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Presentation on theme: "AVIATION OPHTHALMOLOGY 2 MEDICAL FACTORS"— Presentation transcript:

Wg Cdr Malcolm Woodcock RAF Ophthalmology Centre for Defence Medicine University Hospital Birmingham, UK

2 Ocular Adenexae Blepheritis Chalazion Epiphora
Orbital Blowout fracture

3 External eye disease Blepharitis Dry eye (keratoconjunctivitis sicca)
Lid hygiene Topical/systemic tetracycline Dry eye (keratoconjunctivitis sicca) Ocular lubricants Ocular allergic disease Mast cell stabilisation (Na Chromoglycate) Topical steroids Systemic antihistamines A bar to flight training

4 Eyelid disease

5 Epiphora (Watery Eye) Reflex – corneal or conjunctival irritation
Obstructive – mechanical obstruction of nasolacrimal drainage system Functional – Failure of lacrimal pump system through lack of tone in lower lid (ectropion, VII nerve palsy)

6 Blowout Fracture Opacification of maxillary sinus with entrapment of inferior rectus / its attachments. Patient is looking up. Loss of infraorbital sensation and subcutaneous crepitus are useful signs.

7 Anterior Segment Episcleritis Recurrent Erosion Syndrome
Keratoconjunctivitis sicca Ketatitis (microbial, adenoviral, herpetic) Keratoconnus Uveitis Ocular hypertension and glaucoma Cataract

8 Bacterial keratitis Serious ocular infection
Requires admission and expert management Treatment Corneal scrape and culture Topical antibiotics Visual result depends on amount and position of retinal scarring

9 Viral Keratitis HSV keratitis Dendritic ulcer Metherpetic disease
Topical Aciclovir Metherpetic disease 20-25% (Disciform keratitis) Top Aciclovir/steroids Oral Aciclovir 1yr (not aircrew despite RCT) Adenoviral keratitis Follicular keratoconjunctivitis Highly infectious Corneal stromal opacities Can affect optic axis May require topical steroids

10 Keratoconus Corneal ectactic disease Conical cornea Management Glasses
Hard contact lenses Penetrating keratoplasty

11 Keratoconus in aircrew
Often develops in teens to 20s ‘Forme fruste’ of keratoconus may be present in aircrew applicants No test for progression Piggy-back CL hard centre with soft surround Possible use in fast-jet aircrew Not tested yet

12 PK for keratoconus

13 Penetrating keratoplasty
Visual rehabilitation uncertain Astigmatism Rejection Graft failure May require permanent topical medication Aircrew unfit agile aircaft / ejection

14 Uveitis Inflammation of eye Anterior Intermediate Posterior
Idiopathic Infectious Systemic disease Anterior Intermediate Posterior Pan-uveitis Treatment Topical / systemic Anterior uveitis often controlled with topical steroids Flying category usually preserved with limitations Systemic immunosuppression

15 Uveitis

16 Glaucoma POAG ACG Ocular hypertension
Syndrome of characteristic optic neuropathy associated with a raised IOP Familial ACG Acute glaucoma associated with narrow iridocorneal angles Ocular hypertension Not galucoma risk of POAG Retinal vascular occlusion

17 POAG Visual field loss Treatment Monitored
Flying category depends on this Treatment Medical (Beta Blockers safe in aircrew) Surgical (ALT / Trabeculectomy)

18 Cataract Lens opacity Treat if symptomatic In aircrew
Congenital Acquired Treat if symptomatic In aircrew Usually congenital Trauma / Surgery Inflammation (Fuchs) Metabolic (DM) Drugs (Steroids) Small inscision surg Phacoemulsification Micronuclear Rapid rehabilitation Tiny corneal scar IOL PMA / Acrylic / Si Same SG as aqueous Ejection / vibration should be safe

19 Phacoemulsification in aircrew
5 Aircrew operated on for LO Traumatic 3 Inflammatory 1 Congenital 1 All achieved 6/6 VA All fit flying 2 Fast Jet 2 Helicopter 1 Transport

20 Amblyopia ‘Where the Doctor and patient sees nothing’
Central suppression of image to avoid diplopia Visual maturation by age 7 Associated Strabismus Anisometropia Visual deprivation Refractive Treatment with patching as child Untreatable as adult Important if good eye lost

21 Strabismus Concomitant A bar to aircrew entry unless Incomitant
Childhood A bar to aircrew entry unless Alternate with good vision on each side Microtropia (test stereopsis) Incomitant Extraocular muscle palsy Often diplopia (prisms / surgery)

22 Monocular aircrew Reduced stereopsis Reduced field of vision USA FAA
Blind spot USA FAA No difference in accident rate between uniocular and binocular pilots Usually restricted to fly as or with qualified co-pilot

