Eye Flashcards
1
Q
What are the signs of raised ICP?
A
Early morning headache Postural (worse with rising) Worse with coughing/sneezing N and V Visual obscurations
2
Q
What are the causes of photophobia?
A
Meningitis Migraine Uveitis Orbital cellulitis Acute angle glaucoma Raised ICP Corneal ulcer (surface of the eye and therefore cause photophobia) Scleritis
3
Q
What headaches may present at an eye clinic?
A
Migraine
Cluster headaches
Raised ICP
Giant cell arteritis
4
Q
What are the reasons for lid irritation?
A
Stye
5
Q
What is the difference between stye and cholazian?
A
Stye= blocked hair follicle Cholazian= mabomian gland is blocked
Stye is closer to the eyelashes whereas cholasian is found on the lid
6
Q
What is the treatment of stye?
A
Fusidic acid
7
Q
What irt if isual disturbance can you get?
A
Generalized blurring Central blurring Black spots, blob, curtain Photopsia Double vision- monocular or binocular Vertical or horizontal Colour changes
8
Q
What are the causes of blurred vision?
A
Dry eyes Cataracts Refractive errors Side effects of drugs (steroids) Pregnant women
9
Q
What is the cause of central blurred vision?
A
Macular degeneration
Diabetic maculopathy
SEs of drugs- tamoxifen (reversible)
FHx- inherited problems that affect the macula
10
Q
What diseases would cause you to see black spots, blob or curtain?
A
TIA will describe curtain (often transient and will go away)
Migraine with aura
Shortsighted people at a younger age
You need to ask whether the curtain moves- if it doesn’t it is a problem with the retina (retina is a fixed structure) so could be detached retina
Flashing lights should ring alarm bells
11
Q
What would photopsia, black sports and curtain that doesnt move be associated with?
A
Detached retina
12
Q
What may be the cause of photopsia?
A
Migraine with aura
13
Q
What is monocular vs binocular double vision?
A
Monocular= pathology within the eye
Seeing double with one eye closed
The problem is within the eye
Binocular= normally neurological causes of double vision
Think of nerve (cranial nerve palsies), neuromusclar junction (myasthenia gravis), muscle (thyroid eye disease- the first thing to think about in an exam)
14
Q
What pathology gives patients a double vision?
A
Vertical double vision- trochlear, superior oblique
Nystagmus
3rd nerve palsies (superior and inferior rectus, inferior oblique) can be partial or full
Thyroid eye disease
Mitochondrial disease
15
Q
What would cause vertical vs horizontal visual disturbance
A
Joko
16
Q
What are the causes of colour changes in the eye?
A
Macular dystrophy (inherited)- bottom of the list
Any optic nerve neuropathy
(Ethambutol, Isoniazid
Trauma)
Cataracts (relative reduction in colour)
17
Q
What are the medical conditions which cause eye problems?
A
Diabetes- retinopathy, cranial nerve palsies, infection, vascular occlusion
Hypertension- hypertensive retinopathy (rare), crnial nerve lalsies, vascular occlusions, malignant
Thyroid eye disease- lid retraction, eye lid lag, exophthalmos, dry eye, ocular motility restriction, optic neuropathy
Ankylosing spondylitis- anterior uveitis and SEs from treatment ie: oral steroids
Arthritis- RA, reactive arthritis
18
Q
What can Rheumatoid arthritis cause in the eye?
A
Cornea perforation,no pain
19
Q
What is the triad of reactive arthritis?
A
. Urethritis
Uveitis
Arthritis
20
Q
What is the blind spot?
A
Where the optic nerve is
21
Q
What are the vascular complications of diabetes?
A
Macrovascular
Brain- TIA, CVA, dementia
Heart- ACS, CHF
PVD
Microvascular
Eye- retinopathy, glaucoma, cataracts
Renal- micro albuminuria, nephropathy, ESRD
Neuropathy- peripheral, autonomic
22
Q
What is the prevalence of diabetic retinopathy?
A
Risk of blindness in diabetic patients is 5x of non diabetics
Its the mosr common cause of blindness in the working age group population
After 15 years of diabetes (DM 1 is 97% and DM 2 is 78%)
23
Q
What is the pathogenesis of diabetic retinopathy?
A
Triggers are hypertension and hyperglycaemia
This causes biochemical, haemodynamic and endocrine pathways which leads to damage of the retinal capillaries
24
Q
What are the causes of glaucoma?
A
Poor blood supply to the optic nerve head causing optic nerve damage
Or
Trabeculae meshwork becomes blocked and aq humour builds up
This causes damage to the optic nerve, which looks ‘caves in’ and is called ‘cupped’
25
What are the classifications of glaucoma?
