Medicine - Ophthalmology Flashcards
Recall the features of optic atrophy
Mnemonic: Optic Atrophy Can Reduce Sight
Optic disc pale
Acuity reduced
Colour vision reduced (especially red)
RAPD (relative afferent pupil defect)
Scomata centrally
What are the 2 most common causes of optic atrophy?
MS
Glaucoma
Recall 4 red flags when assessing red eyes
Photophobia
Poor vision
Fluorescein staining reveals foreign material
Abnormal pupil
Is photophobia more likely to be present in acute glaucoma or anterior uveitis?
Anterior uveitis
What are the typical signs and symptoms of acute closed angle glaucoma?
Reduced acuity
Nausea and Vomiting
Haloes around lights
Severe pain
What may be seen on examination in acute closed angle glaucoma?
Cloudy/red cornea
Fixed and dilated pupil
Photo source: https://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/acute-angle-closure.html
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What are some risk factors for acute closed angle glaucoma?
Hypermetropia is the key one
Female
Family history
Old age
What sort of examination can examine fluid drainage from the eye?
Gonioscopy with slit lamp
What are the general principles of management of acute closed angle glaucoma?
Refer
Medicate
Laser peripheral iridiotomy
Lens extraction
What drugs can be used to treat acute closed angle glaucoma?
IV:
Carobonic anhydrase inhibitor (reduces aqueous formation)
Top:
Carobonic anhydrase inhibitor
Beta blocker (also reduces aqueous formation)
Alpha-2 agonist (miosis opens blockage)
How does anterior uveitis usually present?
Acute pain, photophobia, reduced acuity, hypopyon
How does the eye appear in anterior uveitis?
Irregular and small pupil, hypopyon
Photo source: https://www.researchgate.net/figure/Hypopyon-and-nasal-synechiae-in-the-left-eye-of-a-young-patient-suffering-from-acute_fig1_333459995
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What is episcleritis?
Inflammation below the conjuctiva in the episcleral layer
How does episcleritis usually present?
Asymptomatic
What is scleritis and what conditions is it associated with?
Vasculitis of sclera:
Granulomatosis polyangiitis
Rheumatoid arthritis
Systemic Lupus Erythematous
Vasculitis
What is the main symptom of scleritis?
Severe pain worse on eye movement
What can be seen on examination in scleritis and how can it be differentiated from episcleritis?
Conjunctival oedema
Scleritis much more diffuse than episcleritis
If you add phenylephrine drops the sclera goes white in episcleritis but stays red in scleritis
photo source: https://www.msdmanuals.com/professional/eye-disorders/conjunctival-and-scleral-disorders/scleritis
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How should you manage scleritis as a junior dr?
Urgent referral (\<24 hours) Cortisosteroids/ immunosuppressants
How can viral vs bacterial vs allergic conjunctivitis be differentiated by appearance?
Viral: waterey and unilateral
Bacterial: sticky and unilateral
Allergic: pruritic, bilateral
Why do contact-lens wearers need urgent referral if they get conjunctivitis?
Difficult to distinguish between cojunctivitis and microbial keratitis which requires prompt treatment
How does the management of viral vs bacterial vs allergic conjunctivitis differ?
Viral: nil
Bacterial: chloramphenicol drops
Allergic: antihistamine drops
What classifies as a “corneal abrasion”?
Epithelial breech without keratitis
How can corneal abrasion be investigated?
Fluorescein stains the defect green
How can corneal abrasion be managed?
You just use antibiotic infection prophylaxis (chloramphenicol ointment)
How does a corneal ulcer/keratitis appear?
visible defect and white corneal opacity
Photo source: lhttps://thesgem.com/2021/01/sgem315-comfortably-numb-with-topical-tetracaine-for-corneal-abrasions/
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Why is corneal ulcer/keratitis an emergency?
It can cause scarring and vision loss
What is the cause of ophthalmic shingles?
CN VI reactivation of shingles
What is Huntchinson’s sign?
Nose-tip zoster (nasocilliary branch) –> ophthalmic involvement
How should ophthalmic shingles be managed?
Oral aciclovir +/- topical corticosteroids
Recall 2 possible complications of ophthalmic shingles?
Post-herpetic neuralgia
Ptosis
Which artery is involved in anterior ischaemic optic neuropathy?
Posterior ciliary artery
What is the cause of arteritic anterior ischaemic optic neuropathy?
Giant cell arteritis
What are the 4 main symptoms of optic neuritis?
CRAP
Central scomata
RAPD
Acuity loss
Pain on movement
What is the most common cause of optic neuritis?
Multiple sclerosis
How should optic neuritis be managed (immediately and ongoing)?
