summary eye disease - universitas...
TRANSCRIPT
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Dr. G ita lis a Andayani, S pMDepartment of Opthalmology
FKUI/RS CM1
SUMMARY OF EYE
PROBLEMS
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EYE PROBLEMS
• Red eyes (normal and decreased vision) • Chronic visual (progressive) loss• Acute visual (persistent) loss• Trauma• Abnormalities in ocular alignment and
motility• Refractive disorders
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- Congestion of conjunctival blood vessels- If clarity of media disturbedvision decreased
- In developing countries accounts for 40% eye problems
RED EYES
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Red Eyes, normal vision
Conjunctivitis (bacterial/viral/chlamidyal/allergic)
Pterygium Subconjunctival hemorrhage Episcleritis and scleritis
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CONJUNCTIVITISClinical presentation Nonspecific:
watery eyes, irritation, stinging, foreign body sensation, photophobia or itchiness
Discharge: watery, mucoid, purulent or mucopurulent
Conjunctival injection Eyelid swelling Tarsal conjunctiva:
papillae/follicles/membrane Cornea and pupils usually normal
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CONJUNCTIVITIS
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CONJUNCTIVITIS
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CONJUNCTIVITIS
Conjunctivitis Bacterial Conjunctivitis
Chlamidial conjunctivitis (trachoma) Allergic/vernal conjunctivitis
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CONJUNCTIVITISManagement
- Can be done by GP
- Eye hygiene
- Eyedrops:
viral self-limiting, antibiotics
bacterial antibiotics
allergic/vernal antiallergy, steroids(!)
- 3 days w/o improvement: refer
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PTERYGIUM
• growth of triangular fibrovaskular tissue invading the cornea
• patients in hot climate, chronic dryness and high sunlight exposure
• difference from pinguekula: yellow-white deposit at nasal/temporal from limbus (collagen degeneration, calcification)
• apex always in the cornea side, often with Fe deposits
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PTERIGIUM
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PTERYGIUM
Management:
• Excision with conjuctical graft
• Lamellar keratoplasty
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SUBCONJUNCTIVAL HEMORRHAGE
• No pain, no discharge
• Well-demarcated
• Self-limiting within 2 weeks
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EPISCLERITIS AND SCLERITIS
• Sclera covered by 3 vascular layers:
- Conjungtival blood vessels
- Superfisial episcleral vessels
(in Tenon layer);
with phenilephrin: blanching
- Deep vascular plexus
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EPISCLERITIS AND SCLERITIS
Episcleritis:
• common, benign, self-limiting
• young adult
• related to systemic disease
• types: - simple (sectoral,diffuse)
- nodular
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EPISCLERITIS AND SCLERITIS
Scleritis:
• granulomatous inflammation
• rheumatoid arthritis, connective tissue disorder
• less common
• severity: mild-severe (necrotizing)• types: - anterior scleritis (non-necrotizing / necrotizing)
- scleritis posterior
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EPISCLERITIS AND SCLERITIS
Simple, sectoral episcleritis non-necrotizing, diffuse scleritis
early necrotizing scleritis Scleral necrosis
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Episcleritis and Scleritis
Management:Episcleritis - Steroids/NSAID eyedrops
- Systemic ibuprofen/flurbiprofen
Scleritis- Oral NSAID
- Oral Steroid
- Combination
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Red Eyes, Decreased Vision
Keratitis
Cornea Ulcer
Anterior Uveitis (iritis, iridocyclitis)
Acute Glaucoma
Endophthalmitis
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KERATITISC ornea: Frontmost part of eye Main component in refraction (70% ) Tear film
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KERATITIS
Keratitis: Inflammatory cells infiltration Corneal opacity Superficial / deep Cause: Infection (Viral/bacterial/fungal) Also: Dry eyes, trauma, drug toxicity, UV exposure,
contact lens irritation, allergy, immunogenic states, chronic conjunctivitis
May progress to cornea ulcer
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KERATITIS-CORNEAL ULCER
Clinical presentation
- photophobia
- periocular pain
- foreign body sensation
- ciliary flush
- corneal opacity
Diagnosis : - reduced cornea sensibility
- fluorescein test
- assessment of corneal regularity
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KERATITIS – CORNEAL ULCER
Keratitis with fluorescein staining
Corneal ulcer (fungal) Perforating corneal ulcer
Photo-s courtesy of dr Lukman Edwar
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Corneal Ulcer
Cause Pseudomonas Strepcococcus pneumonia
Virus Fungi Allergy
Location central central central central central
Excavation + + - - -
Color greenish yellow yellow abcess satelites infiltrates
Hypopion + + -/+ + -
Appearence purulent discharge purulent discharge
quiet abcess Diffuse
Sensibility normal normal decreased increased normal
Perforation frequent frequent rare frequent none
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KERATITIS – CORNEAL ULCER
Management:
- Refer to ophthalmologist
- Medication based on causative microorganism
virus antiviral
bacteria antibiotics
fungi antifungal
- Corneal scar
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ANTERIOR UVEITIS
• Inflammation of iris and ciliary body• Usually auto-immune• Isolated or part of systemic condition:
