常見小兒眼疾

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2 眼科專科醫生香港中文大學臨床助理教授 ( 榮譽 ) 香港大學內外全科醫學士 MBBS (HK) 英國愛丁堡皇家外科醫學院院員 MRCS (Edin) 新加坡國立大學眼科醫學碩士 M Med (Ophth) (Singapore) 香港中文大學內科醫學文憑 Dip. Med 愛丁堡皇家外科醫學院院士 ( 眼科 ) FRCSEd (Ophth) 香港醫學專科學院院士 ( 眼科 ) FHKAM (Ophthalmology) 香港眼科醫學院院士 FCOphth (HK)

3 Ocular emergency Infective keratitis Acute angle closure glaucoma Rheumatogenous retinal detachment Central retinal artery occlusion Ocular trauma

4 Infective keratitis

5 Vision can be severely impaired by the resultant scar, esp if visual axis involved Aim of management: Control the infection as soon as possible, thus control the scar size, and avoid corneal scar involving visual axis

6 Risk factor: compromised cornea Trauma Contact lens wear i.e. extended wear Decreased corneal sensation (e.g herpetic eye disease, CN V palsy)

7 Bacteria, parasite, fungus, virus

8 Management Corneal scraping Ideally should be done before initiation of antibiotics Send for Microscopy and culture Initial antibiotic cover depends on severity of disease and suspicion of causative organism

9 Steroid Reduce damage resulting from host response Used with caution

10 Pseudomonas aeruginosa Associated with contact lens wear Rapid progression

11 Acanthamoeba keratitis Contact lens wear Trauma and exposure to contaminated water Pain+++ (due to lipase secretion)

12 Fungal keratitis More common in patients with chronic corneal disorders and immunosuppresion Associated with plant injury i.e. tree branch

14 What is Glaucoma? Glaucoma is a kind of optic neuropathy caused by intra-ocular pressure (IOP) Normal IOP should be 21 or below Glaucoma with normal IOP named normal tension glaucoma

16 Classification of glaucoma 慢性青光眼 : Primary open angle glaucoma 開角性青光眼 Primary angle closure glaucoma 閉角性青光眼急性青光眼 : Acute Angle closure glaucoma Normal Tension glaucoma 繼發性 Secondary glaucoma 例如 : 白內障過熟, 血管增生性糖尿眼, 虹膜炎, 長期使用類固醇

17 急性青光眼

18 Acute angle closure glaucoma Rapid visual lose, can cause irreversible blindness within a few days unilateral headache and eye pain Red eye mid dilated pupil hazzy cornea Nausea and vomitting IOP can reach You can feel stony hard with your fingers!

19 眼壓 (IOP) 測量正常應低於 21mmHg

21 Risk factor Narrow iridocorneal angles angle (asian, age) Condition triggering mid dilated pupil i.e. watching TV in dim night local and systemic drugs, including adrenergic, both anticholinergic and cholinergic, antidepressant and antianxiety, sulfa-based, and anticoagulant agents. Esp cold med, eye drops to dilate pupil for examination

22 Medical Treatment Medical treatment Decrease Aqueous film ( 房水 ) production IV and oral Diamox IV mannitol Different eye drops

23 Laser treatment 激光手術 (Laser) Laser Iridotomy 激光虹膜造口常用於急性青光眼, 於虹膜上造一個小孔, 引流房水

24 視網膜脫落 Retinal detachment

25 classification Rheumatogenous retinal detachment Tractional retinal detachment Exudative retinal detachement

27 Rheumatogenous retinal detachment Caused by a retinal break

28 Retinal break can be idiopathic, traumatic or due to posterior vitreous detachment Posterior vitreous detachment is a normal aging process, usually happen ~ years old, earlier for high myopic patient Retina detached when fluid get into the retinal break

29 Time is vision! Patient with retinal detachment can lead to total blindness in hours Usually visual field lose from peripheral towards the central Operation should be done before macula involvement If macula is detached, early operation still provide better prognosis

