Dr.Aghlab Khoury AlQuds medical school basr ABC OF EYES HISTORY AND EXAMINATION Dr.Aghlab Khoury AlQuds medical school basr

ABC OF EYES HISTORY AND EXAMINATION Previous ophthalmic history Medical history Family history Drug history

ABC OF EYES HISTORY AND EXAMINATION Visual symptoms: details to establish Monocular or binocular Type of disturbances Onset Presence and type of field loss Associated symptoms Effect on lifestyle

ABC OF EYES HISTORY AND EXAMINATION Vision VF Pupils Ocular motility Eye position Eyelids,conjunctiva,sclera and cornea Intraocular pressure Ophthalmoscopy

ABC OF EYES HISTORY AND EXAMINATION Vision test

ABC OF EYES HISTORY AND EXAMINATION Visual field test

ABC OF EYES HISTORY AND EXAMINATION Pupils

ABC OF EYES HISTORY AND EXAMINATION Ocular motility

ABC OF EYES HISTORY AND EXAMINATION Eye position

ABC OF EYES HISTORY AND EXAMINATION Eyelids

ABC OF EYES HISTORY AND EXAMINATION Conjunctiva

ABC OF EYES HISTORY AND EXAMINATION Cornea

ABC OF EYES HISTORY AND EXAMINATION Sclera

ABC OF EYES HISTORY AND EXAMINATION Intraocular pressure

ABC OF EYES HISTORY AND EXAMINATION Ophthalmoscopy

ABC OF EYES RED EYE

ABC OF EYES RED EYE History Onset Severity Previous attacks Other family members Contact lenses

ABC OF EYES RED EYE Symptoms Sings Blurring of vision Pain Photophobia FB sensation Itching Sings Type of redness Discharge FB Corneal edema Corneal opacity Lid swelling Abnormal pupil

ABC OF EYES RED EYE Conjunctivitis Bacterial Viral Chlamydial conjunctivitis Conjunctivitis in infants Allergic

ABC OF EYES RED EYE Conjunctivitis Bacterial

ABC OF EYES RED EYE Conjunctivitis Viral

ABC OF EYES RED EYE Conjunctivitis Chlamydial

ABC OF EYES RED EYE Conjunctivitis Ophthalmia neonatorum

ABC OF EYES RED EYE Conjunctivitis Allergic

ABC OF EYES RED EYE – Episcliritis and Scleritis

ABC OF EYES RED EYE – Corneal Ulcers

ABC OF EYES RED EYE - Uveitis

ABC OF EYES RED EYE – Acute Angle Closure Glaucoma

ABC OF EYES RED EYE – Subconjunctival Haemorrhage

ABC OF EYES RED EYE – Inflamed Pterygium & Pingueculum

ABC OF EYES REFREACTIVE ERRORS

ABC OF EYES REFREACTIVE ERRORS

ABC OF EYES REFREACTIVE ERRORS - Myopia

ABC OF EYES REFREACTIVE ERRORS - Hypermetropia

ABC OF EYES REFREACTIVE ERRORS - Astigmatism

ABC OF EYES REFREACTIVE ERRORS – Pinhole Test

ABC OF EYES REFREACTIVE ERRORS - Presbyopia

ABC OF EYES REFREACTIVE ERRORS – Contact Lenses Soft contact lenses Gas permeable contact lenses Hard contact lenses

ABC OF EYES REFREACTIVE ERRORS – Contact Lenses Indications Personal appearance High refractive errors High anisometropia Corneal surface irregularities Therapeutic indications

ABC OF EYES REFREACTIVE ERRORS – Contact Lenses Contraindications Atopy Dry eyes Previous glaucoma surgery Inability to handle CL Active ocular surface infection

ABC OF EYES REFREACTIVE ERRORS – Contact Lenses Complications Corneal abscess Corneal abrasions Corneal pannus

ABC OF EYES REFREACTIVE ERRORS – Refractive Surgery RK ICR PRK LASIK CLE ICL Bioptics

