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Ophthalmic review for GP

Ophthalmic review for the General Practitioner

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Ophthalmic review for GP

  1. 1. Ophthalmic reviewOphthalmic review forfor General PractitionersGeneral Practitioners Dr. Riyad G. BanayotDr. Riyad G. Banayot
  2. 2. EyelidsEyelids Applied anatomy Stye and chalazion Blepharitis Madarosis & Poliosis Diffuse eyelid disease Benign eyelid lesions Malignant eyelid tumors
  3. 3. Applied anatomyApplied anatomy Cross section of lower eye lid
  4. 4. Eye Lid RednessEye Lid Redness External Hordeolum - Stye  Infection of lid gland  Local pain redness and swelling  No need to refer  Treatment: compresses, topical antibiotic
  5. 5. Eye Lid RednessEye Lid Redness Chalazion  Granulomatous inflammation of Meibomian gland  Slow course - months  Compresses at onset; antibiotics no benefit  If non-resolving refer electively for transconjunctival incision & curettage
  6. 6. Treatment of chalazion Injection of local anaesthetic Insertion of clamp Incision and curettage
  7. 7. Eye Lid RednessEye Lid Redness Blepharitis - staphylococcal  Chronic infection with periodic flare-ups  Staphylococcal or seborrheic  Irritation, burning and itching  Scales or crusting on lashes  Treatment: lid hygiene & topical antibiotics Staphylococcal
  8. 8. Eye Lid RednessEye Lid Redness Blepharitis - seborrheic  Chronic infection with periodic flare-ups  Staphylococcal or seborrheic  Irritation, burning and itching  Greasy scales or lashes stuck together  Treatment: lid hygiene & topical antibiotics seborrheic
  9. 9. Madarosis Local causes • Chronic anterior lid margin disease • Infiltrating tumours • Burns, radiotherapy or cryotherapy Systemic causes • Generalized alopecia • Myxoedema • SLE • Syphilis • Leprosy Following removal Decrease in number or complete loss of lashes
  10. 10. Poliosis Premature localized whitening of hair Ocular associations • Chronic anterior blepharitis • Sympathetic ophthalmitis • Vogt-Koyanagi-Harada syndrome • Waardenburg syndrome Systemic associations
  11. 11. Diffuse eyelid diseaseDiffuse eyelid disease Acute allergic edema Contact dermatitis Atopic dermatitis Systemic causes of lid edema
  12. 12. Acute allergic oedemaAcute allergic oedema • Causes - insect bites, urticaria and angioedema • Unilateral or bilateral • Painless, red, pitting oedema • Chemosis may be present • Self-limiting
  13. 13. Contact dermatitisContact dermatitis • Sensitivity to topical medication • Unilateral or bilateral • Painless oedema and erythema • Vesiculation and crusting • Thickening if chronic
  14. 14. Atopic dermatitisAtopic dermatitis • Associated with asthma and hay fever • Chronic itching and scratching Facial - in young children Flexural - knees, elbows, wrists and ankles
  15. 15. Ocular associations of atopic dermatitisOcular associations of atopic dermatitis Angular blepharitis Vernal disease Thickening, crusting and fissuring Staph. blepharitis
  16. 16. Ocular associations of atopic dermatitisOcular associations of atopic dermatitis KeratoconusKeratoconjunctivitis Shield-like cataract Retinal detachment
  17. 17. Systemic causes of lid oedemaSystemic causes of lid oedema • Myxoedema • Renal disease • Congestive heart failure • Obstruction of superior vena cava • Fabry's disease
  18. 18. Benign eyelid lesionsBenign eyelid lesions Xanthelasma Capillary hemangioma Naevus flammeusNaevus flammeus
  19. 19. XanthelasmaXanthelasma • Usually bilateral and located medially • Common in elderly or those with hypercholesterolemia • Yellowish, subcutaneous plaques containing cholesterol and lipid
