Optom General Flashcards
Prevalence of glaucoma in Oz by age
1.8% in those <60 years,
3.0% in those aged 60–69 years,
4.2% in those aged 70–79 years and
6.7% in those aged ≥80 years
Near phoria: normal ranges
1eso - 4exo
Near BO ranges
30/25 break/recovery
Near BI Ranges
12/10 break/recovery
NPC jump
10cm, held
Accommodation flippers norms
Flippers Clears -3.50 and +2.00 Cycles on +/-2.00
AC/A normal
3:1
Distance vergence norms
5BI and 15BO
Gls to CL’s. What are the effects on acc/verg?
Exo shift and more acc required (inc lag) for myopes
Vice Versa for Hyperopes
Premyopes (High risk of developing myopia) have…
Higher AC/A ratios Greater variability in accommodative responses.
I-Care tends to…
Overestimate at low IOPs and vice versa
CTT less than…. is a risk factor for POAG
555um
What % of OHT develop POAG?
9.5%
VF indicies must be below this percentage to be reliable…
FL < 33%, FN and FP <20%
Sensitivity v Specificity
Sensitivity is the ability of a test to correctly identify those with the disease (true positive rate)
Specificity is the ability of the test to correctly identify those without the disease (true negative rate)
Amblyopia Tx in 3-6yo. What to tell parents.
Average improvement is 3logMar lines for both moderate and severe amblyopia.
Tell parents 80% achieve maximum acuity by 4/12; 97% by 8months;
Amblyopia Tx in 7-17yo. What to tell parents.
Average improvement is 3logMar lines for both moderate and severe amblyopia.
Tell parents Max acuity achieved (ie. ~3lines improvement or >= 6/7.5) in 83% by 10wks (2.5months); 97% by 20wks (5months).
moderate v severe amblyopia and tx;
Moderate amblyopia ie. 6/12 – 6/30 -> 2hrs patching/day or weekend atropine
Severe Amblyopia ie. >6/30 – 6/120 -> 6hrs patching/day or daily atropine
Prescribe near activities ie. Colouring, reading etc.
recurrence rate for moderate amblyopia.
25% of mod amblopyia that is txed will recur
optical correction alone is enough in what percentage of 7 to 17yo?
optical correction alone is enough in 25% of 7 to <18yo.
ipen results
ipen results: Mild: 300-320; Moderate 320-340; Severe 340+
Monash Eye Centre (public system)
search: Ophthalmology - monash health; click on referral guidelines
Shanisha smith’s parents?
Paulina and jason
What does MPS 1 stand for?
Mucopolysaccharidosis Type 1
MPS1 criteria for suspicion?
Widespread stromal corneal dystrophy in children and adolescents
MPS1 in absence of corneal clouding can still be suspected if child has at least two of…
Papilloedema, optic atrophy, pigmentary retinopathy
Fabry disease main criteria for suspicion
Corneal verticillata: eccentric corneal scar.
Does not usually affect vision.
Yellowish brown colour
Fabry disease lesser criteria
in the absence of verticillata, at least two of…
anterior cortical cataract
retinal vascular lesions: retinal vascular tortuosity at posterior pole
conjunctival vascular lesions: tortuosity or MA in conj vessels.
If suspect MPS1 or Fabry disease refer to…
Metabolic Specialist: Dept of Nephrology, Royal Melb Hospital
mean CCT in normal v keratoconus
Normal: 550um +/- 35
Keratoconus: 448 +/- 58
Osmolarity cut-off
>=317mOsmol/L
Sensitivity : 96%
Specificity: 67%
NIBUT cut-off
<=5s
Sens: 95.9%
Spec: 90.8%
Rate of DR within 20 years?
Almost all type 1 diabetes and more than 60% of type 2 diabetes will develop diabetic eye disease within 20 years of diagnosis.
Rate of >40yo with DM+ who have DR?
almost one-third (29.1%) of Australians with diabetes
SES: Sagging eye syndrome prevalence?
SES: Sagging eye syndrome.
~25% of >60yr old w diplopia have SES (Sagging eye syndrome) as cause of their diplopia.
SES: Sagging eye syndrome signs/sx’s?
Sx: Acute/Chronic horizontal/vertical diplopia.
Non-commutative version (looking diagonally to the up/left or up/right) is higher than a consecutive version (looking left the up or right then up).
divergence paralysis” esotropia for distant targets
SES may asymptomatically and symmetrically reduce supraduction
Bilaterally asymmetrical LR pulley sag results in hypotropia and excyclotropia of the eye with the greater sag, causing symptomatic cyclovertical diplopia
how does BP affect risk for glaucoma?
low BP and long term high BP are risk factors for glaucoma
don’t just ask about hypertension
understand BP duration, severity and medical therapy
WHat are two modifiable factors to reduce risk of glaucoma?
Diet, exercise are modifiable factors
alpha and beta zones difference.
Parapapillary atrophy can be differentiated into an outer “alpha” and inner “beta” zone that borders the optic disc. The outer alpha zone may be characterized by irregular hypo- and hyperpigmentation, followed by the inner beta zone, which reveals sclera at the optic disc border as well as large visible choroidal vessels.
what is the significance of beta zone in glaucoma?
Glaucoma is associated with a larger beta zone compared w normals.
Evaporative dry eye is a feature in what % of DED?
86%
Grading MGD expression
Grade0: clear fluid expressed
Grade1: greasy, slgithly turbid fluid expressed.
Grade2:opaque expression
Grade3:semi-solid substance expressed
Grade4:waxy substance if anything at all expressed
When to refer for tropias reference location?
dropbox SRC 2019 Day 1 Session 1.8
Birth to <3mo ocular development
Horizontal Saccades
Vertical Upgaze
Pursuits 12deg object, slow moving
Fixation/saccade to face
OKN
VOR (Vestibular ocular reflex)
What is standard parameters for Frame Fit for Zeiss?
PT 9
Wrap 6.5
BVD 12
Zeiss MF’s Frame Fit parameters req’d for the designs…
Superb and Individual
Pure comes in corridor lengths of …
10
12
14
Pure Plus comes in corridor length of …
10 to 16
Individual comes in 3 designs which are…
Balanced (dist bias)
Intermediate bias
Near bias
What is Zeiss luminous technology and which lenses have it?
Takes into account large pupil size for night time
Drivesafe and Individual have it
If rx is plano, +2.00 Add and p uses VDU a lot then use zeiss…
Superb/Individual as will give wider Int
What is the Dye Disappearance Test?
Instil NaFl in both eyes and check for drainage after 5min. (especially obvious if unilateral blockage)
If not draining then do irrigation to check for blockage.
