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Causes of blindness and symptoms of eye
disorders
Dr Ashish Tripathi
WHO Definition of Blindness
WHO defines Blindness as a corrected visual
acuity in the better eye of less than 3/60, and
Se...
Category of visual
impairment
Visual acuity
Cat I (Low vision) 6/18-6/60
Cat II (Low vision) <6/60-3/60
Cat III (Blind) <3...
0.4 - 0.6 0.6 - 1 > 1%< 0.4%Prevalences:© WHO
W Pacific
26%
Africa
17%
Middle East
10%
Americas
10%
Europe
10%
SE Asia
27%
Best corrected
visual acuity
< 6/18 (0.3)
© W...
CATARACT
47%
TRACHOMA
4%
ONCHO
1%
AMD
9%
GLAUCOMA
12%
OTHERS
13%
CORNEAL OPACITY
5%
DIABETIC
RETINOPATHY
5%
CHILDHOOD
BLIN...
Cataract
42 %
Trachoma
15 %
Glaucoma
14%
Oncho.
1 %
Other
28 %
Cataract
47 %
Trachoma
4 %
Glaucoma
12%
Oncho.
1 %
Other
13...
Cataract
5%
Glaucoma
18%
Other
4%
ARMD
50%
Ch Bl
3%
DR
17%
CO
3%
Cataract
50 %
Trachoma
4 %
Glaucoma
12%
Oncho 0.8 %
Other...
Women
64%
Men
36%
Men
Women
© WHO
Defective vision
Sudden painless loss of vision
 Vitreous hemorrhage
 Retinal detachment
 Optic neuritis
 Central reti...
Sudden painful loss of vision
 Acute congestive glaucoma
 Trauma
 Chemical injuries
 Foreign body in the eye
 Giant c...
Gradual painless diminution of vision
 Cataract
 Open angle glaucoma
 Refractive error
 Age related macular degenerati...
Gradual painful diminution of vision
 Corneal ulcer ( keratitis)
 Chronic iridocyclitis
Transient loss of vision (Amaurosis fugax)
 Carotid artery disease
 Papilloedema
 Migraine
 Prodormal symptom of CRAO
Night blindness
 Vitamin A deficiency
 Retinitis pigmentosa and other retinal dystrophies and
degenerations
 Congenital...
Day blindness (Hamarlopia)
 Central nuclear or polar cataract
 Central corneal opacity
 Central vitreous opacity
 Cong...
Other visual symptoms
Floaters( Black spots in front of eyes)
 Vitreous degeneration: Myopia or senile degeneration
 Exu...
Flashes of light in front of eyes (photopsia)
 Posterior vitreous detachment
 Prodromal symptoms of retinal detachment
...
Distorted vision
 Micropsia (Small size of objects)
 Macropsia (Larger size of objects)
 Metamorphopsia (distorted shap...
Colored haloes
 Acute congestive glaucoma
 Mucopurulent conjunctivitis
 Mature / Hypermature cataract
Diplopia (double vision)
Binocular diplopia:
 Paralytic and restrictive strabismus: Nerve palsies, Myasthenia
gravis, Thy...
Watering from the eye
 Lacrimation
 Epiphora: nld blockage
Discharge from the eyes
 Watery
 Purulent / mucopurulent
 Hemorrhagic
 Ropy discharge
Itching burning and foreign body sensation
 Chronic conjunctivitis , allergic or other
 Trachoma
 Dry eyes
 Trichiasis...
 Sub-conjunctival hemorrhage
 Conjunctivitis
 Episcleritis
 Kerato-conjunctivitis
 Scleritis
 Corneal ulcer
 Acute ...
Ocular or periocular pain: @GITA
 Acute congestive glaucoma
 Iridocyclitis
 Trauma
 Giant cell arteritis
Headache
 ICSOL
 Pseudotumor cerebri
 Sinusitis
 Migraine
Asthenopic symptoms
 Convergence/ fusional insufficiency
 ...
Impairment of vision
 Causes
• Defects in clear image formation on retina
 Eg. Cataract
• Defect in retinal processing ...
 Watering
 Photophobia
 Buphthalmos
 Clinical features
 Pain/headache, redness, DVA, Colored haloes
 Ciliary congestion
 Corneal edema
 High IOP
 Mid di...
 Retinopathy
 Cotton-wool spots
 Hard exudates
 Extensive hemorrhage
 Retinal oedema
 Choroidopathy
 Exudative deta...
 Sudden onset of DVA preceded by
 Photopsia / flashes of light
 Floaters
 Clinical presentation
 Leucocoria
 Strabismus
 Endophthalmitis like feature
 Proptosis
 Feature of raised intraocul...
Confusion :
Superimposition of two images
Diplopia : Binocular
Strabismus
Classification of strabismus
Heterophoria (Latent) Heterotropia (Manifest)
Esophoria
Exophoria
Hyper / hypophor...
Asymptomatic
Exophoria
Eye strain (asthenopia)-headache
Equal vision or blurring of vision
Amblyopia due to anisometr...
 Rabies
 Hepatitis B
 Retinoblastoma
 Bacterial or fungal keratitis
 Corneal dystrophy
 HIV
 HSV
 Painful red eye
 Decrease in vision
 Corneal oedema
 Anterior chamber reaction
 Cells
 Flare
 KP’s/nodules
 Mioti...
Symptoms
 Redness
 Pain: Iritis, glaucoma
 Photophobia
 Diffuse blur :Inflammatory cells, debris
 Decrease vision : c...
