ENT and Ophthalmology Flashcards
Definition of BPPV
Inner ear disorder characterised by recurrent brief attacks of positional vertigo
What triggers vertigo episodes in BPPV?
Positional - change in had position
What is the average length of a vertigo period in BPPV?
10-20 seconds
What is a positive Dix-Hallpike manoeuvre?
patient experiences vertigo
rotatory nystagmus
What provides symptomatic relief for BPPV?
Epley manoeuvre
What is Meniere’s diseae?
Disorder of the inner ear caused by a change in fluid volume in the labyrinth causing tinnitus and vertigo
Endolymphatic hydrops (Excess fluid in the inner ear) due to impaired endolymph resorption
What are the aetiological agents of Meniere’s disase?
Allergy Viral infection Syphillis Lyme disease Hypothyroidism
What are the features associated with Meniere’s disease?
Recurrent episodes of vertigo,
Tinnitus and hearing loss (sensorineural).
Vertigo
Aural fullness
What is vertigo length for Meniere’s disease?
Minutes to hours
What are the key signs for Meniere’s? (Two clinical tests)
Fukuda’s stepping test - turning towards the affected ear side
Romberg’s test
What are the investigations for Meniere’s diseae?
Audiometry - Presence of Sensorineural hearing loss
What is the management for acute vertigo attacks in Meniere’s diseae?
Vestibular suppressant drugs - Benzodiazepines, antihistamines
Recurrence prevention
-Limit salt, caffeine and alcohol consumption, smoking cessation and manage stress
What is the maintenance therapy for Meniere’s disease?
Diuretics
What is a thyroglossal cyst?
An epithelial lined cyst between Adam’s apple and chin
Median age 5 years
What are the main symptoms of a thyroglossal cyst?
Lump on the midline of the neck
Compressive
Moves upwards when tongue is protruded after swallowing
What is the management of a thyroglossal cyst?
Elective surgical excision
What is the definition of cataracts?
Opacification of the lens resulting in a gradual loss of visual acuity
What is the aetiology of cataracts?
The normal proteins that make up the lens of the eye degrade overtime and become opaque
What are the symptoms of cataracts?
Reduced vision
Faded colour vision: making it more difficult to distinguish different colours
Glare: lights appear brighter than usual
Halos around lights
What clinical sign is observed in cataracts?
A Defect in the red reflex: the red reflex is essentially the reddish-orange reflection seen through an ophthalmoscope when a light is shone on the retina. Cataracts will prevent light from getting to the retina, hence you see a defect in the red reflex.
What are the investigations for cataracts?
Slit-lamp examination - Reveals cataracts as black against a red reflex
loss of visual acuity - Snellen’s eye chart
Reduced red reflex on fundoscopy
Normal pupillary response
What is the definitive management for cataracts?
Phacoemulsification with an intraocular lens implant
What type of discharge is associated with bacterial conjunctivitis?
Purulent discharge
Eyes may be ‘stuck together’ in the morning
What type of discharge is associated with viral conjunctivitis?
Serous discharge
What is the most common cause of viral conjunctivitis?
EBV, herpes and adenoviru s
What are the most common causes of bacterial conjunctivitis?
Staphylococcus aureus
Streptococcus pneumoniae
Haemophilus influenzae
What is the management of infective conjunctivitis?
Chloramphenicol drops
Topical fusidic acid
What are the general symptoms associated with conjuncivitis?
Eye redness
Discharge
Itchiness
Crusty formation
What type of discharge is associated with allergic conjunctivitis?
Clear, watery discharge
What is the difference in terms of eye involvement for conjunctivitis (Infective v allergic)?
Viral - unilateral progressing to bilateral
Bacterial - Unilateral
Allergic - Bilateral
What is the conjunctival appearance in viral conjunctivitis?
Small swollen papules in the palpebral surface
What is the management for viral conjunctivitis?
Self-limiting
Anti-histamine drops
Topical antivirals (Acyclovir - if HSV is cause)
Management for allergic conjunctivitis?
Cold compress
Allergen avoidance
Anti-histamine drops
What is glaucoma?
Increased intraocular pressure which results in damage to the retina and optic nerve
What is open-angle glaucoma?
In primary open-angle glaucoma (POAG), the iris is clear of the meshwork. The trabecular network functionally offers an increased resistance to aqueous outflow, causing increased IOP.
What are the risk factors for open-angle glaucoma?
> 40/year old
Diabetes mellitus
FHx
African descent
What are the symptoms for open-angle glaucoma?
Bilateral progressive (chronic) visual field loss.
Peripheral to central
Nasal scotomas progressing to ‘tunnel vision’
decreased visual acuity
optic disc cupping
What investigations are indicated in glaucoma?
