Practical Opthalmology [1 ed.]

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DR. ANIL BAJAJ

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch

A PRACTICAL GUIDE FOR STUDENTS WITH 90 ILLUSTRATIONS

PRACTICAL OPHTHALMOLOGY Eye examination, Instruments, Optics, Case History and Important Questions

Author

DR. ANIL V. BAJAJ MBBS, DOMS, MS (OPHTH) FCLI, MRSH (LONDON)

Consultant Ophthalmic Surgeon, Blind Relief Mission, Nagpur. Ex-Lecturer, Govt. Medical College, Nagpur.

Foreword by

DR. P. J. DIKKAR

MBBS, DOMS, MS (OPHTH) Associate Professor of Ophthalmology, Indira Gandhi Medical College, Nagpur.

rabash an R

124 Reshimbag, Nagpur - 440 009

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Published by Sanjay A. Deshpande for

ANANT PRAKASHAN 124, Reshimbag, Nagpur-9

Ph.: 2746209

Copyright: DR. ANIL V. BAJAJ 1991.

All rights reserved. No part of this publication may be reproduced stored In a retrieval

system, or transmitted in any form or by any means, electronic, mechanical, photocopy­ ing. recording or otherwise, without written permission of the Author and Publisher.

First Published

1991

This Revised Reprint

2009 Reprint 2012

Repnni 2016

Price . Rs. 220/-

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PREFACE / present this book on ‘Practical Ophthalmology' in this beleif that knowl­ edge of basic clinical Signs and Symptoms Is an essential prerequisite which can meet the

undergraduate and postgraduate students need. The Increasing demand of my previous

book entitled Instruments and Optics In Ophthalmology’ made me to come out with this book. Special emphasis has been laid on clinical examination of eyes which still forms the mainstay of diagnosis of eye disorders. Additional feature is Inclusion of clinical

cases of day to day importance. I hope this comprehensive book on Practical Ophthalmol­ ogy will create a long lasting Impression In the minds of undergraduate students ophthalmic assistants and optometrists.

My heart felt gratitude to may student who inspired me to bring out this book.

My sincere thanks to our publisher Mr. Sanjay A. Deshpande for immense patience and compliance In framing and printing this book. Acknowledgements to near, dear friends and fraternity those who approved and Inspired me.

DR. ANIL BAJAJ

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FOREWORD Dr. Anil Bajaj Is my brilliant student and a close colleague practising oph­

thalmology with great zeal and sincerity. I ‘am really very proud to know that he has written this book on "Practical Ophthalmology” which was a long felt need of undergraduate stu­ dents. ophthalmic assistants and optometrists.

This concise book Is extremely Informative, easily readable with logical and well arranged presentation, has excellent diagrams and Is examination oriented. I Congratulate Dr. Anil Bajaj for the Immense efforts taken by him and wish

him success with a hope that this book will be widely circulated and win acclaim all over.

Dr. R J. DIKKAR

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CONTENTS

Chapter

No.

Examination of an Eye Case

//.

///

IV.

Page

1

1. History

3

2. External Examination of the Eye

9

3. Examination of Retinal Functions

37

4. Examination of the Fundus

45

Ophthalmic Instruments

49

1. Surgical Instruments

51

2. Sterilization and Care of Instruments

94

3. Fumigation and Derumlgatlon of Operation Theatre

96

Optics

97

1. Optical Instruments

99

2. types of Refractive Errors

119

Clinical Ophthalmic Cases 1. Cataract

121 123

A. Senile Cataract

126

B. Congenital Cataract

134

2. Aphakia

138

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Chapter

No.

Page

3. Glaucoma

142

A. Congenital glaucoma

143

B. Narrow angle glaucoma

145

C. Chronic simple glaucoma

152

4. Corneal ulcer

157

5. Iridocyclitis

169

6. Trachoma

176

7. Blepharitis

179

A. Squamous blepharitis B. Ulcerative blepharitis

179

.

180

8. Entropion

181

9. Pterygium

182

10 . Stye

184

11. Chalazion

-

186

12 Pinguecula

188

13. Bitot's spot

189

14. Phlycten

190

15. Squint

193

V................................ Important Question*................................................................. f pp

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I

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Examination Of An Eye Case 1.

I.

Examination OfAn Eye Case

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch 2. Practical Ophthalmology PROFORMA OF CLINICAL CASE SHEET

1) NAME AND ADDRESS

2) AGE

3) SEX

4) OCCUPATION

5) RELIGION

6) HISTORY OF PRESENTING COMPLAINTS AND DURATION

7) PAST HISTORY

8) PERSONAL HISTORY

9) FAMILY HISTORY

10) GENERAL EXAMINATION

11) EXAMINATION OF BOTH EYE IN DETAIL

12) SYSTEMIC EXAMINATION

13) PROVISIONAL DIAGNOSIS

14) INVESTIGATION

15) FINAL DIAGNOSIS

16) TREATMENT

17) RESULT

18) FOLLOW UP

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Examination Of An Eye Case 3.

1. History History in detail form Is an integral part of ophthalmic manifestations. Before exam­ ining the patients eye, complete history of his ocular complaints should be recorded In chronological order. The following points are to be noted.

1. Name and Address

It is recorded for patient’s identification.

2. Age

Many eye diseases are related to age e.g. Cataract,

glaucoma, dystrophies, retinal diseases, presbyopia, arcus senilis, congenital anamolies, myopia etc. 3. Sex

Some eye diseases are more common In particular sex. e.g. glaucoma, retinitis pigmentosa, trachoma, dacryocystitis, temporal arteritis, colour blindness etc.

4. Occupation

Ophthalmic manifestations due to occupational hazards are well known, e.g. injuries, foreign bodies, cataract, conjunc­ tivitis, keratitis etc.

5. Religion

Few eye diseases are more common in particular commu­ nity e.g. Familial lipid degenerations etc.

6. Presenting complaints

of the patient, its duration and mode of onset. Common eye

complaints are a) Diminution of vision (D.O.V.)

j) Stickiness of lids

s) Trauma

b) Watering of eyes

k) Swelling

t) Micropsia

c) Redness

l) Foreign body sensation

u) Macropsia

d) Headache

m) Black spots before eyes

v) Metamorphopsia

c) Pain

n) Coloured halos

w) Asthenopia (eye strain)

f) Discharge

o) Night blindness

x) Chromatopsia

g) Diplopia

p) Day blindness

y) Oscillopsia

h) Photophobia

q) Colour blindness

z) Hallucinations

i) Itching

r) Scotoma

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--------------------------------------- ---

7. PiJSt history a) Redness of eyes

e) Leprosy

i) Acute Infectious fever

b) Tuberculosis

f) Syphilis

j) Wearing spects,

c) Diabetes

g) Operation on eyes

d) Hypertension

h) Previous trauma

contact lenses k) Taking drugs

8. Personal history a) Tobacco b) Alcohol

c) Drugs d) Smoking

9. Family history a) Similar complaints In the

c) Congenital cataract

e) Glaucoma

d) Night blindness

f) Corneal opacity

family of D.O.V. b) Squint

10. General examination

Pallor, jaundice, pulse, B.P, respiration, etc. 11. Examination of both eyes in detail 12. Systemic examination

C.V.S.. R.S. PA., C.N.S. 13. Investigations : Relevant to the particular case 14. Diagnosis

15. Treatment 16. Results 17. Follow up

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Examination Of An Eye Case 5.

CAUSES OF COMMON EYE COMPLAINTS

A.

DIMINUTION OF VISION (IXO.V.)

a) Sudden D.O.V.

(Within hours or minutes)

1) Central retinal artery occlusion

9) Head injury

2) Vitreous haemorrhage

10) Acute keratoconus

3) Chemical injury to eye

11) Macular detachment

4) Perforating injury

12) Central sehlrrous retinopathy

5) Acute congestive glaucoma

13) Quinine poisoning

6) Optic neuritis

14) Avulsion of optic nerve

7) Central retinal vein occlusion

15) Acute iridocyclitis

8) Methyl alcohol poisoning

16) Retinal haemorrhage

b) Transient loss of vision (amourosls fugax) 1) Papilloedema

4) Cerebro vascular insufficiency

2) Migraine

5) Impending C.RA. and C.R.V. occlusion

3) Toxaemia of pregnancy

6) Circulatory disturbances

c) Gradual progressive diminution of vision (G.P.D.O.V.) (a) Conjunctiva

1) Progressive pterygium invading pupillary area

(b) Cornea

1) Corneal degeneration 2) Corneal dystrophies

3) Vitamin A deficiency 2) Chronic simple cyclitis

(c) Iris

1) Chronic iridocyclitis

(d) Angle of a.c.

1) Chronic simple glaucoma

(e) Lens

1) Senile cataract

(f) Vitreous

1) Senile vitreous degeneration

(g) Optic nerve

1) Toxic amblyopia

2) Developmental cataract

2) Post papilloedemic optic atrophy (h) Retina

1) Hypertensive retinopathy 2) Diabetic retinopathy

. 3) Retinitis pigmentosa (i) Macula

1) Senile macular degeneration

2) Berlin’s oedema

0) Refractive error B. DIPLOPIA - It means double vision, a) Uniocular diplopia

1) Double pupil

4) Retinal detachment

2) Dislocated lens

5) Improper spectacle

3) Incipient cataract

6) Keratoconus

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6

Practical Ophthalmology b) Binocular dipiopia

__ 1) 3rd 4th. 6th nerve palsy

3) Abnormal refinal correspondence (A.R.C.) (paradoxical diplopia)

2) Blow out fracture

4) Spectacles in aphaklcs having magnification dis­ parity

C. WATERING OF EYES Two terms are used In connection with watering of eyes. They are epiphora and ocnmation

a) EPIPHORA It means watering due to obstruction to outflow of tears l.e. defect in the drainage part ot lacrimal apparatus.

1) Stenosis of lacrimal puncta

2) Eversion of lower puncta due to ectropion 3) Obstruction in canaliculus, lacrimal sac, nasolacrimal duct (chronic dacryocystitis)

b) LACRIMATION It means watering due to excess secretion of tears 1) Sensory irritation in structures of eyeball by corneal foreign body, keratitis, comeal ulcer, other inflammations of the eyeball 2) Exposure to bright light 3) Action of certain drugs like pilocarpine 4) Emotional state

5) Mickulicz syndrome D PHOTOPHOBIA AND BLEPHROSPASM -

While dealing with photophobia and blephrospasm differentiation should be made as fo«ows -

Photophobia

Blephrospasm

1) It means dislike for light

It is a condition In which the lids are firmly closed due to involuntary forc­ ible contraction of orbicularis ocull as a result of corneal Irritation.

2) It occurs due to irritation of optic nerve

It Is due to Irritation of 5th nerve.

3) ft is abolished in dark

It Is abolished by Instillation of 4% xylocalne.

4) Causes are-AIbmism. mydriatles.

Causes are corneal abrasion and ulceration, buphthalmos, emotion, drugs membranous and pseudomembranous conjunctivitis, corneal foreign body, Vit. A defi­ ciency, buphthalmos, Iridocyclitis.

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Examination Of An Eye Case 7. E. COLOURED HALOS -

it means coloured rings around light, outer red inner blue. 1) Acute congestive glaucoma

4) Corneal scar

2) Early stages of cataract

5) Hazy ocular media

3) Mucopurulent conjunctivitis

6) Drugs

(mucus on cornea) F. NIGHT BLINDNESS (NYCTALOPIA) * 1) Vitamin-A deficiency

5) Other Tepeto-retlnai degeneration

2) Open angle glaucoma

6) Congenital

3) Retinitis pigmentosa

7) Pathological myopia

4) Cortical cataract G. DAY BLINDNESS (HAMERLOPIA) -

1) Central nuclear or polar cataract

3) Central vitreous opacity

2) Central comeal opacity

4) Central scotoma

H. SPOTS BEFORE EYES -

1) Vitreous haemorrhage

4) Lenticular opacity

2) High myopia

5) Foreign body

3) Corneal opacity

6) Carbon tetrachloride poisoning

I. FLASHES BEFORE EYES (PHOTOPSIA) -

1) Traction of vitreous on retina

4) Impending retinal detachment

(Moorens light reflex) 2) Retinitis

5) Focal lesion of occipital region

3) Migraine

6) Glaucoma (rare).

J. MICROPSIA-

Objects appear smaller than normal size due to separation of cones in retinal diseases.

K. MACROPSIA -

Objects appear larger than normal size due to crowding of cones in retinal disorders.

L. METAMORPHOPSIA -

Objects appear distorted in retinal disorders.

M. CHROMATOPSIA -

Coloured vision. Erythropsia (Red vision)

Cyanopsia (Blue vision), Xanthopsia (yellow), Chloropsia (green) Seen in aphakia, vitreous haemorrhage. Certain drug intake.

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8.

Practical Ophthalmology

N. PAIN IN EYES -

1) All Inflammatory conditions of the eye like Conjunctivitis, Episcleritis, Scleri tls, Keratitis, Iridocyclitis, Retrobulbar neuritis, Endophthalmitis, Panoph thalmitis etc.

2) Acute glaucoma

3) Refractive errors 4) Injury

5) Foreign body in eye

O REDNESS OF EYES (D/D OF RED EYE) 1) Conjunctivitis

7) Endophthalmitis

2) Keratitis, corneal ulcers

8) Panophthalmitis

3) Scleritls, episcleritis

9) Orbital cellulitis

4) Uveitis

10) Foreign body in eye

5) Glaucoma (narrow angle and

11) Injuries to the eye

secondary glaucoma)

6) Sub-conjunctival haemorrhage

12) Systemic causes

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Examination Of An Eye Case 9.

2. External Examination of the Eye Examination of anterior segment of eye can be made by three methods.

I. LOCAL OCULAR EXAMINATION II. EXAMINATION IN FOCAL (OBLIQUE) ILLUMINATION

III. EXAMINATION OF RECESS OF ANGLE OF A.C.

LOCAL OCULAR EXAMINATION - In good diffuse torch light (discussed later) .. FOCAL OR OBLIQUE ILLUMINATION - It is done by using the corneal loupe or slit lamp as per given methods.

Methods

a) The patient is seated in a dark room with a light focused about two feet away from the patient and to the side. Concentrate the light on the eye by a strong convex lens. Light can be focused on iris by moving lens close to the eye. Then magnify the spot of light by looking through a corneal loupe (convex lens.) Management of two lenses require little practice. b) In focal Illumination torch light is focused on the required spot

& corneal loupe is directly brought near the spot to look through it. c) S.L.E.- It is done to examine the anterior segment of eye thor­ oughly and is the best method. Bright illumination and various grades of magnification can be used. . EXAMINATION OF RECESS OF ANGLE OF A.C. is done by Gonloscopy

it Is a method to visualise the recess of the angle of the anterior chamber with the help of a gonloscope and slit lamp. The best used gonioscope Is goldmann 3 mirror.

Other types of Gonioscoples are a) Direct Gonloscope - Koeppes, Barkans, Worst gonioscopes b) Indirect Gonloscope - Goldmann (1, 2 & 3 mirror), Zeis 4 minor. Alien Thorpes.

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—-----------------------

Practical Ophthalmology

Normal structures seen through gonioscope from behind'

forward are (1) Anterior surface of Iris (2) Anterior medial surface of ciliary body (3) ftabecular meshwork (4) Schwalbes line

Gonloscopy is helpful In visualising 1) To classify glaucoma and grading the angle of Anterior Chamber:

Grade 0 - wide open : all structures of angle are seen Grade I - Hard to see over iris root and recess of angle Grade II - Ciliary body not seen.

Grade III - Trabecular meshwork not seen Grade IV - Closed angle : only shwalbe line visible

2) Peripheral anterior synechia. 3) Neovascularisation in angle

4) Congenital mesodermal tissue in angle. 5) To do goniotomy with koeppes lens 6) Pigmentation in angle 7) Iridodyalysis

8) Success of trabeculectomy operation I.

LOCAL OCULAR EXAMINATION (EXTERNAL EXAMINATION OF THE EYE IN TORCH LIGHT) - Examination of each eye should be done separately. RIGHT EYE

LEFT EYE

1) Visual acuity (V/A) 2) Head posture

(Same as right eye)

3) Fore-head

4) Eyebrows 5) Lids

A) Lid proper

C) Lid margin

B) Eyelashes

D) Lacrimal puncta

6) Palpebral Fissure 7) Conjunctiva

8) Sclera 9) Cornea

10) Anterior chamber (A.C.)

