All Conditions

Question 1

Acute Angle Closure Glaucoma

Answer 1

Narrowing of the drainage channel at the front of the eye, causing a buildup of fluid and pressure inside the eye. This pressure is causing damage to the nerve at the back of your eye.

• Red eye?
• SUDDEN, SEVERELY Painful eye?
• Sudden onset whilst in dark room?
• Blurry vision? HALOES AROUND LIGHTS? (latter caused by corneal oedema)
  -HEADACHE
• Nausea/vomiting?
• Family History?

Medication to lower IOP:
TABLETS called acetazolamide which reduces pressure.
Once you’re pressure has come down slightly, eye drops called pilocarpine to help open the blockage and allow fluid to drain from the front of the eye (explain to patient pupils will temporarily become smaller)
?Eye drops called dexamethasone to reduce inflammation in eye.

Definitive treatment:
Laser treatment to both the affected and unaffected eye. The laser creates a hole in the iris, the coloured part of the eye, to widen the drainage channel, allow fluid to drain and reduce the pressure.
(takes place in a room using laser connected to slit lamp. Not in theatre!)

Question 2

Amaurosis fugax

Answer 2

Temporary loss of vision in one eye, which is often a warning for a future stroke. Caused by a temporary blockage to the blood vessels supplying the back of the eye.

-Exclude GCA (headache?, jaw claudication?, scalp tenderness?)
-weakness in arms/legs?, drooping of face?
-Palpitations? Lost consciousness/collapsed?
-High Blood pressure? High Cholesterol? Smoking?

Amaurosis fugax is a TIA, so focus is on secondary prevention

Aspirin, BP medication
Urgent referral to TIA clinic, ECG +/- Echo, Carotid Doppler

Question 3

Age Related Macular Degeneration

Answer 3

Retina is the nerve tissue at the back of the eye which detects light coming in. AMD refers to damage to the central part of the retina over time, affecting central and fine detailed vision.

-Trouble reading?
-Straight lines appearing curvy?

Dry
Stop smoking
Specific vitamin supplements to slow down the damage progressing

Wet
Injections into the eye to prevent abnormal blood vessels growing and leaking.

Question 4

Bell’s palsy

Answer 4

Temporary weakness affecting one side of your face. Caused by inflammation of the nerve controlling muscles in your face.

-Exclude stroke (can they lift their eyebrow?, weakness in arms/legs, problems with speech?)
-Exclude Ramsay-Hunt (rash on face around ear?, hearing loss?)
-Can they close eyes? Can they smile?

Steroid tablets for 10 days (need to be started promptly within 3 days)
Protect the eye from drying out with lubricating eye drops/ointment, taping eye shut at night.

Improves after 6 months usually

Question 5

Cataracts

Answer 5

When the clear lens inside the eye becomes cloudy. Usually happens through the process of getting older.

• Reduced vision?
• Glare?
• Steroid eye drops/tablets?
• Diabetes?
• Smoking?

-Surgery to remove the cloudy lens and replace it with a clear artificial lens made of a material similar to plastic

Question 6

Cataract pre-op considerations and care

Answer 6

-Wash hands and face with antibacterial 1 week before
-Cleaning eyelids daily for 1 week before to reduce risk of infection or inflammation around eyelashes (which would cancel surgery)
-Avoid contacts or makeup for 1 week before
-If unwell with any infection (including cold/runny nose), to inform us as will need to cancel
-wash hair evening before operation

Reasons for cancellation:
- any systemic infection (including coryza symptoms)
- uncontrolled BP (increase risk of bleeding in the eye)
- raised blood sugars (HbA1c >8.5% or fasting glucose >11mmol) (increased risk of infection and reduces eye’s ability to heal post-op)
- any reason suggesting inability to lie still (e.g. cough) (dangerous to delicate structures in eye)
-EYE REASONS: raised/uncontrolled IOP; uveitis (operating under these conditions would make IOP or inflammation worse, hinder post-op recovery.

Question 7

Cataract intra-op complications

Answer 7

• Posterior capsular rupture (breaking of the bag which holds the lens). The cloudy lens might slip into the jelly of the eye, which could require a second operation to improve. Would also increase recovery time by a few weeks, but final visual outcome usually the same.

