Images Flashcards
Central retinal artery occlusion
Inflammatory (uveitic) glaucoma
Central retinal artery occlusion
Central retinal vein occlusion
Punctate epithelial erosions
The clinical appearance of a patient with right orbital cellulitis.
A CT scan showing a left opaque ethmoid sinus and subperiosteal orbital abscess.
Preseptal cellulitis
The ocular signs of a carotid-cavernous sinus fistula. Contrast the dilated vessels on the right to the normal appearance on the left.
capillary haemangioma
A CT scan showing a left-sided orbital metastasis.
A left dermoid cyst
Mild left ptosis
Entropion
Ectropion
Chalazion
Molluscum contagiosum
Squamous cell papilloma
Keratoacanthoma
BCC
Orbital cellulitis
Infection affecting the fat and muscles posterior to the orbital septum, within the orbit but not affecting the globe
Pre-septal or periorbital cellulitis
Orbital mucormycosis
Bacterial keratitis
Fungal keratitis
Acanthamoeba keratitis
Herpes simplex keratitis
Hepres simplex keratitis - specifically endothelial/disciform keratitis
Herpes zoster ophthalmicus
Interstitial keratitis
Stromal inflammation +/neovascularization (infective or immune reaction)
Chlamydial conjunctivits
Trachoma
Trachoma
Endophthalmitis
Tuberculosis uveitis
Onchocerciasis African River Blindness)
Cat Scratch Neuroretinitis
CMV retinitis
Appearance described as ‘pizza pie’ / ‘cottage cheese with ketchup’ due to haemorrhages
Toxoplasmosis
White focal retinitis with overlying vitreous inflammation ‘headlight in the fog’ with accompanying pigmented scar
Uveitis
Uveitis
Specifically: precipitates (corneal endothelium)
Upper image = Keratic precipitates (acute, white, round, PMNs - as they age become pigmented & irregular)
**Bottom image **= Mutton fat precipitates (chronic, whiteyellow, greasy, granulomatous, clumped-up cells)
Uveitis
Cell and flare on slit lamp (graded according to SUN criteria)
Cornea on very left, lens on the very right - green area is the anterior chamber - notice the dotted cells in the anterior chamber
ACUTE inflammatory response
Koeppe nodules + Bussaca nodules
Seen in uveitis
Koeppe nodules (inflammatory cell precipitates that lie at pupillary marginfound in both non & granulomatous)
Bussaca nodules (lie on the iris surface - pathognomonic for granulomatous uveitis)
Optic atrophy
cat-scratch fever resulting in optic neuritis
This is a macular star
Optic neuritis
Papilloedema
CN 3 palsy (right sided)
CN 3 palsy
CN 6 palsy
CN 4 palsy
CN 7 palsy
Leukocoria
Coloboma
Brown syndrome
Congenital cataract
Premature pupil
Coloboma
Congenital glaucoma / Buphthalmos
Chlamydial conjunctivitis
Capillary haemangioma
Tear lab device for measuring the osmolarity of the tear film.
Dry eye disease
Tear breakup following the instillation of fluorescein dye. Note hypofluoescent streaks and also punctate staining.
Fluorescein staining demonstrating corneal and conjunctival punctate lesions in a severe dry eye.
Trabeculectomy bleb
Normal Tension Glaucoma (NTG) - a variant of POAG
D: Progressive optic neuropathy despite a normal or low lOP.
RF: Systemic conditions (BP, migraines, vascular insult)
Acute Angle Closure Glaucoma (AACG)
Rubeotic glaucoma
Pseudoexfoliation syndrome
Pigment dispersion syndrome
Krukenberg spindle
Seen in pigment dispersion syndrome (a rare cause of glaucoma)
Fundoscopy showing a vitreous haemorrhage. This patient had poorly controlled diabetes mellitus and presented with floaters in the left eye.
Note the background of treated proliferative diabetic retinopathy
Image showing scleritis in a patient with underlying rheumatoid arthritis
Which calcium imbalance predisposes to cataracts?
HYPOcalcaemia
retinitis pigmentosa
Acute angle closure glaucoma of the right eye - note the semi-dilated pupil and erythema
Photograph showing acute angle-closure glaucoma
A hypermature age-related cortico-nuclear cataract with a brunescent (brown) nucleus.
