6.1.5. Recognises common ocular abnormalities and refers when appropriate. Flashcards
Not quite complete. We need to have a satisfactory glaucoma episode.
Blepharitis treatment
- Posterior - dry warm compress 10 minutes twice daily, eyelid bag >40 degrees to melt meibum
- Anterior - wet warm compress to loosen collarettes and crusts for anterior bleph
- Lid massage (mixed/posterior) – melt the meibum and encourage blockage out
- Lid cleansing to remove deposits and bacteria from lid margin - gel e.g. TTO/blephasol or wipes e.g. Blephademodex/blephaclean
- Avoid cosmetics directly on lid margin
- Once symptoms resolve can reduce measures to minimum of twice weekly
Other options - Chloramphenicol ointment bds, rubbing onto lid margin with finger
- Demodex if over 70 and/or CD
- Weekly in office treatments with 50% TTO to kill mites
- Nightly treatment with 5% TTO/products with terpinene-4-ol to prevent mating/migration
- Initial management followed by referral if three months of treatment does not produce sufficient response
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Allergic Conjunctivitis
SAC & PAC
o Avoid allergen, cold compress, avoid eye rubbing to prevent degranulation of mast cells
o Ocular lubricants to be used 3-4x daily for symptomatic relief i.e. viscotears
o Topical AH to relieve itching i.e. antazoline sulphate 0.5% tds
o Topical MCS i.e. sodium cromoglicate 2% qds
o Oral antihistamine i.e. loratadine od
Allergic Conjunctivitis
VKC
o Cold compress when acute
o Ocular lubricants symptomatic relief ^
o Topical MCS e.g. sodium cromo 2% qds
o Refer to HES urgently if active limbal or corneal involvement
Allergic Conjunctivitis
AKC
o Cold compress
o Lid hygiene for associated blepharitis
o Avoid known allergens
o Local pharmacy for loratadine od
o Topical MCS i.e. sodium cromo 2% qds
o Urgent referral if active limbal or corneal involvement
Allergic Conjunctivitis
Acute allergic
o Most resolve spontaneously within a few hours
o Avoid eye rubbing
o Cool compress for symptomatic relief
o Identify allergen and avoid future contact
o Ocular lubrication for symptomatic relief
o If recurrent, prophylactic topical MCS e.g. sodium cromo 2% as POM
Bacterial conjunctivitis
- Self-limiting 5-7 days without treatment
- Bathe eyelids with cooled boiled water
- Advice on contagious nature of condition
- Topical antibiotic may improve short term outcome:
Drops 0.5%, dose: - 1 drop every 2 hours for 48 hours
- Then, every 4 hours during waking hours
- Eye drops may be supplemented with ointment at night
- Treatment course should last 5 days
Ointment 1% dose - qds for 2 days
- bds for 5 days
- CL wearer – quinolone i.e. levofloxacin (PoM)
Viral conjunctivitis
Self-limiting 1-2 weeks
Cold compress
Generally caused by adenovirus
Anti-viral agents are generally ineffective
Artificial tears may relieve symptoms
Sub conjunctival haemorrhage
Refer for BP check if necessary
Reassurance, condition usually clears within 5-10 days
Cold compress may reduce discomfort
Ocular lubrication if irritation is present
Episcleritis
Self-limiting in 7-10days
Cold compress
If severe discomfort, ocular lubricants for 1-2wks
PoM if IP if px is particularly symptomatic e.g. FML
Corneal abrasion
- Rule out multiple parts, incl. double lid eversion
- Loose FBs irrigated with saline
- FB on conjunctiva removed with sterile cotton bud
- Assess depth & carry out seidel test
- Remove FB under topical anaesthetic
- Topical antibiotic, chloramphenicol 0.5% 4x daily for 5 days if likelihood of infection
- CL wearer – quinolone
Hordeolum
- External (stye) – associated gland of zeiss/moll - tender inflamed swelling of lid margin, may point anteriorly through skin
- Internal – acute bacterial infection of MG - tender inflamed swelling within tarsal plate – more painful than a stye, may point anteriorly through skin or posteriorly through conj
- Most resolve spontaneously or discharge, following by resolution in case of external
- Hot compress
- AB ointment in case of copious mucopurulent discharge – chloramphenicol 1% tds for 1 week (fusidic acid if allergic/bf/pregnant)
- Rare – refer routinely for incision in cases than do not discharge (more common in internal)
Chalazion
- Most result on conservative management – hot compress, lid massage (B2 – no referral)
- Regular lid hygiene for bleph – most likely posterior
- Routine refer if: persistent, recurrent, causing significant astigmatism, cosmetically unacceptable
OCT - layers of retina ( and where abnormalities would be)
- Inner limiting membrane
- RNFL
- Ganglion cell layer
- Inner plexiform layer
- Inner nuclear layer
- Outer plexiform layer
- Outer nuclear layer
- Outer limiting membrane
- Photoreceptor layer
^^neurosensory retina
