OPHTHALMOLOGY

Introduction: Role of medical officers

Visual screening, preventive and curative measures against ophthalmic diseases.

Initiate early treatment of minor eye ailments.

Timely referral to the next level of health care.

Complete management of diseases like conjunctivitis, stye, foreign body (superficial) etc.

PREPARATION OF BLIND REGISTER

Engage the Paramedical Ophthalmic Assistant to prepare a blind register Obtain assistance of other health visitors, community health workers etc.

Collect information and finally verifying all facts.

EYE CARE IN PAEDIATRIC AGE GROUP

SCHOOL CHILDREN EYE SCREENING

Detection of subnormal vision in children at an early age. Preliminary visual check up will be carried out by school teachers. Teachers of a school(2 or more) to be trained by medical officer. Ophthalmic assistant will be informed for refraction and prescription of glasses at the base hospital )PHC)/or at the school.

VITAMIN A DEFICIENCY

CAUSES OF VITAMIN A DEFICIENCY: Prolonged defective absorption of Vitamin A e.g. chronic diarrhoea. Prolonged diminished intake, daily requirement being 3000 – 4000 IU. Excessive utilization during rapid growth or debilitating disorder.

WHO classification:

Primary Signs Secondary SignsX1A – conjunctival xerosis XN – NyctalopiaX1B – Bilot`s spot XF – Fundal changeX2 – corneal xerosis XS– Corneal xerosisX3A – corneal ulceration (<⅓ of cornea)X3B – corneal ulceration (>⅓ of cornea)

Treatment of Vitamin A deficiency ORAL

Age Dose Schedule< 6 months 50,000 I.U. 1st day – 2nd day – 28th day6 – 12 months 1,00,000 I.U. " " "> 12 months 20,00,000 I.U. " " "

Prevention of Vitamin A deficiencyAge Dose

9 months 1,00,000 I.U. 18 months 2,00,000 I.U. 24 months 2,00,000 I.U. 30 months 2,00,000 I.U. 36 months 2,00,000 I.U.

OTHER OPHTHALMIC CONDITIONS IN PAEDIATRIC AGE GROUPS

Inclusion conjunctivitis/blenorrhoea in newborn:

Just after birth in the newborn.Viral infection and gonococci infection from birth passage.Conditions to be kept in mind as complications may be as severe.

White reflex in the eye – Common conditions may be

Congenital cataractRetinoblastomaRetinopathy of prematurityThe child needs to be referred to ophthalmologist for further management

OCULAR EMERGENCIES

FOREIGN BODY IN THE EYE

•History of entry of foreign body, foreign body sensation might be present.•Photophobia.•Watering of the eye.•Pain and redness of the eye.•Blepharospasm.

Management:•Wash the eye with water copiously.•Examination of the Eye in good light after instillation of 4% Lignocaine.•Removal of the foreign body from the Fornix or Cornea. •Gentamicin eye drops (0.3%), 1 drop 3-4 times a day for 5 days or,•Ciprofloxacin Eye drop (0.3%) 3-4 times a day.•Examine the patient after 1-2 days positively

EYE TRAUMA

Blunt trauma (Contusion) :

• Eye lid: Bruise, swelling or laceration. Treated by warm compress, analgesics and Local Antibiotic Eye ointment(Ciprofloxacin/Gentamicin).

• Corneal abrasion: Severe pain, lacrimation, blepharospasm. Local Antibiotic drops and Analgesics. If no response in 48 hours, the patient should be referred. Check the cornea with Fluorescein stain to eliminate corneal abrasion. Eye pad should be used only in severe cases.

Burns : Alkali or acid.

• Wash eyes with profuse amount of clean water using a syringe, • Check for corneal abrasion with Fluorescein stain.• If pain is severe, instill a drop of 4% lignocaine.• Ciprofloxacin Eye drop (0.3%), 1 drop 3-4 times daily.• Homatropine Eye drop (1%), 1 drop 3-4 times daily.• After providing initial treatment, refer the patient to an ophthalmologist.

CORNEAL ULCER

• History of injury or foreign body removal is usually present.• Pain, redness, watering, discharge, reduced visual acuity and photophobia.• Swelling of lids, conjunctival congestion and hypopyon.• Irregular pupil may be non reacting.

Management:Start the treatment with Ciprofloxacin Eye Drop (0.3%) every one hour Atropine 1% eye drop twice a day Refer the patient to Ophthalmologist.

CONJUNCTIVITIS

•Irritation of eyes•Watering/Discharge from eyes•Conjunctival congestion•Oedema of the lids•Matted eyelashes•Pupillary reaction to be noted to exclude acute iridocyclitis.

Management:•Wearing of Dark glasses.•Wash with Normal saline twice a day.•Gentamicin Eye drop (0.3%), 1drop 3-4s times a day for 5 days. OR•Chloramphenicol eye ointment (0.5%), to apply at bed time for 5 days. OR •Ciprofloxacin (0.3%), 1 drop 3-4 times a day for 5 days. •Avoid local steroids.

STYE

•Red painful swelling usually with a pus point and very tender to touch.•Conjunctiva may be congested.•Adjoining facial cellulites.•Preauricular lymph nodes may be enlarged and tender.

Management:• Hot fomentation on the lid to hasten suppuration.• Cotrimoxazole/Ciprofloxacin) and Local Eye Ointment (Ciprofloxacin).• Analgesic• Pulling out one or more cilia will evacuate the pus.• Pus points fail to respond to treatment given, refer to an Ophthalmologist.• Recurrent stye: check for Blepharitis and treat accordingly.

