1. Anterior Segment - Common Clinical Presentations in Optometry
CENTRAL COAST DAY HOSPITAL OPTOMETRIST CONFERENCE - 26 FEBRUARY 2012
DR VIVEK CHOWDHURY
Anterior Segment - Common Clinical Presentations in Optometry

2. Fuchs endothelial dystrophy Pseudophakic Bullous Keratopathy
Progression
Gradual increase in
cornea guttata with peripheral spread
Later central stromal
oedema - STROMA
Eventually bullous
keratopathy - EPI

3. Fuchs endothelial dystrophy Pseudophakic Bullous Keratopathy
SYMPTOMS:
Acuity. Haloes/Glare.
Diurnal Variation.
Discomfort/Pain
SIGNS
Guttae and Endothelial Opacity.
Stromal Oedema
Epithelial Oedema/Erosions.
Corneal Thickness/Pachymetry

4. Fuchs endothelial dystrophy Pseudophakic Bullous Keratopathy
In Patients with Corneal Endothelial Decompensation, all of the following may indicate progression of the disease except:
Increased Corneal Thickness.
Epithelial Defects
Deteriorating Visual Acuity
Symptoms Worse in the Afternoon

6. ANTERIOR CHAMBER IOLS
Primary Cataract Surgery – Problems with Capsular Bag/Zonular Support – PXF Patients/Hx Trauma.
Secondary IOL - Aphakic Patient
Problems Related to:
ACIOL Itself
Complications of the Primary Surgery

7. ANTERIOR CHAMBER IOLS
Look out For:
Cornea: Corneal Endothelial Decompensation/Bullous Keratopathy. Corneal Wounds.
AC: Inflammation/Uveitis, AC Vitreous, Hyphaema.
Iris: Irregular Pupil, Iris Tuck, Angle Closure, PI.
Angle: Trauma from Haptics, Glaucoma.
Capsule: Residual Capsule in Pupillary Axis, Lens Material
Retina: CME, Breaks, Detachment, Lens remnants

8. 2. In a patient with an anterior chamber intraocular lens – It is usually important to check for all of the following except:
Raised Intraocular Pressure
Corneal Decompensation.
Uveitis.
Iris Naevus

9. TRAUMA 1. Eyelid 2. Orbital blow-out fractures 3. Globe Injuries
Haematoma
Margin laceration
Canalicular laceration
2. Orbital blow-out fractures
Floor
Medial wall
3. Globe Injuries
Anterior segment
Posterior segment

10. Anterior segment complications of blunt trauma
Hyphaema
Iridodialysis
Vossius ring
Sphincter tear
Cataract
Lens subluxation
Angle recession
Rupture of globe

11. Posterior segment complications of blunt trauma
Choroidal rupture and
haemorrhage
Avulsion of vitreous base
and retinal dialysis
Commotio retinae
Equatorial tears
Macular hole
Optic neuropathy

12. Complications of penetrating trauma
Flat anterior chamber
Uveal prolapse
Damage to lens and iris
Vitreous haemorrhage
Tractional retinal detachment
Endophthalmitis

13. 3. In a patient with a past history of blunt trauma to the eye - which of the following is incorrect:
A deep AC means there is a low risk of glaucoma
cataract may be associated with zonule laxity/phacodonesis
there is an increased risk of retinal breaks
the patient may have a dilated pupil

14. Adenoviral - Signs of keratitis
Focal, subepithelial keratitis
Focal, epithelial keratitis
Transient
May persist for months
Treatment
- topical steroids if visual acuity
diminished by subepithelial keratitis

15. Progression of vernal conjunctivitis
Diffuse papillary hypertrophy, most marked on superior tarsus
Formation of cobblestone papillae
Rupture of septae - giant papillae

16. Limbal vernal
Trantas dots
Mucoid nodule

17. Progression of vernal keratopathy
Punctate epitheliopathy
Epithelial macroerosions
Plaque formation (shield ulcer)
Subepithelial scarring

18. Progression of ocular cicatricial pemphigoid
Diffuse hyperaemia
Pseudomembrane formation
Subepithelial fibrosis and shrinkage
Symblepharon

19. Naevus Presents in first two decades Most frequently juxtalimbal
Sharply demarcated and slightly
elevated
30% are almost non-pigmented

