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1
Q

definition of glaucoma

A

optic nerve damage due to a significant rise in intraocular pressure caused by a blockage in aqueous humour trying to escape the eye

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2
Q

anatomy of the chambers of the eye

A
  • anterior = between cornea and iris
  • posterior = between iris and lens
  • vitreous = between lens and optic nerve
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3
Q

normal intraocular pressure

A

10-21mmHg

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4
Q

anatomy of the aqueous humour in the eye

A
  • produced by ciliary body
  • flows around lens and under iris, through anterior chamber and through trabecular meshwork into the canal of schlemm
  • then enters general circulation
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5
Q

pathophysiology of open-angle glaucoma

A

gradual increase in resistance through trabecular meshwork making it more difficult for aqueous humour to flow through and exit the eye
-> slow and chronic onset of glaucoma

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6
Q

pathophysiology of acute angle-closure glaucoma

A

iris bulges forward and seals off trabecular meshwork from the anterior chamber, preventing aqueous humour being able to drain away
-> continual build-up of pressure = emergency

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7
Q

ophthalmoscopy finding in glaucoma

A

cupping of the optic disc (centre of the normal optic disc usually <1/2 size of disc but pressure on eye in glaucoma causes it to increase to >1/2 size)

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8
Q

risk factors for open-angle glaucoma

A
  • increasing age
  • FHx
  • Black ethnic origin
  • nearsightedness (myopia)
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9
Q

presentation of open-angle glaucoma

A
  • may be picked up on routine screening
  • gradual loss of peripheral vision -> tunnel vision
  • gradual onset of fluctuating pain, headaches, blurred vision and halos around lights
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10
Q

how to measure intraocular pressure

A
  • non-contact tonometry -> puff of air at cornea and measuring corneal response
  • golwmann applanation tonometry -> contact with cornea and apply different pressures
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11
Q

diagnosis of glaucoma ix

A
  • goldmann applanation tonometry
  • fundoscopy
  • visual field assessment
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12
Q

medical management of open-angle glaucoma

A

aim to reduce pressure

  • prostaglandin analogue eye drops (latanoprost) increase uveoscleral outflow
  • beta-blockers to reduce production of aqueous humour
  • carbonic anhydrase inhibitors reduce production
  • sympathomimetics reduce production and increase outflow
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13
Q

when to treat open-angle glaucoma

A

pressure of 24mmHg or above

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14
Q

surgical management of open-angle glaucoma

A

trabeculectomy -> creating new channel from anterior chamber, through sclera to location under conjunctiva
produces ‘bleb’ where aqueous humour drains

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15
Q

risk factors for closed-angle glaucoma

A
  • increasing age
  • female: male = 4:1
  • FHx
  • Chinese and East Asian (rare in Black ethnic origin)
  • shallow anterior chamber
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16
Q

medications which can precipitate angle-closure glaucoma

A
  • adrenergic meds e.g. noradrenaline
  • anticholinergic meds e.g. oxybutynin
  • tricyclic antidepressants e.g. amitriptyline
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17
Q

presentation of angle-closure glaucoma

A
  • generally unwell
  • severely painful red eye
  • blurred vision
  • halos around lights
  • associated headache, nausea and vomiting
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18
Q

examination findings in angle-closure glaucoma

A
  • red eye
  • teary
  • hazy cornea
  • decreased visual acuity
  • dilation of affected pupil
  • fixed pupil size
  • firm eyeball on palpation
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19
Q

initial mx of angle-closure glaucoma in primary care

A
  • lie patient on their back without a pillow
  • pilocarpine eye drops: 2% for blue eyes, 4% for brown eyes (mitotic agent)
  • acetazolamide 500mg PO
  • analgesia and antiemetic if required
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20
Q

secondary care medical mx of angle-closure glaucoma

A
  • pilocarpine
  • acetazolamide
  • hyperosmotic agents e.g. glycerol, mannitol
  • timolol
  • dorzolamide
  • sympathomimetics
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21
Q

definitive tx of angle-closure glaucoma

A

laser iridectomy -> laser to make hole in iris to allow aqueous humour to flow from posterior chamber into anterior chamber

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22
Q

definition of age-related macular degeneration

A

degeneration in macular causing progressive deterioration in vision

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23
Q

types of macular degeneration

A

wet (10%) -> worse prognosis

dry (90%)

