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Identifying and Managing Eye Emergencies
Signs, symptoms, management and avoiding major disasters
Professor Charles McGhee Maurice Paykel Professor of Ophthalmology
University of Auckland
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OUTLINE
Assessment
– History
– Examination
Common Acute Presentations
Sight threatening conditions
Life threatening conditions
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• Discharge
• Watering
• Loss of vision
• Photopsia
• Diplopia
Mostly a combination of a small
number of the following symptoms:
Presenting Complaint
• Redness
• Pain
• Photophobia
• Grittiness
• Itchiness
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HISTORY
TRAUMA
DISCHARGE
PAIN
– Nature
– Onset
– Photophobia
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HISTORY: EYE AND THE SOMA
PAST MEDICAL HISTORY
– Ocular history
– Medical and drug history
– Family history
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EXAMINATION
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SNELLEN VISUAL ACUITY
Distance patient
read chart
Line read
6/60
6/18
6/6
6/4
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RECORDING POOR VISUAL ACUITY
CF HM PofL NPL
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OCULAR APPEARANCE
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APPEARANCE : CONSIDER DYE
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APPEARANCE
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APPEARANCE
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APPEARANCE
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PUP LS
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EYE MOVEMENTS
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Life Threatening
Orbital Cellulitis
Third Nerve Palsy
Common Conditions
Subconjunctival haemorrhage
Conjunctivitis
Keratitis
Episcleritis/Scleritis
Uveitis
BRVO/CRVO
BRAO/CRAO
Retinal Detachment
Eye Emergencies
Sight Threatening Endophthalmitis
Acute Angle Closure
Giant Cell Arteritis
Trauma
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SUBCONJUNCTIVAL HAEMORRHAGE
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CONJUNCTIVITIS
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VIRAL CONJUNCTIVITIS
• Usually caused by adenovirus
• Clear watery discharge
• Highly Contagious
• Associated features – Viral
• URTI
• Pre auricular nodes
• Treatment – Hygiene
– Supportive measures
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BACTERIAL CONJUNCTIVITIS
• Purulent discharge
• Staphylooccus, streptococcus, haemophilus, neisseria etc
– Secondary to nasolacrimal duct obstruct
• Treatment
– Chloramphenicol
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BACTERIAL CONJUNCTIVITIS
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CHLAMYDIA
• Mucopurulent discharge
• Associated features – Reiters Syndrome
• Treatment
– Doxycycline 100mg po bd one week
– Azithromycin 1g stat dose
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OPHTHALMIA NEONATORUM
• Conjunctivitis in the first three weeks of life
• Infection transmitted during delivery
– Chlamydia
– Gonorrhoea
– Staph aureus
– Herpes Simples
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ALLERGIC CONJUNCTIVITIS
Watery itchy eyes
Types – Seasonal (hayfever)
/ Perennial (dust mites)
– Vernal
– Atopic
Treatment – Mast cell stabilisers
– Antihistamine
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K
E
R
A
T
I
T
I
S
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Keratitis : history
Key points in history:
1. Past ocular disease + or - 2. Decreased vision + to ++ 3. Pain and severity ++ 4. Photophobia ++ 5. Ocular discharge + 6. Systemic symptoms -
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Predisposition to infective Keratitis
Dry eye
Lid malposition
Trauma
Prior surgery
Contact lenses
Topical Corticosteroids
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VIRAL KERATITIS
Herpes Simplex virus
Dendritic lesion
Treatment – Acyclovir ointment
5x day
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EPISCLERITIS AND SCLERITIS
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EPISCLERITIS AND SCLERITIS
SCLERITIS
• Relatively uncommon
• Severe boring pain
• Injection of deep scleral vessels
EPISCLERITIS
• Relatively common
• Mild ocular discomfort
• Injection of episcleral vessels
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SCLERITIS AND EPISCLERITIS
SCLERITIS
• Can be associated with systemic conditions – Rheumatoid arthritis
– HZO
• Can lead to blindness if untreated
EPISCLERITIS
• Generally no systemic associations
• Symptomatic relief
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SCLERITIS AND EPISCLERITIS
SCLERITIS (systemic Rx)
• Usually associated with rheumatoid in general practice
• Requires systemic Rx – NSAIDS
– Prednisone
– Immunosuppressants
EPISCLERITIS (Topical Rx)
• Trivial
• Topical lubricants
• Topical NSAIDS
• RARELY topical steroids
Practice Points Episcleritis does not progress to Scleritis. Episcleritis can generally be managed in practice scleritis should be referred
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ANTERIOR UVEITIS
• Moderate aching pain
• Photophobia
• Past History
• Screen for systemic symptoms
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Seronegative arthropathies Inflammatory bowel disease Sarcoid Behcets Infections
e.g TB, Syphillis
ASSOCIATIONS
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IRIS APPEARANCE: Synechiae
