Eye 2020

EYE
Dr Cintia Fornaso
Dr.CCF 1
LOOK.AT.ME.2020
Visual Failure
Ranges from refractive errors to full

blown blindness
In Australia, legally blind is at 6/60

bilaterally
Minimum to drive is 6/12
Using the Snellen chart
Dr.CCF LOOK.AT.ME.2020 2
Ishihara colour vision test
REFRACTIVE
ERRORS
LOOK.AT.ME.2020 Dr.CCF 4
Refractive errors
MYOPIA HYPEROPIA ASTIGMATISM
REFRACTORY ERRORS TYPES:
MYOPIA ‘short-sight’
• Seen in teens
• Complications: macular degeneration or retinal
detachment
HYPERMETROPIA ‘long-sight’
• Seen in 30+
• Most common complication is closed angle glaucoma
REFRACTORY ERRORS TTPES:
PRESBYOPIA
• Similar presentation to Hypermetropia

• Much older patients
ASTIGMATISM
• Blurring of vision due to changes in the shape of

cornea
PINHOLE TEST
• Acts as a universal correcting

lens
• If visual acuity is NOT

normalised by looking through a
card with a 1mm pinhole →
defect is NOT solely by refractive
error
• Exception is in some cataracts,

in which pin hole might help
You are seeing Mr McManaman, a 68 year-old man, who has
been having a difficulty reading his telephone book, which
started three months ago. What is the most likely diagnosis?
A. Myopia
B. Cataract
C. Hypermetropia
D. Presbyopia
E. Diabetic retinopathy
You are seeing Mr McManaman, a 68 year-old man, who has been
having a difficulty reading his telephone book (who uses telephone
books now?), which started three months ago. What is the most likely
diagnosis?
A. Myopia
B. Cataract
C. Hypermetropia
D. Presbyopia
E. Diabetic retinopathy
You are seeing a 6 year-old child, who has been having a difficulty
reading the white board at school, but has no problem whilst using
his computer at home. His vision is improved with pinhole test.
What is the most likely diagnosis?
A. Myopia
B. Cataract
C. Hypermetropia
D. Normal variant
E. Glaucoma
You are seeing a 6 year-old child, who has been having a difficulty
reading the white board at school, but has no problem whilst
using his computer at home. His vision is improved with pinhole
test. What is the most likely diagnosis?
A. Myopia
B. Cataract
C. Hypermetropia
D. Normal variant
E. Glaucoma
REFRACTORY ERRORS – MANAGEMENT
Glasses with concave lenses

MYOPIA ‘short-sight’ Contact lenses
Laser surgery
Glasses with convex lenses

HYPEROPIA ‘long-sight’
Surgery
PRESBYOPIA Multifocal lenses
Corrective lens more curved in

