Introduction to Introduction to Clinical Clinical

MedicineMedicineOphthalmology ReviewOphthalmology Review

AcknowledgmentsAcknowledgments Chapter 1 – Chapter 1 – Dina AbdulmannanDina Abdulmannan Chapter 2 – Chapter 2 – Mohammed Al-AbriMohammed Al-Abri Chapter 3 – Chapter 3 – Ahmed Al-HinaiAhmed Al-Hinai Chapter 4 – Chapter 4 – Chantal AresChantal Ares Chapter 5 – Chapter 5 – Ashjan BamahfouzAshjan Bamahfouz Chapter 6 – Chapter 6 – Serene JouhargySerene Jouhargy Chapter 7 – Chapter 7 – David LedererDavid Lederer Chapter 8 – Chapter 8 – Norman MainvilleNorman Mainville Chapter 9 – Chapter 9 – Abdulla NaqiAbdulla Naqi

Editors – Editors – Kashif BaigKashif Baig

Hady SahebHady SahebMahshad DarvishMahshad Darvish

AcknowledgmentsAcknowledgments Chapter 1 – Chapter 1 – The Eye ExaminationThe Eye Examination Chapter 2 – Chapter 2 – Acute Visual LossAcute Visual Loss Chapter 3 – Chapter 3 – Chronic Visual LossChronic Visual Loss Chapter 4 – Chapter 4 – Red EyeRed Eye Chapter 5 – Chapter 5 – Ocular and Orbital InjuriesOcular and Orbital Injuries Chapter 6 – Chapter 6 – Amblyopia & StrabismusAmblyopia & Strabismus Chapter 7 – Chapter 7 – Neuro-OphthalmologyNeuro-Ophthalmology Chapter 8 – Chapter 8 – Ocular Manifestations of Systemic DiseaseOcular Manifestations of Systemic Disease Chapter 9 – Chapter 9 – Drugs and the EyeDrugs and the Eye

Source: Source: Basic Ophthalmology for Medical Students Basic Ophthalmology for Medical Students and Primary Careand Primary Care

(Cynthia Bradford)(Cynthia Bradford)

OutlineOutline

Chapter 1 – The Eye ExaminationChapter 1 – The Eye Examination Chapter 2 – Acute Visual LossChapter 2 – Acute Visual Loss Chapter 3 – Chronic Visual LossChapter 3 – Chronic Visual Loss Chapter 4 – Red EyeChapter 4 – Red Eye Chapter 5 – Ocular and Orbital InjuriesChapter 5 – Ocular and Orbital Injuries Chapter 6 – Amblyopia & StrabismusChapter 6 – Amblyopia & Strabismus Chapter 7 – Neuro-OphthalmologyChapter 7 – Neuro-Ophthalmology Chapter 8 – Ocular Manifestations of Systemic DiseaseChapter 8 – Ocular Manifestations of Systemic Disease Chapter 9 – Drugs and the EyeChapter 9 – Drugs and the Eye

Source: Basic Ophthalmology for Medical Students and Primary CareSource: Basic Ophthalmology for Medical Students and Primary Care(Cynthia Bradford)(Cynthia Bradford)

The Eye The Eye Examination Examination

Chapter 1Chapter 1

AnatomyAnatomy

AnatomyAnatomy

Extraocular Extraocular movements movements

MedialMedial LateralLateral Upward Upward DownwardDownward IncyclotorsionIncyclotorsion Excyclotorsion Excyclotorsion

Basic Physical ExamBasic Physical Exam

General physical examination should General physical examination should include :include : Visual acuityVisual acuity Pupillary reactionPupillary reaction Extraocular movementExtraocular movement Direct ophthalmoscope Direct ophthalmoscope Dilated exam (in case of visual loss or retinal Dilated exam (in case of visual loss or retinal

pathology)pathology)

Visual Acuity Visual Acuity

Distance or NearDistance or Near Distance visual acuity at age 3Distance visual acuity at age 3

early detection of amblyopia early detection of amblyopia

TerminologyTerminology VA - Visual acuity VA - Visual acuity OD - ocular dexterOD - ocular dexter OS - ocular sinisterOS - ocular sinister OU - oculus uterqueOU - oculus uterque

Distance Visual Acuity Distance Visual Acuity TestingTesting

Nomenclature:Nomenclature:

Distance between the patient and the eye chart Distance between the patient and the eye chart __________________________________________________________________________________________

Distance at which the letter can be read by a person Distance at which the letter can be read by a person with normal acuity with normal acuity

Normal: 20/20Normal: 20/20 Below normal: 20/40, 20/400Below normal: 20/40, 20/400 Better than normal: 20/15Better than normal: 20/15

Distance Visual Acuity Distance Visual Acuity TestingTesting

Place patient at 20 ft from Snellen Place patient at 20 ft from Snellen chart chart

OD then OSOD then OS VA is line in which > ½ letters are VA is line in which > ½ letters are

read read Pinhole if < 20/40Pinhole if < 20/40

Snellen eye Snellen eye chart chart

Rosenbaum Rosenbaum pocket chart pocket chart

Distance Visual Acuity Distance Visual Acuity TestingTesting

If VA < 20/400If VA < 20/400 Reduce the distance between the pt and Reduce the distance between the pt and

the chart and record the new distance (eg. the chart and record the new distance (eg. 5/400)5/400)

If < 5/400If < 5/400 CF – count fingers (include distance)CF – count fingers (include distance) HM – hand motion (include distance)HM – hand motion (include distance) LP – light perceptionLP – light perception NLP – no light perceptionNLP – no light perception

Near Visual Acuity Near Visual Acuity TestingTesting

Indicated when Indicated when Patient complains about near visionPatient complains about near vision Distance testing difficult/impossible Distance testing difficult/impossible

Distance specified on each card Distance specified on each card (35cm)(35cm)

Pupillary ExaminationPupillary Examination

Direct penlight into eye while Direct penlight into eye while patient looking at distancepatient looking at distance

Direct Direct Constriction of ipsilateral eyeConstriction of ipsilateral eye

Consensual Consensual Constriction of contralateral eyeConstriction of contralateral eye

Ocular Motility Ocular Motility

Rt superior rectusRt superior rectus

Lt inferior oblique Lt inferior oblique Lt superior rectusLt superior rectus

Rt inferior obliqueRt inferior oblique

Rt lateral rectusRt lateral rectus

Lt medial rectusLt medial rectusLt lateral rectusLt lateral rectus

Rt medial rectusRt medial rectus

Rt inferior rectusRt inferior rectus

Lt superior Lt superior oblique oblique

Lt inferior rectusLt inferior rectus

Rt superior Rt superior obliqueoblique

Direct Ophthalmoscopy Direct Ophthalmoscopy

Tropicamide or phenylephrine for Tropicamide or phenylephrine for dilationdilation unless shallow anterior chamberunless shallow anterior chamber unless under neurological evaluationunless under neurological evaluation

Use own OD to examine ODUse own OD to examine OD Same for OSSame for OS

Intraocular Pressure Intraocular Pressure Measurement Measurement

Range: 10 - 22Range: 10 - 22

Anterior chamber depth Anterior chamber depth assessment assessment

Likely shallow if Likely shallow if ≥ ≥ 2/3 of nasal iris in shadow2/3 of nasal iris in shadow

