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OPHTHALMOLOGY LECTURE 2 Vijay Lakshmanan Vijay.Lakshmanan@lthtr .nhs.uk CASE 1 A 64 year old female presents toA&E with Eye pain . Sudden onset severe right eye pain accompanied with Headache,blurry vision and Nausea. Right eye appears red.Patient reports seeing halos around lights. PMH – HTN.No relevant ocular history Meds – Ramipril 5mg daily CASE 1 A 64 year old female presents toA&E with Eye pain . Sudden onset severe right eye pain accompanied with Headache,blurry vision and Nausea. Right eye appears red.Patient reports seeing halos around lights. PMH – HTN.No relevant ocular history Meds – Ramipril 5mg daily WHAT EXAMS/INVESTIGATIONS WOULD YOU LIKE TO ORDER? • AFRO –ACUITY, VISUAL FIELDS,PUPIL REFLEXES,OPHTHALMOSCOPY • SLIT LAMP EXAMINATION • TONOMETRY • GONIOSCOPY WHAT DIFFERENTIALSWOULDYOU CONSIDER? Acute angle glaucoma,Anterior Uveitis,Conjunctivitis,Scleritis/Episcleritis INVESTIGATIONS • Slit lamp - Hazy cornea,Shallow anterior chamber • Fundoscopy – Cupping of disc (if prolonged raised GoldmannApplanation tonometry – IOP) Measuring intraocular pressure • Gonioscopy – Narrow angle • Tonometry – Confirms elevated intraocular pressure (Normal 10 - 21 mmHg).Acute often > 30 mmHg • Visual fields – Useful later on to assess optic nerve damage Gonioscopy –Visualisation of the angle ACUTE ANGLE CLOSURE GLAUCOMA Symptoms • Severe unilateral eye pain (Sudden onset) • Blurred vision (Halos around light) • Headache,nausea,vomiting • Photophobia • Worse with mydriasis (WatchingTV in the dark) Signs • RedTeary and Injected Eye • Hazy eye (due to corneal oedema) • Semi-dilated non-reacting pupil • Firm on palpation IT IS AN EMERGENCY! RISK FACTORS • Iris bulges forward and INCREASINGAGE closes off the trabecular HYPERMETROPIA meshwork FEMALES > MALE • Aqueous humour cannot CHINESEAND EASTASIAN drain anymore → IOP ETHNICITY increases rapidly SHALLOWANTERIOR CHAMBER • Refer for same day assessment by ophthalmology MANAGEMENT • Urgent referral to Ophthalmology Laser Iridotomy Tiny hole in the peripheral iris • Lie patient on back without pillow to allow aqueous humour to flow • Reduce IOP –T opical beta blockers (Timolol), Pilocarpine, Alpha-agonist (Apraclonidine) • IVAcetazolamide – Reduces aqueous secretion DEFINITIVE MANAGEMENT – LASER PERIPHERAL IRIDOTOMY OPEN ANGLE GLAUCOMA • Trabecular meshwork offers increased resistance to aqueous outflow → Raised IOP (Gradual) • RF –Age,Black ethnic origin,FH,Myopia,Steroid use • HAMP – Hypermetropia –Acute,Myopia – Primary open • Presentation – Often asymptomatic picked up on optometry appts,Progressive loss of peripheral vision (tunnel) • Fundoscopy – C:D ratio > 0.7,Disc pallor Management • SLT – 360 Selective laser trabeculoplasty • Medication – ProstaglandinAnalogues,Betablockers,Miotics… Trabeculectomy Bleb • Surgery:Trabeculectomy used in refractory cases Medication Action Key point Prostaglandin Increases outflow Brown pigmentation Analogues iris,eyelash length POAG Eg - Latanoprost MEDICATION – Beta blockers Reduces production Avoid inAsthma/Heart EgTimolol block KEY POINTS Sympathomimetics Both Avoid in MAOI or Eg Brimonidine TCAs Miotics Increases outflow SE – headache,blurred Eg - Pilocarpine vision CASE 2 75 year old male presents to GP clinic with GradualVision Loss Progressive worsening of vision over 2 years Difficulty driving due to glare from headlights.Struggles to read even with glasses. PMH –T2DM,HTN.Meds – Metformin,Amlodipine No pain or red eye,Bilateral pupil reflexes normal WHAT ARE YOUR DIFFERENTIALS? • CATARACTS • DIABETIC RETINOPATHY • AGE RELATED MACULAR DEGENERATION • REFRACTIVE ERROR INVESTIGATIONS? • AFRO – DecreasedVA • SLIT LAMP –A Lens opacity noted • OCT (Macular degeneration) CATARACTS Symptoms • Gradual painless progressive vision loss (worse at night) • Glares (Especially night driving) • Blurring of vision • Reduced colour intensity Signs • Lens opacity on slit lamp • Loss of fundal reflex (advanced stages) • DecreasedVA CATARACTS • Lens of eye gradually opacifies,reducedVA • Risk Factors:Increasing age,Smoking,Alcohol,Diabetes, Steroids (subcapsular),Hypocalcaemia • Presentation:Gradual onset ReducedVA,Faded colour vision,Glares and Halos • Signs – Defect