أرشيفات التصنيف: Student_Ophthalmology

Struck in the Eye (Acase study

Struck in the Eye

A 36-year-old man with presents to the emergency department 15 minutes after being struck in his right eye (OD) while playing basketball. He has loss of vision and pain in his right eye but not in his left eye (OS). He no other facial or head trauma and no other complaints.
His visual acuity is recorded as OS 20/20 and OD 20/400, without pinhole improvement. The left pupil is 2 mm and reactive, whereas the right pupil is 6 mm and minimally reactive. The patient has red discoloration over 30% of the inferior aspect of the right anterior chamber (top image). No afferent pupillary defect is observed, though the cornea of the affected eye has a hazy appearance. Intraocular pressures (IOPs) measured on tonometry are OS 12 and OD 42 mm Hg. On fluorescein examination, no corneal abrasions are observed and the slitlamp examination reveals cells in the OD anterior chamber. The fundi are within normal limits.
What is the diagnosis and pharmacologic treatment? Why is checking for an afferent papillary defect (APD) important?

***** HINT *****
The red discoloration of the anterior chamber and the corneal haziness are abnormal
***** ANSWER *****

Hyphema with traumatic iritis and increased IOP: The patient has a hyphema with traumatic iritis and an acute increase in IOP. Postinjury accumulation of blood in the anterior chamber can be a sign of major intraocular trauma with associated damage to vascular and other intraocular tissues. Blunt trauma to the globe results in tears to the ciliary body, iris, and other anterior segment structures. These tears cause shearing of blood vessels, including those that make up the major arterial circle of the anterior segment and are responsible for hyphema formation. The potential for secondary hemorrhage and persistent elevations in IOP can result in poor final visual result.

Symptoms of hyphema include pain and photophobia. The patient’s visual acuity can be affected as a result of obstructing cells and blood. Initially, the IOP can markedly rise, as in this case, because of the disruption of the normal egress of aqueous humor into the trabecular meshwork from clogging by red blood cells and their byproducts or from direct trauma to the meshwork itself from the initial trauma.

Regarding the management of acute traumatic hyphema, first assess for concomitant injuries (eg, globe rupture, intraocular foreign body) that require emergency consultation with an ophthalmologist. If no emergency associated injuries exist, the goal of acute management is minimizing the risk of rebleeding and decreasing any pathologic increase in IOP. Rebleeding can occur with any activity that places additional shear forces on the affected blood vessels. Patients should avoid activities such as reading, tasks requiring excessive eye movements, or moving between different lighting conditions, which may cause papillary play (ie, the normal constriction and dilation of the iris in response to light). A long-acting cycloplegic agent, such as atropine or cyclopentolate (ophthalmic) can eliminate accommodation and dilate the pupil to desired effect. Topical steroids can help with associated iritis.

IOP above 24-30 mm Hg should be treated. The hyphema should be allowed to layer. Pharmacologic therapy with a topical beta-blocker (which decreases the production of aqueous humor) should be initiated. Use of carbonic anhydrase inhibitor agent, which rapidly decreases the production of aqueous humor, should be considered in patients who do not have sickle cell disease, as should an osmotic diuretic agent, such as intravenous mannitol or oral glycerol. Activities that increase IOP (eg, coughing, vomiting) should be avoided.

This patient was treated by ordering bed rest, elevating the head of the bed, and administering a topical beta-blocker and a carbonic anhydrase inhibitor. The hyphema decreased in volume and became layered by gravity (bottom image). In addition, his posttherapeutic IOP was 19 mm Hg, which made surgical washout of the anterior chamber unnecessary. A hard eye patch was placed, and follow-up with an ophthalmologist was arranged for the next morning.

Hyphema or glaucoma does not usually result in an APD unless the optic nerve is damaged as a result of persistent or marked elevations in IOP. Reducing this pressure on an emergency basis can help preserve the vision of patients with a hyphema and associated elevations in IOP.