23 Corneal disease Keratoconus Keratitis Viral Bacterial Corneal grafts

24 Micro-detonator cord Splatter (MDC)
Occurs during ejection May cause skin tattooing Corneal burns possible Ophthalmic examination if ocular pain or reduced VA

25 Harrier Ejection

26 Vitreoretinal Conditions
Floaters, holes and detachments Central Serous retinopathy Retinovascular disease

27 Vitreoretinal disease
Posterior vitreous detachment Retinal detachment (1:10,000) External repair (Cryopexy/scleral buckle) Internal repair (Vitrectomy/laser/cryopexy/internal tamponade) Intraocular tamponade agents


29 Posterior vitreous detachment (PVD)
Separation of vitreous gel from retina Flashes and floaters (Weis ring) Abnormal VR adhesion (haemorrhage, tears) 65% by 65yrs Earlier if Myopic If acute symptomatic 10% risk retinal tear Indirect ophthalmoscopy with indentation Laser retinopexy if necessary

30 Symptomatic floater in flyer!
Navigator 36 yo emmetropic (LVA 6/5) 6 month history left floater Left PVD, prominent Weiss ring Felt unsafe to fly as kept on thinking aircraft closing in periphery Left vitrectomy (uncomplicated) Kept full flying category No problems at 1 year (Minimal myopic shift)

31 Complications of vitrectomy
Entry site iatrogenic retinal breaks 2-4% in simple vitrectomy Risk of retinal detachment Index myopia and cataract formation Nuclear sclerosis accelerated in all cases 75% cataract extraction by 3 years if gas used

32 Complications of scleral explants
Myopia Especially if encirclement Astigmatism Extraocular muscle damage Diplopia Suture complications Retinal perforation Extrusion

33 Gas intraocular tamponade
Posturing required for 1-2 weeks Gases Air 2 days SF6 2 weeks C3F8 2 months No sight until bubble above optical axis Boyles law expansion of bubble if atmospheric pressure decreases Decompression danger with >10% gas in eye

34 Si oil intraocular tamponade
Permanent tamponade Non-expansile No immediate visual loss Less posturing Hypermetropic shift (+6 dioptres) Less IOP regulation increased effects of G forces

35 Factors affecting fitness to fly
Visual acuity (Macula on/off) Visual field Variable effects Distortion ERM Retinal translocation Refraction Diplopia

36 Case of RD in Chinook pilot
45 y.o. pilot Crash 1985 BK amputation left leg Facial trauma Routine eye test left visual field defect VAL 6/6

37 Retinal detachment Before After

38 Outcome Visual field became full VAL remained at 6/6
Fit full flying duties Must have at least 2 legs and 3 eyes in the cockpit

39 Retinal degeneration Congenital / acquired Age related maculopathy
Dry /exudative Macular drusen common Commonest cause of blindness in UK Hereditary retinal dystrophy End stage often macular degeneration

40 Macular degeneration

41 Centroserous Retinopathy
Localised serous chorioretinal detachment Unknown aetiology Early mid-aged males affected VA slightly reduced (hypermetropia) Diagnosis confirmed on FFA Spontaeneous resolution the rule Hastened by laser Slight residual decrease in VA

42 Amaurosis fugax Transient uniocular loss of vision <10 mins Embolic
Carotid artery Cardiac Hyperviscosity states Cranial arteritis Flying category depends on treatment of underlying disease

43 Central Retinal Vein Occlusion
Sudden painless visual impairment Disc oedema and scattered retinal haems Risk factors: Age, hypertension, smoking, obesity, blood dyscrasias Seen in a subset of younger patients Poorer prognosis if it becomes ischaemic It has been postulated that it may be caused by a congenital abnormality in the central retinal vein at the level of the lamina cribrosa, which gives rise to turbulent flow and thrombus formation.

44 Neurophthalmic disease
Optic neuritis Reduced VA (6/18-6/60) Central scotoma Impaired colour vision Ocular pain 75% develop MS 70% recover 6/6 in 8 weeks Optic disc drusen Incidental finding Visual field defects Nystagmus Physiological Congenital Acquired (always needs further investigation)

45 Optic nerve atrophy and drusen


47 Laser eye injury Ocular hazard of modern warfare
Increasing incidence of laser incidents Dazzle Glare Retinal damage Fright!!



50 Laser guided bomb


52 Wg Cdr Malcolm Woodcock
Department of Ophthalmology Worcestershire Royal Hospital Tel:

53 Contact details Wg Cdr Robert A.H. Scott
RAF Consultant Adviser in Ophthalmology Centre for Defence Medicine, Selly Oak Hospital, Raddlebarn Rd, B’ham B29 6JD (Sec) / 8922 (Fax)


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