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SUDDEN PAINLESS LOSS OF VISION
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RETINAL DETACHMENT
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BRANCH RETINAL VEIN OCCLUSION
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CENTRAL RETINAL VEIN OCCLUSION
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BRANCH RETINAL ARTERY OCCLUSION
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CENTRAL RETINAL ARTERY OCCLUSION
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ARTERY OCCLUSION
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VITREOUS HAEMORRHAGE
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SIGHT THREATENING CONDITIONS
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ACUTE ANGLE CLOSURE
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PREDISPOSITION
• Incidence 1/1,000 pop’n > 40 yrs
4:1 female to male
• Predisposition
– Short Eye
– Narrow Angle
– Large Lens
– Therefore older hypermetrope at risk
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ACUTE ANGLE CLOSURE GLAUCOMA
Intense ocular pain
Decreased vision
Headache
Photophobia
Haloes around lights
Nausea and vomiting
Premonitory symptoms
Hypermetrope
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BEWARE OF THE MASQUERADE
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ACUTE ANGLE CLOSURE Rx
• REDUCE IOP – Medical
• Topical: – Alpha-agonist, Beta-
blockers, Mitotics (Pilocarpine)
• Systemic – Carbonic anhydrase
inhibitors (Diamox), Osmotics (Mannitol
– Surgical • Peripheral iridotomy
• Clear lens extraction/trabeculectomy
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TEMPORAL ARTERITIS
• SIGHT THREATENING
• Systemic inflammatory vasculitis of unknown Aetiology
• Time is vision
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TEMPORAL ARTERITIS
• General History
– Jaw claudication,
– scalp tenderness,
– weight loss, sweats, shoulder girdle pain
• Ophthalmic presentation
– Sudden vision loss,
– amaurosis fugax,
– visual obscurations,
– diplopia
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TEMPORAL ARTERITIS
• Investigations
– ESR, CRP, FBC, temporal artery biospy
• Treatment
– IV methylpred 1g for three days
– High dose oral prednisone
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ENDOPHTHALMITIS
• Inflammatory condition of the intraocular cavities.
• Typically caused by infection
• May be endogenous or exogenous
• “Tap and inject”
• SIGHT THREATENING
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TRAUMA
T
R
A
U
M
A
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BLUNT TRAUMA
• Mild – moderate
– “bruise” ocular tissues
– Eye wall intact
• Moderate – severe
– Rupture eye wall
– Very severe consequences
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BLUNT TRAUMA
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BLUNT TRAUMA
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BLUNT TRAUMA
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BLUNT TRAUMA
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BLUNT TRAUMA
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BLUNT GLOBE RUPTURE
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ORBITAL FRACTURES
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ORBITAL FRACTURES
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CORNEAL FOREIGN BODY
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FOREIGN BODY
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SUB TARSAL FOREIGN BODY
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LACERATING TRAUMA
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LACERATING TRAUMA
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CHEMICAL BURNS
• SIGHT THREATENING
• Acid vs Alkali
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IMMEDIATE AND COPIOUS IRRIGATION
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LIFE THREATENING CONDITIONS
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THIRD NERVE PALSY
LIFE THREATENING
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THIRD NERVE PALSY
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ORBITAL CELLULITIS
• LIFE THREATENING
• Proptosis
• Reduced ocular motility
• Chemosis
• Other symptoms
– Fever
– Malaise
– Lid swelling
– Redness
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To see or not to see that is the question: Quiz
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Question 1: Happy labourer
• History
• 26 year old carpenter
• Hammering masonry nail
• Felt something bounce of eye (2pm)
• Foreign body sensation and red eye
• Black “spot” in temporal field
• Attends at 8pm for review
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Question 1: Signs
OD: UAVA 6/6
OS: UAVA 6/5
Right eye red
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Differential Diagnosis
1. Corneal foreign body
2. Penetrating eye injury
3. Subconjunctival haemorrhage
4. Traumatic macular haemorrhage
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Differential Diagnosis
1. Corneal foreign body
2. Penetrating eye injury
3. Subconjunctival haemorrhage
4. Traumatic macular haemorrhage
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Always suspect penetrating injury
• Hammer & nail
• Hammer and chisel
• Power tools
• Management
– Urgent referral
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Obvious foreign bodies
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Question 2: which is the most potent anti-inflammatory
corticosteroid?
