INTRODUCTION TO OPHTHALMOLOGY DR MAHMOOD FAUZI ASSIST PROF OPHTHALMOLOGY AL MAAREFA COLLEGE.
Introduction to Clinical Ophthalmology
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Transcript of Introduction to Clinical Ophthalmology
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Introduction to Introduction to Clinical Clinical
Ophthalmology Ophthalmology
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The Eye The Eye Examination Examination
Chapter 1Chapter 1
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AnatomyAnatomy
Extraocular Extraocular movements movements
MedialMedial LateralLateral Upward Upward DownwardDownward
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Visual Acuity Visual Acuity General physical examination should include :General physical examination should include :
Visual acuityVisual acuity Pupillary reactionPupillary reaction Extraocular movementExtraocular movement Direct ophthalmoscope Direct ophthalmoscope Dilated exam (in case of visual loss or retinal Dilated exam (in case of visual loss or retinal
pathology)pathology) Distance or NearDistance or Near Distance visual acuity at age 3Distance visual acuity at age 3
early detection of amblyopia early detection of amblyopia
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Distance Visual Acuity Distance Visual Acuity TestingTesting
VA - Visual acuity VA - Visual acuity OD - ocular dexterOD - ocular dexter OS - ocular sinisterOS - ocular sinister OU - oculus uterqueOU - oculus uterque
20/20 20/20
Distance between the patient and the eye chart Distance between the patient and the eye chart __________________________________________________________________________________________
Distance at which the letter can be read by a person with Distance at which the letter can be read by a person with normal acuity normal acuity
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Distance Visual Acuity Distance Visual Acuity TestingTesting
Place patient at 20 ft from Snellen Place patient at 20 ft from Snellen chart chart
OD then OSOD then OS VA is line in which > ½ letters are VA is line in which > ½ letters are
read read Pinhole if < 20/40Pinhole if < 20/40
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Snellen eye Snellen eye chart chart
Rosenbaum Rosenbaum pocket chart pocket chart
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Distance Visual Acuity Distance Visual Acuity TestingTesting
If VA < 20/400If VA < 20/400 Reduce the distance between the pt and Reduce the distance between the pt and
the chart and record the new distance (eg. the chart and record the new distance (eg. 5/400)5/400)
If < 5/400If < 5/400 CF (include distance)CF (include distance) HM (include distance)HM (include distance) LPLP NLPNLP
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Near Visual Acuity Near Visual Acuity TestingTesting
Indicated when Indicated when Patient complains about near visionPatient complains about near vision Distance testing difficult/impossible Distance testing difficult/impossible
Distance specified on each card Distance specified on each card (35cm)(35cm)
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Pupillary ExaminationPupillary Examination Direct penlight into eye while Direct penlight into eye while
patient looking at distancepatient looking at distance
Direct Direct Constriction of ipsilateral eyeConstriction of ipsilateral eye
Consensual Consensual Constriction of contralateral eyeConstriction of contralateral eye
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Ocular Motility Ocular Motility
Rt superior rectusRt superior rectusLt inferior oblique Lt inferior oblique
Lt superior rectusLt superior rectusRt inferior obliqueRt inferior oblique
Rt lateral rectusRt lateral rectusLt medial rectusLt medial rectus
Lt lateral rectusLt lateral rectusRt medial rectusRt medial rectus
Rt inferior rectusRt inferior rectusLt superior Lt superior oblique oblique
Lt inferior rectusLt inferior rectusRt superior Rt superior obliqueoblique
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Direct Ophthalmoscopy Direct Ophthalmoscopy
Tropicamide or phenylephrine for Tropicamide or phenylephrine for dilationdilation unless shallow anterior chamberunless shallow anterior chamber unless under neurological evaluationunless under neurological evaluation
Use own OD to examine ODUse own OD to examine OD Same for OSSame for OS
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Intraocular Pressure Intraocular Pressure Measurement Measurement
Range: 10 - 22Range: 10 - 22
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Anterior chamber depth Anterior chamber depth assessment assessment
Likely shallow if Likely shallow if ≥ ≥ 2/3 of nasal iris 2/3 of nasal iris
in shadowin shadow
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Summary of steps in eye Summary of steps in eye examexam
Visual AcuityVisual Acuity Pupillary examinationPupillary examination Visual fields by confrontationVisual fields by confrontation Extraocular movementsExtraocular movements Inspection of Inspection of lids, conjunctiva and lids, conjunctiva and
corneacornea Anterior chamber depthAnterior chamber depth Lens clarityLens clarity Tonometry Tonometry Fundus examination (Fundus examination (Disc, Disc,
Macula, vessels) Macula, vessels)
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Acute Visual LossAcute Visual Loss
Chapter 2Chapter 2
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HistorHistoryy
AgeAge POH & PMHPOH & PMH OnsetOnset DurationDuration Severity of visual lossSeverity of visual loss Monocular vs. Monocular vs.
