9 - Ophthalmology Presentations 1 Flashcards

1
Q

If somebody presents with sudden loss of vision what differentials should you consider?

(Important card)

A

Painful:

  • GCA
  • Optic neuritis
  • Acute angle closure glaucoma

Painless:

- Amaurosis Fugax

  • CRAO (very fast loss compared to CRVO)
  • AION
  • Wet AMD
  • Vitreous haemorraghe
  • Retinal detachment
  • Stroke
  • Papilloedema
  • Migraine
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2
Q

When is sudden loss of vision urgent?

A
  • CRAO of <6h
  • Suspected GCA
  • Any sudden loss occuring in <6h
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3
Q

What questions can you ask to help work out the cause of sudden vission loss?

A

HELLP

- Headache? Consider ESR if yes as could be GCA

- Eye movements hurt? Could be optic neuritis

- Lights/Flashers before vision loss? Could be retinal detachment

- Like a curtain? Could be amaurosis fugax

- Poorly controlled DM? Could be vitreous haemorraghe

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4
Q

When should you suspect GCA in vision loss?

A

Causes vision loss by arteritic ION (AION)

  • Jaw claudication
  • New onset headache
  • Tender temples/scalp
  • Has polymyalgia rheumatica (pain in shoulder and hip girdles worse in the morning)
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5
Q

How do you manage a patient with sudden vision loss that you suspect could be GCA?

A

Ix:

  • ESR, CRP, Temporal artery biopsy (but could be skip lesions)

Mx

  • Need to start IV methylprednisolone ASAP as other eye is at risk!!!!! If no visual loss just PO prednisolone
  • Taper steroids with ESR levels but might take about a year and can relapse
  • Once lost vision irreversible
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6
Q

If someone has sudden loss of vision that is transient what differentials should you consider?

A
  • TIA
  • Migraine
  • MS
  • Papilloedema
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7
Q

What are the different types of allergic eye disease?

A

Type 1 IgE hypersensitivity reaction

  • Seasonal allergic conjunctivitis
  • Perennial allergic conjunctivitis
  • Vernal keratoconjuctivitis (VKC)
  • Atopic keratoconjunctivitis (AKC)
  • Giant papillary conjunctivitis
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8
Q

How does seasonal allergic conjunctivitis present and how is it managed?

A
  • Symptoms are seasonal and mild but may continue long after allergen exposure
  • Examination shows small papillae on the tarsal conjunctiva
  • It is self-limiting and not sight-threatening

- Rx: Antihistamine drops (eg ketotifen, azelastine) or 2nd line Diclofenac 0.1% drops

Can us mast cell stabilisers prophylactically (nedocromil)

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9
Q

How does perennial allergic conjunctivitis present and how is it managed?

A
  • Symptoms may persist all year with seasonal exacerbations
  • Small papillae are found on the tarsal conjunctiva

- Rx: Olopatadine (antihistamine and mast cell stabilizer) or Nedocromil (mast cell stabilizer).

Over-the-counter sodium cromoglicate drops

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10
Q

How does Vernal keratoconjuctivitis (VKC) present and how is it managed?

A
  • Typical patient is atopic boy living in a warm, dry climate with severe bilateral symptoms in spring (itchy eyes, foreign body sensation, pho- tophobia) and giant cobble-stone papillae under the upper eye lid
  • Lid skin is spared, unlike AKC

- Rx: Olopatadine drops. If uncontrolled or if corneal disease devel-ops, steroid drops are needed (eg 1% prednisolone acetate/2h; taper rapidly).

Corneal involvement needs careful eye clinic review and coverage with steroids, antibiotic drops, and lid hygiene to limit staphylococcal colonisation

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11
Q

How does Atopic keratoconjunctivitis (AKC) present?

A
  • Symptoms are severe with pain, redness, and reduced vision.
  • Associated with atopic dermatitis
  • Signs include conjunctival papillae on lower lid and eventual conjunctival scarring which can lead to corneal opacification and neovascularization.
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12
Q

How can you tell the difference between Atopic Keratoconjunctivitis and Vernal Keratoconjunctivitis?

A

BOTH CAN BE SIGHT THREATENING IF NOT TREATED

BILATERAL ALLERGIC EYE DISEASE

VKC is seasonal at first

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13
Q

What is Giant papillary conjunctivitis and how is it managed?

