eye problems! Flashcards
Eye conditions
Common causes of Sudden PAINLESS loss of vision? (5)
Good migraine
GCA
Occlusion central retinal vein
occlusion of central retinal artery
Detachment retinal
retinal migraine
anything “retina” involved is painless bc there is no trigeminal nerve in the retina!
CRVO vs CRAO
cx, pathophys, fundoscopy, Ix, Mx
What is the screening for someone with strong family history of glaucoma?
Those with a positive family history of glaucoma should be
screened annually from aged 40 years
open angle vs closed angle Glaucoma
– Trabecular meshwork deteriorates (age:chronic) open angle glaucoma>> COMMON
– Narrowing of irido-corneal angle (acute):
closed angle glaucoma
Pathophysiology of OPEN angle glaucoma
- RFx (4)
- Presentation
- Signs
- Dx
- Mx
A 62-year-old man who is followed up for primary open angle glauoma. He has a history of asthma.
gradual increase in resistance in trabecular meshwork–> difficult for aqueous humour to flow through the meshwork & exit eye–> pressure slowly builds in eye –> gives a slow and chronic onset of glaucoma.
RFx
- Increasing age
- Family history
- Black ethnic origin
- Diabetes, steroids
- Nearsightedness (myopia) ‘
Presentaton:
Asymptomatic
- Glaucoma affects the peripheral vision first.
- Gradually becomes tunnel vision.
signs
- arcuate scotoma (Tunnel vision)
- decreased visual acuity
- Raised IOP
- optic disk cupping
Dx
- Goldmann applanation tonometry –> check IOP
- Fundoscopy assessment –> check for optic disc cupping & optic nerve health.
- Visual field assessment –> check for peripheral vision loss.
Mx
1st line: PG analogue eyedrops (latanoprost) Or topical b blocker (timolol)
If not resolved:
- If not work then : Combine PG analogue + b- blocker
- 2nd line: Switching to, or adding in a
- topical sympathomimetic
- topical CA inhibitor
- topical miotic.
- Sympathomimetics (e.g. brimonidine)–> increase uveoscleral outflow
- Tim the prostitute caused trouble in the meshwork*
- lost his peripheral vision and now he cannot twerk*
- he cannot see the tree*
- also his familyyy*
- so i’ll guess we’ll do a gold tonometryyyy*
Ans: Muscarinic agonist, bc beta blockers r contraindicated in asthmatics
what do you see on visual fields in open angle glaucoma?
and what type of visual field test is most commonly used?
MOST COMMONLY THE HUMPHREY VISUAL FIELD TEST
Acute angle closure glaucoma (AACG)
- RFx (4)
- Presentation
narrowing of IC angle–> blockage in AH trying to escape the eye–> rise in IOP in post chamber
RFx
- Increasing age
- Females 4 x more
- FHx
- Chinese and East Asian ethnic origin.
- Mydriatic drops are a known precipitant of acute angle closure glaucoma.
Presentation
- Sudden PAAAIN–>characteristic in evening!
- relieved by going to sleep (the pupil constricts during sleep, so relieving the attack)
- Red eye
- Blurred vision
- Halos around lights–>bc of corneal edema
- Headache, N & V
3 signs of fudoscopy for glaucoma
Examination feautres of AACG (7)
- Red eye
- Teary
- Hazy cornea–> corneal oedema
- Decreased visual acuity
- Dilatation of the affected pupil
- Fixed pupil size
- Firm eyeball on palpation
Mx : Acute angle closure Glaucoma
Referral
SPAM-T
specialist ophthalmology assessment and treatment.
SUPINE no pillows
Pilocarpineantimuscuranic in sphincter muscles in the iris and causes constriction of the pupil –> a miotic agent.
causes ciliary muscle contraction–> flow of AH from ciliary body, around the iris & into the trabecular meshwork open ups
Acetazolamide oral or IV -> CA inhibitor–> reduces the production of AH
Mannitol: increase the osmotic gradient between the blood and the fluid in the eye
What is the DEFINITIVE mx for AACG
laser iridotomy
Drugs for eye
Define, Rf, presentation, Signs Mx,
what 3 things depends on referrel for Sx accoding to NICE?
what level of vision do most people undergo surgery?
