EYE PROBLEMS

Dr. Gitalisa Andayani, SpM

Department of Opthalmology
FKUI/RSCM
1
EYE PROBLEM-TOPICS

• Red eyes (normal and decreased vision)

• Chronic visual (progressive) loss
• Acute visual (persistent) loss
• Refractive disorders
• Trauma
 RED EYES
- Congestion of conjunctival blood vessels
- If clarity of media disturbed
 decrease of vision
- In developing countries: accounts for 40%
of eye problems
Red Eyes, normal vision

 Conjunctivitis
(bacterial/viral/chlamidyal/allergic)
 Pterygium
 Subconjunctival hemorrhage
 Episcleritis and scleritis
CONJUNCTIVITIS
Clinical presentation
 Nonspecific:
watery eyes, irritation, stinging, foreign body
sensation, photophobia or itchiness
 Discharge:
watery, mucoid, purulent or mucopurulent
 Conjunctival injection
 Eyelid swelling
 Tarsal conjunctiva:
papillae/follicles/membrane
 Cornea and pupils usually normal
CONJUNCTIVITIS
CONJUNCTIVITIS
CONJUNCTIVITIS

Conjunctivitis Bacterial Conjunctivitis

Chlamidial conjunctivitis (trachoma) Allergic/vernal conjunctivitis

CONJUNCTIVITIS
Management
- Can be done by GP
- Eye hygiene
- Eyedrops:
viral  self-limiting, antibiotics
bacterial  antibiotics
allergic/vernal  antiallergy, steroids(!)
- 3 days w/o improvement: refer
PTERYGIUM
• growth of triangular fibrovascular tissue invading
the cornea
• patients in hot climate, chronic dryness and high
sunlight exposure
• yellow-white deposit at nasal/temporal from
limbus (collagen degeneration, calcification)
• apex always in the cornea side, often with Fe
deposits
PTERYGIUM
PTERYGIUM

Management:
• Excision with conjuctical graft
• Lamellar keratoplasty
SUBCONJUNCTIVAL HEMORRHAGE
• No pain, no discharge
• Well-demarcated
• Self-limiting within 2 weeks
EPISCLERITIS AND SCLERITIS

• Sclera covered by 3 vascular layers:

- Conjungtival blood vessels
- Superfisial episcleral vessels
(in Tenon layer);
with phenilephrin: blanching
- Deep vascular plexus
EPISCLERITIS AND SCLERITIS

Episcleritis:
• common, benign, self-limiting
• young adult
• related to systemic disease
• types: - simple (sectoral,diffuse)
- nodular
EPISCLERITIS AND SCLERITIS

Scleritis:
• granulomatous inflammation
• rheumatoid arthritis, connective tissue disorder
• less common
• severity: mild-severe (necrotizing)
• types: - anterior scleritis (non-necrotizing /
necrotizing)
- scleritis posterior
EPISCLERITIS AND SCLERITIS

Simple, sectoral episcleritis non-necrotizing, diffuse scleritis

early necrotizing scleritis Scleral necrosis

Episcleritis and Scleritis
Management:
Episcleritis
- Steroids/NSAID eyedrops
- Systemic ibuprofen/flurbiprofen

Scleritis
- Oral NSAID
- Oral Steroid
- Combination
Red Eyes, Decreased Vision

 Keratitis

 Cornea Ulcer

 Anterior Uveitis (iritis, iridocyclitis)

 Acute Glaucoma

 Endophthalmitis
KERATITIS
Cornea:
 Frontmost part of eye
 Main component in refraction (70%)
 Tear film
KERATITIS
Keratitis:
 Inflammatory cells infiltration
 Corneal opacity
 Superficial / deep
 Cause: Infection (Viral/bacterial/fungal)
 Also: Dry eyes, trauma, drug toxicity, UV exposure,
contact lens irritation, allergy, immunogenic states,
chronic conjunctivitis
 May progress to cornea ulcer
KERATITIS-CORNEAL ULCER

Clinical presentation
- photophobia
- periocular pain
- foreign body sensation
- ciliary flush
- corneal opacity
Diagnosis : - reduced cornea sensibility
- fluorescein test
- assessment of corneal regularity
KERATITIS – CORNEAL ULCER
Photo-s courtesy of dr Lukman Edwar

Keratitis with fluorescein staining

Corneal ulcer (fungal) Perforating corneal ulcer

 Corneal Ulcer

Cause Pseudomonas Strepcococcus Virus Fungi Allergy

pneumonia
Location central central central central central

Excavation + + - - -

Color greenish yellow yellow abcess satelites infiltrates

Hypopion + + -/+ + -

Appearence purulent discharge purulent quiet abcess Diffuse

discharge
Sensibility normal normal decreased increased normal

Perforation frequent frequent rare frequent none

KERATITIS – CORNEAL ULCER

Management:
- Refer to ophthalmologist
- Medication based on causative microorganism
virus  antiviral
bacteria  antibiotics
fungi  antifungal
- Corneal scar
ANTERIOR UVEITIS
• Inflammation of iris and ciliary body
• Usually auto-immune
• Isolated or part of systemic condition:
- ankylosing spondilitis
- juvenile rheumatoid arthritis
- Reiter Syndrome
- sarcoidosis
- herpes simpleks
- herpes zoster
- Behçet Syndrome (with stomatitis aftosa)
ANTERIOR UVEITIS