30 What are the symptoms? Floaters 飛蚊症? 飛蚊症 : 眼前看到半透明黑色物體, 飄來飄去, 可以點狀, 線狀, 雲狀或圓圈中年或高度近視容易造成此現象, 那是因自己看到自己眼球內玻璃體的渾濁, 通常會習慣但如飛蚊增加, 或合併有閃光的發生, 就有視網膜裂孔或剝離的可能如果發現視野中的某一區塊變暗變黑, 一定要到醫院詳細眼底檢查

31 Retinal break means retinal detachment? Retinal break may be associated with some degenerative change (i.e. lattice degeneration) Prophylactic barrier laser should be applied if retinal break appear, or retinal degeneration noticed in high risk patients Floaters persist even barrier laser applied

32 High risk group High myopia Trauma Family history Systemic connective tissue disease Eczema

33 Why high myopic patient has higher risk for retinal detachment? High myopic patients has longer eyeball More retinal thinning / degenerative change Earlier posterior vitreous detachment

34 Operation for rheumatogenous retinal detachment 傳統的鞏膜扣壓術 (scleral buckling) 玻璃體切除術 (posterior vitrectomy) 空氣填充術 (pneumatic retinopexy) > 90% success rate if operate early

35 Factor affecting visual recovery after operation Is macula 黃班點 detached? When was operation done? How about current HA condition?

36 How about eye exercise or eye massage? No evidence, better not do it

37 Retinal vessel occlusion Central retinal vein occlusion (CRVO) Central retinal artery occlusion (CRAO) Branch retinal vein occlusion (BRVO) Branch retinal artery occlusion (BRAO)

38 Retina is the only site to observe vessel directly

39 Risk Factor for retinal vessel occlusion Artherosclerosis: HT, DM, high lipid, smoker Autoimmune disease, vasculitis High IOP Symptom Sudden visual loss Central retinal artery occlusion carry the worst prognosis and can lead to complete blindness

40 Management of CRAO Ocular message Paper breathing Medication like diamox and timolol Paracentesis

41 CRAO Laser for NV CRVO / BRVO Anti-VEGF Intravitreal steroid Laser for NV and ME of BRVO

42 Prognostic factor CRAO: blind unless embolus removed CRVO / BRVO: ischaemic or not, macula involved or not Complication: Macula edema, NVG, VH

43 Ocular trauma Remove the foreign body Suture the wound Start antibiotics

44 Refractive Surgery

46 白内障是什麽? 白内障 = 眼睛用來聚焦的晶體變得混濁 Cataract = Opacification of the crystalline lens

47 白内障是什麽?

48 白内障是什麽?

49 白内障是什麽? 沒有藥物能夠治療或預防白内障, 接受手術是治療白内障的唯一辦法

50 形成白内障的主要原因 Major causes of cataract 自然老化 (Degeneration) 眼部受損 (Trauma) 疾病 (Diseases) 藥物 (Drug-related)

51 自然老化 (Degeneration) Effect of UV damage

52 自然老化 (Degeneration) Worsen by smoking

53 眼部受損 (Traumatic cataract)

54 疾病 (Diseases) 糖尿病 Diabetic

55 藥物 (Drug-induced) 類固醇 (Steroid)

56 白内障有什麽症狀? Symptoms of cataract 視力模糊 (Blurred vision)

57 白内障有什麽症狀? Symptoms of cataract 景物顔色暗淡 (Discoloration)

58 白内障有什麽症狀? Symptoms of cataract 閲讀困難 (Difficulty in reading) 怕光 (Photopsia)

59 如何治療白内障? 接受手術是治療白内障的唯一辦法

60 白内障手術的發展 Development of cataract surgery ICCE ECCE Phacoemulsification Small Incision Cataract Surgery (Bimanual phaco) Femtocataract Surgery

61 白內障囊內摘出術 Intracapsular Cataract Extration ICCE Wound size around 10-15mm Need suture around 5-10 stitches Could not implant IOL

62 白內障囊外摘出術 Extracapsular Cataract Extration ECCE Wound size around 10-15mm Need suture around 5-10 stitches Could implant IOL

63 超聲乳化晶體摘除術 Phacoemulsification

64 超聲乳化晶體摘除術 Phacoemulsification Wound size around mm Self-sealing wound May not require suture

65 超微創白内障手術 Small Incision Cataract Surgery Wound size only 1.0 mm Self-sealing wound No suture Surgery time 5-10 min

