preview all eyes on english by Vanicha Srathongoil

“Viewed freely, the English language is the accretion and growth of every dialect, race, and range of time, and is both the free and compacted composition of all.” Walt Whitman

Preface

Walt Whitman was correct. English has become a lingual franca— de facto universal language. English is used as the business language virtually everywhere in the world. It is also an essential gateway to information and opportunities. In clinical practices, including ophthalmology, English conversation skill provides the opportunity to use our clinical skills to care for a more diverse patient population. As the world becomes increasingly more globalized, the ability to communicate in English is no longer an optional luxury but a crucial skill for ophthalmologists. These are the reasons behind the Royal College of Ophthalmologists of Thailand’s (RCOPT) commission of this book. We designed “All Eyes on English” to function as a practical guide, suggesting sample scripts to be adapted in several clinical scenarios. We would like to thank Major General Suthat Vanichseni whose idea sparked the genesis of this book. It has been a pleasure putting together what you are holding in your hands. We hope that readers will find this book helpful. The Authors

Refractive errors

Eye Strain

12 page

Introduction

Viral Conjunctivitis

Red Eye

19 page

40 Gonioscopy

70 page

page

Congenital Esotropia and Amblyopia

85 page

Diplopia

page

Visual Field Testing

48 page

page

OCT in Retina

Orbit, Eyelid and Lacrimal System

page

Contact lens

63 page

page

Hordeolum Cataract

Vitreous Degeneration

Central Serous Chorioretinopathy

page

56 page

page

Laser Peripheral Iridotomy

Retinal Nerve Fiber Layers Scan

80 page

Authors

page

Greeting the Patient • • • • • • •

Mister (Sir), Madam, Miss, Please come in. Please sit down (Have a seat, please) How are you doing? (How are you today?) What is your name? What would you like to be called? How old are you please? When was your last visit here?

Important Signs and Symptoms Vision

• How has your vision been? • Is your vision stable, decreasing, or improving?

Appearance

• Do you have any redness? • When did your eye become red?

Discomfort

Associated Signs and • Are you having any difficulties Symptoms

Introduction Puwat Charukamnoetkanok

• What condition makes it with your eyes? (Are you better or worst? having any trouble with your • Do you have any discharge eyes?) from your eye? • Do you have any eye pain? • What is the color of the • What type (kind) of pain do discharge? you feel? • Do you have increased tearing? • How long have you had these symptoms? 9

Taking History Medication

have you had any problems with? • What medications are you - Head/Ear/Nose/Throat currently taking? - Endocrine glands • What eye drops are you using? - Skin (rash) • Have there been any changes - Lungs, Heart, Circulation in your medications? - Stomach, Bowel • Are you taking any pills? - Genito-urinary system • How do you use this - Nervous system medication? (How many - Muscle, Bone, Joints times a day do you take - Numbness, Weakness this pill?) • Do you smoke cigarettes? • When did you stop taking - How many years did you this medication? smoke? • Do you have allergies to any When did you stop medications or food groups? smoking? Past Medical History • How old were you when you • Do you have diabetes, high started to use reading glasses? blood pressure, or high • Do you have a lazy eye? cholesterol? Surgical History • How long has it been since you were diagnosed with • Have you had any surgeries? diabetes? • Were there any changes after • Do you currently have or the surgery?

Visual Acuity Distant Vision

• • • • • • • • • • •

Hold this for me please. Can you read this line? Can you see any of this? How about now? What is the smallest line that you can see? Anything below that? Please read the one below that. Can you read the bottom line? How about here? Nothing below that? Now let’s try another eye.

Pinhole Vision

• Please hold this for me. • Please look through one of the holes. • Please read this line for me.

• How about the one below that? For vision worse than 20/400 • Can you see my fingers? • How many fingers do you see? • Can you see the light? Which direction is it coming from?

Near Vision

• When you read, do you put your glasses on or take them off? • Please cover your left (right) eye with your left (right) hand. • Please hold this card for me. • What is the smallest line that you can read? • Can you read this line? • Anything below that?

Common Phrases Do you have glasses?

Please take off your glasses.

01 Please put them (glasses) on.

Please try this one again.

03 Dr.______will come to see you shortly.

Please put your chin in the chinrest.

Please look over here.

07 Please put your chin down.

09 Please keep your chin down and forehead against the bar (strap).

Please dab your eyes.

10 Please look up.

05 Please sit down.

08 Please place (keep) your forehead against the bar.

11 Please look down.

Please look to the left.

Please look to the right.

Please look up and to the right.

Please look down and to the left.

Please look down and to the right.

18 Letâ&#x20AC;&#x2122;s check the other eye.

Please look up and to the left.

May I flip up your lid?

Please keep both eyes open.

The light is quite bright but it is not harmful for your eyes.

Please try not to move your eyes.

Please look straight ahead.

Please keep your head straight.

Please lift your chin a little more.

Taking History • How long have you experienced blurry vision in your right/ left/ both eyes? • Is the haziness/ blurriness generalized or localized only at the center? • When do you experience difficulty in seeing things? • Reading/ sewing/ writing/ using a cell phone or tablet • Using a computer • Watching TV or a movie /

driving/ golfing • Do you have any problems focusing on small objects or fine print? • Have you ever used any eyeglasses or contact lenses? • Have you undergone any refractive surgery/ eye surgery? • Have any other members of your family had similar problems when they were your age?

Eye Examination

Refractive Errors Voraporn Chaikitmongkol

• Visual acuity (with pinhole) • Let’s check your distant vision. • Do you see the eye chart over there? • Can you please read the numbers from the top row to the bottom row for me? • Can you make a guess? (when the patient is uncertain/ cannot see clearly) • Great/ Well done/ Good job/ Excellent (when the patient has finished reading) • Next, please look through a pinhole and read from the top row again/ start reading from this line/ read this line. • Anterior segment examination • Posterior segment examination 15

Diagnosis & Patient Education • We have completed the eye examination. Good news! The cause of blurry vision in your right/left/both eye(s) is/are called “refractive errors,” which is a common eye disorder for people of your age. It occurs when the eye cannot focus the image of an object precisely on the retina (the light-sensitive tissue at the back part of your eye) because the eye is either too long or too short, changes in the shape of the cornea (the front part of your eye), or aging of the lens. • There are four types of refractive errors.

Treatment

Nearsightedness

Eyeglasses

The objects up close appear clear, while objects far away appear blurry. With this condition, light comes to focus in front of the retina.

Farsightedness

The distant objects may be seen more clearly than the objects that are near. However, people may experience this condition differently. Some people may not notice any problems with their vision, especially when they are young. For people with significant farsightedness, vision can be blurry for objects at any distance, near or far. With this condition, light comes to focus behind the retina. 16

Astigmatism

The eye cannot focus light evenly on the retina. This can cause the images to appear blurry and stretched out at any distance.

Presbyopia

The cause of blurry vision in your eyes is called presbyopia, which is an age-related condition where the eye progressively loses the ability to focus on near objects. This condition is usually noticed between the ages of 40 to 50.

Refractive errors can be treated with eyeglasses, contact lenses, or refractive surgery

The simplest and safest way to correct refractive errors

Contact lenses

benefits of refractive surgery will be different for each person and need to be discussed thoroughly before the surgery.

