1. None-urgent eye problems David Kinshuck, associate specialist David Kinshuck, Good Hope Hospital,

2. None-urgent eye problems …working in pairs, (1 minute) write down Common conditions Rarer & serious conditions

3. Draw an eye and name the parts…working in pairs, (30 s) : parts Parts relevant to conditions

4. www.websightmd.com

5. Aqueous flow

6. Chronic eye conditions Adults cataracts Armd...age-related macular degeneration Glaucoma Diabetic retinopathy Others (retinal vein occlusion, inherited retina, corneal etc) children Squints Watery eye Cataracts Glaucoma rarer

7. Cataracts Symptoms How to examine Operation refraction

8. Cataracts symptoms, in pairs ?

9. Cataracts symptoms Glare Misty vision Blurred vision Cannot see distances/faces

10. Cataracts...symptoms....blurred

11. Cataracts...symptoms....glare

12. Examining for cataract…red reflex Looking through ophthalmoscope, check red reflex from 10 cm, focusing on iris rim

13. ‘white’ reflex www.occhioallaretina.it/Immagini/leucocoria.JPG http://oftalmologo.bravepages.com/Leucocoria%201.jpg ?retinoblastoma

14. Cataracts...operation Link http://www.goodhopeeyeclinic.org.uk/eye cataractpatient.html

15. Cataracts...refraction...in pairs, which is myopia etc

16. Cataracts...refraction –Emmetropia.. no dist. specs –Hypermetropia, small eyes –Myopia –High myopia

17. Presbyopia...need reading spectacles, >45y

18. Retina –Diabetic retinopathy –Retinal vein occlusion –Armd...age-related macular degeneration –Others retinal vein occlusion inherited retina (eg retinal pigmentosa)

19. Diabetic retinopathy, in pairs, 45 seconds What are the disease processes What one chemical in particular mediates these processes (and we can block its effect) What does laser do http://medweb.bham.ac.uk/easdec/dmret.html http://medweb.bham.ac.uk/easdec/mechanism animation.htm

20. Diabetic retinopathy

21. dot and blot ischaemic areas VEGF leakage new vessels

22. Diabetic retinopathy dot and blot ischaemic areas VEGF leakage new vessels

23. Diabetic retinopathy

25. Diabetic retinopathy http://reference.medscape.com/features/slideshow/retina

26. Diabetic retinopathy, in pairs, how do you prevent, 30s

27. Prevent diabetes…exercise, weight, low glycaemic index foods Screen for diabetes…everyone >40y, high risk if lower (lifestyle/family etc), HbA1c >6.5% = diabetes HbA1c 6.0-6.5% = pre-diabetes Control diabetes HbA1c <6.5-75, BP <130/80, statin, ARB Screen diabetic patients for retinopathy etc

28. Diabetic retinopathy HbA1c Blood pressure Smoking Lipids Duration of ‘high’ HbA1c similar for BP/smoking/lipids

29. Retinal vein occlusion 7 highs cigarettes Cholesterol Blood pressure Glucose Viscosity –Myeloma –White cells

30. Macula..in pairs, 1 minute What do you know about armd Symptoms Types etc

31. Macular Central visual changes suggest macula disease: Eye casualty same week

32. Central vision

33. OCT optical coherence tomogram … wet ARMD http://www.goodhopee yeclinic.org.uk/images /lucentis.html

34. Dry, ‘geographic atrophy’ Areas of atrophy enlarge over a couple of years, seriously reducing central vision

38. Glaucoma, in pairs, explain with diagram, 1 min

39. Glaucoma, mechanism Aqueous produced in ciliary body (carbonic anhydrase enzyme) Flows into >anterior chamber, >through trabecular >meshwork, >canal of schlemm, >episcleral veins > otherwise pressure

40. Glaucoma, loss of visual field Visual loss over years 2/3 chronic glaucoma has a high pressure…pressure is detected by whom Apatient Boptometrist

41. Glaucoma, loss of visual field Visual loss over years 2/3 chronic glaucoma has a high pressure…pressure is detected by whom Apatient Boptometrist

42. Glaucoma, in pairs, which normal eye, 30s http://www.goodhopeeyeclinic.org.uk/glaucomacase3.htm ABAB

43. Glaucoma, in pairs, which normal eye, 30s http://www.goodhopeeyeclinic.org.uk/glaucomacase3.htm 1.Vessels deviated nasally 2.Pale central area with cribriform pits 3.thin rim 4.Other minor changes

44. Glaucoma, lowering pressure Laser trabecular meshwork Drops –Prostaglandin inhibitors –Carbonic anhydrase inhibitor –Betablockers tablets –Carbonic anhydrase inhibitor surgery

