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

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NBE CME programme for DNB consultantsenquire about the following – is it associated with psychological or physical stress, unilateral oralternating, constant or intermittent for distance or near or both?; Previous treatment, if any, bereviewed such as occlusion therapy, spectacle correction orthoptic therapy any eye muscle surgery;Past & present medication should be recorded, along with drug sensitivities and/or allergicresponses, surgical history, anaesthetic methods used & their results; Family history of strabismusor any other eye disorders.Clinical Examination -Visual acuity assessment ( Distance & Near) – Verbal Children (above 3years) Distance acuity by snellen letters. Often isolated letters can be used, that may lead tomeasurement underestimating amblyopia. ‘Crowding bars’ may help to alleviate this problem; Inpreverbal & non verbal children – CSM method. (C – Corneal light reflex location as the child fixatesexaminer’s light under monocular conditions i.e., opposite eye covered., S – Steadiness of fixationon examiner’s light. M – Ability of the child to maintain alignment first with one eye, then with theother, as opposite eye is uncovered. Maintenance if fixation is evaluated under binocular conditions.); Corrected near acuity is recorded with a near card at 14 inches (35cm).Other Aspects of visualfunction That may be affected in amblyopia should be tested. Such as – Binocular vision andstereo acuity – by worth four-dot test. Some other functions that are affected e.g. contrast sensitivity,motion perception & processing and spatial localization can be done if facilities areprovided.Assessment of ocular movement. Tests of ocularalignment Cover test, corneal light reflex test.Investigations - To rule out any organic cause of visual loss and identify the underlying cause ofamblyopia. Rule out ‘malingering’ in teens & adults.Management- Principles are— Elimination of any obstacle to vision such as cataract, centralcorneal opacity, severe ptosis occurring during infancy or in childhood; Correction of refractiveerror; In most unilatcral or asymmetric cases forcing use of the poorer eye by limiting use of thebetter eye.Refrective Correction- Full refractive error as determined under cycloplegia should be correctd;Refractive correction following cataract surgery/keratoplasty/correction of ptosis/ correction of squintmust be provided promptly.Occlusion therapy & optical degradation Amblyopia Treatment Study (ATS) Demonstrated equalefficacy of Penalization (Atropine treatment 1-3 days a week) & Occlusion in their early reports.Long term follow up data not yet available.Factors affecting success of abmblyopia treatment - Age of onset; Depth of amblyopia; Compliancewith treatment regime; Presence of associated anomaliesCriteria for Visual Improvement- Isoacuity between the good and the previously amblyopia eye;Equal speed of reading for both the eyes; Free alteration of fixation ensures that a cure has beenobtainedWhen to stop amblyopia treatment - Isoacuity between the good and the previously amblyopia eye;When there is persistent deficit in visual acuity – if poor compliance can be ruled out continuetreatment until no further improvement is noted on three consecutive follow up visits separated byat least 3-4 weeks; Once treatment is stopped, the child must be checked periodically until 9 yearsof age to detect recurrence of amblyopia. Recurrence may occur in about 50% of patients whenamblyopia treatment is discontinued after fully or partially successful completion of occlusiontherapy. However, this can nearly always be reversed with renewed therapeutic effort. Repeatedbacksliding can be prevented by an acuity maintenance regimen, typically patching for 1-3 hours aday or equivalent. Once the need for maintenance occlusion is established, it should be continueduntil 8-10 years of age.Surgical Treatment of Treatable Cases to Prevent Amblyopia If dense cataract in one eye, CataractSurgery should be done at the earliest; If unilateral myopia/hypermetropia, refractive corneal surgerymay be done; If unilateral corneal opacity, corneal transplantation should be done at the earliest;114
