Anterior Segment - Common Clinical Presentations in Optometry CENTRAL COAST DAY HOSPITAL OPTOMETRIST CONFERENCE - 26 FEBRUARY 2012 DR VIVEK CHOWDHURY Anterior Segment - Common Clinical Presentations in Optometry

Fuchs endothelial dystrophy Pseudophakic Bullous Keratopathy Progression Gradual increase in cornea guttata with peripheral spread Later central stromal oedema - STROMA Eventually bullous keratopathy - EPI

Fuchs endothelial dystrophy Pseudophakic Bullous Keratopathy SYMPTOMS: Acuity. Haloes/Glare. Diurnal Variation. Discomfort/Pain SIGNS Guttae and Endothelial Opacity. Stromal Oedema Epithelial Oedema/Erosions. Corneal Thickness/Pachymetry

Fuchs endothelial dystrophy Pseudophakic Bullous Keratopathy In Patients with Corneal Endothelial Decompensation, all of the following may indicate progression of the disease except: Increased Corneal Thickness. Epithelial Defects Deteriorating Visual Acuity Symptoms Worse in the Afternoon

ANTERIOR CHAMBER IOLS Primary Cataract Surgery – Problems with Capsular Bag/Zonular Support – PXF Patients/Hx Trauma. Secondary IOL - Aphakic Patient Problems Related to: ACIOL Itself Complications of the Primary Surgery

ANTERIOR CHAMBER IOLS Look out For: Cornea: Corneal Endothelial Decompensation/Bullous Keratopathy. Corneal Wounds. AC: Inflammation/Uveitis, AC Vitreous, Hyphaema. Iris: Irregular Pupil, Iris Tuck, Angle Closure, PI. Angle: Trauma from Haptics, Glaucoma. Capsule: Residual Capsule in Pupillary Axis, Lens Material Retina: CME, Breaks, Detachment, Lens remnants

2. In a patient with an anterior chamber intraocular lens – It is usually important to check for all of the following except: Raised Intraocular Pressure Corneal Decompensation. Uveitis. Iris Naevus

TRAUMA 1. Eyelid 2. Orbital blow-out fractures 3. Globe Injuries Haematoma Margin laceration Canalicular laceration 2. Orbital blow-out fractures Floor Medial wall 3. Globe Injuries Anterior segment Posterior segment

Anterior segment complications of blunt trauma Hyphaema Iridodialysis Vossius ring Sphincter tear Cataract Lens subluxation Angle recession Rupture of globe

Posterior segment complications of blunt trauma Choroidal rupture and haemorrhage Avulsion of vitreous base and retinal dialysis Commotio retinae Equatorial tears Macular hole Optic neuropathy

Complications of penetrating trauma Flat anterior chamber Uveal prolapse Damage to lens and iris Vitreous haemorrhage Tractional retinal detachment Endophthalmitis

3. In a patient with a past history of blunt trauma to the eye - which of the following is incorrect: A deep AC means there is a low risk of glaucoma cataract may be associated with zonule laxity/phacodonesis there is an increased risk of retinal breaks the patient may have a dilated pupil

Adenoviral - Signs of keratitis Focal, subepithelial keratitis Focal, epithelial keratitis Transient May persist for months Treatment - topical steroids if visual acuity diminished by subepithelial keratitis

Progression of vernal conjunctivitis Diffuse papillary hypertrophy, most marked on superior tarsus Formation of cobblestone papillae Rupture of septae - giant papillae

Limbal vernal Trantas dots Mucoid nodule

Progression of vernal keratopathy Punctate epitheliopathy Epithelial macroerosions Plaque formation (shield ulcer) Subepithelial scarring

Progression of ocular cicatricial pemphigoid Diffuse hyperaemia Pseudomembrane formation Subepithelial fibrosis and shrinkage Symblepharon

Naevus Presents in first two decades Most frequently juxtalimbal Sharply demarcated and slightly elevated 30% are almost non-pigmented

Lipodermoid Presents in adulthood Soft, movable, subconjunctival mass Most frequently at outer canthus