Central retinal artery occlusion: note the pale retina
CRVO
Pre-proliferative diabetic retinopathy
Hypertensive retinopathy stage 4 - cotton-wool spots, retinal haemorrhages, a ‘macular star’ composed of intraretinal lipid exudates. The optic nerve head is swollen, the feature that separates grade 3 and grade 4 hypertensive retinopathy
blepharitis
foam in tear film
symblepharon
A lateral tarsorrhaphy protects a previously exposed cornea.
Dacryocystitis pointing through the skin
Follicles
Conjunctival sign
Pannus
Chronic keratitis may stimulate the peripheral ingrowth of subepithelial blood vessels.
Trachoma: scarring of (a) the upper lid (everted) and (b) the cornea.
The appearance of giant (cobblestone) papillae in vernal conjunctivitis.
Vernal keratoconjunctivitis (VKC or spring catarrh)
Shield ulcer - an opaque, oval plaque which in severe disease replaces an upper zone of the corneal epithelium
Seen in vernal keratoconjunctivitis (VKC or spring catarrh)
Pterygium
Pinguecula
A dendritic ulcer seen in herpes simplex infection
Herpes zoster ophthalmicus (VZV)
bacterial corneal ulcer
The clinical appearance of acanthamoeba keratitis. Arrows indicate keratoneuritis.
Granular dystrophy - a dominant stromal dystrophy.
Keratoconus
Keratoconus
Sudden rupture of Descemet membrane and endothelium may cause acute corneal oedema (hydrops).
Band-shaped keratopathy
Corneal arcus
Band-shaped keratopathy
What is the classical approach in corneal allograft?
Penetrating keratoplasty
Involves replacement of a full thickness disc of cornea with a donor disc, which is sutured in place
A full thickness corneal graft.
Note the interrupted and the continuous 10/0 nylon sutures at the interface between graft and host.
Scleritis
The clinical appearance of cataract at the slit lamp. (a) A nuclear cataract (b) a cortical spoke cataract, silhouetted against the red reflex and (c) a posterior subcapsular cataract.
(a) An opacified posterior capsule. (b) The opacity is cleared by laser capsulotomy.
External ocular appearance in a patient with anterior uveitis. Note the inflammatory response at the limbus.
Anterior uveitis
Keratic precipitates on the corneal endothelium
Anterior uveitis
Posterior synechiae (adhesions between the lens and iris) = results in irregular pupil shape
Anterior uveitis
A hypopyon - white cells gravitated to form a fluid level in the inferior anterior chamber.
Retinitis in a patient with sarcoidosis.
Ocular toxoplasmosis
Ocular toxoplasmosis
The appearance of (a) an inactive toxoplasma retinitis and (b) a reactivated lesion. The active lesion appears pale with indistinct edges; it lies adjacent to the inactive one.
The retinal appearance in a patient with AIDS and CMV retinitis. Note the cotton-wool spot at the 1 o’clock position.
The appearance of the rubeotic iris. Note the irregular pattern of the new blood vessels on the surface.
Comparison of (a) a normal optic disc, (b) a glaucomatous optic disc. (c) A disc haemorrhage (arrowed) is a feature of patients with normal tension glaucoma. (d) A glaucomatous notch (arrowed) in the disc.
(ab) A scanning laser ophthalmoscope (Heidelberg) picture of the optic nerve head. The thin green circle in (b) outlines the optic nerve head, allowing the machine to calculate the area of the cup (red in (a)) and neuroretinal rim in different sectors of the disc. (c) An OCT of the retinal nerve fibre layer (RNFL).
An OCT of the retinal nerve fibre layer (RNFL). The scan measures the thickness of the RNFL at a uniform distance from the centre of the optic disc (the outer red circle on the left-hand image). This is then converted to a straight line and compared to an agematched population and shown graphically (lower right-hand picture). The lower red area of the graph indicates an RNFL that is likely to be abnormally thin (arrowed). The two diagrams of the optic nerve on the left show the area of abnormal RNFL as it relates to the optic nerve.
The optic disc picture shows a focal defect of the neuroretinal rim inferiorly (arrowed). This corresponds to the thinning of the RNFL shown on the scan (arrows).
The characteristic pattern of visual field loss in chronic open-angle glaucoma. Visual field of the right eye. (a) An upper arcuate scotoma, reflecting damage to a cohort of nerve fibres entering the lower pole of the disc (remember - the optics of the eye determine that damage to the lower retina creates an upper field defect). A nasal step is another classical glaucomatous field defect. (b) The field loss has progressed: a small central island is left (tunnel vision), and sometimes this may be associated with sparing of an island of vision in the temporal field.
angle-closure glaucoma
How is neovascular (rubeotic) glucoma treated?
