Ophthalmology
Medications to dilate pupil
1. Atropine: longer half life, hence prolonged dilation and blurry vision, but less sting
effect
2. Tropicamide 0.5%: shorter half life but more sting effect
a. Sometimes administered in combination with hydroxyamphetamine
b. Issues: glaring and blurry vision for up to 4h
Antihistamines:
Sedating Non-sedating
Promethazine Loratidine
Chlorphenamine Desloratidine
Cinnarizine Cetrizine
Clemastine Levocetrizine
Cyproheptadine Fexofenadine
Ketotifen Mizolastine
Alimemazine Rupatadine
Bilastine
Acrivastine
Central retinal artery occlusion: sudden visual loss + “cherry red spot” on macula
Layers of Cornea:
1. Anterior epithelium: smooth surface that absorbs O and nutrients from tears and
distribute to the other parts of cornea nd blocks passage of foreign materials
2. Bowman layer
3. Corneal stroma: collagen essential to enhance the light conducting transparency
4. Descemet membrane: thin strong sheet of tissue that serve as protective barrier
against Microbes
5. Endothelium: dehydrate the cornea, otherwise, dysfunction cause corneal edema
Retina:
• Neurosensory retina: deep inside the eye (IN: inside)
• Pigmented retina: outside the neurosensory (OP: outer)
Check the eyes in
• Headaches
• Weird neurological presentation: MS, raised intracranial pressure
• Visual complains
Minimum driving standards: 6/12 corrected visual acuity on at least one
eye is required as minimum
ALWAYS ADJUST SLITLAMP AND MAKE SURE VERY CLEAR BEFORE
YOU USE IT! Note that your tears actually moves upwards on the
surface of the eye!
Always have ophthalmology review for anyone who are strangled: might
have conjunctival haemorrhage and hypertensive hemorrhages at the
retina
Mouth wash:
• Mouth toilet: more rigorous teeth and mouth clearning
, • Peter Mac mouthwash: mouth wash with NSAIDs and freshness
• Bonjela: gel with NSAIDs
• Biotene: prevent mouth dryness
Emergent orbital decompression in tense orbital hemorrhage:
• Cathotomy: incision of the lateral canthus
§ Indication:
• Retrobulbar bleed
• Decreased visual acuity
• Afferent papillary defect
• Proptosis/exophthalmos
• Increased intraocular pressure: >40mmHg
§ Contraindication:
• Globe rupture
• Hyphaema
• Irregular shaped pupil
• Subconjunctival haemorrhage
• Enopthalmos
• Conjunctival tear
• Cantholysis: Cathotomy with disinsertion of at least the inferior
crus of the lateral cathal tendon
Common medications to learn:
• Pseudoephedrine works, but NOT phenylephrine (SE of hypertension, H/A, N/V,
mydriasis, seizures, tachycardia, palpitations etc but the topical ones are less
SE)
o Pseudoephedrine (30-60mg QID): works better
o Phenylephrine (10mg QID): doesn’t work
• Nasal decongestant: Oxymetazoline (works but limited effect, only for 3-5d)
, • Mucolytics: Bromhexine (bisolvon), shows adequate evidence
• Cought suppressant: Dextromethorphan (robitussin)
Fun facts:
• Complete transection of 1 optic nerve, what is the resting pupil size?
o Both equal and constricted. This is due to consensual light reflex through the
working optic nerve to the lateral geniculate body and then to edinger
westphal nuclei which are both parasympathetic fibres (CN3), causes
constriction
• Complete transection of both optic nerve, what is the resting pupil size?
o Both are dilated. No light is registered and hence will be dilated. If cause of
blindness Is posterior to lateral geniculate bodies, light reflex will remain
intact
• CN3:
o Parasympathetic fibres on the outside of CN3: ptosis and isolated dilation
(PNS affected/dysfunction) means macrovascular
§ CN 3 palsy or aneurysm
o Sympathetic fibres on the inside of CN3: Ptosis and isolated constriction
(SNS affected/dysfunction) means microvascular/ischemia
§ Horner syndrome or diabetes
• Macula is supplied by both the PCA and MCA. Hence, there are be macula sparing
hemianopia
CN3: Down and out CN4: Cannot read/walk down stairs CN6: inward deviation
Vasculopathic tumour Vasculopathic tumour Vasculopathic tumour
Aneurysm Congenital trauma Cranial pressure
Eye system review:
• Lid abnormalities: pain, lumps, bumps, bruising
• Any trauma
• Any discharge
• Any increased tearing
• Any pain
• Any redness
• Any foreign body sensation
• Any photophobia
• Any double vision
• Any headache
• Any flashers
• Any floaters
• Any wavy lines seen
• Do you use spectacles or contact lens
• Any area of blindness
, Evaluation of Red eyes
History:
Is vision affected? Can you Require clinical examination and may need ophthalmic referral
still read ordinary print
with affected eye?