 Eyelid and skin: Nodules, vitiligo
 Conjunctiva: nodules, congestion
 Cornea: Kps
Fresh, old, large mutton fat
 Anter...
 Redness
 Self limiting
 Diffuse or localized
 Non tender/ no pain
 No discharge
 Pain
 Red eye
 Decrease vision
 Anterior chamber reaction
 Vitreous exudates
 Loss of red fundal glow
 Corneal causes
 Conjunctivitis
 Dry eye
 Acute angle closure glaucoma
 Sub-acute angle closure glaucoma
 Iritis
 o...
 Eye trauma
 Intraocular inflammation
 Neovascularization
 Iris malformation eg coloboma, aniridia.
 Cataract surgery
 Old age
 Intraocular inflammation
 Sleep
 Pontine hemmorhage
 Pilocarpine /phospholine iodide use
 Horner syndrome
 Increased intraocular pressure.
 Drugs
1. Anticholinergics: Atropine, homatropine, tropicamide
2. Sympathomimetics: Phe...
 Argyll Robertson pupil
 Tonic pupil (Holmes-Adies syndrome)
 Light reflex absent but near reflex is preserved
 Usually bilateral but asymmetrical
 Small and irregular pupil
 The ...
 Caused by postganglionic parasympathetic pupillomotor
damage
 Pupils are dilated and poorly reacting
 Constrict to the...
 Characterized by:
1. Ptosis, miosis enophthalmous ,anhydrosis
2. Iris heterochromia in congenital type. Affected iris ap...
 Enumerate the causes of blindness.
 List the symptoms of eye diseases. Give examples.
 promotion of public awareness about eye donation
 tissue harvesting,
 tissue evaluation,
 tissue preservation, and
 ...
 Donor eye collected by 6 hours after death
 Moist chamber storage from the site of collection to the
hospital
 McCarey...
 Chondroitin sulphate based media – 7 days
 K-sol, Opti-sol – 7 days
 Cryo preservation for one year
 Intracapsular cataract extraction ICCE
 Extracapsular cataract extraction: ECCE
Conventional extracapsular
Small inscis...
 Papillae
 Follicles
 Congestion
 Chemosis
 Sub conjunctival Hemorrhages
 Discharge
 Membrane and Pseudomembrane
 These are dilated telangiectatic conjunctival blood vessels,
varying from dot like changes to enlarged tufts surrounded
...
 Focal lymphoid nodules with accessory vascularization.
 Seen in: Benign lymphoid foliculosis
Adenoviral conjunctivitis
...
 True membrane:
Beta hemolytic streptococci
Diphtheria
 Pseudo membrane:
Severe adenoviral conjunctivitis
Gonococcal con...
 Chlamydia :Oral erythromycin 50 mg/kg/day in four divided
doses for 14 days
 Gram-negative, gonococcal :Intravenous or ...
 Follicular trachoma
 Intense inflammatory trachoma
 Trachomatous Scarring
 Trichiasis
 Corneal Opacity
The key to the treatment of trachoma is the SAFE strategy
developed by the WHO.
 Surgery
 Antibiotic therapy
 Facial cl...
 Pathogenesis
 Conjunctival vasodilation
 Increased vascular
permeability
 Leucocyte chemotaxis
 Ocular surface destr...
 Characteristic features
 Inflammation
 Recurrence
 Chronicity
 Itching – main complaint
 Bilateral, recurrent, during warm
months
 Itching, rubbing,
 Thin ropy discharge
 Papillary hyperplasia
 Tranta’s do...
 Residence in a cool place –air conditioning or climate
 Acetylcystein gt 10% - mucolytic agent
 Steroid drops – carefu...
 Scarring of conjunctiva
 Thickening of tarsal plate
 Meibomian orifice occlusion
 Symblepharon
 Destruction of acces...
 Symptoms
 Mimics bacterial keratitis
 Slow & torpid course, less pain
 Signs
 Filamentous keratitis
 A greyish stro...
STAGING CLINICAL FEATURES
XN Night Blindness
X1A Conjunctival Xerosis
X1B Bitot’s Spot
X2 Corneal Xerosis
X3A Corneal ulce...
 Orbital cellulitis
 Pseudotumor
 Dermoid and epidermoid
 Capillary hemangioma
 Lymphangioma
 Rhabdomyosarcoma
 Opt...
 Thyroid related orbitopathy
 Pseudotumour
 Metastatic neoplasms
 Secondary spread
 Cavernous hemangioma
 Lymphangio...
 Orbital cellulitis
 Rhabdomyosarcoma
 Leukaemia
 Metastatic neuroblastoma
 Bleeding into lymphangioma
 Ruptured der...
1. Pain
2. Proptosis
3. Progression
4. Palpation
5. Pulsation
6. Periorbital changes
 Congenital Cataract
 RB
 ROP
 Toxocariasis
 Coat’s disease
 HPPV
 Organised vitreous H’ge
 Incontinentia pigmenti
 MICROVASCULAR OCCLUSION
 Capillary changes: pericyte loss, thickening of basement
membrane and damage and proliferation...
 MICROVASCULAR LEAKAGE
 Break down of inner blood retinal barrier leading to
 Retinal oedema (diffuse and localized)
 ...
# Leukocoria
# Strabismus
 Proptosis
 Glaucoma (Buphthalmos)
 Vitreous hemorrhage
 Hyphema
 Ocular and peri-ocular in...
