elder Flashcards
1
Q
Xerophthalmia
A
A major cause of childhood blindness in Africa
Due to Severe Vitamin A deficiency → lack of tear production → dry eyes
Presentation
Characteristic Bitot’s spots - triangular conjunctival keratin buildups
Investigations Standard findings in dry eye: Tear film break up time time is reduced (<5) Schirmer's test is positive >10mm Ocular surface staining
2
Q
What vitamin deficiency is most likely to cause with xerophthalmia?
A
A
3
Q
Blepharitis associated with which bacteria?
A
chronic inflammation of the eyelid of any cause. It is typically associated with Staphylococcus aureus infection.
Anterior - lashes and eyelid crusts, staphylococcus,
Posterior - eyelids normal, foamy tear film - worser tx response
4
Q
what is the presentation of blepharitis?
A
crusts at eyelid margin and lashes
foamy tear film
meibomian cysts with posterior blepharitis
5
Q
what risk is associated with recurrent unilateral blepharitis?
A
sebaceous cell carcinoma
6
Q
what is the glaucoma triad?
A
raised IOP, abnormal disc, visual field defects?
IOP can be normal in glaucoma.
Gold standard for IOP - Goldmann tonometry 11-21mhg
7
Q
what does the neuroretinal rim and optic cup contain?
A
neuroretinal rim - retinal neuronal cells
optic cup - central retinal vessels.
8
Q
normal optic cup-to-disc ratio?
A
0.3
9
Q
retinal detachment signs?
A
curtain fall over vision, floaters (PVD), shaffer sign (pigment cells in vitreous) Weiss ring (PVD)
10
Q
what method attached neurosensory retain to retinal pigment epithelium?
A
hydrostatic forces
11
Q
Difference between rhegmatogenous, tractional and exudative RD
A
rhegmatogenous - break/tear in neurosensory retina, fluid accumulate between NSR and RPE , PVD associated
tractional - scar tissue - adhesional vitreous traction on retina DR and ROP associated
exudative - sub-retinal fluid accumulation due to failure of blood-retinal barrier –> uveitis, choroidal tumour/neovascularization, uveal effusion syndrome.
12
Q
refractive power =
A
1/focal length of lens (m)
total RP - 60Dioptres
cornea 2/3
lens 1/3
13
Q
axial length normal range
A
22-24mm
Myopia - long eye , focal point in front of retina, short-sighted
hyperopia - short eye, focal point behind retina, long-sighted (further away object allows focal point move forwards)
14
Q
astigmatism
A
refractive power of corneal not uniform due to shape of it. blurry vision, two inaccurate focal points.
15
Q
What is the wavelength of the ND:YAG laser used in peripheral iridotomy?
A
1064
16
Q
horners syndrome
orders?
What is used to diagnose horners
A
First order : lesions of brain and spinal cord
Second order : Pancoast tumour and neck trauma
Third order: no anhidrosis. Caused by cavernous sinus lesions and internal carotid dissection.
cocaine and apraclonidine (alpha agonist - mydriasis) – more dilation
hydroxyamphetamine and dilute adrenaline - localise 3rd order disease
17
Q
Painful Horners
A
carotid dissection until proven otherwise.
18
Q
CN4 palsy test??
A
Park Bielschowsky
1- find hypertrophic eye in primary position
2. assess change in diplopia with horizontal gaze - diplopia worse with contralateral gaze direction
left affected - right movement worse
3. head tilt - diplopia worse on ipsilateral head tilt
19
Q
pseudoxanthoma elasticum
A
- angioid streaks
- radiating sections of Bruch membrane of chorioid that are calcified and broken
- from optic disc out retina
- can cause choroidal neovascularisartion and visual loss
20
Q
Angioid streaks
A
PEPSI pseudoxanthoma elasticum pagests Sickel cell idiopathic
21
Q
which glands involved in sebaceous gland carcinoma
A
meibomian and zeis
misdiagnosed as unilateral blepharitis
associated with Muir Torre syndrome –>
Muir-Torre syndrome (MTS) rare inherited disorder that involves at least one sebaceous tumor and/or keratoacanthoma in addition to one visceral malignancy eg colorectal cancer. Sebaceous adenomas are the most common cutaneous tumors in MTS - multiple yellow papules or bumps on areas such as the trunk, face, and scalp.
22
Q
The cyst in degenerative retinoschisis typically forms between which layers of neurosensory retina?
A
the outer plexiform and inner nuclear layers of the retina
23
Q
common cause of infant epiphora and cause?
A
congenital nasolacrimal duct obstruction
imperforate membrane over valve of hasher.
<12 months of age Massage + topical antibiotics + observation >12 months of age Syringing and probing Silicone stent intubation Dacryocystorhinostomy (DCR)
24
Q
ametropia
A
refractive error present
myopia or hyperopia
25
spherical lenses
Used to correct ametropia and presbyopia
-ve D lenses are concave and diverge light → correct myopia
A myopic patient
+ve D lenses are convex and converge light → correct hyperopia and presbyopia
E.g : A hyperopic patient would like spectacles to allow reading at 20cm. What power should the lenses be?
The lens has to have a focal point which matches the far point
The far point in this case is 20cm, so a lens with a focal length of 20cm is needed
Power=1/focal length(m)
P=1/0.2 = 5
Answer = +5D
26
topic lenses
Used to correct astigmatism
Is composed of a sphere and cylinder
The sphere acts in all meridians
The cylinder only acts in a specific meridian, this allows it to treat astigmatism.
27
Inclusion Body Chlamydial Conjunctivitis
Chlamydia trachomatis, a gram negative intracellular obligate organism
Associated with serotypes D-K
Subacute (2-3wks) unilateral conjunctivitis in young people
Associated with STI symptoms such as urethritis
Inferior follicular conjunctivitis with persisting mucopurulent discharge and lymphadenopathy
Immunotypes L1, L2, L3 cause Lymphogranuloma Venereum
28
Inclusion Body Chlamydial Conjunctivitis Tx
1g oral azithromycin STAT or 100mg doxycycline BD for 14 days
29
POAG
Chronic glaucomatous change due to optic nerve damage with an open anterior chamber angle.