binocularbinocular Any associated Any associated
symptoms symptoms
VA assessmentVA assessment Visual fieldsVisual fields Pupillary reactions Pupillary reactions slit lamp slit lamp
examinationexamination Intraocular pressureIntraocular pressure OphthalomoscopyOphthalomoscopy - red reflex - red reflex
- clarity of media- clarity of media - direct inspection - direct inspection
of the fundusof the fundus
ExaminatioExaminationn
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Media OpacitiesMedia Opacities
Corneal edemaCorneal edema:: - ground glass appearance- ground glass appearance - R/O AACG- R/O AACG
Corneal abrasionCorneal abrasion
HyphemaHyphema - Traumatic, spontaneous- Traumatic, spontaneous
Vitreous hemorrhageVitreous hemorrhage - darkening of red reflex with clear - darkening of red reflex with clear
lens, AC and cornea lens, AC and cornea
- traumatic - traumatic - retinal neovascularization- retinal neovascularization
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Retinal DiseasesRetinal Diseases Retinal detachmentRetinal detachment - flashes, floaters, shade - flashes, floaters, shade
over visionover vision - RAPD (if extensive RD)- RAPD (if extensive RD) - elevated retina +/- folds- elevated retina +/- folds Macular diseaseMacular disease - decrease central vision - decrease central vision - metamorphopsia- metamorphopsia
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Central Retinal Artery Central Retinal Artery Occlusion (CRAO)Occlusion (CRAO)
True ophthalmic emergency!True ophthalmic emergency! Sudden painless and often severe Sudden painless and often severe
visual lossvisual loss Permanent damage to the Permanent damage to the
ganglion cells caused by ganglion cells caused by prolonged interruption of retinal prolonged interruption of retinal arterial blood flowarterial blood flow
Characteristic “ cherry-red spot ”Characteristic “ cherry-red spot ” No optic disc swelling unless No optic disc swelling unless
there is ophthalmic or carotid there is ophthalmic or carotid artery occlusionartery occlusion
Months later, pale disc due to Months later, pale disc due to death of ganglion cells and their death of ganglion cells and their axonsaxons
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CRAOCRAO TreatmentTreatment Ocular massage:Ocular massage: -To dislodge a small embolus in CRA and -To dislodge a small embolus in CRA and
restore circulationrestore circulation -Pressing firmly for 10 seconds and then -Pressing firmly for 10 seconds and then
releasing for 10 seconds over a period of ~ releasing for 10 seconds over a period of ~ 5 minutes5 minutes
Ocular hypotensives, vasodilators, Ocular hypotensives, vasodilators, paracentesis of anterior chamberparacentesis of anterior chamber
R/O giant cell arteritis in elderly patient R/O giant cell arteritis in elderly patient without a visible emboluswithout a visible embolus
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Branch Retinal Artery Occlusion Branch Retinal Artery Occlusion (BRAO)(BRAO)
Sector of the retina Sector of the retina is opacified and is opacified and vision is partially vision is partially lostlost
Most often due to Most often due to embolusembolus Treat as CRAOTreat as CRAO
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Central Retinal Vein Occlusion Central Retinal Vein Occlusion (CRVO)(CRVO)
Subacute loss of visionSubacute loss of vision Disc swelling, venous engorgement, Disc swelling, venous engorgement,
cotton-wool spots and diffuse cotton-wool spots and diffuse retinal hemorrhage.retinal hemorrhage.