1. Betnesol 0.5% (betamethasone phosphate)
2. Predforte 1.0% (prednisone acetate)
3. Maxidex 0.1% (dexamethasone alcohol)
4. Predsol 0.5% (prednisone phosphate)
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Question 2: which is the most potent anti-inflammatory
corticosteroid?
1. Betnesol 0.5% (betamethasone phosphate)
2. Predforte 1.0% (prednisone acetate)
3. Maxidex 0.1% (dexamethasone alcohol)
4. Predsol 0.5% (prednisone phosphate)
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Question 3: male nurse redeye
• History
• 24 year old charge nurse in urology
• Overnight shift - struck in left eye by catheter wielding patient at 2am
• Attends same day at 6pm with red eye
• Watery discharge
• Vision slightly “fuzzy”
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Case 3: signs
• VAR – 6/6 VAL – 6/12
• Right eye white – left moderately red
• Minor discharge
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Case 3
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Acute Red Eye – differential
1. Conjunctivitis 2. Corneal abrasion 3. Keratitis 4. Uveitis 5. Acute angle closure crisis 6. Scleritis / episcerlitis 7. Subconjunctival haemorrhage 8. Ocular Trauma 9. Herpes zoster ophthalmicus
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Acute Red Eye – differential
1. Conjunctivitis 2. Corneal abrasion 3. Keratitis 4. Uveitis 5. Acute angle closure crisis 6. Scleritis / episcerlitis 7. Subconjunctival haemorrhage 8. Ocular Trauma 9. Herpes zoster ophthalmicus
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Look again: Michael Segal, photographer
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Question 4: Saturday afternoon graft
History
• Attends optometrist 4pm on Saturday afternoon
• Corneal transplant six months earlier
• Advised 4 weeks ago graft healthy and should attend own optometrist for temporary spectacle correction
• Feels vision generally good,
• Eye has been a little gritty and minimally photophobic since graft, perhaps minimally more in last two weeks.
