11 - Ophthalmology Conditions 1 Flashcards

Question

What is blepharospasm, what causes it and how is it treated?

Answer 1

Focal dystonia resulting in involuntary eye closure. Made worse by exaggerated blinking **_Causes:_** Idiopathic, Parkinson's, Neuroleptics, paraneoplastic **_Treatment:_** Botox injections, Anticholinergics, Dopamine agonists

Answer 2

- Reduced tear production due to old age - Sjogrens, Sarcoidosis - Mucin deficiency in tears - Excessive evaporation of tears in post-exposure keratitis - Allergies - Blepharitis **_Ix:_** Schirmer's Test \>15mm in 5 minutes **_Mx:_** Artificial tears, Lubricating drops, surgery to decrease size of punctum lacrimale so slower drainage of tears

Answer 3

**- Bacterial:** mucopurulent discharge, can be bilateral but starts unilateral and spreads to other, worse in the morning **- Viral (usually adenovirus):** watery discharge, usually unilateral, lasts longer, often lymph node swelling pre-auricular **- Allergic**: watery discharge, seasonal or triggers, bilateral, cobblestone papillae on eyelid

Answer 4

- Red eyes - Bloodshot - Itchy or gritty sensation - Discharge from the eye (watery in viral, mucopurulent in bacterial) * Should be no pain, photophobia or decline in visual acuity * Highly contagious

Answer 5

**Hyperacute:** rapidly progressive that is caused by N.Gonorrhoea and N.Meningitidis. Eye produces large amounts of purulent discharge. Severe and potentially sight-threatening. **Opthalmia Neonatorum:** conjunctivitis in the first 28 days of life, usually due to Chlamydia or Gonorrhoea **Trachoma:** Inflammation of cornea and conjunctivitis. Chlamydia trachomatis in children in sub-Saharan Africa. Leading cause of infective blindness worldwide.

Answer 6

**- Self limiting** in 1-2 weeks **- Symptomatic relief:** cool compress, lubricating eye drops, cleaning eyes with cooled boiled water - **Prevent spread:** good hand hygeine and separate towels **- Safety netting:** if photophobia, change in vision etc - Don't wear contact lenses until resolved **- Medical:** if bacterial can give ***Chloramphenicol*** and ***fuscidic acid drops*** to speed up recovery but will still resolve on it's own without these - If in baby \<1month urgent referral as sight threatening and risk of complications like pneumonia

Answer 7

- Contact lens wearers - Immunocompromised - Sexually transmitted

Answer 8

**- Antihistamine drops or PO:** Emedastine or olopatadine **- Sodium cromoglicate:** Mast cell stabilisers to stop mast cells producing histamine. Need to use for few weeks before seeing effect **- Steroid drops**

Answer 9

Opacifiation of the lens. One of the leading causes of blindness - Congenital - Age related - Trauma - Uveitis - Scleritis - Intra-ocular tumours - Radiation - Medications (e.g. corticosteroids, amiodarone) - Systemic disease (e.g. diabetes mellitus, myotonic dystrophy, severe atopic dermatitis)

Answer 10

- Increasing age - Smoking - Alcohol - Diabetes - Steroids - Hypocalcaemia - UV exposure

Answer 11

Depending on the location of the lens affected **Nuclear:** Involves central nucleus of the lens. Clinically there is central opacification, significant loss of colour and slow progression **Cortical:** Involves the cortex of the lens. Less degradation of vision and slow progression **Posterior subcapsular:** Involves the subcapsular cortex. Disabling glare to bright lights, quicker progression. Linked to diabetes and steroid use

Answer 12

Absence of red reflex in newborn screening

Answer 13

Lens is made of soluble protein **crystallin** Due to poor blood supply, containment within a capsule and inability to shed non-viable cells, lens is susceptible to damage from normal ageing and environmental insults (e.g. UV light and oxidative stress) **Central nucleus may become compressed,** hardened and undergo **nuclear sclerosis**, which is seen clinically as **opacification** Without transparency, light is unable to be refracted onto the retina