Current treatment options
 Photocoagulation
 Chemotherapy
 External beam radiation therapy
 Enucleation/Exenteration
 Stage of progressive infiltration
 Stage of active ulceration
 Stage of regression
 Stage of cicatrisation
 Causes –
 Extreme proptosis
 Bell’s palsy
 Ectropion
 Symblepheron
 Lagopthalmus
 Pathogenesis –
 Due to exposure...
 Toxic iridocyclitis
 Secondary glaucoma
 Desmatocele formation-sign of impending
perforation
 Perforation of corneal ...
 May be caused by sneezing, coughing, etc.
 Acute rise of IOP
 Weak ulcer floor unable to support this pressure
 Perfo...
 Clinical features
 Symptoms
 Similar to bacterial keratitis but less prominent than equal sized bacterial
ulcer
 Sign...
 Acute pain, redness, lacrimation
 Photobhobia and blurring of vision
 Signs – CCC, initially numerous white plaques of...
 The diagnosis of corneal ulcer is made by-
[A] Clinical evaluation
• Thorough History taking
• General Physical examinat...
Routine lab investigations
 Hb, TLC, DLC, ESR,
 Blood Sugar
 LFT
Microbiological investigations
 These are done to ide...
• Can be performed with slit lamp under topical anaesthesia(0.5%propacaine hydrochloride)
• Heat-sterilized platinum (kimu...
 Primary staining of heat fixed smear with crystal violet for 1 min
 Pour off crystal violet and add grams iodine
 Keep...
 Conventional route ( Trabecular) : 90%
 Unconventional ( Uveo-scleral) : 10%
 Visual acuity
 Young children
 Catford drum
 Acuity cards
 Preferential looking
Children > 3 years
Symbol matching g...
Paralytic squint
 Onset- sudden
 Diplopia-present
 Ocular movements-limited
in direction of pralyzed
muscles
 False pr...
Maturation of cortical cataract
 Lamellar seperation
 Stage of incipient cataract
Cuneiform
Cupuliform
 Immature senile...
 Anxiety
 Nausea & gastritis
 Irritative or allergic conjunctivitis
 Corneal abrasion
 d/t LA: retrobulbar hhg, oculo...
 Sup. Rectus ms laceration
 Excessive bleeding
 Injury to cornea, iris & lens
 Posterior capsule rupture
 Vitreous lo...
 Hyphaema
 Iris prolapse
 Shallow ant. Chamber
 Post-op ant. Uveitis
 Bact. Endophthalmitis
 Cystoid macular edema
 Delayed post-op endophthalmitis
 Retinal detachment
 2ry cataract
 glaucoma
 Avascularity
 Tight packed nature of cells
 Arrangement of the lens protein
 Semipermeability of capsule
 Pumping me...
Symptoms
 Frequent change of glass
 Decreased visual acuity
 Myopic shift
 Loss of abilty to see in bright light
 Mon...
 Two light descrimination test
 Maddox rod test
 Entoptic phenomenon
 Laser interferometry
 Photo stress test
 ERG
...
 Suppression
 Amblyopia – continued monocular suppressions
 Anomalous retinal correspondence
 Abnormal Head Posture
Pupillary Light Reflex
Parasym. : 4 Neurons
1st order : Photoreceptors of Retina to Pretectal
Nucleus in Midbrain at level...
Sympathetic Nerve Supply
3 Neurons
1st order : Posterior hypothalamus
to Ciliospinal centre of Budge
located between C8 an...
 Insidious
 Asymptomatic
 Mild headache
 Eyeache
 Defect in visual field
 Frequent change in presbyopic glassse
 De...
 Ant. Segment signs: sluggish pupillary reflex, hazy cornea
 IOP: falls during evening
 Optic disc changes: early
 ver...
 Marked cupping 0.7-0.9
 Thinning of neuroretinal rim
 Nasal shifting of retinal vessels
 Pusation of retinal arteriol...
 Isopter contraction
 Baring of blind spot
 Paracentral scotoma
 Seidel’s acotoma
 Arcuate or bjerrum’s scotoma
 Rin...
Complete
blindness
• Causes
Complete
blindness:
• Optic atrophy
• Traumatic avulsion of optic nerve
• Indirect optic neuro...
Ipsilateral blindness,
Contralateral
hemianopia
Distension of
3rd ventricle
Atheroma of
carotids
parietal lobe: inferior
quadrantic hemianopia
 Pie on the floor
Temporal lobe: superior
quadrantic hemianopia
Pie in the ...
 Mechanism of action
 They bind to β-adrenergic receptors and block sympathetic
transmission
 Lower IOP by reducing aqu...
 Side effects
 Ocular
 Stinging, burning, photophobia, blurred vision, dry eye, corneal
anesthesia & allergic conjuncti...
 Contraindications
 Congestive heart failure
 Bradycardia
 Heart block
 Diabetic pts prone to hypoglycemia
 Asthma
...
Drug receptor concentration Dose
Timolol nonselective 0.25%, 0.5% BD
betaxolol β-1 selective 0.5% OD
Levobunolol nonselect...
 Both topical and systemic carbonic anhydrase inhibitors
(CAIs) reduce IOP by reducing aqueous production.
 Topical CAIs...
Side effects
Ocular side effects
Irritation, stinging, superficial punctate keratitis and allergic
conjunctivitis.
 Anore...
Contraindications
 sulpha allergy
 Systemic not to be used in patients with renal lithiasis, renal
insufficiency, severe...
 Nonselective – epinephrine and dipivefrin
 Not used any more due to irritation & injection
 α-2 selective – apraclonid...
 Mechanism of action
 Apraclonidine – reduces IOP by increasing outflow
facility, decrease production, and decreasing ep...