-Bleeding into the eye (more serious)

Question 8

Cataract post-op care and complications

Answer 8

Eye patch placed over eye intially
Usually no stitch used - the cut made on the surface of the eyeball for the operation closes itself.
Eye will be a little red and gritty initially - should improve over 4 weeks. If any worsening pain/redness/vision however, to contact us ASAP (essential to safety-net for endophthalmitis)
Antibiotic eye drops given to reduce infection risk.
Follow up appt usually booked 4 weeks time.

Most common complication is posterior capsular opacification (clouding of the bag which holds the new artificial lens). Can be easily treated by using a laser beam to create a hole in the cloudy bag to allow light to pass through.

Question 9

Choroidal metastases

Answer 9

Cancer from another part of the body has spread to your eye

• Flashes/floaters?
• Reduced vision?
• History of cancer/known active cancer
• FLAWS

-Break bad news
-Refer to both ocular oncology and medical oncology
-PET-CT to check for where the cancer has spread from and where else it has spread to
-Treatment options include chemotherapy, plaque radiotherapy

Question 10

Conjunctivitis

Answer 10

Inflammation of the surface of your eye, which can cause it to be itchy, red and watery.

-Itchy?
-Red?
-Discharge? Colour? (clear/green)
-Eyelids stuck together in the mornings?
-Exclude keratitis and anterior uveitis (conjunctivitis is not painful and does not reduce vision)
-Runny/blocked nose/sore throat/fever?
-Hayfever/allergies?

-Viral: should get better on its own, might take up to 2-3 weeks. Does not respond to antibiotic drops

-Bacterial: antibiotic eye drops

• To help with symptoms, can use lubricant eye drops
• To keep eyelids clean, flannel soaked in warm water to remove the discharge
• AVOID WEARING CONTACT LENSES

-Prevent spreading the infection by washing your hands, discarding used tissues and not sharing towels with others.

Question 11

Corneal Abrasion

Answer 11

Scratch to the front clear window of the eye

-Painful eye?
-Photophobia?
-Red?
-Feeling of something stuck in the eye?
-CL use?
-Ask about reduced vision?
-Has this happened before?(recurrence may suggest dystrophy)

Antibiotic ointment (or drops if infection or CL-associated)
Lubricating eye drops
Dilating eye drops
Avoid CL use until healed (2-4 weeks)
Sunglasses for photophobia
Avoid rubbing the eye

Question 12

Corneal Ulcer

Answer 12

Infection of the cornea, which is the clear front window of the eye

-Red, painful eye?
-Gritty sensation, like sand stuck in your eye?
-Reduced vision?
-Photophobia?
-CL wear? Do they have good hygiene.. sleep/shower/swim in lenses? Dailies vs Monthlies? Re-use dailies?
-Trauma? Dry Eyes?
-Rash on face? (exclude HSV)

-Antibiotic Eye Drops (used very frequently, every hour, for the first 48 hours, including at night)
-Sample of cornea (scrape)
-Avoid wearing CL’s during treatment and for a while afterwards until reviewed by CL practitioner
-Follow up review important
-Advise on good CL hygiene to reduce risk of it happening again

Question 13

Keratitis

Answer 13

Infection of the cornea, which is the front clear window of the eye

(difference between corneal ulcer and keratitis: ulcer usually caused by infection or trauma or dry eyes, whereas keratitis is infection or inflammation which can lead to an ulcer)

-Same Qs as corneal ulcer

-Mx same as corneal ulcer

Question 14

Central Retinal Artery Occlusion

Answer 14

A stroke of the eye. Blood supply to the retina, the nerve tissue at the back of the eye which detects light, has been affected.

-Drooping of the face?
-Changes to speech?
-Weakness in arms or legs?
-Numbness in arms or legs?
-Any changes to your vision?
-Headache? Jaw claudication? Scalp tenderness?
-Stroke or heart attack before?
-High blood pressure? Diabetes? High cholesterol?

-NB// mini-breaking bad news as unlikely to regain lost vision
-Urgent assessment by the medical/stroke team, which will be in A+E
-Imaging of the artery in the neck to check for any narrowing or clots
-ECG to check for abnormal heart rhythm
-Secondary prevention from stroke team afterwards: control BP, control blood sugar, reduce cholesterol
-Write to GP
-Follow up eye exam
-ECLO
-Need to inform DVLA

Question 15

Central Retinal Vein Occlusion

Answer 15

Blockage in the main vein of the eye which prevents blood draining properly. This causes bleeding and swelling to the retina, the tissue at the back of the eye which detects light.

