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Case 1 56 year old man presents for routine examination and these are the fundus photos. L L R.

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Presentation on theme: "Case 1 56 year old man presents for routine examination and these are the fundus photos. L L R."— Presentation transcript:

1 Case 1 56 year old man presents for routine examination and these are the fundus photos. L L R

2 Case 2 65 year old female presents with monocular diplopia

3 Case 3 65 year old smoker male presents blurred vision centrally

4 Case 4 65 year old diabetic male presents with blurred vision centrally

5 Acute Visual Loss Potential causes: Cornea Acute keratitis (bacterial, fungal, viral) Angle closure glaucoma Anterior chamber Hyphema Lens Cataract (usually traumatic) Vitreous Hemorrhage Retina Vascular occlusions Arterial Venous Wet AMD Retinal detachments Optic nerve Optic neuritis Ischemic optic neuropathy Giant cell arteritis Brain Cerebrovascular accident trauma

6 Case 1 65 year old male presents with sudden painful loss of vision. States it was preceded by nausea and vomiting.

7 Case 2 23 year old diabetic presents with sudden visual loss following being hit with a softball.

8 Case 3 57 year old man with 30 year history of DM presents with sudden onset of rapidly progressive acute visual loss.

9 Case 4 65 year old make presents with sudden painless loss of vision. Preceded by flashes of light and floaters.

10 Case 5 65 year old make presents with sudden painless loss of vision. No RAPD. Eye appears white.

11 Case 6 65 year old male presents with sudden painless loss of vision. No RAPD. Eye appears white. PMHX smoker, HTN and diabetes.

12 Case 7 77 year old make presents with sudden painless loss of vision. No RAPD. Eye appears white. Smoker, HTN (190/110).

13 Case 8 77 year old make presents with new distortion. No RAPD. Eye appears white.

14 Case 9 88 year old make presents with sudden loss of vision and says that it hurts when she chews. RAPD present. Eye appears white.

15 Case year old female with rapid loss of vision and decreased colour vision in the right eye. RAPD present. Eye is white.

16 Extraocular Causes Blepharitis/Styes Lid malpositions Ectropion Entropion 7 th Nerve Palsy Cellulitis Preseptal Orbital Conjunctival/Scleral Causes Conjunctivitis Viral Bacterial Allergic Subconjunctival hemorrhage Pinguecula/Pterygium Episcleritis/Scleritis Causes of a Red Eye

17 Corneal Causes Infectious keratitis Viral (HSV) Bacterial Fungal Trauma Foreign Body Abrasion Contact lens issues Intraocular Causes Hypopyon Iritis Post-operative Endophthalmitis Acute angle closure glaucoma Trauma Hyphema Causes of a Red Eye

18 Case 2

19 Case 3

20 Case 6 Episcleritis – inflammation of the episclera Scleritis – inflammation of the sclera

21 Case 7 Viral keratitis – HSV – viral infection of the cornea usually in a characteristic dendritic pattern

22 Case 8 Bacterial keratitis – bacterial infection of the cornea Fungal keratitis – fungal infection of the cornea

23 Case 9 Corneal Abrasion – loss of the surface epithelium of the cornea

24 Case 11 Hypopyon – finding on exam - variety of causes – infection, inflammation - collection of WBC in the inferior aspect of the anterior chamber

25 Case12 Endophthalmitis – inflammatory condition of the intraocular cavities (AC/vitreous) usually caused by infection

26 Basic Ocular Anatomy Extraocular Muscles - LR 6 SO 4 Lateral Rectus Laterally CN VI Medial Rectus Medially CN III Inferior Rectus Down and out CN III Inferior Oblique Up and in CN III Superior Oblique Down and in CN IV Superior Rectus Up and out CN III

27 Diplopia Monocular = refractive or retinal Dx: disappears when affected eye is covered but persists when unaffected eye is covered Binocular = ocular misalignment Dx: cover test reveals strabismus. Disappears if either eye is covered

28 DiplopiaMonocular Non-urgent referral BinocularComitant Non-urgent referral IncomitantRestrictiveParalytic

29 Strabismus - diagnosis Right gaze Left gazePrimary gaze Upper 3 photos show comitant strabismus Lower 3 photos show incomitant strabismus

30 Restrictive Strabismus Orbital fracture - Hx of trauma Grave’s disease – Hx of hyperthyroidism, proptosis Orbital inflammation – red eye, proptosis, pain Orbital tumor – loss of vision, proptosis, usually no pain or redness

31 A 24 year old man complains of vertical diplopia worsening over the past 2-3 years. He notes he can lessen the problem by tipping his head to his left side. Cover test shows a small right hypertropia. The right eye does not depress in adduction as well as the left eye does in abduction. Review motility photos. What is the diagnosis?

