9 - Ophthalmology Presentations 1 Flashcards
If somebody presents with sudden loss of vision what differentials should you consider?
(Important card)
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
When is sudden loss of vision urgent?
- CRAO of <6h
- Suspected GCA
- Any sudden loss occuring in <6h
What questions can you ask to help work out the cause of sudden vission loss?
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
When should you suspect GCA in vision loss?
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)
How do you manage a patient with sudden vision loss that you suspect could be GCA?
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
If someone has sudden loss of vision that is transient what differentials should you consider?
- TIA
- Migraine
- MS
- Papilloedema
What are the different types of allergic eye disease?
Type 1 IgE hypersensitivity reaction
- Seasonal allergic conjunctivitis
- Perennial allergic conjunctivitis
- Vernal keratoconjuctivitis (VKC)
- Atopic keratoconjunctivitis (AKC)
- Giant papillary conjunctivitis
How does seasonal allergic conjunctivitis present and how is it managed?
- 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)
How does perennial allergic conjunctivitis present and how is it managed?
- 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
How does Vernal keratoconjuctivitis (VKC) present and how is it managed?
- 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
How does Atopic keratoconjunctivitis (AKC) present?
- 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.
How can you tell the difference between Atopic Keratoconjunctivitis and Vernal Keratoconjunctivitis?
BOTH CAN BE SIGHT THREATENING IF NOT TREATED
BILATERAL ALLERGIC EYE DISEASE
VKC is seasonal at first
What is Giant papillary conjunctivitis and how is it managed?
- 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.
In general how is allergic eye disease managed?
What is the difference between monoocular and binocular diplopia?
- 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
Why should you be concerned with new onset binocular diplopia?
First sign of temporal arteritis or posterior communicating artery aneurysm
If someone has diplopia what are important questions to ask?
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
What are some causes of monocular and binocular diplopia?
Binocular:
- Optic neuritis
- Diabetic retinopathy
- Strabismus
- Cranial Nerve Palsies
- MG
- Thyroid eye disease
- MS
Monocular:
- Cataracts
- Astigmatism
- Dry eye
What are the DVLA driving rules for the following:
- Visual Acuity
- Visual Fields
- Diplopia
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
What are some eye issues that can occur with eye trauma?
- Cataract
- Retinal detachment
- Vitreous haemorraghe
- Corneal ulcer/abrasions
- Sympathetic ophthalmia
- Intraocular bleeds (hyphema)
- Secondary haemorraghe causing secondary glaucoma
- Orbital blow out fracture
How do you take a history and examination with a foreign body that has caused trauma to the eye?
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)
Why is penetrating trauma to the eye so serious (e.g knife) and how do you manage it?
- 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
How may a foreign body in the eye present?
- Chemosis
- Subconjunctival bleeds
- Irregular pupils
- Iris prolapse
- Hyphaema
- Vitreous haemorrhage
- Retinal tears
How do you manage a foreign body in the eye?
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
How do you deal with chemical burns to the eye and what are the complications of this?
- 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.
What is photokeratitis and how is it managed?
- 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
What are the complications of an intraocular bleed? (hyphema)
- Glaucoma
- Corneal staining
- Re-bleeding
How may an orbital blow out fracture present and why does it occur?
- 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
What are occulovagal symptoms?
- Bradycardia
- Hypotension
- Nausea/vomiting
Vagal stimulation by pressure to intraorbital structures
How does an orbital blow out fracture appear on an X-ray?
- Black eyebrow sign: due to orbital emphysema
- Tear Drop sign: due to herniation of orbital contents into maxillary sinus
How is an orbital blow out fracture investigated and managed?
- 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
What is the occular trauma score? (OTS)
- 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
What are some differentials for periorbital swelling?
- Periorbital cellulitis
- Myxedema due to hypothyroidism
- Nephrotic syndrome
- Sinusitis
- Conjunctivitis
- Mononucleosis
- Hyperthyroidism
- Trauma
What are some causes of floaters in the vision?
- 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
What is the pathophysiology of floaters?
- 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)
How are floaters in the vision managed?
- 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
What are some causes of photopsia and what is the pathophysiology of this? (flashing lights in vision)
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
What are some causes of gradual loss of vision?
- Cataract
- Macular degeneration
- Glaucoma
- Diabetic retinopathy
- Hypertension
- Optic atrophy
- Slow retinal detachment
What are some causes of optic atrophy and how does it appear on fundoscopy?
Optic disc appears pale!
Causes:
- Inreased IOP (Glaucoma)
- Retinal damage
- Retinal ischaemia (CRVO/CRAO)
- MS
- Syphillis
- Intracranial tumour pushing on nerve
What is the pathophysiology of drusen and what does it mean if there is drusen on the optic disc?
- 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
