"Dr. Smita Dheer is the One Of The Best Eye Specialist in Ahmedabad. Dr. Smita Dheer is Top Eye Surgeon Doctors in Ahmedabad. Dr. Smita Dheer Provide Best Eye Care Solution in Ahmedabad at affordable Cost. Born to doctor parents, state rank holder in HSC and SSC, Dr. Smita Dheer received scholarship for meritorious performance from the government, which she gave up to help the needy students. After finishing her MBBS from Gandhi medical college BHOPAL, she perused her Master of surgery (M.S) from REGIONAL INSTITUTE OF OPHTHALMOLOGY BHOPAL in 2000. She did her fellowship in SMALL INSCISION CATARACT SURGERY from B.A.B.T EYE HOSPITAL Mumbai. She gathered working experience under renowned surgeonSPITAL run by Lions Club Sight Savers in AHEMDABAD. She served in the organisation for a decade as CHIEF SURGEON from 2007 TO 2016. During her tenure, she handled complicated cases and polished her administrative and surgical skills. She did her post graduate diploma in hospital and health care management (PGDHHM) from SYMBIOSIS PUNE in 2005, and did a certificate course in clinical research (CCCR) in 2008. Now she is associated with CIMS HOSPITAL as CONSULTANT OPHTHALMOLOGIST."

1. Eyecare Review—
For Primary Care
Practitioners

2. Primary Care Practitioners
 See variety of eye problems
 Discuss treatment options
 Facilitate referrals
 Positioned to explain
optometry's role as
primary eye care providers

3. Outline
 Anatomy
 Optics
 Turned Eyes
 Lazy Eye
 External Conditions
 Internal Conditions
 Diabetic Retinopathy

4. ANATOMY

5. Basic Anatomy
Sclera
Cornea
Pupil
Lens
Iris
Ciliary Body
Choroid
Retina
Fovea
Optic Nerve

6.  Lashes—protection
from foreign material
 Glands—lubricate
anterior surface
o Meibomian glands
o Glands of Zeis
o Glands of Moll
Lids

7.  Thin, transparent,
vascular layer lining
o Backs of eyelids
o Fornices
o Anterior sclera
Conjunctiva

8.  Tough outer shell
 Composed of
collagen bundles
 Protects from
penetration
Sclera

9.  Composed of regularly
oriented collagen fibers
 5 layers
Cornea

10.  Space between
cornea and iris
 Filled with aqueous
humor produced by
ciliary body
Anterior Chamber

11.  Iris gives eye color
 2 muscles:
o Dilator—opens
o Sphincter—constricts
Iris

12.  Allows light to enter
 Enables view to back
of eye and eye health
evaluation
Pupil

13.  Located behind iris
 Focuses light on
retina
 Allows for
accommodation
 Normally transparent
 Where cataracts form
Lens

14.  Primary functions
o Pulls on lens for
accommodation
o Epithelium secretes
aqueous fluid that
fills anterior chamber
Ciliary Body

15. Red Reflex
 Light reflection off
retina
 Useful for assessing
media clarity
 Affected by any
opacity of cornea, lens,
vitreous
 White reflex = leukocoria
Refer immediately!

16. Vitreous Humor
 Gel-like fluid that
fills back cavity
 Serves as support
structure for blood
vessels while eye
formed—before birth
 After birth, just
‘hangs out’ in there
 Where floaters are located

17. Fundus
 Interior surface
of eye
 Includes
o Optic nerve
o Retina
o Vasculature

18. Optic Nerve Head
 Collection of nerve
fibers and blood
vessels from retina
 Transfers info to
brain’s visual cortex
 Slightly yellow-pink
when healthy
 White ‘full moon’
appearance can
mean trouble!