CATARACT
Cataracts are where the LENS in eye becomes cloudy and opaque –> reduces visual acuity by reducing the light that enters the eye.
RFx
- Increasing age (MOST COMMON)
- Smoking
- Alcohol
- Diabetes
- Steroids
- Hypocalcaemia
Presentation
asymmetrical as both eyes are affected separately.
- Very slow reduction in vision
- Progressive blurring of vision
- Change of colour of vision with colours becoming more brown or yellow
- “Starbursts” can appear around lights,mainly at night
Signs
A key sign for cataracts is the loss of RED REFLEX
The lens can appear grey or white (LEUKOCORIA) when testing the red reflex. This might show up on photographs taken with a flash.
Mx
NICE suggests that referral for surgery depends on whether a:
- visual impairment is present MORE THAN 6️⃣
- impact on quality of life
- patient choice.
- Phacoemulsification* Cataract surgery involves drilling and breaking the lens into pieces, removing them & implant an artificial lens into the eye. This is usually done as a day case under LA. It usually gives good results!
- “A cat called ben**, lost his lens ..& he began to cry. I Cannot see, colours r yellowyy, i guess i need surgeryyy.”*
what is this?
how would u manage it?
Endophthalmitis-complication of cataract Sx
inflammation of the aqueous and/or vitreous humour of the eye, cx by infection.
Mx
intravitreal antibiotics injected into the eye. This can lead to loss of vision and loss of the eye itself.
List 3 risks of cataract surgery
Periop
– Posterior capsular rupture and vitreous loss
Early post-operative
– Infection “Endophthalmitis”
Late post-operative
– Posterior capsule opacification THICKENING OF THE LENS
which is a Build up of debris on the capsule
Macular Degeneration
types, rfx (4) symp (3) , ex and ix, Tx
Beta-carotene vitamen has been found to increase the risk of lung cancer and hence antioxidant dietary supplements are not recommended for smokers.
Posterior vitreous detachment
Signs, symp, Ix, Cx, Mx, complications
The vitrous humour is made up of 99% water and 1% collagen and that collagen is what makes the vitrous jelly,
as we age this gel substance starts to break down and forms CLUMPS and hair like strands which r floaters
the gel sac is firmly attached to the optic N. And there more gel substance around it and when that plugs off, it usually plugs of pretty hard and this is what is weiss ring and thats the LARGE floater that u get
bc the vitrous humour is stuck to the retinal layer like a velcro, when it starts to detach it tugs on the retina, and the brain doesnt really know what to do with that and its not like a normal visual signal so its sees it as a flashing light
problem? risk factors? symptoms? treatment (3)? referral?
retina separates from the choroid underneath.(photoreceptors no longer able to function resulting in visual disturbance cuz it gets its BS from underlying choroid layer)
Refer to on call team
Rfx
- Posterior vitreous detachment
- Diabetic retinopathy
- Trauma to the eye
- Retinal malignancy
- Older age (vitreous jelly shrinks as you get older, and slowly pulls away from the inside surface of the eye)
- FHx
Sympx
- Dense shadow starts peripherally & progresses towards central vision
- Flashes & floaters (**bc of changes in the vitrous)
- sudden painless loss of vision
Mx
Management of retinal tears aims to create adhesions between the retina and the choroid to prevent detachment. This can be done using:
- Laser therapy
- Cryotherapy
Reattaching the retina can be done using one of three options:
- Vitrectomy involves removing the relevant parts of the vitreous body and replacing it with oil or gas.
- Scleral buckling involves using a silicone “buckle” to put pressure on the outside of the eye (the sclera) so that the outer eye indents to bring the choroid inwards and into contact with the detached retina.