Risk factors: age, HTN, Risk factors: age, HTN, arteriosclerotic vascular disease, arteriosclerotic vascular disease, conditions that increase blood conditions that increase blood viscosity (polycythemia vera, sickle viscosity (polycythemia vera, sickle cell disease, lymphoma , leukemia)cell disease, lymphoma , leukemia)
Needs medical evaluationNeeds medical evaluation Long term risk for neovascular Long term risk for neovascular
glaucoma, so periodic ophtho f/u glaucoma, so periodic ophtho f/u
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Optic Nerve DiseaseOptic Nerve Disease
Non-Arteritic Ischemic Optic Non-Arteritic Ischemic Optic Neuropathy (NAION)Neuropathy (NAION)
- vascular disorder- vascular disorder pale, swollen disc +/- splinter pale, swollen disc +/- splinter
hemorrhagehemorrhage loss of VA , VF ( often altitudinal )loss of VA , VF ( often altitudinal ) Arteritic Ischemic Optic Arteritic Ischemic Optic
Neuropathy (AION)Neuropathy (AION)- Symptoms of giant cell arteritisSymptoms of giant cell arteritis- ESR, CRP, PlateletsESR, CRP, Platelets- Rx : systemic steroids Rx : systemic steroids
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Optic Nerve DiseaseOptic Nerve Disease Optic neuritisOptic neuritis - idiopathic or associated with multiple sclerosis- idiopathic or associated with multiple sclerosis - young adults- young adults - decreased visual acuity and colour vision- decreased visual acuity and colour vision -RAPD-RAPD -pain with ocular movement-pain with ocular movement -bulbar (disc swelling) or retrobulbar (normal disc)-bulbar (disc swelling) or retrobulbar (normal disc)
Traumatic optic neuropathyTraumatic optic neuropathy - direct trauma to optic nerve- direct trauma to optic nerve - indirect : shearing force to the vascular supply - indirect : shearing force to the vascular supply
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Visual Pathway Disorders HemianopiaHemianopia - Causes: vascular or tumors- Causes: vascular or tumors
Cortical Blindness Cortical Blindness - aka central or cerebral- aka central or cerebral - Extensive bilateral damage to - Extensive bilateral damage to
cerebral pathwayscerebral pathways - Normal pupillary reactions and - Normal pupillary reactions and
fundifundi
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Chronic Visual Chronic Visual LossLossChapter 3Chapter 3
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Introduction:Introduction:
1994: 38 million blind people (age >60 yrs) 1994: 38 million blind people (age >60 yrs) worldwideworldwide
1997: in western countries, leading causes 1997: in western countries, leading causes of blindness in people over 50 yrs of ageof blindness in people over 50 yrs of age
1)1) Age-Related Macular Degeneration Age-Related Macular Degeneration 2)2) CataractCataract3)3) GlaucomaGlaucoma4)4) DiabetesDiabetes
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GlaucomaGlaucoma Risk factors:Risk factors: Old ageOld age African-American raceAfrican-American race
Blood HypertensionBlood HypertensionDiabetes MellitusDiabetes MellitusSmokingSmokingHigh IOPHigh IOP MyopiaMyopiaFamily HistoryFamily History
Classification:Open-angle glaucoma vs. angle closure glaucoma Primary vs. secondary
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GlaucomaGlaucoma Evaluation:Evaluation:
complete historycomplete history complete eye examinationcomplete eye examination
(including IOP, gonioscopy, optic (including IOP, gonioscopy, optic disc)disc)
PerimetryPerimetry
normal Abnormal
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GlaucomaGlaucoma Treatment Options:Treatment Options:
Medical:Medical: drops to decrease aqueous secretion or increase aqueous drops to decrease aqueous secretion or increase aqueous
outflowoutflow systemic medicationssystemic medications
Laser:Laser: IridotomyIridotomy IridoplastyIridoplasty TrabeculoplastyTrabeculoplasty
Surgical:Surgical: Filtration Surgery (e.g. Trabeculectomy)Filtration Surgery (e.g. Trabeculectomy) Tube shuntTube shunt
Cyclodestructive proceduresCyclodestructive procedures
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CataractCataract congenital vs. congenital vs.
