Masters in Surgery Flashcards
Peripheral flashing lights and ‘floaters’
Patient may also complain of ‘black curtain’ or ‘shadow’
Rhegmatogenous retinal detachment
- may have reduced visual acuity
- may have field defect
- may have RAPD
What might the retina look like if it has been detached?
Anteriorly placed, slightly pale retina may be seen ballooning forwards
-treatment is surgical
Posterior vitreous detachment
Floaters and peripheral floating
Symptoms normally settle after a few months
Opthalmoscopy shows pigmentary mottling in the macular region around areas of pale atrophic-looking retina
Well demarcated yellow deposits may be seen in association with these deposits
Dry ARMD
-in wet ARMD, haemorrhage or grey subretinal neovascular membrane may be seen
Patients complain of disortion
(wet) ARMD
Treatment for ARMD
Magnifiers
Photodynamic therapy
anti-VEGF
Amaurosis Fugax
Visual disturbance/loss but lasts less than 24 hours
Swollen pale retina with a ‘cherry red spot’
Retinal artery occlusion
CRVO treatment
Based on treatment of systemic or ocular causes (eg hypertension, diabetes, glaucoma)
Monitor : may develop complications due to development of new vessels (laser treatment may be required to avoid complications from these vessels eg vitreous haemorrhage)
More recently, anti- VEGFs used (VEGF = vascular endothelial growth factor)
Ischaemic optic neuropathy?
Sudden, profound visual loss with swollen disc
Sudden, profound visual loss with swollen disc
Ischaemic optic neuropathy
Arteritic ION?
Medium to large size vessels
Vitrous haemorrhage
Symptoms Loss of vision ‘Floaters’ Signs Loss of red reflex No RAPD – unless associated with other pathology Management Identify cause Vitrectomy for non-resolving cases
Red reflex and RAPD in vitreous haemorrhage?
Loss of red reflex but no RAPD (unless associated with other pathology)
Vitreous haemorrhage and bleeding? Where does the bleeding come from?
Bleeding occurs from abnormal vessels
Associated with retinal ischaemia and new vessel formation eg after retinal vein occlusion or diabetic retinopathy
Bleeding occurs from retinal vessels
Usually associated with a retinal tear
Retinal detachment
Symptoms
Painless loss of vision
Sudden onset of flashes/floaters (mechanical separation of sensory retina from retinal pigment epithelium)
Signs
May have RAPD
May see tear on ophthalmoscopy
Signs and symptoms of wet ARMD
Symptoms
Rapid central visual loss
Distortion (metamorphopsia)
Signs
haemorrhage/exudate
TREATMENT = anti-VEGF
Causes of gradual visual loss? (CARDIGAN)
Cataract
Age related macular degeneration (dry type)
Refractive error
Diabetic retinopathy (covered in other lecture)
Inherited diseases e.g. retinitis pigmentosa
Glaucoma
Access (to eye clinic) Non-urgent
Management for cataract
Management is surgical removal with intra-ocular lens implant if patient is symptomatic
Symptoms and signs of dry ARMD
Symptoms
Gradual decline in vision
Central vision ‘missing’
Signs Drusen – build up of waste products below RPE RPE changes – atrophy/ hyperplasia
Refractive error
Myopia (‘short-sighted’)
Hypermetropia (‘long- sighted’)
Astigmatism (usually irregular corneal curvature)
Presbyopia (loss of accommodation with aging)
Open angle glaucoma
Symptoms
Often NONE
Optician screening important
Signs
Increased intraocular pressure
Cupped disc
Visual field defect
Arcuate field defect
Glaucoma
Increased cup
Open angle glaucoma treatment
Treatment - pressure-lowering eye drops or occasionally surgery
Patients need regular monitoring in eye clinic
Chronic inflammation of the lid margins and associated meibomian glands
Blepharitis
-eyes are persistently gritty and sore
Lid hygiene – daily bathing / warm compresses
Supplementary tear drops
Oral doxycycline for 2-3 months
Very difficult to eradicate
Ptosis causes
Neurogenic -third nerve cranial palsy -horners syndrome Myogenic -weakness of levator muscle (e.g. senile ptosis) Neuromyogenic -myasthenia gravis Mechanical -cysts or swelling of upper eyelid
Acute-onset, red, gritty eyes with a purulent discharge that characteristically causes eyelids to be stuck together on wakening
Bacterial conjunctivits
-Most common causative pathogens are staph, strep and haemophilus influenzae
Treatment for bacterial conjunctivits
Chloramphenicol topical drops
Difference between anterior and posterior blepharitis
Anterior
Seborrhoeic (squamous) scales on the lashes
Staphylococcal – infection involving the lash follicle
Lid margin redder than deeper part of lid
Posterior
Meibomian gland dysfunction
( M.G.D.)