Clinical presentation:
- periocular pain
- photophobia
- usually mild decrease of vision
- ciliary flush
- small, irregular pupil, due to adhesion to
lens surface permukaan lensa
ANTERIOR UVEITIS

Clinical presentation:
- indistinct iris crypts
- cornea opacity
- cells and flare in AC
 keratic precipitates, hypopion
- IOP changes
 ANTERIOR UVEITIS
Photo-s courtesy of dr Lukman Edwar

Normal iris Iris nodules

Posterior synechia Hypopion

ANTERIOR UVEITIS

Keratic precipitates
ANTERIOR UVEITIS

Management:
- Refer to Ophthalmologist
- Work-up
- Medication:
- cycloplegics eyedrops
- corticosteroids eyedrops
- oral corticosteroids oral (prn)
- Glaucoma drugs
ACUTE GLAUCOMA

• ocular emergency
• sudden IOP elevation
• block of aqueous humor outflow
• elder patients
• Asians >>
 Acute Glaucoma

Clinical presentation:
• mostly unilateral
• occipital pain
• nausea, vomitting
• extremely red eye
• conjunctival chemosis
• cloudy cornea
• midilated pupil
• pupillary reflex none/poor
• shallow AC
• hard eyes
Acute Glaucoma
Management:
- Refer to ophthalmologist
- Immediately lower IOP:
Pilocarpine 2%
Timolol 0.5%
Asetazolamid
Oral glycerin /IV manitol
surgery / laser iridotomy
ENDOPHTHALMITIS

• Purulent intraocular infection

• Caused by infection through the cornea, trauma
post-surgery (mainly: cataract surgery), or
endogenous
• Bacterial/fungal
• Most common: staphylococcus aureus, proteus
and pseudomonas
• If with extraocular infection: panophtalmitis
Endophthalmitis

Clinical presentation:
- periocular pain
- chemosis
- eyelid swelling
- corneal opacity
- anterior uveitis
- hypopion
Endophthalmitis

Management:
- Refer to ophthalmologist
- Aqueos / vitreous tap
- intravitreal antibiotic/antifungal
- systemic antibiotic
- Panoftalmitis: evisceration
Chronic visual loss

 cataract
 glaucoma (chronic: open and closed angle)
 Retinopathies (mainly: diabetic retinopathy)
 Macular Degeneration
(AMD=age-related macular degeneration)
 Others: e.g. retinitis pigmentosa
Cataract

 Lens opacity
 Penyebab:
- degeneration: senile/age-related
- complication of ocular disease / metabolic /
drug-induced(komplikata)
- congenital
- traumatic

cataract
Cataract
Symptoms
 Early
- no symptoms
- fog
- glare
- difficulty in reading

 Late
- blur of vision
- leucocoria
Cataract
Management
 Depend on patient’s demand; if interfering
with daily activity: Cataract surgery

 Technique:
- Intracapsular Cataract Extraction(ICCE)
 now rarely done
- Extracapsular Cataract Extraction(ECCE)
- Phacoemulsification
- Small-incision

Phacoemulsification
Glaucoma

• Optic neuropathy, mainly caused by chronic IOP

elevation due to increased outflow resistance
• visual field defects
• 2 types: - open angle glaucoma
- closed angle glaucoma
 Optic disc changes in glaucoma

Normal Optic Disc Glaucomatous disc Advanced glaumatous disc

 Glaucoma

Symptoms
• IOP > 21 mmHg (normal 10-21)
• Open angle: asymptomatic; if there is indicating
late stages (frequently bumping, rainbow halo,
periocular pain)
• Closed angle: predisposition to acute glaucoma
• Constricted visual field
Glaucoma

Management
• Observation
• Glaucoma drugs: - beta-blocker
- acetazolamid
- pilocarpine
• Laser (iridotomy, trabeculotomy, trabeculoplasty)
• Surgery (iridectomy, trabeculektomy, implant)
RETINOPATHIES

 Non-inflammatory retina disorders

 2 most common:

- hypertensive retinopathy

- diabetic retinopathy
Retina anatomy

Lapisan
serabut saraf
Fotoreseptor

RPE=
epitel
pigmen
retina
Membran Bruch
Koroid

Sklera
Hypertensive retinopathy

• caused by chronic hypertension

• depend on onset
• - Grade I: narrowing of vessels
- Grade II: + narrowing of veins at crossing
- Grade III: + intraretinal hemorrhages, exudates
- Grade IV: optic disc edema, star figured
macular exudates
 Hypertensive retinopathy
Arteriolar constriction

Focal Generalized Arteriolosclerosis (A-V changes)

