None-urgent eye problems David Kinshuck, associate specialist David Kinshuck, Good Hope Hospital,
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Transcript of None-urgent eye problems David Kinshuck, associate specialist David Kinshuck, Good Hope Hospital,
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None-urgent eye problems
David Kinshuck, associate specialistDavid Kinshuck, Good Hope Hospital,
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None-urgent eye problems …working in pairs, (1 minute) write down
• Common conditions
• Rarer & serious conditions
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Draw an eye and name the parts…working in pairs, (30 s) :
• parts
• Parts relevant to conditions
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www.websightmd.com
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www.websightmd.com
Aqueous flow
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Chronic eye conditions
AdultscataractsArmd...age-related macular degenerationGlaucomaDiabetic retinopathyOthers (retinal vein occlusion, inherited retina, corneal etc)
childrenSquintsWatery eyeCataractsGlaucomararer
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Cataracts
Symptoms
How to examine
Operation
refraction
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Cataracts symptoms, in pairs
• ?
• ?
• ?
• ?
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Cataracts symptoms
Glare
Misty vision
Blurred vision
Cannot see distances/faces
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Cataracts...symptoms....blurred
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Cataracts...symptoms....glare
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Examining for cataract…red reflex
Looking through ophthalmoscope, check red reflex from 10 cm, focusing on iris rim
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‘white’ reflex
www.occhioallaretina.it/Immagini/leucocoria.JPG
http://oftalmologo.bravepages.com/Leucocoria%201.jpg
?retinoblastoma
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Cataracts...operation
Linkhttp://www.goodhopeeyeclinic.org.uk/eyecataractpatient.html
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Cataracts...refraction...in pairs, which is myopia etc
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Cataracts...refraction
–Emmetropia..no dist. specs
–Hypermetropia, small eyes
–Myopia
–High myopia
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Presbyopia...need reading spectacles, >45y
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Retina
–Diabetic retinopathy–Retinal vein occlusion–Armd...age-related macular
degeneration–Others
• retinal vein occlusion• inherited retina (eg retinal pigmentosa)
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Diabetic retinopathy, in pairs, 45 seconds
• What are the disease processes• What one chemical in particular mediates
these processes (and we can block its effect)• What does laser dohttp://medweb.bham.ac.uk/easdec/dmret.htmlhttp://medweb.bham.ac.uk/easdec/mechanismanimation.htm
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Diabetic retinopathy
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Diabetic retinopathy• dot and blot
• ischaemic areas• VEGF
• leakage • new vessels
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Diabetic retinopathy• dot and blot
• ischaemic areas• VEGF
• leakage • new vessels
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Diabetic retinopathy
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Diabetic retinopathy
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Diabetic retinopathy http://reference.medscape.com/features/slideshow/retina
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Diabetic retinopathy, in pairs, how do you prevent, 30s
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Diabetic retinopathy, in pairs, how do you prevent, 30s
• Prevent diabetes…exercise, weight, low glycaemic index foods
• Screen for diabetes…everyone >40y, high risk if lower (lifestyle/family etc),
• HbA1c >6.5% = diabetes• HbA1c 6.0-6.5% = pre-diabetes• Control diabetes
HbA1c <6.5-75, BP <130/80, statin, ARB• Screen diabetic patients for retinopathy• etc
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Diabetic retinopathy
• HbA1c• Blood pressure• Smoking• Lipids• Duration of ‘high’ HbA1c
similar for BP/smoking/lipids
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Retinal vein occlusion
7 highs
• cigarettes• Cholesterol• Blood pressure• Glucose• Viscosity
– Myeloma– White cells
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Macula..in pairs, 1 minute
• What do you know about armd• Symptoms• Types• etc
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Macular
Central visual changes suggest macula disease: Eye casualty same week
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Central vision
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OCT optical coherence tomogram … wet ARMD
http://www.goodhopeeyeclinic.org.uk/images/lucentis.html
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Dry, ‘geographic atrophy’
Areas of atrophy enlarge over a couple of years, seriously reducing central vision
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Glaucoma, in pairs, explain with diagram, 1 min
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Glaucoma, mechanism
• Aqueous produced in ciliary body (carbonic anhydrase enzyme)
• Flows into >anterior chamber, >through trabecular >meshwork, >canal of schlemm, >episcleral veins
• > otherwise pressure
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Glaucoma, loss of visual field
• Visual loss over years• 2/3 chronic glaucoma has
a high pressure…pressure is detected by whom
• A patient• B optometrist
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Glaucoma, loss of visual field
• Visual loss over years• 2/3 chronic glaucoma has
a high pressure…pressure is detected by whom
• A patient• B optometrist
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Glaucoma, in pairs, which normal eye, 30s
http://www.goodhopeeyeclinic.org.uk/glaucomacase3.htm
A B
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Glaucoma, in pairs, which normal eye, 30s
http://www.goodhopeeyeclinic.org.uk/glaucomacase3.htm
1. Vessels deviated nasally
2. Pale central area with cribriform pits
