Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
International Council of Ophthalmology Handbook for Medical Students Learning Ophthalmology 2015 Edited and updated by Instituto de Ciencias de la Vision based on Handbook for Medical Students Learning Ophthalmology of the International Council of Ophthalmology (2009) DearMedicalStudentWelcometoOphthalmology! Inthisbookletwehaveputtogethertablesofcoreknowledgethatwethinkyouneedtoknowandkey ophthalmicdisorderswethinkyouneedtohaveseen. TherearedescriptionsandcolorpicturesofthedifferentcausesofTheRedEyeandthecommoncausesof acutelossofvision.Thispocketsizedbooksummariesthekeypointsintheophthalmologycurriculum compliedbytheTaskForceoftheInternationalCouncilofOphthalmologyandisaformatthatisvery portable!Wehopeyoufindthisuseful.Ophthalmologyisafascinatingdisciplineandyoucanseethe pathologydirectly.Wehopethatwecanstimulateyourinteresttoreadfurtherandtofurtherdevelopyour skills. GoodLuck!! SueLightmanandPeterMcCluskey onbehalfoftheInternationalCouncilofOphthalmology2009 Thisdocumentwaseditedandupdated JuanCarlosGarcíadelaRiva,MD Contributors: MaríadelCarmenBerganzaG.,MD SigfridoRodasDíaz,MD AlexisCastro,MD ofthePostgraduateprogramofOphthalmology InstitutodeCienciasdelaVisión 2015 Page2 Have you seen? Check if yes Remember: How is it treated? What are its causes? Red eye Dry eye Dilated pupil Herpes simplex keratitis Acute uveitis Conjunctivitis: viral and bacterial Conjunctivitis: allergic Keratoconus Infective keratitis Corneal abrasion Subconjunctival hemorrhage Lagophthalmos Chalazion Blepharitis Pterygium Cataract surgery with intraocular lens insertion Corneal foreign bodies Page3 Supervisor Have you seen? Check if yes Remember: How is it treated? What are its causes? Normal optic disc Pale optic disc Cupped optic disc Papilledema Normal fundus Central and branch retinal vein occlusion Artery occlusion/ embolus Diabetic retinopathy Hypertensive retinopathy Age Related Macular Degeneration Toxoplasmosis Myopia related fundus changes HIV related fundus manifestations Retinal Detachment Glaucoma: Diagnosis and treatment options Rubeosis Iridis Scleritis Page4 Supervisor Check if yes Have you seen? Pupillary responses: normal and abnormal Remember: How is is treated? What are its causes? Ocular trauma and treatment options Facial nerve palsies 3rd Cranial nerve palsy 4th Cranial nerve palsy 6th Cranial nerve palsy Nystagmus Esodeviations Exodeviations Orthoptic assessment Leucocoria Refractive errors Manual refraction Automated refraction Presbyopia Types of lenses used Visual acuity testing Low vision evaluation and rehabilitation Page5 Supervisor Have you done? Check if yes Points to Remember External examination of a normal eye Used a Snellen chart Written visual acuity correctly Tested color vision Tested pupillary reflexes Tested eye movements Tested visual fields to confrontation Dilated a pupil Direct ophthalmoscopy with each hand Seen the optic disc Seen the retina and normal blood vessels Seen a fluorescein angiography Seen an optical coherence tomography (OCT) Seen automated visual field tests Page6 Supervisor ACUTEREDEYE Therearemanyconditionsthatcanleadtoaredeye,seriousandnotserious.Maybepainfulorpainless anddetailedexaminationrequiredtosortthemout. Remember: Itisrareforapainlessredeyetorequireanurgent(sameday)ophthalmologicalassessment. Diffuseconjunctivalredness Blepharitis Very common non specific generalized inflammation of the eyelids. Treat with daily lid hygiene, low dose tetracylines/doxycline, lubrication as required with routinereferral. Ectropion Lidturningoutwardswithexposureofconjunctivalsac.Eye