Overview of Common Eye Conditions Ian Tan MBBS VI

Case 1 70 year old man PC: R Sudden loss of vision Denies pain Visual acuity – 6/9 L, CF R Right – RAPD Fundus Exam shows cherry red spot at macula on pale retina

Case 1 What is the likely diagnosis? What investigations would you order?

CRAO Symptom: Sudden painless loss of vision (except in GCA) VA Severely reduced Profound RAPD Fundus – cherry red spot ESR and CRP to exclude GCA

Case 2 81 year old lady Sudden onset of pain in left eye + blurring of vision and seeing haloes. VA – HM in left, 6/9 in right Slit lamp exam: L eye mid-fixed dilated pupil, shallow anterior chamber, corneal oedema

Case 2 What is the diagnosis? What would you do next? What is the definitive management in the acute setting?

Acute Angle Closure Glaucoma Occurs when trabecular meshwork is occluded by the peripheral iris  obstructed flow Risk factors – >60, female, race, family history, refraction Symptoms – blurred vision, halo, pain, systemic symptoms High IOP > 60mmHg Visual acuity 6/60 or HM Immediate management – acetazolamide, timolol, apraclonidine, prednisolone Bilateral laser iridotomy Acetazolamide 500mg PO or IV Timolol 0.5% Apraclonidine 0.5-1% Prednisolone 1% +/- Pilocarpine 2-4% Bilateral laser iridotomy

Case 3 31 year old man Presents with 3 day history of L red eye Accompanied by mild discomfort, blurred vision and excessive watering Reduced corneal sensation Slit exam shows diffuse conjunctival injection What would you do next?

Case 3  Slit lamp exam: Dendritic ulcer evident with fluorescein under cobalt blue light

Case 3 What is the diagnosis? What investigations needs to be done? How would you manage this patient?

HSV Keratitis Predominantly HSV 1 Principally clinical diagnosis Symptom – red eye + blurred vision, watering Under fluorescein for dendritic ulcer Treatment – topical acyclovir/ganciclovir

Case 4 62 year old woman PC: Sudden L monocular painless loss of vision Past Hx: hypertension + diabetes VA counting fingers L RAPD Fundus: Diffuse haemorrhages throughout fundus, swollen optic disc.

Case 4 What is the diagnosis? Diagnosis CRAO

CRVO Symptom – Sudden painless loss of vision Poor VA RAPD present Risk of neovascular glaucoma Fundus: extensive blot and flame shaped hemorrhages involving Intravitreal anti-VEGF injection or dexamethasone implant for macular edema

Case 5 38 year old man Suspected foreign body in right eye Complains of blurred vision and mild photophobia Using angle grinder, wearing protective glasses VA 6/6 L, 6/18 R Slit lamp examination

Case 5 Slit lamp exam: rust ring foreign body evident at 9 o’clock position

Case 5 What is the next step in your management? What do you do if no foreign body is found on the surface of the eye?

Foreign Body Superficial vs IOFB High index of suspicion for IOFB CT if IOFB is suspected Examination under lid Topical Analgesia Sterile Blunt needle vs burr Fluorescein to assess epithelial defect

Case 6 25 year old man Presents with 2 day history of red eye (L) Accompanied by pain and photophobia Third episode Examination – cloudy AC with cells Small hypopyon VA 6/6 R, 6/9 L IOP 7 in L, 11 in R

Case 6 What is the likely diagnosis? What investigations would you order? How would you treat this patient?

Anterior Uveitis Inflammation of iris and anterior part of ciliary body Commonly idiopathic or HLA B27 related Symptoms – Unilateral pain, photophobia, redness and watery discharge Mildly reduced VA Signs – hypopyon, cells in AC, posterior synechiae Mx – 1st line topical steroids (pred 1% or dex 0.1%)

Common Medications Diamox (Acetazolamide) Mydriatics – tropicamide 1% Chlosig (chloramphenicol) drops/ointment Hypromellose drops/gel (Genteal, Polytears)

SUMMARY CRVO CRAO Acute Angle Closure Glaucoma Foreign body Corneal Ulcers Uveitis

References Kanski’s Clinical Ophthalmology – A systematic approach Emergency Eye Manual – An illustrated Guide