A
  • Giant papillae on tarsal conjunctiva
  • Iatrogenic condition related to foreign bodies, eg contact lenses, ocular prosthesis and sutures
  • Not allergic eye disease

- Management: Removal of foreign body and treatment with topical mast cell stabilizers or steroids.

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14
Q

In general how is allergic eye disease managed?

A
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15
Q

What is the difference between monoocular and binocular diplopia?

A

- Binocular diplopia: occurs only when both eyes are open and can be corrected by covering either eye

- Monocular diplopia persists in one eye despite covering the other eye and can usually be corrected by using a pinhole

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16
Q

Why should you be concerned with new onset binocular diplopia?

A

First sign of temporal arteritis or posterior communicating artery aneurysm

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17
Q

If someone has diplopia what are important questions to ask?

A

1. Sudden Onset (Red Flag) or Gradual Onset?

2. Monocular or Binocular (Red Flag)?

3. Comnitant or Non-Comnitant (Red Flag)? Different gazes different diplopia

18
Q

What are some causes of monocular and binocular diplopia?

A

Binocular:

  • Optic neuritis
  • Diabetic retinopathy
  • Strabismus
  • Cranial Nerve Palsies
  • MG
  • Thyroid eye disease
  • MS

Monocular:

  • Cataracts
  • Astigmatism
  • Dry eye
19
Q

What are the DVLA driving rules for the following:

  • Visual Acuity
  • Visual Fields
  • Diplopia
A

Visual Acuity: must be able to read number plate at 20m (6/10 on Snellen)

Visual Fields: If binocular vision >120 degrees fields, if monocular vision need full visual field

If diabetic retinopathy need yearly visual field tests

Diplopia: Not allowed unless mild or eye patch correctable

20
Q

What are some eye issues that can occur with eye trauma?

A
  • Cataract
  • Retinal detachment
  • Vitreous haemorraghe
  • Corneal ulcer/abrasions
  • Sympathetic ophthalmia
  • Intraocular bleeds (hyphema)
  • Secondary haemorraghe causing secondary glaucoma
  • Orbital blow out fracture
21
Q

How do you take a history and examination with a foreign body that has caused trauma to the eye?

A

History:

  • Mechanism of injury
  • What caused the injury

Examination

  • Record visual acuity in both eyes
  • If cannot open eye give local anaesthetic drops
  • Evert eye lids
  • If irregular pupil may mean globe rupture
  • If RAPD low chance of vision referring
  • Send for CT (not MRI in case foreign body magnetic)
22
Q

Why is penetrating trauma to the eye so serious (e.g knife) and how do you manage it?

A

- Refer urgently as risk of ocular extrusion and infection

  • Also risk of sympathetic opthalmia (granulotomous inflammation to other eyes uvea)

Management:

  • Don’t try to remove a large foreign body (knife; dart). Support object with padding. Transport supine. Pad the unaffected eye to prevent damage from conjugate movement
  • Send for x-ray of skull and eye to rule out intraocular and cranial involvement
23
Q

How may a foreign body in the eye present?

A
  • Chemosis
  • Subconjunctival bleeds
  • Irregular pupils
  • Iris prolapse
  • Hyphaema
  • Vitreous haemorrhage
  • Retinal tears
24
Q

How do you manage a foreign body in the eye?

A

Exam:

  • Evert the eye lid to look at all areas
  • Consider X-Ray if could be metal object
  • If high velocity FB use orbital US

Management

  • If small remove with triangle of card
  • Give chloramphenicol drops after to prevent infection
25
Q

How do you deal with chemical burns to the eye and what are the complications of this?

A
  • Treat promptly
  • Give anaesthetic drops (tetracaine 1%) every 2min till the patient is comfortable as eyes close due to severe pain
  • Bathe eyes in copious clean water while the specific antidote is sought.

Complications: corneal scarring, opacification, lid damage. Alkali burns are more serious than acid.

26
Q

What is photokeratitis and how is it managed?