maybesoreandwatery.Routinereferralandmayrequire surgery Entropion Lidsturninginwardsandeyelashesmayabradecornea- checkconditionofcorneawithfluorescein. Ifcornealstaining,tapebackeyelidawayfromthecornea andrefersameday Page7 Trichiasis Ingrowingeyelashes-epilatewhentouchingcornea, lubricatewithroutinereferral. Eyelidlesion(chalazionorstye) Provided there are no overt eyelidinfectionorinflammation and no ocular involvement, routinereferral. Considertopicalantibiotics. Pterygium Araisedwhite/yellowishfleshylesionatthelimbusthatmaybecome painfulandredifinflamed.Treatment:lubricationandsunglasses. Routineophthalmologicalreferralforfurthermanagement Page8 Cornealforeignbodyandoculartrauma Referforremovalofforeignbody Check for more severe ocular trauma such as penetration of the eye; treat with topical antibiotics if traumaareaissmall Beware signs of perforation of the eye: eye soft, iris protruding, and irregular pupil Chemical injury copiousirrigationneeded Cornealerosion Symptoms:somethingwentintotheeye,verysore,watering++ Signs: eye red and watery, area where corneal epithelium not intactstainswithfluorescein Management:checknoforeignbody,topicalantibioticsandcan padeyealthoughthisdoesnothelphealing. Seeifpainorvisionworsen Herpessimplexkeratitis Symptoms:soreredeye,notsticky Signs:abnormalcornealepitheliumindendritepatternwhich stainwithfluorescein Management:Topicalaciclovir,AVOIDTOPICALSTEROIDS andseeophthalmologistthefollowingday Page9 Bacterialcornealinfection Symptoms:eyesoreandred,oftenincontact lenswearer,visionmaybeaffectedSigns:white areaoncornea,maybeperipheralorcentral Management:urgent(sameday)referralto ophthalmologist Marginalkeratitis Symptoms: sore red eye, may be sticky, may or may not haveblurryvision Signs: white areas on periphery of cornea which may be thinnerthannormalusuallyassociatedwithblepharitis Management:refertoophthalmologistsameday Allergicconjunctivitis Symptoms:eyesitch++andare redandsore Signs:swellingandsignsofatopy e.g.asthma,eczema Management:Removeallergens wherepossible,topicalantihistamines,coolcompresses,refer ifnotbetterin3days Page10 Viralconjunctivitis Contacthistorywithrecenteyeorupperrespiratorytract infectionsymptoms(especiallychildren).Highlycontagious Symptoms:Burningsensationandwaterydischarge (differentfrompurulentexudateinbacterialinfections). Classicallybeginsinoneeyewithrapidspreadtotheother, oftenpre-auricularlymphadenopathy Signs:eyeredandwatery.Swollenconjunctivaparticularly inlids Management:Willresolveonownandtreatmentaimedatcomfort.Coolcompresses,regularlubricants (withoutpreservative).Antibioticdropsifindicated.Resolutionmaytakeweeks.Referifphotophobia anddecreaseinvisualacuity,severediseaselastinglongerthan3weeks. Subconjunctivalhemorrhage Blood under the conjunctiva - usually unilateral, localized andsharplycircumscribed.Underlyingscleranotvisible. No inflammation, pain or discharge. Vision unchanged. Possible association with minor injuries including rubbing. Common with use of anti-platelet agents and anticoagulants. Management: reassure. Check BP, blood coagulation studies or INR if indicated. Routine referral only if conditionworsensorpaindevelops. Painful-mostcasesofconjunctivitisarepainfulbutthereareothercausesaswell. Hyphema Symptoms:eyeisredandseverelossofvisionfollowing trauma-considernon-accidentalinjuryinchildrenand blooddyscrasias. Signs:eyehasvisiblebloodinsideandcorneamayalso bestained.Eyemaybeverysoreifintraocularpressureis raised Management:Bedrest,eyepad.Urgent(sameday) assessmentbyophthalmologist. Page11 Bacterialconjunctivitis Symptoms:eyeredandsticky,oftenbilateral Signs:redeyeswithpurulentdischargeNocornealor