OPTHALMOLOGY. 1. Which of the given disease correctly corresponds to the given fluorescein angiography image:

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Morgan Little
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angiography image: Refer Image No. 34 a. NPDR b. PDR c. Familial dominant drusen d.

2 10 OPTHALMOLOGY 1. Which of the given disease correctly corresponds to the given fluorescein angiography image: Refer Image No. 34 a. NPDR b. PDR c. Familial dominant drusen d. Birdshot retinopathy This picture shows Fundus Fluorescein Angiography (FFA) of a patients. Features seen in this picture are Refer Image No. 68 Ans. 1. (b) PDR

3 OPTHALMOLOGY 73 a. Diffuse leak along superior arcade ( red circle) suggestive of NVE b. Multiple CNP (capillary non perfusion ) areas (yellow circle) c. Multiple pin pointed leaks ( green circle) suggestive of dot and blot hemorrhage Above all findings suggestive of PDR In NPDR, there will be no diffuse leak as circled in red circle. Pathologic Patterns of Fluorescence Pattern Cause Example Hyper fluorescence Leakage AMD (CNVM) Neovascular tissue CSCR Staining Pooling Window defect Scar Scleral show Pigment epithelial defect Tumor Loss of RPE RPE tear Drusen Hypo fluorescence Blockage Blood Pigment Fibrous tissue Nonperfusion Vascular occlusion Coloboma Appearance on angiogram Hyperfluorescence increase with time (both intensity of dye and size of lesion) Amount of dye visible increases Size of lesion stays constant Dye accumulating in a fluid-filled space (well-defined border, elevation o clinical exam) Normal fluorescence of choroid accentuated (most apparent early, fades late) Fluorescence of dye blocked by opaque medium Vessels do not fill properly Absence of tissue/ vessels AMD, age-related macular degeneration; CNVM, chorodial neovascular membrane; CSCR, central serous chorioretinopathy; RPE, retinal pigment epithelium. 2. The most likely cause of bulging of cornea in a patient of acute congestive glaucoma is? a. Keratoconus b. Descemetocele c. Staphyloma d. Decreased corneal thickness Ans. 2. (c) Staphyloma

4 74 A staphyloma is an abnormal protrusion of the uveal tissue through a weak point in the eyeball. The protrusion is generalily black in colour, due to the inner layers of the eye. It occurs due to weakening of outer layer of eye (cornea or sclera) by an inflammatory or degenerative condition. It may be of 5 types, depending on the location on the eyeball (bulbus oculi). ANTERIOR (corneal) staphyloma In the anterior segment of the eye, involving the cornea and the nearby sclera. It is an ectasia of pseudocornea ( the scar formed from organised exudates and fibrous tissue covered with epithelium) which results after sloughing of cornea with iris plastered behind, it is known as anterior staphyloma. INTERCALARY staphyloma It is the name given to the localised bulge in limbal area, lined by the root of the iris. It results due to ectasia of weak scar tissue formed at the limbus, following healing of a perforating injury or a peripheral corneal ulcer. There may be associated secondary angle closure glaucoma, may cause progression of the bulge if not treated. Defective vision occurs due to marked corneal astigmatism. Treatment consists of localised staphylectomy under heavy doses of oral steroids. CILIARY Staphyloma As the name implies, it is the bulge of weak sclera lined by ciliary body, which occurs about 2 3 mm away from the limbus. Its common causes are thinning of sclera following perforating injury, scleritis & absolute glaucoma. it is part of anterior staphyloma EQUATORIAL staphyloma On the equator of the eye (region circumferencing the largest diameter orthogonal to the visual axis). Its causes are scleritis & degeneration of sclera in pathological myopia. It occurs more commonly in the regions of sclera which are perforated by vortex veins. POSTERIOR staphyloma Posterior staphyloma beneath the optic disc (right eye) In the posterior segment of the eye, typically diagnosed at the region of the macula, deforming the eye in a way that the eye-length is extended associated with myopia (nearsightedness). It is diagnosed by ophthalmoscopy, which shows an area of retinal excavation in the region of the staphyloma. Intercalary Equatorial Anterior lens Posterior Ciliary

OPTHALMOLOGY 75 3. A patient on post op day 5 after cataract surgery developed the following complication. Treatment include a/e: Refer Image No. 35 a. Pars plana vitrectomy b. Topical antibiotic c.