ASTIGMATISM
one meridian
Myopia vs. Hyperopia
PRESBYOPIA
ASTIGMATISM
LOSS OF VISION
➢ In Latin – Amaurosis (darkening)
and Fugax (fleeting)
➢ Transient loss of vision in one eye
AMAUROSIS (unilateral)
FUGAX ➢ Painless
➢ Classically described as ‘a curtain
dropped over the eye’
➢ LASTS: <60 mins
➢ DUE TO: occlusion of retinal artery
➢ CAUSED BY: embolus from an
AMAUROSIS atheromatous carotid artery
FUGAX
➢ Could be accompanied by transient
hemiparesis
➢ Source must be investigated (↑↑ chance
of STROKE)
A patient comes to the ED with repeated episodes of blurring of
vision for a few weeks with floaters. He now says that a curtain has
come over his sight.
What is the most likely cause?
A. Amaurosis Fugax
B. Retina detachment
C. Carotid Artery occlusion
D. Post-convulsive icteric status
E. Central retinal vein thrombosis
A patient comes to the ED with repeated episodes of blurring of
vision for a few weeks with floaters. He now says that a curtain has
come over his sight.
What is the most likely cause?
A. Amaurosis Fugax
B. Retina detachment
C. Carotid Artery occlusion
D. Post-convulsive icteric status
E. Central retinal vein thrombosis
➢ Separation of the retina from the
back of the eye
➢ CAUSES:
➛ Trauma
➛ Thin retina (high myopia)
➛ Prior surgery
➛ Diabetic retinopathy
RETINAL
DETACHMENT
CLINICAL FEATURES:
▪ Sudden onset of floaters or
flashes
▪ Blurred vision in one eye
▪ ‘A curtain came down over the
RETINAL eye’
DETACHMENT ▪ Fundoscopy: large shadow in
vitreous cavity
MANAGEMENT:
✓ IMMEDIATE referral
✓ Laser surgery (to prevent
further detachment)
✓ Pneumatic dilatation
Arterial obstruction by Atherosclerotic
emboli/thrombi
CLINICAL FEATURES:
▪ Sudden loss of vision in one eye
▪ Not improved by pinhole
CENTRAL ▪ No light perception
▪ Fundoscopy: classic cherry red spot
RETINAL at macula
ARTERY
OCCLUSION
(CRAO)
CENTRAL MANAGEMENT:
RETINAL
ARTERY ✓ Within 30 mins of presentation:
 Massage eye-globe directly
OCCLUSION (direct digital pressure)
(CRAO)  Re-breathe CO2 (paper bag)
✓ IV acetazolamide
✓ Refer urgently
A patient presented to the ED, three hours, after a sudden loss of
vision. He is known hypertensive, well-controlled on oral anti-
hypertensive therapy. The retinal image shows a typical cherry red
spot.
Which of the following would be an appropriate management?
A. Hyperbaric O2
B. IV acetazolamide
C. Ocular massage
D. Pilocarpine
E. Intraocular cream installation (to make a cherry and cream eye
pie)
A patient presented to the ED, three hours, after a sudden loss of
vision. He is known hypertensive, well-controlled on oral anti-
hypertensive therapy. The retinal image shows a typical cherry red
spot.
Which of the following would be an appropriate management?
A. Hyperbaric O2
B. IV acetazolamide
C. Ocular massage
D. Pilocarpine
E. Intraocular cream installation (to make a cherry and cream eye
pie)
CENTRAL
RETINAL VEIN ➢ Usually seen in elderly patients
THROMBOSIS
(CRVT) ➢ CLINICAL FEATURES:
▪ Sudden loss of central vision in one eye
(can be gradual too)
▪ Not improved by pinhole
▪ Improves with distorted image
▪ Fundoscopy: stormy sunset appearance
➢ MANAGEMENT:
✓ No specific treatment
✓ Laser photocoagulation
VISION IN CRVO
Ophthalmoscopy
MACULAR DEGENERATION (MD)
➢ Seen in elderly
➢ TWO TYPES:
1 WET – exudative
2 DRY – pigmented
MACULAR ❑ WET MD:

DEGENERATION ▪ Neovascular membranes develop
(MD) under retina and leak fluid
▪ Serious condition
❑ DRY MD:
▪ Accumulation of debris between
retina and choroid
▪ More common
CLINICAL FEATURES:
▪ Sudden fading of central vision
▪ Distortion of vision
MACULAR ▪ Straight lines may seem wavy and
DEGENERATION objects distorted
(MD) ▪ Peripheral vision is normal
▪ FUNDUSCOPY: white exudate,
haemorrhage
▪ AMSLER GRID: distorted lines
MANAGEMENT:
✓ No specific treatment
✓ WET MD:
 Fluorescein angiography
 Laser photocoagulation
Normal fundus
Age-related MACUALR DEGENERATION (AMD)
Mrs Taylor, is a 32 year-old, who comes to see you with a unilateral
mild painful loss of vision for the past 12 hours. There is no
associated headache or redness. Examination revealed normal
fundus findings, visual acuity on left 6/60 and right 6/6.
Which of the following is the best investigation to detect her
diagnosis?
A. CT head
B. Lumbar puncture
C. Temporal artery biopsy
D. Serum ESR
E. Visual evoked potential
Mrs Taylor, is a 32 year-old, who comes to see you with a unilateral
mild painful loss of vision for the past 12 hours. There is no
associated headache or redness. Examination revealed normal
fundus findings, visual acuity on left 6/60 and right 6/6.
Which of the following is the best investigation to detect her
diagnosis?
A. CT head
B. Lumbar puncture
C. Temporal artery biopsy
D. Serum ESR
E. Visual evoked potential
OPTIC NEURITIS
Inflammation of the optic nerve
➢ CAUSES:
➛ Multiple sclerosis
➛ Neurosyphilis
➛ Toxins
OPTIC
NEURITIS
➢ CLINICAL FEATURES:
▪ Usually 20–40 years female
▪ Loss of vision over a few days
▪ Usually ‘Central Scotoma’
▪ Fundoscopy: optic atrophy (late)
➢ TESTS:
➛ MRI: baseline and first
RETRO ➛ Visual evoked potential for
uncertain cases
BULBAR ➛ LP: much less commonly used
NEURITIS
➢ MANAGEMENT:
✓ IV methyl prednisolone
EYE
LIDS
• Blocked meibomian glands Inflammation
of the ‘meibomian gland’
• May rupture through conjunctiva and
Chalazion cause granuloma
• Benign
ORGANISM: Staph. aureus
CLINICAL FEATURES:
• Tender irritating lump in the lid
• Painless, round, firm lesion within tarsal plate
• Inflamed eyelid
• Resembles sebaceous carcinoma
Chalazion
MANAGEMENT:
• Steam/heat compression warm compress,
massage
• Chloramphenicol ointment if inflamed
• LARGE: incision and curettage + Antibiotics
(oral)
Signs of chalazion (meibomian cyst)
Painless, roundish, firm lesion May rupture through conjunctiva