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Eye examination

Eye examination

http://i1.wp.com/www.willseye.org/images/beforeafterpupil.gif?w=474


Nystagmus examination

Nystagmus_20examination.WMV

Ocular movement (basic examination)

Ocular_20movement.WMV

Prism cover test (right esotropia)

Prism_20cover_20test.WMV


Fourth nerve palsy

Fourth_20nerve_20palsy.WMV

Aberrant third nerve regeneration

Aberrant_20third_20nerve_20regeneration.WMV

Chronic progressive external ophthalmoplegia

Chronic_20progressive_20external_20ophthalmoplegia .WMV

Orbit examination (basic)

Orbit_20examination.WMV

Thyroid status examination

Thyroid_20status_20examination.WMV

Abnormal eyelid position

Abnormal_20eyelid_20position.WMV

Three cases of ptosis

Three_20cases_20of_20ptosis.WMV

Pupil examination (basic examination)

abnormal_20pupil_20examination.WMV

Pupil examination (abnormal pupil reaction)

abnormal_20pupil_20examination.WMV

Examination of an enucleated socket

Examination_20of_20an_20enucleated_20socket.WMV

Examination of rheumatoid hands

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Facial nerve examination & abnormalities

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Video lectures by Doctor Saif-Ophthalmology

Video Lectures By Doctor Saif


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Ophthalmology Examination Videos

Ophthalmology Examination Videos

Facial nerve synkinesis – 446KB ( The patient develops a right facial nerve synkinesis after recovering from Ramsey-Hunt’ s syndrome. Note the winking of the right eye with mouth movement.


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2. Hemifacial spasm – 183KB ( This patient develops a left hemifacial spasm after recovering from a left facial nerve palsy. She is also known to suffer from sarcoidosis. Note the contraction of the facial muscles and eyelid closure. The patient has difficulty in opening the right eye.


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3. Blepharospasm – 1,488KB ( This patient complains of a two-year history of recurrent spasmodic contraction of both eyelids which has got worse over the year. Slit-lamp examination of the anterior segment is normal. The spasm is reduced with pre-tarsal botulinum toxin injection.)


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4. Mobiussyndrome – 608KB ( The patient has expressionless face and is unable to blow her cheeks or frown. There is poor eyelid closure despite lateral tarsal strips and medial canthoplasties in both eyes. The horizontal eye movement is restricted as shown by the need of the patient to move her
head in order to follow the finger. Vertical eye movement is normal. There is also wasting of the tongue muscles.


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5. Mobiussyndrome and Poland’s anomaly – 640KB ( The patient has features similar to video 2.
In addition, she has micrognathia and Poland’s anomaly which consists of congenital distal limb abnormalities with syndactylism and amputation):


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6. Congenital exotropia – 570KB ( The patient has congenital exotropia with visual acuities of 6/60 in the right eye and 6/6 in the left. She had has two previous operation to correct the right exotropia.
Cover tests show bilateral latent nystagmus worse in the right eye. The left eye also shows DVD – dissociated vertical deviation. Ocular motility reveals A-pattern exotropia and right superior oblique
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7. Partial third nerve palsy – 722KB ( This patient developed a sudden onset right ptosis and diplopia.
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8. Third nerve palsy – 1,427KB( This patient who suffers from diabetes mellitus and hypertension develops a sudden onset right ptosis. Examination reveals that the right eye has limited movement in those muscles supplied by the third nerve. The pupil is not involved. The appearance is that of a medical thrid nerve palsy.


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9. Left fourth nerve palsy – 880 KB(This young girl has a abnormal head posture. The cover/uncover tests are normal with the head tilted. But with the head in the primary position, there is a left over right. Ocular motility shows left inferior oblique overaction and poor depression of
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Cataract

Cataract


A cataract is a cloudy or opaque area in the normally clear lens of the eye. Depending upon its size and location, it can interfere with normal vision. Most cataracts develop in people over age 55, but they occasionally occur in infants and young children. Usually cataracts develop in both eyes, but one may be worse than the other.

