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Acute Visual Loss (Painful) Flashcards

1
Q

What are the key causes of painful acute vision loss?

A
  1. Acute congestive glaucoma
  2. Acute iridocyclitis
  3. Endophthalmitis
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2
Q

What is glaucoma?

A
  • progressive optic neuropathy caused by increased IOP (controlled by aqueous humor)
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3
Q

What is aqueous humor?

A

Clear watery fluid that fills ant chamber (0.25 mL) and post chamber (0.06 mL) of eyeball

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4
Q

What are the functions of aqueous humor?

A
  1. Maintains IOP
  2. Provide nutrition and removes metabolites from the cornea & lens
  3. Maintains optical transparency
  4. Removes blood, macrophages, lens remnants & inflammatory products from ant chamber
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5
Q

What are the risk factors for acute angle-closure glaucoma?

A
  • Hereditary = shallow ant chamber, narrow angle
  • Age = 6th & 7th decade
  • Gender = F>M
  • Ocular risk factors = hypermetropic eyes (shallow ant chamber, short axial length) & narrow ant chamber angle
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6
Q

What are the stages of angle-closure glaucoma?

A
  1. Primary angle - closure suspect
  2. Primary angle - closure
  3. Primary angle - closure glaucoma
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7
Q

What are the symptoms of acute angle closure glaucoma?

A
  1. Transient blurring & haloes around lights
  2. Rapid, progressive unilateral visual loss
  3. Severe orbital pain + N&V
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8
Q

What are the signs of acute closure glaucoma?

A
  1. Red eye with prominent vessels
  2. Corneal haze, epithelial bullae, filamentary keratitis
  3. Shallow anterior chamber
  4. Dilated, non-reactive popular
  5. Very high IOP
  6. +ve eclipse sign (shadow on nasal iris)
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9
Q

What investigations confirm acute angle-closure glaucoma?

A
  1. Tonometry = measure IOP
  2. Gonioscopy = assess angle of ant chamber
  3. Ultrasonic biomicroscopy & ant segment OCT = structural imaging of ant chamber
  4. Visual field analysis
  5. Optic disk evaluation
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10
Q

What is prone-darkroom test?

A
  1. Ptn lie prince in darkroom for 1 hour (must stay awake)
  2. Measure IOP before & after
    - IOP increase > 8 mmHg (diagnostic)
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11
Q

What is the medical treatment for acute angle closure glaucoma?

A
  • Prostaglandin analogues = latanoprost
  • Topical beta blockers = timolol
  • Carbonic anhydrase inhibitors = acetazolamide
  • Pilocarpine
  • Mannitol
  • Analgesic, anti-emetics
  • Topical steroids
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12
Q

What are the definitive treatment for acute angle closure glaucoma?

A
  1. Laser peripheral iridotomy
  2. Filtration surgery
  3. Clear lens extraction
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13
Q

What are the complications for acute angle closure glaucoma?

A
  1. Corneal ulceration (prolonged high IOP)
  2. Staphyloma formation (sclera becomes thin, atrophic & bulged out)
  3. Atrophic bulbi (ciliary body degenerates, IOP falls & eyeball sinks)
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14
Q

What is acute iridocyclitis?

A

Inflammation of the iris & ciliary body as they share a common blood supply

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15
Q

What are the exogenous etiology of acute iridocyclitis?

A

External infection
- during surgery

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16
Q

What are the endogenous etiology of acute iridocyclitis?

A
  • eye disease
  • systemic disease
  • auto-immune disease
17
Q

What are the signs of acute iridocyclitis?

A
  • red eyes
  • lid edema
  • miosis, irregular, sluggish of pupil
  • corneal edema
  • iris edema, muddy colored, nodules, post synechiae
  • tenderness in ciliary body
18
Q

What are the symptoms of acute iridocyclitis?

A
  • pain
  • headache
  • photophobia
  • decreased visual acuity
19
Q

What are the investigation for acute iridocyclitis?

A
  1. Lab test = CBC, ESR, CRP, serological test
  2. Ocular imaging = site of inflammation
  3. Iris, vitreous, conjunctival biopsy
20
Q

What are the complication seen in acute iridocyclitis?

A
  • Synechiae formation
  • Secondary formation
  • Complicated cataract
  • Cystoid macular edema
  • Cyclitic membrane behind the lens
21
Q

What are the local drugs given for acute iridocyclitis?

A
  1. Cyclopegic drugs = Atropine sulphate
  2. Corticosteroids = Dexamethasone, Prednisolone
22
Q

What are the systemic drugs given for acute iridocyclitis?

A
  1. Corticosteroids (if resistant to topical)
  2. NSAIDS
  3. Broad spectrum antibiotics
  4. Analgesics
  5. Immunosupressive
23
Q

What is endopthalmitis?

A

Purulent inflammation of the intraocular fluid (vitreous and aqueous) usually due to infection

24
Q

What is the exogenous etiology of endopthalmitis?

A
  1. Post op
    - acute < 6 weeks
    - delayed onset > 6 weeks
  2. Post traumatic
25
What is the endogenous etiology of endopthalmitis?
1. Hematogenous spread 2. Ptn with underlying disease or IV access 3. Liver abscess
26
Organism causing acute post-op endopthalmitis?
1. Gram +ve = S epidermidis, S aureus, streptococci 2. Gram -ve = pseudomonas, h influenza, klebsiella, E. coli, bacillus spp 3. Anaerobes
27
Organism causing delayed post-op endopthalmitis?
1. Bacteria = propionibacterium, streptococci 2. Fungi = aspergillus, candida, fusarium, penicilium
28
What are the symptoms of acute post op endophthalmitis?
1. Blurred vision 2. Red eye 3. Pain 4. Swollen lid
29
What are the sign of acute post op endophthalmitis?
1. Hazy media 2. Eye lid swelling 3. Chemosis 4. Conjunctiva injection & discharge 5. Vitritis with impaired view of fundus
30
What are the investigation of acute post op endophthalmitis?
1. B scan ultrasound 2. Sample - Vitreous tap 3. Culture = aerobic, anaerobic, fungal, gram staining, PCR
31
What are the intravitreal antibiotics given for acute post op endophthalmitis?
Immediately after sampling - Ceftazidime (G+) and Vancomycin (G-)
32
What are the oral antibiotics given for acute post op endophthalmitis?
Fluoroquinolones (Moxifloxacin) 400mg daily for 10 days & Clarithromycin 500mg BD (G-)
33
What is the oral steroid given for acute post op endophthalmitis?
Prednisolone 1mg/kg daily in severe cases after 12-24 hours
34
What is the topical mydriatic given for acute post op endophthalmitis?
Atropine 1% BD
35
What surgery can be done for acute post op endophthalmitis?
Pars plana vitrectomy
36
What are the symptoms of delayed post op endophthalmitis?
- Painless mild progressive visual deterioration - Floaters- may present
37
What are the signs of delayed post op endophthalmitis?
- Low-grade anterior uveitis - medium large keratic precipitates - a degree of vitritis - enlarging capsular plaque composed of organisms sequestrated in residual cortex within the peripheral capsular bag
38
What is the initial treatment for delayed post op endophthalmitis?
- Moxifloxacin - Empirical treatment 10-14 days - (alt - Clarithromycin) prior to invasive option
39
What is the treatment for delayed post op endophthalmitis if it persistant?
- Intravitreal antibiotics alone are not enough - Combined, Vancomycin - Removal of capsular bag, Residual cortex and IOL - PPV - Secondary IOL implantation considered later

Ophthal (18 decks)

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