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Stage 1 Visit 1 > Competency 6.1.11 > Flashcards

Competency 6.1.11 Flashcards

1
Q

Systemic Cataract Preoperative Considerations

A

Can patient lie flat?
- COPD where lying supine may cause shortness of breath
- Spinal abnormalities

Alpha blockers
- Tamulosin and naftopidil can cause floppy iris syndrome

Allergy
- Allergy to shellfish may indicate iodine allergy

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2
Q

Ocular Cataract Preoperative Considerations

A

Deep set eyes & shallow AC
- can make surgery more difficult

Lids and Adnexa
- Blepharitis or lid malposition can predispose to endophthalmitis

Fundus Examination
- Coexisting pathology can impact visual outcome

Refraction
- Consider K values, AL and refraction to leave patient at emmetropia
- Consider any previous refractive suprise
- Consider previous laser eye surgery

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3
Q

What is Phacoemulsification?

A
  • Is standard method of cataract surgery
  • Is a device which breaks up the lens using ultrasonic waves which can then be vacuumed out
  • Surgery is a 30 minute affair which takes place under local anaesthetic
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4
Q

Phacoemulsification Procedure

A
  • Incisions either 60 or 180 degrees apart at limbus to allow access
  • Opening of anterior lens capsule (capsularhexis)
  • Removal of lens material using phaco, many techniques including divide and conquer
  • Removal of lens material
  • Insertion of IOL into lens caspsule
  • Incisions may be sealed with stromal saline injection
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5
Q

Extracapsular Cataract Extraction

A
  • Requires larger incision and so has slower recovery rate
  • Used in very dense cataract where higher phaco powers would potentially cause issues
  • The larger incision allows the cataract to be removed in one piece.
  • requires stitches after surgery
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6
Q

Post Surgery Pharmacological Treatment

A
  • Dexamethasone 0.1% or prednisolone 1.0% bds for 4 weeks
  • Chloramphenicol bds for 4 weeks
  • May be given topical NSAID if diabetic
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7
Q

Post Surgery Non-Pharmacological Treatment

A
  • Eye shield to wear every night for first week after surgery to protect eye during night can also be used in shower to protect when washing hair
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8
Q

Post Surgical Advice

A
  • No swimming for 4 to 6 weeks
  • Take it easy, no intense exercise
  • Can use electronic devices
  • Use shield or glasses outdoors
  • Bathe and shower as usual
  • No driving until advised safe to do so
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9
Q

Cataract Surgery Complications

A
  • Rupture of Posterior Lens Capsule
  • Posterior dislocation of IOL
  • Endophthalmitis
  • Double Vision/Ptosis
  • Increased IOP
  • Corneal oedema
  • CMO
  • Dysphotopsia
  • Posterior capsular opacification
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10
Q

Rupture of Posterior Lens Capsule

A
  • Can be accompanied by vitreous loss, posterior migration of lens material and expulsive haemorrhage
  • Vitreous loss can lead to:
    • CMO
    • Retinal detachment
    • Endophthalmitis
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11
Q

Posterior Dislocation of IOL

A
  • Rare
  • IOL ends up in vitreous cavity
  • Occurs in eyes with fragile zonular attachments e.g. in pseudoexfoliation where in entire capsular bag may dislocate
  • Can lead to:
    • Vitreous haemorrhage
    • Chronic CMO
    • Uveitis
    • Retinal detachment
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12
Q

Endophthalmitis Risk Factors

A
  • Posterior capsular rupture
  • Prolongued procedure time
  • Combined procedure
  • Diabetes
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13
Q

How does Endophthalmitis Damage the Eyes?

A
  • Acute intraocular infection
  • Damage is done by toxins produced by infecting bacteria and inflammatory response
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14
Q

Endophthalmitis Treatment

A
  • Intravitreal antibiotics
  • Subconjunctival antibiotics injections
  • Topical antibiotics
  • Oral antibiotics
  • Oral steroids
  • Pars plana vitrectomy
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15
Q

Double Vision/Ptosis After Cataract Surgery

A
  • Can occur post-operatively due to clamps used during surgery
  • Can unmask existing phoria
  • Usually self resolving
  • Needs investigated to rule out unrelated neurological event
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16
Q

Increased IOP After Surgery

A

Causes:
- Steroid responder
- Leftover viscoelastic material

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17
Q

What is Viscoelastic?

