Pembahasan TO1 soal mata UKMPPD part 2.pdf

PEMBAHASAN MATA_

+ struktur yang
bervaskuler >
sklera

onjungtiva

tidak
menghalangi
media refraksi
onjungtivitis
murni

Trakoma

mata kering,

xeroftalmia

Pterigium

Pinguekula

+ Episkleritis

+ skleritis

mengenai media
refraksi (kornea,
uvea, atau
seluruh mata)

+ Keratitis

+ Keratokonjungti
vitis

+ Ulkus Kornea

+ Uveitis

+ glaukoma akut

+ Endoftalmitis

+ panoftalmitis

NN

uveitis posterior
perdarahan
vitreous

Ablasio retina
oklusi arteri atau
vena retinal
neuritis optik
neuropati optik
akut karena obat
(misalnya
etambutol),
migrain, tumor otak

+ Katarak

+ Glaukoma

+ retinopati
penyakit
sistemik

* retinitis
pigmentosa

+ kelainan
refraksi

Anatomi bola mata

Suspensory Ligament of Lens

Vitreous Body o K / Lens

AS

Anterior Chamber
Macula SS x Y

Blood Vessels

AN
N

DD

Optic Nerve \ Posterior Chamber
Sclera ~ > 7 x

7 Ciliary Body and Muscle

Choroid Retina”

WWW.MEDSCAPE.COM

Acute Glaucoma Pupilllary block

Acute Infection, Allergy
Conjunctivitis

Simpathetic Surgical, trauma to
Ophthalmia one eye, systemic
disease

Acute uveitis Systemic disease;
psoriasis, syphilis

nfectious/s

www.wikipedia.org

Acute onset of ocular pain, nausea, headache, vomitting,
blurred vision, haloes (+), palpable increased of IOP(>21 mm
Hg), conjunctival injection, corneal epithelial edema, mid-
dilated nonreactive pupil

itching and burning or a gritty, foreign-body sensation,
mucopurulent discharge, visual acuity is normal

bilateral granulomatous uveitis, The ocular inflammation in the
fellow eye becomes apparent usually within 3 months after
injury.

acute anterior uveitis with mutton-fat keratic precipitates. The
posterior segment manifests moderate to severe vitritis,
usually accompanied by multiple yellowish-white choroidal
lesions

Floating spots, pain, photophobia

Pain, redness, photophoia, excessive tearing, decreased
vision, limbic injection, miosis, might be followed by glaucoma

copurulent discharge from eye,
ight tivity, Pain
inflammation eyelids and conjunctiva, ciliary injection

Fluorescein st St melting, lagophtalmus, hypopyon

gn body sensation,

+ struktur yang
bervaskuler >
sklera

onjungtiva

tidak
menghalangi
media refraksi
onjungtivitis
murni

Trakoma

mata kering,

xeroftalmia

Pterigium

Pinguekula

+ Episkleritis

+ skleritis

mengenai media
refraksi (kornea,
uvea, atau
seluruh mata)

+ Keratitis

+ Keratokonjungti
vitis

+ Ulkus Kornea

+ Uveitis

+ glaukoma akut

+ Endoftalmitis

+ panoftalmitis

uveitis posterior
perdarahan
vitreous

Ablasio retina
oklusi arteri atau
vena retinal
neuritis optik
neuropati optik
akut karena obat
(misalnya
etambutol),
migrain, tumor otak

+ Katarak

+ Glaukoma

+ retinopati
penyakit
sistemik

* retinitis
pigmentosa

+ kelainan
refraksi

WWW.MEDSCAPE.COM www.wikipedia.org

Cataract Decreased visual acuity, contours, shadows and color
vision are less vivid, Being sensitive to glare, Cloudy, fuzzy,
foggy, or filmy vision, Difficulty seeing at night or in dim
light, myopic shift, shadow test (+)

Glaukoma progressive visual field loss, and optic nerve changes
(increased cup-to-disc ratio on fundoscopic examination)

Macular loss of vision in the center of the visual field (the macula) ,
Degeneration difficult or impossible to read or recognize faces

Hypertensive Cooper wired shaped vessels, cotton wool spots, clear lens
retinopathy

Diabetic Blurred vision, progressive visual los, dot & blot
Retinopathy hemorrhage, neovascularization

www.wikipedia.org

RATOBAET

or in its ‘envelope (lens capsule)

x Sign & symptoms:
+ Near-sightedness (myopia shift)> Early in the development of
age-related cataract, the power of the lens may be increased

+ Reduce the perception of blue colors>gradual yellowing and
opacification of the lens
+ Gradual vision loss
+ Almost always one eye is affected earlier than the other
+ Shadow test +
x Senile cataract
+ Elderly
+ Opacity in the lens
+ Subsequent swelling of the lens
+ Shrinkage with complete loss of transparency

zZ

www.wikipedia.org

x» Morgagnian cataract

+ The cataract cortex liquefies to form a milky white fluid

+ Cause severe inflammation if the lens capsule ruptures
and leaks>phacomorphic glaucoma

x Etiology:

zZ

+ Diabetes

+ Eye inflammation

+ Eye injury

+ Family history of cataracts

+ Long-term use of corticosteroids (taken by mouth) or
certain other medications

+ Radiation exposure

+ Smoking

+ Surgery for another eye problem

+ Too much exposure to ultraviolet light (sunlight)

CLASSIFICTION AGE-
RELATED CATARACT

x Cortical senile cataract

+ Immature senile cataract (IMSC)
x partially opaque lens, disc view
hazy
x Shadow test +
+ Mature senile cataract (MSC)

x completely opaque lens, no disc
view

x Shadow test -

+ Hypermature senile cataract
(HMSC)
x liquefied cortical
matter Morgagnian cataract

x Senile nuclear cataract
+ Cataracta brunescens
+ Cataracta nigra

ja | Cataracta rubra

www.wikipedia.org

Cortical Catar

0

eyescure.com

www.wikipedia.org

TREATMENT

x Extracapsular cataract extraction (ECCE) and
+ Removing the lens, but leaving the majority of the
lens capsule intact
+ High frequency sound waves
(phacoemulsification) > break up the lens before

extraction
x lintracapsular cataract extraction (ICCE)
+ Removing the lens and lens capsule>rare
x The cataractous lens is removed and replaced
with a plastic lens (an intraocular lens implant)

2 Wil stays in the eye permanently.

http://emedicine.medscape.com/article/798100

55. CORNEAL ULCER
An inflammatory or more seriously, infective condition of the
cornea involving disruption of its epithelial layer with
involvement of the corneal stroma

Fungal

Protozoa infection
(Acanthamoeba)

Viral

Staphylococcus
(marginal ulcer)

Pseudomonas
Streptococcus

connective tissue
disease

Fusarium & candida species, conjungtival
injection, satellite lesion, stromal infiltration,
hypopion, anterior chamber reaction

associated with contact lens users swimming in
pools

HSV is the most common cause, Dendritic lesion,
decrease visual accuity

Rapid corneal destruction; 24-48 hour, stromal
abscess formation, corneal edema, anterior
segment inflammation. Centered corneal ulcers.
Traumatic events, contact lens, structural
malposition

RA, Sjógren syndrome, Mooren ulcer, or a
systemic vasculitic disorder (SLE)

Natamycin,
amphotericin B,
Azole derivatives,
Flucytosine 1%

Acyclovir

Tobramycin/cefazol
in eye drops,
quinolones
(moxifloxacin)

Corneal diagnoses and systemic disease Mooren's ulcer vs. PUK: The difference can mean life or
death

PERIPHERAL ULCERATIVE KERATITIS (PUK)

Ulcer progressing slowly and easily, circumferentially,
and deeper toward the center of the cornea
Etiology>connective tissue disease

rheumatoid arthritis (RA)

Sjogren syndrome

Mooren ulcer
systemic vasculitic disorder (eg, systemic lupus
erythematosus [SLE], Wegener granulomatosis,
polyarteritis nodosa).