Causes of Epiphora
PLOPCDN
Overproduction: Dry eye/Exposure
Poor Drainage: Conjunctivalchalasis
Lids
Punctal Stenosis
Canaliculitis
Dacryocystitis
NLDO
the 2 categories of tear deficiency?
Sjogren’s and Non-Sjogren’s
2 categories of Sjogren’s
Primary and Secondary
4 Categories of Non-Sjogren’s
- Primary lacrimal gland deficiency
- Secondary lacrimal gland deficiency
- Obstruction of lacrimal gland ducts
- Reflex Hyposecretion
2 Caterogories of Evaporative dry eye
Intrinsic and Extrinsic
Sjogren’s profile and Dx
91% Female av age 51
Dx: any 2 of…
Postiive Blood Test
Ocular Staining Score >=3 (SICCA)
Salivary Gland Biopsy
4xIntrinsic causes of evap DED
Intrinisic: picture arrow pointing INto..
1. MGD… Meibomian Gland
2. Disorders: expand gland to look like a messy and disorderly room
3. Low: MG filled with Meibum but has flashing sign saying low.
4. Drug: needle sticking into MG injecting drug.
MGD, DisLoD
- MGD
- disorders of lid aperture
- Low Blink Rate
- Drug Action: Eg Accutane
4x Extrinsic causes of DED
- Vit A deficiency
- Topical Drugs Preservative
- CL Wear
- Ocular Surface Disease Eg. Allergy
What is the rate of PCO following cat surgery?
~20%
Jones 1 Test
Check difference in drainage of NaFl after 5min
Lacrimal lake should be…
~1mm is normal
LG method
Examine eye immediately after LG instilled.
Make sure to get p to blink several times
SICCA Ocular Staining Score. Scoring system for cornea is…
Cornea:
G0:0
G1: 1-5
G2: 6-30
G3: >30
SICCA Ocular Staining Score. Scoring system for LG conjunctiva…
G0: 0-9
G1: 10-32
G2: 33-100
G3: >100
SICCA Ocular Staining Score. Scoring system for extra points:
cornea only: +1 for each of…
- patches of confluent staining
- staining in pupillary area
- 1 or more filaments
DED % breakdown into type
35% EDE
10% ADDE
25% both
30% neither
Red lid margins give…
Hycor ointment
DED w red eyes give…
FML qid for 2wks, then bid for 4wks. Rev at 2wk and 6wk mark.
for scleral fits, aim for PLTT (post lens tear thickness) of…
immediately: 200um
after 30min: 150um
floppy eye lid syndrome is associated with…4things
obesity, obstructive sleep apnea, Down syndrome, and keratoconus.
Moisture chamber goggles can be used for… 6things
nocturnal lagophthalmos,
compromised lid seal,
floppy eye syndrome,
recurrent corneal erosions,
air travel,
CPAP eye protection.
WWOP Mx:
- rev 1-2yrly depending on risk
- rev 6/12ly posterior borders scalloped and extensive vitreous degeneration.
- p’s in 40s/50s, have increased risk of associated retinal breaks and detachment because of increased vitreous liquefaction and/ or vitreous detachment (PVD).
- high myopia is a risk
Risk factors for DR
Chol
BP
Insulin
pregnancy
renal disease
Indigineous/non-english speaking background
retinal arteriorlar tortuosity
Infants >3mo norms
FiVeS-Co
Fixation to: lights, visual/auditory objects
Vertical downgaze
Saccade to penlight
Co-ordinated head-eye movents
eye movements that are abnormal at any age… x3
Asymmetries in…
- binocular OKN
- Smooth Pursuits
- Nystagmus
What % of OSA have NTG?
and vice versa?
- 7%
- 7%
Conjunctivalchalsis mechanism
Friction->exposure-> Inflamm->worse reflex tearing
Conjunctivalchalasis tx
drops, steroids, surgery
Congenital NLDO is estimated to occur in …% of infants? and usually resolve in…?
Mx?
Congenital NLDO is estimated to occur in 20% of infants and most commonly resolve in 1 year.
If doesn’t resolve by 6mo then refer for NLD probing.
3 Possible outcomes of lavage if open…
• BLOCKAGE NOT PRESENT AND ANOTHER CAUSE OF
EPIPHORA SHOULD BE EVALUATED
• BLOCKAGE WAS RELEASED DURING lavage
• POSSIBLE FUNCTIONAL BLOCKAGE
Outcomes of lavage if blocked…
DIFFICULTY DEPRESSING PLUNGER OR FLUID MAY REGURGITATE FROM INFERIOR OR SUPERIOR PUNCTA
- INFERIOR REFLUX: INFERIOR CANALICULUS BLOCKAGE
- SUPERIOR REFLUX: COMMON CANALICULUS OR LACRIMAL
SAC
• IF THIS OCCURS, PRESS SUPERIOR PUNCTUM AGAINST ORBITAL RIM TO OCCLUDE AND IRRIGATE AGAIN
What is a functional block of drainage?
FUNCTIONAL BLOCKAGE
- PATENT SYSTEM UNDER HIGH-PRESSURE IRRIGATION
- PATHWAY COLLAPSES UNDER LOW-PRESSURE SITUATIONS
OF NORMAL TEAR DRAINAGE
• JONES DYE TESTS USED TO HELP DIFFERENTIATE FUNCTIONAL BLOCKAGE VS. PATENT SYSTEMS -> refer if suspect functional block.
If questioning by non-eye care professionals suggests DED, but recommended treatments do not result in a marked improvement in symptoms within…, a detailed eye examination is recommended.
about a one-month period
staining procedures results +ve for DED…
nafl: >5 corneal spots (view after 1min)
LG: >9 conj spots (view after 1min)
LWE procedure and outcome
LG: 2drops per strip x2;
+ve is >=2mm length and/or
>= 25% sagittal width
view after 3min
Diff Dx of disc edema and pseudopapilledema…
+ve is OCT nasal RNFL > 86um,
gives 80% sens and spec
Triaging Q’s for dry eye x9
Six Dioptres of Long Vision in One eye. It Can Grow Muck
- How severe is the eye discomfort?
- Do you have any mouth dryness or swollen glands?
- How long have your sx’s lasted and was there any triggering event?
- Is your vision affected and does it clear on blinking?
- Are the sx’s or any redness much worse in one eye than the other?
- Do the eyes itch, appear swollen or crusty, or have given off any discharge?
- Do you wear CL’s?
- Have you been Dx’d with any GH conditions (incl recent respitory inf) or
- are you taking any meds?
ipen how to use:
close eyes for 30s, depress just 2-3mm below lid margin at angle of 30deg.
