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The art of coarse Ophthalmology

The art of coarse Ophthalmology. Alistair Bennett Dyfed road health centre NEATH! NEATH! NEATH!. Main topics. History and examination Red eyes Visual disturbance and loss Cold cases Social aspects Refractive surgery. J`accuse. Poor undergraduate teaching Poor postgraduate teaching

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The art of coarse Ophthalmology

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  1. The art of coarse Ophthalmology Alistair Bennett Dyfed road health centre NEATH!NEATH!NEATH!

  2. Main topics • History and examination • Red eyes • Visual disturbance and loss • Cold cases • Social aspects • Refractive surgery

  3. J`accuse • Poor undergraduate teaching • Poor postgraduate teaching • Snellen charts • Medical short cases • A different language with confusing terminology • Textbooks with endless pictures of red eyes

  4. History • Does it hurt ? • Can you see clearly • Foreign body • timescale

  5. History • PAIN • VISUAL DISTURBANCE

  6. Visual disturbancesymptoms • Distortion • Haloes • Floaters • Flashes • Diploplia

  7. Distortion • Kinks • Amsler chart • Metamorphopsia • IT`S A MACULAR THING

  8. Floaters • Spots • Blobs • Flies • Cobwebs • IT`S A VITREOUS THING

  9. Photopsia • Flashing lights • If it ain`t migraine IT`S A RETINAL THING

  10. Haloes • Acute angle closure (spectral) • Monochromic(cataract)

  11. Examination • Record VA • If you do nothing else record VA • Use a pinhole

  12. Visual acuity • CF • HM • PTL • NPTL

  13. Examination • Outside in • Fundus last and with a differential diagnosis in mind • Do not expect to see anything through an undilated pupil

  14. Red eye • If pain and or reduced VA • Eye casualty

  15. Visual loss/disturbance • Sudden visual loss • Sudden blurring • Gradual blurring • Double vision

  16. Sudden visual loss • CRA occlusion • CRV occlusion • Macular haemorrhage • Retinal detachment • Migraine • Amaurosis fugax

  17. Gradual blurring • Cataract • Age related macular degeneration

  18. Distorted vision • Wet ARMD • Macular hole • Cellophane maculopathy

  19. Flashes and floaters • Posterior vitreous detachment • Vitreous haemorrhage • Retinal hole • Retinal detachment • migraine

  20. Retinal Detachment • Sudden onset floaters • Intermittent flashing lights • Within 24 hours • Peripheral shadow or curtain coming down • Same day

  21. Binocular double vision • Cranial nerve palsy • Blow-out fracture

  22. Cold ophthalmology • Cataracts • Primary open angle glaucoma • Age related macular degeneration

  23. Cataract symptoms • Gradual mist / clouding • Gradual decrease VA • Myopic shift • Glare • Monocular diploplia

  24. Cataract surgery • Day case regional anaesthetic • Corticosteroids for 3 weeks • Optician for refraction 6 weeks

  25. Cataract surgery complications • Posterior capsule rupture • Lens fragment in vitreous • Endophthalmitis • Retinal detachment • Pain should become less and vision improve every day in the immediate post-op period

  26. If it ain`t broke don`t fix it • 2 in 100 worse off • 1 in 1500 blind • 1 in 14000 sympathetic ophthalmitis

  27. Indications for surgery • Only when cataract visually significant and the benefits outweigh the risks • Can patient read,drive,satisfy DVLA standard,faces,steps,kerbs

  28. Conservative measures • Refraction for myopic shift • Sunglasses and a hat with a brim for glare • Large print • Light behind • Talking books

  29. Primary open angle glaucoma • It’s a triad • Raised IOP (normal <21mmHg) • Optic disc cupping • Visual field defects • Asymptomatic • Picked up by optician

  30. Occular hypertension • IOP>21mmHg (2SD) • Important risk factor for glaucoma • 10% over 10 years • Remember normal tension glaucoma

  31. ARMD • Age related macular degeneration • Commonest cause of blindness in uk • Dry and wet types • Wet type “treatable” infact prevents rapid decline • Wet type can develop on dry type

  32. ARMD exudative/wet type • Amsler distortion • Metamorphopsia • Sudden deteriation

  33. Wet Type AMD Treatments • Macugen (pegaptanib) • Lucentis ( ranibizumab) • Monoclonal antibodies against the vascular endothelial growth factor

  34. Wet AND treatments • Early studies encouraging • May halt or slow deteriation in some patients • Administered by intravitreal injections every 4-6 weeks for life • Considerable cost

  35. ARMD referral • Confirmation of diagnosis • L.V.A • Registration • Co-morbidity • Wet type

  36. Social aspectsvisual impairment registration • Registration triggers both social services and voluntary group support • Adaptations to house,visual aids,tapes and large print books • Social worker visit • Benefits DLA/AA,housing benefit,tax allowances • Free prescriptions/sight tests • Rail telephone concessions

  37. Quality of life and visual rehabilitation: an observational study of low vision in General Practice in West Glamorgan Eye 2006, Williams, Austin Bennett et al

  38. Main Findings • 66 patients • 85% over 70 years • 70% female • 80% received a visit from social services • 33% still in contact with social services • 36% had a white stick • None had a guide dog

  39. Main Findings • 66% had to negotiate steps to front door • 36% had mobility and safety aids (handrails etc) • 44% speaking clock • 41% lived alone

  40. Charles Bonnet Syndrome • Visual hallucinations in those with visual impairment • Simple patterns and lines to complex pictures • Can be distressing but not confused with reality

  41. Full blind registration • Vision must be worse than 3/60 in both eyes • OR • Vision worse than 6/60 in both eyes with restricted field

  42. Partial sight registration • Vision worse than 6/60 in both eyes • Vision worse than 6/18 in both eyes with a restricted field • hemianopias

  43. DVLA standards • Number plate at 20.5 metres • Visual field 60 degrees either side of fixation

  44. Smoking and the Eye • AMD • Glaucoma • Cataracts • CRVO • Ischaemic neuropathy • Diabetic retinopathy

  45. Vitamin supplements • Some studies have suggested that zinc, anti-oxidants and vitamin supplements can slow the progression of dry AMD • Effect small • Marketing of supplements e.g. I-Caps

  46. Refractive Laser Surgery • PRK photorefractive keratectomy • LASEK laser epithelial keratomilieusis • LASIK laser in situ keratomilieusis • ETC

  47. Complications • www.rcophth.ac.uk/about/public/laser • Dry/sensitive eyes • Presbyopia • Minor refractive error • Anisometropia • Infection • Decreased night vision, glare, haloes, starburst

  48. Drugs with Occular side Effects • Vigabatrin • Tamoxifen • Chloroquine • Amiodarone • ethambutol

  49. 78 year old man, hypertensive smoker, sudden loss of vision right eye, fundoscopy normal

  50. Central retinal artery occlusion

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