Eyes and vision Flashcards
Risk factors cataracts
Increasing age
Diabetes
Smoking
Long exposure UV light
Long-term corticosteroids
Previous eye injuries
FHx
Red flags for eye problems in children
Same day ophthalmology:
Red reflex absent or very dull, white, or markedly asymmetric in a young child (urgent ref if>3m)
Signs of preseptal or orbital cellulitis, corneal ulcer, corneal haze or opacity
New, sudden onset strabismus or binocular diplopia in the older child
Purulent eye discharge in a neonate
Complete ptosis
hyphaema (blood in front of iris).
penetrating eye injury or eyelids swollen shut.
aged 6 years or younger with herpes simplex keratitis or herpes zoster ophthalmicus.
Same days paeds if: orbital/preseptal cellulitis
urgent optometry assessment if:
anterior uveitis.
glaucoma.
new-onset of strabismus.
What could purulent eye discharge in a neonate indicate?
Toxoplasma, others (syphilis, varicella-zoster, parvovirus B19), rubella, cytomegalovirus, herpes (TORCH) infections in pregnancy
How to assess children’s vision at different ages
0 to 3 months – visual interest and fixation is variable.
4 to 12 months – should be interested in your face and fixate on a toy well.
1 to 2 years – should fixate on toys and pictures, a container of hundreds and thousands (cake decoration) at 50 cm.
2 years+ – vision can be measured using appropriate paediatric eye charts. This is done by an optometrist who can organise an onward referral to an orthoptist if necessary
Horner’s syndrome
More than 2 mm difference in pupil size and mild ptosis on the side of the smaller pupil, hemifacial anhidrosis
Corneal ulcer vs abrasion
Painful, red, photophobic eye.-> urgent optometry
Ulcer:
Loss of corneal epithelium with positive fluorescein staining, not caused by trauma.
Sight‑threatening.
The affected area has an opaque appearance.
Abrasion:
An area in which the cornea is devoid of its surface epithelium due to ocular trauma.
Common.
cornea clear.
Risk factors for corneal ulcers
Dry eyes
Bell’s palsy
Ectropion
Immunocompromised
Contact lens wearer (microbial keratitis)
Signs/symptoms herpes zoster ophthalmicus
Pain around the eye.
Rash in VI dermatome, spreads into hairline.
Eyelid swollen.
Vesicular lesions on the tip of the nose are high‑risk for more serious ocular involvement (nasociliary branch of the VI nerve innervates the globe, Hutchinson’s sign).
Early conjunctivitis, and occasional faint, patchy fluorescein staining of the cornea
If iritis/keratitis: redcued vision, severe pain, photophobia, hazy iris, irregular pupil
Management herpes zoster ophthalmicus
Treat immediately with aciclovir tablets 800 mg, five times a day for 7 days
Lubricant drops
+ urgent optometry (or admit ophthalmology if endophthalmitis)
Pterygium vs Pinguecula
Pterygium:
A triangular wedge of fibrovascular conjunctival tissue that typically starts medially on the nasal conjunctiva and extends laterally onto the cornea.
Associated with chronic sun exposure.
Pinguecula:
A degenerative eye condition
A yellowish, slightly raised conjunctival lesion.
Remains confined to the conjunctiva without corneal involvement.
Eye drops, refer routine optometry if cornea affected by>3mm by pterygium
Management ectropion
Apply bland moisturiser to lower lid with upward massage
Copious lubricant drops, gels, ointments
Routine ophthalmology referral
Management entropion
Use tape to stabilise lid
Copious lubricant drops, gels, ointments
Urgent referral
Common benign eyelid lesions and appearances
Chalazion: meibonian gland blockage, inner eyelid red lump
Cyst of Moll: blocked gland of Moll at base of an eyelash, papule/nodule
Eyelid skin papilloma: overgrowth skin, no lash loss or destruction of tissue
Red flags eyelid lesion
Progressive enlargement over months
Distortion or destruction of normal lid architecture, e.g. lashes missing, notch or dip in lid contour
Pearly solid lump, sometimes with a depression in the centre (rodent ulcer), lower lid and medial canthus – typical BCC
Inflammation + tissue distortion and ulceration – SCC or aggressive BCC
Management chalazion
Hot compress 2-3x daily for 5-10 mins
If purulent, chloramphenicol eye drops for 7 days
If >6 weeks refer routine ophthalmology
Meibomianitis
Inflammation is centred around the openings of the meibomian glands, located posterior to the eyelashes.
Heat is needed to soften the oil blocking the glands so it can be cleaned away:
Apply a hot compress to closed eye for a few minutes
Massage the eyelids with the tip of the index finger using firm downward strokes on the upper lid, and upward strokes on the lower lid.
Bathe the eye with cooled boiled water and cotton wool or cotton buds to remove excess oily material and any crusts on the lashes.