An effective way to correct If you are interested in wearing refractive errors if fitted and glasses or contact lenses: used properly. However, there are some risks for eye infection. • I will do refractions or measure the lens power for your It is very important to wash glasses or contact lenses – your hands and clean the contact before prescribing glasses/ lenses as instructed to decrease contact lenses for you (Or, the risk of infection. I will refer you to an optician Refractive surgery to have him (or her) measure A surgical procedure which the lens power for your glasses/ will be performed in the operating contact lenses). room. It aims to change the • If you are interested in shape of the cornea (the front refractive surgery, I will refer part of the eye) permanently. you to a specialist for further There are many types of refracevaluation. tive surgery. The risks and

Doctor: Hello Mrs. Smith. How can I help you today? Patient: Good afternoon doctor. I’ve been having some eye pain for the past few days. It’s worse on some days than others. I also get headaches if the eye pain does not go away after a while. Doctor: So it’s not constant. Is the pain related to anything or any activity in particular? Patient: Umm, I’ve noticed that my symptoms are worse after using the computer. Doctor: Have you been using the computer much lately? Patient: Oh yes! My daughter just showed me how to use Facebook and LINE so now I’m addicted! I’ve been using my iPad a lot. Is that related to my eye pain? Doctor: Possibly. One of the most common causes for eye strain is working on the computer for long periods, although any activity that requires long, intense use of the eyes such as reading, writing and driving can cause eye discomfort or fatigue. I will have a look at your eyes to check for any underlying causes. Patient: Ok doctor. Performing slit lamp examination Doctor: Ok Mrs. Smith, first I will examine the front part of your eyes. Please put your chin on the chin rest and press your forehead against the bar. Hmm, the cornea, iris and lens look normal. Next, I will have a look at the retina and optic nerve. (78D lens in front of RE) Look towards my ear with your left eye. (lens in front of LE) Now look towards my ear with your right eye. Good. Everything looks normal.

Eye Strain Atchareeya Wiwatwongwana

Performing applanation tonometry Doctor: Now I’m going to measure your eye pressure. I will administer some numbing drops first and dab a yellow stain on the surface of your eye. The drops will sting a little. Are you ready? Patient: Yes doctor, just a little nervous.

Doctor: Don’t worry, just relax and bend your head back a bit so I can administer the drops. Good, now please place your chin on the chin rest again. This equipment with the blue light will touch the surface of your eye but it won’t hurt. I will hold your eyelids open and please try not to squeeze your eyes. Doctor: Your eye pressures are 13 and 14 mmHg. (millimeters of mercury), within the normal range. Doctor: I’d like to do a quick refraction to see if you need glasses. Patient: That would be great doctor. Doctor: Well Mrs. Smith, your eyes are normal and you don’t need glasses. The main cause of your eye strain is likely from working at a computer screen for long periods of time. If you could take a short break every 20 minutes to rest your eyes, for example try closing your eyes for a few minutes or looking out the window, that could really help. Symptoms usually go away with rest. Patient: Thank you very much doctor.I’m relieved it’s nothing serious!

Red Eye Tharikan Sujirakul

History Taking Present History

• When did you first notice that your eye(s) became red? • Do you have any associated pain/ irritation/ itching/ burning in your eye? • Are there any light sensitivity? • Are there any abnormal or increasing eye discharge? • Could you please describe it for me? (color/ watery/ mucous) • Is it getting (worse/better/ staying stable) over time? • Have you ever had the same problem before? Does it happen off and on? • Are you using any eye drops? • Have you had a cold or sore throat recently? • Have you been in contact with people who have had red eyes recently?

Past and Personal History

• Do you have any history of allergy or asthma? • Do you have any underlying diseases such as diabetes, hypertension or a bleeding disorder? • Are you taking Aspirin or other blood thinning medications? • Are you a contact lenses wearer? • Did you ever have a herpes infection or any vesicles/ blebs around your eyelids? • Do you have any history of trauma around your eyes? (eye rubbing / heavy coughing/ straining) • Do have any history of vaginitis/ urethritis/ cervicitis? (when Chlamydia or Gonorrhea conjunctivitis is suspected)

Examination Outline VA / Slit lamp / Lid eversion / Lymph nodes • I am going to administer a numbing drop in your eyes. You might feel a little sting, but it will go away after a couple of blinks. • It is important to examine the back of your eyelid, would you mind if I flip your lid? • I am going to check if you have any associated lymph node enlargement. • Does it hurt when I touch here?

Common Diseases with Red Eye Viral Conjunctivitis

• Your red eye is caused by a viral infection; it is a self-limiting condition. • It usually resolves itself within 1-2 weeks. However, the symptoms might get worse during the first 3-4 days. • No antibiotic treatment is required. But the use of an anti-histamine or lubrication drops might help you to feel more comfortable. • This condition is contagious, so please avoid communal activity if possible such as working in a school, daycare or in healthcare until you recover. • It is important to wash your hands frequently. Please avoid touching or rubbing the eyes and sharing towels with others. • You should come back immediately if your eye discharge becomes yellow/green, you notice blurring of vision or the symptoms are getting worse or persisting after 2 weeks.

Bacterial Conjunctivitis

• I will have your eyes swabbed and send the sample for analysis to further identify the causing organism. (In case of atypical conjunctivitis such as Neonatal, hyperacute/ chronic or non-responding cases) • I will prescribe antibiotic eye drops. Please administer them 4 times a day for 1 week as instructed. Your symptoms should improve in 1-3 days after starting the drops. • This is a contagious condition, so please wash your hands often and avoid communal activity for at least 1-3 days or until the infection clears. • You should come back immediately if the symptoms are worsening or no improvement is observed.

Allergic Conjunctivitis

• Your condition is caused by an allergy, which is often associated with airborne pollens, dust mites or animal dander, etc. • Please carefully observe in what environment your symptoms become aggravated and, if possible, identify the allergens and avoid contact with them. However, most of the time, the allergens cannot be identified. • I will prescribe: Antihistamine/ vasoconstrictor/a low potency steroid … times a day to relieve your symptoms. Artificial tears to help diluting the allergens. • In addition, cold compresses or ice packs over your eyes will relieve your symptoms. • I will see you back in 2-4 weeks for a follow-up.

Subconjunctival Hemorrhage

• This may look scary but it is not a serious condition. The redness is caused by breakage of small blood vessels in your eye. This is like bruising on your arms or legs, which is usually caused by minor trauma. • The redness will slowly clear up over 1-2 weeks. • No treatment is required unless you feel discomfort over the lesion. If so, I will prescribe an artificial tear. • If this occurs repeatedly, you should come back. We will need to check for other underlying diseases such as hypertension or a bleeding disorder.

Pterygium and Pingecula

• This is an irritating degenerative condition. It is not dangerous. • Risk factors include UV radiation, hot and dry climates and an outdoor lifestyle. • Therefore, avoiding such environment could slow the progression or help prevent it from becoming inflammed. • In case of inflammation, I will give you an antihistamine and lubricating drops to relieve the symptoms. • We can discuss about the surgery later if there is any indication for excision such as the lesion is progressing, causing irritation that is not controlled with eye drops, or starting to disturb your vision. • You should come back to see me in 3-7 days.

Keratitis

• Your cornea is infected. This is a serious condition.

• I will have to scrape your cornea and send the sample to the laboratory to further identify the causing organism. • You must stop wearing contact lenses and also bring your lenses, lens case and lens solution for culture to further identify the causing organism. • Meanwhile, I will prescribe broad-spectrum antibiotic eye drops, please strictly administer the drop every 1 hour as instructed. We will schedule follow-up visits on a daily basis until your condition improves.

Anterior Uveitis

• Your eye condition is caused by the inflammation of the iris and/or ciliary body. It can be associated with systemic autoimmune disease but the majority of patients do not have identifiable causes. We might need an extensive work up if this condition occurs repeatedly or if symptoms and signs indicate a systemic association. • I will prescribe steroid eye drops. Please administer the drop every 2 hours to treat the inflammation.

Acute Angle Closure Glaucoma

• This is a very serious condition caused by a sudden rise of intraocular pressure which occurs when the iris blocks a water drainage system of the eye. If left untreated, you can become blind. • To treat this, first, I will give you both oral and topical intraocular pressure lowering drugs. After the pressure is lowered, I will perform a laser iridotomy to eliminate the iris blocking effect. • I highly recommend having a prophylaxis laser iridotomy done in the other eye as well.