32 Superior oblique function in various positions of gaze Primary position adductionabduction

33 Trochlear (4 th n.) Palsy What is the time course of the diplopia? If acute, then more likely vascular What other problems does patient have? Trauma, diabetes, BP, headache, vomiting Etiology Children – trauma, congenital Adults – trauma, vascular, (tumor)

34 Oculomotor (3rd n.) Palsy

35 Oculomotor (3 rd n.) palsy Without pupil involvement: Ischemia: Diabetes, hypertension, migraine, giant cell arteritis Incomplete palsies: Tumor, hematoma, aneurysms Viral Meningeal infiltration (eg leukemia)

36 Oculomotor (3 rd n.) palsy With pupil involvement: Aneurysms (ICA, PCA, Basilar a.) Interpeduncular cistern lesions Cysts Schwannoma Angioma Meningitis Surgical/accidental trauma Carotid-cavernous fistula

37 Abducens (6 th n.) Palsy What is the time course of the diplopia? If acute, then more likely vascular What other problems does patient have? Trauma, diabetes, BP, headache, vomiting Etiology Children – trauma, post-viral, otitis, tumor Adults – vascular, trauma, tumor, ICP

38 Pupils Pupillary Pathways Pupillary Light Reflex CN II CN III Pupillary Size Sympathetic system - dilation Parasympathetic system – constriction Pupillary light reflex

39 Pupil Size Pathways

40 Approach to Anisocoria 1 st Question? Which pupil is the abN pupil? 2 nd Question? - What tests will I do on exam to figure that out? Pupil Size in Bright Light Pupil Size in Dim Light Pupillary Light Reaction

41 Horner’s Syndrome - DDx Damage to the sympathetic pathway resulting in a relatively small pupil Congenital Acquired 1 st order neuron – central lesions (hypothalamospinal pathway) Stroke, tumour, MS, cervical spinal cord lesions 2 nd order neuron - pre-ganglionic lesions Adult-Tumour apex of the lung (Pancoast) Child- Neuroblastoma 3 rd order neuron – post-ganglionic (internal carotid) Internal carotid artery dissection, cavernous sinus thrombosis, prolactinoma

42 Horner’s Syndrome - Ix Generally - neuroimaging CT/MRI brain and neck CTA or head/neck or Carotid doppler – carotid dissection CT chest – Pancoast tumour suspected

43 3 rd Nerve Palsy Parasympathetic fibres are involved when pupil unable to constrict – Pupillary fibres run along the outside of the 3 rd CN Pupil involved +/- oculomotor dysfunction – Compressive lesions are more likely » Aneurysm, tumour, uncal herniation – Motor fibres are more central in 3 rd CN Oculomotor dysfunction of CN III AND pupil spared – Intrinsic lesions are more likely » Ischemic lesions Seen in DM, GCA

44 3 rd Nerve Palsy - Ix Pupil involved +/- oculomotor dysfunction – Neuroimaging CTA (CT angiogram) Angiogram Oculomotor dysfunction of CN III + pupil spared – Observation » Should resolve in 8-12 weeks If not completely resolved at that point - neuroimaging

45 Quick Childhood Eye Exam Fixation (vision) Alignment Inspection – asymmetry of lids, globe prominence, pupils, corneas - redness, discharge, masses Red Reflex (retina) = FAIR Exam

46 Bruckner test The simultaneous comparison of the red reflex from both eyes using ophthalmoscope (note difference in red reflex between eyes)

47 Amblyopia – diagnosis In verbal patient – measure acuity using the hardest test the child can do Allen picture chart (easy), tumbling E chart (harder), Snellen chart (hardest)

48 Amblyopia Definition Loss of visual acuity not correctable by glasses in an otherwise healthy eye (generic definition) A maldevelopment or loss of vision caused by abnormal binocular interaction or form vision deprivation during visual maturation (patho-physiologic definition) Prevalence 2 – 4 % of population Causes more visual loss and “legal” blindness (20/200 acuity) under age 45 than all other causes combined

49 Amblyopia – causes 1. Strabismus 2. Anisometropia / ametropia (glasses) 3. Vision deprivation ptosis, cataract, hemorrhage

50 Amblyopia – treatment Only works during “sensitive period” (roughly 0 – 6 years) Success varies inversely with age Eliminate any causes first (glasses, ptosis repair, etc.) Occlusion therapy (patching) is the gold standard

51 Strabismus - prevalence 2 – 4% of population (same as amblyopia, since they are so closely related)

52 Strabismus - diagnosis Cover test is key (gold standard)

53 TROPIA / PHORIA CONSTANT TROPIA: Eye turn present all of the time – Constant esotropia INTERMITTENT TROPIA: Eye turn present some of the time – Intermittent exotropia PHORIA: Eye turn present only when fusion broken – Esophoria

54 Strabismus - definition Misalignment of the eyes Types: Esotropia Exotropia Hyper/hypotropia ESOTROPIA HYPERTROPIA

55 Need to know about leukocoria – a presenting sign of retinoblastoma Ambient light reflecting off the tumor appears white or yellow-white within the pupil Strabismus is a common feature in retinoblastoma Why is leukocoria important?