The lens is located inside the eye behind the iris, the colored part of the eye. The lens focuses light on the back of the eye, the retina. The lens is made of mostly proteins and water. Clouding of the lens occurs due to changes in the proteins and lens fibers.

The lens is composed of layers like an onion. The outermost is the capsule. The layer inside the capsule is the cortex, and the innermost layer is the nucleus. A cataract may develop in any of these areas and is described based on its location in the lens:

* A nuclear cataract is located in the center of the lens. The nucleus tends to darken changing from clear to yellow and sometimes brown.
* A cortical cataract affects the layer of the lens surrounding the nucleus. It is identified by its unique wedge or spoke appearance.
* A posterior capsular cataract is found in the back outer layer of the lens. This type often develops more rapidly.



Normally, the lens focuses light on the retina, which sends the image through the optic nerve to the brain. However, if the lens is clouded by a cataract, light is scattered so the lens can no longer focus it properly, causing vision problems.

Cataracts generally form very slowly. Signs and symptoms of a cataract may include:

* Blurred, hazy, or vision
* Reduced intensity of colors
* Increased sensitivity to glare from lights, particularly when driving at night
* Increased difficulty seeing at night
* Change in the eye’s refractive error

While the process of cataract formation is becoming more clearly understood, there is no clinically established treatment to prevent or slow their progression. In age-related cataracts, changes in vision can be very gradual. Some people may not initially recognize the visual changes. However, as cataracts worsen vision symptoms tend to increase in severity.



What causes a cataract

Most cataracts are due to age-related changes in the lens. However, other factors can contribute to their development including:

* Diabetes mellitus – Persons with diabetes are at higher risk for cataracts.

* Drugs – Certain medications have been found to be associated with the development of a cataract. These include:
o Corticosteroids
o Chlorpromazine and other phenothiazine related medications

* Ultraviolet radiation – Studies have shown that there is an increased chance of cataract formation with unprotected exposure to ultraviolet (UV) radiation.

* Smoking – An association between smoking and increased nuclear opacities has been reported.

* Alcohol – Several studies have shown increased cataract formation in patients with higher alcohol consumption compared with people who have lower or no alcohol consumption.

* Nutritional deficiency – Although the results are inconclusive, studies have suggested an association between cataract formation and low levels of antioxidants (e.g. vitamin C, vitamin E, carotenoids). Further studies may show that antioxidants have a significant effect on decreasing cataract development.

Rarely, cataracts can be present at birth or develop shortly after. They may be inherited or develop due to an infection, i.e. rubella, in the mother during pregnancy. A cataract may also develop following an injury to the eye or surgery for another eye problem, such as glaucoma.

While there are no clinically proven approaches to preventing cataracts, simple preventive strategies include reducing exposure to sunlight through UV blocking lenses, decreasing or discontinuing smoking and increasing antioxidant vitamin intake through consumption of leafy green vegetables and nutritional supplements.


How is a cataract diagnosed

Cataracts can be diagnosed through a comprehensive eye examination. This examination may include:

* Patient history to determine vision difficulties experienced by the patient that may limit their daily activities and other general health concerns affecting vision.

* Visual acuity measurement to determine to what extent a cataract may be limiting clear vision at distance and near.

* Refraction to determine the need for changes in an eyeglass or contact lens prescription.

* Evaluation of the lens under high magnification and illumination to determine the extent and location of any cataracts.

* Evaluation of the retina of the eye through a dilated pupil.

* Measurement of pressure within the eye.

* Supplemental testing for color vision and glare sensitivity.

Additional testing may be needed to determine the extent of impairment to vision caused by a cataract and to evaluate whether other eye diseases may limit vision following cataract surgery.