Viral Conjunctivitis

Tharikan Sujirakul 26

Doctor: Good morning Msâ&#x20AC;Ś.., How can I help you today? Patient: Good morning doctor. My eyes have become red and been very irritated for 2 days. Doctor: Are they itchy? Patient: Sometimes, but mostly just irritated. Doctor: Do you wear contact lenses? Patient: No, I have never worn them. Doctor: Any blurred vision or sensitivity to light? Patient: No. Doctor: Do you have any abnormal eye discharge? Patient: Yes. Doctor: Can you describe the discharge for me, is it watery or mucous and what color is it? Patient: Just watery, no abnormal color. Doctor: Have you ever had red eyes before? Patient: No. Doctor: I see. Have you had a cold or sore throat recently, or have you been in contact with people with red eyes recently? Patient: Not that I remember. Doctor: Do you have any underlying diseases or are you using any medications right now? Patient: No. But I have been using artificial teardrops since my eyes became irritated and red, but it is not helping. Doctor: I see. Let me take a careful look at your eyes, after that I will administer numbing drops in your eyes. You will feel a bit of a stinging sensation, but it will go away after a couple of blinks. Then I will flip your eyelids and examine the inner side of them. 28

(Anterior segment examination including palpebral conjunctiva and cervical lymph node examination were performed) Doctor: You have conjunctivitis. In your case, it has been caused by a viral infection. This is a self-limiting condition. It usually resolves itself within 1 - 2 weeks, but the symptoms might get worse during the first 3 - 4 days. Patient: Doctor, how did I get it? Doctor: It is a highly contagious, usually airborne condition just like a cold. You may also have had direct contact with the virus. Patient: I see. so What should I do now doctor? Do I have to use any antibiotic drops? Doctor: No antibiotic treatment is required, but an antihistamine, artificial tear, or cold compression might help you feel more comfortable. Patient: Ok. What else should I do? Doctor: Since it is highly contagious, the most important thing is to avoid communal activity as much as possible. If you are a healthcare worker or a day care or school teacher, you might want to take a few days off until your symptoms subside. Washing your hands frequently and avoiding touching or rubbing the eyes and sharing towels with others will help to keep the virus from spreading to others. Patient: I can do that. Doctor: Later on if your eye discharge become yellow/ green in color or if you notice any blurring of vision, please come back and see me again. Patient: Thank you very much for your explanation doctor. Doctor: My pleasure. Have a nice day.

Basic questions for contact lens wearers • • • • • • • • • •

What’s type of CLs do you use? Soft lens/ hard lens/ RGP Daily wear/ extended wear How do you clean and disinfect your CLs and lens case? How often do you replace your CLs and lens case? Do you wash your hands before lens handling? How about the wearing duration? How long do you typically wear you lenses? Do you sleep with your contact lenses in overnight? Do you work in areas that might have high amounts of dust, dirt or debris? How long have you been using CLs?

Explore for chronic user or inexperienced CL users • • •

Contact Lens

•

Contact LensRelated Eye Diseases in Routine Practice

Ask about predisposing factors: Do you have any underlying diseases or eye problems? Systemic diseases, trauma, ocular surgery, smoking, immunosuppressive drugs Ocular diseases: dry eye, blepharitis, allergic conjunctivitis Contaminated eye drops

The problems associated with wearing CLs may be

• Problems with the lenses themselves • Associated with conjunctival problems • Associated with corneal problems

Vatookarn Roongpoovapatr

Problems with the lenses themselves Poor lens fit/poor lens care/lens damage/lens drying/CLARE (Contact Lens-Induced Acute Red Eye)

Scenario : CLARE

CLARE because they do not allow for metabolic waste to be cleared from underneath the lenses. Moreover, sleeping with the lenses in enables metabolic waste to build up under the lens, which can cause CLARE. Furthermore, missing a cleaning step can result in the build up of debris on the lens. You should throw out the lenses and wear glasses until you are completely better. Questions The conditions will subside • Have you been sleeping with following temporary discontiyour lenses in overnight? nuation of CL use along with • Can you please describe aggressive ocular lubrication, step-by-step how you have topical corticosteroid and adminibeen cleaning your lenses? stration of antibiotic eye drops. If you return to using a new lens Patient education too early, this condition can CLARE is a sterile inflamreoccur. All in all, if you want matory event of cornea and to use CLs again, something conjunctiva. You have this con- will have to change to prevent dition because of multiple factors. recurrence, such as improving First, after I assessed the lens the lens fit, switching to daily fit I found that these CLs are wear lenses, and not sleeping too tight. Tight lenses can cause with your lenses in overnight. • A 37-year-old female came to your office because of photophobia, moderate pain and irritation in her left eye that occurs upon awakening following extended use of soft contact lenses. • The eye examination revealed conjunctival injection 2+, small anterior stromal infiltrations at the peripheral cornea.

Associated with conjunctival problems Scenario : Contact Lens – Induced Papillary Conjunctivitis : CLPC

Patient education

The condition that you are encountering is called CLPC. It • A 28-year-old man who has is an allergic response to coated and deposited CLs and mechabeen wearing soft CLs for 10 nical irritation from deposits. years has been experiencing It happens less frequently in decreased lens tolerance and an increase in lens awareness, patients who replace their lenses frequently. You should revise mucous production, redness, your cleaning regimens, disburning, and itching for the continue wearing CLs for 3 to past 3 months. 4 weeks and replace your lenses Questions more frequently with a preference • Which type of CLs do you use? toward a daily disposable, proper • How often do you replace edge design. I will prescribe antiyour lenses? allergic eye drops to speed up • Can you explain your the recovery. cleaning regimens?

Associated with corneal problems Scenario : Dry eye • A 55-year-old woman has been presented with decreased vision during the day when wearing CLs for long periods and complains of burning, dryness, and irritation. • The eye examination revealed MGD, excessive debris in the tear layers, decreased tear meniscus as well as tear breakup time. A Schirmer test and fluorescein staining are compatible with dry eye.

Patient education Dry eye is a common problem among CL and non CL wearers but symptoms may be more pronounced if you wear CLs. Moreover, cessation of CL use will often allow for more rapid resolution of dry eye symptoms. In most cases, dry eye is multifactorial but it occurs more frequently in CLs with high water content (water loving). Management includes administration of artificial teardrops, lid and lens hygiene and frequent lens Questions replacement to reduce the • Which type of CLs do you use? incidence of protein deposits. • How long per day do you It seems that some redness or use CLs? debris on your lid may impact • Do you use lubricating eye adequate tear flow so I would drops? like you to place a warm, wet • Do you have any concomitant washcloth on your eyelids for ocular diseases? 5 minutes and gently massage • Are you talking any them one or two times per day. medications?

Scenario : Keratitis

• An 18-year-old boy came to your office because of severe pain, photophobia redness and discharge in his left eye for the past 3 days. He usually sleeps with his CLs in overnight. • The eye examination revealed lid swelling, conjunctival injection 3+, 2 mm mid-peri pheral anterior to mid stromal infiltration with overlying epithelial defect and minimal hypopyon.

• Did you recently swim in a river or lake with your CLs in? • Did you use steroids? • Have you experienced any improvement following discontinuation of CL use? [Early microbial keratitis can overlap with severe Contact Lens-induced Peripheral Ulcer (CLPU).]

Patient education

Microbial keratitis is the most serious complication of wearing Questions CLs. CLs decrease oxygen trans• Which type of CLs do you use? mission to the cornea, impair • Can you describe your routine wound healing, and increase risk lens disinfection, replacement, of infection. I will prescribe an and hygiene? antibiotic eye drop for you to use • Have you suffered any eye in your left eye every hour. You trauma or had foreign bodies have to follow up every day until in the eye? clinical resolutions. 35

General patient education for CL wearers

• Having a routine checkup is strongly recommended for every CL wearer as it can detect early abnormalities and assess proper fitting of your CLs. • Poor lens case hygiene, inadequate cleaning, using contaminated solution and/or poor hand hygiene can increase the risk of complications. • Any ocular injection or discomfort that fails to resolve within 24 hours or worsens after removal of your CLs should prompt urgent eye care. • I want to confirm that I have covered everything, so could you please repeat the instructions that I just gave you.