Open angle glaucoma (primary and secondary)
Angle closure glaucoma
(Primary or secondary)
Developmental (congenital/reiters)
Secondary (trauma, uveitic, steroid)
26
How is glaucoma treated?
Treatment is to reduce intra ocular pressures (IOPs), even in normal tension Glaucoma
27
What is normal IOP?
Individuals differ, IOP is taken into account with central corneal thickness, when deciding what is ‘normal’ for the individual
Normal is 10 to 22mmHg, mean of 16
28
How is IOP measured?
Goldmann Applanation Tonometry is the Gold stabmdard test
29
What are the glaucoma related eye emergencies?
Acute angle glaucoma
Glaucoma surgery related eye problems
Adverse ocular reaction to glaucoma medication
30
What are the acute congestive glaucoma signs and symptoms?
```
Red, painful eye
Nausea
Ciliary injection
Corneal oedema
Fixed, dilated oval pupil
Shallow anterior chamber
```
31
How do you treat acute glaucoma?
Acetozolamide injection
Tpical therapy: pilocarpine (2%) QDS
Timolol (0.5%)
Laser perioheral iridotomy
32
What is a cataract?
Swelling of a lens
33
What is accommodation?
The ability to focus objects
34
What are the aetiology reasons behind refractive errors?
Most cases
Have average corneal power
Anomalous axial length
Or
Average axial length
Anomalous corneal power
Can be physiological or pathological
35
What are the 3 refractive errors?
Myopia (short sight)
Hypermetropia (long sight)
Astigmatism
36
How does orbital cellulitis present?
Sudden onset unilateral swelling of the eye, accompanied by proptosis and reduced eye movements
There may be pain and other visual changes depending on the severity
37
Who does retinoblastoma usually affect?
Children under 5 years old
38
What is orbital cellulitis?
It is the result of an infection affecting the fat and muscles posterior to the orbital septum, within the orbit but not involving the globe
39
What is the usual cause of orbital cellulitis?
Usually caused by a spreading URTI from the sinuses and carries a high mortality rate.
It is a medical emergency which requires hospital admission and urgent senior review
40
What is periorbital (preseptal) cellulitis?
Less serious superficial infection which is anterior to the ORBITAL SEPTUM, resulting from superficial tissue injry (chalazion, insect bite etc...)
It can progress to orbital cellulitis
41
What are the risk factors for orbital cellulitis?
```
Childhood
Previous sinus infection
Lack of Hib vaccination
Recent eyelid infection/insect bite on eyelid (peri- orbital cellulitis)
Ear or facial infection
```
42
What is the presentation of orbital cellulitis?
```
Redness and swelling around the eye
Severe ocular pain
Visual disturbance
Proptosis
Opthalmoplegia/pain with eye movements
Eyelid oedema and ptosis
Drowsiness +/- Nausea/vomiting in meningeal involvement (Rare)
```
43
How do you differentiate orbital from preseptal cellulitis?
Preseptal cellulitis will not have reduced visual acuity, proptosis, opthalmoplegia/pain with eye movements
44
What investigations are done to look for peri orbital cellulitis?
FBC- WBC elevated, raised inflammatory markers.
Clinical examination involving complete ophthalmological assesment (decreased vision, afferent pupillary defect, proptosis, dysmotility, oedema, erythema)
CT with contrast will show inflammation of the orbital tissues deep to the septum, may show sinusitis
Blood vulture and micfobiological swab to determine organism
45
What are the most common causes of orbital cellulitis?
. Most common bacterial causes – Streptococcus, Staphylococcus aureus, Haemophilus influenzae B.
46
What is the management of orbital cellulitis?
Admission to hospital for IV ABx
47
What can be seen on fundoscopy of macular degeneration?
Drusen can be seen around the macula (degeneration of retinal photoreceptors)
48
What is the most common cause of blindness in the UK?
Age related macular degeneration
49
What are the types of macular degeneration?
Dry (90% of cases, geographic atrophy) macular degeneration characterised by drusen (yellow round spots in Bruch’s membrane)
Wet (10% of cases, exudative, neovascular) macular degeneration
Chatacterised by choroidal neovascularisation
Leakage of serous fluid and blood can subsequently result in rapid loss of vision, carries the worst prognosis.
(Old)
Recently there has been a move to a more updated classification:
early age-related macular degeneration (non-exudative, age-related maculopathy): drusen and alterations to the retinal pigment epithelium (RPE)
late age-related macular degeneration (neovascularisation, exudative)
50
What is an opthalmoscope?
