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Introduction to Eye Problems in Indonesia
Gitalisa Andayani
G
Department of Ophthalmology, FKUIJakarta 2008
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The EYE Most vital sensory organ
(80% of information obtained from vision) Delicate Eye problems:
- encountered in everyday clinical practice- may cause visual impairment- worldwide health problem
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Visual impairment Definitions (WHO): Visual impairment: low vision and blindness - Low vision: best corrected visual acuity of 6/18 to 3 m counting fingers (CF) - Blindness: best corrected visual acuity of 3 m CF or less
Mostly: avoidable (preventable and/or curable)
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Global blindness
WHO, 1990: prevalence of blindness ranged from 0.08% in children to 4.4% adults over 60 years; overall global prevalence of 0.7% at least 7 million people become blind each year the number of blind people worldwide was increasing by 1–2 million per year
Source: Global Initiative for the Elimination of Avoidable Blindness : action plan 2006-2011, WHO, 2007
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Source: Global Initiative for the Elimination of Avoidable Blindness : action plan 2006-2011, WHO, 2007
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Source: Global Initiative for the Elimination of Avoidable Blindness : action plan 2006-2011, WHO, 2007
Global causes of blindness
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Impact of blindness
Social burden: Becoming other people’s responsibility Immobilition of otherwise healthy
individuals Financial loss:
Cost of surgery / treatment / rehabilitation Mental impact:
patients feel disabled, leads to depression
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Blindness in Indonesia Blindness prevalence in Indonesia: 1.5%
(high, compared to other South East Asian countries)
Major causes of blindness in Indonesia: - cataract- glaucoma- refractive errors- retinal diseases- corneal diseases(Survei Kesehatan Rumah Tangga, Depkes, 1993)
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Problem
Indonesia: sporadic, local data in several regions
Most recent national data >10 years ago: Survei Kesehatan Rumah Tangga 1996 (1.5%)
No data on Childhood Blindness
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SKRT: Survei Kesehatan Rumah Tangga (1993, 1996)
Prevalence of Blindness in Indonesia: increase from 1.2% to 1.5%
Prevalence of main causes of blindness:- Cataract: est. 52% (backlog 1.5 million) - Glaukoma from 0.1% in 1983, to 0.2% in 1996
Hospital-based (RS Cipto Mangunkusumo, 1982) incidence of Glaucoma 1.8% among new patients aged ≥ 40 yo, 65% of them blind
- Refractive Errors: 0,14%. Jakarta: prevalence of school myopia 21 – 52%
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- Diabetic Retinopathy: included in ”other cause of blindness”, 28%, but estimated to be 0.13% (SKRT 1996)
- AMD: Universitas Gajah Mada, Yogyakarta: study on a population ≥ 40 yo of 3000 in 2004, found prevalence of 1.1%
-Childhood Blindness-Blindness from cataract est. 1-4 per 10.000. -ROP caused blindness in 1.1% in Blind
Schools in Java Island
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Prevention of blindness
‘VISION 2020: the Right to Sight’ : an established partnership between the World
Health Organization (WHO) and the International Agency for the Prevention of Blindness (IAPB)
launched in 1999 with the 2 aims:- eliminating avoidable blindness by 2020- preventing the projected doubling of avoidable visual impairment between 1990 and 2020.
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Prevention of Blindness
Involves: Facilities Human resources Funds Awareness
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Prevention of blindness and eyecare Health care personnels:
GPs, opthalmologists, nurses, optometrists
Organizations Government NGOs Profession
(Indonesia: PERDAMI) Collaborative groups
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Ophthalmology for GP Knowing the anatomy and physiology of
the eye, and the pathogenesis of eye diseases
Basic eye examination Diagnosis of eye problems Treatment planning: complete, initial, or
referral
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Anatomy of the eye
Lateral Canthus
Punctum lacrimalis
CorneaLimbus
Conjunctiva
PupilIris
Karunkula
Upper eyelid
Lower eyelid
Medial Canthus
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Anatomy of the eyeCiliary body
Vitreous(‘glass jelly’)
Cornea
Optic nerve
Macula
Pupil
Iris
Lens
Limbus {
Anterior Chamber
Posterior Chamber
Lens zonulesExtraocular
Muscles
Retina
ChoroidSclera
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Classification of Eye Problems
Red eyes (normal and decreased vision) Chronic visual (progressive) loss Acute visual (persistent) loss Trauma Abnormalities in ocular alignment and
motility Refractive disorders
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Red eyes
Clear refractive media: normal vision Opacity of refractive media: decreased vision Vasodilation of vessels of the conjunctiva
/episclera / sclera / cornea Inflammatory (infection and non-infection) Normal vision: conjunctivitis, scleritis, episcleritis,
pterygium, pinguecula Decreased vision: acute glaucoma, keratitis, uveitis,
endophthalmitis
Conjunctivitis
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Chronic visual decrease Caused by chronic changes in the clarity of
refractive media or function Abnormality of neural pathway (from
retina tovisual cortex) Mostly: degenerative process E.g: cataract, chronic glaucoma, diabetic
retinopathy, age-related macular degeration (AMD)