19. Optic Nerve Head
 Cup is natural
depression in center
of nerve
 Cup size varies
between people
 Very large cup, or
change in appearance
over time, can
indicate glaucoma
Physiologic
Cup
Optic Disc
Optic Nerve

20. Macula
 Dense collection
of cone photoreceptors
 Fine detail and
color vision
 Macular degeneration
affects this area

21. Retinal Vessels
 Include arteries and veins
 Only place in body
where you can directly
visualize blood vessels
 Excellent indicators
of systemic diseases
o HTN
o Diabetes
o High cholesterol
o Carotid disease

22. Peripheral Retina
 Can only be evaluated
with dilated pupil
 Important to evaluate
periodically to fully
assess eye health

23. OPTICS

24. Optics Review
 Myopia
 Hyperopia
 Astigmatism
 Presbyopia

25. Myopia
 Nearsightedness
 See well up close
but blurry in distance
 Eye is too long
 Light focuses in
front of retina

26. Hyperopia
 Farsightedness
 See well in distance
 Eye is too short
 Focus point is
behind retina

27. Hyperopia
 Blurry image on retina
 Lens focuses to compensate
 Hyperopes often
asymptomatic much
their of lives
 Can cause headaches or
eyestrain with extended
reading
 These problems can
get worse after age 40

28. Astigmatism
 Surface of cornea is
irregular or misshapen
 Light focuses at
various points causing
distorted vision
 Often combined with
nearsightedness and
farsightedness

29. Presbyopia
 Normal, age-related
change
 Near vision becomes
difficult
 Mid-40s lens becomes
less elastic and loses
ability to change focus
 Time for bifocals…

30. MISALIGNED
EYES

31. Turned Eyes - Strabismus
 Eye misalignment
o One or both turn
in, out, up or down
 Caused by muscle
imbalance
 3 Kinds of Strabismus
o Esotropia
o Exotropia
o Hypertropia

32. 1. Esotropia
 Eye turns in
towards nose

33. 3 Types of Esotropia
 Infantile (congenital)
o Develops in first 3 months of life
o Surgery usually recommended—
along with vision therapy and glasses
 Accommodative
o Usually noted around age 2
o Child typically farsighted
o Focusing to make images clear can
cause eyes to turn inward
o Treated with glasses but
vision therapy may also be needed

34. 3 Types of Esotropia
 Partially Accommodative
o Combination of
 accommodative dysfunction and
 muscle imbalance
o Glasses and vision therapy
won’t completely correct
eye turn
o Surgery may be required
for best binocularity

35. If you see Esotropia
 Refer to pediatric
optometrist or
ophthalmologist
 Sooner the better for
best chance of good
vision

36. 2. Exotropia
 Eye turns outward
 Congenital—present
at birth
 Surgery usually needed
to re-align
 Many exotropias are
intermittent
o May occur when patient is tired or not paying attention
o Concentration can force eyes to re-align
o Vision therapy and/or glasses can help

37. 2. Exotropia
 When intermittent
o Brain sometimes receives
info from both eyes
(binocular)
o Less chance of amblyopia
o However, important to be
seen by eyecare provider
when deviation noted

38. 3. Hypertropia
 One eye vertically
misaligned
 Usually from paresis
of an extra-ocular
muscle
 Typically much more
subtle for patient to
describe and provider
to diagnose

39. 2 Types
 Congenital
o Most common type
o Patients can compensate for
years by tilting head
o Can be discovered by looking at
childhood photos

40. 2 Types
 Acquired
o Trauma—
Extra-ocular muscle ‘trapped’
by orbital fracture
o Vascular infarct—
Systemic diseases that affect
blood supply to nerves can
cause temporary nerve palsy
 Diabetes and HTN most
common
 Palsies tend to resolve over
weeks or months
o Neurological—
In rare cases a tumor or
aneurysm can cause symptoms

41. LAZY EYE

42. Lazy Eye - Amblyopia
 Decreased vision
uncorrectable by glasses
or contacts—not due to
eye disease
 For some reason, brain
doesn’t fully acknowledge
images seen

43. Lazy Eye - Amblyopia
 3 Types of Amblyopia
o Strabismic
o Anisometropic
o Stimulus deprivation

44. 1. Strabismic Amblyopia
 One eye deviates from other and
sends conflicting info to brain
 Brain doesn’t like to see double—
so “turns off” info from deviated
eye
 Results in under developed visual
cortex for that eye
 Can usually be reversed or
decreased if treated during first
9 years
 Need to visit eyecare provider
ASAP to determine cause

45. Treatment
 If caught early, treatment
can teach brain how to
see better
o Vision therapy/patching
o Glasses
o Surgical re-alignment
 Early vision screenings
are critical!

