Day 3 Ophthalmology Flashcards
Which eye condition is common in diabetics, causing sudden loss of vision?
Vitreous haemorrhage
Nasolacrimal duct obstruction treatment
nasolacrimal duct massage
In which condition do you see central scotoma
optic neuritis
Which condition is associated with hypermetropia?
Which condition is associated with myopia?
Acute angle closure glaucoma is associated with hypermetropia,
Primary open-angle glaucoma is associated with myopia
A 49-year-old woman who is known to have multiple sclerosis presents to see her GP. Her partner has noticed a change in the appearance of her eyes over the past few weeks. On examination she has a ptosis on the left side associated with a small left pupil. Fundoscopy is nomal. What is the most likely diagnosis?
Horner’s
define Mydriasis
Anisocoria is unequal pupil size.
Commonly caused by third nerve palsy
A 65-year-old man with a history of primary open-angle glaucoma presents with sudden painless loss of vision in his right eye. On examination of the right eye the optic disc is swollen with multiple flame-shaped and blot haemorrhages. What is the most likely diagnosis?
Central retinal vein occlusion
Which infective organism causes acute penumonia most in COPD
Haemophilus influenzae
Define Heuristic
A technique, is any approach to problem solving or self-discovery that employs a practical method that is not guaranteed to be optimal
What are The Cardiff Acuity Test and LogMar charts?
alternative methods for testing visual acuity
A 79-year-old gentleman presents with a 3 months history of a red swollen left upper eyelid. He remembers initially developing a bump on the eyelid which was uncomfortable but then got bigger forming a hard lump. He reports no pain currently and has not noted any problems with his vision and the eye itself appears healthy.
A meibomian cyst presents as a firm painless lump in the eyelid
Which of the following is the strongest risk factor for subcapsular cataracts?
steroid use
A 6-year-old girl presents to your general practice surgery with her father.
He describes that for the past year, she develops intermittent flares of red, itchy eyelids.
This appears to bother her most in the mornings.
These episodes normally self-resolve with no intervention, but this flare has been particularly protracted - lasting over a month - and he would like some advice.
She has never experienced any visual changes.
Blepharitis - hot compresses to both eyes
Treatment of ARMD
- vascular endothelial growth factor (VEGF)
- laser photocoagulation
A 22-year-old woman presents with a red painful eye.
She describes the pain as tearing. When asked to scale the degree of pain, she gave a score of 7 out of 10.
She also reported that she uses contact lenses frequently.
microbial keratitis
Contact lens wearers who present with a red painful eye should be referred to eye casualty to exclude microbial keratitis
What is Argyll-Robertson syndrome?
Argyll-Robertson pupil is one of the classic pupillary syndromes.
It is sometimes seen in neurosyphilis.
Typically the pupil accommodates but doesn’t react.
A mnemonic used for the Argyll-Robertson Pupil (ARP) is Accommodation Reflex Present (ARP) but Pupillary Reflex Absent (PRA)
Sympathomimetics (e.g. brimonidine, an alpha2-adrenoceptor agonist)
Mechanism of action?
Notes?
Reduces aqueous production and increases outflow
Avoid if taking MAOI or tricyclic antidepressants
Adverse effects include hyperaemia
Which conditions can cause an RAPD?
(3)
Large retinal detachment
central retinal artery/vein occlusion
optic nerve ischaemia
A 50-year-old man presents with red-eye associated with slight watering and mild photophobia. He reports no pain or tenderness and vision is not affected
What is the most likely diagnosis?
Episcleritis
Patient has sudden painless loss of vision, severe retinal haemorrhages on fundoscopy
Central retinal vein occlusion
retinal haemorrhages on fundoscopy, due to increased venous pressure following downstream occlusion.
most common cause of persistent watery eye in infants??
Nasolacrimal duct obstruction
A 67-year-old woman presents to an out-of-hours general practitioner with a painful, red left eye and nausea.
On examination, she has a left-sided, semi-dilated pupil that does not react to light with some surrounding conjunctival injection.
Acute closed-angle glaucoma presents with a fixed dilated pupil with conjunctival injection
A 25-year-old female patient presents to her GP due to a severe throbbing headache which is worst first thing in the morning. This has been happening for several weeks with no response to paracetamol. She has also been vomiting on most mornings and feels that her vision has been blurry.