redness is in deeper part of lid
lid margin often quite normal looking
Staphylococcal blepharitis
lid margin red
Lashes distorted, loss of lashes, ingrowing lashes - trichiasis
Styes, ulcers of lid margin
corneal staining, marginal ulcers (due to exotoxin)
Seborrhoeic blepharitis?
Lid margin red
Scales ++
Dandruff+
(No ulceration, lashes unaffected)
Posterior blepharitis?
Lid margin skin and lashes unaffected M.G. openings pouting & swollen Inspissated (dried) secretion at gland openings Meibomian Cysts (chalazia) Associated with Acne Rosacea (50%)
What is posterior blepharitis associated with?
Associated with Acne Rosacea (50%)
Acne rosacea also associated with corneal ulcer
Chalazion?
Opening of meibomian gland blocked and the gland swells to create a chalazion
Treatment for blepharitis?
Lid hygiene – daily bathing / warm compresses
Supplementary tear drops
Oral doxycycline for 2-3 months
Very difficult to eradicate
Skin condition associated with conjunctivits?
Eczema
Acute bacterial conjunctivitis
red sticky eye
papillae
is self limiting - will clear up in about 14 days
without treatment
topical antibiotics clear it faster
Most common organisms: Staph. aureus, Str. pneumoniae, H. infuenzae
Causes of anterior uveitis
Autoimmune
Reiter’s, Ulc colitis, Ank Spondylitis, Sarcoidosis
Infective
T.B. Syphylis, Herpes simplex, Herpes zoster
Malignancy
Eg. leukemia
Other
idiopathic, traumatic, secondary to other eye disorders etc
Anterior uveitis symptoms and signs
Symptoms Pain (+ referred pain) Vision may be reduced Photophobia Red eye (circumcorneal) Signs Ciliary injection (i.e. circum-corneal ) Cells & flare in anterior chamber Keratic precipitates Hypopyon Synechiae Small or irregular pupil
What is episcleritis associated with?
Episcleritis is associated with gout
Acute closed angle glaucoma
Circumcorneal injection
Cornea cloudy (oedematous)
Pupil mid dilated
Eye stony hard
Scleritis
Scleritis is a chronic, painful, and potentially blinding inflammatory disease that is characterized by edema and cellular infiltration of the scleral and episcleral tissues.
What is scleritis commonly associated with
Scleritis is commonly associated with systemic autoimmune disorders, including rheumatoid arthritis, systemic lupus erythematosus, relapsing polychondritis, spondyloarthropathies, Wegener granulomatosis, polyarteritis nodosa, and giant cell arteritis.
Conjunctivitis
the most common cause of red eye, is characterized by vascular dilation of the superficial conjunctival blood vessels, cellular infiltration, and exudation. Patients with conjunctivitis usually do not experience visual changes or ocular pain
What is blepharitis often associated with?
Conjunctivitis
Patients may have decreased visual acuity and photophobia and often complain of severe eye pain. An epithelial defect may be evident on slit-lamp examination or may require fluorescein staining for visualization. Corneal inflammation or infection may be accompanied by anterior chamber reaction.
Keratitis
bacterial keratitis associated with contact lens wearing
What is episcleritis associated with?