- Pneumatic retinopexy involves injecting a gas bubble into the vitreous body and positioning the patient so the gas bubble creates pressure that flattens the retina against the choroid and close the detachment.
Increased eyelash length, what drug caused this?
what other sympmtoms to they get?
Lantoprost, Pg analogues
iris pigmentation and periocular pigmentation
Causes? Presentation? Investigation (4), Treatment? referral?
top tip: they have history of sinusitis
Preorbital doesnt affect eye movemnt lana muscles r not affected
Periorbital (post septal) reduced visual acuity and painful eye and reduced eye move and exopthalmus and proptosis
Ix
- FBC – high WBC, high inflammatory markers.
- Clinical examination involving complete ophthalmological assessment – Decreased vision, afferent pupillary defect, proptosis, dysmotility, oedema, erythema. check temp too!
- CT with contrast – Inflammation of the orbital tissues deep to the septum, sinusitis.
- Blood culture and swab to determine the organism. Most common bacterial causes – Streptococcus, Staph A, H influenzae B.
Mx
- Preorbital : high dose oral antibiotics (co-amoxiclav)
refer to rapid access clinic if unresponsive to antiobitoics
- Orbital (post orbital): admit for IV antibiotics +/- abscess drainage
- refer to oncall team! emergency*
Periorbital vs orbital cellulitis
List 8 eyelid disorders you know
- Bleupheritis
- Style
- Chalazion
- Periorbital Cellulitis
- Orbital Cellulitis
- Entropion
- Ectropion
- Trichiasis
?
Cx (3) features,Mx
Blepharitis: inflammation of the eyelids.
- Blocked meibomian gland dysfunction
- seborrhoeic dermatitis/staph infection
- common in patients with rosacea
- Dry eyes
- Symptoms are usually bilateral
- Grittiness & discomfort
- Eyes may be Sticky in the morning
Mx
- hot compresses x2 a day
- ‘lid hygiene’ - mechanical removal of the debris from lid margins
- cotton wool buds dipped in a mixture of cooled boiled water and baby shampoo is often used
differenttiate btw them
presentation?
treatment?
stye and chalzion
Stye
“hordeolum”
How is uveitis classified?
Anterior uveitis - inflammation affecting the iris (iritis) +/- the ciliary body (iridocyclitis)
Intermediate uveitis - inflammation of the posterior part of the ciliary body and nearby peripheral retina and choroid
Posterior uveitis – inflammation of the retina and choroid Panuveitis – inflammation of the whole uveal tract
Anterior Uveitis
- what is it?
- types
- presentations
- associations
- Mx
- referral?
- “iritis” Inflammation of the Choroid layer
- cycloplegics (dilates the pupil which helps to relieve pain and photophobia) e.g. Atropine, cyclopentolate
- Inflammatory cells in the Anterior chamber cause floaters in the patient’s vision.
- Sphincter pupilla muscle in iris contracts causing miosis (constricted pupil)
- Photophobia due to ciliary muscle spasm
- Floaters> bc inflammatory cells in ant chamber
- Abnormal pupil> bc posterior synechiae (adhesions) pulling the iris into abnormal shapes
REFER TO RAPID ACCESS CLINIC FOR STEROIDS
orbital blow-out fracture
presemtation?
fracture is the floor (inferior wall) of the orbit (maxilla bone)
maxilla forming the floor, is incredibly thin!!>
eyeball can drop into maxillary sinus!
which can occur due to direct impact to the front of the eye e.g. by a ball or fist
label conditions
conjunctivitis
how do patients present?
types (4)
treatment
(what is conjuctiva)
when inflammed> BV dilate and the eye appears red.
report their eye feeling uncomfortable and ‘gritty’ (rather than painful) with accompanying tearing of the eye.