Normal IOP, visual field defects
Black people - myopia -> POAG
Asians - hyperopia Angle closure
30
side effects of Latanoprost in Glaucoma
increase uveoscleral outflow
```
Iris pigmentation
Lash lengthening
Hyperaemia
Uveitis
Macular oedema
```
Avoid in uveitis as it worsens inflammation
31
Beta blockers side effects
reduces aqueous production
Bradycardia
worsen asthma
avoid in lung path and breast-feeding
32
Alpha agonist SE
Decrease aqueous production and increase uveoscleral outflow
Dry mouth
Dry eyes
A2 selective blockers are lipophilic, and can cross the blood brain barrier, resulting in respiratory depression in the young
33
Cholinergic agonists (e.g Pilocarpine) SE
ciliary contraction, opening the trabecular meshwork → Increases trabecular outflow
causes miosis which relieves pupil block, where the the pupil has fallen down and is obstructing the flow of aqueous
```
Polyuria
Diarrhea
Lacrimation
Sweating
salivation
```
34
Carbonic anhydrase inhibitors (e.g Brinzolamide)
SE
Inhibit anhydrase isoenzyme II → reduce aqueous production
Hypokalemia
Metabolic acidosis
contras
Sulfonamide sensitivity
Renal/liver failure
35
what is metamorphopsia
distortion of visual objects
| seen in macular disease eg macular hole, macular degeneration
36
normal IOP in infants
10-12mmhg
37
primary congenital glaucoma
glaucoma in the first year of life due to malformed anterior chamber angles
Mostly sporadic but can be AR
CYP1B1 gene mutation association
Presentation
Hx: infant boy + haab striae + buphthalmos + large corneal diameter + epiphora
Investigation
Elevated IOP (normal in infants is 10–12 mmHg)
Widened corneal diameter
Management
Angle surgery: Goniotomy if the cornea is clear. If the cornea is cloudy, then trabeculotomy can be attempted.
38
how many layers of tear film
```
3
Lipid layer
The thinnest and most superficial layer
Produced by the meibomian gland (Sebaceous).
Prevents evaporation of the tear film.
```
Aqueous layer
Produced by the lacrimal gland.
Thickest layer
Has an immune function
Mucin layer
Deepest layer
Produced by conjunctival goblet cells.
Spreads the film evenly and keeps it stable on the ocular surface.
39
glands of lacrimation
Lacrimal Gland (main)
Sensory innervation → lacrimal nerve (branch of CNV1)
Lacrimation (secretomotor) → Parasympathetic (CN7)
Accesory Lacrimal Glands
Krause and Wolfring glands are accessory lacrimal glands which maintain a basal aqueous layer
Krause glands are found at the conjunctival fornices and are more abundant in the upper fornix
Wolfring glands a less numerous but bigger. They are found at the tarsal plate.
Eyelash Associated Glands
The glands of Moll and Zeis both service eyelash follicles
Moll glands are apocrine (modified sweat glands)
Zeis (and Meibomian glands) are holocrine (sebaceous)
40
What muscle is involved in the lacrimal pump mechanism?
Orbicularis
41
what is the Lamella
The eyelid is anatomically divided into 2 lamella (sections) by the Gray line, the outermost margin of the orbicularis muscle.
Anterior lamella contains: skin and orbicularis
Posterior lamella contains: tarsal plate and conjunctiva
42
muscles for eyelid retraction
levator palpebrae superioris, mullers and frontalis
levator - cn3
frontalis - CN7
muller - SNS
43
muscles for eyelid
obicularis - CN7
44
most common primary intraocular malignancy in children?
Retinoblastoma
Arises from Photoreceptor cells
Associated with RB1 mutation on Ch13.
Most commonly sporadic but can be AD
Histopathology classically shows Flexner rosettes
Presentation : 3 year old + leukocoria (often unilateral) + strabismus + decreased visual acuity + white round mass in fundus + ultrasound shows calcification
45
Mx of retinoblastoma
enucleation
46
strabismus ? eye direction disorder
esotropia - in
exotropia - out
hypotonia - down
hypertropia - up
47
vergence ?
Biconcave lens vergence
Biconvex lens vergence
vergence
Vergence is the amount of spreading (divergence) or coming(convergence) together of light. It is measured in diopters (D), where D is the reciprocal of the distance to the point where light rays would intersect if extended in either direction (focal length). D=1/f(m).
images form at the light intersection
A plus lens converges light / biconvex ()
A minus lens diverges light / biconcave )(
48
lens formula
U+D=V
U → vergence of light entering lens (object rays)
D → vergence added to light by lens (lens power)
V → vergence of light leaving the lens (image rays)
Light from an object 2m away is travelling to a +2D lens. At what distance is the image going to be formed?
- U= 1/2 = -0.5D
- Light coming from a natural object is divergent (minus)
- D = +2D
- V = -0.5+2 = +1.5D
- Recall that D=1/f(m), therefore, 1/1.5 = 0.67m
- The image will form 0.67m on the other side of the lens
D = reciprocal of distance
49
Which medication is most likely to cause bilateral primary angle closure?
topiramate
50
POAG
PACG can manifest in several different:
- Anatomically narrow drainage angle (ANDA): On gonioscopy the AC angle is narrow and the person is likely to be at higher risk of angle closure
- Iridotrabecular contact (ITC): on gonioscopy the AC angle is closed
- Acute primary angle closure (APAC): ITC + acute symptomatic elevated IOP
- Primary angle closure glaucoma: ITC + Glaucomatous damage + elevated IOP or PAS or APAC episodes
51
pathology of POAG
Pathology
Pupil block mechanism (Majority):
Apposition of iris to lens → abnormal aqueous flow through the pupil → increase in pressure difference between the posterior and anterior chambers → anterior bowing of the peripheral iris leading → peripheral anterior synechiae (PAS) → angle closure → obstructed aqueous outflow → elevated IOP → glaucomatous optic nerve damage
Plateau iris configuration (East asian):
Flat iris + anteriorly positioned ciliary processes → iris is pushed forward → angle closure.
52
signs of Resolved/Past APAC attacks?
Descemet's membrane folds
| Glaukomflecken
53
Mx of POAG?
APAC
First line: urgent admission + IV acetazolamide
Adjuncts: timolol + apraclonidine + steroids + pilocarpine + lie the patient supine
Monitor and consider systemic hyperosmotics (IV mannitol)
Definitive treatment is bilateral peripheral iridotomy.