Mooren ulcer
rapidly progressive, painful, ulcerative keratitis
initially affects the peripheral cornea, spread
circumferentially and then centrally

can only be diagnosed in the absence of an infectious or
systemic cause.

http://emedicine.medscape.com/article/79810

+ struktur yang
bervaskuler >
sklera

onjungtiva

tidak
menghalangi
media refraksi
onjungtivitis
murni

Trakoma

mata kering,

xeroftalmia

Pterigium

Pinguekula

+ Episkleritis

+ skleritis

mengenai media
refraksi (kornea,
uvea, atau
seluruh mata)

+ Keratitis

+ Keratokonjungti
vitis

+ Ulkus Kornea

+ Uveitis

+ glaukoma akut

+ Endoftalmitis

+ panoftalmitis

NN

uveitis posterior
perdarahan
vitreous

Ablasio retina
oklusi arteri atau
vena retinal
neuritis optik
neuropati optik
akut karena obat
(misalnya
etambutol),
migrain, tumor otak

+ Katarak

+ Glaukoma

+ retinopati
penyakit
sistemik

* retinitis
pigmentosa

+ kelainan
refraksi

http://emedicine.medscape.com/article/1206147

GLAUCOMA

x Disturbance of the structural or functional
integrity of the optic nerve that causes
characteristic atrophic changes in the optic
nerve, which may also lead to specific visual

field defects over time

x Usually can be arrested or diminished by
adequate lowering of intraocular pressure (IOP)

zZ

JENIS GLAUKOMA :

1. Primer yaitu timbul pada mata yang
mempunyai bakat bawaan, biasanya
bilateral dan diturunkan.

2. Sekunder yang merupakan penyulit
penyakit mata lainnya (ada
penyebabnya) biasanya Unilateral

zZ

http://emedicine.medscape.com/article/1206147 www.wikipedia.org

TYPES OF GLAUCOMA

Open-angle
(chronic)
glaucoma

Congenital
glaucoma

Secondary
glaucoma

Absolute
glaucoma

Pupilllary bl

Unknown

abnormal eye
development,
congenital infection

Drugs
(corticosteroids)
Eye diseases
(uveitis)

Systemic diseases
Trauma

of ocular pain eadache, vomitting,
d of IOP(>21 mm

)ithelial edema, mid
hyperopia, and

History of eye pain or redness, Multicolored halos, Headache,
IOP steadily increase, Gonioscopy Open anterior chamber
angles, Progressive visual field loss

present at birth, epiphora, photophobia, and blepharospasm.
buphtalmus (>12 mm)

Sign and symtoms like the primry one. Loss of vision

end stage of all types of glaucoma, no vision, absence of
pupillary light reflex and pupillary response, stony appearance.
Severe eye pain. The treatment > destructive procedure like

cyclocryoapplication, cyclophotocoagulation, injection of 100%

GLAUKOMA

Form of
‘laucoma

Open angle
glaucoma

Angle closure
glaucoma

juvenile
glaucoma

Incidence

Primary - Over20%of all
glaucomas

2-4%0fall
glaucomas

Primary 5
(pupillary glaucomas
block

glaucoma)

Secondary
glaucomas

1%0fal
glaucomas

Physiology of aqueous humor circulation,

Canal of Schlemm
Collecting channel 3

Eplscleral venous plexus

Conjunctia

Fig.10.1 As it flows from the nonpigmented cells of the cian

beneath the conjunctiva ®). the aqueous humor overcome:

epithelia @) to

yslologi resist

from two sources: the resistance ofthe pupil EJand the resistance of the trabecular

meshwork €

aucoma that develops
after the 3rd year of life

http://emedicine.medscape.com/article/1206147

OPEN-ANGLE (CHRONIC) GLAUCOMA

Most common type

Chronic and progressive >
acquired loss of optic nerve
fibers

Open anterior chamber angles
Visual field abnormalities
An increase in eye pressure
occurs slowly over
time>pushes on the optic
nerve

Funduskopi: cupping and
atrophy of the optic disc
Risk factors

elevated intraocular pressure,
advanced age, black race, and
family history

glaucomatous eyes

Normal

Vides

A: Optic nerve photography: small central cup in healthy eye;
enlarged cup and loss of inferotemporal neuroretinal rim in
glaucomatous eye; 8: Retinal nerve fibre layer photagraphy
uniform reflections in healthy eye; poor reflections in
inferotempor & glaucomatous eye, Reprinted
with permission from: Wein Khaw, PT. Primary open-angle
glaucoma, Lancet 2004; Copyright © 2004 Elsevier.

http://emedicine.medscape.com/article/1206147

TREATMENT

x OP >28 mm Hg
+ Treated
+ Follow-up care in 1 month to assess treatment
+ The goal is reached>follow-up care every 3-4 months
» |OP 26-27 mm Hg
+ Follow-up care > 2-3 weeks to recheck pressure
+ If IOP is still within 3 mm Hg of the initial reading>follow-up every 3-4 months
+ Visual field and dilated optic nerve evaluation once a year
+ If IOP is lower> longer time to follow up
x. IOP 22-25 mm Hg

+ Follow-up care> 2-3 months later for recheck of IOP at different times of the day
(ie, 8 am, 11 am, 1 pm, 4 pm)

+ If itis still within 3 mm Hg of the initial reading > follow-up at 6 months

+ Humphrey visual field testing and dilated optic nerve evaluation, repeating it at
least yearly.

http://emedicine.medscape.com/article/1206147

MEDICATION

x Alpha-agonists
+ decreasing aqueous production
x Beta-blockers
+ decrease aqueous humor production by the ciliary body
Carbonic anhydrase inhibitors

+ Reduce secretion of aqueous humor by inhibiting carbonic
anhydrase (CA) in the ciliary body

Miotic agents

+ contraction of the ciliary muscle, tightening the trabecular
meshwork and allowing increased outflow of aqueous through
traditional pathways

Prostaglandin analogs

al Increase uveoscleral outflow of aqueous

http://emedicine.medscape.com/article/798811

ANGLE-CLOSURE (ACUTE) GLAUCOMA

x The exit of the aqueous humor fluid is sud
x At least 2 symptoms:
+ ocular pain
+ nausea/vomiting
+ history of intermittent blurring of vision with halos

x AND at least 3 signs:
+ IOP greater than 21 mm Hg
+ conjunctival injection
+ corneal epithelial edema
+ mid-dilated nonreactive pupil
+ shallower chamber in the presence of occlusiondenly

blocked

zZ

Open Angle Glaucoma: Blockage of
the trabecular meshwork slows
drainage of the aqueous humor,
which increases intraocular pressure,
Source: The Mayo Clinic (www.
mayodinic.com)

NORMAL AQUEOUS
FLOW

"Aqueous vein
Schlemm's canal

Angle Closure Glaucoma: The anglé

formed by the corea and the iris

narrows, preventing the aqueous

humor from draining out of the eye.