'

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11) Iris 12) Pupil 13) Lens 14) Nasolacrimal passage (N.L.R)

15) Intraocular tension (T.O.T.) 16) Palpation A) Preauricular lymph node

C) Eyeball

B) Orbit

17) Ocular movements A) Uniocular

B) Binocular

18) Transillumination

PROFORMA FOR CLINICAL EXTERNAL EXAMINATION OF THE EYE

I. LOCAL OCULAR EXAMINATION (External Examination of the eye in torch light)

1) Visual acuity

a) Distance (with and without glasses

b) Near and with pinhole)

2) Examination of Head Posture ’ a) Elevation or depression

c) Tilt

b) Turn

d) Ocular torticolis

3) Examination of Forehead a) Wrinkles

4) Examination of Eyebrows a) Elevation

d) Whitening

b) Falling of hair (Madarosis)

e) Coarse eyebrows

c) Lack of outer 1/3 of eyebrows (Hertogh’s sign)

5) Examination of Lids

A. Lid proper a) Thickness

f) Black eyelid

b) Redness

g) Lagophthalmos

c) Oedema

h) Lid lag

d) Localised swelling

I) Coloboma

e) Pigmentation

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12. Practical Ophthalmology B. Eye lashes a) Trichiasis

d) Matting

b) Madarosis

e) Nits

c) Poliosis

f) Disfichiasis

C. Lid margin

a) Entropion or ectropion b) Any ulcers or scales c) Thickness of lid margin (Tylosis)

d) Redness of lid margin

(Milphosis)

e) Normal opening of mebomian duct f) Continuity of lid margin

D. Lacrimal puncta

a) Situation

c) Inflammation

b) Open or close

d) Eversion.

Examination of Palpebral Fissure

b) Wide

a) Narrow

Examination of Conjunctiva A. Bulbar Conjunctiva a) Normal or congested

f) Pinguecula

b) Discharge

g) Bitot's spot

c) Chemosis or Oedema

h) Pigmentation

d) Subconjunctival haemorrhage

i) Cyst, nodule

e) Pterygium

j) Symblepharon

B. Tarsal Conjunctiva a) Arrangement of blood vessels

e) Scarring f) Foreign body

b) Papillary hyperplasia

g) Membrane

c) Follies

h) Tumor mass

d) Concretions C. Limbal Conjunctiva a) Circum corneal congestion

d) Nodule

b) Phlycten

e) Follicle

c) Scar of surgery

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Examination Of An Eye Case 13. 8) Examination of Sclera

a) Nodule

c) Blue colouration

b) Congestion

9) Examination of cornea a) Size

g) Vascularisatlon

b) Shape

h) Keratic precipitates

c) Surface

i) Ulcer, abrasion

d) Corneal transparency

j) Bullae, vesicles

e) Corneal opacity

k) Pigmentation of cornea

f) Corneal sensation

10) Examination of Anterior Chamber (A.C)

a) Depth

b) Contents

11) Examination of Iris

a) Colour

f) Atrophic patches

b) Pattern

g) Vascularisation

c) Iridodonesis

h) Gap or ho'e in iris

d) Synechia

i) Iridodialysis

e) I.O.L.

j) Ectropion of uveal pigment

12) Examination of Pupil a) Size

e) Pupillary margin

b) Shape

f) Pupillary area

c) Reaction

g) Number

d) Position

h) I.O.L.

13) Examination of Lens a) Pupillary reflex

c) Subluxation or dislocation

b) Lens opacity

d) Purkinje samson image

14) Examination of nasolacrimal passage

a) Redness or swelling over sac area b) Fistula

c) Any regurgitation on pressure over sac area

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14. Practical Ophthalmology 15) Examination of Intra-Ocular Tension (I.O.T.) a) Digital method

16) Examination by palpation a) Eyeball

bl Instrumental method ’ c> L'mph node5

b) Orbit

17) Examination of ocular movements a) Uniocular

b> Binocular

18) Examination by Transillumination a) Trans-scleral

c> Trans-puplllary

b) Indirect transillumination

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_______________________ ___________________ Examination Of An Eye Case 15.

DETAILS OF CLINICAL EXTERNAL EXAMINATION OF THE EYE 1. Visual acuity

Before examining the various parts of the eye, the visual acuity should be recorded. Details on page 39 and 40.

2. Examination of Head Posture

Normally It Is straight and forward

a) ELEVATION OR DEPRESSION 1) Vertical muscle palsy 2) Ptosis

b) TURN 1) Horizontal muscle palsy

c) TILT 1) Oblique muscle palsy d) OCULAR TORTICOLIS Ocular torticolis is seen in cases of congenital incomitant squint. There is a turn and tilt of the head. It should be differentiated from orthopaedic torticolis which is due to contraction of sternomastoid muscle. 3. Examination of Fore-head

Normally there are no wrinkles on the forehead of a young patient.

a) WRINKLES 1) Senile

2) Acquired

Acquired wrinkles are due to over-action of frontalis muscle. They are seen in ptosis and are usually unilateral.

4. Examination of Eyebrows

Normally seen at equal level

a) ANY ELEVATION

1) Ptosis b) FALLING OF HAIR (MADAROSIS) 1) Leprosy

2) Plucking of hair in females (cosmetic)

c) WHITENING

1) Albino

3) Leprosy

2) Vitiligo

4) Ageing

d) LACK OF OUTER ]/3rd OF EYEBROW (HERTOGH'S SIGN) 1) Leprosy

2) Endocrinopathies (myxoedema)

3) Scleroderma

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16. Practical Ophthalmology e) COARSE EYEBROWS 1) Hurler’s syndrome

2) Normal

3) Hunters syndrome

Normally upper lid covers about 1-2 mm. of cornea at clock and lower lid is tangent to the limbus at 6 O' clock

5. Examination of Lids

A) Lid proper B) Condition of eye lashes

C) Lid margin D) Lacrimal puncta

A. LID PROPER a) Thickness of lids - It gets thickened in 1) Trachoma 4) Tarsitis 2) Chronic conjunctivitis 5) Multiple chalazia

3) Blephritis b) Redness - Inflammatory conditions like iridocyclitis, blephritis, stye. c) Oedema (1) Active oedema 1) Hordeolum

2) Allergic 3) Insect bite 4) Trauma

5) Dermatitis

7) Conjunctivitis

8) Cyclitis 9) Panophthalmitis

10) Orbital cellulitis 11) Acute dacryocystitis

6) Lid abscess

(2) Passive oedema 1) Congestive cardiac 3) Cavernous sinus thrombosis failure 4) Angioneurotic oedema 2) Renal failure d) Localised swelling 1) Chalazion

3) Growth

2) Cyst e) Pigmentation (1) Hyper pigmentation

1) Telangiectasis

3) Drugs

2) Addisons disease (2) Hypo pigmentation

1) Vitiligo

3) Drugs

2) Leprosy

4) Albinism

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f) Coloboma

g) Black eyelid - Haemorrhage In scalp h) Lagophthalmos - On closing the eye eyelid does not close, seen In

1) Extreme proptosls

3) Paralytic (7 nerve palsy)

2) Cicatrial ectropion (Bell’s palsy) i) Lid lag - On looking down lid lags behind. Seen in

1) Thyroid myopathy (grates sign)

3) Extra pyramidal syndrome

2) Congenital ptosis

4) Iatrogenic

j) Drooping of upper lid (Ptosis) k) Scar of surgery

Normally there are 2 upper rows and lower single row

B. EYE LASHES

a) Misdirection of eyelashes (Trichiasis) b) Any loss or scantiness of eye lashes (Madarosis), seen in

1) Trauma

4) Radiation

2) Endocrine disease

5) Drugs

3) Squamous blephritis

6) Chronic skin disease

c) Any whitening of eye lashes (Poliosis)

1) Albino

3) Vitiligo

2) Leprosy d) Any nits - Seen as eggs of lice as white shining dots

e) Any matting of lashes- due to mucopurulent discharge f) Long lashes (Trichomegaly)

g) Accessory row of lashes (Distichiasis). It grows from meibomian gland opening and is usually misdirected. C. LID MARGIN a) Any entropion (Inverted lid margin) (cicatrical, congenital, spastic mechanical) or Ectropion (everted lid margin) (Congenital, cicatrical, spastic, mechanical, paralytic, senile).

b) Any ulcers or scales (Blephritis).

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______________ ____________

18. Practical Ophthalmology

c) Thickness of lid margin (Tylosis) d) Redness of lid margin (Milphosls) e) Normal opening of meibomian duct f) Continuity of lid margin (for proper drainage of tears)

Normally situated on medial side on the papilla and j$ patent. It is in contact with the eye.

D. LACRIMAL PUNCTA

6.

a) Situation

c) Any inflammation

b) Open or closed

d) Any eversion

Examination of Palpebral Fissure

a. NARROW

Normal dimensions are vertically (8-9mm) and horizontally (20-25mm.). It may be -

b. WIDE

a) Causes of narrow palpebral aperture

1) Atrophic bulbi

6) Homer’s syndrome

2) Pthysis bulbi

7) Microphthalmos

3) Ptosis

8) Carpenter’s syndrome

4) Lid oedema

9) Down’s syndrome

5) Congenital b) Causes of wide palpebral aperture

1) Lid retraction

2) Proptosis

3) Exophthalmos 7. Examination of Conjunctiva A. BULBAR Conjunctiva B. TARSAL Conjunctiva (Upper and Lower)

C. LIMBAL Conjunctiva Method of eversion of upper lid and upper fornix. *

1) The best, and often the easiest, method is as follows: Stand facing the patient. To ever the left upper lid, place the right thumb on the lower lid near the margin while the pc tient looks up. Then ask the patient to look down so that the upper lid tends to fall over the lower and the surgeon’s thumb. Lay the side of index Finger along the upper lid above the tarsus exerting a steadying pressure upon it downwards. With the patient still looking down an upward rotatory movement of the thumb then everts the lid and as the finger is withdrawn the thumb is rotated to support the everted lid against the orbital margin. W right lid is everted in the same manner, using the left hand.

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Examination Of An Eye Case 19.

2) Patient Is asked to look towards his feet. A probe or thin pencil is placed horizontally on the skin of the upper lid at the level of the tarsus. Hold the eye lashes In between the left

Index Finger and thumb, stretch the lid away from the globe, keeping the probe at a fixed point. The lid Is rotated In a vertical direction round the probe, thus everting the lid. The probe Is gently withdrawn.

3) In many cases we have to evert the lid of a patient who Is lying In the bed. In such a case the best method Is that the patient Is asked to look towards his/her feet. The ’‘left index Finger is placed vertically upon the lid. Hold the eye lashes with the right Index

finger and thumb, and rotate the lid around the tip of the left index finger. Method of eversion of upper fornix - 4% xylocaine as local anaesthesia is adminis­ tered in the eye. Evert the upper lid as done earlier and then insert a lid retractor under the

everted lid into the fornix. In this way the lid is once more everted upon itself and thus we can visualise the upper fornix. A. BULBAR Conjunctiva

a) Normal or congested

g) Bitot’s spots

b) Any discharge

h) Pigmentation.

c) Any chemosis or oedema

i) Cyst, nodule or growth

d) Sub-conjunctival haemorrhage.

j) Symblepheron

e) Pterygium

k) Pallor

f) Pinguecula

B. TARSAL Conjunctiva a) Arrangement of blood vessels

e) Scarring.

b) Papillary Hyperplasia

f) Foreign body

c) Follicles

g) Membrane

d) Concretions

h) Tumour mass

C. LIMBAL Conjunctiva a) Circum corneal congestion (c.c.c.)

d) Follicle

b) Phlycten

e) Scar of surgery

c) Nodule

(cataract/glaucoma)

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20. Practical Ophthalmology

Dl.«”ngulshlng points between : Ciliary congestion

Conjunctival congestion 1) Congestion Is more marked at fornix

1) Congestion is more marked at limbus

2) Bright red 3) Vessels superficial and branching

2) Pinkish red 3) Deep and radially arranged

4) Vessels fill up from fornix to limbus

4) Vessels fill up from limbus to fornix

5) Vessels move with conjunctiva

5) Dose not move with conjunctiva

6) Anterior and posterior conjunctival vessels

6) Episcleral branches of anterior ciliary arteries

7) Vasconstriction with phenylepherlne

7) Dose not constrict 8) seen in corneal and iris inflammation & acute congestive glaucoma

8) Seen In conjunctival inflammation

D/D of Nodule at Limbus 1) Inflammatory - Trachomatous follicles (Herbert’s pits), episcleritis, scleritis.

2) Immune allergic - Phlycten, vernal catarrh 3) Degenerative - Pterygium, pinguecula, amyloid 4) Neoplastic - Epithelial benign papillomata, viral, precancerous carcinoma in situ, Invasive carcinoma

Lymphoma - Benign, malignant Fibrous - Histiocytoma

Pigmented - Nevi, malignant melanoma Lipoma

5) Toxic limbal follicles - Due to pilocarpine and IDU eye drops 6) Surgical and traumatic - Granulomas, foreign body, inclusion cysts, scar, filtering bleb, uveal prolapse, keloid, phacocoele

7) Congenital - Dermoids, ectopic lacrimal gland, vascular haemartomas, nevus. 8) Systemic - Gaucher’s disease, neuro-fibromatosis, alkaproteinuria 9) Vitiligo - Vogt - Koyanagi - Harda syndrome, suglura’s sign

10) Intercalary and ciliary staphylomas D/D of follicles of conjunctiva

I) ACUTE

II) CHRONIC

1) ACUTE CONDITIONS

1) Of unknown etiology a. Beal syndrome

b. Perinaud syndrome

c. Angeluceis syndrome

d. Floppy eyelid syndrome

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_______________________ Examination Of An Eye Case 21.

2) Conditions of Infective etiology : Viral and chlamydial a) Viral 2) Due to RNA viruses

1) Due to DNA viruses 1) Due to DNA viruses

i) Epidemic keratoconjunctivitis II) Pharyngo conjunctival fever lii) Primary herpes simple iv) Herpes zoster conjunctivitis v) Follicles in small pox

2) Due to RNA viruses

I) Newcastle disease II) Follicles In measles

iil) Follicles in mumps

iv) In influenza

v) Acute haemorrhagic conjunctivitis b) Chlamydial 1) Trachoma 2) Inclusion conjunctivitis 3) Cat scratch fever

II) CHRONIC CONDITIONS

1) Of unknown etiology a) Of axenfield

c) Miliary follicles

b) Lymphatic hypertrophy with opaline nodule 2) Constitutional: Folliculosis

3) Chronic irritative due to drugs 4) Infective

a) Bacterial (I) Follicular type of T.B. conjunctivitis

(ii) Granular type of syphilitic conjunctivitis

b) Viral molluscum contagiosa

c) Chlamydial (I) Trachoma

(lii) Trie virus

(ii) Inclusion conjunctivitis

(iv) Follicles in LGV infection

5) Allergic spring cattarh.

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22. Practical Ophthalmology________________________________________________ 8. Examination of Sclera

Normally the sclera is whitish in adults and bluish in children

a) NODULE - Episcleritis shows raised congested nodule b) CONGESTION - Deep scleritls shows dusky ciliary congestion

c) BLUE COLORATION - Physiological in young children and pathological in adults Cause of blue sclera

1) Ciliary staphyloma

6) Injury

2) Scleritls

7) Glaucoma (congential)

3) Curzon disease

8) Thrber's syndrome

4) Ehler’s Danlos syndrome

9) Werner's syndrome

5) Marfan’s syndrome

10) Osteogenesis imperfecta

d) PIGMENTATION - Melanotic tumor

e) ECTASIA 9. Examination of cornea a) Size

h) Keratic precipitates (k.p.)

b) Shape

l) Abrasion and ulcer

c) Surface

j) Vesicles

d) Transparency

k) Pigmentation

e) Opacity

L) Specular microscopy

f) Sensations

m) Pachymetry

g) Vascularisation a) SIZE

Normally cornea encroaches sclera at 12 O’clock position. Diam eter of cornea is horizontally 12 mm., vertically 10-11 mm. 1) Size increased-megalocornea, buphthalmos

2) Size decreased-microcornea, microphthalmus b) SHAPE

Normally not uniform throughout. It may be flat, conical or globular.

1) Flat In cornea plateau, atrophic bulbl

2) Conical in keratoconus 3) Globular In anterior staphyloma, buphthalmos, keratoglobus

c) SURFACE

Normally it is smooth and regular. Surface is seen with

1) Window reflex 2) Placldo’s disc reflex (Keratoscopic disc)

3) Corneal staining (Fluorescein)

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch _______________________________________ Examination Of An Eye Case 2 3.