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24
Q

key finding on fundoscopy in macular degeneration

A

drusen = yellow deposits of proteins and lipids appear between retinal pigment epithelium and Bruch’s membrane

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25
Q

features of both types of macular degeneration

A
  • drusen on fundoscopy
  • atrophy of retinal pigment epithelium
  • degeneration of photoreceptors
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26
Q

pathophysiology of wet macular degeneration

A
  • development of new vessels growing from choroid layer into retina
  • vessels leak fluid or blood and cause oedema and more rapid loss of vision
  • chemical stimulating vessel development = vascular endothelial growth factor (VEGF)
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27
Q

risk factors for macular degeneration

A
  • age
  • smoking
  • white or Chinese ethnic origin
  • FHx
  • CVD
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28
Q

presentation of macular degeneration

A
  • gradual worsening central visual field loss
  • reduced visual acuity
  • crooked/wavy appearance to straight lines
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29
Q

examinations in suspected macular degeneration

A
  • snellen chart (reduced acuity)
  • scotoma (central patchy of vision loss)
  • amsler grid test (distortion of straight lines)
  • fundoscopy (drusen)
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30
Q

ix in suspected macular degeneration

A
  • slit-lamp biomicroscopic fundus exam
  • optical coherence tomography
  • fluorescein angiography (see blood supply to retina)
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31
Q

mx of dry macular degeneration

A

lifestyle measures to slow progression:

  • avoid smoking
  • control BP
  • vitamin supplementation
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32
Q

mx of wet macular degeneration

A
  • anti-VEGF (vascular endothelial growth factor) e.g. ranibizumab, bevacizumab, pegaptanib
  • injected directly into vitreous chamber once a month
  • slow and even reverse progression by blocked neovascularization
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33
Q

definition of diabetic retinopathy

A

blood vessels in the retina are damaged by prolonged exposure to hyperglycaemia

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34
Q

pathophysiology of diabetic retinopathy

A

hyperglycaemia causes damage to retina small vessels and endothelial cells
increased vascular permeability leaks to leakage, blot haemorrhages and formation of hard exudates

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35
Q

what are cotton wool spots

A

fluffy white patches on the retina due to damaged nerve fibres e.g. diabetic or hypertensive retinopathy

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36
Q

fundoscopy findings in proliferative diabetic retinopathy

A
  • cotton wool spots
  • microaneurysms
  • hard exudates
  • blot haemorrhages
  • neovascularization
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37
Q

classification of diabetic retinopathy

A

non-proliferative:

  • mild: microaneurysms
  • moderate: microaneurysms, blot haemorrhages, hard exudates, cotton wool spots and venous beading
  • severe: blot haemorrhages and microaneurysms in 4 quadrants, venous beading in 2 quadrants, intraretinal microvascular abnormality

proliferative:

  • neovascularization
  • vitreous haemorrhage
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38
Q

complications of diabetic retinopathy

A
  • retinal detachment
  • vitreous haemorrhage
  • rebeosis iridis (blood vessel formation in iris)
  • optic neuropathy
  • cataracts
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39
Q

mx of diabetic retinopathy

A
  • laser photocoagulation
  • anti-VEGF
  • vitreoretinal surgery
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40
Q

definition of hypertensive retinopathy

A

damage to small blood vessels in the retina relating to systemic hypertension (either chronic or malignant hypertension)

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41
Q

fundoscopy findings in hypertensive retinopathy

A
  • cotton wool spots
  • silver wiring
  • hard exudates
  • arteriovenous nipping
  • retinal haemorrhages
  • papilloedema
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42
Q

classification of hypertensive retinopathy

A

Keith-Wagener classification

  • stage 1 = mild narrowing of arterioles
  • stage 2 = focal constriction of blood vessels and AV nipping
  • stage 3 = cotton wool patches, exudates and haemorrhages
  • stage 4 = papilloedema
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43
Q

mx of hypertensive retinopathy

A

control BP and other risk factors such as smoking and lipid levels

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44
Q

definition of cataracts

A

lens in the eye becomes cloudy and opaque leading to reduced visual acuity

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45
Q

risk factors for cataracts

A
  • increasing age
  • smoking
  • alcohol
  • diabetes
  • steroids
  • hypocalcaemia
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46
Q

presentation of cataracts

A

symptoms usually asymmetrical

  • very slow reduction in vision
  • progressive blurring
  • change of colour vision (become more brown)
  • starbursts appear around lights
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47
Q

mx of cataracts

A
  • no intervention if manageable symptoms

- cataract surgery -> drilling and breaking lens into pieces and replacing with artificial lens

