clinical Flashcards
1
Q
what is conjunctivitis?
A
Condition where the conjunctiva is inflamed with infection of the superficial vessels
2
Q
what are the causes of conjunctivitis?
A
Infectious causes:
1.Viral is main cause: Adenovirus
other viral causes: Herpes simplex, Varicella zoster
- bacteria not as big of a cause: Streptococcus pneumoniae, Staphylococcus aureus and Haemophilus influenzae
other causes: chlamydia
- Chlamydia can also cause Ophthalmia neonatorum (conjunctivitis of new born)
Non infectious causes:
- Allergic conjunctivitis
- Drugs
- autoimmune
- skin disease - eczema
3
Q
What are the signs and symptoms of conjunctivitis?
A
symptoms
foreign body sensation
discharge - sticky eye
itch = allergy
Signs:
Red eye - not the pattern of redness
discharge - serous or mucopurulent
Papillae or follicles
sub conjunctivitis haemorrhage
Chemosis
pre-auricular glands swelling - if viral
VISION IS UNAFFECTED
4
Q
how do you diagnose conjunctivitis?
A
mainly on signs and symptoms
examine eye
can do conjunctival cultures - really only needed for gonococcal/chlamydial infection
Viral PCR and bacterial swabs
5
Q
what are the distinct features of viral conjunctivitis?
A
follicular inflammation
subconjunctival haemorrhages.
Epidemic keratoconjunctivitis (due to adenovirus)
Less discharge (usually watery) than bacterial conjunctivitis.
Upper respiratory tract infection and pre-auricular lymphadenopathy.
itchy
- Herpes simplex typically presents as unilateral red eye with vesicular lesions visible
- Herpes zoster infection should be assumed if lesions are present at the tip of the nose (Hutchinson’s sign).
6
Q
what are the main causes of follicular conjunctivitis?
ii. what is follicular conjunctivitis secondary to?
A
Viral (adeno, HS and HZ)
chlamydial
drugs e.g. propine, trusopt
ii. Molluscum contagiosum
7
Q
what are the main distinct features of bacterial conjunctivitis?
A
Purulent or mucopurulent discharge with crusting (gritty) of the lids which may be stuck together on waking.
mild or no pruritus
papillae inflammation
self limiting - will clear after 14 days
8
Q
what is the clinical presentation of chronic conjunctivitis?
A
Blepharitis - inflammation of the eyelids
chlamydial infection
keratoconjunctivitis sicca
lacrimal disease
sensitive to topical glaucoma medication
sub-tarsal foreign body
9
Q
How do you manage conjunctivitis?
A
- Most cases are viral and only need symptomatic relief with artificial tears and cold compress ]
- bacterial and viral (non-herpetic) are usually self- limiting (2 weeks)
- Bacterial conjunctivitis can use antibiotics to decrease duration of symptoms:
1st line: bathe/clean eyelids regularly to remove crusting
2nd line: Chloramphenicol 0.5% eyedrops applied four times daily for less severe infections
Continue for 48 hours after
resolution.
3rd line: Send swab prior to treatment. Fusidic acid 1% eye drops applied bd (Note: no gram negative activity). Continue
- Seek specialist advice if very severe, vision affected or infection persists for >10-14 days after treatment initiated.
Consider Chlamydia trachomatis or gonococcal infection if sexually active
10
Q
what is subconjunctival haemorrhage?
A
bleeding into the subconjunctival space.
may occur spontaneously or as a result of trauma
11
Q
what is the clinical presentation of subconjunctival haemorrhage?
A
bright red blood overlying the sclera
well defined borders - masks the overlying conjunctival markings
painless
12
Q
What investigations would you need to do for subconjunctival haemorrhage?
A
if the patient has a history of trauma ensure there is no globe rupture
13
Q
how do you manage subconjunctival haemorrhage?