Method of examination :

1) Window reflex - Ask the patient to face the window. Stand In front and while directing the patient to follow the Index finger which Is moved in all directions, observe carefully the image of the window In the cornea (cor­ neal reflex). If the surface of the cornea Is normal there will be no distortion of the reflex as It passes over It. If the surface is roughened the Image will be distorted and less clearly defined.

2) Placido’s Keratoscoplc disc - Hold the keratoscopic disc In front of the patients eye. Look through a lens In the centre of the keratoscoplc disc at the patient’s cornea. A sharp well defined image of the keratoscopic disc will be seen in a normal cornea. If there Is any Irregularities of the corneal surface the image of the ring on the corneal surface appears distorted. 3) Corneal staining

(Fluorescein staining) -

I) Superficial staining of cornea and bulbar conjunctiva - A strip of fluorescein is kept in the lower fornix of the eye for few seconds or alternatively a drop of 2% fluorescein sodium is instilled into the eye and patient is asked to close the eye and again open for spread of the stain over the surface of the eyeball. The patient’s eye is examined under slit lamp with blue Filter.

Interpretation Denuded epithelium of cornea (abrasions, ulcer, ero­ sions) stains brilliant green, while lesion of conjunctiva stain orange-yel­ low. It is noted that descemets membrane is not stained by fluorescein so that only the sides and margins of very deep ulcer show the stain. Escape of aqueous from perforating wound or fistula can be seen by fluo­ rescein stain. II) Deep staining of cornea - Fluorescein dye is allowed to remain In the conjunctiva) sac for few minutes by closing the lids so that fluo­ rescein penetrates the intact epithelium and stains the endothelial de­ fects if present.

Interpretation Endothelial defects and keratic precipitate are seen as minute green dots. OTHER DYES used are -

Bengal rose - It stains devitalised cells as red colour Acian blue - Stains the mucus selectively

Causes of uneven surface or distorted corneal reflex are i) Corneal abrasions

iv) Corneal facets

II) Corneal ulcers

v) Astigmatism

iii) Old healed opacity

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24. Practical Ophthalmology d) CORNEAL TRANSPARENCY - Normally cornea is transparent. Transparency is due to compactness and parallel arrangement of lamillae, avascularity, demylenated nerves and relatively dehydrated cornea.

1) Hazy due to corneal oedema In keratitis, acute congestive glaucoma, Iridocyclitis, acute hydrops in keratoconus. e) CORNEAL OPACITY - At least destruction of Bowman’s membrane (B.M.) is required to form corneal opacity.

Grades of opacity

1) Nebular - B.M. involved

2) Macular - B.M. + Stroma involved 3) Leucoma - B.M. + Stroma+Endothelium

Nebular grade cause more discomfort to vision because it causes irregular refrac­ tion (treatment is tattooing)

In corneal opacity look for Its -

I) Density

ill) Any pigmentation

ii) Situation and extent in relation to pupil

iv) Adherent leucoma

Causes of corneal opacity 1) Degeneration

3) Inflammations

2) Dystrophy

4) Trauma

f) CORNEAL SENSATIONS

Method of examination - Patient is asked to look straight with both eyes wide open. Then a whisp of cotton is brought close to the patient’s eye from the temporal side and the cornea is touched with it, the blinking reflex of the lids is seen.

Cornea is supplied by ophthalmic division of the 5th nerve. Cornea has no kinesthetic sensations.

Causes behind loss of corneal sensation 1) Herpse simplex

6) Lesion of the 5th nerve

2) Herpes zooster

7) Contact lens wearer

3) Acute congestive glaucoma

8) After corneal surgery

4) Absolute glaucoma

9) Keratomalacia

5) Corneal dystrophy

10) Leprosy

g) VASCULARISATION OF CORNEA 1) Localised or circumferential

2) Its site and extent

See whether it is 3) Superficial or deep

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Examination Of An Eye Case 25.

Causes of corneal vascularlsatlon

1) Corneal ulcers

5) After keratoplasty

2) Syphilitic keratitis

6) Degenerative

3) Trachoma

7) Diabetic rubeosis

4) Leprosy Differentiation between

Superficial vascularlsatlon

Deep vascularlsatlon

1) Bright red and well defined

1) Dull red

2) Branching present

2) Straight radial vessels

3) Continuous with conjunctival vessels

3) Not continuous with vessels conjunctival

4) May raise epithelium over them

4) Does not raise epithelium

h) KERATIC PRECIPITATES (K.R) These are deposits of inflammatory cells on cor­ neal endothelium and are best seen with slit lamp. They may be

1) Fine

3) Pigmented

2) Mutton fat

4) New or old.

Cause - Inflammatory condition of uveal tract.

I) ABRASION AND ULCER Describe ulcer in detail, its margin, extent, floor, whether central or peripheral. Staining of the ulcer should be done with 2% fluorescein.

J) VESICLES AND BULLAE 1) Absolute glaucoma k) PIGMENTATION OF CORNEA 1) Melanosis 2) Blood staining 3) Metal staining with Cu, Fe, Ag

l)

Specular microscope to know endothelial cell count

m) Pachymeter to measure corneal thickness

10. Examination of Anterior Chamber (A.C.) iris. Normally it is about 2.5 mm. deep.

It is the space between cornea and

a) DEPTH

1) Normal

3) Deep

2) Shallow

4) Irregular

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26. Practical Ophthalmology_____________________

b) CONTENTS - Blood (Hyphaema), Pus (Hypopyon), Malignant cells (pseudophypo pyon) Lens matter. Inflammatory cells (aqueous flare), I.O.L.

Causes of DEEP A.C.

1. Physiological -

(I) Infants (2) High myopia

2. Cornea -

(3) Kerato conus (4) Keratoglobus

(5) Buphthalmos.

3. Lens -

(6) Aphakia (7) Posterior dislocation of lens

(8) Hyper-mature shrunken lens

4. Iris -

(9) Iridocyclitis (total posterior synaechiae)

Causes of SHALLOW A.C.

1. Physiological -

1) Adolescence 2) Old age 3) Hypermetrope

2. Cornea -

(4) Flat Cornea (5) Microcornea

3. Lens -

6)lntumescentcataract 7)Traumaticcataract

(8) Anterior dislocation of lens (9) Morgagnian cataract

4. Angle -

(10) Narrow angle glaucoma

5. Choroid -

(II) Choroidal detachment

6. Iris -

(12) Peripheral anterior synechia

7. Operation -

(13) Loss of aqueous from corneal wound (14) Post-operative trabeculectomy (large conjunctival bleb)

8. Pupil -

(15) Pupillary block

Causes of IRREGULAR A.C.

(1) Subluxation of lens

(4) Angle recession

(2) Iris bom be (funnel shaped A.C .)

(5) Tumour of iris or ciliary body

(3) Adherent leucoma

II. Examination of Iris a) Colour

f) Vascularisation

b) Pattern

g) Gap or hole

c) Irldodonesis

h) Iridodyalasls

d) Synechia

I) Ectropion of uveal pigment

e) Atrophic patches

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_____________________________________________ Examination Of An Eye Case 27. a) COLOUR It depends on concentration of pigment. Normally it Is brown.

1) Dirty white (muddy) In Iridocyclitis

3) Pigmented spots - nevus

4) Raised nodules - melanoma, tubercle

2) Grey white spots - atrophic b) PATTERN

1) Syphilis - It Is altered

3) Coloboma - a gap

2) Iridocyclitis - (waterlogged and

4) Retained intraocular foreign body a hole

spongy)

c) IRIDODONESIS (Tremulousness of iris) It occurs due to loss of support to iris by lens. Causes are -

1) Aphakia

3) Shrinkage of lens

2) Dislocation of lens

4) Slackness of suspensory ligaments

d) SYNECHIAE Any adhesions of iris anteriorly to the cornea or posteriorly to the lens or vitreous.

1) Peripheral anterior synechiae

3) Ring or annular synechiae

2) Total posterior synechiae

4) Only posterior synechiae

e) ATROPHIC PATCH Causes are

1) Glaucoma

2) Cyclitis

3) Ischaemia

4) Diabetes

f) VASCULARISATION Causes are

1) Diabetes

2) C.R.A. and C.R.V. occlusion

3) Sickle cell

g) ANY GAP OR HOLE IN IRIS Iridectomy, coloboma

h) ANY IRIDODIALYSIS It is tearing of iris from ciliary body

i) ECTROPION OF UVEAL PIGMENT EPITHELIUM

Above - With a deep anterior chamber, nearly entire iris is illuminated.

Below - With a shallow an­ terior cham­ ber, when the iris is bowed forward, only proximal portion is illu­ minated, and a shadow is seen in the distal half. Figure showing - Depth of ANTERIOR CHAMBER

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28. Practical Ophthalmology 12. Examination of pupil

a) Size

e) Pupillary margin

b) Shape

f) Pupillary area

c) Reaction

g) Number

d) Position

h) I.O.L.

a) SIZE Normally 3-4 mm. in size. Causes of dilated and reacting well pupils (bilateral) 1) Myopia

3) Sympathetic stimulation

2) Nervous excitment

4) Drugs

Causes ot unilateral dilated pupil and reacting

1) Irritation of cervical sympathetic

4) Thoracic aneurysm

chain

2) Apical pneumonia or pleurisy 3) Accessory cervical rib

5) Syringomyelia, anterior poliomyelitis, meningitis

Causes of unilateral dilated and fixed pupil 1) Drugs (in one eye) i. parasympathetic blocking - mydriatic ii. sympathetic stimulating - adrenaline and cocaine

2) Ocular causes i. acute congestive glaucoma (oval)

iii. trauma to eyeball (traumatic mydriasis)

il. iris atrophy

iv. myotonic pupil

3) Lesion in efferent path of light reflex

i. optic atrophy 4) Lesion of efferent path of light reflex I. 3rd nerve palsy

ii. 3rd nerve nucleus involvement

5) Absolute glaucoma 6) Central lesion - head injury, tumor of cortex

Cause of bilateral dilated and fixed pupil: 1) Drugs (In both eyes)

I. parasympathetic blocking

ii. sympathetic stimulating

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Examination Of An Eye Case 2 9.

2) Bilateral optic atrophy 3) Poisoning

1. datura

ill. quinine

li. belladona

Iv. organophosphorus

4) Very deep general anaesthesia

5) After death

Causes of unilateral constriction of pupil 1) Drug action (In one eye)

i. Parasympathetic stimulating - eserine, pilocarpine ii. Sympathetic depressant - ergotamine and ergotoxine

2) Ocular causes I. old iritis with synechiae il. acute iritis (sluggish)

iii. after opening of A.C. during operation

3) Irritative lesions of efferent pathway i. along 3rd nerve and its nucleus

4) Paralytic lesion of cervical sympathetic I. homers syndrome

5) Central lesion i. Argyll

Robertson pupil

ii. lesion of corpus straitum

Causes of bilateral constriction of pupil 1) Physiological I. infants and old age

ii. hypermetropia 2) Drugs (in both eye) - miotics

3) Ocular causes - bilateral iritis 4) Poisoning - morphine and opium b) SHAPE 1) Vertically oval-acute congestive glaucoma

2) Irregular - synechia, sphinture lacerations 3) Festooned-posterior synechia at few places

iii. sleep

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30. Practical Ophthalmology 4) D-shaped (lipdrawn) - Irldodialvsls, vitreous loss, large peripheral button hole Iridectomy

5) Oblique In nasal quadrant - congenital coloboma of iris c) REACTION Normally It is brisk and well sustained. See for

1) Direct reaction

Well sustained or

2) Consensual reaction

Ill-sustained

3) Reaction to convergence and accommodation (1) Direct reaction to light Is elicited by the following method. Cover one eye of the patient with your palm. Throw torch light on the patient’s uncovered eye and note the constriction of the pupil and look whether the constriction is well maintained. Repeat the procedure for the other eye. Finer movements of pupil can be elicited on the slit lamp. f2J For the Consensual reaction Place a cardboard or hand vertically on the nose inbetween the two eyes so that light will not pass from one eye to the other eye. Now throw light on one eye and note the constriction of pupil of the other eye. Repeat the procedure for the other eye. [Note - light thrown on one eye should not fall on the other eye). Swinging Flash Light TestThrow bright light on one pupil and note its constriction. After two or three seconds immediately transfer the light to the opposite pupil. Repeat the procedure several times by swinging the light to and fro and observe the response of the pupil to which the light is transferred. As the direct and the consensual response have the same magnitude, the pupil to which the light is transferred will remain tightly con­ stricted because the in-put of both the input from that diseased side will be less than from the normal side. In such cases on transferring the light to the diseased eye its pupil will dilate, and by swinging back to the normal eye the pupil will constrict. Dilatation of pupil of diseased eye (escape) which occurs is because the light is removed from The normal side. This is known as Marcus Gunn pupil (afferent pupillary defect). This may be an early sign of optic nerve disease.

(3) Reaction to convergence and accommodation The patient is asked to look at a distant object. A finger is held six inches away from the patient’s nose and the patient is asked to look suddenly at the finger. Reaction of the pupil is noted when the patient converges his eye towards the finger. Afferent pathway for pupillary reflex is through optic nerve and efferent pathway is through oculomotor nerve.

d) POSITION

1) Centric,

2) Eccentric, 3) Drawn in one side. e) PUPILLARY MARGINAny adhesion due to synechia.

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Examination Of An Eye Case 31.

f) PUPILLARY AREA 1) Clear

3) I.O.L. Implant

2) Occluded g) NUMBER

1) Single

13.

Examination

2) Multiple

of Lens

a) Pupillary reflex

c) Subluxated or dislocated lens

b) Lens opacity

d) Purkinje Images

a) PUPILLARY REFLEX Normally It Is blackish. 1) Jet black - aphakia

5) Pearly white - mature senile cataract

2) Greyish white - immature senile cataracta

6) Brownish - cataract brunescens

3) Milky white - hypermature margagnian cataract

7) Black - cataracta nigra

4) Chalky white - calcium deposition

8) Sea green - glaucoma

D/d of Leuckokoria (white reflex in eye) (Amaurotic cat’s eye reflex)

(1) Cataract

(8) Retinal dysplasia

(2) Retinoblastoma

(9) Organised vitreous

(3) Endophthalmitis

(10) Angiomatosis of retina

(4) Primary hyperplastic posterior vitreous

(11) Coloboma of choroid and optic nerve

(5) Coats disease

(12) Inflammatory pupillary membrane

(6) Total retinal detachment

(13) T.B. choroiditis

(7) Retrolental Fibroplasia

b) ANY LENS OPACITY It is best seen with slit lamp and ophthalmoscope. Opacity may be central, peripheral, total. Opacity can be demonstrated by iris shadow. Iris shadow is a shadow of pupillary margin on lens, produced when light is thrown obliquely on iris at pupillary margin. Iris shadow requires three things to form i) Opaque structure to make shadow ii) Opaque surface to receive shadow

iii) Clear transparent space In between

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32. Practical Ophthalmology

"

c) ANY SUBLUXATION OR DISLOCATION

-

This will cause tremlou

lenj

(Phacodonesis). Causes :

3) Marfan’s

1) Trauma

2) Homocystinurla d) PRESENCE OR ABSENCE OF PURKINJE darkroom with candle light or pen torch

4) Hypermature shrunken lens SANSON IMAGES

It is seen |n

1 st image -

Anterior surface of cornea

2nd image -

Posterior surface of cornea

3rd image -

Anterior lens surface

4th image -

Posterior lens surface

1 st, 2nd and 3rd images move with the movement of light (convex surfaces)

1 st and 4th Image -

olearly visible'

2nd and 4th -

seen in bright light in darkroom

If 4th image is absent -

lens is opaque

If 3rd and 4th images are absent-

Aphakia (absence of lens)

e. PSEUDOPHAKOS - (I.O.L.) (Intraocular lens)

Figure showing maturity of cataract

Above - I.S.C. showing JI-IS shadow

Below - M.S.C. with no iris shadow

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Examination Of An Eye Case 3 3. 14. Examination of Nasolacrimal Passage (N.L.P) If there Is conjunctival congestion of one eye only then there Is suspicion of sac Infection. Normally, there Is no regurgitation on pressure over sac area. Look for a. ANY REDNESS OR SWELLING OVER SAC AREA b. ANY FISTULA ON SKIN OVER SAC AREA

c. ANY REGURGITATION of watery, mucoid or purulent discharge through the puncta on pressure over sac area. N.L.R PATENCY TEST - Before doing the patency test one should differentiate epiphora from lacrimation by 1) Syringing the lacrimal passage

2) Instillation of coloured fluid in conjunctival sac and demonstrating

3) Probing of the lacrimal passage 4) Radiological examination by injection of radioopaque dye in the N.L.P - It is more informative procedure 5) By radioactive tracer

(1) Syringing the lacrimal passage ; -

Procedure 4% xylocaine Is put on the punctum and In the lower fornix of the eye. The doctor stands on the patient's head side and asks the patient to look towards him. Then evert the lower lid with the thumb and dilate the punctum with punctum dilator. Then fill 5 ml syringe with saline with lacrimal canula attached to it. Insert the tip of lacrimal canula in the punctum' and Into the canaliculus first vertically and then horizontally. Push saline and note the following results. i) If the passage is freely patent, saline appears in the nose at once. (Patient will tell the surgeon that saline has come In his throat) ii) If considerable pressure is required to push the saline and a part of saline appears in the nose while a part of it outflows through the upper punctum then it indicates a par­ tial block.

iii) After pushing the saline no fluid comes In the nose but it is regurgitated through the upper punctum then there is a complete block below the common canaliculus. The nature of fluid regurgitated (clear, mucoid or purulent) gives indication of infection. iv) Finally if saline introduced returns through the same lower punctum it is a clear indica­ tion of block in the lower canaliculus. In such a condition, syringing should be repeated from the upper punctum to know the patency of rest of the lacrimal passage.