PACG
Aim is to control IOP over time
Bilateral peripheral iridotomy
Cataract extraction is effective in acute and chronic stages
POAG
Asymptomatic at first but will develop visual field defec
Topical IOP lowering medications (1st line)
- Topical prostaglandin or beta-blocker (others options are alpha-2 agonists, carbonic anhydrase inhibitors)
- No IOP reduction → try alternative first line
- Insufficient IOP reduction → combine topical medications
Surgical IOP lowering procedures (2nd line)
Issue with medical adherence but IOP is controllable → Selective laser trabeculoplasty (SLT)
Uncontrolled IOP despite maximum meds→ Trabeculectomy with anti-scarring mitomycin C (MMC) or 5-FU
54
blood supply of CN2
Intraocular → short posterior ciliary artery
| Rest → ophthalmic artery (Pial vessels)
55
presbyopia?
With age, the lens hardens and the anterior capsule thickens
Lens power decreases because it loses the ability to change shape with accommodation
The decline of accommodative power with age:
At birth → 16D
25 years → 8D
50 years → 2D
60 years → <1D
People around the age of 50 invariably require reading glasses
Presbyopia is delayed in myopes (short-sighted people)
56
hyphema ?
blood in the anterior chamber
ocular trauma
microhyphema - RBC visible only on slit lamp
```
Treatment
Admit for steroids and bedrest
Monitor IOP for red cell glaucoma
No improvement → AC paracentesis
No - trabeculectomy
```
57
what are the three types of ametropia
ametropia results if power or axial length of eye is outside normal range.
1- myopia = high refractive power, focus in-front retina, short-sighted, -ve lens
2- hyperopia = low refractive power, focus at-back of retina, long-sighted, +ve lens
58
Bacterial Conjunctivitis MX
red gritty sticky eyes and purulent discharge.
Practice good hand and eye hygiene
Switch to spectacles from contact lenses during the episode
Topical chloramphenicol drops
Systemic antibiotics are reserved for gonococcal conjunctivitis in adults or H.influenzae/Meningococcal conjunctivitis in children
H.influenzae → PO Co-amoxiclav
59
what causes Bacterial Conjunctivitis in
cool climate
warm climate
children
cool - Strep p , H.I
warm - Haemophilus aegyptius
Children → Haemophilus influenzae
60
Giant fornix syndrome
Bacterial conjunctivitis where
| sequestration of bacteria in the upper fornix of the conjunctiva and is typically seen in the elderly.
61
order of neuroretinal rim thickness of the optic disc, from thickest to thinnest?
Inferior → Superior → Nasal → Temporal
62
Parinaud syndrome
supranuclear palsy of upgaze . It is caused by a lesion in the dorsal midbrain
63
signs of Parinaud syndrome
```
Signs
Bilateral lid retraction - Collier sign
Upgaze paresis
Convergence retraction nystagmus
Large pupil with light-near dissociation (light reflex lost but near accommodation reflex intact)
```
64
optic neuritis types
Papillitis: Inflammation of the optic disc. Typically presents in post-viral children with flame hemorrhages and an oedematous optic nerve
Retrobulbar neuritis: disc is spared but the segment behind the eyeball is affected. The disc looks normal in this acute setting. More common in adults
Neuroretinitis: The disc and retina are both involved. Occurs in lyme disease and cat scratch
65
what causes cat scratch
bartonella henselae and is transmitted by cats.
66
clinical manifestations of optic nerve disease?
Loss of central vision and eye pain on movement
RAPD
Red green colour loss
67
clinical manifestations of macular disease?
Distortion of vision (metamorphosia) and loss of central vision
Hyperopic shift (see distance better)
Blue yellow colour loss
68
what are the two mechanisms of epiphora?
nasolacrimal drainage failure and hyper-secretion.
69
epiphora causes
```
Obstruction of the nasolacrimal system
Punctal eversion
Canalicular fibrosis
Lacrimal sac obstruction
Nasolacrimal duct obstruction.
Orbicularis pump failure
Lid laxity
CN7 palsy
Lateral dermatochalasis
Overzealous punctoplasty
Hypersecretion
Irritation hyper-secretion is typically caused by a foreign body on the ocular surface or lashes rubbing on the ocular surface as in trichiasis and entropion
Autonomic abnormalities and pro-secretory drugs like pilocarpine can also cause hypersecretion.
```
70
Which condition is most associated with posterior blepharitis
Acne rosacea
71
retinal hole
A full thickness retinal defect due to atrophy without vitroretinal traction
72
retinal tears
Retinal tears are full thickness breaks through the retina. Retinopexy is used as treatment in cases which are high risk for progression into retinal detachment (RD). Tears are commoner in myopic eyes, because the surface area of the retina is greater.
73
types of retinal tears
U-shaped
Typically occurs in the context of PVD
High risk for progression to RD
Symptomatic U-shaped tears are treated with laser retinopexy
```
Giant
Describes are tear which extends greater than a quarter of the retina.
Typically occurs in the context of PVD
Very high risk for progression to RD
Treat with laser retinopexy
```
Retinal Dialysis
Disinsertion of the retina at the ora serrata (most anterior edge of retina)
Traumatic dialysis is typically located superonasally
Idiopathic dialysis is typically located inferotemporally
High risk for progression to RD
Treat with retinopexy if there is no associated RD
Treat with scleral buckling if there is RD
74
image quality of biconcave and biconvex lenses
image created by a minus lens (biconcave) is virtual, erect and diminished.
image created by a plus lens (biconvex) can be real or virtual, erect or inverted, and magnified or diminished; all depending on the distance of the object relative to the focal point of the lens.
75
sympathetic pathway in eye?
1st Hypothalamus → T1 → 2nd Superior cervical ganglion→ 3rd ICA → long ciliary nerve → dilator pupillae.
This sympathetic pathway is compromised in Horner syndrome.
76
Carotid Cavernous fistula CCF what is it and what are the 2 types?
V malformation between the internal carotid artery and the cavernous sinus
1. direct CCF
High flow direct connection between internal carotid artery and cavernous sinus
trauma leading to a fistula
ocular bruit, whooshing sound heard by patient, raised IOP and visual defects
Management is with embolisation
2. indirect
Low flow connection between the internal carotid artery and cavernous sinus via meningeal branches
Typically occurs spontaneously in elderly hypertensive women
gradual onset irritated eye, increased IOP and corkscrew epibulbar vessels
Most cases self resolve
77
astigmatism
common and generally treatable imperfection in the curvature of the eye that causes blurred distance and near vision. Astigmatism occurs when either the front surface of the eye (cornea) or the lens inside the eye has mismatched curves.