Using the information obtained from these tests, your optometrist can determine if you have cataracts and advise you on options for treatment.

How is a cataract treated

The treatment of cataracts is based on the level of visual impairment they cause.

If a cataract affects vision only minimally, or not at all, no treatment may be needed. Patients may be advised to monitor for increased visual symptoms and follow a regular check-up schedule.

In some cases, a change in eyeglass prescription may provide temporary improvement in visual acuity. Increasing the amount of light used when reading may be beneficial. The use of anti-glare coatings on clear lenses can help reduce glare for night driving.

When a cataract progresses to the point that it affects a person’s ability to do normal everyday tasks, surgery may be needed. Cataract surgery involves removing the lens of the eye and replacing it with an artificial lens. The artificial lens requires no care and can significantly improve vision. New artificial lens options include those that simulate the natural focusing ability of a young healthy lens.

Two approaches to cataract surgery are generally used:

* Small incision cataract surgery involves making an incision in the side of the cornea, the clear outer covering of the eye, and inserting a tiny probe into the eye. The probe emits ultrasound waves that soften and break-up the lens so it can be removed by suction. This process is called phacoemulsification.

* Extracapsular surgery requires a somewhat larger incision in the cornea and the lens core is removed in one piece.

Once the natural lens has been removed, it is replaced by a clear plastic lens called an intraocular lens (IOL). For situations where implanting an IOL is not possible because of other eye problems, contact lenses and in some cases eyeglasses may be an option to provide needed vision correction.

As with any surgery, cataract surgery has risks from infection and bleeding. Cataract surgery also slightly increases the risk of retinal detachment. It is important to discuss the benefits and risks of cataract surgery with your eye care providers. Other ocular conditions may increase the need for cataract surgery or prevent a person from being a cataract surgery candidate.

Cataract surgery is one of the safest and most effective types of surgery performed in the United States today. Approximately 90 percent of cataract surgery patients report better vision following the surgery.

cataract surgery

Cataract surgery is a procedure used to remove the natural lens in the eye when it becomes clouded, and replace it with an artificial lens in order to restore clear vision. Cataract surgery is indicated when the cataract impairs vision to the extent that it interferes with normal daily activities. Cataract extraction is one of the most frequently performed surgical procedures in the world.

A cataract is a cloudy or opaque area in the normally clear lens of the eye. Depending upon its size and location, it can interfere with normal vision. Most cataracts develop in persons over age 55, but they occasionally occur in infants and young children. Usually cataracts develop in both eyes, but one eye may have somewhat worse vision than the other. There is no way to prevent the development of cataracts and currently the only way to treat them is to surgically remove the natural lens in the eye.

Early symptoms of cataracts include blurred vision, glare, and difficulty reading. Cataracts generally progress very slowly, and surgery may not be needed for many years, if at all. In some cases, periodic changes in your eyeglass or contact lens prescription may be all that is needed to continue to provide you with good vision.

Waiting to have surgery usually won’t harm your eyes. The decision to proceed with surgery is primarily based on the amount of difficulty you have performing your usual daily activities.

When considering cataract surgery, you need to ask yourself:

  • Can I see to perform my job and drive safely?
  • Do I have problems reading or watching television?
  • Do vision problems affect my level of independence?

When your vision has decreased to the point where you can no longer easily and safely perform daily activities, then it’s time to consider cataract surgery.

Your doctor of optometry can assist you in making that decision. He or she is most familiar with your current and past eye health and vision history and can answer specific questions you may have about cataract surgery. Following a comprehensive eye examination, he or she can advise you on your current level of visual abilities and the potential benefits and risks of cataract surgery.

If you decide to proceed with cataract surgery, your optometrist can assist you in locating a qualified cataract surgeon in your area. In many cases, he or she will also be available to provide the follow-up care you will need as your eyes heal following surgery.


