CENTRAL COAST DAY HOSPITAL OPTOMETRIST CONFERENCE - 26 FEBRUARY 2012 Anterior Segment - Common...
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Transcript of CENTRAL COAST DAY HOSPITAL OPTOMETRIST CONFERENCE - 26 FEBRUARY 2012 Anterior Segment - Common...
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CENTRAL COAST DAY HOSPITAL OPTOMETRIST CONFERENCE - 26 FEBRUARY 2012
Anterior Segment - Common Clinical Presentations in Optometry
DR VIVEK CHOWDHURY
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Fuchs endothelial dystrophy
Eventually bullous keratopathy - EPI
Later central stromal oedema - STROMA
Gradual increase in cornea guttata with peripheral spread
Progression
Pseudophakic Bullous Keratopathy
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Fuchs endothelial dystrophy
Pseudophakic Bullous Keratopathy
SYMPTOMS:Acuity. Haloes/Glare.Diurnal Variation.Discomfort/Pain
SIGNSGuttae and Endothelial Opacity.Stromal OedemaEpithelial Oedema/Erosions.Corneal Thickness/Pachymetry
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Fuchs endothelial dystrophy
Pseudophakic Bullous Keratopathy
1. In Patients with Corneal Endothelial Decompensation, all of the following may indicate progression of the disease except:a. Increased Corneal Thickness.b. Epithelial Defectsc. Deteriorating Visual Acuityd. Symptoms Worse in the Afternoon
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ANTERIOR CHAMBER IOLS
Primary Cataract Surgery – Problems with Capsular Bag/Zonular Support – PXF Patients/Hx Trauma.
Secondary IOL - Aphakic Patient
Problems Related to:ACIOL ItselfComplications of the Primary Surgery
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ANTERIOR CHAMBER IOLS
Look out For:
Cornea: Corneal Endothelial Decompensation/Bullous Keratopathy. Corneal Wounds.AC: Inflammation/Uveitis, AC Vitreous, Hyphaema.Iris: Irregular Pupil, Iris Tuck, Angle Closure, PI.Angle: Trauma from Haptics, Glaucoma.Capsule: Residual Capsule in Pupillary Axis, Lens MaterialRetina: CME, Breaks, Detachment, Lens remnants
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2. In a patient with an anterior chamber intraocular lens – It is usually important to check for all of the following except:
a. Raised Intraocular Pressureb. Corneal Decompensation.c. Uveitis.d. Iris Naevus
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TRAUMA
1. Eyelid
2. Orbital blow-out fractures• Floor• Medial wall
• Haematoma• Margin laceration• Canalicular laceration
3. Globe Injuries• Anterior segment• Posterior segment
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Anterior segment complications of blunt trauma
Sphincter tear
Cataract Angle recession
Hyphaema
Lens subluxation
Iridodialysis Vossius ring
Rupture of globe
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Macular hole Optic neuropathyEquatorial tears
Posterior segment complications of blunt trauma
Choroidal rupture and haemorrhageCommotio retinae Avulsion of vitreous base
and retinal dialysis
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Complications of penetrating trauma
Flat anterior chamber
Vitreous haemorrhage
Damage to lens and iris
EndophthalmitisTractional retinal detachment
Uveal prolapse
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3. In a patient with a past history of blunt trauma to the eye - which of the following is incorrect:a.A deep AC means there is a low risk of glaucomab.cataract may be associated with zonule laxity/phacodonesisc.there is an increased risk of retinal breaksd.the patient may have a dilated pupil
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Adenoviral - Signs of keratitis
Treatment
• Focal, epithelial keratitis • Focal, subepithelial keratitis • May persist for months
- topical steroids if visual acuity diminished by subepithelial keratitis
• Transient
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Progression of vernal conjunctivitis Diffuse papillary hypertrophy, most marked on superior tarsus
Formation of cobblestone papillae Rupture of septae - giant papillae
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Limbal vernal
Trantas dotsMucoid nodule
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Progression of vernal keratopathy
Punctate epitheliopathy Epithelial macroerosions
Plaque formation (shield ulcer) Subepithelial scarring
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Progression of ocular cicatricial pemphigoid
Diffuse hyperaemia
Subepithelial fibrosis and shrinkage
Symblepharon
Pseudomembrane formation
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Naevus
• 30% are almost non-pigmented
• Most frequently juxtalimbal• Sharply demarcated and slightly elevated
• Presents in first two decades
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Lipodermoid
• Presents in adulthood• Soft, movable, subconjunctival mass• Most frequently at outer canthus
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Intraepithelial neoplasia(carcinoma in situ)
• Juxtalimbal fleshy avascular mass
• May become vascular and extend onto cornea