Summary of steps in eye Summary of steps in eye examexam

1.1. Visual AcuityVisual Acuity

2.2. Pupillary examinationPupillary examination

3.3. Visual fields by Visual fields by confrontationconfrontation

4.4. Extraocular movementsExtraocular movements

5.5. Inspection ofInspection of1.1. Lids and surrounding Lids and surrounding

tissuetissue

2.2. Conjunctiva and scleraConjunctiva and sclera

3.3. Cornea and irisCornea and iris

6.6. Anterior chamber Anterior chamber depthdepth

7.7. Lens clarityLens clarity

8.8. Tonometry Tonometry

9.9. Fundus Fundus examinationexamination

1.1. DiscDisc

2.2. MaculaMacula

3.3. Vessels Vessels

Acute Visual LossAcute Visual Loss

Chapter 2Chapter 2

HistorHistoryy

Age POH & PMH Onset Duration Severity of visual loss

compared to baseline Monocular vs.

binocular ? Any associated

symptoms Ophtho enquiry

Visual acuity assessment

Visual fields Pupillary reactions Penlight or slit lamp

examination Intraocular pressure Ophthalomoscopy - red reflex

- assessment of clarity of media

- direct inspection of the fundus

ExaminatioExaminationn

Media OpacitiesMedia Opacities

Corneal edemaCorneal edema:: Ground glass appearanceGround glass appearance Rule out: acute angle closure Rule out: acute angle closure

glaucomaglaucoma

Corneal abrasionCorneal abrasion

HyphemaHyphema Traumatic, spontaneousTraumatic, spontaneous

Vitreous hemorrhageVitreous hemorrhage

Darkening of red reflex with clear Darkening of red reflex with clear lens, AC and cornealens, AC and cornea

Traumatic Traumatic Retinal neovascularizationRetinal neovascularization

Retinal DiseasesRetinal Diseases

Retinal detachmentRetinal detachment Flashes, floaters, Flashes, floaters,

shade over visionshade over vision RAPD (if extensive RD)RAPD (if extensive RD) elevated retina +/- elevated retina +/-

foldsfolds Macular diseaseMacular disease

Decreased central Decreased central vision vision

MetamorphopsiaMetamorphopsia

Central Retinal Artery Central Retinal Artery Occlusion (CRAO)Occlusion (CRAO)

True ophthalmic emergency!True ophthalmic emergency! Sudden painless and often Sudden painless and often

severe visual losssevere visual loss Permanent damage to the Permanent damage to the

ganglion cells caused by ganglion cells caused by prolonged interruption of prolonged interruption of retinal arterial blood flowretinal arterial blood flow

Characteristic “ cherry-red Characteristic “ cherry-red spot ”spot ”

No optic disc swelling unless No optic disc swelling unless there is ophthalmic or carotid there is ophthalmic or carotid artery occlusionartery occlusion

Months later, pale disc due to Months later, pale disc due to death of ganglion cells and death of ganglion cells and their axonstheir axons

CRAO TreatmentCRAO Treatment

Ocular massage:Ocular massage: To dislodge a small embolus in CRA and To dislodge a small embolus in CRA and

restore circulationrestore circulation Pressing firmly for 10 seconds and then Pressing firmly for 10 seconds and then

releasing for 10 seconds over a period of releasing for 10 seconds over a period of ~ 5 minutes~ 5 minutes

Ocular hypotensives, vasodilators, Ocular hypotensives, vasodilators, paracentesis of anterior chamberparacentesis of anterior chamber

R/O giant cell arteritis in elderly patient R/O giant cell arteritis in elderly patient without a visible emboluswithout a visible embolus

Branch Retinal Artery Occlusion Branch Retinal Artery Occlusion (BRAO)(BRAO)

Sector of the retina Sector of the retina is opacified and is opacified and vision is partially vision is partially lostlost

Most often due to Most often due to

embolusembolus Treat as CRAOTreat as CRAO

Central Retinal Vein Occlusion Central Retinal Vein Occlusion (CRVO)(CRVO)

Subacute loss of visionSubacute loss of vision Disc swelling, venous Disc swelling, venous

engorgement, cotton-wool engorgement, cotton-wool spots and diffuse retinal spots and diffuse retinal hemorrhage.hemorrhage.

Risk factors: age, HTN, Risk factors: age, HTN, arteriosclerotic vascular arteriosclerotic vascular disease, conditions that disease, conditions that increase blood viscosity increase blood viscosity (polycythemia vera, sickle (polycythemia vera, sickle cell disease, lymphoma , cell disease, lymphoma , leukemia)leukemia)

Needs medical evaluationNeeds medical evaluation Long term risk for Long term risk for

neovascular glaucoma, so neovascular glaucoma, so periodic ophtho f/u periodic ophtho f/u

Optic Nerve DiseaseOptic Nerve Disease

Non-Arteritic Ischemic Optic Non-Arteritic Ischemic Optic Neuropathy (NAION)Neuropathy (NAION) Vascular disorderVascular disorder Pale, swollen disc +/– splinter Pale, swollen disc +/– splinter

hemorrhagehemorrhage Loss of VA , VF ( often Loss of VA , VF ( often

altitudinal )altitudinal ) Arteritic Ischemic Optic Arteritic Ischemic Optic

Neuropathy (AION)Neuropathy (AION) Symptoms of giant cell arteritisSymptoms of giant cell arteritis ESR, CRP, Platelets +/– TABxESR, CRP, Platelets +/– TABx Rx : systemic steroids Rx : systemic steroids

Optic Nerve DiseaseOptic Nerve Disease Optic neuritisOptic neuritis

Idiopathic or associated with multiple sclerosisIdiopathic or associated with multiple sclerosis Young adultsYoung adults Decreased visual acuity and colour visionDecreased visual acuity and colour vision RAPDRAPD Pain with ocular movementPain with ocular movement Bulbar (disc swelling) or retrobulbar (normal Bulbar (disc swelling) or retrobulbar (normal

disc)disc)

Traumatic optic neuropathyTraumatic optic neuropathy Direct trauma to optic nerveDirect trauma to optic nerve Indirect : shearing force to the vascular supply Indirect : shearing force to the vascular supply

Visual Pathway DisordersVisual Pathway Disorders

HemianopiaHemianopia Causes: vascular or tumorsCauses: vascular or tumors

Cortical BlindnessCortical Blindness AKA central or cerebral blindnessAKA central or cerebral blindness Extensive bilateral damage to Extensive bilateral damage to

cerebral pathwayscerebral pathways Normal pupillary reactions and Normal pupillary reactions and

fundifundi

Chronic Visual Chronic Visual LossLossChapter 3Chapter 3

IntroductionIntroduction

1994: 38 million blind people (age >60 yrs) 1994: 38 million blind people (age >60 yrs) worldwideworldwide

1997: in western countries, leading causes 1997: in western countries, leading causes of blindness in people over 50 yrs of ageof blindness in people over 50 yrs of age

