ABC OF EYES HISTORY AND EXAMINATION. ABC OF EYES HISTORY AND EXAMINATION History Previous...

DR.AGHLAB KHOURYALQUDS MEDICAL SCHOOLBASR

ABC OF EYES

HISTORY AND EXAMINATION

ABC OF EYESHISTORY AND EXAMINATION

HistoryPrevious ophthalmic historyMedical historyFamily historyDrug history

ABC OF EYESHISTORY AND EXAMINATION

Visual symptoms: details to establishMonocular or binocularType of disturbancesOnsetPresence and type of field lossAssociated symptomsEffect on lifestyle

ABC OF EYESHISTORY AND EXAMINATION

ExaminationVisionVFPupilsOcular motilityEye positionEyelids,conjunctiva,sclera and corneaIntraocular pressureOphthalmoscopy

ABC OF EYESHISTORY AND EXAMINATION

Vision test

ABC OF EYESHISTORY AND EXAMINATION

Visual field test

ABC OF EYESHISTORY AND EXAMINATION

Pupils

ABC OF EYESHISTORY AND EXAMINATION

Ocular motility

ABC OF EYESHISTORY AND EXAMINATION

Eye position

ABC OF EYESHISTORY AND EXAMINATION

Eyelids

ABC OF EYESHISTORY AND EXAMINATION

Conjunctiva

ABC OF EYESHISTORY AND EXAMINATION

Cornea

ABC OF EYESHISTORY AND EXAMINATION

Sclera

ABC OF EYESHISTORY AND EXAMINATION

Intraocular pressure

ABC OF EYESHISTORY AND EXAMINATION

Ophthalmoscopy

ABC OF EYESRED EYE

ABC OF EYESRED EYE

History

OnsetSeverityPrevious attacksOther family membersContact lenses

ABC OF EYESRED EYE

Symptoms

Blurring of visionPainPhotophobiaFB sensationItching

Sings

Type of rednessDischargeFBCorneal edemaCorneal opacityLid swellingAbnormal pupil

ABC OF EYESRED EYE

Conjunctivitis

BacterialViralChlamydial conjunctivitisConjunctivitis in infantsAllergic

ABC OF EYESRED EYE

Conjunctivitis

Bacterial

ABC OF EYESRED EYE

Conjunctivitis

Viral

ABC OF EYESRED EYE

Conjunctivitis

Chlamydial

ABC OF EYESRED EYE

Conjunctivitis

Ophthalmia neonatorum

ABC OF EYESRED EYE

Conjunctivitis

Allergic

ABC OF EYESRED EYE – Episcliritis and Scleritis

ABC OF EYESRED EYE – Corneal Ulcers

ABC OF EYESRED EYE - Uveitis

ABC OF EYESRED EYE – Acute Angle Closure Glaucoma

ABC OF EYESRED EYE – Subconjunctival Haemorrhage

ABC OF EYESRED EYE – Inflamed Pterygium & Pingueculum

ABC OF EYESREFREACTIVE

ERRORS

ABC OF EYESREFREACTIVE ERRORS

ABC OF EYESREFREACTIVE ERRORS - Myopia

ABC OF EYESREFREACTIVE ERRORS - Hypermetropia

ABC OF EYESREFREACTIVE ERRORS - Astigmatism

ABC OF EYESREFREACTIVE ERRORS – Pinhole Test

ABC OF EYESREFREACTIVE ERRORS - Presbyopia

ABC OF EYESREFREACTIVE ERRORS – Contact Lenses

Soft contact lenses Gas permeable contact lenses Hard contact lenses

ABC OF EYESREFREACTIVE ERRORS – Contact Lenses

Indications

Personal appearanceHigh refractive errorsHigh anisometropiaCorneal surface irregularitiesTherapeutic indications

ABC OF EYESREFREACTIVE ERRORS – Contact Lenses

Contraindications

AtopyDry eyesPrevious glaucoma surgeryInability to handle CLActive ocular surface infection

ABC OF EYESREFREACTIVE ERRORS – Contact Lenses

Complications

Corneal abscessCorneal abrasionsCorneal pannus

ABC OF EYESREFREACTIVE ERRORS – Refractive Surgery

RK ICR PRK LASIK CLE ICL Bioptics

ABC OF EYESEYELID, ORBITAL, and LACRIMAL

DISORDERS

ABC OF EYESEYELID DISORDERS - Lumps

Importance

May need disfiguring operation if leftMay be life threateningMay cause visual disturbanceMay cause amblyopia in childrenMay indicate systemic disease