Glaucoma eye drops
Beta blockers- timolol- risk wheeze/hypotension
Carbonic anhydrase inhibitors- acetazolamide- lethargy
a2-agonists- brimonidine- hypotension
Muscarinic agonists- pilocarpine- myopia
Prostaglandin analogues- latanoprost- lash growth, iris pigmentation
Symptoms and signs of acute angle closure glaucoma
Narrowing or closure of the anterior chamber angle and a rapid rise of intraocular pressure
Red severely painful eye, nausea and vomiting, halos around light, blurring of vision
Eyeball hard on palpation
Unreactive semi-dilated pupil
Redness around hazy cornea
Cornea cloudy (oedematous)
Diagnosis? Sudden unilateral blurred vision. headache, tender scalp
temporal arteritis
+ jaw claudication
ESR/CRP raised, plts raised
Treat with steroids, bone protection
Symptoms retinal detatchment
Floaters
Flashes
Curtain being drawn across vision
Distortion if macula is involved
If due to traction in diabetes it is gradual vision loss
Treatment retinal artery occlusion
Rule out temporal arteritis
Screen for cardiovascular risk factors
Fluorescein angiography
Aim to reduce intra-ocular pressure (acetazolamide, aspirin, hyperventilate)
Treatment retinal vein occlusion
Investigate for cardiovascular risk factors
Autoimmune disease/clotting disorders/glaucoma screening
Monitor regularly
Low dose aspirin
Treat risk factors
Signs and symptoms central retinal artery occlusion
Thromboembolic blockage causing retinal infarction
Painless sudden visual loss
RAPD
Retina pale with cherry red spot of macula
Signs and symptoms retinal vein occlusion
Thrombosis of retinal veins, branch is more common than central
Causes painless visual loss unilaterally, retinal flame haemorrhages and cotton wool spots. Vitreous haemorrhage, swollen optic disc, tortuous vessels
Signs of hypertensive retinopathy
Retinal damage due to chronic hypertension
Cotton wool spots, flame haemorrhages, papilloedma is advanced/malignant hypertension
* Acute ischaemia in choroid
* Optic disc swelling
Chronic hypertension
* Arteriosclerosis (copper wiring)
* AV nipping
What is thyroid eye disease
Autoimmune
Anti-TSH receptor antibodies target extraocular muscles
Irritable red eyes
Aching
Pain on eye-movement
Double vision
Signs thyroid eye disease
Proptosis
Lid retraction
Lid lag on downward gaze
Systemic signs (tremor, low BMI, heat intolerance)
Thyroid function tests, anti TSH antibodies, CT scan for extraocular swelling
What is uveitis associated with? Treatment?
Ankylosing spondylitis
Psoriatic arthritis
IBD
Sarcoidosis
Syphilis
Treated with steroids
Differences between scleritis and episcleritis
Scleritis: subacute severe pain,, worse on eye movement, immobile hyperaemic vessels, associated with rhematoid/SLE/IBD/vasculitis-> globe perforation (acute ophthalm)
Episcleritis: common, acute mild pain, mobile hyperaemic vessels, self limiting
5 non emergency causes of red eye
Subconjunctival haemorrhage
Dry eyes
Conjunctivitis
Corneal abrasion
Keratitis
8 causes acute visual loss
Painless:
Central retinal artery occlusion
Vitreous haemorrhage (retinal vein occlusion/diabetic retinopathy)
Anterior ischaemic optic neuropathy (after temporal arteritis)
Retinal detachment
Stroke/TIA
Painful:
Acute angle closure glaucoma
Optic neuritis
3 causes flashers/floaters
Posterior vitreous detachment
Migraine with aura
Retinal detachment (risk after trauma, myopia, recent cataract/laser surgery)- acute optometry if<6 weeks
What is optic neuritis?
Autoimmune demyelination of the optic nerve
1st presentation of MS
Blurred optic disc, RAPD, reduced visual acuity, pain on eye movement, colour perception impaired (red desaturates)
Features of macula degeneration
Central vision loss, distortion, smokers incr risk
Dry: retinal atrophy with drusen
Wet: neovascularisationm haemorrhages distorting macula. Can be treated with anti-VEGF
What is amblyopia?
Squint causing double vision
Brain ignores one side-> abnormal development if not corrected by age 7
Corrected with temporary patching of good eye
What visual loss can you still drive with?
6/12 in at least 1 eye (read reg plate at 20m)
4 types of allergic conjunctivitis
seasonal- pollen.
perennial- dust mites or pets.
contact dermatoconjunctivitis – eye drops or cosmetics.
giant papillary conjunctivitis – contact lenses.
Topical treatment allergic conjunctivitis
Mast cell stabilisers (e.g. sodium cromoglicate) to prevent symptoms before they occur as they can take 6 weeks to show an effect- OTC
Combined antihistamine and mast cell stabiliser (e.g. olopatadine)
What is anterior uveitis and endomphthalmitis? + risk factors
Anterior uveitis encompasses iritis (inflammation of the iris) and iridocyclitis (inflammation of the iris and ciliary body).
Endophthalmitis is an inflammation of the internal eye tissues, most commonly caused by an infection. It occurs after surgery and is a genuine ophthalmological emergency
Recent eye surgery – endophthalmitis
Previous iritis, ank spond, reactive arthritis, IBD
Symptoms + signs endophthalmitis / iritis
Endophthalmitis-> acute opthalmology:
Short history of unilateral red eye and deep aching pain.
Significant sensitivity to light.
Blurred vision.
Eyelid swelling, chemosis, and and discharge.
Sluggish pupil reflex or reduced red reflex, cells in the anterior chamber (exudate or hypopyon)
Iritis-> acute optometry:
Poorly reactive pupil/unreactive disorted pupil
Risk factors for acute angle closure glaucoma
Older age
Female
Asian
FHx
Short hyperopic eyes
Antidepressants – safe in open‑angle glaucoma or who have had a cataract removed. If a patient has angle‑closure glaucoma, antidepressants can be used with caution and advised if symptoms of eye pain, reduced vision or nausea, they should get optometry assessment.
Causes of transient monocular vision loss
giant cell arteritis.
amaurosis fugax: embolic retinal disease, usually originating in the carotid artery/carotid stenosis, painless, curtain closes over few secs, lasts few minutes- treat as TIA
optic neuropathy.
carotid artery dissection- pulsatile tinnitus, stroke
retinal migraine.
Management dry AMD
Diet rich in vitamins A, C, E
antioxidants (AREDS2 combination)
Stop smoking, modify CV risk factors