The normal spontaneous blink rate is…
reported to occur from 10 to 15 blinks per minute
OSDI Scoring
Normal 0-12
Mild 13-22
Moderate 23-32
Severe 33-100
TNO cut off
If fails then implies…
240” ie. Test Plate V
If fails -> possible amblyopia/squint
Titmus Norms
5yo 70-100”
6yo 40”
Titmus Wirt rings Number and disparity
- 800 2. 400 3. 200
- 140 5. 100 6. 80
- 60 8. 50 9. 40
Anterior Chamber Angle Structures x5
Schwalbe’s line
Anterior TM (non-pigmented)
Posterior TM (pigmented)
SS
CB
Shaffer Grading system for gonio
G0: Closed Schwalbe’s line not visible
G1: Schwalbe’s line visible
G2: Ant TM visible
G3: SS visible
G4: Ciliary band visible
G0+G1: high risk
G2: Medimum risk
G3-4: lower risk
PXF risk for glaucoma
50% eventually develop glauc
3 things that differentiate allergic from DED
CONEYECON
conjunctival chemosis,
eyelid edema
conjunctival papillae
allergic rhinitis is present in more than what % of ocular allergy cases
80% of ocular allergy;
but is not a symptom known to be associated with DED
Other findings frequently detected in ocular allergy include…3things
“Family atop as”
family history,
atopic dermatitis
asthma
For px’s taking oral antihistamines be aware that….
AntiH can cause dry eye -> reduced tear volume -> more allergans -> more ocular allergy.
Prescribing Add for accomm lag:
Mx for the following flipper/MEM results…
- Fast to clear -3.50/-2.00 and MEM+1.25/+1.50 -> no add req’d.
- slow/fail -3.50 + fast -2.00 + MEM(+0.50 to +1.50)
- > Rev 6/12ly watch for decomp - slow/fail -3.50 and -2.00 + MEM(+1.25/+1.50)
- > needs add - MEM >= +1.75 (give Add)
normal accommodative lag falls between …
normal accommodative lag falls between +0.50 and +1.00 inclusive,
accommodative facility vision training (VT)…
reading through plus/minus flippers for 20 minutes per day, flipping every sentence to challenge the accommodative response to demand (use +/-2 Flippers)
key differentiating findings b/w DED and GPC
include large upper tarsal papillae and hyperemia with usually minimal corneal or bulbar conjunctival involvement
Optos channels. Red is for… Green is for…
Red is for choroid.
Green is for sensory retina
What is FAF?
Autofluorescence imaging is a brightness map reflecting the distribution of lipofuscin and other ocular fluorophores and reflects how the RPE is functioning
FAF: hyper/hypo fluorescence indicates…
Hyperfluorescence indicates metabolic compromise, “sick” RPE under stress Hypofluorescence indicates dead or absent RPE
Krimsky what and how…
Quantify Hirschberg test when squint present.
Place increasing prism powers in front of fixating eye so that both eyes have symmetric hirschberg reflexes. This gives estimate of magnitude of deviation.
For esoT, use BO prism.
Bruckner Test how to…
Use ophthalmoscope at 1m in dark room.
Don’t use if <8months old.
Visuoscopy: When to use and how…
If suspect microtropia
Shine grid on child’s hand and ask to touch the center.
MUST occlude other eye
Dim ophthalmoscope.
Sometimes easier if dilated.
Grading of ACR
G0 = zero
G0.5+: 1-5
G1+: 6-15
G2+: 16-25
G3+: 26-50
G4+: >50
optic disc hemorrhaging Diff Dx…
P-HOARD
Numerous other conditions, such as Posterior vitreous detachment, hypertension, optic neuropathy, anemia, retinal vascular disease, diabetes.
what is the significance of seeing a Disc Haemorrhage? 2 points.
- The observation of a disc hemorrhage should prompt a thorough investigation for glaucoma, and individuals with disc hemorrhages should be considered glaucoma suspects.
- In individuals with known glaucoma, a disc hemorrhage may be a sign of active disease and progression. Thus, while a disc hemorrhage does not need to be treated, per se, its presence may signal the need to initiate or intensify IOP-lowering therapy.
A study at University of Tokyo found that Disc haemorrhages have a prevelance of…
- 4% in normals
- 5% in low tension glaucoma
- 2% in POAG
PDS % that become OHT/Glauc?
PDS 30% become OHT/Glauc
AKC v DED?
C-PACKS
Conjunctivitis (potentially cicatrizing),
Periorbital eczema,
Anterior polar cataracts
Corneal neovascularization that could lead to eventual conjunctivalization of the cornea,
Keratoconus
Symblepharon
Types of RD
Rhegmatogenous and
non rhegmatogenous
Types of non-rhegmatogenous RD
Tractional: Scar-related, Vitreo-retinopathy
Exudative: Mass, inflamm, posterior scleritis
Types of rhegmatogenous RD
Atropic Holes: retinal thinning
Retinal Tears: Vitreous traction -> Operculated or flap tears
How to measure magnitude of Strab?
ACT and prism over the non-fixating eye to neutralize.
simultaneous prism cover test: how and when to use…
how: place neutralizing prism over non-fixating eye while covering the fixating eye simultaneously. Do so briefly to prevent dissociation.
when: Only used to measure small angle tropias
VKC v DED
Vernal keratoconjunctivitis (VKC) signs…
Same: Rapid fluorescein breakup time, SPK associated with sodium fluorescein staining and increased conjunctival lissamine green staining
PIECoB
Diff: intense Itching, Burning, Epiphora, Conjunctival injection and Photophobia
MaCHS
VKC: younger Male patients most notably those under age 18
large Cobblestone papillae and/or
Horner-Trantas dots
Shield ulcers and scarring
RD v Retinoschisis:
location, Commonest location
Appearance, Refractive error
Monocular/bilateral
Tobacco dust, flashes & floaters
Associated field defect
Location: Neurosensory retina separates from RPE v Within neurosensory retina between inner/outer layers
Commonest location Superior temporal v Inferior temporal
Appearance
Rippled, irregular, drifts with eye movements v Smooth, shiny, stationery
Refractive error Myopes over-represented v 70% in hyperopes
Monocular/bilateral Tends to be unilateral (or at least one eye at a time) v
Tends to be bilateral
Tobacco dust, flashes & floaters: Present v Absent
Associated field defect Relative, progressive v Absolute, stable
If Pass TNO then…
- rules out constant strab
- If intermittent strab then implies good sensory fusion when straight
Viral Conj v DED
MUCO
Morning crusting is also common.
recent Upper respiratory tract infection
close Contact with someone with a red eye.
redness and irritation in One eye initially, often spreading to the fellow eye within a few days.