How is cataract surgery performedCataract surgery involves removing the natural lens of the eye and replacing it with an artificial lens (intraocular lens implant or IOL). The plastic artificial lens is permanent, requires no care, and can significantly improve vision. Newer artificial lens options include those that simulate the natural focusing ability of a young lens, allowing for distance and some near vision, as well.

Cataract surgery is typically an outpatient procedure that takes less than an hour. Most patients are awake during the procedure and need only local anesthesia. If you need to have cataracts in both eyes removed, the procedure is typically scheduled for two separate surgeries. This allows time for the first eye to heal before the second eye surgery takes place.

Two approaches to cataract surgery are currently used:

1. Small incision cataract surgery involves making an incision in the side of the cornea, the clear outer covering of the eye, and inserting a tiny probe into the eye. The probe emits ultrasound waves that soften and break-up the lens into little pieces so it can be removed by suction. This process is called phacoemulsification.

During this procedure, the surgeon removes the cataract but leaves most of the thin outer membrane of the lens, called the lens capsule, in place. Since the incision made for this procedure is so small, sutures are generally not needed to close the opening.

2. Extracapsular surgery requires a somewhat larger incision in the cornea to allow the lens core to be removed in one piece. This approach may be used if your cataract has advanced to the point where phacoemulsification can’t break up the clouded lens. Through this incision your surgeon opens the lens capsule, removes the central portion of the lens and leaves the capsule in place.

Once the natural lens has been removed, it is generally replaced by a clear plastic lens called an intraocular lens (IOL). The IOL is placed in the lens capsule that was left in the eye. The artificial lens has the appropriate lens power to focus light onto back of the eye and improve vision. For situations where implanting an IOL is not possible because of other eye problems, contact lenses and in some cases eyeglasses may be an option to provide the needed vision correction.

Intraocular lenses come in two basic forms: monofocal and multifocal lenses.

1. Monofocal lenses are the most commonly implanted lenses. They have the same power in all areas of the lens. They can have a fixed focus or allow for changes in focus.

* Fixed Focus Monofocal IOLs can provide excellent distance vision. However, since these lenses have a fixed focus set for distance vision, reading glasses need to be used for good near vision.

* Accommodating Monofocal IOLs are a relatively new lens option that can be used when both good distance and near vision are desired without the use of eyeglasses or contact lenses. These lenses also have a single focusing power. However, they can shift from focusing on distance objects to focusing on near ones by physically moving inside the eye in response to the focusing action of the muscles of the eye.

2. Multifocal lenses are like bifocal eyeglasses. Several areas of the lens have different powers that allow individuals to see clearly at distance, intermediate, and near. However, these multifocal lenses are not suitable for everyone. They may cause more problems with night vision and glare than monofocal IOL lenses for some individuals.

The type of intraocular lens implant that would work best for you will depend on your current vision status and your vision and lifestyle needs. Your optometrist and cataract surgeon can advise you on the type of lens implant that would be most suitable.

What are the risks of cataract surgeryWhile cataract surgery is one of the safest surgical procedures available and has a high rate of success, problems can arise. Complications after cataract surgery are relatively rare, and most can be treated successfully. However, if they occur, they may result in significant vision loss. They include:

* inflammation or infection of the eye
* bleeding in the eye
* swelling of the cornea
* detachment of the retinaincreased pressure inside the eye
* dislocation of the implanted lens
* accumulation of fluid in the retina
* drooping eyelid

The risk of these complications is greater for people who have other eye diseases or serious medical problems.

In addition, the presence of cataracts can mask additional eye problems, such as retinal damage, that neither the doctor nor patient is aware of prior to surgery. Since such conditions will continue to impair sight after cataract removal, the eventual outcome of cataract surgery may depend on the treatment of these other problems.

Cataract surgery can also contribute to the progression of age-related macular degeneration (AMD), a degeneration of the central part of the retina. Therefore, AMD patients with cataracts must weigh the potential risks of the possible loss of central vision against the visual improvement provided by cataract surgery.

