4. Refractive Errors
Disorders of the lids
Conjunctivitis
Corneal disorders
Episcleristis / Scleritis
Sub Conjunctival Haemorrhages
Dry eye syndrome
Cataracts
Glaucoma
Uveitis
Disorders of the retina
Loss of vision
Amarausis Fugax
Temporal arteritis
Hypertensive changes in the retina
Diabetic eye disease
Strabismus
5.
6.
7. Eye Condition Treatment (spectacles, contact
lenses or excimer laser)
Emmetropia Normal refraction of the cornea
and lens
Myopia Short sightedness Corrective– Concave lenses
Hypermetropia Long sightedness Convex lenses
Presbyopia The ability of the lens to change the
convexity is lost after the fourth
decade of life – causing difficulties
with near vision
Bifocals
Astigmatism The eye is not the same curvature
of radius for refraction. (e.g.
myopic in one plane and
emmetropic in the other)
Cylindrical lenses corrected
according to the axis
12. Conditions Treatment
Entropion Inward rolling of the lid margins
Rubbing of the eye lashes
against the globe
Irritation
Mimics conjunctivitis
Surgical Correction
Ectropion The eyelid margins are not
apposed to the globe
Lacrimal puncta cannot drain
tears
Causes a watery eye
Surgical treatment
Dacrocystitis Inflammation of the lacrimal
sac
Presents as a painful lump by
the side of the nose
Broad spectrum antibiotics
Ophthalmologist referral for
surgical treatment
Blepharitis Inflammation of the eyelid
margin
Stye- Inflammation of the
eyelashes and lash follicles
Chalazion -Inflammation and
blockage of the Meibomian
glands
Lid toilet
Topical antibiotics –
Chloramphenicol or Fusidic
acid
If orbital cellulitis – Broad
spectrum antibiotics
If residual lump – Incision and
13.
14.
15.
16.
17.
18.
19. Commonest cause of Red eye
Causes: Viral, Bacterial, Chlamydial, Allergic
Clinical features:
◦ Redness
◦ Soreness (sandy gritty sensation)
◦ Discharge
◦ Vision not impaired
◦ Usually bilateral involvement
20. Aetiology Dischar
ge
Preaur
icular
node
Corneal
Involve
ment
Comment Treatment
Bacterial (5%)
(Gonococcus -
copious
H. Influenzae
S.
Pneumoniae
Staphylococcu
s
Moraxella)
Mucopurule
nt
-ve
except
gonococc
i
+ve
Gonococcu
s
Rapid onset
Gonococcal infection in the
neonate – symptoms occur
within 2 days of birth
Gonococcal –
Conjunctival swab
shows diplococci
Treated with Oral and
Topical Penicillin
Chloramphenicol
Viral
Adenovirus
HSV 1
commonly
Molluscum
Contagiosum
Watery +ve +ve
Adenovirus
50% Unilateral
Cold and / or sorethroat
Ass. With chemosis, lid oedema
May cause blurring of vision
due to corneal involvement
Adenoviral – Very contagious
Dendritic corneal ulcer
HSV – Vesicles around the eye
Molluscum – umbilicated lesions
on eyelids
Adenoviral – Self
limiting
Lubricants
Cold compress
Prevent cross
infection
If intense – may
require steroids
HSV – Self limiting
Some may use
Aciclovir topically
Molluscum-
Ophthalmologist
referral for surgical
treatment
If severe - Steroids
21. Aetiology Discharge Preauricular
node
Corneal
Involvem
ent
Comment Treatment
Chlamydial
(Chlamydia
trachomatis)
Watery + ve +ve GU discharge
Slow onset of
symptoms
Sexually transmitted
(in active individuals)
Neonatal – with
maternal reproductive
tract secretions (2
weeks)
Trachoma –blindness
Topical
erythromycin bd
Adolescents and
adults to GU
surgeon
Neonates to
paediatrician to
exclude
associated
pneumonitis or
otitis
Allergic
Seasonal
Perinnial
Stringy/ sticky -ve +ve Itchy Avoidence of
allergens
Topical anti-
histamines like
azelastine
Topical mast cell
stabilizer like Na
Chromoglicate
Steroids avoided
generally
25. Condition Features Treatment
Corneal Abrasions – a
focal area of the
epithelium gets rubbed
away
Intense pain
Inability to open the eye
(blepharospasm)
Lacrimation
Visual acuity reduced
Ex: may require topical anaesthetic
(Tetracaine)
Use Florescin (orange) dye with a blue
lamp examination to identify the
abrasion (in green colour)
G. Chloramphenicol qds X 5
days
Pad the eye X 24 hours
Corneal Foreign
body
e.g. flies
Lacrimation
Photophobia
Remove gently with copious
amounts of saline
Topical antibiotics
(Choramphenicol and Fusidic
acid)
Direct Trauma FB may be visible
Flat anterior chamber
Hyphaemia (Blood in anterior
chamber) SCH
Brusing if associated blunt trauma
Instill no drops
Refer to an ophthalmologist
urgently
26.