A
no management is required as the haemorrhage will reabsorb over 10 to 14 days
lubricants are helpful to prevent conjunctival desiccation and ulceration
14
Q
what is blepharitis?
A
inflammation of the eye lids
15
Q
what are the two types of blepharitis?
A
Anterior- seborrheic scales form on the lashes. Lid margin redder than deeper part of lid
posterior- Meibomian gland dysfunction. redness is in deeper part of lid. Lid margin often quite normal looking
16
Q
what are the causes of blepharitis?
A
Staph aureus
seborrheic dermatitis
acne rosacea
dry eyes- from contact lens
demodex infestatin - mites
17
Q
What are the signs and symptoms of Blepharitis?
A
Gritty eye lids
Redness/irritation of the lid and eye
+/- marginal keratitis (sterile inflammation of the cornea).
mild discharge
foreign body sensation
- Anterior signs:
A. seborrhoeic:
eye lid is margin red
Scales
dandruff
no ulcerations and unaffected lashes
B. Staphylococcal
eye lid is margin red
lashes distorted, loss of lashes or trichiasis
ulcers of lid margin
corneal staining, marginal ulcers due to exotoxin
- Posterior blepharitis signs:
“Meibomian gland disease”
Lid margin skin and lashes unaffected
Meibomian gland openings and swollen
inspissated secretion at gland openings
Meibomian cysts (chalazia)
associated with ance rosacea
18
Q
how do you manage blepharitis?
A
Lid hygiene - daily bathing/ warm compresses
supplementary tear drops
oral doxycycline for 2-3 months
difficult to remove
19
Q
what is keratitis? (corneal disease)
A
inflammation of the cornea - identified by a white area on the cornea indicating a collection of white cells in corneal tissue
it is an umbrella term
20
Q
what is corneal ulcer?
A
an open sore of the cornea it is a specific type of keratitis
21
Q
what are the causes of corneal ulcers?
A
1.Central causes:
viral e.g. Herpes simplex virus Type 1.
fungal - candida, aspergillus
bacterial - pseudomonas
acanthamoeba
- Peripheral causes (autoimmune):
Rheumatoid arthritis
hypersensitivity e.g. marginal ulcers
N.B Herpes simplex causes dendritic corneal ulcers - epithelial keratitis
22
Q
what are the signs and symptoms of corneal ulcers?
A
symptoms:
Pain - feels needle like .
photophobia
profuse lacrimation
reduced vision (maybe)
red eye
Signs:
Redness- circumcorneal
corneal reflex is abnormal
23
Q
what special types of corneal ulcers are there?
A
- Exposure keratitis
- keratoconjunctivitis sicca
- neurotrophic keratitis
- vitamin A deficiency
24
Q
how do you diagnose corneal ulcers?
A
Examine eye - fluorescein stain
Corneal scrape for gram stain and culture
25
How do you manage corneal ulcers?
Bacterial - topical fluoroquinolone e.g. ofloxacin or Gentamicin + cefuroxime
Herpes simplex - ganciclovir (Acyclovir was discontinued according NHS Tayside formulary)
Fungal - Amphotericin
Acanthamoeba - Propamidine 0.1% + Chlorhexidine 0.02%
26
what is anterior uveitis?
inflammation of the middle layer of the eye
27
what are the causes of anterior uveitis?
1. Ankylosing spondylitis
2. IBD
3. reactive arthritis
4. sarcoidosis
5. TB
7. syphilis
8. Herpes simplex
9. Herpes zoster
10. Leukaemia
11. idiopathic
12. trauma
28
What are the signs and symptoms of anterior uveitis?
Symptoms
1. Pain - referred pain too
2. vision may be reduced
3. photophobia
4. Red eye (circumcorneal)
Signs
1. Ciliary injection
2. Cells & flare in anterior chamber
3. Keratic precipitates
4. Hypopyon
5. Synechiae - small or irregular pupil
29
how do you diagnose anterior uveitis?
slit lamp with a dilated pupil - you see leucocytes in the anterior chamber
intraocular pressure can be reduced in effected eye
30
How do you manage anterior uveitis?