1)1) Age-Related Macular Degeneration Age-Related Macular Degeneration

2)2) CataractCataract

3)3) GlaucomaGlaucoma

4)4) DiabetesDiabetes

IntroductionIntroduction

According to WHO estimates, the most According to WHO estimates, the most common causes of blindness around the common causes of blindness around the world in 2002 were:world in 2002 were:

1.1. cataracts (47.9%)cataracts (47.9%)

2.2. glaucoma (12.3%)glaucoma (12.3%)

3.3. age-related macular degeneration (8.7%)age-related macular degeneration (8.7%)

4.4. corneal opacity (5.1%)corneal opacity (5.1%)

5.5. diabetic retinopathy (4.8%)diabetic retinopathy (4.8%)

6.6. childhood blindness (3.9%)childhood blindness (3.9%)

7.7. trachoma (3.6%)trachoma (3.6%)

8.8. onchocerciasis (0.8%)onchocerciasis (0.8%)

GlaucomaGlaucoma

Classification:Classification: Open-angle glaucoma vs. angle-closure Open-angle glaucoma vs. angle-closure

glaucomaglaucoma Primary vs. SecondaryPrimary vs. Secondary

GlaucomaGlaucoma

Risk factors:Risk factors: Old ageOld age MyopiaMyopia African-American raceAfrican-American race Systemic HypertensionSystemic Hypertension Family HistoryFamily History High IOPHigh IOP SmokingSmoking

Glaucoma EvaluationGlaucoma Evaluation

Complete historyComplete history Complete examinationComplete examination

IOPIOP GonioscopyGonioscopy Optic discOptic disc Visual FieldsVisual Fields

Glaucoma TherapyGlaucoma Therapy

MedicalMedical Drops to decrease aqueous secretion or Drops to decrease aqueous secretion or

increase aqueous outflowincrease aqueous outflow Systemic medications (PO or IV)Systemic medications (PO or IV)

Laser:Laser: IridotomyIridotomy IridoplastyIridoplasty TrabeculoplastyTrabeculoplasty

Glaucoma TherapyGlaucoma Therapy

SurgicalSurgical Filtration Surgery (e.g. Filtration Surgery (e.g.

Trabeculectomy)Trabeculectomy) Tube shuntTube shunt

Cyclodestructive proceduresCyclodestructive procedures

CataractCataract

Opacification of the lensOpacification of the lens Congenital vs. acquiredCongenital vs. acquired Often age-relatedOften age-related Different formsDifferent forms

Nuclear, cortical, PSCCNuclear, cortical, PSCC Very successful surgeryVery successful surgery

CataractCataract

HistoryHistory Ocular ExaminationOcular Examination Others: A-scan, ± B-scan , ± PAMOthers: A-scan, ± B-scan , ± PAM TreatmentTreatment

SurgicalSurgical Excision and IOL implantationExcision and IOL implantation

Age-Related Macular Age-Related Macular Degeneration (ARMD)Degeneration (ARMD)

Two typesTwo types WetWet

Choroidal NeovascularizationChoroidal Neovascularization DryDry

DrusenDrusen RPE changes (atrophy, hyperplasia)RPE changes (atrophy, hyperplasia)

Neovascular / Wet ARMDNeovascular / Wet ARMD

CNV – choroidal CNV – choroidal neovastcularizationeovastcularizationn LeaksLeaks BleedsBleeds Severe visual lossSevere visual loss

TreatmentTreatment LaserLaser Injections of anti-Injections of anti-

VEGFVEGF

Dry ARMDDry ARMD DrusenDrusen

No neovascular No neovascular membranemembrane

Atrophy of the RPEAtrophy of the RPE

Treat with Treat with Vitamins (!)Vitamins (!) Vit C & E, β-Vit C & E, β-

carotene, minerals carotene, minerals (cupric oxide & zinc (cupric oxide & zinc oxide) oxide)

Omega-3Omega-3

The Red EyeThe Red Eye

Chapter 4Chapter 4

DDx Red EyeDDx Red Eye Acute angle closure glaucomaAcute angle closure glaucoma Iritis or iridocyclitisIritis or iridocyclitis Herpes simplex keratitisHerpes simplex keratitis Conjunctivitis (bacterial, viral, Conjunctivitis (bacterial, viral,

allergic, irritative)allergic, irritative) EpiscleritisEpiscleritis Soft contact lens associatedSoft contact lens associated ScleritisScleritis Adnexal Disease Adnexal Disease

(dacryocystitis, stye, (dacryocystitis, stye, blepharitis, lid lesions, blepharitis, lid lesions, thyroid..)thyroid..)

Subconjunctival hemorrhageSubconjunctival hemorrhage PterygiumPterygium Keratoconjunctivitis siccaKeratoconjunctivitis sicca Abrasions or foreign bodiesAbrasions or foreign bodies Corneal ulcerCorneal ulcer 2’ to abnormal lid function2’ to abnormal lid function

THINKTHINK Anatomy “front to Anatomy “front to

back”back” Acute vs. chronicAcute vs. chronic Visually Visually

threatening?threatening?

HistoryHistory Onset? Sudden? Progressive? Constant?Onset? Sudden? Progressive? Constant? Family/friends with red eye?Family/friends with red eye? Using meds in eye?Using meds in eye? Trauma?Trauma? Recent eye surgery?Recent eye surgery? Contact lens wearer?Contact lens wearer? Recent URTI?Recent URTI? Decreased VA? Pain? Discharge? Itching? Decreased VA? Pain? Discharge? Itching?

Photophobia? Eye rubbing?Photophobia? Eye rubbing? Other symptoms?Other symptoms?

Red Eye: Symptoms Red Eye: Symptoms *Decreased VA (i*Decreased VA (inflamed cornea, iridocyclitis, nflamed cornea, iridocyclitis,

acute glaucoma)acute glaucoma) *Pain (k*Pain (keratitis, ulcer, iridocyclitis, acute glaucoma)eratitis, ulcer, iridocyclitis, acute glaucoma) *Photophobia (*Photophobia (iritis)iritis) *Colored halos (*Colored halos (acute glaucoma)acute glaucoma) Discharge (Discharge (conj. or lid inflammation, corneal conj. or lid inflammation, corneal

ulcer)ulcer) Purulent/mucopurulent: BacterialPurulent/mucopurulent: Bacterial Watery: ViralWatery: Viral Scant, white, stringy: allergy, dry eyesScant, white, stringy: allergy, dry eyes

Itching (Itching (allergy)allergy)

* can indicate serious ocular disease* can indicate serious ocular disease

Physical ExamPhysical Exam VisionVision Pupil asymmetry or irregularityPupil asymmetry or irregularity Inspect: Inspect:

pattern of redness (heme, injection, ciliary flush)pattern of redness (heme, injection, ciliary flush) Amount & type of dischargeAmount & type of discharge Corneal opacities or irregularitiesCorneal opacities or irregularities

AC shallow? Hypopyon? Hyphema?AC shallow? Hypopyon? Hyphema? Fluorescein stainingFluorescein staining IOPIOP Proptosis? Lid abnormality? Limitation EOM?Proptosis? Lid abnormality? Limitation EOM?