This can lead to a rapid increase in
traocular pressure. Source: The

Mayo Clinic (www.mayodinic.com)

e

ANGLE-CL
GLAUCOMA

http://emedicine.medscape.com/article/798811

TREATMENT
» Aim:

+ JOP reduction
x Acetazolamide >500 mg IV followed by 500 mg PO or 4x 250 mg
x topical beta-blocker (ie, carteolol, timolol) > 0.25%-0.5% 1-2 dd
x Sol.Glycerin 50% 4 x 100-150 cc>Hiperosmotic agent
x Kel 3x 0,5 gr

+ suppression of inflammation
x 1-2 doses of topical steroids

+ reversal of angle closure

x Pilocarpine (miotic) 2% 1 hour after beginning treatment,
administered every 15 minutes for 2 doses.then 3 times a day

x Initial attack>the elevated pressure in the anterior chamber
causes a pressure-induced ischemic paralysis of the iris>
pilocarpine ineffective

x 2% 3 times a day
» Extraocular symptoms:
+ analgesics

+ antiemetics
+ Placing the patient in the supine position >lens falls away
from the iris decreasing pupillary block

http://emedicine.medscape.com/article/1206081

57, BUPHTHALMOS

x Characterized by eye enlargement that results from

elevated IOP, which is ofte
congenital glaucoma

x Rarely present at birth
x Primary congenital glauco

n caused by primary

ma

+ the result of abnormal formation of anterior chamber angle
(site of draining the eye fluid), causing obstruction of the

fluid outflow and elevated
+ Develops within months a
+ Classic triad
x Photophobia
x Tearing

eye pressures
ter birth

ja | x blepharospasm in bright ligl

Acute Glaucoma

Open-angle
(chronic)
glaucoma

Secondary
glaucoma

Absolute
glaucoma

Pupilllary block

Unknown

tal infection

(corticosteroids)
Eye diseases
(uveitis)

Systemic diseases
Trauma

Acute onset of ocular pain, nausea, headache, vomitting,
blurred vision, haloes (+), palpable increased of IOP(>21 mm
Hg), conjunctival injection, corneal epithelial edema, mid-
dilated nonreactive pupil, elderly, suffer from hyperopia, and
have no history of glaucoma

History of eye pain or redness, Multicolored halos, Headache,
IOP steadily increase, Gonioscopy Open anterior chamber
angles, Progressive visual field loss

phora, photophobia, and ble

Sign and symtoms like the primry one. Loss of vision

end stage of all types of glaucoma, no vision, absence of
pupillary light reflex and pupillary response, stony appearance.
Severe eye pain. The treatment > destructive procedure like
cyclocryoapplication, cyclophotocoagulation, injection of 100%
alcohol

+ struktur yang
bervaskuler >
sklera

onjungtiva

tidak
menghalangi
media refraksi
onjungtivitis
murni

Trakoma

mata kering,

xeroftalmia

Pterigium

Pinguekula

+ Episkleritis

+ skleritis

mengenai media
refraksi (kornea,
uvea, atau
seluruh mata)

+ Keratitis

+ Keratokonjungti
vitis

+ Ulkus Kornea

+ Uveitis

+ glaukoma akut

+ Endoftalmitis

+ panoftalmitis

uveitis posterior
perdarahan
vitreous

Ablasio retina
oklusi arteri atau
vena retinal
neuritis optik
neuropati optik
akut karena obat
(misalnya
etambutol),
migrain, tumor otak

+ Katarak

+ Glaukoma

+ retinopati
penyakit
sistemik

* retinitis
pigmentosa

+ kelainan
refraksi

Disorders

Myopia

Hypermetropia

Astigmatisma

Presbyopia

Anisometropia

Feature

the light that comes in does not directly focus on the
retina but in front of it>image at a distant object to
be out of focus but in focus when looking at a close
objec.

imperfection in the eye (often when the eyeball is too
short or the lens cannot become round enough).
Difficult focusing on near objects

Unspherical corneal structure; distorted image

the eye exhibits a progressively diminished ability to
focus on near objects with age, eyestrain, difficulty
seeing in dim light, problems focusing on small
objects

two eyes have unequal refractive power, leading to
diplopia and asthenopia.

www.wikipedia.org

Correction

Concave lens. The
smallest Dioptri to
corret the visual
aquity to 6/6

Convex lenses. The
largest Dioptri to
corret the visual
aquity to 6/6

Lens correction,
laser ceratotomy

Correction lens

Iseikonic lenses

http://en.wikipedia.org/wiki/Myopia

MYOPIA

Classification:
Low myopia>-3.00
diopters or less (i.e.
closer to 0.00).[6]
Medium myopia
> -3.00 and -6.00
diopters
High myopia >-6.00 or
more.[6] People with
high myopia
more likely to have retinal
detachments and
primary open angle
glaucoma

more likely to experience
floaters

http://www.aoa.org/documents/CPG-16.pdf www.wikipedia.org

HYPERMETROPIA

x Classification:
+ Low hyperopia > +2.00 diopters (D) or less
+ Moderate hyperopia>+2.25 to +5.00 D
+ High hyperopia> +5.00 D

x Clinical categories:

+ Simple hyperopia>normal biological variation, can be
of axial or refractive etiology

+ Pathological hyperopia > abnormal ocular anatomy
due to maldevelopment, ocular disease, or trauma

+ Functional hyperopia paralysis of accommodation

zZ

=(8> ar |

hyperopia, uncorrected, he image is
focused virtually pst the retiré hyperopia, correcte with plu lens

+ —_
A

myopia, uncorreted, he image imgopa, corrected with
falls stort of the retina minus ens

Hyperopia C Astigmatism D

Lens
—> 7 Corea
» » | Pupil

estignétism, uncorrected. The two estignatism, corrected. The two
uréqualy focused part of he image ae unequally presented part ofthe image
inated by the sli nd ceed lines are fun te retins

Light

Retina ==>

, Presbyopia E

http://www.eyecarecontacts.com/optical_lenses.GIF

59.
CATARACT

Anel Test

Schimmer test

Shadow test

Fluorescein test

Humphrey visual
Tiel@etest

http://www.nim.nih.gov/medlineplus/ency/articl
e

Determines the excretion function of the ductus
acrimalis

determines whether the eye produces enough
ears to keep it moist. N : A negative (>10 mm of
moisture on the filter paper in 5 minutes)

Detect immature cataract lens

detect foreign bodies in the eye and detect
damage to the cornea

Determine visual field

+ struktur yang
bervaskuler >
sklera

onjungtiva

tidak
menghalangi
media refraksi
onjungtivitis
murni

Trakoma

mata kering,

xeroftalmia

Pterigium

Pinguekula

+ Episkleritis

+ skleritis

mengenai media
refraksi (kornea,
uvea, atau
seluruh mata)

+ Keratitis

+ Keratokonjungti
vitis

+ Ulkus Kornea

+ Uveitis

+ glaukoma akut

+ Endoftalmitis

+ panoftalmitis

uveitis posterior
perdarahan
vitreous

Ablasio retina
oklusi arteri atau
vena retinal
neuritis optik
neuropati optik
akut karena obat
(misalnya
etambutol),
migrain, tumor otak

+ Katarak

+ Glaukoma

+ retinopati
penyakit
sistemik

* retinitis
pigmentosa

+ kelainan
refraksi

http://emedicine.medscape.com/article/1217083 Optic_neuropathy.htm

60. OPTIC NEUROPATHY

Retrobulbar multiple demyelinating inflammation of optic nerve, young

neuritis sclerosis (MS) adults (30s), affects only one eye,decrease vision,
dyschromatopsia, ocular pain, exacerbated by
heat/exercise (Uhthoff phenomenon) and eye
movement.
Objects moving in a straight line may appear to have a
curved trajectory (Pulfrich prenomienon), central
scotoma, headache, sudden color blindness,impaired
night vision,impaired contrast sensitivit

http://emedicine.medscape.com/article/1217083

http://www.cdc.gov/conjunctivitis/about/treatment. html

61. KONJUNGTIVITIS

Bacterial staphylococc Acute onset of redness, grittiness, | topical antibiotics
istreptococci | burning sensation, usually Artificial tears
, gonocci bilateral eyelids difficult to open
Corynebacte on waking, diffuse conjungtival
rium strains | injection, mucopurulent
discharge, Papillae +

Adenovirus | Unilateral watery eye, redness, Days 3-5 of > worst, clear
herpes discomfort, photophobia, eyelid | up in 7-14 days without
simplex virus edema & pre-auricular treatment
or varicella- lymphadenopathy, follicular Artificial tears >relieve
zoster virus conjungtivitis, pseudomembrane dryness and inflammation
(+/-) (swelling)
Antiviral >herpes simplex
virus or varicella-zoster
virus