Topical steroids e.g. prednisolone - reduces inflammation and prevent complication such as glaucoma and adhesions
Mydriatic drops e.g. cyclopentolate - dilates pupil which reduces pressure and pain in the eye
31
what is episcleritis?
relatively common, benign, self limiting condition where the episclera becomes inflamed
32
what are the signs and symptoms of episcleritis?
diffuse scleral redness with:
mild discomfort
no changes in vision or other ocular symptoms
mainly found in women and normally unilateral
33
how do you manage episcleritis?
Self limiting
topical NSAIDS
artificial tears
34
What is scleritis?
Generalised inflammation of the sclera itself with oedema of the conjunctiva, scleral thinning and vasculitis changes.
A serious disease and much more rarer disease than episcleritis
35
What are diseases is scleritis associated with?
rheumatoid arthritis
granulomatosis with polyangiitis (Wegener's granulomatosis)
uveitis
36
what are the signs and symptoms of scleritis
deep severe pain of the globe : necrotising scleritis can also cause globe perforation
severe dull ache
violaceous hue
reduced vision
37
how do you diagnose scerlitis?
When differentiating episcleritis from scleritis, clinicians often use the phenylephrine blanching technique:
episcleritis vessels will blanch
scleritis vessels wont blanch
38
How do you manage scerlitis?
Oral NSAIDs
Oral steroids
steroid sparing agents
39
what is acute closed angle glaucoma?
Acute angle-closure glaucoma (AACG) is an acute rise in intraocular pressure associated with narrowing of the anterior chamber angle of the eye (the angle between the iris and cornea) causing optic nerve damage.
40
what are the signs and symptoms of an acute closed angle glaucoma
painful red eye
Fixed mid-dilated pupil
increased IOP makes eye feel hard
cornea is cloudy - oedematous
headache
nausea
vomiting
Visual changes such as blurred vision and halos around lights at night
41
how do you diagnose acute closed angle glaucoma?
Gonioscopy is the gold standard investigation for assessing the angle between the iris and cornea
Tonometry is used to measure intraocular pressure. In AACG, intraocular pressure is typically >30mmHg.
42
how do you manage acute closed angle glaucoma?
Pharmacological to lower IOP:
Topical timolol: a beta-blocker to decrease aqueous humour production
Topical pilocarpine: a miotic that constricts the pupil and increases aqueous humour outflow
Oral or intravenous acetazolamide: a carbonic anhydrase inhibitor to decrease aqueous humour production
can also use analgesia and antiemetics
surgery:
peripheral iridotomy (laser and surgery) - done in both eyes once IOP is controlled
43
when should you urgently refer somebody if they have red eye?
when the red eye is:
1. affecting their vision
or
2. causing marked photophobia
44
what is the pathophysiology of closed- angle type glaucoma?
In AACG, there is reduced drainage of aqueous humour due to anterior chamber angle narrowing.
This causes a rapid rise in intraocular pressure and subsequent optic nerve damage.
A common cause of anterior chamber angle closure is pupillary block, which occurs when aqueous humour outflow is obstructed due to contact between the iris and lens.
45
what is endophthalmitis?
inflammation of the internal eye, often secondary to infection following surgery
46
what is a glaucoma?
A progressive optic neuropathy with characteristic changes in the optic nerve head and corresponding loss of visual field
47
what is an open angle glaucoma?
The drainage angle formed by the cornea and iris remains open, but the trabecular meshwork is partially blocked. This causes pressure in the eye to gradually increase. This pressure damages the optic nerve.
48
what are the signs and symptoms of an open angle glaucoma?
Usually asymptomatic - picked up by optician . can have loss of peripheral vision
signs:
Cupped disc ( loss of retinal ganglion cells)
Visual field defect
may/May not have have high IOP
49
how do you diagnose open angle glaucoma?