Practical English Guideline for Cataract Counseling

Cataract Sritatath Vongkulsiri

Pre-operative counseling Your vision problem is being caused by a cataract, which is a clouding of the lens that obstructs light from entering into your eye. Cataracts are actually a normal part of aging. Cataracts can also occur in the eye that has suffered previous trauma, inflammation, or undergone eye surgery. You need cataract surgery in order to see better, or you can wait for years until the poor vision beings to interfere with your quality of life. You can safely wait if the cataract is not mature. Letâ&#x20AC;&#x2122;s set up regular follow-up appointments to keep an eye on it. If you decide to have the surgery, it is generally very safe and effective. The hazy lens will be taken out and replaced with an artificial lens. The procedure, done through a small corneal wound smaller than 3 mm, usually takes half an hour. The surgeon will either administer numbing drops or a numbing shot near your eye before the surgery. You will not feel pain but will be awake and aware of the surgery. You may feel a sense of touch and the sensation of a light pressure on the eye. If you are claustrophobic or have trouble lying down, you may choose to use a general anesthetic. During the surgery, you should keep your eye open and look straight at the light. You do not have to worry about blinking. There will be a device to help keep your eye open. You can still move your eye if the numbing drops are used. Therefore, you need to keep your eye on the overhead light during the operation. If the numbing shot is selected, you will not be able to move your eyes.

However, there are infrequent complications associated with the numbing shot such as bleeding in the back of the eye, double vision, eye penetration, arrhythmia, drowsiness, cessation of breath, and shock. Although cataract surgery is very safe, I need to let you know about the potential complications that could occur. The common problems are bleeding in the conjunctiva, eye irritation, tearing, dry eye and refractive error. These symptoms usually improve with time or are corrected easily with eye drops or glasses. The lens capsule may rupture and the lens may drop into the eye during surgery, complications which may require a longer surgery or a second operation. The serious problems that are rare but can cause poor vision include infection, glaucoma, bleeding in your eye, macular edema, or retinal detachment. They could occur many years after the surgery, so you will be required to have regular check ups. There are many types of artificial lenses available. The monofocal lens is the most commonly used lens. It focuses sharply at one distance. Most people adapt easily to this lens but you may need the reading glasses for near work. Alternatively, you may decide to have monovisionâ&#x20AC;&#x201D; one eye for distance vision and another for near vision. 39

If you have a large degree of astigmatism, you may benefit from toric lenses that can correct the astigmatism. After the surgery, you may not need the glasses for long distance vision but still require the reading glasses. The multifocal lenses allow you to be independent from glasses. The success rate of achieving glasses-free functioning vision is about ….%. However, some patients experience problems with the quality of vision such as experiencing a glare and halos around lights at night, waxy vision, and loss of contrast especially in low light conditions. This lens is suitable for you if you do not want to use reading glasses and do not do a lot of night driving. Do you have any questions about the surgery? Do you have any underlying diseases? Are you taking any medications? If you take an anticoagulant such as aspirin, clopidogrel or warfarin, you should inform me. You will need an evaluation and specific instruction from your medical doctor. If you develop a cough or cold on the day of operation, your operation may need to be postponed.

Post-operative counseling • The operation was done smoothly/ with little problem. • The vision will be better with time. • How is your vision? • You are doing well. • You will need to have the stitch(es) removed one month after the surgery. • I prescribed (2) eye drops for you. Please take …every … hours/ 4 times a day / at bedtime. • Avoid washing your face/ facing down/ exposure to heavy dust/ lifting heavy weights for (7) days/ a month. • I would like to appoint you back for a follow-up eye examination next week/ next month/ on ...day. • If you experience blurry vision, soreness of the eye, pink eye or abnormal eye discharge, your eye may be infected and you should come back to visit me immediately. Do not wait until the follow-up appointment. You can call my office to schedule an urgent appointment. 41

Doctor: Good morning. How are you today? Patient: Not very well doctor. I have had a red lump on my left eyelid for a week. It hurts. Could you please take a look? Doctor: Sure. Don’t worry. Most eye problems can be treated. Do you have any other symptoms? Patient: No doctor, just a painful bump on my upper eyelid. Doctor: Are you taking any medications? Are you wearing contact lenses? Patient: I do wear contact lenses but have not started any medications yet. …after completion of the eye examination… Doctor: Well, you have a very common condition, called a stye. It is an inflamed swelling on the edge of the eyelid, caused by a bacterial infection of the gland at the base of an eyelash. This occurs because these oil-producing glands become obstructed. Patient: Is it contagious? Is this dangerous? Doctor: Please don’t worry. This condition is neither dangerous nor contagious. The infection itself is caused by normal skin germs. This bacterium can easily enter your eyelid when you rub your eyes with dirty hands. Some people have an eyelid condition called blepharitis which can also cause them to be more prone to developing styes. Patient: How can you treat this condition, doctor? Doctor: I will give you some antibiotics pills and also want you to apply a warm compress to your eyelid. Patient: Can I do that myself?

Hordeolum Chaisiri Jumroendararasme

Doctor: Yes, it is very easy. Hold a clean washcloth, which has been soaked in warm water, gently but firmly against your closed eye. It will help to relieve your pain and inflammation. The warm compression may also help to accelerate the healing process. Apply the compression for a duration of 5-10 minutes, and repeat 3-4 times per day. You should avoid wearing contact lenses until the stye and infection are gone. It is important not to try to squeeze a stye. 43

Patient: How can I prevent this condition from happening again? Doctor: Unfortunately, there are no specific preventive measures for styes. However, keeping your eyelids and eyelashes clean is important. To do this, add three drops of baby shampoo to a small bowl of warm water. Soak a clean cotton ball in the solution, and then gently scrub both eyelids for 30–60 seconds with your eyes closed. Rinse with warm tap water. Additional general preventive steps include: • Avoid sharing eye make-up with others. • Avoid sharing towels and other linens such as pillowcases or washcloths. • Do not touch or rub your eyes, especially if you have a style. Patient: How soon do you expect me to get better?

Doctor: I hope to see some improvement, especially in your pain and swelling, within 3-5 days after starting the medications. If there is no improvement, you will need to have an incision and curettage of this stye. Patient: I hope I will not need to do that. Doctor: I hope so too. Let’s see. Patient: Could you briefly tell me about the procedure? Doctor: Certainly. An incision and curettage is a simple procedure. I will give you a numbing medication after cleaning your lid with some antiseptics. A small incision will be created at the site of that stye to release the pus. You may need to have your eye patched after the procedure for a few hours. That’s it. I will let you know again if you need to have it done. May I ask you to make an appointment in another 5-7 days? Patient: Sure doctor. Let’s do that. Doctor: Do you have any other questions for me? Patient: No. Thank you very much doctor. Doctor: You’re welcome. See you next week.

Gonioscopy Weerawat Kiddee

Before the examination Explain the indications What is a gonioscopy doctor?

• A gonioscopy is an eye examination to see whether the area where fluid drains out of your eye is open or closed.

Why do I need a gonioscopy examination?

• A gonioscopy helps me to see whether or not you are at risk of developing glaucoma. • If you already have glaucoma, a gonioscopy can help me see which type of glaucoma you have. • If your drainage part of the eye is shallow, this helps me to decide whether or not you should have a laser treatment done.

Brief the procedure and what to expect during the examination.

• A gonioscopy is usually done in the office during the slit lamp examination. • Before the examination, I’ll administer small drops of an anesthetic drug. • Eye drops are used to numb your eye so that you will not feel the lens touching your eye during the examination. • Then, by holding your eyelids open, I’ll put some gel together with a small lens on your eye. • A special lens is placed lightly on the front of your eye, and a narrow beam of bright light is pointed into your eye. • This lens allows me to look at the drainage part of the eyes. • This might cause a bit of discomfort and a sticky sensation, but it won’t take long. • You have to try not to blink. • Sometimes the patients squeeze the eyelids until the lens pops out, so I might have to reinsert it. • I usually do the right eye then move to the left eye. • After finished, I’ll give you antibiotic eye drops.

During the examination

• Before the gonioscopy, do you have any specific concerns? • Please take off your glasses. • Next, I am going to administer eye drops used to numb your eyes, this may burn a little. • Please place your chin on the chin rest. • Please move your forehead against the support bar. • I am going to hold your lids open. • Please look straight ahead and open your eyes nice and wide. • I am going to place a lens lightly on the front of your eye. • You may find it hard to keep from blinking, but try not to blink or squeeze please. • Well, that’s it. • Everything is finished. Excellent.