within tarsal plate and cause granuloma
• Abscess of meibomian gland
• UsuallyStaphylococcus
• Tender swelling with inflammation
Internal • May discharge through skin or
hordeolum conjunctiva
• Rx: warm compresses, may require
systemic antibiotics; incision and
drainage if recurrent
ACUTE
CHALAZION
• Abscess of lash follicle
• ORGANISM: Staph. Aureus
• CLINICAL FEATURES:
▪ Red tender swelling of lid margin
▪ Usually medial side
External ▪ Tender swelling on lid margin
hordeolum ▪ May discharge through skin
(stye)
MANAGEMENT:
✓ Steam/heat to help it discharge
✓ Lash epilation
✓ Chloramphenicol (if infection is
spreading)
EXTERNAL HORDEOLUM (STYE)
Signs
• Crops of small vesicles
• Rupture and crust
• Heal without scarring after 7 days
Herpes simplex Complications

• Follicular conjunctivitis
• Keratitis
Treatment – topical antivirals
HERPES
SIMPLEX
Herpes zoster ophthalmicus
Painful vesicles and pustules • Crusting ulceration

Periorbital oedema Treatment - oral antivirals
• Causes - insect bites, urticaria and
angioedema
• Unilateral or bilateral
Acute allergic • Painless, red, pitting oedema
oedema • Chemosis may be present
• Self-limiting
ACUTE ALLERGIC OEDEMA
• Sensitivity totopical medication
• Unilateral or bilateral
Contact • Painless oedema and erythema
dermatitis • Vesiculation and crusting
• Thickening if chronic
CONTACT DERMATITIS
• Most common human malignancy
• Usually affects the elderly
• Slow-growing, locally invasive
• Does not metastasize
Basal cell • 90% occur on head and neck
carcinoma • Of these 10% involve eyelids
• Accounts for 90% of eyelid
malignancies
• Loss of eye lashes – high suspicion of
malignancy
BASAL CELL CARCINOMA
Nodular basal
cell carcinoma
Early
• Shiny, indurated nodule
• Surface vascularization
Nodular basal
cell carcinoma
Advanced:
• Slow progression
• May destroy large
portion of Eyelid
• Less common but more aggressive than
BCC
Squamous cell • May arise de novo or from actinic
carcinoma keratosis
• Predilection for lower lid
Squamous cell carcinoma
Nodular SCC Ulcerative SCC
INFECTIONS • Congenital nasolacrimal duct obstruction
OF LACRIMAL • Congenital dacryocele
PASSAGES • Chronic canaliculitis

• Dacryocystitis: Acute / Chronic
Congenital
nasolacrimal
duct obstruction
•Caused by delayed
canalization near valve of
Hasner
•On pressure reflux of
purulent material from
punctum
Congenital
nasolacrimal
duct obstruction
• Infrequently acute
Dacryocystitis
• Distension of lacrimal sac by trapped
amniotic fluid.
• Caused by imperforate valve of Hasner
• Bluish cystic swelling at or below medial
canthus
Congenital • May become secondarily infected
dacryocele • Do not mistake for encephalocele