acquiredacquired often age-relatedoften age-related different forms different forms
(nuclear, cortical, (nuclear, cortical, PSCC)PSCC)
reversiblereversible very successful very successful
surgerysurgery
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CataractCataract
Evaluation:Evaluation: HistoryHistory Ocular ExaminationOcular Examination Others: A-scan, Others: A-scan, ±± B-scan , B-scan , ±± PAM PAM
Treatment:Treatment: SurgicalSurgical IOL implantationIOL implantation
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Age-Related Macular Age-Related Macular DegenerationDegeneration
Types:Types:1) Dry:1) Dry: - - drusen, RPE changes (atrophy, hyperplasia)drusen, RPE changes (atrophy, hyperplasia)2) Wet:2) Wet: - - choroidal neovascularizationchoroidal neovascularization
drusen
RPE atrophy
CNV
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Age-Related Macular Age-Related Macular DegenerationDegeneration
Fluorescein Angiography
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Age-Related Macular Age-Related Macular DegenerationDegeneration
Treatment:Treatment: micronutrient supply micronutrient supply
vit C & E, vit C & E, ββ-carotene, minerals (cupric -carotene, minerals (cupric oxide, zinc oxide) oxide, zinc oxide)
treat wet ARMD treat wet ARMD laserslasers intra-vitreal injections of anti-VEGFintra-vitreal injections of anti-VEGF surgery surgery low vision aidslow vision aids
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The Red EyeThe Red EyeChapter 4Chapter 4
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Diff. DiagnosisDiff. Diagnosis: : Red EyeRed Eye Acute angle closure glaucomaAcute angle closure glaucoma Iritis or iridocyclitisIritis or iridocyclitis Herpes simplex keratitisHerpes simplex keratitis ConjunctivitisConjunctivitis EpiscleritisEpiscleritis Soft contact lens associatedSoft contact lens associated ScleritisScleritis Adnexal DiseaseAdnexal Disease Subconjunctival hemorrhageSubconjunctival hemorrhage PterygiumPterygium Keratoconjunctivitis siccaKeratoconjunctivitis sicca Abrasions or foreign bodiesAbrasions or foreign bodies Corneal ulcerCorneal ulcer abnormal lid functionabnormal lid function
THINKTHINK Anatomy “front to Anatomy “front to
back”back” Acute vs. chronicAcute vs. chronic Visually Visually
threatening?threatening?
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HistoryHistory Onset? Sudden? Progressive? Constant?Onset? Sudden? Progressive? Constant? Family/friends with red eye?Family/friends with red eye? Using meds in eye?Using meds in eye? Trauma?Trauma? Recent eye surgery?Recent eye surgery? Contact lens wearer?Contact lens wearer? Recent URTI?Recent URTI? Decreased VA? Pain? Discharge? Itching? Decreased VA? Pain? Discharge? Itching?
Photophobia? Eye rubbing?Photophobia? Eye rubbing? Other symptoms?Other symptoms?
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Red Eye: Symptoms Red Eye: Symptoms *Decreased VA (i*Decreased VA (inflamed cornea, iridocyclitis, acute nflamed cornea, iridocyclitis, acute
glaucoma)glaucoma) *Pain (k*Pain (keratitis, ulcer, iridocyclitis, acute glaucoma)eratitis, ulcer, iridocyclitis, acute glaucoma) *Photophobia (*Photophobia (iritis)iritis) *Colored halos (*Colored halos (acute glaucoma)acute glaucoma) Discharge (Discharge (conj. or lid inflammation, corneal ulcer)conj. or lid inflammation, corneal ulcer)
Purulent/mucopurulent: BacterialPurulent/mucopurulent: Bacterial Watery: ViralWatery: Viral Scant, white, stringy: allergy, dry eyesScant, white, stringy: allergy, dry eyes
Itching (Itching (allergy)allergy)
* can indicate serious ocular disease* can indicate serious ocular disease
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Physical ExamPhysical Exam VisionVision Pupil asymmetry or irregularityPupil asymmetry or irregularity Inspect: Inspect:
pattern of redness (heme, injection, ciliary flush)pattern of redness (heme, injection, ciliary flush) Amount & type of dischargeAmount & type of discharge Corneal opacities or irregularitiesCorneal opacities or irregularities
AC shallow? Hypopyon? Hyphema?AC shallow? Hypopyon? Hyphema? Fluorescein stainingFluorescein staining IOPIOP Proptosis? Lid abnormality? Limitation EOM?Proptosis? Lid abnormality? Limitation EOM?