 Side effects
 About 1/3rd of patients develop ocular allergy with apraclonidine
 Allergy to brimonidine is less common...
 Mechanism of action
 They reduce the IOP by increasing the osmolality
of the intravascular fluid
 As blood barrier pre...
 Side effects
 Avoided in patients with compromised cardiac function
 Cerebral dehydration causes headache and disorien...
 Preparation & administration
Drugs Concentration Dose
Latanoprost 0.005% OD
Bimatoprost 0.03% OD
Travoprost 0.004% OD
Is...
Mechanism of action
 Increase uveoscleral and also trabecular outflow
 Decrease production
Eye Diseases
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Eye Diseases

Eye symptoms and signs, Blindness, Basics of ophthalmology.

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Eye Diseases

  1. 1. Causes of blindness and symptoms of eye disorders Dr Ashish Tripathi
  2. 2. WHO Definition of Blindness WHO defines Blindness as a corrected visual acuity in the better eye of less than 3/60, and Severe visual impairment as a corrected acuity in the better eye of less than 6/60.
  3. 3. Category of visual impairment Visual acuity Cat I (Low vision) 6/18-6/60 Cat II (Low vision) <6/60-3/60 Cat III (Blind) <3/60-1/60 Cat IV (Blind) <1/60-PL Cat V ( Blind) NPL
  4. 4. 0.4 - 0.6 0.6 - 1 > 1%< 0.4%Prevalences:© WHO
  5. 5. W Pacific 26% Africa 17% Middle East 10% Americas 10% Europe 10% SE Asia 27% Best corrected visual acuity < 6/18 (0.3) © WHO
  6. 6. CATARACT 47% TRACHOMA 4% ONCHO 1% AMD 9% GLAUCOMA 12% OTHERS 13% CORNEAL OPACITY 5% DIABETIC RETINOPATHY 5% CHILDHOOD BLINDNESS. 4% Best corrected Visual Acuity < 3/60 (0.05) © WHO
  7. 7. Cataract 42 % Trachoma 15 % Glaucoma 14% Oncho. 1 % Other 28 % Cataract 47 % Trachoma 4 % Glaucoma 12% Oncho. 1 % Other 13 % ARMD 9% Ch Bl 4% DR 5% CO 5% 1995 2002
  8. 8. Cataract 5% Glaucoma 18% Other 4% ARMD 50% Ch Bl 3% DR 17% CO 3% Cataract 50 % Trachoma 4 % Glaucoma 12% Oncho 0.8 % Other 14 % ARMD 6% Ch Bl 4% DR 4% CO 5% More Developed Countries Less Developed Countries
  9. 9. Women 64% Men 36% Men Women © WHO
  10. 10. Defective vision Sudden painless loss of vision  Vitreous hemorrhage  Retinal detachment  Optic neuritis  Central retinal vein occlusion  Central retinal artery occlusion
  11. 11. Sudden painful loss of vision  Acute congestive glaucoma  Trauma  Chemical injuries  Foreign body in the eye  Giant cell arteritis
  12. 12. Gradual painless diminution of vision  Cataract  Open angle glaucoma  Refractive error  Age related macular degeneration  Diabetic retinopathy  Corneal dystrophy and degeneration  Optic atrophy
  13. 13. Gradual painful diminution of vision  Corneal ulcer ( keratitis)  Chronic iridocyclitis
  14. 14. Transient loss of vision (Amaurosis fugax)  Carotid artery disease  Papilloedema  Migraine  Prodormal symptom of CRAO
  15. 15. Night blindness  Vitamin A deficiency  Retinitis pigmentosa and other retinal dystrophies and degenerations  Congenital stationary night blindness  Pathological myopia  Peripheral cortical cataract
  16. 16. Day blindness (Hamarlopia)  Central nuclear or polar cataract  Central corneal opacity  Central vitreous opacity  Congenital deficiency of cones
  17. 17. Other visual symptoms Floaters( Black spots in front of eyes)  Vitreous degeneration: Myopia or senile degeneration  Exudates in vitreous  Intermediate uveitis  Vitreous hemorrhage
  18. 18. Flashes of light in front of eyes (photopsia)  Posterior vitreous detachment  Prodromal symptoms of retinal detachment  Traction bands in the retina
  19. 19. Distorted vision  Micropsia (Small size of objects)  Macropsia (Larger size of objects)  Metamorphopsia (distorted shape of the image In macular diseases ARMD, CSR
  20. 20. Colored haloes  Acute congestive glaucoma  Mucopurulent conjunctivitis  Mature / Hypermature cataract
  21. 21. Diplopia (double vision) Binocular diplopia:  Paralytic and restrictive strabismus: Nerve palsies, Myasthenia gravis, Thyroid diseases, blow out fracture of globe Uniocular diplopia  Subluxated lens  Double pupil  Decentered IOL  High Astigmatism
  22. 22. Watering from the eye  Lacrimation  Epiphora: nld blockage
  23. 23. Discharge from the eyes  Watery  Purulent / mucopurulent  Hemorrhagic  Ropy discharge
  24. 24. Itching burning and foreign body sensation  Chronic conjunctivitis , allergic or other  Trachoma  Dry eyes  Trichiasis  Foreign body
  25. 25.  Sub-conjunctival hemorrhage  Conjunctivitis  Episcleritis  Kerato-conjunctivitis  Scleritis  Corneal ulcer  Acute congestive glaucoma  Anterior uveitis Red eye
  26. 26. Ocular or periocular pain: @GITA  Acute congestive glaucoma  Iridocyclitis  Trauma  Giant cell arteritis