Is there a foreign body Foreign body is CARDINAL SYMPTOM for active corneal
sensation as though process.
something is in your eye or
interfering your ability to Objective evidence of foreign body sensation where
keep your eyes open? patients cannot spontaneously open eyes, suggest corneal
involvement. Other than those of initial presentation of corneal
abrasion or foreign body, these episodes warrant immediate
ophthalmologist referral.
Subjective foreign body sensation such as “scratchy
feeling”, “grittiness” or “sand in my eyes”, dry eyes, viral
conjunctivitis, does not suggest corneal problem that needs
referral
Is there photophobia Photophobic patients needs to be examined by clinician
Active corneal process have objective signs of
photophobia and foreign body sensation. Present with
sunglasses/hats or covering the affected eye.
Iritis may have objective signs of photophobia but no
foreign body sensation
Was there trauma? Any injuries at all? Including sharp and blunt trauma
Do you wear contact Keratitis should be suspected in setting of discharge and red
lenses? eye with a history of contact lens
Is there dischange, other Mornign crusting followed by watery discharge is characteristic
than tears that continues of many self-limiting process such as allergy, stye, hordeolum,
thoughout the day? viral conjunctivitis, allergic conjunctivits and dry eyes.
Bacterial conjunctivitis and bacterial keratitis cause opaque dischage throughout the day and
required specific therapy. Bacterial conjunctivitis NOT associated with reduced visual acuity,
foreign body sensation, photophobia can be treated by GP. Bacterial keratitis should be
referred to ophthalmologist.
Examination (penlight)
Does pupil react to light? Closed angle glaucoma: fixed in mid dilation
Is the pupil small? Pinpoint: corneal abrasion, infectious keratitis, iritis
Abrasion VS iritis by presence of fluorescein staining and
objective foreign body sensation (both not present in iritis)
Is there purulent discharge Baceterial conjunctivitsis or bacterial keratitis if present
What is pattern of redness Diffuse injection involving both conjunctiva inside the lid and
on globe: primary conjunctival problem: conjunctivitis
(bacterial, viral, allergic, toxic, nonspecific (dry eyes))
Ciliary flush (injection most marked at limbus) is
characteristic of more serious entities such as infectious
keratitis, iritis, angle closure glaucoma
If redness appears haemorrhagic rather than pattern of
injection, diagnosis of subconjunctival hemorrhage should
be considered.
White spot, opacity or White spot or opacity on cornea suggests infectious
foreing body? keratitis. Seen without aid of fluorescein.
Medications to dilate pupil
1. Atropine: longer half life, hence prolonged dilation and blurry vision, but less sting
effect
2. Tropicamide 0.5%: shorter half life but more sting effect
a. Sometimes administered in combination with hydroxyamphetamine
b. Issues: glaring and blurry vision for up to 4h
Antihistamines:
Sedating Non-sedating
Promethazine Loratidine
Chlorphenamine Desloratidine
Cinnarizine Cetrizine
Clemastine Levocetrizine
Cyproheptadine Fexofenadine
Ketotifen Mizolastine
Alimemazine Rupatadine
Bilastine
Acrivastine
Central retinal artery occlusion: sudden visual loss + “cherry red spot” on macula
Layers of Cornea:
1. Anterior epithelium: smooth surface that absorbs O and nutrients from tears and
distribute to the other parts of cornea nd blocks passage of foreign materials
2. Bowman layer
3. Corneal stroma: collagen essential to enhance the light conducting transparency
4. Descemet membrane: thin strong sheet of tissue that serve as protective barrier
against Microbes
5. Endothelium: dehydrate the cornea, otherwise, dysfunction cause corneal edema
Retina:
• Neurosensory retina: deep inside the eye (IN: inside)
• Pigmented retina: outside the neurosensory (OP: outer)
Check the eyes in
• Headaches
• Weird neurological presentation: MS, raised intracranial pressure
• Visual complains
Minimum driving standards: 6/12 corrected visual acuity on at least one
eye is required as minimum
ALWAYS ADJUST SLITLAMP AND MAKE SURE VERY CLEAR BEFORE
YOU USE IT! Note that your tears actually moves upwards on the
surface of the eye!