27. Corneal inflammation
Causes: HSV infection, Contact lens, blepharitis
Cilnical features: Redness, Pain, Lacrimation,
Sensation of a foreign body, photophobia
HSV- Dendritic ulcer
◦ The Virus remains dorment in the CN V
◦ Gets activated in immunosuppression
◦ Can lead to a geographical ulcer
28. Contact Lens Keratitis
◦ Can be life threatening
◦ Urgent referral to an ophthalmologist
Blepharitis
◦ Staphelococcus aureus is responbible for most of the
cases
◦ Rx: with Chloramphenicol
29. Episcleritis (between the conjunctiva and the sclera)
Localized, deep redness
Tender area +/-
Not painful
No discharge
Normal vision
No photophobia
Normal pupils and cornea
Rx: topical/oral steroids
Scleritis
Symptoms are intense
Painful loss of vision
Severe form associated with Rheumatoid arthritis causes Scleromalacia
perforans
Urgent referral
30. Symptoms – A bright red eye due to a bleed beneath the
conjunctiva caused by rupture of a small blood vessel
Causes –
◦ Raised intracranial pressure (Coughing, sneezing)
◦ Trauma
◦ Violent rubbing
◦ Bleeding disorders or anticoagulants (recurrent)
◦ Hypertension
Management
◦ Control of the cause
◦ Mild analgesics
◦ Eye lubricants
◦ Reassurance of resolution within weeks
◦ Make sure the line doesn't extend beyond the visible sclera (may be
associated with orbital fracture)
33. Cause Conjunct
iva
Injection
Unilater
al/Bilater
al
Pain Photoph
obia
Vision Pupil Intraocul
ar
pressure
Conjunctiv
itis
Diffuse Bilateral
(in
Bacterial)
Gritty Occasiona
lly with
Adenoviru
s
Normal Normal Normal
Anterior
Uveitis
Circum-
corneal
Unilateral Painful Yes Reduced Constricte
d
Normal or
raised
Acute
Glaucoma
Diffuse Unilateral Severe Mild Reduced Mild
dilated
Raised
37. Commonest cause of reversible blindness
The commenest surgical procedure so far
Aetiology
◦ Senile (legal blindness <6/12)
◦ Congenital – Maternal infection, Familial
◦ Metabolic – Diabetes, galactosaemia, Wilson’s disease,
hypocalcaemia
◦ Drug induced – Corticosteroids, amiodarone
◦ Traumatic
◦ Inflammatory – Uveitis
◦ Disease associated – Down’s, Dystrophia myotonica
38. Clinical features –
◦ Gradual painless deterioration of vision is the
commonest symptom
◦ Problems with night vision
◦ Glare – Common with posterior subcapsular cataract
Investigations
◦ Diabetes
◦ Hypocalcaemia
Management
◦ Early detection and ophthalmologist referral is essential in the
infants to prevent development of amblyopia later on in life
◦ Correction of the aetiological factor
◦ Mild cases – spectacles
◦ If opacified – Extraction of cataracts and intra ocular lens
insertion
Most popular – Phacoemulsification
39. Elevation of the internal pressure of the eye
>21mmHg
◦ (Normal : 10-21mmHg)
Second commonest cause of blindness – via optic
nerve damage
◦ Mainly visual field defects
40. Primary open angle Glaucoma Acute angle closure glaucoma
Commonest Ophthalmic emergency – Acute rise of pressure
>50mmHg
Aetiology Due to blockage of the trabecular
meshwork, drainage of aqueous
humor is impeded
Pushing of the lens anteriorly pressing against the
meshwork
Commonly when the pupil is maxiamaly dilated
Risk factors Elderly
Black race
Family history
Myopia
Elderly –
Shallow anterior chambers in Women and
Hypermetropics
Clinical
features
Gradual painless loss of peripheral
visual field
Red painful eye
Headache
Nausea, Vomiting
Eye is injected, hard and tender
Haziness of cornea
Diagnosis Ophthalmoscopy – Cupping of the
fundus
IOP measurement is the definitive
IOP measurement or clinically
Treatment Reduction of AH production –
Topical Timolol and Acetozolamide
(Topical and Oral)
Increasing the drainage of AH -
Prostaglandin analogues
(Travoprost)
Emergency referral to an ophthalmologist
Analgesic
Antiemetics
(IV Acetozolamide
Pilocarpine to constrict pupils
Prostaglandin analogues, Beta blockers
IV Mannitol if resistant
43. Classical Triad
◦ Redness (genaralized)
◦ Pain
◦ Photophobia
Signs
◦ Cells with keratic precipitates in the anterior chamber, pus
◦ IOP may be raised due to the cells clogging up the There may be
posterior synechiae
◦ trabecular meshwork
Treatment
◦ Ophthalmologist referral
◦ Dexamethasone 0.1% topically
◦ Cyclopentolone to prevent posterior synechiae also allowing
fundoscopy
◦ Mx of raised IOP
44.