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Red Eye: SignsRed Eye: Signs *Ciliary flush*Ciliary flush (corneal inflammation, iridocyclitis, acute glaucoma) (corneal inflammation, iridocyclitis, acute glaucoma) Conjuctival hyperemiaConjuctival hyperemia (nonspecific sign) (nonspecific sign) *Corneal opacification *Corneal opacification (iritis, corneal edema, acute glaucoma, (iritis, corneal edema, acute glaucoma,
keratitis, keratitis, ulcer) ulcer)
*Corneal epithelial disruption *Corneal epithelial disruption (corneal inflammation, abrasion)(corneal inflammation, abrasion) *Pupil abnormality (*Pupil abnormality (iridocyclitis, acute glaucoma)iridocyclitis, acute glaucoma) *Shallow AC (*Shallow AC (acute angle closure glaucoma)acute angle closure glaucoma) *Elevated IOP *Elevated IOP (iritis, acute glaucoma)(iritis, acute glaucoma) *Proptosis *Proptosis (thyroid disease, orbital or cavernous sinus mass, (thyroid disease, orbital or cavernous sinus mass,
infection)infection) Preauricular LN Preauricular LN (viral conjunctivitis, Parinaud’s oculoglandular (viral conjunctivitis, Parinaud’s oculoglandular
syndrome)syndrome)
* can indicate serious ocular disease* can indicate serious ocular disease
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Red eye management for Red eye management for care physicianscare physicians Blepharitis:Blepharitis:
Warm compresses, lid care, Abx ointment or oral Warm compresses, lid care, Abx ointment or oral (if rosacea or Meibomian gland dysfunction)(if rosacea or Meibomian gland dysfunction)
Stye:Stye: Warm compresses (refer if still present after 1 Warm compresses (refer if still present after 1
month)month) Subconj heme:Subconj heme:
Will resolve in 10-14 daysWill resolve in 10-14 days Viral conjunctivitisViral conjunctivitis
Cool compresses, tears, contact precautionsCool compresses, tears, contact precautions Bacterial conjunctivitisBacterial conjunctivitis
Cool compresses, antibiotic drop/ointmentCool compresses, antibiotic drop/ointment
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Important Side EffectsImportant Side Effects Topical anesthetics:Topical anesthetics:
Not to be used except for aiding in examNot to be used except for aiding in exam Inhibits growth & healing of corneal epitheliumInhibits growth & healing of corneal epithelium Possible severe allergic reactionPossible severe allergic reaction Decrease blink reflex: exposure to dehydration, injury, Decrease blink reflex: exposure to dehydration, injury,
infectioninfection Topical corticosteroids:Topical corticosteroids:
Can potentiate growth of herpes simplex, Can potentiate growth of herpes simplex, fungusfungus
Can mask symptomsCan mask symptoms Cataract formationCataract formation Elevated IOPElevated IOP
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Ocular & Orbital Ocular & Orbital InjuriesInjuries
Chapter 5Chapter 5
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Anatomy & FunctionAnatomy & Function Bony orbitBony orbit
Globe, EOM, vessels, nervesGlobe, EOM, vessels, nerves Rim protectiveRim protective
““Blow out” fractureBlow out” fracture Medial fracture -> subQ emphysema of eyelidsMedial fracture -> subQ emphysema of eyelids
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Anatomy & FunctionAnatomy & Function EyelidsEyelids
Reflex closing when eyes threatenedReflex closing when eyes threatened Blinking rewets the corneaBlinking rewets the cornea Tear drainageTear drainage
CN VII palsy -> exposure keratopathyCN VII palsy -> exposure keratopathy
Lacrimal apparatusLacrimal apparatus Tear drainage occurs at medial canthusTear drainage occurs at medial canthus
Obstruction -> chronic tearing (epiphora)Obstruction -> chronic tearing (epiphora)
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Anatomy & FunctionAnatomy & Function Conjunctiva & corneaConjunctiva & cornea
Quick reepitheliization post-abrasionQuick reepitheliization post-abrasion
Iris & ciliary bodyIris & ciliary body Blunt trauma -> pupil margin nick (tear)Blunt trauma -> pupil margin nick (tear) Blunt trauma -> hyphemaBlunt trauma -> hyphema Blunt trauma -> iritisBlunt trauma -> iritis
(pain, redness, photophobia, miosis)(pain, redness, photophobia, miosis)