Intraepithelial neoplasia (carcinoma in situ) Signs Progression Presents in late adulthood May become vascular and extend onto cornea Malignant transformation is uncommon Juxtalimbal fleshy avascular mass

Primary acquired melanosis (PAM) Signs Types Presents in late adulthood PAM without atypia is benign Unilateral, irregular areas of flat, brown pigmentation PAM with atypia is pre-malignant May involve any part of conjunctiva

Conjunctival melanoma From PAM with atypia From naevus Primary Most common type Very rare Solitary nodule Sudden appearance of nodules in PAM Sudden increase in size or pigmentation Frequently juxtalimbal but may be anywhere

Squamous cell carcinoma Signs Progression Arises from intraepithelial neoplasia or de novo Slow-growing May spread extensively Presents in late adulthood Rarely metastasizes Frequently juxtalimbal

Marginal keratitis Hypersensitivity reaction to Staph. exotoxins May be associated with Staph. blepharitis Unilateral, transient but recurrent Progression Subepithelial infiltrate separated by clear zone Circumferential spread Bridging vascularization followed by resolution Treatment - short course of topical steroids

Phlyctenulosis Uncommon, unilateral - typically affects children Severe photophobia, lacrimation and blepharospasm Conjunctival phlycten Corneal phlycten Small pinkish-white nodule near limbus Usually transient and resolves spontaneously Starts astride limbus Resolves spontaneously or extends onto cornea Treatment - topical steroids

Herpes simplex epithelial keratitis Dendritic ulcer with terminal bulbs May enlarge to become geographic Stains with fluorescein Treatment Aciclovir 3% ointment x 5 daily Debridement if non-compliant

Herpes simplex disciform keratitis Signs Associations Central epithelial and stromal oedema Occasionally surrounded by Wessely ring Folds in Descemet membrane Small keratic precipitates - topical steroids with antiviral cover Treatment

Herpes zoster keratitis Acute epithelial keratitis Nummular keratitis Develops in about 50% within 2 days of rash Develops in about 30% within 10 days of rash Small, fine, dendritic or stellate epithelial lesions Multiple, fine, granular deposits just beneath Bowman membrane Tapered ends without bulbs Halo of stromal haze Resolves within a few days May become chronic Treatment - topical steroids, if appropriate

4. A patient is complaining of blurry vision after cataract surgery, but the visual acuity is 6/6 unaided, It is important to check all of the following except. The tear film. The posterior capsule and IOL position. The macula. The eyebrows.

Simple episcleritis Common, benign, self-limiting but frequently recurrent Typically affects young adults Seldom associated with a systemic disorder Simple sectorial episcleritis Simple diffuse episcleritis Treatment Topical steroids

Nodular episcleritis Less common than simple episcleritis May take longer to resolve Treatment - similar to simple episcleritis Localized nodule which can be moved over sclera Deep scleral part of slit-beam not displaced

Grading of severity of chemical injuries Grade I (excellent prognosis) Clear cornea Limbal ischaemia - nil Grade II (good prognosis) Grade III (guarded prognosis) Grade IV (very poor prognosis) Cornea hazy but visible iris details No iris details Opaque cornea Limbal ischaemia > 1/2 Limbal ischaemia < 1/3 Limbal ischaemia - 1/3 to 1/2

Medical Treatment of Severe Injuries 1. Copious irrigation ( 15-30 min ) - to restore normal pH 2. Topical steroids ( first 7-10 days ) - to reduce inflammation 3. Topical and systemic ascorbic acid - to enhance collagen production 4. Topical citric acid - to inhibit neutrophil activity 5. Topical and systemic tetracycline - to inhibit collagenase and neutrophil activity

5. My patient with blepharitis is back again asking me to look for the sand that’s in his eye, I am going to do all the following except: Change to a preservative free artificial tear supplement and/or a more viscous artificial tear supplement, and/or a thick artificial tear gel just before sleep. Prescribe Chloramphenicol ointment to the lid margins. Trial Steroid ointment to the lid margins, and/or a short, tapering course of a mild topical steroid. Get my receptionist to tell them that I’ve gone on holiday.

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