anteriorchamberInvolvement.Systemicallywell. Management:regularhygienetominimizesecretion buildup,topicalantibioticsfor5days.Referifvisionis affected,ifdoesnotimprovewithtreatmentafter2days orworsensandifaftertreatmentfor5days. DryEye Commonchronicocularconditionthatisoftencausedby,or coexistswithotheroculardiseases. Symptoms:soreness,grittinessoftenworsensintheevening. Signs:dependsondegreeofdryness.Ifnotsevere,eye injectedwithpoortearfilm.Fluoresceinstainingofcorneal epithelium Management:Usuallygoodreliefwithlubricants-putinas oftenasnecessarytorelievesymptoms-usepreservative freedropsif>x4perdayandointmentoneyeballbefore sleep.Routinereferralifsymptomsnotimproved. Acuteangleclosureglaucoma Symptoms:Painfuleyewithsystemicsymptomsincluding headache,nauseaandvomiting Signs:MorecommoninAsianraces,eyered,verytenderand feelshardonpalpation,corneausuallyhashazyappearance, andanteriorchamberisshallowwithirregularsemidilated pupil. Management:Urgent(sameday)referraltoophthalmologist. Page12 Ciliaryinjection/scleralinvolvement Scleritis Diffuse Nodular Necrotizing Symptoms:eyepainwhichradiatestoheadandwakesthematnight Signs:Eyeisred,mayhavenodulesandnecroticpatch,scleramaybediscoloredandistenderto palpation.Associatedhistoryofrheumatoidarthritis,vascularorconnectivetissuedisease Management:Urgent(sameday)referraltoophthalmologist AcuteAnteriorUveitis(Iritis) Symptoms:photophobia,eyeredandsore,visionmayor maynotbeaffected Signs:redeyewithciliaryinjectionaroundiris,anterior chamberappearscloudyfromcellsandflare. Management:urgent(sameday)referraltoophthalmologist Hypopyon Visibleaccumulationofwhitecellsinferiorlyseeninsevere uveitis. Urgent(sameday)referralforinvestigationofinfection, inflammationorocularmalignancy Page13 Acutevisualdisturbance/Suddenlossofvision TransientIschemicAttack(AmaurosisFugax) Symptoms: Monocular visual loss that usually lasts seconds to minutes,butmaylast1-2hours.Visionreturnstonormal. Signs: Essentially normal fundus exam (an embolus within a retinal arteriole is only occasionally seen. Other neurological signsassociatedwithischemiaofcerebralhemispheres. Investigation and management: Assessment of cardiovascular risk factors, blood count, electrolytes, lipids, fasting blood sugar, thrombophilia screen. Echocardiogram. Carotid doppler studies.Startaspirin,referraltoneurology/cardiologyorvascularsurgeryasappropriate.Patientswith recurrentepisodesofamaurosisfugaxrequireimmediatediagnosticandtherapeuticintervention. CentralRetinalVeinOcclusion Symptoms:Suddenand painlesslossofvision. Signs:dilatedtortuousveins, cottonwoolspots,opticdisc swelling,retinal hemorrhagevisibleinallfour quadrantswhichmayobscure muchoffundusdetail. Predisposingfactors: increasingage,hypertension, anddiabetes. InvestigationandManagement:Screenfordiabetesandhypertension,excludeglaucoma.Routine referralforanophthalmologicalopinion. CentralRetinalArteryOcclusion Symptoms:Suddenandpainlesslossofvision. Signs:Visualacuity<6/60,RelativeAfferentPupillary Defect(RAPD)Fundusexamination:paleretinal(abnormal andasymmetricalredreflex)cherryredspot-areaof cilioretinalsparing InvestigationandManagement:Urgent(sameday)ESRand CRPtoexcludeGiantCellArteritis.,urgent(sameday) referraltoophthalmologisttoseewhetheranyimmediate treatmentispossible.TIAworkup Page14 Opticneuritis Symptoms:Painlesslossofvisionoverhourstodays.Visionloss canbesubtleorprofound.Orbitalpainusuallyassociatedwitheye movement. Signs:Usuallyfemalesaged18-45,mayhaveotherfocal neurologicalsigns,reducedvisualacuityandcolorvision.Relative AfferentPupillaryDefect(RAPD),centralscotoma,opticdiscmay