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Anatomy & FunctionAnatomy & Function LensLens
CataractCataract Lens dislocation (ectopia lentis)Lens dislocation (ectopia lentis)
Vitreous humorVitreous humor Decreased transparencyDecreased transparency
(hemorrhage, inflammation, infection)(hemorrhage, inflammation, infection) RetinaRetina
Hemorrhage Hemorrhage Macular damage (reduce visual acuity)Macular damage (reduce visual acuity)
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Management or ReferralManagement or Referral Chemical burnChemical burn
Alkali>Acid b/c more rapid penetrationAlkali>Acid b/c more rapid penetration OPHTHALMIC EMERGENCYOPHTHALMIC EMERGENCY ALL chemical burns require ALL chemical burns require
immediate and perfuse irrigation, immediate and perfuse irrigation, THEN ophtho referralTHEN ophtho referral
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Urgent SituationsUrgent Situations Penetrating injuries of the globePenetrating injuries of the globe Conjunctival or corneal foreign bodiesConjunctival or corneal foreign bodies Hyphema Hyphema Lid laceration (sutured if not deep and neither Lid laceration (sutured if not deep and neither
the lid margin nor the canaliculi are involved)the lid margin nor the canaliculi are involved) Traumatic optic neuropathyTraumatic optic neuropathy Radiant energy burns (snow blindness or Radiant energy burns (snow blindness or
welder’s burn)welder’s burn) Corneal abrasionCorneal abrasion
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Semi-urgent SituationSemi-urgent Situation Orbital fractureOrbital fracture Subconjuctival hemorrhage in blunt Subconjuctival hemorrhage in blunt
traumatrauma Refer patient within 1-2 daysRefer patient within 1-2 days
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Treatment SkillsTreatment Skills Ocular irrigationOcular irrigation Foreign body removalForeign body removal Eye meds (cycloplegics, antibiotic Eye meds (cycloplegics, antibiotic
ointment, anesthetic drops and ointment, anesthetic drops and ointment)ointment)
Patching (pressure patch, shield)Patching (pressure patch, shield) Suturing for simple eyelid skin Suturing for simple eyelid skin
lacerationlaceration
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Take-home PointsTake-home Points Teardrop-shaped pupil & flat anterior Teardrop-shaped pupil & flat anterior
chamber in trauma are associated with chamber in trauma are associated with perforating injuryperforating injury
Avoid digital palpation of the globe in Avoid digital palpation of the globe in perforating injuryperforating injury
In chemical burn patient immediate In chemical burn patient immediate irrigation is crucial as soon as possibleirrigation is crucial as soon as possible
Traumatic abrasions are located in the Traumatic abrasions are located in the center or inferior cornea due to Bell’s center or inferior cornea due to Bell’s phenomenonphenomenon
Know and respect your limitsKnow and respect your limits
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Chapter 6Chapter 6
Amblyopia & Amblyopia & StrabismusStrabismus
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AmblyopiaAmblyopia DefinitionDefinition
loss of VA not correctable by glasses in loss of VA not correctable by glasses in otherwise healthy eyeotherwise healthy eye
2% in US2% in US Strabismic(50%) > refractive > deprivationStrabismic(50%) > refractive > deprivation The brain selects the better image and The brain selects the better image and
suppresses the blurred or conflicting imagesuppresses the blurred or conflicting image Cortical suppression of sensory input Cortical suppression of sensory input
interrupts the normal development of visioninterrupts the normal development of vision
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StrabismusStrabismus Misalignment of the two eyesMisalignment of the two eyes Absence of binocular visionAbsence of binocular vision
Concomitant: angle of deviation equal in all directionConcomitant: angle of deviation equal in all direction EOM: normalEOM: normal Onset: childhoodOnset: childhood Rarely caused by neurological disease <6 yearsRarely caused by neurological disease <6 years Can be due to sensory deprivation Can be due to sensory deprivation