IOP measurement - tonometry
central corneal thickness measurement
Peripheral anterior chamber configuration and depth assessments - gonioscope
visual field measurement
optic nerve assessment with slit lamp
NHS free eye test for patients >40
50
how do you manage open angle glaucoma?
Pharmacological
1st line: Topical prostaglandin analogues such as latanoprost, tafluprost, travoprost, or bimatoprost . increases uveoscleral outflow
2. Beta blockers e.g. Timolol or betaxolol. decreases production of aqueous
3. alpha adrenergic agonist e.g. Brimonidine, apraclonidine. decreases production of aqueous
4. carbonic anhydrase inhibitors e.g. dorzolamide, brinzolamide and acetazolamide. Decrease production of aqueous
5. Milotic's
6. combination drops (fixed - dose)
surgery: used if drugs fail
Trabeculectomy
trabeculoplasty (laser)
51
what is a cataract?
a cloudiness of the lens
abnormal changes in les proteins (crystallins) result in their chemical and structural alteration, leading to loss of transparency
52
what are the risk factors of the cataract?
age related
systemic disease ( diabetes)
ocular disease (uveitis)
smoking
alcohol excess
UV light
trauma
radiotherapy
congenital
53
what types of cataracts are there?
Nuclear cataracts: they change the lens refractive index
cortical cataracts : spoke-like wedge-shaped opacities which have milder effects on vision
posterior sub capsular cataracts: typically progress faster and cause the classic glare from sunlight
congenital cataracts
54
what are the signs and symptoms of cataracs?
clouded/blurred vision
unilateral cataracts are unnoticed
loss of stereopsis - affects judgement distance
dazzling in bright light
monocular diplopia
55
how do you manage cataracts?
if patient is symptomatic than offer surgery:
phacoemulsification
56
what is orbital cellulitis?
Severe sight and life-threatening emergency
infection of soft tissues posterior to the orbital septum
57
What are the causes of orbital cellulitis?
Strep Pneumoniae
Staph aureus
Strep pyogenes
Haemophilius Influenzae
58
what are the sign and symptoms of orbital cellulitis?
inflammation in the orbit
fever
lid swelling
decrease in eye mobility
diplopia
painful eye movements
conjunctival swelling
proptosis
59
How do you diagnose orbital cellulitis?
CT sinus and orbit
60
how do you manage orbital cellulitis?
Medical Emergency: Transfer to hospital immediately and refer to ENT and/or Ophthalmology.
Ceftriaxone IV 2g bd + Flucloxacillin IV 2g qds + Metronidazole IV 500mg tds
(Penicillin allergy: seek advice)
Step down to Co-amoxiclav PO 625mg tds (10-14 days total)
61
What is Periorbital/ pre septal orbital cellulitis?
infection effects the anterior of the eye orbital
62
what is Periorbital/ pre septal orbital cellulitis caused by?
caused by infection to adjacent structures
dacryocystitis
insect bite
hordeolum
trauma
63
What are the signs and symptoms of Periorbital/ pre septal orbital cellulitis?
inflamed eye-lids
white eyes are normal
no proptosis
no reduction in vision
no pain or limitation of eye movement
64
How do you diagnose Periorbital/ pre septal orbital cellulitis?
same as orbital cellulitis
65
How do you manage Periorbital/ pre septal orbital cellulitis?
Co-amoxiclav PO 625mg tds or IV 1.2g tds
(Pencillin allergy: PO Clindamycin <50kg 300mg tds 50-90kg 450mg tds
>90kg or very severe illness 600mg tds or 450mg qds)
Duration: 7-10 days If any concerns seek specialist opinion from Ophthalmology
66
Give examples of conditions which cause sudden vision loss?
1. Acute glaucoma
2. central retinal artery occlusion
3. Vitreous haemorrhage
4. Branch retinal artery occlusion
5. Central retinal vein occlusion
6. branch retinal vein occlusion
7. macular degeneration (wet)
67
Give examples of conditions which cause gradual vision loss?