–< SUBRETINAL; above RPE but below neurosensory retina, where subretinal fluid would be i.e., WET AMD
- RPE; maintains the photoreceptors; cells absorb stray light, form the outer blood retinal barrier and regenerate’s visual pigment; highly pigmented layer between neurosensory retina and Bruchs membrane
–< SUB RPE; where drusen would be i.e. DRY AMD
- Bruch’s membrane; involved in the controlled passage of nutrients and waste products to and from retina
- Choroid; provides 2/3 of nutrients to retina and RPE; made up of vessels which supply the outer retina; important at macula where retinal circulation is absent
- Sclera
Macula scan: raster cube scan
- 50% total RGCs at macula
- GCC (ganglion cell complex i.e. innermost 5 layers, ILM, RNFL, GCL, IPL, INL)
- GChart only measures thickness of GCC i.e. NRR, not things like disc swelling
- Peripheral macular thickness asymmetry can occur in healthy eyes, but central macular thickness is highly symmetrical
Retinal nerve fibre layer: circumpapillary scan
- Provides thickness measurements of RNFL
- Produces a RNFL thickness map beginning and ending nasally, with superior, temporal and nasal quadrants in between
- Thickness compared to normative data base, plotted on a probability graph depicting 95%, 5% and 1% confidence limits
- The greater amount of nerve fibre layers coming from superior and inferior sections of the disc is highlighted by the double hump of RNFL thickening at those poles (absence of double hint = indicates nerve fibre loss in these areas
Common macula problems
- Central serous retinopathy / central serous chorio-retinopathy
- Sudden onset of visual symptoms i.e., distortion, micropsia, partial scotoma
- Raised area at macula
- OCT visible dark area of sub-retinal fluid i.e., above RPE but below sensory retina
- This is a serous detachment (serous = fluid)
- CSR occurs most commonly in younger male patients / type A
- Generally, resolves in 4-6 weeks without treatment
Macular hole
- Routine referral to ophthalmology if full thickness / VA drop
- Vitrectomy which can help to close hole with some slow recovery to normal VA
ERM & wrinkling of retinal surface
- Routine referral if symptomatic / px wants surgery
- Vitrectomy & membrane peel
Drusen Vs Hard Exudates
- Drusen are formed between Bruch’s membrane and the retinal pigmented epithelium
- Hard exudates form within the retina predominantly at the level of the outer plexiform layer
- Exudates normally by area of oedema - therefore if you see exudates, suspect oedema!
Types of PEDs & Common Associated Conditions
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3 Types:
1. Drusenoid (AMD)
2. Serous (dome shape due to fluid) - CSR, idiopathic
3. Fibrovascular (membrane & oedema) - wet AMD -
Commonly Associated Conditions
- Wet AMD
- Diabetic Maculopathy
- Central Serous Retinopathy
- Secondary to Cataract / Ocular surgery
Lid lesions (signs of malignancy)
- Bleeding
- Asymmetrical shape
- Change in colour
- Ulceration, irregularity, telangiectasia, pearly appearance, and loss of eyelid margin architecture (notching)
- Diplopia or Proptosis indicating orbital invasion!
Glaucoma or Glaucoma suspects
- Vertical elongation of cup
- Thinking of ISNT - may do OCT to double check
- Disc haems
Sqamous cell papilloma
- Descript - benign epithelial tumour, skin-tag & wart like
- Causes - human papilloma virus
- Management - normally goes by itself, excision, cryotherapy & laser or chemical ablation
Serborrhoeic Keratosis (basal cell papilloma) (look in kanski!)
- Descript - light- to dark-brown plaque with a friable, greasy, verrucous surface and a ‘stuck-on’ appearance
- Causes - elderly, common, numerous
- Management - shave biopsy, excision, laser, cryotherapy
Melanocytic naevus (low chance for malignancy)
- Descript - can be congenital (kissing naevus possible), compound naevus (rasied & scaly), junctional naevus (uniform & brown), intradermal naevus (most common, no malignancy potential)
- Management - complete excision if suspect melanoma
Molluscum Contagiosum
- Descript - viral infection; caused by poxvirus, very young or adults immuno compromised
- Causes - linked with AIDs, eczema, swimming pools
- Sxs - Skin nodule(s) (typically 2-3 mm diam), often with a central depression (‘umbilicated’), Can cause conjunctivitis - follicles, redness, watering, photophobia, epitheliopathy etc
- White cheesy material can be discharged
- Management - self-limiting (goes after few weeks or months), referral if no resolve for excision
- White cheesy material can be discharged
Basal cell carcinoma
- Risk Factors - Old, White, UV exposure
- Types:
- Nodular - pearl like, few dilated vessels
- Nodulo-ulcerative - centre ulcerated, pearly rolled edges, telangiectasia
- Sclerosing - looks clear, margins hard to define. Don’t mistake for blepharitis!