  20. 20. Capillary haemangiomaCapillary haemangioma • Rare tumour which presents soon after birth • Starts as small, red lesion, most frequently on upper lid • Blanches with pressure and swells on crying • Grows quickly during first year • May be associated with intraorbital extension • Begins to involute spontaneously during second year
  21. 21. Periocular haemangiomaPeriocular haemangioma • Steroid injection in most cases • Surgical resection in selected cases • High-out heart failure Treatment options Occasional systemic associations • Kasabach-Merritt syndrome - thrombocytopenia, anemia and reduced coagulant factors • Maffuci syndrome - skin haemangiomas, endrochondromas and bowing of long bones
  22. 22. Port-wine stain (naevus flammeus)Port-wine stain (naevus flammeus) • Rare, congenital subcutaneous lesion • Segmental and usually unilateral • Does not blanch with pressure • Ipsilateral glaucoma in 30% • Sturge-Weber or Klippel-Trenaunay-Weber syndrome in 5% Associations
  23. 23. Malignant eyelid tumorsMalignant eyelid tumors Basal cell carcinoma Squamous cell carcinoma Meibomian gland carcinoma Melanoma Kaposi sarcoma
  24. 24. Basal Cell Carcinoma (BCC)Basal Cell Carcinoma (BCC) 1. Most common human malignancy 2. Usually affects the elderly 3. Slow-growing, locally invasive 5. 90% occur on head and neck 6. Of these 10% involve eyelids 7. Accounts for 90% of eyelid malignancies 4. Does not metastasize
  25. 25. Frequency of location of BCCFrequency of location of BCC Lower lid - 70% Medial canthus - 15% Upper lid - 10% Lateral canthus - 5%
  26. 26. Nodular BCCNodular BCC Early • Shiny, indurated nodule • Surface vascularization • Slow progression Advanced • May destroy large portion of eyelid
  27. 27. Ulcerative BCCUlcerative BCC (rodent ulcer)(rodent ulcer) Early Chronic ulceration Advanced Raised rolled edges and bleeding
  28. 28. Sclerosing BCCSclerosing BCC • Indurated plaque with loss of lashes Advanced • Spreads radially beneath normal epidermis Early • May mimic chronic blepharitis • Margins impossible to delineate
  29. 29. Squamous cell carcinomaSquamous cell carcinoma • Predilection for lower lid • Hard, hyperkeratotic nodule • Less common but more aggressive than BCC • May develop crusting fissures • May arise de novo or from actinic keratosis Ulcerative • No surface vascularization • Red base • Borders sharply defined, indurated and elevated Nodular
  30. 30. Meibomian gland carcinoma Spreading Nodular • Very rare aggressive tumour with 10% mortality • Predilection for upper lid Hard nodule; may mimic a chalazion Very large tumour Diffuse thickening of lid margin and loss of lashes Conjunctival invasion; may mimic chronic conjunctivitis
  31. 31. MelanomaMelanoma From lentigo maligna (Hutchinson freckle) Nodular • Blue-black nodule with normal surrounding skin • Plaque with irregular outline • Variable pigmentation • Affects elderly • Slowly expanding pigmented macule• May be non-pigmented Superficial spreading
  32. 32. Kaposi sarcomaKaposi sarcoma AdvancedEarly Pink, red-violet lesion • Vascular tumour occurring in patients with AIDS • Usually associated with advanced disease • Very sensitive to radiotherapy May ulcerate and bleed
  33. 33. Treatment OptionsTreatment Options 3. Cryotherapy 2. Radiotherapy • Small BCC not involving medial canthus 1. Surgical excision • Method of choice • Small and superficial BCC irrespective of location • Adjunct to surgery in selected cases • Kaposi sarcoma
  34. 34. Applied anatomyApplied anatomy Orbital septum which separates the anterior structures from the orbit
  35. 35. Eye RednessEye Redness Cellulitis  Preseptal cellulitis – Same as cellulitis anywhere else – No orbital signs – No need to refer
  36. 36. Eye RednessEye Redness Cellulitis  Orbital cellulitis – Proptosis, restricted extraocular movements, pain – Urgent referral for IV antibiotics – CT helps differentiate preseptal form