Causes of epiphora

l) Congenital i. Unformed

II. Atresia of N.L.R

iii. Obstruction in N.L.P

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34. Practical Ophthg|mo|oav

_____ ______________________

2) Dacryocystitis 3) Eversion ot lower punctum

4) Inadequacy of lacrimal pump 5) Traumatic 6) Malposition of lower puncta

15. Examination of Intra-Ocular Tension (I.O.T.) : Normal I.O.T. is 15 to 22 mm Hg. schiotz Doubtfully increased I.O.T. -22 to 25 mm. Hg. schiotz

Raised intra-ocular tension - more than 25mm. Hp. schiotz Hypotony - I.O.T. less than 12.5 mm. Hg. schiotz Method of recording of I.O.T.

a) DIGITAL METHOD b) INSTRUMENTAL METHOD i. Indentation tonometer (Schiotz)

ii. Applanation tonometer

iii. Non-contact tonometer a) Procedure of digital method : The tension may be assessed by fingers, somewhat in an inaccurate manner as follows. The patient is asked to keep looking towards his feet, and, the index Fingers of both hands are placed side by side upon the upper lid above the upper level of the tarsal plate, steadied by other Fingers lightly applied to the brow. One ‘finger is kept quite still, pressing upon the globe through the lid while the globe is indented with the other finger, pressing directly down-wards, meanwhile, attention being con­ centrated on the impression of fluctuation which is conveyed to the station­ ary Finger. The normal fluctuation can only be appreciated by practice. When the eye is very hard fluctuation is absent, if very soft the response resembles a waterbag. I.O.T. is then graded as felt normal, felt high or felt low.

b) Instrumental method - see page no. 92.

16. Examination by Palpation a) LYMPH NODES 1) Preauricular 2) Sub-maxillary Outer half of lid, complete lacrimal gland and conjunctiva drain into preau­ ricular nodes. Inner half of lid, lacrimal passage drain into sub-maxillary nodes.

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Examination Of An Eye Case 35. b) ORBIT see for 1) Any Irregularity of margins

2) Any mass

3) Any tenderness c) EYEBALL see for 1) Any tenderness 2) Any growth

3) Any pulsations 17. Examination of Ocular Movements eyes together.

First test each eye separately and then both

All extra-ocular muscles are supplied by 3rd nerve except lateral rectus (6th) and superior oblique (4th).

a. UNIOCULAR movements b. BINOCULAR movements

Actions of extra-ocular muscles starting from primary position Main action

Subsidiary action

1. Superior rectus

Elevation

Adduction & intorsion

2. Inferior rectus

Depression

Adduction & extorsion

3. Superior oblique

Intorsion

Depression & abduction

4. Inferior oblique

Extorsion

Elevation & abduction

Restricted movements of eye arc seen in muscle palsy

RIGHT

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch

----- ^-J^SSLQphthalmology__________________ Mo

Action Of Ocular Muscle For Binocular Movements

LU?

LEFT

RMR

• LSO

RSO/LSO

RSO

18. Examination by Transillumination

a) TRANSSCLERAL An intense beam of light Is thrown on the conjunctiva and sclera whereupon the pupil normally appears red. If solid mass Is present In the path of light, the beam is obstructed and pupil appears black.

b) INDIRECT TRANSILLUMINATION A powerful source of light is placed in the mouth illuminating the eyes from behind. Normally the pupils have a strikingly luminos appearance but if a solid mass occupies the fundus, it appears black.

c) TRANSPUPILLARY The patient is seated in a darkroom. A beam of light is thrown obliquely through a dilated pupil. Normally a red glow is visible on scleral sur­ face. If there is a growth or mass In any meridian then the glow is not properly seen in that meridian.

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch

Examination Of An Eye Case 3 7.

3. Examination of Retinal Functions 1. SUBJECTIVE EXAMINATION A) VISUAL ACUITY

a. Subjective method

1) For distance by Snellen’s chart. With & without glasses, with pinhole. 2) For near by N-series b. Objective method

1) Optokinetic nystagmus

2) Photostress test

B) COLOUR VISION

a. Lantern test

d. Nagel's anomaloscope

b. Holmgren’s wool test

e. Fornsworth 100 Hue test

c. Ishihara (Pseudo-isochromatic plates)

C) LIGHT SENSE By photometer or adoptometer

D) FIELD OF VISION a. Confrontation test b. Perimetry

1) Kinetic

(1) Arc perimeter

(2) Goldman spherical perimeter

2) Static

(1) Goldman (2) Turbinger perimeter

c. Campimetry

(1) Bjerrum’s screen

d. Chart test

(1) Amsier’s grid

(2) After image test

II. OBJECTIVE EXAMINATION A. Electroretinogram (E.R.G.)

B. Electrooculogram (E.O.G.) C. Visual evoked response (VE.R.)

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch

38. Practical Ophthalmology

SNELLEN'S DISTANT VISION CHART

E DN HCU OLAF DHLEN CTPALO DNHOBUC Various charts are available in different languages, for illiterates and for children.

Each latter makes an angle of 5 degrees at nodal point.

6/24

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch

___________________________ _________________ Examination Of An Eye Case 39. III. SUBJECTIVE EXAMINATION

A) VISUAL ACUITY It is the power of the eye by which objects are distinguished from each other. It Is also a measure of the smallest retinal image which can be appreciated for Its shape and size.

1) DISTANT VISION : Normal distant vision Is 6/6. It is recorded from a dis­ tance of 6 metres (20 feet). Why 6 metre (20 feet) distance? Reason - Rays coming from 6 metres or more, are parallel for all practical purposes though they are somewhat divergent i.c. by amount -0.17 degree (negligible), that Is why 6 metre distance is taken for recording distant vision. Examine Vision of * Right eye and left eye separately * Both eyes open

* Right eye with pinhole if V/A is less than 6/6 * Left eye with pinhole if V/A is less than 6/6 * Right eye with spectacles * Left eye with spectacles

* Both eyes with spectacles For illiterate persons Dot chart, E chart. Ring chart (landolt’s chart)

For children below 3 years of age -

Picture chart. Toys V/A is written as Numerator/Denominator

Neumerator is distance of the patient from the chart. Denominator is distance at which person with normal vision can read

OR the distance at which patient should be able to read. (e.g. V/A = 6/24 means that the patient reads from a distance of 6 mfrs. What a normal person can read from a distance of 24 meter OR The patient reads from a distance of 6 metres, what the patient should be able to read from 24 meters)

PROCEDURE OF RECORDING DISTANT VISION A chart known as Snellen’s chart containing snellen’s test types is taken. In this the letters gradually diminish in size from First line to last line. i. The patient is asked to sit or stand at a distance of 6 metres (20 ft.) away from the chart. The patient is then asked to close one eye without pressure. The patient is then asked to read from top line downward. The last line that he reads is recorded as the visual acuity, eg. 1st. line is 6/60, 2nd line is 6/36, 3rd line is 6/24 and so on.

40. Practical Ophthalmology

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch

-

___

II. If the patient cannot read first line I.e. his vision is less than brought towards the chart at a distance of 5 metres. 4 metres. 3 ime the patient Is able to see the biggest letters of the top line and e v 5/60, 4/60, 3/60 and so on respectively.

IT? r„rordpd.

III. If the patient cannot read top line from a distance of one asked to count the surgeon’s Fingers against a well illuminated bac g tance at which he can count the fingers is recorded and written as e.g. ing Finger 1/2 metre in that eye.

^"2*!Js coun*

Iv. If the patient cannot count the Fingers then the surgeon moves the patient’s eye, if patient can distinguish the movement of hand corded as V/A Hand movements (from that distance).

v. If the patient cannot see hand movement then the patient is seated in a darkroom^ One eye of the patient is closed with the palm and light is thrown on e eye from all the four directions i.e. from up, down, nasal and tempora patient is asked if he can see the glow of the light from all the four irec rately. This is known as PLPR (perception of light and projection of rays) an i as .
iris has a firm contact with lens functional pupillary block

(b) Periphery of iris is in folds -> Aqeons collects in posterior chamber -> iris at periphery bulges forwards -> causes angle closure -> factors (a) & (b) causes raised I.O.T. 2) MYDRIASIS - Pupil is fully dilated -> crowding of

iris at the root of iris -> angle

closure -> increased I.O.T.

ciliary body in region of angle and forward bulge of lens causes angle closure -> increased I.O.T.

3) ACCOMMODATION - Increase in bulk of

STAGES OF NARROW ANGLE GLAUCOMA

1) Prodromal stage. 2) Stage of constant instability.

3) Acute congestive stage. 4) Chronic congestive stage.

5) Absolute glaucoma. 6) Degenerative stage. PROVOCATIVE TEST FOR NARROW ANGLE GLAUCOMA

1) Mydriatic test.

2) Dark room test. 3) Reading test. 4) Priscol test. 5) Prone text. 6) Tonography.

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch

Clinical OphthalmicCases 147.

Narrow Angle Glaucoma

clinical case

AGE

More common between 50 to 60 yrs. of age.

SEX

More common in females 4:1.

BILATERALITY

Usually bilateral.

HEREDITARY

Autosomal dominant.

SEASONAL

Common in winter in India. Maximum incidence is in June and July due to middilated position of pupil in cloudy weather.

type of eye

1) Small eye

2) Hypermetropic

3) Shallow A.C.

4) Narrow angle

5) Plateau Iris

6) Relatively large size of lens

Myopic c\ es are immune to narrow angle glaucoma. TYPE OF PATIENT

,

PRESENTING SYMPTOMS

Usually female, Hypermetropic, nervous. Presenting symptoms depends on the stage of disease.

1) IN PRODROMAL STAGE

a) Blurring of vision

c) Mild pain in eye

b) Coloured haloes around light

d) Headache

There is reversal of symptoms and comes at irregular intervals usually pre­ cipitated by factors like anxiety, fatigue, overwork in evenings. 2) STAGE OF CONSTANT INSTABILITY

Symptoms are the same as that of stage one, but it appears at regular intervals and frequency increase. 3) ACUTE CONGESTIVE STAGE

a) Severe pain in and around the eye e) Bilious vomiting, perspiration b) Headache

(usually unilateral)

c) Sudden and total loss of vision d) Watering and redness of eyes

f) Prostration, irregular pulse

g) I.O.T. comes to baseline (normal) with medical treatment

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch

148. Practical Ophthalmology 4) CHRONIC CONGESTIVE STAGE

a) Dull and constant pain In the eye

c) I.O.T. does not come to baseline (normal) with medical treatment

b) Marked diminution of vision 5) ABSOLUTE STAGE

a) Pain in eye which is severe and irritating

c) Watering and redness of eye

b) Headache

d) Vision is - No P L

PAST HISTORY

1) Vasomotor Instability

2) Instillation of any drug in the eyes, or consumed 3) History of any surgery in the eye PERSONAL HISTORY

1) Nervous temperament 2) Vasomotor instability GENERAL EXAMINATION

During Acute congestive stage

1) Bradycardia

2) Pulse may be irregular 3) Prostration TORCH LIGHT EXAMINATION OF THE EYE

It depends upon the stage of glaucoma 1) IN PRODROMAL STAGE

a) Eye is white and quiet

b) A.C. is shallow c) I.O.T. may or may not be raised 2) STAGE OF CONSTANT INSTABILITY

a) Cornea is hazy b) A.C. is shallow

c) Pupil is semidilated d) I.O.T. is raised

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch

Clinical Ophthalmic Cases 149. 3) ACUTE CONGESTIVE STAGE

a) Lid oedema Is present and there is watering of eye,

b) Palpabral aperture is narrow, c) Conjunctival congestion and chemosis is seen,

d) C.C.C. is present,

e) Cornea is hazy, f) Corneal sensations are impaired,

g) A.C. is shallow, may be funnel shaped, h) Iris colour and pattern is altered due to oedema, i) Pupil is vertically oval, semidilated and fixed, j) I.O.T. is markedly raised,

k) Fundus may shows papilloedema and pulsating arteries. 4) CHRONIC CONGESTIVE STAGE

a) Mild lid oedema, b) Palpabral aperture is slightly narrow, c) Mild conjunctiva] congestion is seen,

d) C.C.C. is present,

e) A.C. is shallow,

f) Iris colour and pattern is altered (patches of iris atrophy), g) Pupil is semidilated and sluggishly reacting, h) Lens shows glaucomatous flecks (glaucoma fleckens), i) Fundus shows glaucomatous optic atrophy j) I.O.T. is moderately raised. 5) ABSOLUTE GLAUCOMA STAGE

a) Eyeball is stony hard, I.O.T. is very high,

b) Mild lid oedema and palpebral aperture is narrow, c) Dilated and tortuous circumciliary vessels, d) Cornea is hazy and oedematous,

e) Bullous and filamentary kerotopathyis present, f) A.C. is shallow,

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch

150, Practical Ophthalmology_________________ _________________ g) Iris atrophy and ectropion of uveal pigment is seen,

h) Pulpl Is dilated and Fixed,

1) Lens shows cataractous changes, j) Staphyloma may be seen,

k) Fundus show glaucomatous optic atrophy. 6) IN DEGENERATIVE STAGE

a) Extreme thining and discoloration of sclera,

b) I.O.T. is low. (due to ciliary atrophy), c) Atrophic bulbi,

d) Degenerative pannus. DIFFERENTIAL DIAGNOSIS OF ACUTE CONGESTIVE GLAUCOMA

1) Acute conjunctivitis

2) Acute iritis MANAGEMENT OF NARROW ANGLE GLAUCOMA I. INVESTIGATIONS

1) Visual acuity 2) I.O.T. - raised or normal (differential tonometry) 3) Gonioscopy -

(a) To see the grade of angle and planning of treatment. (b) To see for synecha and angle structure of A.C. 4) Provocative tests in doubtful cases of early stage a) Dark room test

d) Priscol test

b) Mydriatic test

e) Tonography

c) Reading test

f) Prone test

5) Slit lamp examination II. TREATMENT

The treatment of narrow angle glaucoma depends on the stage at which the dis­ ease is diagnosed. 1) In the prodromal stage ana stage of constant instability -

Pilocarpine I to 4% eye drops four times a day & prophylactlcally before provocative factors.

A) Medical line of treatment -

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch Clinical Ophthalmic Cases 151. B) Surgical line of treatment - Alternatively surgical or laser

peripheral button hole iridectomy can be done. 2) In Acute congestive stage - Treatment should be instant A) Medical treatment -

a) To lower I.O.T. 1) Pilocarpine 1% to 2% eye drops frequently till the tension returns to normal and the pupil constricts.

In addition Timolol 0.5% eye drops twice daily is

instilled. 2) Tablet Acetazolamide 250 mg. is given orally 3-4 times daily.

3) 20% I.V. Mannitol is given In rapid drip (1-3 gm/ kg. body wt.)

4) Oral glycerol (3 gm/kg. body wt.). b) Analgesic is given to releive pain

c) Local heat may be applied

B) Surgical treatment -

a) If I.O.T. returns to normal with medical line of treatment within 24 to 36 hrs. then wait till the eye becomes quiet

and then do gonioscopy. 1) If a large portion of angle is open and periph­

eral anterior synechiae are not extensive then a

peripheral button hole iridectomy at 12 O'clock is done.