Her pupils are equal and reactive and systemic examination is normal.
Which of the following would you expect to see on fundoscopy?
Increased intracranial pressure
Papilloedema is associated with blurring of optic disc margin on fundoscopy
How does primary open-angle glaucoma present/?
Primary open-angle glaucoma does not typically present acutely and has a more insidious onset.
Most cases are asymptomatic and if symptoms are noted, it will present as loss of peripheral vision. Pupillary changes are not seen in this case.
A 36-year-old female teacher presents to emergency eye casualty with unilateral right-sided red eye which is acutely painful. She complains of burning pain around the eye, photophobia and you note her eye is tearing excessively. Fluorescein staining shows a linear, branching epithelial defect. She is not a contact lens wearer and she has no past medical history of note.
Which option below is the most appropriate management?
Treatment for herpes simplex keratitis is topical aciclovir
Patient presents with eye pain, and often pain on eye movements.
Optic neuritis
A 75-year-old woman presents to surgery complaining of ‘blurry’ vision in her right eye for the past few months. She also notes that straight lines appear crooked or wavy. This only seem to affect the centre of her right visual field and no problems are noted with the left eye. She has never worn glasses or contact lens. On examination a central scotoma is noted in the right eye.
ARMD
What is Topical sodium cromoglicate used for?
Mast cell stabilizers in allergies
How does Horner’s syndrome present in eyes?
ptosis + constricted pupil = Horner’s
A 75-year-old lady, who has been a diabetic for over 25 years attend her regular follow-up sessions. During the consultation, the lady mentions to her GP that she has had difficulty with her vision over the past few months, especially in the left eye. She described it as a blurry vision and also reported seeing round figures around lights at night. The lady has never had problems with her vision in the past. She currently also takes medications to manage her blood pressure and cholesterol levels. Physical examination is otherwise unremarkable.
This patient has a classic presentation of cataract. The long history of diabetes mellitus in an elderly presentation along with unilateral blurry vision and halos surrounding light sources are strongly suggestive of a diagnosis of cataract.
Miotics (e.g. pilocarpine, a muscarinic receptor agonist)
Mechanism of action?
Notes?
Increases uveoscleral outflow
Adverse effects included a constricted pupil, headache and blurred vision
In ophthalmology, what is Aciclovir used to treat?
viral keratitis
What is “wet ARMD”?
- 10% of cases
- also know as exudative or neovascular macular degeneration
- characterised by choroidal neovascularisation
- leakage of serous fluid and blood can subsequently result in a rapid loss of vision
- carries worst prognosis
An 84-year-old man presents with loss of vision in his left eye since the morning.
He is otherwise asymptomatic and of note has had no associated eye pain or headaches.
His past medical history includes ischaemic heart disease but he is otherwise well.
On examination he has no vision in his left eye. The left pupil responds poorly to light but the consensual light reaction is normal. Fundoscopy reveals a red spot over a pale and opaque retina. What is the most likely diagnosis?
Central retinal artery occlusion
What is this?
A chalazion (Meibomian cyst) is a retention cyst of the Meibomian gland. It presents as a firm painless lump in the eyelid. The majority of cases resolve spontaneously but some require surgical drainage
Patient complains of “flashes and floaters” with no pain
Retinal detachment
A 73-year-old female presents to her GP with left shoulder and arm pain which came on quite suddenly a week ago and has been worsening. The pain is now unmanageable with regular co-codamol. The GP also notes that the patient’s left pupil is smaller than the other side and the eyelid is lagging slightly.
Pancost’s
characteristics of uveitis
(3)
small, fixed oval pupil, ciliary flush
investigation for cellulitis
Where orbital cellulitis is suspected, a contrast enhanced-CT scan of the orbits, sinuses and brain should be considered to support the diagnosis and to search for possible complications such as abscess which may require surgical drainage.*
A 42-year-old man is diagnosed with syphilis following months of ill health. On examination he is noted to have bilateral small pupils which accommodate but do not respond to light. What is the most likely diagnosis?
Argyll-Robertson pupil
Why might digoxin levels be higher than prescribed?