  37. 37. Applied anatomyApplied anatomy
  38. 38. Congenital nasolacrimal duct obstructionCongenital nasolacrimal duct obstruction Acute dacryocystitisEpiphora and matting
  39. 39. Congenital nasolacrimal ductCongenital nasolacrimal duct obstructionobstruction
  40. 40. Eye RednessEye Redness Nasolacrimal Duct Obstruction  Dacryocystitis (acute/chronic) if infected  Swelling or abscess in lower inner canthus – Depending on severity, may need hospitalization – Referral is required – Initial treatment: IV or PO Antibiotics +/- external drainage
  41. 41. Eye RednessEye Redness  Laceration – Usually requires referral – Assume all lacerations medial to punctum involve lacrimal drainage system – Canalicular lacerations should be repaired within 24 hours Intubation of the lacrimal system following repair of torn upper and lower canaliculi
  42. 42. ConjunctivitisConjunctivitis  Bacterial  Chlamydial  Adult  Neonatal  Trachoma  Viral  VKC  Atopic Keratoconjunctivitis  Allergic  Ophthalmia neonatorum
  43. 43. ConjunctivitisConjunctivitis Irritation FB sensation Photophobia Diffuse redness Tearing
  44. 44. Bacterial ConjunctivitisBacterial Conjunctivitis Exudate: Pus Scraping: PMNs Preauricular Lymph nodes: Not palpable
  45. 45. Adult chlamydial keratoconjunctivitisAdult chlamydial keratoconjunctivitis Treatment • Infection with Chlamydia trachomatis serotypes D to K • Concomitant genital infection is common Subacute, mucopurulent follicular conjunctivitis Variable peripheral keratitis - topical tetracycline and oral tetracycline or erythromycin
  46. 46. Neonatal chlamydial conjunctivitisNeonatal chlamydial conjunctivitis Treatment • May be associated with otitis, rhinitis and pneumonitis • Presents between 5 and 19 days after birth Mucopurulent papillary conjunctivitis - topical tetracycline and oral erythromycin
  47. 47. Trachoma Treatment - systemic azithromycin • Infection with serotypes A, B, Ba and C of Chlamydia trachomatis • Fly is major vector in infection & re-infection cycle Acute follicular conjunctivitis Conjunctival scarring (Arlt’s line) Herbert pits Pannus formation Trichiasis Entropion Progression
  48. 48. Viral ConjunctivitisViral Conjunctivitis Usually bilateral, acute watery discharge and follicles Subconjunctival haemorrhages & pseudomembranes if severe Exudate: Profuse watery Scraping: Mononuclear Preauricular Lymph nodes: Palpable
  49. 49. Vernal KeratoconjunctivitisVernal Keratoconjunctivitis (VKC) - (spring catarrh)(VKC) - (spring catarrh) Main symptoms: Intense ocular Itching Exudate: Profuse watery Scraping: Mononuclear Preauricular Lymph nodes: Palpable
  50. 50. Atopic keratoconjunctivitisAtopic keratoconjunctivitis • Typically affects young patients with atopic dermatitis • Eyelids are red, thickened, macerated and fissured • Infiltration of tarsal conjunctiva causing featureless appearance
  51. 51. Allergic ConjunctivitisAllergic Conjunctivitis Exudate: Watery +/- mucoid Scraping: Eosinophil Preauricular Lymph nodes: Not palpable
  52. 52. Ophthalmia NeonatorumOphthalmia Neonatorum Neonatal conjunctivitisNeonatal conjunctivitis  Contamination of infant’s eyes when passing through vagina and cervix  Gonococcus: – Rapid blindness, 2ry corneal ulceration – Onset 2-3 days after birth – Broad spectrum topical antibiotics  Chlamydia: – Less destructive, may last months – Onset 5-12 days – topical tetracycline and oral erythromycin
  53. 53. Subconjunctival HemorrhageSubconjunctival Hemorrhage  Common  Causes: trauma, operation, uncontrolled HTN, valsalva, cough, vomiting, straining maneuvers  No treatment; reassurance
  54. 54. Pingueculum / PterygiumPingueculum / Pterygium  Pingueculum: – On conjunctiva only  Pterygium: – Invading cornea  Chronic diseases / degeneration  Refer if symptomatic  Treatment: surgical excision – high recurrence rate
