Common eye conditions
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Transcript of Common eye conditions
Dr. Chamath FernandoMBBS (Sri Jayewardenepura)
LecturerDepartment of Family Medicine
FMSUSJP
Common Symptoms Blurring of vision Redness Pain Loss of vision Photophobia Discharge
Refractive Errors Disorders of the lids Conjunctivitis Corneal disorders Episcleristis / Scleritis Sub Conjunctival Haemorrhages Dry eye syndrome Cataracts Glaucoma Uveitis Disorders of the retina Loss of vision Amarausis Fugax Temporal arteritis Hypertensive changes in the retina Diabetic eye disease Strabismus
Eye Condition Treatment (spectacles, contact lenses or excimer laser)
Emmetropia Normal refraction of the cornea and lens
Myopia Short sightedness Corrective– Concave lenses
Hypermetropia Long sightedness Convex lenses
Presbyopia The ability of the lens to change the convexity is lost after the fourth decade of life – causing difficulties with near vision
Bifocals
Astigmatism The eye is not the same curvature of radius for refraction. (e.g. myopic in one plane and emmetropic in the other)
Cylindrical lenses corrected according to the axis
Bifocals
Conditions TreatmentEntropion Inward rolling of the lid
marginsRubbing of the eye lashes against the globeIrritationMimics conjunctivitis
Surgical Correction
Ectropion The eyelid margins are not apposed to the globe Lacrimal puncta cannot drain tearsCauses a watery eye
Surgical treatment
Dacrocystitis Inflammation of the lacrimal sacPresents as a painful lump by the side of the nose
Broad spectrum antibioticsOphthalmologist referral for surgical treatment
Blepharitis Inflammation of the eyelid marginStye- Inflammation of the eyelashes and lash folliclesChalazion -Inflammation and blockage of the Meibomian glands
Lid toilet Topical antibiotics – Chloramphenicol or Fusidic acidIf orbital cellulitis – Broad spectrum antibioticsIf residual lump – Incision and curettage
Commonest cause of Red eye Causes: Viral, Bacterial, Chlamydial, Allergic Clinical features:
◦ Redness◦ Soreness (sandy gritty sensation)◦ Discharge◦ Vision not impaired◦ Usually bilateral involvement
Aetiology Discharge
Preauricular node
Corneal Involvement
Comment Treatment
Bacterial (5%)(Gonococcus - copiousH. InfluenzaeS. PneumoniaeStaphylococcusMoraxella)
Mucopurulent
-ve except gonococci
+ve Gonococcus
Rapid onsetGonococcal infection in the neonate – symptoms occur within 2 days of birth
Gonococcal – Conjunctival swab shows diplococciTreated with Oral and Topical PenicillinChloramphenicol
ViralAdenovirusHSV 1 commonly Molluscum Contagiosum
Watery +ve +ve Adenovirus
50% UnilateralCold and / or sorethroatAss. With chemosis, lid oedemaMay cause blurring of vision due to corneal involvementAdenoviral – Very contagiousDendritic corneal ulcer
HSV – Vesicles around the eye
Molluscum – umbilicated lesions on eyelids
Adenoviral – Self limitingLubricantsCold compressPrevent cross infectionIf intense – may require steroidsHSV – Self limitingSome may use Aciclovir topicallyMolluscum- Ophthalmologist referral for surgical treatment If severe - Steroids
Aetiology Discharge Preauricular node
Corneal Involvement
Comment Treatment
Chlamydial(Chlamydia trachomatis)
Watery + ve +ve GU dischargeSlow onset of symptomsSexually transmitted (in active individuals)Neonatal – with maternal reproductive tract secretions (2 weeks)Trachoma –blindness
Topical erythromycin bdAdolescents and adults to GU surgeonNeonates to paediatrician to exclude associated pneumonitis or otitis
AllergicSeasonalPerinnial
Stringy/ sticky -ve +ve Itchy Avoidence of allergensTopical anti-histamines like azelastineTopical mast cell stabilizer like Na ChromoglicateSteroids avoided generally
1. Trauma 2. Keratitis
Condition Features TreatmentCorneal Abrasions – a focal area of the epithelium gets rubbed away
Intense painInability to open the eye (blepharospasm)LacrimationVisual acuity reducedEx: may require topical anaesthetic (Tetracaine)Use Florescin (orange) dye with a blue lamp examination to identify the abrasion (in green colour)
G. Chloramphenicol qds X 5 daysPad the eye X 24 hours
Corneal Foreign bodye.g. flies
LacrimationPhotophobia
Remove gently with copious amounts of salineTopical antibiotics(Choramphenicol and Fusidic acid)
Direct Trauma FB may be visibleFlat anterior chamberHyphaemia (Blood in anterior chamber) SCHBrusing if associated blunt trauma
Instill no dropsRefer to an ophthalmologist urgently
Corneal inflammation Causes: HSV infection, Contact lens,
blepharitis Cilnical features: Redness, Pain, Lacrimation,
Sensation of a foreign body, photophobia
HSV- Dendritic ulcer◦ The Virus remains dorment in the CN V◦ Gets activated in immunosuppression◦ Can lead to a geographical ulcer
Contact Lens Keratitis ◦ Can be life threatening◦ Urgent referral to an ophthalmologist
Blepharitis◦ Staphelococcus aureus is responbible for most of
the cases◦ Rx: with Chloramphenicol
Episcleritis (between the conjunctiva and the sclera)
Localized, deep redness Tender area +/- Not painful No discharge Normal vision No photophobia Normal pupils and cornea Rx: topical/oral steroids
Scleritis Symptoms are intense Painful loss of vision Severe form associated with Rheumatoid arthritis causes
Scleromalacia perforans Urgent referral
Symptoms – A bright red eye due to a bleed beneath the conjunctiva caused by rupture of a small blood vessel
Causes – ◦ Raised intracranial pressure (Coughing, sneezing)◦ Trauma◦ Violent rubbing◦ Bleeding disorders or anticoagulants (recurrent)◦ Hypertension
Management◦ Control of the cause◦ Mild analgesics◦ Eye lubricants◦ Reassurance of resolution within weeks◦ Make sure the line doesn't extend beyond the visible sclera
(may be associated with orbital fracture)
Loss of vision?