-reduced vision?
-previous blood clots? blood disorders? COCP?
-smoke?
-high blood pressure?
-diabetes?
-glaucoma?

(Nb// non-ischaemic vs ischaemic)

-Control of risk factors for secondary prevention
-OCT to check for macular oedema
-If macular oedema, anti-VEGF injections (monthly injections and over 50% of patients notice improvements to vision, small portion don’t)
-If abnormal blood vessel growth -> laser treatment (does not improve vision but prevents worsening)

Question 16

Chalazion

Answer 16

Painless lump on your eyelid, caused by a blocked oil gland.

-Pain? (chalazion should not be painful)
-Discharge? (should not have)
-eyelid swelling? redness?
-vision affected? pain on eye movement? fever? (excluding cellulitis)
-have they had this before?

Warm compress (boiling water, let it cool slightly and soak clean flannel in warm water and apply for 3mins)

Then massage the eyelids towards the eyelashes

Do daily

If persistent after 6 months, can refer for surgery - warn patient bruising is common post-op and take up to 2 weeks to disappear. Also risk of recurrence. Continue applying warm compress and clean eyelids twice daily to prevent.

Question 17

Diabetic Retinopathy

Answer 17

When high blood sugar levels damage the blood vessels on the retina, the surface at the back of the eye that detects light. This causes vision problems over time.

NB// Complications - macular oedema, neovascularisation, vitreous haemorrhage, tractional retinal detachment.

Reduced vision?
Floaters?
Black curtain coming down?
Black spots?
Diabetes? How long for? Do you attend annual eye checks? Do you take your medication?
High BP?
Smoke?

NB// split into non-proliferative and proliferative

-Conservative: good control of blood sugar, annual eye screening (as early stages asymptomatic), BP control, smoking cessation
-Medical: if macular oedema - anti-VEGF injections (x2/3 sessions, each lasting 30mins). If neovascularisation, PRP laser (sacrifice outer vision to preserve central vision)

Question 18

Dry eyes

Answer 18

Usually caused by your eyes not producing enough tears or the tears evaporating too quickly from the surface of your eyes

-uncomfortable, gritty?
-blurry vision that improves when blinking?
-watery eyes? (due to reflex tearing)
-CL use? recent surgery?
-Dry mouth? Joint Pain? (checking for Sjogren’s)
-medication? (e.g. antihistamines, beta blockers)

Tear film break up time
Examination with fluorescein

Lubricating eye drops during the day
Lubricating eye ointment at night
Using a humidifier
Reducing screen time

If refractory, can consider punctal plugs.

Question 19

Endophthalmitis

Answer 19

Serious infection of the jelly inside the eye

-Reduced vision?
-Red eye?
-Pain?
-Pain when looking at light?
-RECENT EYE SURGERY OR INJECTIONS INTO EYE?
-Fever?
-Diabetes? Steroids? (as with any infection)

NB// Mini-breaking bad news station, as they are unlikely to regain the affected vision.
-Urgent Antibiotic injection into the eye (typically vancomycin and amikacin, but check local guidelines)
-At the same time, take a sample of the jelly from inside the eye and send to lab to see which bugs are growing inside causing the infection
-After that can go home with oral antibiotics (e.g moxifloxacin) but with DAILY FOLLOW UP REVIEW
-Only need to be admitted if severe infection requiring IV Abx (discuss all cases with consultant however)
-All cases of endophthalmitis need to be DATIXed and investigated.

Question 20

Giant cell arteritis

Answer 20

Inflammation of the blood vessels in your head and neck, which can cause headaches and vision problems

Headache?
Vision loss? (painless vision loss due to arteritic anterior ischaemic optic neuropathy)
Double vision?
Scalp tenderness?
Pain in jaw when chewing?
Stiffness in shoulders?