  55. 55. Immuno-bullous diseasesImmuno-bullous diseases Cicatricial pemphigoid Stevens-Johnson syndrome
  56. 56. Cicatricial pemphigoidCicatricial pemphigoid • Chronic and progressive • Typically affects elderly women • Increased prevalence of HLA-B12 Oral mucosal lesions in most cases Skin lesions are less common
  57. 57. Progression of ocular cicatricial pemphigoidProgression of ocular cicatricial pemphigoid Diffuse hyperemia Subepithelial fibrosis and shrinkage Symblepharon Pseudomembranes
  58. 58. Complications of ocular cicatricial pemphigoidComplications of ocular cicatricial pemphigoid Ankyloblepharon Corneal keratinization Metaplastic lashes Cicatricial entropion Obliteration of fornices 2ry bacterial keratitis
  59. 59. Stevens-Johnson syndromeStevens-Johnson syndrome • Acute, and self-limiting • Hypersensitivity to drugs or infection • Typically affects young men Lesions of oral mucosa and lips Maculopapules which may develop into target lesions Vesiculobullous, hemorrhagic and necrotic lesions
  60. 60. Ocular complications of Stevens-Johnson syndrome Transient conjunctivitis and lid crusting without sequelae membranous or pseudo- membranous conjunctivitis Focal fibrotic patches and occasionally symblepharon Metaplastic lashes
  61. 61. Applied anatomyApplied anatomy layers of precorneal tear film
  62. 62. Dry EyesDry Eyes  Chronic redness  Burning  No need to refer  Treatment: artificial tear drops
  63. 63. Applied anatomyApplied anatomy The cornea consists of the five layers: 1- epithelium 2- Bowman's layer 3- stroma 4- Descemet's membrane 5- endothelium
  64. 64. KeratitisKeratitis  Bacterial – Contact lens wearers – White infiltrate in cornea – Pain, reduced vision – Should be referred – Treatment: topical antibiotics
  65. 65. KeratitisKeratitis  Fungal – Frequently preceded by ocular trauma with organic matter – Grayish white infiltrate surrounded by feathery infiltrate in cornea – Pain, reduced vision – Should be referred – Treatment: topical antifungal agents & systemic therapy if severe
  66. 66. KeratitisKeratitis  Acanthamoeba – Contact lens wearers at particular risk – Anterior stromal infiltrates, ulceration, ring abscess & stromal opacification – Pain, reduced vision – Should be referred – Treatment: chlorhexidine or polyhexamethylenebiguanide
  67. 67. KeratitisKeratitis  Viral Herpes Simplex – Recurrent dendrites, corneal edema, iritis – Refer – Treatment: Acyclovir ointment
  68. 68. KeratitisKeratitis  Viral Herpes Zoster – V1 Dermatome – Dendrites, iritis, other ocular inflammation – Treatment: Oral Acyclovir; start and then refer
  69. 69. keratoconuskeratoconus Nipple cone Oval cone Globus cone Small and steep curve Larger and ellipsoidal Largest cone
  70. 70. Signs of keratoconusSigns of keratoconus Bilateral in 85% but asymmetrical Oil droplet reflex Prominent corneal nervesVogt striae Acute hydropsMunson signFleischer ring & scarring Bulging of lower lids on downgaze
  71. 71. Systemic associations of keratoconusSystemic associations of keratoconus Crouzon syndromeMarfan's syndrome Osteogenesis imperfecta Atopic dermatitis Down syndrome Ehlers-Danlos syndrome
  72. 72. Vortex keratopathyVortex keratopathy
  73. 73. Toxic maculopathyToxic maculopathy
  74. 74. Peripheral corneal involvement inPeripheral corneal involvement in rheumatoid arthritisrheumatoid arthritis • Chronic and asymptomatic • Circumferential thinning with intact epithelium (‘contact lens cornea’) • Acute and painful • Circumferential ulceration and infiltration Treatment - systemic steroids and/or cytotoxic drugs Without inflammation With inflammation