Vernal

Inclusion

Candida spp. can
cause
conjunctivitis
Blastomyces
dermatitidis
Sporothrix
schenckii

Allergy

Chlamydia
trachomatis

Not common, mostly occur in
immunocompromised patient,
after topical corticosteroid and
antibacterial therapy to an
inflamed eye

Chronic conjungtival bilateral
inflammation, associated atopic
family history, itching,
photophobia, foreign body
sensation, blepharospasm,
cobblestone pappilae, Horner-
trantas dots

several weeks/months of red,
irritable eye with mucopurulent
sticky discharge, acute or

subacute onset, ocular irritation,

foreign body sensation,
watering, unilateral swollen
lids,chemosis ,Follicles

Topical antifungal

Removal allergen
Topical antihistamine
Vasoconstrictors

Doxycycline 100 mg
PO bid for 21 days OR
Erythromycin 250 mg
PO qid for 21 days
Topical antibiotics

Table 1
Signs and Symptoms of Common Types of Conjunctivitis

‘Onset!
Etiology Condition Duration Symptom:

Hyperacute

Puulent discharge, sometimes pain
bacterial =

Acute bacterial ft Tearing, lid crasting

Chronic bacterial Lid crusting, foreign body sensatii

[u Tearin, upon

Herpetic ut Te

Seasonal WV) trohing,

Weınal = Itching.

Giant papillary intolerance,

Chlamydial | Chlamydial

62. CONTACT LENS

Causes changes in the
cornea
structure, turnover, tear

production and oxygen and

carbon dioxide levels
Associted with:

type of lens used (eg soft,
rigid, gas-permeable)

the frequency with which
the lenses are changed,

the cleaning systems
Clinical manifestation:

pain and irritation or
watering of the eye anda
red eye

http://www. patient.co.uk/doctor/ContactLens-
Problems.htm

+ Predisposing factors:

Dry eye

Blepharitis.

Atopic or allergic
conjunctivitis.

Poor lens care or
inexperienced CL user.
Prolonged lens wear
including overnight wear.
Smoking.
Immunosuppression.
Trauma or surgery.
Increasing age.
Systemic disease.

http://www. patient.co.uk/doctor/ContactLens-
Problems.htm

POOR LENS CARE

x Accumulation of protein and lipid deposits on
the lens
+ cause irritation of the cornea and impaired visual
acuity
+ Bacteria, protozoa and fungi> form a film over the
lens and the fungal filaments may invade the lens
itself

+ Ensure that the patient is using the lenses correctly
so as to prevent future deposit formation.

zZ

http://www. patient.co.uk/doctor/ContactLens-
Problems.htm

ACANTHAMOEBA KERATITIS

x» Sign & symptom:
+ Pain
+ watery eyes
+ Irritation
+ photophobia + red eye
+ usually unilateral
+ Initially present with a dendritic-type ulcer

x any dendritic keratitis in a CL wearer should be assumed to
be caused by Acanthamoeba spp. until proved otherwise.

x Treatment
+ combinations of anti-amoebic agents

zZ

63. ASTIGMATISM

x Vision is blurred due to the inability of the optics of
the eye to focus a point object into a sharp focused
image on the retina

Cause:
+ irregular or toric curvature of the cornea or lens

x Types

+ Regular
x arising from either the cornea or crystalline lens
x can be corrected by a toric lens
+ Irregular
x caused by a corneal scar or scattering in the crystalline lens

x cannot be corrected by standard spectacle lenses
ja x can be corrected by contact lenses

CLASSIFICATION
x Simple-astigmatism
+ Simple hyperopic astigmatism

x first focal line is on retina, while the second is located
behind the retina.

+ Simple myopic astigmatism

x first focal line is in front of the retina, while the second is
on the retina.

x Compound astigmatism
+ Compound hyperopic astigmatism
x both focal lines are located behind the retina.
+ Compound myopic astigmatism
x both focal lines are located in front of the retina.
x Mixed astigmatism

+ focal lines are on both sides of the retina (straddling
ja the retina).

‘Compound Myopic Astigmatism Compound Hyperopic Astigmatism

a

http://www.improveeyesighthq.com/Corrective-Lens-Astigmatism.html

http://en.wikipedia.org www.medscape.com

64, CONGENITAL GLAUCOMA

Ambliopia

Congenita
glaucoma

Retinoblastom
a

Katarak
congenital

Peters anomaly

'3

Decrease of vision; disuse/inadequate foveal/peripheral retinal
stimulation and/or abnormal binocular interaction that cause
different visual input

abnormal eye development, congenital infection
present at birth, epiphora, photophobia, and blepharospasm,
buphtalmus (>12 mm)

rapidly developing cancer that develops in the cells of retina,
amaurotic cat's eye reflex, deterioration of vision, a red and
irritated eye with glaucoma, and faltering growth or delayed
development,strabismus

clouding of the lens of the eye that is present at birth, Leukocoria
or white reflex, nfant doesn't seem to be able to see, nystagmus
anterior segment dysgenesis , may have an inherited pattern,
Central, paracentral, or complete corneal opacity,no
vascularization of this opacity occurs

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMHO00258

pa

Retinoblastoma

CONGENITAL

GLAUCOMA
http://www.wrighteyecare.com/Peters_Anomaly.html http://www.stjude.org/Images/misc-retinoblastoma-0602 jpg

http://emedicine.medscape.com/article

CONGENITAL GLAUCOMA

x Primary
+ Improper development of the eye's aqueous outflow

system, leading to increased intraocular pressure (IOP),

with consequent damage to ocular structures, resulting

in loss of vision

+ developmental abnormality that affects the trabecular
meshwork

x Secondary
+ associated ocular or systemic anomalies
+ inflammation, trauma, and tumors
+ Exp:Peters anomaly, Rubella infection, Toxoplasma

infection
1]

NEUROLOGI

MIDBRAIN & CRANIAL NERVES

N. OLFACTORIUS (I)

x Sensation of smell
x Cara:

+ Kooperatif

+ Mata terpejam

Hidung bebas
hambatan

Dg kopi, tembakau,
teh

P Sat a Lubang dites satu
A persatu

N. OPTICUS (II)

x Visus:
+ Snellen card (6/6)
+ Jari (../60)
+ Lambaian tangan (.../300)

+ Cahaya (.../~) wm Cc B mn

» Warna (Ishihara) - DUE ME

x Visual fields mo PY BR >

+ Tes konfrontasi “"-PFEBDR=--
om OF LETTE mu

+ Tes perimetri APLORTDZ

w-um NPRTVEBDTERO mm

1]

ER

TRE

TRS
HLT RES a
ne
EG.
SS

FIG. 10-7. The normal visual ld,

perimetri

Pem fundus:
Discus (papil edema, atrofi)
Arteri & vena
Retina (perdarahan,

eksudat, tuberkel)

N. OCULOMOTORIUS (III)

Ptosis (klp mata jatuh)
Gerakan bola mata

+ Ke medial, atas, bawah
Refleks cahaya (+/-)
Ukuran pupil (mm)

+ Cahaya dari lateral mata
Bentuk pupil (isokor/anisokor)
Diplopia (pandangan dobel)

Nistagmus (gangg balans tonus
otot bola mata)

zZ

Paralisis NU ki

N. TROCHLEARIS (IV)

x Gerak bola mata ke
lateral bawah

x Diplopia (pandangan
dobel)

x Nistagmus (gangg balans
tonus otot bola mata)

zZ

N. ABDUCENS (VI)

x Gerak bola mata ke
lateral

x Diplopia (pandangan
dobel)

x Nistagmus (gangg balans
tonus otot bola mata)

zZ

N. TRIGEMINUS (V)

x Fungsi:

+ Sensasi wajah

+ Gerakan mengunyah
x Refleks cornea

+ Sentuhan kapas basah
pd limbus cornea

+ Bilateral blink (+)

zZ

x Gerakan mengunyah:
+ Palpasi otot masseter
+ Buka mulut
+ Jaw jerk (Sulit)

Saraf peka nyeri

Gambar 57
Refleks maseter

N. FACIALIS (VII)

x Fungsi:
+ Gerakan wajah

+ Pengecap 2/3 lidah
depan

+ Sekresi gid lacrimalis
& gid salivarius

Gerakan wajah:
+ Meringis
+ Tutup mata
+ Kerutkan dahi

Pengecap:

+ Gula, garam, cuka, kinina
+ Disentuh dg cottonbuds
x Sekresi:
+ Inhalasi amonia (lakrimal)
+ Bumbu yg keras (saliva)

N. AUDITORIUS (VIII)

x» Fungsi:
+ Pendengaran (cochlear
nerve)
+ Keseimbangan (vestibular
nerve)
* Pendengaran:
+ Garputala
x Rinne's test
udara/tulang
x Weber's test: tulang
x Schwabach's test:
pt/examiner

zZ

A. Test Schwabach,
B. Test Rinne.
C. Test Weber,

x Keseimbangan:

+ Rotational test:

x Diputar di kursi 10x

selama 20 detik
+ Caloric test:

x lrigasi dg air 250 ml
selama 40 dtk, suhu
30°C & 44°C

+ Romberg test:

x Berdiri kaki rapat,
buka & tutup mata

zZ

N. GLOSSOPHARYNGEUS (IX)

x Fungsi:

+ Mengatur otot
palatum & pharynx

+ Sensasi di pharynx,
tonsil, palatum, lidah
bikg

x Refleks muntah

+ Pengecap 1/3 blkg

lidah

Saraf peka nyeri

zZ

N. VAGUS (X)

x Fungsi:
+ Mengatur otot palatum &
pharynx
x Refleks menelan
x Disfagia
+ Sensasi di pharynx, tonsil,
palatum, lidah blkg
+ Mengatur otot pita suara

Saraf peka nyeri

zZ

N. ACCESSORIUS (XI)
: Otot-otot leher

Otot-otot bahu

N. HYPOGLOSSUS (XII)

&

124 |

x
m

x Otot lidah
x Di

a

sartria (gangg
tikulasi)
enjulurkan lidah:
encong

x Fasikulasi, tremor,

a

trofi (tanda perifer)

CSF PRESSURE

x Normal
+ 1-15 mmHg or <200mm H,O

€
x Low pressure o?
IN

Z

+ Dehydration
x Increased pressure

+ Valsalva,Tumor, Subdural Hematoma,
Subarachnoid Hemorrhage, Infections,

Hydrocephalus
a

SYMPTOMS OF INCREASING ICP

x Headache « Aniscoria
x Visual changes + Hemiparesis
x Nausea ¢ Vital sign

« Vomiting changes
x Behavior changes — Cushing

Triad
x« Changes in LOC

x Seizures

zZ

CUSHING’S TRIAD

x Vital Sign Changes in ICP:

1. Systolic pressure increases (widened pulse
pressure results).

2. Slowing of heart occurs—bradycardia (occurs as
result of reflexive slowing in response to
increased systolic pressure)

2 Respiration changes—becomes slowed

zZ

DIAGNOSIS OF INCREASED INTRACRANIAL
PRESSURE

Overt symptoms

Papilledema
Nuchal rigidity

x Vascular abnormalities
+ AV malformations, aneurisms, stroke
x Diffuse cerebral ischemia

+ Closed head trauma, shaken baby, vasospasm
» CNS infections
x Tumors

x Trauma
x Obstruction of CSF flow

zZ

DIFFERENTIAL DIAGNOSIS OF LOW
BACK PAIN

Mechanical low back pain (97%)
Lumbar strain or sprain (> 70%) Diffuse pain in lumbar muscles; some radiation to buttocks
Degenerative disk or facet process (10%) Localized lumbar pain; similar findings to lumbar strain
Herniated disk (4%) Leg pain often worse than back pain; pain radiating below knee
Osteoporotic compression fracture (4%) Spine tenderness; often history of trauma

Spinal stenosis (3%) Pain better when spine is flexed or when seated, aggravated by

walking downhill more than uphill; symptoms often bilateral

Spondylolisthesis (2%) Pain with activity, usually better with rest; usually detected with

imaging; controversial as cause of significant pain

Nonmechanical spinal conditions (1%)

Neoplasia (0.7%) Spine tenderness; weight loss
Inflammatory arthritis (0.3%) Morning stiffness, improves with exercise
Infection (0.01%) Spine tenderness; constitutional symptoms

Nonspinal/ visceral disease (2%)
Pelvic organs—prostatitis, pelvic inflammatory disease,

endometriosis

Lower abdominal symptoms common

Renal organs—nephrolithiasis, pyelonephritis Usually involves abdominal symptoms; abnormal urinalysis
Aortic aneurysm - Epigastric pain; pulsatile abdominal mass

Gastrointestinal system—pancreatitis, cholecystitis, peptic ulcer Epigastric pain; nausea, vomiting
Shingles - Unilateral, dermatomal pain; distinctive rash

“Estimated percentage of patients with this condition among all adult patients with low back pain in primary care.

DIAGNOSES &

Cancer
Age > 50
History of Cancer
Weight loss
Unrelenting night
pain

Failure to improve

Infection
IVDU
Steroid use
Fever
Unrelenting night
pain

Failure to improve

Fracture
Age >50
Trauma
Steroid use
Osteoporosis

Cauda Equina
Syndrome
Saddle anesthesia

Bowel/ bladder
dysfunction

Loss of sphincter control
Major motor weakness

HERNIATED NUCLEUS PULPOSUS

Clinical Features

Injury: history of falling, or | fting heavy
weights \
Leg pain : Root irritation or compression
produces pain in the distribution of the
affected root. Coughing, sneezing or
straining aggravates the leg pan which is
more severe than backache

sc hemvalion

Parasthesia : Numbness or tingling
occurs in the distributing of affected root

Muscle weakness or fatigue in the
buttocks, legs and feet

Soreness or stiffness

NEUROLOGIC EXAMINATION
(L4 LEVEL)

x Motor L4 vee ||
+ Tibialis Anterior NEUROLOGIC [+ y
x Resisted inversion of ankle
x Reflexes
+ Patellar Reflex (L2, L3, L4)
x Sensory
+ Medial side of leg

ÿ
Y
I 2) Fig. 30. Neurologic level LA.

NEUROLOGIC EXAMINATION
(PO PEVER}
x Motor

+ Extensor Hallicus Longus L5
+ Resisted dorsiflexion of great toe NEUROLOGIC

MOTOR
+ Reflexes - none VEL
» Sensory 5

+ Dorsum of foot in midline L5

1
IM

NEUROLOGIC EXAMINATION

(St LEVEL)

x Motor
+ Peroneus Longus and Brevis
+ Resisted eversion of foot
x Reflexes
+ Achilles
» Sensory
+ Lateral side of foot

zZ

Ss 1 MOTOR

NEUROLOGIC |
LEVEL LR

REFLEX 13
LS

Fig. 32. Neurologic level S1.

STRAIGHT LEG RAISING (SLR) TEST

L5 8: S1 COMRPRESION CAUSES
LIMITATION TO LESS THAN 60°
FROM HORIZONTAL AND
PRODUCES PAIN DOWN THE
BACK OF LEG.

DORSOFLEXION OF THE FOOT
WHILE THE LEG IS ELEVATED
AGGRAVATES THE PAIN.
ELEVATION OF THE GOOD LEG
MAY PRODUCE PAIN IN THE
OTHER LEG.