• Pulsatile swelling above medial canthal
tendon
MX
• Initially massage
• Probing if massage fails
CONGENITAL
DACRYOCELE
• Usually secondary to nasolacrimal duct
obstruction
• Tender canthal swelling
• Mildpreseptal cellulitis
• May develop into abscess
• Inflammation over medial canthus
• History of watery eye for months
Acute
Dacryocystitis
MANAGEMENT:
• Local heat
• Analgesics
• Initially: Flucloxacillin (change after
result of Gram stain)
• Recurrent: dacryocystorhinostomy
ACUTE DACRYOCYSTITIS
ORBIT
PRESEPTAL
CELLULITIS
Causes
• Skin trauma or insect bites of lids or
eyebrows
• Spread from local infection
• Or an Upper respiratory or ear
infection
Preseptal
cellulitis Signs
• Usually unilateral
• Tender and red Periorbital oedema
Treatment - systemic antibiotics
ORBITAL CELLULITIS
• Potentially life-threatening and blinding
• More common in children
• Systemically unwell (toxic) patient
• Infection behind orbital septum

• Usually secondary to ethmoiditis
• Presentation - severe malaise, fever and
Orbital orbital signs
cellulitis • Severe eyelid Oedema and redness
• Proptosis - most frequently lateral and down
• Sinus tenderness
• Ocular nerve compromise (vision and pupil
affected)
• PAINFUL eye movements ophthalmoplegia
⟶ differs it from ‘peri-orbital cellulitis’
• Raised intraocular pressure
• Retinal vasculature occlusion
• Optic neuropathy
Complications Orbital:
of orbital • Orbital or subperiosteal abscess
cellulitis
Intracranial:
• Meningitis, brain abscess
• Cavernous sinus thrombosis
COMPLICATIONS OF ORBITAL
CELLULITIS
Management of
orbital cellulitis
• Immediate referral to hospital
for specialist treatment
• IV Cefotaxime + Flucloxacillin
till afebrile
• Followed by
Amoxicillin/Clavulanate oral
for 10 days
POST-
TREATMENT
ACUTE
RED EYE
Painful/discomfort
• Diffuse superf. redness (conjunctivitis)

• Diff. deep redness (anterior scleritis)
Normal • Circumlimbal redness (keratitis,
anterior uveitis, corneal foreign body)
vision • Sectoral redness (episcleritis, marginal

keratitis)
Painless
• Subconjunctival haemorrhage
Normal IOP
• Corneal abrasion, keratitis, anterior

uveitis, endophthalmitis
Reduced
vision
Increased IOP
• Acute glaucoma
CONJUNCTIVA
CONJUNCTIVAL INFECTIONS
Conjunctival inflammation lasting <3 weeks
Bacterial
• Simple bacterial conjunctivitis

• Gonococcal keratoconjunctivitis
Viral
• Adenoviral keratoconjunctivitis
• Molluscum contagiosum conjunctivitis
• Herpes simplex conjunctivitis
Chlamydial
• Adult chlamydial keratoconjunctivitis

• Neonatal chlamydial conjunctivitis
• Trachoma
• Usually bilateral, acute watery discharge
and follicles
Signs of
conjunctivitis
Subconjunctival haemorrhage and
pseudomembranous if severe
• Treatment - Symptomatic
Signs of
conjunctivitis
• History of contact usually
presents
• Spreads easily by contaminated objects
(e.g. clothes, utensils)
• CAUSATIVE ORGANISMS:
• Streptococcus pneumonia
BACTERIAL • Haemophilus influenza
CONJUNCTIVITIS • Staphylococcus aureus
• Gritty eyes
• Purulent discharge – eyes stuck in the
morning
• Clear cornea
DIAGNOSIS:
▪ Clinical
▪ Swab if: severe / neonates
MANAGEMENT:
▪ MILD: saline irrigation
▪ SEVERE: chloramphenicol (antibiotic)
drops
BACTERIAL
CONJUNCTIVITIS
Signs
• Crusted eyelids and conjunctival Injection
• Treatment – broad spectrum antibiotics

topical, in Australia Chloramphenicol 1st line
Simple bacterial
conjunctivitis
Signs
• Subacute onset of mucopurulent
Discharge
• Treatment – broad spectrum antibiotics

topical, in Australia Chloramphenicol 1st
line
Simple bacterial
conjunctivitis
Signs
• Acute, profuse, purulent discharge,
• hyperemia and chemosis
Gonococcal
keratoconjunctivitis
Complications
• Corneal ulceration, perforation
• and endophthalmitis if severe
MX
• Topical ciprofloxacin
• Ceftriaxone IM
Gonococcal
• Similar to bacterial conjunctivitis
• Increased redness and development of follicles –
brick red eye
• SEEN IN:
• Neonates
• Young people with venereal infection
• Isolated aboriginals with trachoma
• MANAGEMENT:
CHLAMYDIAL • Swabs for PCR
• Azithromycin single dose
CONJUNCTIVITIS • Treat partner/family
Neonatal
chlamydial
conjunctivitis
Pharyngoconjunctival fever:
• Adenovirus types 3 and 7

