nw2006 high-risked red eye for medical students
TRANSCRIPT
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Nawat Watanachai Nawat Watanachai
Ramathibodi Hosp Ramathibodi Hospitalital Mahidol University Mahidol University
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Low Risk Low Risk Red EyeRed Eye
LidLid• BlepharitisBlepharitis
Lacrimal system Lacrimal system• DacryocystitisDacryocystitis
ConjunctivaConjunctiva• ConjunctivitisConjunctivitis• Pterygium & Pinguecula Pterygium & Pinguecula
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High Risked High Risked Red EyeRed Eye
1 .1 . Corneal defects Corneal defects• AAbrasionbrasion• UlcerationUlceration
2.2. Acute glaucoma Acute glaucoma
3.3. Acute uveitis Acute uveitis
4.4. ScleritisScleritis
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1. Corneal Defects1. Corneal Defects
1.1 Abrasion1.1 Abrasion
1.2 ulceration1.2 ulceration
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1.1. Corneal defectsCorneal defects
1.1 corneal abrasion1.1 corneal abrasion- Only corneal epithelium lostOnly corneal epithelium lost- cleanercleaner
1.2 cornel ulcer1.2 cornel ulcer- Epithelium defect with Epithelium defect with
stromal defectstromal defect- Much more severe/ infectedMuch more severe/ infected
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1.11.1 Corneal abrasion Corneal abrasion
HistoryHistory• TraumaTrauma
SymptomsSymptoms• Sudden Sudden PainPain• LacrimationLacrimation• PhotPhotoophobiaphobia• Blurred vision Blurred vision
SignsSigns• Ciliary injectionCiliary injection• Irregular light Irregular light
reflexreflex• Fluorescein Fluorescein
stainingstaining
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1.1 Corneal Abrasion 1.1 Corneal Abrasion RxRx
Remove FB+/-Remove FB+/- Pressure patching Pressure patching DebridementDebridement Contact lens Contact lens LubricationLubrication Stromal puncture Stromal puncture
Generally cure in 24-48 Generally cure in 24-48 hrshrs
Watch closely for Watch closely for superimposed infectionsuperimposed infection
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1.2 corneal ulceration1.2 corneal ulceration
HistoryHistory• Trauma+/-Trauma+/-
Vegetative materialsVegetative materials Occupational accidentOccupational accident
• Immune defectImmune defect SymptomsSymptoms : pain, lacrimation, : pain, lacrimation,
photophobia, photophobia, blurred visionblurred vision SignSign : ciliary injection, : ciliary injection, white corneal white corneal
stromal lesionstromal lesion, F stain, F stain
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1.2 Corneal ulceration1.2 Corneal ulceration
InfectionInfection• BacteriaBacteria : Staph, Strept, : Staph, Strept,
Pseudomonas, BacillusPseudomonas, Bacillus• FungusFungus : Aspergillus, Penicillium: Aspergillus, Penicillium• VirusVirus : HSV, HZV: HSV, HZV• ParasiteParasite
Non infectionNon infection• NeurotrophicNeurotrophic• Immune mediatedImmune mediated
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1.2 Corneal Ulceration Rx1.2 Corneal Ulceration Rx
Antimicrobial age Antimicrobial agentsnts• Broad spectrumBroad spectrum• Rapidly heavily Rapidly heavily
treattreat CycloplegicsCycloplegics -Steroid +/ -Steroid +/
Penetrating Penetrating keratoplastykeratoplasty
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2. 2. AAcutecute glaucoma glaucoma Sudden onset of Sudden onset of
increasing intraocular increasing intraocular pressurepressure
Pressure may as high as Pressure may as high as 50-60 mmHg50-60 mmHg
Rapid optic nerve damage Rapid optic nerve damage due to insufficient due to insufficient vascular supplyvascular supply
Other structural damageOther structural damage
Normal IOP is around 8-Normal IOP is around 8-21 mmHg21 mmHg
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2. Acute glaucoma2. Acute glaucoma - angle closure glaucoma- angle closure glaucoma
