Acute Ophthalmology 2 Flashcards
Ophthalmic trauma: causes
Chemical injury - EMERGENCY
Blunt trauma
Sharp and penetrating trauma
Ophthalmic trauma: causes of loss of vision due to trauma
- Corneal scarring and anterior segment damage - alkali burn
- Disrupted globe - penetrating trauma
- Siderosis bulbi (iron deposition) - intraocular metallic foreign body
- Compressive optic neuropathy - retrobulbar haemorrhage
- Traumatic optic neuropathy - bony or shearing injury
Ophthalmic trauma - types
Eyelid, periocular, orbital haematoma
Orbital bony wall fracture
Subtarsal foreign body
Lid laceration
Lacrimal drainage system - oculoplastic repair + stent
Conjunctival laceration - suturing
Corneal abrasion - abx + cycloplegia
Corneal foreign body
Penetrating injury of cornea, sclera, iris, lens, retina
Hypahaema - blood in anterior chamber ; glaucoma
Lens dislocation
Traumatic cataract
Glaucoma - damage to trabecular meshwork
Vitreous haemorrhage + retinal commotio - retinal degeneration due to blunt trauma
Retinal tear
Choroid rupture - vision loss if underlying macula
Scleral perforation
Retrobulbar haemorrhage - canthotomy
Traumatic optic neuropathy
Ophthalmic trauma - chemical injury: substances, why is alkali most destructive?
Alkali Acid Detergents Irritants (mace, pepper) Superglue
Alkalis cause liquefactive necrosis
Continue to penetrate eye to deep layers, causing ischaemia, scarring of cornea and blindness
(Vs acid cause coagulative necrosis thus impede own progress)
Ophthalmic trauma - chemical injuries: management
Wash out eye IMMEDIATELY
Measure pH of tear w litmus paper
Topical anaesthetic drops
Copious irrigation (saline, Ringers solution)
Check remaining foreign body: evert eyelid, swipe fornices
Examine eye: visual acuity, IOP, dilate pupils for fundal examination
Further Mx
Topical: abx, vitamin C, cycloplegia (pain)
Oral Vitamin C
Surgery: limbs cell transplant, corneal graft
Ophthalmic trauma - blunt injuries: aetiology
Sport (balls), leisure activities, road traffic accidents, fist
Ophthalmic trauma - blunt injuries: features
Lid ecchymosis Orbital haemorrhage Subconjunctival haemorrhage Hyphaemia Lens dislocation Orbital wall fracture Vitreous haemorrhage Commotio retinae Retrobulbar haemorrhage
Ophthalmic trauma - blunt injuries: examination
From lids to retina, front to back
Eye movements - exclude orbital wall fracture
Infra-orbital numbness
Cornea + conjunctiva - FBs
Fluorescein drops - exclude corneal abrasion
Fundus examination
Ophthalmic trauma - blunt injury: hyphaema definition and management
Blood in anterior chamber
Blackball hyphaema: blood fills entire AC
Exclude vitreous, supra, subretinal haemorrhage - fundus Exam, USS if not visible
Topical steroids and dilating drops - minimise inflammation and reboeeding
Ophthalmic trauma - blunt trauma: traumatic iritis definition and management
Inflammation of anterior chamber occurring commonly after blunt trauma
Topical steroids and mydriatic drops
Ophthalmic trauma - blunt trauma: retrobulbar haemorrhage significance, features, management
EMERGENCY: Cause rapid blindness from compartment syndrome; raised IOP, compressive optic neuropathy
Pain, proptosis, reduced vision, poor pupil reaction (test consensual reflex in bruised eye)
Emergency lateral conthotomy and cantholysis
Ophthalmic trauma - blunt trauma: commotio retinae definition, features, management
Retinal opaqueness due to fragmentation of photoreceptor layer and oedema following blunt trauma
Blurred vision if macula affected
Retina appears opaque
Completely resolves
Ophthalmic trauma - blunt trauma: orbital floor fracture features and management
Diplopia - orbital tissue/eom entrapment
Enophthalmos
Orbital floor repair
Ophthalmic trauma - penetrating trauma: features
high velocity injuries - intraocular FB
Misshapen pupils
Ophthalmic trauma - penetrating injuries: superficial corneal injury causes, features
Corneal FB, Subtarsal FB
Pain, photophobia, watering, red eye, FB sensation
Corneal FB: visible on pen torch, slit lamp
Subtarsal FB: visible on everting lid, vertical abrasions
Ophthalmic trauma - penetrating trauma: corneal abrasion features, management, RES
Pain, red eye, photophobia, watering, FB sensation