in red reflex • Management:Non-surgical – stronger lens,brighter light • Surgery if affecting QOL,phacoemulsification + Intraocular lens implant COMPLICATIONS FOLLOWING SURGERY • Posterior capsule opacification:thickening of the lens capsule • Retinal detachment • Posterior capsule rupture • Endophthalmitis:inflammation of aqueous and/or vitreous humour CASE 3 A 58 year old man presents toA&E Sudden painless loss of vision in right eye 1 hour ago Complete blurring of right eye PMH – HTN,Hyperlipidaemia,Excess smoking Meds –Atorvastatin,Amlodipine CASE 3 DIFFERENTIALS – Painless loss of vision? Retinal detachment,Amaurosis fugax,CRAO,Optic neuritis EXAMS/INVESTIGATIONS? Pupil reflexes - RAPD noted in right eye Fundoscopy - Pale retina with a cherry red spot → CRAO Urgent ESR/CRP to rule out Giant cell arteritis Carotid doppler ultrasound ECG – Cardiac sources of emboli (Echo?) CENTRAL RETINAL ARTERY OCCLUSION • Blockage to blood flow via central retinal artery to the retina • Thromboembolism (Atherosclerosis) orArteriris (GCA) • Presentation:sudden painless loss of vision,RAPD,fundoscopy = pale retina with cherry red spot • Management:If suspected then go to eye casualty,treat suspected GCA with high dose steroids. • Immediate:Ocular massage,Removing fluid from the anterior chamber,Inhaling carbogen,Sublingual isosorbide dinitrate • Long term management involves treating reversible risk factors and secondary prevention of CVD CENTRAL RETINAL VEIN OCCLUSION Signs and Symptoms • Sudden unilateral loss of vision/reduction inVA Features • Flame and blot haemorrhages • Optic disc oedema • Macula oedema CRVO – Flame Risk Factors haemorrhages in all 4 quadrants • HTN,High cholesterol,Diabetes,Smoking,Glaucoma,Systemic inflammatory conditions (e.g.SLE) Management • Most cases conservatively • Laser photocoagulation – Retinal neovascularisation • Macular oedema – intravitreal anti-VEGF Branch retinal vein occlusion CASE 4 72 year old female presents with blurred central vision in both eyes Gradual painless blurring over the past few months Difficulty reading and recognising faces No improvement with glasses PMH – HTN,Ex-smoker,T2DM CASE 4 DIFFERENTIALS? AMD,Diabetic retinopathy,Open angle glaucoma EXAMS • Visual acuity – 6/18 (right),6/12 (left) • No evidence of cataracts on slit lamp • Amsler grid – at home eye test Wavy lines noted onAmsler grid Metamorphopsia –A form of distorted vision causing linear objects to look curvy/rounded AGE RELATED MACULAR DEGENERATION • Degeneration of the macula - Most common cause of blindness in the UK • 90% = dry,10% = wet (carries worse prognosis) • Key finding = drusen (yellow deposits of protein and fats) on fundoscopy,however in wet you also see new blood vessels forming. • Typical Presentation = Gradual worsening central visual field loss,Reduced visual acuity,crooked or wavy appearance to straight lines (Metamorphopsia) NON-EXUDATIVE AMD • “Dry” as there is no new vessel formation • Stages – Early,Intermediate andAdvanced • Characterised by the presence of drusen and geographic atrophy IntermediateAMD – Multiple medium drusen • Visual deterioration is usually very slow • Risk factors – AGE,Smoking,Family history • Visual Hallucinations – Charles-Bonnet Syndrome (commonly assoc.with AMD) MANAGEMENT • Combination of zinc with anti-oxidant vitaminsA,C and E (Recommended in intermediate dryAMD) AdvancedAMD – GeographicAtrophy EXUDATIVE AMD • Relatively rapid onset of symptoms in patients with knownAMD • Requires urgent ophthalmological review • Intravitreal anti-VEGF therapy • Examples of anti-VEGF agents include ranibizumab,bevacizumab and pegaptanib,. The agents are usually administered by 4 weekly injection. Subretinal haemorrhage –A sign of neovascularAMD CASE 5 Patient is a 6 year old girl Parents noticed right eye drifting outwards when tired or seeing something distant No significant vision problems Birth history and development unremarkable Father had a“lazy eye” as a child CASE 5 Normal ocular alignment Reflection appears as a pin point near • WHAT’S GOING ON? centre of both pupils STRABISMUS • WHAT EXAMINATION CAN BE DONE? CORNEAL LIGHT REFLEXTEST –Will show misalignment COVERTEST – Focus on object and cover one eye.Observe movement of