NEUROLOGIC EXAMINATION

OTHER INVESTIGATION
FEMORAL STRECH TEST

TEST FOR IRRITATION OF HIGHER NERVE ROOTS ( L4 AND
ABOVE) x X- Ray Lumbosacral :

+ limited benefit, excluding
other pathology e.q
matastatic carcinoma

x CT scan:
Sy fa x MRI:
À A + best choice
4 L NN x Radiculography

PEN ff
ae

AL

i

f
a

HERNIATED NUCLEUS PULPOSUS

x Nonoperative Care
+ Initial bed rest

+ Nonsteroidal anti-
inflammatory (NSAID)
medication

+ Physical therapy
x Exercise/walking
+ Steroid injections

x Operatitive Care
+ Reccurent attacks of leg
pain
+ Severe unremitting leg pain
+ The development of

7] neurological deficit

=
À ¡LE J dise Degeneration
Ñ La ) Prolapse

Y aa) Extrusion

Sequestration

ACUTE MANAGEMENT

x Medications
+ Pain control
x Tylenol/NSAID's
x minimize narcotic use
+ Muscle relaxers
x use Valium for short
term (1-2 days)
+ Corticosteroids

x 2m8/Kg burst for 5-7
days

zZ

x TIA
x Ramsay Hunt Syndrome
x Acoustic Neuromas

x Heerfordt's Syndrome
x Melkersson-Rosenthal Syndrome

zZ

HERPES ZOSTER OTICUS
(RAMSAY HUNT SYNDROME)

x 10-15%

x Lesions
EAC or s

of acute facial palsy cases

may involve the external ear, the skin of
oft palate

x Associated symptoms - hearing loss, dysacusis
and vertigo

x Additional involvement of CN V, IX and X and

cervical
x Pathoge
point be
ja | genicula

branches 2, 3 and 4

nesis - Neural injury due to edema at
tween the meatal foramen and the

te fossa in the labyrinthe segment

MELKERSSON-ROENTHAL SYNDROME

x Triad
+ Recurrent orofacial
edema
+ Recurrent facial palsy
(50-90%)
+ Lingua plicata (fissure
tongue) - 25%

Lips become chapped,
fissured and red-brown in

appearance

Biopies identify
granulomatous changes
Facial nerve decompression
may be indicated if facial
paralysis is severe and
recurrent

WHAT IS BELL’S PALSY?

Bell’s Palsy :

Is a paralysis

Causes weakness of

the muscles

Causes facial muscles :

to droop 7

} muscles

AFFECTS

Affects one side of the
face

The sense of taste

As well as the ability to
make tears and saliva

CAUSES

Cause is not clear, some
cases are linked to the
herpes virus

Mostly caused by
inflammation of the
nerve that controls the
facial muscles

Some are linked to brain
tumors or lyme disease
But is NOT caused by a
Stroke

SIGNS AND SYMPTOMS

x Unilateral facial x Pain behind the ear
paralysis

x Inability to close the
eye

x Tearing
x Drooling

x Absence of the + Hyperacusis
nasolabial fold x Sag of the eyebrow

x May be loss of taste
on anterior tongue

zZ

DIAGNOSIS

x» Based on clinical findings

x Imaging studies used to rule out other
pathology

x Lyme titers, PCR testing may indicate
cause

zZ

TREATMENT

x Corticosteroids (efficacy not proven)
x Analgesics
x Lubricating eye drops

x Taping eye closed at night
x Massage of the weakened muscles

zZ

PROGNOSIS

x Generally very good

x Most patients get significantly better in
about 2 weeks even without treatment

x 80-85% recover completely within 3
months

» 10% have permanent disfigurement or
other long term sequelae

zZ

DIAGNOSTIC FEATURES

x Four Cardinal Signs
+T remor
+R igidity
+A kinesian and bradykinesia
+P ostural instability

zZ

Clinical features of PD

Resting tremor: Most common first symptom, usually asymmetric and most
evident in one hand with the arm at rest.

Bradykinesia: Difficulty with daily activities such as writing, shaving, using a knife
and fork, and opening buttons; decreased blinking, masked facies, slowed chewing
and swallowing.

Rigidity: Muscle tone increased in both flexor and extensor muscles providing a
constant resistance to passive movements of the joints; stooped posture,
anteroflexed head, and flexed knees and elbows.

Additional clinical features of PD

Postural instability: Due to loss of postural reflexes.
Dysfunction of the autonomic nervous system: Impaired
gastrointestinal motility, bladder dysfunction, sialorrhea, excessive head and neck

sweating, and orthostatic hypotension.

Depression: Mild to moderate depression in 50 % of patients.

Cognitive impairment: Mild cognitive decline including impaired visual-spatial
perception and attention, slowness in execution of motor tasks, and impaired
concentration in most patients; at least 1/3 become demented during the course of
the disease.

DEFINITION

x Two or more seizures without recovery or
consciousness in between.

x Single seizure >20-30 min.

zZ

MANAGEMENT

x First aid
+ Ensure airway patent
+ Give oxygen
+ Secure IV access
+ Draw blood for glucose, E/U& Cr, LFT, etc

+ Give diazepam 10 mg IV, repeat once only after
15mins, after 30mins give phenytoin 15mg/kg O
50mg/min, after 30-60mins intubate and give
general anaesthesia (propofol, thiopental)

zZ

vergency toar te

Propofel bonne Weaning
sky bolls Ui rrg/hig
a athgit N08 15 make

MENE
Karl dEl

W 0-1-2 ago

sata
Alp 110 ring
§ mop/in

Den

ESS

‘Ainway, blood pressure, temperature, intravenous access, electrocardiagraphy,CBC, glucose, electrolytes, AED bevels, ARG, tox screen; central line?
As A |

PRIMARY, IDIOPATHIC HEADACHES

Tension type of
headache

Headaches

Migraine E Cluster: | Tension: | Migraine:

pee, A
ke a band | and vi

Cluster headache | Fr a =
Other, rare types

of primary

headaches

Table 3. Clinical Characteristics Of The Primary Headache Syndromes*

Feature Migraine without Migraine with Tensiontype | Cluster headache
| aura cura headache (episodic)
| (episodic) _
| Prevalence Common Uncamenon Common Rara
Gender Femolas> Famales> Fomales> Males>>
L Males Males Males Famales
|_Fomily history | Frequent Frequent Froquent Rare
Age at yr) 10-30 1030 20-40 20-40
Site of pain | Hemicranial, bilateral | Hemicrarsal, bänteral | Bilateral, occipital, | Unilataral, Fronto-
frontal tamporal, periorbital
Character of pain Pulsatile Pulsatile ‘Aching, tight, Boring
| squeezing
Severity of pain | Moderate lo severe | Moderate to severe | Mild to moderate ‘Severe
‘Onset to peak pain | Minutas to hours Minutes 10 hours Hours Minutes (rapid)
Duration of pain Usually 424 hes Usually 4-24 hes Hours to days 30-90 min

Frequency ofatiack | Variable, several per | Variable, several per | Variable, several par | Daily during cluster
month

month month
Poriodicity of attacks | No [axception, No (exception, No
menstrual migraine] | menstrual migraine)
Accompaniments Nausea, vomiting, Nausea, vomiting, Nouseo on occasion | Ipsilateral nasal
photophobia, photophobia, congestion,
phonaphobio, phonaphabia, thinortheo,
osmaphobia osmophobia canjunctival injection,
ptosis, lacrimation
Behavior during Still, quiet Still, quiet No change Pace
headache
Nocturnal attacks of
pain
Triggering factors Multiple Multiple Stress, exhaustion | Alcohol, sleep,
amotional upset

period

| Can occur Con occur Very rore Extremely frequent

Terapi Profilaksis
+ menghindari
+ menggunakan secara teratur

Profilaksis: bukan analgesik, memperbaiki pengaturan proses
fisiologis yang mengontrol aliran darah dan aktivitas sistem
syaraf