-If suspecting, give oral steroids before Ix
-If eye affected, IV steroids
-Blood tests to check level of inflammation in body (ESR)
-Ultrasound scan to visualise inflammation in blood vessels
-The most accurate test is taking a sample of the blood vessel and asking the lab to examine it for any signs of inflammation
-Medical team should look after patient
-Steroid advice: will likely be for a few months. Explain side effects, importance of not suddenly stopping.
PPI cover, if diabetic needs regular sugar checking, BP checking, maybe bone protection.
-Rheumatology referral for ongoing care whilst on steroids.

Question 21

Herpes Zoster Ophthalmicus

Answer 21

Ophthalmic shingles, which is shingles affecting the eye. It’s caused by the same virus as chickenpox.

Important to ask about immunosuppression (increases risk of re-activation, but also life-threatening shingles)

-Rash on face? (specifically which part, one side or both, painful, tingling, blistering?)
-Fever?
-Eye redness/pain/pain to light/gritty feeling/loss of vision?
-CL wear?
-Steroids? Diabetes? Conditions which lower your immune system? Recent treatment for cancer?

-Slit lamp microscope to examine eye (cornea, urea, retina)
-Pain relief (paracetamol, ibuprofen)
-Aciclovir tablets (x5/day for 10 days)
-Ganciclovir eye ointment (x5/day for 10 days)
-Discuss with consultant - if corneal infection of deeper layers, steroid drops as senior decision.
-follow up by cornea in 1 week
-Inform patient they are contagious to people who have not had chickenpox before - avoid vulnerable people such as newborn babies, pregnant women, elderly, immunocompromised.
-Safety-net eye signs - loss of vision, worsening redness
-GP letter. Advice even after rash disappears, pain may persist in some patients - specific nerve painkillers can be prescribed at the time.

Question 22

Horner’s syndrome

Answer 22

Nerve supplying the muscles that keep the eyelids open and control your pupils, is damaged.

It is important to know where the damage to the nerve is and what’s causing it as sometimes the cause can be serious. Examples of serious causes we need to rule out include a stroke, break in the wall of the neck arteries and a lung tumour.

-Small pupil?
-Drooping of eyelid?
-Reduced sweating on one side of face?
-Neck pain? High blood pressure? Trauma to neck?
-Weight loss? Smoking? Cough?

Apraclonidine eye drop test to see if pupil dilates (should do, which confirms Horner’s)
Urgent medic referral and CT angiogram to exclude carotid artery dissection
CT head for stroke?
CXR (less urgent) to check for tumour at top of the lung

Prognosis: Horner’s itself does not suggest damage to eye or cause loss of vision, but indicates damage to the nerve which can be caused by a serious condition

Question 23

Idiopathic Intracranial Hypertension

Question 24

Myasthenia Gravis

Answer 24

Your immune system damages the communication system between the nerves and muscles, making the muscles weak and easily tired. Often the eye muscles are affected first.

Drooping eyelids?
Double vision?
(Worse towards the end of the day?)
Difficulty swallowing?
Difficulty with your speech?
Difficulty breathing?
[3 S’s = speech, swallowing, SOB]

NB// It is a clinical diagnosis supported by serological, electrophysiological evidence.

Neurology referral

Blood tests to check for antibodies (anti-AChr) (THIS IS THE MAIN TEST ALL PATIENTS WILL HAVE TO START WITH)
Ice pack test (improves ptosis)
Electromyography (electrical tests of your nerves and muscles. Involves inserting small needles into your muscles to measure their electrical activity)

Pyridostigmine (AChesterase inhibitor)
Long term steroids
(IV immunoglobulins)
Spirometry if SOB
CT chest (thymoma. thymus gland is a small gland in the chest part of immune system. In myasthenia gravis, can be abnormally larger).

If breathing or swallowing difficulties - urgent medic review, spirometry and likely need admitting. If not present currently, safety-net to attend ED if they develop in future.

Remember - if patient asks, thymoma is technically cancer. If found, the main treatment is surgery to remove.

Question 25

Non Accidental Injury

Answer 25

'These types of symptoms aren't consistent with any common underlying condition we expect to see, so we're concerned they may represent a non-accidental injury. It's important we follow policies to protect the child and exclude any safeguarding concerns' (retinal haemorrhages, vitreous haemorrhages, retinal detachments) If suspecting the child, ADMIT and photograph injuries. Refer to SAFEGUARDING LEAD, refer to paediatrics, inform social services.