- ankylosing spondilitis- juvenile rheumatoid arthritis- Reiter Syndrome- sarcoidosis- herpes simpleks- herpes zoster- Behçet Syndrome (with stomatitis aftosa)
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ANTERIOR UVEITIS
Clinical presentation:- periocular pain- photophobia- usually mild decrease of vision- ciliary flush- small, irregular pupil, due to adhesion to
lens surface permukaan lensa
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ANTERIOR UVEITIS
Clinical presentation:- indistinct iris crypts- cornea opacity- cells and flare in AC keratic precipitates, hypopion- IOP changes
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Posterior synechia
Iris nodules
Hypopion
ANTERIOR UVEITISPhoto-s courtesy of dr Lukman Edwar
Normal iris
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ANTERIOR UVEITIS
Keratic precipitates
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ANTERIOR UVEITIS
Management:- Refer to Ophthalmologist- Work-up- Medication: - cycloplegics eyedrops - corticosteroids eyedrops - oral corticosteroids oral (prn) - Glaucoma drugs
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ACUTE GLAUCOMA
• ocular emergency• sudden IOP elevation• block of aqueous humor outflow• elder patients• Asians >>
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Acute Glaucoma
Clinical presentation:• mostly unllateral• occipital pain• nausea, vomitting• extremely red eye• conjunctival chemosis• cloudy cornea• midilated pupil• pupillary reflex none/poor• shallow AC• hard eyes
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Acute Glaucoma
Management:- Refer to ophthalmologist- Immediately lower IOP: Pilocarpine 2% Timolol 0.5% Asetazolamid Oral glycerin /IV manitol surgery / laser iridotomy
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ENDOPHTHALMITIS
• Purulent intraocular infection• Caused by infection through the cornea, trauma post-surgery (mainly: cataract surgery), or endogenous• Bacterial/fungal• Most common: staphylococcus aureus, proteus and pseudomonas• If with extraocular infection: panophtalmitis
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Endophthalmitis
Clinical presentation:- periocular pain - chemosis - eyelid swelling- corneal opacity- anterior uveitis- hypopion
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Endophthalmitis
Management:- Refer to ophthalmologist- Aqueos / vitreous tap- intravitreal antibiotic/antifungal- systemic antibiotic - Panoftalmitis: evisceration
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Chronic visual loss
cataract
glaucoma (chronic: open and closed angle)
Retinopathies (mainly: diabetic retinopathy)
Macular Degeneration
(AMD=age-related macular degeneration) Others: e.g. retinitis pigmentosa
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Cataract
Lens opacity Penyebab:
- degeneration: senile/age-related- complication of ocular disease / metabolic / drug-induced(komplikata)- congenital- traumatic
cataract
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Cataract
Symptoms Early
- no symptoms- fog- glare- difficulty in reading
Late- blur of vision- leucocoria
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CataractManagement Depend on patient’s demand; if interfering
with daily activity: Cataract surgery
Technique:- Intracapsular Cataract Extraction(ICCE) now rarely done- Extracapsular Cataract Extraction(ECCE)- Phacoemulsification- Small-incision
Phacoemulsification
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Glaucoma
• Optic neuropathy, mainly caused by chronic IOP elevation due to increased outflow resistance• visual field defects• 2 types: - open angle glaucoma
- closed angle glaucoma
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Opt i c di s c changes i n gl aucoma
Normal Optic Disc Glaucomatous disc Advanced glaumatous disc
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Glaucoma
Symptoms • IOP > 21 mmHg (normal 10-21)• Open angle: asymptomatic; if there is indicating late stages (frequently bumping, rainbow halo, periocular pain)• Closed angle: predisposition to acute glaucoma• Constricted visual field
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Glaucoma
Management• Observation• Glaucoma drugs: - beta-blocker
- acetazolamid - pilocarpine
• Laser (iridotomy, trabeculotomy, trabeculoplasty)• Surgery (iridectomy, trabeculektomy, implant)
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RETINOPATHIES
N on-inflammatory retina dis orders
2 mos t c ommon:
- hypertensive retinopathy
- diabetic retinopathy
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Retina anatomy
Sklera
Koroid
Membran Bruch
RPE=epitel
pigmen retina
Fotoreseptor
Lapisan serabut saraf
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Hypertensive retinopathy
• caused by chronic hypertension• depend on onset• - Grade I: narrowing of vessels - Grade II: + narrowing of veins at crossing - Grade III: + intraretinal hemorrhages, exudates - Grade IV: optic disc edema, star figured
macular exudates
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Hypertensive retinopathy
Cotton-wool spots and macular star
Disc oedema
Focal Generalized
Arteriolar constriction
Extravascular signs
Flame-shaped retinal haemorrhages
Arteriolosclerosis (A-V changes)
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Grading of arteriolosclerosis
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Diabetic retinopathy
Complication of diabetesComplication of diabetes Chronic hyperglycemiaChronic hyperglycemia damage to microvasculars Chronic visual lossChronic visual loss Main cause of blindness in DM 50% of diabetics within 10 yrs will have retinopathy