ABC OF EYES EYELID, ORBITAL, and LACRIMAL DISORDERS

ABC OF EYES EYELID DISORDERS - Lumps Importance May need disfiguring operation if left May be life threatening May cause visual disturbance May cause amblyopia in children May indicate systemic disease

ABC OF EYES EYELID DISORDERS - Lumps Chalazion

ABC OF EYES EYELID DISORDERS - Lumps Stye

ABC OF EYES EYELID DISORDERS - Lumps Papilloma

ABC OF EYES EYELID DISORDERS - Lumps Xanthelasma

ABC OF EYES EYELID DISORDERS - Lumps Basal cell carcinoma

ABC OF EYES EYELID DISORDERS – Inflammatory disease Blepharitis

ABC OF EYES EYELID DISORDERS – Inflammatory disease Chalazion Stye Acute dacryocyctitis Allergy Herpes simplex Herpes zoster ophthalmicus

ABC OF EYES EYELID DISORDERS – Malposition Entropion

ABC OF EYES EYELID DISORDERS – Malposition Ectropion

ABC OF EYES EYELID DISORDERS – Malposition Trichiasis

ABC OF EYES EYELID DISORDERS – Malposition Ptosis May indicate a life threatening condition May indicate a disease that needs systemic treatment May cause irreversible amblyopia

ABC OF EYES ORBITAL DISORDERS – Proptosis Causes Orbital cellulitis Orbital inflammatory disease Thyroid eye disease Orbital lymphoma Lacrimal gland tumors Orbital invasion from adjacent sinus Big eye

ABC OF EYES ORBITAL DISORDERS – Enophthalmos Causes Blowout fracture Microphthalmos Atrophy of orbital contents Cicatrizing orbital lesions

ABC OF EYES LACRIMAL SYSTEM

ABC OF EYES LACRIMAL SYSTEM – Tear film

ABC OF EYES LACRIMAL SYSTEM – Watering eye Excessive tears production Punctal malposition Punctal stenosis Blockage

ABC OF EYES LACRIMAL SYSTEM – Dry eye Symptoms Causes Diagnosis Treatment

ABC OF EYES EYE INJURIES

ABC OF EYES EYE INJURIES History The mechanism The circumstances Injuries in children

ABC OF EYES EYE INJURIES Examination VA Inspection Lids Globe Pupil Flurescein

ABC OF EYES EYE INJURIES Corneal abrasions

ABC OF EYES EYE INJURIES Foreign bodies

ABC OF EYES EYE INJURIES Radiation damage (flash burn)

ABC OF EYES EYE INJURIES Chemical burn Irrigate, irrigate then irrigate Remove loose particles Beware alkalis Refer patient to ophthalmic department

ABC OF EYES EYE INJURIES Chemical burn

ABC OF EYES EYE INJURIES Blunt eye injuries

ABC OF EYES EYE INJURIES Blunt eye injuries

ABC OF EYES EYE INJURIES Penetrating eye injuries If suspected, the eye should be examined very gently Special attention: history of high velocity injury

ABC OF EYES EYE INJURIES Penetrating eye injuries Signs to look for Distorted pupil Cataract Prolapsed uveal tissue

ABC OF EYES EYE INJURIES Penetrating eye injuries Protect the eye from any pressure and refer the patient immediately to the nearest eye department

ABC OF EYES ACUTE VISUAL DISTURBANCE

ABC OF EYES ACUTE VISUAL DISTURBANCE History Onset Old or new Previous ophthalmic history General health Understand the disturbance VF loss Scotoma Distortion Floaters Flashing lights Amarosis fugax Zigzag lines Headache Pain on eye movement

ABC OF EYES ACUTE VISUAL DISTURBANCE Examination VA Pupillary reaction Red reflex VF testing Fundoscopy

ABC OF EYES ACUTE 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 EYES ACUTE VISUAL DISTURBANCE Vitreous Haemorrhage Sudden onset of floaters and loss of vision Common in diabetics Refer to ophth. to clarify the cause and treat underlying disease

ABC OF EYES ACUTE VISUAL DISTURBANCE Retinal detachment Floaters and flashes VF loss Variable in VA More likely to occur in high myopic patients after trauma or intraocular operation Common in PDR Needs surgical intervention

