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Group C Presentation

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by

Charlene Shekhar

on 29 March 2015

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Transcript of Group C Presentation

History Taking
History Taking continued...
Group C Presentation
Group Members:
Akilio
Arishma
Charlene
Shayal
Apikali
Tomasi
Jashneel
Soana
Ashley
Presenting Complain
A 7 and a half year old girl complaining of constant headaches and can not concentrate in class.
Pediatric History
Normal gestational period
Normal vaginal delivery
No complications
Normal milestone development
Birth weight 3.9kg
All vaccinations up to date
Physical Examination
Slit lamp:
-clear cornea, no opacity.
- No ulcers.
-No edema.
-normal conjunctiva.
- normal anterior chamber and aqueous humor.
- no cells and no flare in anterior chamber.
-clear lens.
-no abrasion.
-no ciliary flush
-no inflammatory cells in anterior chamber.
➢ Fundoscopy:
-healthy blood vessels.
-red reflex present in both eyes.
-nice and crisp optic disc with no blurry margins.
- cup to disc ratio of 0.3
➢ Retinoscopy:
-some refractive error present (hyperopia)
headache started 2 months ago
mostly localized to her forehead
pain is intermittent
takes Panadol to reduce pain
can not concentrate in class due to reduced vision, hence she has been moved to the front bench
Inability to concentrate in class since earlier this year
pain mostly appears during the day
no history of recent trauma
HPC
Review Of Systems
Does not have fever now but has a history of fever- onset 1/52 ago, lasted for 2-3 days
Vomiting - onset 2/7 ago on 28/02 and 01/03,vomited 5 times, decreases headache
Has become sensitive to light
Mum noticed her sitting closer to the Tv
No ear pain, no discharge
No problem in night vision
Optic History
History of sty - since last year, recurrent infection, history of purulent discharge, used eye drops prescribed by a doctor ( can not remember the name)
Does not wear spectacles
Past Medical History
No history of hospitalization or operation
No history of chronic illnesses
Medicine Hx.
No allergies
Currently on Panadol
Family Hx.
Has one sibling
6 people in the family
No one else in the family has similar disease
Social Hx.
father works overseas
good living standards
first child of the family
Diet Hx.
Has a well balanced diet
Special Tests
1) Visual Acuity
Use of Snellen Eye Chart
Used to check for the sharpness of vision
There should proper lighting of the room
Make the patient stand at 6m
Assess one eye at a time ( other eye is closed)
The patient is asked to read out the letters on the chart
Note down the results

Visual acuity= distance of patient from chart (6m)
distance from which a normal person can read

Interpretation of results
Disadvantages of Snellen Test Type
Letters not of equally legible eg; O and E
Non-uniform progression of letter sizes
Unequal number of letters on each line
Irregular spacing between letters and lines
Inadequate scoring (6/9+2, etc)

RESULT=Inaccurate results, especially for those with low vision

Therefore LogMAR ( logarithm of minimal angle of resolution) Chart is used

LogMAR Chart (read at 3m)
Results
Researchers suggested a logarithmic progression in size of letters on test chart gives most accurate VA measurement
Scoring LogMAR
- Each letter has a score value of 0.02 log units; 5 letters per line
- Each line represents a change of 0.1 log units

LogMAR / Snellen equivalent results
LogMAR Snellen
0 6/6
0.18 6/9
0.30 6/12
0.48 6/18
0.60 6/24
0.78 6/36
1.00 6/60
Advantages of LogMAR
Equal number of letter per line
Regular spacing between lines and letters
Uniform progression in letter size
Final score based precisely on total of all letters read
Finer grading scale allows greater accuracy and improved test/retest reliability

2) Pinhole test
Temporarily removes the effects of refractive errors such as myopia
A device that can determine if the problem with vision is the result of refractive error or due to some other process
The patient is asked to view the Snellen chart with normal eye. If he has problem with the vision, then he is asked to look through the ‘pin hole occluder’
If vision improves when looking through the pinhole occlude, then the problem is due a refractive error

Fundoscopy
Use of an ophthalmoscope to examine the eye
Look : red reflex, cornea, lens, retinal vessels, optic disc.

Slit lamp
Is a binocular microscope  provides the examiner with a 3-D view of the eye.
A ‘slit’ of light is used ( whose height and width can be adjusted)
Slight of light  directed at angle  prominence of anatomic structures (about 10-25 X magnification than normal) 
Much more effective in diagnosing a number of traumatic and non-traumatic disorders
Magnified look at the eyelashes, conjunctiva, cornea, anterior chamber, iris and lens.


Retinoscopy
Retinoscopy is a technique to objectively determine the refractive error of the eye (farsighted, nearsighted, astigmatism)
The patient should be focusing on a far object
Shine the light and observe the red reflex
The examiner then introduces lenses in front of the eye until the movement is neutralized. The power of the lens required to neutralize the movement is the refractive error of the eye and indicates the lens strength needed to optimize vision
Use of a retinoscope

How to interpret?
Retinoscope projects a beam of light into the eye
Light is moved vertically and horizontally -----> and the red reflex from the retina is observed
Normal: the red reflex is at the same point when light moved up and down and side to side
Refractive error: the red reflex moves up and down and sideways -----> keep adding different power (+) lens till the error corrects ----> the reflex stops moving

How it works?
Myopia: the red reflex moves in opposite direction
Hypermetropia: the red reflex moves in same direction


Farsightedness:
corrected by a convex lens 
Retinoscope
Assessment
Bilateral Blepharitis with recurrent chalazion and sty.
Refractive error - Hyperopia

Overview
• It is the inflammation of the eyelid margins that maybe acute or chronic.
• Symptoms and signs include itching and burning of the lid margins with associated redness and edema.
• Diagnosis is by history and physical examination and that there are no confirmatory diagnostic tests or laboratory investigations.
Blepharitis
Classification

Symptoms common to all forms of blepharitis include:
1. Itching.
2. Burning sensations of the eyelid margins.
3. Conjunctival irritation with lacrimation.
4. Photophobia


Symptoms and Signs
According to its predominant anatomic location, i.e. anterior and posterior.