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48
Q

complication of cataract surgery

A

endophthalmitis -> inflammation of inner contents of the eye, usually caused by infection
can lead to loss of vision and loss of the eye itself

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49
Q

mechanism of pupil constriction

A

circular muscles in the iris cause constriction via stimulation by parasympathetic nerves (CN III) using ACh

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50
Q

mechanism of pupil dilation

A

dilator muscles stimulated by sympathetic nervous system using adrenaline

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51
Q

causes of mydriasis (dilated pupil)

A
  • CN III palsy
  • raised ICP
  • congenital
  • trauma
  • stimulants such as cocaine
  • anticholinergics
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52
Q

causes of miosis (constricted pupil)

A
  • Horners syndrome
  • cluster headaches
  • opiates
  • nicotine
  • pilocarpine
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53
Q

presentation of third nerve palsy

A
  • ptosis (drooping of upper eyelid)
  • dilated, non-reactive pupil
  • divergent strabismus (squint) causing down and out position of eye
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54
Q

causes of third nerve palsy

A
  • idiopathic
  • tumour
  • trauma
  • cavernous sinus thrombosis
  • posterior communicating artery aneurysm
  • raised ICP
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55
Q

what is a partial third nerve palsy

A

sparing of the pupil -> indicates microvascular cause as the parasympathetic fibres are spared
may be due to: diabetes, hypertension, ischaemia

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56
Q

triad of horners syndrome

A
  • ptosis
  • miosis
  • anhidrosis
    may be enopthalmos (sunken eye)
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57
Q

anatomy of sympathetic nerves to the face

A
  • arise from spinal cord in the chest (pre-ganglionic)
  • enter sympathetic ganglion at base of neck and exit as post-ganglionic
  • post-ganglionic travel to the head alongside internal carotid artery
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58
Q

how to differentiate between pre-ganglionic, central and post-ganglionic causes of horners syndrome

A

central lesions cause anhidrosis of arm and trunk as well as face
pre-ganglionic lesions cause anhidrosis of only the face
post-ganglionic lesions cause no anhidrosis

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59
Q

causes of horners syndrome and mnemonic

A

4 Ss (Sentral), 4 Ts (Torso - pre-ganglionic), 4 Cs (Cervical - post-ganglionic)

  • S = stroke, mS, swelling (tumour), syringomyelia
  • T = tumour (pancoast), trauma, thyroidectomy, top rib (cervical rib)
  • C = carotid aneurysm, carotid artery dissection, cavernous sinus thrombosis, cluster headache
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60
Q

definition of blepharitis

A

inflammation of the eyelid margins

causes gritty, itchy, drug eyes

61
Q

mx of blepharitis

A
  • hot compresses and gentle cleaning of eyelid margins

- lubricating eye drops

62
Q

pathophysiology of a stye

A

‘hordeolum externum’ = infection of glands of Zeis or glands of Moll (sweat/sebaceous glands) causing tender red lump along eyelid that may contain pus
‘hordeolum internum’ = infection of meibomian glands - deeper, more painful

63
Q

tx of styes

A

hot compresses and analgesia

consider topical abx if associated with conjunctivitis or persistent

64
Q

definition of a chalazion

A

blockage and swelling of a meibomian gland ‘meibomian cyst’

65
Q

presentation of chalazion

A

swelling in eyelid not typically tender

can be tender and red

66
Q

tx of chalazion

A

hot compress and analgesia

consider topical abx if acutely inflamed

67
Q

definition of entropion

A

eyelid turns inwards with lashes against eyeball - can result in corneal damage and ulceration

68
Q

mx of entropion

A

taping down eyelid

surgical intervention as definitive tx

69
Q

definition of ectropion

A

eyelid turns outwards with inner aspect of eyelid exposed (usually bottom lid)
can result in exposure keratopathy