20. Lipodermoid Presents in adulthood Soft, movable, subconjunctival mass
Most frequently at outer canthus

21. Intraepithelial neoplasia
(carcinoma in situ)
Signs
Progression
Presents in late adulthood
May become vascular and extend onto
cornea
Malignant transformation is uncommon
Juxtalimbal fleshy avascular mass

22. Primary acquired melanosis (PAM)
Signs
Types
Presents in late adulthood
PAM without atypia is benign
Unilateral, irregular areas of flat,
brown pigmentation
PAM with atypia is pre-malignant
May involve any part of conjunctiva

23. Conjunctival melanoma
From PAM with atypia
From naevus
Primary
Most common type
Very rare
Solitary nodule
Sudden appearance of
nodules in PAM
Sudden increase in size
or pigmentation
Frequently juxtalimbal
but may be anywhere

24. Squamous cell carcinoma
Signs
Progression
Arises from intraepithelial
neoplasia or de novo
Slow-growing
May spread extensively
Presents in late adulthood
Rarely metastasizes
Frequently juxtalimbal

25. Marginal keratitis Hypersensitivity reaction to Staph. exotoxins
May be associated with Staph. blepharitis
Unilateral, transient but recurrent
Progression
Subepithelial infiltrate
separated by clear zone
Circumferential spread
Bridging vascularization
followed by resolution
Treatment - short course of topical steroids

26. Phlyctenulosis Uncommon, unilateral - typically affects children
Severe photophobia, lacrimation and blepharospasm
Conjunctival phlycten
Corneal phlycten
Small pinkish-white nodule
near limbus
Usually transient and resolves
spontaneously
Starts astride limbus
Resolves spontaneously or extends
onto cornea
Treatment - topical steroids

27. Herpes simplex epithelial keratitis
Dendritic ulcer with terminal bulbs
May enlarge to become geographic
Stains with fluorescein
Treatment
Aciclovir 3% ointment x 5 daily
Debridement if non-compliant

28. Herpes simplex disciform keratitis
Signs
Associations
Central epithelial and stromal oedema
Occasionally surrounded by
Wessely ring
Folds in Descemet membrane
Small keratic precipitates
- topical steroids with antiviral cover
Treatment

29. Herpes zoster keratitis
Acute epithelial keratitis
Nummular keratitis
Develops in about 50% within
2 days of rash
Develops in about 30% within
10 days of rash
Small, fine, dendritic or stellate
epithelial lesions
Multiple, fine, granular deposits
just beneath Bowman membrane
Tapered ends without bulbs
Halo of stromal haze
Resolves within a few days
May become chronic
Treatment - topical steroids, if appropriate

30. 4. A patient is complaining of blurry vision after cataract surgery, but the visual acuity is 6/6 unaided, It is important to check all of the following except.
The tear film.
The posterior capsule and IOL position.
The macula.
The eyebrows.

31. Simple episcleritis
Common, benign, self-limiting but frequently recurrent
Typically affects young adults
Seldom associated with a systemic disorder
Simple sectorial episcleritis
Simple diffuse episcleritis
Treatment
Topical steroids

32. Nodular episcleritis Less common than simple episcleritis
May take longer to resolve
Treatment - similar to simple episcleritis
Localized nodule which can be moved over sclera
Deep scleral part of slit-beam
not displaced

33. Grading of severity of chemical injuries
Grade I (excellent prognosis)
Clear cornea
Limbal ischaemia - nil
Grade II (good prognosis)
Grade III (guarded
prognosis)
Grade IV (very poor
prognosis)
Cornea hazy but visible
iris details
No iris details
Opaque cornea
Limbal ischaemia > 1/2
Limbal ischaemia < 1/3
Limbal ischaemia - 1/3 to 1/2

34. Medical Treatment of Severe Injuries
1. Copious irrigation ( min ) - to restore normal pH
2. Topical steroids ( first 7-10 days ) - to reduce inflammation
3. Topical and systemic ascorbic acid - to enhance collagen production
4. Topical citric acid - to inhibit neutrophil activity
5. Topical and systemic tetracycline - to inhibit collagenase and neutrophil activity

35. 5. My patient with blepharitis is back again asking me to look for the sand that’s in his eye, I am going to do all the following except:
Change to a preservative free artificial tear supplement and/or a more viscous artificial tear supplement, and/or a thick artificial tear gel just before sleep.
Prescribe Chloramphenicol ointment to the lid margins.
Trial Steroid ointment to the lid margins, and/or a short, tapering course of a mild topical steroid.
Get my receptionist to tell them that I’ve gone on holiday.

36. THE END