A
  • Welders and sunbed users who don’t use UV protection may damage the cornea

- FB sensation, watering, blepharospasm, intense pain 6–12hrs after UV exposure

- Mx: Generous oral analgesics, analgesic eye drops for home use are not advised due to ocular toxicity. Give antibiotic ointment and it will recover in 24h

27
Q

What are the complications of an intraocular bleed? (hyphema)

A
  • Glaucoma
  • Corneal staining
  • Re-bleeding
28
Q

How may an orbital blow out fracture present and why does it occur?

A
  • Blunt injury (eg from a football) causes sudden increase in pressure within the orbit so fractures weakest walls of orbit. Orbital contents herniate into maxillary sinus

- Diplopia (upward gaze): Tethering of IR and IO

- Eye movement restriction

- Infraorbital Anaesthesia: sensation over the lower lid skin. Loss of sensation indicates infra-orbital nerve injury, confirming a blowout fracture.

- Enopthalmos

- Occulovagal symptoms

29
Q

What are occulovagal symptoms?

A
  • Bradycardia
  • Hypotension
  • Nausea/vomiting

Vagal stimulation by pressure to intraorbital structures

30
Q

How does an orbital blow out fracture appear on an X-ray?

A
  • Black eyebrow sign: due to orbital emphysema

- Tear Drop sign: due to herniation of orbital contents into maxillary sinus

31
Q

How is an orbital blow out fracture investigated and managed?

A
  • Do CT to diagnose, will see fracture of posterior orbital floor

Mx:

  • Often conservative and see what happens once oedema has gone down

- Surgical Decompression if significant enophthalmos, significant diplopia or muscle entrapment. Risk of fibrosis so limited eye movement with surgery

32
Q

What is the occular trauma score? (OTS)

A
  • Gives prognostic information (the higher the better prognosis)

Assign a point value for initial visual acuity from row 1 of the table. Then subtract the appropriate points for each diagnosis from subsequent rows

33
Q

What are some differentials for periorbital swelling?

A
  • Periorbital cellulitis
  • Myxedema due to hypothyroidism
  • Nephrotic syndrome
  • Sinusitis
  • Conjunctivitis
  • Mononucleosis
  • Hyperthyroidism
  • Trauma
34
Q

What are some causes of floaters in the vision?

A
  • Vitreous haemorraghe (hundreds of tiny black spots)
  • Posterior Vitreous detachment (lots of large spots)
  • Retinal detachment
  • Diabetic retinopathy
  • Posterior uveitis
  • Myopia
  • Cataract surgery
  • Trauma
  • Tumour seeding from metastases
35
Q

What is the pathophysiology of floaters?

A

- RBCs (anything that causes new vessel formation on the retina can lead to vitreous haemorraghe)

- WBCs (from infective/inflammatory causes such as choroiditis)

- Tumour seeding

- Degenerative causes (opacities in the vitreous as it ages, when the eye is resting the floaters still move)

36
Q

How are floaters in the vision managed?

A
  • Examine the vitreous and retina, and treat the cause before reassuring
  • If sudden showers of floaters in one eye with flashes needs urgent referral within 48h as could be retinal detachment
37
Q

What are some causes of photopsia and what is the pathophysiology of this? (flashing lights in vision)

A

As retinal tissues is disturbed, it produces phosphenes (the experience of seeing light without light entering the eye)

  • Migraine with aura
  • Posterior vitreous detachment
  • Early retinal detachment
38
Q

What are some causes of gradual loss of vision?

A
  • Cataract
  • Macular degeneration
  • Glaucoma
  • Diabetic retinopathy
  • Hypertension
  • Optic atrophy
  • Slow retinal detachment
39
Q

What are some causes of optic atrophy and how does it appear on fundoscopy?

A

Optic disc appears pale!

Causes:

  • Inreased IOP (Glaucoma)
  • Retinal damage
  • Retinal ischaemia (CRVO/CRAO)
  • MS
  • Syphillis
  • Intracranial tumour pushing on nerve
40
Q

What is the pathophysiology of drusen and what does it mean if there is drusen on the optic disc?

A
  • Optic nerve-head axonal degeneration
  • Abnormal axonal metabolism leads to intracellular mitochondrial calcification. Axons rupture and mitochondria are extruded into the extra-cellular space. Calcium is deposited here and drusen form
  • Yellow lumpy matter with absent optic cup
41
Q
A