1. “It’s all blurry Doc”
Dr Sanj Fernando

2. Case 1 “Deserves a therapeutic wait”

3. Case 1 62 yo female PHx Asthma (mild-moderate) – seretide only
Ex smoker

4. Case 1 Last 3 months Blurry vision
Symptoms present to varying degrees every day
Symptoms worse in the evenings and at night time
Occasional headaches

5. Case1 No Fever Cough / Coryzal symptoms
Muscle weakness or coordination problems
Weight loss
Generalised fatigue
Palpitations
Altered temperature perception

6. Case 1 Examination Visual acuity : 6/6 left, 6/9 right
Right eye corrects to 6/6 with pinpoint
Does not wear glasses
No opthalmoplegia, no nystagmus
With binocular vision visual acuity 6/9 – does not correct with pinpoint
No cranial nerve signs – PEARL (direct /consensual)
6/6 = 6meters / the distance that a 6/6 person could discern the charcters: i.e: 6/12 = a normal person could discern the characters at 12 meters away or put another way the person with 6/12 vision has half the visual acuity of a 6/6 person.
6/3 is better than average performance
6/6 – means that at 6 meters the normal person can discern figures 1.75mm apart

7. Case 1 ?
? More information

8. Case 1 More history No clear relationship with temperature noticed
Worse double vision at the end of the day
Worse when she is tired or stressed
Worse on bright sunny days

9. Diagnosis? Ocular Myasthenia Gravis
Case 1
Diagnosis? Ocular Myasthenia Gravis

10. Ocular Myasthenia Gravis
Ocular myasthenia is when MG confines itself to the eye muscles.
The impact of the condition on eye muscles include:·
a drooping of one or both eyelids,
double or blurred vision
weakness of the muscles that move the eyeballs.
During a fatigue ocular episode, a myasthenic's window of vision becomes restricted to the narrow slits between the droopy upper lids and the lower lid.
Bright lights can aggravate the symptom.
In a minority of myasthenics (around 15%), MG is limited to ocular problems. But for most whose first symptoms are ocular, MG eventually moves onto other parts of the body within a couple of years.
For this reason, a number of myasthenics walk around with their noses in the air

11. Ocular Myasthenia Gravis
Ptosis with prolonged upward gaze
After a few minutes of rest, the eyelids have returned to near-normal position.
Ice or cold pack placed on eyelids inhibits acetylcholinestsrase
Improves the ptosis

12. Case 2 “peek-a-boo”

13. Case 2 70 yo male Phx = H/T Meds = amlodipine NKA Previously very well
Retired but very active

14. Case 2 - Hx
Playing peek a boo with grand kids and realised that he has lost the majority of central vision in right eye
No pain, No fever, No illness, No redness
Non smoker
Read the paper normally two days ago

15. Case 2 Exam Pupillary reflexes normal Other cranial nerves normal
Red reflex present
Vision
Right Left
6/9 in peripheries 6/6
6/21 in centre
No correction with pinpoint

16. ?

17. Mydriasis versus cycloplegia
Pupillary dilation (mydriasis) paralysis of accommodation (cycloplegia)
Mydriasis versus cycloplegia
Cyclopentolate 0.5% and 1%solutions
Compress lacrimal sac prior to and one minute after installation (esp in children)
maximum effect is produced 30 to 60 minutes after instillation
accommodation recovers within 24 hours.
Tropicamide 1%and 0.5% solution
1-2 drops 15 min prior to exam repeated in 5 min and again in 20 min
Mydriasis
within 20 to 40 minutes of instillation
lasts for about six hours;
Cycloplegia
maximal within about 30 minutes
complete recovery of accommodation normally within six hours
Phenylephrine 2.5% and 10%
Topical anaesthesia first
1 drop each eye, Repeat at 1hr if needed
Maximal mydriasis occurs in minutes with recovery after 5-7 hours
Mydiatics act by temporarily dilating the iris sphincter so that the pupil is maximally dilated
Cycloplegics temporarily paralyze the cilliary muscle preventing it’s action on the lens to accommodate for far vision

18. Post dilation

19. Macular haemorrhage Causes: Valsalva retinopathy
Terson syndrome (vitreous haemorrhage a/w subarachnoid haemorrhage)
arteriosclerosis and vasculitis
hypertension
retinal artery or vein occlusion
diabetic retinopathy
retinal macroaneurysm
chorioretinitis,
shaken baby syndrome
age‐related macular degeneration
trauma

20. Valsalva retinopathy

22. Macular haemorrhage
Spontaneous reabsorption of the haemorrhage may occur, but this could take 1–2 months,
during which time the persistence of blood may irreversibly damage the retina and cause permanent visual loss
preretinal tractional membrane
proliferative vitreoretinopathy.

23. Management Reverse anticoagulants Control BP Opthalmology Controvesy :
Conservative Mx
Laser membranotomy
Surgical removal

24. Blurry vision – other differentials
CVA – field defect / occipital MS
Temporal arteritis
Retinal detachment
Cataract
Glaucoma
Iritis
Corneal opacity

25. Questions?