Astigmatism is when the refractive power is different across the surface of the same medium. E.g the superior cornea might have 49D and and the inferior cornea might have 34D.
78
What visual field defect is most associated with chronic papilloedema?
Papilloedema is a red flag sign that needs immediate investigation
Acute papilloedema causes an enlarged blind spot
Chronic papilloedema results initially in the loss of the inferior nasal quadrant of vision
79
causes of epiphora
```
Obstruction of the nasolacrimal system
Punctal eversion
Canalicular fibrosis
Lacrimal sac obstruction
Nasolacrimal duct obstruction.
```
```
Orbicularis pump failure
Lid laxity
CN7 palsy
Lateral dermatochalasis
Overzealous punctoplasty
```
Hypersecretion
Irritation hyper-secretion is typically caused by a foreign body on the ocular surface or lashes rubbing on the ocular surface as in trichiasis and entropion
Autonomic abnormalities and pro-secretory drugs like pilocarpine can also cause hypersecretion.
80
what is the commonest cause of traumatic retinal detachment in children?
traumatic retinal dialysis
81
what is retinal dialysis
disinsertion of retina at ora serrata
Traumatic dialysis is typically located superonasally
Idiopathic dialysis is typically located inferotemporally
82
what is the Tx for retinal tears
laser retinoplexy
83
PNS in eye afferent limb
fferent Limbs
Pupillary light reflex (meiosis in response to light)
Retinal ganglion cells → optic nerve → chiasm → exit at optic tract before the lateral geniculate nucleus (LGN) → enter dorsal midbrain → synapse with ipsilateral pretectal nucleus → projections to bilateral Edinger-Westphal nuclei
Near reflex (accommodation) (meiosis, lens thickening and eye convergence)
Visual cortex / CN3 → Frontal lobe eye fields → CN3/Edinger-Westphal nucleus
CN3 → Medial recti → Convergence
Edinger-Westphal nuclei → Pupil constriction and lens thickening
84
PNS efferent limb ?
Edinger-Westphal nuclei → CN3 → Ciliary ganglion → Short ciliary nerves → Sphincter pupillae and ciliary body
Sphincter pupillae → meiosis
Ciliary body → contraction of ciliary muscle → zonular relaxation → lens thickens (accomodation)
85
SNS pathway for dilatation / mydriasis
3 order system:
First order fibres start in the hypothalamus and project down the spinal cord to T1 (ciliospinal centre of budge)
Second order preganglionic fibres leave spinal cord, traverse over the lung apex and synapse at the superior cervical ganglion at the carotid bifurcation.
Third order post-ganglionic fibres traverse the wall of the internal carotid artery and enter the globe via long ciliary nerves to innervate the dilator pupillae
86
signs of conjunctival disease
Hyperaemia (conjunctival injection)
Enlargement of conjunctival vessels
Chemosis (conjunctival oedema)
Transparent swelling of the conjunctiva
Conjunctival membranes
Exudative adherences of the conjunctiva
Cicatrization
Scarring of the conjunctiva
Follicles
Discrete lesions which appear like transparent grains of rice. No vessels inside the lesion
Papillae
Lesions confined to the palpebral conjunctiva with a vascular center.
87
nclusion Body Chlamydial Conjunctivitis
Caused by Chlamydia trachomatis, a gram negative intracellular obligate organism
Associated with serotypes D-K of Chlamydia trachomatis
Inferior follicular conjunctivitis with mucopurulent discharge and lymphadenopathy
mx 1g oral azithromycin STAT or 100mg doxycycline BD for 14 days
88
What laser is used for peripheral iridoplasty?
argon
Peripheral iridoplasty - contraction burns of the peripheral iris pull it away from the angle
Temporising measure in acute angle closure
Argon (455-529nm)
Peripheral iridotomy - creates a hole in the peripheral iris to allow aqueous flow through a closed angle
Definitive treatment in acute angle closure
ND:YAG (1064nm)
Selective laser trabeculoplasty (SLT) - laser applied to the trabecular meshwork to facilitate drainage
Used in open angle glaucoma where medical treatment is untolerated
Frequency doubled Q-switched ND:YAG (532nm)
89
horners syndrome pathology
First order : lesions of brain and spinal cord
Second order : Pancoast tumour and neck trauma
Third order: no anhidrosis. Caused by cavernous sinus lesions and internal carotid dissection
90
localising lesion in horners
cocaine - no dilatation in affected eye but in non-affected
apraclonidine - alpha agonist -horner eye dilates more due to denervation hypersensitivity
hydroxyamphetamine - distinguish 3rd order lesions
this releases NA from 3rd order neutron ending for dilation = lesion = no dilation in Horner eye
if dilation = 1/2 order lesion
adrenaline - more dilation if 3rd order lesion due to denervation hypersensitivity
91
Albinism presentation
Presentation: dVA (foveal hypoplasia) + nystagmus + strabismus + iris hypopigmentation
Oculocutaneous albinism (AR) is more common than ocular albinism (XL)
Decreased visual acuity is typically due to foveal hypoplasia
x linked
optic chasm = more temporal cross links
treat the ametropia.
92
what is macular oedema
The mechanism of oedema is similar to elsewhere in the body, involving vessel hyper-permeability and high flow.
The fluid gathers within the intercellular spaces of the retina, most commonly the outer plexiform layer.
Macular oedema results in dVA because the fluid obstructs light.
93
Common cause of macular oedema
inflammation due to cataract surgery
other causes
- uveitis
- diabetic nephropathy
- retinitis pigmentosa
94
presentation of macular oedema
blurry vision, scotoma, metamorphopsia
95
Dx and Mx of macular oedema
OCR, FFA for vessel leakage
Mx
1 - steroid drops
2- 1m - topical + periorbital injection
3- another 1m intavitreal or systemic steriods
4- anti-VEGF, carbonic anhydrase inhibitors
96
what is entropion and what can it lead to
inwardly rolled eyelid
| leads to pseudotrichiasis and corneal irritation
97
cause of entropion and Mx
Involutional
Commonest type**.**
Caused by lower retractor weakness/dehiscence.
Cicatricial
Caused by shortening of the posterior lamella by vertical scarring.
Most commonly caused by trachoma (upper lid)
Mx
Retractor weakness → Everting sutures, transverse tarsotomy or Jones procedure
Scarring → Membrane graft or posterior lamella reconstruction
Botox can be used to weaken overactive muscles
98
What is 1 correct letter on the logMAR chart worth?