- Management - needs referral (soon) for biopsy
Squamous cell carcinoma
- Risk Factors - Old, White, UV exposure, Immunocompromised
- Types:
- Nodular - hyperkeratotic with crusting, erosions, fissures
- Ulcerating - red base, defined “hard looking” borders with a slight crusty look
- Cutaneous horn
- Management - needs referral (urgent within a week) for biopsy
Ectropian
- Outward rotation of lid margin
- TESTS:
- Distraction test
- if lower lid can be pulled >6mm from globe, it is lax, positive test indicates canthal tendon laxity
- Snap-back test
- with finger, pull lower lid down towards inferior orbital margin
release: lid should snap back
lid slow to return to its normal position: indicates poor orbicularis tone
- with finger, pull lower lid down towards inferior orbital margin
- Types - Involutional (age related causing laxity), Cicatricial (scarring of skin), Paralytic (facial palsy i.e. Bell’s), Mechanical (tumour, lid swelling etc), Congenital (rare bilateral condition)
- Management - less lid rubbing (induces laxity), drops, routine referral if severe
Entropian
- Inward rotation of lid margin
- TESTS:
- Distraction test
- if lower lid can be pulled >6mm from globe, it is lax, positive test indicates canthal tendon laxity
- Snap-back test
- with finger, pull lower lid down towards inferior orbital margin
release: lid should snap back
lid slow to return to its normal position: indicates poor orbicularis tone
- with finger, pull lower lid down towards inferior orbital margin
- Test of Induced Entropion (TIE-2 test)
- ask patient to look down
hold upper lid up as high as possible
ask patient to close the eyes as tightly as possible
The TIE-2 test is positive if this provokes an intermittent lower lid
entropion
- ask patient to look down
- Types - Involutional, Cicatricial (scarring & contraction of palp conj e.g. in chronic bleph), Spastic (random orbicularis contraction e.g. after surgery or blepharospasm), Congenital (rare)
- Management - Lash epilation, Lubrication, routine referral if severe
Keratocanthoma
- Descript - Rare, rapidly growing, keratin filled crater, pink dome
- Causes - white, UV, immunosuppresive therapy
- Management - spotaneous involution after growing for 2-3 months, taking up to a year!! leaving a scar! Excision also works
Conjunctival lesions
- Pinguecula
- UV protection. Lubricants. If inflammed, steroids. Referral if vision affected or cosmetically unacceptable
- Pterygium
- UV protection. Lubricants. If inflammed, steroids. Referral if vision affected or cosmetically unacceptable or astigmatism induced
- Retention cyst
- Goes by itself, or punctured with a needle using a topical anaesthetic
- Conjunctivochalasis
- Lubrication & treat chronic bleph. Conjunctival resection (cutting out tissue) if severe.
- Concretions
- Lubrication. Removed using needle under topical anaesthesia.
Retinitis Pigmentosa
- Descript - inherited diffuse retinal degenerative disease affecting rods then cones
- Cause - genes
- Signs - Dark adaptation trouble, VF loss, Bone-spicules, Narrower A/V, Disc pallor, Possible maculopathy
- Management - Genetic counselling, LVAs & adaptations like expanding FOV
Fuch’s Dystrophy
- Descript - bilateral endothelial loss, >women
- Causes - inherited, middle age onset
- Signs - blurring more in morning due to oedema, corneal guttata, beaten bronze appearance
Choroidal Naevus Vs Melanoma
- C - Close to ON
- O - Orange pigment lipofuscin
- N - No drusen
- S - Symptoms (F+F, visual disturbance if raised)
- T - Thickness (>2mm)
- A - Absence of halo (ring of pallor)
- N - New
- T - Too big (>5mm)
CHRPE
common benign lesion, usually congenital. Can be single or grouped (bear tracks) Linked to FAP (familial adenomatous polyposis) (liver condition) if 4 or more CHRPEs that are separated more than bear tracks are detected.
- Low malignancy risk so just monitor