2) If peripheral anterior synechiae have formed then trabeculectomy is done.

b) If the I.O.T. is not controlled by medical line within 24 to

36 hrs. then filtering surgical procedure is done.

c) P.B.I. is done in the fellow eye as a prophylactic

measure. 3) In chronic congestive stage - Surgical procedure is only the mode of

treatment. A Filtering surgery is done & a prophylactic PB.I, in the fellow eye.

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch 152. Practical Ophthalmology

4) In stage of Absolute glaucoma a) If the eye Is very painful then it is best to enucleate the eye.

b) If the eye cannot be enucleated for any reasons the pain is con­ trolled by Retrobulbar injection of 2% Xylocaine + 80% alcohol and analgesics are given. c) A drainage procedure may be done (Scion’s implant) or (AGV glau­ coma valve).

d) Cyclocryo may be tried.

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch Clinical Ophthalmic Cases 153.

C.

CHRONIC SIMPLE GLAUCOMA

DEFINITION

It Is a chronic, slowly progressive, usually bilateral disease clinically characterised by raised I.O.R, an open angle, glaucomatc js cup­

ping of disc and visual Field loss. CAUSATIVE MECHANISM 1) Sclerotic process in trabecular meshwork or schlemn's canal or collecting chan­ nels -> drainage is impeded -» raised I.O.R

2) Plenty of uveal pigment in the angle -> blocks pores —> raised I.O.R

3) Vascular sclerosis -> hampers absorption of aqueous, raised I.O.R

PATHOPHYSIOLOGY 1) Due to raised I.O.T. -> atrophy of nerve fibre bundles and ganglion cells, 2) Lamina cribrosa is depressed backwards -> known as cupping of optic disc,

3) Cavernous atrophy of optic nerve, 4) Sclerosis of the trabecular with pigment deposition, 5) In late stage whole uveal tract becomes atrrophic.

CARDINAL FEATURES 1) Raised intraocular tension,

2) Cupping of the optic disc, 3) Typical Field changes,

4) Open angle. CUPPING OF OPTIC DISC

It is due to -

1) Mechanical pressure

2) Ischaemia.

FIELD CHANGES IN CHRONIC SIMPLE GLAUCOMA

1) Enlargement of the angioscotoma,

5) Roenne’s Nasal step,

2) Baring of the blind spot,

6) Only tubular field remains,

3) Sickle shaped scotoma (Seidel's sign)

7) Small path of temporal periphery is retained,

4) Arcuate scotoma (Bjerrum’s scotoma),

8) Blind eye.

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch 154. Practical Ophthalmology

Chronic Simple Glaucoma Or Wide Or Open Angle Glaucoma

CLINICAL CASE

AGE

Common in late middle life and early old age.

SEX

Occurs in either sex.

BILATERALITY

Essentially bilateral.

HEREDITARY

Genetically determined.

TYPE OF EYE

More common in high myopic eyes.

PRESENTING SYMPTOMS

It is a quiet and slowly progressive disease which is usually symptomless. Mild symptoms may be experienced by the patient in the form of -

1) Blurred vision,

5) Frequent change in presbyopic

glasses,

2) Difficulty in reading, 6) Delayed dark adaptation, 3) Eyeache,

7) Increase light minimum.

4) Scotoma,

PAST HISTORY 1) History of any use of drugs locally or systemically,

2) History of surgery in any of the eyes.

GENERAL EXAMINATION For any metabolic disorder.

LOCAL TORCH LIGHT EXAMINATION

1) CONJUNCTIVA

Minimal changes are seen. Visible dilatation of anterior ciliary artery.

2) CORNEA

Slight haziness-> Bullous or filamentary keratopathy in late stages of the diseases -> Hypoaesthesia.

3) IRIS

Atrophic patches, -> colour and pattern of iris is altered. There is loss of crypts.

4) ANTERIOR CHAMBER No obvious change in depth of A.C.

5) PUPILS

Sluggishly reacting pupils in advanced stages and widely dilated

Fixed pupil in absolute stage is seen.

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch Clinical Ophthalmic Cases 155.

___________ ____

6) LENS

Pseudoexfollatlon of lens capsule may be seen. Complicated cataract may be seen.

7) FUNDUS EXAMINATION

It Is a very Important examination -

(a) Pallor and cupping of optic disc,

e) Focal notching of the Cup rim,

(b) Horizontal Cup : Disc ratio Is more than 0.4, f) Bayoneting of blood vessels,

(c) Splinter haemorrhages on disc,

g) Thinning of neural rim,

(d) Nasal shifting of blood vessels at the disc,

h) Retinal nerve fibre damage.

8) INTRA OCULAR TENSION Differential tonometry Is more reliable. I.O.T. may or may not be more than 21 mm/Hg. Single reading of the I.O.R is valueless. Hence the patient should be hospitalised and a record of I.O.T. every two hourly should be recorded and a diur­ nal curve obtained. The amount of variation In the I.O.T. is noted (Diurnal variation). Provocative tests for diagnosis of chronic simple glaucoma are :

a) Water drinking test,

d) Jugular vein compression,

b) Priscol test,

e) Amyl nitrate test,

c) Steroid test,

g) Cafine test.

9) VISUAL FIELDS

Particularly the central field show typical field changes like -

a) Enlargement of angioscotoma, b) Baring of the blind spot, c) Siedel’s sicklescotoma,

d) Bjerrum’s arcuate scotoma, e) Annulars scotoma,

Peripheral fields may show f) Roennes nasal step, (upper or lower nasal sectorial defects),

g) In late stage tubular Field is present, h) In the last stage only a patch of temporal field persists and ends in blindness.

10) OCULAR ASSOCIATIONS

a) High Myopia,

b) Retinal vein occlusion, c) Retinal detachment, d) Fuch’s endothelial dystrophy,

e) Retinitis pigmentosa.

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch 156

Practical Ophthalmology

MANAGEMENT OF CHRONIC SIMPLE GLAUCOMA A) INVESTIGATIONS

1) Estimation of I.O.T.,

6) Visual fields (central & peripheral)

2) Gonloscopy

7) Slit lamp examination,

3) Provocative tests,

8) Visual acuity,

4) Facility of aqueous outflow (C ’ Value) - If less than 0.12 it is diagnostic of glaucoma,

9) Fundus examination.

5) Diurnal variation (It is an important test),

B) TREATMENT Principle of treatment is to control the intraocular tension within the normal limits . id thus prevent Field loss. Efforts should be made to control the I.O.T. by medical treat­ ment. Surgical line of treatment is the last choice of treatment in chronic simple glaucoma.

1) Medical Treatment

With medical line of treatment a proper periodic record of

vision, I.O.T. and Field charting is a must. Drugs used to control I.O.T. are i) Beta-adrenergic blocking agents - Timolol (0.25, 0.5%) eyedrops locally, b.d. or

Betoxolol 0.5% eye drops b.d. ii) Miotics - Pilocarpine 0.5% to 4% eye drops 3 to 4 times a day. iii) Tablet Acetazolamide

- given orally in the dose of 125- 250 mg. QID.

Treatment should be started with Timolol 0.25% eye drops b.d. if I.O.T is not con­ trolled then 0.5% drops are instilled. If with timolol alone the I.O.P is not controlled then pilocarpine eye drop in various strength is combined with it. If still I.O.P is not controlled then tablet diamox is added to the above treatment. If the combination of the above trio fails to control the I.O.P. then filtering operation is undertaken. Other drugs which can be used locally are Adrenaline 0.5% eye drop, Demecarium bromide 0.25% - 0.5%, Ecothiopate Iodide 0.03% - 0.25% Carbachol. These drugs are not used routinely. 2) Surgical Treatment Drainage of aqueous is facilitated from anterior chamber to the sub-conjunctival tissue with the help of filtering bleb. Various filtration surgeries done are -

a) Trabeculectomy, b) Trabeculocyclostomy,

c) Trephining.

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch

Clinical Ophthalmic Cases 157. d) Lagrange's operation, e) Scheie's thermosclerostomy operation,

f) Prezlosls operation,

g) Irldenclelsis. Other Surgeries are a) Stallard’s operation,

b) Laser Trabeculoplasty.

low-tension glaucoma In this condition the I.O.R is less than 21 mm/hg. but the optic nerve damage and field changes are similar to POAG. In this condition the IOT should be maintained below 12 mm/hg. so as to prevent visual Field changes.

OCULAR HYPERTENSION

It is a condition in which the I.O.R is more than 21 mm/hg. but there are no optic nerve damage or field loss. There is no way to predict whether patients of ocular hyperten­ sion will develop POAG or not. GLAUCOMA SUSPECT

Definition -

A person suspected of having or who is likely to develop glaucoma.

(Proper evaluation and follow up of patient is required in this condition).

Divided Into 1) With normal I.O.R

a) No optic nerve damage

b) Suspected optic nerve damage

2) With elevated I.O.R

a) No optic nerve damage

b) Suspected optic nerve damage

Conditions Increasing suspicion of glaucoma 1. Optic nerve - Large cup disc ratio, vertical oval cupping, haemorrhages on disc margin.

asymmetry of cup size,

2. Visual fields - Generalised constriction, baring of the blind spot, enlarged blind spot, nerve fiber bundle defects, relative paracentral scotoma.

Patient with normal I.O.T. at a higher risk of developing glaucoma 1. Strong family history of glaucoma

4. Uveitis

2. Pseudo-exfoliation of lens capsule

5. Trauma

3. Pigmentary dispersion

6. Vascular occlusion

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch 158. Practical Ophthalmology

4. Corneal Ulcer DEFINITION

Breach In the continuity of corneal epithelium due to infection with or with­

out involving the other layers of the cornea and thus forming a local raw excavated defect.

ETIOLOGY

1) Exogenous 2) From ocular tissue

Disease of - conjuntiva, sclera, uvealtract.

3) Endogenous From circulation

Allergic in nature PATHO - PHYSIOLOGY

3 Stages -

1) Progressive stage - Localised necrosis of most anterior layer of cornea -> Desquama­ tion of epithelia and also bowmans membrane -> Saucer shaped ulcer -> Wall of ulcer is raised due to swelling of corneal lamellae -> Floor of ulcer is covered with slough -► surrounding area is packed with leucocyte and other inflammatory cells. (Grey zone of infiltration).

2) Regressive Stage - -> Grey line appears which consist of polymorphs and form sec­ ond line of defence. -> Leukocytes exert digestive function and dissolves necrotic tis­

sue. -> Necrotic material is sloughed off -> cloudiness disappears -> Size of epithe­ lial defect increases -> Ulcer is shallow with sloping margins -> Transparency improves -> Patient is symptomatically better.

3) Cicatrization Stage - Healing occurs with scar formation -> Ulcer becomes vascularised -> Ulcer crater Fills up with fibrous tissue derived from Fixed corneal cells, mono­ nuclear cells and endothelial cells. New fibre are laid hapazardly so they cause irregu­ lar refraction (Bowman membrane is never regenerated). -> Epithelium grows from mar­ gin of ulcer and covers the cornea -> This laid fibrous tissue causes opacity of cornea

and depending on its density forms 3 grades of opacity known as nebular, macular and leucoma. Nebular opacity in pupillary area interferes more with vision due to irregular refraction of rays.

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch Clinical Ophthalmic Cases 159

Corneal Ulcer AGE

CLINICAL CASE

Can occur at any age.

SEX

More common in males due to more chances of injury to the eyes and exposure to infection because of outdoor activity.

PRESENTING SYMPTOMS (Complaints of patient) -

1) Pain in eye

5) Lacrimation

2) Redness

6) Diminution of vision

3) Photophobia

7) Foreign body sensation

4) Blephrospasm

8) Discharge

PREDISPOSING FACTORS

Patient may give history

1) Injury to the eye by vegetable matter, nail, foreign body etc.

5) Contact lens wearer 6) Dental problem

2) Acute or chronic conjunctivitis 3) Chronic dacryocystitis 4) Chronic foreign body sensation in

7) E.N.T. problem

eye as in trichiasis and concretion OTHER PREDISPOSING FACTORS ARE

8) Vitamin - A deficiency

11) PC. malnutrition

(Keratomalacia) 9) Xerosis / Drying of Cornea 10) Loss of corneal sensations

12) Allergy 13) Steroids

(Neuroparalytic keratitis) PAST HISTORY

Patient may give history of -

1) Diabetes mellitus

• 7) Measles

2) Tuberculosis

8) U.R.I.

3) Gonorrhoea

9) Diptheria

4) Syphilis

9) Diptheria

5) Influenza

11) Leprosy

6) Herpes

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch 160. Practical Ophthalmology PERSONAL HISTORY

1) Alcoholic - It causes diminished

2) Drug addiction - Heroin,

body resistance

etc-

SOCIO-ECONOMIC STRATA

1) Low

a) PC. malnutrition

b) Vitamin - A deficiency

GENERAL EXAMINATION 1) See for any signs of Vitamin - A deficiency 2) Built of patient whether malnourished or cachexic SYSTEMIC EXAMINATION

For focus of infection in the body including E.N.T., Dental checkup.

LOCAL OCULAR EXAMINATIONS VISUAL ACUITY

Diminished.

WATERING AND DISCHARGE

Profuse watering is present, serous, mucoprulent or purulent discharge may be present.

LID

- blephrospasm, - lid oedema is present, - see lid margin for trachiasis if any, - eye lashes are matted because of discharge.

CONJUNCTIVA

- Conjunctival congestion is present, - Circum-Corneal congestion is present, - Concretions may be present on tarsal conjunctiva.

CORNEA

- Look for site of ulcer whether centrally situated or peripheral,

- See for shape of ulcer, - See and describe the margin, extent & floor of ulcer (better seen with 2% fluorescene staning and blue filter), - Window reflex is distorted or absent at site of ulcer,

- There is loss of normal corneal transparency'. Cornea is hazy or a rough and raw ulcer may be seen,

Corneal sensations may be diminished or absent,

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch

Clinical Ophthalmic Cases 161,

- Superficial peripheral comeal vasculansatlon may be seen, - A descematococle may sometimes be seen.

ANTERIOR CHAMBER

Hypopyon (Sterile pus) may or may not be seen.

IRIS

Slightly muddy (Indicates mild iritis).

PUPIL

May be constricted If Iritis is present.

LENS

Is transparent, complicated cataract may be present or a simple senile cataract may be seen.

Usually normal. I.O.T. is raised if hypopyon or associated uvei­

I ■ O. T.

tis Is present (Secondary glaucoma).

I.O.T. is low if the ulcer perforates. Note : Never record I.O.T. with schiotz tonometer in Corneal ulcer. Use non­

contact tonometer. NASO LACRIMAL PASSAGE

Mucoid or purulent regurgitation may or may not be present.

If regurgitation is present then the infected lacrimal sac is the cause of corneal ulcer. Sac should be immediately excised. IN A PERFORATED CORNEAL ULCER

CORNEA

A minute hole i.e. perforation is seen (Best seen with S.L.E) or a pseudocornea may be seen or a adherent leucoma may be seen. A.C. Collapsed, very shallow or irregular.

IRIS

Partial or total prolapse of iris occurs in the perforated part of ulcer or anterior synechia may form, depending on the size and site of perforation.

PUPIL

.

Irregular in shape.

LENS

Anterior polar cataract forms. Dislocation or expulsion of lens may some­ times occur if perforation is large.

I.O.T.

is low.

EYE MOVEMENTS

Become restricted if panophthalmitis supervenes.

DIFFERENTIAL DIAGNOSIS OF CORNEAL ULCER

Firstly

Differentiate Corneal ulcer from corneal abrasion and corneal opacity.

Secondly

Describe the type of corneal ulcer whether.

Fungal/Bacterial/VIral/Degenerative/Nutritional etc. SEQUELIS OF CORNEAL ULCER 1) Corneal opacities of various grades viz. -

Nebular, Macular, Leucoma,

(See Page -168).

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch 162. Practical Ophthalmology

_

_

2) Corneal staphyloma - Partial or Total,

3) Adherent leucoma, 4) Degeneration of Cornea, 5) Keratectasla, 6) Astigmatism. COMPLICATIONS OF CORNEAL ULCER The following are the complications of Corneal Ulcer -

1) Corneal Fistula,

2) Intraocular haemorrhage, 3) Total corneal perforation and expulsion of occular contents, 4) Iridocyclitis, 5) Hypopyon, 6) Secondary glaucoma (inflammatory), 7) Complicated cataract,

8) Subluxation/Dislocation of lens, 9) Endophthalmitis, 10) Panophthalmitis,

11) Secondary glaucoma (post inflammatory),

12) Pthysis.