This is what opthalmologists wear on their head to look at the retina
51
What is a TORCH virus?
Toxoplasmosis
Rubella
CMV
52
How do you treat cataracts in children?
Remove if vision is compromised
| However leave if not
53
When do you do a cover test?
Do it to look for euphoria which is a squint which is not always present, they can manifest when you cover one eye
54
What is an entropion?
A condition in which the eyelid, usually the lower one, is turned inward so that your eyelashes rub against your eyeball, causing discomfort
55
What is an ectropion?
Ectropion is when your lower eyelid turns or sags outward, away from your eye, exposing the surface of your inner eyelid. This condition can cause eye dryness, excessive tearing, and irritation. Ectropion may be due to several factors, including facial paralysis and injury.
56
What problems can occur with the eyelid?
blepharitis: inflammation of the eyelid margins typically leading to a red eye
stye: infection of the glands of the eyelids
chalazion (Meibomian cyst)
entropion: in-turning of the eyelids
ectropion: out-turning of the eyelids
57
What is a stye?
Infection of the sebaceous glands of the eyelid
58
What are the different types of stye?
1) external (hordeolum externum): infection (usually staphylococcal) of the glands of Zeis (sebum producing) or glands of Moll (sweat glands).
2) internal (hordeolum internum): infection of the Meibomian glands. May leave a residual chalazion (Meibomian cyst)
59
What is the management of a stye?
management includes hot compresses and analgesia. CKS only recommend topical antibiotics if there is an associated conjunctivitis
60
What is a chalazion?
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
61
A 71-year-old man presents with severe pain around his right eye and vomiting. On examination the right eye is red and decreased visual acuity is noted. Which one of the following options is the most appropriate initial management?
This is the presentation of acute glaucoma and therefore the patient should be immediately sent to hospital
62
What is glaucoma?
Group of disorders which are characterised by optic neuropathy, usually due to raised intra ocular pressure
63
How is there a rise in Intra ocular pressure in terms of acute angle closure glaucoma?
There is a rise in intra ocular pressure secondary to an impairment of aqueous outflow
64
What are the factors that predispose to acute angle closure glaucoma?
hypermetropia (long-sightedness)
pupillary dilatation
lens growth associated with age
65
What is classed as high intraocular pressure?
>21mmHg
66
What is open angle glaucoma?
This is the most common type of glaucoma, the angle between the iris and cornea is open, in this type the drainage system slowly gets clogged over time.
There is a gradual pressure increase which gradually puts pressure on the optic nerve
Initially you get outer rim atrophy resulting in a decrease in peripheral vision, as the pressure increases even more there is continued damage to the optic nerve which eventually leads to central vision loss
67
What is angle closure glaucoma?
The angle between the iris and cornea is too small, meaning the passage for aqueous humour is too narrow and therefore gets blocked again, this time it causes a abrupt onset of symptoms.
68
What are the symptoms you get with angle closure glaucoma?
Blurry vision, eye pain and redness, headaches, nausea, visual halos.
69
What is normal tension glaucoma? (low pressure)
This is when the intra ocular pressure is not raised
It is thought that the optic neuropathy is damaged by hypoperfusion (low blood flow) or genetic hypersensitivity to normal ocular pressures.
70
How do you diagnose glaucoma?
Tonometry can be done to assess for raised intra ocular pressure
Visual field testing
look for optic nerve damage (either through imaging or direct observation)
71
What does pressure on the optic nerve eventually lead to?
Leads to thinning of the outer rim of the nerve
| which starts to give it this cup shape (cupping)
72
Can glaucoma be cured?
It cannot be cured however it can be slowed with treatment
If the problem is intra ocular hypertension then it can be managed by taking medications to decrease the pressure in the eye
73
What medications can be used to decrease the pressure in the eye?
Decrease production of aqueous humour
beta adrenergic receptor antagonists
carbonic anhydrase inhibitors
Increase outflow of aqueous humour
prostaglandin analogues
Decrease production and increase outflow
Alpha adrenergic agonists
Surgical treatment-
Trabeculoplasty-
(where a laser is used to open the trabeculae meshwork, this is used to treat open angle glaucoma).
Iridotomy-
This is used to punch a hole in the iris and is used to treated closed angle glaucoma
There are also other laser treatments, which can be used to destroy humour producing cells as well as creating a new channel where aqueous fluid can be drained out.
There are also implants which shunt fluid out of the anterior chamber, bypasses the meshwork and collecting system.
74
What is the management of acute angle closure glaucoma specifically?
