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None-urgent eye problems David Kinshuck, associate specialist David Kinshuck, Good Hope Hospital,
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None-urgent eye problems …working in pairs, (1 minute) write down Common conditions Rarer & serious conditions
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Draw an eye and name the parts…working in pairs, (30 s) : parts Parts relevant to conditions
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www.websightmd.com
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Aqueous flow
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Chronic eye conditions Adults cataracts Armd...age-related macular degeneration Glaucoma Diabetic retinopathy Others (retinal vein occlusion, inherited retina, corneal etc) children Squints Watery eye Cataracts Glaucoma rarer
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Cataracts Symptoms How to examine Operation refraction
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Cataracts symptoms, in pairs ?
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Cataracts symptoms Glare Misty vision Blurred vision Cannot see distances/faces
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Cataracts...symptoms....blurred
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Cataracts...symptoms....glare
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Examining for cataract…red reflex Looking through ophthalmoscope, check red reflex from 10 cm, focusing on iris rim
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‘white’ reflex www.occhioallaretina.it/Immagini/leucocoria.JPG http://oftalmologo.bravepages.com/Leucocoria%201.jpg ?retinoblastoma
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Cataracts...operation Link http://www.goodhopeeyeclinic.org.uk/eye cataractpatient.html
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Cataracts...refraction...in pairs, which is myopia etc
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Cataracts...refraction –Emmetropia.. no dist. specs –Hypermetropia, small eyes –Myopia –High myopia
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Presbyopia...need reading spectacles, >45y
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Retina –Diabetic retinopathy –Retinal vein occlusion –Armd...age-related macular degeneration –Others retinal vein occlusion inherited retina (eg retinal pigmentosa)
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Diabetic retinopathy, in pairs, 45 seconds What are the disease processes What one chemical in particular mediates these processes (and we can block its effect) What does laser do http://medweb.bham.ac.uk/easdec/dmret.html http://medweb.bham.ac.uk/easdec/mechanism animation.htm
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Diabetic retinopathy
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dot and blot ischaemic areas VEGF leakage new vessels
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Diabetic retinopathy dot and blot ischaemic areas VEGF leakage new vessels
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Diabetic retinopathy
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Diabetic retinopathy http://reference.medscape.com/features/slideshow/retina
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Diabetic retinopathy, in pairs, how do you prevent, 30s
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Prevent diabetes…exercise, weight, low glycaemic index foods Screen for diabetes…everyone >40y, high risk if lower (lifestyle/family etc), HbA1c >6.5% = diabetes HbA1c 6.0-6.5% = pre-diabetes Control diabetes HbA1c <6.5-75, BP <130/80, statin, ARB Screen diabetic patients for retinopathy etc
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Diabetic retinopathy HbA1c Blood pressure Smoking Lipids Duration of ‘high’ HbA1c similar for BP/smoking/lipids
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Retinal vein occlusion 7 highs cigarettes Cholesterol Blood pressure Glucose Viscosity –Myeloma –White cells
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Macula..in pairs, 1 minute What do you know about armd Symptoms Types etc
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Macular Central visual changes suggest macula disease: Eye casualty same week
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Central vision
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OCT optical coherence tomogram … wet ARMD http://www.goodhopee yeclinic.org.uk/images /lucentis.html
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Dry, ‘geographic atrophy’ Areas of atrophy enlarge over a couple of years, seriously reducing central vision
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Glaucoma, in pairs, explain with diagram, 1 min
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Glaucoma, mechanism Aqueous produced in ciliary body (carbonic anhydrase enzyme) Flows into >anterior chamber, >through trabecular >meshwork, >canal of schlemm, >episcleral veins > otherwise pressure
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Glaucoma, loss of visual field Visual loss over years 2/3 chronic glaucoma has a high pressure…pressure is detected by whom Apatient Boptometrist
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Glaucoma, loss of visual field Visual loss over years 2/3 chronic glaucoma has a high pressure…pressure is detected by whom Apatient Boptometrist
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Glaucoma, in pairs, which normal eye, 30s http://www.goodhopeeyeclinic.org.uk/glaucomacase3.htm ABAB
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Glaucoma, in pairs, which normal eye, 30s http://www.goodhopeeyeclinic.org.uk/glaucomacase3.htm 1.Vessels deviated nasally 2.Pale central area with cribriform pits 3.thin rim 4.Other minor changes
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Glaucoma, lowering pressure Laser trabecular meshwork Drops –Prostaglandin inhibitors –Carbonic anhydrase inhibitor –Betablockers tablets –Carbonic anhydrase inhibitor surgery
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Glaucoma, quiz Patient detects glaucoma Y N