5 OPTHALMOLOGY A patient on post op day 5 after cataract surgery developed the following complication. Treatment include a/e: Refer Image No. 35 a. Pars plana vitrectomy b. Topical antibiotic c. Intravenous antibiotic d. Intraocular antibiotic Signs present in this picture are, Diffuse congestion Corneal edema Hypopyon All this signs along with recent history of cataract surgery suggestive of endophthalmitis Endophthalmitis It is an inflammation of the internal layers of the eye resulting from intraocular colonization of infectious agents and manifesting with an exudation into vitreous cavity. It can be exogenous or endogenous. Classification Post surgical endophthalmitis a. Fulminant (<4 days) Gram negative bacteria Streptococci Staphylococcus Aureus b. Acute (5-7 days) Staph. Epidermidis Coagulase negative cocci Ans. 3. (d) Intraocular antibniotic

6 76 c. Chronic (>4 weeks) 1. Delayed entry Bleb related 2. Delayed onset P. acne Fungi Staph epidermidis Symptoms and signs in endophthalmitis Pain Rapid diminution of vision Absent fundus glow Anterior chamber reaction Pupillary membrane Hypopyon Confirmation of diagnosis All unexpected inflammatory response following intraocular surgery should be considered endophthalmitis unless proven otherwise. Treatment Three most important determinant in outcome following endophthalmitis area. Duration b. Virulence and load c. Pharmacokinetics and spectrum of activity 1. ANTIMICROBIAL THERAPY a. Intravitreal antibiotics in post-surgical endophthalmitis b. Intravenous antibiotics in post-surgical bacterial endophthalmitis found to be poor intraocular penetration. c. Topical and subconjunctival antibiotic can be considered 2. ANTI-INFLAMMATORY THERAPY: ROLE OF CORTICOSTEROIDS 3. PARS PLANA VITRECTOMY Close differential of endophthalmitis in a post surgical patient is TASS (Toxic Anterior Segment Syndrome)

OPTHALMOLOGY 77 TASS ENDOPHTHALMITIS Timing The day after sx, 12-48 hrs Usually >2 day

Discharge Watery Purulent Lid edema No Yes Conjunctival No Yes chemosis Corneal edema

36 a. Pterygium b. Pinguicula c. Chemical injury d. Fibrodysplasia PINGECULA A B A.

7 OPTHALMOLOGY 77 TASS ENDOPHTHALMITIS Timing The day after sx, hrs Usually >2 day after surgery, commonly 4-7 days Mild to moderate pain More pain (25% no pain) Discharge Watery Purulent Lid edema No Yes Conjunctival No Yes chemosis Corneal edema Limbus to limbus Localized or segmental 4. Identify the given pathology: Refer Image No. 36 a. Pterygium b. Pinguicula c. Chemical injury d. Fibrodysplasia PINGECULA A B A. Pinguecula B. Pinguecula with calci cation Refer Image No. 69 Refer Image No. 70 Ans. 4. (a) Pterygium

71 Refer Image No. 72 Refer Image No. 73 A.

Stockers line in pterygium Refer Image No.

$burn 5. Identify the refractive error: a.$

8 78 PTERYGIUM C C. Pinguculitis Refer Image No. 71 Refer Image No. 72 Refer Image No. 73 A. Pterygium showing cap, head and body B. Stockers line in pterygium Refer Image No. 74 C. Pseudopterygium secondary to chemical burn 5. Identify the refractive error: a. Myopia b. Hypermetropia c. Compound astigmatism d. Mixed astigmatism Ans. 5. (a) Myopia

9 OPTHALMOLOGY 79 Myopia corrected by minus lens Hyperopia correct by plus lens (A) Simple hyperopic astigmatism; (B), (E) simple myopic astigmatism; (C) compound hyperopic astigmatism; (D) compound myopic astigmatism; (E) mixed astigmatism

80 www.aim4aiims.in 6. A patient presented with drooping of right upper eye lid as shown in image A. The patient was given a certain drug after which the condition improved as shown in image B.

10 A patient presented with drooping of right upper eye lid as shown in image A. The patient was given a certain drug after which the condition improved as shown in image B. Which of the following is the possible diagnosis? Before Drug After Drug Refer Image No. 37 a. Tolosa-Hunt syndrome b. Myasthenia gravis c. Trigeminal neuralgia d. Multiple sclerosis The image shows the Tensilon test used for the diagnosis of Myasthenia Gravis. The Tensilon test is used to diagnose Myasthenia Gravis. Patients positive for the disease should show an improvement in muscular strength following administration of Tensilon - Edrophonium - IV. Edrophonium is a very short acting Anticholinesterase and therefore increases the effective amount of acetylcholine at the neuromuscular junction in patients with Myasthenia Gravis. Pathogenesis of Myasthenia Gravis THE NEUROMUSCULAR JUNCTION A Normal Axon B MG Mitochondria Vesicle Nerve terminal Muscle AChR AChE Ans. 6. (b) Myasthenia Gravis

11 OPTHALMOLOGY Important points in myasthenia gravis Most sensitive test: EMG (decremental response) 2. Most specific test: Antibody against Ach Esterase antibody 3. Treatment of Myasthenic crisis: Plasmapheresis and IVIG 4. Indications for thymectomy in MG a. Anti < 15 years and > 55 years b. Anti MuSK positive c. Generalized MG Osserman classification of Myasthenia Gravis (MG) Occular MG Bullbar weakness Generalized MG Respiratory weakness/ crisis

Ophthalmology. Juliette Stenz, MD

Ophthalmology. Juliette Stenz, MD Ophthalmology Juliette Stenz, MD Required Slide Disclosures NO SIGNIFICANT FINANCIAL, GENERAL, OR OBLIGATION INTERESTS TO REPORT Required Slide At the end of this session, students will be able to: 1.