MANAGEMENT OF A CASE OF CORNEAL ULCER I INVESTIGATIONS

A) LOCAL OCULAR INVESTIGATION 1) Conjunctiva) swab and smear for culture & antibiotic sensitivity, 2) Corneal smear for Grams staining and KOH examination, 3) Lacrimal sac syringing to know patency of N.L.P.,

4) Fluorescein staining of cornea, 5) Slit lamp examination,

6) I.O.T. examination by non-contact tonometer or digitally, 7) Corneal sensation.

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch Clinical Ophthalmic Cases 163. B) SYSTEMIC INVESTIGATION

1) Blood analysis - TIC, DLC, Hb%, E.S.R., MX, MMR, peripheral smear,

2) Blood sugar, 3) ENT check up, 4) Dental Check up,

5) Check up to rule out septic foci in body. II TREATMENT OF CORNEAL ULCER

Treatment of Corneal ulcer may be divided Into following categories A) Treatment of Uncomplicated corneal ulcer,

B) Treatment of Non-healing corneal ulcer,

C) Treatment of Perforated (complicated) corneal ulcer, D) Treatment of Healed corneal ulcer (corneal opacity). A) TREATMENT OF UNCOMPLICATED CORNEAL ULCER

1) Control of infection by appropriate antibiotics,

2) Cleanliness and hygiene of eye,

3) Heat, 4) Rest,

5) Protection to the eye, Other measures include -

6) Removal of causative agent, 7) Releif of symptoms,

8) Specific treatment if any, 9) Supportive treatment 1) Control of infection-A broad spectrum antibiotic is immediately started by a) Local frequent instillation of eye drops in the day and eye ointment at night,

b) Subconjunctival injection is given,

c) Oral or parenteral antibiotic having good ocular penetration is administered,

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch 164. Practical Ophthalmology - In the mean time ulcer scraping and con­ junctiva) swab is sent for culture and sen­ sitivity and on getting the report appro­ priate antibiotic is given.

- Fungal ulcers are treated by local Nystatin eye ointment, Amphotericin B Trlchomycin. -

Viral ulcers are treated with I.D.U. Drops, Acyclovir 3% eye ointment, Trifloridine 1 % eye drops.

- Steriods are contraindicated in infected calomel ulcers. They may be given in cases of allergic and toxic corneal ulcers and herpes zooster but under full cover of antibiotics.

2) Cleanliness and hygiene of eve - Remove the discharge from eye, - Wash the eye with saline or antiseptic boric solution. 3) Heat Irrigation of eye with warm saline -

- Hot compresses.

It helps in Improving circulation of eye & rapid healing. 4) Rest to the eye - By topical application of 1 % Atropine eye ointment.

5) Protection Pad and bondage for rapid healing of ulcer.

6) Removal of Causative factors

if present -

- Do sac excision if sac is infected,

- Remove foreign body if present,

- Epilate eyelash if trachiasis is present, - Remove concretion if present,

- Tarsorraphy in cases of neuroparalytic ulcer.

7) Relief from pain

Analgesics and antiinflammatory

8) Specific treatment if any - Manage the cause like diabe­ tes, T.B., syphilis, anaemia, malnutrition, vit. A deficiency,

9) Supportive treatment - Multivitamins, high protein diet. Restrain from alcohol and drug addiction.

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch _____ _________________________________ Clinical Ophthalmic Cases 165. B) TREATMENT OF NONHEALING CORNEAL ULCER a) Medical - The routine line of treatment as seen earlier is car­

ried out apart from it other measures Include -

1) in cases of impending perforation and descemetocoele then measures to immediately reduce the I.O.T. should be taken by tab, diamox, oral glycerol or osmotic agent. At the same time support to descemetocoele is given by firm pressure and bandage or soft contact lens. b) Surgical

1) Debridement and curratage of corneal ulcer,

2) Cauterization of ulcer, 3) Kerato-Cryo therapy (under trial), 4) Paracentesis, 5) Conjunctival flapping, 6) Therapeutic lamellar keratoplasty, 7) Tarsorrhaphy. C) TREATMENT OF PERFORATED (COMPLICATED) CORNEAL ULCER

Treatment depends on size and site of perforation -

1) If corneal perforation is small and central then prolapse of iris is not feared. T/t given - Rest in bed, - Antibiotic and Atropine 1 % eye oint. locally, - Patient should avoid straining,

- Pressures pad and bandage to the eye. 2) if perforation is small and paracentral or peripheral then adhesion of iris to the cornea usually occurs. Treatment Is same as above.

3) If perforation is larger and prolapse of Iris occurs. - Excise the prolapsed part of Iris (Prolapsed Iris should not be reposited because of danger of intraocular spread of infection), - Rest treatment is same as above.

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch

166, Practical Ophthalmology 4) In Keratocoele - Rest to the eye, - Pressure pad and bandage,

- Conjunctival flapping, keratoplasty, - Rest of the treatment same as above. D) TREATMENT OF HEALED CORNEAL ULCER

1) If corneal opacity Is present then either of the following modali­ ties of treatment Is preferred according to the site and grade 'of opacity - Dlono resolvent eye ointment may be applied to the eye If opacity Is very superficial, - Tattolng of corneal opacity (now a days usualy not done), - Cosmetic contact lens, - Optical Iridectomy, - Optical keratoplasty.

Vascularised corneal opacity requires peritomy or B-irradition.

2) If Adherent leucoma - is present then combined keratoplasty with synechiotomy is done. 3) Complicated cataract - If there is good PLPR and cataract is associated with corneal opacity then keratoplasty is done followed by cataract extraction at a later stage with I.O.L. implantation or a combined procedures may be done. 4) Corneal Staphyloma is managed by corneal grafting.

5) Secondary glaucoma is managed by Antiglaucoma Surgery (Post inflammatory). CAUSES OF NON - HEALING CORNEAL ULCER

A) Decreased resistance of the patients in conditions like 1) Patients on immuno suppressive therapy, 2) Chronic alcoholism,

3) Severe malnutrition, 4) Old age,

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch Clinical Ophthalmic Cases 167.

5) Infancy, 6) Diabetes mellltus,

7) Tuberculosis, Syphilis, Leprosy, 8) Drug addiction, 9) Immuno deficiency syndrome,

10) Extensive body burns, 11) Pregnancy,

12) Active Infective focus in the body, 13) Presence of malignancy. B) Local Ocular causes

1) Lagophthalmos,

2) Meibomlnltls, 3) Trichiasis & Entropion, 4) Conjunctiva concretions, 5) Active trachoma, 6) Xerosis,

7) Chronic Dacryocystitis,

8) Decreased corneal sensation (Neuroparalytic Keratitis), 9) Dry eye states,

10) Ocular burns, 11) Topical drug abuse, 12) Contact lens abuse, 13) Glaucoma.

-J

DIFFERENTIATION

BETWEEN

DIFFERENT

FUNGAL

TYPES

OF

CORNEAL

VIRAL

ULCERS

NUTRIONAL

DEGENERATIVE

1) ORIGIN & CAUSE

Usually traumatic or secondary to ocular cause

Usually trauma by vegetable matter

Secondary to viral infection

Seen in old age

Seen in marasmic children & malnourished old people,

2) SITE

Central or para­ central

Usually central

Central or peripheral

Peripheral

Peripheral

3) SYMPTOMS

Marked

Less marked as compared to the size of ulcer.

Marked

Minimal

Not marked

4) COLOUR

Greyish white

Dull dry yellowish

May be small single or multiple

Whitish

Whitish

Thick curdy discharge.

Serous

No discharge

Mucopurulent discharge

Preserved

Impaired

Impaired

Preserved

white 5) DISCHARGE

Mucopurulent or purulent discharge

6) CORNEAL SENSATIONS Preserved

7) HYPOPYON

Present

Massive & thick

Usually not

No

No

8) SPREAD & COURSE

Rapid

Slow & torpid

Rapid

Slow

Gradual

9) ASSOCIATED PATHOLOGY

Iritis, secondary glaucoma

Iritis present

Iris may be present.

Nil

Iritis may be present

10) CHANCE OF

Occurs if untreated

Does not perforate

Does not perforate

Does not perforate

Perforates

Present

Not present

Not present

Present

Absent

12) SWAB & CULTURE

Both Positive

Both positive

Swab-negative Culture-positive

Swab may be positive

Negative

13) FLUORESCEIN STAIN

Positive

Positive

Positive

Negative

Positive

14) SYSTEMIC SIGNS

Absent

Absent

Usually present

Absent

Present

PERFORATION 11) CORNEAL VASCU-

LARISAT1ON

168. P ractical O p h th a lm o lo g y

BACTERIAL

THE

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch

DIFFERENTIATION

CORNEAL ULCER 1) VISUAL ACUITY

Moderately/Markedly affected depending on severity and site of ulcer

2) CORNEA

Superficial and deeper layers of cornea are affected and shows an ulcer.

3) SYMPTOMS

CORNEAL OPACITY

Moderately/Markedly af­ fected depending upon site & grade of opacity

Minimally affected

Only comeal epithelium is abraded

Corneal scarring occurs involving superficial and deeper layers of cornea

All symptoms of Corneal ulcer are present. Patient is symptomless

Always infected

Only watering, mild photophobia and foreign body sensation is present in the eye.

May or may not be infected.

Absent 5) FLUORESCEIN STAINING

Positive

Positive Negative

6) HEALING

Heals very rapidly without leaving any mar

Takes time to heal & complications may occur

It Is already a healed lesion

C lin ic a l O p h th a lm ic Cases 169.

4) INFECTION

CORNEAL ABRASION

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch

170. Practical Ophthalmology

5.

Iridocyclitis Inflammation of Iris and ciliary body is known as Iridocyclitis.

DEFINITION

ETIOLOGY

1) EXOGENOUS :

Organism come from outside as in perforated ulcer or injury usually resulting in suppuration and pan-ophthalmitis.

2) ENDOGENOUS :

Infection is through blood stream, like bacterial, viral, fungal, k protozoal.

3) SECONDARY:

Spread of infection from Cornea, Sclera, Retina.

4) ALLERGIC :

Due to Antigen - Antibody reaction, (Common cause).

5) SYSTEMIC :

(autoimmune/Collagen disorders) - Rhematoid, gout, ankylosing spondylitis, polyarteritis nodusa, S.L.E.

6) UNKNOWN

etiology

: Sympathetic ophthalmitis.

CLASSIFICATION 1) GRANULOMATOUS. 2) NON-GRANULOMATOUS. PATHOPHYSIOLOGY

1) Infection - Vasodilatation - Hyperaemia - exudation of cells and plasma - Iris edema - Muddy Iris.

2) Irritation to the nerves and muscles because of toxins - Straightening of radial vessels - Pupillary Constriction. 3) Oedema of Iris - Sphlncture muscle overcomes the dilator - Sluggishly reacting Pupil. 4) Exudate pours out into the aqueous - turbid - cells and proteins- Aqueous flare.

5) Increase Viscosity - Cells block trabecular meshwork - Secondary glaucoma. 6) Endothelial degeneration - Floating cells in aqueous adhere to posterior corneal surface - Keratlc precipitates (Fine K.R and mutton fat K.P).

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch

Clinical OphthalmicCases 171.

7) Cells settle at the bottom In A.C. - Sterile pus - Hypopyon.

8) Rerely haemorrhage may occur - Hyphaema - hemorrhagic uveitis. 9) Posterior surface of Iris - Iris In contact with anterior surface of itns - adhere to lens - Posterior synechia. 10) Complete posterior surface of pupillary margin may adhere to the an surface - Ring posterior synechia.

11) Organic pupillary block - Seclusie puplllae. 12) Aqueous accuracies in Posterior chamber - Pusher iris forward - periphery of Iris bulges forward - Iris Bombe. , ide /-iHharAs to the posterior surface of cornea 13) Periphery of anterior surface of Iris adheres to p peripheral Anterior synaechae. 14) Pupil a totally occluded with exudate - Occlusion puplllae.

15) Entire posterior surface of Iris adhere to the lens - Total posterior sy 16) Exudates pour Into the vitreous and behind the lens - get organised b

lens like a membrane - Cyclltlc membrane. 17) Increase in I.O.T. due to viscosity and cellular contents - Hypertensive Uveitis Hypertensives Irldocyclltlc crisis (Posner - Sloschman syndrome).

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch

1 72. Practical Ophthalmology

Iridocyclitis (Anterior Uveitis) In children -

AGE

In adults

SEX

-

clinical case

Uveitis is rare.

Most common is exudative uveitis with hypersensitivity.

Around 50 yrs. of age

Rheumatoid complicating uvellis is seen.

Old age

Uveitis is less common.

-

Male

Acute anterior uveitis is more common.

Female

Chronic anterior uveitis is common.

COMPLAINTS OF PATIENT (Symptoms) 1) PAIN Due to rich supply from trigeminal nerve. Pain radiates all over distribution of trigeminal nerve,

2) PHOTOPHOBIA Due to irritation, 3) LACRIMATION Due to trigeminal nerve irritation, 4) REDNESS Due to hyperaemia, 5) DIMINUTION OF VISION Due to exudative deposits on corneal endothelium, plasmoid aqueous, corneal oedema and exudates in pupillary area. HISTORY OF PRESENT ILLNESS

1) History of allergic conditions like bronchial asthma, hay fever, allergic rhinitis, skin allergy, 2) History of fever (septicemia),

3) Burning in micturation or discharge - Urethritis (gonococcal etc.), 4) Pain in joints - Rheumatoid disease, 5) Trauma - Same eye and other eye,

6) Dental problem, 7) E.N.T. problem.

PAST HISTORY 1) History of similar attacks in the eye In the past, 2) History of conjunctivitis, keratitis, sclerltis,

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch

Clinical Ophthalmic Cases 173.

3) History of injury to the eye In the past, 4) History of bacterlal/viral/protozoal infection ljke J_B_’ ^gasies^mum^amoebiapneumonia, meningitis tonsillitis, urogenital infection, measles, mump sis, malaria, etc,,

5) History of allergy,

6) History of autoimmune disorder, 7) History of diabetes, gout, rheumatoid arthritis, collagen disease GENERAL EXAMINATION 1) Any Focus of infection, bacterial/virai/protozoal in the body,

2) E.N.T, check up, 3) Dental check up, 4) Lymphadenopathy,

5) Joint mobility and swelling. LOCAL OCULAR EXAMINATION 1) VISUAL ACUITY Diminished,

2) LID Slight oedema of lid margin is seen, ' 3) CONJUNCTIVA Hyperaemia, c.c.c.,

4) CORNEA Hazy, K.R’s by S.L. examination, oedema, 5) A.C. : a) Hypopyon,

b) Aqueous flare is seen, C) A.C. depth may be funnel shaped because of iris bombe if total poste­

rior ring synechiae is present, d) Hyphema (seen only in gonococcal, herpes and erythema nodusum).

6) IRIS Colour changed from brown to muddy reddish yellow - Pattern is altered (Oedematous), - Nodules may be seen on iris surface in cases of granulomatus iritis, - Posterior or ring synechia may be formed, - Atrophic patches may be seen in chronic iridocyclitis, - Iris bombe may be seen.

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch 174. Practical Ophthalmology

7) PUPIL Constricted and irregular in early stages -

- Pupillary reaction Is sluggish, - Koeppes nodules may be seen at pupillary border (in granulomatous uveitis).

8) PUPILLARY AREA Exudates may be seen In pupillary area - Occlusive or seclusio puplllae may be seen.

9) LENS Iris pigment dispersal seen on anterior lens capsule - Iris adhesion may be seen on anterior lens capsule,

- Exudate may be seen on anterior lens surface, - Complicated cataract.

10) I.O.T Intraocular tension may be raised or lowered. It Is raised Firstly In hyper­ tensive uveitis and secondly In pupillary block secondary glaucoma. I.O.T. Is low­ ered in acute cyclitis. 11) FUNDUS Details of fundus are not clearly seen because all medias are hazy due to Inflammatory reaction. 12) NASOLACRIMAL PASSAGE See for mucopurulent regurgitation. PALPATION

Ciliary tenderness is present.