The condition is highly contagious
Also aku Contact induced conjunctivitis >> ropy discharge
conjcutiva: vascularozed thin serous membrane covering over the sclera and reflected onto the inner surface of the upper and lower eyelids. > prodcues mucous & tears IT DOESNT NOT COVER THE CORNEA
Chlamydial conjunctivitis
- Ix
- referral?
Confirm diagnosis with chlamydia swab
If positive, refer to GUM clinic for screening
presentation?
causes?
trigger?
tx?
subconjunctival haemorrhage
This occurs when one of the small conjunctival blood vessels ruptures (often spontaneously).
The blood that escapes is immediately visible under the transparent conjunctival layer
- not pain and resolves itself
CAN GIVE LUBRICATING EYE DROPS IF FOREIGN BODY SENSATION
complication of this dude
Cavernous sinus thrombosis
meningitis
Initial and definitive managment
Entropion
eyelid turns inwards with the lashes against the eyeball. This results in pain and can result in corneal damage and ulceration.
- Initial management is by taping the eyelid down to prevent it turning inwards
- Definitive management is with surgical intervention. When the eyelid is taped down it is essential to prevent the eye drying out by using regular lubricating eye drops.
A SAME DAY referral to ophthalmology is required if there is a risk to sight.
Ectropion is where the eyelid turns outwards with the inner aspect of the eyelid exposed.
It usually affects the bottom lid. This can result in exposure keratopathy as the eyeball is exposed and not adequately lubricated and protected.
Mx
- Mild cases may not require treatment.
- Regular lubricating eye drops are used to protect the surface of the eye.
- More significant cases may require surgery to correct the defect.
A same day referral to ophthalmology is required if there is a risk to sight.
What is this
causes (5), most common organism, symp, Ix (3)
Referral?
- Viral infection with herpes simplex
- Bacterial infection with pseudomonas or staphylococcus
- Fungal infection with candida or aspergillus
- Contact lens acute red eye (CLARE)
- Exposure keratitis is caused by inadequate eyelid coverage (e.g. eyelid ectropion)
Need 1-2 hourly topical Levofloxacin
Refer to Emergency Eye Clinic
Dx
- fluorescein will show a dendritic corneal ulcer. Dendritic describes the appearance of branching and spreading of the ulcer.
- Slit lamp examination to find and diagnose keratitis.
- Corneal swabs or scrapings can be used to isolate the virus using a viral culture or PCR.
Mx
- Aciclovir (topical or oral)
- Ganciclovir eye gel
- Topical steroids may be used alongside antivirals to treat stromal keratitis
- Corneal transplant may be required after the infection has resolved to treat corneal scarring caused by stromal keratitis.
Referral?
Herpes Zoster Ophthalmicus
Refer to Rapid Access Clinic if eye red or vision blurred
Mx : Give oral antiviral (acyclovir 800mg 5 x per day for 7 days)
Symp, treatment, causes,
what happens when apply pressure of vessels?
Simple analgesia, cold compresses and safetynet advice are appropriate.
More severe cases may benefit from systemic NSAIDs (e.g. naproxen) or topical steroid eye drops.
In episcleritis, the injected vessels are MOBILEE when gentle pressure is applied on the sclera, indicating much more superficially involved vessels
What is this?
which eye problem is typically associated with autoimmune conditions?
what r some examples of these autoimmne conditions?
Uveitis!
ankylosing spondylitis & inflammatory bowel disease, sarcoidosis, RA
albinism
what do they do to protoct their eyes?
a congenital disorder causing partial or complete absence of melanin in skin, hair and eyes
- wear tinted sunglasses or contact lens to help reduce the scattering of light that enters the eye, given the pigmented retinal layer, like much of the rest of their body, is absent of melanin.*
- Melanin:helps absorb scattered light that pased in the eye, reduces refelction and aloows us to fcocus*
What is this? What caused it?
This is optic disc swelling caused by raised ICP. The swelling is usually bilateral and can occur over a period of hours to weeks.
explain this finding ?
In Glaucoma!>>
Rise in intra-ocular pressure and damage to optic nerve
– Optic disc cupping> thinning of outer rim of optic head!