PreWERM
Preauricular lymphadenopathy is also commonly present, watery, edematous, red lids, mucoid discharge
For atrophic holes…
more likely to refer if…
SOMSS
Significant sub-retinal/serous fluid (say more than one disc diameter)
overlying vitreous on edges of the hole
More highly myopic patient,
symptomatic,
superior location
For atrophic holes…
less likely to refer if…
PIG-HOLE
Pigmentation evident around edge of hole
Hole has been present for longer time
Atrophic hole v Operculated Tear v Flap tear..
Shape
Vitreous Traction
Retinal or vitreous haemorrhages
Sx’s
Incidence of detachment
Referral/treatment
Atrophic hole v Operculated Tear v Flap tear
Shape: Round or oval v Round, disc-shaped operculum floating above
v U-shaped with central flap
Vitreous traction None v
Initially created the break, but absent once the operculum has separated
v Usually continuous
Retinal or vitreous haemorrhages
Never v Rarely v Often
Symptoms
Only if clinically significant detachment v
Possible in traction phase, or if clinically significant detachment v
Frequent in traction phase
Incidence of detachment Uncommon but possible v
1 in 6 (less if asymptomatic) v 1 in 3
Referral/treatment :
Generally monitor, but refer if symptomatic or significant localised detachment v Generally monitor, but refer if symptomatic or significant localised detachment
v Always refer promptly, treat with barrier laser
What 3 Peripheral degenerations are associated with retinal detachment in high myopia
Lattice degeneration,
white without pressure and
posterior vitreous detachments
Lattice Degen:
Occurs in…
w/ PVD -> incr risk of RD up to ….%
Mx: Refer if…
occurs in young/myopic eyes, 6-10% of normal pop
40% risk
refer if Flashes/floaters else annual review.
OPTOS WWOP is more apparent on…. channel
green
x2 Benign peripheral retinal degen…
snowflake/microcystic degen
Reticular/Honeycomb degen (common in elderly)
Tip for Diff Retinoschisis v RD
Get 90D and shine a v small light on affected area.
If can’t see it then it is schisis
EKC sx’s and signs.
EKC is when adenovirus invades cornea -> corneal infiltrates -> irritation/pain/vision blur lasting months/years.
Periorbital edema and inflamm which may involve EOMs.
Early stage has PAN on ipsilateral side of red eye, 1wk later corneal infiltrates start.
CHRPE:
Significance
Appearance
Results in…
Association…
Congenital Hypertrophy of the Retinal Pigment Epithelieum (CHRPE)
Significance: Common benign lesion
Can appear as pigmented, with lacunae, or become depigmented over time
Result in RPE defects
Association of CHRPE-like lesions with familial links to bowel cancer (FAP)
If see 4+ CHRPE then screen for cancer.
Choroidal naevi
Incidence
Rate that transform into melanoma?
Choroidal naevi
Incidence of choroidal naevi in Caucasians estimated to be 5-8%, in Asians 1.5%
1 in nearly 9,000 naevi transform into melanoma
Choroidal Melanoma Mneumonic
Choroidal Melanoma – “To Find Small Ocular Melanoma Using Helpful Hints Daily”
Thickness >2mm
Fluid (sub-retinal)
Symptoms
Orange (lipofuscin) pigment
Margin within 3mm of disc
Ultrasonic Hollowness
Halo absent (unlike naevus)
Drusen absent
Choroidal Nevus/Melanoma/CHRPE
seen on…
Red/Green/AF?
Red: All visible
Green: All visible except nevus
FAF: Nevus: not visible except drusen
Melanoma: Hyper/Hypo
CHRPE: Black
Birdshot Choroiditis. What is it?
inflamm of choroid
small, yellowish choroidal spots and vitreous inflamm
FAF shows hyper spots
MEWDS: what is it?
Multifocal Evanescent White Dot Syndrome
White dots in deep retina caused by inflamm
FAF shows hyper dots in central and peripheral retina.
W4D response of 4dots seen indicates…
normal fusion or AC
to differentiate, do UCT while p fixates white dot (tell p to look by position rather than colour). If there is refixation of either eye on covering fellow eye -> Strab+AC
If no mvt then normal fusion.
PCF
What is it?
Signs/Sx’s
Pharyngoconjunctival fever: Caused by adenovirus
acute high fever, pharyngitis, bilateral follicular conjunctivitis, PAN
Often in children and those living in close quarters
Self-resolves in 1wk
Uveitis and FAF
Areas of hypo and hyper can be seen
How long does it take to reach end-stage for glaucoma?
Most are slow taking 20years.
~10% are fast and takes 10years.
Retinal Toxicity 3 drugs and FAF
Hydroxychloroquine
Didanosine (HIV drug)
Thioridazine (Schizophrenia)
FAF shows hyper ring around macula
Detecting VF progression. 3main changes in order of frequency…
Deepening > enlargement > new defect.
If (diastolic BP - IOP) < …. then high risk of glaucoma progression
50
Should decisions on VF progression be made by comparing only the most recent VF with the one before?
No
VF Baseline Testing protocol…
Baseline Data –first 2 years –At least 2 reliable VF within the first 6 months • 3 within first 6 months when there is a high likelihood of visual disability –
At least 2 further VF within the next 18 months –VF testing should be repeated sooner than scheduled if possible progression is identified –SIX VF within the first 2 years allows the clinician to identify rapid progression
After 2yrs VF frequency should be… in low/moderate risk and high risk px?
In low‐and moderate‐risk: yearly
(Sooner if possible VF progression –OR‐on other clinically tests)
high risk: 6monthly
What is event analysis?
Event analysis (EA): change from baseline greater than a predefined threshold based on test‐retest variability according to the level of damage
What is Trend analysis?
Trend analysis (TA) (VFI): rate of change over time; significance is determined by both the magnitude of change and the variability of the measurement
When to use Event Analysis?
In general, event analysis is used for follow‐up when fewer VF are available –When suspected progression is identified, at least TWO further tests should confirm that
When to use trend analysis?
In general, trend analysis (rate) is used
later in the follow up (later than 2 years)
Event Analysis Pearls…
About 5% chance that a single point will fall outside the expected change on a single test –Much less likely that same point will do the same in a subsequent test
If point is in same region of VF as existing defect –much more likely to be “real” change –Point in central 10 degrees exceeding expected change is much more likely to be “real” change
Prostaglandin Analogs (PGAs) •
Mechanism of action:
Effect:
Dosing:
Side effects:
Prostaglandin Analogs (PGAs)
Mechanism of action: increase uveosceral outflow
Effect: excellent (25-35% reduction)
Dosing: once daily (doesn’t matter am/pm)
Side effects: – Minimal systemic
Ocular: (3Hyper-Deep)
Hyperemia • Hypertrichiasis •
Hyperpigmentation –iris and periorbital skin •
deepening of upper eyelid sulcus
When to reconsider using PG?
