Blind People Avi Dayal

1. BLIND PAINFUL EYE

2. Painful Blind Eye
Definition
 Terminal ocular condition
 Vision is unsalvageable (NLP/LP)
 Mild to Severe ocular pain
 Management plan
 Aim reduce debilitating effects of pain on quality of life.
 Stepwise approach
 Medical
 Minimally invasive therapy’s
 Surgical

3. Common causes of Blind Painful eye
1. Uveitis / Endopthalmitis
2. Glaucoma with Markedly Elevated IOP
3. Corneal decompensation (Bullous Keratopathy)
4. Hypotony:
Retinal detachment
Choroidal detachment
Ciliary body shutdown
Ciliary body detachment
Post trauma (e.g. perforated eye)
Painful Blind Eye

4. Work-Up
History
Determine the etiology and duration of the blindness/pain
Effect of the pain on the patient ADL
Examination
VA: NLP/LP
Cornea: Corneal Decompensation/corneal defects
AC/Iris/Angle : AC Activity (cells / flare) neovascularization of the iris and angle
IOP
Fundoscopy: retinal detachment, intraocular tumors
B-scan: retinal detachment, choroidal or ciliary body detachment
CT scan or MRI: rarely indicated.

5. Effectiveness of Treatment Options
 Medical therapy (cycloplegics, steroids, antihypertensives) 39%
 Minimally invasive therapy (cyclophotocoagulation, retrobulbar injection) 75%
 Surgical therapy (Enucleation or evisceration) 100%

6. Inflammation/Hypotony
 Uveitis/Endopthalmitis – Reduce Inflamation
 Steroids – Topical/Subtenons/Orbital Floor
 NSAIDS (ketolorac)
 Cycloplegia (atropine)
 Hypotony - Resolve the cause of the hypotony
 Repair wound leak
 Treat ciliochoroidal detachment
 Retinal detachment  PPV repair

7. Sterile corneal decompensation
 Lubricating drops and ointment
 Antibiotic ointment (e.g. erythromycin)
 Cycloplegia (atropine 1%)
 Nightly patching
 Surgical options
 Tarsorrhaphy
 Amniotic membrane graft or Gunderson conjunctival flap

8. Elevated IOP
 Topical beta-blocker (timolol 0.5%) / adrenergic agonist (brimonidine 0.2%)
Topical carbonic anhydrase inhibitors (dorzolamide 2%)
 Topical Prostaglandin analogues – can incite inflamation
 Oral CAI/Glycerol (short term relief)
 NVG : Becivizumab IVT / PRP
 If IOP remains markedly increased:
Cyclodestructive procedure (Cyclophotocoagulation or Cyclocryotherapy)

9. Cyclophotocoagulation
 Refractory glaucoma
 Diode laser (810 nm) transscleral (endoscopic probe)
 Melanin in the ciliary epithelium absorbs this wavelength -
targeted destruction with less inflammation
 can be performed with local anesthesia/block
 Typically effective for 1 year. Can be repeated
 S/E: AC reaction/Uveitis, Scleritis, Hyphema, Conjuctival
burns, Hypotony, Sympathetic ophthalmia in the fellow eye

10. Retrobulbar Alcohol
 Pain refractory to medical treatment
 Analgesia through the destruction of nerve cells
 Alcohol 95% /100% (Chlorpromazine 0.25mg/ml)
 Typically effective for 3 to 6 months, but can be effective 1 year.
 Technique same as for retrobulbar block
 2 to 3 mL of 2% lidocaine/macaine
 2 to 3mls of Alcohol after 2 minutes
 S/E: swelling of the eyelid, restrictive strabismus, ptosis (temporary)

11. Cyclocryotherapy
 anterior edge of cryoprobe placed
at 2mm posterior to the limbus
 care to avoid 3 / 9 o'clock locations
(long posterior ciliary vessels)
 1 freeze-spot per clock-hour (45–
60 seconds)
 180 degrees (6 clock hours) of the
eye's circumference
 S/E: AC reaction, Scleritis, Hyphema,
Hypotony, retinal detachment, Phthisis

12. Enucleation or evisceration
last resort for patients with a blind painful eye
Ocular pain refractory to retrobulbar injections
Evisceration
 cornea + ocular contents are removed
 scleral shell and EOM are left intact
Enucleation
 removal of the entire globe
 suturing of the extraocular muscles to the spherical implant
Enucleation should be performed if intraocular malignancy is suspected

13.  THE WILLS EYE MANUAL
Office and Emergency Room
Diagnosis and Treatment of Eye Disease
S I X T H E D I T I O N
 American Academy of Opthalmology
(https://eyewiki.aao.org/Blind_Painful_Eye)