70
Q

mx of ectropion

A

mild cases don’t require tx
lubricating eye drops
may require surgery

71
Q

definition of periorbital cellulitis

A

eyelid and skin infection in front of the orbital septum

72
Q

presentation of periorbital cellulitis

A

swelling, redness and hot skin around the eyelids and eye

73
Q

ix in periorbital cellulitis

A

important to exclude orbital cellulitis (sight and life threatening) -> CT

74
Q

mx of periorbital cellulitis

A 
systemic abx (oral or IV)
may require admission as can develop into orbital cellulitis
75
Q

definition of orbital cellulitis

A

infection around eyeball involving tissues behind orbital septum

76
Q

features of orbital cellulitis which differentiate from periorbital

A 
pain on eye movement 
reduced eye movements
changes in vision 
abnormal pupil reactions
forward movement of eyeball (proptosis)
77
Q

mx of orbital cellulitis

A

medical emergency
admission + IV abx
may require surgical drainage

78
Q

definition of conjunctivitis

A

inflammation of the conjunctiva (thin layer of tissue covering the inside of the eyelids and the sclera)

79
Q

3 types of conjunctivitis

A

bacterial
viral
allergic

80
Q

presentation of conjunctivitis

A

red eyes
bloodshot
itchy or gritty sensation
eye discharge

81
Q

differentiating between bacterial and viral conjunctivitis

A 
bacterial = purulent discharge and inflamed conjunctiva, worse in the morning, highly contagious
viral = clear discharge, associated with other symptoms (dry cough, sore throat), may have tender preauricular lymph nodes
82
Q

causes of a painless red eye

A
  • conjunctivitis
  • episcleritis
  • subconjunctival haemorrhage
83
Q

causes of a painful red eye

A
  • glaucoma
  • anterior uveitis
  • scleritis
  • corneal abrasions or ulceration
  • keratitis
  • foreign body
  • traumatic or chemical injury
84
Q

mx of conjunctivitis

A
  • usually self-resolving in 1-2 weeks
  • advice on good hygiene to avoid spread
  • clean eyes with cooled boiled water and cotton wool
  • consider abx eye drops if bacterial
85
Q

when to refer conjunctivitis for ophthalmology review

A

patients <1 month old

neonatal conjunctivitis can be associated with gonococcal infection which can cause loss of sight

86
Q

presentation of allergic conjunctivitis

A

swelling of conjunctival sac and eye lid with watery discharge and itch

87
Q

mx of allergic conjunctivitis

A

antihistamines (oral or topical)

topical mast-cell stabilisers

88
Q

definition of anterior uveitis

A

inflammation in the anterior part of the uvea (iris, ciliary body and choroid)

89
Q

pathophysiology of anterior uveitis

A

inflammation and immune cells in the anterior chamber - chamber is infiltrated by neutrophils, lymphocytes and macrophages

90
Q

causes of anterior uveitis

A
  • autoimmune
  • infection
  • trauma
  • ischaemia
  • malignancy
91
Q

conditions associated with acute anterior uveitis

A

HLA B27:

  • ankylosing spondylitis
  • IBD
  • reactive arthritis
92
Q

conditions associated with chronic anterior uveitis

A
  • sarcoidosis
  • syphilis
  • lyme disease
  • TB
  • herpes virus
93
Q

presentation of anterior uveitis

A
  • dull, aching, painful red eye
  • ciliary flush (red ring)
  • reduced visual acuity
  • floaters and flashes
  • miosis (constricted pupil)
  • photophobia
  • pain on movement
  • excess lacrimation
  • abnormally shaped pupil
  • hypopyon (collection of WBC in anterior chamber seen as yellow fluid collection in iris with fluid level)
94
Q

mx of anterior uveitis

A
  • steroids
  • cycloplegic-mydriatic meds (atropine eye drops) to dilate pupil and reduce pain
  • immunosuppressants
  • laser therapy, cryotherapy or surgery
95
Q

definition of episcleritis

A

benign and self-limiting inflammation of episclera (outermost layer of sclera)

96
Q

conditions associated with episcleritis

A

rheumatoid arthritis

IBD

97
Q

presentation of episcleritis

A

acute onset unilateral:

  • no-mild pain
  • segmental redness (patch in lateral sclera is common)
  • foreign body sensation
  • dilated episcleral vessels
  • watering of eye, no discharge
98
Q

mx of episcleritis

A
  • self-limiting and resolves in 1-4 weeks
  • lubricating eye drops for symptom relief
  • simple analgesia, cold compress and safety net advice
  • severe: systemic NSAIDs or topical steroid eye drops
99
Q

definition of scleritis

A

inflammation of the whole thickness of the sclera

100
Q

complication of scleritis

A

necrotising scleritis -> visual impairment but no pain, can lead to perforation of the sclera