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KATARAK Kekeruhan lensa Penyebab:
- degenerasi (senilis): usia tua- penyakit mata lain/metabolik/obat
(komplikata)- bawaan (kongenital)- trauma (traumatik)
kekeruhan lensa (katarak)
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KATARAKTanda dan gejala Dini:
- terkadang belum ada keluhan- melihat kabut/asap- silau- sulit membaca
Lanjut:- buram- bercak putih pada pupil (lekokoria)
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KATARAKPenatalaksanaan Bergantung kebutuhan penderita; bila sudah mengganggu: OPERASI KATARAK
Teknik:- Intracapsular Cataract Extraction(ICCE) sudah ditinggalkan- Extracapsular Cataract Extraction(ICCE)
mulai ditinggalkan- Phacoemulsification- Small-incision
Phacoemulsification
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GLAUKOMA• kerusakan saraf optik, umumnya akibat peningkatan tekanan intra okular (karena hambatan outflow)• gangguan lapang pandang• 2 tipe: - glaukoma sudut terbuka
- glaukoma sudut tertutup
Saraf optik normal Saraf Glaukoma Saraf Glaukoma Lanjut
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GLAUKOMATanda dan gejala • Tekanan bola tinggi > 21 mmHg (normal 10-21)• Sudut terbuka: tanpa gejala; bila ada sudah lanjut (sering menabrak2, halo pelangi, nyeri sekitar mata)• Sudut terbuka: bisa terjadi glaukoma akut
tanda sisa serangan akut (katarak, pupil lebar, iris atrofi)• Lapang pandang menyempit
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GLAUKOMA
Penatalaksanaan • Observasi• Obat-obat glaukoma: - beta-blocker
- asetazolamid- pilokarpin
• Laser (iridotomi, trabekulotomi, trabekuloplasti)• Operasi (iridektomi, trabekulektomi, implant)
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Retinopati diabetik
Gangguan retina akibat komplikasi diabetesGangguan retina akibat komplikasi diabetes GGlukosa darah meninggi lama-lama pembuluh darah organ-organ (terutama ginjal, saraf, mata) rusak Penurunan penglihatanPenurunan penglihatan Penyebab kebutaan terbesar pada penderita diabetes 50% penderita diabetes setelah 10 tahun akan menderita retinopati
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Mekanisme kebutaan pada retinopati diabetik
kebocoran cairan, lemak dan darah di retina
dari pembuluh darah yg rusak Edema makula
aliran darah ke retina menurun iskemia
neovaskularisasi PDR
-perdarahan vitreus- Jar fibrovaskular- retinal traction ablasi retina
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Retinopati diabetik
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Retina normal
Retinopati diabetik proliferatif Retinopati diabetik proliferatif dengan traksi
Retnopati diabetik non-proliferatif FFA
Retnopati diabetik non-proliferatif
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AMD=age-related macular degeneration
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• Penurunan visus sentral perlahan akibat
degenerasi makula pada usia lanjut
• mengenai kedua mata
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Acute visual loss Caused by acute changes in
refractive media or function, or acute disturbances in visual pathway
May be associated with systemic disease
E.g: retinal detachment, retinal vascular occlusive diseases, vitreous hemorrhage, optic neuritis, optic neuropathies
Retinal detachment
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Trauma Penetrating/perforating injury Blunt injury Chemical injury
Chemical injury
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Abnormalities of ocular alignment and motility
Strabismus (squint) Nystagmus Diplopia Paresis of external ocular muscles Orbital tumors
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Refractive problems Myopia Hypermetropia Astigmatism Presbyopia
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Learning ObjectivesKnowledge:
- pathology- epidemiology, clinical features, pathogenesis- scientific basis- management, referral- promotion and prevention
Skills:- communication with patients- integration of history and examination- investigation
Attitudes:- ethical behaviour- confidentiality- respect social, cultural backgrounds
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Core clinical problems and conditions
Acute decreased visionChronic decreased visionRed eye, normal vision
Red eye, decreased visionOcular injury
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Physical examination skills
-Eye examination-Visual acuity test
-Funduscopy-Tonometry
Medical imaging knowledge and skills
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Learning activities
-PKK: Bedside teaching tutorials
-PKK: Outpatient department
-PSSS
-Diskusi pagi: topic sessions
-Case presentations
-Night shift: 4 – 8 PM
-Ujian: written & portfolio
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Ophthalmology Department, FKUI/RSCM
Sub-specialty Clinics Cornea & Refractive Surgery Vitreo-Retina Neuro-Ophthalmology Tumor (Oncology) Oculoplastic – Reconstructive Pediatric Ophthalmology Strabismus Glaucoma Infection dan Immunology Refraction
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Ophthalmology Department
Operating Rooms Ward: Public Wing (7th floor) Emergency clinic
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Ophthalmology examination
Refraction
Snellen Chart
Pinhole test
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Ophthalmology examination
Funduscopy
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Ophthalmology examination
Digital palpation
Schiotz Tonometry
Slitlamp biomicroscopy+ applanation tonometer
Confrontation test
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Welcome to Eye Department….
Use your time well
advice:- do your best……….!
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Thank you