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Ophthalmology > Acute Ophthalmology 2 > Flashcards

Acute Ophthalmology 2 Flashcards

1
Q

Ophthalmic trauma: causes

A

Chemical injury - EMERGENCY
Blunt trauma
Sharp and penetrating trauma

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2
Q

Ophthalmic trauma: causes of loss of vision due to trauma

A
  1. Corneal scarring and anterior segment damage - alkali burn
  2. Disrupted globe - penetrating trauma
  3. Siderosis bulbi (iron deposition) - intraocular metallic foreign body
  4. Compressive optic neuropathy - retrobulbar haemorrhage
  5. Traumatic optic neuropathy - bony or shearing injury
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3
Q

Ophthalmic trauma - types

A

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

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4
Q

Ophthalmic trauma - chemical injury: substances, why is alkali most destructive?

A 
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)

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5
Q

Ophthalmic trauma - chemical injuries: management

A

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

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6
Q

Ophthalmic trauma - blunt injuries: aetiology

A

Sport (balls), leisure activities, road traffic accidents, fist

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7
Q

Ophthalmic trauma - blunt injuries: features

A 
Lid ecchymosis 
Orbital haemorrhage 
Subconjunctival haemorrhage 
Hyphaemia 
Lens dislocation 
Orbital wall fracture 
Vitreous haemorrhage 
Commotio retinae
Retrobulbar haemorrhage
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8
Q

Ophthalmic trauma - blunt injuries: examination

A

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

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9
Q

Ophthalmic trauma - blunt injury: hyphaema definition and management

A

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

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10
Q

Ophthalmic trauma - blunt trauma: traumatic iritis definition and management

A

Inflammation of anterior chamber occurring commonly after blunt trauma

Topical steroids and mydriatic drops

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11
Q

Ophthalmic trauma - blunt trauma: retrobulbar haemorrhage significance, features, management

A

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

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12
Q

Ophthalmic trauma - blunt trauma: commotio retinae definition, features, management

A

Retinal opaqueness due to fragmentation of photoreceptor layer and oedema following blunt trauma

Blurred vision if macula affected
Retina appears opaque

Completely resolves

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13
Q

Ophthalmic trauma - blunt trauma: orbital floor fracture features and management

A

Diplopia - orbital tissue/eom entrapment
Enophthalmos

Orbital floor repair

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14
Q

Ophthalmic trauma - penetrating trauma: features

A

high velocity injuries - intraocular FB

Misshapen pupils

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15
Q

Ophthalmic trauma - penetrating injuries: superficial corneal injury causes, features

A

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

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16
Q

Ophthalmic trauma - penetrating trauma: corneal abrasion features, management, RES

A

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

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17
Q

Acute loss of vision in inflamed eye - Uveitis: anatomical types

A

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

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18
Q

Acute LOV in inflamed eye - uveitis: anterior uveitis features

A

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)
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19
Q

Acute LOV in inflamed eye - uveitis: intermediate uveitis features

A

Floaters, blurred vision, no pain

Vitreous cells
Snowballs (pre-retinal inflammatory aggregates)
Snow-banking (pars plana exudation)
Macular oedema

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20
Q

Acute LOV in inflamed eye - uveitis: posterior uveitis features

A

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
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21
Q

Acute LOV in inflamed eye - uveitis: investigations

A

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
22
Q

Acute LOV in inflamed eye - uveitis: infective management

A

Idiopathic - treat as infective

Infective:
topical abx
Topical steroids (reduces Jarisch-Herxheimer reaction - inflammatory reaction against bacterial lysis once antimicrobials commence, in TB, syphillis)

23
Q

Acute LOV in inflamed eye - uveitis: inflammatory uveitis management

A

Corticosteroids - topical, peri-ocular, oral, IV

Sustained release implants in vitreous - minimise SE due to blood-retinal barrier

24
Q

Acute LOV in inflamed eye - posterior scleritis: features

A 
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

25
Q

Acute LOV in inflamed eye - posterior scleritis: investigations

A 
Inflammatory cause: 
Rh factor
ANA
P-ANCA 
C-ANCA
26
Q

Acute LOV in inflamed eye - posterior scleritis: management

A

NSAIDs - non-necrotising disease
Corticosteroids - topical, peri-ocular, oral, IV
Rheumatology referral

27
Q

Acute LOV in inflamed eye - advanced keratitis: features

A

Opaque cornea

Severe reduction in visual acuity

28
Q

Acute LOV in inflamed eye - advanced keratitis: predisposing factors

A

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

29
Q

Acute LOV in inflamed eye - peripheral ulcerative keratitis: definition, cause, treatment