After the examination

Explain the results and follow-up suggestions • The drainage parts of the eyes are wide open. It seems that your chances of developing angle closure glaucoma are very low. However, I would suggest having a gonioscopy done once a year. • The drainage parts of the eyes are narrow. Therefore, you have a chance of developing angle closure glaucoma. I would suggest keeping an eye on it by having a gonioscopy done every 3-6 months. • The drainage parts of the eyes are very narrow (or already closed). It seems that you have developed angle closure (or you have a significant risk of doing so). This compromises the drainage system of your eye(s). I would suggest having a laser iridotomy done.

Before the examination Explain the indication Doctor, what is visual field testing?

• The visual field test is an objective measure of central and side vision. • The visual field test is designed to map your field of seeing. • It is “a clicky test,” you click when you see the spot of light.

Why do I need to take a visual field test?

• It can evaluate loss of vision due to damage of the visual pathways from the eyes to the brain. • It is used to diagnose, determine the severity of, and monitor your glaucoma. • This information is useful for me in choosing a target intraocular pressure and determining follow-up.

Visual Field Testing Weerawat Kiddee

Brief the procedure and what to expect during the examination

• The visual field test is performed at the initial visit or as soon as glaucoma is suspected. • The technical staff at our office will assist you during the test. • You will not feel pain and there is no need to numb your eyes. • During the test you should relax and only press the button when you are sure that you see a flash of light. • All the while, remain looking straight ahead at the fixation spot in front of you. • Don’t worry if you cannot see and don’t try to alter the test by looking around or continuously pressing the button. • You should just do your best.

After the examination

Explain the results • The test results show that you might have glaucoma. We need to repeat the test to confirm the diagnosis. • The test results show that your fields of seeing are normal in both eyes. • The test results show that you were not doing well during the test today. The results are unreliable and inconclusive. We need to confirm your results. • The visual fields vary over time and there is a learning curve when taking the test, so I may ask you to repeat the test. • Following this, I will repeat the visual field test to check for any worsening of the disease. • This test may be repeated every 3-12 months depending on the severity of your glaucoma. • If there are worsening defects, a change in therapy may be needed.

During the examination (done by a technician)

• Please place your chin on the chin rest and forehead against the bar. • If you could, look steadily at the fixation spot. • I am going to place the corrective lens in front of your eyes. • I have to hold your droopy lids up a bit. • Remember! Only press the button when you actually see a flash of light. • That’s it. Well done. • You did a good job. 52

Before the examination Explain the indication What is a retinal nerve fiber scan doctor?

• The retinal nerve fiber scan utilizes a special light to image the back part of the eyes or the retina. • There is no radiation, therefore the procedure is safe for your eyes. • OCT is one of the optic nerve imaging techniques to image the retina.

Why do I need the retinal nerve fiber scan done by the OCT?

Retinal Nerve Fiber Layers Scan

• An RNFL scan done by the OCT allows me to quantify the certain parameters related to the optic nerves. • The nerve fiber layer is the part of the retina that contains the axons of the retinal ganglion cells. • In glaucoma, there is a thinning of the retinal nerve fiber layer. • I can also determine if your nerve fiber layer thickness is less than normal, indicating signs of glaucoma. • If the thickness has decreased since the last examination, it may indicate a progression of glaucoma. • This information can help me to make treatment decisions.

Weerawat Kiddee

Brief the procedure and what to expect during the examination

• A retinal nerve scan is usually done in the office by a well-trained technician. • You will not feel pain because it is a non-touching eye imaging procedure. • No need to numb your eyes. • Dilation may be required, so you may be asked to have dilating drops administered to facilitate the imaging. • It takes about 10 minutes for both eyes and is not harmful or painful. • You have to place your chin on the chin rest and look steadily at the target light in the machine. • The result is a color-coded map of the optic nerve head.

During the examination (done by a technician)

After the examination

Explain the results and offer follow-up suggestions • The OCT printout shows your nerve fiber layer thickness is normal. • The OCT printout shows your nerve fiber layer thickness is less than normal, indicating signs of glaucoma. • You may have glaucoma. However, we need to confirm the diagnosis by doing another test that we call visual field testing. • You should have a retinal nerve scan done every 6-12 months depending on the stage of the glaucoma. • I will see you in (3 months).

• Please place your chin down on the chin rest and forehead against the bar. • Please look steadily at the fixation spot in the machine. • You can blink if you feel uncomfortable. • OK, now don’t move and don’t blink, please. • Please move your chin to the right/left to examine the other eye. • Well, that’s it. • Everything is finished. You did a good job.

Before the procedure Explain the indications What is an iridotomy doctor?

• Iridotomy uses a very focused beam of a laser to create a hole on the outer edge of the colored part of your eyes that we call the iris. • This permanent very tiny hole allows fluid to flow between the front part of your eye and the area behind the iris.

Why do I need a laser iridotomy?

• A laser iridotomy can usually prevent angle closure if you are at risk for closed-angle glaucoma. • A laser iridotomy can also prevent further episodes of sudden acute glaucoma in your other eye. • This procedure also usually prevents or relieves the sudden build-up of eye pressure.

Laser Peripheral Iridotomy Weerawat Kiddee 56

Brief the procedure, what to expect during the examination and common questions.

• Where will the procedure be done? - A laser iridotomy can be done without admitting you to a hospital. • What kind of preparation is needed for an iridotomy? - It’s a good idea to have a friend or relative accompany you. - You may need a pair of sunglasses to help with light sensitivity following the procedure. • How much pain is there during the procedure? - You might feel a mild dull sensation in the eye during this procedure, but there is usually no pain after a laser iridotomy. • What kind of anesthesia will be used? - Eye drops are used to numb your eye so that you will not feel the lens touching your eye during the application of the laser. • How long will the procedure take? - It takes about 5- 10 minutes for each eye, depending on the thickness of the iris. • How successful is this procedure? - It works well in most patients. • What are the risks and possible side effects associated with a laser iridotomy? - There is no risk of intraocular infection.

- You will usually have mild inflammation for a few days. - So you will have to use anti-inflammatory eye drops for a few days. - Your eye pressure might spike after the treatment. - I usually administer an anti-glaucoma drop 30 minutes before the procedure to prevent the pressure spike. - And I normally ask all my patients to wait for at least 1 hour after the iridotomy before rechecking the eye pressure. - You might experience some glare when seeing in bright light or at some certain eye positions. • How long will I have to stay after the procedure? - You will be asked to wait 1-1.30 hours after the procedure to make sure that everything is fine before going home. • How will I feel after the iridotomy? - You might experience minor blurry vision in both eyes. - Some patients may feel a mild, dull aching sensation around the orbit. - You can take a mild painkiller to relieve this. 59 59

After the procedure

During the procedure Conversation during the procedure

• Please take off your glasses. • Next, I am going to administer eye drops to numb your eye, this may burn a little. • Place your chin on the chin rest. • Make sure your forehead is pressed against the support bar during application of the laser. • I am going to hold your lids open. • Please look straight ahead and open your eyes nice and wide. • I am going to place a lens lightly on the front of your eye. • Try not to blink or squeeze please. • Look straight [down, up, down or up to your right or left] please. • Well, that’s it. You did a good job with the first eye. • Please move your chin to the [right/left] to administer the laser to the second eye. • All right, everything is finished. Well done. • Now you can sit back, take a big deep breath and relax. • I am going to administer some antibiotic eye drops. • You can now take a seat and wait for about 1 hour before we recheck your eyes. 60

Explain the results • Everything is fine. • The laser holes are patent; these allow for fluid to flow between the front part of your eye, and the area behind the iris. • There are no serious problems, so you can go home. • You will also need to see me for a follow-up exam in one week. • I’ll take a look at the drainage part of your eyes by doing a gonioscopy.