  27. 27. Headache  ICSOL  Pseudotumor cerebri  Sinusitis  Migraine Asthenopic symptoms  Convergence/ fusional insufficiency  refractive error  astigmatism
  28. 28. Impairment of vision  Causes • Defects in clear image formation on retina  Eg. Cataract • Defect in retinal processing of image  Eg Retinal detachment • Defect in impulse transmission to occipital cortex  Eg. Optic neuritis
  29. 29.  Watering  Photophobia  Buphthalmos
  30. 30.  Clinical features  Pain/headache, redness, DVA, Colored haloes  Ciliary congestion  Corneal edema  High IOP  Mid dilated pupil and shallow AC  Glaukomflecken – anterior capsular or subcapsular lens opacities
  31. 31.  Retinopathy  Cotton-wool spots  Hard exudates  Extensive hemorrhage  Retinal oedema  Choroidopathy  Exudative detachment  Elschnig spots  Seigrist streaks  Optic neuropathy  Disc oedema  AION  Optic atrophy
  32. 32.  Sudden onset of DVA preceded by  Photopsia / flashes of light  Floaters
  33. 33.  Clinical presentation  Leucocoria  Strabismus  Endophthalmitis like feature  Proptosis  Feature of raised intraocular pressure
  34. 34. Confusion : Superimposition of two images Diplopia : Binocular
  35. 35. Strabismus Classification of strabismus Heterophoria (Latent) Heterotropia (Manifest) Esophoria Exophoria Hyper / hypophoria Nonparalytic ( Concomitant ) Paralytic ( Incomitant ) Vertical Hypertropia Hypotropia Exotropia Intermittent Alternate Constant ( RDS / LDS) Esotropia Accommodative Nonaccommodative Infantile 3rd Nerve Palsy 4th Nerve Palsy 6th Nerve Palsy
  36. 36. Asymptomatic Exophoria Eye strain (asthenopia)-headache Equal vision or blurring of vision Amblyopia due to anisometropia Diplopia (horizontal & crossed) Photophobia Micropsia( due to use of accommodative convergence) Increase in temporal visual field called as panoramic viewing -
  37. 37.  Rabies  Hepatitis B  Retinoblastoma  Bacterial or fungal keratitis  Corneal dystrophy  HIV  HSV
  38. 38.  Painful red eye  Decrease in vision  Corneal oedema  Anterior chamber reaction  Cells  Flare  KP’s/nodules  Miotic pupil
  39. 39. Symptoms  Redness  Pain: Iritis, glaucoma  Photophobia  Diffuse blur :Inflammatory cells, debris  Decrease vision : cataract, macular edema retinal lesions  floaters: vitreous cells, exudates  Asymptomatic
  40. 40.  Eyelid and skin: Nodules, vitiligo  Conjunctiva: nodules, congestion  Cornea: Kps Fresh, old, large mutton fat  Anterior chamber: Cells, Flare
  41. 41.  Redness  Self limiting  Diffuse or localized  Non tender/ no pain  No discharge
  42. 42.  Pain  Red eye  Decrease vision  Anterior chamber reaction  Vitreous exudates  Loss of red fundal glow
  43. 43.  Corneal causes  Conjunctivitis  Dry eye  Acute angle closure glaucoma  Sub-acute angle closure glaucoma  Iritis  optic neuritis  Orbital infection, inflammation  Paralysis of muscles  Cavernous sinus thrombosis  ICSOL  Idiopathic intracranial hypertension  GCA  Refractive errors  Trigeminal neuralgia  Focusing spasm (eyestrain)  Tension type headache  Cluster headache  Migraine
  44. 44.  Eye trauma  Intraocular inflammation  Neovascularization  Iris malformation eg coloboma, aniridia.  Cataract surgery
  45. 45.  Old age  Intraocular inflammation  Sleep  Pontine hemmorhage  Pilocarpine /phospholine iodide use  Horner syndrome
  46. 46.  Increased intraocular pressure.  Drugs 1. Anticholinergics: Atropine, homatropine, tropicamide 2. Sympathomimetics: Phenylephrine,cocaine, amphetamine  Eye trauma  III Nerve palsy
  47. 47.  Argyll Robertson pupil  Tonic pupil (Holmes-Adies syndrome)
  48. 48.  Light reflex absent but near reflex is preserved  Usually bilateral but asymmetrical  Small and irregular pupil  The condition is pathognomonic of central nervous system syphilis
  49. 49.  Caused by postganglionic parasympathetic pupillomotor damage  Pupils are dilated and poorly reacting  Constrict to the near reflex but redilates very slowly  Includes other features such as diminished deep tendon reflexes, orthostatic hypotension. Common in females.  Unilateral in 80% of cases.
  50. 50.  Characterized by: 1. Ptosis, miosis enophthalmous ,anhydrosis 2. Iris heterochromia in congenital type. Affected iris appear lighter.  Localization of lesion in Horner syndrome is important . 1. First order neuron lesions: central disorders of nervous system 2. Second order neuron lesion caused by apical lung tumors
  51. 51.  Enumerate the causes of blindness.  List the symptoms of eye diseases. Give examples.
  52. 52.  promotion of public awareness about eye donation  tissue harvesting,  tissue evaluation,  tissue preservation, and  tissue distribution.
