Geriatric ophthalmology

Powerpoint presentation on Geriatric ophthalmology. It covers vast topic of eye disorder in elderly

1. GERIATRIC OPHTHALMOLOGY Dr. ARVIND CHAUHAN PROF & HEAD DEPT. OF OPHTHALMOLOGY

2. ‘Senior citizen’ or ‘Elderly’ as a person who is of age 60 years or above. Geriatrics or Geriatric Medicine: specialty that focuses on health care of elderly people aims to promote health by preventing and treating diseases and disabilities in older adults The elderly population (aged 60 years or above) account for 7.4% of total population in 2001. Geriatrics

3. About 64 per thousand elderly persons in rural areas and 55 per thousand in urban areas suffer from one or more disabilities. Most common- Loco motor disability 3% H earing disability 1.5% Blindness (1.7% in rural areas, and 1% in urban areas) Health Problems in Old persons

4. PROBLEM STATEMENT Visual impairment is important health problem in elderly. With advancing age normal visual function decreases and there is increase in ocular pathology. Untreated visual disturbance lead to increased incidence of falls, depression , social isolation and dependency. Active screening for visual impairment should be a part of health examination. Elderly should have visual assessment 1-2 yearly for early detection and prevention of permanent visual impairment.

5. The m/c causes: Age-related Cataract 52% ARMD NonExudative - 25% Exudative -5% Glaucoma 2-10% Diabetic Retinopathy. I ncidence rates increase with increasing age. According to WHO Visual impairment <6/18-6/60 Severe visual Impairment <6/60-3/60 Blind <3/60-1/60 Visual impairment

6. Loss of transparency of Optical Media like : Cornea-Ulcer / Scar / Opacity / Degeneration /Dystrophy/ Dry EYE Lens- Cataract / Dislocation/ Subluxation Vitreous-Degeneration/ Haemorrhage Retinal Layers-DR / ARMD / HTN Loss of Normal Architecture- DR / Glaucoma / ARMD High Refractive Errors-Myopia / Hyperopia Presbyopia Visual Impairment is due any of the following causes:

7. Other than Blindness Ocular Surface Diseases : Blepharitis Entropion / Ectropion Pterygium Dry Eye Corneal Ulcer or Keratitis Corneal Degeneration Corneal Dystrophy Ophthalmological Problems in Elderly

8. OPHTHALMIC EXAMINATION Demographic Data History Systemic illness H/o Drug H/O Detailed Eye Examination Visual acuity IOP Detailed Fundus Examination Investigations

9. XANTHELESMMA They are creamy yellow lipid deposit near the medial canthus at upper or lower eyelid. They represent lipid deposit in histiocytes in dermis of skin of lids. Mostly seen in middle aged women Associated with Diabetes and High cholesterol level

10. ENTROPION Inward turning of eyelid margin Symptoms due to trichiasis – rubbing of eyelashes on cornea and conjunctiva leads to FB sensation, Photophobia, Pain and lacrimation . It can be Cicatrical Spastic Senile / Involutional Mechanical

11. ECTROPION Outward turning of eyelid margin Epiphora is the main complaint Mild photophobia and irritation due to chronic conjunctivitis It can be Cicatrical Senile Paralytic Spastic Mechanical

12. PTERYGIUM It is triangular encroachment of vascularized granulation tissue covered by conjunctiva in interpalpeberal area. Bilateral, nasal induce astigmatism Treatment : Excision with autograft

13. ARCUS SENILIS Bilateral Superior and inferior quadrant. Annular ring of lipid infiltration at corneal periphery.

14. CORNEAL ULCER Infection of cornea due to organism causing necrosis and pus. Symptom : Pain , lacrimation , photophobia, blurring of vision, redness Treatment: Antibiotics topical , Homatropine ,

15. HERPES SIMPLEX KERATITIS Infection of cornea with Herpes simplex virus. Skin lesions associated with corneal punctate / stromal keratitis . Pain, photophobia, lacrimation Treatment : Antiviral

16. CORNEAL BLINDNESS In elderly corneal degeneration and dystrophy are common which leads to corneal opacity and scarring. Treatment : Keratoplasty

17. STEPS OF PENETRATING KERATOPLASTY

18. DRY EYE Dry Eye occurs due to inadequate tear film or function resulting in unstable tear film and ocular surface disease. MC symptoms dryness, grittiness, and burning sensation,. Stringy discharge , transient blurring of vision

19. PRESBYOPIA Caused due to hardening or sclerosis of the lens substance , or loss of ciliary muscle and choroidal elasticity. The lens gradually becomes thicker and loses its flexibility over time resulting in failure to accommodate light from objects of various distances. Difficulty in near vision…reading fine prints. Treatment : Spectacles

20. CATARACT Leading cause of vision loss in elderly Three distinct types of cataract are seen clinically according to the anatomical area of opacity: (1) N uclear sclerotic cataracts are associated with central lens opacification , (2 ) Cortical cataracts consist of radial spokes extending from the periphery and (3 ) Posterior subcapsular cataracts are located in the posterior cortical layer and often involve the central visual axis.