A
  • Facilitates surgery by ensuring spaces such as AC remain open throughout procedure
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18
Q

Cystoid Macular Oedema After Cataract Surgery

A
  • Occurs 6 to 10 weeks after surgery but can take longer to appear
  • Presents with symptoms of blurring especially at near along with possible distortion
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19
Q

Corneal Oedema After Cataract Surgery

A
  • Can be caused by high-powered phaco used to break up a very dense cataract
  • Treated with 0.1% dexamethasone or 1.0% prednisolone
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20
Q

Dysphotopsia After Cataract Surgery

A
  • Positive dysphotopsia is flashing lights and floaters
  • Negative dysphotopsia is dark scotomas
  • Investigate as risk of retinal detachment
  • Rounded edge IOL are less likely to cause negative photopsia
  • Phenomena tends to reduce over time
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21
Q

Posterior Capsular Opacification After Cataract Surgery

A
  • Proliferation of leftover lenticular cells which have remained within lens capsule
  • Results in variable degree of reduced vision
  • Square edge design though to be less susceptible
  • Treatment is via YAG laser known on posterior capsulotomy
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22
Q

Dry AMD Advice

A

Smoking cessation
- Associated with earlier AMD onset
- Associated with faster progression

Dietary Advice
- Encourage intake of food with lutein and zeaxathin content such as kale, red pepper or leafy green veg
- Supplementation (careful in smokers)

UV Protection
- Can protect back of eye

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23
Q

Two Main Wet AMD Medical Interventions

A
  • Anti-VEGF
  • Photodynamic therapy
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24
Q

What do Anti-VEGF Medications do in Wet AMD?

A
  • VEGF is a protein which allows for the formation of new blood vessels when produce by the body
  • These vessels can damage vision via leakage
  • Anti-VEGF therapy slows development of new vessels and helps maintain vision
  • Injection itself takes on 20 seconds
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25
Q

Types of Anti-VEGF Therapy

A

Ranibizumab
- Lucentis injections given every 4 weeks for as long as necessary
Brolucizumab
- Beovu injections every 12 weeks

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26
Q

Photdynamic Therapy In Wet-AMD

A
  • Verteporfin is light activated drug that is injected into arm and eventually enters circulation of vessels at the macula
  • Ophthalmologist can use a laser focussed by a contact lens which activates drug and causes destruction of the abnormal vessels
  • Multiple treatments are required
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27
Q

Features Suggestive of R3 DR

A
  • 4 or more dot/blot haemorrhages
  • IRMA
  • Venous beading
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28
Q

General Points for Management of DR

A

Patient Education
- Emphasise need to comply with review and treatment schedules
- Attend DR screening
- Information on weight management

Diabetic Control
- Optimised control of diabetes

Other Risk Factors
- HBP and high cholesterol control

Other Factors
- Smoking stopped
- Renal failure issues addressed
- Anaemia addressed

29
Q

Treatment of Diabetic Macular Oedema

A
  • Intravitreal anti-VEGF Agents
  • Focal/Grid Laser Photocoagulation
30
Q

What is the Difference Between Focal/Grid Laser?

A
  • Focal laser is applied directly to the cause of oedema
  • Grid laser is applied to more general areas where there is leakage coming from IRMA or capillary beds
31
Q

Intravitreal Anti-VEGF in DMO Treatment

A

Intravitreal anti-VEGF Agents
- Intravitreal ranibizumab improves VA more effectively than focal/grid laser for centre involved DMO
- Laser treatments should be deferred for 6 months after this point
- Good outcomes can be expected for around 5 years

32
Q

Focal/Grid Laser Photocoagulation in DMO Treatment

A
  • Laser burns applied directly to the causes of oedema
  • Treats areas no closer than 500 microns from fovea
  • Only indicated with non-centre involved DMO
33
Q

Treatment of Proliferative Diabetic Retinopathy

A
  • Scatter Laser Treatment (PRP)
  • Intravitreal anti-VEGF
  • Pars plana vitrectomy
34
Q

