Eye Disease Flashcards
what are important aspects of a history involving the eye
Visual loss Onset - gradual or sudden Duration? Progressive or non-progressive? Transient, improving? Localisation - central, peripheral, bilateral? Pain - localised or referred Glare Distortion (metamorphopsia) Photophobia Flashing lights / floaters Diplopia (monocular or binocular) Discomfort / dryness / f.b. sensation Abnormal appearance (red/swollen) Itch Discharge / watering / epiphora
what should be examined in an ophthalmic examination
Facial appearance Lids Conjunctivae - where is the redness? Cornea - corneal reflex / opacity / fluorescein Pupils Red reflex
what eye drops can be used to make examination easier
Fluorescein
Anaesthetic drops
Mydriatic drops
how is visual functioned tested
Visual acuity
Visual field
Colour vision
what does swollen optic discs mean
disc swelling secondary to ANY cause
what is papilloedema
specific term meaning swollen optic discs secondary to raised intracranial pressure (ICP)
what should patients with bilateral optic disc swelling be investigated for
having raised ICP due to space occupying lesion (SOL)
what is raised ICP considered
a medical emergency
how can bilateral disc swelling be identified
ophthalmoscopy
how is CN II examined
Ophthalmoscopy visual acuity pupil exam visual field assessment colour vision
how does disc swelling appear
loss of clarity of edge of disc
disc margins hidden
haemorrhages
prominent vessels
papilloedema + few haemorrhages + headache worse in the morning located in the frontal region + young obese woman = ?
benign intra-cranial hypertension
how does papilloedema occur
- Subarachnoid space (SAS) around optic nerve (ON)
- intracranial pressure increases, this is transmitted to the SAS then to the ON
- interruption of axoplasmic flow and venous congestion= swollen discs
what is intracranial pressure a sum of
Brain
Blood
CSF
what does Monro-Kellie hypothesis state in relation to intracranial pressure
an increase in one variable will result in a decrease of one/both other variables
what happens to the brain in raised ICP
brain is squeezed through foramen magnum, brainstem compressed, patient stops breathing and dies
what should be checked with disc swelling in a patient
blood pressure
how is idiopathic intracranial hypertension diagnosed
Lumbar puncture showing raised CSF opening pressure
what happens if disc swelling becomes chronic
Disc swelling subsides, discs become atrophic and pale.
Loss of visual function occurs and blindness may result.
causes of sudden visual loss
Vascular aetiology
Retinal detachment
Age related macular degeneration (ARMD) -wet type
Closed angle glaucoma
Optic neuritis
Stroke
what are vascular causes of sudden visual loss
Haemorrhage from
- abnormal blood vessels (eg diabetes, wet ARMD)
- retinal tear
Occlusion of
- retinal artery
- optic nerve head circulation
Sx of central retinal artery occlusion
Sudden visual loss
Profound - CF or loss
Painless
signs of CRAO
Pale oedematous retina, thread-like retinal vessels
RAPD (relative afferent pupil defect)
what can causes CRAO
Stroke
Carotid artery disease
what is CRAO classified as
a stroke
Patient is at risk of another
Mx of CRAO if presents within 24 hours
- ocular massage (trying to reintroduce retinal blood flow by reducing intraocular pressure)
- establish source of embolus via carotid doppler
- Assess and manage risk factors => BP, diabetes putting them at risk of further CV events
what should be excluded in cases of CRAO
temporal arteritis
how else could intra ocular pressure be decreased in CRAO
surgical removal of aqueous from anterior chamber
antihypertensive treatmetn
what are the other types of retinal artery occlusion
Branch retinal artery occlusion
Amaurosis fugax a.k.a Transient CRAO
Sx of Amaurosis fugax a.k.a Transient CRAO
transient painless visual loss
‘like a curtain coming down’
lasts~5mins with full recovery
nothing abnormal seen on examination
Mx of Amaurosis fugax a.k.a Transient CRAO and why
Immediate referral TIA clinic
At risk of full blown stroke
Tx of Amaurosis fugax a.k.a Transient CRAO
Aspirin»_space; to help circulation
what are other causes of Amaurosis fugax a.k.a Transient CRAO and why
Migraine»_space; visual loss followed by headache
what are causes of central retinal vein occlusion (CRVO)
Systemic/Ischaemic causes:
Atherosclerosis }
Hypertension } Virchow’s triad
Hyperviscosity }
Ocular causes/Not ischaemic: raised IOP (venous stasis)
Sx of CRVO
Sudden visual loss
Moderate to severe visual loss (not as profound as CRAO)
signs of CRVO
Retinal haemorrhages
Dilated tortuous veins
Disc swelling and macular swelling
Very red retina (very different from the pale retina in CRAO)
Tx of CRVO
based on cause
CRVO: uncomplicated
observation plus management of underlying risk factors
CRVO: with macular oedema
intravitreal therapy plus management of underlying risk factors
CRVO: with neovascularisation
Pan-retinal photocoagulation