Follow-up care after the procedure and the patient’s questions

• What kind of follow-up care will I need to practice at home? - No special care is need. Just avoid bright light and administer the eye drops for a few days. • How soon can I resume regular activities? - When the blurriness is gone. • What symptoms should I watch out for and report? - If your eye becomes red, or if you develop a strong sensitivity to light. - If you have pain in or around the eye that is not relieved through the use of painkillers. - If you have a severe headache or vomiting. • Are there any activity limitations? - There are no specific activity limitations. - You should avoid driving on the same day that you have had an iridotomy done. • You have to administer anti-inflammatory eye drops.

At a follow-up visit after the procedure and questions to ask the patient • • • • • • • • • • • •

How is your eye? How is your vision? Any complications? Have your eyes been red? Have you had any trouble with your eyes following the iridotomy? Any itchiness or irritation? Have there been any changes in your vision, distortion of images, or any glare? Do you feel pain in or around the eyes? Are you sensitive to light? Are you still taking the anti-inflammatory eye drops? Next, I will examine your vision. Could you read the chart please? Then, I’ll take a look at the drainage part of the eyes by performing a gonioscopy.

Vitreous Degeneration Chaisiri Jumroendararasme

Doctor: Good morning Mr….. How may I help you today sir? Patient: Good morning Doctor. I have been seeing something moving in my eye for a week.

Patient: Okay Doc. I came with my wife, she can drive me home. Will it hurt?

Doctor: What do they look like? / Could you describe their shape? In which eye do you see the floaters? Patient: I see them in both eyes but more in my left one. They look like parts of a web or a thin shadowy curtain moving around. There is no pain.

Doctor: No, it is not painful but the drops may burn a little bit. I will administer a numbing drop first. After your pupils are dilated, I will use a bright light to check the back part of your eyes. Patient: Good. I hope that you will not find anything bad.

Doctor: Are they increasing in number? Have you also been seeing any flashing lights? Patient: They are not increasing but they never disappear and they are quite annoying. I sometimes see a sparkling light, especially at the corner of my left eye.

After fundus examination:

Doctor: Are you nearsighted? What is the power of your glasses? Patient: Yes, I am nearsighted. I am wearing minus four diopter glasses. Doctor: I see. There are a few conditions that could cause a problem like this. May I take a look at your eyes? Explaining and asking to perform pupil dilatation: Doctor: After taking a careful look, the front parts of your eyes appear normal. There is no inflammation. I would like to administer some eye drops to dilate your pupils, so that I can better see what is happening inside your eyes. This will take roughly 20 minutes and you may experience blurry vision for 4-6 hours afterward, is that okay? Did you drive your car here today?

Doctor: I have good news for you. You have a simple condition that we call “vitreous degeneration.” This is a condition that happens to every single individual at your age and is a part of the normal aging process. I will explain more about this condition. Human eyes normally contain a clear gel inside called vitreous. As we age, this gel will also change and degenerate over time. The degenerating vitreous contains hazy particles inside. It can also shrink and cause some traction on your retina, which is a thin tissue located at the back part of your eye. The traction can sometimes cause a small hole or tear of your retina, which could lead to a condition called retinal detachment. This retinal detachment can cause poor vision. For this reason, we need to check your eyes with the pupils dilated.

But donâ&#x20AC;&#x2122;t worry, after a complete examination, I found that you have only a simple degeneration of your vitreous. There is no tear of your retina. However, in the future, there is a small chance that the retinal tear or detachment could happen, so I will need to see you periodically to follow-up until things are stable. In the meantime, I would like you to periodically check yourself by closing each of your eyes separately. You need to come back sooner than your appointment if you notice any of the following: 1. Decreased vision 2. A significant increase in the number of floaters. 3. Repeated episodes of flashing light, especially if at the same location and accompanied by increasing floaters. 4. Narrowing of your visual field. If you experience any of these, please call an eye care facility immediately to arrange for an urgent appointment. Patient: I see. Thank you very much Doc.

Central Serous Chorioretinopathy Voraporn Chaikitmongkol

Doctor: Good morning Mr. Johnson. What can I do for you today? Patient: Good morning doctor. I think my right eye has been blurry for 2 weeks, and I also noticed a black spot in my right eye while I was reading.

Doctor: Well, this condition could happen by itself without any known cause, or there may be some aggravating factors including steroid use, or stress. Do you have any of these risk factors? Patient: Hmm… I don’t think so.

Doctor: I see. What does the black spot look like and is it floating around? Patient: It’s round-shaped like a coin… grayish… and I think it does not move… it just stays in my central vision.

Doctor: Do you have any underlying medical diseases? Patient: Nope.

Doctor: Got it. Do you have any distorted vision? For example, when you look at the doorframe or a straight line, does it became distorted? Patient: Yes, I have had distorted vision in my right eye for a couple of days. Doctor: I see. Let me take a look at your eyes. Anterior segment examination and fundus evaluation were performed. Doctor: The cause of blurriness in your right eye is a condition called “central serous chorioretinopathy” which is an accumulation of fluid at the back part of your eye. Let me show you the diagram of the human eye, the back part of your eye is called the retina, and the area responsible for central vision is called the macula. Right now you have a small amount of fluid accumulated under your macula, which is the cause of the blurry and distorted vision. Patient: So... why has this condition happened to my eye?

Doctor: Have you taken any dietary supplements or herbal medicines lately? Patient: No. Doctor: I see. So, it’s possible that your condition might occur by itself, and today we can just observe your right eye. In 80-90% of people with this condition, the retinal swelling improves by itself within 3-4 months without any treatment. If the fluid persists after 3-4 months, then we will need further treatment to get rid of the fluid. Well, this is not a serious condition and would not lead to blindness. Please don’t worry, and just observe your symptoms. Patient: Do I need any eye drops? Doctor: No, the eye drops will not help. Just be reassured and observe your symptoms. I would like to see you again in 4 weeks. Patient: I see. I will see you in 4 weeks. Thank you so much doctor. Doctor: My pleasure. See you then. Have a great day.

Introduction You seem to have a problem with your retina at the back of the eye. I recommend a retina imaging exam. The procedure is called Optical Coherence Tomography “OCT.” This machine is similar to an ultrasound but uses light instead of sound to produce images. It will give us information about the cross section of your retina. You will not feel any pain. It is not harmful for your eyes. The entire procedure only takes a couple of minutes. You just have to place your chin on the chin rest and forehead against the bar. Look straight and steadily at the red/blue/green light in the machine. During the exam, you can blink if you feel uncomfortable but try not to blink frequently.

Procedure Explanation Guide of Optical Coherence Tomography

OCT in Retina

• Please place your chin on the chin rest and forehead against the bar. • Look steadily at the spot of light in the machine with your right/left eye. • You can blink if you feel uncomfortable. • Blink your eye, please.

• Stay still, please. • Follow the light (in the machine), please. • Please move your chin to the right/left to examine your other eye. • You can sit back. • We are done.

Sritatath Vongkulsiri

Reporting the result The OCT shows • Swelling/ thinning/ loss/ of your retina. • Cyst/ haziness/ accumulations in (on, beneath, under) the retina. These findings are consistent with….(diagnosis)…. Compared to the last exam, it’s improved (better/worse/the same). Compared to the last study, it decreases (increases) in …………. You should have….(treatment)…. I will see you in….(FU period)…. These images are your baseline and will be used for comparison with images after treatment. You will have to do this imaging again before you meet with me next time (after you have the screening exam).

Orbit, Eyelid and Lacrimal System Preamjit Saonanon

Eyelid History and Physical Examination

• How long have you experienced these symptoms? Has it been since birth? • Does it get worse over the day? Does anything make it better/worse? • Did you have any pervious accidents or surgery around your eyes? • Do you see double? • I will check your eye (eyelid movement), please follow my finger. • Squeeze your eyes shut, please. • I will check your eye with this flashlight, look straight ahead. • I will turn your eyelid inside out, please look down. • I will pull down on your eyelid, please look up. • I will pull your eyelid and let go, please try not to blink.

