Wg Cdr Malcolm Woodcock RAF Ophthalmology Centre for Defence Medicine

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AVIATION OPHTHALMOLOGY 2 MEDICAL FACTORS. Wg Cdr Malcolm Woodcock RAF Ophthalmology Centre for Defence Medicine University Hospital Birmingham, UK. Ocular Adenexae. Blepheritis Chalazion Epiphora Orbital Blowout fracture. Blepharitis Lid hygiene Topical/systemic tetracycline - PowerPoint PPT Presentation

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<ul><li><p>Wg Cdr Malcolm WoodcockRAF OphthalmologyCentre for Defence MedicineUniversity Hospital Birmingham, UKAVIATION OPHTHALMOLOGY 2 MEDICAL FACTORS</p></li><li><p>Ocular AdenexaeBlepheritisChalazionEpiphoraOrbital Blowout fracture</p></li><li><p>External eye diseaseBlepharitisLid hygieneTopical/systemic tetracyclineDry eye (keratoconjunctivitis sicca)Ocular lubricants</p><p>Ocular allergic diseaseMast cell stabilisation (Na Chromoglycate)Topical steroidsSystemic antihistamines A bar to flight training</p></li><li><p>Eyelid disease</p></li><li><p>Epiphora (Watery Eye)Reflex corneal or conjunctival irritationObstructive mechanical obstruction of nasolacrimal drainage systemFunctional Failure of lacrimal pump system through lack of tone in lower lid (ectropion, VII nerve palsy)</p></li><li><p>Blowout FracturePatient is looking up. Loss of infraorbital sensation and subcutaneous crepitus are useful signs.Opacification of maxillary sinus with entrapment of inferior rectus / its attachments.</p></li><li><p>Anterior SegmentEpiscleritisRecurrent Erosion SyndromeKeratoconjunctivitis siccaKetatitis (microbial, adenoviral, herpetic)KeratoconnusUveitisOcular hypertension and glaucomaCataract</p></li><li><p>Bacterial keratitisSerious ocular infectionRequires admission and expert managementTreatmentCorneal scrape and cultureTopical antibioticsVisual result depends on amount and position of retinal scarring</p></li><li><p>Viral KeratitisHSV keratitisDendritic ulcerTopical AciclovirMetherpetic disease20-25% (Disciform keratitis)Top Aciclovir/steroidsOral Aciclovir 1yr (not aircrew despite RCT)Adenoviral keratitisFollicular keratoconjunctivitisHighly infectiousCorneal stromal opacitiesCan affect optic axisMay require topical steroids</p></li><li><p>KeratoconusCorneal ectactic diseaseConical corneaManagementGlassesHard contact lensesPenetrating keratoplasty</p></li><li><p>Keratoconus in aircrewOften develops in teens to 20sForme fruste of keratoconus may be present in aircrew applicantsNo test for progressionPiggy-back CL hard centre with soft surroundPossible use in fast-jet aircrewNot tested yet</p></li><li><p>PK for keratoconus</p></li><li><p>Penetrating keratoplastyVisual rehabilitation uncertainAstigmatism RejectionGraft failureMay require permanent topical medicationAircrew unfit agile aircaft / ejection</p></li><li><p>UveitisInflammation of eyeIdiopathic Infectious Systemic diseaseAnteriorIntermediatePosteriorPan-uveitisTreatmentTopical / systemicAnterior uveitisoften controlled with topical steroidsFlying category usually preserved with limitationsSystemic immunosuppression</p></li><li><p>Uveitis</p></li><li><p>GlaucomaPOAGSyndrome of characteristic optic neuropathy associated with a raised IOPFamilialACGAcute glaucoma associated with narrow iridocorneal anglesOcular hypertensionNot galucomarisk of POAGRetinal vascular occlusion</p></li><li><p>POAGVisual field lossMonitoredFlying category depends on thisTreatmentMedical (Beta Blockers safe in aircrew)Surgical (ALT / Trabeculectomy)</p></li><li><p>CataractLens opacityCongenitalAcquiredTreat if symptomaticIn aircrewUsually congenitalTrauma / SurgeryInflammation (Fuchs)Metabolic (DM)Drugs (Steroids)Small inscision surgPhacoemulsificationMicronuclear Rapid rehabilitationTiny corneal scarIOLPMA / Acrylic / SiSame SG as aqueousEjection / vibrationshould be safe </p></li><li><p>Phacoemulsification in aircrew5 Aircrew operated on for LOTraumatic 3Inflammatory 1Congenital 1All achieved 6/6 VAAll fit flying 2 Fast Jet2 Helicopter1 Transport</p></li><li><p>AmblyopiaWhere the Doctor and patient sees nothingCentral suppression of image to avoid diplopiaVisual maturation by age 7AssociatedStrabismusAnisometropiaVisual deprivationRefractiveTreatment with patching as childUntreatable as adultImportant if good eye lost</p></li><li><p>StrabismusConcomitantChildhoodA bar to aircrew entry unlessAlternate with good vision on each sideMicrotropia (test stereopsis)IncomitantExtraocular muscle palsyOften diplopia (prisms / surgery)</p></li><li><p>Monocular aircrewReduced stereopsisReduced field of visionBlind spotUSA FAANo difference in accident rate between