46. 2. Anisometropic Amblyopia
 Anisometropia—significant
difference in Rx between eyes
 Commonly one eye more
farsighted
 Farsighted eye works hard to
see clearly—and sometimes
gives up
 Brain relies on info from
other eye

47. 2. Anisometropic Amblyopia
 If not caught, one eye
won’t learn to see as well
as other
 Vision therapy and glasses
are both beneficial
 Sooner the better

48. 3. Deprivational Amblyopia
 Any opacity in visual
pathway can be devastating
to developing visual system
o Congenital cataracts
o Corneal opacities
o Ptosis (droopy eyelid)
o Other media opacities

49. EXTERNAL
CONDITIONS

50. Common External Ocular
Conditions
 Blepharitis
 Hordeolum—stye
 Preseptal cellulitis
 Orbital cellulitis
 Pterygium
 Corneal ulcer
 Conjunctivitis
o Viral “pink eye”
o Adenovirus
o Bacterial
o Allergic
o Hyperacute
o Chlamydial

51. Blepharitis
 Inflammation of
eyelids (anterior or
posterior)
 Symptoms
o Itching
o Burning
o Crusting
o Dry eye sensation
o Foreign body
sensation

52. Blepharitis
 Signs
o Crusts on lid margins
o Thickened, reddened
eyelids
o Plugged or inspisated
meibomian glands
along eyelid
 Treatment
o Warm compresses,
10 minutes 1-2 x/day
o Lid scrubs with
diluted baby
shampoo
o Artificial tears
o Erythromycin
ointment at night

53. Hordeolum (stye)
 Abscessed
meibomian gland
 Raised, tender
nodule
 Often gets larger
over days to a week

54. Hordeolum
 Signs
o Raised nodule
protruding out from
or under lid
o Red, swollen lid
o Capped glands at
site of infection
 Treatment
o Warm compresses,
BID-TID for 10 mins
o Topical meds don’t
penetrate abscess
o Oral antibiotics if no
response to traditional
treatment

55. Preseptal Cellulitis
 Bacterial infection of
eyelid anterior to
orbital septum
 Can arise from
o concurrent sinus
infection
o penetrating lid trauma
o dental infection
o hordeolum
o insect bite

56. Preseptal Cellulitis
 Signs
o Painful, swollen lid
extending past
orbital rim
o May be unable to
open eye
o No decreased vision,
restricted ocular
motility or proptosis
o White conjunctiva
 Treatment
o Amoxicillin
(augmentin) 500 mg
PO TID
o Treat infection
quickly to minimize
risk of orbital cellulitis

57. Orbital Cellulitis
 Serious infection of soft
tissues behind orbital
septum
 Can be life-threatening
 Causes
o Sinus infection
o Extension of preseptal
cellulitis
o Dental infection
o Penetrating lid injury
o After ocular surgery

58. Orbital Cellulitis
 Signs
o Tender, warm
periorbital lid edema
o Proptosis
o Painful
ophthalmoplegia
o Decreased vision
o Severe malaise, fever
and pain
 Treatment
o Medical emergency
o Hospitalization with
IV antibiotics
o Consider orbit/head
CT to look for
abscess
o Consult pediatrician
or infectious disease
specialist

59. Preseptal vs. Orbital Cellulitis
 Preseptal
o Painful, swollen lid
extending beyond
orbital rim
o Normal vision
o Full EOMs
o White conjunctiva
o No proptosis
o No fever
 Orbital
o Painful, swollen lid
that stops at orbital
rim
o Decreased vision
o Restricted ocular
motilities
o Proptosis
o Fever/malaise

60. Pterygium
 Triangular-shaped
growth of conjunctival
tissue onto cornea
 Causes
o UV exposure
o Dryness
o Irritants
 Smoke
 Dust

61. Pterygium
 Signs
o Dry eye
o Irritation
o Redness
o Blurred vision
 Management and
Treatment
o UV tint on glasses
o Avoid irritating
environments
o Artificial tears
o Topical vasoconstrictor
or mild steroid
o Surgery

62. Corneal Ulcer
 Infection of cornea
o Bacterial
o Fungal
o Acanthamoeba
 Causes
o SCL wearer
o Trauma
o Compromised
cornea from pre-
existing condition

63. Corneal Ulcer
 Signs
o Pain
o Photophobia
o Blurred vision
o Discharge
o Hypopyon
 Treatment:
o Start immediately
 Fortified antibiotics
 Fluoroquinolones
o Culture may not be
necessary if ulcer is
small
o Must be monitored
daily!