45. Glaucoma, quiz Patient detects glaucoma Y N

46. Glaucoma, quiz Are there symptoms early Y N

47. Glaucoma, quiz Examining the eye –Cupped disc Y N

48. Glaucoma, quiz Examining the eye –Raised pressure 66%Y N

49. Glaucoma, quiz –Examine angle at onset Y N

50. Glaucoma, quiz –Visual field Y N

51. Glaucoma, other types –Yearly checks stable Y N

52. Glaucoma, quiz Patient detects glaucoma N Are there symptoms early N Examining the eye –Cupped disc Y –Raised pressure 66%Y –Examine angle at onset Y –Visual field Y –Yearly checks Y

53. Glaucoma, other types Low tension Narrow angle http://www.goodhopeeyeclinic.org.uk/pi.html http://www.goodhopeeyeclinic.org.uk/pi.html Genetic –Many conditions –congenital baby Secondary surgery/trauma/steroids

54. Glaucoma, –Congenital (www.nature.com/eye)

55. Loss of sight over weeks/days/hours Retinal detachment, with flashes/floaters Ischaemic optic neuropathy (older patients) (%GCA with GCA symptoms) With pain on movement & reduced colour (red) vision: optic neuritis (younger patients)

56. Retinal detachment 1.Vitreous gel liquifies (floaters) 2.May pull retina if attached (flashes) 3.Causes a hole 4.Fluid enters hole 5.Retina peels off (more floaters, vision affected) 6.Dilate pupil, with careful look usually obvious, refer same day

58. Eye & major trauma

59. Visual acuity T NC EN OTNC LOXEW TYURNG TYURNG TYURNG 6/60 6/36 6/24 6/18 6/12 6/9 6/6 6/5

60. Visual fields

62. Pupils Pupils (needs Flash player installed)Pupils

63. Some helpful eye examination ‘pearls’ Pressing on the eye will detect high pressure (acute glaucoma) Won’t detect slightly high pressure chronic glaucoma DILATE PUPILS to examine the eye if risk of detachment...cannot exclude detachment otherwise Optometrists can check for chronic disease

64. Children, chronic disease Rare –Cataracts –Glaucoma –Lots Common –watery eyes –(lacrimal sac abscess/mucocoel) –Squints –Allergic eye disease

65. Children, chronic disease---watery eyes

66. Children, squint

67. Convergent Divergent vertical

68. Children, squint, issues Amblyopia –important to know this, as may spend lots of time looking for the cause of poor sight –Initially amblyopia need patching Squint surgery Binocular vision amblyopia without squint may be refractive, cataract, etc

69. Children, cover test http://www.youtube.com/watch?v=yyIA- dl49Lghttp://www.youtube.com/watch?v=yyIA- dl49Lg

70. 3 rd nerve palsy In pairs...what is this?

71. 3 rd nerve palsy

72. Other chronic eye diseases TED...thyroid eye disease Lid entropian/ectropian Trichiasis Eyelid tumours Watery eyes..epiphora Blocked naso-lacrimal duct Diplopia/squint Dry eyes Corneal diseases Optic atrophy, alcohol, smoking, B12 genetic Orbital/optic nerve tumours

73. 3 rd nerve palsy In pairs...what is this?

74. 3 rd nerve palsy www.patient.co.uk..thyroid eye disease

75. 3 rd nerve palsy www.patient.co.uk..thyroid eye disease Auto-immune +thyroid damage >> TRH receptors on muscles and fat in orbit Low TSH and smoking increase TRH receptors >> fat muscles swell >> exophthalmos + optic nerve compression

76. 3 rd nerve palsy In pairs...what is this?

77. 3 rd nerve palsy In pairs...what is this? nhs.uk

78. 3 rd nerve palsy In pairs...what is this? cosmeticsurg.com

79. Dry eye link Mild forms very common, not serious, troublesome Very dry, and dry mouth, ?Sjogrens Very severe dry extremely uncommon: corneal melts and perforates..severe autoimmune disease

80. Corneal disease Lots of uncommon corneal diseases In poor countries, trachoma >> corneal scarring http://www.goodhopeeyeclinic.org.uk/fuchs.htmlhttp://www.goodhopeeyeclinic.org.uk/fuchs.html Dry eye

81. trachoma

82. Dry eyes http://www.goodhopeeyeclinic.org.uk/dryeye.html

83. Dry eyes http://www.d ryeye.org/im ages/colorba r.jpg

84. Fuchs corneal dystrophy etc http://www.goodhopeeyeclinic.org.uk/fuchs.html Keratoconus

85. Optic atrophy Low B12 Secondary to retinal artery occlusion or ION Tobacco alcohol amblyopia (vitamin B deficiency)

86. Retinal dystrophy http://geneticpeople.com/?tag=retinitis- pigmentosahttp://geneticpeople.com/?tag=retinitis- pigmentosa

87. Summary, go round the room 1.. 2.. 3.. 4.. 5.. 6.. 7.. 8.. 9.. 10.. 11.. 12.. 13.. 14.. 15.. 16.. 17..