  53. 53.  Donor eye collected by 6 hours after death  Moist chamber storage from the site of collection to the hospital  McCarey-Kaufman (MK) media – 4 days
  54. 54.  Chondroitin sulphate based media – 7 days  K-sol, Opti-sol – 7 days  Cryo preservation for one year
  55. 55.  Intracapsular cataract extraction ICCE  Extracapsular cataract extraction: ECCE Conventional extracapsular Small inscision cataract extraction SICE Phacoemulsifiation  Lensectomy
  56. 56.  Papillae  Follicles  Congestion  Chemosis  Sub conjunctival Hemorrhages  Discharge  Membrane and Pseudomembrane
  57. 57.  These are dilated telangiectatic conjunctival blood vessels, varying from dot like changes to enlarged tufts surrounded by edema and inflammatory cells.  Seen in : bacterial conjunctivitis, allergic conjunctivitis.
  58. 58.  Focal lymphoid nodules with accessory vascularization.  Seen in: Benign lymphoid foliculosis Adenoviral conjunctivitis Herpes viral conjunctivitis Molluscum contagiosum conjunctivitis Drug induced eg: dipeveprin
  59. 59.  True membrane: Beta hemolytic streptococci Diphtheria  Pseudo membrane: Severe adenoviral conjunctivitis Gonococcal conjunctivitis Stevens Johnson's syndromes.
  60. 60.  Chlamydia :Oral erythromycin 50 mg/kg/day in four divided doses for 14 days  Gram-negative, gonococcal :Intravenous or intramuscular ceftriaxone 25–50 mg/kg/day once a day for 7 days  Povidine Iodine for prophylaxis
  61. 61.  Follicular trachoma  Intense inflammatory trachoma  Trachomatous Scarring  Trichiasis  Corneal Opacity
  62. 62. The key to the treatment of trachoma is the SAFE strategy developed by the WHO.  Surgery  Antibiotic therapy  Facial cleanliness  Environmental change
  63. 63.  Pathogenesis  Conjunctival vasodilation  Increased vascular permeability  Leucocyte chemotaxis  Ocular surface destruction  Subsequent repair
  64. 64.  Characteristic features  Inflammation  Recurrence  Chronicity  Itching – main complaint
  65. 65.  Bilateral, recurrent, during warm months  Itching, rubbing,  Thin ropy discharge  Papillary hyperplasia  Tranta’s dots in limbus  Eosinophils, plasma cells, mast cells,  Tears IgG and histamine
  66. 66.  Residence in a cool place –air conditioning or climate  Acetylcystein gt 10% - mucolytic agent  Steroid drops – careful use  Antihistamine drops  Mast cell stabilizer – Sodium chromoglycate  NSAID
  67. 67.  Scarring of conjunctiva  Thickening of tarsal plate  Meibomian orifice occlusion  Symblepharon  Destruction of accessory lacrimal glands  Dry eye  Punctal and canalicular occlusion
  68. 68.  Symptoms  Mimics bacterial keratitis  Slow & torpid course, less pain  Signs  Filamentous keratitis  A greyish stromal infiltrate with a dry texture and indistinct elevated rolled out margins  A surrounding feathery ,finger like extensions into stroma  Multiple, small Satellite lesions  Big Hypopyon (may not be sterile, static)  Corneal vascularisation is conspicuously absent  Perforation in Mycotic ulcers are rare but can occur.  Resembles bacterial keratitis, however usually there is a history of preexisting chronic corneal disease Fungal ulcer
  69. 69. STAGING CLINICAL FEATURES XN Night Blindness X1A Conjunctival Xerosis X1B Bitot’s Spot X2 Corneal Xerosis X3A Corneal ulcer involving <1/3rd corneal surface X3B Corneal ulcer involving >1/3rd corneal surface XS Corneal Scar XF Xerophthalmic Fundus
  70. 70.  Orbital cellulitis  Pseudotumor  Dermoid and epidermoid  Capillary hemangioma  Lymphangioma  Rhabdomyosarcoma  Optic nerve glioma  Neurofibroma  Leukemia  Metastic neuroblastoma
  71. 71.  Thyroid related orbitopathy  Pseudotumour  Metastatic neoplasms  Secondary spread  Cavernous hemangioma  Lymphangioma  Lacrimal gland tumour  Lymphoma  Meningioma  Dermoid / epidermpoid
  72. 72.  Orbital cellulitis  Rhabdomyosarcoma  Leukaemia  Metastatic neuroblastoma  Bleeding into lymphangioma  Ruptured dermoid
  73. 73. 1. Pain 2. Proptosis 3. Progression 4. Palpation 5. Pulsation 6. Periorbital changes
  74. 74.  Congenital Cataract  RB  ROP  Toxocariasis  Coat’s disease  HPPV  Organised vitreous H’ge  Incontinentia pigmenti
  75. 75.  MICROVASCULAR OCCLUSION  Capillary changes: pericyte loss, thickening of basement membrane and damage and proliferation of endothelial cells.  Hematological changes: RBC deformation and increased rouleaux formation. Increased platelet stickiness and aggregation.  Consequence:  Capillary non-perfusion and ischaemia, which leads to  Arteriovenous shunts (IRMA’s)  Neovascularisation (NVD and NVE)
  76. 76.  MICROVASCULAR LEAKAGE  Break down of inner blood retinal barrier leading to  Retinal oedema (diffuse and localized)  Hard exudates  Heamorrhage
  77. 77. # Leukocoria # Strabismus  Proptosis  Glaucoma (Buphthalmos)  Vitreous hemorrhage  Hyphema  Ocular and peri-ocular inflammation  Hypopyon
  78. 78. Current treatment options  Photocoagulation  Chemotherapy  External beam radiation therapy  Enucleation/Exenteration
  79. 79.  Stage of progressive infiltration  Stage of active ulceration  Stage of regression  Stage of cicatrisation
  80. 80.  Causes –  Extreme proptosis  Bell’s palsy  Ectropion  Symblepheron  Lagopthalmus  Pathogenesis –  Due to exposure, corneal epithelium dries up followed by dessication and after the epithelium is cast off, invasion by infective organism occurs
  81. 81.  Toxic iridocyclitis  Secondary glaucoma  Desmatocele formation-sign of impending perforation  Perforation of corneal ulcer  Sequalae of corneal perforation  Corneal scarring
  82. 82.  May be caused by sneezing, coughing, etc.  Acute rise of IOP  Weak ulcer floor unable to support this pressure  Perforation occurs  Ones perforation occurs – leakage of aqueous – fall of IOP – iris-lens diaphragm moves forward, leading to iris prolapse, subluxation or ant. Disloction of lens, anterior synachia, adherent leucoma, anterior capsular cataract, corneal fistula, purulent uveitis, endophthalmitis, panophthalmitis, intraocular hhg etc.