Red eye, fluorescein staining of epithelial defect, every lid for STFB
Wipe off CFB, STFB w cotton bud
Topical Chloramphenicol
Topical cyclopentolate - if photophobia
RES: with v sharp injuries, new epithelium do not adhere to stroma and repeatedly slough off
Tx = lubricating drops, bandage contact lens
Acute loss of vision in inflamed eye - Uveitis: anatomical types
Anterior uveitis - iris, ciliary body (AC inflammation)
Intermediate uveitis - vitreous, ciliary body (vitreous inflammation)
Posterior uveitis - choroid, retina (retina/choroid inflammation)
Pan-uveitis - iris, ciliary body, vitreous, choroid, retina
Acute LOV in inflamed eye - uveitis: anterior uveitis features
Pain - due to inflammation of ciliary body, pain on contraction
photophobia
watering
Red eye w circumciliary injection (around cornea) Hazy cornea (Keratoprecipitates/WBC on corneal endothelium) Irregular pupil (Posterior synechiae - adhesion of lens to iris due to inflammatory cells) Cells and flares in AC (inflammatory breakdown of iris-blood barrier)
Acute LOV in inflamed eye - uveitis: intermediate uveitis features
Floaters, blurred vision, no pain
Vitreous cells
Snowballs (pre-retinal inflammatory aggregates)
Snow-banking (pars plana exudation)
Macular oedema
Acute LOV in inflamed eye - uveitis: posterior uveitis features
Painless blurring of vision, floaters, photopsia (flashing lights)
Cells in AC, vitreous Choroiditis - raised lesions wo pigment Retinitis - cotton wool spots, haemorrhages Macular oedema Vitreal detachment Retinal detachment
Acute LOV in inflamed eye - uveitis: investigations
Slit lamp
B scan ocular ultrasonography (in AAU to exclude posterior involvement when fundus cannot be seen)
First uveitis not investigated - majority idiopathic In recurrent uveitis - distinguish bw infective, inflammatory FBC, U+E ACE (sarcoidosis) CXR (TB, sarcoidosis) Syphilis HLA B27, A29 ANA ANCA
Acute LOV in inflamed eye - uveitis: infective management
Idiopathic - treat as infective
Infective:
topical abx
Topical steroids (reduces Jarisch-Herxheimer reaction - inflammatory reaction against bacterial lysis once antimicrobials commence, in TB, syphillis)
Acute LOV in inflamed eye - uveitis: inflammatory uveitis management
Corticosteroids - topical, peri-ocular, oral, IV
Sustained release implants in vitreous - minimise SE due to blood-retinal barrier
Acute LOV in inflamed eye - posterior scleritis: features
Visual loss (thickened posterior sclera) Severe pain, not relieved by analgesia Ocular tenderness Diplopia Painful eye movements (due to EOM insertion on inflamed sclera + myosotis)
Dilated fundoscopy: exudative retinal detachment
B scan US: thickened posterior sclera
Acute LOV in inflamed eye - posterior scleritis: investigations
Inflammatory cause: Rh factor ANA P-ANCA C-ANCA
Acute LOV in inflamed eye - posterior scleritis: management
NSAIDs - non-necrotising disease
Corticosteroids - topical, peri-ocular, oral, IV
Rheumatology referral
Acute LOV in inflamed eye - advanced keratitis: features
Opaque cornea
Severe reduction in visual acuity
Acute LOV in inflamed eye - advanced keratitis: predisposing factors
Contact lens wear - bacterial, Acanthamoebal keratitis
Previous HSV, HZV infection - viral keratitis
Travel to tropical country - fungal keratitis
Loss of corneal sensation - neurotrophic keratitis
Inability to close eye (lagophthalmos) - exposure keratitis
Acute LOV in inflamed eye - peripheral ulcerative keratitis: definition, cause, treatment
Immune complex deposition in peripheral cornea, which causes damage to stroma via release of matrix metalloproteinase
RA, Wagner’s granulomatosis
Systemic immunomodulator
Acute painful LOV in non-inflamed eye - causes
Giant cell arteritis
Optic neuritis
Migraines
Idiopathic Intracranial Hypertension
Acute Painful LOV in non-inflamed eye - GCA: ophthalmic features
Suspect in >50yo w headache + visual disturbance
Unilateral altitudinal field defect:
anterior ischaemic optic neuritis (disc swollen)
posterior ischaemic optic neuritis (disc normal)
Unilateral field defect:
central retinal artery occlusion
Acute painful LOV in non-inflamed eye - optic neuritis: definition
