Introduction to Eye Problems in Indonesia. Gitalisa Andayani Department of Ophthalmology, FKUI Jakarta 2008

Introduction to Eye Problems in Indonesia

Gitalisa Andayani Department of Ophthalmology, FKUI Jakarta 2008 1

The EYE 

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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

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

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Mostly: avoidable (preventable and/or curable)

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

Source: Global Initiative for the Elimination of Avoidable Blindness : action plan 20062011, WHO, 2007

Global causes of blindness

Source: Global Initiative for the Elimination of Avoidable Blindness : action plan 20062011, WHO, 2007

Impact of blindness 

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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

Blindness in Indonesia 

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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)

Problem 

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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 9

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%

- 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

Prevention of blindness ‘VISION 2020: the Right to Sight’ : 

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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.

Prevention of Blindness

Involves:  Facilities  Human resources  Funds  Awareness

Prevention of blindness and eyecare 

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Health care personnels: GPs, opthalmologists, nurses, optometrists Organizations  Government  NGOs  Profession

(Indonesia: PERDAMI) 

Collaborative groups

Ophthalmology for GP 

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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 Punctum lacrimalis

Upper eyelid

Lateral Canthus

Karunkula

Conjunctiva Limbus

Cornea Lower eyelid

Pupil

Iris

Medial Canthus

Anatomy of the eye Ciliary body

Lens zonules

Extraocular Muscles Macula

Cornea Iris

Vitreous (‘glass jelly’)

Pupil

Optic nerve

Lens Limbus

{ Retina Choroid Anterior Posterior Chamber Chamber Sclera

Classification of Eye Problems     

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Red eyes (normal and decreased vision) Chronic visual (progressive) loss Acute visual (persistent) loss Trauma Abnormalities in ocular alignment and motility Refractive disorders 18

Red eyes   

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Clear refractive media: normal vision Conjunctivitis 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 19

Chronic visual decrease 

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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) 20

KATARAK  

Kekeruhan lensa Penyebab: - degenerasi (senilis): usia tua - penyakit mata lain/metabolik/obat (komplikata) - bawaan (kongenital) - trauma (traumatik)

kekeruhan lensa (katarak)

KATARAK Tanda dan gejala  Dini: - terkadang belum ada keluhan - melihat kabut/asap - silau - sulit membaca 

Lanjut: - buram - bercak putih pada pupil (lekokoria)

KATARAK Penatalaksanaan  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

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

GLAUKOMA Tanda 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

GLAUKOMA Penatalaksanaan • Observasi • Obat-obat glaukoma: - beta-blocker - asetazolamid - pilokarpin • Laser (iridotomi, trabekulotomi, trabekuloplasti) • Operasi (iridektomi, trabekulektomi, implant)

Retinopati diabetik  Gangguan retina akibat komplikasi diabetes  Glukosa darah meninggi  lama-lama pembuluh darah organ-organ

(terutama ginjal, saraf, mata) rusak  Penurunan penglihatan  Penyebab kebutaan terbesar pada penderita diabetes 50% penderita diabetes setelah 10 tahun akan menderita retinopati

Mekanisme kebutaan pada retinopati diabetik

kebocoran cairan, lemak dan darah di retina dari pembuluh darah yg rusak Edema makula

-perdarahan vitreus - Jar fibrovaskular - retinal traction  ablasi retina

aliran darah ke retina menurun  iskemia

neovaskularisasi  PDR 7

Retinopati diabetik

Retina normal

Retnopati diabetik non-proliferatif

Retnopati diabetik non-proliferatif

FFA

Retinopati diabetik proliferatif

Retinopati diabetik proliferatif 7 dengan traksi

AMD=age-related macular degeneration • Penurunan visus sentral perlahan akibat degenerasi makula pada usia lanjut • mengenai kedua mata

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Acute visual loss 

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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 Retinal detachment vascular occlusive diseases, vitreous hemorrhage, optic neuritis, optic neuropathies 31

Trauma   

Penetrating/perforating injury Blunt injury Chemical injury

Chemical injury 32

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 Objectives Knowledge: - 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 vision Chronic decreased vision Red eye, normal vision Red eye, decreased vision Ocular injury

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Physical examination skills -Eye examination -Visual acuity test -Funduscopy -Tonometry Medical imaging knowledge and skills 37

Learning activities -PKK: Bedside teaching tutorials -PKK: Outpatient department -PSSS -Diskusi pagi: topic sessions -Case presentations -Night shift: 4 – 8 PM -Ujian: written & portfolio 38

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

Ophthalmology Department   

Operating Rooms Ward: Public Wing (7th floor) Emergency clinic

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Ophthalmology examination

Snellen Chart

Refraction Pinhole test

Ophthalmology examination

Funduscopy

Ophthalmology examination

Schiotz Tonometry Digital palpation

Slitlamp biomicroscopy + applanation tonometer

Confrontation test

Welcome to Eye Department…. Use your time well

advice: - do your best……….!

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Thank you