uniocular and binocular pilotsUsually restricted to fly as or with qualified co-pilot</p></li><li><p>Corneal diseaseKeratoconusKeratitisViralBacterialCorneal grafts</p></li><li><p>Micro-detonator cord Splatter(MDC)Occurs during ejectionMay cause skin tattooingCorneal burns possibleOphthalmic examination if ocular pain or reduced VA</p></li><li><p>Harrier Ejection</p></li><li><p>Vitreoretinal ConditionsFloaters, holes and detachmentsCentral Serous retinopathyRetinovascular disease</p></li><li><p>Vitreoretinal diseasePosterior vitreous detachmentRetinal detachment (1:10,000)External repair (Cryopexy/scleral buckle)Internal repair (Vitrectomy/laser/cryopexy/internal tamponade)Intraocular tamponade agents</p></li><li><p>Posterior vitreous detachment(PVD)Separation of vitreous gel from retinaFlashes and floaters (Weis ring)Abnormal VR adhesion (haemorrhage, tears)65% by 65yrsEarlier if MyopicIf acute symptomatic 10% risk retinal tearIndirect ophthalmoscopy with indentationLaser retinopexy if necessary</p></li><li><p>Symptomatic floater in flyer!Navigator 36 yo emmetropic (LVA 6/5) 6 month history left floaterLeft PVD, prominent Weiss ringFelt unsafe to fly as kept on thinking aircraft closing in peripheryLeft vitrectomy (uncomplicated)Kept full flying categoryNo problems at 1 year (Minimal myopic shift)</p></li><li><p>Complications of vitrectomyEntry site iatrogenic retinal breaks2-4% in simple vitrectomyRisk of retinal detachmentIndex myopia and cataract formationNuclear sclerosis accelerated in all cases75% cataract extraction by 3 years if gas used</p></li><li><p>Complications of scleral explantsMyopia Especially if encirclementAstigmatismExtraocular muscle damageDiplopiaSuture complicationsRetinal perforationExtrusion</p></li><li><p>Gas intraocular tamponadePosturing required for 1-2 weeksGasesAir 2 daysSF6 2 weeksC3F8 2 monthsNo sight until bubble above optical axisBoyles law expansion of bubble if atmospheric pressure decreasesDecompression danger with &gt;10% gas in eye</p></li><li><p>Si oil intraocular tamponadePermanent tamponadeNon-expansileNo immediate visual lossLess posturingHypermetropic shift (+6 dioptres)Less IOP regulationincreased effects of G forces</p></li><li><p>Factors affecting fitness to flyVisual acuity (Macula on/off)Visual fieldVariable effectsDistortionERMRetinal translocationRefractionDiplopia</p></li><li><p>Case of RD in Chinook pilot45 y.o. pilotCrash 1985BK amputation left legFacial traumaRoutine eye test left visual field defectVAL 6/6</p></li><li><p>Retinal detachmentBeforeAfter</p></li><li><p>OutcomeVisual field became fullVAL remained at 6/6Fit full flying dutiesMust have at least 2 legs and 3 eyes in the cockpit</p></li><li><p>Retinal degenerationCongenital / acquiredAge related maculopathy Dry /exudativeMacular drusen commonCommonest cause of blindness in UKHereditary retinal dystrophyEnd stage often macular degeneration</p></li><li><p>Macular degeneration</p></li><li><p>Centroserous RetinopathyLocalised serous chorioretinal detachmentUnknown aetiologyEarly mid-aged males affectedVA slightly reduced (hypermetropia)Diagnosis confirmed on FFASpontaeneous resolution the ruleHastened by laserSlight residual decrease in VA</p></li><li>Amaurosis fugaxTransient uniocular loss of vision </li><li><p>Central Retinal Vein OcclusionSudden painless visual impairmentDisc oedema and scattered retinal haemsRisk factors: Age, hypertension, smoking, obesity, blood dyscrasiasSeen in a subset of younger patientsPoorer prognosis if it becomes ischaemic</p></li><li><p>Neurophthalmic diseaseOptic neuritisReduced VA (6/18-6/60)Central scotomaImpaired colour visionOcular pain75% develop MS70% recover 6/6 in 8 weeks</p><p>Optic disc drusenIncidental findingVisual field defectsNystagmusPhysiologicalCongenitalAcquired (always needs further investigation)</p></li><li><p>Optic nerve atrophy and drusen</p></li><li><p>Laser eye injuryOcular hazard of modern warfareIncreasing incidence of laser incidentsDazzleGlareRetinal damageFright!!</p></li><li><p>Laser guided bomb</p></li><li><p>Wg Cdr Malcolm WoodcockDepartment of OphthalmologyWorcestershire Royal Hospital</p><p>Tel: 07891 655845malcolmwoodcock@doctors.org.uk</p></li><li><p>Contact detailsWg Cdr Robert A.H. ScottRAF Consultant Adviser in OphthalmologyCentre for Defence Medicine, Selly Oak Hospital, Raddlebarn Rd, Bham B29 6JD0121 627 8535 (Sec) / 8922 (Fax)rob.scott@lineone.net</p><p>It has been postulated that it may be caused by a congenital abnormality in the central retinal vein at the level of the lamina cribrosa, which gives rise to turbulent flow and thrombus formation. </p><p>*</p></li></ul>