  75. 75. Rosacea keratitisRosacea keratitis Peripheral inferior vascularization Subepithelial infiltration Thinning and perforation if severe • Affects 5% of patients with acne rosacea • Bilateral and chronic Progression Treatment - topical steroids and systemic tetracycline or doxycycline
  76. 76. Metabolic KeratopathyMetabolic Keratopathy
  77. 77. Corneal Foreign BodyCorneal Foreign Body If metal striking-metal is the mechanism of injury always get an X-Ray/CT scan of skull (This is mandatory if there is an open globe injury or suspicion of entry wound) Superficial corneal FB can be removed with Q-tip or needle tip, otherwise refer Rust rings develop after initial removal
  78. 78. UV burnUV burn
  79. 79. Applied anatomyApplied anatomy The scleral stroma is composed of collagen bundles of varying size and shape that are not uniformly oriented There three vascular layers that cover the anterior sclera: conjunctival, superficial episcleral and deep vascular plexus
  80. 80. Applied anatomy of vascular coatsApplied anatomy of vascular coats Scleritis • Maximal congestion of deep vascular plexus • Slight congestion of episcleral vessels • Maximal congestion of episcleral vessels EpiscleritisNormal • Radial superficial episcleral vessels • Deep vascular plexus adjacent to sclera
  81. 81. Episcleritis / ScleritisEpiscleritis / Scleritis  Episcleritis: – Common – Localized inflammation, lasts 2 wks. – Treatment with topical steroids or oral NSAIDs  Scleritis: – Rare – Granulomatous or necrotizing, Vision threatening. – Treatment with immunosuppression
  82. 82. UveitisUveitis  Pain, reduced vision, ciliary flush  Systemic association: Sarcoid, HLA B-27, inflammatory bowel disease, TB, syphilis  Refer  Treatment: topical steroids, dilating drops
  83. 83. Applied anatomyApplied anatomy
  84. 84. Acute Angle ClosureAcute Angle Closure GlaucomaGlaucoma  Sudden severe pain, loss vision, N & V  Red eye with ciliary flush, pupil fixed & mid dilated, cornea steamy, increased IOP  Emergency referral  Treatment: drops to lower IOP, constrict pupil, diuretics, laser iridotomy
  85. 85. Eye chemical injuriesEye chemical injuries Chemical burns – irrigate immediately – NEVER give acid for alkali or vice versa For all but least severe trauma – refer Always protect the eye from further injury during transfer
  86. 86. Acquired cataractAcquired cataract Age related Diabetes Myotonic dystrophy Atopic dermatitis Trauma Drugs Complicated (secondary)
  87. 87. Age related cataractAge related cataract Nuclear Cortical Subcapsular Christmas
  88. 88. Diabetic cataractDiabetic cataract Juvenile • White punctate or snowflake posterior or anterior opacities • May mature within few days Adult • Cortical and subcapsular opacities • May progress more quickly than in non-diabetics
  89. 89. Myotonic dystrophy cataractMyotonic dystrophy cataract • Myotonic facies • Frontal balding • 90% of patients after age 20 years • Stellate posterior subcapsular opacity • No visual problem until age 40 years
  90. 90. Atopic dermatitis cataractAtopic dermatitis cataract • Cataract develops in 10% of cases between 15-30 years • Bilateral in 70% • Frequently becomes mature • Anterior subcapsular plaque (shield cataract) • Wrinkles in anterior capsule
  91. 91. Traumatic cataractTraumatic cataract Penetration Concussion ‘Vossius’ ring from imprinting of iris pigment Flower-shaped • Ionizing radiation • Electric shock • Lightning Other causes
  92. 92. DrugsDrugs Chlorpromazine • Long-acting miotics Other drugs • Amiodarone • Busulphan - initially posterior subcapsular Systemic or topical steroids - central, anterior capsular granules
  93. 93. Complicated cataractComplicated cataract • Chronic anterior uveitis • High myopia Posterior subcapsular • Hereditary fundus dystrophies • Central, anterior subcapsular opacities Glaukomflecken • Follows acute angle closure glaucoma