ABC OF EYES ACUTE VISUAL DISTURBANCE Arterial occlusion Occlusion of the retinal artery may be caused by Arteriosclerotic changes Embolus (from heart or carotid artery) Inflammation (rare)

ABC OF EYES ACUTE 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 EYES ACUTE 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 EYES ACUTE 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 EYES ACUTE VISUAL DISTURBANCE – Arterial Occlusion

ABC OF EYES ACUTE 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 EYES ACUTE VISUAL DISTURBANCE –Venous Occlusion History Sudden onset painless blurred vision The patient might experience a visual field defect

ABC OF EYES ACUTE VISUAL DISTURBANCE –Venous Occlusion Examination The 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 EYES ACUTE VISUAL DISTURBANCE –Venous Occlusion Management Refer within 24 hours. Identify and treat any underlying cause Antiplatelets therapy Follow-up in the clinic is arranged so that those at risk of neovascular glaucoma may be treated with PRP

ABC OF EYES ACUTE VISUAL DISTURBANCE –Venous Occlusion

ABC OF EYES ACUTE VISUAL DISTURBANCE – Disciform MD History Sudden onset of disturbance in the central vision Elderly are usually affected Caused by choroidal neovascular membrane leak or hemorrhage

ABC OF EYES ACUTE VISUAL DISTURBANCE – Disciform MD Examination VA depends on the extent of macular involvement Distorted line on Amsler chart Fundoscopy and FFA

ABC OF EYES ACUTE VISUAL DISTURBANCE – Disciform MD

ABC OF EYES ACUTE VISUAL DISTURBANCE – Disciform MD Management Laser Photodynamic therapy Lucentis and Avastin Vitamins and minerals Surgery

ABC OF EYES ACUTE VISUAL DISTURBANCE – Optic Neuritis History Sudden unilateral Loss of vision Central VF loss Age 20-40 (usually woman) Pain that worsen on eye movement H/o previous attacks Symptoms of MS

ABC OF EYES ACUTE VISUAL DISTURBANCE – Optic Neuritis Examination VA from 6/6 to PL APD Color vision disturbances Central scotoma Normal or swollen optic nerve head

ABC OF EYES ACUTE VISUAL DISTURBANCE – Optic Neuritis Management Usually spontaneous recovery Steroids in selected cases SOL should be ruled out in uncertain cases

ABC OF EYES GRADUAL VISUAL DISTURBANCE

ABC OF EYES GRADUAL VISUAL DISTURBANCE History Onset Old or new Previous ophthalmic history General health Understand the disturbance VF loss Scotoma Distortion

ABC OF EYES GRADUAL VISUAL DISTURBANCE - Causes Refractive errors Longstanding history Pinhole test

ABC OF EYES GRADUAL VISUAL DISTURBANCE - Causes Corneal disease

ABC OF EYES GRADUAL VISUAL DISTURBANCE - Causes Cataract

ABC OF EYES GRADUAL VISUAL DISTURBANCE - Causes Age related macular degeneration

ABC OF EYES GRADUAL VISUAL DISTURBANCE - Causes Macular hole

ABC OF EYES GRADUAL VISUAL DISTURBANCE - Causes Diabetic maculopathy

ABC OF EYES GRADUAL VISUAL DISTURBANCE - Causes Hereditary retinal degeneration

ABC OF EYES GRADUAL VISUAL DISTURBANCE - Causes Compressive lesions of optic pathways

ABC OF EYES GRADUAL VISUAL DISTURBANCE - Causes Drugs Alcohol Smoking Chloroquine Tetracycline Steroids

ABC OF EYES GRADUAL VISUAL DISTURBANCE - Cataract Causes of acquired cataract Age Diabetes Inflammation Trauma Steroids

ABC OF EYES GRADUAL VISUAL DISTURBANCE - Cataract Indications for surgery No need to wait far a cataract to be mature No set level of vision Depends on the patient's needs

ABC OF EYES GRADUAL VISUAL DISTURBANCE - Cataract Surgical techniques Phacoemulsification

