Transcript Orbital Cellulitis - Wakefield Optometry Home Page

Acute Eye Emergencies
&
Advances in Lens Implants
for Cataract Surgery
Andy Chung
B.Sc (Hons), MB.ChB., MRCS (Ed), FRCOphth
Consultant Ophthalmic Surgeon
Mid-Yorkshire Hospitals NHS Trust
Specialist Training
Leeds Medical School
 Intercalated B.Sc (Hons)

90-96
93-94
◦ - Pathological Science

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Basic Ophthalmic Training
Advanced Ophth Training
97-01
01-06
◦ (both in Yorkshire)
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Fellowship (dual):
05-06
◦ Manchester – Cornea/Refractive
◦ Leeds - Oculoplastics
Mid-Yorkshire (Sept 06)

General Ophthalmologist
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Special interests:
*Cataract/Cornea/Oculoplastic/Refractive
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Clayton/Pontefract/Dewsbury (NHS)
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Methley Park/Yorkshire Eye Hosp
(Private)
Acute Eye Emergencies
Patient A
65 yo F
 Sudden onset painful right eye
 Extremely unwell
 Nausea and vomiting
 VA – HM only
 Injected eye
 Hazy cornea
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
??
Acute angle closure glaucoma
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Aqueous outflow obstructed by closure of ant
chamber angle
1:1000 > 40yo
M:F
1:4
AACG
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Symptoms:
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Sudden onset red and painful eye (usually unilateral)
Nausea and Vomiting
Reduce VA
**+/- Mimic acute abdo!
Signs:
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Cloudy cornea
Mid-dilated pupil (not reactive)
Inflammed eye
Tender++
Unwell pt
AACG Management
Immediate:
 i.v. diamox 500mg
 Oral diamox 250mg qds
 +/- i.v. mannitol
 G.pilocarpine (BOTH eyes –fellow eye at risk)
 G.timolol/xalatan
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AACG Management
Longterm:
 Yag peripheral iridotomies (Bilateral)