  94. 94. Congenital cataractCongenital cataract • 33% - idiopathic - may be unilateral or bilateral • 33% - inherited - usually bilateral • 33% - associated with systemic disease - usually bilateral • Other ocular anomalies present in 50%
  95. 95. Classification of congenital cataractClassification of congenital cataract Anterior polar Posterior polar Coronary Cortical spoke-like Lamellar Central pulverulent Sutural Focal dots
  96. 96. Causes of cataract in healthy neonateCauses of cataract in healthy neonate Hereditary (usually dominant) Idiopathic With ocular anomalies • PHPV • Aniridia • Coloboma • Microphthalmos • Buphthalmos
  97. 97. Causes of cataract in unwell neonateCauses of cataract in unwell neonate Intrauterine infections • Rubella • Toxoplasmosis • Cytomegalovirus • Varicella Metabolic disorders • Galactosaemia • Hypoglycaemia • Hypocalcaemia • Lowe syndrome
  98. 98. Ectopia lentis - AcquiredEctopia lentis - Acquired Trauma • Buphthalmos • Megalocornea Anterior uveal tumours Degenerate eye Stretched zonules
  99. 99. Ectopia lentis - ADEctopia lentis - AD Systemic features of Marfan's syndrome • Limb-trunk disproportion • Arachnodactyly • Pectus excavatum • High-arched palate • Aortic dilatation, dissection and regurgitation • Mitral valve prolapse
  100. 100. Ocular features of Marfan syndromeOcular features of Marfan syndrome Lens • Upward subluxation • Zonule usually intact Retinal detachment • Axial myopia Blue scleraCornea planaAngle anomaly and glaucoma • Lattice degeneration
  101. 101. Ectopia lentis - AREctopia lentis - AR Weill-Marchesani syndrome Systemic features • Short stature Ocular features • Short stubby fingers (brachydactyly) • Mental handicap • Microspherophakia • Angle anomaly and glaucoma • Anterior lens subluxation
  102. 102. Ectopia lentis - AREctopia lentis - AR Homocystinuria (Defect in cystathionine synthetase) Systemic features • Malar flush and fine, fair hair • Marfanoid habaitus • Increased platelet stickiness • Mental handicap Ocular features • Downward lens subluxation • Disintegration of zonule
  103. 103. Congenital glaucomaCongenital glaucoma Corneal edema associated with lacrimation and photophobia Buphthalmos
  104. 104. Dysthyroid OphthalmopathyDysthyroid Ophthalmopathy  Bilateral autoimmune swelling of extraocular muscles +/- orbital inflammation  Findings: – Proptosis (exophthalmos) – Restricted EOM – Inflammation – Optic nerve compression – Corneal exposure  Treatment: steroids / radiotherapy when active surgery when “burnt out”
  105. 105. Diabetic RetinopathyDiabetic Retinopathy  Background / Non- proliferative – Leaking vessels cause edema & exudates – Treatment: referral for laser if VA less than 6/9  Proliferative – Ischemic retina secretes vascular growth factor – fragile new vessels rupture & bleeding may lead to scar and retinal damage / detachment – Treatment: referral for PRP
  106. 106. Exposure keratopathyExposure keratopathy
  107. 107. Rosacea keratitisRosacea keratitis
  108. 108. Keratitis in systemic collagenKeratitis in systemic collagen vascular disordersvascular disorders
  109. 109. Applied anatomyApplied anatomy
  110. 110. Pituitary adenomaPituitary adenoma Visual field defects caused by compression of chiasm from below by pituitary adenoma Axial CT scan of right pituitary adenoma invading right cavernous sinus
  111. 111. Optic NeuritisOptic Neuritis  Mostly unilateral sudden loss of vision, disturbance in color vision and pain with EOM  50% go on to develop MS  Findings: poor vision, poor color vision, afferent pupillary defect, optic nerve usually normal, visual field defect  Treatment: usually refer to neurologist, IV not oral steroids Axial MRI scan showing periventricular plaques of demyelination (left: T1; right: T2)

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