  83. 83.  Clinical features  Symptoms  Similar to bacterial keratitis but less prominent than equal sized bacterial ulcer  Signs  Dry looking, yellowish white, with indistinct margin  Delicate, feathery, finger-like projections into adjacent stroma  May be surrounded by greyish halo and multiple satellite lesions  Overlying epithelium is elevated  Hypopyon more common
  84. 84.  Acute pain, redness, lacrimation  Photobhobia and blurring of vision  Signs – CCC, initially numerous white plaques of epithelial cells appear on cornea – superficial punctate keratitis (SPK’s)  Erosions coalesce together, spread in all directions forming dendritic figures (pathognomonic)  Ulcer bed stains with fluorescein & rose bengal  Corneal sensation diminished or absent  Geographical keratitis – enlargement
  85. 85.  The diagnosis of corneal ulcer is made by- [A] Clinical evaluation • Thorough History taking • General Physical examination • Ocular Examination [B] Laboratory investigations • Routine Laboratory investigations • Microbiological investigations
  86. 86. Routine lab investigations  Hb, TLC, DLC, ESR,  Blood Sugar  LFT Microbiological investigations  These are done to identify causative organism, confirm the diagnosis & guide the treatment to be instituted.  Specimens used Corneal scraping Corneal Biopsy
  87. 87. • Can be performed with slit lamp under topical anaesthesia(0.5%propacaine hydrochloride) • Heat-sterilized platinum (kimura) spatula blade, a No.15 BP blade or a large gauge hypodermic needle is used to scrape corneal tissues from advancing borders of infected area • Specimens obtained are usually small in quantity and should be inoculated directly onto appropriate culture media in order to maximize culture yield • While plating the culture medium, the specimen is inoculated in C streaks on fresh blood agar plate to differentiate valid bacterial growth from plating contamination. Corneal Scraping
  88. 88.  Primary staining of heat fixed smear with crystal violet for 1 min  Pour off crystal violet and add grams iodine  Keep for 1 min and wash with water  Decolourise with an organic solvent (alcohol or acetone) for 10-30 sec  Wash with water  Counterstain with a dye of contrasting colour (safranin, carbol fuchsin) for 20 sec
  89. 89.  Conventional route ( Trabecular) : 90%  Unconventional ( Uveo-scleral) : 10%
  90. 90.  Visual acuity  Young children  Catford drum  Acuity cards  Preferential looking Children > 3 years Symbol matching games Naming the pictures on a chart
  91. 91. Paralytic squint  Onset- sudden  Diplopia-present  Ocular movements-limited in direction of pralyzed muscles  False projection-positive  Head posture-particular  Nausea & vomiting-present  2ry deviation > 1ry deviation  Pathologic sequelae of muscles in old cases  Slow  Usually absent  Full  Negative  Normal  Absent  2ry deviation = 1ry deviation  absent Non-paralytic
  92. 92. Maturation of cortical cataract  Lamellar seperation  Stage of incipient cataract Cuneiform Cupuliform  Immature senile cataract  Mature cataract  Hypermature cataract Morgagnian, Sclerotic
  93. 93.  Anxiety  Nausea & gastritis  Irritative or allergic conjunctivitis  Corneal abrasion  d/t LA: retrobulbar hhg, oculocardiac reflex, perforation of globe, subconj. Hhg
  94. 94.  Sup. Rectus ms laceration  Excessive bleeding  Injury to cornea, iris & lens  Posterior capsule rupture  Vitreous loss  Expulsive choroidal hhg
  95. 95.  Hyphaema  Iris prolapse  Shallow ant. Chamber  Post-op ant. Uveitis  Bact. Endophthalmitis
  96. 96.  Cystoid macular edema  Delayed post-op endophthalmitis  Retinal detachment  2ry cataract  glaucoma
  97. 97.  Avascularity  Tight packed nature of cells  Arrangement of the lens protein  Semipermeability of capsule  Pumping mechanisms  Auto oxidation and high concentration of reduced glutathione
  98. 98. Symptoms  Frequent change of glass  Decreased visual acuity  Myopic shift  Loss of abilty to see in bright light  Monocular diplopia  Glare  Coloured haloes around light
  99. 99.  Two light descrimination test  Maddox rod test  Entoptic phenomenon  Laser interferometry  Photo stress test  ERG  VER
  100. 100.  Suppression  Amblyopia – continued monocular suppressions  Anomalous retinal correspondence  Abnormal Head Posture
  101. 101. Pupillary Light Reflex Parasym. : 4 Neurons 1st order : Photoreceptors of Retina to Pretectal Nucleus in Midbrain at level of Superior Colliculus 2nd order : Pretectal Nucleus to Both Edinger – Westphal nuclei. 3rd order : Edinger – Westphal nuclei to Ciliary Ganglion . Parasym fibres come by Inf div of 3rd nerve via Nerve to Inf oblique muscle. 4th order : Ciliary Ganglion to Sphincter pupillae via short ciliary nerves
  102. 102. Sympathetic Nerve Supply 3 Neurons 1st order : Posterior hypothalamus to Ciliospinal centre of Budge located between C8 and T2. 2nd order : CSC of Budge to Superior Cervical Ganglion in Neck 3rd order : Along ICA to enter skull and joins Ophthalmic div of V Nerve . Sym fibres reach Ciliary body and Dilator pupillae via Nasociliary and long ciliary nerves.