Red Eye: SignsRed Eye: Signs

*Ciliary flush*Ciliary flush (corneal inflammation, iridocyclitis, acute glaucoma) (corneal inflammation, iridocyclitis, acute glaucoma) Conjuctival hyperemiaConjuctival hyperemia (nonspecific sign) (nonspecific sign) *Corneal opacification *Corneal opacification (iritis, corneal edema, acute glaucoma, (iritis, corneal edema, acute glaucoma,

keratitis, keratitis, ulcer) ulcer)

*Corneal epithelial disruption *Corneal epithelial disruption (corneal inflammation, abrasion)(corneal inflammation, abrasion) *Pupil abnormality (*Pupil abnormality (iridocyclitis, acute glaucoma)iridocyclitis, acute glaucoma) *Shallow AC (*Shallow AC (acute angle closure glaucoma)acute angle closure glaucoma) *Elevated IOP *Elevated IOP (iritis, acute glaucoma)(iritis, acute glaucoma) *Proptosis *Proptosis (thyroid disease, orbital or cavernous sinus mass, (thyroid disease, orbital or cavernous sinus mass,

infection)infection) Preauricular LN Preauricular LN (viral conjunctivitis, Parinaud’s oculoglandular (viral conjunctivitis, Parinaud’s oculoglandular

syndrome)syndrome)

* can indicate serious ocular disease* can indicate serious ocular disease

                                                             

                                               

                                               

Red eye management for Red eye management for 11°° care physicians care physicians

Blepharitis:Blepharitis: Warm compresses, lid care, Abx ointment or oral Warm compresses, lid care, Abx ointment or oral

(if rosacea or Meibomian gland dysfunction)(if rosacea or Meibomian gland dysfunction) Stye/ChalazionStye/Chalazion

Warm compresses (refer if still present after 1 Warm compresses (refer if still present after 1 month)month)

Subconj heme:Subconj heme: Will resolve in 10-14 daysWill resolve in 10-14 days

Viral conjunctivitisViral conjunctivitis Cool compresses, tears, contact precautionsCool compresses, tears, contact precautions

Bacterial conjunctivitisBacterial conjunctivitis Cool compresses, antibiotic drop/ointmentCool compresses, antibiotic drop/ointment

Important Side EffectsImportant Side Effects Topical anesthetics:Topical anesthetics:

Not to be used except for aiding in examNot to be used except for aiding in exam Inhibits growth & healing of corneal epitheliumInhibits growth & healing of corneal epithelium Possible severe allergic reactionPossible severe allergic reaction Decrease blink reflex: exposure to dehydration, Decrease blink reflex: exposure to dehydration,

injury, infectioninjury, infection

Topical corticosteroids:Topical corticosteroids: Can potentiate growth of herpes simplex, Can potentiate growth of herpes simplex,

fungusfungus Can mask symptomsCan mask symptoms Cataract formationCataract formation Elevated IOPElevated IOP

Ocular & Orbital Ocular & Orbital InjuriesInjuries

Chapter 5Chapter 5

Anatomy & FunctionAnatomy & Function Bony orbitBony orbit

Globe, EOM, vessels, nervesGlobe, EOM, vessels, nerves Rim protectiveRim protective

““Blow out” fractureBlow out” fracture Medial fracture -> subQ emphysema of eyelidsMedial fracture -> subQ emphysema of eyelids

Anatomy & FunctionAnatomy & Function EyelidsEyelids

Reflex closing when eyes threatenedReflex closing when eyes threatened Blinking rewets the corneaBlinking rewets the cornea Tear drainageTear drainage

CN VII palsy -> exposure keratopathyCN VII palsy -> exposure keratopathy

Lacrimal apparatusLacrimal apparatus Tear drainage occurs at medial canthusTear drainage occurs at medial canthus

Obstruction -> chronic tearing (epiphora)Obstruction -> chronic tearing (epiphora)

Anatomy & FunctionAnatomy & Function

Conjunctiva & corneaConjunctiva & cornea Quick reepitheliization post-abrasionQuick reepitheliization post-abrasion

Iris & ciliary bodyIris & ciliary body Blunt trauma -> pupil margin nick (tear)Blunt trauma -> pupil margin nick (tear) Blunt trauma -> hyphemaBlunt trauma -> hyphema Blunt trauma -> iritisBlunt trauma -> iritis

(pain, redness, photophobia, miosis)(pain, redness, photophobia, miosis)

Anatomy & FunctionAnatomy & Function

LensLens CataractCataract Lens dislocation (ectopia lentis)Lens dislocation (ectopia lentis)

Vitreous humorVitreous humor Decreased transparencyDecreased transparency

(hemorrhage, inflammation, infection)(hemorrhage, inflammation, infection) RetinaRetina

Hemorrhage Hemorrhage Macular damage (reduce visual acuity)Macular damage (reduce visual acuity)

Management or ReferralManagement or Referral

Chemical burnChemical burn Alkali worsen than Acid Alkali worsen than Acid Why? more rapid penetration of alkaliWhy? more rapid penetration of alkali

OPHTHALMIC EMERGENCYOPHTHALMIC EMERGENCY ALL chemical burns require ALL chemical burns require

immediate and perfuse irrigation, immediate and perfuse irrigation, THEN ophtho referralTHEN ophtho referral

Urgent SituationsUrgent Situations

Penetrating injuries of the globePenetrating injuries of the globe Conjunctival or corneal foreign bodiesConjunctival or corneal foreign bodies Hyphema Hyphema Lid laceration (sutured if not deep and Lid laceration (sutured if not deep and

neither the lid margin nor the canaliculi are neither the lid margin nor the canaliculi are involved)involved)

Traumatic optic neuropathyTraumatic optic neuropathy Radiant energy burns (snow blindness or Radiant energy burns (snow blindness or

welder’s burn)welder’s burn) Corneal abrasionCorneal abrasion

Semi-urgent SituationSemi-urgent Situation

Orbital fractureOrbital fracture Subconjuctival hemorrhage in blunt Subconjuctival hemorrhage in blunt

traumatrauma Refer patient within 1-2 daysRefer patient within 1-2 days

Treatment SkillsTreatment Skills

Ocular irrigationOcular irrigation Foreign body removalForeign body removal Eye meds (cycloplegics, antibiotic Eye meds (cycloplegics, antibiotic

ointment, anesthetic drops and ointment, anesthetic drops and ointment)ointment)

Patching (pressure patch, shield)Patching (pressure patch, shield) Suturing for simple eyelid skin Suturing for simple eyelid skin

lacerationlaceration

Take-home PointsTake-home Points Teardrop-shaped pupil & flat anterior Teardrop-shaped pupil & flat anterior

chamber in trauma are associated with chamber in trauma are associated with perforating injuryperforating injury

Avoid digital palpation of the globe in Avoid digital palpation of the globe in perforating injuryperforating injury

In chemical burn patient immediate In chemical burn patient immediate irrigation is crucial as soon as possibleirrigation is crucial as soon as possible