Scatter Laser Treatment in Proliferative DR Treatment

A
  • Mainstay of Proliferative DR Treatment (AKA pan retinal photocoagulation)
  • Performed under topical anaesthesia
  • Laser applied to peripheral retina which causes shrinkage of vessels and inhibits future growth
  • Reduces risk of vitreous haemorrhage and retinal detachment
  • Multiple treatments may be required
35
Q

Intravitreal Anti-VEGF Agents in Proliferative DR Treatment

A
  • Intravitreal ranibizumab is as effective as PRP in patients at risk of proliferative DR
  • Macular oedema risk reduced when compared to PRP
  • Peripheral vision better preserved compared to PRP
36
Q

Pars Plana Vitrectomy in Proliferative DR Treatment

A
  • For advanced DR
  • Sometimes combined with PRP
  • Indications include retinal detachment and vitreous haemorrhage
37
Q

Types of Surgical Glaucoma Management

A
  • Selective Laser Trabeculoplasty (SLT)
  • Laser iridotomy
  • Trabeculotomy
38
Q

Selective Laser Trabeculoplasty in Glaucoma Management

A
  • Now first line treatment according to SIGN
  • Used in treatment of POAG
  • Laser focussed onto trabecular meshwork which stimulates better drainage through a biological/chemical process
  • Often results in 25% drop in pressure
  • Around 80% of patients can expect to be drop free and at target pressure after 3 years
  • Effects wane over time but surgery can be repeated again
  • Complications include ocular inflammation
39
Q

Selective Laser Trabeculoplasty vs Argon Laser Trabeculplasty

A
  • Less intense complications compared to Argon Laser
  • In Argon Laser there is also mechanical opening of trabecular meshwork which contributes to IOP lowering
40
Q

Laser Iridotomy in Glaucoma Management

A
  • Used in treatment of ACG
  • Focussed laser beam is used to create and opening in iris to allow passage of trapped aqueous
  • Complications include:
    • Iritis
    • Corneal burns
    • Cataract formation
    • Monocular diplopia when coincident with lid margin
41
Q

Trabeculotomy

A
  • Creation of a fistula which allows aqueous from AC into subtenant space protected by a flap created in the sclera
  • Aqueous drains out and forms a blur which is hidden under upper lid, where it is absorbed into the blood stream
  • Indicated in advanced glaucoma/young patient where low IOP targets are needed
  • Complication can include infection of bleb leading to Endophthalmitis
42
Q

Glaucoma Drops Order of Prescribing

A

1st Line: Prostaglandin Analogues
2nd Line: Beta Blocker/Carbonic Anhydrase Inhibitor/Alpha Agonist
3rd Line: As for 2nd but add from a different class
4th Line: As for 3rd but can also include pilocarpine in some cases

43
Q

Prostaglandin Analogues Mechanism of Action

A
  • Prostaglandins are pro-inflammatory molecules
  • They act at F2 receptors in the ciliary muscle and increase outflow by inducing ciliary muscle relaxation
44
Q

Prostaglandin Analogues Effectiveness

A
  • Several weeks from starting treatment until maximum effect is enjoyed
  • Can expect a 25-35% decreased in IOP
  • Initial effect after 2 hours
  • Peak effect after 8 to 12 hours
  • Duration of effect for 24 hrs
45
Q

Prostaglandin Analogues Examples

A
  • Latanoprost (od)
  • Travoprost (od)
  • Bimatoprost (od)
  • Tafluprost (od)
46
Q

Prostaglandin Analogues Contraindications

A
  • Uveitis
  • CMO
  • HSK
  • Aphakia and pceudoaphakia (risk of CMO)
  • Pregnancy (effect on uterus)
47
Q

Prostaglandin Analogues Side Effects

A
  • Conjunctival hyperaemia
  • Punctate keratopathy/FB sensation/ocular irritation
  • Increased iris/lower lid pigmentation
  • Lengthening of lashes
  • CMO/Uveitis/HSK
48
Q

Carbonic Anhydrase Inihibitors Mechanism

A
  • Lower IOP via inhibiting the enzyme carbonic anhydrase found in ciliary body epithelium which reduces aqueous production
  • Potential protective effect on optic nerve head
49
Q

