Case 21- SAP and Physiology

Question 1

How ones own prejudice can impact clinical decision making?

Answer 1

Decreased doctor patient relationship
Missed diagnosis
Lack of empathy towards patient
Incomplete diagnosis

Question 2

Attribution

Answer 2

Refers to the fact that humans are motivated to assign causes to their actions and behaviours, as either being internal or external

E.g. is someone angry because something bad happened or because they have a bad temper - it is up to us to attribute an answer to this

Question 3

Interpersonal attribution

Answer 3

The tendency for individuals to tell a story in a way that characterises them in the best light possible

Question 4

Predictive attribution

Answer 4

We assign things in ways that allow us to make future predictions

E.g. if your car is broken in to you attribute it to the fact you parked in a particular place so wont park there again

Question 5

Explanatory attribution

Answer 5

The tendency for us to make attributions that help us make sense of the world around us (i.e. explaining something as God’s plan)

Question 6

Origins and nature of stereotyping

Answer 6

Stereotyping is creating an oversimplified image of a particular group of people by making one rule and assuming everyone else in the group fits under this rule

Stigmas are labels that form these stereotypes

Question 7

Origins and nature of prejudice

Answer 7

Prejudice is having a preconceived opinion that is not based on reason or actual experience

Question 8

Attribution value model of prejudice

Answer 8

People are prejudiced against groups that they feel they have some negative attribute for which they are held responsible for

E.g. thinking overweight people are lazy

Question 9

Origins and nature of discrimination

Answer 9

Discrimination is unjustifiable negative behaviours and treatment towards a group and its members which leads to adverse consequences

Question 10

Pathology- conjunctiva

Answer 10

Conjunctiva- lines the inside of the eyelids and reflects to cover the sclera, attaching at the limbus (where the sclera and cornea join)

Pathology: Conjunctivitis

Question 11

Pathology- Subconjunctival area

Answer 11

Subconjunctival region- under the conjunctiva

Pathology: Subconjunctival haemorrhage

Question 12

Pathology- Sclera and cornea

Answer 12

Outer fibrous layer of the eyeball-sclera and cornea

Pathology: Episcleritis (outer/superficial layer of sclera), Scleritis (deeper layers), Corneal ulcer/abrasion.

Question 13

Pathology- Anterior chamber

Answer 13

Anterior chamber-chamber between the iris and cornea

Pathology: Glaucoma-closed angle

Question 14

Pathology- Uvea/middle layer of the eyeball

Answer 14

Uvea/Middle layer of the eyeball-choroid, ciliary body and process, iris
Pathology: Uveitis

Question 15

Painful red eye- Bacterial keratitis

Answer 15

Inflammation of the cornea.

Anything that disrupts the epithelial surface of the cornea can predispose it to infection e.g. trauma or contact lens wear.

Features:
Pain
Blurred vision
Photophobia
Gritty sensation
Forms a round lesion on fluorescein staining

Question 16

Bacterial keratitis- Management

Answer 16

Diagnosis- Use fluorescein eye drops to visualise infective keratitis. It stains any defects in the corneal epithelium.
Management- Refer the patient to the emergency eye service for same-day assessment due to the risk of visual loss. Do not continue to wear the contact lenses and take the lenses to the hospital to be swabbed.

Question 17

Painful red eye- viral keratitis

Answer 17

History of cold sores
Dendritic/branching ulceration
Reduced corneal sensation
Management- Refer the patient to the emergency eye service for same-day assessment due to the risk of visual loss. Do not continue to wear the contact lenses and take the lenses to the hospital to be swabbed.

Question 18

Painful red eye- Anterior scleritis

Answer 18

Uncommon, Associated with autoimmune disease, infections and trauma.

Features:
Severe boring pain with globe tenderness.
Worse at night waking the patient from sleep.
Reduction in vision.
Photophobia
Sectoral or diffuse redness
Sclera may appear blue/grey- the sclera becomes more translucent

Question 19

Anterior scleritis- management

Answer 19

Refer patients with severe eye pain and a significant reduction in vision immediately for same-day assessment

Question 20

Painful red eye- acute angle closure glaucoma

Answer 20

The iris pushes forward against the trabecular meshwork preventing the drainage of aqueous humour.