SymptomsSevere PainPhotophobiaReduced visionColoured halos around the point of light in patient’s visionProptosisSmaller pupilOn Examination Raised IOP Shallow anterior chamber depth Corneal Epithelial disruption
Cause Conjunctiva Injection
Unilateral/Bilateral
Pain Photophobia
Vision Pupil Intraocular pressure
Conjunctivitis
Diffuse Bilateral (in Bacterial)
Gritty Occasionally with Adenovirus
Normal Normal Normal
Anterior Uveitis
Circum-corneal
Unilateral
Painful Yes Reduced Constricted
Normal or raised
Acute Glaucoma
Diffuse Unilateral
Severe Mild Reduced Mild dilated
Raised
Associated with Keratoconjunctivitis Sicca / Sjogren’s syndrome
Clinical Features: ◦ FB sensation/ gritty feeling in the eye◦ Mucoid discharge◦ Photophobia◦ Blurred vision
Management◦ Artificial tears◦ Eye lubricants◦ Moisture chambers glasses at night◦ Secretogogues e.g rebamipide ◦ Punctal plugs◦ Ophthalmologist referral
Moisture chamber
Commonest cause of reversible blindness The commenest surgical procedure so far
Aetiology◦ Senile (legal blindness <6/12)◦ Congenital – Maternal infection, Familial◦ Metabolic – Diabetes, galactosaemia, Wilson’s
disease, hypocalcaemia◦ Drug induced – Corticosteroids, amiodarone◦ Traumatic◦ Inflammatory – Uveitis◦ Disease associated – Down’s, Dystrophia myotonica
Clinical features –◦ Gradual painless deterioration of vision is the
commonest symptom◦ Problems with night vision◦ Glare – Common with posterior subcapsular cataract
Investigations◦ Diabetes◦ Hypocalcaemia
Management◦ Early detection and ophthalmologist referral is
essential in the infants to prevent development of amblyopia later on in life
◦ Correction of the aetiological factor◦ Mild cases – spectacles◦ If opacified – Extraction of cataracts and intra ocular
lens insertion Most popular – Phacoemulsification
Elevation of the internal pressure of the eye >21mmHg◦ (Normal : 10-21mmHg)
Second commonest cause of blindness – via optic nerve damage◦ Mainly visual field defects
Primary open angle Glaucoma
Acute angle closure glaucoma
Commonest Ophthalmic emergency – Acute rise of pressure >50mmHg
Aetiology Due to blockage of the trabecular meshwork, drainage of aqueous humor is impeded
Pushing of the lens anteriorly pressing against the meshworkCommonly when the pupil is maxiamaly dilated
Risk factors
ElderlyBlack raceFamily historyMyopia
Elderly – Shallow anterior chambers in Women and Hypermetropics
Clinical features
Gradual painless loss of peripheral visual field
Red painful eyeHeadacheNausea, VomitingEye is injected, hard and tenderHaziness of cornea
Diagnosis Ophthalmoscopy – Cupping of the fundusIOP measurement is the definitive
IOP measurement or clinically
Treatment Reduction of AH production – Topical Timolol and Acetozolamide (Topical and Oral)Increasing the drainage of AH - Prostaglandin analogues (Travoprost)
Emergency referral to an ophthalmologistAnalgesicAntiemetics
(IV AcetozolamidePilocarpine to constrict pupilsProstaglandin analogues, Beta blockersIV Mannitol if resistantSurgical – Hole in the peripheral iris
Uveal Tract – ◦ Iris – Iritis/ Anterior Uveitis◦ Cilliary body – Intermediate Uveitis ◦ Choroid – Posterior uveitis◦ Entirely – Pan uveitis
Symptoms ◦ Blurred vision◦ Redness◦ Photophobia◦ Pain – Mainly anterior symptom◦ Floaters – Mainly posterior symptom
Associated diseases◦ Ankylosing spondilitis◦ Arthritis◦ Inflammatory Bowel disease◦ Sarcoidosis◦ TB◦ Syphilis◦ Toxoplasmosis◦ Behcets syndrome◦ Lymphoma◦ Viruses – CMV, HSV, HIV◦ Idiopathic
Classical Triad◦ Redness (genaralized)◦ Pain◦ Photophobia
Signs◦ Cells with keratic precipitates in the anterior chamber, pus◦ IOP may be raised due to the cells clogging up the There
may be posterior synechiae◦ trabecular meshwork
Treatment◦ Ophthalmologist referral◦ Dexamethasone 0.1% topically◦ Cyclopentolone to prevent posterior synechiae also
allowing fundoscopy◦ Mx of raised IOP
Central Retinal Vein Occlusion
Central Retinal Artery Occlusion