looknormal(retrobulbarneuritis)orbeswollen. InvestigationandManagement:Completeophthalmicand neurologicalexamination.Bloodcount,ErythrocyteSedimentation Rate(ESR),urgent(sameday)referraltoophthalmologistmaybe indicatedforfurtherMRIinvestigationandintravenoussteroidtreatmentmayberequired.Thereare NOindicationsfororalcorticosteroidsasinitialtreatment. IschemicOpticNeuropathy(AION)/GiantCellArteritis Transient visual loss may precede an ischemic optic neuropathyorcentralretinalarteryocclusion. Symptoms: Temporal headache. scalp tenderness, jaw claudication, fever and night sweats, generalized muscle painandweakness. Signs: Typically affects patients greater than 50 years. May include the following: Afferent pupillary defect, poor visual acuity, often count fingers only, palpable and tender nonpulsatiletemporalartery,swollenpaleopticdisc. InvestigationandManagement:ImmediateESR/CRP(NBclassicallybutnotalwaysraisedinGCA), referraltoophthalmologistforurgent(sameday)(sameday)steroidtreatmentandtemporalartery biopsy. Page15 Theeyeinsystemichypertension (reproducedwithpermissionWongTY,MitchellP.Hypertensiveretinopathy.NEJM2004Nov25;351(22):2310-7) Mildhypertensiveretinopathy Generalizedarteriolarnarrowing,focalarteriolarnarrowing,a-vnicking,opacityofarteriolarwall (copperwiring)systemicassociations:OR1-2stroke,coronaryheartdiseaseanddeath Moderatehypertensiveretinopathy Anytypeofhemorrhage,microaneurysm,CWS,exudatesorcombination Systemicassociation:OR>2stroke,cognitivedecline,deathfromcardiovascularcauses Severehypertensiveretinopathy Signsofmoderateretinopathyplusopticdiscswelling.Strongassociationwithdeath Page16 Theeyeindiabetes Classicfeaturesofbackgroundretinopathywithafewexudates(leftpicture)and moresevere(rightpicture)withhemorrhages,venousbeadingandcottonwoolspot Severediabeticmaculopathywithexudatesandclinicallysignificantmacularedema(leftpicture)and anothereyeaftermacularlaser(rightpicture)showinglaserburns Severeproliferativeretinopathy(leftpicture)withnewvesselsarisingfromopticdiscandrightpicture showslotsoflaserburnsusedtodestroytheperipheralischemicretinaandcausethenewvesselsto regress Page17 RetinalDetachment RetinalDetachmentoccurswhenthereisseparationofsensory retinafromtheretinalpigmentepithelium.Mostcommon etiologyisapredisposingretinalholetear,oftenassociatedwith myopiabutmayfollowtrauma Symptoms:painlesslossofvision.Thepatientmayhave encounteredarecenthistoryofincreasednumberofvisual floatersandorvisualflashes.Theremaybea“darkshadow”inthe visionoftheaffectedeye. Signs:greyareaofretinawhichiswhereitisdetached,vision reducedifretinadetachesandinvolvesthemacula. Management:urgent(sameday)referraltoophthalmologist AgeRelatedMacularDegeneration ChangesinAgeRelatedMacularDegenerationdryform(left)andneovascularmembrane wetform(right). AgeRelatedMacularDegeneration(ARMD)isacommoneyeconditionandaleadingcauseofvision lossamongpeopleage50andolder.Itcausesdamagetothemacula.RiskfactorsincludeSmoking, FamilyhistoryandGenetics. Theearlyandintermediatestagesofthediseaseusuallystartwithoutsymptoms.Theeyeexammay includethefollowing:Visualacuitytest,dilatedeyeexam,Amslergrid,Fluoresceinangiogram.Optical coherencetomography(OCT). Toxoplasmosis AccordingtotheCenterforDiseaseControl(CDC), Toxoplasmosisisoneofthemostcommonhumaninfections throughouttheworld.Eyedisease(mostfrequently retinochoroiditis)leadstoanacuteinflammatorylesionofthe retina,whichresolvesleavingretinochoroidalscarring. Symptomsofacutediseaseincludeeyepain,photophobia, tearingoftheeyes,blurredvision Personswithcompromisedimmunesystemsmayexperience severesymptomsthatincludefever,confusion,headache, seizures,nausea,andpoorcoordination. Page18