0.02 units
A score between 1-0 is given where 0 is best.
0 LogMAR = 6/6 snellen
1 Logmar = 6/60 snellen
99
Which AB used in the management of Acanthamoeba keratitis
chlorhexidine
Acanthamoeba is found in water and soil. It causes acanthamoeba keratitis (an orphan disease), typically in contact lens wearers who do not remove lenses whilst swimming or are storing lenses incorrectly.
Toxoplasma gondii is transmitted to humans via cats (definitive host). It can also be transmitted vertically by humans and cause congenital toxoplasmosis
100
Phacoemulsification Procedure
| for cataract
Generic preparations with antiseptic, appropriate anesthesia (typically topical or peribulbar) and mydriasis
Cleaning the external ocular structures with 5% povidone-iodine (is the most important step in preventing endophthalmitis)
1 main incision and 1/2 side ports created on the sclera using a blade or femtosecond laser
Capsulorhexis - creation of a continuous curvilinear opening in the anterior capsular bag
Hydrodissection - saline solution injected between the capsule and cortex to allow rotation
Phacoemulsification - cataract broken with direct contact of the ultrasound tip on the nucleus and fragments asperitated
IOL insertion - Fill bag with viscoelastic gel and inject IOL
Remove viscoelastic gel
Inject intracameral cefuroxime - another important step in preventing endophthalmitis
The femtosecond laser is an automated method of creating reproducible incisions
The ultrasound tip is called the phaco tip and it vibrates at 30-60kHz
Extracapsular cataract extraction (ECCE) is a manual operative method which has been superceded by phacoemulsification. It requires a larger incision, resulting in longer recovery and higher risk for complications.
ECCE may still be used if the cataract is extremely hard and the surgeon is unable to break it with ultrasound.
101
IOL
biometry is conducted to decide which type of lens implantation is best for the patient
IOLmaster
Measurements include the axial length, corneal curvature and anterior chamber depth
crystalline lens, which is the one you’re born with
102
risks of cataract surgery
0.1% risk of sight threatening complications such as endophthalmitis, retinal detachment and choroidal haemorrhage
The commonest intra-op complication is posterior capsular rupture with vitreous loss - 4% risk
The commonest post-op complications is posterior capsular opacification, 10% risk in 2 years
103
angioid streaks ?
sections of the bruch's membrane of the choroid that are calcified and broken -->can lead to choroidal neovascularization which is most often the cause of visual loss in these patients
104
commonest cause of angioid streaks
most common association is pseudoxanthoma elasticum where patients present with yellow papules and wrinkling of skin folds around the neck, armpits and groin : ‘plucked chicken appearance'
PEPSI: Pseudoxanthoma Elasticum, Pagets, Sickle cell, Idiopathic
105
topic vs spherical lenses
Spherical
Used to correct ametropia and presbyopia
-ve D lenses are concave and diverge light → correct myopia
A myopic patient
+ve D lenses are convex and converge light → correct hyperopia and presbyopia
E.g : A hyperopic patient would like spectacles to allow reading at 20cm. What power should the lenses be?
The lens has to have a focal point which matches the far point
The far point in this case is 20cm, so a lens with a focal length of 20cm is needed
Power=1/focal length(m)
P=1/0.2 = 5
Answer = +5D
Toric
Used to correct astigmatism
Is composed of a sphere and cylinder
The sphere acts in all meridians
The cylinder only acts in a specific meridian, this allows it to treat astigmatism.
106
which condition shows dendritic ulcer on fluorescein eye stain?
herpes simplex keratitis
107
what is the presentation and what is seen on funduscopy fro central retinal vein occlusion?
CRVO
CRVO - painless sudden loss of vision, RAPD
severe retinal haemorrhages on fundoscopy
RF for CRVO
- age
- glaucoma
- polycythaemia
108
what is presentation and what is seen on funduscopy for central retinal artery occlusion
CRAO
CRAO - sudden, painless, RAPD.
cherry red spot in macula
pale, thin retina
atheromatous plaques
109
squint / strabismus divided into what two categories
1. concomitant (common)
- imbalance in EOM
- convergent (entropia) more common than divergent (exotropia)
2. paralytic (rare)
- paralysis of EOM
110
what are the risk factors of glaucoma?
```
increasing age
genetics
afro-caribbean
asian
myopia
HTN
DM
Steriods
```
111
what are the symptoms of POAG
- peripheral visual field loss - nasal scotomas progressing to 'tunnel vision'
- decreased visual acuity
- optic disc cupping >0.7
112
fundoscopy signs of POAG
1. Optic disc cupping - cup-to-disc ratio >0.7 (normal = 0.4-0.7), occurs as loss of disc substance makes optic cup widen and deepen
2. Optic disc pallor - indicating optic atrophy
3. Bayonetting of vessels - vessels have breaks as they disappear into the deep cup and re-appear at the base
4. Additional features - Cup notching (usually inferior where vessels enter disc), Disc haemorrhages
113
how does anterior uveitis present
```
acute painful red eye
photophobia
small pupil
reduced visual acuity
often hypopyon - pus (white cells and debris) in anterior chamber
```
114
mx of anterior uveitis
steroids and cycloplegic (pupil dilation) e.g. atropine cyclopentolate
115
scleritis sx
inflammation of sclera
associated with rheumatology systemic disease (RA, SLE, AS)
Painful eye movement
Eye pain which is 'boring' and 'aching'
Deep pink colour to the eye
Visual acuity is usually preserved until very late
Steriods
116
episcleritis
inflammation of episclera
```
no pain
bright red - dilated vessels
gritty eye sensation
systemic condition
resolve on its own
```
117
hypertensive retinopathy Keith-Wagener classification
```
I Arteriolar narrowing and tortuosity
Increased light reflex - silver wiring
II Arteriovenous nipping
III Cotton-wool exudates
Flame and blot haemorrhages
IV Papilloedema
```
118
what is age-related macular degeneration
degeneration of retinal photoreceptors
119
risk factors of ARMD
smoking, age, FHx, CVD, HTN, DM
120
what are the 2 forms of ARMD
- dry macular degeneration
90% of cases
also known as atrophic
characterised by drusen - yellow round spots in Bruch's membrane
- wet macular degeneration
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
121
sx of ARMD
| signs ?
reduced visual acuity
difficult night adaptation
visual disturbance
photopsia (flashes, floaters)
signs - distortion of line perception amsler grid
fundoscopy - drusen, red patches of leakage or haemorrhage in wet
Tx
dry - zinc, anti-oxidant vitamins A C E
wet - anti-VEGF
122
what factors predispose to acute angle closure glaucoma?
hyperopia (small eyes, long sightedness)
pupillary dilatation
lens growth with age
123
features of acute angle closure glaucoma?