Features:
Pain
Blurred vision
Nausea and vomiting
Haloes 
Mid dilated fixed pupil
Cloudy cornea
Conjunctival injection

Question 21

Acute angle closure glaucoma- management

Answer 21

Refer the patient to the emergency eye service for same-day assessment due to the risk of visual loss
Occurs in individuals with risk factors- narrow anterior chamber, long sighted, cataracts

Question 22

Painful red eye- Anterior uveitis

Answer 22

Inflammation of the iris and ciliary body

Causes= Idiopathic, Trauma, infection, autoimmune conditions-HLA-B27

Features:
Photophobia-due to the movement of an irritated iris
Pain
Blurred vision-due to debris in the anterior chamber
Headache
Watery eye
Peri-limbal hyperaemia
Abnormal pupil shape
Hypopyon- inflammatory cells in the anterior chamber

Question 23

Anterior uveitis- management

Answer 23

Refer patients with severe eye pain and a significant reduction in vision immediately for same-day assessment

Question 24

Painful red eye- Endophthalmitis

Answer 24

Infection of the aqueous and vitreous humour.

Post surgery
Post trauma
Endogenous – associated with severe systemic infection or intravenous drug use

Features:
Blurred vision
Red eye
Pain
Photophobia
Swollen lid
Hypopyon- inflammatory cells in the anterior chamber 
Hazy appearance

Question 25

Endophthalmitis- management

Answer 25

Refer patients with severe eye pain and a significant reduction in vision immediately for same-day assessment. Patients with endogenous endophthalmitis can become very unwell

Question 26

Flow chart- Episcleritis

Answer 26

Pain- mild/none | Redness- Focal

Question 27

Flow chart- Subconjunctival haemorrhage

Answer 27

Pain- mild/none Redness- Diffuse Discharge- None

Question 28

Flow chart- Chlamydial conjunctivitis/Bacterial conjunctivitis

Answer 28

Pain- mild/none Redness- diffuse Discharge- mucopurulent

Question 29

Flow chart- Allergic conjunctivitis

Answer 29

Pain- mild/none Redness- diffuse Discharge- watery, itchy

Question 30

Flow chart- viral conjunctivitis

Answer 30

Pain- mild/none Redness- diffuse Discharge- watery, no itch

Question 31

Flow chart- viral keratitis

Answer 31

Pain- mod/severe | Fluorescein stain uptake- yes, branching

Question 32

Flow chart- bacterial keratitis

Answer 32

Pain- mod/severe | Fluorescein stain uptake- yes, round

Question 33

Flow chart- corneal abrasion

Answer 33

Pain- mod/severe | Fluorsecein stain uptake- yes, neither branching or round

Question 34

Flow chart- Scleritis

Answer 34

Pain- mod/severe Fluoescein stain uptake- no Pupil- pupil small or normal, deep pain

Question 35

Flow chart- anterior uveitis

Answer 35

Pain-mod/severe Fluorscein stain uptake- no Pupil small or normal Photophobia

Question 36

Flow chart- acute angle glaucoma

Answer 36

Pain- Mod/severe Fluorsecein stain uptake- no Pupil enlarged and fixed

Question 37

Visual loss- Acute painful

Answer 37

``` Migraine Keratitis Anterior uveitis Optic neuritis Endophthalamitis Orbital cellulitis Acute angle closure glaucoma ```

Question 38

Visual loss- acute painless

Answer 38

``` Retinal detachment Acute ischaemic optic neuropathy Central retinal vein occlusion Wet ARMD Central retinal artery occlusion Vitrous haemorrhage Stroke ```