What happens after cataract surgeryNormally you can go home on the same day of your surgery, but you won’t be able to drive. It’s a good idea to make sure you have necessary help because your doctor may limit activities such as bending and lifting for a few days.

It is normal to feel itching and some mild discomfort after cataract surgery. You may also have temporary fluid discharge from your eye and be sensitive to light. Avoid rubbing or pressing on your eye. Try not to bend from the waist to pick up objects on the floor. Do not lift any heavy objects. You can walk, climb stairs, and do light household chores.

Your doctor may prescribe medications to prevent infection and control eye pressure. After a couple of days, all discomfort should disappear. Often, complete healing occurs within about eight weeks.

During this healing time your eye health and vision need to be monitored. In many cases, your optometrist will co-manage your follow-up care with the doctor who did the cataract surgery. Typical follow-up visits would occur at: 1 day, 1 week, 3-4 weeks, 6-8 weeks and 6 months after surgery.

Once your eyes have healed, your optometrist can evaluate your need for eyeglasses or contact lenses to provide optimum vision. Most people need to wear glasses after cataract surgery, at least for some activities.

If you did not receive an accommodating or multifocal intraocular lens implant, you will also need a lens prescription for reading and close work. This may be in the form of reading glasses, bifocal or progressive addition lenses (no-line multifocals) or monovision or bifocal contact lenses.

Although your vision may be adequately corrected following cataract surgery, you will still need to have regular eye and vision exams to monitor your eye health and vision. If cataract surgery was only performed on one eye, your optometrist can continue to monitor the other eye and assist you in making arrangements for surgery on the second eye, when needed.

What is a secondary cataractYou may have heard about a condition called “secondary cataract” or “after-cataract”. This occurs when the lens capsule, the membrane that wasn’t removed during surgery and supports the lens implant, becomes cloudy and impairs your vision. Another term for this condition is posterior capsular opacification (PCO).

A secondary cataract can develop months or years after cataract surgery. You may have the sensation that the cataract is returning because your vision is becoming blurry again. The gradual clouding of vision is the result of cell growth on the back of the capsule.

There is no way to know who may develop clouding of the lens capsule after cataract surgery. However, up to 50% of cataract surgery patients experience this problem.

Treatment for a secondary cataract is fairly simple. It involves a technique called YAG laser capsulotomy, in which a laser beam is used to make a small opening in the clouded capsule to allow light through. It is a short, painless outpatient procedure that usually takes less than five minutes. Afterward, you typically stay in the doctor’s office for about an hour to make sure your eye pressure doesn’t increase. Generally, most patients will immediately experience improved vision, while some experience gradual improvement over several days.

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MCQ program

MCQ program

Medexam is a new free MS Windows based software program containing over 700 questions each with 5 parts allowing students to test their knowledge and learn medical information in a clear and concise way. It is not an attempt to recreate any particular exam, the information learned will help any candidate get through Medical school, USMLE and MRCP and many other medical exams. Subjects included are both basic sciences as well as clinical sciences. The questions are a mixture of MCQs and MEQs and each one comes with an explanation and images and links to other reliable sources of medical information on the internet.

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Top 20 Principal Ophthalmic Conditions

Top 20 Principal Ophthalmic Conditions

Topics:

Basal Cell Carcinoma

Central Retinal Artery

Central Retinal Vein Occlusion

Vitreous Detachment

Retinal Break

Retinal Detachment

Age-related Macular Degeneration: Retinal Drusen

Age-related Macular Degeneration: Submacular Hemorrhage

Swollen Optic Disc

Glaucoma

Choroidal Melanoma

Iris Melanoma

Ischemic Optic Neuropathy

Retinoblastoma

Retinopathy of Prematurity

Strabismus: Accommodative Esotropia

Amblyopia

Optic Neuritis

Refractive Disorders

Cataract

Principal Ophthalmic Conditions.htm