• Typically affects children
• Upper respiratory tract infection
• Keratitis in 30% - usually mild
ADENOVIRAL
KERATO-
CONJUNCTIVITIS
Epidemic keratoconjunctivitis:
• Adenovirus types 8 and 19

• Very contagious
• No systemic symptoms
• Keratitis in 80% of cases - may be severe
• Most common organism – adenovirus
• Associated with URTIs
• Follicular growth on lids
• Watery discharge
• Pre-auricular lymph node palpable
• MANAGEMENT:
• Educate about hygiene
• Topical lubricants
Viral • Avoid corticosteroids
conjunctivitis
• Produces a follicular conjunctivitis
• Diagnostic ‘dendritic ulcer’ on cornea seen
on fluorescein stain
• MANAGEMENT:
• Acyclovir ointment for2 weeks
Primary Herpes • Atropine to prevent reflex vasospasm of
simplex pupil
infection
• Dendritic ulcer with terminal bulbs
• Stains with fluorescein
• May enlarge to become geographic
Herpes simplex
epithelial
keratitis
• NOT an inflammation/infection
• Beefy red localised haemorrhage
• Has a definite posterior margin
• If no posterior margin, then it indicates
SUBCONJUNCTIVAL orbital fracture
HAEMORRHAGE
• SEEN IN:
• Trauma
• Increased intraocular pressure
• MANAGEMENT:
• Self resolving
• Education and reassurance
ALLERGIC
CONJUNCTIVITIS
• Allergic
rhinoconjunctivitis
• Vernal
• Atopic

• Frequentlyassociated with atopy: asthma, hay
fever and dermatitis
• Recurrent, bilateral
• Affects children and young adults
• More common in males and in warm climates
• Itching, mucoid discharge and lacrimation
Vernal
keratoconjunctivitis Types:
• Palpebral
• Limbal
• Mixed
Treatment:
• Topical mast cell stabilizers
• Topical steroids

• Diffuse papillary hypertrophy, most
marked on superior tarsus
Progression of
vernal
conjunctivitis

• Formation of cobblestone papillae
Progression of
vernal
conjunctivitis

• Rupture of septae - giant papillae
Progression of
vernal
conjunctivitis

Atopic keratoconjunctivitis
• Eyelids are red, thickened, macerated and fissured
• Typically affects young patients with atopic dermatitis
Dr.CCF
LOOK.AT.ME.2020 105
CORNEA

Without inflammation
• Chronic and asymptomatic
• Circumferential thinning with intact
• Epithelium (‘contact lens cornea’)
Peripheral
corneal
involvement in
rheumatoid
arthritis

With inflammation
• Acute and painful
• Circumferential ulceration and
infiltration
Treatment - systemic steroids and/or
cytotoxic drugs
Peripheral
corneal
involvement in
rheumatoid
arthritis

• Circumferential and central ulceration
Peripheral
corneal
involvement in
Wegener
granulomatosis
and
polyarteritis
nodosa

• Sclera may also become involved
• Treatment - systemic steroids and
Peripheral cyclophosphamide
corneal
involvement in
Wegener
granulomatosis
and
polyarteritis
nodosa

Mr Adams is a 56 year-old admitted patient, day 3 post cataract
extraction. Today he woke up with eye pain, lid swelling with little
hypopyon and red conjunctiva. The pupil seemed small. His visual
acuity is also decreased.
What is his most likely diagnosis?
A. Hypopyon
B. Acute iritis
C. Acute conjunctivitis
D. Glaucoma
E. Cataract re-emergence
Dr.CCF
Mr Adams is a 56 year-old admitted patient, day 3 post cataract
extraction. Today he woke up with eye pain, lid swelling with
little hypopyon and red conjunctiva. The pupil seemed small. His
visual acuity is also decreased.
What is his most likely diagnosis?
A. Hypopyon
B. Acute iritis
C. Acute conjunctivitis
D. Glaucoma
E. Cataract re-emergence
Dr.CCF
A 35 year-old female presents with recurrent Chalazion of the upper eyelid. A
curettage is scheduled and subjected to histopathological examination.
Which of the following must be ruled out?
A. Squamous cell carcinoma