Incomitant: angle of deviation varies with direction of Incomitant: angle of deviation varies with direction of gazegaze EOM : abnormalEOM : abnormal **Paralytic : CN, MG ****Paralytic : CN, MG ** Restrictive: orbital disease, traumaRestrictive: orbital disease, trauma
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StrabismusStrabismus Phoria: latent deviationPhoria: latent deviation
Tropia: manifest deviation Tropia: manifest deviation
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Corneal Light ReflexCorneal Light Reflex
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Cover TestCover Test
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TreatmentTreatment Refractive correction (glasses)Refractive correction (glasses) PatchingPatching SurgerySurgery
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Chapter 7Chapter 7
**35% of the sensory fibers entering the brain are in the **35% of the sensory fibers entering the brain are in the optic nerves and 65% of intracranial disease exhibits optic nerves and 65% of intracranial disease exhibits
neuro-ophthalmic signs or symptoms**neuro-ophthalmic signs or symptoms**
Neuro-Neuro-OphthalmologyOphthalmology
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The Neuro-Ophthalmic The Neuro-Ophthalmic ExamExam
Visual acuityVisual acuity Confrontation visual fieldsConfrontation visual fields Pupil size and reaction Pupil size and reaction
(Efferent vs Afferent (Marcus Gunn) problem)(Efferent vs Afferent (Marcus Gunn) problem) Ocular motility for strabismus, limitation and Ocular motility for strabismus, limitation and
nystagmusnystagmus Fundus exam (optic nerve swelling and venous Fundus exam (optic nerve swelling and venous
pulsations)pulsations)
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ParasympatheticParasympathetic
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SympatheticSympathetic
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Efferent vs Afferent defectEfferent vs Afferent defect
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Selected Pupillary Selected Pupillary DisordersDisorders
Mydriasis Mydriasis CN III palsyCN III palsy
Herniation of temporal lobe or AneurysmHerniation of temporal lobe or Aneurysm Adie’s Tonic PupilAdie’s Tonic Pupil
Young women, unilateral, sensitive to dilute pilocarpine, benignYoung women, unilateral, sensitive to dilute pilocarpine, benign MiosisMiosis
PhysiologicPhysiologic Horner’s SyndromeHorner’s Syndrome
Etiologic localization (cocaine and hydroxyamphetamine)Etiologic localization (cocaine and hydroxyamphetamine) Argyll Robertson Pupil of tertiary syphilisArgyll Robertson Pupil of tertiary syphilis
small, irregular, reacts to near stimulus onlysmall, irregular, reacts to near stimulus only
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Selected Motility Selected Motility DisordersDisorders
True diplopia is a binocular phenomenonTrue diplopia is a binocular phenomenon Etiologies of monocular diplopia?Etiologies of monocular diplopia?
Do not forget to check ALL cranial nerves (especially 5/7/8)Do not forget to check ALL cranial nerves (especially 5/7/8) CN IVCN IV
Vertical diplopia, head tilt toward OPPOSITE sideVertical diplopia, head tilt toward OPPOSITE side Think closed head trauma or small vessel diseaseThink closed head trauma or small vessel disease
Myasthenia GravisMyasthenia Gravis Chronic autoimmune condition affecting skeletal muscle Chronic autoimmune condition affecting skeletal muscle
neuromuscular transmission (verify with Tensilon test)neuromuscular transmission (verify with Tensilon test) Can mimic any nerve palsy and often associated with ptosisCan mimic any nerve palsy and often associated with ptosis NEVER affects pupilNEVER affects pupil
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CN III PalsyCN III Palsy
Think: PCOM Aneurysm, Brain Tumor, Trauma Think: Trauma, Elevated ICP, HTN, Diabetes and viral infections
CN VI PalsyCN VI Palsy
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Internuclear Ophthalmoplegia (INO)Internuclear Ophthalmoplegia (INO)
Think: Think: Elderly-small vessel Elderly-small vessel diseasediseaseYoung Adult-MSYoung Adult-MSChild-Pontine GliomaChild-Pontine Glioma
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Nystagmus Nystagmus - selected - selected typestypes