Myasthenia gravis Dermatochalasis and Blepharoptosis Entropion Discussion

• You might have a muscle problem called Myasthenia Gravis (MG). To confirm this diagnosis, I will place this ice pack over your eyelid for 2 minutes. Please close your eye. After I remove the ice pack, open your eye and look straight forward. • I will show you the results, you can see that your eyelid is not drooping anymore. I will have you run some more tests including a blood exam to confirm the diagnosis. If you have MG, your droopy eye can be treated with medication and you might not need surgery. • You have a condition call blepharoptosis (dermatochalasis), which means that you have droopy eyelids. This occurs in most people when they get older. We can help you by performing an eyelid surgery to tighten your eyelid muscle (get rid of the excessive skin). • You have an inward (outward) rotation of you eyelid. Your lashes touch the eye and make your eye uncomfortable. This occurs in some people as they get older. We can help you by performing a surgery to set your eyelid back to the proper position. 75

Discussion

Proptosis History and Physical Examination

• How long have you noticed your eye popping out? • Did it come on suddenly or has it been gradually getting worse? • Has it gotten better, worse or stayed the same since you first noticed the condition? • Do you have any pain (pain when your move your eye)? • Do you have a thyroid disease? Do you feel your heart racing? Any weight loss? Any change in your appetite? • Do you see double? • How is your vision? • I will check your eye muscles, please follow my finger. • I will check your eye with this flashlight, please look at my nose. • I will check your eyes, place your chin on this chin rest and lean your head forward. • Let me touch around your eye, please close your eyes. • I will use this instrument (Hertel) to measure your bulging eye, please look at my nose. • To check your vision, I will send you to have a visual field and color test. 76

• The examination shows that your eye is completely normal. I think you might have a problem behind your eyeball that is pushing your eye forward. We need to perform a CAT scan to see what is going on. • I think you might have a thyroid disease. With this disease, your own immune system attacks your body. The thyroid gland and the eyes can be attacked at the same time. You will need a blood test to assess your thyroid function. At this time, we are still unsure as to why this happens. A series of surgeries will help to return your eye to the previous position, but we have to wait until it is stable first.

Lacrimal system History and Physical Exam

• How long have you had a watery eye? Which eye, left, right or both? • Any discharge from your eyes? • Dose it come and go or is it constant? • Have you had any pervious accidents or surgeries around your eyes? • Have you experienced pain and swelling around this area (lacrimal sac)? Have you had any prior infections of the lacrimal sac? • I will check your tear system by using this small cannula. It is not a needle. I will administer numbing drops into your eye first.

Discussion

• You have a watery eye because the tear duct inside your nose is obstructed. This can occur when you get older. We can help you by creating a new tear passage to reconnect your tear system and the drainage channel in your nose. There are 2 options for you. We can do the surgery through your skin where you will have a small surgical cut at the medial corner of your eye. Alternatively, we can do it through your nose. The first option is simpler, has a little bit higher success rate and can be done under local anesthesia. The second option is a bit more complicated and requires general anesthesia but there will be no scar on your face. You can also choose to do nothing but you have to be aware that the tear duct might get infected. • Dacryocystitis: You have an infection of your lacrimal sac. This occurs because you have an obstructed tear duct. I will prescribe an antibiotic and ask you to come for a follow-up appointment in one week. You will most likely need surgery afterward or it can get infected again. • You have a watery eye because your eyelid is not in the proper position. When you blink, your eyelid functions as a pump to drain your tears out. This condition can occur when you get older. If this is bothering you enough, we can help you by performing an eyelid surgery. 79

A 59-year-old man presented with double vision. Doctor: Good morning Mr……. Please have a seat. How are you today? Patient: Good morning doctor. I’m fine. How are you? Doctor: I’m good. Thank you. What can I do for you today? Patient: I have been experiencing double vision for the last 2 days, and it has been progressively worsening. Doctor: I see. Is the double vision present with both eyes open and absent when either eye is closed? Patient: The double vision disappears when I close either eye. Doctor: Could you please describe your double vision? Is the separation of images vertical, horizontal, or oblique? Patient: The two separated images are side-by-side. Doctor: Do you have it all the time or intermittently? Patient: I see it all the time, it’s so annoying! Doctor: Is there any particular gaze or head position that makes it disappear? And, is there any specific gaze or head position that makes the double vision more pronounced? Patient: When I look to the left-handed side, the double vision appears more separated. So I prefer to turn my head slightly to the left to avoid the double vision. Doctor: Is the double vision worse at a distance or when focusing near to you? Patient: At a distance. I can read and see near to me quite well.

Diplopia Supharat Jariyakosol

Doctor: Does the double vision change as the day goes on? Patient: Umm, not really. It’s about the same all day long.

Doctor: Do you have allergies to any medications? Patient: Not that I’m aware of.

Doctor: Have you experienced any drooping of the eyelids? Patient: No, doctor.

Doctor: Are there any medical problems or eye problems that run in your family? Patient: There were no eye problems in my family. My father was diagnosed with prostate cancer when he was 60 years old.

Doctor: Do you have any fever, headache or pain when you move your eyes? Patient: Not at all. Doctor: Do you have any neurological symptoms such as dizzy spells, ringing in your ears, weakness, or abnormal sensations? Patient: No, sir. Doctor: How is your vision? Patient: When I close either eye, I can see normally. Doctor: Have you ever had any eye problems, such as a lazy eye or squint? Did you have to patch your eyes as a child? Patient: Not as far as I know. Doctor: Do you have any health problems such as diabetes, high blood pressure, or hyperlipidemia? Patient: I don’t think so. I have always had normal blood pressure. Actually, I have never been checked for diabetes or my cholesterol level. Doctor: I see. Are you currently taking any medications? Patient: I take a multivitamin once a day. Doctor: Do you smoke or drink alcohol? Patient: I used to smoke 2 cigarettes per day for a few years. I quit smoking about 20 years ago. 82

Doctor: Oh, so sorry about that. Thank you for your information. Let me examine your eyes. (Complete Neuro-ophthalmologic examination and funduscopic examination were performed) Doctor: The cause of your double vision is a condition called “cranial nerve sixth palsy” in the left eye. The cranial nerve sixth normally innervates the ocular muscle which moves the eyes away from the nose to the temporal gaze. You have a weakness of the left cranial nerve sixth, which causes your left eye to cross inward toward the nose with a limitation of the left gaze in the left eye. As you have been noticing, the separation between the two images is greatest in your left gaze. Patient: Why does this condition happen to me? Is it dangerous? Doctor: There are several possible causes of this condition, such as poor blood supply, inflammation, infection, or a mass lesion compressing on the cranial nerve sixth. I would like to obtain a blood work-up and order MRIs of the brain and orbits for further evaluation. I also recommend an ENT consultation for a nasopharyngeal mass examination. We will discuss things again later once you have completed all investigations.

(After complete investigation) Doctor: Your brain orbits and MRI were completely normal. But, your fasting blood sugar was highly elevated up to 320 mg/dl, consistent with a diagnosis of diabetes mellitus. I recommend that you follow up with your family doctor to control your blood sugar. Patient: Oh, is it related to my double vision?

Doctor: Yes. The normal brain orbits imaging indicates that the most likely diagnosis is diabetes mellitus. Your symptoms are probably caused by a microvascular sixth nerve palsy-a cranial nerve sixth ischemia. Your double vision might show some improvement over the next 3-6 months. I recommend that you occlude your left eye with a frosted lens since your ocular alignment may change with time. Let me show you how to tape a lens to your glasses to suppress your double vision in the interim. Patient: Umm, I like this technique. I see single now! Doctor: After 3-6 months, if there is a stable small residual ocular deviation, I will prescribe prism glasses to correct your double vision. Finally, if there is a large residual ocular deviation at 1 year, we will consider strabismus surgery. Patient: I see. Doctor: I have arranged to see you back in 1 month for a follow-up, but please contact me sooner should any new concerns arise. Any questions, sir? Patient: No. Thank you very much doctor. I really do appreciate your explanation. See you in a month. Doctor: My pleasure. Have a great day.