1. Cataract
2. Glaucoma (open angle)
3. Macular degeneration (dry)
4. Diabetic retinopathy
5. optic atrophy
6. Retinal dystrophies
68
What is central retinal artery occlusion?
disease of the eye where the flow of blood through the central retinal artery is blocked (occluded)
this is an emergency as there is a dramatic loss in vision within seconds of occlusion
69
what are the causes of central retinal artery occlusion?
thromboembolic- carotid artery disease
atherosclerosis
Giant cell arteritis (GCA)
70
what are the signs and symptoms of central retinal artery occlusion?
Symptoms:
Sudden visual loss (painless)
Signs:
RAPD (relative afferent pupil defect)
Pale oedematous retina
retina appears white with a cherry red spot at the macula
signs of atherosclerosis (bruits and hypertension)
94% of cases, vision is usually reduced to counting fingers (worse suggests that the ophthalmic artery may also be affected).
71
How do you diagnose central retinal artery occlusion?
rule out is giant cell arteritis: fluorescein angiography and optical coherence tomography
Urgent ESR and CRP are measured in patients over 60 years of age, when a diagnosis of giant cell arteritis cannot be exclude
FBCs to check for vasculitis
HbA1c and lipid profile: to assess for underlying cardiovascular risk factors
ECG: to look for atrial fibrillation
72
How do you manage central retinal artery occlusion?
Immediate management:
Ocular massage: repeatedly massaging the globe over the closed lid for ten seconds with five-second interludes may occasionally dislodge the obstructing thrombus.
Increase blood oxygen content and dilate retinal arteries: administration of sublingual isosorbide dinitrate or oral pentoxifylline. Inhalation of a carbogen or hyperbaric oxygen.
Reduce intraocular pressure: to increase retinal artery perfusion pressure with intravenous acetazolamide and mannitol, plus anterior chamber paracentesis.
If the patient presents within 24 hours, intra-arterial fibrinolysis through local injection of urokinase into the proximal part of the ophthalmic artery,
Long term management:
Diet and lifestyle management
73
what are the two further variants of retinal arterial occlusion?
Brach retinal artery occlusion
Amaurosis fugax
74
what is branch retinal artery occlusion
occlusion of branch retinal arteries
not as bad as its central counterpart
doesnt have any cherry red spots and has less profound vision loss
oh yeah its occlusion is in the BRANCH arteries and not the CENTRAL arteries
75
What is amaurosis fugax (transient central retinal arterial occlusion)?
painless temporary loss of vision in one or both eyes
its when a TIA effects the eye
its due to transient blockage of the central retinal artery
76
what are the signs and symptoms of amaurosis fugax?
symptoms:
transient painless visual loss -"like a curtain coming down"
lasts 5 mins then has full recovery
no abnormal signs
77
How do you manage amaurosis fugax?
same as TIA;
lipid modification drugs
anti coagulants
Anti-hypertensive drugs
Antiplatelet therapy
B vitamins or folate; vitamins A, C, or E; selenium; and calcium
78
what is retinal vein occlusion?
2nd most common retinal vascular disease after diabetic retinopathy
occlusion of retinal veins lead to sudden visual loss
79
what types of retinal vein occlusion are there?
Central - occurs at level of the optic nerve
Branch - occurs at arteriovenous crossing and may be asymptomatic if the macula is not affected
80
What are the signs and symptoms of central retinal vein occlusion?
sudden, painless unilateral visual loss - more gradual than CRAO
Relative afferent pupillary defect (RAPD): suggestive of ischaemia (?)
Visual field defect
signs:
Retinal haemorrhages
dilated tortuous veins
disc swelling and macular swelling
81
What are the risk factors of central retinal vein occlusion?