Traumatic abrasions are located in the Traumatic abrasions are located in the center or inferior cornea due to Bell’s center or inferior cornea due to Bell’s phenomenonphenomenon

Know and respect your limitsKnow and respect your limits

Chapter 6Chapter 6

Amblyopia & Amblyopia & StrabismusStrabismus

AmblyopiaAmblyopia DefinitionDefinition

Loss of VA not correctable by glasses in otherwise Loss of VA not correctable by glasses in otherwise healthy eyehealthy eye

2% in US2% in US Causes:Causes:

Strabismic (50%) > refractive > deprivationStrabismic (50%) > refractive > deprivation The brain selects the better image and The brain selects the better image and

suppresses the blurred or conflicting imagesuppresses the blurred or conflicting image Cortical suppression of sensory input interrupts Cortical suppression of sensory input interrupts

the normal development of visionthe normal development of vision

StrabismusStrabismus

Misalignment of the two eyesMisalignment of the two eyes Absence of binocular visionAbsence of binocular vision

Concomitant: angle of deviation equal in all directionConcomitant: angle of deviation equal in all direction EOM: normalEOM: normal Onset: childhoodOnset: childhood Rarely caused by neurological disease <6 yearsRarely caused by neurological disease <6 years Can be due to sensory deprivation Can be due to sensory deprivation

Incomitant: angle of deviation varies with direction of Incomitant: angle of deviation varies with direction of gazegaze EOM : abnormalEOM : abnormal **Paralytic : CN, MG ****Paralytic : CN, MG ** Restrictive: orbital disease, traumaRestrictive: orbital disease, trauma

StrabismusStrabismus

Phoria: latent deviationPhoria: latent deviation

Tropia: manifest deviation Tropia: manifest deviation

Corneal Light ReflexCorneal Light Reflex

Cover TestCover Test

TreatmentTreatment

Refractive correction (glasses)Refractive correction (glasses) PatchingPatching SurgerySurgery

Chapter 7Chapter 7

**35% of the sensory fibers entering the brain are in the **35% of the sensory fibers entering the brain are in the optic nerves and 65% of intracranial disease exhibits optic nerves and 65% of intracranial disease exhibits

neuro-ophthalmic signs or symptoms**neuro-ophthalmic signs or symptoms**

Neuro-Neuro-OphthalmologyOphthalmology

Neuro-Ophthalmic ExamNeuro-Ophthalmic Exam

Visual acuityVisual acuity Confrontation visual fieldsConfrontation visual fields Pupil size and reaction Pupil size and reaction

Efferent vs Afferent (Marcus Gunn) problemEfferent vs Afferent (Marcus Gunn) problem Ocular motilityOcular motility

Strabismus, limitation and nystagmusStrabismus, limitation and nystagmus Fundus exam Fundus exam

Optic nerve swelling and spontaneous Optic nerve swelling and spontaneous venous pulsationsvenous pulsations

ParasympatheticParasympathetic

SympatheticSympathetic

Efferent vs Afferent Efferent vs Afferent defectdefect

Selected Pupillary Selected Pupillary DisordersDisorders

Mydriasis Mydriasis CN III palsyCN III palsy

Herniation of temporal lobe or AneurysmHerniation of temporal lobe or Aneurysm Adie’s Tonic PupilAdie’s Tonic Pupil

Young women, unilateral, sensitive to dilute Young women, unilateral, sensitive to dilute pilocarpine, benignpilocarpine, benign

MiosisMiosis PhysiologicPhysiologic Horner’s SyndromeHorner’s Syndrome

Etiologic localization (cocaine and Etiologic localization (cocaine and hydroxyamphetamine)hydroxyamphetamine)

Argyll Robertson Pupil of tertiary syphilisArgyll Robertson Pupil of tertiary syphilis small, irregular, reacts to near stimulus onlysmall, irregular, reacts to near stimulus only

Selected Motility Selected Motility DisordersDisorders

True diplopia is a binocular phenomenonTrue diplopia is a binocular phenomenon Etiologies of monocular diplopia?Etiologies of monocular diplopia?

Do not forget to check ALL cranial nerves (esp V/VII/VIII)Do not forget to check ALL cranial nerves (esp V/VII/VIII) CN IVCN IV

Vertical diplopia, head tilt toward OPPOSITE sideVertical diplopia, head tilt toward OPPOSITE side Think closed head trauma or small vessel diseaseThink closed head trauma or small vessel disease

Myasthenia GravisMyasthenia Gravis Chronic autoimmune condition affecting skeletal muscle Chronic autoimmune condition affecting skeletal muscle

neuromuscular transmission (verify with Tensilon test)neuromuscular transmission (verify with Tensilon test) Can mimic any nerve palsy and often associated with Can mimic any nerve palsy and often associated with

ptosisptosis NEVER affects pupilNEVER affects pupil

CN III PalsyCN III Palsy

PCOM PCOM AneurysmAneurysm

Brain Brain TumorTumor

TraumaTrauma HTNHTN DiabetesDiabetes

CN VI PalsyCN VI Palsy

TraumaTrauma Elevated ICPElevated ICP Viral infectionsViral infections

Internuclear Internuclear Ophthalmoplegia (INO)Ophthalmoplegia (INO)

Elderly: small vessel diseaseElderly: small vessel disease Young Adult: MSYoung Adult: MS Child: Pontine GliomaChild: Pontine Glioma

Nystagmus – Selected Nystagmus – Selected TypesTypes

May be benign or indicate ocular and/or May be benign or indicate ocular and/or central nervous system diseasecentral nervous system disease

Definition according to fast phaseDefinition according to fast phase End-point NystagmusEnd-point Nystagmus

Seen only in extreme positions of eye movementSeen only in extreme positions of eye movement Drug-induced NystagmusDrug-induced Nystagmus

Anticonvulsants, Barbiturates/Other sedativesAnticonvulsants, Barbiturates/Other sedatives Searching/Pendular NystagmusSearching/Pendular Nystagmus

Common with congenital severe visual impairmentCommon with congenital severe visual impairment Nystagmus associated with INONystagmus associated with INO

Selected Optic Nerve Selected Optic Nerve DiseasesDiseases

Congenital Anomalous Disc ElevationCongenital Anomalous Disc Elevation AbsenceAbsence of edema, hemorrhage of edema, hemorrhage PresencePresence of SVP of SVP Consider:Consider:

Optic disc drusen Optic disc drusen HyperopiaHyperopia

Selected Optic Nerve Selected Optic Nerve DiseasesDiseases

PapilledemaPapilledema PresencePresence of bilateral edema, hemorrhage of bilateral edema, hemorrhage AAbsencebsence of SVP of SVP Consider Consider

Hypertension (must check BP) Hypertension (must check BP) Brain tumorBrain tumor

Papillitis/Anterior Optic NeuritisPapillitis/Anterior Optic Neuritis Unilateral edema, hemorrhageUnilateral edema, hemorrhage ConsiderConsider

inflammatoryinflammatory

Selected Optic Nerve Selected Optic Nerve DiseaseDisease

Optic AtrophyOptic Atrophy Consider: Consider:

PreviousPrevious optic neuritis optic neuritis PreviousPrevious ischemic optic ischemic optic

neuropathyneuropathy Long-standing Long-standing

papilledemapapilledema Optic nerve compression Optic nerve compression

by a mass lesionby a mass lesion Glaucoma Glaucoma

Selected Optic Nerve Selected Optic Nerve DiseaseDisease

Ischemic Optic NeuropathyIschemic Optic Neuropathy Pallor, swelling, hemorrhagePallor, swelling, hemorrhage Altitudinal Visual Field LossAltitudinal Visual Field Loss

Selected Visual Field Selected Visual Field DefectsDefects

Ocular Ocular Manifestations of Manifestations of Systemic DiseaseSystemic Disease

Chapter 8Chapter 8

Systemic DiseasesSystemic Diseases Many systemic diseases have ocular Many systemic diseases have ocular

manifestations and sequelaemanifestations and sequelae Exam may aid with diagnosis, assessment of Exam may aid with diagnosis, assessment of

disease activity, prognosisdisease activity, prognosis Common conditionsCommon conditions

DiabetesDiabetes HypertensionHypertension PregnancyPregnancy Sickle cell anemiaSickle cell anemia Thyroid diseaseThyroid disease Sarcoidosis and inflammatory/autoimmuneSarcoidosis and inflammatory/autoimmune MalignancyMalignancy AidsAids SyphilisSyphilis Systemic infectionSystemic infection

DiabetesDiabetes

Leading cause of vision loss (18-64 yrs)Leading cause of vision loss (18-64 yrs) Intensive glycemic controlIntensive glycemic control reduced risk of reduced risk of

development and progression of retinopathy (DCCT)development and progression of retinopathy (DCCT) Risk of developing retinopathy Risk of developing retinopathy with with duration of duration of

diseasedisease (type 1 23% @ 5 yrs, 80% @ 15 yrs, rates (type 1 23% @ 5 yrs, 80% @ 15 yrs, rates lower for type 2)lower for type 2)

Non-proliferative changes (NPDR)Non-proliferative changes (NPDR) Mild - ModerateMild - Moderate

MicroaneurysmsMicroaneurysms Dot-blot hemorrhagesDot-blot hemorrhages Hard exudatesHard exudates Venous beadingVenous beading Intraretinal microvascular abnormalities (IRMA)Intraretinal microvascular abnormalities (IRMA) Nerve fiber layer infarcts – cotton wool spotsNerve fiber layer infarcts – cotton wool spots

DiabetesDiabetes Non-proliferative changes (NPDR) contNon-proliferative changes (NPDR) cont

SevereSevere 4 quads of 4 quads of hemorrhageshemorrhages, 2 quads of beading or 1 quad of , 2 quads of beading or 1 quad of

IRMAIRMA

Proliferative (PDR)Proliferative (PDR) Responsible for most of the profound visual lossResponsible for most of the profound visual loss NeovascularizationNeovascularization in response to ischemia in response to ischemia

Disc, retina, irisDisc, retina, iris If untreated → vitreous hemorrhage, tractional retinal If untreated → vitreous hemorrhage, tractional retinal

detachmentdetachment

Macular Edema Macular Edema Most common cause of mild-mod VA lossMost common cause of mild-mod VA loss

DiabetesDiabetes ManagementManagement

Frequency of examsFrequency of exams Type 1 – initial exam when post-pubertal and within 5 yrs of Type 1 – initial exam when post-pubertal and within 5 yrs of

DxDx Type 2 – exam at time of DxType 2 – exam at time of Dx All patients – generally examine q1yr unless poor glycemic All patients – generally examine q1yr unless poor glycemic

control, HTN, anemia, proteinuria, mod-severe NPDR or PDR control, HTN, anemia, proteinuria, mod-severe NPDR or PDR which require more freq F/Uwhich require more freq F/U

Pregnant + type I – first trimester + q3monthsPregnant + type I – first trimester + q3months TreatmentTreatment

Focal laserFocal laser Panretinal photocoagulationPanretinal photocoagulation Vitrectomy with laserVitrectomy with laser

HypertensionHypertension

Arteriolar SclerosisArteriolar Sclerosis Extent relates to duration + severity of Extent relates to duration + severity of

HTNHTN Thickening and sclerosis of arteriolesThickening and sclerosis of arterioles

light reflex width (copper light reflex width (copper silver wire) silver wire) A-V nickingA-V nicking

May predispose to BRVO if severeMay predispose to BRVO if severe

Acute BP elevationAcute BP elevation Fibrinoid necrosis Fibrinoid necrosis exudates, CWS, flame exudates, CWS, flame

hemorrhages, optic disc swellinghemorrhages, optic disc swelling

HypertensionHypertension

DiagnosisDiagnosis ClassificationClassification

Grade 0 – no changesGrade 0 – no changes Grade 1 – barely detectable arterial narrowingGrade 1 – barely detectable arterial narrowing Grade 2 – obvious arterial narrowing with focal Grade 2 – obvious arterial narrowing with focal

irregularitiesirregularities Grade 3 – gr 2 + retinal hemorrhages or exudateGrade 3 – gr 2 + retinal hemorrhages or exudate Grade 4 – gr 3 + disc swelling Grade 4 – gr 3 + disc swelling

ManagementManagement Control BPControl BP

Avoid nocturnal hypotension – ischemic optic Avoid nocturnal hypotension – ischemic optic neuropathy, glaucomatous field lossneuropathy, glaucomatous field loss

PregnancyPregnancy Physiologic Physiologic ΔsΔs

IOP, IOP, corneal sensitivity, corneal sensitivity, accommodation, accommodation, dry eye, Δ in refractiondry eye, Δ in refraction

Avoid changing glasses, contacts, refractive Avoid changing glasses, contacts, refractive surgerysurgery

Pathologic ΔsPathologic Δs risk of CSR, uveal melanomarisk of CSR, uveal melanoma Pre-eclampsia/eclampsiaPre-eclampsia/eclampsia

Scotoma, diplopia, dimnessScotoma, diplopia, dimness Vascular ΔsVascular Δs Hemorrhages, exudates, retinal edema, disc swellingHemorrhages, exudates, retinal edema, disc swelling Serous exudative RD in 10% of eclampsiaSerous exudative RD in 10% of eclampsia

Diabetes – exacerbated retinopathyDiabetes – exacerbated retinopathy

Sickle Cell AnemiaSickle Cell Anemia

SC and S Thal more likely to have eye involvedSC and S Thal more likely to have eye involved Arteriolar occlusionArteriolar occlusion

intravasc sickling intravasc sickling hemolysis hemolysis hemostasis hemostasis

thrombosis thrombosis capillary non-perfusion capillary non-perfusion

Similar to diabetes – poor perfusion = retinal Similar to diabetes – poor perfusion = retinal ischemia ischemia neovascularization neovascularization

Laser Tx – can prevent vision lossLaser Tx – can prevent vision loss

Thyroid diseaseThyroid disease

GravesGraves AutoimmuneAutoimmune SignsSigns

**Retraction of upper + lower lids****Retraction of upper + lower lids** Upper lid lag in Upper lid lag in gaze gaze Most common cause of unil & bil proptosis in adultsMost common cause of unil & bil proptosis in adults Eyelid swelling, conj vascular congestionEyelid swelling, conj vascular congestion