(Anti-VEGFs can be used)
plus control intra-ocular pressure
how can intra-ocular pressure be controlled
ophthalmic beta-blockers, alpha-2 agonists, or carbonic anhydrase inhibitors
what are risk factors CRVO
atherosclerosis
systemic hypertension, diabetes mellitus,
history of smoking, cardiovascular disease
how does branch CRVO/CRAO differ
vision loss is only contained to the area of vision that branch supplies
Sx of branch occlusion
unilateral vision loss
fundal appearance confined to an area
what is occlusion of optic nerve circulation
a.k.a Ischaemic optic neuropathy
Posterior ciliary arteries (PCA) become occluded by either inflammation or atheroma, resulting in infarction of the optic nerve head
what are the causes of ION
Arteritic 50% - inflammation (GCA) just gets so glogged it blocks
Non-arteritic 50% - atherosclerosis
Sx of ION
sudden, profound visual loss with pale/swollen disc
irreversible blindness
what is at risk in ION
the other eye is at risk of vision loss until treated
Sx of GCA/Temporal Arteritis
Headache (usually temporal) Jaw claudication Scalp tenderness (painful to comb hair) Tender/enlarged scalp arteries Amaurosis fugax Malaise
what is seen on Ix of GCA
Very High ESR , PV and CRP
what is used to IX GCA
Temporal artery biopsy
Tx of ION due to GCA
Prednisolone 80mg/24hr PO promptly
what is non-arteritic AION associated with
increased BP
increased lipid
DM
smoking
what can lead to the formation of new vessels in the eye
ischaemia caused by»_space;
- DM retinopathy
- branch or central retinal vein occlusion
what can cause a vitreous haemorrhage
bleeding from abnormal vessels»_space; retinal ischaemia and new vessel formation
bleeding from normal vessels»_space; retinal tear or retinal detachment or trauma
Sx of vitreous haemorrhage
Loss of vision
‘Floaters’
when there is enough blood in a vitreous haemorrhage to affect vision what are the signs
loss of red reflex
retina may not be seen
haemorrhage seen on fundoscopy
Mx of vitreous haemorrhage
Identify cause - B-scan ultrasonography needed
Can fix themselves
Vitrectomy for non-resolving cases or if retinal torn or detached
Sx of retinal detachment
Painless loss of vision Flashes of light Floaters Field loss 'curtain falling over vision'
Signs of retinal detachment
May have RAPD
May see tear on ophthalmoscopy
how does the retinal detachment relate to the visual field loss
in superior detachments field loss is inferior
Mx of retinal detachment
Surgery
- vitrectomy
- laser coagulation
what is the most common cause of blindness in Uk over 65
age related macular degeneration
what are the 2 types of ARMD and how do they differ
dry (gradual reduction in vision)
wet (sudden reduction in vision)
what happens in wet ARMD
New blood vessels grow under retina – leakage causes build up of fluid/blood and eventually scarring
Sx of Wet ARMD
Rapid central visual loss
Distortion of vision (metamorphopsia)
Signs of ARMD
haemorrhage/exudate due to leaky blood vessels
Tx of ARMD
Intra-vitreal anti-VEGF treatment
Intra-vitreal steroids can be given as well e.g. Triamcinolone
what are features of gradual visual loss
Bilateral – usually
Often asymmetrical
May present early with reduced VA
May present late with decreased field
what are causes of gradual vision loss
CARDIGAN
Cataract ARMD (dry type) Refractive error Diabetic retinopathy Inherited diseases e.g. retinitis pigmentosa Glaucoma Access (to eye clinic) Non-urgent
what should be done if cataract is discovered
test fasting plasma glucose to exclude DM
what can cause cataracts
Age related Congenital – intrauterine infection (importance of checking red reflex in neonates) Traumatic Metabolic – diabetes Drug-induced (steroids)
what vitamin deficiency can cause blindness
Vitamin A deficiency
what is cataracts in basic terms
cloudiness of the lens
what are the different types of cataract
Nuclear cataract Posterior subcapsular cataract
Christmas tree cataract (a.k.a polychromatic cataract)
Congenital cataract
Tx of cataract if it is SYMPTOMATIC
surgical removal with intra-ocular lens implant
how do cataracts often present
blurred vision
gradual loss of vision
Sx of Dry ARMD
Gradual decline in vision
Central vision ‘missing’ (scotoma)
Signs of Dry ARMD
Drusen – build up of waste
products below RPE
Atrophic patches of retina
Tx of dry ARMD
No cure – treatment is supportive with low vision aids eg magnifiers
what are the refractive errors
Myopia (‘short-sighted’) light focuses infront of retina
Hypermetropia (‘long- sighted’) light focuses behind retina
Astigmatism (usually irregular corneal curvature) not allowing light being transmitted to the back
Presbyopia (loss of accommodation with aging)
what lenses are given in myopia and hypermetropia
myopia - Concave lens
hypermetropia - convex lens
what happens in presbyopia
ciliary muscles reduces tension in the lens, allowing it to get more CONVEX, for close focusing
With age, lens stiffens and presbyopia occurs. Reading glasses needed etc.