Age
Atherosclerosis: hyperlipidaemia, hypertension and diabetes
Open-angle glaucoma
Inflammatory causes: sarcoidosis, Lyme disease
Hypercoagulable states: smoking, oral contraceptive pill, pregnancy, malignancy, sickle cell disease
Myeloproliferative disorders
Systemic vasculitis: Behcet’s disease, polyarteritis nodosa
82
how do you diagnose CRVO?
General:
FBC
glucose
BP
ESR
Imaging:
Fundus fluorescein angiography for retinal ischaemia
Fundal photography: typically wide-field views
Optical coherence tomography: for assessment of macula oedema
83
How do you manage CRVO?
1. Treatment for macular oedema:
anti VEGF agents (ranibizumab, aflibercept or bevacizumab)
Intravitreal steroid implant (dexamethasone)
Macular laser therapy: less common
2. photocoagulation for neovascular complications caused by retinal ischaemia
84
compare colour of artery to vein retinal occlusion
Arterial retinal occlusion is pale
vein retinal occlusion is dark
85
what two types of Ischaemic optic neuropathy are there?
Arteritic (temporal arteritis)
Non arteritic
86
what is ischaemic optic neuropathy?
is the loss of structure and function of a portion of the optic nerve due to obstruction of blood flow to the nerve
87
What are the causes of arteritic ischaemic optic neuropathy?
Giant cell arteritis
88
what are the signs and symptoms of arteritic ischaemic optic neuropathy?
New onset headache
scalp tenderness
temporal arteries - arteries are thickened and absent pulse
malaise
jaw/tongue claudication
visual loss is typically monocular
associated with polymyalgia rheumatica
89
How do you diagnose Arteritic ischaemic optic neuropathy?
Raised ESR and CRP
FBC: raise in platelets
temporal artery biopsy
90
How do you manage Arteritic ischaemic optic neuropathy?
Other eye is at risk so give high dose of oral steroids e.g. prednisolone
also give PPI with low dose aspirin
91
what is the cause of Non arteritic ischaemic optic neuropathy?
Associations
Hypertension
hyperlipidaemia
smoking
DM
92
What are the signs and symptoms of NAION?
same as GCA temporal arteritis
93
How do you manage NAION?
Management of CVS risk factors
94
What is a vitreous haemorrhage?
Vitreous haemorrhage is the extravasation, or leakage, of blood into the areas in and around the vitreous cavity
95
what are the causes of vitreous haemorrhage?
Bleeding from abnormal vessels: diabetic retinopathy, RVO (neovascularisation - weak vessels which grow in response to ischaemia)
Bleeding from normal retinal vessels: bridging a retinal tear
retinal detachment
trauma
96
What are the signs and symptoms of vitreous haemorrhage?
Symptoms:
sudden loss of vision - if really big
floaters (patient describe dark dots)
signs:
loss of red reflex - if really big
97
How do you diagnose vitreous haemorrhage?
test Visual acuity
test pupil reactions
fundoscopy helps see haemorrhage
ophthalmoscope to test for red reflex
98
How do you manage vitreous haemorrhage?
1.urgent vitrectomy
Remove vitreous haemorrhage, if the haemorrhage prevents visualisation of the retina
```
2.Intravitreal anti-VEGF agents
These agents (eg, bevacizumab) are used to cause regression of neovascularisation in proliferative retinopathies
```
99
what is retinal detachment ?
the separation of sensory retina from retinal pigment epithelium by subretinal fluid (SRF)
100
what two types of retinal detachment are there?
Rhegmatogenous - caused by a retinal break
Non rhegmatogenous- no retinal tear. caused by:
traction : Vitreous membranes pull on the retina which separates it from the epithelial layer beneath. There are no tears or holes formed. This is more common in patients with diabetic retinopathy.
or
exudate: an underlying retinal disease leads to the build-up of exudative fluid underneath the retina (e.g. exudative tumours, inflammation and posterior scleritis).
101
what is the pathogenesis of rhegmatogenous RD?