• Would like photosensitive lenses in new spectacles
• Still unhappy comes in for further opinion
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Question 4: Signs
• Bilateral penetrating keratoplasties
– OD 5 year ago, OS 6 months ago
• OD – 6/6 BSCVA (–2.00/-3.50 x 78)
• OS – 6/9 BSCVA (–1.25/-5.00 x 140)
• Both eyes minimally pink
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Question 4: slit lamp signs
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Question 4: Differential diagnosis
1. Bilateral dry eye with PEE
2. Adenovirus keratoconjunctivitis
3. Corneal allograft rejection
4. Topical drop toxicity
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Question 4: Differential diagnosis
1. Bilateral dry eye with PEE
2. Adenovirus keratoconjunctivitis
3. Corneal allograft rejection
4. Topical drop toxicity
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QUESTION 5: bonus points - name those lesions
1. Kaye dots
2. Krachmer’s spots
3. Seilor’s spots
4. Mittendorf’s dots
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QUESTION 5: bonus points - name those lesions
1. Kaye dots
2. Krachmer’s spots
3. Seilor’s spots
4. Mittendorf’s dots
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End of Section 1
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Question 6: chronic red, raised lumps
• 32 year old male
• Medial aspect of eye - red, raised lump
• Chronic redness & grittiness
• BSCVA 6/18 & 6/6
• POH – childhood squint
• GP Rx
– Chloramphenicol
– Fucithalmic
– Dexamethasone
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Question 6: chronic red, raised lumps
• 26 year old male
• Inner lower lid red, raised lump
• Chronic redness & grittiness
• BSCVA 6/6 & 6/6
• POH - nil
• GP Rx
– Fucithalmic
– Dexamethasone
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Question 6: chronic red, raised lumps common differential diagnosis
1. Severe nodular episcleritis
2. Conjunctival granuloma
3. Infective conjunctivitis
4. Ocular surface squamous neoplasia
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Question 6: chronic red, raised lumps common differential diagnosis
1. Severe nodular episcleritis
2. Conjunctival granuloma
3. Infective conjunctivitis
4. Ocular surface squamous neoplasia
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Question 6: Pyogenic & Suture Granuloma
• Lesions typically follow conjunctival inflammation
• Often post surgery
• Granulation tissue
– fibroblasts, capillaries & inflammatory cells
• No Granulomas
• May be associated with sutures
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Question 7: Severe conjunctivitis “It came on with a rash”
• Three week history of “chest infection”
• Two week history of conjunctivitis
• Severe vesicular rash
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Question 7: Severe conjunctivitis “It came on with a rash”
Diagnosis
1. Measles conjunctivitis
2. Chickenpox conjunctivitis
3. Stevens-Johnson syndrome
4. Severe atopic conjunctivitis
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Question 7: Severe conjunctivitis “It came on with a rash”
Diagnosis
1. Measles conjunctivitis
2. Chickenpox conjunctivitis
3. Stevens-Johnson syndrome
4. Severe atopic conjunctivitis
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Q 7 : Stevens Johnson Syndrome (Erythema multiforme major)
Topical or systemic drugs
– Sulfonamides
– Penicillin
– Aspirin
– Tropicamide
– Proparicaine
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Question 8: Ancient Egyptian eyes
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Question 8: Cleopatra
Which plant did Cleopatra use on Caesar ?
1. Juniper berries
2. Foxglove extract
3. Belladonna extract
4. Acacia gum
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The seer
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Question 9 : a routine refraction?
HISTORY
• In a hurry to get new spectacles and get back on the road –
chose optoemtry practice from the web-site whilst having a
cappuccino and donut during regular pit-stop at the internet
cafe
• 48 year old business man, low myope
• Overweight, Rx for hypertension, otherwise well
• notes problem driving at night over last 12 months, last saw
optometrist 2 years ago
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Question 9: signs
• On examination
– Visual acuity 6/9 Right & Left with
– Existing spectacles
– Right –1.50D, Left –1.75D
– Pinhole 6/5 each eye
• Optometrists Refraction today
VAR 6/6 with –2.50/-0.25 x 80
VAL 6/5 with –3.00D
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9: examination
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Question 9: fundi
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Question 9 : Cause of reduced VA
1. Non-pathological myopic progression
2. Diabetic maculopathy
3. Hypertensive retinopathy
4. Acquired lenticular myopic shift
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Question 9: Cause of reduced VA
1. Non-pathological myopic progression
2. Diabetic maculopathy
3. Hypertensive retinopathy
4. Acquired lenticular myopic shift
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End of section 2
Young woman receives gifts from Venus and the three graces: Sandro Botticelli (1444-1510)
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Question 10: Painful red eye 6 weeks
Keratoconic difficulty with RGP CL fit for 2 years
Awoke to Sudden pain & redness
Red eye
Photophobic
Watering
Vision CF
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Case 10: diagnosis
1. Bacterial Keratitis
2. Acute corneal hydrops
3. Acanthamoeba keratitis
4. Fuchs endothelial dystrophy
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Question 10: diagnosis
1. Bacterial Keratitis
2. Acute corneal hydrops
3. Acanthamoeba keratitis
4. Fuchs endothelial dystrophy
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When the going gets tough...