Patient B
72 yo M
 2/52 left sided headache
 Constant, not relieved by analgesia
 Recent loss of appetite and weight loss
 Sudden reduced VA left eye
 VA – HM
 Eyes not inflammed
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??
Temporal Arteritis
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Idiopathic vasculitis of medium and large
arteries
>50 yo
Both M & F
TA
Symptoms:
 Temporal tender – severe
 Jaw claudication (ischaemia of masseter)
 Non-specific – reduced appetite & weight
 Polymyalgia rheumatica
 +/- Sudden onset reduced VA
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◦ Anterior Ischaemic Optic Neuropathy (AION) – 25%
◦ Amaurosis fugax/Retinal Artery Occlusion
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Diplopia
◦ CN III, IV, VI Palsy
TA
Signs
 Gross VA loss ++ (<finger counting)
 Tender temporal region
 Absent pulsation
 Swollen optic disc
(AION)
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TA
Ix
 ESR – significant if: M - > (Age +10)/2
F - > Age/2
** 20% Norm ESR
** also false +ve (arthritis etc)
 CRP – more sensitive
 Biopsy - **20% -ve (skip lesion)
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◦ Treat pts with –ve biopsy but highly clinically suspicious
TA
Management:
 **Treat immediately
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◦ Biopsy result not compromised within 1/52 of Rx
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Oral Prednisolone – 1mg/kg
◦ Then reduced slowly – clinical / ESR
◦ Lansoprazole & Calcichew
◦ Trial of stopping Rx in 12 months
Patient C
23 yo F
 3/7 redness & swelling left peri-orbital
region
 Unwell, pyrexia
 Painful
 Unable to open eyelids
 Hx of sinus disease
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??
Orbital Cellulitis
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Important to distinguish pre-septal cellulitis
(benign) from orbital cellulitis (sight
threatening)
Orbital Cellulitis
Pre-septal Cellulitis
Orbital Cellulitis
Location
Superficial
Deep in orbit
Aetio
Localised infection
e.g. chalazion
Sinus-related
Post trauma/surgery
Age
Any (esp children)
Any
Pre-septal Cellulitis
Orbital Cellulitis
Orbital Cellulitis
Pre-septal Cellulitis
Orbital Cellulitis
VA
Not usually affected
Affected
Pupil reaction
Norm
ABN
Proptosis
No
Yes
Restricted eye Not typically
movement
Yes
Temp
Usually Norm (well)
Pyrexia (unwell)
Optic disc
Norm
+/- disc swelling
Orbital Cellulitis
Management
Pre-septal Cellulitis
Orbital Cellulitis
Oral + topical Abx
I.V. abx/antifungal
CT: scan
Drainage of abscess
Patient D
46 yo M
 1/52 floaters/flashing light right eye
 High myopia
 No reduced VA
 Shadow: bottom half of vision right eye
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??
Retinal Detachment
1:10000/per year
 Any age/sex
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Risk factors:
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Trauma
High myopia
Family History
Intra-ocular surgery (incl cataract surg)
Diabetic (tractional/exudative RD)
Syndromes e.g Marfan’s
Post vitreous detachment
Incidence
Post Vitreous
Detachment
RD
Common
Rare
Floaters
+
+
Flashing light
+/-
typical +
Shadow
-
+
Reduced VA
-
+/-
Treatment
None
Laser/Surgery
Prognosis
Good
Depends on extent
RD
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Floaters/flashing light – no reduced VA
◦ Optom – if Norm – see ophthalmologist (ideally within
1/52)
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Floaters/flashing light – shadow/reduced VA
◦ Ophthalmologist – ASAP
Patient E
79 yo F
 Hx Hypertension, MI, CVA
 Sudden painless reduced VA left eye
 VA – HM only
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??
Retinal Arterial Occlusion
Embolisation of retinal artery
 Heart – calcified valve embulus
- vegetation from endocarditis
 Carotid artery disease – stenosis
 Giant cell arteritis
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Central/Branch RAO
RAO
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Sudden-onset painless reduced VA/visual field
defect (if branch RAO)
RAO
Retinal ischaemia within few hours of onset
 But worth treating within 48 hrs
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Immediate
i.v. diamox 500mg
Firm ocular massage
Others:
◦ 5%CO2 & 95% O2
◦ Anterior chamber paracentesis
RAO
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Long-term:
◦ Oral Aspirin/Clopidogrel
◦ Aim: Prevent episode in fellow eye
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Ix:
◦ FBC/ESR/Lipid/Gluc
◦ Carotid Dopplers
◦ Cardiac ECHO
 Oops!!
Summary
Acute Angle Closure Glaucoma
 Temporal Arteritis
 Orbital Cellulitis
 Retinal Detachment
 Retinal Arterial Occlusion
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Advances in Lens Implants - Cataract
Surgery
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Small incision cataract surgery
(Phacoemulsification) – 1990s
96% - VA >6/12 (no ocular path)
Most visual outcome concentrate on distance
VA
These pts still need to wear spectacles for
reading
Monofocal lens implants
New era
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Presbyopia – loss of ability to accommodate
i.e. ability for close vision (onset – 45 yo)
◦ Reduced muscle tone of ciliary muscle
◦ Increased rigidity of lens
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Patients nowadays also demand spectaclesfree vision for distance & near
2 Options/Types
Multi-focal
 Zonal technology
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Accommodative
 Mimic natural lens
movement
 ? Vitreous pressure
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Multi-focal Lens
Various designs
 ReZoom
 Pupil dependent
 Best for distance &
intermediate
vision e.g. computer
work
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Technis
Pupil independent
Best for distance &
near e.g. reading
=> “Mix & Match” Strategy
one lens each
Multifocal lens
“Mix & Match” strategy
 FDA clinical trial – 80% spectacles independent
 Adverse effect:
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◦ Glare/haloes – up to 25% (most adapt)
◦ vs 7-8% in monofocal lens implants
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Not suitable for everyone
◦ Keratoconus/Corneal path
◦ Significant astigmatism
◦ Macular/Retinal disease e.g. AMD
Accommodative Lens
Crystalens (Accommodative Lens
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Manufacturer’s statement
100% pass a driver’s test without glasses
100% see intermediate (24” to 30”) without glasses, the
distance for most of life’s daily activities
98.4% could see well enough to read print the size of the
NYSE quotes in the newspaper, or phone numbers in the
white pages of a telephone book without glasses
Some patients did require glasses for some tasks after
implantation of the crystalens®
Younger patients with refractive error
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Useful alternative in pts not suitable for
refractive laser e.g. high+ myopia >12D
Phakic intra-ocular lens implant (phakic IOL)
Phakic IOLs
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Advantage
◦ Cornea untouched – no corneal ablation
◦ Reversible – important when pt needs cataract surgery
when older
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Potential issues
◦ Intra-ocular surgery – risk of endophthalmitis
◦ Longterm impact on corneal endothelial cell counts
◦ Risk of inducing cataract (low)
Thank
you