Visual disturbance with eye pain, commonly in young women, due to inflammation of optic nerve
Acute painful LOV in non-inflamed eye - optic neuritis: types
Papillitis: inflammation of optic nerve head - swollen optic disc
Retrobulbar neuritis: inflammation of optic nerve behind globe - normal optic disc
Acute painful LOV in non-inflamed eye - optic neuritis: aetiology
Idiopathic MS: most common cause of retrobulbar neuritis; 50% MS patients develop ON, 30% ON patients have underlying MS Infection (viral) Granulomatous inflammation Autoimmune
Acute painful LOV in non-inflamed eye - optic neuritis: features
Acute LOV: complete; reduced colour vision (red desaturation) Eye pain (on movement) Features of undiagnosed MS: paraesthesia, bladder/bowel dysfunction, limb weakness
Acute painful LOV in non-inflamed eye - optic neuritis: management
IV corticosteroids: helps w speeding recovery but not outcome; if vision loss in both eyes or severe pain
MRI brain: assess risk of MS
Acute painful LOV in non-inflamed eye - migraine: features
Visual disturbance + headache
Fortification spectra (zigzag lines)
Scintillating scotoma
Transient LOV
Acute painful LOV in non-inflamed eye - IIH: features
Young obese women
Headache
Transient Visual Obscurations: Uni/bilateral, Triggered by movement / postural changes; due to papilloedema
Papilloedema
Visual field loss
Acute painful LOV in non-inflamed eye - IIH: management
MRI: rule out SOL
MR-angiography: rule out venous sinus thrombosis
Urgent treatment - risk of permanent visual field loss
Weight loss, stop medications (NSAIDs)
Acetazolamide (carbonic anhydrase inhibitor)
Shunts: lumbo-/ventriculo-peritoneal
Acute painless LOV - Vitreous haemorrhage: features
Sudden painless loss of vision
Large haemorrhage: Total loss of vision, loss of red reflex
Small haemorrhage: Floaters
Subretinal haemorrhage: central dark scotoma
Acute painless LOV - Vitreous haemorrhage: causes
Trauma
Proliferative retinopathy: rupture of fragile new vessels, due to neovascularisation caused by ischaemia
Age-related macular degeneration: neovascularisation in wet ARMD
Retinal Detachment
Posterior Vitreous Detachment
Acute painless LOV - vitreous haemorrhage: management
Emergency - referral to ophthalmologist
Treat complications - glaucoma due to RBCs clogging up trabecular meshwork
Acute painless LOV - retinal detachment: types
Rhegmatogenous: secondary to retinal tear
Exudative: secondary to inflammation or vascular abnormalities
Tractional: secondary to fibrovascular tissue (from inflammation or neovascularisation)
Acute painless LOV - retinal detachment: features
Sudden painless loss of vision
Pre-ceeding: Photopsia, floaters, Visual field defects
Macula-on: peripheral vision lost, visual acuity normal
Macula-off: central vision lost
Acute painless LOV - retinal detachment: management
Macula-on = emergency (surgery before macular detachment preserves vision)
Investigations:
New flurry of floaters/photopsia = emergency; need to exclude retinal tears
Tobacco dust: retinal pigmented cells in vitreous
Peripheral tear: retinopexy (laser to retinal hole) + vitrectomy
Macula hole: vitrectomy + epiretinal peel
Acute painless LOV - vascular occlusion: CRVO/BRVO causes
Systemic HTN
Raised intraocular pressure
Hyperviscosity syndrome
Vessel wall disease (DM, Sarcoidosis)
Acute painless LOV - vascular occlusion: CRVO features
Tortuous vessels
flame-shaped haemorrhages
Acute painless LOV - vascular occlusion: CRAO/BRAO causes
Raised intraocular pressure
Emoboli: Carotid, AF, valve disease
Occlusion by atheroma or inflammation (GCA)
Acute painless LOV - vascular occlusion: CRAO feautres
Cherry red spot
Visible emboli
Acute painless LOV - vascular occlusion: AION, PION definition
Anterior ischaemic optic neuropathy
Posterior ischaemic optic neuropathy
Hypoperfusion of small vessels supplying optic nerve head (AION) or posterior optic nerve (PION)
Acute painless LOV - vascular occlusion: AION, PION features
AION - optic disc swollen, splinter haemorrhages at disc
PION - optic disc normal
Acute painless LOV - vascular occlusion: AION, PION risk factors
Arteriosclerosis
HTN
Hypotensive episode
Smoking and ‘disc at risk’ (small optic head)