1. Anterior blepharitis
Less common than post. and is characterized as inflammation of the base of the eyelids.
Patients with ant. blepharitis, compared with those with posterior are more likely to be
female and younger
.
Two variants/ subtypes have been identified:
staphylococcal
and
seborrheic
.
In
staphylococcal ant. Blepharitis
, colonization of the staphylococci org.(Aureus) not only causes infection but also the formation of fibrinous scales and crusts around the eyelashes.
In
seborrheic ant. Blepharitis
, characterized by dandruff-like skin changes around the base of the eyelids, resulting in greasy scales around the eyelashes.

2. Posterior blepharitis
More common condition and is characterized by the inflammation of the inner portion of the eyelids, at the level of the meibomian glands.
It is often described as
meibomian gland dysfunction.
found to be in association with other skin conditions like rosacea and seborrheic dermatitis.
Typically presents with adherent materials around the eyelashes.

In
seborrheic blepharitis
, easily removable scales develop on the lid margins.

Staphylococcal blepharitis
- hard crusts develop around the eyelashes as a collarette.
• Most patients with seborrheic blepharitis and meibomian gland dysfunction have secondary keratoconjunctivitis sicca, which also causes a foreign body sensation, grittiness, eye strain,fatigue and blurring with prolonged visual effort.
Chalazion and Hordeolum

Is a chronic inflammatory lesion that develops when the Zeis or meibomian tear gland of the eyelid becomes obstructed.
This causes the extravasation of irritating lipid material in the eyelid soft tissues and focal inflammatory response.
May first present with eyelid swelling and erythema and then evolve into a painless, rubbery, nodular lesion.
It is commonly seen in patients with eyelid margin blepharitis and in those with rosacea.
An inflamed hordeolum will often calm and scar into a hard chalazion.


Is an acute pyogenic infection or abscess of the eyelid that may either be external or internal.
There is presence of inflammatory cells and bacteria most commonly Staphylococcal Aureus.

Chalazion
Hordeolum
Chalazia and hordeola are initially indistinguishable; both cause lid hyperemia and edema, swelling and pain.
After 1 to 2 days, an external hordeolum becomes localized to the lid margins, whereas chalazion centers in the body of the eyelid.
A chalazion points towards the inner surface of the eyelid and rarely, the outer surface.

Prevention
Prevention of Blepharitis
Proper Eyelid Hygiene is crucial in the prevention of blepharitis
- Avoid touching eye frequently
- Avoid rubbing eye

Eye makeup may contribute to acute blepharitis especially when the patient uses eye liner.
-Removing eye makeup before going to bed
-Avoid applying eyeliners behind the eye lashes
-Use eye liners that wash off easily, since they are less likely to plug the glands.


Normal happy child.
Vitals signs are normal.
➢ HEENT
>Head: -no lesion
-no signs of inflammation or infection.
-No facial flushing , no swollen blood vessels on cheeks and nose.
>Eyes: -Normal white sclera. (both eyes)
-no ptosis, no lid lag/lid retraction.
-Chalazion on the upper left eyelid .
-sty on both eyes. But no abnormal discharge.
-Scarring on both upper eyelids causing distortion of the eyelashes.
-No periorbtal edema.
-flaking eyelashes on both eyes.
-no red eye ,no jaundice, no hemorrhage .
-normal oil secretion.
-crusting and uneven eyelid margins noted suggestive of recurrent inflammation .
-Eversion of eyelids showed no foreign body, no exudate.
> Ears, Nose and Throat normal.
Orbit: - eyeball well placed in socket.
- No exophthalmos.
- No discharge.


➢ Visual acuity: R= 6/6 L= 6/7.5 +2
➢Pinhole examination was not done.
➢ Pupillary reflex ( direct and consensual) present in both eyes.
➢ Visual fields were normal for both eyes. No defects.
➢Extraocular muscle movements were normal in both eyes.
-no limitation of movement.
-no diplopia.
-no strabismus, no nystagmus, no dysconjugate movements.
➢Accommodation reflex: present in both eyes.

Differential Diagnosis
Bacterial conjunctivitis
Contact dermatitis
Dry eye syndrome
Refractive error - Myopia
Headache
Can't concentrate in class due to reduced vision
Chalazion
Hordeolum
Hyperopia
Scarring on both upper eyelids

Problem list :
Management :
Patient education and counseling
Good lid hygiene.
Warm compression
Lid massage
Lid washing
Antibiotics :
>Topical Ointment - Erythromycin or Sulfacetamide
>Oral -tetracycline
Topical glucocorticoids- under ophthamologist supervision
Patient Management :
Mother adviced:
>to do frequent lid wash and massage
>on lid hygiene
Topical ointment
Referred to refractive clinic
Reference :
UpTo Date
Medscape
The Merck Manual 18th edition
http://prezi.com/ub8ifbre2yqi/?utm_campaign=share&utm_medium=copy
Where to access the slides?
Anterior Blepharitis
Posterior Blepharitis
In meibomian gland dysfunction:
Examination reveals dilated, inspissated gland orifices that exude a waxy, thick, yellowish secretion with pressure.
Chalazion
Hordeolum
Pathophysiology :
- 06/03/15
Full transcript