56 Lesion to Optic Nerve

57 Crossing of nasal retina, which represents temporal hemifield Optic Chiasm

58 Lesion to Optic Chiasm

59 Lesions to Optic Tract upper bank of calcarine fissure Lower bank of calcarine fissure Includes visual abnormalities RAPD

60 Lesion of Dorsal Optic Radiation upper bank of calcarine fissure Lesions in deep parietal lobe or Occipital lobe- upper bank Calcarine fissure

61 Lesion of Ventral Optic Radiation (Meyer’s Loop) Lower bank of calcarine fissure Lesions in temporal lobe (classically) Occipital cortex-lower bank Calcarine fissure

62 Non-penetrating eye injuries (usually blunt) (abrasion, corneal FB, contusion, rupture, chemical burn) Penetrating eye injuries (usually sharp) (laceration, intraocular FB) Injuries to the eyelids (blunt: contusions, sharp: lacerations, lacrimal) Orbital trauma (contusion, penetrating injury/FB, fractures, traumatic optic neuropathy,) Eye trauma classification -

63 5 Golden of eye trauma 1. Check vision 1st 2. Agent-of-injury is King ! c onsider FB 3. severe hemorrhage ? o pen eye 4. Stat irrigation for burns 5. Multi-trauma: ! e xamine globe 1st

64 Eye Trauma – timing of Rx Immediate: chemical burn * Urgent (hrs): ruptured globe, intraocular foreign body Semi-urgent (48h): lid & lacrimal repair Less urgent (1-2 weeks): orbital fractures

65 Focused history - Details: how, when, where.. Prior vision, eye condition Tetanus status Time of last food/drink Bedside eye exam -

66 Teaching point: Intraocular Foreign Body May have pain or NO pain Decreased vision or normal vision (asymptomatic!) Signs: as ruptured globe or minimal entry wound or none ! Hx: high index of suspicion (! agent-of-injury) 1 st Rx: as in ruptured globe Urgent referral for surgery NB: always check vision Consider CT, X -ray

67 Teaching points: Ruptured Globe CC: trauma (blunt or sharp), pain, decreased vision, ‘agent-of-injury’ Signs: conj swelling, Hb++ (3D), hyphema +/- extruded uvea, irregular pupil… 1 st Rx: protect eye with shield, NPO, bedrest, anti-nausea meds Urgent transfer to ophthalmology Caution: do not press on lids during exam ( vision –> shield –> refer )

68 What is your management ? Orders: – shield over Left eye – Bedrest – NPO – anti-nausea medication prn – (antibiotics..) – urgent referral to Ophthalmology

69 Globe contusion/internal disruption Subconjunctival hemorrhage Corneal edema, traumatic iritis Hyphema Iris tears, traumatic mydriasis, angle recession Lens subluxation, cataract Vitreous/retinal hemorrhage Commotio retinae, retinal detachment Optic nerve avulsion, disruption

70 Teaching points: Orbital trauma Proptosis, ecchymosis, diplopia Orbital fractures: floor (blow out #), medial wall, lateral wall (zygoma), roof, complex Assoc. injuries: muscle entrapment, orbital Hb, emphysema, traumatic optic neuropathy Extra-orbital injury ! Rx : If mild w. no compromise of function: ice, elevation, rest If severe/compromise of function/fractures: refer

71 Mechanical * Disc elevates * Margin blurs Peripapillary changes Cup fills Vascular * Hyperemia * Vessels engorge Hemorrhages Infarcts Exudates * Early signs

72 Causes of Disc Swelling Bilateral Papilledema = raised Intracranial Pressure Space Occupying Lesion Intracranial Hypertension Pseudopapillema Unilateral Ischemic Infiltrative Infectious Autoimmune Neoplastic and… Pseudopapilledema

73 The Normal Optic Disc

74 Slide #10

75 Slide #6

76 Slide #4

77 Case: Jill’s Headaches Jill, 35 y.o has had headaches, nausea, and vomiting for the past month She experiences brief episodes of dimming vision lasting seconds She also notices a pulsing noise in her head.

78 Jill’s Optic Discs: Right EyeLeft Eye


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