• Presents in late adulthood
• Malignant transformation is uncommon
Signs Progression
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Primary acquired melanosis (PAM)
• PAM without atypia is benign• PAM with atypia is pre-malignant • Unilateral, irregular areas of flat,
brown pigmentation• May involve any part of conjunctiva
• Presents in late adulthood
Signs Types
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Conjunctival melanoma
From PAM with atypia
• Sudden appearance of nodules in PAM
From naevus
• Sudden increase in size or pigmentation
Primary
• Solitary nodule• Frequently juxtalimbal but may be anywhere
• Very rare• Most common type
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Squamous cell carcinoma
• Rarely metastasizes
• Arises from intraepithelial neoplasia or de novo
• Frequently juxtalimbal
• Slow-growing
• Presents in late adulthood• May spread extensively
Signs Progression
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Marginal keratitis
Subepithelial infiltrate separated by clear zone
Circumferential spread Bridging vascularization followed by resolution
• Hypersensitivity reaction to Staph. exotoxins• May be associated with Staph. blepharitis• Unilateral, transient but recurrent
Progression
Treatment - short course of topical steroids
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Phlyctenulosis
• Small pinkish-white nodule near limbus• Usually transient and resolves spontaneously
• Starts astride limbus• Resolves spontaneously or extends onto cornea
• Uncommon, unilateral - typically affects children• Severe photophobia, lacrimation and blepharospasm
Conjunctival phlycten
Treatment - topical steroids
Corneal phlycten
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Herpes simplex epithelial keratitis
• Dendritic ulcer with terminal bulbs
• Stains with fluorescein• May enlarge to become geographic
• Aciclovir 3% ointment x 5 daily
• Debridement if non-compliant
Treatment
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Herpes simplex disciform keratitis
• Central epithelial and stromal oedema
• Folds in Descemet membrane
• Small keratic precipitates
- topical steroids with antiviral cover
• Occasionally surrounded by Wessely ring
Treatment
Signs Associations
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Herpes zoster keratitis
• Develops in about 50% within 2 days of rash• Small, fine, dendritic or stellate epithelial lesions• Tapered ends without bulbs• Resolves within a few days
• Develops in about 30% within 10 days of rash• Multiple, fine, granular deposits just beneath Bowman membrane• Halo of stromal haze
Nummular keratitisAcute epithelial keratitis
• May become chronic
Treatment - topical steroids, if appropriate
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4. A patient is complaining of blurry vision after cataract surgery, but the visual acuity is 6/6 unaided, It is important to check all of the following except.
a. The tear film.b. The posterior capsule and IOL
position.c. The macula.d. The eyebrows.
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Simple episcleritis• Common, benign, self-limiting but frequently recurrent• Typically affects young adults
Treatment
• Seldom associated with a systemic disorder
Simple sectorial episcleritis Simple diffuse episcleritis
• Topical steroids
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Nodular episcleritis• Less common than simple episcleritis• May take longer to resolve• Treatment - similar to simple episcleritis
Localized nodule which can be moved over scleraDeep scleral part of slit-beam not displaced
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Grading of severity of chemical injuries
• Clear cornea
Grade I (excellent prognosis)
• Limbal ischaemia - nil
• Cornea hazy but visible iris details
Grade II (good prognosis)
• Limbal ischaemia < 1/3
• No iris details
Grade III (guarded prognosis)
• Limbal ischaemia - 1/3 to 1/2
• Opaque cornea
Grade IV (very poor prognosis)
• Limbal ischaemia > 1/2
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Medical Treatment of Severe Injuries
1. Copious irrigation ( 15-30 min ) - to restore normal pH
2. Topical steroids ( first 7-10 days ) - to reduce inflammation
3. Topical and systemic ascorbic acid - to enhance collagen production
4. Topical citric acid - to inhibit neutrophil activity
5. Topical and systemic tetracycline - to inhibit collagenase and neutrophil activity
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5. My patient with blepharitis is back again asking me to look for the sand that’s in his eye, I am going to do all the following except:
A. Change to a preservative free artificial tear supplement and/or a more viscous artificial tear supplement, and/or a thick artificial tear gel just before sleep.
B. Prescribe Chloramphenicol ointment to the lid margins.
C. Trial Steroid ointment to the lid margins, and/or a short, tapering course of a mild topical steroid.
D. Get my receptionist to tell them that I’ve gone on holiday.
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THE END