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Wg Cdr Malcolm Woodcock RAF Ophthalmology Centre for Defence Medicine University Hospital Birmingham, UK AVIATION OPHTHALMOLOGY 2 MEDICAL FACTORS.

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Presentation on theme: "Wg Cdr Malcolm Woodcock RAF Ophthalmology Centre for Defence Medicine University Hospital Birmingham, UK AVIATION OPHTHALMOLOGY 2 MEDICAL FACTORS."— Presentation transcript:

1 Wg Cdr Malcolm Woodcock RAF Ophthalmology Centre for Defence Medicine University Hospital Birmingham, UK AVIATION OPHTHALMOLOGY 2 MEDICAL FACTORS

2 Ocular Adenexae Blepheritis Chalazion Epiphora Orbital Blowout fracture

3 External eye disease Blepharitis –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 Patient is looking up. Loss of infraorbital sensation and subcutaneous crepitus are useful signs. Opacification of maxillary sinus with entrapment of inferior rectus / its attachments.

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 –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 –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 –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 –Monitored –Flying category depends on this Treatment –Medical (Beta Blockers safe in aircrew) –Surgical (ALT / Trabeculectomy)

18 Cataract Lens opacity –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 –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 –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

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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

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

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

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50 Laser guided bomb

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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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