Answer 14

**_Symptoms_** - Painless slow loss of vision - Blurring of vision - Poor night vision - Seeing 'Starbursts' around lights and sensitivity to light - Reduction in colour intensity, everything yellow/brown **_Signs on Examination_** - Reduced visual acuity on Snellen charts - Loss of red reflex - White/grey pupil - Nystagmus

Answer 15

Clinical diagnosis by finding opacification on opthalmoscopy: - Loss, or darkening, of the red reflex - Opacification seen within the red reflex - Obscuration of ocular detail Refer non-urgently to opthalmologist to look in slit lamp

Answer 16

Cataracts surgery is indicated **when vision is impaired to the point it is having a significant effect on activities of daily living** Removal of the diseased lens and replacement with an artificial lens Can be done by **Phacoemulsification** or **Standard extracapsular cataract extraction** After surgery can see retina and may be underlying pathology e.g AMD, diabetic retinopathy

Answer 17

- Phacoemulsification used in the UK - Done under local anaesthetic with patient prone - Entry to eye made via limbus (peripheral cornea) with self sealing incision - Circular incision in anterior lens capsule is made and lens removed via US - New lens with refractive correction placed in patients eye

Answer 18

**- Retinal detachment** **- Anterior uveitis** **- Vitreous haemorraghe** **- Glaucoma** **- Posterior capsule thickening** **- Astigmatism** **- Endophalmitis:** Inflammation of the inner contents of the eye, usually infection that can lead to loss of vision. Intravitreal antibiotics injected into the eye

Answer 19

- Use topical antibiotics for 3-6 weeks postop - If phacoemulsification can return home immediately and resume normal activities the next day. Other methods take longer to recover

Answer 20

- Stop smoking - Wear sunglasses with UV protection - Eat antioxidants e.g vit c, caffeine

Answer 21

Needs to be treated within first 4 weeks to prevent significant deprivation amblyopia

Answer 22

**Occlusion of the central retinal artery** (branch of ICA) which causes ischaemia of the retina and **sudden monocular visual loss** **Opthalmic emergency** as is a stroke of the CRA

Answer 23

**- Carotid artery atherosclerosis** **- GCA** - Cardioembolic event from AF - Carotid artery dissection - Fibromuscular dysplasia

Answer 24

- Any atherosclerosis risk factors - Any GCA risk factors

Answer 25

**- Sudden painless loss of vision** **- May have central vision sparing** if patent cilioretinal artery **- RAPD** **- Fundoscopy:** will see ***pale retina*** (lack of blood supply) and ***cherry red spot*** (macula thinner so can see choroid through it)

Answer 26

GCA!!! As steroids can be sight saving. Always do ESR/CRP and temporal artery biopsy and start high dose steroids in case!!!!

Answer 27

**_Immediate (\<100 min still poor chance of regaining vision)_** **- Ocular massage** **- Remove fluid** from anterior chamber to reduce IOP **- Inhaling carbogen** (a mixture of 5% carbon dioxide and 95% oxygen) to dilate the artery **- Sublingual isosorbide dinitrate** to dilate the artery **_Long term:_** - Reduce CVS risk factors - Consider need for antiplatelets, statins, antihypertensives

Answer 28

**- Permanent loss of vision:** even if caught early **- Increased risk of CVD** **- Glaucoma and Vitreous haemorraghe**: the retinal ishcaemia may lead to neovascularisation and these vessels can leak

Answer 29

- Arteriosclerosis - HTN - Diabetes - Polycythaemia - Glaucoma

Answer 30

**Sudden painless loss of vision** if central retinal vein due to macular oedema and ischaemia. If branch retinal vein can be asymptomatic. More common than CRAO **_Pathophysiology_**: Blockage of blood flow so pooling of blood in retina, ***fluid leakage*** that causes ***macular oedema*** and ***retinal haemorraghes***. Leads to the release of ***VEGF*** so ***neovascularisation*** occurs

Answer 31

- Flame and blot haemorrhages (cotton wool spots) - Optic disc oedema - Macula oedema

Answer 32

- Full medical history - FBC for leukaemia - ESR for inflammatory disorders - Blood pressure for hypertension - Serum glucose for diabetes