64. Conjunctivitis (red eye)
 Various Causes
1. Viral/Adenovirus
2. Bacterial
3. Allergic
4. Chlamydial
5. Herpetic
6. Toxic

65. Conjunctivitis
 Signs
o Irritation
o Burning/stinging
o Watering
o Photophobia
o Pain or foreign body
sensation
o Itching
 Discharge
o Watery
o Mucoid
o Mucopurulent
o Purulent

66. 1. Viral Conjunctivitis (pink eye)
 Most viral infections are fairly mild
and self-limiting
 Signs & Symptoms
o Watering
o Redness
o Photophobia
o Discomfort/foreign body sensation
o Palpable preauricular node

67. 1. Viral Conjunctivitis
 Patients often have recent history of URI
 Treat symptoms
o Cool compresses
o Artificial tears
o Topical vasoconstrictors or mild anti-
inflammatory
 Frequent handwashing
 Usually runs course in
1-3 weeks

68. 2. Adenoviral Conjunctivitis
 Highly contagious
 Most common types
o Pharyngoconjunctival fever (PCF)—
can be caused by adenovirus
types 3, 4 & 7
o Epidemic keratoconjunctivitis (EKC)—
caused most commonly by adenovirus
types 8 & 19

69. 2. Adenoviral Conjunctivitis
 Signs
o Watering
o Conjunctival follicles
o Subconjunctival
hemorrhages
o Chemosis
o Pseudomembranes
o Lymphadenopathy
o Keratitis

70. 3. Bacterial Conjunctivitis
 Common, especially in
children
 Usually self-limiting
 Signs/symptoms
o Acute redness
o Burning/grittiness
o Mucopurulent
discharge
o Lids stuck shut in
morning

71. 3. Bacterial Conjunctivitis
 Common organisms: S. aureus, S. epidermidis,
S. pneumonia, H. influenza (esp. peds)
 Usually self-limiting
 But important to use broad-spectrum antibiotic
until discharge cleared (5-7 days)
 Antibiotics
o Tobramycin
o Polytrim—polymyxin + trimethoprim
o Fluoroquinolones like
Ocuflox or Ciloxan

72. 5. Hyperacute Conjunctivitis
 Cause
o Sexually transmitted
o Neisseria gonorrhoeae
 Signs
o Swollen, tender lids
o Copious purulent
discharge
o Significant conjunctival
redness and swelling
o Lymphadenopathy

73. 5. Hyperacute Conjunctivitis
 Treatment
o Lavage
o Take scrapings for culture and sensitivity
testing
o Patients usually hospitalized and started on
IM Ceftriaxone
o Topical antibiotics not effective

74. 6. Chlamydial Conjunctivitis
 Cause
o Sexually transmitted ocular infection
 Signs
o Patients typically have mild but persistent
follicular conjunctivitis non respondent to
topical antibiotics
o Any conjunctivitis lasting longer than 3
weeks despite therapy should be suspect

75. 6. Chlamydial Conjunctivitis
 Patients can have concomitant genital
infection (could be asymptomatic)
o Refer for work-up if necessary
 Treatment
o Oral—Azithromycin 1g, doxycycline 100mg
bid x 7 days, erythromycin 500mg qid x 7
days. Also need to tx partners!
o Topical—erythromycin, tetracycline, or
sulfacetamide ung bid-tid x 2-3 weeks

76. 4. Allergic Conjunctivitis
 Can be seasonal or
acute
 Signs/symptoms
o Itching is hallmark
o Conjunctival redness
o Chemosis
o Lid edema
o Thin, watery discharge
o No palpable preauricular
nodes

77. 4. Allergic Conjunctivitis
 Treatment
o Eliminate offending agent
o If mild
 Cool compresses
 Artificial tears/vasoconstrictors
o If moderate or severe
 Topical antihistamine/mast-cell stabilizer (ie. Patanol)
 Topical NSAID
 Topical steroid
 Oral antihistamine

78. INTERNAL
CONDITIONS

79. Internal Ocular Conditions
 Glaucoma
 Cataracts
 Macular
Degeneration
 Retinal detachment

80. Glaucoma
 Progressive loss of Nerve
fiber layer at ONH
(increased cupping)
 Can lead to peripheral
visual field loss
 Sometimes caused by
elevated intraocular
pressure