• When to reconsider: ACUPUN
Acute rise in IOP
CME Hx or risk of CME (ok in DM+)
Unilateral therapy
Pregnancy
Uveitic glaucoma (???)
Neovascular glaucoma (???)
If VF progression then must consider cause….
optical is more likely if…
Optical explanation MORE LIKELY if…
No increase in PSD, in cases where MD is better than -10dB
New baseline VF’s when…
target IOP is adjusted or
significant change in therapy
Last 2 tests that confirmed progression can be
new baseline exams
Frequency of testing needs to increase again
Which VF indicies if high, them must discard test?
False Positives.
GPA can’t be used once MD gets to…
~20
beta blockers
action:
Efficacy
dosing
side effects
beta-adrenergic antagonists (beta blockers) •
Mechanism of action: decrease aqueous production •
Efficacy: very good (25-30% reduction)
- Dosing: once vs twice daily
- Side effects: – Minimal ocular side effects –
Systemic: • Bradycardia • Bronchial constriction •
** CHECK EXISTING MEDS, VITALS •
Short term escape (days-weeks)
& long term drift (months-years)
Bacterial Conjunctivitis
More or Less a wet uni more
More Common in children
Less common v viral/allergy
Wet DC v dry and crusty esp in morning (matted lashes)
Unilateral or bilateral
More conjunctival injection v DED/viral
Beta-Blockers: when to use…
When to use: – First line therapy for patients with
contraindications to prostaglandins
– Need rapid lowering of IOP –
Cost (generic is cheap) –
Added drug for prostaglandin users •
Different mechanism of action •
Beta Blockers When to reconsider…
When to reconsider:
- Heart Disease
- Pulmonary Disease Eg. Asthma
– Patient on oral bb (+/-)?
– Normal tension glaucoma
(may reduce perfusion to ON)
Beta blockers: available drugs
–timolol maleate (Timoptol, Timoptol-XE)
non-selective (better option) 29% reduction
–betaxolol(Betoptic, BetoQuin) 26% reduction
selective beta1 receptor blocker
fewer systemic side effects not causing
bronchospasm.
Accommodative Insufficiency Mx
Correct even small refractive errors as even small amounts can cause fatigue.
Correcting differences b/w eyes recovers normal accomm-verg in 63% of cases.
Give ADD
ONH Hypoplasia
MoPS, R, 3VC
Most common OD anomaly.
Peripapillary Halo (yellowing, mottled)
Small ONH (pink, grey or pale)
Ring of incr/decr pigm bordering halo (‘double ring’ sign)
Veinous tortuosity
VA: 6/6 to NLP
VF defect possible
CNS abnormalities (strong association) -> MRI req’d
Glaucoma –alpha-adrenergic agonist
mechanism
efficacy
dosage
side effects
Glaucoma –alpha-adrenergic agonist •
Mechanism of action: – Decrease in aqueous production
– Increase in uveoscleral outflow •
Efficacy: good (20-25% reduction) •
Dosing: tid vs bid
• Side effects:
– Systemic: DiDS
- Somnolence (sleepiness)
- Dry mouth
- Dizziness/fainting
– Ocular: • allergy
alpha agonist trade name
Alphagan
Alphagan-P (Preservative Free) -
use for those allergic to preservative.
PseudoesoT
Tests to do:
Mx:
Tests: hirschberg, Bruckner, TNO (if old enough),
wise to do cyclo Ret
Mx: rev 3-4mo;
if at review normal then rev 6/12 after this.
IOP Asymmetry
Absence of IOP asymmetry between the fellow eyes is associated with a 1 percent probability of having glaucoma. A difference of 3 mmHg is associated with a 6 percent probability and a difference of >6 mmHg with a 57 percent probability of having glaucoma
When to use brimonidine
RAPP
Rapid IOP lowering (esp in combo)
- Additivity: Excellent additivity with prostaglandin/Good with beta-blocker
– Preservative toxicity/allergy
– Pregnancy Category B -can use in 1st trimester
(discontinue in breastfeeding)
Setting Target IOPs
Target IOP –2 methods
• Stage of Disease:
–Mild: ~30% IOP drop from highest IOP
–Moderate: 30-40% drop
–Severe Loss: 40-50% drop •
Stage of Disease:
–Mild: high teens
–Moderate: mid teens
–Severe loss: low teens
Which glaucoma med is neuroprotective in NTG?
Brimonidine
(alpha-agonist)
Glaucoma –carbonic anhydrase inhibitors
- Mechanism of action:
- Efficacy:
- Dosing:
- Side effects: – Topical:
Glaucoma –carbonic anhydrase inhibitors
- Mechanism of action: decreased aqueous production
- Efficacy: excellent (oral –40-50%+); good (topical –15-20%)
- Dosing: bid –tid
- Side effects: – Topical:
- Bitter taste
- Stinging • Hyperemia
- Corneal endothelial probs (if lots of guttates don’t use CAI)
AMD rate in Australia
55yo+: prevalence of AMD is 3%
40+ yo: 10% have some signs of AMD (whether early/intermediate/late)
Glaucoma -CAIs • When to consider:
When to avoid:
• Available as:
Glaucoma -CAIs • When to consider:
– Good addition to prostaglandin
– Brimonidine allergy
• When to avoid: – Fuchs corneal endothelial dystrophy
– Pregnancy – Sulfa allergy (???)