3. thin rim4. Other minor changes
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Glaucoma, lowering pressure
• Laser trabecular meshwork• Drops
–Prostaglandin inhibitors–Carbonic anhydrase inhibitor –Betablockers
• tablets–Carbonic anhydrase inhibitor
• surgery
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Glaucoma, quiz
• Patient detects glaucoma Y N
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Glaucoma, quiz
• Are there symptoms early Y N
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Glaucoma, quiz
• Examining the eye–Cupped disc Y N
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Glaucoma, quiz
• Examining the eye–Raised pressure 66% Y N
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Glaucoma, quiz
–Examine angle at onset Y N
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Glaucoma, quiz
–Visual field Y N
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Glaucoma, other types
–Yearly checks stable Y N
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Glaucoma, quiz
• Patient detects glaucoma N• Are there symptoms early N• Examining the eye
–Cupped disc Y–Raised pressure 66% Y–Examine angle at onset Y–Visual field Y–Yearly checks Y
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Glaucoma, other types
• Low tension• Narrow angle http://www.goodhopeeyeclinic.org.uk/pi.html
• Genetic– Many conditions–congenital baby
• Secondary surgery/trauma/steroids
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Glaucoma,
–Congenital (www.nature.com/eye)
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Loss of sight over weeks/days/hours
• Retinal detachment, with flashes/floaters
• Ischaemic optic neuropathy (older patients)(%GCA with GCA symptoms)
• With pain on movement & reduced colour (red) vision: optic neuritis (younger patients)
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Retinal detachment1. Vitreous gel liquifies (floaters)
2. May pull retina if attached (flashes)
3. Causes a hole
4. Fluid enters hole
5. Retina peels off (more floaters, vision affected)
6. Dilate pupil, with careful look usually obvious, refer same day
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Eye & major trauma
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Visual acuity
TNCEN
OTNCLOXEWTYURNG
TYURNG
TYURNG
6/606/36
6/246/186/126/9
6/6
6/5
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Visual fields
paper
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paper
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Some helpful eye examination ‘pearls’
• Pressing on the eye will detect high pressure (acute glaucoma)
• Won’t detect slightly high pressure chronic glaucoma
• DILATE PUPILS to examine the eye if risk of detachment...cannot exclude detachment otherwise
• Optometrists can check for chronic disease
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Children, chronic disease
• Rare– Cataracts– Glaucoma– Lots
• Common – watery eyes– (lacrimal sac abscess/mucocoel)– Squints – Allergic eye disease
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Children, chronic disease---watery eyes
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Children, squint
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Children, squint
• Convergent
• Divergent
• vertical
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Children, squint, issues
• Amblyopia– important to know this, as may spend lots of
time looking for the cause of poor sight– Initially amblyopia need patching
• Squint surgery• Binocular vision• amblyopia without squint may be
refractive, cataract, etc
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Children, cover test
• http://www.youtube.com/watch?v=yyIA-dl49Lg
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3rd nerve palsy
In pairs...what is this?
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3rd nerve palsy
3rd nerve palsy
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Other chronic eye diseases
• TED...thyroid eye disease• Lid entropian/ectropian• Trichiasis• Eyelid tumours• Watery eyes..epiphora• Blocked naso-lacrimal duct• Diplopia/squint• Dry eyes• Corneal diseases• Optic atrophy, alcohol, smoking, B12• genetic• Orbital/optic nerve tumours
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3rd nerve palsy
In pairs...what is this?
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3rd nerve palsy
www.patient.co.uk..thyroid eye disease
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3rd nerve palsy
www.patient.co.uk..thyroid eye disease
Auto-immune +thyroid damage >> TRH receptors on muscles and fat in orbit Low TSH and smoking increase TRH receptors >> fat muscles swell >> exophthalmos + optic nerve compression
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3rd nerve palsy
In pairs...what is this?
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3rd nerve palsy
In pairs...what is this? nhs.uk
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3rd nerve palsy
In pairs...what is this? cosmeticsurg.com
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Dry eye
• link• Mild forms very
common, not serious, troublesome
• Very dry, and dry mouth, ?Sjogrens
• Very severe dry extremely uncommon: corneal melts and perforates..severe autoimmune disease
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Corneal disease
• Lots of uncommon corneal diseases• In poor countries, trachoma >> corneal
scarring• http://www.goodhopeeyeclinic.org.uk/fuchs
.html• Dry eye
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trachoma
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Dry eyes
http://www.goodhopeeyeclinic.org.uk/dryeye.html
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Dry eyes
http://www.dryeye.org/images/colorbar.jpg
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Fuchs corneal dystrophy etc
• http://www.goodhopeeyeclinic.org.uk/fuchs.html
• Keratoconus
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Optic atrophy
• Low B12• Secondary to retinal artery occlusion or ION• Tobacco alcohol amblyopia (vitamin B
deficiency)
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Retinal dystrophy
• http://geneticpeople.com/?tag=retinitis-pigmentosa
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Summary, go round the room 1. .2. .3. .4. .5. .6. .7. .8. .9. .10. .11. .12. .13. .14. .15. .16. .17. .