Features
severe pain: may be ocular or headache
decreased visual acuity
symptoms worse with mydriasis (e.g. watching TV in a dark room)
hard, red-eye
haloes around lights
semi-dilated non-reacting pupil
corneal oedema results in dull or hazy cornea
systemic upset may be seen, such as nausea and vomiting and even abdominal pain
124
mx of acute angle closure glaucoma
1. 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)
2. a beta-blocker (e.g. timolol, decreases aqueous humour production)
3. an alpha-2 agonist (e.g. apraclonidine, dual mechanism, decreasing aqueous humour production and increasing uveoscleral outflow)
4. intravenous acetazolamide
reduces aqueous secretions
Definitive management
laser peripheral iridotomy
creates a tiny hole in the peripheral iris → aqueous humour flowing to the angle
125
Red eye - glaucoma or uveitis?
glaucoma: severe pain, haloes, 'semi-dilated' pupil, hazy cornea
uveitis: pain, blurred vision and photophobia, small fixed oval pupil, ciliary flush,
126
optic neuritis causes ?
MS
Dm
syphilis
127
features of optic neuritis
unilateral decrease in visual acuity over hours or days
poor discrimination of colours, 'red desaturation'
pain worse on eye movement
relative afferent pupillary defect
central scotoma
128
MX
MRI for MS
high-dose steroids
recovery usually takes 4-6 weeks
129
Papilloedema
optic disc swelling that is caused by increased intracranial pressure.
130
causes of Papilloedema
```
space-occupying lesion: neoplastic, vascular
malignant hypertension
idiopathic intracranial hypertension
hydrocephalus
hypercapnia
```
131
pathophysiology of cotton wool spots
pre-capillary arteriolar occlusion, leading to retinal infarction.
132
Differentiate posterior vitreous detachment, retinal detachment and vitreous haemorrhage ?
PVD - Flashes of light (photopsia) - in the peripheral field of vision
Floaters, often on the temporal side of the central vision
RD
Dense shadow that starts peripherally progresses towards the central vision
A veil or curtain over the field of vision
Straight lines appear curved
Central visual loss
VH
Large bleeds cause sudden visual loss
Moderate bleeds may be described as numerous dark spots
Small bleeds may cause floaters
133
cataracts presentation ?
reduced vision, faded colours, glare and halos. Fundoscopy shows normal fundus and optic nerve
134
signs of wet macular degeneration
reduction in visual acuity, particularly for near field objects, worse at night and red patches representing intra-retinal or sub-retinal fluid leakage or haemorrhage visible on fundoscopy
135
character of wet MD
choroidal vascularisation and subsequent leakage - exudative
136
differential sign/sx of vitreous haemorrhage?
red hue, dark spots in vision
137
myopia and hyperopia are risk factors of what conditions
myopia - large eye (shortsighted) - open angel glaucoma
hyperopia - small eyes (long sighted) - angle closure glaucoma
138
what is posterior vitreous detachment?
PVD - vitreous shrinks and pulls away from the retina. About 10% of patients with PVD develop a retinal tear, which is an important risk factor for a retinal detachment
139
features of thyroid eye disease
not acute
| lid retraction, exophthalmos, lid lag, and ophthalmoplegia.
140
what is Keratoconjunctivitis sicca and sx?
dry eye
gritty painful eye sensation
conjunctival redness
141
differentiate orbital from preorbital (preseptal) cellulitis?
preorbital - infection of soft tissues anterior to orbital septum eg eyelids. common in children in winter due to respiratory tract infections so associated with fever.
orbital - infection of soft tissue behind orbital septum - more serious
142
features of orbital and preorbital cellulitis?
preorbital =
erythema
oedema of the eyelids, which can spread onto the surrounding skin
Partial or complete ptosis of the eye due to swelling
absence of orbital signs
orbital cellulitis signs
- pain on movement of the eye -restriction of eye movements, -proptosis
- visual disturbance
- chemosis
- RAPD
143
inx for orbital and preorbital cellulitis?
Mx ?
Bloods - raised inflammatory markers
Swab of any discharge present
Contrast CT of the orbit may help to differentiate between preseptal and orbital cellulitis. It should be performed in all patients suspected to have orbital cellulitis
Mx - co-amoxiclav
144
optic neuritis features?
MX
```
unilateral decrease in visual acuity
poor discrimination if colours
pain worse of eye movement
RAPD
central scotoma
```
high dose steroids
145
what is Argyll-Robertson pupil ?
pupillary syndrome seen in DM and syphilis.
Argyll-Robertson puil (ARP) is Accommodation reflex present
pupillary reflect absent.
small pupils
146
what Inx should be done if you're suspecting orbital cellulitis in someone with ocular signs eg proptosis and limited eye movement?
constrast enhanced CT scan of orbit, sinus and brain.
147
pupil defects
adie - PNS damage, eye dilated
Marcus gunn - RAPD
horners - meiosis
argyll-robertson - bilateral small pupils , accommodation no light reflex
Hutchinsons - unilateral dilation, compression of occulomotor
148
age related macular degeneration vs POAG visual loss
ARMD - Macular degeneration is associated with central field loss
POAG - peripheral visual field loss defect
149
Mx of Acute angle closure glaucoma
direct parasympathomimetic (pilocarpine) and beta blocker
alpha 2 adrenoreceptor against - dual mechanism - decreasing aqueous humour production and increasing uveoscleral outflow
IV acetazolamide - carbonic anhydrase inhibitor
definitive - laser iridotomy
150
cause of stye?
staphylococcus
151
what is a chalazion
meibomian cyst
152
internal and external hordeolum (stye) ?
external infection of Zeis or moll (sweat) (apocrine)
internal infection of meibomian glands (eccorine)
153
keratitis?
inflammation of the cornea. Microbial keratitis is potentially sight threatening and should therefore be urgently evaluated and treated.