IRIDOCYCLITIS AND ACUTE CONGESTIVE GLAUCOMA:

Red eye, ciliary congestion, pain in the eye with irregular small sluggishly reacting pupil (acute iridocyclitis) and dilated non reacting pupil (acute congestive glaucoma) should be referred to Ophthalmologist.

TOXIC DRUGS:

All patient receiving antituberculous drugs, chloroquine should be routinely checked by Ophthalmologist.

SUDDEN LOSS OF VISION

Patients with sudden loss of vision are to be referred to Ophthalmologist.

SUB-CONJUNCTIVAL HAEMORRHAGE: Level of consciousness Harmless but alarming looking collection of blood behind the conjunctiva.History of trauma/factors causing strain e.g. whooping cough/Hypertension If recurrent, look for a bleeding diathesis and check Blood pressurePupillary reaction to be noted.

Management:Usually requires no treatment, the blood getting absorbed within 1-2 weeks.Ciprofloxacin/Gentamicin eye drop may be given.If the vision in the affected eye is impaired compared to the normal eye, it is advisable to refer the patient to an ophthalmologist.Treat for hypertension if the Blood pressure is high.

REFRACTIVE ERRORS

•Diminished vision for distance or near.•Eyestrain and headache.•Squint may be present.

Management:•Record visual acuity using the Snellen`s chart (6.0 metres, 20 feet). •The room is to be kept well illuminated.•The patient is asked to read with one eye.•Visual acuity is to recorded for each eye separately.•Prescription of glasses to be made in case of impaired Visual acuity.•If no proper response is seen then refer to an Ophthalmologist.

CHRONIC EYE CONDITIONS

CATARACT:

•Progressive, painless, gradual dimness of vision.•History of glare and misty vision.•History of monocular diplopia or polyopia.•Presence of grayish or pearly white opacity in papillary area.

Management:•Differentiate with corneal opacity by oblique illumination•Look for iris shadow and Purkinje`s image.•Correction of refractive error if any by optometrist.•Distant direct ophthalmoscopy•Refer to higher centre for surgery.

BLEPHARITIS:

•In the Squamous variety: Lid margins are red and swollen with whitish scales like dandruff clinging to base of the eyelash.

•In the Ulcerative variety: Suppuration around the bases of the eyelashes with crust formation is usually seen. Lashes are usually distorted,

Management:•Periodic shampooing containing Selenium.•Scales and crusts must be removed.•Ciprofloxacin/Terramycin/Soframycin eye ointment.•Antibiotic Corticosteroid ointment.•Refraction should be checked•Check the health of the scalp hair. Avoid dandruff.

CHALAZION:

•A painless nodule in the lid a few mm. •Away from its margin which gradually increases in size or stationary.•It is firm and fixed to the tarsus but not to the skin. •On everting the lid, the conjunctiva over the nodule is found.•Occasionally, the chalazion might be infected. Management:•Small Chalazion requires no treatment.•Antibiotic with steroid ointment of the conjunctival sac•Infected Chalazion: Hot compress, Systemic Antibiotics, Local Eye Antibiotic ointment and analgesics (if reqd.) are to be given.

CONGENITAL DACRYOCYSTITIS:

•Membranous blockage of the lower end of nasolacrimal duct. •The obstruction is present in nearly 10% of new born at birth. • Lacrimation begins until about 6 weeks after birth.•The condition may be bilateral and manifests as Epiphora in new born.

Treatment•Massage over the sac area and frequent installation of any antibiotic drop•This hydrostatic pressure massage may cure 95% of the patient.•Probing and syringing under General Anaesthesia is warranted •In failed cases patient should be referred to an Ophthalmologist.

ACUTE DACRYOCYSTITIS

•Acute pain and swelling over the side of the nose below the inner canthus, •Watering, and conjunctival congestion.•Skin over the swelling is red and inflamed.•The area is very tender to touch, preauricular lymph node tender.

•Treatment consists of immediate administration of Systemic Antibiotics •Hot compress. Analgesics and Antibiotic Eye drops to reduce the infection.•Do not try to check regurgitation by pressure over sac area.•Subsequently, the patient should be referred to an Ophthalmologist

CHRONIC DACRYOCYSTITIS

• Chronic inflammation of the lacrimal sac.•Persistent watering and discharge.•Pressure over the region of the sac causes regurgitation of mucopus.•Refer to Ophthalmologist for surgery.

SQUINT:

•History of Ocular deviation.•Diplopia.•Abnormal position of the head.•Poor vision in the deviating eye.•Eyestrain.•Very important to note the onset.

Management:•Refer to the Ophthalmologist at the earliest, especially in case of Children.

DIABETIC RETINOPATHY

Refer the patient to Ophthalmologist if•Patient is more than 30 years of age at the time of diagnosis.•After 5 years of diabetes if patient is less than 30 years of age.•1st trimester in pregnancy of diabetic mother; then every trimester.

CHRONIC SIMPLE GLAUCOMA:•These patients are to be diagnosed and treated by Ophthalmologist.

INSTRUMENTS THAT SHOULD BE AVAILABLE AT PHC LEVEL

• Vision chart• Refraction trial box• Schiotz tonometer• Lacrimal canula • Punctum dialator• Eye speculum • Lid retractors • Plain forceps.