21. Symptoms : foggy, blurred vision colour perception may also be affected. Driving at night may be difficult as they experience glare from oncoming headlights especially for those with posterior subcapsular cataract. If a patient has an associated refractive error, double vision in one eye or monocular diplopia may be a feature.

22. Cataract…. Nuclear Cortical Posterior SubCapsular Anterior SubCapsular

23. Classification according to maturity Immature Mature Hypermature Morgagnian

24. TREATMENT Modern cataract surgery is very safe and can be performed as an outpatient procedure under local anaesthesia. The techniques commonly applied are extracapsular cataract extraction and phacoemulsification with intraocular lens implantation.

25. glaucoma Glaucoma is defined as progressive optic neuropathy resulting in a characterstic appearance of the optic disc and a specific pattern of irreversible visual field defects that are associated frequently but not invariably with raised intraocular pressure (IOP). Prevalence is about 3-4% in patients above 70 yrs. Significant cause of blindness in the world

26. Pathogenesis : There is obstruction to aqueous outflow at trabecular meshwork. It results in increased IOP which causes mechanical damage to retinal ganglion cells Raised IOP causes microcirculation stasis which leads to impairment of nutrients and gluatamate toxicity.

27. Symptoms in POAG is headache, eyeache , Visual field defect - peripheral loss of vision Frequent changes in presbyopic glasses Delayed Dark adaptation PACG – Acute red eye. Pain , severe headache, redness , blurred vision , colored halos, raised IOP due to angle closure seen on Gonioscopy .

28. Normal optic disc

29. Early glaucomatous disc

30. Advanced glaucomatous optic disc

31. Visual field defects in glaucoma

32. Intraocular pressure Normal range 11- 21 mmHg It is measured using Tonometer It is only modifiable factor. Therefore all treatment modalities are based on controlling IOP.

33. Treatment of glaucoma Medical Topical : 1. Beta blockers 2. Carbonic anhydrase inhibitor 3. Alpha 2 agonist 4. Prostaglandin analogue 5. Pilocarpine Syestemic : Mannitol20% IV Acetazolamide Surgical Argon Laser trabeculoplasty Filtering surgery

34. DIABETIC RETINOPATHY Changes in retina due to high blood sugar level. Most important associated with duration of Diabetes. MC cause of visual loss in patients with Diabetes Two types of DR Non proliferative DR Proliferative DR

35. Mild NPDR Moderate NPDR Severe NPDR Very Severe NPDR

36. Moderate PDR Severe PDR Diabetic Maculopathy

37. HYPERTENSIVE RETINOPATHY Refers to fundus changes occuring due to Hypertension. Grading of hypertensive retinopathy Keith and Wegner (1939) Grade I It consists of mild generalized arteriolar attenuation, particularly of small branches, with broadening of the arteriolar light reflex and vein concealment. Grade II : It comprises marked generalized narrowing and focal attenuation of arterioles associated with deflection of veins at arteriovenous crossings Grade III : Grade II changes plus copper-wiring of arterioles, banking of veins distal to arteriovenous crossings , tapering of veins on either side of the crossings and right-angle deflection of veins . Flame-shaped haemorrhages , cotton-wool spots and hard exudates are also present. Grade IV : Grade III chnages plus silver-wiring of arterioles and papilledema

38. Grade 1 HTN R Grade2 HTN R Grade 3 HTN R Grade 4 HTN R

39. AGE RELATED MACULAR DEGENERATION Blindness > 60 yrs of age Bilateral Two types : Dry ARMD Wet ARMD Symptoms : Central visual field defect, metamorphosia or distorted images. Treatment : Laser photocoagulation Photodynamic therapy

40. DRY ARMD WET ARMD

41. BASAL CELL CARCINOMA Commonest malignant tumor of eyelid. Locally invasive tumor Mc lower lid > Medial canthus > Upper lid > lateral canthus Nodule with pearly rolled out margins. Tumor grows by burrowing the local tissue hence rodent ulcer. Treatment : Surgical wide excision with reconstructon

42. SQUAMOUS CELL CARCINOMA Second MC malignant tumor Arise from eyelid margin Ulcerated growth with elevated and indurated margins. Metastasis to submandibular LN Treatment : Wide excision with surgical reconstruction

43. SEBACEOUS CELL CARCINOMA Tumour arising from meibomian gland. Mostly in upper lid Mimic as chalazion Metastasis common Treatment : Wide excision with lid reconstruction

44. MALIGNANT MELANOMA Rare malignant tumor Arise from pre exisiting nevus or de novo from melanocytes of skin. It appears as flat or raised nevus with variegated pigmentation irregular border which ulcerate and bleeds . Metastasis via lymphatics and blood stream. Treatment : Surgical excision with reconstruction