154
causes of keratitis
- bacterial
typically Staphylococcus aureus
Pseudomonas aeruginosa is seen in contact lens wearers
- fungal
- amoebic
acanthamoebic keratitis
accounts for around 5% of cases
increased incidence if eye exposure to soil or contaminated fresh water (with contact lenses)
- parasitic: onchocercal keratitis ('river blindness')
155
mx and complications of keratitis?
stop using contact lens until the symptoms have fully resolved
topical antibiotics
typically quinolones are used first-line
cycloplegic (paralysis of ciliary muscle) for pain relief
e.g. cyclopentolate
```
Complications may include:
corneal scarring
perforation
endophthalmitis
visual loss
```
156
anterior uveitis presentation
acute onset
ocular discomfort & pain (may increase with use)
pupil may be small +/- irregular due to sphincter muscle contraction
photophobia (often intense)
blurred vision
red eye
lacrimation
ciliary flush: a ring of red spreading outwards
hypopyon; describes pus and inflammatory cells in the anterior chamber, often resulting in a visible fluid level
visual acuity initially normal → impaired
157
anterior uveitis associated conditions
```
ankylosing spondylitis
reactive arthritis
ulcerative colitis, Crohn's disease
Behcet's disease
sarcoidosis: bilateral disease may be seen
```
158
Anterior uveitis mx
urgent review by ophthalmology
cycloplegics (dilates the pupil which helps to relieve pain and photophobia) e.g. Atropine, cyclopentolate
steroid eye drops
159
differentiate bacterial and viral conjunctivitis
Bacterial conjunctivitis Purulent discharge
Eyes may be 'stuck together' in the morning)
Viral conjunctivitis
Serous discharge
Recent URTI
Preauricular lymph nodes
160
mx of infective conjunctivitis
normally a self-limiting 1-2 weeks
topical antibiotic therapy is commonly offered to patients, e.g. Chloramphenicol. Chloramphenicol drops are given 2-3 hourly initially where as chloramphenicol ointment is given qds initially
topical fusidic acid is an alternative and should be used for pregnant women. Treatment is twice daily
contact lens should not be worn
advice should be given not to share towels
school exclusion is not necessary
161
cause of dendritic corneal ulcer
herpes simplex keratitis
| Tx - topical acyclovir
162
stye? and types
infection of eyelid glands
hordeolum externum
hordeolum internum
163
what is hordeolum externum ?
infection (usually staphylococcal) of Zeis (sebum producing) or Moll (sweat) glands
164
what is hordeolum internum?
infection of Meibomian glands. May leave a residual chalazion (Meibomian cyst).
165
mx of eyelid infection / stye
warm compress, hygiene and, analgesia
166
Acute angle closure causes
hypermyopia
pupil dialtion - mydriatic drugs
lens growth in age
167
Acute angle closure sx
severe pain: may be ocular or headache
decreased visual acuity
symptoms worse with mydriasis (e.g. watching TV in a dark room)
hard, red-eye
haloes around lights
semi-dilated non-reacting pupil
corneal oedema results in dull or hazy cornea
nausea and vomiting and even abdominal pain
168
Acute angle closure mx
combination of eye drops =
1. direct parasympathomimetic (pilocarpine) pupil constriction and increase flow
2. beta blocker timolol - decrease production
3. alpha-2 agonist apraclonidine - dual mechanism
- IV acetazolamide (carbonic anhydrase inhibitor) reduce AH secretion
definitive = laser peripheral iridotomy
169
blepharitis
inflammation of eyelid margin
posterior - meibomian gland dysfunction
anterior - seborrhoeic dermatitis /staphylococcal infection, acne rosacea
170
sx of blepharitis
| mx
```
bilateral
grittiness, dryness, irritation
sticky in morning
eyelid margins red
styes and chalazions
secondary conjunctivitis
```
mx
hot compress
lid hygiene
artificial tears
171
posterior uveitis
loss of vision
| floaters
172
in which condition cause injected vessels to move on light pressure ?
episcleritis = painless red eye, mobile injected blood vessels
scleritis - vessels are deeper hence not mobile
phenylephrine = differentiate scleritis from episcleritis = if redness improves with phenylephrine ==> episcleritis
173
POAG - optic neuropathy
glaucomatous damage of optic nerve
- optic disc cupping - optic disc ration = >0.7
- optic disc pallor
- optic cup notching and disc haemorrhages
- bayonetting of blood vessels
174
herpes zoster ophthalmicus
features
mx
complications
ophthalmic nerve involvement
vesicular rash around eye
Hutchinson's sign - rash on tip or side of nose = nasocillary involvement = strong risk for ocular involvement
mx - oral acyclovir
steroids = inflammation of eye
complications
ocular - conjunctivitis, episcleritis, keratitis, anterior uveitis
ptosis
post-herpetic neuralgia
175
optic neuritis
ms \dm \syphilis
unilateral decrease in visual acuity over hours or days
poor discrimination of colours, 'red desaturation'
pain worse on eye movement
relative afferent pupillary defect
central scotoma
176
lens properties
Biconvex, avascular, non-innervated
10mm by 4mm
Relationships
3 layers– capsule, cortex, nucleus
3 parts - capsule, lens epithelium, lens fibres
Connected to the ciliary processes by zonules
177
embryology of lens
from lens placode on ectoderm at day 27
178
lens physiology
```
High protein content - α- (epithelium), β- and Ƴ-crystallins (fibres)
5% lipid content
Nutrition from anaerobic respiration
High concentration of K and Glutathione
Refractive index 1.41
```
179
lens function
ACCOMODATION
REFRACTION – 15-120D
MAINTENANCE OF TRANSPARENCY
BLOCK UV LIGHT
180
types of cataracts
age related
traumatic
systemic disease
secondary
181
age related cataracts and types
nuclear sclerotic - Thickening and cloudiness of the nucleus. Exaggerated ageing process. Initial symptom is myopia
cortical - Swelling/hydration of any part of the cortex causing spoke/wedge-like peripheral cloudiness.
posterior sub capsular - Opacity in the posterior capsule of the lens, often seen in younger individuals, steroid users, and diabetics. These are usually the most visually significant. Due to swollen migratory epithelial cells
182
cataracts in systemic disease
DIABETES MELLITUS – glycosylation of lens proteins causes overhydration
MYOTONIC DYSTROPHY – B/L iridiscent opacities
ATOPIC DERMATITIS – B/L anterior subcapsular plaques
NF2 – early cataracts
183
secondary cataracts (to primary ocular conditions)
Chronic AU
AAC - Glaucomflecken
Secondary to Steroids (PSC)
184
traumatic cataracts
Unilateral, presents in young patients with history of previous ocular trauma
Stellate/flower shaped cataract
185
surgery for cataracts
extracapsualr cataract extraction and
Large anterior capsulotomy performed, incision at the limbus. The nucleus is then expressed following hydrodissection with aspiration of cortical contents. An IOL is introduced and the incision is then sutured.
phacoemulification (most commonly performed)
gaining access corneal incisions
capsulorhexis - scrape anterior capsule membrane
hydrodissection
removal of lens material by phacoemulification
insertion of IOL
186
complications of cataract surgery
posterior capsule puncture
suprachoroidal haemorrhage
posterior loss of lens material
187
post op complications
Endophthalmitis
- 1-2 weeks. Symptoms include redness, pain and worsening vision. Signs include hypopyon, fibrin, red eye and vitreous inflammation.Source of infection is usually the patient’s eyelid flora. Treatment is with intravitreal antibiotics.