66 飛秒激光白内障手術 Femto-Cataract Surgery

67 飛秒激光白内障手術 Femto-Cataract Surgery

68 飛秒激光白内障手術 Femto-Cataract Surgery Femtolaser Wound creation, capsule opening, lens fragmentation More precise More safe

69 人工晶體 Intraocular lens 單焦距人工晶體 (Monofocal IOL) 散光單焦距人工晶體 (Toric IOL) 多焦距人工晶體 (Multifocal IOL) 散光多焦距人工晶體 (Toric + Multifocal IOL) 高清人工晶體 (HD IOL) 淡黃人工晶體 (Yellow filter IOL)

70 人工晶體 Intraocular lens 散光單焦距人工晶體 (Toric IOL)

71 人工晶體 Intraocular lens 多焦距人工晶體 (Multifocal IOL) For both distant and near vision Corrective presbyopia

72 何時接受白内障手術? When to receive cataract surgery? 視力下降致影響工作 / 日常生活 Vision after occupation / daily activites 考慮一併矯視 Could operate for refractive purposes

73 何時接受白内障手術? When to receive cataract surgery? 不要等待熟才做手術 Never wait until mature 併發症機會大增, 即使手術亦不能恢復視力 Vision cannot regain despite surgery if complications occur

74 什麼是近視, 遠視, 散光? 正常遠視近視散光

75 矯正近視眼鏡隠形眼鏡 LASIK 激光矯視

76 矯視手術的發展改變眼角膜弧度矯正視力 Radial Keratotomy (RK) Photo Refractive Keratectomy (PRK) LASIK (1994)

77 LASIK 激光矯視手術先揭起上層角膜再利用激光打磨下層角膜弧度

78 SMILE 微笑矯視 SMall Incision Lenticule Extraction 2011 年面世 2014 年引入香港用激光切割眼角膜不需要角膜瓣傷口只有約 2mm

79 SMILE 手術過程激光直接切割眼角膜中層激光開一個約 2mm 小切口用儀器抽出切割了的眼角膜部份

81 Smile 減少眼乾情況

82 術後角膜強度影響輕微減少角膜變形機會

83 SMILE 矯視近視散光適合 SMILE 人士近視 1000 度以下散光 500 度以下眼乾接觸性運動人士

84 SMILE vs LASIK LASIK SMILE 手術原理打磨眼角膜切割眼角膜手術準確度高極高角膜瓣移位機會有沒有手術傷口約 20mm 約 2mm 術後角膜強度影響一般輕微術後乾眼情況一般輕微水上活動 1 個月後數天後手術費用 $$ $$$

85 什麼是老花? 退化眼球的晶狀體逐漸硬化影響變焦能力

86 晶狀體退化年齡晶狀體變焦能力 0 40 歲 1500 度歲 200 度 > 70 歲 0 度

87 老花對日常生活的影響老花影像

88 老花的矯視

89 老花的矯視老花隱形眼鏡

90 老花的矯視手術 LASIK / SMILE (Mono Vision 單眼視力 ) 左眼右眼

91 老花的矯視手術人工晶體置換手術 ( 超微創白內障手術 )

92 Raindrop 雨點矯視

93 Raindrop 雨點矯視

94 Raindrop 雨點矯視矯正老花只需一隻眼進行手術可同時看遠及近景物不影響夜間視力一次性可還原手術手術過程只需要數分鐘

95 矯視手術目的改善視力減少對眼鏡或隱形眼鏡的依賴帶來生活上的方便

96 Thank you Contacts: Tel : drernielo@gmail.com Clinic: 1303, 13/F, 9 Queen s Road, Central, Hong Kong 706, 7/F, Wai Fung Plaza, 664 Nathan Road, Mongkok, Kowloon Shop H, G/F, Glamour Garden, 1-5 Chik Fai Street, Tai Wai, N.T.

HKSH 22

HKSH 22 第 22 期 2005 年 9 月最準確的斜視眼手術可調較法 (Adjustable Suture Technique) 謝道欣醫生斜視是指雙眼的視線不能中力, 從而減少眼睛疲累, 改善視力質素對成年人來說, 斜同時注視同一目標, 當一隻眼睛向前望時, 另一隻眼睛