ABC OF EYES GRADUAL VISUAL DISTURBANCE - cataract Extracapsular method

ABC OF EYES GRADUAL VISUAL DISTURBANCE - Cataract Intracapsular method

ABC OF EYES GRADUAL VISUAL DISTURBANCE - Cataract Complications of cataract surgery Intraoperative Ocular perforation Subconjunctival hemorrhage Suprachoroidal hemorrhage Iris prolapse Posterior capsular tear Vitreous loss

ABC OF EYES GRADUAL 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 EYES GRADUAL VISUAL DISTURBANCE - Cataract Optical correction after surgery Glasses Contact lenses Secondary IOL implantation

ABC OF EYES GLAUCOMA

ABC OF EYES GLAUCOMA A progressive damage of the optic nerve which might be associated with increased intraocular pressure The commonest cause of irreversible blindness

ABC OF EYES GLAUCOMA

ABC OF EYES GLAUCOMA

ABC OF EYES GLAUCOMA Symptoms & signs Raised IOP

ABC OF EYES GLAUCOMA Symptoms & signs Haloes

ABC OF EYES GLAUCOMA Symptoms & signs Cloudy cornea

ABC OF EYES GLAUCOMA Symptoms & signs Pain

ABC OF EYES GLAUCOMA Symptoms & signs Visual field loss

ABC OF EYES GLAUCOMA Symptoms & signs Optic disc changes

ABC OF EYES GLAUCOMA Symptoms & signs Venous occlusion

ABC OF EYES GLAUCOMA Symptoms & signs Enlargement of the eye

ABC OF EYES GLAUCOMA – Primary Open Angle Glaucoma Symptoms No symptoms until sever damage occurs Best detected by screening

ABC OF EYES GLAUCOMA – Primary Open Angle Glaucoma Risk factors Ageing Positive family history Black race Level of IOP Myopia Thin corneas

ABC OF EYES GLAUCOMA – Primary Open Angle Glaucoma Signs Optic nerve cupping Asymmetry Optic disc hemorrhages VF loss Increased IOP

ABC OF EYES GLAUCOMA – Acute Angle Closure Glaucoma

ABC OF EYES GLAUCOMA – Acute Angle Closure Glaucoma Symptoms Red painful eye Headaches Nausea and vomiting Blurred vision Haloes H/o previous attacks

ABC OF EYES GLAUCOMA – Acute Angle Closure Glaucoma Groups at risk Hypermetropes Old age Female patient

ABC OF EYES GLAUCOMA – Acute Angle Closure Glaucoma Signs Decreased VA Corneal edema Semidilated pupil poorly reacted to light Palpation = eye hard and tender

ABC OF EYES GLAUCOMA – Acute Angle Closure Glaucoma Management Admit to hospital Acetazolamide IV 500mg Topical Timolol drops 0.5% Pilocarpine 4% drops Manitol 20% YAG laser PI Surgical PI Iridoplasty Drainage procedure

ABC OF EYES GLAUCOMA – Other types of Glaucoma Inflammatory Steroid induced Rubeotic glaucoma Post traumatic Congenital Postoperative

ABC OF EYES GLAUCOMA – Medical Treatment The aim of the treatment is to reduce the IOP to stop the progression of optic nerve damage

ABC OF EYES GLAUCOMA – Medical Treatment B – blockers Timolol Betaxolol Sympathomimetic agents Adrenalin Brimonidin Carbonic anyhdrase inhibitors Dorzolamide Acetazolamide Parasympathomimetic agents Pilocarpine Prostaglandin analogues Latanoprost Travoprost Bimatoprost

ABC OF EYES GLAUCOMA – Laser Treatment Laser trabeculoplasty Laser iridotomy Laser iridoplasty Laser ciliary body ablation

ABC OF EYES GLAUCOMA – Surgical Treatment Iridectomy Drainage procedure

ABC OF EYES GLAUCOMA – Surgical Treatment Complications Failure ( scarring ) Hypotony Cataract Reduction in BCVA Endophthalmitis