what is astigmatism
present if cornea or lens don’t have the same degree of curvature in horizontal or vertical planes
image of objects is distorted either longitudinally or vertically
what is glaucoma and what are the different types
Progressive optic neuropathy resulting in optic nerve damage and visual loss
1 - Chronic simple/Open angle
2 -Acute Closed angle
how does Acute Closed angle Glaucoma present
Acute Uniocular headache nausea + vomiting due to pain very painful red eye visual loss Halos around light at night
what causes acute closed angle glaucoma
blocked flow of aqueous from the anterior chamber via the canal of Schlemm
Mx of acute closed angle glaucoma
Need to lower IOP with drops/oral medication to prevent patient going blind within a matter of hours
how does the pupil appear in acute closed angle glaucoma
fixed dilated pupil
Tx of acute closed angle glaucoma
Lower IOP
- carbonic anhydrase inhibitors and/or topical beta-blocker and/or topical alpha-2 agonist
> > Pilocarpine (miosis - opens closed channel) + Acetazolamide (carbonic anhydrase inhibitor)
Sx of open angle glaucoma
Often none
Incidental finding or found by optician
Signs of open angle glaucoma
Enlarged Cupped disc - Cup-to-disc ratios >0.4 Visual field defect Peripheral visual loss Scotomas (seen on visual field testing) May/may not have high IOP
what is a Scotoma
a partial loss of vision or blind spot in an otherwise normal visual field.
Tx of open angle glaucoma
1 - eye drops to lower IOP
- carbonic anhydrase inhibitors and/or topical beta-blocker and/or topical alpha-2 agonist
2 - eye drops fail; laser or surgery trabeculoplasty
Patient needs to be monitored by eye clinic
in open angle glaucoma, how does the vision deteriorate
nasal and superior fields lost first
temporal lost last
what are causes of red eye
Conjunctivitis Keratitis Anterior uveitis Scleritis / Episcleritis Acute Angle Closure Glaucoma
Subconjunctival haemorrhage
Orbital disease e.g. cellulitis
what immunoglobulins are present in tears
IgA
IgG
what is blepharitis
inflamed eyelids
what are causes of blepharitis
Anterior:
Seborrhoeic (squamous) - scales on the lashes
Staphylococcal – infection involving the lash follicle
Posterior:
Meibomian gland dysfunction
( M.G.D.)