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Mekanisme kebutaan pada diabetic retinopathy
leakage of exudates, lipid and blood to the retina
Macular edeme
Decreased blood flow to the retina
iskemia
neovascularization PDR
-vitreous hemorrhage- Fibrovascular scar
- retinal traction retinal detachment
7
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Diabetic retinopathy
7
Normal retina
PDR vitreuous hemorrhage Fibrovascular scar in PDR
Early PDR FFA
NPDR
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AMD=age-related macular degeneration
7
• Chronic visual loss caused by changes of the macula
• bilateral
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AMD=age-related macular degeneration
7
• Problem world wide
• 4 th in global cause blindness
• Treatment:
- Photodynamic therapy
- Anti-VEGF
- others
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Acute (persistent) visual loss
retinal detachment
vitreous hemorrhage
retinal vein occlusion
Retinal artery occlusion
Optic neuritis
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Retinal detachment
• detachment of neurosensory retina from RPE
• mainly caused by retinal breaks
• floaters, photopsia, shadow curtain
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retinal detachmentManagement• pneumatic retinopexy• vitreoretina surgery
- Scleral buckling- Vitrectomy
Scleral buckling (SB) Vitrectomy
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Vitreous hemorrhage
• Blood in the vitreous
• Rupture of blood vessels
• Cause: trauma, retinal breaks, DM, hypertension
• On examination: fundus reflex absent
• Vitrectomy maybe needed
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Oklusi (sumbatan) arteri retina
• Sumbatan arteri retina akibat radang / spasme / trombus / melambatnya aliran darah
• Mengenai satu mata
• Tidak sakit
• Berhubungan erat dengan kelainan jantung
• Tanda: retina pucat, cherry-red spot
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Retinal vein occlusion
• Central/branch
• Unilateral
• Painless
• Systemic risk factors
• flame-shaped hemorrhages, cotton wool spots
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Optic neuritis• inflammation/intoxication/demyelination of the optic nerve
• may be accompanied by pain
• unilateral
• sluggish pupil reflex, RAPD +
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OCULAR TRAUMA
• Chemical/thermal burn• Corneal erosion• Corneal and conjunctival foreign body• Blunt trauma• Penetrating/perforating trauma• Hyphema• Intraocular foreign body• Orbital wall fracture
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Chemical burn
• Alkali:- pestisides- household products (cleaners, etc)
• Asam (acid):- batteries
→ damage to cornea• Thermal:
- flame- hot water- metal liquid, etc
→ usually milder
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Chemical burn
Penatalaksanaan:
• immediate
• topical anesthetics
• Corneal edema/chemosis? Opacity?
• Irigate eyeball with 1-2 liter water/ NaCl
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Chemical burn
Managenment
• Clean the eyelid sac from debris
• Topical medications (steroid+antibiotics,
EDTA, tetracycline)
• Bandage lens if necessary
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Corneal erosion
• Superficial (epithelial)• Common causes: fingernail, comb/brush contact lens• Risk for infection• Pain, photophobia, watery, irritation, foreign body sensation
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Corneal erosion
Management:• Topical anesthetics• Fluorescein test• Check tarsal conjunctiva of upper eyelid
→ retained foreign body? • Antibiotics eyedrop• Bandage lens/patching• Re-epithelisation) within 24-48 jam
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Conjunctival/corneal foreign body
Conjunctival foreign body Corneal foreign body
• Dust, occupational, etc• Photophobia, watery, foreign body sensation• Management: foreign body extraction
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Blunt trauma
• Eyelid hematoma
• Hyphema
• Subconjunctival hemorrhage
• Vitreous/Retinal hemorrhage
• Orbital fracture
• Retinal commotion
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Blunt trauma
Hematoma + subconjunctival subhemorrhage RE
(good eye movement)
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Hyphema
Hyphema(clotting) Hyphema occupying ½ AC
Full hyphema
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Hyphema
Management:
• hospitalization (risk: visual loss, IOP
elevation, re-bleeding in 30% cases)
• bed-rest, semi-fowler position
• tranexamic acid (e.g Transamin)
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Lens subluxation
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Iridodialisis
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Kommosio retina
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Penetrating/perforating injury
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Penetrating/perforating injury
Management:
• refer to ophthalmologist
• antibiotics eyedrop
• oral antibiotics
• ATS, TT
• patch eyes
• primary repair
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Laceration/ruptur of eyelid and face
- ATS, TT
- NaCl / Betadine compress
- Immediate repair
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Or bi t al wal l f r act ur e
Enophthalmus, restriction of eye movement
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I nt r aocul ar f or ei gn bi dy
Management:
-Immediate extraction for foreign body
-Oral and intravitreal foreign body
-Corticosteroids
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