ABC OF EYESEYELID DISORDERS - Lumps

Chalazion

ABC OF EYESEYELID DISORDERS - Lumps

Stye

ABC OF EYESEYELID DISORDERS - Lumps

Papilloma

ABC OF EYESEYELID DISORDERS - Lumps

Xanthelasma

ABC OF EYESEYELID DISORDERS - Lumps

Basal cell carcinoma

ABC OF EYESEYELID DISORDERS – Inflammatory disease

Blepharitis

ABC OF EYESEYELID DISORDERS – Inflammatory disease

Chalazion Stye Acute dacryocyctitis Allergy Herpes simplex Herpes zoster

ophthalmicus

ABC OF EYESEYELID DISORDERS – Malposition

Entropion

ABC OF EYESEYELID DISORDERS – Malposition

Ectropion

ABC OF EYESEYELID DISORDERS – Malposition

Trichiasis

ABC OF EYESEYELID DISORDERS – Malposition

Ptosis

May indicate a life threatening condition

May indicate a disease that needs systemic treatment

May cause irreversible amblyopia

ABC OF EYESORBITAL DISORDERS – Proptosis

Causes

Orbital cellulitisOrbital inflammatory

diseaseThyroid eye diseaseOrbital lymphomaLacrimal gland tumorsOrbital invasion from

adjacent sinusBig eye

ABC OF EYESORBITAL DISORDERS – Enophthalmos

Causes

Blowout fractureMicrophthalmosAtrophy of orbital

contentsCicatrizing orbital

lesions

ABC OF EYESLACRIMAL SYSTEM

ABC OF EYESLACRIMAL SYSTEM – Tear film

ABC OF EYESLACRIMAL SYSTEM – Watering eye

Excessive tears production

Punctal malposition Punctal stenosis Blockage

ABC OF EYESLACRIMAL SYSTEM – Dry eye

Symptoms

Causes

Diagnosis

Treatment

ABC OF EYESEYE INJURIES

ABC OF EYESEYE INJURIES

History

The mechanismThe circumstances

○ Injuries in children

ABC OF EYESEYE INJURIES

Examination

VAInspection

○ Lids○ Globe○ Pupil

Flurescein

ABC OF EYESEYE INJURIES

Corneal abrasions

ABC OF EYESEYE INJURIES

Foreign bodies

ABC OF EYESEYE INJURIES

Radiation damage (flash burn)

ABC OF EYESEYE INJURIES

Chemical burn

Irrigate, irrigate then irrigateRemove loose particlesBeware alkalisRefer patient to ophthalmic department

ABC OF EYESEYE INJURIES

Chemical burn

ABC OF EYESEYE INJURIES

Blunt eye injuries

ABC OF EYESEYE INJURIES

Blunt eye injuries

ABC OF EYESEYE INJURIES

Penetrating eye injuries

If suspected, the eye should be examined very gently

Special attention: history of high velocity injury

ABC OF EYESEYE INJURIES

Penetrating eye injuries

Signs to look for○ Distorted pupil

○ Cataract

○ Prolapsed uveal tissue

ABC OF EYESEYE INJURIES

Penetrating eye injuries

Protect the eye from any pressure and refer the patient immediately to the nearest eye department

ABC OF EYESACUTE VISUAL DISTURBANCE

ABC OF EYESACUTE VISUAL DISTURBANCE

HistoryOnsetOld or newPrevious ophthalmic

historyGeneral healthUnderstand the

disturbance○ VF loss○ Scotoma○ Distortion

FloatersFlashing lightsAmarosis fugaxZigzag linesHeadachePain on eye

movement

ABC OF EYESACUTE VISUAL DISTURBANCE

Examination

VAPupillary reactionRed reflexVF testingFundoscopy

ABC OF EYESACUTE VISUAL DISTURBANCE

Posterior vitreous detachment

The most common cause of floaters

Might be associated with flashes

May result in retinal hole and retinal detachment

Needs urgent referral

ABC OF EYESACUTE VISUAL DISTURBANCE

Vitreous Haemorrhage

Sudden onset of floaters and loss of vision

Common in diabeticsRefer to ophth. to clarify

the cause and treat underlying disease

ABC OF EYESACUTE VISUAL DISTURBANCE

Retinal detachmentFloaters and flashesVF lossVariable in VAMore likely to occur in

high myopic patients after trauma or intraocular operation

Common in PDR

Needs surgical intervention

ABC OF EYESACUTE VISUAL DISTURBANCE

Arterial occlusion

Occlusion of the retinal artery may be caused by Arteriosclerotic changesEmbolus (from heart or carotid artery)Inflammation (rare)

ABC OF EYESACUTE VISUAL DISTURBANCE – Arterial Occlusion

History

Sudden painless visual loss which may be complete (due to central retinal artery occlusion) or partial (due to branch retinal artery occlusion)

Patient usually have a history of hypertension or heart disease

ABC OF EYESACUTE VISUAL DISTURBANCE – Arterial Occlusion

Examination

The visual acuity is reduced in CRAO but may be normal in BRAO

Relative afferent pupillary defect is present in CRAO

The retinal arteries are narrow or collapsed.  In CRAO, the fovea shows a cherry-red spot

against the white infarcted retina.  In BRAO, the white infarcted retina corresponds

to the occluded retina.  Emboli may be seen in the arteries if the cause

is emboli

ABC OF EYESACUTE VISUAL DISTURBANCE – Arterial Occlusion

Management

Immediate referral if the visual loss is less than 6 hours. 