• Available: – Dorzolamide (Trusopt, Trusamide, APOdorzolamide)
– Brinzolamide (Azopt, BrinzoQuin)
Glauc - oral CAI
Name:
Dose:
When to use:
Glaucoma -acetazolamide (diamox)
- Typically used in emergency/acute situations rather than long term due to systemic side effects:
- Typical use: – Post-surgical IOP elevation
– Acute angle closure (NON-PUPILLARY BLOCK ONLY)
– Extremely elevated IOP
• Dosing: – 250 mg tablets qid(generic)
– 500 mg time-released capsules (Sequels ®, generic) bid
Glaucoma -pilocarpine •
Mechanism of action
Efficacy:
Dosing:
Side effects:
• Use:
Glaucoma -pilocarpine •
Mechanism of action –increase trabecular outflow
- Efficacy: good (25%)
- Dosing: qid
- Side effects: – Accommodative spasm – Browache – Bronchial constriction
- Use: acute angle closure with pupillaryblock(low concentration)
Fixed Combination Medications
• (Azarga)
Fixed Combination Medications
• CAI + timolol –Brinzolamide/timolol (Azarga)
(Cosopt, Cosdor)
–Dorzolamide/timolol (Cosopt, Cosdor)
(Combigan)
• Brimonidine + timolol (Combigan)
Simbrinza
• Brinzolamide + brimonidine (Simbrinza)
(Ganfort, Ganfort PF)
(Xalacom, Xalamol, Lantim)
(Duotrav)
• PGA + timolol
–Bimatoprost + timolol (Ganfort, Ganfort PF)
–Latanoprost + timolol (Xalacom, Xalamol, Lantim)
–Travoprost+ timolol (Duotrav)
Disc Haemorrhages w/ Glaucoma rev in..
3months as new RNFL dropout may be seen.
Frame standard dimensions for caucasian…
ie. wrap, PT, BVD
standard dimensions PT 7, wrap 5, BVD 13mm
Cycloplegic refraction in
infants ie. 0-12months old
and
>=1yr old
Use 0.5% in 0-12months old.
Instil one drop in both eyes twice 5mins apart.
(Clinician to do it as must observe for adverse affects within 30min)
Note: Blond hair/blue eyes particulary susceptible.
examine after 30min.
for >=1yr old use cyclo 1%
For high powers remember to give the lab…
BVD of glasses and BVD of phoropter so they can compensate
If same prescription and going from a frame fit or
Incr BVD and/or decr PT
need to compensate by…
increasing the corridor length.
Mohindra Retinoscopy
wd?
adjustment?
wd 50cm
- 0.75 for <2yo
- 1.00 for over 2+yo
Orbital Cellulitis
Signs
CCOPP
Chemosis of lids
conjunctival injection
ON dysfunction: VA down, CVD, RAPD
Painful Ophthalmoplegia (EOM paralysis)
Proptosis
For short people, when fitting MF’s need to consider…
PT very different when standing vs sitting.
They tend to tilt head back to look up at people when standing.
It can be as much as 10deg and 5mm Ht diff
When fitting SV or SVN with vertical prism must take…
Heights!! Else unwanted prism can be induced as lab will fit it on datum.
When measuring prism with trial frame, make sure to compensate for deviation of the eye by….
vary the PD of the trial frame 0.3mm for every prism diopter
away from the base.
Eg. RE 8BO prism -> reduce the pd in that eye by 2.4mm
Standards for cyl axis
- 25 +/-16
- 50 +/-9
- 75 +/-6
- 00 to 1.50 +/-4
- 75 to 2.50 +/-3
>2.50 +/-2
What affect does the following have on a MF reading zone?
PT?
BVD?
PT: Incr tilt -> drops the near zone lower and increases effective VF.
BVD: Incr BVD -> lifts the near zone higher and reduces effective VF.
Central Serous Chorioretinopathy CSCR Tx options
(2 broad categories)
Observation
or
Tx
CSCR
Observation if…
First Stop Cushing’s Sleep
First acute episode in a young patient and less than 3 months onset
- STOP corticosteroids!: oral, nasal sprays, joint injections, skin ointments
- Consider Cushing’s Disease: A condition that occurs from exposure to high cortisol levels for a long time. (Signs are a fatty hump between the shoulders, a rounded face and pink or purple stretch marks.)
- Treat sleep problems: shift work, sleep apnea
CSC (Central Serous Chorioretinopathy)
tx if…
SOC 40
Severe Vision loss
- Occupational need for excellent binocular vision
- Chronic sub-retinal fluid (3-6 months)
- > 40 years of age
Try and aim for a spectacle magnification difference between the eyes of…
<= 1.3%
Medmont binocular driving test
- roving v fixating
Use roving if central VF defect
for everything else use fixating
Medmont binocular driving test
When printing results remember…
LAANN
Level map
124 Numeric
Numeric Tic Marks
Annotations
Attributes
Anisocoria Evaluation protocol
1st step
and implication
Is it worse in light or dark? also check light reaction.
Implication: worse in light and poor light reaction in one eye means the more dilated pupil is abnormal.
worse in dark and good light reaction means the smaller pupil has problems dilating.
Anisocoria: If worse in the dark check for…
and what are the implications
10% cocaine test results
dilation lag (dodgy pupil takes about 10-15sec to dilate cf normal pupil which takes 3-5sec)
Implications: If dilation lag is absent then it is physiologic anisocoria. (Dilation occurs with 10% cocaine)
If dilatation lag present -> Horner’s syndrome (dilation doesn’t occur with 10% cocaine).
Explain 10% cocaine test in Dx Horner’s: How and interpretation
How: Instill cocaine drops in both eyes.
Cocaine stops the reuptake of Nor-Adrenaline and therefore prolongs the affect of dilation (as there is more NA binding with he a1-receptor causing dilation).
In normal -> this will cause dilation in both eyes.
In Horner’s: there is disruption of the nerve pathway and therefore less/no NA has been released at the synapse and therefore no dilation will occur. The normal pupil will dilate but the Horner’s pupil will not dilate.
Horner’s Syndrome: Sx’s and Signs
Miosis (also Dilation Lag)
Anhydrosis (lack of sweat of affected side)
Ptosis (Affected side)
Heterochromia (Affected iris lighter)
Explain how to Dff Dx pre/post-ganglionic Horner’s
Use Paredrine (1% Hydroxyamphetamine) in horner’s eye.
paredrine acts to release NA from nerve terminal.
Pre-ganglionic Horner’s: Dilation occurs as the 3rd order nerve is normal and still has NA to be released.
Post-ganglinic Horner’s: Dilation does not occur
as the 3rd order nerve is abnormal and has no NA to be released.
Anisocoria: If worse in lit room, then check…
- S/L exam of iris
- Check Near constriction
- Consider 0.125% pilocarpine test
What is Light/Near Disocciation and what are it’s implications?
L/N Dissociation has..