• PrimaryPrimary• SecondarySecondary
Lens dislocation Lens dislocation Neovascular glaucoma Neovascular glaucoma
- Open angle glaucoma- Open angle glaucoma• Acute uveitis Acute uveitis• Phacolytic glaucoma Phacolytic glaucoma
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2.2.AcuteAcute Angle-Closure Glaucoma Angle-Closure Glaucoma MechanismMechanism
• Relative pupillary b Relative pupillary blocklock
• Iris bombe Iris bombe• Iridotrabecular con Iridotrabecular con
tacttact
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2. 2. AcuteAcute Angle-Closure Glaucom Angle-Closure Glaucomaa
• Relatively common in Orientals Relatively common in Orientals• > > 40 40 yearsyears• Women > men Women > men
POAG POAG Risk factors Risk factors
• Increased lens thickness Increased lens thickness• Small corneal diameter Small corneal diameter• Short axial length Short axial length
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2.2.AcuteAcute Angle-Closure Glaucoma Angle-Closure Glaucoma
SymptomsSymptoms- Very severe Very severe PaPa
inin- Nausea & vomit Nausea & vomit
inging- HalosHalos- Blurred vision Blurred vision- Marked rMarked r ed eye ed eye
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2.2.AcuteAcute Angle-Closure Glaucoma Angle-Closure Glaucoma
SignsSigns• Ciliary flush Ciliary flush• Elevated IOP Elevated IOP• Corneal edema Corneal edema• Fixed,oval, dilate Fixed,oval, dilate
d pupil d pupil• GlaukomfleckenGlaukomflecken
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2. Acute Angle-Closure 2. Acute Angle-Closure Glaucoma Glaucoma
AIMAIM• Decrease IOPDecrease IOP• Restore visionRestore vision• Prevent re-increase IOPPrevent re-increase IOP
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2.Acute2.Acute Angle-Closure Glaucoma Angle-Closure GlaucomaMedical RxMedical Rx
Hyperosmotic agents Hyperosmotic agents Carbonic anhydrase inhibitors Carbonic anhydrase inhibitors -Beta blockers-Beta blockers Alpha 2 agonists Alpha 2 agonists MioticsMiotics
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2.2.AAACG Surgical RxACG Surgical Rx
Iridectomy : the definitive treatmentIridectomy : the definitive treatment
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2.A2.AACG Surgical RxACG Surgical Rx
GoniosynechialysisGoniosynechialysis For case of anterior For case of anterior
synechiasynechia
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2.A2.AACG Surgical RxACG Surgical Rx
Filtering Filtering surgery : surgery : trabeculectomytrabeculectomy
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3. Uveitis3. UveitisInflammation of the uveal tractInflammation of the uveal tract
Opaque media blurred vision
Inflammation red, pain, swell
Tissue damage glaucoma, cataract, retinitis etc.
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3. 3. UveitisUveitis : Classification : Classification
AnatomicalAnatomical ClinicalClinical EtiologicalEtiological
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3. Uveitis3. Uveitis : : Anatomical ClassificationAnatomical Classification
Anterior uveitis Anterior uveitis Intermediate uveitis Intermediate uveitis Posterior uveitis Posterior uveitis PanuveitisPanuveitis
A
I
P
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3. Uveitis3. Uveitisanatomical classificationanatomical classification
ant
post
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3. 3. UveitisUveitis : : Clinical Clinical cclassificationlassification
AcuteAcute• Sudden onset Sudden onset• < <66 week persistence week persistence• RecurrentRecurrent
cchronichronic• Prolonged persistenc Prolonged persistenc
ee• Less symptomatic Less symptomatic
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3. Uveitis3. Uveitis : : Etiological ClassificationEtiological Classification
ExogenousExogenous• Infectious eg. Infectious eg.