May be benign or indicate ocular and/or central May be benign or indicate ocular and/or central nervous system diseasenervous system disease
Definition according to fast phaseDefinition according to fast phase End-point NystagmusEnd-point Nystagmus
seen only in extreme positions of eye movementseen only in extreme positions of eye movement Drug-induced NystagmusDrug-induced Nystagmus
Anticonvulsants, Barbiturates/Other sedativesAnticonvulsants, Barbiturates/Other sedatives Searching/Pendular NystagmusSearching/Pendular Nystagmus
common with congenital severe visual impairmentcommon with congenital severe visual impairment Nystagmus associated with INONystagmus associated with INO
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Selected Optic Nerve Selected Optic Nerve DiseaseDisease Congenital Anomalous Disc ElevationCongenital Anomalous Disc Elevation
absenceabsence of edema, hemorrhage and of edema, hemorrhage and presencepresence of SVP of SVP Think: optic disc drusen and hyperopiaThink: optic disc drusen and hyperopia
Papilledema (def?)Papilledema (def?) PresencePresence of bil edema, hemorrhage and of bil edema, hemorrhage and absenceabsence of SVP of SVP Think: hypertension (must check BP) and Think: hypertension (must check BP) and
brain tumorbrain tumor Papillitis/Anterior Optic NeuritisPapillitis/Anterior Optic Neuritis
unil edema, hemorrhageunil edema, hemorrhage Think: inflammatoryThink: inflammatory
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Selected Optic Nerve Selected Optic Nerve DiseaseDisease
Ischemic Optic NeuropathyIschemic Optic Neuropathy Pallor, swelling, hemorrhagePallor, swelling, hemorrhage altitudinal visual field lossaltitudinal visual field loss
Optic AtrophyOptic Atrophy Think: Think: previousprevious optic neuritis or ischemic optic neuritis or ischemic
optic neuropathy, long-standing papilledema, optic neuropathy, long-standing papilledema, optic nerve compression by a mass lesion, optic nerve compression by a mass lesion, glaucoma glaucoma
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Selected Visual Selected Visual Field DefectsField Defects
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Drugs & The EyeDrugs & The EyeChapter 8Chapter 8
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Topical Drugs Used for Topical Drugs Used for Diagnosis:Diagnosis:
Fluorescin DyeFluorescin Dye Fluorescein strip:Fluorescein strip:
water solublewater soluble
No systemic complications No systemic complications Beware of contact lens stainingBeware of contact lens staining
Cobalt blue light
Orange becomes green
Orange yellow dye
Eye with corneal ulcer
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AnestheticsAnesthetics Example: Example:
Propracaine Hydrochloride 0.5% (Alcaine)Propracaine Hydrochloride 0.5% (Alcaine) Tetracaine 0.5%Tetracaine 0.5%
Uses:Uses: Anesthetize cornea within 15 sec, last 10 minsAnesthetize cornea within 15 sec, last 10 mins Remove corneal foreign bodiesRemove corneal foreign bodies Perform tonometryPerform tonometry Examine damaged corneal surfaceExamine damaged corneal surface
Side effects: Side effects: Allergy: local or systemicAllergy: local or systemic Toxic to corneal epithelium ( inhibit mitosis, Toxic to corneal epithelium ( inhibit mitosis,
migration) migration)
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Mydriatics (pupil Mydriatics (pupil dilation)dilation)
Two classes:Two classes:1.1. Cholinergic-blocking ( parasympatholytic)Cholinergic-blocking ( parasympatholytic)2.2. Adrenergic-stimulating (sympathomimetic) Adrenergic-stimulating (sympathomimetic)
Iris sphincter constrict pupil
Pupillary dilator muscles
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Adrenergic Stimulating Adrenergic Stimulating DrugsDrugs
Phenylephrine 2.5% or 10%Phenylephrine 2.5% or 10% Dilates in 30 mins, no effect on Dilates in 30 mins, no effect on
accommodationaccommodation Pupil remains reactive to lightPupil remains reactive to light Combine with Tropicamide for maximal Combine with Tropicamide for maximal
dilatationdilatation Infants combine Cyclopentolate 0.2% & Infants combine Cyclopentolate 0.2% &
Phenylephrine 1%Phenylephrine 1% Side effects:Side effects:
acute hypertension or MI (with 10%)acute hypertension or MI (with 10%)