DIFFERENTIAL DIAGNOSIS OF IRIDOCYCLITIS

Iridocyclitis is to be differentiated from 1) Conjunctivitis and

2) Acute congestive glaucoma Because the treatment of iridocyclitis and acute congestive glaucoma is totally op­ posite. Atropine and topical steroids are contraindicated in glaucoma while It is indicated in cases of Iridocyclitis. So if by mistake atropine ointment and topical steroids are instilled in the eye in case of glaucoma then this wrong treatment will cause irreversible damage to the eye.

MANAGEMENT OF IRIDOCYCLITIS INVESTIGATIONS (1) OCULAR

a) Silt lamp examination - Used to look for corneal edema, K.R's, aqueous flare, hypopyon, hyphema, peripheral anterior synechiae, iris colour pattern and iris adhesions to the lens, iris nodules, pupil and pupillary area, exudates, posterior synechiae, complicated cataract. b) I.O.T. - Whether raised, lowered or normal.

c) Conjunctival swab for culture and sensitivity.

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch Clinical Ophthalmic Cases 175. (2) SYSTEMIC Important investigation are -

a) For Acute anterior Uveitis

- Urine for W.B.C, X-ray joints, E.S.R, C-reactive protein (for rheumatism), - Mantoux, X-ray chest (for sarcoidosis and T.B.), - K.T., V.D.R.L (secondary syphilis), - E.N.T, dental, gynaec checkup for focus of infection, - Blood for TLC, DLC, - Urine for microscopic, culture, albumin, sugar (for Infective focus and D.M.),

-HLA-B27, - Stool - ova, cyst,

- Serum uric acid (gout). b) For chronic anterior uveitis :

- Antinuclear - antibody (still’s disease), - M x. X-ray chest (sarcoidosis, T.B.),

- Skin clipping, M x (leprosy), - Stool for ova, cyst (protozoal and helminthic infection),

- K.T., V DRL (syphilis), - X-ray Sacroiliac (ankylosing spondylitis).

TREATMENT 1. LOCAL TREATMENT a) Atropine 1 % eye drops or ointment 3-4 times a day. By virtue of Its strong mydri­ atic action atropine prevents the formation of posterior synechia and if synechia have already formed it breaks the synechiae and thus releives pupillary block. By its cycloplegic action atropine gives rest to the inflammed ciliary body and iris. It also increases the blood flow of the tissue and helps in bringing the antibodies. b) Steroid + Antibiotics drops or ointment are used to reduce the antigen - anti­ body reaction and control of Infection by antibiotics.

c) Local hot fomentation is done to releive the pain. d) Dark glasses to prevent photophobia and reduce lacrimation.

e) Injection subconjunctival steroids + antibiotic may be given in severe cases. f) Flurbiprofen eye drops 2 hly. then q.i.d.

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch

1 76. Practical Ophthalmology

2. SUPPRESSIVE TREATMENT

Oral/Parenteral administration of large doses of steroids is given under cover of an­ tibiotics in autoimmune disorder or allergic disorders (40-80 mg. of prednisolone may be given in tapering doses along with antacids). 3. SPECIFIC TREATMENT Broad spectrum antibiotic is given for control of infection. Desensitisation may be done In allergic condition. Specific chemotherapy in cases of T.B., syphilis, gonorrhea, lep­ rosy, etc. is given.

4. RELIEF OF PAIN AND INFLAMMATION By use of non-steroidal anti-inflammatory drugs like ibuprofen, phenyl butazone, as­ pirin etc. They are given alongwith antacids after meals. They are not given alongwith ste­ roids.

5. MANAGEMENT OF RAISED I.O.T Is done by tablet acetazolamide, I.V. mannitol, oral glycerol, timolol eye drops, or if necessary by paracentesis (in hypertensive uveitis). COMPLICATIONS OF IRIDOCYCLITIS

1) Annular ring synechiae, 2) Secondary glaucoma,

3) Endophthalmitis, Panophthalmitis, 4) Complicated cataract, 5) Macular oedema, 6) Exudative retinal detachment, 7) Optic neuritis,

8) Sympathetic ophthalmitis.

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch

DIFFERENTIATION

GRANULOMATOUS UVEITIS

NON -

GRANULOMATOUS

UVEITIS

AETIOLOGY

Non Purulent Organism

Allergic reaction to proteins or toxins of organisms

2.

ONSET

Insidious Onset

Acute Onset

3.

SYMPTOMS

Minimal symptoms or Asymptomatic

Symptomatic

4.

COURSE

Chronic Course

Rapid Course

5.

INFLAMMATION (SIGNS)

Minimal signs of inflammation

Fiery red eye

6.

INFILTRATION

Focal, around organisms

Widspread infiltration

7.

HEALING

By necrosis and scarring

8.

CELLULAR EXUDATE

Mainly epitheloid cells and mononuclear histiocytes

Polymorphs followed by chronic inflammatory cells

9.

AQUEOUS FLARE

Less marked

More marked

Mutton fat K.P’s, few

Fine K.P’s, multiple

10.

K.P’S NODULES AND FLOCULES

Koeppe and Busacca

Absent

12.

RECURRENCE

Rare

Common

13.

FUNDUS

Nodular lesions

Diffuse Involvement

177.

11.

C linical O phthalm lcCases

1.

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch

178. Practical Ophthalmology

6. Trachoma

CLINICAL CASES

AGE

Any age. More common In children below 10 years.

SEX

More common In females.

CLIMATE

High incidence In April-May and July-Sept, because of dry humid climate.

ADDRESS

More common in Punjab, Gujarat, Rajasthan, U.R World wide distribution.

SOCIO ECONOMIC

Poverty, customs of applying Kajal, poor hygiene.

TRANSMISSION

Directly and indirectly from fomites and flies.

CAUSATIVE ORGANISM

Chlamydia trachomatis.

SYMPTOMS

1) Lacrimation,

2) Photophobia,

3) Foreign body sensation,

4) Itching.

SIGNS

1) VISUAL ACUITY May be reduced if corneal involvement is present.

2) LID Changes depends upon stage of the disease. Lid oedema is present. Mechanical ptosis may be present. Trichiasis, entropion of upper lid Is present in cicatrial stage.

3) CONJUNCTIVA Changes are present depending upon the stage of the disease. Following changes are seen mainly In upper palpebral conjunctiva and fornix. Lower fornix shows minimal changes a) Papillary hyperplasia, b) Follicles, c) Velvety red conjunctiva,

d) Cicatricial line of Arlt,

e) Chemosis of bulbar conjunctiva.

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch

Clinical Ophthalmic Cases 179 4) CORNEA Involvement Is mainly in the upper limbus -

a) Superficial keratitis

b) Trachomatous pannus

c) Herbert's pits

d) Corneal ulcers and opacities may occur as a complication

5) LACRIMAL GLAND Dacryoadenitls may occur,

6) LACRIMAL SAC Infective dacryocystitis may occur,

7) PREAURICULAR LYMPH NODES - May be enlarged & tender. sequale

1) Lid deformities in the form of thickening, entropion, ptosis, trichiasis,

2) Xerosis, 3) Corneal astigmatism, opacities, 4) Lacrimal canaliculi obliteration. CLINICAL DIAGNOSIS

At least 2 out of these 4 signs should be present to clinically diagnose trachoma 1) Presence of follicles,

2) Epithelial keratitis, 3) Pannus in upper limbus, 4) Cicatrization in upper tarsal conjunctiva.

LABORATORY DIAGNOSIS 1) Cytological demonstration of inclusion bodies,

2) Isolation and cultivation of virus, 3) IgG antichlamydial antibody in tear. DIFFERENTIAL DIAGNOSIS

1) Epidemic keratoconjunctivitis,

2) Herpetic conjunctivitis, 3) Phlyctenular keratoconjunctivitis,

4) Inclusion conjunctivitis, 5) Folliculosis,

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch

180. Practical Ophthalmology_______________

_____

6) Palpebral spring catarrh, 7) Pharyngo-conjunctival fever,

8) Chronic follicular conjunctivitis, 9) Molluscum contagiosum,

10) Follicular T.B. conjunctivitis, 11) Drugs, 12) Granular syphilitic conjunctivitis, 13) Perinaud’s disease,

14) New castle disease.

TREATMENT Progressive and healing stages of trachoma are treated by medicinal line of treat­ ment while stage of complication need surgical interference.

1) Medicinal line of treatment a) Locally - Sulphacetamide 20% or 30% eye drops and tetracycline eye ointment or floxacin eye ointment locally. b) Systemically - Sulphamethaxozole 30 mg/Kg. body weight or cap. Tetracycline/ Erythromycin 250 mg. QID or Cap. Doxycycline 1.5 mg/Kg. for 3 weeks. 2) Surgical line of treatment a) Corrective lid surgeries for lid deformities,

b) Keratoplasty in corneal opacity.

CLASSIFICATION OF TRACHOMA Mac Callan’s Classification - is based on presence of follicular, papillary hypertrophy & conjunctival scarring. Degree of corneal involvement is not taken into consideration.

Stage I

- Incipient trachoma (Prefollicular Stage).

Stage II

- Established trachoma (Follicular Stage).

Ila

- Follicular hypertrophy predominant.

lib

- Papillary hypertrophy predominant.

Stage III

- Cicatrization.

Stage IV

- Healed trachoma.

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch

Clinical Ophthalmic Cases 181.

Blepharitis 1. SQUAMOUS BLEPHARITIS : CLINICAL CASE AGE

Usually children, any age.

SEX

Equally common in tooth sexes.

LATERALITY

Usually bilateral.

PREDISPOSING FACTORS

Exposure to dust, wind, smoke, cosmetics. Dandruff, unhygienic conditions, seborrhoea, allergy, refractive error, conjunctivitis, parasites.

SYMPTOMS

Itching, discomfort in eyes, watering of eyes.

SIGNS

1) White crusty dandruff like scales on the lid margin,

2) Slight hyperaemia of lid margin, 3) Slight thickening of lid margin,

4) Falling of eye lashes. TREATMENT It is a chronic condition and recurrence after treatment is common. Essentially the treatment is removal of the cause and supportive therapy. 1) Local treatment

a) Lid margins are cleaned daily with sodabicarb lotion 3% and crusts are removed. b) Application of broad spectrum antibiotic ointment combined with steroid is applied to the lid margins with clean fingers. 2) General treatment a) Good balanced diet with lots of fruits and low carbohydrate diet,

b) Multivitamins,

c) Treatment of dandruff In scalp If present, d) Good hygiene, e) Treatment of metabolic cause and Seborrhea If any.

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182. Practical Ophthalmology

II. ULCERATIVE BLEPHARITIS : CLINICAL CASE AGE

Common In childrens.

SEX

Equally common.

LATERALITY

Usually bilateral.

CAUSATIVE ORGANISM

Coagulase positive staphylococci, parasites.

PREDISPOSING FACTORS

Same as that of squamous blephrltls.

SYMPTOMS

Lacrimation, Itching, photophobia, soreness of lid margins.

SIGNS

a) Matting of eye lashes,

b) inflamed lid margin, c) Crusts, small ulcers and bleeding spots on lid margins,

d) Misdirected or absence of eye lashes, In untreated cases -

e) Tylosis, f) Ectropion,

g) Trichiasis, h) Madarosis. TREATMENT

1) Local treatment

a) Lid margins are cleaned daily with Sodabicarb lotion 3% and crust are removed,

b) Application of broad spectrum antibiotic to the lid margins,

c) Steroid ointment or 2% yellow oxide of mercury applied only after complete healing of ulcers and infection takes place, d) Treatment of sequale,

e) Treatment of cause like conjunctivitis, etc. 2) General treatment a) Good balanced diet with lots of fruits, b) Multivitamins,

c) Good hygiene.

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Clinical Ophthalmic Cases 183.

8. Entropion

CLINICAL CASES

2) Any age

AGE

1) Congenital

SEX

Equally common in both sexes

COMPLAINTS OF PATIENT

1) Watering

2) Pain 4) Foreign body sensation

3) Diminution of vision

HISTORY OF PRESENT ILLNESS 1) History of bandaging of eye 2) History of inflammatory eye lesion, specially corneal condition and lid conditions

PAST HISTORY

1) Prolonged bandaging of eye

4) Membranous conjunctivitis

2) Trachoma stage IV

5) Ulcerative blepharitis

3) Membranous Conjunctivitis

6) Operation or injury to the lid

SIGNS 1) Lid margin is rolled inwards, 2) Tarsal conjunctiva may show signs of stage IV trachoma in upper lid entropion,

3) Corneal opacity, keratitis, ulceration or pannus may be seen,

4) Pthysis bulbi may be present, 5) Signs of old injury or burns may be seen, 6) Skin may be lax, inelastic and atrophic.

TREATMENT It depends on the type of entropion. Acute spastic entropion can be treated by treating the cause of blephrospasm. Other types of entropion are treated by surgery. TYPES OF ENTROPION

1) Congenital

4) Cicatrical

2) Spastic

5) Mechanical

3) Senile

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184. Practical Ophthalmology

9. Pterygium PTERYGIA

It Is a Greek word which means a ‘Wing’.

DEFINITION

It Is a degenerative condition of sub-conjunctival tissue which proliferates as vascularised granulation tissue to invade the cornea.

ETIOLOGY

Exact etiology Is not known but there are definite predisposing factors like 1) Exposure to heat, dust, fumes, 2) Exposure to sunlight (u.v. rays), 3) Decreased lacrimal secretion.

TYPES

Two types -

1) True Pterygium TRUE PTERYGIUM

2) Pseudopterygium

PSEUDOPTERYGIUM

1) It is a degenerative and hyperplasic process in which the conjunctiva actively invades the cornea

1) It is the result of inflammatory process, a fold of inflamed conjunctiva becomes adherent to a progressive ulcer near the comeal margin and being passively dragged across the cornea

2) True Pterygium Is incorporated with the corneal tissue throughout its extent, being most firmly Fixed at Its apex

2) It is adherent only at its apex, forming a bridge over the limbus along which a probe can be passed

3) It occurs only medially and laterally in the palpebral aperture

3) It can occur at any part of the corneal margin

4) Progressive

4) Stationary

INCIDENCE SEX INCIDENCE

HEREDITY

Found commonly in sunny, hot, dusty regions.

Male : Female ratio Is 2:1 because of outdoor activities in male. Dominant Inheritance.

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Clinical Ophthalmic Cases 185.

VARIOUS THEORIES OF CAUSE OF PTERYGIUM 1) Inflammatory basis

2) Allergic basis

4) Neuro trophic conditions

5) Circulatory disturbance

SYMPTOMS

3) Trophic changes

1) Cosmetic disadvantage seen as a growth on the cornea,

2) Usually symptomless but may cause slight irritation or foreign body sensation, 3) Causes diminution of vision by producing astigmatism due to traction on the cornea,

4) It It approaches the pupillary area then causes gross diminution

5) Rarely diplopia If thick and Fibrous (recurrent pterygium) due to mechanical

restriction of ocular movements. • PARTS OF PTERYGIUM

Mpad 91 Heaa 2)

l)Cap

3) Neck

4) Body

CLINICAL TYPES OF TRUE PTERYGIUM 1) Progressive pterygium

2) Regressive pterygium

3) Pterygium sicca

4) Malignant pterygium

DIFFERENTIAL DIAGNOSIS

1) Pseudo Pterygium.

COMPLICATIONS

1) Gross corneal astigmatism

2) Comeal opacity

3) Permanent visual loss if it encroaches the pupillary area

MANAGEMENT OF A PTERYGIUM

1) Medical

1) Topical steroids,

2) Mitomycin-C eye drops (antimitotic) may be helpful in early stages and recurrent pterygium.

2) Surgical

1) Excision and bare sclera technique,

2) Rotation of head towards fornix (McReynaud’s Operation), 3) Excision with pattern lamellar graft,

4) Division of head Into two parts and sutured into superior and Inferior fornix.

3) Radiation

B - Irradiation

4) Cryocoagulation 5) Laser treatment

PREVENTION OF PTERYGIUM Use of dark glasses

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186. Practical Ophthalmology

10. Stye (Hordeolum Externum) CLINICAL CASE

STYE is derived from the word steigon meaning ‘to rise’. HORDEOLUM Is a Latin word meaning ‘barley’.

DEFINITION

Stye is a localised suppurative inflammation of the lid margin com­ mencing in connection with a ciliary follicle and involving particu­ larly the associated gland of zeis. OR stye can be defined as an acute suppurative inflammation of the gland of zeis.

ETIOLOGY

It is caused by suppurative organism Staphylococcus aureus.

AGE

Common In children and young adults.