Toxoplasmosis, Toxoplasmosis, Toxocariasis, TBToxocariasis, TB
EndogenousEndogenous• systemic disease systemic disease
s s eg. SLE, RAeg. SLE, RA• IdiopathicIdiopathic
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3.1 Anterior Uveitis3.1 Anterior Uveitis
SymptomsSymptoms• PhotophobiaPhotophobia• PainPain• Decreased vision Decreased vision• LacrimationLacrimation
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3.1 Anterior3.1 Anterior Uveitis Uveitis
• SignsSigns Ciliary injectionCiliary injection Keratic precipitatesKeratic precipitates hypopyonhypopyon Aqueous cells/flareAqueous cells/flare Iris atrophyIris atrophy SynechiaeSynechiae
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3.2 Intermediate Uveitis3.2 Intermediate Uveitis
SymptomsSymptoms FloatersFloaters Decreased visionDecreased vision Mild eye painMild eye pain
SignsSigns Anterior vitreous Anterior vitreous
cellscells Mild ciliary Mild ciliary
injectioninjection
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3.3 Posterior uveitis3.3 Posterior uveitis
SymptomsSymptoms• FloatersFloaters
• Impaired vision Impaired vision SignsSigns
Vitreous Vitreous cells/flarecells/flare
ChoroiditisChoroiditis RetinitsRetinits VasculitisVasculitis
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3. Uveitis & Arthritis3. Uveitis & Arthritis
Ankylosing spondylitis Ankylosing spondylitis Reiter’s syndrome Reiter’s syndrome Psoriatis arhritis Psoriatis arhritis Juvenile RA Juvenile RA
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3. Uveitis & Systemic disease3. Uveitis & Systemic diseasessNon-infectiousNon-infectious
SarcoidosisSarcoidosisBehcet’s diseaseBehcet’s disease
Vogt-Koyanaki-Harada syndromeVogt-Koyanaki-Harada syndromeInfectiousInfectious
AIDSAIDSAcquired syphilisAcquired syphilisTuberculosisTuberculosisLeprosyLeprosy
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3. Uveitis & Infections3. Uveitis & Infections
ParasiteParasite• ToxoplasmosisToxoplasmosis• ToxocariasisToxocariasis
FungusFungus• HistoplasosisHistoplasosis• Candidiasis Candidiasis
VirusVirus• Herpes zosterHerpes zoster• Herpes simplexHerpes simplex• Congenital rubellaCongenital rubella
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3.3.UveitisUveitisGoal of Goal of TreatmentTreatment
Prevent visual complications Prevent visual complications Relieve discomfort Relieve discomfort Treat the underlying disease, Treat the underlying disease,
if possible if possible
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3.3.UveitisUveitisTreatmentTreatment
Cycloplegics / mydriatics Cycloplegics / mydriatics• Relieve ciliary spas Relieve ciliary spasmm• Prevent posterior synechia formati Prevent posterior synechia formati
onon• SynechialysisSynechialysis
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3.3.UveitisUveitisTreatment Treatment OptionsOptions
SteroidsSteroids• TopicalTopical• PeriocularPeriocular• SystemicSystemic
Side effectsSide effects• OcularOcular
GlaucomaGlaucoma CataractCataract Corneal Corneal
complicationscomplications• SystemicSystemic
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3.3.UveitisUveitisTreatment oTreatment optionsptions
Immunosuppressive Immunosuppressiveagentsagents• Cytotoxic drugs Cytotoxic drugs• CyclosporinsCyclosporins
0001
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4. Scleritis4. Scleritis DiffuseDiffuse NodularNodular
-Inappropriate pain
-Scleral thickening
-Systemic disease
-Not response to drugs
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High and Low Risked Red EyeHigh and Low Risked Red Eye
Red eyeRed eye High riskHigh risk Low riskLow risk
SymptomsSymptoms PainPain Discomfort/ Discomfort/ irritationirritation
InjectionInjection CiliaryCiliary ConjunctivalConjunctival
PupilPupil Dilate/ constrict/ NRDilate/ constrict/ NR Normal/ reactiveNormal/ reactive
VAVA DecreaseDecrease normalnormal
Red reflexRed reflex Decrease/ absentDecrease/ absent NormalNormal
IOP IOP Increase/ decrease/ Increase/ decrease/ normalnormal
normalnormal
CorneaCornea Cloudy/ irregularCloudy/ irregular Clear/ normalClear/ normal
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May the ‘May the ‘lightlight’ be with you!’ be with you!