A

Immune complex deposition in peripheral cornea, which causes damage to stroma via release of matrix metalloproteinase

RA, Wagner’s granulomatosis

Systemic immunomodulator

30
Q

Acute painful LOV in non-inflamed eye - causes

A

Giant cell arteritis
Optic neuritis
Migraines
Idiopathic Intracranial Hypertension

31
Q

Acute Painful LOV in non-inflamed eye - GCA: ophthalmic features

A

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

32
Q

Acute painful LOV in non-inflamed eye - optic neuritis: definition

A

Visual disturbance with eye pain, commonly in young women, due to inflammation of optic nerve

33
Q

Acute painful LOV in non-inflamed eye - optic neuritis: types

A

Papillitis: inflammation of optic nerve head - swollen optic disc
Retrobulbar neuritis: inflammation of optic nerve behind globe - normal optic disc

34
Q

Acute painful LOV in non-inflamed eye - optic neuritis: aetiology

A 
Idiopathic
MS: most common cause of retrobulbar neuritis; 50% MS patients develop ON, 30% ON patients have underlying MS
Infection (viral) 
Granulomatous inflammation
Autoimmune
35
Q

Acute painful LOV in non-inflamed eye - optic neuritis: features

A 
Acute LOV: complete; reduced colour vision (red desaturation) 
Eye pain (on movement) 
Features of undiagnosed MS: paraesthesia, bladder/bowel dysfunction, limb weakness
36
Q

Acute painful LOV in non-inflamed eye - optic neuritis: management

A

IV corticosteroids: helps w speeding recovery but not outcome; if vision loss in both eyes or severe pain
MRI brain: assess risk of MS

37
Q

Acute painful LOV in non-inflamed eye - migraine: features

A

Visual disturbance + headache
Fortification spectra (zigzag lines)
Scintillating scotoma
Transient LOV

38
Q

Acute painful LOV in non-inflamed eye - IIH: features

A

Young obese women

Headache
Transient Visual Obscurations: Uni/bilateral, Triggered by movement / postural changes; due to papilloedema

Papilloedema
Visual field loss

39
Q

Acute painful LOV in non-inflamed eye - IIH: management

A

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

40
Q

Acute painless LOV - Vitreous haemorrhage: features

A

Sudden painless loss of vision

Large haemorrhage: Total loss of vision, loss of red reflex
Small haemorrhage: Floaters
Subretinal haemorrhage: central dark scotoma

41
Q

Acute painless LOV - Vitreous haemorrhage: causes

A

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

42
Q

Acute painless LOV - vitreous haemorrhage: management

A

Emergency - referral to ophthalmologist

Treat complications - glaucoma due to RBCs clogging up trabecular meshwork

43
Q

Acute painless LOV - retinal detachment: types

A

Rhegmatogenous: secondary to retinal tear
Exudative: secondary to inflammation or vascular abnormalities
Tractional: secondary to fibrovascular tissue (from inflammation or neovascularisation)

44
Q

Acute painless LOV - retinal detachment: features

A

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

45
Q

Acute painless LOV - retinal detachment: management

A

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

46
Q

Acute painless LOV - vascular occlusion: CRVO/BRVO causes

A

Systemic HTN
Raised intraocular pressure
Hyperviscosity syndrome
Vessel wall disease (DM, Sarcoidosis)

47
Q

Acute painless LOV - vascular occlusion: CRVO features

A

Tortuous vessels

flame-shaped haemorrhages

48
Q

Acute painless LOV - vascular occlusion: CRAO/BRAO causes

A

Raised intraocular pressure
Emoboli: Carotid, AF, valve disease
Occlusion by atheroma or inflammation (GCA)

49
Q

Acute painless LOV - vascular occlusion: CRAO feautres

A

Cherry red spot

Visible emboli

50
Q

Acute painless LOV - vascular occlusion: AION, PION definition

A

Anterior ischaemic optic neuropathy
Posterior ischaemic optic neuropathy
Hypoperfusion of small vessels supplying optic nerve head (AION) or posterior optic nerve (PION)

51
Q

Acute painless LOV - vascular occlusion: AION, PION features

A

AION - optic disc swollen, splinter haemorrhages at disc

PION - optic disc normal

52
Q

Acute painless LOV - vascular occlusion: AION, PION risk factors

A

Arteriosclerosis
HTN
Hypotensive episode
Smoking and ‘disc at risk’ (small optic head)

Ophthalmology (7 decks)

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