Extravascular signs

Flame-shaped retinal Cotton-wool spots and Disc oedema

haemorrhages macular star
Grading of arteriolosclerosis
Diabetic retinopathy

 Complication of diabetes
 Chronic hyperglycemia
 damage to microvasculars
 Chronic visual loss
 Main cause of blindness in DM
50% of diabetics within 10 yrs
will have retinopathy
Mekanisme kebutaan pada
diabetic retinopathy

Decreased blood
leakage of exudates, flow to the retina
lipid and blood to the retina
 ischemia
Macular edema

-vitreous hemorrhage
- Fibrovascular scar neovascularization
- retinal traction  PDR
 retinal detachment

7
 Diabetic retinopathy

Normal retina Early PDR FFA

NPDR PDR vitreuous hemorrhage Fibrovascular scar in PDR

7
AMD=age-related macular degeneration

• Chronic visual loss caused by changes of

the macula
• bilateral

7
AMD=age-related macular degeneration

• Problem world wide

• 4 th in global cause blindness
• Treatment:
- Photodynamic therapy
- Anti-VEGF
- others

7
Acute (persistent) visual loss

 retinal detachment
 vitreous hemorrhage
 retinal vein occlusion
 Retinal artery occlusion
 Optic neuritis
 Retinal detachment
• detachment of
neurosensory retina from
RPE
• mainly caused by retinal
breaks
• floaters, photopsia,
shadow curtain
retinal detachment
Management
• pneumatic retinopexy
• vitreoretina surgery
- Scleral buckling
- Vitrectomy

Scleral buckling (SB) Vitrectomy

Vitreous hemorrhage

• Blood in the vitreous

• Rupture of blood vessels
• Cause: trauma, retinal
breaks, DM, hypertension
• On examination: fundus
reflex absent
• Vitrectomy maybe needed
Oklusi (sumbatan) arteri retina
• Sumbatan arteri retina akibat radang / spasme
/ emboli / melambatnya aliran darah
• Mengenai satu mata
• Tidak sakit
• Berhubungan erat dengan kelainan jantung
• Tanda: retina pucat, cherry-red spot
Retinal vein occlusion
• Central/branch
• Unilateral
• Painless
• Systemic risk factors: e.g. hypertension
• flame-shaped hemorrhages, cotton wool spots
Optic neuritis
• inflammation/intoxication/demyelination of the
optic nerve
• may be accompanied by pain
• unilateral
• sluggish pupil reflex, RAPD +
 OCULAR TRAUMA

• Chemical/thermal burn
• Corneal erosion
• Corneal and conjunctival foreign
body
• Blunt trauma
• Penetrating/perforating trauma
• Hyphema
• Intraocular foreign body
• Orbital wall fracture
Chemical burn
• Alkali:
- pestisides
- household products
(cleaners, etc)
• Asam (acid):
- batteries
 damage to cornea
• Thermal:
- flame
- hot water
- metal liquid, etc
 usually milder
Chemical burn

Penatalaksanaan:
• immediate
• topical anesthetics
• Corneal edema/chemosis? Opacity?
• Irigate eyeball with 1-2 liter water/ NaCl
Chemical burn

Management
• Clean the eyelid sac from debris
• Topical medications (steroid+antibiotics,
EDTA, tetracycline)
• Bandage lens if necessary
 Corneal erosion

• Superficial (epithelial)
• Common causes:
fingernail, comb/brush
contact lens
• Risk for infection
• Pain, photophobia, watery,
irritation, foreign body
sensation
Corneal erosion

Management:
• Topical anesthetics
• Fluorescein test
• Check tarsal conjunctiva of upper eyelid
 retained foreign body?
• Antibiotics eyedrop
• Bandage lens/patching
• Re-epithelisation) within 24-48 jam
 Conjunctival/corneal foreign body

Conjunctival foreign body Corneal foreign body

• Dust, occupational, etc

• Photophobia, watery, foreign body sensation
• Management: foreign body extraction
Blunt trauma

• Eyelid hematoma
• Hyphema
• Subconjunctival hemorrhage
• Vitreous/Retinal hemorrhage
• Orbital fracture
• Retinal commotion
Blunt trauma

Hematoma + subconjunctival subhemorrhage RE

(good eye movement)
Hyphema

Hyphema(clotting) Hyphema occupying ½

AC

Full hyphema
Hyphema

Management:
• hospitalization (risk: visual loss, IOP
elevation, re-bleeding in 30% cases)
• bed-rest, semi-fowler position
• tranexamic acid (e.g Transamin)
Lens subluxation
Iridodialisis
Kommosio retina
Penetrating/perforating injury
Penetrating/perforating injury

Management:
• refer to ophthalmologist
• antibiotics eyedrop
• oral antibiotics
• ATS, TT
• patch eyes
• primary repair
 Laceration/ruptur of eyelid
and face

- ATS, TT
- NaCl / Betadine compress
- Immediate repair
Orbital wall fracture

Enophthalmus, restriction of eye movement

 Intraocular foreign body

Management:
-Immediate extraction for foreign body
-Oral and intravitreal foreign body
-Corticosteroids
THANK YOU