B. Basal cell carcinoma
C. Marjolin’s ulcer
D. Sebaceous carcinoma
E. Malignant melanoma

A 35 year-old female presents with recurrent Chalazion of the upper eyelid. A
curettage is scheduled and subjected to histopathological examination.
Which of the following must be ruled out?
A. Squamous cell carcinoma

B. Basal cell carcinoma
C. Marjolin’s ulcer
D. Sebaceous carcinoma
E. Malignant melanoma

A child presents to the ED with eye lid oedema, proptosis and restricted
painful eye movement. What is his most likely diagnosis?
A. Peri-orbital cellulitis
B. Migraine
C. Conjunctivitis
D. Orbital cellulitis
E. Optic nerve glioma

A child presents to the ED with eye lid oedema, proptosis and restricted
painful eye movement. What is his most likely diagnosis?
A. Peri-orbital cellulitis
B. Migraine
C. Conjunctivitis
D. Orbital cellulitis
E. Optic nerve glioma

UVEITIS

• Inflammation of the iris and ciliary
body – anterior uveitis
• Inflamed iris ⟶ sticks to lens ⟶
pupil distortion ⟶ blurring vision
UVEITIS
(IRITIS)

CLINICAL FEATURES:
• Hypopyon (leucocytic exudate in the
ant. chamber)
• Eye redness
• Blurred vision
UVEITIS • Pain
(IRITIS) • Small pupil
MANAGEMENT:
• Atropine – pupil dilatation
• Topical steroids – reduce
inflammation

• Spondyloarthropathies
Juvenile arthritis
IMPORTANT •
• Sarcoidosis
SYSTEMIC • Reactive arthritis
ASSOCIATIONS • IBD
OF UVEITIS • TI nephritis

• Majority are men
• 45% are positive for HLA-B27
• Initially no systemic disease
• Subsequently develop ankylosing
spondylitis
Acute anterior
uveitis in young
adults

Acute anterior uveitis
Fibrinous exudate Residual pigment on lens

Complications of uveitis
Posterior synechiae - 30% Cataract -20%

Complications of uveitis
Glaucoma due to PAS - 15%

Band keratopathy - 10%

1- Soft tissue involvement:
• Periorbital and lid swelling
• Conjunctival hyperemia
• Chemosis
• Superior limbic keratoconjunctivitis
THYROID EYE 2-Eyelid retraction

DISEASE
3-Proptosis
4- Optic neuropathy
5- Restrictive myopathy

THYROID EYE DISEASE
• Risk factors for diabetic retinopathy:
• duration of DM, poor DM control, HT,
increased lipids, proteinuria, anemia,
pregnancy, smoking
• 5-10% of diabetic patients develop

Diabetic diabetic retinopathy each year very
retinopathy common problem
• Systemic management:
• strict blood sugar control, blood lipid
control, HbA1c, exercise, cease
smoking, weight control

Classification:
• Non-proliferative DR –mild, moderate,
severe
• Proliferative DR
Diabetic Signs:
• NPDR: microaneurysms, intraretinal
retinopathy haemorrhages, venous beading,
intraretinal microvascular abnormalities
• PDR: characterised by
neovascularisations (risk of bleeding and
retinal traction)

PROLIFERATIVE DR
CATARACT

➢ Opacity in the lens
➢ Causes progressive visual loss
➢ CAUSES:
 Age
CATARACT  DM
 Steroids
 Radiation
 TORCH – congenital
cataracts
 Trauma

CLINICAL FEATURES
▪ Difficulty in reading
▪ Difficulty in recognising faces
▪ Difficulty in driving at night
▪ Halos around lights

EXAMINATION
▪ ↓↓ visual acuity
▪ ↓↓ red reflex on ophthalmoscopy

➢ Extraction when patient can not cope
➢ No medical treatment
➢ After removal of cataractous lens, an
intraocular lens is implanted
➢ 150.000 cataract operation / year
CATARACT –
➢ 36.000 Australians are visually
MANAGEMENT impaired
➢ CONTRAINDICATIONS:
 Intraocular inflammation
 Severe diabetic retinopathy