NBE CME programme for DNB consultantsIf squint with or without nystagmus, correction of squint should be done at the earliest.Refractive Correction following a froe said surgeries must be given prompthy.Acute DacryocystitisHistory – Previous episodes? Concomitant ENT infection; External Examination – Gentlecompression of the lacrimal sac with cotton tipped swab in an attempt to express discharge fromthe punctum. This is done bilaterally to uncover subtle contralateral dacryocystits; Ocular Examination– Check extraocular movements and look for proptosis (Hertels exopthalmometry); Gram stain,blood agar culture chocolate agar culture in children) f discharge expressed from the punctum; CTscan (axial and coronal) of orbital and PNS in atypical or severe cases or cases unresponsive /worsening to antibiotics. Probing/Irrigation is contraindicated during the acute stage.Etiology- NLD obstruction; lacrimal sac diverticula; dacryolith; nasal or sinus surgery; trauma or;lacrimal sac tumor (rare)Symtoms- Pain, Redness, Swelling over the innermost aspect of lower eyelid ( over lacrimal Sac)tearing, Discharge; Fever; may be recurrent.Signs- Erythematous, tender swelling centered over the nasal aspect of the lower eyelid andextending over the periorbital area nasally; Mucoid/purlent discharge expressed from the punctumwhen pressure is applied over the lacrimal etc.; Dacryocystitis has swelling below the medicalcentral tendon; Lacrimal sac tumor (rare) if swelling is above the medical canthal tendon shouldbe considered; Fistulas after emerging from skin below the medical canthal tendon; Rarely orbitalor facial cellulitesMicrobiology- Staphyiococci, Streptococci, Diphtheroids.Differential Diagnosis- Facial Cellulits involving the medical canthus (discharge cannot be expressedfrom the punctum by placing pressure over the lacrimal sac and radiographically patient lacrimaldrainage system); Acute Ethmoid sinusitis (Pain, tenderness, erythema over the nasal bonemedical to the inner canthus) Frontal headache and nasal obstruction are common. Patients areoften febrile; Acute frontal sinusitis (Inflammation predominantly involves upper eyelid. The foreheadis tender on palpation).Treatment Children- Afebrile, systemically well, mild case, reliable patient-Amoxycillin/Clavulanateor Cefaclor 20-40 mg/kg/d in 3 divided doses Febrile, acutely ill, moderate to severe care, Cefuroxime50-100 mg./kg/d IV in 3 divided doses. Adults- Cephalexin 500 mg. PO Q 6H IV Cefazolin 1g Q 8H;Topical antibiotic drops; Warm compress and gentle massage to the inner canthal region qid; I &D of pointing abscess; DCR with silicone intubation after resolution especially in chronicdacryocystitisVitreous HemorrhageHistory- Age; Trauma; Chronic illness; Diabetes; Hypertension; Glaucoma or its treatment;Similar episode; Diminution of vision/redness/painClinical Examination - Vision; Rule out Trauma – Corneal/scleral laceration, angle recession, iristear, foreign body, lens dislocation etc. ; Evidence of inflammation – Flare/Cells in aqueous,Hypopyon, Posterior Synechiae, Pigment on the lens surface, Keratic precipitates. ; Iris/Angleneovascularisation; Intraocular pressure; If fundus is visible – Renital Detachment (RD), discneovascularisation, neovascularisation elsewhere, peripheral retinal tears, Macularneovascularisation, evidence of vessel occlusion, foreign bodyInvestigations - General- Blood Hb, TLC, DLC, Erythroytic sedimentation Rate; Urine Routine;Blood Sugar – Fasting and Post-prandial; X-ray Chest PA View; Montoux Test. Ophtalmologic - X-Ray Orbit – AP and lateral view; Ultrasound, if media is hazy – to see for posterior vitreous detachment/RD/Tumour/foreign body; CAT Scan, if a foreign body is suspected to be in the coats of the eye;Culture of forinces/aqueous/vitreous, if there is a suspicion of infectionDifferential Diagnosis - Hazy Viterous due to Posterior Uveitis; Asteroid Hyalosis; ChronicEndophthalmitis115
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