Occurs secondary to retinal ischaemia often
anti-VEGF intravitreal injection - causes new vessels on the iris to shrink
This is followed by pan-retinal photocoagulation to reduce VEGF production by the ischaemic retina.
bilateral buphthalmos
dry AMD: note the discrete scattered yellowish sub‐retinal drüsen
wet AMD: note the small haemorrhage associated with the sub‐retinal membrane (arrowed)
The clinical appearance of angioid streaks (arrow) in pseudoxanthoma elasticum. The arrow indicates a streak.
Macular hole
(a) The pattern of fluid accumulation in central serous retinopathy; (b) an OCT scan demonstrating the accumulation of fluid between retina and RPE (black space on the scan arrowed).
(a) The pattern of fluid accumulation in macular oedema (schematic). (b) An OCT scan showing cysts of fluid in the retina of a patient with macular oedema, compared to (c) a normal scan.
Bull’s-eye appearance in chloroquine maculopathy.
The formation of a rhegmatogenous retinal detachment. (a) The detaching vitreous has torn the retina; the vitreous continues to pull on the retina surrounding the break (vitreous traction). (b) Fluid from the vitreous cavity passes through the break, detaching the neuroretina from the underlying retinal pigment epithelium.
The clinical appearance of a retinal detachment. Note the retinal tear (arrowed). The retina has completely detached.
What is the treatment of choice in a retinal detachment?
Internal approach (vitreoretinal surgery)
The repair of a retinal detachment. (a) External approach: a silicone sponge has been sutured to the globe to indent the sclera over the retinal break following drainage of the sub-retinal fluid and application of cryotherapy. (b) Sagittal section of the eye showing the indent formed by the silicone sponge: the retina is now reattached and traction on the retinal break by the vitreous is relieved. (c) Internal approach: following removal of the vitreous gel and drainage of subretinal fluid an inert fluorocarbon gas has been injected into the vitreous cavity.
The clinical appearance of the peripheral retina in retinitis pigmentosa.
Note the transillumination of light reflected from the retina through the albino iris.
retinal astrocytoma
congenital hypertrophy of the retinal pigment epithelium (CHRPE)
The comet tail appearance of a CHRPE lesion.
Choroidal melanoma
Microaneurysms
Sign of retinal vascular disease
cotton-wool spots (less distinct margins)
Sign of retinal vascular disease
New vessels (note also venous beading)
Sign of retinal vascular disease
Fluoresceine angiogram showing the vascular architecture + absent filling of the retinal capillary circulation (arrow)
The bright, hazy areas indicate leakage from the new vessels
Sign of retinal vascular disease
An OCT scan showing diabetic macular oedema. Note the cystic spaces in the retina demonstrating the accumulation of fluid on the greyscale picture on the right. The coloured circle represents the thickness of the macula as a contour map. Note the significant thickening in the central foveal region shown as white.
What is the mainstay of treatment for sight-threatening diabetic retinopathy?
laser therapy, although anti-VEGF and steroids injections are playing an increasing part in the treatment of diabetic macular oedema.
Background diabetic retinopathy, with dot (microaneurysms) and blot haemorrhages away from the macula.
Diabetic maculopathy: note the circinate exudate, temporal to the macula.
Preproliferative retinopathy with a venous loop (arrow).
d + e
Proliferative retinopathy: new vessels have formed on the retina, their presence demonstrated by leakage of fluorescein (hyperfluorescence) on the fluorescein angiogram; closure of some of the retinal capillary network is demonstrated by its failure to fill with fluorescein (dark appearance on the angiogram).
Advanced diabetic retinopathy: the neovascularization has caused a tractional retinal detachment superiorly.
retinal laser burns
The contrast between: (a) an inferior branch retinal artery occlusion with a white, oedematous retina below, and (b) a superior branch vein occlusion, with diffuse haemorrhage above.
BRVO
The retina has developed new vessels (arrowed) due to the ischaemic retina.
The fundus in malignant (now accelerated) hypertension. The disc is swollen, and there are retinal haemorrhages and cotton-wool spots.
The fundus appearance in retinopathy of prematurity.
Note the tortuosity of the retinal vessels.
Small retinal haemorrhages can be seen superiorly while the peripheral retina is avascular.
Widefield colour photo of retina in a premature infant showing vascularized ridge demarcating vascularized and avascular retina. Note dilated retinal vessels indicating ‘plus disease’.