uncovered eye. STRABISMUS • Misalignment of visual axes • Important to correct in early stages → Can lead to amblyopia (lazy eye) • REFERTO SECONDARY CARE • EYE PATCHES MAY HELP PREVENTAMBYLOPIA CASE 6 55 year old male presents with sudden vision loss Sudden onset of“flashes of light” Followed by loss of vision“like a curtain coming down” Reports many floaters past few days.No pain/trauma PMH – High myopia,No DM or HTN CASE 6 ON EXAMINATION • VisualAcuity – Right eye 6/60,Left Eye 6/9 • Fundoscopy – Hazy view (unable to visualise retina) DIFFERENTIALS? • Retinal Detachment • Posterior vitreous detachment • Vitreous haemorrhage • RetinalArtery/vein Occlusion RETINAL DETACHMENT • Separation of neurosensory (inner layer) retina from retinal pigment epithelium • Sight threatening ocular emergency! Retinal detachment • Urgent referral to Ophthalmology • Reversible cause of visual loss,provided it is recognised and treated before the macula is affected Retinal tear → Detachment RETINAL DETACHMENT AETIOLOGY CLINICAL PRESENTATION RISK FACTORS • Painless loss of vision • Diabetes Mellitus • Most commonly secondary to full thickness retinal • Flashes and Floaters • Myopia tear →Vitreous fluid build- • “Cobwebs in peripheral • Age >40 up behind neurosensory vision” • Previous ocular surgery retina • Shadow/Curtain across (Cataracts) visual field • Ocular trauma • Posterior vitreous detachment (PVD) often O/E precedes retinal • ReducedVA,RAPD,Loss of detachment (Vitreous gel Red reflex separates from retina) MANAGEMENT Any patients with new onset flashes and floaters → Urgent (< 24 hours) ophthalmology assessment for Slit lamp and Indirect ophthalmoscopy for pigment cells and vitreous haemorrhage RETINALTEAR • Laser photocoagulation in clinic • Most cases are treated at this point and do not progress to a retinal detachment. RETINAL DETACHMENT • Vitrectomy (Most common treatment) • Pneumatic retinopexy • Scleral buckleVISUAL FIELD DEFECTS JUSTTHE EXAM POINTSOPTICAL TRACTS VISUAL FIELD DEFECTS Homonymous Hemianopia Monocular vision loss optic nerve/retina • Often due to stroke or brain Bitemporal Hemianopia Optic neuritis,Retinal tumours detachment • MCA stroke – Optic tract – No • Lesion at optic chiasm → Often macular sparing pituitary tumours • PCA stroke – Occipital cortex – Quadrantanopia Macular sparing PITS Inferior – Posterior lobe Superior –Temporal lobe Central scotoma Lesion in macula or optic nerve Macular degeneration COMMON INVESTIGATIONS • PERIMETRY • Fundoscopy • MRI BRAIN – For neurological causes (Tumours,Strokes or demyelinating disease) • Optical CoherenceTomography – Optic nerve or retinal pathology • Blood pressure and CV risk assessments • Hormone levels in suspected pituitary adenoma PRACTICE QUESTIONS A 74-year-old woman presents to the emergency department with sudden,painless loss of vision in her right eye.Her past medical history is significant for hypertension and type II diabetes mellitus. On examination,the patient's pupils are equal,round,and reactive to light and accommodation.Visual acuity is 6/6 in the left eye and 6/60 in the right eye.Fundoscopy reveals several flame-shaped haemorrhages in all four retinal quadrants.Slit lamp examination of the anterior chamber is unremarkable. What is the most likely diagnosis? A Central RetinalArtery Occlusion B) Central RetinalVein Occlusion C) Retinal Detachment D) PosteriorVitreous Detachment E)Vitreous Haemorrhage PRACTICE QUESTIONS A 74-year-old woman presents to the emergency department with sudden,painless loss of vision in her right eye.Her past medical history is significant for hypertension and type II diabetes mellitus. On examination,the patient's pupils are equal,round,and reactive to light and accommodation.Visual acuity is 6/6 in the left eye and 6/60 in the right eye.Fundoscopy reveals several flame-shaped haemorrhages in all four retinal quadrants.Slit lamp examination of the anterior chamber is unremarkable. What is the most likely diagnosis? A Central RetinalArtery Occlusion B) Central RetinalVein Occlusion C) Retinal Detachment D) PosteriorVitreous Detachment E)Vitreous Haemorrhage PRACTICE QUESTION A 72-year-old woman presents to the eye casualty department reporting bilateral worsening vision over the