ‘safe’level,

Progression is uncommon if the IOP is<16 mmHg.

Each 1 mmHg reduction in IOP leads to a 10% reduction in the rate of nerve fibre loss.

Management Aim…

Medical Topical Anti-glaucoma Systemic Anti-glaucoma Surgical Trabeculectomy-M/C surgical procedure Shunt operation-Ahmed valve Argon laser trabeculoplasty (ALT) or

Selective laser trabeculoplasty (SLT) Argon or Nd:YAG laser- trabeculum to enhance aqueous outflow

Management..

Progressive dysfunction of the Retinal vasculature caused by chronic Hyperglycemia resulting in structural damage to the neural retina.

Associated features: Vitreous hemorrhage Retinal Detachment Neovascular Glaucoma Early onset Cataract Cranial nerve palsies

Diabetic Retinopathy

Nonproliferative retinopathy

Microanuerysms & Hard Exudates

Blot hemorrhages, splinterhemorrhages, cotton-wool spots.

Severe Nonproliferative retinopathy.

Cotton-wool spots,Intraretinal microvascular abnormalities, Venous beading.

Fluorescein angiography shows severe capillary non-perfusion.

Although the Macular edema, Exudates, and capillary occlusions seen in NPDR often cause legal blindness, affected patients usually maintain at least ambulatory vision.

PDR-may result in Severe Vitreous hemorrhage or Retinal Detachment, with hand movements vision or worse.

Approximately 50% of patients with very severe NPDR progress to PDR within one year.

Proliferative Diabetic Retinopathy

Neovascularization of the disc with some fibrous proliferation.

Neovascularization elsewhere.

Antiplatelet therapy Antiangiogenesis agents Pegaptanib sodium Ranibizumab Bevacizumab Aflibercept Corticosteroids Panretinal Photocoagulation PRP Peripheral Retinal Cryotherapy Focal laser for Macular edema Vitrectomy

Mangement..

Photocoagulation..

Grid Pattern of focal macular Photocoagulation

Neovascularization of theDisc and initial, incomplete Panretinal photocoagulation.

Thank you