The management of AACG is an emergency and should prompt urgent referral to an ophthalmologist. Emergency medical treatment is required to lower the IOP with more definitive surgical treatment given once the acute attack has settled.
There are no guidelines for the initial medical treatment emergency treatment. An example regime would be:
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
75
What is the uvea and how does uveitis present?
The uvea is made up of the ciliary body, choroid and the iris.
Uveitis presents with an oval, small, fixed pupil with a ciliary flush, as well as pain, blurred vision and photophobia.
76
How does scleritis present?
Severe pain (worse on movement)
Red eye
Tenderness
Patient tend to have underlying auto-immune disease eg: Rheumatoid arthritis
77
How does conjunctivitis present?
Red eye
Patients report their eye feeling 'gritty'
Purulent discharge if bacterial
Clear discharge if viral
78
How does subconjunctival haemorrhage present?
There is usually a history of trauma or coughing bouts
79
How does endopthalmitis present?
Red eye
| Pain and visual loss following intraocular surgery
80
What is endopthalmitis?
Inflammation of the internal eye tissues
81
What are the possible causes of 'red eye'?
```
Endopthalmitis
Scleritis
Anterior Uveitis
Conjunctivitis
Acute angle closure glaucoma
Subconjunctival haemorrhage
```
82
A 22-year-old medical student is complaining of severe right eye pain after recently returning from an elective placement in the US. On further questioning, he revealed that he went swimming in fresh water with his contact lens on. On examination, his right eye seemed slightly red but no other major clinical findings were noted.
What is the most likely causative organism of his presentation?
Acanthamoeba
Pain out of proportion of clinical presentation, contact lens and recent freshwater swimming is a classical presentation of acanthamoeba keratitis
83
What would you expect with a HSV keratitis?
A dendritic ulcer
84
What is keratitis?
Inflammation of the cornea
| It is not like conjunctivitis, keratitis is really serious and should be seen and treated immediately
85
What are the causes of keratitis?
Bacterial
Staph aureus
Pseudomonas aeruginosa (Seen in contact lens wearers)
Fungal
Amoebic
acanthamoebic keratitis
accounts for around 5% of cases
increased incidence if eye exposure to soil or contaminated water
parasitic: onchocercal keratitis ('river blindness')
```
Remember, other factors may causes keratitis:
viral: herpes simplex keratitis
environmental
photokeratitis: e.g. welder's arc eye
exposure keratitis
contact lens acute red eye (CLARE)
```
86
What are the features of keratitis?
Red eye: Pain and erythema
Photophobia
Foreign body, Gritty sensation
Hypopyon may be seen
87
What is the management of keratitis?
Need same day referral to eye specialist- diagnosis can only be made with a slit lamp, this allows them to rule out microbial keratitis
Stop using contact eyes until the symptoms have fully resolved
Topical Abx- quinolones are used first line
Cycloplegic for pain relief- cyclopentolate
88
What are the complications of keratitis?
Corneal scarring
Perforation
Endopthalmitis
Visual loss
89
A 22-year-old woman books an urgent appointment. She reports a two day history of progressive soreness, redness and discharge from her left eye. She reports a gritty feeling in the eye. She denies any exposure to foreign bodies. She is systemically well. She concedes that she has been wearing contact lenses daily up to 16 hours at a time. She has not worn contact lenses since her symptoms began and is using her glasses instead.
On examination the left eye is red and inflamed with excessive tearing. The right eye is normal. There is no abnormality of the periorbital tissues. Visual acuity is normal whilst wearing her glasses.
What is the most appropriate management?
Refer for same day ophthalmology assessment
The most common cause for unilateral red eye is conjunctivitis, however it is important to take more caution when the patient is an eye contact lenses wearer, this is because it could be microbial keratitis and therefore they need to be seen by an opthalmologist to look at their eye with a slit lamp.
90
What is retinitis pigmentosa?
It is a genetic condition which causes vision loss
| It usually affects the peripheral retina causing tunnel vision
91
What would you see on fundoscopy of someone with retinitis pigmentosa?
You would see black bone spicule shaped pigmentation in the peripheral retina, mottling of the retinal pigment epithelium.
92
What are the associations with retinitis pigmentosa?
```
Refsum disease: cerebellar ataxia, peripheral neuropathy, deafness, ichthyosis
Usher syndrome
abetalipoproteinemia
Lawrence-Moon-Biedl syndrome
Kearns-Sayre syndrome
Alport's syndrome
```
93
What would you suspect if a 35 year old came in with a family hx of blindness and tunnel vision and night time blindness?
You would suspect retinitis pigmentosa!