Question 26

Ophthalmia Neonatorum

Answer 26

Eye infection in newborns, usually caught during birth Most common cause = chlamydia Introduce this cause gently - 3rd person language. Explain infection can be caused by bacteria patients might not know they have, as they don't always cause symptoms. An example of this bacteria is chlamydia. Dysuria? Vaginal discharge? STI screen? Baby: saline irrigation, swab for culture, IM/IV ceftriaxone if gonorrhoea, PO erythromycin if chlamydia Mum: Sexual Health clinic

Question 27

Optic Neuritis

Answer 27

Inflammation of the nerve at the back of the eye -Sudden reduced vision? -Pain, especially worse on eye movement? -Reduced colour vision/red colours seeming washed out? -Any numbness/tingling/weakness/balance problems recently? We're not sure what causes most cases of optic neuritis (idiopathic). Sometimes linked to a condition called multiple sclerosis, so we're going to discuss with the neurologist to rule this out. (other causes: infection, auto-immune) -Neuro-ophthalmology and neurology referrals -Discuss with consultant if appropriate for steroids (some evidence shows can improve visual recovery time, but no effect on final vision) -Bloods (check CRP, ESR) -MRI scan Prognosis = -pain improves in a few days -vision significantly improves whether treated or not, but may not return completely to normal -start to see vision improvement after week or two, but can take as long as 6 months. -MOST PATIENT WITH A FIRST EPISODE OF OPTIC NEURITIS WILL NOT DEVELOP MS

Question 28

Orbital Cellulitis

Answer 28

Serious infection of the tissue behind the eye (Children higher risk of developing orbital cellulitis as they have no septum) (Risk of intracranial infection and sepsis) -Swelling around eye? -Redness around eye? -Reduced vision? -Pain at rest and on eye movement? -Reduced eye movement? -Recent cough/cold? -Trauma? -One eye or both? (if bilateral, ask if known allergies/taken anything new) -Fever? -Headache? -Pain looking at light? -Neck stiffness? -Admit, MDT approach -If child, under paediatrics) -IV Abx immediately -Urgent CT Orbits -If not responding to Abx or if abscess, may need surgery -Discuss with ENT -Oculoplastics f/u

Question 29

Papilloedema

Answer 29

swelling of the nerves at the back of both your eyes, which is caused by an increase in pressure in the brain (the priority is referring to medics to urgently exclude life-threatening cause such as Cerebral venous sinus thrombosis. Explain to the patient they will undergo brain scan with contrast injected into veins, and potentially a spinal tap (needle used to take a sample of fluid from the spine)). -temporary blacking out of vision? -blurring of vision? -headache? worse on lying down/mornings? -recent weight gain? -fever? neck stiffness? photophobia? -weight loss/night sweats/previous or active cancer? -COCP? Previous blood clots? -trauma? blood thinning medication? -Urgent medic referral -MRI Head and venogram -LP Prognosis: Depends on the cause but raised pressure if left untreated can cause permanent loss of vision.

Question 30

Primary Open Angle Glaucoma

Answer 30

Gradual damage to the nerve at the back of your eye, usually due to an increase in pressure inside the eye. It can affect your outer vision to begin with and if left untreated can progress to affect your central vision. -Reduced outer/edges of vision? -Haloes around lights? -Sudden pain in the eye? -Short/long sighted? -Family history of glaucoma? -Steroid use? Diabetes? -Measure pressure in eye -Test outer vision (Humphrey's VF testing) -1st line = SLT or prostaglandin analogues -2nd line = alpha agonists, beta blockers, CA inhibitors Prognosis: THERE IS NO CURE FOR GLAUCOMA but with monitoring and treatment, most people retain useful sight for life. Eye drops don't cure glaucoma. They try to prevent vision loss. Even SLT does not cure glaucoma - you may still need drops afterwards. Also the effects of laser tend to wear off after 2-5 years and you might need to have another round. (Laser procedure lasts 10mins) -LIFELONG REGULAR MONITORING of pressure, visual fields and optic nerve (every 6 months - 2 years)