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Bonus question: eye on the artist
1. Claude Monet
2. Rene Magritte
3. Edouard Manet
4. Henri Matisse
The beautiful relations/Les Belles Relations: Rene Magritte 1967
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Au revoir Rene
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Question 11. Confused red eye
• 77 year old brought in by son
• Often confused and poorly oriented
• Red painful eye for 3 days
• Watery discharge
• Complains vision is blurred
• Rx g chloramphenicol QDS
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Case 11: Signs
• VAR 6/12
• VAL 6/36
• Red eye
• Poorly cooperative
• Appears dehydrated
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Case 11. Differential Diagnosis
1. Microbial keratitis
2. Acute closed angle glaucoma
3. Acute anterior uveitis/iritis
4. Adenoviral keratoconjunctivitis
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Case 11. Differential Diagnosis
1. Microbial keratitis
2. Acute closed angle glaucoma
3. Acute anterior uveitis/iritis
4. Adenoviral keratoconjunctivitis
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Eye of the beholder 1: Gerry Charm
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Question 12: Whose Eyes?
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Question 12: Whose Eyes?
WOLF HIPPOPOTAMOUS CROCODILE
RABBIT TIGER EAGLE
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Question 13: what is this red lump on my eye?
• 25 year old male tour guide
• Chronic red eye for 3 months
• Raised “lump”
• Otherwise well
• BSCVA 6/4
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Question 13: diagnosis
1. Kaposi’s sarcoma
2. Squamous cell carcinoma of conjunctiva
3. Conjunctival papilloma
4. Pseudo-pterygium
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Question 13 : diagnosis
1. Kaposi’s sarcoma
2. Squamous cell carcinoma of conjunctiva
3. Conjunctival papilloma
4. Pseudo-pterygium
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Question 13: Conjunctival papilloma
• Benign
• Multiple fibrovascular tissue cores with overlying epithelium
• Sessile or pedunculated
• Papilloma virus
• May be pre-malignant in older adults
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Question 14 : It became worse after my bowel operation
• 23 year old female
• Sectorial redness 4/52
• Gritty
• 6/5
• Crohns disease
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Q 14: Episcleritis clinical features
Which of the following statements is most true of episcleritis:
1. Usually self-limiting
2. Typically requires topical steroids
3. Frequently progresses to scleritis
4. Usually associated with systemic disease
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Q 14: Episcleritis clinical features
Which of the following statements is most true of episcleritis:
1. Usually self-limiting
2. Typically requires topical steroids
3. Frequently progresses to scleritis
4. Usually associated with systemic disease
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Question 15 : I get terrible headaches when I study too hard!
• 31 year old Italian male registrar
• Studying for postgraduate medical degree
• Severe frontal headaches, from brow spreading back to occiput
• No visual phenomena but occasionally has to lie in dark when really severe
• Worse in the last 3 months
• Often worst at night
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Question 15 : signs
• UAVA OD 6/9 OS 6/12
• Refraction +2.50D +3.00D
• BSCVA 6/5 6/5
• Eyes quiet and comfortable
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Question 15 : clinical signs
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Question 15 : management
1. Urgent referral to Ophthalmologist
2. Routine referral to ophthalmologist
3. Referral to GP
4. Update spectacles and review
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Question 15 : management
1. Urgent referral to Ophthalmologist
2. Routine referral to ophthalmologist
3. Referral to GP
4. Update spectacles and review
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Q 15: Diagnosis & management
• Normal or abnormal?