Intravenous acetazolamide and globe massage to lower the intraocular pressure and hopefully re-establish the arterial flow.

Cardiovascular assessment.

An ESR is usually performed in the absence of obvious embolus to exclude arteritic causes.

Long term low dose aspirin is advised to reduce the risk of occurrence

ABC OF EYESACUTE VISUAL DISTURBANCE – Arterial Occlusion

ABC OF EYESACUTE VISUAL DISTURBANCE –Venous Occlusion

Retinal vein occlusion is a common vascular disorder caused by impaired venous blood flow.

It is second only to diabetes mellitus as a vascular cause of impaired vision

Hyperviscosity of the blood and hypertension are common causes

ABC OF EYESACUTE VISUAL DISTURBANCE –Venous Occlusion

History

Sudden onset painless blurred vision The patient might experience a visual field

defect

ABC OF EYESACUTE VISUAL DISTURBANCE –Venous Occlusion

ExaminationThe visual acuity is reduced in CRVO. However,

the reduction is dependent on the severity of the occlusion.

In BRVO, the visual acuity may be normal if the fovea is not involved. 

Relative afferent pupillary defect may be present in patient with severe CRVO

Ophthalmoscopy reveals extensive intraretinal and pre-retinal hemorrhage with distended retinal veins.

ABC OF EYESACUTE VISUAL DISTURBANCE –Venous Occlusion

ManagementRefer within 24 hours. Identify and treat any underlying causeAntiplatelets therapyFollow-up in the clinic is arranged so that those

at risk of neovascular glaucoma may be treated with PRP

ABC OF EYESACUTE VISUAL DISTURBANCE –Venous Occlusion

ABC OF EYESACUTE VISUAL DISTURBANCE – Disciform MD

History

Sudden onset of disturbance in the central vision

Elderly are usually affectedCaused by choroidal neovascular membrane

leak or hemorrhage

ABC OF EYESACUTE VISUAL DISTURBANCE – Disciform MD

Examination

VA depends on the extent of macular involvement

Distorted line on Amsler chartFundoscopy and FFA

ABC OF EYESACUTE VISUAL DISTURBANCE – Disciform MD

ABC OF EYESACUTE VISUAL DISTURBANCE – Disciform MD

Management

LaserPhotodynamic therapyLucentis and AvastinVitamins and mineralsSurgery

ABC OF EYESACUTE VISUAL DISTURBANCE – Optic Neuritis

History

Sudden unilateral Loss of visionCentral VF lossAge 20-40 (usually woman)Pain that worsen on eye movementH/o previous attacksSymptoms of MS

ABC OF EYESACUTE VISUAL DISTURBANCE – Optic Neuritis

ExaminationVA from 6/6 to PLAPDColor vision disturbancesCentral scotomaNormal or swollen optic nerve head

ABC OF EYESACUTE VISUAL DISTURBANCE – Optic Neuritis

Management

Usually spontaneous recovery

Steroids in selected cases

SOL should be ruled out in uncertain cases

ABC OF EYESGRADUAL VISUAL DISTURBANCE

ABC OF EYESGRADUAL VISUAL DISTURBANCE

HistoryOnsetOld or newPrevious ophthalmic historyGeneral healthUnderstand the disturbance

○ VF loss○ Scotoma○ Distortion

ABC OF EYESGRADUAL VISUAL DISTURBANCE - Causes

Refractive errors

Longstanding historyPinhole test

ABC OF EYESGRADUAL VISUAL DISTURBANCE - Causes

Corneal disease

ABC OF EYESGRADUAL VISUAL DISTURBANCE - Causes

Cataract

ABC OF EYESGRADUAL VISUAL DISTURBANCE - Causes

Age related macular degeneration

ABC OF EYESGRADUAL VISUAL DISTURBANCE - Causes

Macular hole

ABC OF EYESGRADUAL VISUAL DISTURBANCE - Causes

Diabetic maculopathy

ABC OF EYESGRADUAL VISUAL DISTURBANCE - Causes

Hereditary retinal degeneration

ABC OF EYESGRADUAL VISUAL DISTURBANCE - Causes

Compressive lesions of optic pathways

ABC OF EYESGRADUAL VISUAL DISTURBANCE - Causes

Drugs

AlcoholSmokingChloroquineTetracyclineSteroids

ABC OF EYESGRADUAL VISUAL DISTURBANCE - Cataract

Causes of acquired cataract

AgeDiabetesInflammationTraumaSteroids

ABC OF EYESGRADUAL VISUAL DISTURBANCE - Cataract

Indications for surgery

No need to wait far a cataract to be matureNo set level of visionDepends on the patient's needs