101
Q

conditions associated with scleritis

A
  • rheumatoid arthritis
  • SLE
  • IBD
  • sarcoidosis
  • granulomatosis with polyangiitis
102
Q

presentation of scleritis

A
  • unilateral or bilateral
  • severe pain, pain on movement
  • photophobia
  • eye watering
  • reduced visual acuity
  • abnormal pupil light reaction
  • tenderness to palpation of eye
103
Q

mx of scleritis

A
  • consider underlying systemic condition
  • NSAIDs (topical or systemic)
  • steroids (topical or systemic)
  • immunosuppression appropriate to underlying condition
104
Q

mx of red eye with potentially sight-threatening cause

A

refer for same day assessment by ophthalmologist

105
Q

causes of corneal abrasion

A
  • contact lenses
  • foreign bodies
  • finger nails
  • eyelashes
  • entropion
106
Q

what to consider in corneal abrasions associated with contact lenses

A

pseudomonas infection

107
Q

presentation of corneal abrasion

A
  • hx of contact lenses or foreign body
  • painful red eye
  • foreign body sensation
  • watering eye
  • blurring vision
  • photophobia
108
Q

diagnosis of corneal abrasion

A

fluorescein stain -> yellow/orange colour stain which collects in abrasions or ulcers

109
Q

mx of corneal abrasion

A
  • simple analgesia
  • lubricating eye drops
  • abx eye drops
  • return in 1 week to check if healed
  • cyclopentolate eye drops dilate pupil and improve symptoms
110
Q

definition of keratitis

A

inflammation of the cornea

111
Q

causes of keratitis

A
  • viral: herpes simplex
  • bacterial: pseudomonas, staphylococcus
  • fungal: candida, aspergillus
  • contact lens acute red eye (CLARE)
  • exposure keratitis in ectropion
112
Q

presentation of herpes keratitis

A
  • painful red eye
  • photophobia
  • vesicles around eye
  • foreign body sensation
  • watering eye
  • reduced visual acuity
113
Q

diagnosing herpes keratitis

A
  • fluorescein stain shows dendritic (branching) corneal ulcer
  • slit-lamp examination
  • corneal swabs/scrapings for culture/PCR
114
Q

mx of herpes keratitis

A
  • aciclovir (topical or oral)
  • ganciclovir eye gel
  • topical steroids if stromal keratitis
  • may require corneal transplant due to scarring
115
Q

definition of subconjunctival haemorrhage

A

one of small blood vessels in conjunctiva ruptures and releases blood into space between sclera and conjunctiva

116
Q

conditions which predispose to subconjunctival haemorrhage

A
  • hypertension
  • bleeding disorders e.g. thrombocytopaenia
  • whooping cough
  • meds (warfarin, DOACs, antiplatelets)
  • non-accidental injury
117
Q

presentation of subconjunctival haemorrhage

A
  • patch of bright red blood underneath conjunctiva and in front of sclera covering white of eye
  • painless
  • no vision changes
  • hx of precipitating event e.g. coughing fit, heavy lifting
118
Q

mx of subconjunctival haemorrhage

A
  • resolve spontaneously without any tx in 2 weeks
  • manage underlying/predisposing conditions such as HTN
  • lubricating eye drops can help with symptoms
119
Q

presentation of posterior vitreous detachment

A
  • asymptomatic
  • painless
  • spots of vision loss
  • floaters
  • flashing lights
120
Q

mx of posterior vitreous detachment

A

no tx necessary

can predispose to retinal tears and retinal detachment

121
Q

definition of retinal detachment

A

retina separates from choroid underneath, usually due to retinal tear that allows vitreous fluid to get under retina and fill space

122
Q

risk factors for retinal detachment

A
  • posterior vitreous detachment
  • diabetic retinopathy
  • trauma to eye
  • retinal malignancy
  • older age
  • FHx
123
Q

presentation of retinal detachment

A
  • painless peripheral vision loss, often sudden like a shadow coming across
  • blurred or distorted vision
  • flashes, floaters
124
Q

mx of retinal detachment

A

reattach retina and reduce traction/pressure + tx of retinal tears:

  • vitrectomy (removal of vitreous body and replace with oil/gas)
  • scleral buckling
  • pneumatic retinopexy
125
Q

mx of retinal tears

A

create adhesions between retina and choroid to prevent detachment:

  • laser therapy
  • cryotherapy
126
Q

definition of central retinal vein occlusion

A

blood clot (thrombus) forms in retinal veins and blocks drainage of blood from retina

127
Q

pathophysiology of central retinal vein occlusion

A
  • clot in retinal veins causes blockage
  • results in fluid/blood leakage causing macular oedema and retinal haemorrhage
  • damage to retinal tissue and loss of vision
  • stimulates release of VEGF => neovascularization
128
Q

presentation of retinal vein occlusion

A

sudden painless loss of vision

129
Q

risk factors for retinal vein occlusion

A
  • hypertension
  • high cholesterol
  • diabetes
  • smoking
  • glaucoma
  • SLE etc.
130
Q

characteristic fundoscopy findings in retinal vein occlusion

A
  • flame and blot haemorrhages
  • optic disc oedema
  • macula oedema
131
Q

ix in retinal vein occlusion

A

check for associated conditions:

  • FBC (leukaemia)
  • ESR (inflammatory disorders)
  • BP (HTN)
  • glucose (DM)
132
Q

mx of retinal vein occlusion

A

refer to ophthalmologist to tx macular oedema and prevent neovascularization:

  • laser photocoagulation
  • intravitreal steroids (dex implant)
  • anti-VEGF
133
Q

definition of central retinal artery occlusion

A

blockage to flow through retinal artery, normally secondary to atherosclerosis

134
Q

aetiology of central retinal artery occlusion

A
  • atherosclerosis

- GCA

135
Q

risk factors for central retinal artery occlusion

A
  • older age
  • FHx
  • smoking & alcohol
  • HTN
  • DM
  • poor diet
  • inactivity
  • obesity
  • GCA: white females >50yo with GCA/PMR
136
Q

presentation of central retinal artery occlusion

A

sudden painless loss of vision

137
Q

signs of central retinal artery occlusion on examination

A

relative afferent pupillary defect (pupil in affected eye constricts more when light shone into other eye)

138
Q

signs of central retinal artery occlusion on fundoscopy

A
  • pale retina (ischaemia)

- cherry-red spot (macula is thinner and shows red choroid below)

139
Q

mx of retinal artery occlusion

A
  • ESR and temporal artery biopsy to ix for GCA (-> high-dose steroids)
  • attempt to dislodge thrombus
140
Q

4 steps of retinal artery occlusion mx to attempt to dislodge thrombus

A
  1. ocular massage
  2. removal of fluid from ant chamber
  3. inhale carbogen (CO2 + O2) to dilate artery
  4. sublingual isosorbide dinitrate
141
Q

long term tx of retinal artery occlusion

A

tx reversible risk factors

secondary prevention of CVD

142
Q

definition of retinitis pigmentosa

A

congenital inherited condition where there is degeneration of the rods and cones in the retina

143
Q

presentation of retinitis pigmentosa

A

most cases start in childhood (FHx)

  • night blindness (rods degenerate more than cones)
  • peripheral vision lost before central vision
144
Q

fundoscopy findings in retinitis pigmentosa

A
  • pigmentation -> ‘bone-spicule’ pigmentation (looks like bone matrix)
  • pigmentation most concentrated around mid-peripheral area
  • associated narrowing of arterioles and waxy/pale appearance of optic disc
145
Q

general mx of retinitis pigmentosa

A
  • referral
  • genetic counselling
  • vision aids
  • sunglasses to protect retina from accelerated damage
  • driving limitations (inform DVLA)
  • regular follow up
146
Q

medical mx options for retinitis pigmentosa

A
  • vitamin and antioxidant supplementation
  • oral acetazolamide
  • topical dorzolamide
  • steroid injections
  • anti-VEGF
147
Q

differentials for painless vision loss

A
  • retinal artery occlusion
  • retinal vein occlusion
  • retinal detachment
  • episcleritis
  • optic neuritis
  • vitreous haemorrhage
148
Q

differentials for painful vision loss

A
  • acute angle-closure glaucoma
  • scleritis
  • anterior uveitis

Ophthalmology (2 decks)

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