Digoxin is excreted by the kidneys, CKD patients will build up
Patient presents with a triad of a painful eye, vision loss and impaired colour vision.
optic neuritis
Which condition is associated with hypermetropia?
Which condition is associated with myopia?
Acute angle closure glaucoma is associated with hypermetropia
primary open-angle glaucoma is associated with myopia
Characteristics of Central retinal artery occlusion
(3)
- causes sudden unilateral visual loss
- due to thromboembolism (from atherosclerosis) or arteritis (e.g. temporal arteritis)
- features include afferent pupillary defect, ‘cherry red’ spot on a pale retina
A 25-year-old lady presents to the GP with itchy eyes. She describes a gritty feeling in both her eyes and has noticed that they stick together in the morning. The grittiness is also worst first thing when she wakes up. She complains of no other symptoms.
Given her presentation what is the most likely diagnosis?
blepharitis
Carbonic anhydrase inhibitors (e.g. Dorzolamide)
Mechanism of action?
Notes?
Reduces aqueous production
Systemic absorption may cause sulphonamide-like reactions
Patient complains of multiple dark spots in her vision, as well as sudden vision loss
she has diabetes
she has ben in an accident
vitreous haemorrhage
What is a LBBB
Delayed depolarisation of the left ventricle
One of the most common ways to remember the difference between LBBB and RBBB is WiLLiaM MaRRoW
in LBBB there is a ‘W’ in V1 and a ‘M’ in V6
in RBBB there is a ‘M’ in V1 and a ‘W’ in V6
Which infection of the eye presents with dendritic ulceration?
HSV
What is Adie pupil?
Tonically dilated pupil, slowly reactive to light with more definite accommodation response. Caused by damage to parasympathetic innervation of the eye due to viral or bacterial infection. Commonly seen in females, accompanied by absent knee or ankle jerks.
A 30-year-old male presents with sudden onset loss of vision. He denies any preceding warning signs or head trauma, and does not complain of any pain. You perform a fundoscopy and find severe retinal haemorrhages on fundoscopy.
Which of the following is the most likely diagnosis?
Central retinal vein occlusion
sudden painless loss of vision, severe retinal haemorrhages on fundoscopy
Which condition is associated with short-sightedness?
Cataracts are associated with aging and high myopia
(severe short-sightedness)
A 71-year-old patient with a background of hypertensive retinopathy presents for an eye check. Fundoscopy demonstrates retinal arteriole tortuosity with nil other abnormalities noted. According to the Keith-Wagener classification, which grade of hypertensive retinopathy is this most likely to represent?
grade 1
How is Anterior uveitis is most likely to be treated?
with a steroid + cycloplegic (mydriatic) drops
28-year-old patient presents to the emergency department with a right red eye and sensitivity to light that started 1 hour ago.
Examination of the right eye reveals a painful, red eye, with a small and irregularly-shaped pupil.
Anterior uveitis
Prostaglandin analogues (e.g. latanoprost)
Mode of action?
Side effects?
Increases uveoscleral outflow
Adverse effects include brown pigmentation of the iris, increased eyelash length
Causes pupillary constriction, blurred vision and headaches
Pilocarpine
A 67-year-old man presents as he has developed a painful blistering rash around his right eye.
On examination a vesicular rash covering the right trigeminal nerve dermatome is seen.
HSV
Risk factors for vitreous haemorrhage include: (5)
Diabetes
Trauma
Anticoagulants
Coagulation disorders
Severe short sightedness
In which conditions do you see haloes?
cataracts, glaucoma
What is Hutchinson’s pupil?
Unilaterally dilated pupil which is unresponsive to light. A result of compression of the occulomotor nerve of the same side, by an intracranial mass (e.g. tumour, haematoma)
On examination, the boy appears unsettled and is crying constantly.
His temperature is 38°C and other vital signs are normal.
On examination of the affected eye, the eyelid is erythematous and oedematous.