GLAUCOMA

➢ Problem in drainage of aqueous humor
➢ Increasing pressure of the outflow on
the eye
➢ Progressive damage of the optic nerve
GLAUCOMA ➢ Leads to progressive blindness
➢ TYPES:
▪ Chronic – open angle
▪ Acute – closed angle
▪ Congenital
▪ Secondary

•CLINICAL FEATURES:
☞ Familial tendency
☞ NORMAL central vision
☞ Progressive restriction of visual
field
CHRONIC
GLAUCOMA •TESTS:
➛ Tonometry >22mmHg
➛ Ophthalmoscopy >30% of total
disc area is cupped

MANAGEMENT:
• Eye drops
• Timolol (can cause systemic
CHRONIC complications)
GLAUCOMA • Latanoprost
• Pilocarpine
• Acetazolamide
• Laser therapy
• Surgery

Mr Gru is a 30 year-old patient came to see you complaining of sudden
onset decreased vision with haloes. You have examined him to find his
eyes feel hard on palpation. What is the most appropriate next step in
his management?
A. Topical pilocarpine
B. Oral acetazolamide
C. Topical danazol
D. Intraocular needle aspiration
E. IV steroids

Mr Gru is a 30 year-old patient came to see you complaining of sudden
onset decreased vision with haloes. You have examined him to find his
eyes feel hard on palpation. What is the most appropriate next step in
his management?
A. Topical pilocarpine
B. Oral acetazolamide
C. Topical danazol
D. Intraocular needle aspiration
E. IV steroids

➢ Acute RED painful eye in middle
age
➢ CLINICAL FEATURES:
ACUTE ➛ Pain in one eye
GLAUCOMA ➛ Impaired vision
➛ Halos around lights
➛ Hazy cornea
➛ Fixed semi-dilated pupil
➛ Eye feels hard to touch

➢ MANAGEMENT:
✓ Urgent ophthalmic referral
✓ Acetazolamide IV +
Pilocarpine drops
ACUTE
GLAUCOMA

• 250.000 Australians, ½ of them
undiagnosed
Risks:
Primary open • positive FHx
angle glaucoma • Myopia

• DM
• HT
• Age
• race (Africans)

Signs of Acute
congestive angle-
closure glaucoma
• Severe corneal
oedema
• Dilated, unreactive,
vertically oval pupil

Signs of Acute
congestive angle-
closure glaucoma
• Ciliary injection
• Shallow anterior chamber

Signs of Acute
congestive angle-
closure glaucoma
• Very high IOP
• Acute red eye
• Pain
• Complete angle closure

• Acetazolamide 500 mg i.v.
• Hyperosmotic agents - if appropriate
• Oral glycerol 1-1.5 g/kg of 50%
solution in lemon juice
Treatment of • Intravenous mannitol 2g/kg of 20%
Acute solution
Congestive
Topical therapy
Angle-Closure • Pilocarpine 2% to both eyes
Glaucoma • Beta-blockers
• Steroids
• YAG laser iridotomy - To both eyes when
cornea is clear
•
Clinical features of primary congenital glaucoma
• Depend on age of onset

• Bilateral in 75% but frequently asymmetrical
Corneal oedema associated with Buphthalmos if IOP becomes elevated

lacrimation and photophobia prior to age 3 years.

Breaks in Descemet membrane Optic disc cupping

TRAUMA

Eyelid haematoma
Usually innocuous but exclude associated trauma to globe or orbit
Orbital roof fracture if associated with subconjunctival

haemorrhage without visible posterior limit
Eyelid haematoma
Basal skull fracture - bilateral ring haematoma (‘panda eyes’)

Pathogenesis of orbital floor blow-out fracture

Signs of orbital floor blow-out fracture
• Periocular ecchymosis and oedema

• Infraorbital nerve anaesthesia
Ophthalmoplegia - typically in up- and down- gaze (double diplopia)

• Periocular ecchymosis • Ophthalmoplegia - • Enophthalmos - if severe

and oedema typically in up- and down-
• Infraorbital nerve gaze (double diplopia)
anaesthesia

Downloaded from: Clinical Ophthalmology, 6th Edition (on 10 May 2011 09:30 AM)
© 2007 Elsevier
Lid margin laceration

Grade I (excellent prognosis)
• Clear cornea
• Limbal ischaemia – nil
Grade II (good prognosis)

• Cornea hazy but visible iris details
Grading of
• Limbal ischaemia < 1/3
severity of
chemical
injuries