Carbonic Anhydrase Inihibitors Examples

A
  • Dorzolamide (bd/tds)
  • Brinzolamide (bd)
  • Drops are in suspesion form so need shaking prior to use
50
Q

Carbonic Anhydrase Inihibitors Effect

A
  • Around 20% reduction
51
Q

Carbonic Anhydrase Inihibitors Side Effects

A
  • Hyperaemia
  • Ocular irritation/FB sensation/ocular pain
  • Transient blurred vision
  • Corneal thickening and clouding in unhealthy endotheliums
  • Aplastic anaemia or Stevens-Johnsons Syndrome (rare in topical use)
52
Q

Beta Blockers Mechanism

A
  • Reduce aqueous production by reducing ultrafiltration, which is one of three methods of by which aqueous is produced
53
Q

Beta Blockers Effect

A
  • Around 20 - 30% reduction in IOP
  • Suffer from tachyphylaxis
  • No effect difference in concentration
54
Q

Beta Blockers Examples

A
  • Timolol
  • Betaxolol
55
Q

Beta Blockers Side Effects

A

Ocular side effects of Beta Blockers include:
- Corneal hypaesthesia
- Punctate keratopathy/dry eye/burning/stinging
- Pseudopemphigoid

Systemic side effects of Beta Blockers include:
- Anxiety
- GI disturbances
- Reynauds
- Arrhythmia
- Systemic hypotension
- Exacerbation of asthma

56
Q

Beta Blockers Cautions

A
  • Patients with arrhythmias/cardiac failure/COPD
  • Patients on systemic beta blockers
  • Elderly patients
57
Q

Alpha-2 Agonists Mechanism

A
  • Reduces aqueous by acting on alpha-2 receptors which inhibit enzymes involved in aqueous production
58
Q

Alpha-2 Agonists Effect

A
  • Around 20 - 25% reduction
  • Usually additive with other agents, not at effective as monotherapy
  • Apraclinidine suffers from tachyphylaxis
59
Q

Alpha-2 Agonists Examples

A
  • Apraclonidine
  • Brimonidone
60
Q

Alpha-2 Agonists Side Effects

A
  • High rate of ocular allergy (hyperaemia and follicular conjunctivitis)
  • Dry mouth
  • Drowsiness
  • Systemic blood pressure reduction
61
Q

Alpha-2 Agonists Contraindications

A
  • Patients taking MAOIs or tricyclic antidepressants
  • Severe cardiac disease
62
Q

Acute Allergic Conjunctivitis Management

A
  • Avoidance of allergen
  • Avoidance of eye rubbing
  • Cold compresses for symptomatic relief
  • Prophylactic sodium cromoglicate 2% qds
  • Olopatidine bds whilst symptomatic
63
Q

Seasonal Allergic Conjunctivitis Management

A
  • Advise recurrent nature
  • Avoidance of eye rubbing
  • Cold compresses for symptomatic relief
  • Sodium cromoglicate 2% qds prophylactically
  • Olopatidine bds for immediate relief
  • Oral antihistamine
64
Q

Bacterial Conjunctivitis Management

A
  • Typically self resolving within a week
  • Bathing and cleaning of lid margins with purpose made wipes or cooled boiled water and cotton wool
  • Remove CLs
  • Advice on contagious nature
  • Supply chloramphenicol 1% ointment ads for 1 week
  • Refer if: corneal involvement or non-resolving
65
Q

MGD Management

A
  • Advise there isn’t a “cure”
  • Heat up blockage and massage it out, then remove
66
Q

Anterior Bleph Management

A
  • Advise isn’t a “cure”, likely to flare up
  • Lid hygiene measures still effective
  • Treat associated dry eye with lubricants
  • Chloramphenicol 1% ointment ads for 1 week to reduce bacterial load
  • BlephEx
  • If associated with rosacea then refer to IP colleague for systemic tetracycline use
67
Q

Dry Eye Management

A

Advice
- Give up smoking/avoid smoky enviroments
- Avoid windy environments
- Heated environments
- Air con
- VDU usage
- Medication as a cause

  • Artificial tears
  • Unmedicated ointment at nightime
  • Acetylcystine 5% for mucus strands
68
Q
A

Stage 1 Visit 1 (11 decks)

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