NBE CME programme for DNB consultants - National Board Of ...

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NBE CME programme for DNB consultantswith time as with open angle glaucoma, averaging 50% or less by 5 years. There have been lessreports of success with re-treatment.Surgical Treatment - Indications for filtration surgery and the outcomes are as with open angleglaucoma.Points to remember- Whitish Material in the papillary area; Non-Dilating pupil; LenticularSubluxation; Unilateral Glaucoma — All these call for an evaluation of PEX.Sellar TumoursThe most important point to note in the case of sellar tumours is that the main entity is a pituitarytumour and pituitary tumours usually give ocular symptoms till they grow to a macroadenomaHistory - Visual Symptoms - common with non-functional adenomas - Painless asymmetric visualloss and mono-ocular blindness This is the predominant ocular symptom; almost 2/3 have visualsymptoms and 2/3 of them have loss of vision as the presenting complaint; the great majority of thevisual symptoms consist of visual loss in one or both eyes; Many patients are unaware of theirvisual loss; The visual loss precedes other symptoms of headache and endocrinopathy in almosthalf the cases; The duration between the visual disturbances and the other symptoms would varybetween less than a month to more than ten years; Attacks of amaurosis some lasting as long asan hour may precede permanent visual loss; Occasionally acute mono-ocular visual loss in apreviously healthy individual is the first evidence of a pitpitary tumour( confused with retro-bulbarneuritis); Central vision may be reduced in both eyes acutely, though still asymmetric (one shouldsuspect acute pre-chiasmal expansion); Vision decomposition in patient with known bitemporalhemianopia is suggestive of pituitary apoplexy. Hemifield Slide Phenomena Intact nasal fieldswhen overlap produce a sensory diplopia(non-paraetic diplopia), or separate to where objectsseem to disappear from the central vision. Postfixation Blindness In a complete bitemporalhemianopia when a patient converges to a point, his blind hemianopic visual fields align behindfixation; when the patient attempts to thread a needle, for example, the thread enters the eye of theneedle, but does not appear to exit on the other side.Non-visual - Headache fairly common; bursying headache is considered characteristic of pituitaryadenoma; frequently frontal, bitemporal or retro-orbital; Decreased libido, impotence; Amenorrhoea;Galactorrhoea, oligomenorrhea; Infertility Asthenia; Acromegaly in adults and gigantism in young;Cushing’s syndrome; Pituitary Dwarfism (delayed body growth); rohlich’s syndrome(adiposogenital dystrophy); immond’s disease (reduced hair growth, intolerance to coldtemperatures, weight gain, cachexia)Clinical Examination - isual field defects with respect for the vertical border- Bitemporal hemianopiathat is greater near fIXation is the pathognomonic of visual field defect of an intra-sellar tumour;seen in 70% of the cases; Mono-ocular central scotoma with supero-temporal defect in the othereye (junctional scotoma of Traquair) is as diagnostic of a chiasmallesion as is Bitemporalhemianopia; Mono-ocular field loss alone in the form of central scotoma or temporal anopia orsuperor or inferior temporal depression may occur; Nerve fibre bundle defects; Homonymoushemianopia with a prefixed chiasm as the growth compresses the tracts. Optic nerve head defectA late sign of chiasmal affection, weakly correlated with duration of the symptoms and stronglycorrelated to persistent decreased post-operative visual acuity; visual acuity loss, relative afferentpapillary deficit, dyschromatopsia, pallor of the neuro-retinal rim of the optic disc and dropout of thenerve fibre layer (Disc pallor was once seen in about 2/3 of the cases; with improved endocrinologicaldiagnosis this has come down to about 2% only)Investigations Perimetry any type of perimeter will produce the typical field defects of a sellartumour; the kinetic perimetry programme by the computerised perimeters will give a field withwhich the neuro-surgeons are conversant with Neuro-iD.1aging the hall mark of the investigationfor a chiasmallesion; CT picks up calcification seen in 90% of craniopharyngiomas and inmeningiomas of this region; but MRI will be the investigation of choice Endocrinological evaluationMust112