• Headaches with apparently swollen discs
• However, has uncorrected hyperopia
• Studying hard – near work +++
• Otherwise well
• Management – trial with correction, reassurance, no referral, but inform GP
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Examine very carefully
End of Section 4
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Question 16: flying and the untoward effects of infra-red light
1. Narcissus
2. Icarus
3. Daedelus
4. Iapetus
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Question 16: flying and the untoward effects of infra-red light
1. Narcissus
2. Icarus
3. Daedelus
4. Iapetus
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Q 17 : My glasses hurt the side of my head
History • 85 year old lady • Rather frail looking, feels tired, otherwise well • Notes that spectacles hurt right side of head
when she puts them on and off • Generally had a bit of a right sided headache for a
few weeks • Noted vision “blurred” for about 10 minutes, in
one or other eye – cant remember which - last week
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Question 17 : signs
• UAVA 6/12 OD, 6/7.5 OS
• Refraction +2.00D OD, +1.00D OS
• Pupil reactions normal
• Eye movements normal
• Gonioscopy – angles open
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Question 17 : Fundus
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Question 17 : referral
1. Urgent referral to Ophthalmologist
2. Routine referral to ophthalmologist
3. Referral to GP
4. Update spectacles and review
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Question 17 : referral giant cell (temporal) arteritis
1. Urgent referral to Ophthalmologist
2. Routine referral to ophthalmologist
3. Referral to GP
4. Update spectacles and review
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An emergency lunch
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Question 18 : bilateral acute painful red eye over 1 week
56 year old female
Rheumatoid arthritis
Onset over 2-3 days
No discharge
Pupils reactive
Pain keeping patient awake at night
BSCVA 6/6 and 6/5
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Question 18 : bilateral acute painful red eye over 1 week
Diagnosis?
1. Conjunctivitis
2. Anterior uveitis
3. Keratitis
4. Anterior scleritis
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Question 19. The news doesn’t look so good!
• 42 year old overweight female
• Recently noticed problems reading newsprint
• Distance vision fine - never had eye test for spectacles before
• Diagnosed with type II diabetes, 6 months ago - diet controlled
• Has mildly elevated blood pressure - takes ACE inhibitor
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Question 19 : Signs
• VAR: 6/7.5 VAL: 6/6
• Rx: R: +1.50 / -0.50 x 100 6/5-
L: +1.00 / -0.25 x 75 6/5-
• Reads N5 R & L with above Rx
• Gross examination: media clear and eyes white/quiet
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Question 19: Ophthalmoscopy RE
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Question 19 : referral ?
1. Urgent referral to Ophthalmologist
2. Routine referral to ophthalmologist
3. Referral to GP
4. Update spectacles and review
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Question 19 : referral ?
1. Urgent referral to Ophthalmologist
2. Routine referral to ophthalmologist
3. Referral to GP
4. Update spectacles and review
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Q 19: Diagnosis & management
• Normal or abnormal?
• Symptoms of presbyopia
• However, has uncorrected hyperopia
• Systemic disease controlled
• Myelinated nerve fibres
• Management – reassurance, no referral, prescribe spectacles
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End of Section 5
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Question 20: My eye stings & waters when I wake up early in the morning
• 54 year old astrologer, daily wear SCL
• After driving from London to Glasgow noted a sudden stinging pain in right eye, pain and watering lasted about 30 minutes
• Since then has been awoken on about 7-8 occasions in the early hours of the morning over a three month period
• Sharp stabbing pain, watering, lasts about 5-20 minutes, only when awakening from sleep
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Question 20 : clinical signs
• -3.00D OU SCL
• VAR 6/5 VAL 6/5
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Question 20: clinical signs
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Q 20: Diagnosis & management
1. Sterile infiltrates
2. Map dot fingerprint dystrophy
3. Recurrent corneal erosion syndrome
4. CL related corneal flecks
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Q 20: Diagnosis & management
1. Sterile infiltrates
2. Map dot fingerprint dystrophy
3. Recurrent corneal erosion syndrome
4. CL related corneal flecks
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The Blind Girl George Everett Millais
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Question 21: who is the patron saint
of oculists?
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Question 29: who is the patron saint
of oculists?
1. Saint Kylie
2. Saint Winifred
3. Saint Lucy
4. Saint Charlene
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End of section 6
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Final Bonus Question 22
Name the artist
1. Jackson Pollock
2. Claude Monet
3. Andy Warhol
4. Georges Seaurat
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Thank you