CENTRAL COAST DAY HOSPITAL OPTOMETRIST
CONFERENCE - 26 FEBRUARY 2012
DR VIVEK CHOWDHURY
Anterior Segment - Common Clinical
Presentations in Optometry
Fuchs endothelial dystrophy
Pseudophakic Bullous Keratopathy
Progression
Gradual increase in
cornea guttata with
peripheral spread
Later central stromal
oedema - STROMA
Eventually bullous
keratopathy - EPI
Fuchs endothelial dystrophy
Pseudophakic Bullous Keratopathy
SYMPTOMS:
Acuity. Haloes/Glare.
Diurnal Variation.
Discomfort/Pain
SIGNS
Guttae and Endothelial Opacity.
Stromal Oedema
Epithelial Oedema/Erosions.
Corneal Thickness/Pachymetry
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 Defects
c. Deteriorating Visual Acuity
d. Symptoms Worse in the Afternoon
ANTERIOR CHAMBER IOLS
Primary Cataract Surgery – Problems with Capsular
Bag/Zonular Support – PXF Patients/Hx Trauma.
Secondary IOL - Aphakic Patient
Problems Related to:
ACIOL Itself
Complications of the Primary Surgery
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 Material
Retina: CME, Breaks, Detachment, Lens remnants
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 Pressure
b. Corneal Decompensation.
c. Uveitis.
d. Iris Naevus
TRAUMA
1. Eyelid
• Haematoma
• Margin laceration
• Canalicular laceration
2. Orbital blow-out fractures
• Floor
• Medial wall
3. Globe Injuries
• Anterior segment
• Posterior segment
Anterior segment complications of blunt trau
Hyphaema
Sphincter tear
Cataract
Lens subluxation
Iridodialysis
Angle recession
Vossius ring
Rupture of globe
Posterior segment complications of blunt trau
Commotio retinae
Choroidal rupture and
haemorrhage
Avulsion of vitreous base
and retinal dialysis
Equatorial tears
Macular hole
Optic neuropathy
Complications of penetrating trauma
Flat anterior chamber
Uveal prolapse
Vitreous haemorrhage Tractional retinal detachment
Damage to lens and iris
Endophthalmitis
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
glaucoma
b. cataract may be associated with zonule
laxity/phacodonesis
c. there is an increased risk of retinal breaks
d. the patient may have a dilated pupil
Adenoviral - Signs of keratitis
•
Focal, epithelial keratitis
•
•
Transient
•
Focal, subepithelial keratitis
May persist for months
Treatment - topical steroids if visual acuity
diminished by subepithelial keratitis
Progression of vernal conjunctivitis
Diffuse papillary hypertrophy, most marked on superior tarsus
Formation of cobblestone papillae
Rupture of septae - giant papillae
Limbal vernal
Mucoid nodule
Trantas dots
Progression of vernal keratopathy
Punctate epitheliopathy
Plaque formation (shield ulcer)
Epithelial macroerosions
Subepithelial scarring
Progression of ocular cicatricial pemphigoi
Diffuse hyperaemia
Subepithelial fibrosis and
shrinkage
Pseudomembrane formation
Symblepharon
Naevus
•
•
Presents in first two decades
Sharply demarcated and slightly
elevated
•
Most frequently juxtalimbal
•
30% are almost non-pigmented
Lipodermoid
•
Presents in adulthood
Soft, movable, subconjunctival mass
•
Most frequently at outer canthus
•
Intraepithelial neoplasia
(carcinoma in situ)
Signs
Progression
•
Presents in late adulthood
•
•
Juxtalimbal fleshy avascular mass
•
May become vascular and extend onto
cornea
Malignant transformation is uncommon
Primary acquired melanosis (PAM)
Signs
•
•
•
Presents in late adulthood
Unilateral, irregular areas of flat,
brown pigmentation
May involve any part of conjunctiva
Types
•
•
PAM without atypia is benign
PAM with atypia is pre-malignant
Conjunctival melanoma
From PAM with atypia
•
•
Most common type
Sudden appearance of
nodules in PAM
From naevus
•
•
Very rare
Sudden increase in size
or pigmentation
Primary
•
•
Solitary nodule
Frequently juxtalimbal
but may be anywhere
Squamous cell carcinoma
Signs
•
•
•
Arises from intraepithelial
neoplasia or de novo
Presents in late adulthood
Frequently juxtalimbal
Progression
•
Slow-growing
•
May spread extensively
Rarely metastasizes
•
Marginal keratitis
•
•
•
Hypersensitivity reaction to Staph. exotoxins
May be associated with Staph. blepharitis
Unilateral, transient but recurrent
Progression
Subepithelial infiltrate Circumferential spread Bridging vascularization
followed by resolution
separated by clear zone
Treatment - short course of topical steroids
Phlyctenulosis
•
•
Uncommon, unilateral - typically affects children
Severe photophobia, lacrimation and blepharospasm
Conjunctival phlycten
•
•
Small pinkish-white nodule
near limbus
Usually transient and resolves
spontaneously
Corneal phlycten
•
•
Starts astride limbus
Resolves spontaneously or extends
onto cornea
Treatment - topical steroids
Herpes simplex epithelial keratitis
• Dendritic ulcer with terminal bulbs
• May enlarge to become geographic
• Stains with fluorescein
Treatment
• Aciclovir 3% ointment x 5 daily
• Debridement if non-compliant
Herpes simplex disciform keratitis
Signs
Associations
• Central epithelial and stromal oedema • Occasionally surrounded by
Wessely ring
• Folds in Descemet membrane
• Small keratic precipitates
Treatment- topical steroids with antiviral cover
Herpes zoster keratitis
Acute epithelial keratitis
Nummular 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
May become chronic
Treatment - topical steroids, if appropriate
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.
Simple episcleritis
• Common, benign, self-limiting but frequently recurrent
• Typically affects young adults
• Seldom associated with a systemic disorder
Simple sectorial episcleritis
Treatment
• Topical steroids
Simple diffuse episcleritis
Nodular episcleritis
• Less common than simple episcleritis
• May take longer to resolve
• Treatment - similar to simple episcleritis
Deep scleral part of slit-beam
Localized nodule which can be moved over sclera
not displaced
Grading of severity of chemical injuries
Grade I (excellent prognosis)
•
•
Clear cornea
Limbal ischaemia - nil
Grade II (good prognosis) Grade III (guarded
prognosis)
•
•
Cornea hazy but visible
iris details
Limbal ischaemia < 1/3
Grade IV (very poor
prognosis)
•
No iris details
•
• Limbal ischaemia > 1/2
Limbal ischaemia - 1/3 to 1/2
•
Opaque cornea
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
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.
THE END