72 hours IV methylprednisolone
11 days prednisolone PO
Recall the signs and symptoms of vitreous haemorrhage
Small bleeds –> small black dots in vision and ring floaters
Large bleeds –> loss of red reflex, retina not visualised
Fundal photo source: https://www.glycosmedia.com/education/diabetic-retinopathy/diabetic-retinopathy-features-of-diabetes-vitreous-haemorrhage/
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What is the most common cause of vitreous haemorrhage?
Diabetes - causes angiogenesis
What is the best investigation for vitreous haemorrhage?
Brightness scan ultrasonography
How should small vitreous haemorrhages be managed?
They should resorb spontaneously
How should large vitreous haemorrhages be managed?
Vitrectomy
What is the aetiology of retinal detachment?
Holes in retina allow fluid to separate retina from the pigmented epithelium
What is the most common cause of retinal detachment?
Diabetes
Recall the 4 main signs and symptoms of retinal detachment
Floaters
Flashes
Field loss
Fall in acuity
Describe the appearance of the retina in retinal detachment
Grey, opalescent retina, ballooining forwards
Photo is of retinal detatchment secondary to horseshoe retinal tear - source: https://geekymedics.com/retinal-detachment/
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On the other side of the card is a fundal photo of a central retinal vein occlusion for reference
Photo source: https://www.glycosmedia.com/education/diabetic-retinopathy/diabetic-retinopathy-features-of-diabetes-vitreous-haemorrhage/
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On the other side of this card is a fundal photo of branch retinal vein occlusion for reference
Photo source: https://en.wikipedia.org/wiki/Branch_retinal_vein_occlusion
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How should retinal detachment be managed?
Urgent vitrectomy and gas tamponade with laser coagulation
Differentiate the symptoms of central retinal vs branch retinal vs cilioretinal artery occlusion
Central RAO: sudden painless total loss of vision + RAPD
Branch RAO: sudden painless partial loss of vision with NO RAPD
Ciliretinal AO: painless central vision loss
Recall 3 things that must be done to investigate possible retinal artery occlusion
- CVS RF history
- Temporal artery biopsy
- ESR
Recall some ways of managing retinal artery occlusion
First thing to do is an eyeball massage (?!)
Then options include:
- Carbogen therapy (inhalation of 95% O2 and 5% CO2)
- Haemodilution
- Vasodilators
- Measures to decrease IOP
Recall three possible causes of retinal vein occlusion
DM
HTN
Glaucoma
How does the nature of vision loss in retinal vein occlusion indicate whether it is ischaemic or non-ischaemic in nature?
If it is sudden total vision loss = ischaemic
If it is subacute partial vision loss = non-ischaemic
If RAPD = ischaemic
What is the best investigation for imaging retinal vein occlusion?
Fluorescin angiography
How can retinal vein occlusion be managed?
Can only be managed actively if ischaemic cause
Mx = panretinal photocoagulation
What is the phrase ‘cherry red macula’ usually associated with?
Central retinal artery occlusion
Photo source: https://en.wikipedia.org/wiki/Cherry-red_spot
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What is the most common cause of blindness in >60yo?
Age-related macular degeneration ARMD
What are the 2 types of age-related macular degeneration?
Wet and dry
Dry = geographic atrophy
Wet = subretinal neovascularisation
What are drusen?
White fluffy spots around macula caused by fat deposits under retina
Seen in dry ARMD
Photo source: https://morancore.utah.edu/basic-ophthalmology-review/wet-versus-dry-macular-degenerative-changes/
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What is the timeline of decline of vision in wet vs dry ARMD?
Dry: 1-2 years
Wet: days to weeks
What is the relative prevalence of wet vs dry ARMD?
Wet = 10% of ARMD Dry = 90% of ARMD
What is the aetiology of wet ARMD?
Aberrant vascular growth into the retina from the choroid that leads to haemorrhage
What test is used during eye examiation to identify macular degeneration?
Amsler grid
How can wet ARMD be managed?
Photodynamic therapy
VEGF inhibitors
How should ARMD be investigated?
Urgent referral to ophthalmology
1st = slit lamp microscopy to identify pigmentory, haemorrhage, exudative changes
If wet ARMD –> fluorescin angiography as this detects abnormal neovascularisation
All pts should get a high-res image of retina = Optical Coherence Tomography
What lifestyle measure is most useful for slowing the progression of ARMD?
Smoking cessation
How can dry ARMD be managed?
Antioxidant vitamins (ACE) and zinc
What is tobacco-alcohol ambylopia?