Question 39

Visual loss- Chronic painless

Answer 39

``` Cataract Tumour Dry ARMD Open angle glaucoma Diabetic retinopathy ```

Question 40

Acute painful visual loss- Optic neuritis causes

Answer 40

Inflammation of the optic nerve ``` Cause: Demyelination-may be the first presentation of multiple sclerosis Inflammation Infection Ischaemia ```

Question 41

Acute painful visual loss- Optic neuritis Features

Answer 41

``` Visual loss Relative afferent pupillary defect Pain on eye movement Reduced acuity Impaired colour vision Visual field loss Mild disc swelling or normal disc ```

Question 42

Visual loss acute painful- Migraine

Answer 42

``` Cause: Many triggers specific to an individual Features: Preceding aura Headache Nausea Photophobia Phonophobia Scintillating scotoma – zig-zag lines ```

Question 43

Visual loss acute painful- Orbital cellulitis (Causes, features)

Answer 43

Cause: Cellulitis (bacterial infection) in this region is divided into- Pre-septal- anterior to the orbital septum Orbital- posterior to the orbital septum Features: Emergency-risk of intracranial infection, sepsis and visual loss. Double vision, pain on eye movements, reduced acuity.

Question 44

Orbital cellulitis- Treatment

Answer 44

1) Emergency referral to ophthalmology | 2) IV antibiotics

Question 45

Acute painless visual loss- Retinal artery occlusion (Risk factors, symptoms)

Answer 45

Risk factors: Embolism Vasculitis (giant cell arteritis) Clotting disorders Symptoms: Varied degrees of visual loss-dependent on the point of occlusion Causes ischaemia distal to the occlusion

Question 46

Retinal artery occlusion- On examination / Management

Answer 46

``` O/E: Pale retina due to nerve fibre ischaemia Cherry red spot at macula-due to visible choroid in this region Visual field loss Loss of visual acuity ``` Management: If presenting within 12 hours of vision loss-ocular massage, rebreathing into a paper bag, acetazolamide. Management of cardiovascular risk factors-high risk of stroke

Question 47

Visual loss- acute painless= Retinal vein occlusion (Risk factors/cause)