45. Central Retinal Vein
Occlusion
Central Retinal Artery
Occlusion
Retinal
detachment
Age related
macular
degeneration
Symptoms Sudden profound painless
loss of vision of one eye
Sudden profound painless
loss of vision of one eye
Painless
progressive visual
field loss
Floaters and
flashes prior to
detachment
Progressive loss
of central vision
Pathogenesis Obstruction of venous
outflow and increased
intravascular pressure
leading to dilated veins,
retinal haemorrhages,
retinal oedema and cotton
wool spots
Results in infarction of the
inner 2/3 of the retina
90 minutes
Oedema of the retina
thinning
Cherry red spot
The area of visual
field loss
corresponds to the
area of detachment
of the retina
Lipofucin
deposits can be
seen deposited
under the retina
Risk Factors DM, HT, Cardiovascular
disease, Glaucoma,
Vasculitis and Blood
dyscrasias
DM, HT, Cardiovascular
disease, Glaucoma,
Vasculitis and Blood
dyscrasias
Elderly
Smoking
HT
Hypercholestera
emia
UV exposure are
suggested
Treatment Rx underlying condition
Refer to ophthalmologist
Emergency referral
Ocular massage
Breathing into a bag
CO2 Vasodilatation
Dislodging of Emboli
Iv Acetazolamide
Paracentesis
Urgent referral to
the ophthalmologist
Referral to the
ophthalmologist
Modification of
risk factors
46.
47.
48.
49.
50. Sudden Transient Loss of Vision in one eye.
Due to thromboembolism
Embolus may be visible at ophthalmoscopy during an
attack
Implications:
◦ May be the first evidence of internal carotid artery stenosis
◦ Hamiparesis may follow
◦ DD: Migraine, GCA
51. Common in elderly
Presentation: Sudden painless loss of unilateral vision
(May have preceded by Amaurosis fugax)
◦ May proceed to bilateral disease
Associations:
◦ Severe unilateral temporal headache (along the distribution of the
artery with features of inflammation). The artery is thickened and
pulseless
◦ Severe facial pain in chewing
◦ IHD, microangiopathic neuropathy
Management
◦ Ix: ESR elevated
◦ Diagnosis confimed by : Bx
◦ Rx: High dose steroids
52.
53. Painless Painful
Cataract Acute angle closure glaucoma
Open angle glaucoma Giant cell arteritis
Retinal detachment Optic neuritis
Central retinal vein occlusion Uveitis
Central retinal artery occlusion Scleritis
Diabetic retinopathy Keratitis
Vitreous Haemorrhage Shingles
Age related macular degeneration Orbital cellulitis
Optic nerve compression Trauma
Cerebrovascular disease
54. Keith Wagener Classification of Hypertensive
Retinopathy
◦ Grade 1 – Tortuosity of the retinal arteries with increased
reflectiveness “Silver wiring”
◦ Grade 2- Grade 1+ “Arteriovenous nipping”
55. ◦ Grade 3 – Grade 2 + Flame shaped haemorrhages and
Cotton wool spots
◦ Grade 4 - Grade 3 + Papilloedema (blurring of the optic
disc margin
57. Diabetic retinopathy – A microvascular
complication
Cataract
External Ocular palsies
Sixth and third cranial nerve palsies
◦ CN III palsies recover within a period of 3-6 months
58. Progression of the disease is rapid in type 1 >type
2 diabetics
Types
I. Background retinopathy
II. Preproliferative and proliferative retinopathy
III. Maculopathy
IV. Mixed retinopathy
59. ◦ Dot haemorrhages - Microaneurysms
◦ Blot hamemorrhages - Intra retinal haemorrhages
◦ Cotton wool spots – Micro infarcts (lasts longer than
those due to HT)
60. Retinal ischaemia Neovascularization
fibrous tissue forming around the new vessels
62. Many features mentioned above present together
Rx:
◦ Aggressive control of glycaemia
◦ Ophthalmologist referral (surgical procedures e.g laser
photocoagulation)
63. Mal alignment of the two eyes/ visual axi
Cause : Poor coordination of the extra ocular muscles
groups
Due to: e.g. CP, syndromes like Noonan, stroke, botulism,
diabetes
Implications:
◦ Cosmesis
◦ Diplopia
◦ Amblyopia (Lazy eye)
Tests: Corneal light reflex, Cover-uncover test (read)
Treatment:
◦ Spectacles
◦ Cover the better eye to improve the amblyopic eye
◦ Ophthalmologist (Muscle surgery)
64.
65.
66. Kumar and Clark – Clinical Medicine
Medscape
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