None-urgent eye problems David Kinshuck, associate specialist David Kinshuck, Good Hope Hospital,

None-urgent eye problems

David Kinshuck, associate specialistDavid 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

AdultscataractsArmd...age-related macular degenerationGlaucomaDiabetic retinopathyOthers (retinal vein occlusion, inherited retina, corneal etc)

childrenSquintsWatery eyeCataractsGlaucomararer

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

www.occhioallaretina.it/Immagini/leucocoria.JPG

http://oftalmologo.bravepages.com/Leucocoria%201.jpg

?retinoblastoma

Cataracts...operation

Linkhttp://www.goodhopeeyeclinic.org.uk/eyecataractpatient.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 dohttp://medweb.bham.ac.uk/easdec/dmret.htmlhttp://medweb.bham.ac.uk/easdec/mechanismanimation.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.goodhopeeyeclinic.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 patient• B optometrist

Glaucoma, loss of visual field

• Visual loss over years• 2/3 chronic glaucoma has

a high pressure…pressure is detected by whom

• A patient• B optometrist

Glaucoma, in pairs, which normal eye, 30s

http://www.goodhopeeyeclinic.org.uk/glaucomacase3.htm

A B

Glaucoma, in pairs, which normal eye, 30s

http://www.goodhopeeyeclinic.org.uk/glaucomacase3.htm

1. Vessels deviated nasally

2. Pale central area with cribriform pits

3. thin rim4. Other minor changes

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 N• Are there symptoms early N• Examining the eye

–Cupped disc Y–Raised pressure 66% Y–Examine angle at onset Y–Visual field Y–Yearly checks 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 detachment1. 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

TNCEN

OTNCLOXEWTYURNG

TYURNG

TYURNG

6/606/36

6/246/186/126/9

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=yyIA-dl49Lg

3rd nerve palsy

In pairs...what is this?

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

3rd nerve palsy

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

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

3rd nerve palsy

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

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.dryeye.org/images/colorbar.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=retinitis-pigmentosa

Summary, go round the room 1. .2. .3. .4. .5. .6. .7. .8. .9. .10. .11. .12. .13. .14. .15. .16. .17. .