None-urgent eye problems
David Kinshuck, associate specialist
David Kinshuck, Good Hope Hospital,
None-urgent eye problems …working in pairs, (1 minute) write down
• Common conditions
• Rarer & serious conditions
Draw an eye and name the parts…working in pairs, (30 s) :
• parts
• Parts relevant to conditions
www.websightmd.com
www.websightmd.com
Aqueous flow
Chronic eye conditions
Adults
cataracts
Armd...age-related macular
degeneration
Glaucoma
Diabetic retinopathy
Others
(retinal vein occlusion,
inherited retina, corneal etc)
children
Squints
Watery eye
Cataracts
Glaucoma
rarer
Cataracts
Symptoms
How to examine
Operation
refraction
Cataracts symptoms, in pairs
• ?
• ?
• ?
• ?
Cataracts symptoms
Glare
Misty vision
Blurred vision
Cannot see distances/faces
Cataracts...symptoms....blurred
Cataracts...symptoms....glare
Examining for cataract…red reflex
Looking through
ophthalmoscope,
check red reflex
from 10 cm,
focusing on iris
rim
‘white’ reflex
?retinoblastoma
www.occhioallaretina.it/Immagini/leucocoria.JPG
http://oftalmologo.bravepages.com/Leucocoria%201.jpg
Cataracts...operation
Link
http://www.goodhopeeyeclinic.org.uk/eye
cataractpatient.html
Cataracts...refraction...in pairs, which is myopia etc
Cataracts...refraction
– Emmetropia..
no dist. specs
– Hypermetropia,
small eyes
– Myopia
– High myopia
Presbyopia...need reading spectacles, >45y
Retina
– Diabetic retinopathy
– Retinal vein occlusion
– Armd...age-related macular
degeneration
– Others
• retinal vein occlusion
• inherited retina (eg retinal pigmentosa)
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 do
http://medweb.bham.ac.uk/easdec/dmret.html
http://medweb.bham.ac.uk/easdec/mechanism
animation.htm
Diabetic retinopathy
Diabetic retinopathy
• dot and blot
• ischaemic areas
• VEGF
• leakage
• new vessels
Diabetic retinopathy
• dot and blot
• ischaemic areas
• VEGF
• leakage
• new vessels
Diabetic retinopathy
Diabetic retinopathy
Diabetic retinopathy http://reference.medscape.com/features/slideshow/retina
Diabetic retinopathy, in pairs, how do you prevent, 30s
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
Diabetic retinopathy
•
•
•
•
•
HbA1c
Blood pressure
Smoking
Lipids
Duration of ‘high’ HbA1c
similar for BP/smoking/lipids
Retinal vein occlusion
7 highs
•
•
•
•
•
cigarettes
Cholesterol
Blood pressure
Glucose
Viscosity
– Myeloma
– White cells
Macula..in pairs, 1 minute
•
•
•
•
What do you know about armd
Symptoms
Types
etc
Macular
Central visual changes suggest macula
disease: Eye casualty same week
Central vision
OCT optical coherence tomogram … wet ARMD
http://www.goodhopee
yeclinic.org.uk/images
/lucentis.html
Dry, ‘geographic atrophy’
Areas of
atrophy
enlarge over a
couple of
years, seriously
reducing
central vision
Glaucoma, in pairs, explain with diagram, 1 min
Glaucoma, mechanism
• Aqueous produced in
ciliary body
(carbonic anhydrase
enzyme)
• Flows into
>anterior chamber,
>through trabecular
>meshwork,
>canal of schlemm,
>episcleral veins
• > otherwise pressure
Glaucoma, loss of visual field
• Visual loss over years
• 2/3 chronic glaucoma has
a high pressure…pressure
is detected by whom
• A
• B
patient
optometrist
Glaucoma, loss of visual field
• Visual loss over years
• 2/3 chronic glaucoma has
a high pressure…pressure
is detected by whom
• A
• B
patient
optometrist
Glaucoma, in pairs, which normal eye, 30s
A B
http://www.goodhopeeyeclinic.org.uk/glaucomacase3.htm
Glaucoma, in pairs, which normal eye, 30s
1. Vessels deviated
nasally
2. Pale central area with
cribriform pits
3. thin rim
4. Other minor changes
http://www.goodhopeeyeclinic.org.uk/glaucomacase3.htm
Glaucoma, lowering pressure
• Laser trabecular meshwork
• Drops
– Prostaglandin inhibitors
– Carbonic anhydrase inhibitor
– Betablockers
• tablets
– Carbonic anhydrase inhibitor
• surgery
Glaucoma, quiz
• Patient detects glaucoma
Y
N
Glaucoma, quiz
• Are there symptoms early Y
N
Glaucoma, quiz
• Examining the eye
– Cupped disc
Y
N
Glaucoma, quiz
• Examining the eye
– Raised pressure 66%
Y
N
Glaucoma, quiz
– Examine angle at onset
Y
N
Glaucoma, quiz
– Visual field
Y
N
Glaucoma, other types
– Yearly checks stable
Y
N
Glaucoma, quiz
• Patient detects glaucoma
• Are there symptoms early
• Examining the eye
– Cupped disc
– Raised pressure 66%
– Examine angle at onset
– Visual field
– Yearly checks
N
N
Y
Y
Y
Y
Y
Glaucoma, other types
• Low tension
• Narrow angle http://www.goodhopeeyeclinic.org.uk/pi.html
• Genetic
– Many conditions
– congenital baby
• Secondary surgery/trauma/steroids
Glaucoma,
– Congenital (www.nature.com/eye)
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)
Retinal detachment
1. 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
Eye & major trauma
Visual acuity
T
6/60
NC
6/36
EN
6/24
OTNC
6/18
LOXEW
6/12
TYURNG
6/9
TYURNG
TYURNG
6/6
6/5
Visual fields
paper
paper
Pupils
• Pupils (needs Flash player installed)
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
Children, chronic disease
• Rare
– Cataracts
– Glaucoma
– Lots
• Common
–
–
–
–
watery eyes
(lacrimal sac abscess/mucocoel)
Squints
Allergic eye disease
Children, chronic disease---watery eyes
Children, squint
Children, squint
• Convergent
• Divergent
• vertical
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
Children, cover test
• http://www.youtube.com/watch?v=yyIAdl49Lg
In pairs...what is this?
3rd nerve palsy
3rd nerve palsy
3rd nerve palsy
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
In pairs...what is this?
3rd nerve palsy
www.patient.co.uk..thyroid eye disease
3rd nerve palsy
www.patient.co.uk..thyroid eye disease
3rd nerve palsy
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
In pairs...what is this?
3rd nerve palsy
In pairs...what is this? nhs.uk
3rd nerve palsy
In pairs...what is this? cosmeticsurg.com
3rd nerve palsy
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
Corneal disease
• Lots of uncommon corneal diseases
• In poor countries, trachoma >> corneal
scarring
• http://www.goodhopeeyeclinic.org.uk/fuchs
.html
• Dry eye
trachoma
Dry eyes
http://www.goodhopeeyeclinic.org.uk/dryeye.html
Dry eyes
http://www.d
ryeye.org/im
ages/colorba
r.jpg
Fuchs corneal dystrophy etc
•http://www.goodhopeeyeclinic.org.uk/fuchs.html
•Keratoconus
Optic atrophy
• Low B12
• Secondary to retinal artery occlusion or ION
• Tobacco alcohol amblyopia (vitamin B
deficiency)
Retinal dystrophy
• http://geneticpeople.com/?tag=retinitispigmentosa
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