Terapi abortif
menggunakan obat-obat penghilang nyeri dan/atau
vasokonstriktor

+ Analgesik ringan : aspirin (drug of choice), parasetamol
v NSAIDs:

+ Menghambat sintesis prostaglandin, agragasi platelet, dan
pelepasan 5-HT

» Naproksen terbukti lebih baik dari ergotamin

» Pilihan lain: ibuprofen, ketorolak
+ Golongan triptan
+ Agonis reseptor 5-HT,, > menyebabkan vasokonstriksi
+ Menghambat pelepasan takikinin, memblok inflamasi neurogenik

y Efikasinya setara dengan dihidroergotamin, tetapi onsetnya lebih
cepat
+ Sumatriptan oral lebih efektif dibandingkan ergotamin per oral

Memblokade inflamasi neurogenik dengan menstimulasi reseptor
5-HT1 presinaptik
Pemberian IV dpt dilakukan untuk serangan yang berat

Digunakan untuk mencegah mual muntah

Diberikan 15-30 min sebelum terapi antimigrain, dapat diulang
setelah 4-6 jam

Dapat mengurangi inflamasi

Contoh : butorphanol

Beta bloker

o Merupakan drug of choice untuk prevensi migrain

a Contoh: atenolol, metoprolol, propanolol, nadolol
Antidepresan trisiklik

o Pilihan: amitriptilin, bisa juga: imipramin, doksepin, nortriptilin

a Punya efek antikolinergik, tidak boleh digunakan untuk pasien
glaukoma atau hiperplasia prostat

Metisergid
a Mipk senyawa ergot semisintetik, antagonis 5-HT2
Asam/Na Valproat

a Dapat menurunkan keparahan, frekuensi dan durasi pada 80%
penderita migrain

a Aspirin dan naproksen terbukti cukup efektif
a Tidak disarankan penggunaan jangka panjang karena dpt
menyebabkan gangguan Gl

a Merupakan terapi lini kedua atau ketiga

a Sudah diuji klinis, terbukti mengurangi kejadian migrain

GBS DEFINITION

x A variety of acute, acquired, immune- mediated,
often self-limiting polyneuropathies

History of an inciting event, such as a diarrheal
illness or vaccination, recovering from a febrile illness

zZ

DIFFERENTIAL DIAGNOSIS OF NEUROPATHIES BY
CLINICAL COURSE

Guillain-Barré
syndrome

Maintained exposure to
toxic
agents/medications

Hereditary motor
sensory
neuropathies

Guillain-Barré
syndrome

Acute intermittent
porphyria

Persisting nutritional
deficiency

Dominantly
inherited sensory
neuropathy

CIDP

Critical illness
polyneuropathy

Abnormal metabolic
state

CIDP

HIV/AIDS

Diphtheric
neuropathy

Paraneoplastic
syndrome

Toxic

Thallium toxicity

CIDP

Porphyria

Antibodies

Acute inflarmatory demyelinating polyradiculoneuropaty (AIDP,
tor and sensory axoral neuropathy (AMSAN)
Acute motor axonal reuropathy (AMAN)
Acute y neuroropathy
Acute pandysautonomia
Fegionalvariants
Fisher's syndrome
Oropharyngeal
Overlap

fisher'ssyndrome/ Guillain-3arré-syndrome overlap syıdrome

Unknown,
GM1, GMab, GD1a

GM1, GM1b, GD1a, GalNac-GD1a
GD1b

GQub, GTia
Gria

G91b, GM1, GM1b, GD1a, GalNac-GD1a

Table 1: Classification ot Guillain-Barré syndrome and related disorders and typical antigangiioside
antibodies, by pathology

x A raised CSF protein concentration is present in
about 80% of patients

x But CSF protein content is more likely to be

normal during the first days of the illness

x CSF should be analysed before treatment with
intravenous immunoglobulin (IVIg), which can
cause aseptic meningitis

zZ

CLINICAL COURSE

x In typical cases, the first symptoms
+ Numbness
+ Paraesthesia feet then hands
+ Pain : especially back pain
+ Weakness in the limbs
x The weakness may initially be proximal, distal, or a
combination of both
» Numbness and paraesthesia usually affect the
extremities and spread proximally

zZ

x

zZ

In 25% of cases, weakness of the respiratory
muscles requires artificial ventilation

+ Rapid progression

+ Bulbar palsy

+ Upper limb involvement

+ Autonomic dysfunction

x Autonomic involvement is common
+ Urine retention

+ lleus
+ Sinus tachycardia

+ Hypertension
+ Cardiac arrhythmia
+ Postural hypotension
x The disease reaches its nadir by 2 weeks in most
cases and in 4 weeks in nearly all

zZ

x Recovery begins with return of proximal,
followed by distal, strength over weeks or
months.

x Between 4% and 15% of patients die

* Up to 20% are disabled after a year despite
modern treatment

zZ

INVESTIGATION

Panel 3: Investigations for Guillain-Barré syndrome

Studies related to establish ing the diagnosis
Electrodiagnostic studies: a minimum study could include three sensory nerves
(conduction velocity and amplitude), three motor nerves (distal latency, amplitude, and

conduction velocity) with F waves and bilateral tibial H-reflexes
Cerebrospinal fluid examination: a minimum study could include glucose, protein,
count, and bacterial culture

Studies to be done in special drcums tances
Urine porphobilinogen and delta- aminolaewulinic acid concentrations
Antinuclear factor

HIV testing in at risk subjects

Drug ancl toxin screen

Studies related to general medical care
Urine analysis

Complete blood count

Erythrocyte sedimentation rate
Biochernical screening

Coagulation studies

ECG

Chest radiograph

Pulmonary function tests

Studies related to understanding causation
Stool culture and serology tor Cjejuni

Stool culture for poliovirus in pure motor syndromes

Acute and convalescent serology for rtomegalovirus, Epstein Barr virus and
M pneumoniae as a minimum

Antibodies to gangliosicles GM1, GD1a, and GQ1b

SUPPORTIVE CARE

Monitor Resp status closely (follow NIFs), up
to 30% may req ventilatory support

In severe cases, intrarterial monitoring may

be necessary given the significant blood
pressure fluctuations

Neuropathic pain plagues most, often
managed w/ Gabapentin or Carbamazepine

1]

DISEASE MODIFYING TREATMENT

IVIG : typically given for 5 d at 0.4 gram/kg/d (may
need to extend course depending on response)
Plasmapheresis: usually 4-6 treatments over 8-10
days

The choice b/w plasma exchange and IVIG is dep on
availability, pt contraindications, etc. Because of
ease of administration, IVIG is frequently preferred.
The cost and efficacy of the 2 treatments are
comparable.

Glucocorticoids have NO ROLE!!

NAS EAN GLASGow Coma SCALE

Eye Opening

Spontaneous

To verbal command
To pain

No response

Verbal Response

Oriented and converses
Disoriented and converses
Inappropriate words
Incomprehensible sounds
No response

Motor Response

Obeys verbal commands
Localizes pain

Withdraws from pain (flexion)

Abnormal flexion in response to pain (decorticate rigidity)
Extension in response to pain (decerebrate rigidity)
No response

Subdural hematomas

Most frequently from
tearing of a bridging vein
between the cerebral
cortex and a draining

venous sinus.