Proptosis of the left eye is noted and there seems to be limited ocular movement as well.
orbital cellulitis
In which condition would you see leukoria
retinoblastoma
Treatments for acute angle-closure glaucoma
combination of eye drops, for example:
- a direct parasympathomimetic (e.g. pilocarpine, causes contraction of the ciliary muscle → opening the trabecular meshwork → increased outflow of the aqueous humour)
- a beta-blocker (e.g. timolol, decreases aqueous humour production)
- an alpha-2 agonist (e.g. apraclonidine, dual mechanism, decreasing aqueous humour production and increasing uveoscleral outflow)
intravenous acetazolamide
- reduces aqueous secretions
Definitive management
- laser peripheral iridotomy
- creates a tiny hole in the peripheral iris → aqueous humour flowing to the angle
Adverse effects include brown pigmentation of the iris
Latanoprost59
A 72-year-old man presents with a painful, red eye to the Emergency Department. Due to the severity of his symptoms and reduced visual acuity he is referred on to ophthalmology who make a diagnosis of acute glaucoma. Which of the following should be the aims of treatment?
Reducing aqueous secretion + inducing pupillary constriction
A 30-year-old woman presents with a 2 day history of a painless red eye. She is otherwise well and has not noticed a decrease in her vision. The patient has no past medical history of note and is not on any long-term medications. On examination, her eyes are red and injected bilaterally. Upon applying light pressure on her eye with a cotton bud, you notice that the injected vessels seem to move.
Episcleritis
What kind of drug is Amiloride?
potassium sparing diuretic
Acetazolamide is a carbonic anhydrase inhibitor that is used in managing what?
acute angle-closure glaucoma
stye treatment
analgesia + warm compress
A 64-year-old woman with type 2 diabetes mellitus presents as she has started to bump into things since the morning. Her medications include metformin, simvastatin and aspirin. Over the previous two days she had noticed numerous ‘dark spots’ over the vision in her right eye. Examination reveals she has no vision in her right eye. The red reflex on the right side is difficult to elicit and you are unable to visualise the retina on the right side during fundoscopy. Examination of the left fundus reveals changes consistent with pre-proliferative diabetic retinopathy. What is the most likely diagnosis?
The history of diabetes, aspirin use, complete loss of vision in the affected eye and inability to visualise the retina point towards a diagnosis of vitreous haemorrhage.
How is an RAPD diagnosed?
Both pupils will dilate when light is swung to the affected eye
Beta-blockers (e.g. timolol, betaxolol)
mode of action?
notes?
Reduces aqueous production
Should be avoided in asthmatics and patients with heart block
What medicine is likely to have caused his eyelashes to grow in length?
Key side effects of prostaglandin analogues include increased eyelash length, iris pigmentation and periocular pigmentation
glaucoma characteristics
(3)
severe pain, haloes, ‘semi-dilated’ pupil
A 45-year-old woman attends eye casualty complaining of blurred vision and glare from bright lights. She has a history of asthma, polymyalgia rheumatica and gout. The ophthalmologist finds a lens opacity in her left eye that is located just deep to the lens in the visual axis.
cateracts
How does Latanoprost work?
Latanoprost is a prostaglandin analog used in glaucoma. It works by increasing uveoscleral outflow
in which condtions do you see Homonymous hemianopia
It is a visual field defect that arises from the optic tract, which is after the optic chiasm
What is Argyll-Robertson pupil?
Bilaterally small pupils that accommodate but don’t react to bright light.
Causes include neurosyphilis and diabetes mellitus
differences between orbital and periorbital cellulitis
Periorbital (preseptal):
Absence of painful movements, diplopia and visual impairment indicates the former
On fundoscopy, a ‘cherry red spot’ can often be seen in the macula where the retina is thinner.
Central retinal artery occlusion
Patient presents with no pain, describes curtain over vision + spider webs + flashing lights in vision
retinal detachment
Which condition presents with a fixed dilated pupil with conjunctival injection
Acute closed-angle glaucoma
The most common causes of a sudden painless loss of vision are: (3)
ischaemic/vascular
vitreous haemorrhage
retinal detachment
A 63-year-old gentleman is diagnosed with primary open angle glaucoma. He asks how untreated glaucoma is most likely to affect vision?
Glaucoma primarily causes visual field defects
Glaucoma causes an optic neuropathy, that most frequently affects patients visual field. This tends to commence in the peripheries, and if untreated, eventually leads to tunnel vision.
