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

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NBE CME programme for DNB consultantsPlease note If folds are present in descemet’s membrane a contact lens has no benefit in terms ofvision.Surgical Management Failing vision in the presence of epithelial edema and stromal haze, whichcannot be treated by the instillation of 5% sodium chloride drops and ointment, necessitatesrecourse to surgery. A selection has to be made between the following 2 options (1) keratoplastyalone, when no cataract formation is present, or (2) if cataract is present and adds significantly tovisual disability and specular endothelial microscopy results suggest the need for a corneal graft,then a combined corneal transplant, cataract extraction, and lens implant procedure should beperformed. Conditions that increase occlusion and decrease tear evaporation eg., ptosis, shouldbe corrected. Total conjunctival flap for patients with limited usual potential due to other causesthan corneal edema eg., ARMD (This is suffer for long term than a bandage contact lens). Penetratingkeratoplasty (PKP) for vision restoration in patients whose normal day to day activities are affected,has a good prognosis (early surgery in young age, poor vision in fellow eye, high visual requirement).Anesthesia - Local anesthesia with 50/50 mixture of 0.75 % bupivacaine and 2% lidocaine and 150U of hyaluronidase; Anesthesia may be retrobulbar or peribulbar. Good hypotony should be obtainedwith a mechanical presure device (eg, Honan balloon, Super Pinky ball, mercury bag); After thoroughlyascertaining cardiovascular status, general anesthesia may be used in selected cases; CombinedPKP + cataract extraction + IOL triple procedure depends on CCT + specular 10% variation incorneal thickness between morning and evening central corneal thickness and stromal edema onslit lamp. Severity of cataract118
NBE CME programme for DNB consultantsDisadvantages for individual Procedures - Increased cost and rehabilitation time; Cornealgraft more likely to fail; Poor visibility during the second procedure; Difficult to calculate IOLDower.Others – Histology - In early stages, the focal thickening of the Descemet membrane is similarto those seen in the Hassall-Henle warts of the peripheral cornea. The corneal endotheliumappears stretched and thinned over the dome of the excrescences; In advanced cases, ageneralized thickening of Descemet membrane is observed. This thickening appears to “bury”the cornea guttata that formed in the earlier stages; In normal corneas, histologic preparationsshow lamellar separation as an artifact. In the cases of corneal edema, the artifactitiouslamellar separation of the lamellae is reduced. Subepithelial bullae fomlation is seen at theanterior corneal surface. In the periphery of the cornea, subepithelial fibrous tissue usually isseen. Intraepithelial cysts filled with cellular debris are seen. Intraepithelial basementmembrane formation may occur due to the misdirection of the epithelial cells. Bowmanmembrane is normal, unless it has been involved in ulcer formation and keratitis, after therupture of a bulla.Post Chemical BurnsHistory - of contact with chemical agent, type and nature of agent, quantity involved, whethereye wash / irrigation was done, associated face injuries, unilateral/bilateral. Details of treatmentreceived whether medical / surgical. Any other significant history.Clinical Examination - Visual eiuty, Injuries over the face / eylids, Upper lids/both lid involvement,Loufmctival involvement – Limber ischaemia , Modified Rooparhll classification, Presence orAbsence of Necrosis, Corneal Clarify / effinthetal defects/ vascularisation of corma, presenceor absence of particulate matter, Any symbepharma in old case / harmic burns AE to lensstatusInvestigations - Fluotoscime staining to see the efithehal defects shirmer test / drug eye / protrose Bengal stainingMedical Management - Acute Cases ( Irrigation; Removal of partials of chemical; Debribemcut; Tear Substitutes; Antibiotics; Antiglaucoma Medication; Cycloplegics; role ofcortieosterouds; Ascorbate CitrateSurgical - Tissue Adhesives; Glass Rod for prevention of rymblopharaous; Bandage contactlens; Luibal stem care transplantation; AMT; Symplepharas Release; Penetrating keralohlasty; Conjunctival slappingDiabetic RetinopathyHistory - Duration of diabetes, Age of onset of diabetes, Control of Blood Sugar, Historysuggestive of Neuropathy, History suggestive of Nephropathy, Associated H/O Hypertension,Pregnancy, HeredityClinical Examination - Venous dilation; Microaneurysms; Intra retinal haemorrhages- dot andblot haemmorrhages; Hard exudates; Macular oedema - Focal /Diffuse; Soft exudates;Venous beading and loops; Neovascularisation of disc or periphery; Fibrovascular bands;Tractional retinal detachment; Preretinal membrane formation; Vitreous haemorrhage;Posterior vitreous detachment; Iris Neovascularisation.Investigations - Blood sugar; Kianey function tests . Lipid profile; USG in opaque media to seevitreous haemorrhage(diffuse!organized) & retinal detachment .Fluoresceine Angiography - Areas of capillary nonperfusion; Distortion of foveal avascularzone; Intra retinal neovascularization; Intra retinal micro vascular abnormalities; Macularoedema- focal! diffuse; CSME; Areas of leaks - Disc! macula/elsewhere.Differential Diagnosis - BRVO,CRVO; Hypertensive retinopathy; Renal retinopathy; Eales,119
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