  103. 103.  Insidious  Asymptomatic  Mild headache  Eyeache  Defect in visual field  Frequent change in presbyopic glassse  Delayed dark adoption
  104. 104.  Ant. Segment signs: sluggish pupillary reflex, hazy cornea  IOP: falls during evening  Optic disc changes: early  vertically oval cup  Asymmetry of cups  Large cup ≥ 0.6mm  Splinter hhg  Pallor area on disc  Atrophy of retinal nerve fibre layer
  105. 105.  Marked cupping 0.7-0.9  Thinning of neuroretinal rim  Nasal shifting of retinal vessels  Pusation of retinal arterioles seen at disc margin  Lamellar dot sign  Optic disc changes: glaucomatous optic atrophy
  106. 106.  Isopter contraction  Baring of blind spot  Paracentral scotoma  Seidel’s acotoma  Arcuate or bjerrum’s scotoma  Ring or double arcuate scotoma  Roenne’s central nasal step  Peripheral field defects  Tubular vision
  107. 107. Complete blindness • Causes Complete blindness: • Optic atrophy • Traumatic avulsion of optic nerve • Indirect optic neuropathy • Acute optic neuritis
  108. 108. Ipsilateral blindness, Contralateral hemianopia
  109. 109. Distension of 3rd ventricle Atheroma of carotids
  110. 110. parietal lobe: inferior quadrantic hemianopia  Pie on the floor Temporal lobe: superior quadrantic hemianopia Pie in the sky
  111. 111.  Mechanism of action  They bind to β-adrenergic receptors and block sympathetic transmission  Lower IOP by reducing aqueous production by as much as 30% to 50%  Most β-blockers are nonselective  Betaxolol is β-1 selective, used to reduce pulmonary side effects.
  112. 112.  Side effects  Ocular  Stinging, burning, photophobia, blurred vision, dry eye, corneal anesthesia & allergic conjunctivitis.  Systemic  Heart block, cardiac failure, asthma
  113. 113.  Contraindications  Congestive heart failure  Bradycardia  Heart block  Diabetic pts prone to hypoglycemia  Asthma  COPD
  114. 114. Drug receptor concentration Dose Timolol nonselective 0.25%, 0.5% BD betaxolol β-1 selective 0.5% OD Levobunolol nonselective 0.25%, 0.5% BD metipranolol nonselective 0.3% BD Carteolol nonselective 1% BD
  115. 115.  Both topical and systemic carbonic anhydrase inhibitors (CAIs) reduce IOP by reducing aqueous production.  Topical CAIs dorzolamide & brinzolamide
  116. 116. Side effects Ocular side effects Irritation, stinging, superficial punctate keratitis and allergic conjunctivitis.  Anorexia, weight loss, paresthesia, fatigue, malaise and depression  Potassium loss due to diuresis – hypokalemia  Steven Johnson syndrome, blood dyscrasias, renal lithiasis.
  117. 117. Contraindications  sulpha allergy  Systemic not to be used in patients with renal lithiasis, renal insufficiency, severe obstructive pulmonary disease and diabetic ketoacidosis.
  118. 118.  Nonselective – epinephrine and dipivefrin  Not used any more due to irritation & injection  α-2 selective – apraclonidine and brimonidine
  119. 119.  Mechanism of action  Apraclonidine – reduces IOP by increasing outflow facility, decrease production, and decreasing episcleral venous pressure  Brimonidine – reduces IOP by decreasing aqueous production and increasing uveoscleral outflow and may act as neuroprotective agent
  120. 120.  Side effects  About 1/3rd of patients develop ocular allergy with apraclonidine  Allergy to brimonidine is less common  Newer formulation with purite preservative has even further reduced incidence of allergy  Life threatening hypotension and apnea have been reported in infants treated with brimonidine
  121. 121.  Mechanism of action  They reduce the IOP by increasing the osmolality of the intravascular fluid  As blood barrier prevents their entry into vitreous, an osmotic gradient is established, causing fluid to leave the vitreous to enter intravascular space
  122. 122.  Side effects  Avoided in patients with compromised cardiac function  Cerebral dehydration causes headache and disorientation  Oral glycerol avoided in diabetics  Contraindications  Renal failure  Cardiac failure  Glycerol avoided in diabetics
  123. 123.  Preparation & administration Drugs Concentration Dose Latanoprost 0.005% OD Bimatoprost 0.03% OD Travoprost 0.004% OD Isopropyl unoprostone 0.15% BD
  124. 124. Mechanism of action  Increase uveoscleral and also trabecular outflow  Decrease production

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