Quick NR but no/sluggish LR
If see this… REFER!!
could be Parinaud’s Syndrome or Argyll-robertson pupil
first time myopes in PAL’s use…
While first time wearers will most often be placed in a softer design it may prove beneficial to implement a harder design for first time myopes in PAL’s.
myopia stabilization stats…
48% by age 15 years;
77% by age 18 years;
90% by age 21 years;
96% By age 24 years,
Adie’s Pupil Signs
STonCon
Sector iris palsy (Iris streaming)
Tonic near constriction (Delayed NR)
Constriction w 0.125% pilo (cholinergic supersensitivity)
Anisocoria: 3rd NP test results…
round pupil
poor near constriction
no constriction with 0.125% pilo
constriction with 1%pilo
Eyes down and out
Anisocoria: Pharmacologic Pupil Dilation
Round Pupil
Poor NR
No constriction w 0.125% pilo
No constriction w 1% pilo
Anisocoria: Traumatic Iris Damage
Torn Pupillary Border
Sluggish NR
If VA is down and no obvious cause do…
check pupils for RAPD
colour vision
RAPD indicates…
Abnormality along Optic Nerve most commonly and rarely at the optic tract.
It may also indicate wide-spread retinal damage.
How to measure RAPD
Place neutral density filter over good eye and then retest MG+
Increase density until MG disappears.
Make sure to quickly ‘bleach’ both eyes b/w increases so as to equalise the LR
search youtube under “how to measure the rapd moran core”
How to estimate ACD
In lit room, get p to look straight ahead,
over the other eye, use iphone with a flash from the side.
ACD(mm) = -3.3(E:Z) + 4.2,
where E is limbus to centre of pupil and
Z is limbus to cornea.
<2.5mm is high risk for AGC
Prism Balance Point with anisometropia and MF’s.
What to do….
Go to AAOO calculator under oblique astigmatism tab
Enter dist rx and corridor lenght in cm
Work out net vert prism and trial frame this with the add.
If p able to fuse then don’t compensate for it, else ask the lab to compensate.
Anisometropia greater than how many dioptres may cause problems?
>1D
If you suspect anisometropia is causing problems Eg. Diplopia, what simple test can you do?
Get the p to look eccentrically to induce diplopia.
Anisometropia: Ask this Q… and implications.
Are you susceptible to motion sickness?
Higher rate of rejection of MF and BF’s (especially BF’s)
OrthoK
Flat K’s: There is a trend towards undercorrection of myopia if K’s <…
and avoid flat corneas that are…
<43.5D
flatter than 8.5mm
or orders w BC>9.2mm
Subconj haem: if nasal and 24hrs after head inj then…
strongly associated w fractures of the base of skull.
Must ask if there is a recent head injury.
Be careful of this potential side-effect of brimonidine…
Brimonidine Uveitis.
Can occur even after using it without problems for a long time eg. 10months.
Possible side-effect of topical dorzolamide…
periorbital dermatitis. Can cause hypersensitivity after taking topical dorzolamide and become allergic to BAK and so must use non-preserved.
DVP is ?% more scracth resistant than glass
35%
HC has ?% more reflections than MC
40%
Muscle Contraction (Tension) HA’s;
px setting:
PX setting: any age; 70-80% Female; FH in 40-50%; often emotional factors
Muscle Contraction (Tension) HA’s;
H/A setting:
strong boo versus lazy imps with nits
steady, non-pulsatile dull ache - back, neck/bitemporal/bilateral
- bilateral in 90% radiating to neck, temples, shoulders
- variable severity; build slowly to peak (hours)
- lasts hours upto 1 day, over several months; rarely interrupts sleep
- improved w analgesics, sedatives, rest, massage
- worse w activity/stress
- Neuro sx’s in 10%; maybe nausea/light-headed
Migraine: Px setting
Frequency
M/F Ration
FH
age
other:
types:
Very common 12-35% of general population
70% Females
FH in 65-90%
Usu begins age 5 to 30
Emotional factors operative
Types include: common (80%), Classic (12%),
Complicated (3%), Cluster (5%)
AMD wet v dry percentage
dry 85-90%
remainder wet
A spectacle magnfication difference of ? to ? is generally accepted as a point of non-fusion
3% to 7%
Smith’s technique for ACD with SL
This technique should be carried out in a dark room
Set the patient up at the slit-lamp and advise them to fixate straight ahead
Lock the illumination at 60° temporally to the patient
The viewing microscope should be set straight ahead
Set the magnification to 10-16x
Use a thin 1-2mm beam and turn it horizontally
Place the beam over the temporal pupil margin, focused on the cornea
A second beam on the iris/anterior lens will be visible on the nasal pupil margin
Increase the height of the beam until the edges of the two beams just touch
The illumination must be rotated 60° to the other side to measure the other eye
Smith’s technique ACD.
how to calculate
average ACD
ACG risk if <….
SL measurement x 1.31
average is 3.15
ACG risk if <2.5mm
Anisometropia MF’s: Solutions
see emails Optometry: Anisometropia and work out an eg. with AAOO v4 excel spreadsheet
changing script,
manipulating corridor length and
moving the prism balance point
or a combination of these
Which frame paramenter has greatest affect on lens performance?
A change from standard of only 3° will cause a drop in lens performance of…
a face form angle of 10° (which is only 5° different to standard) causes a drop to less than…
Wrap.
25%
50% in the performance of a progressive lens that does not take account of individual parameters.
Individual progressive lenses still have a performance of almost 100%.
For PD’s…. should consider zeiss individual else inset will be out.
>73mm (they will converge too much for the near zone)
<58mm (they won’t converge enough for near zone)
Centre distance CooperVision Biofinity multifocal lenses with a +2.50D slows progression of myopia by…
43%
CooperVision MiSight reported less myopia of ….
59%
Dff Dx of Transient Vision Loss for…
Migraine v Carotid Disease (TIA) v Vertebrobasilar Insufficiency
Onset/Age
Duration
Field Loss
Featuers
Medical Risk Factors
Migraine: Gradual, 20-30min, binocular, homonymous, march with time (spread), flickering lights, photophobia. No med risk factors.
Carotid Disease (TIA): Sudden, mid-aged and older, 1-7min, monocular, stationary, total or partial “grey-out”, “black-out”, “shade” or “veil”, med risk factors present
v Vertebrobasilar Insufficiency: Sudden, older, 1-7min, binocular, stationary, total or partial “grey-out”, “black-out”, “shade” or “veil”, med risk factors present
Classic Migraine
Severe, Unilateral, pulsatile, visual disturbance, prodrome 20-30min,
contralateral HA to sx’s in 80%;
Occurs after stressful stiuation Eg. weekends;
HA lasts hrs and in cycles which may last over days
Neurological sx’s: nausea, vomiting, photophobia
Triggers: stress, depression, menopause, menstruation, CP, histamines in choc, wine, nuts; tyramine in cheese, nitrates in meat;
Common Migraine
Similar to classic migraine except HA is main sx
Vague or absent prodrome
Neurologic sx’s rare
Cluster Migraines
20-50yo males M/F 5/1;
emotional factors present
unilateral; knife-like pain around eye, v intense
radiates to temple, maxilla, gum
sweat/heat imbalance
worse w stress/alcohol
clusters of 1-6/day lasting 10-60min starts early 4am
occurs at intervals of 1-3months
ipsilateral, facial flush, nasal congestion, horner’s (33%), sweating
Complicated Migraine
5 forms
HOOBA
- Hemiplegic - gives paresis in some body part
- Ophthalmoplegic: gives paresis of EOM
- Acephagic - HA is absent w only visual sx’s
- Ocular: transient monocular vision loss, may or may not be mild HA (dx of exclusion) Cf. TIA’s: in older people w vascular disease.