Question 31

Retinitis Pigmentosa

Answer 31

Gradually progressive genetic condition affecting the layer of nerve tissue at the back of the eye. NB - caused by approx 100 genes Difficulty seeing at night/dim light? (early stage) Reduced outer vision? (early stage) Family history? Flashes? Central vision affected? (late stage) Refer to medical retina (consultant decision regarding treatment options e.g. vitamin A may slow down progression, experimental gene therapy - there is treatment for RP caused by this one specific gene defect). They will require regular follow up to monitor progression. Refer to genetics +/- genetic counselling

Question 32

Retinoblastoma

Answer 32

Rare type of eye cancer that can affect children -white spot when looking at the eye or in photos taken with flash? -family history of retinoblastoma or childhood cancers? -eye pain? -involuntary eye movements? Aim of treatment is to get rid of the cancer. Unfortunately high chance child may lose some or all the vision in the affected eye. -refer to ocular oncology -US/MRI scan to assess size -If tumour small, laser therapy and freezing therapy tried. If really small, sometimes laser alone can be successful -Chemotherapy (medicine to kill cancer cells) -Radiotherapy (radiation to kill cancer cells) -Surgery to remove the eyeball if above alone does not work. Signpost to ECLO and childhood eye cancer trust -genetic testing (RB1 genes) +/- genetic counselling -lifelong monitoring for recurrence

Question 33

Retinal Detachment

Answer 33

The thin layer of nerve tissue at the back of the eye peels away. -sudden painless loss of vision? (i.e. black curtain coming down?) -flashes or floaters? -long sighted? -diabetes? -trauma? -CVS risk factors (to assess CRAO/CRVO risk) Causes: retinal tear (causes fluid to enter space under retina), pulling off the retina (e.g. scar tissue from abnormal delicate blood vessels in diabetic retinopathy), fluid under the retina (leaking out from blood vessels and building up) Serious condition, which if not treated urgently, can cause sight loss. Surgery to repair the tear and/or stick the nerve tissue layer back onto the back of the eye (needs to take place within 48hrs). Prognosis:

Question 34

Scleritis

Answer 34

Inflammation of the white of the eye Serious condition which can cause vision problems and requires long term follow up -Red, painful eye (worse than episcleritis). The redness is all over the eye. -Photophobia Half of cases unknown cause, but can be associated with conditions causing inflammation elsewhere in the body e.g rheumatoid arthritis. Requires tablets to reduce inflammation (either one similar to ibuprofen (flurbiprofen) or steroids) Follow up ?

Question 35

Episcleritis

Answer 35

Inflammation of the white of the eye. -red eye? (may be more localised than scleritis) -painful? (not as painful as scleritis) -painful looking at lights? -gritty? Most cases, we're not sure what causes it or how to prevent it. Usually resolves itself in 2-3 weeks. It is not a sight threatening condition. Lubricating eye drops If moderate/severe, topical steroid drops or oral NSAIDs

Question 36

Squint

Answer 36

One of the eyes is out of line with the other, which means they're not working together to focus on the same object. (condition where the eyes do not line up properly) Double vision? Reduced 3D vision? (e.g. climbing stairs, catching a ball) Tilting their head? (in an attempt to realign their eye) Long sighted? Family history of squint? Children do not tend to grow out of a squint. Important to correct a squint to improve 3D vision, improve double vision and ensure development of vision in the misaligned eye. If left untreated, the vision in the misaligned eye won't develop as well, causing a lazy eye. Management: - Checking prescription and correcting long/short sightedness with glasses - Wearing an eye patch over the stronger eye for a few hours each day to help the vision the weaker eye develop - Surgery to correct the squint (involves tightening/loosening muscles around the misaligned eye). Reassure parents squint surgery is one of the most common eye surgeries for children. Most patient do see an improvement with surgery to correct a squint. However, important to know that it might not completely correct the squint - may under or overcorrect it. This may require a second surgery in the future.

Question 37

Third Nerve Palsy

Answer 37

Weakness of one of the nerves that controls the muscles that help move the eye, your eyelids and your pupil. Some of the rarer, but more serious causes include a swelling/bulging of a nearby blood vessel which we need to check for. If this is present and left untreated, it can burst and be life-threatening. Double vision? Difficulty moving eyes? Blurring of vision/reduced vision? Drooping of the eyelid? Sudden vs gradual onset? Headache? GCA symptoms? (GCA can cause 3rd nerve palsy!) History of diabetes or high blood pressure? Urgent discussion with medical team - will need CT/MRI angiogram to exclude PCA aneurysm (swelling/bulging of a blood vessel). - urgent bloods to exclude inflammation of the blood vessels (GCA) - if above normal, controlling BP and diabetes (CVS risk modification) NB// improvement depends on the cause. If medical cause (BP, diabetes), 3rd nerve palsy tends to spontaneously improve after 6-12 weeks.

