Ophthalmology for Finals 3rd February 2013 Dr Alexander Ross Dr Thomas Marjot

Content Eye examination Anatomy Inflammatory conditions Lens and iris Retina and choroid Vascular disease Glaucoma Infectious eye disease Trauma Pupillary and visual pathways Eye movement disorders

Examination of the eye

Retina and Choroid Retinal disease Macula Peripheral Blurred vision/ metamorphopsia Micropsia, macropsia Field loss Night blindness AMD Macular oedema Retinal detachment RP Dry Wet

Macular disease Age related macular degeneration Pathogenesis Commonest irreverisible loss of vision in west Bruch’s membrane - Drusen VEGF choroid angiogenesis  Subretinal neovascular membrane

Investigation of AMD Clinical Fluorescein angiography

Geographic atrophy – degeneration of RPE

Macular disease Age related macular degeneration Pathogenesis Commonest irreverisible loss of vision in west Bruch’s membrane - Drusen VEGF choroid angiogenesis  Subretinal neovascular membrane

Autofluorescence optical coherence tomography

Amsler

Treatment of AMD Dry Wet ?high dose antioxidants Stop smoking Anti-VEGF 8% over 75s

Retina and Choroid Retinal disease Macula Peripheral Blurred vision/ metamorphopsia Micropsia, macropsia Field loss Night blindness AMD Macular oedema Retinal detachment RP Dry Wet

Macular oedema Intraocular surgery Inflammation (uveitis) Cystoid macular oedema Retinitis pigmentosa Retinal vascular disease Diabetic macular oedema Rx NSAIDs, cortisone, Anti-VEGF

Retina and Choroid Retinal disease Macula Peripheral Blurred vision/ metamorphopsia Micropsia, macropsia Field loss Night blindness AMD Macular oedema Retinal detachment RP Dry Wet

Retina and Choroid Retinal disease Macula Peripheral Blurred vision/ metamorphopsia Micropsia, macropsia Field loss Night blindness AMD Macular oedema Retinal detachment RP Dry Wet

Retinitis Pigmentosa Genetic disorder XR/AR/AD - rhodopsin Photoreceptors

RP - symptoms Night vision  tunnel vision  blurred Cataracts Macular oedema

RP - investigation Field mapping Electroretinography DNA testing

Clumps of pigmentation Attenuation of retinal arterioles optic atrophy

RP treatment Vitamin A Genetic therapy Mx of associated cataracts etc

Extra points ?Deaf  Usher ?Ophthalmoplegia  Kearns-Sayre

Retinal Vascular Disease Lipid Fluid Leak Blood Vessel Obstruction of axoplasmic flow. Central – thicker retina – white scatter light neoangiogenesis Block Ischaemia Cotton wool spots

Diabetic Retinopathy Hypertensive Retinal Vascular Disease CRAO Arterial Occlusive BRAO CRVO Venous BRVO

Diabetic Retinopathy Commonest blindness of middle age Associated with cataracts, glaucoma, and extraocular muscle palsy

Investigation Annual fundoscopy 5y after DM onset (DRP)

Classification NON-PROLIFERATIVE PROLIFERATIVE Background, preproliferative, maculopathy, proliferative

Non-proliferative Nerve-fiber layer infarcts (cotton wool spots) Intraretinal hemorrhages Hard exudates Microvascular abnormalities Macular oedema

New vessels lack pericytes Microaneurysms Disorganised blood supply

Treatment Maculopathy – circinate laser treatment Proliferative – Photocoagulation

Diabetic Retinopathy Hypertensive Retinal Vascular Disease CRAO Arterial Occlusive BRAO CRVO Venous BRVO

Hypertensive retinopathy Keith Wagener Barker (KWB) Grade 1 Generalised arteriolar constriction - seen as `silver wiring` and vascular tortuosities. Copper wiring. Hard opaque vessel wall Grade 2 Grade 1 + AV nipping Grade 3 Grade 2 + with cotton wool spots and flame-hemorrhages Grade 4 Grade 3 + papilledema

Diabetic Retinopathy Hypertensive Retinal Vascular Disease CRAO Arterial Occlusive BRAO CRVO Venous BRVO

Arterial Occlusion Transient – Amaurosis fugax Permanent – sudden painless loss of vision Signs – atrophic retina – cherry red spot Visible choroid through retina

Retinal vein occlusion