5 Epiphora (Watery Eye) Reflex – corneal or conjunctival irritation Obstructive – mechanical obstruction of nasolacrimal drainage systemFunctional – Failure of lacrimal pump system through lack of tone in lower lid (ectropion, VII nerve palsy)
6 Blowout FractureOpacification of maxillary sinus with entrapment of inferior rectus / its attachments.Patient is looking up. Loss of infraorbital sensation and subcutaneous crepitus are useful signs.
8 Bacterial keratitis Serious ocular infection Requires admission and expert managementTreatmentCorneal scrape and cultureTopical antibioticsVisual result depends on amount and position of retinal scarring
11 Keratoconus in aircrew Often develops in teens to 20s‘Forme fruste’ of keratoconus may be present in aircrew applicantsNo test for progressionPiggy-back CL hard centre with soft surroundPossible use in fast-jet aircrewNot tested yet
16 Glaucoma POAG ACG Ocular hypertension Syndrome of characteristic optic neuropathy associated with a raised IOPFamilialACGAcute glaucoma associated with narrow iridocorneal anglesOcular hypertensionNot galucomarisk of POAGRetinal vascular occlusion
17 POAG Visual field loss Treatment Monitored Flying category depends on thisTreatmentMedical (Beta Blockers safe in aircrew)Surgical (ALT / Trabeculectomy)
18 Cataract Lens opacity Treat if symptomatic In aircrew CongenitalAcquiredTreat if symptomaticIn aircrewUsually congenitalTrauma / SurgeryInflammation (Fuchs)Metabolic (DM)Drugs (Steroids)Small inscision surgPhacoemulsificationMicronuclearRapid rehabilitationTiny corneal scarIOLPMA / Acrylic / SiSame SG as aqueousEjection / vibrationshould be safe
19 Phacoemulsification in aircrew 5 Aircrew operated on for LOTraumatic 3Inflammatory 1Congenital 1All achieved 6/6 VAAll fit flying2 Fast Jet2 Helicopter1 Transport
20 Amblyopia ‘Where the Doctor and patient sees nothing’ Central suppression of image to avoid diplopiaVisual maturation by age 7AssociatedStrabismusAnisometropiaVisual deprivationRefractiveTreatment with patching as childUntreatable as adultImportant if good eye lost
21 Strabismus Concomitant A bar to aircrew entry unless Incomitant ChildhoodA bar to aircrew entry unlessAlternate with good vision on each sideMicrotropia (test stereopsis)IncomitantExtraocular muscle palsyOften diplopia (prisms / surgery)
22 Monocular aircrew Reduced stereopsis Reduced field of vision USA FAA Blind spotUSA FAANo difference in accident rate between uniocular and binocular pilotsUsually restricted to fly as or with qualified co-pilot
29 Posterior vitreous detachment (PVD) Separation of vitreous gel from retinaFlashes and floaters (Weis ring)Abnormal VR adhesion (haemorrhage, tears)65% by 65yrsEarlier if MyopicIf acute symptomatic 10% risk retinal tearIndirect ophthalmoscopy with indentationLaser retinopexy if necessary
30 Symptomatic floater in flyer! Navigator 36 yo emmetropic (LVA 6/5)6 month history left floaterLeft PVD, prominent Weiss ringFelt unsafe to fly as kept on thinking aircraft closing in peripheryLeft vitrectomy (uncomplicated)Kept full flying categoryNo problems at 1 year (Minimal myopic shift)
31 Complications of vitrectomy Entry site iatrogenic retinal breaks2-4% in simple vitrectomyRisk of retinal detachmentIndex myopia and cataract formationNuclear sclerosis accelerated in all cases75% cataract extraction by 3 years if gas used
32 Complications of scleral explants MyopiaEspecially if encirclementAstigmatismExtraocular muscle damageDiplopiaSuture complicationsRetinal perforationExtrusion
33 Gas intraocular tamponade Posturing required for 1-2 weeksGasesAir 2 daysSF6 2 weeksC3F8 2 monthsNo sight until bubble above optical axisBoyles law expansion of bubble if atmospheric pressure decreasesDecompression danger with >10% gas in eye
34 Si oil intraocular tamponade Permanent tamponadeNon-expansileNo immediate visual lossLess posturingHypermetropic shift (+6 dioptres)Less IOP regulationincreased effects of G forces
38 Outcome Visual field became full VAL remained at 6/6 Fit full flying dutiesMust have at least 2 legs and 3 eyes in the cockpit
39 Retinal degeneration Congenital / acquired Age related maculopathy Dry /exudativeMacular drusen commonCommonest cause of blindness in UKHereditary retinal dystrophyEnd stage often macular degeneration
41 Centroserous Retinopathy Localised serous chorioretinal detachmentUnknown aetiologyEarly mid-aged males affectedVA slightly reduced (hypermetropia)Diagnosis confirmed on FFASpontaeneous resolution the ruleHastened by laserSlight residual decrease in VA
42 Amaurosis fugax Transient uniocular loss of vision <10 mins Embolic Carotid arteryCardiacHyperviscosity statesCranial arteritisFlying category depends on treatment of underlying disease
43 Central Retinal Vein Occlusion Sudden painless visual impairmentDisc oedema and scattered retinal haemsRisk factors: Age, hypertension, smoking, obesity, blood dyscrasiasSeen in a subset of younger patientsPoorer prognosis if it becomes ischaemicIt 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 neuritisReduced VA (6/18-6/60)Central scotomaImpaired colour visionOcular pain75% develop MS70% recover 6/6 in 8 weeksOptic disc drusenIncidental findingVisual field defectsNystagmusPhysiologicalCongenitalAcquired (always needs further investigation)
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