AU
- inflammation of the anterior uvea (iris and ciliary body). Patients present with pain, redness, photopobia and blurry vision.
Signs include AC cells.
Treatment is with steroids and cylcloplegic agents.
Cystoid macular oedema
- accumulation of fluid in the retina in a cystic pattern.
Risk factors include:
Surgical complications, previous retinal diseases, diabetes, uveitis and use of prostaglandins drops.
Treatment options include topical NSAIDs, steroids or carbonic anhydrase inhibitors.
Posterior capsular opacification
- Most common late complication. Occurs due to proliferation of retained lens epithelial cells in capsular bag. Patients present with symptoms similar to a cataract. Typically occurs years post surgery. Treatment is with an Nd:Yag laser capsulotomy.
188
what is gradengio syndrome
6th nerve palsy secondary to mastoiditis (ottis media)
adducted eye, diplopia, periorbital pain, persistent otorrhea.
189
treatment of acute uveitis
topical steroids
| mydriatics - cyclopentolate = reduces pain and breaks posterior synechiae
190
90% of acute anterior uveitis
HLA B27
Seronegative Spondyloarthropathies
• Ankylosing Spondylitis (25%)
• Reactive arthritis / Reiter syndrome (50-75%) • Psoriatic arthritis (7%)
Inflammatory Bowel Disease
• Ulcerative Colitis (5%) • Crohns Disease ( 3%)
191
fuch's uveitis
unilateral in 90-95%
gradual blurring due to cataracts, floaters
signs - heterochromia, white eyes, stellate KP, iris nodules - koeppe pupillary border and busacca stroma
192
Birdshot Chorioretinopathy
MiddleagedwomenofNorthEuropeandescent
• StrongassociatedwithHLA-A29
• Potentially an autoimmune reaction to retinal antigen S
Blurry vision, nyctalopia (night blindness) , floaters and disturbance of colour vision
• ‘Birdshot’ lesions:
• Cream oval shaped lesions at the level of choroid and RPE • Optic disc = periphery along underlying choroidal vessels
Other features:
• Retinal vasculitis
• Cystoid macular oedema • Optic disc inflammation
193
behcet's
Chronic and relapsing systemic vasculitis
HLA-B51
Non-ocular features
• Recurrent oral, urogenital ulcers and skin lesions
Ocular features
• Non-granulomatous necrotising obliterative vasculitis - panuveitis
Anterior segment:
• Mobile hypopyon seen in 25%
Posterior segment:
• Retinal vasculitis retinal ischaemia
retinal and iris neovascularisation
• Vasculitis of larger vessels = BRVO and BRAO
• Vitritis and CMO
• Optic neuritis = optic atrophy
194
what is bulls eye maculopathy and drug associated with it
depigmented zone of RPE around macular - atrophy
| drugs eg hydroxychloroquine
195
drug associated with salt and pepper pigmentary disturbance
chlorpromazine - antipsychotic
| corneal oedema also
196
tamoxifen causes ?
crystalline maculopathy
| bilateral fine yellow deposits in retina
197
Vogt-Koyanagi-Harada syndrome
Chronic bilateral diffuse granulomatous panuveitis:
• Unknown aetiology ?autoimmune reaction to melanocyte
• Associated with HLA-DR4 and HLA-DR1
igmented ethnic groups >> Caucasians
• Particularly common in Japan (8% of all uveitis)
198
signs of Vogt koyanagi harada
Severe (anterior) uveitis, alopecia, poliosis (white eyelashes) , cutaneous as well as perilimbal vitiligo (at sclera), panuveitis
Cns meningism NV
auditory - tinnitus and sensorineural hearing loss
199
Onchocerciasis (River blindness)
Caused by Onchocerca volvulus (parasitic worm)
• Vector = Simulium blackfly
• Fly bite > onchocercoma formed in subcut tissue > intense inflammatory reaction
• Maculopapular rash (onchodermatitis)
• Hypo- hyper-pigmentation on shins (leopard skin)
• Non-tender subcutaneous nodules (onchocercomata)
• Live microfilariae seen in the cornea/anterior chamber
• Ocular: anterior uveitis, keratitis, chorioretinitis, optic neuritis
• Mx: Ivermectin (Moxdectin) + prednisolone
200
toxoplasma retinitis signs
headlight in the fog - focal white retinitis + severe vitritis, pigmented retinal scar, diffuse venous sheathing, arteriolar sheathing = kyrielieis arteriolitis
blurry hazy vision floaters
201
toxoplasma retinitis tx
corticosteroids + sulfadiazine, pyrimethamine.
202
Sympathetic Ophthalmia
Bilateral granulomatous non-necrotising panuveitis
Trauma to one (exciting) eye --> latent period = bilateral uveitis
Penetrating eye injuries and intra-ocular surgery
• Delayed hypersensitivity reaction to melanin-containing structures of photoreceptors
• Association with HLA-DR4
Clinical features
• Irritation, blurry vision, photophobia, loss of accommodation
Prevention and treatment
• Enucleation or evisceration within 2 weeks of injury • Immunosuppression
203
fundal features of sympathetic ophthalmia
dulled fuchs nodules
multifocal choroiditis
exudative retinal detachment
204
thyroid eye disease and its stages
Inferior rectus most commonly affected followed by medial, superior, levator and lateral rectus. (Anti-clockwise!)
Congestive (inflammatory) stage - eyes rede painful
fibrotic quiescent stage - eyes white, motility defect?
205
what is the most common cause of bilateral and unilateral proptosis in an adult
thyroid eye disease