Retinal detachment
Age related macular degeneration
Symptoms Sudden profound painless loss of vision of one eye
Sudden profound painless loss of vision of one eye
Painless progressive visual field lossFloaters and flashes prior to detachment
Progressive loss of central vision
Pathogenesis Obstruction of venous outflow and increased intravascular pressure leading to dilated veins, retinal haemorrhages, retinal oedema and cotton wool spots
Results in infarction of the inner 2/3 of the retina90 minutesOedema of the retina thinningCherry red spot
The area of visual field loss corresponds to the area of detachment of the retina
Lipofucin deposits can be seen deposited under the retina
Risk Factors DM, HT, Cardiovascular disease, Glaucoma, Vasculitis and Blood dyscrasias
DM, HT, Cardiovascular disease, Glaucoma, Vasculitis and Blood dyscrasias
ElderlySmokingHTHypercholesteraemiaUV exposure are suggested
Treatment Rx underlying conditionRefer to ophthalmologist
Emergency referralOcular massageBreathing into a bag CO2 VasodilatationDislodging of Emboli
Iv AcetazolamideParacentesis
Urgent referral to the ophthalmologist
Referral to the ophthalmologistModification of risk factors
Sudden Transient Loss of Vision in one eye. Due to thromboembolism Embolus may be visible at ophthalmoscopy
during an attack
Implications:◦ May be the first evidence of internal carotid artery
stenosis◦ Hamiparesis may follow
◦ DD: Migraine, GCA
Common in elderly Presentation: Sudden painless loss of unilateral
vision (May have preceded by Amaurosis fugax)◦ May proceed to bilateral disease
Associations: ◦ Severe unilateral temporal headache (along the
distribution of the artery with features of inflammation). The artery is thickened and pulseless
◦ Severe facial pain in chewing◦ IHD, microangiopathic neuropathy
Management◦ Ix: ESR elevated◦ Diagnosis confimed by : Bx◦ Rx: High dose steroids
Painless PainfulCataract Acute angle closure glaucomaOpen angle glaucoma Giant cell arteritisRetinal detachment Optic neuritisCentral retinal vein occlusion UveitisCentral retinal artery occlusion ScleritisDiabetic retinopathy KeratitisVitreous Haemorrhage ShinglesAge related macular degeneration Orbital cellulitisOptic nerve compression TraumaCerebrovascular disease
Keith Wagener Classification of Hypertensive Retinopathy◦ Grade 1 – Tortuosity of the retinal arteries with
increased reflectiveness “Silver wiring”◦ Grade 2- Grade 1+ “Arteriovenous nipping”
◦ Grade 3 – Grade 2 + Flame shaped haemorrhages and Cotton wool spots
◦ Grade 4 - Grade 3 + Papilloedema (blurring of the optic disc margin
The significance of Grade 3 and 4?◦ Malignant Hypertension
Diabetic retinopathy – A microvascular complication
Cataract External Ocular palsies Sixth and third cranial nerve palsies
◦ CN III palsies recover within a period of 3-6 months
Progression of the disease is rapid in type 1 >type 2 diabetics
TypesI. Background retinopathyII. Preproliferative and proliferative retinopathyIII. MaculopathyIV. Mixed retinopathy
◦ Dot haemorrhages - Microaneurysms◦ Blot hamemorrhages - Intra retinal haemorrhages◦ Cotton wool spots – Micro infarcts (lasts longer
than those due to HT)
Retinal ischaemia Neovascularization fibrous tissue forming around the new vessels
Exudates around the macula within one optic disc’s width
Many features mentioned above present together
Rx:◦ Aggressive control of glycaemia◦ Ophthalmologist referral (surgical procedures e.g
laser photocoagulation)
Mal alignment of the two eyes/ visual axi Cause : Poor coordination of the extra ocular
muscles groups Due to: e.g. CP, syndromes like Noonan, stroke,
botulism, diabetes Implications:
◦ Cosmesis◦ Diplopia◦ Amblyopia (Lazy eye)
Tests: Corneal light reflex, Cover-uncover test (read) Treatment:
◦ Spectacles◦ Cover the better eye to improve the amblyopic eye◦ Ophthalmologist (Muscle surgery)
Kumar and Clark – Clinical Medicine Medscape
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