Question 38

Thyroid Eye Disease

Answer 38

Autoimmune condition associated with an overactive thyroid gland (the gland in your neck that releases a hormone which controls metabolism). In this condition you develop swelling of the muscles and normal fat tissue around the eyes, causing them to bulge forward. BULGING OF EYES AND DOUBLE VISION? Pain/ache around eyes? Redness? Dry, grittiness? Swelling around eyes? Symptoms of hyperthyroidism (weight loss, palpitations, heat intolerance) Important to exclude serious complications - optic neuropathy (reduced colour vision), exposure keratopathy (inability to close eyelids, increasing risk of ulcers to the front window of the eye) SMOKING? NB// important to demonstrate holistic, MDT approach to management 40% of patients with graves' develop TED, but mostly in mild form If appearance is a concern for patient, reassure patients this improves as inflammation settles MRI ORBITS -lubricating eye drops -stop-smoking programme (reduces risk/severity of TED and improves response to treatment) -prism glasses for double vision -steroid tablets -follow up in eye clinic (oculoplastics) -thyroid blood tests -refer to endocrinology clinic -write to GP -signpost to patient support groups (acknowledge serious impact TED can have on QoL due to change in appearance - patients can find this distressing) -Safety-net for optic neuropathy and exposure keratopathy

Question 39

Anterior Uveitis

Answer 39

Inflammation of the front part of your eye Painful red eye? Photophobia? Joint pain? Back pain? Skin rashes? Abdominal pain? Change to bowels? Oral or genital ulcers? Cough? (sarcoidosis) Smoking? (risk factor) In around 40% of patients, we don't find the cause. Can be caused by infection or be related to inflammation in other parts of the body. If left untreated can cause irreversible sight problems. Patients may worry about the risk of glaucoma or cataracts from steroid eye drops, but the risk of leaving untreated is developing these same complications faster. If not already done, must examine back of eye to exclude posterior uveitis. Management: - steroid eye drops - dilating eye drops (cyclopentalate) - warn patient may make vision blurry and not to drive during this. - can give IOP lowering drops, if develop raised IOP either from inflammation or the steroids. - Stop-smoking programme - Sunglasses/tinted glasses when photophobic - OPHTHAL FOLLOW UP 4-6 weeks - RHEUM REFERRAL +/- blood tests (including testing for HLA B27 gene) - WRITE TO GP

Question 40

Posterior Uveitis

Answer 40

Inflammation of the back of the eye (choroid +/- retina)

Question 41

Sarcoidosis (as a cause of anterior uveitis)

Answer 41

Autoimmune condition that tends to affect your lymph nodes and lungs Dry cough, erythema nodusum, lupus pernio, swinging fever, weight loss Needs rheum referral, bloods, CXR and treated with oral steroids.

Question 42

Behcet's (as a cause of anterior uveitis)

Answer 42

Inflammation of blood vessels throughout the body Mouth ulcers? Goin ulcers? Erythema nodosum? Needs rheum referral and is treated with oral steroids.

Question 43

TB (as a cause of anterior uveitis)

Answer 43

Bacterial infection, usually affecting the lungs but can also affect other parts of the body including the eyes Cough? Coughing blood? Fevers, weight loss, night sweats, tiredness? CXR, referral to infectious diseases, antibiotic treatment for atleast 6 months

Question 44

Vitreous haemorrhage

Answer 44

Bleeding into the jelly of the eye Floaters? Sudden painless reduced vision? History of diabetes and specifically diabetic eye disease? Most common cause is diabetic retinopathy (high blood sugar levels damaging blood vessels at the back of the eye). Retinal tear/detachment is another cause. The vitreous haemorrhage is caused by abnormal delicate blood vessels, which grow in diabetic eye disease, bleeding. If small bleed, monitor with regular follow up If several/large bleeds, surgery to remove part of the jelly - prevents further bleeding.