ABC OF EYESGRADUAL VISUAL DISTURBANCE - Cataract

Surgical techniquesPhacoemulsification

ABC OF EYESGRADUAL VISUAL DISTURBANCE - cataract

Extracapsular method

ABC OF EYESGRADUAL VISUAL DISTURBANCE - Cataract

Intracapsular method

ABC OF EYESGRADUAL VISUAL DISTURBANCE - Cataract

Complications of cataract surgery

Intraoperative○ Ocular perforation○ Subconjunctival hemorrhage○ Suprachoroidal hemorrhage○ Iris prolapse○ Posterior capsular tear○ Vitreous loss

ABC OF EYESGRADUAL VISUAL DISTURBANCE - Cataract

Complications of cataract surgery

Postoperative○ Infective endophthalmitis○ Retinal detachment○ Residual refractive error○ Uveitis○ Cystoid macular edema○ Glaucoma○ Posterior capsular opacification

ABC OF EYESGRADUAL VISUAL DISTURBANCE - Cataract

Optical correction after surgery

GlassesContact lensesSecondary IOL implantation

ABC OF EYESGLAUCOMA

ABC OF EYESGLAUCOMA

A progressive damage of the optic nerve which might be associated with increased intraocular pressure

The commonest cause of irreversible blindness

ABC OF EYESGLAUCOMA

ABC OF EYESGLAUCOMA

ABC OF EYESGLAUCOMA

Symptoms & signsRaised IOP

ABC OF EYESGLAUCOMA

Symptoms & signsHaloes

ABC OF EYESGLAUCOMA

Symptoms & signsCloudy cornea

ABC OF EYESGLAUCOMA

Symptoms & signsPain

ABC OF EYESGLAUCOMA

Symptoms & signsVisual field loss

ABC OF EYESGLAUCOMA

Symptoms & signsOptic disc changes

ABC OF EYESGLAUCOMA

Symptoms & signsVenous occlusion

ABC OF EYESGLAUCOMA

Symptoms & signsEnlargement of the eye

ABC OF EYESGLAUCOMA – Primary Open Angle Glaucoma

Symptoms

No symptoms until sever damage occursBest detected by screening

ABC OF EYESGLAUCOMA – Primary Open Angle Glaucoma

Risk factors

AgeingPositive family historyBlack raceLevel of IOPMyopiaThin corneas

ABC OF EYESGLAUCOMA – Primary Open Angle Glaucoma

Signs

Optic nerve cuppingAsymmetryOptic disc hemorrhagesVF lossIncreased IOP

ABC OF EYESGLAUCOMA – Acute Angle Closure Glaucoma

ABC OF EYESGLAUCOMA – Acute Angle Closure Glaucoma

Symptoms

Red painful eye HeadachesNausea and vomitingBlurred visionHaloesH/o previous attacks

ABC OF EYESGLAUCOMA – Acute Angle Closure Glaucoma

Groups at risk

HypermetropesOld ageFemale patient

ABC OF EYESGLAUCOMA – Acute Angle Closure Glaucoma

Signs

Decreased VACorneal edemaSemidilated pupil poorly reacted to lightPalpation = eye hard and tender

ABC OF EYESGLAUCOMA – Acute Angle Closure Glaucoma

Management

Admit to hospitalAcetazolamide IV 500mgTopical Timolol drops 0.5%Pilocarpine 4% dropsManitol 20%YAG laser PISurgical PI IridoplastyDrainage procedure

ABC OF EYESGLAUCOMA – Other types of Glaucoma

Inflammatory Steroid induced Rubeotic glaucoma Post traumatic Congenital Postoperative

ABC OF EYESGLAUCOMA – Medical Treatment

The aim of the treatment is to reduce the IOP to stop the progression of optic nerve damage

ABC OF EYESGLAUCOMA – Medical Treatment

B – blockersTimololBetaxolol

Sympathomimetic agentsAdrenalinBrimonidin

Carbonic anyhdrase inhibitorsDorzolamideAcetazolamide

Parasympathomimetic agentsPilocarpine

Prostaglandin analoguesLatanoprostTravoprostBimatoprost

ABC OF EYESGLAUCOMA – Laser Treatment

Laser trabeculoplasty

Laser iridotomy

Laser iridoplasty

Laser ciliary body ablation

ABC OF EYESGLAUCOMA – Surgical Treatment

Iridectomy Drainage procedure

ABC OF EYESGLAUCOMA – Surgical Treatment

Complications

Failure ( scarring )HypotonyCataractReduction in BCVAEndophthalmitis