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Glaucoma, quiz Are there symptoms early Y N
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Glaucoma, quiz Examining the eye –Cupped disc Y N
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Glaucoma, quiz Examining the eye –Raised pressure 66%Y N
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Glaucoma, quiz –Examine angle at onset Y N
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Glaucoma, quiz –Visual field Y N
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Glaucoma, other types –Yearly checks stable Y N
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Glaucoma, quiz Patient detects glaucoma N Are there symptoms early N Examining the eye –Cupped disc Y –Raised pressure 66%Y –Examine angle at onset Y –Visual field Y –Yearly checks Y
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Glaucoma, other types Low tension Narrow angle http://www.goodhopeeyeclinic.org.uk/pi.html http://www.goodhopeeyeclinic.org.uk/pi.html Genetic –Many conditions –congenital baby Secondary surgery/trauma/steroids
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Glaucoma, –Congenital (www.nature.com/eye)
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Loss of sight over weeks/days/hours Retinal detachment, with flashes/floaters Ischaemic optic neuropathy (older patients) (%GCA with GCA symptoms) With pain on movement & reduced colour (red) vision: optic neuritis (younger patients)
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Retinal detachment 1.Vitreous gel liquifies (floaters) 2.May pull retina if attached (flashes) 3.Causes a hole 4.Fluid enters hole 5.Retina peels off (more floaters, vision affected) 6.Dilate pupil, with careful look usually obvious, refer same day
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Eye & major trauma
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Visual acuity T NC EN OTNC LOXEW TYURNG TYURNG TYURNG 6/60 6/36 6/24 6/18 6/12 6/9 6/6 6/5
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Visual fields
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Pupils Pupils (needs Flash player installed)Pupils
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Some helpful eye examination ‘pearls’ Pressing on the eye will detect high pressure (acute glaucoma) Won’t detect slightly high pressure chronic glaucoma DILATE PUPILS to examine the eye if risk of detachment...cannot exclude detachment otherwise Optometrists can check for chronic disease
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Children, chronic disease Rare –Cataracts –Glaucoma –Lots Common –watery eyes –(lacrimal sac abscess/mucocoel) –Squints –Allergic eye disease
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Children, chronic disease---watery eyes
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Children, squint
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Convergent Divergent vertical
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Children, squint, issues Amblyopia –important to know this, as may spend lots of time looking for the cause of poor sight –Initially amblyopia need patching Squint surgery Binocular vision amblyopia without squint may be refractive, cataract, etc
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Children, cover test http://www.youtube.com/watch?v=yyIA- dl49Lghttp://www.youtube.com/watch?v=yyIA- dl49Lg
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3 rd nerve palsy In pairs...what is this?
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3 rd nerve palsy
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Other chronic eye diseases TED...thyroid eye disease Lid entropian/ectropian Trichiasis Eyelid tumours Watery eyes..epiphora Blocked naso-lacrimal duct Diplopia/squint Dry eyes Corneal diseases Optic atrophy, alcohol, smoking, B12 genetic Orbital/optic nerve tumours
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3 rd nerve palsy In pairs...what is this?
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3 rd nerve palsy www.patient.co.uk..thyroid eye disease
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3 rd nerve palsy www.patient.co.uk..thyroid eye disease Auto-immune +thyroid damage >> TRH receptors on muscles and fat in orbit Low TSH and smoking increase TRH receptors >> fat muscles swell >> exophthalmos + optic nerve compression
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3 rd nerve palsy In pairs...what is this?
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3 rd nerve palsy In pairs...what is this? nhs.uk
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3 rd nerve palsy In pairs...what is this? cosmeticsurg.com
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Dry eye link Mild forms very common, not serious, troublesome Very dry, and dry mouth, ?Sjogrens Very severe dry extremely uncommon: corneal melts and perforates..severe autoimmune disease
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Corneal disease Lots of uncommon corneal diseases In poor countries, trachoma >> corneal scarring http://www.goodhopeeyeclinic.org.uk/fuchs.htmlhttp://www.goodhopeeyeclinic.org.uk/fuchs.html Dry eye
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trachoma
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Dry eyes http://www.goodhopeeyeclinic.org.uk/dryeye.html
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Dry eyes http://www.d ryeye.org/im ages/colorba r.jpg
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Fuchs corneal dystrophy etc http://www.goodhopeeyeclinic.org.uk/fuchs.html Keratoconus
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Optic atrophy Low B12 Secondary to retinal artery occlusion or ION Tobacco alcohol amblyopia (vitamin B deficiency)
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Retinal dystrophy http://geneticpeople.com/?tag=retinitis- pigmentosahttp://geneticpeople.com/?tag=retinitis- pigmentosa
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Summary, go round the room 1.. 2.. 3.. 4.. 5.. 6.. 7.. 8.. 9.. 10.. 11.. 12.. 13.. 14.. 15.. 16.. 17..
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