Investigation for ARMD
slit-lamp microscopy is the initial investigation of choice, to identify any pigmentary, exudative or haemorrhagic changes affecting the retina which may identify the presence of ARMD. This is usually accompanied by colour fundus photography to provide a baseline against which changes can be identified over time.
fluorescein angiography is utilised if neovascular ARMD is suspected, as this can guide intervention with anti-VEGF therapy. This may be complemented with indocyanine green angiography to visualise any changes in the choroidal circulation.
ocular coherence tomography is used to visualise the retina in three dimensions, because it can reveal areas of disease which aren’t visible using microscopy alone.
70-year-old man is investigated for blurred vision.
Fundoscopy reveals drusen, retinal epithelial and macular neovascularisation.
age related macular degeneration
Which test is most suitable to investigate for a refractive error?
A pinhole occluder is useful to identify refractive errors as the cause of blurred vision
What kind of drug is Bumetanide?
loop diuretic
Contact lens wearers who present with a red painful eye should be referred to eye casualty to exclude what?
microbial keratitis
how does an oculomotor nerve lesion present?
“down and out” eye
Ptosis + dilated pupil
A 60-year old man presents with a one month history of worsening visual acuity. He describes blurring of the smaller words in the newspaper and has noticed that straight lines, such as those on the wallpaper in his lounge appear ‘curvy’. He has also started to see a grey patch in his central field of vision. On examination his acuity is 20/30 bilaterally. Ophthalmoscopy demonstrates choroidal neovascularisation. What is the most likely diagnosis?
ARMD
What is azathioprine used for?
Crohn’s
What is Bronchiolitis?
Bronchiolitis is a common lower respiratory tract infection that affects babies and young children under two years old
most common infection for swimmers wearing contact lenses
Acanthamoeba
Chloramphenicol is an antibiotic used in treating what?
Bacterial conjunctivitis without the need for steroids?
Patient presents with a painful eye and examination findings of a fixed pupil, hazy cornea and increased ocular pressures
Acute glaucoma
What causes “bilateral gritty-ness”?
Bilateral grittiness - think blepharitis
What is Hutchinson’s sign
Presence of the rash on the tip of his nose
A 24-year-old male presents to the emergency department with an acutely painful red eye, which is associated with photophobia, lacrimation and reduced visual acuity. He has a past medical history of ankylosing spondylitis. Examination identifies a small, irregularly shaped pupil.
anterior uveitis
treat with steroids + mydriatic
A 47-year-old man presents to the emergency department with sudden painless loss of vision on the left side.
This was preceded by dark ‘floaters’ in his vision and a ‘red hue’ prior to total loss of vision on the affected side.
This was worst when lying flat. He has a history of poorly controlled type 1 diabetes, proliferative diabetic retinopathy, hypertension and a metallic aortic valve for which he is on warfarin.
Vitreous haemorrhage is an important differential for sudden visual loss in diabetics
What is treated with a steroid + cycloplegic (mydriatic) drops?
Anterior uveitis
Pilocarpine is a muscarinic receptor agonist and can be used in managing what?
primary open-angle glaucoma and acute close angle glaucoma
A 55-year-old lady presents to the emergency department with problems with her vision. She describes a red hue of her vision along with some dark spots in her right eye. The doctor refers her to eye casualty where they suspect a vitreous haemorrhage.
Vitreous haemorrhage
A 27-year-old male attends the emergency department with a sudden onset painful left eye and slightly blurred vision. He has no past medical history of note and does not wear glasses or contact lenses. His family history includes type 2 diabetes and Crohn’s disease.
He is wearing sunglasses in the department as he finds the lighting too bright. On removal, you note his left eye is red and his complaint of photophobia is so severe he cannot tolerate ophthalmoscopy. On close inspection, you see a white fluid level visible in the inferior part of the anterior chamber and his pupil appears small and irregular.
Due to these findings, you urgently contact ophthalmology - what is your working diagnosis?
Anterior uveitis
dorzolamide eye drops.
What is the mechanism of action of this drug?
carbonic anhydrase inhibitor
Stages of diabetic retinopathy (5)
- Mild NPDR
- Moderate NPDR
- Severe NPDR
- Proliferative retinopathy
- Maculopathy
A 31-year-old man presents with a painful swelling of his right upper eyelid for the past 3 days. On lifting the eyelid a yellow head pointing at the lid margin can be seen.
Stye
