Introduction to Eye Problems

in Indonesia

Gitalisa Andayani
Department of Ophthalmology, FKUI
Jakarta 2008
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The EYE
Most vital sensory organ
(80% of information obtained from vision)
Delicate
Eye problems:
- encountered in everyday clinical practice
- may cause visual impairment
- worldwide health problem
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 12 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
Global causes of blindness

Source: Global Initiative for

the Elimination of Avoidable
Blindness : action plan 2006-
2011, WHO, 2007
Impact of blindness
Social burden:
Becoming other peoples 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)
Problem
Indonesia:
sporadic, local data in several regions
Most recent national data >10 years ago:
Survei Kesehatan Rumah Tangga 1996
(1.5%)
No data on Childhood Blindness

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SKRT:
Survei Kesehatan Rumah Tangga (1993, 1996)

Prevalence of Blindness in Indonesia:

increase from 1.2% to 1.5%

Prevalence of main causes of blindness:

- Cataract: est. 52% (backlog 1.5 million)
- Glaukoma from 0.1% in 1983, to 0.2% in 1996
Hospital-based (RS Cipto Mangunkusumo, 1982)
incidence of Glaucoma 1.8% among new patients
aged 40 yo, 65% of them blind
- Refractive Errors: 0,14%.
Jakarta: prevalence of school myopia 21 52%
- 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 Involves:
Blindness 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
Ophthalmology for GP
Knowing the anatomy and physiology of
the eye, and the pathogenesis of eye
diseases
Basic eye examination
Diagnosis of eye problems
Treatment planning: complete, initial, or
referral

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Anatomy of the eye

Upper eyelid Punctum

lacrimalis

Lateral Karunkula
Canthus

Conjunctiva Medial
Limbus Canthus
Cornea
Iris
Pupil
Lower eyelid
Anatomy of the eye
Ciliary Lens zonules
body Extraocular
Muscles

Macula
Cornea
Iris Vitreous Optic
Pupil (glass jelly) nerve
Lens
Limbus {

Retina

Anterior Posterior Choroid

Chamber Chamber Sclera
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 Conjunctivitis

Opacity of refractive media: decreased vision
Vasodilation of vessels of the conjunctiva
/episclera / sclera / cornea
Inflammatory (infection and non-infection)
Normal vision: conjunctivitis, scleritis, episcleritis,
pterygium, pinguecula
Decreased vision: acute glaucoma, keratitis, uveitis,
endophthalmitis
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Chronic visual decrease
Caused by chronic changes in the clarity of
refractive media or function
Abnormality of neural pathway (from
retina tovisual cortex)
Mostly: degenerative process
E.g: cataract, chronic glaucoma, diabetic
retinopathy, age-related macular
degeration (AMD)

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

kekeruhan lensa (katarak)

KATARAK
Tanda dan gejala
Dini:

- terkadang belum ada keluhan

- melihat kabut/asap
- silau
- sulit membaca

Lanjut:
- buram
- bercak putih pada pupil (lekokoria)
KATARAK
Penatalaksanaan
Bergantung kebutuhan penderita; bila

sudah mengganggu: OPERASI KATARAK

Teknik:
- Intracapsular Cataract Extraction(ICCE)
sudah ditinggalkan
- Extracapsular Cataract Extraction(ICCE)
mulai ditinggalkan
- Phacoemulsification
- Small-incision

Phacoemulsification
GLAUKOMA
kerusakan saraf optik, umumnya akibat peningkatan

tekanan intra okular (karena hambatan outflow)

gangguan lapang pandang
2 tipe: - glaukoma sudut terbuka
- glaukoma sudut tertutup

Saraf optik normal Saraf Glaukoma Saraf Glaukoma Lanjut

 GLAUKOMA
Tanda dan gejala
Tekanan bola tinggi > 21 mmHg (normal 10-21)
Sudut terbuka: tanpa gejala; bila ada sudah lanjut
(sering menabrak2, halo pelangi, nyeri sekitar mata)
Sudut terbuka: bisa terjadi glaukoma akut
tanda sisa serangan akut
(katarak, pupil lebar, iris atrofi)
Lapang pandang menyempit
GLAUKOMA
Penatalaksanaan
Observasi
Obat-obat glaukoma: - beta-blocker
- asetazolamid
- pilokarpin
Laser (iridotomi, trabekulotomi, trabekuloplasti)
Operasi (iridektomi, trabekulektomi, implant)
Retinopati diabetik

Gangguan retina akibat komplikasi diabetes

Glukosa darah meninggi
lama-lama pembuluh darah organ-organ

(terutama ginjal, saraf, mata) rusak

Penurunan penglihatan
Penyebab kebutaan terbesar pada
penderita diabetes
50% penderita diabetes setelah
10 tahun akan menderita retinopati
 Mekanisme kebutaan pada
retinopati diabetik

kebocoran cairan, aliran darah ke retina

lemak dan darah di retina menurun iskemia
dari pembuluh darah yg rusak
Edema makula

-perdarahan vitreus
- Jar fibrovaskular neovaskularisasi
- retinal traction PDR
ablasi retina

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 Retinopati diabetik

Retina normal Retnopati diabetik non-proliferatif FFA

Retnopati diabetik non-proliferatif Retinopati diabetik proliferatif Retinopati diabetik proliferatif

dengan traksi 7
AMD=age-related macular degeneration
Penurunan visus sentral perlahan akibat
degenerasi makula pada usia lanjut
mengenai kedua mata

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Acute visual loss
Caused by acute changes in
refractive media or function, or
acute disturbances in visual
pathway
May be associated with systemic
disease
E.g: retinal detachment, retinal
Retinal detachment
vascular occlusive diseases,
vitreous hemorrhage, optic neuritis,
optic neuropathies
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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 Objectives
Knowledge:
- pathology
- epidemiology, clinical features, pathogenesis
- scientific basis
- management, referral
- promotion and prevention
Skills:
- communication with patients
- integration of history and examination
- investigation
Attitudes:
- ethical behaviour
- confidentiality
- respect social, cultural backgrounds 35
Core clinical problems and
conditions

Acute decreased vision

Chronic decreased vision
Red eye, normal vision
Red eye, decreased vision
Ocular injury

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Physical examination skills
-Eye examination
-Visual acuity test
-Funduscopy
-Tonometry

Medical imaging knowledge

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

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Ophthalmology Department, FKUI/RSCM
Sub-specialty Clinics
Cornea & Refractive Surgery
Vitreo-Retina
Neuro-Ophthalmology
Tumor (Oncology)
Oculoplastic Reconstructive
Pediatric Ophthalmology
Strabismus
Glaucoma
Infection dan Immunology
Refraction
Ophthalmology Department
Operating Rooms
Ward: Public Wing (7th floor)
Emergency clinic

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 Ophthalmology
examination

Snellen Chart

Refraction
Pinhole test
Ophthalmology examination

Funduscopy
Ophthalmology examination

Schiotz Tonometry

Digital palpation Slitlamp biomicroscopy

+ applanation tonometer

Confrontation test
Welcome to Eye Department.

Use your time well

advice:
- do your best.!

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Thank you