Sx of blepharitis
eyes have ‘burning’ itching red margins
scales on lashes
gritty eyes
mild discharge
Tx of blepharitis
Clean crusts off lashes (cotton bud)
Supplementary tear drops - tears Naturale
Oral doxycycline for 2-3 months
signs of anterior blepharitis i.e. lid margin
Seborrhoeic: Lid margin red Scales ++ Dandruff+ (No ulceration, lashes unaffected)
Staphylococcal:
lid margin red
Lashes distorted, loss of lashes, ingrowing lashes - trichiasis
Styes, ulcers of lid margin
corneal staining, marginal ulcers (due to exotoxin)
what is trichiasis
ingrowing eye lashes
what is posterior blepharitis caused by and how does it present
Meibomian gland disease
Lid margin skin and lashes unaffected
M.G. openings pouting & swollen
Inspissated (dried) secretion at gland openings
Meibomian Cysts (chalazia)
what is posterior blepharitis associated with
Acne Rosacea (50%)
Sx of conjunctivitis
red eye foreign body sensation – gritty eye discharge – sticky eye; can stick eye together Itch = allergy vision unaffected
signs of conjunctivitis
Red eye Discharge - serous or mucopurulent Papillae or Follicles Sub conj. haemorrhage Chemosis = oedema Pre-auricular glands (if viral)
Sx and Tx of acute bacterial conjunctivitis
red sticky eye
papillae
is self limiting - will clear up in about 14 days
without treatment
topical antibiotics clear it faster
what organisms commonly cause bacterial conjunctivitis
Staph. aureus
Strep. pneumoniae
H. influenza
what causes follicular conjunctivitis
viral (Adeno-, HS, HZ)
molluscum contagiosum
chlamydial
drugs e.g. propine, trusopt
what are the layers of the cornea
Epithelium
Stroma
Endothelium
what causes CENTRAL corneal ulcers
Viral
Fungal
Bacterial
Acanthamoeba
what causes PERIPHERAL (autoimmune) corneal ulcers
rheumatoid arthritis
hypersensitivity e.g.marginal ulcers
Sx of corneal ulcers
Pain+ – needle like severe Photophobia Profuse lacrimation Vision may be reduced Red eye - circumcorneal
what can affect corneal sensation via corneal ulcers
herpes viruses
signs of corneal ulcers
Redness – circumcorneal
Corneal reflex (reflection abnormal)
Corneal opacity
hypopyon
Ix of corneal ulcers
Staining with fluorescein
Corneal reflex
Corneal scrape
what is a feature of a viral corneal ulcer
dendritic ulcer
what is Keratoconjunctivitis Sicca seen in
Sjogrens
what is seen in H zoster or V1 corneal ulcers
Neurotrophic keratitis
what can cause exposure keratitis
thyroid, VII palsy
Tx for corneal ulcer
ID cause via corneal scape
Antimicrobial if bacterial infection
- Eg ofloxacin hourly
Antiviral if herpetic
- Aciclovir ointment 5 x day
Anti-inflammatory if autoimmune
- Oral / topical steroids
what are autoimmune causes of anterior uveitis
Reactive arthritis
Ulc colitis
Ank Spondylitis
Sarcoidosis
what are infective causes of anterior uveitis
T.B.
Syphylis
Herpes simplex
Herpes zoster
Sx of anterior uveitis
Acute Pain (+ referred pain) Vision may be reduced Photophobia Red eye (circumcorneal) Decreased acuity Watery discharge
Signs of anterior uveitis
Ciliary injection (i.e. circum-corneal ) Cells & Flares in anterior chamber Keratic precipitates Hypopyon Synechiae - Small or irregular pupil
what are Keratic
Precipitates
inflammatory cells on the corneal endothelium.
Mx of anterior uveitis
Topical Prednisolone to decrease inflammation
Mydriatics - Cyclopentolate to prevent adhesions between lens and iris
investigate for systemic associations if recurrent or chronic
what is episcleritis
inflammation below the conjunctiva in the episclera
nodules may occur
often recurrent
episcleritis associations
gout
Tx of episcleritis
self limiting
Tx of episcleritis
self limiting
Lubricants / topical NSAIDs / mild steroids
Sx of scleritis
VERY painful and red
inflamed sclera
oedema of conjunctiva
scleral thinning
what is scleritis associated with
RA
Wegener’s
Associated uveitis common
what is scleritis associated with
RA
Granulomatosis with polyangiitis (Wegener’s)
SLE
Associated uveitis common
Ix of scleritis
FBC
U&Es
ESR
CRP
c-ANCA
Rheumatoid factor
Tx of scleritis
Oral NSAIDs
Oral Steroids
Steroid Sparing Agents
what is seen in vascular retinopathy
hard exudates
macular oedema
haemorrhages
papilloedema
what is seen in Wilson’s disease
Kayser-Fleischer rings
what is seen in hypo/hyperparathyroidism in relation to the eye
hypo - lens opacities
hyper - conjunctival and corneal calcification
what can toxoplasmosis cause
uveitis
what eye diseases are seen in SLE
conjunctivitis
episcleritis
what eye diseases are seen in Reiter’s syndrome/reactive arthritis
conjunctivitis
uveitis
what is seen in polyarteritis nodosa
episcleritis
what is seen in AS
uveitis
what is seen in dermatomyositis
orbital oedema
with retinal haemorrhages
what is seen in Behcet’s syndrome
uveitis
what does temporal arteritis lead to
ischaemic damage to the optic nerve
what do people with HIV get
CMV retinitis with retinal spots + flame haemorrhages