Answer 33

- Refer immediately to oncall opthalmologist - Treatment to control secondary complications e.g **macular oedema, vision loss**, **neovascularisation** **_Treatment:_** - Anti VEGF if vision loss to prevent neovascularisation - Intravitreal steroid (dexamethasone) - Laser photocoagulation if neovascularisation has already occured Intravitreal steroids (e.g. a dexamethasone intravitreal implant)

Answer 34

**Always vascular occlusion or vascular haemorraghe!!!** ## Footnote - Hyperglycaemia damages retinal small vessels and endothelial cells **Increased vascular permeability** leads to leakage from the blood vessels, **blot haemorrhages** and the formation of **hard exudates** - Damage to blood vessel walls leads to **microaneurysms** and **venous beading** - Damage to nerve fibres in the retina causes fluffy white patches to form on the retina called **cotton wool spots** **- Intraretinal microvascular abnormalities (IMRA)** is where there are dilated and tortuous capillaries in the retina. These can act as a shunt between the arterial and venous vessels in the retina. **- Neovascularisation** due to VEGF released

Answer 35

**_Non-proliferative diabetic retinopathy: (Ischaemia)_** **- Mild:** microaneurysms **- Moderate:** microaneurysms, blot haemorhages, hard exudates, cotton wool spots and venous beading **- Severe:** blot haemorrhages plus microaneurysms in 4 quadrants, venous beating in 2 quadrates, intraretinal microvascular abnormality (IMRA) in any quadrant **_Proliferative Retinopathy (New vessels on retina that can leak)_** - Neovascularisation - Vitreous haemorrhage **_Maculopathy (Vessels leak close to macula)_** - Macular oedema - Ischaemic maculopathy

Answer 36

- Maculopathy - Severe NPDR - Proliferative retinopathy

Answer 37

Pre-symptomatic screening to allow **faster laser photocoagulation treatment** Both type 1 and type 2 need **screening on diagnosis and annualy after** Screening by **dilated fundus photography.** Usually in posterior pole

Answer 38

**- Ensure good diabetic control and BP \<140/80**: do not correct refractive errors until good glycaemic control as refractive index becomes more hypermetropic with treatment **- Laser photocoagulation:** for proliferative retinopathy and macula oedema **- Intravitreal Anti-VEGF and Vitreoretinal surgery:** addition to photocoagulation with macula oedema

Answer 39

- Pregnancy - Dyslipidaemia - HTN - Renal disease - Smoking - Anaemia

Answer 40

- Retinal detachment - Vitreous haemorrhage - Rebeosis iridis (new blood vessel formation in the iris) - Optic neuropathy - Cataracts - Glaucoma - CN palsies (3 and 6) with pupil sparing

Answer 41

Inflammation of the cornea, usually due to infection **- Viral:** Herpes simplex **- Bacterial**: Pseudomonas or Staphylococcus **- Fungal:** Candida or Aspergillus **- Contact lens acute red eye (CLARE)** **- Exposure keratitis:** Inadequate eyelid coverage (e.g. eyelid ectropion)

Answer 42

Usually need disruption to the epithelial surface of the cornea: - Contact lenses - Dry eyes - Trauma - Corneal disease - Immunocompromised

Answer 43

**- Painful red eye** (free nerve endings exposed and increased vascularity) **- Watery eye** **- White deposit on cornea** (corneal infiltrate) - May have **hypopyon** **- Drop in visual acuity** (due to corneal oedema)

Answer 44

**_Presentation:_** painful red eye, photophobia, watery eye Can lead to stromal necrosis, vascularisation and **corneal scarring** so **corneal blindness**!!! Need to ask about previous mouth and genital ulcers

Answer 45

**_- Slit lamp exam with fluroscein staining:_** will show ***dendritic ulcer*** **_- Corneal scrapings/swab_:** send for PCR

Answer 46

**- Same day referral to** opthalmology **- Topical aciclovir or ganiclovir ointment** **- Steroid drops** (for stromal keratitis only use with aciclovir cover as otherwise risk of scarring and blindness) **- Corneal transplant** (if significant blindness from stromal keratitis)