RECURRENT CAUSES 1) Diabetes, 2) Focal Infection,

3) Debility, 4) High carbohydrate diet, 5) Uncorrected refractive errors. CLINICAL STAGES

1) Early stage (Stage of Induration),

2) Late stage (Stage of suppuration). SYMPTOMS 1) Feeling of fullness or heaviness in the eyelid, 2) Acute pain,

3) Extreme tenderness over Infected area.

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Clinical Ophthalmic Cases 187.

COMPLICATIONS 1) Orbital thrombophlebitis,

2) Spreading cellulitis, 3) Staphylococcal septicemia. SIGNS

1) Swelling, redness and oedema of the affected lid margin,

2) Severe tenderness at the point of Inflammation of lid, 3) Chemosis of bulbar conjunctiva, 4) White pus point becomes visible on the lid margin in relation with the root of the follicle or cilia, 5) Enlargement of Pre-auricular lymph node of affected side. TREATMENT

Treatment of stye depends on the clinical stage -

1) Medical -

I) Hot fomentation till pus points out,

ii) Neomycin eye ointment and Norfloxacin eye drops locally, Hi) Systemic antibiotics and anti-inflammatory drugs,

iv) Low carbohydrate diet. 2) Surgical Epilation of the affected eye lash.

Note -

The lid margin should never be squeezed because of danger of retrograde spread of infection.

Incision of stye -

If the stye Is very large and pus is pointing then make a small nick on the pus point.

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188. Practical Ophthalmology

11. Chalazion (Meibomian Cyst) CLINICAL CASE

DEFINITION

It Is a chronic inflammatory granuloma caused by retention of secretions of meibomian (tarsal) gland.

PREDISPOSING FACTORS 1) Seborrhea,

5) Vitamin - A deficiency,

2) Blepharitis,

6) Foreign body reaction,

3) Conjunctival infection,

7) Diabetes,

4) Low grade infection,

8) Refractive errors.

AGE

More common in adults.

SYMPTOMS

1) Usually symptomless (painless nodule),

2) Cosmetic disfigurement if it is large, 3) Heaviness over lid,

4) D.O.V. due to astigmatism caused by pressure of chalazion over lid. CLINICALLY

Skin surface over chalazion is normal and mobile.

- Non-tender, - Conjunctival surface is velvety red and swollen, - Tumor may remain stationary or resolve by itself or grow in size or become secondarily infected, - Very rarely may become malignant If recurrent. Marginal chalazion

May develop on the duct of a tarsal gland and it projects like a nipple from the lid margin and is flattened in the posterior part.

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Clinical Ophthalmic Case3 189. differential diagnosis

1) Tarsltls, 2) Neoplasm,

3) Tuberculomata. , .... . Medicinal

TREATMENT

1) Anti-Inflammatory drugs, 2) Intralesion steroid. Surgical 1) If chalazion is very small and symptomless without any cosmetic defect then no treatment is required.

2) If chalazion is large than incision and curretage with or without carbolisation.

Stye

Chalazion

Internal hordeolum

1) Definition

Suppurative inflammation gland of Zeis

Chronic inflammatory granuloma of meibomian gland

Suppurative inflammation of Meibomian gland

2) Site of swelling

Near lid margin

away from lid margin

away from lid margin

3) More prominent

Skin side

Skin side

Palpebral conjunctival side

4) Symptoms

Symptoms of acute inflammation

symptomless

Symptoms of acute Inflammation

5) Treatment

- Epilation

- Intralesional

Incision and

- Incision and drainage

steroid - Incision and curretage

curretage

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190, Practical Ophthalmology

12. Pinguecula

CLINICAL CASE

Pingueous In Latin means ‘Fat’.

DEFINITION

It Is a yellowish small triangular patch formed by elastic de generation of connective tissue, situated in the bulbar con­ junctiva on either side of the cornea, being combined expression of changes due to senility and exposure.

AETIOLOGY 1) Exposure to sun, wind, dust, 2) Age changes,

It may be a precursor of pterygium.

CLINICAL PICTURE 1) it is usually asymptomatic. Occasionally it may cause foreign body sensation,

2) it affects First the nasal and then the temporal side, 3) it appears as a raised yellowish area in bulbar conjunc tlva near the limbus, 4) Its base of triangle is towards the limbus,

5) As a rule it remain stationary, 6) It Is avascular, 7) Occasionally It might get inflamed.

TREATMENT

No treatment is required for It. If large and causing foreign body sensation or turning into pterygium then excision may be done.

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch Clinical Ophthalmic Cases 191.

Bitot’s Spot DEFINITION

Small grey or white sharply demarcated areas, cheese like foamy, occurring on either side of the limbus but specially in the temporal area of the conjunctiva.

AGE

Children. OCCURRENCE Common in countries where malnutrition is prevalent.

SEX

More common in males.

CAUSES

Vitamin - A deficiency, pellagra, exposure, congenital, idiopathic.

Patho­ physiology

It appears as an oval or triangular greyish or whitish sharply demarcated area. Appears either as a cheese like patch or as a Film covered with dry foam like material. It occurs on either side of limbus at 3 and 9 O'clock, usually on the temporal side in the palpebral aperture. It may become pig­ mented due to melanin or kajal. Bitot's spots are accumulation of debris and fatty material and the foam like appearance is due to vesicular forma­ tion and irregularities of the superficial layer of the keratinised epithelium said to be accentuated by gas formed and trapped by c. Xerosis. Clinical and ocular diseases do not always corelate with serum levels of vitamin A.

CLINICAL

1) Night blindness,

PICTURE

2) Triangular greyish cheese like patch on either side of limbus at 3 and 9 O’clock, more frequently on the temporal side in the palpebral aperture, 3) Child is malnourished, 4) Keratomalacia - In the last stage of vitamin-A deficiency the cornea becomes soft and perforates leading to blindness.

TREATMENT

1) Restoration of nutrition,

2) Injection Vitamin-A I lac units I.M. biweekly X3-5 injections,

3) Administration of high vitamln-A diets In the form of egg yolk, carrots, green vegetables, cod liver oil, ground nut, milk, 4) Instillation of hypermellose eye drops frequently, 5) Bitots spot can be excised for cosmetic reason after correction of Vita­ min -A deficiency because Bitot’s Spot may persist even after actual cor­ rection of Vitamin-A deficiency, 6) Treatment of the cause.

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192. Practical Ophthalmology

Phlycten

CLINICAL CASE

DEFINITION

It is an inflammatory nodule at limbus secondary to allergic reaction usually occuring in children and young adults.

ETIOLOGY

1) Allergic manifestation to tubercular organism,

3) Allergy to intestinal parasite,

2) Allergy to dust, smoke, chemical,

4) Allergy to bacterial origin.

1) Watering and spot redness of eyes,

4) Slight mucoid discharge may be present,

2) Hyperaemic nodule at limbus,

5) Other constitutional symptoms of T.B., worm infestations, U.R.I. or infectious fever may be present.

SYMPTOMS

3) Slight pain in eyes may be present, SIGNS

COMPLICATIONS

1) Pinkish while nodule at limbus (single 3) Watering and discharge may or be multiple). 1-3 mm. present,

2) In size hyperaemia around nodule,

4) Other constitutional signs may be present.

1) Fascicular ulcer,

2) Kerato conjunctivitis.

MANAGEMENT Investigations 1) MX,

E.S.R.,

5) Dental check up,

TREATMENT

2) T.L.C., D.L.C.,

3) Stool for ova and cyst,

4) E.N.T. check up.

1) Locally steroid eye drops in the day time,

2) Locally steroid-antibiotic eye ointment at night, 3) Systemic anti-inflammatory drug,

4) Locally atropine 10% eye ointment if corneal involvement is present, 5) Systemic steroids has to be given with care in resistant cases, 6) Treatment of cause if detected, 7) High protein diet and fresh fruits,

8) Low carbohydrate diet.

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DIFFERENTIATION

EPISCLERITIS

PHLYCTENULAR CONJUNCTIVITIS

SCLERITIS

1) AGE

Young

Elderly

Elderly

2) APPEARANCE

Pinkish white

Purplish

Pinkish red

3) LOCATION

At or near limbus

Away from limbus

Sector of Sclera

4) LATERALITY

Usually unilateral

Usually bilateral

Usually bilateral

5) TENDERNESS

Non-tender

Tender

Marked tenderness present

6) ULCERATION

Ulcerates

Never ulcerates

No ulceration

7) CONGESTION

Congestion limited around area of Phlycten

Episcleral vessels seen Hyperaemia of Conjunctiva

Over a sector with hyperaemia of conjunctiva

8) NODULE

Small round, grey or yel­ low nodule present

Hard, Immovable & tender

No nodule

9) RECURRENCE

Common

Common

Not common

10) MOBILITY

Mobile

Not mobile

Not mobile

11) ASSOCIATED PATHOLOGY

Cornea may be Involved

Cornea, uveal tract not Involved

Cornea and uveal tract are Involved

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194. Practical Ophthalmology

Common Clinical Cases Kept In Examination CASE - I 1) Cataract a) Senile (Mature and Immature),

c) Traumatic,

b) Congenital.

2) Aphakia 3) Glaucoma a) Congenital,

d) Operated case of glaucoma,

b) Acute congestive,

e) Absolute glaucoma.

c) Secondary glaucoma,

4) Corneal ulcer 5) Iridocyclitis a) Acute

b) Chronic

6) Squint - Vertical muscle a) Paralytic

b) Non-paralytlc

7) Ptosis

CASE - II IJStye

10) Nodule at limbus

2) Trachoma

11) Pinguecula

3) Chalazion

12) Scleritis

4) Ectropion

13) Episcleritis

5) Entropion

14) Phlycten

6) Trichiasis

15) Corneal opacity

7) Blephritis

16) Hypopyon

8) Bitots spot

17) Iridectomy

9) Pterygium

18) Acute dacryocystitis & Chronic dacryocystitis

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Clinical Ophthalmic Cases 195.

Squint EXAMINATION OF CASE OF SQUINT NAME

AGE/SEX

ADDRESS

OCCUPATION

DIAGNOSIS

MAIN COMPLAINTS AND RELEVANT HISTORY :

CLINICAL HISTORY

a) Age of Onset

b) Mode of Onset

-Type - Progress

- Sudden or Gradual - Intermittent/Constant c) Precipitating factors

- Schooling - Emotional breakdown

- Systemic cause - Ocular cause d) Diplopia

e) Abnormal head posture f) Difficulty in reading

g) Mlle stones

h) Obstetrical history

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196. Practical Ophthalmology

______________

RELEVANT PAST AND PERSONAL HISTORY

FAMILY HISTORY

a) Squint b) Refractive error c) Musculofacial deformity

d) Congenital anomaly e) Psychological disturbances

TREATMENT HISTORY a) Optical b) Occlusion

c) Operation d) Orthoptics

e) Drugs

ANY OBVIOUS SYSTEMIC ABNORMALITY OPHTHALMIC EXAMINATION

a) Head Posture b) Turn c) Tilt

d) Chin elevation/depression e) Forehead

f) Vision

RE

Without glasses.

With glasses (with P.H.)

IE

g) Refraction (under cyclopleglc)

h) Anterior Segment i) Fundus j) Fixation-Foveal/erratic/parafoveal/paramacular/centrocaecal. k) Cover Test - Nature of deviation

(a) Cover

- uncover test for near and distance

- Constant/lntermittent

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch Clinical Ophthalmic Cases 197.

_______ ____________ _________

- Uniocular/Alfernate - Concomitant/lncomitant With glasses - Near/Distance

(b) Alternate Cover Test

Without glasses - Near/Distance l) Angle of Squint Hirschblerg's

-Near/Distance

PBCT

-Near/Distance

Under Cyclopleglc

m) Ocular movements

- Uniocular

- Binocular n) Nystagmus

ORTHOPTIC INVESTIGATIONS a) Maddox wing b) Maddox rod c) WFDT (Cover Test) d) Near point of convergence-subjective and objective

e) Near point of accommodation

f) Ac/A ratio g) Bagolinis striated glass test

h) Diplopia charting i) Hess chart SYNOPTOPHORE EXAMINATION

a) IPD b) Angle kappa

c) Angle of squint Objective - for near and for Distance Subjective - for Near, for Distance

d) SMP e) Fusion Adduction f) AV Syndrome Type

g) ARC

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198

Practical Ophthalmology

CLINICAL EXAMINATION a) Lids b) Anterior Segment

CLINICAL PHOTOGRAPH : Preoperative and Postoperative MANAGEMENT a) Occlusion

b) Orthoptics

c) Surgical indications Type of Surgery and amount of correction - Anaesthesia - Incision

- Suture - for muscle

- For conjunctiva - Force duction test - Complication

intraoperative

post operative

CONDITION ON DISCHARGE - Residual - Over correction TREATMENT ON DISCHARGE

- Glasses - Exercises

- Drugs FOLLOW UP Visual acuity

- Angle of deviation

- Diplopia - Synoptophore examination

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch

V. Important Questions

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch

200_P[actlcal Ophthalmology

@Ganesh Agrawal @Ram Padiya @Yash Lohiya 2018 Batch Important Questions 201.

Common Questions Asked In Examination LONG QUESTION 1) Hypopyon Corneal ulcer and its treatment. 2) Herpes simplex and herpes zoster. 3) Treatment of non-healing corneal ulcer. 4) Causes ot Non-healing corneal ulcer. 5) Clinical features, complications and treatment of acute Iridocyclitis.

6) Differences between acute and chronic Iridocyclitis (granulomatous and non granulomatous iridocyclitis). 7) Types of uveitis.

8) Congenital cataract. 9) Senile cataract. 10) Buphthalmos (Infantile glaucoma). 11) Stages of closed angle glaucoma, clinical features and its treatment. 12) Chronic simple glaucoma, diagnosis and treatment. 13) Drugs used in glaucoma.

14) Secondary glaucoma, causes and treatment. 15) Concomitant squint. 16) Incomitant squint. 17) Epiphora and chronic dacryocystitis.

SHORT NOTES

I.

REFRACTION 1) Myopia.

6) Aphakia.

2) Presbyopia.

7) Sturm’s conoid.

3) Astigmatism.

8) Mydriatlcs.

4) Hypermetropia.

9) Gonioscopy.

5) Retinoscopy.

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202. Practical Ophthalmology II. CONJUNCTIVA

1) Ophthalmia neonatorum.

7) Angular conjunctivitis.

2) Trachoma.

8) Membranous conjunctivitis.

3) Phlyctenular conjunctivitis.

9) Concretions.

4) Spring Catarrh.

10) Bitot's Spot or Xerosis or vitamin-A deficiency.

5) Pinguecula.

11) Red eye.

6) Pterygium. III. SCLERA

1) Scleritls.

2) Episcleritis.

1) Stye (Ext. Hordeolum).

5) Entropion.

2) Chalazion.

6) Ectropion.

3) Squamous blepharitis.

7) Ptosis.

4) Ulcerative blepharitis.

8) Trichiasis.

1) Hypopyon.

6) Keratoconus.

2) Keratomalacia.

7) Tattoing.

3) Keratic precipitates.

8) Nodule at limbus.

4) Neroparalytlc keratitis.

9) Interstitial keratitis.

5) Corneal opacity.

10) Hyphaema.

LID

V. CORNEA

VI. IRIS 1) Rubeosis.

2) Synechiae.

.1. GLAUCOMA 1) Macular oedema.

5) Retinitis.

2) Diabetic retinopathy.

6) Detachment of retina.

3) Hypertensive retinopathy.

7) Night blindness.

4) Eale’s disease.

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Important Questions 203.

IX. OPTIC NERVE 1) Papllloedema.

3) Optic atrophy.

2) Optic neuritis. X. SQUINT

1) Diplopia.

2) Amblyopia.

1) After cataract.

3) Dislocation of lens.

XI. LENS

2) Traumatic cataract.

XII. ORBIT 1) Orbital cellulitis.

3) Retinoblastoma.

2) Cavernous sinus thrombosis.

4) Sympathetic ophthalmitis.

1) Fluorescein angiography.

3) Intraocular lens.

2) Ultrasonography.

4) Acute dacryocystisis.

XIII. OTHERS

XIV. SURGICAL OPERATIONS

1) Iridectomy.

5) Enucleation.

2) Paracentesis.

6) Dacryocystorhinostomy

3) Needling and discission.

7) Intracapsular cataract extraction.

4) Evisceration.

8) Extracapsular cataract extraction.



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204. Practical Ophthalmology

flesh & Urr A^owo