NBE CME programme for DNB consultantsDifferential Diagnosis of Visual Fields Bilateral optic nerve lesions - Primary Open Angle Glaucoma(POAG), Disc anomalies; Testing artifacts; Psychogenic visual loss; 4. An empty sella syndromeshould be entertained particularly in patients with pseudo- tumour cerebri and in patients who haveundergone pituitary tumour resection. Of Optic nerve deficit - POAG The field defects would bedifferent; however in doubtful cases neuro- imaging is a must; in a few cases both could co-exist;Retro Bulbar Neuropathy (RBN) monocular vision loss with a normal looking optic nerve-headwould give a diagnosis of RBN and steroid therapy has been instituted with improvement in thecondition only to deteriorate with the cessation of the same; MRI would be diagnostic for both.Non-Surgical Management - Bromocriptine/ octreotide for functional adenomas and in macroadenomas prior to surgery for shrinking the massSurgical Treatment Trans-sphenoidal/ trans-ethmoidal for miro-adenomas; Trans-frontal for macroadenomas.Post -surgical radiation is necessary for prevention of re-growthPoints to Remember In any case with pale optic disc, a chiasmallesion should be kept in mind. Thefollowing are some pointers - A pale optic disc with normal Intra-Ocular Pressure, Nonglaucomatousfields with a pale disc, Rapid deterioration of visual parameters in a patient on antiglaucomatreatment. A working classification of sellar turnours Primary intracranial turnours - A.Intrasellar (Pituitary adenoma, Pituitary carcinoma ), B. Extrasellar (Craniopharyngioma, Sphenoidridge meningioma, Tuberculum sella meningioma, Dysgeminoma, Optic, chiasmal andhypothalamic gliomas, Cavernous sinus turnour ) ; Primary cranial turnours (Sarcoma, Chondroma,Multiple myeloma, Giant cell turnour), Metastatic (Nasopharyngeal (by direct spread), TumoUTS ofthe breast, lung, stomach, kidney and colon(mainly by hematogenous spread) )Adherent LeucomaSymptoms- Onset, duration and progression of following symptoms should be asked – Diminishedvision for near and distance; Cosmetic disfigurement; Redness and pain present or not; Presenceof squintPast History - Regarding trauma should be asked, if it is since childhood then age of onset shouldbe asked-Regarding exanthematous fever, Regarding vitamin A deficiency – opacity usually bilateral,Regarding any keratitis – bacterial, fungal, viralClinical Examination - Vision status for distance and near –Torch Light Examination-To localize siteand size of the opacity; Pupillary reaction – very unpredictable as a part of the iris is incarcerated inthe wound; Anterior chamber depth; Cover test to detect phoria and tropia; Projection and perceptionof rays of lights. Slit lamp Examination-For site, size, vasculature and extent of adherent leucoma;AC Depth; Distance from limbus; Assessment of Cataract; Intra Ocular Pressure (IOP) – ideallyshould be taken with pneumotonometer / digitally.Investigations- B Scan; Fluorescein Stain; Dilatation and refraction; Post mydriatic test for correctionif possible; Corneal Topography & Specular, Microscopy, Pachymetry, AC Depth assessmentDifferential Diagnosis- Active Ulcer; Abscess; Limbal Dermoid; Band Shaped Keratopathy; CornealScar due to injury;Non-Surgical Management - Contact Lens; Cosmetic Contact Lens; TattooingSurgical Options-Optical Iridectomy; Cosmetic Keratoplasty; PK with synechiolysis with ACreconstruction; Cataract and IOL SOS; Squint operations for cosmetic reasonsOther relevant points- Recent advance in keratoplasty, eye banking and various newer mediasavailable for better preservation of donor cornea, keratoprosthesis – newer modalities, suturematerials, suturing techniques.AmblyopiaHistory- Mother’s pregnancy history, gestational age at time of birth, birth weight & neonatal history;Ask about developmental milestones as developmental delay of the child, positive family history,prematurity increases a child’s chance of developing amblyopia; If the child has strabismus –113
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