last 10 years.The patient says that this is affecting her ability to read books. On examination,a central visual impairment is detected.Metamorphopsia is also demonstrated using an Amsler grid.Small yellow deposits are visualised in the macula on fundoscopy. Based on the most likely diagnosis,what is the most appropriate medical management for this patient? A – Monthly IntravitrealAnti-VEGF injection B – Omega 3 fish capsules C - Phacoemulsification D – Photodynamic therapy E –Vitamin supplementation PRACTICE QUESTION A 72-year-old woman presents to the eye casualty department reporting bilateral worsening vision over the last 10 years.The patient says that this is affecting her ability to read books. On examination,a central visual impairment is detected.Metamorphopsia is also demonstrated using an Amsler grid.Small yellow deposits are visualised in the macula on fundoscopy. Based on the most likely diagnosis,what is the most appropriate medical management for this patient? A – Monthly IntravitrealAnti-VEGF injection B – Omega 3 fish capsules C - Phacoemulsification D – Photodynamic therapy E –Vitamin supplementation PRACTICE QUESTION A 52-year-old man attends his GP regarding problems with his vision.For the past few months,he has been having some difficulty driving as he has been struggling to see cars coming toward him from the sides of his vision. He reports no pain around his eyes. His past medical history includes peripheral vascular disease,type II diabetes,and short-sightedness,and often does not wear his glasses. What is the most likely diagnosis? A –Age related Macular degeneration B – Central RetinalVein Occlusion C – Cataracts D – Primary open angle glaucoma E - Scleritis PRACTICE QUESTION A 52-year-old man attends his GP regarding problems with his vision.For the past few months,he has been having some difficulty driving as he has been struggling to see cars coming toward him from the sides of his vision. He reports no pain around his eyes. His past medical history includes peripheral vascular disease,type II diabetes,and short-sightedness,and often does not wear his glasses. What is the most likely diagnosis? A –Age related Macular degeneration B – Central RetinalVein Occlusion C – Cataracts D – Primary open angle glaucoma E - Scleritis PRACTICE QUESTION Which of the following is the strongest risk factor for subcapsular cataracts? A – OcularTrauma B – Steroids C –Allopurinol D – Myopia E – Hypermetropia PRACTICE QUESTION Which of the following is the strongest risk factor for subcapsular cataracts? A – OcularTrauma B – Steroids C –Allopurinol D – Myopia E – Hypermetropia PRACTICE QUESTION A 65-year-old man presents to the emergency department with 1 hour of severe pain around his left eye.This has never occurred before and he now has vision blurring and nausea.He has hypermetropia and rheumatoid arthritis,and he smokes 35 cigarettes daily. He is agitated and restless,and the left eye is red and injected.The left cornea is hazy and the pupil is semi- dilated and uncreative.The right eye is normal and the examination is limited as turning the lights off exacerbates his pain. Which option is the best initial step in his management? A –Corticosteroids +Tropicamide eye drops B – IVAcetazolamide +Timolol and pilocarpine eyedrops C – Laser trabeculoplasty and consider latanoprost eyedrops D – Oral NSAIDs E – Subcutaneous sumatriptan and 100% oxygen therapy PRACTICE QUESTION A 65-year-old man presents to the emergency department with 1 hour of severe pain around his left eye.This has never occurred before and he now has vision blurring and nausea.He has hypermetropia and rheumatoid arthritis,and he smokes 35 cigarettes daily. He is agitated and restless,and the left eye is red and injected.The left cornea is hazy and the pupil is semi- dilated and uncreative.The right eye is normal and the examination is limited as turning the lights off exacerbates his pain. Which option is the best initial step in his management? A –Corticosteroids +Tropicamide eye drops B – IVAcetazolamide +Timolol and pilocarpine eyedrops C – Laser trabeculoplasty and consider latanoprost eyedrops D – Oral NSAIDs E – Subcutaneous sumatriptan and 100% oxygen therapy THANK YOU Vijay.Lakshmanan@lthtr.nhs.uk