Answer 47

Can be acute or chronic (\>3months and often granulomatous) **Anterior uveitis:** inflammation affecting the iris (iritis) or ciliary body (iridocyclitis) **Intermediate uveitis:** inflammation of posterior part of ciliary body and nearby peripheral retina and choroid **Posterior uveitis**: inflammation of retina and choroid **Panuveitis:** inflammation of whole uveal tract

Answer 48

- Autoimmune conditions - Infection - Trauma - Ischaemia - Malignancy

Answer 49

**_Symptoms_** - Unilateral symptoms that occur spontaneously with no trauma - Painful red eye - Photophobia - Epiphoria (watery eye) - Reduced visual acuity - Floaters **_Signs_** - Ciliary flush (circumcorneal injection) - Keratic precipitates - Cells and flare in anterior chamber - Posterior synaechiae - Miosis - Hypopyon

Answer 50

Adhesions between iris and anterior lens capsule due to inflammation (image important for anterior uveitis)

Answer 51

- Headache? - Features of systemic disease?

Answer 52

**Slit lamp with dilated pupil** If anterior will see **keratic precipitates** (leucocytes) and **may see flare**. If posterior will not see these Can do fundus fluorescein green-angiograph

Answer 53

- Red eye so same day referral to opthalmology - Treatment is to **prevent glaucom**a, as adhesions can block humour flow, and **decrease inflammation** to improve pain **_Mx:_** **- Prednisolone drops:** decrease inflammation **- Cyclopentalate drops (antimuscarinic):** keep pupil dilated to stop posterior synaechiaea, open up iridocorneal angle, stop ciliary spasm as cycloplegic to stop pain **- Biologics (anti-TNF):** if systemic disease **- Laser therapy** if severe

Answer 54

- Vision loss: less chance in anterior than posterior, panuveitis worse - Macular oedema - Cataracts - Chorioretinal scarring - Glaucoma - Retinal detachment - Vitreous opacities.

Answer 55

Degeneration of the macula causing gradual vision loss. Drusen present. Most common cause of irreversible blindness **- Proteins and lipids deposit between retinal pigment epithelium and Bruch’s membrane (Drusen)** **- Atrophy of the retinal pigment epithelium** **- Degeneration of the photoreceptors**

Answer 56

There are **new vessels that grow from the choroid (Bruch's membrane) into the retina** under control of **VEGF** These vessels leak and cause **oedema** and rapid loss of vision

Answer 57

- Age - Smoking - White or Chinese ethnic origin - Family history - Cardiovascular disease

Answer 58

**- Gradual worsening central visual field loss** (difficulty reading, making out faces, night vision) **- Reduced visual acuity** **- Crooked or wavy appearance to straight lines** **- Fluctuating vision changes** (some days poor some days good) More acute over days in wet AMD that can lead to full bilateral vision loss in 2-3 years

Answer 59

**_Exam:_** **- Snellen chart:** reduced visual acuity **- Scotoma in Visual Field test:** a central patch of vision loss **- Amsler grid test** **- Fundoscopy:** Drusen (lipid deposits) **_Ix:_** **- Slit lamp** fundus exam **- OCT** for wet AMD **- Fluorescein angiography** can see neovascularisation in wet AMD

Answer 60

- Just see drusen, visual loss occurs over decades **_Mx_** - Refer to opthalmologist - No specific treatment just modify risk factors (stop smoking, control BP, vitamin supplements for antioxidants)

Answer 61

- Drusen, haemorraghes, neovascularisation, fluid exudation, localised detachment of the pigment **_Mx (needs to be prompt as fast vision loss)_** **- Stop smoking** and eat lots of greens **- Intravitreal VEGF (ranibizumab, bevacizumab):** give every 1/12 for a year, within first 3 months and can reverse progress **- Laser photocoagulation** **- Photodynamic therapy** **- Self screening** **- Visual aids** if lost vision

Answer 62

**- Arrange a fluorescein angiogram** at the outset and then **4–6-weekly photograph and an OCT** - Use **Amsler grid**, if distortions in straight lines then refer as sign of neovascularisation

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11 - Ophthalmology Conditions 1 Flashcards

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