Gout
Cluster headache
Severe one sided headache
Typically around the eye
Headache differentials
Posterior scleritis Paranasla or paraorbital sinusitis Cluster headache Temporo-mandible joint dysfunction Otitis Giant cell, cranial or temporal arteritis Carotid artery dissection Opthalmic neuralgia
Autoimmune conditions associated with scleritis?
SLE
Rheumatoid arthritis
The importance of tears
tear flow / blinking mucous trapping lysozyme immunoglobulin : IgA, IgG complement
Follicular conjunctivitis
viral (Adeno-, HS, HZ)
chlamydial
drugs e.g. propine, trusopt
Mucosum contagiosum could cause what?
Follicular conjunctivitis
Central corneal ulcers
Central (infective)
Viral
Fungal
Bacterial
Acanthamoeba
Peripheral corneal ulcers
rheumatoid arthritis
hypersensitivity e.g. marginal ulcers
(+ rarely Wegener’s granulomatosis, polyarteritis etc)
Corneal ulcer symptoms and signs
Symptoms Pain+ – needle like severe – i.e. if corneal nerves intact _ note corneal sensation is affected by herpes viruses Photophobia Profuse lacrimation Vision may be reduced Red eye - circumcorneal
Signs Redness – circumcorneal Corneal reflex (reflection abnormal) Corneal opacity Staining with fluorescein hypopyon
Dendritic corneal ulcer?
Herpes simplex
Exposure keratitis (corneal ulcer)
e.g. thyroid, VII palsy
Neurotrophic keratitis? (corneal ulcer)
e.g. herpes zoster
V1
Vitamin deficiency which could cause corneal ulcers?
Vitamin A
Corneal ulcer treatment
Identify cause – ‘corneal scrape’ for gram stain and culture Antimicrobial if bacterial infection Eg ofloxacin hourly Antiviral if herpetic Aciclovir ointment 5 x day Anti-inflammatory if autoimmune Oral / topical steroids
Anterior uveitis treatment
topical steroids and mydriatics
topical steroids
Pred Forte 1% Hourly tapering over 4-8 weeks
Mydriatics eg
Cyclopentolate 1% BD
investigate for systemic associations if recurrent or chronic
What is cyclopentolate?
Mydriatic
What is episcleritis associated with?
Gout
Choroidal folds may be a feature of what?
Thyroid eye disease EXTRAOCULAR Proptosis Lid signs retraction oedema lag pigmentation Restrictive myopathy OCULAR Anterior Segment chemosis injection exposure glaucoma Posterior Segment choroidal folds optic nerve swelling
Most common cause of unilateral and bilateral proptosis?
Thyroid eye disease
Stevens-Johnson syndrome
Reaction to infection/drugs Very serious Starts as a maculopapular rash and spreads and blisters Stomatitis Conjunctivits Symblepharon Occlusion of lacrimal glands Corneal ulcers
Posterior blepharitis is associated with what skin condition?
Acne rosacea
-acne rosacea is also associated with corneal ulcers
Blepharitis treatment
Lid hygiene – daily bathing / warm compresses
Supplementary tear drops
Oral doxycycline for 2-3 months
Very difficult to eradicate
Drugs which could cause follicular conjunctivitis?
Propine
Trusopt
Examination of the cornea
Use of anaesthetics if photophobic Corneal reflex (reflection) Use of fluorescein Vascularisation Opacity Oedema
When might hypopyn be present?
hypopyn = inflammatory cells in the anterior chamber of the eye
You can see this with corneal ulcers
Corneal ulcer treatment
Identify cause – ‘corneal scrape’ for gram stain and culture Antimicrobial if bacterial infection Eg ofloxacin hourly Antiviral if herpetic Aciclovir ointment 5 x day Anti-inflammatory if autoimmune Oral / topical steroids
Malignancy which could cause anterior uveitis?
Leukaemia
Ciliary injection (i.e. circum-corneal ) Cells & flare in anterior chamber Keratic precipitates Hypopyon Synechiae Small or irregular pupil
Anterior uveitis
Neuroendocrine tumour of the adrenal medulla that originates in the chromaffin cells
Phaeochromocytoma