- acute - <24hrs

- subacute — 24hrs-2wks
- chronic - >2wks

INTRA CEREBRAL HEAMATOMA

* Formed within brain tissue & caused by shearing or tensile
forces that mechanically stretch and tear deep small caliber
arterioles

x Most common in temporal and frontal regions

» C/F depend on site involved

CONCUSSION

Temporary & brief interruption of neurological function after
minor head injury

Due to shearing / stretching of white matter fibres at the time
of impact or temporary neuronal dysfunction

C/o headache, confusion, amnesia

CT/MRI cannot detect

zZ

HEAD INJURY

x History

x Initial Assessment
+ Primary Survey
+ Secondary Survey

PRIMARY SURVEY

1112, maintenance with cervical spine protection

INTUBATION WITH CERVICAL INLINE
STABILIZATION

: Intubation precautions
Pre-medicate with Lidocaine, Img/kg IV 2 minutes
prior to attempt
Laryngoscopy produces an ICP Spike

CIRCULATION

» Maintain MAP >90mmhg- adequate
x Hematocrit >30%
x Cushing reflex

INDICATIONS FOR CT SCAN / MRI

Skull fracture
Deteriorating GCS
Neurologic deficit
Amnesia, headache

Seizure

x Brain herniations represent shift of the normal
brain through or across regions to another site due
to mass effect

x Generally complications of mass effect whether
from tumor, trauma, or infection

x 4 large categories :
1. transtentorial
2. subfalcine

3. foramen magnum
4. alar or sphenoid herniation

a

Descending Transtentorial Herniation

Clinical Findings

Imaging Findings

Complications

Ipsilateral dilated pupil
Contralateral hemiparesis
Ipsilateral hemiparesis if

Kernohan’s Notch is present
(false localizer)

Contralateral temporal horn
widening

Ipsilateral ambient cistern
widening

Ipsilateral prepontine cistern
widening

Uncus extending into the
suprasellar

cistern

Occipital infarct from
posterior cerebral artery
compression

Ascending Transtentorial Herniation

Clinical Findings Imaging Findings Complications

Nausea Spinning top appearance of | Hydrocephalus
midbrain
Vomiting Rapid onset of obtundation
Narrowing of bilateral and possibility of death
Obtundation ambient cisterns

Filling of the quadrigeminal
plate cistern

zZ

Subfalcine Herniation

Clinical Findings

Imaging Findings

Complications

Headache

Contralateral leg weakness

Amputation of the ipsilateral
aspect of the frontal horn

Asymmetric anterior falx
Obliteration of the ipsilateral
atrium of the lateral

ventricle

Septum pellucidum shift

Ipsilateral anterior cerebral
artery (ACA) infarction as
ACA is entrapped under the
falx

Other associated
herniations

Foramen Magnum Herniation

Clinical Findings Imaging Findings Complications

Bilateral arm dysesthesia Cerebellar tonsils at the Obtundation and Death
level of the dens on axial
Obtundation images

Cerebellar tonsils on
sagittal images 5mm below
foramen magnum in adults;
7mm below in children

zZ

UPPER LIMB MONONEUROPHATY

BRACHIAL PLEXUS INJURIES

» Loss of sensation will occur along the
medial side of the arm

x Lower lesions can also be produced by a
presence of a cervical rib or malignant
metastases from the lungs in the lower
deep cervical lymph nodes

zZ

LONG THORACIC NERVE
(C5CsC7)

Supplies : Seratus anterior muscle x Damaged by i
+ Carrying heavy object
+ Strapping the shoulder
+ Limited branchia neuritis
+ Diabetes melitus

x Result in :
+ Winging of the scapula
+ Whe arms are streched in

front
a

Right winged scapula

AXILARY NERVE
( CsCe)

Supplies : deltoid & teres minor muscle x Damaged by:
+ Shoulder dislocation

180°

. + Limited bachial neuritis
Na

x Resultin:

4 j + Weakness of abduction of
# j shoulder between 150-900
sone A
Adduction © } a + Sensory loss over the
q outer aspect of the
shoulder

RADIAL NERVE

( C¿C7Cg)

> Damaged by:

+. Fraktur of the humerus

e Prolonged pressure
(satuday night palsy) :
Drunkard falling
asleep with one arm
over the back of a
chair.

e Intramuscular injection

e Lipoma, fibroma,
neuroma

RADIAL NERVE

Result in :

+ Weakness & wasting of
muscle supplied,
characterized by wrist
drop with flexed finger
(weak ekstensor).

+ Sensory loss of dorsum
hand n forearm.

+ Loss of triceps reflex
(when lession in the
axilaa) & supinator
reflexes

MUSCULOCUTANEUS NERVE
(CsCe)

Supply : Coracobrachialis, Damaged by :

biceps, brachialis Fraktur of the humerus
Systemic causes
Sensory supply : lateral border
of the arm

Result in :
Musculocutaneous
Weakness of the elbow
flexion with
characterized sensory
loss

Absent

MEDIAN NERVE
( C7€g)

Sensory supply :

x palmar surfaces of the
radial border of the
hand

Damaged by :
+ Injury in axilla
+ Compression at the
wirst (Carpal Tunnel
Syndrom)

zZ

MEDIAN NERVE
( C7Cs)

Result in:
x Weakness of abduction and apposition of thumb
x Weakness of pronation of the forearm
x Deviation of wrist to ulnar side on wrist flexion
x

Weakness of flexion of distal phalanx of thumb and index
finger
Wasting of thenar muscles is evident

Sensory loss is variable but most marked on index and
middle fingers

zZ

CARPAL TUNNEL SYNDROME

The carpal tunnel is formed by the
concave anterior surface of carpal bones
and closed by flexor retinaculum
Clinically, the syndrome consists of a

& needles along the
distribution of the median nerve,

Lateral 3 & Ye fingers are involved

CARPAL TUNNEL SYNDROME

Condition is relieved
by decompressing
the tunnel by making
a longitudinal incision

through the flexor
retinaculum

ULNAR NERVE
( C7€g)

Sensory supply :
x Both palmar and dorsal
surfaces of the ulnar
border of the hand
Damaged by :
+ Injury at elbow
+ Entrapment at elbow or
distal to the medial
epicondyle
+ Pressure on the nerve in au

the palm
ry:

ULNAR NERVE
( C7€g)

Result in :
Ulnar claw hand
Sensory loss

ULNAR NERVE

( C7Cg)

Sensory supply :

x Both palmar and dorsal
surfaces of the ulnar
border of the hand

Damaged by :
+ Injury at elbow
+ Entrapment at elbow or
distal to the medial
epicondyle
+ Pressure on the nerve
in the palm

zZ

LOWER LIMB MONONEUROPHATY

NERVES OF THE LOWER LIMB

VPR - ventral primary rami

FEMORAL NERVE

(LsL2Lo)

x Damaged by :

+ Fraktur of the upper
femur

+ Congenital dislocation

of the hip
+ Neoplastic infiltration
+ Abses psoas muscle

+ Hematom iliopsoas
muscle

Diabetes melitus
a |

Result in

«Weakness of hip flexion
eWeakness of knee extension with
wasting of thigh muscles

eSensory loss over the anterior and
medial aspect of thigh

eThe knee jerk is lost

FEMORAL NERVE INNERVATION

x

OBTURATOR NERVE
( LoLgbq)

OBTURATOR NERVE

(LoLoLa)

x Damaged by :

+ Same process as the
femoral nerve

+ During labour

+ Compression by hernia
in the obturator canal

zZ

Result in

«Weakness of hip external rotation &
adduction

elnability to cross the affected leg on the
other

eSensory loss innermost aspect of the
thigh

«Adductor reflex is absent

Sciatic Nerve
¢ £7551,52)

Sciatic Nerve
¢ £7551,52)

x Damaged by : Result in
| 2 «Weakness of hamstring muscles with
+ Congenital or traumatic tackled ALLA
hip dislocation «Distal foot and leg muscles are also

+ Penetrating injury affected
i Sensory loss outer aspect of the leg
+ Misplaced

j NON ON Angkle reflex is absent
intramuscular injection
+ Entrapment at sciatic

notch

COMMON FIBULAR/PERONEAL N.
NEUROPATHY

*most often injured nerve of the lower limb

TIBIAL NERVE NEUROPATHY

«Most common entrapment neuropathy in the foot and ankle area

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