Toxic effects of cyanide radicals combined with thiamine deficiency
Recall 3 signs and symptoms of tobacco-alcohol ambylopia
Optic atrophy
Loss of red/green discrimination
Scomata
Recall 5 drugs used to manage chronic glaucoma
Those that reduce aqueous production = ABC
Alpha 2 antagonists
Beta blockers
Carbonic anhydrase inhibitors
Those that Increase uveoscleral outflow:
Prostaglandin analogues
Pilocarpine (2nd line)
What IOP counts as ‘increased’?
>21mmHg
Describe 2 features of the optic disc in chronic OA glaucoma?
Atrophy
Cupping
Photo source: https://www.glaucomaassociates.com/glaucoma/what-is-glaucoma/
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Recall 2 RFs for chronic open angle glaucoma
Myopia
FHx
What is the main symptom of chronic open angle glaucoma?
Peripheral vision loss
When does glaucoma screening begin for people with a strong family history of glaucoma?
40 years old
What are the first and second line options for treating chronic open angle glaucoma?
First line: one, then the other, then both:
- timolol/ betaxolol
- Latanoprost
Second line:
- Brimonidine tartrate (alpha-2 antagonist)
- acetazolamide (carbonic anhydrase inhibitor)
- pilocarpine (topical miotic)
What is the surgical option for managing chronic open angle glaucoma?
Laser trabeculoplasty
What does annual eye screening involve for diabetic patients?
Fundus photography
Fluorescin staining
Recall the stages of diabetic retinopathy and their features on fundoscopy
Background: hard Exudates, Microaneurysms and blot Haemorrhages (it’s the lowkey one so it’s MEH)
Pre-proliferative: cotton wool spots and soft exudate
Proliferative: angiogenesis
Maculopathy: hard exudates near the macula
Photo source: https://www.ophthalytics.com/our-technology/diabetic-retinopathy/
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How should diabetic proliferative retinopathy be managed?
Pan-retinal photocoagulation
How should diabetic maculopathy be managed?
Focal retinal photocoagulation
Recall the types of hypertensive retinopathy and their features on fundoscopy
Grade 1: silver wiring and arteriole tortuosity
Grade 2: AV-nipping
Grade 3: flame haemorrhages and cotton wool exudates
Grade 4: papilloedema
Photo source: https://www.sciencedirect.com/science/article/pii/S093336571730427X
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Describe the typical symptoms of cataracts
Dazzling bright lights, haloes, night vision loss
Recall some risk factors for cataracts
Age
Steroids
Diabetes
Smoking
Hypocalcaemia
How is the red reflex affected by cataracts?
It is darkened
How can cataracts be medically managed?
Mydriatic eye drops (tropicamide)
What is the most common complication of cataract surgery?
Posterior capsular opacification
What are the most common, best prognostic and worst prognostic inheritance pattern of retinitis pigmentosa (it has variable inheritance)?
Most common: AR
Best prognosis: AD
Worst prognosis: X-linked
What are the signs and symptoms of retinitis pigmentosa?
Night-blindness, tunnel-vision, blindness by mid-30s
Recall some fundoscopic findings in retinitis pigmentosa
Pale optic disc
Macula-sparing peripheral retinal pigmentation
Photo source: https://www.ncbi.nlm.nih.gov/books/NBK11553/figure/ch36clinicalerg.F12b/
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What mutation is responsible for hereditary retinoblastoma?
RbP gene mutation (a TSG)
Recall 2 signs of retinoblastoma
Strabismus
Leukocoria
Photo source: https://www.aao.org/eye-health/diseases/what-is-retinoblastoma
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Recall the 2 causes of inflammatory eyelid swelling
Stye (hordeolum externum/internum)
Chalazion
What is a stye?
Abscess in lash follicle
What is a chalazion?
Abscess in Meibomian gland after a hordeolum internum
Photo source: https://my.clevelandclinic.org/health/diseases/17657-chalazion
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What is blepharitis?
Chronic eyelid inflammation
Recall 2 causes of blepharitis
Seborrhoeic dermatitis
Staphylococcus
What are the signs and symptoms of blepharitis?
Red gritty/itchy eyes with scales on the lashes
How should blepharitis be managed?
Warm compresses, warm water cleanse BD and topical ABx (chloramphenicol)
What is lagophthalmos?
Difficulty closing the eyelid over the globe leading to exposure keratitis
Recall the signs and symptoms of orbital cellulitis
Inflammation of the orbit, lid swelling and pain on movement
How do the symptoms of periorbital cellulitis differ from orbital cellulitis?
Periorbital cellulitis does not have pain on eye movement or systemic symptoms or vision loss
How should you investigate suspected orbital cellulitis?
CT scan with contrast (orbits, sinuses and brain to assess for posterior spread
How should orbital cellulitis be managed?