Whats this
what sort of eyedrops cause this?
Steroid eye drops can lead to fungal infections, which in turn can cause corneal ulcers
EXPLAIN what u see
Acute Angle-Closure Glaucoma:
note the irregularly & fixed shaped pupil and conjunctival injection (red eye)
bc corneal muscle cant contract
- condition?
- causes (2)
- Presentation?
congenital inherited condition of degeneration of the rods and cones in the retina.
Cx
- genetics>> rods more than cons (night blind)
- associated with systemic diseases
Presentation
- Night blindness is often the 1st symptom
- tunnel vision is lost B4 the central vision.
explain this fundoscopy?
- Fundoscopy will show pigmentation.
- This is described as “bone-spicule” pigmentation.
- The pigmentation is most concentrated around the mid-peripheral area of the retina.
- There can be associated narrowing of the arterioles and a waxy or pale appearance to the optic disc.
Associated Systemic Diseases with retinosa pigmentosa
- Usher’s Syndrome causes hearing loss plus retinitis pigmentosa
- Bassen-Kornzweig Syndrome is a disorder of fat absorption and metabolism causing progressive neurological symptoms and retinitis pigmentosa
- Refsum’s Disease is a metabolic disorder of phytanic acid causing neurological, hearing and skin symptoms and retinitis pigmentosa
Accommodation Reflex and the Ageing Eye
how do u get colour blind?
who doe sit most commonly effect?
we have 3 types of cones, red, blue and green
(work in bright lights & respond to different light wavelengths)
absence or dysfunction of one of these three cones leads to colour blindness (or colour vision deficiency),
an inherited condition that affects males more
What is scotoma
is an area of partial alteration in the field of vision consisting of a partially diminished or entirely degenerated visual acuity that is surrounded by a field of normal – or relatively well-preserved – vision.
What is amaurosis fugax?
Embolis that temporarily blocks the opthalmic A.
” Feel like curtain coming down their eyes”
Internuclear ophthalmoplegia
features and causes (2)
what structure is damaged?
- a cause of horizontal disconjugate eye movement
- lesion in the medial longitudinal fasciculus (MLF)
- controls horizontal eye movements by interconnecting the 3rd, 4th & 6th cranial nuclei
- located in the paramedian area of the midbrain and pons
Features
- impaired adduction of the eye on the same side as the lesion
- horizontal nystagmus of the abducting eye on the contralateral side
Causes
- multiple sclerosis
- vascular disease
List some refractive errors
Pattern of vision loss
glaucoma
diabetic retinopathy
cataract
macular degeneration
retinitis
Retinitis & glaucoma>> peripheral to central
Macular degeneration> central (scotoma)
diabetic > random (scattered)
When do u see vision imporovment w/ pinhole glasses and WHY.
Cataracts and other refractive errors,
the lens function is that is by changing its shape, to help refract(bend) light to be focused on the retina.
it cataract, the lens becomes cloudy and u view images as blurry images, when wearing a pinhole glasses, it reduces the surface area in which the image swill enter ur eye, therefore focusing it it and u can itshoofena.
(ask rawan if u forgot)
What is this sign called? What is it indicative of?
Hypopyon
Hypopyon is a medical condition involving inflammatory cells in the anterior chamber of the eye. It is a leukocytic exudate, seen in the anterior chamber, usually accompanied by redness of the conjunctiva and the underlying episclera.
Hypopyon can be present in a corneal ulcer. Behcet’s disease, endophthalmitis, panuveitis/panophthalmitis and adverse reactions to some drugs (such as rifabutin).[1]
A patient presents with a lump in her left eyelid and is diagnosed with a Meibomian Cyst. What is this and how does it differ from a stye
another name for meibomian cYst
What is papilloedema and how is it caused? How is it different from optic disc “cupping”?
Why is it not possible to lose a contact lens behind the eye?
Foreign body eye
Cataract in children
