Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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340 Surgery and Healing in the Developing World
Retinal Artery Occlusion
Retinal artery occlusion results in acute loss of vision with an afferent pupillary
reflex defect (loss of direct response to light). Typically on ophthalmoscopy a
cherry-red spot can be viewed at the macula of the retina. There is no dependable
treatment, but if seen within one hour of onset applying firm pressure to the eye and
releasing suddenly may dislodge an embolus.
Acute Glaucoma
This is an important cause of visual deterioration and usually presents with ocular
pain (see below).
Pink-Eye
This is a common complaint, with numerous pathologies. Most cases can be
treated simply and effectively. The key is to determine if they eye needs urgent attention.
The most serious problems involve acute degradation of acuity, severe pain
and slow or absent pupillary reflexes. These symptoms should be assessed in the
presenting patient and the cornea examined.
Conjunctivitis
Conjunctivitis is predominantly bilateral and does not affect acuity or pupillary
reflexes. Discharge may be present (greater amounts in bacterial conjunctivitis) and
can stick the lids together. Allergic, viral and bacterial causes are common. All are
usually self-limiting. Treatment of bacterial conjunctivitis is with antibiotic drops
(e.g., gentamicin 0.3% every 3 hours, 0.3% ointment at night).
Iritis
The patient will complain of acute pain, blurred vision, photophobia, and redness.
There may also be excessive lacrimation and a small or irregular pupil. Pain will
increase when the pupils are caused to constrict by accomodation. Treatment is with
steroid drops (prednisolone 0.5%, 1 drop every 2 hours) to reduce inflammation
and cyclopentolate (0.5%, 1-2 drops every 6 hours) to prevent the lens adhering to
the iris. Treatment should be closely monitored.
Acute Glaucoma (Closed-Angle)
Glaucoma commonly presents with an initial phase of blurred vision or halos
followed by acute uniocular pain. Pain may be accompanied by nausea and vomiting
in servere cases. This pain is caused by a drainage blockage in the anterior chamber
of the eye, causing intraocular pressure to rise above 60 mm Hg (normally 15-20
mm Hg). The cornea will appear red and hazy; the pupil is fixed and dilated.
The treatment of choice is pilocarpine 2-4% drops hourly with acetazolamide
500 mg STAT followed by 250 mg every 8 hours. After symptoms settle the patient
should be treated as for chronic glaucoma.
Manufacturing Antibiotic Eye Drops
It is cheaper, and very simple, to manufacture your own antibiotic eye drops.
The drops should be prepared in multiuse containers using aseptic technique.
Most antibiotic drops can be prepared using normal IV preparations diluted
with normal saline to the required concentration. These drops will remain stable for
the same period as for IV solutions (see product data sheets). One solution that is
prepared slightly differently is gentamicin forte. This can be produced by adding 2