Two components required for retinal break formation:
1. Acute Posterior vitreous detachment
2. predisposing peripheral retinal degeneration
102
what is the pathogenesis for exudative RD?
1. damage to RPE by subretinal disease
| 2. Passage of fluid derived from choroid into subretinal space
103
What are the causes of Exudative RD?
1. choroidal tumours
2. Intraocular inflammation
3. systemic
4. Iatrogenic
5. Miscellaneous
104
what are the signs and symptoms of retinal displacement?
symptoms:
painless loss of vision
sudden onset of flashes/floaters
signs:
may have RAPD
may have detached grey wrinkled retina
may have visible tear
signs of exudative RD:
convex smooth elevation
may be very mobile and deep with shifting fluid
subretinal pigment after flattening
105
how do you manage retinal displacement?
Preventative management
laser photocoagulation
Surgical management
Vitrectomy
most common treatment of RD. The vitreous and the subretinal fluid are drained, which allows the retina to lie flat against the underlying epithelium.
Pneumatic retinopexy:
An expansile gas is injected into the vitreous which flattens and pushes the retina back onto the underlying epithelium.
Scleral buckle - less common
Cryotherapy or laser photocoagulation is used to create a scar around the retinal break.
106
What is optic neuritis?
inflammation of the optic disc
107
what are the signs and symptoms of optic neuritis?
unilateral loss of vision occurs over hours or days with pain which is typically worse on eye movement
Reduced colour vision - especially red desaturation
RAPD
108
what are the causes of optic neuritis?
MS (Main)- 30% of patients with MS have neuritis as there initial presentation
infection (e.g. a tooth abscess in the upper jaw, syphilis, Lyme disease, herpes zoster)
methanol poisoning, Vitamin B12 deficiency, beriberi, dysautonomia
109
how do you diagnose optic neuritis?
Fundoscopy is often normal but the disc may appear pale or swollen.
110
how do you manage Optic neuritis?
investigate for MS
vision usually resolves itself but rarely complete
high does of oral steroids may hasten recovery e.g. methylprednisolone then prednisolone
111
what is age related macular degeneration (AMD)?
the commonest cause of blindness in the UK
degeneration of the macular - pretty fucking simple
112
what are the risk factors for AMD?
Age
family history
smoking
hypertension
raise in BMI
diet low in omega 3 & 6
113
what are the two main types of AMD?
Wet - sudden visual loss
Dry - gradual visual loss
114
what is dry AMD?
gradual deterioration in central vision, usually over decades
it causes 90% of the cases for AMD
115
what is the clinical presentation of Dry AMD?
symptoms:
gradual decline in vision
central vision loss
signs:
Drusen - build up of waste products below RPE
Atrophic patches of retina
116
how do you diagnose dry AMD?
usually through clinical diagnosis
and
Ocular coherence tomography
"ask do window and door frames look straight?" - if distorted then refer
117
How do you manage dry AMD?
No cure
supportive management:
magnifiers
social support (e.g. guide dogs)
118
What is wet AMD?
new blood vessels grow under retina (neovascularisation) - leakage causes build up of fluid/blood and eventually scarring
119
what are the signs and symptoms of wet AMD?
symptoms:
sudden loss of central vision
distortion (metamorphopsia)
signs:
haemorrhage/exudate
120
how do you diagnose Wet AMD?
normally through clinical diagnosis
ophthalmoscopy shows fluid exudation localised detachment of the pigment and sometimes haemorrhage
121
how do you manage Wet AMD?
urgent fluorescein angiogram is performed to determine the type of new vessels alongside OCT which examines extent of intraretinal and subretinal fluid
anti VEGF therapy - decreases formation of new blood vessels and vascular leaks. this increases visual acuity
122
what are the five main ocular motility defects?
IIIrd nerve palsy
IVth nerve palsy
VIth nerve palsy
Inter-nuclear ophthalmoplegia
Supra-nuclear ophthalmoplegia
123
what are the causes of VIth nerve palsy?