White-centred haemorrhages (Roth spots)
Seen in leukaemia, bacterial endocarditis and autoimmune diseases associated with vasculitis
A right ptosis and miosis in Horner syndrome.
Normal disc
Papilloedema – A swollen disc secondary to raised intracranial pressure. Note the lack of a sharp outline to the disc and the dilated capillaries on the disc.
The appearance of optic disc drüsen; note how the solid yellow lesions cause irregularity of the disc margin.
Myelination of the nerve fibres around the nerve head may be mistaken for a swollen optic disc.
A myopic optic disc. Note the extensive peripapillary atrophy.
The clinical appearance of the optic disc and (b) one form of field defect (altitudinal) seen in ischaemic optic neuropathy.
(a) A pale optic disc compared to (b) a normal optic disc.
What type of squint is this?
Right, non-paralytic divergent squint. (a) The right eye is divergent in the primary position of gaze (looking straight ahead). (b) When the eyes look to the left, the angle of deviation between the visual axes of the two eyes (the lines passing through the points of fixation and the foveolae) is unchanged. The same is the case on looking to the right.
What type of squint is this?
Left sixth nerve palsy with paralysis of the left lateral rectus (paralytic squint). (a) With the eyes looking to the right, the visual axes are aligned, there is no deviation between the visual axes of the two eyes. (b) With the eyes looking to the left (the field of action of the left lateral rectus), the left eye is unable to move past the midline as the left lateral rectus is paralysed. This results in a large angle convergent squint.
A child with epicanthic folds, giving the appearance of a convergent squint. Note the light reflex is central in both eyes.
left convergent squint: right eye fixing
a right divergent squint: left eye fixing. Note the position of the light reflection in each eye.
The principles of squint surgery.
(a) Recession. The conjunctiva has been incised to expose the medial rectus muscle. The muscle is then disinserted and moved backwards on the globe.
(b) Resection. Following exposure of the muscle, the anterior tendon and muscle are resected, thus shortening them; the muscle is then reattached to its original position.
Left third nerve palsy left lid elevated by examiner: note the dilated pupil and ptosis as well as the limitation of eye movement.
Left fourth nerve palsy: the defect is maximal when the patient tries to look down when the left eye is adducted.
Left sixth nerve palsy: the left eye is unable to abduct.
Dysthyroid eye disease
A subconjunctival haemorrhage.
An everted lid showing ischaemia of the upper tarsal conjunctiva following an alkali burn.
A diffusely hazy cornea following an alkali burn.
A foreign body, embedded in the cornea.
Hyphaema
Penetrating eye injury (note the eyelashes (arrowed) in the anterior chamber and the distorted iris).
The lens in this patient has become disrupted and cataractous following a penetrating injury.
Removal of a superficial ocular foreign body at the slit lamp using the dominant hand and the patient’s cheek as a rest.
Slit-lamp view of a brown, nuclear cataract.
Follicles on the upper tarsus of a patient with trachoma.
Peripheral corneal scarring in trachoma.
Scarring of the tarsal conjunctiva in trachoma.
Sclerosing keratitis in onchocerciasis.
Uveitis with synechiae formed between iris and lens in onchocerciasis.
The appearance of retinal disease in onchocerciasis.
Bitot spot
Xerosis of the cornea in vitamin A deficiency.
Severe corneal disease with ulceration in vitamin A deficiency.
Bilateral severe corneal scarring in measles.
Left ptosis. Importantly, the pupil is not completely covered.
Hirschberg test. The corneal light reflex is displaced nasally on the left. The child has a divergent squint.
Note the faint white opacity in the right pupil. The child has a congenital cataract. Additionally, the eye is microphthalmic with a right convergent squint. All these signs can be detected by simple examination.
Rhabdomyosarcoma. The right eye is proposed compared to the left when looking down at the child’s face from above.
Preseptal cellulitis - the lid is swollen but the conjunctiva is white, eye movements full and there is no evidence of optic nerve compromise when the child is examined, differentiating it from orbital cellulitis where the eye appears inflamed, proptosed and eye movements grossly restricted.
A capillary haemangioma.
A left dermoid cyst is present temporally.
Both lower lids appear swollen with multiple chalazia.
The pupils are dilated, note the right pupil is white due to the presence of a cataract.
The appearance of Coats disease. There is a marked exudative retinal detachment, the folds of retina are almost touching and covering the optic disc.
Retinoblastoma - the tumours appear white with a solid appearance, contrasting with the flat yellow appearance of Coats disease.