Grade III (guarded prognosis)
• No iris details
• Limbal ischaemia - 1/3 to 1/2
Grading of
severity of
chemical
injuries

Grade IV (very poor prognosis)
• Opaque cornea
• Limbal ischaemia > 1/2
Grading of
severity of
chemical
injuries

Strabismus
Dx:
• Corneal reflections test
• Cover-uncover test
• Alternate cover test

Hirschberg Test
• Rough measure of deviation

• Location of corneal light reflex
Types:
• Convergent
• Esotrpia (manifest)
• Esophoria (latent)
• Divergent
• Exotropia(manifest)
• Exophoria (latent)

Lazy eye
High level vision develops during first 6 years of

age. If either eye not stimulated adequately
during this time – amblyopia
Amblyopia Causes of amblyopia
• Deprivation
• Anisometropia (>2.5D)
• Ametropia (>5.0D or > -10.0D)
• Astigmatism
• Strabismus (no risk if alternating, high
risk if esotropia with one eye preference)

✓ John Murtagh’s GENERAL PRACTICE, 7th
Edition
✓ Handbook of Multiple-Choice Questions - AMC
✓ https://www.tg.org.au/
✓ https://www.racgp.org.au/clinical-
resources/clinical-guidelines
References ✓ https://emedicine.medscape.com
✓ https://www.rch.org.au/clinicalguide
✓ https://www.acrrm.org.au/support/clinicians/c
ommunity-support/clinical-guidelines
✓ https://www.ausdoc.com.au/guidetoguidelines
✓ https://litfl.com/
Dr.CCF 173

Eye 2020

Uploaded by

Copyright:

Available Formats

Eye 2020

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Eye 2020

Uploaded by

Copyright:

Available Formats

EYE

Ranges from refractive errors to full

In Australia, legally blind is at 6/60

Minimum to drive is 6/12

Using the Snellen chart

MYOPIA HYPEROPIA ASTIGMATISM

• Similar presentation to Hypermetropia

• Blurring of vision due to changes in the shape of

• Acts as a universal correcting

• If visual acuity is NOT

• Exception is in some cataracts,

Glasses with concave lenses

Glasses with convex lenses

PRESBYOPIA Multifocal lenses

Corrective lens more curved in

MACULAR ❑ WET MD:

Inflammation of the optic nerve

ORGANISM: Staph. aureus

Painless, roundish, firm lesion May rupture through conjunctiva

Herpes simplex Complications

Treatment – topical antivirals

Painful vesicles and pustules • Crusting ulceration

Nodular SCC Ulcerative SCC

OF LACRIMAL • Congenital dacryocele

PASSAGES • Chronic canaliculitis

dacryocele • Do not mistake for encephalocele

Treatment - systemic antibiotics

• Infection behind orbital septum

• Diffuse superf. redness (conjunctivitis)

vision • Sectoral redness (episcleritis, marginal

• Corneal abrasion, keratitis, anterior

Conjunctival inflammation lasting <3 weeks

• Simple bacterial conjunctivitis

• Adult chlamydial keratoconjunctivitis

• Treatment – broad spectrum antibiotics

• Treatment – broad spectrum antibiotics

• Adenovirus types 3 and 7

• Adenovirus types 8 and 19

Dr.CCF LOOK.AT.ME.2020 100

Dr.CCF LOOK.AT.ME.2020 101

Dr.CCF LOOK.AT.ME.2020 102

Dr.CCF LOOK.AT.ME.2020 103

Dr.CCF LOOK.AT.ME.2020 104

LOOK.AT.ME.2020 Dr.CCF 106

Dr.CCF LOOK.AT.ME.2020 107

Dr.CCF LOOK.AT.ME.2020 108

Dr.CCF LOOK.AT.ME.2020 109

Dr.CCF LOOK.AT.ME.2020 110

A. Squamous cell carcinoma

Dr.CCF LOOK.AT.ME.2020 113

A. Squamous cell carcinoma

Dr.CCF LOOK.AT.ME.2020 114

Dr.CCF LOOK.AT.ME.2020 115

Dr.CCF LOOK.AT.ME.2020 116

LOOK.AT.ME.2020 Dr.CCF 117

Dr.CCF LOOK.AT.ME.2020 118

Dr.CCF LOOK.AT.ME.2020 119

Dr.CCF LOOK.AT.ME.2020 120