Tonometry - measures intraocular pressure
Fundoscopy (Gold-standard) - Increased in cupping of the optic disc.
What are the fundoscopy signs in open-angle glaucoma?
- 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
- Optic disc pallor - indicating optic atrophy
- Bayonetting of vessels - vessels have breaks as they disappear into the deep cup and re-appear at the base
- Additional features - Cup notching (usually inferior where vessels enter disc), Disc haemorrhages
What is the distinctive feature of open-angle glaucoma?
Pathological cupping of the optic disc
What is the management for open-angle glaucoma?
first line: prostaglandin analogue (PGA) eyedrop
second line: beta-blocker, carbonic anhydrase inhibitor, or sympathomimetic eyedrop
if more advanced: surgery or laser treatment can be tried2
What is the mechanism of action for prostaglandins analogues in open-angle glaucoma?
Increases uveoscleral outflow
How do beta-blockers work in the management of open-angle glaucoma?
Reduces aqueous production
What are the features of acute angle (closed) glaucoma?
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
What is the aetiology of acute angle glaucoma?
Narrowing of the iridocorneal angle preventing aqueous flowing correctly into the trabecular meshwork
What are the two main risk factors for acute angle glaucoma?
Old age
Mydriasis (Drug-induced - atropine - anti-cholinergic)
What investigations are performed in acute angle glaucoma?
Tonometry -Raised IOP
Slit-lamp - narrowing/closure of the iridocorneal angle
Gonioscopy - Gold standard
What does fundoscopy reveal in acute angle glaucoma?
Increased cupping
Dilated pupil
Examples of prostaglandin analogues used in open-angle glaucoma
Latanoprost
Travoprost
-Increases aqueous humour outflow
What is the surgical management for open angle glaucoma?
Laser/surgical trabeculectomy
What is the first-line management for closed-angle (acute) glaucoma?
Emergency - need to lower IOP - referral to ophthalmologist
Topical beta-blockers (Timolol) - decreases aqueous production
Carbonic anhydrase inhibitors - decreases aqueous production
What is the definitive management for acute angle glaucoma?
laser peripheral iridotomy
creates a tiny hole in the peripheral iris → aqueous humour flowing to the angle
What is anterior uveitis?
Anterior uveitis is one of the important differentials of a red eye. It is also referred to as iritis. Anterior uveitis describes inflammation of the anterior portion of the uvea - iris and ciliary body.
Which part of the eye is inflamed in anterior uveitis?
Iris
Ciliary body
What is anterior uveitis is associated with?
HLA-B27 associated conditions - ankylosing spondylitis, SLE, reactive arthritis
What is the presentation of anterior uveitis?
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
(Flares and pan)
What structures are affected in posterior uveitis?
Retina
Choroid
Retinal vasculature
Optic nerve
What is the main cause of posterior uveitis?
Infections - Viruses - EBV, rubella, syphilis, TB
A slit-lamp examination in anterior uveitis reveals what?
Keratic precipitates - leukocytes in the anterior chamber
Protein in the aqueous humour
Red eye and hypopyon (Inflammatory cells in the anterior chamber in the eye)
Keratic precipitates are associated with what condition?
Anterior uveitis
What are the symptoms of posterior uveitiis?
Painless - Key
Decreased visual acuity
Lacrimation
Floaters/flashes - marks found on vision
What is revealed on examination on a slit-lamp in posterior uveitis?
Leukocytes in the vitreous humour
Inflammation of choroid and retina
What are the complications of uveitis?
Cataracts
Glaucoma
Syenchiae
What is the management of uveitis?
Corticosteroid drops
-Use systemic/oral steroids
Cycloplegic eye drops - relieves pain caused by the spasm of muscles
What are the 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
What is the aetiology of optic neuritis?
Inflammatory demyelination of the optic nerve
What is the main cause of optic neuritis?
Multiple sclerosis - presenting manifestation of MS
What drugs can cause optic neuritis?
Quinine
Arsenic
Ethambutol -TB medication
What is the gold-standard investigation for optic neuritis?
Gadolinium-enhanced MRI of the orbit and brain
- Enlarged optic nerve
- Diagnose multiple sclerosis
What is the management of optic neuritis?
High dose corticosteroids
Define scleritis
Inflammation of the sclera
What is the aetiology of scleritis?
Underlying systemic disorder in 60% of cases
- Rheumatoid arthritis
- SLE
- IBD
- Ankylosing spondylitis
What are the symptoms of scleritis?
Dull eye pain
Sleep disturbances
Pain exacerbated by eye movements
Pain radiates to the rest of the face
Lacrimation
Photophobia
Eye redness
Over several days
What is the key difference between scleritis and episcleritis?
Episcleritis is painless
What is the management for scleritis?
Urgent referral
NSAIDs
High-dose corticosteroids
