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Introduction to Eye Problems in Indonesia

Gitalisa Andayani

G

Department of Ophthalmology, FKUIJakarta 2008

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

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)

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 2006-2011, WHO, 2007

Source: Global Initiative for the Elimination of Avoidable Blindness : action plan 2006-2011, WHO, 2007

Global causes of blindness

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

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

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’ : 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 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

Anatomy of the eye

Lateral Canthus

Punctum lacrimalis

CorneaLimbus

Conjunctiva

PupilIris

Karunkula

Upper eyelid

Lower eyelid

Medial Canthus

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)

KATARAK Kekeruhan lensa Penyebab:

- degenerasi (senilis): usia tua- penyakit mata lain/metabolik/obat

(komplikata)- bawaan (kongenital)- trauma (traumatik)

kekeruhan lensa (katarak)

KATARAKTanda dan gejala Dini:

- terkadang belum ada keluhan- melihat kabut/asap- silau- sulit membaca

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

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

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

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

GLAUKOMA

Penatalaksanaan • Observasi• Obat-obat glaukoma: - beta-blocker

- asetazolamid- pilokarpin

• Laser (iridotomi, trabekulotomi, trabekuloplasti)• Operasi (iridektomi, trabekulektomi, implant)

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

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

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

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

Ophthalmology examination

Refraction

Snellen Chart

Pinhole test

Ophthalmology examination

Funduscopy

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……….!

Thank you