Raised Intracranial pressure
microvascular
tumour
congenital
124
What is the clinical presentation of VIth nerve palsy?
medial deviation of eye with:
Failure in abduction of the eye - palsy effects lateral rectus muscle
horizontal double vision
125
what are the causes of IVth nerve palsy?
congenital decompensated
microvascular
tumour
bilateral IVth nerve palsy due to closed head trauma
126
what are the clinical presentations of IVth nerve palsy?
1. Eyes look up and in
2. superior oblique muscle is effected leads to:
intorsion
depression in adduction
abduction is also weak
head tilt in left IVth nerve palsy - incyclo torsion weak
3. bilateral IVth palsy
torsion
chin depressed
127
what are the causes of third nerve palsy?
Microvascular
tumour
aneurysm - causes really painful third nerve palsy
MS
congenital
128
What is the clinical presentation of third nerve palsy?
1. ocular position is down and out with:
ptosis
may have blown pupil
2.the following muscles are affected:
Medial rectus muscle
inferior rectus
superior rectus
inferior oblique
sphincter pupillae
Levator palpebrae superioris
129
what is inter-nuclear ophthalmoplegia?
where the eyes fail to move together due to failure of the medial longitudinal fasiculus
130
what are the causes of inter-nuclear ophthalomoplegia?
MS (main cause)
vascular
131
what is the clinical presentation of inter-nuclear ophthalmoplegia?
when looking towards the unaffected side:
the affected eye fails to adduct
unaffected eye abducts but with nystagmus
132
what can effect the optic nerve?
ii. what defect does this cause?
optic neuritis
ii. loss of whole visual fields
133
what can effect the optic chiasm?
ii. what defect does this cause?
1. craniopharyngioma
pituitary tumours
meningioma
ii. Bitemporal hemianopia - vertically abiding, bilateral loss of peripheral field without macular sparing
134
what can effect the optic radiation?
ii. what defect does this cause?
1. Stroke
Demyelination
Tumours
ii. Incongruent quadrangular hemianopia without macular sparing
the same as for the optic tracts but just one quarter involved
135
what can effect the optic tract?
ii. what defect does this cause?
Stroke
demyelination
tumours
ii. incongruent homonymous hemianopia without macular sparing. vertically abiding - nasal field defect
136
what can effect the occipital lobe?
ii. what defect does this cause?
stroke
demyelination
ii. congruent homonymous hemianopia with macular sparing
vertically abiding. same side of visual fields affected in both eyes
137
what is papilloedema?
bilateral optic disc swelling secondary to raised intracranial pressure (ICP)
138
what are the causes of papillooedema?
nausea/vomiting - related to rise in ICP
double vision to CN VI palsy
headaches worse in the morning and centred in the frontal region - aggravated by bending down or coughing
139
how do you diagnose papilloedema?
1.imaging:
MRI is gold standard - CT is quicker though
2. measure BP for hypertension
3. Ophthalmoscopy - examination of optic discs;
part of the cranial nerve II examination which also examines:
1. visual acuity
2. pupil exam
3. visual field assessment
4. colour vision
140
give examples of refractive error conditions?
1. myopia - short sighted
2. hypermetropia - long sighted
3. astigmatism - irregular corneal curvature
4. presbyopia - loss of accommodation with ageing
141
what does metamorphopsia indicate?
macular disease
142
what is holmes-adie pupil?
unilateral and then bilateral dilated pupil w/:
Slow and incomplete response to light.
Normal response to accommodation.
Positive pilocarpine test.
143
give examples of drugs which dilute the eye.
Block parasympathetic: Cyclopentolate (long acting), Tropicamide (short acting), atropine.
Stimulate sympathetic: phenylephrine.
144
give examples of drugs which constrict the eye.
Stimulate parasympathetic: Pilocarpine.
Block sympathetic: Timolol, brominidine