Always have ophthalmology review for anyone who are strangled: might
have conjunctival haemorrhage and hypertensive hemorrhages at the
retina
Mouth wash:
• Mouth toilet: more rigorous teeth and mouth clearning
, • Peter Mac mouthwash: mouth wash with NSAIDs and freshness
• Bonjela: gel with NSAIDs
• Biotene: prevent mouth dryness
Emergent orbital decompression in tense orbital hemorrhage:
• Cathotomy: incision of the lateral canthus
§ Indication:
• Retrobulbar bleed
• Decreased visual acuity
• Afferent papillary defect
• Proptosis/exophthalmos
• Increased intraocular pressure: >40mmHg
§ Contraindication:
• Globe rupture
• Hyphaema
• Irregular shaped pupil
• Subconjunctival haemorrhage
• Enopthalmos
• Conjunctival tear
• Cantholysis: Cathotomy with disinsertion of at least the inferior
crus of the lateral cathal tendon
Common medications to learn:
• Pseudoephedrine works, but NOT phenylephrine (SE of hypertension, H/A, N/V,
mydriasis, seizures, tachycardia, palpitations etc but the topical ones are less
SE)
o Pseudoephedrine (30-60mg QID): works better
o Phenylephrine (10mg QID): doesn’t work
• Nasal decongestant: Oxymetazoline (works but limited effect, only for 3-5d)
, • Mucolytics: Bromhexine (bisolvon), shows adequate evidence
• Cought suppressant: Dextromethorphan (robitussin)
Fun facts:
• Complete transection of 1 optic nerve, what is the resting pupil size?
o Both equal and constricted. This is due to consensual light reflex through the
working optic nerve to the lateral geniculate body and then to edinger
westphal nuclei which are both parasympathetic fibres (CN3), causes
constriction
• Complete transection of both optic nerve, what is the resting pupil size?
o Both are dilated. No light is registered and hence will be dilated. If cause of
blindness Is posterior to lateral geniculate bodies, light reflex will remain
intact
• CN3:
o Parasympathetic fibres on the outside of CN3: ptosis and isolated dilation
(PNS affected/dysfunction) means macrovascular
§ CN 3 palsy or aneurysm
o Sympathetic fibres on the inside of CN3: Ptosis and isolated constriction
(SNS affected/dysfunction) means microvascular/ischemia
§ Horner syndrome or diabetes
• Macula is supplied by both the PCA and MCA. Hence, there are be macula sparing
hemianopia
CN3: Down and out CN4: Cannot read/walk down stairs CN6: inward deviation
Vasculopathic tumour Vasculopathic tumour Vasculopathic tumour
Aneurysm Congenital trauma Cranial pressure
Eye system review:
• Lid abnormalities: pain, lumps, bumps, bruising
• Any trauma
• Any discharge
• Any increased tearing
• Any pain
• Any redness
• Any foreign body sensation
• Any photophobia
• Any double vision
• Any headache
• Any flashers
• Any floaters
• Any wavy lines seen
• Do you use spectacles or contact lens
• Any area of blindness
, Evaluation of Red eyes
History:
Is vision affected? Can you Require clinical examination and may need ophthalmic referral
still read ordinary print
with affected eye?
Is there a foreign body Foreign body is CARDINAL SYMPTOM for active corneal
sensation as though process.
something is in your eye or
interfering your ability to Objective evidence of foreign body sensation where
keep your eyes open? patients cannot spontaneously open eyes, suggest corneal
involvement. Other than those of initial presentation of corneal
abrasion or foreign body, these episodes warrant immediate
ophthalmologist referral.
Subjective foreign body sensation such as “scratchy
feeling”, “grittiness” or “sand in my eyes”, dry eyes, viral
conjunctivitis, does not suggest corneal problem that needs
referral
Is there photophobia Photophobic patients needs to be examined by clinician
Active corneal process have objective signs of
photophobia and foreign body sensation. Present with
sunglasses/hats or covering the affected eye.
Iritis may have objective signs of photophobia but no
foreign body sensation
Was there trauma? Any injuries at all? Including sharp and blunt trauma
Do you wear contact Keratitis should be suspected in setting of discharge and red
lenses? eye with a history of contact lens
Is there dischange, other Mornign crusting followed by watery discharge is characteristic
than tears that continues of many self-limiting process such as allergy, stye, hordeolum,
thoughout the day? viral conjunctivitis, allergic conjunctivits and dry eyes.
Bacterial conjunctivitis and bacterial keratitis cause opaque dischage throughout the day and
required specific therapy. Bacterial conjunctivitis NOT associated with reduced visual acuity,
foreign body sensation, photophobia can be treated by GP. Bacterial keratitis should be
referred to ophthalmologist.
Examination (penlight)
Does pupil react to light? Closed angle glaucoma: fixed in mid dilation
Is the pupil small? Pinpoint: corneal abrasion, infectious keratitis, iritis
Abrasion VS iritis by presence of fluorescein staining and
objective foreign body sensation (both not present in iritis)
Is there purulent discharge Baceterial conjunctivitsis or bacterial keratitis if present
What is pattern of redness Diffuse injection involving both conjunctiva inside the lid and
on globe: primary conjunctival problem: conjunctivitis
(bacterial, viral, allergic, toxic, nonspecific (dry eyes))
Ciliary flush (injection most marked at limbus) is
characteristic of more serious entities such as infectious
keratitis, iritis, angle closure glaucoma
If redness appears haemorrhagic rather than pattern of
injection, diagnosis of subconjunctival hemorrhage should
be considered.
White spot, opacity or White spot or opacity on cornea suggests infectious
foreing body? keratitis. Seen without aid of fluorescein.