SymptomsSymptoms Exposure related – lubricate frequentlyExposure related – lubricate frequently

TreatmentTreatment Surgery for severe proptosis, diplopia 2Surgery for severe proptosis, diplopia 2° EOM involvement, ° EOM involvement,

optic nerve decompressionoptic nerve decompression Radiation for inflammatory swellingRadiation for inflammatory swelling

SarcoidosisSarcoidosis

SarcoidosisSarcoidosis Focal non-caseating granulomasFocal non-caseating granulomas Most common African-American females 20 – 40 Most common African-American females 20 – 40

yrsyrs Ca++, Ca++, ACE, abnormal CXRACE, abnormal CXR Ocular involvementOcular involvement

Conj, lacrimal gland – dry eyeConj, lacrimal gland – dry eye Anterior or posterior uveitisAnterior or posterior uveitis Retinal perivasculitis, hemorrhages, neovascularizationRetinal perivasculitis, hemorrhages, neovascularization More likely to have CNS involvement if retina affectedMore likely to have CNS involvement if retina affected Early topical or systemic steroids may prevent Early topical or systemic steroids may prevent

complicationscomplications Cataract, glaucoma, iris to lens adhesionCataract, glaucoma, iris to lens adhesion

AutoimmuneAutoimmune Dry eyeDry eye

Sarcoidosis, SLE, Rheumatoid arthritisSarcoidosis, SLE, Rheumatoid arthritis Healthy pts > 40yrsHealthy pts > 40yrs SymptomsSymptoms

Burning, grittiness esp in PMBurning, grittiness esp in PM crusting in AMcrusting in AM tearingtearing

TreatmentTreatment lubricationlubrication

Anterior uveitisAnterior uveitis Ankylosing spondylitis, Reiter, BehcetAnkylosing spondylitis, Reiter, Behcet Juvenile RA – esp pauciarticular (asymptomatic)Juvenile RA – esp pauciarticular (asymptomatic)

Needs close F/UNeeds close F/U

MalignancyMalignancy Primary ocular malignancy rarePrimary ocular malignancy rare MetastasisMetastasis

Breast, lung most commonBreast, lung most common Usually localize to choroid but EOMs, optic nerve can Usually localize to choroid but EOMs, optic nerve can

be affectedbe affected Lymphoma, leukemiaLymphoma, leukemia

Radiation complicationsRadiation complications Cornea – keratitis / drynessCornea – keratitis / dryness Lens – cataractLens – cataract Optic nerve – neuropathyOptic nerve – neuropathy Retina – vasculopathyRetina – vasculopathy

ChemoChemo Carmustine – retinal artery occlusionCarmustine – retinal artery occlusion

AIDSAIDS CommonCommon

AIDS retinopathyAIDS retinopathy Cotton wool spotsCotton wool spots

CMV retinitisCMV retinitis Leading cause of visual loss in AIDSLeading cause of visual loss in AIDS Hemorrhagic necrosis of retinaHemorrhagic necrosis of retina More common if CD4<50More common if CD4<50

Kaposi’s sarcomaKaposi’s sarcoma Less commonLess common

Herpes zoster, simplex, toxoplasmosisHerpes zoster, simplex, toxoplasmosis Oculomotor dysfcn 2Oculomotor dysfcn 2° CNS involvement° CNS involvement

SyphilisSyphilis Can cause permanent visual loss if dx and tx are Can cause permanent visual loss if dx and tx are

delayeddelayed Congenital vs acquiredCongenital vs acquired

Acute interstitial keratitisAcute interstitial keratitis Bilateral vs unilateralBilateral vs unilateral Age 5 – 25 yrsAge 5 – 25 yrs Pain + photophobiaPain + photophobia Diffusely opaque cornea with Diffusely opaque cornea with V VAA

Late – ghost vessels + opacitiesLate – ghost vessels + opacities SecondarySecondary

Pain, redness, photophobia, blurred vision, floatersPain, redness, photophobia, blurred vision, floaters Iritis, choroiditis, and/or exudates around disc + vesselsIritis, choroiditis, and/or exudates around disc + vessels

TertiaryTertiary Chorioretinitis and/or diffuse neuroretinitis and vascular Chorioretinitis and/or diffuse neuroretinitis and vascular

sheathingsheathing

OthersOthers CandidiasisCandidiasis

Fluffy white-yellow superficial retinal infiltrate, vitritisFluffy white-yellow superficial retinal infiltrate, vitritis Systemic Systemic ± intravitreal ampho B± intravitreal ampho B

Herpes zosterHerpes zoster Varicella zoster virus – reactivation in CN VVaricella zoster virus – reactivation in CN V Hutchinson signHutchinson sign Ocular signsOcular signs

KeratitisKeratitis UveitisUveitis Decreased corneal sensationDecreased corneal sensation Rare – optic neuritis, nerve palsies involving motility Rare – optic neuritis, nerve palsies involving motility

limitation and diplopialimitation and diplopia Post-herpetic neuralgiaPost-herpetic neuralgia

Drugs & The EyeDrugs & The Eye

Chapter 8Chapter 8

Topical Drugs Used for Topical Drugs Used for Diagnosis:Diagnosis:

Fluorescin DyeFluorescin Dye Fluorescein strip:Fluorescein strip:

water solublewater soluble

No systemic complications No systemic complications Beware of contact lens stainingBeware of contact lens staining

Cobalt blue light

Orange becomes green

Orange yellow dye

Eye with corneal ulcer

AnestheticsAnesthetics Example: Example:

Propracaine Hydrochloride 0.5% (Alcaine)Propracaine Hydrochloride 0.5% (Alcaine) Tetracaine 0.5%Tetracaine 0.5%

Uses:Uses: Anesthetize cornea within 15 sec, last 10 minsAnesthetize cornea within 15 sec, last 10 mins Remove corneal foreign bodiesRemove corneal foreign bodies Perform tonometryPerform tonometry Examine damaged corneal surfaceExamine damaged corneal surface

Side effects: Side effects: Allergy: local or systemicAllergy: local or systemic Toxic to corneal epithelium ( inhibit mitosis, Toxic to corneal epithelium ( inhibit mitosis,

migration) migration)

Mydriatics (pupil Mydriatics (pupil dilation)dilation)

Two classes:Two classes:1.1. Cholinergic-blocking ( parasympatholytic)Cholinergic-blocking ( parasympatholytic)

2.2. Adrenergic-stimulating (sympathomimetic) Adrenergic-stimulating (sympathomimetic)

Iris sphincter constrict pupil

Pupillary dilator muscles

Cholinergic-Blocking Cholinergic-Blocking drugsdrugs

ActionAction Dilate by paralyzing iris sphincter muscleDilate by paralyzing iris sphincter muscle Cycloplegia by paralyzing ciliary body muscles Cycloplegia by paralyzing ciliary body muscles