Congenital Esotropia and Amblyopia Warachaya Phanphruk

A parent came to the hospital because she noticed that her 2-year-old child had a squint. Doctor: Hello/Good morning Mr./Miss/Mrs………………… Please have a seat. I’m Dr………………I’ll be your doctor/ ophthalmologist today. How can I help you today? Parent: Good morning doctor. My child has a problem with her eyes. I noticed that sometimes she has crossed eyes. Doctor: Let’s see. How long have you noticed that the child has had a squint? Parent: Actually, I have noticed this since she was about 2 months old. Doctor: Does the child have just brief/intermittent or constant squinting /crossed eyes? Parent: Well, I think that she had just brief squinting previously, but now I have noticed that she has crossed eyes almost all the time.

Doctor: Does the child fixate on your face or a stimulus? Parent: Yes, she can fixate and follow a stimulus or moving object very well. Doctor: May I ask about associated disorders or risk factors of a squint? Was your child born prematurely? Parent: No, she was born as a full-term baby. Doctor: Did your child have perinatal complications such as birth asphyxia or perinatal hypoxia? Parent: No, she did not. Doctor: Does your child have any other associated abnormalities/ problems? Parent: No, she has no underlying diseases. Doctor: Is your child developing normally?/ Has your child had a developmental delay? Parent: She has normal development for her age.

Doctor: Is the squint/crossing worse when the child is tired? Parent: Yes, it is more pronounced when she is tired.

Doctor: Does your child have a family history of strabismus? Parent: No, she does not.

Doctor: Is it most noticeable when the child is looking at a distance or when the child is staring at things near to her? Parent: I think it seems to be almost the same whether she fixates at a distance or at a near target.

Doctor: Has your child had a previous traumatic history? Parent: No, she has not.

Doctor: Did you notice that the child has a deviated eye on either or both eyes? Parent: I think both eyes deviate, but her left eye shows a squint more often. Doctor: Do you think it is getting better or getting worse? Parent: I think it is getting worse.

Doctor: Has your child had any previous treatments for the squint such as patching or glasses? Parent: No, she has not started any treatments yet. Doctor: Alright, thank you very much for the useful information. I have to check if your child’s eyes have any refractive errors or associated abnormalities that may be causing the squint. We will discuss the results of the examinations.

**Advise parent about cycloplegic refraction: • Occasionally, young children with refractive errors may have a squint when trying to see things without glasses. • We have to check if your child’s eyes have any refractive errors that may cause her to have a squint. The cycloplegic drops are needed to obtain an accurate refraction. • The drops may have some ocular side effects such as temporary blurry vision or cause ocular irritation. Rarely a child can develop redness, swelling around the eye, a fever or facial flushing. There is a very rare risk of serious cardiovascular side effects. • We will closely observe and monitor the child for a while during and after administering the drops. • Again, these drops are important for the most accurate measurement of refractive errors in children.

**Advise parent about fundus examination: • The squint may be presenting signs of other eye (ocular) conditions/problems. • The child should be examined for the back (posterior) part of the eyes after pharmacological dilatation of the pupil. We have to put drops on the child’s eyes. It may cause temporary blurry vision for 4-6 hours. The drops may cause ocular or systemic side effects, but serious side effects are highly unusual. After a complete strabismus examination was performed, cycloplegic refraction and fundus examination were evaluated. 88

**Advise parent on results of the examinations: Doctor: As I have completely evaluated your child’s eyes, the examinations showed that the child has a congenital esotropia (eye misalignment) and a fixation preference on her right eye. You may notice that the child prefers to use her right eye which makes her left eye turn inward. A squint causes the deviated eye to develop an amblyopia or lazy eye and may decrease vision. However, the complete examinations reveal no evidence of other associated ocular abnormalities or any significant refractive errors that may cause the squint. The child will need close follow-ups to reevaluate for abnormalities. Parent: Is it possible to treat the lazy eye? Doctor: Absolutely, but the effectiveness of the treatment will depend on the patient’s compliance. We’ll start to treat a lazy eye with an occluding (patching) which is a safe and effective therapy. I will prescribe patching/ occluding over the better-seeing eye to treat your child’s amblyopia for 2 hours/day. The patching can help to encourage the use of the deviated eye and improve vision in that eye over time. We need to make an appointment to reevaluate the visual improvement of the amblyopic eye and verify stability of the squint.

Parent: How about the surgery? Doctor: Well, it is crucial to treat the amblyopia before doing a surgery. The aims of the treatment are to improve the chance of having binocular vision and to reduce the deviation as much as possible. If your child improves her vision in the deviated eye (lazy eye) and the amount of eye deviation remains stable, a surgical correction may also be required to straighten the eyes. Parent: I see. Thank you very much for your advice. Doctor: My pleasure. May I request that you make a follow-up appointment in 2 weeks to check the improvement of the amblyopia after occlusion therapy? Parent: Of course, we will come to see you in two weeks. Doctor: Do you have any further questions? Parent: No, thank you very much. Doctor: Alright, see you again next time. Have a nice day. Parent: See you, doctor. Thank you.

Authors Chaisiri Jumroendararasme, MD

Atchareeya Wiwatwongwana, MD

Retina Service Department of Ophthalmology Phramongkutklao Hospital Phramongkutklao College of Medicine

Assistant Professor, Pediatric Ophthalmology and Strabismus Unit Department of Ophthalmology Faculty of Medicine Chiang Mai University

Puwat Charukamnoetkanok , MD

Preamjit Saonanon, MD

Ophthalmic Plastic and Reconstructive Surgery Unit Department of Ophthalmology Faculty of Medicine Chulalongkorn University

Cornea & External Diseases Unit Department of Ophthalmology Mettapracharak (Wat Rai Khing) Hospital Project Director National Eye Institute of Thailand Initiative Treasurer The Royal College of Ophthalmologists of Thailand

Vatookarn Roongpoovapatr, MD FICO, M.B.A. Tharikarn Sujirakul, MD, FICO Retina Service Department of Ophthalmology Ramathibodi Hospital Mahidol University

Cornea and Refractive Surgery Unit Department of Ophthalmology Mettapracharak (Wat Rai Khing) Hospital

Thitiporn Ratanapojnard, MD

Assistant Professor, Retina Service Department of Ophthalmology Phramongkutklao Hospital Phramongkutklao College of Medicine Secretary General The Royal College of Ophthalmologists of Thailand

Voraporn Chaikitmongkol, MD Retina Division Department of Ophthalmology Faculty of Medicine Chiang Mai University

Weerawat Kiddee, MD Supharat Jariyakosol, MD

Neuro-ophthalmology Unit Department of Ophthalmology Faculty of Medicine Chulalongkorn University

Sritatath Vongkulsiri, MD

Retina Service Department of Ophthalmology Phramongkutklao Hospital Phramongkutklao College of Medicine 92

Warachaya Phanphruk, MD

Assistant Professor, Glaucoma Unit Department of Ophthalmology Faculty of Medicine Prince of Songkla University

Pediatric Ophthalmology and Strabismus Unit Department of Ophthalmology Faculty of Medicine Khon Kaen University

To laugh often and much, To win the respect of intelligent people and the affection of children, To earn the appreciation of honest critics and endure the betrayal of false friends, To appreciate beauty, To find the best in others, To leave the world a bit better, whether by a healthy child, a garden patch or a redeemed social condition, To know even one life has breathed easier because you have lived. This is to have succeeded.

Published by The Royal College of Ophthalmologists of Thailand (RCOPT) 10th Floor, Royal Golden Jubilee Building 2 Soi Soonvijai, Petchaburi Road, Bangkapi, Huaykwang, Bangkok 10310 T. +66 2 718 0715-6 F. +66 2 718 0717 W. www.rcopt.org www.facebook.com/RCOPThailand www.facebook.com/AllAboutEyebyRCOPT Editors Puwat Charukamnoetkanok, MD Thitiporn Ratanapojnard, MD Associate Editor Paisan Ruamviboonsuk, MD Designed by art4d / Corporation 4d 81 Sukhumvit 26 Bangkok 10110 Thailand www.art4d.com Printed by Focal Image All images courtesy of the Royal College of Ophthalmologists of Thailand (RCOPT) ÂŠ 2015 the Royal College of Ophthalmologistsof Thailand (RCOPT) All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy or any storage and retrieval system, without written permission from the publisher. Printed in Thailand

Ralph Waldo Emerson 94