81. Glaucoma
 Pathophysiology of progression not well
understood
 Increased IOP
o Damages nerves as they leave eye, causing cell death
o Reduces blood supply to ONH, indirectly destroying
cells by starving them of oxygen and nutrients
 Abnormal levels of neurotransmitter (glutamate)
cause cells to die off

82. Glaucoma
 Monitoring
o IOP
o ONH appearance
o Visual field testing
o Newer methods include
 HRT (Heidelberg Retinal
Tomograph II)
 GDx Nerve Fiber Analyzer
 Genetic testing

83. Glaucoma
 IOP reduction is mainstay
of treatment
 Decrease aqueous production
o B-blockers
o Alpha-agonists
o Carbonic anhydrase inhibitors
 Increase uveoscleral outflow
o prostaglandin analogs

84. Cataract
 Clouding of natural lens
 Patients experience
o Blurred/dim vision
o Glare, especially
at night
o Halos around lights
o Doubling or ghost
images of objects

85. Etiology
 Everyone develops them if
they live long enough!
 Types of cataracts
o Age-related—senile
o Trauma—blunt or perforating
injury
o Systemic conditions—diabetes
o Medications—steroids

86. Main Types
 Age-related
o Nuclear sclerotic
o Cortical spokes
o Posterior sub-
capsular
o Mature cataract

87. Treatment
 Surgery
 When loss of vision interferes
with daily activities
o Driving
o Reading
o Hobbies

88. Outpatient Surgery
 5-10 minutes with skilled
surgeon
o Incision through cornea
or sclera under upper lid
o Circular tear in anterior
capsule
o Lens broken up with ultra
sound instrument
o Fragments suctioned out
o Lens implant inserted

89. Secondary Cataract
 Cloudiness forms on
posterior capsule after
cataract surgery
 30-50% of patients
 YAG laser used to
create opening
 Vision quickly restored

90. Macular Degeneration
 #1 cause of blindness in
Americans over
age 65

91. Pathophysiology
 Causes not well understood
 Theorized link to
o UV light exposure
o subsequent release of free
radicals
o oxidation within retinal tissues
 Another theory—areas of
decreased vascular perfusion
in retina, lead to cell death

92. Two Types
 Dry (atrophic)
o 90% of those diagnosed
 Wet (exudative)
o 10% of those diagnosed
o But accounts for 90% of
blindness caused by
disease

93. Symptoms
 None
 Blurred vision
 Metamorphopsia—
straight lines appear
wavy or distorted
 Scotomas—missing
areas in vision

94. Dry Form
 Slow, progressive loss of
central vision
 Breakdown of underlying
retinal tissues, resulting in
mottling or clumping of
normal pigment
 Drusen begin to accumulate
 Geographic atrophy can also
occur

95. Wet Form
 Can quickly degrade
central vision
 Break in underlying
tissues allows new blood
vessels or fluid to come
through
 New blood vessels are
weak so frequently break
and bleed

96. Treatment for Dry Form
 Regular eye exams
 Careful discussion regarding
family history
 Education
 UV protection
 Antioxidants
o AREDS
o PreserVision
 Stop smoking

97. Treatment for Wet Form
 Refer to retinal specialist
 Photocoagulation
 Photo-dynamic therapy
(PDT)
 Submacular surgery
 Macular translocation
 Anti-angiogenic drug
therapy

98. Retinal Detachment
 Several types
o Rhegmatogenous—
caused by break in retina
o Exudative—caused by
fluid accumulation
beneath retina
o Tractional—proliferative
fibrovascular vitreal
strands

99. Signs & Symptoms
 Flashing lights in peripheral vision
 New floaters—black spots or ‘cobwebs’
 Peripheral scotoma—dark shadow or
“curtain” blocking vision

100. Emergency
 Patients with these
symptoms must see eyecare
provider immediately
 Additional risk factors
o Highly nearsighted
o Diabetic
o Recent trauma/injury

101. Treatment
 Laser photocoagulation
or cryotherapy
 Pneumatic retinopexy—
gas bubble to
tamponade retina back
into place
 Scleral buckle
 Silicone oil