IV cefuroxime, urgent ophthalmology referral
What would cause the following eye symptoms?:
- engorgement of eye vessels
- lid and conjunctival oedema
- pulsatile exophthalmos
- eye bruit
Carotid cavernous fistula
What is the layterm for strabismus?
Squint
What are the 2 forms of strabismus, and what is the difference between them?
Concomitant - imbalance of extraocular muscles
Paralytic - paralysis of extraocular muscles
Describe the appearance of the eyes in CNIII vs IV vs VI palsy
CNIII: ptosis, fixed/dilated pupil, ‘down and out’
CNIV: diplopia going downwards
CNVI: diplopia in horizontal plane
What are the 2 most common causes of CN III/IV/VI palsies?
DM
Trauma
Recall 2 vascular causes of CNIII palsy
Cavernous sinus thrombosis
PCA aneurysm
Recall 3 central causes of CNIV/VI palsy
MS
SOL
Vascular
What is the most common type of strabismus in children?
Esotropia (towards the nose)
Recall the ‘4 Os’ of strabismus management
Ophthalmological review
Optical (correct refractive errors)
Orthoptic (eye patch to the GOOD eye to prevent ambylopia)
Operations (rectus muscle resections)
What is the possible serious complication of intra-ocular haemorrhage?
Acute closed angle glaucoma
(Large blood volume may restrict outflow)
What is the aetiology of orbital blowout fracture?
Trauma –> increase in IOP –> orbital contents herniate into sinuses
Recall 5 causes of floaters
Retinal detachment (one of the 4 Fs)
Vitrous haemorrhage
Diabetes
Old retinal branch occlusion
Syneresis (degenerative opacities in vitreous)
Recall 3 causes of haloes in the vision
Cataracts
Corneal oedema
Acute glaucoma
Which pathology typically caues jaggered haloes in the vision?
Migraine
What pathology causes haloes with eye pain?
Acute glaucoma
What are the 1st and 2nd line options for managing seasonal allergic conjunctivitis
1st line: topical antihistamine
2nd line: mast cell stabiliser eg cromoglycate
What tropical eye diseases are spread by flies?
Trachoma (Chlamydia trachomitis)
Onchocerciasis (onchocerca volvulus)
How is trachoma managed?
Tetracycyline
How is onchocerciasis managed?
Ivermectin
What is a sudden, painful loss of vision likely to be due to in a patient with a background of MS?
Optic neuritis - treat with methylprednisolone
How should acute closed angle glaucoma be treated initially?
Refer to ophthalmologist
- Pilocarpine eye drops stat
- Timolol topical
- Acetazolamide 500mg IV stat
- Analgseia and anti-emetics
What is the subsequent management of acute closed angle glaucoma once the immediate presentation has been managed?
Bilateral laser peripheral iridotomy once IOP has decreased
What is the uvea?
Pigmented part of the eye and includes iris, ciliary body and choroid
Iris + ciliary body = anterior uvea
How should anterior uveitis be managed?
Prednisolone and cyclopentolate drops
How can episcleritis be managed?
Topical or systemic NSAIDs
What is the main complication of scleritis to be aware of?
Scleromalacia (scleral thinning) leading to globe perforation
What is the most likely viral cause of conjunctivitis?
Adenovirus
What anti-histamine drops can be used to treat allergic conunctivitis?
Emedastine
How should corneal abrasions be managed?
Give chloramphenicol ointment for infection prophylaxis
Recall some differentials for sudden vision loss and how to differentiate between them
HELLP:
Headache-associated = GCA
Eye movements are painful = optic neuritis
Lights/ flashes prceding = detatched retina
Like a curtain descending = TIA/GCA
Poorly-controlled DM = vitreous bleed from new vessels
What is the cause of non-arteritis anterior ischaemic optic neuropathy?
HTN/ DM/ hyperlipidaemia/ smoking
In which field does vision loss begin in chronic open angle glacuoma?
Nasal superior
How should a stye be treated?
Topical fusidic acid
How should orbital cellulitis be managed?
IV cefuroxime
What is the most likely pathogen in contact-lens associated conjunctivitis?
Pseudomonas
Which type of glaucoma is associated with:
a) hypermetropia?
b) myopia?
Hypermetropia - risk factor for acute closed angle glaucoma
Myopia - risk factor for primary open angle glaucoma
How is Herpes zoster ophthalmicus treated?
Urgent ophthalmological review and 7-10 days of oral antivirals
IV aciclovir reserved for severe infection and immunocompromised
What are the 2 possible mechanisms of sight loss in proliferative diabetic retinopathy?
- Vitreous haemorrhage
- Retinal detachment
What would be seen on fundoscopy on central retinal vein occlusion?
Severe retinal haemorrhages