Answer 47

``` Risk factors: Age Smoking Hypertension Diabetes Combined oral contraceptive pill ``` Cause: Thrombus formation Compression by external structures

Question 48

Features of Retinal vein occlusion

Answer 48

Sudden loss of vision-visual acuity is dependent on the level of retinal ischaemia “Stormy sunset” or “blood-and-thunder” appearance: Retinal haemorrhages Cotton wool spots Tortuous retinal veins-due to the swelling of the retina Macula oedema

Question 49

Acute painless visual loss- Anterior ischaemic optic neuropathy

Answer 49

Features: Vision loss with disc swelling and hyperaemia, RAPD Cause: Arteritis-due to giant cell arteritis – waxy pallor to disc Non-arteritic- unknown cause, risk factors include those for CVD, sudden drops in BP, small

Question 50

Anterior ischaemic optic neuropathy- giant cell arteritis

Answer 50

Inflammation in large/medium vessel walls e.g. ophthalmic artery branches. Causes loss of vision via central retinal artery occlusion or anterior ischaemic optic neuropathy Aged 50+ Headache-temporal Scalp tenderness Jaw pain Associated with polymyalgia rheumatica- shoulder and pelvic girdle pain, fatigue Can also cause CNIII, CNIV or CNVI palsies Diagnosis confirmed on blood tests: raised c-reactive protein, raised erythrocyte sedimentation rate, raised platelets.

Question 51

Acute painless visual loss- Wet age related macular degeneration (Causes, Risk factors)

Answer 51

Cause: Blood vessels grow underneath the retina at the macula causing scarring and bleeding Risk factors: Age Smoking Disease in the fellow eye

Question 52

Wet age related macular degeneration- Symptoms/signs

Answer 52

Symptoms: Metamorphopsia-look at an Amsler grid of straight lines and they appear wavy and distorted. Reduction in central vision Signs: Subretinal fluid or haemorrhage- the new vessels are fragile.

Question 53

Visual loss acute painless- Retinal detachment (Symptoms, risk factors)

Answer 53

Symptoms: Sudden onset flashes and floaters Progressive visual field defect Blurred vision ``` Risk factors: High myopia Trauma Previous eye surgery Family history Connective tissue disorders (e.g. Ehlers-Danlos, Stickler, Marfan syndrome) ```

Question 54

Retinal detachment- signs/management

Answer 54

Signs: Retinal tear or hole Detached retina Visual acuity is dependent on the status of the macula Management: Urgent referral to ophthalmology for surgical repair – within 24 hours if macula on, less urgent if macula off

Question 55

Acute painless visual loss- Vitreous haemorrhage causes

Answer 55

Vitreous haemorrhage is bleeding within the vitreous of the eye Causes: Trauma Posterior vitreous detachment Bleeding from abnormal structures in the eye e.g. diabetic retinopathy

Question 56

Vitreous haemorrhage- signs and symptoms

Answer 56

Symptoms: Sudden onset floaters Loss of vision->blurred vision (there is a scale of symptoms) Signs: Reduced red reflex-it is obscured by blood within the vitreous. Haemorrhage on fundoscopy-you cannot see the retinal vessels therefore you know the bleeding has occurred in front of the retina.

Question 57

Acute painless visual loss- Stroke/TIA

Answer 57

Risk factors: CV risk factors, Coagulopathy/anticoagulant medication Symptoms: Sudden visual loss Potentially in association with other features-dependent on the affected artery/territory Signs: Visual field loss affecting both eyes - homonymous hemianopia or quadrantanopia Ocular examination is typically normal May have other neurological signs Management- Refer to stroke team

Question 58

Chronic painless visual loss- Cataracts

Answer 58

Cause: Opacification of the lens- the crystallin proteins become clumped together disrupting their usual structure Symptoms: A myopic shift in glasses prescription-become more short-sighted Gradual decline in vision Glare from bright lights Signs: Clouding to the lens, Reduced red reflex

Question 59

Chronic painless visual loss- Diabetic retinopathy (Risk factors)

Answer 59

Smoking Hypertension Duration of diabetes Diabetic control

Question 60

Diabetic retinopathy- signs/symptoms

Answer 60

Symptoms: Often none until the changes are advanced Blurred vision Signs: Flame retinal haemorrhages (flame-shaped as they track along the nerve fibre layer) this is due to leaking vessels Dot and blot retinal haemorrhages- localised bleeding Retinal exudates-proteins from leaky vessels (yellow patches) Neovascularisation-new vessel formation (look around the optic disc) Cotton wool spots-axonal debris (fluffy white spots)

Question 61

Chronic painless visual loss- Open angle Glaucoma

Answer 61

Symptoms: Often asymptomatic until advanced visual field loss Signs: Elevated intraocular pressure Optic disc cupping Visual field loss

Question 62

Chronic painless visual loss- Dry are related macular degeneration

Answer 62

Cause: Atrophy of the retinal pigmented epithelium (RPE) Symptoms: Gradual decline in vision, particularly reading Mild metamorphopsia- straight lines appear wavy Signs: Macular drusen- yellow deposits RPE hyperpigmentation Can transform into wet macular degeneration and cause acute vision loss.

Question 63

Chromic painless visual loss- Choroidal tumours (melanoma/metastases)

Answer 63

``` Symptoms: Flashes or floaters Blurred vision Sometimes severe pain depending on the location Systemic symptoms e.g. weight loss ``` Signs: Reduced acuity Visual field loss Lesion noted on fundoscopy

Question 64

Chronic painless visual loss- intracranial tumours

Answer 64

Symptoms: Associated neurological symptoms Loss of visual field Pituitary tumours (at chiasm) may have pituitary symptoms Signs: Visual field loss – depending on location of tumour: Anterior to chiasm: monocular At chiasm (pituitary tumour): bitemporal hemianopia Post-chiasm: homonymous quadrantanopia or hemianopia May have bilateral swollen optic discs if raised intracranial pressure (papilloedema