- Basilar: 20-40mins: black/grey outs, usu young Females w severe occiptal HA.
When to refer migraine sufferer
If 30+yo and presents w 1st severe migraine
Trigeminal Neuralgia (Tic Dolereaux)
dolereaux: “Dol-a-rose”
40-50yo; F/M 3/2; MS approx 15%
sharp, quick, unilateral
sudden, sec-minutes;
occurs in spasms but w sx free periods
V1-V3 distribution, but may radiate
trigger points (eye/nose/mouth/teeth), worsens w cold,food etc
Carbamazepine (80%), Phenytoin improves it.
Hysterical HA
TDHS Clever Boo Needs Breakfast Daily
20-50F; c/o multiple somatic sx’s and lots of ops,
depression/anxiety Insomnia
HA: bizarre, ‘band-like’, squeezing, extreme psychological probs
severe pain but indifferent
constant 24/7, days to months
bizarre radiation,
nothing helps worse w stress
blindness, fainting, paralysis
Dx of exclusion
Child <10yo + has myopia >-5D need to….
refer to ophthalmologist to rule out syndromic conditions.
MYOPIA CONTROL
MF’s only useful if…
what add to give?
esoP or Accomm lag
give +1.50 or +2.00 Add
What is the “rule of the pupil”?
The rule states that when aneurysms compress the oculomotor nerve (CN3), the iris sphincter will be impaired, leading to a dilated or sluggishly reactive pupil.
What is the chance of a child being myopic based on having 2 myopic parents?
If a child w 2myopic parents is +0.75D or less at age 6, they have a 75% chance of being myopic by age 13.
What are 2major risk factors for myopia at age 6?
- myopic parents
- <=+0.75D
When measuring eye protrusion, if the measurements are different by …. mm the patient should undergo additional evaluation.
>=2mm
OCT and Glaucoma: What 3 attributes have good diagnositic accuracy?
Several studies have suggested that (in order of importance)
- mean RNFL thickness
- inferior quadrant thickness,
- followed by superior quadrant thickness,
What is the lowest refraction you can start at for myopia control?
-0.50D
NaFl TBUT cut off?
gives a sens/spec of….
a cutoff of 8.0 seconds has 78% sensitivity and 72% specificity for diagnosing DED against tear hyperosmolarity
If eye itching is in the canthal region what is likely cause?
allergic conjunctivitis
A poor blink can be caused by…5 things
VCLIP
Person trying to blink but blocked by VCLIP
Vdu computer reduced blink rate
Cosmetic: on the vdu screen is someone having cosmetic surgery
Laxity: botched surgery leads to lax lids!!
Incomplete: lid closure now as they try to blink
Partial: blink action sometime full sometimes half.
long hour on VDU (reduced rate)
Cosmetic surgery,
Lid laxity,
Incomplete lid closure
Partial blinking,
How does a poor blink cause MGD?
our blink is essential to naturally expressing meibum.
So anything that prevents a proper blink is likely to be a cause of MGD.
What is one of the best tests for incomplete lid closure?
the Korb-Blackie Light Test.
How to perform the Korb-Blackie Light Test?
In your darkened room,
instruct the patient to close their eyes as if sleeping,
but not squeeze.
Place the transilluminator on the closed upper eyelid
and look for light escaping
from the bottom between the eyelids.
Protocol for diabetic macular edema
If VA is 6/7.5 or better, even with CSME, observation v invasive tx gives same VA outcome after 2years. Therefore just observe.
how to Dff DX DED EBMD
Look for consistently blurred vision without dry eye signs,
or a TBUT that consistently breaks up in the same place to be a possible EBMD presentation.
Recommendations for MDEYES and study results
INTERMEDIATE AND ADVANCED AMD (NON-CENTRAL GEOGRAPHIC ATROPHY IN ONE OR BOTH EYES) -> reduces the risk of progression of the disease and loss of visual acuity by about 25% over five years
Anterior Uveitis: Define ACUTE, RECURRENT & CHRONIC
Acute: Totally resolved within 3mo, not caused by another pathology of cornea or post pole. Persistent > 3mo duration.
Recurrent: Repeated episodes, but no recurrence for >=3mo w/o tx in b/w.
Chronic: Recurs <3mo of ceasing tx. Higher risk of vision loss.
Ant Uveitis Mx:
If mild ie. ACR G1 -> PF qid
If severe PF q15 for 1hr then q1h, x2 stat bedtime;
rev 24hrs
If post synechiae: soak cotton tip in atropine 1%, put into inf fornix 15min, repeat in 1hr, then rx: atropine 1% bd/tid
When ACR drops a grade reduce PF to q2h-3h (q2h for 2d, then q3h for 3d) and atropine to qd; then stop atropine.
rev daily until ACR back to G1, then PF qid for 1w, then if G0-0.5 taper ie. reduce 1drop/week;
When to refer AAU…
Paediatric
Atypical, complicated, severe
Non-responsive
Intermediate/Posterior
Chronic
Bilateral
Endophthalmitis possibly
Granulomatous
CL + red eye always…
rev in 24h to ruleout early MK, then again in 1w
MK: send for culture when…
“1223C”
1+ ACR
2mm+ in size
2+ adj lesions
<=3mm from corneal centre
culture cornea, if CL wearer then culture CL and case
Note: if culture required then fortified Ab will be needed therefore send to RVEEH as well
MK: Refer to hospital if…
Sig corneal thinning
Large Area
Compliance concern
Culture required
Episcleritis: use this drop to help diff dx from scleritis
2.5% PNL
Congenital NLDO conservative tx…
Do crigler massage 10-15x/d
How to test VA in 2.5yo+? v <2.5yo+?
2.5yo+ try LEA
<2.5yo use preferential looking/electrophysiology
If suspect accomm esoT what tip can be used to try and ‘bring it out’?
Check CT in all directions using -2 Flipper for D and N (as it stimulates accommodation)
Which group of paediatric population is AccFac no reliable?
Young astigmats (everything is blurry to them)