TropicamideTropicamideCyclopentolateCyclopentolate

Max pupil dilatation 30 minMax pupil dilatation 30 min Complete CycloplegiaComplete Cycloplegia Effect diminishes 4-5 hrsEffect diminishes 4-5 hrs Used for refracting Used for refracting

childrenchildren Side effects: Side effects:

RareRare Nausea / vomitingNausea / vomiting PallorPallor

vasomotor collapsevasomotor collapse Other examples:Other examples:

1.1. Homatropine hydrobromide 1% or 2%Homatropine hydrobromide 1% or 2%2.2. Atropine sulfate 0.5% or 1%Atropine sulfate 0.5% or 1%3.3. Scopolamine hydrobromide 0.25% or 5% (last 1-2 wks)Scopolamine hydrobromide 0.25% or 5% (last 1-2 wks)

Adrenergic Stimulating Adrenergic Stimulating DrugsDrugs

Phenylephrine 2.5% or 10%Phenylephrine 2.5% or 10% Dilates in 30 mins, no effect on Dilates in 30 mins, no effect on

accommodationaccommodation Pupil remains reactive to lightPupil remains reactive to light Combine with Tropicamide for maximal Combine with Tropicamide for maximal

dilatationdilatation Infants combine Cyclopentolate 0.2% & Infants combine Cyclopentolate 0.2% &

Phenylephrine 1%Phenylephrine 1% Side effects:Side effects:

acute hypertension or MI (with 10%)acute hypertension or MI (with 10%)

Topical Therapeutic Topical Therapeutic DrugsDrugs

Decongestants:Decongestants: Over the counter weak Over the counter weak

adrenergic-stimulating adrenergic-stimulating drugsdrugs

Vasoconstriction = Vasoconstriction = white eyes temporarilywhite eyes temporarily

E.g. E.g. Naphazoline 0.012% Naphazoline 0.012% Phenylephrine 0.12% Phenylephrine 0.12% Tetrahdrozaline0.05%Tetrahdrozaline0.05%

Side effect Side effect rebound rebound

vasodilatation, vasodilatation, commoncommon

acute angle closure acute angle closure glaucoma, rareglaucoma, rare

Anti-allergicsAnti-allergics Combination Combination

naphazoline+antazolinenaphazoline+antazoline Decongestant+antihistaminDecongestant+antihistamin

ee Mast cell stabilizersMast cell stabilizers

Anti-inflammatoryAnti-inflammatory Topical steroids should Topical steroids should

NEVER be prescribed by NEVER be prescribed by primary care physicianprimary care physician

Non steroidals: e.g. Non steroidals: e.g. diclofenac diclofenac

Uses : ocular itch, macular Uses : ocular itch, macular edema, prevent pupil edema, prevent pupil constriction during cataract constriction during cataract SxSx

Systemic Side Effects of Systemic Side Effects of Glaucoma MedsGlaucoma Meds

Beta blockersBeta blockers Timolol, Timolol,

levobunolol, levobunolol, metapranolol, metapranolol, carteololcarteolol

NonselectiveNonselective ↓ ↓ Aqueous productionAqueous production Bronchospasm Bronchospasm

ØØ Asthma, COPD Asthma, COPD Bradycardia Bradycardia

Precipitate or worsen Precipitate or worsen cardiac failurecardiac failure

BetaxololBetaxolol Cardio selective Cardio selective

avoids pulm. side avoids pulm. side effectseffects

Cholinergic-Cholinergic-stimulating drugsstimulating drugs PilocarpinePilocarpine

↑↑aqueous outflow aqueous outflow Side effectsSide effects

MiosisMiosis Headache Headache Systemic: lacrimation, Systemic: lacrimation,

N/V, diarrheaN/V, diarrhea EchothiophateEchothiophate

Long acting Long acting anticholinestraseanticholinestrase

Inactivates plasma Inactivates plasma cholinestrase, cholinestrase, pt pt more susceptible to more susceptible to effect of effect of succinylcholine succinylcholine

Prolonged apnea or Prolonged apnea or death reporteddeath reported

Systemic Side Effects of Systemic Side Effects of Glaucoma MedsGlaucoma Meds

Alpha-2 adrenoceptor Alpha-2 adrenoceptor agonistagonist Brimonidine: (Alphagan)Brimonidine: (Alphagan)

↓ ↓ aqueous production, aqueous production, ↑uveoscleral outflow↑uveoscleral outflow

Hypotension & apnea in Hypotension & apnea in infantsinfants

Local allergic conjunctivitisLocal allergic conjunctivitis Dry mouth, fatigue, Dry mouth, fatigue,

headache headache Apraclonidine: (Iopidine)Apraclonidine: (Iopidine)

Used against pressure spikes Used against pressure spikes after iris laserafter iris laser

Orthostatic hypotensionOrthostatic hypotension High allergic conjunctivitisHigh allergic conjunctivitis

Adrenergic-stimulating Adrenergic-stimulating drugs: (Epinephrine, drugs: (Epinephrine, Dipivefrin)Dipivefrin)

Arrhythmias, HTN,Arrhythmias, HTN,

Prostaglandin analogProstaglandin analog Latanoprost (Xalatan) Latanoprost (Xalatan)

PGF2PGF2αα ↑↑ uveoscleral outflowuveoscleral outflow Iris darkeningIris darkening Elongation of eye lashesElongation of eye lashes CMECME

Carbonic anhydrase Carbonic anhydrase inhibitorsinhibitors Oral Acetazolammide Oral Acetazolammide

(Diamox)(Diamox) Sulfur allergySulfur allergy Parasthesia, anorexia, Parasthesia, anorexia,

metallic taste, renal calculimetallic taste, renal calculi Topical Dorzolamide Topical Dorzolamide

(Trusopt)(Trusopt) Same side effects but lowerSame side effects but lower

Ocular side effects of Ocular side effects of systemic drugssystemic drugs

SteroidsSteroids Anti-inflammatoryAnti-inflammatory PSCC, PSCC,

Steroid induced Steroid induced glaucomaglaucoma

ChloroquineChloroquine Rx of RA, SLERx of RA, SLE Corneal depositsCorneal deposits

Bull’s eye maculopathyBull’s eye maculopathy

250mg qd, or 300g 250mg qd, or 300g totaltotal

Digitalis (Digoxin)Digitalis (Digoxin) Atrial FibrillationAtrial Fibrillation Yellow vision most Yellow vision most common sign of common sign of intoxicationintoxication

AmiodaroneAmiodarone Cardiac Cardiac arrhythmiasarrhythmias

Cornea verticillata Cornea verticillata (whorls)(whorls)

DiphenylhydantoiDiphenylhydantoinn

SeizureSeizure Horizontal nystagmus Horizontal nystagmus in lateral gaze, vertical in lateral gaze, vertical nystagmus in up gazenystagmus in up gaze

EthambutolEthambutol TB chemotherapyTB chemotherapy Optic neuropathyOptic neuropathy

ChlorpromazineChlorpromazine SchizophreniaSchizophrenia Punctate Corneal Punctate Corneal epithelial opacities epithelial opacities

ThioridazineThioridazine psychosispsychosis Pigmentary retinopathyPigmentary retinopathy

Good Luck!Good Luck!