Multisystem disease in ophthalmology

Question 1

Describe the pathophysiology of diabetic eye disease

Answer 1

Capillary endothelial change → vascular leak → microaneurysms → capillary occlusion →local hypoxia + ischaemia → new vessel formation. High retinal blood flow caused by hyperglycaemia (and ­ BP and pregnancy) triggers this, causing capillary pericyte damage. Microvascular occlusion causes cotton-wool spots (± blot haemorrhages at interfaces with perfused retina). New vessels form on the disc or ischaemic areas, proliferate, bleed, fibrose, and can detach the retina.

Question 2

What age does diabetic retinopathy start?

Answer 2

12

Question 3

how often do patients have diabetic retinopathy screening check ups?

Answer 3

Once per year

Question 4

How long after having their eyes checked for diabetic retinopathy should a patient not drive for?

Answer 4

6 hours

Question 5

What are the features of background diabetic retinopathy?

Answer 5

1. microaneurysms
2. retinal haemmorhages
   3.

Question 6

What are the features of preproliferative diabetic retinopathy?

Answer 6

• venous beading
• venous reduplication
• IRMA-intraretinal microvascular abnormalities
• multiple deep round haemorrhages
• cotton wool spots

Question 7

What are the features of proliferative diabetic nephropathy?

Answer 7

1. New vessels
2. Pre-retinal or vitreous haemorrhage
3. preretinal fibrosis or tractional detachment

Question 8

What are the features of maculopathy?

Answer 8

1. Exudate within one disc diameter of the macula
2. any microaneurysm near the fovea

Question 9

Which categories of diabetic retinopathy require referral?

Answer 9

preproliferative and above

Question 10

What is the medical management of clinically significant macular oedema?

Answer 10

Eyes with centre-involving CSMO require intravitreal anti-vascular endothelial growth factor (VEGF) therapy. Anti-VEGF therapies include the monoclonal antibodies ranibizumab, bevacizumab, and the fusion protein aflibercept.

Question 11

What is the principle risk of intravitreal injection?

Answer 11

The principal adverse effect of intravitreal anti-VEGF therapy is endophthalmitis, which has an incidence of approximately 0.05% to 1%

Question 12

What is the intervention for high risk proliferative diabetic retinopathy?

Answer 12

Pan retinal photocoagulation

Question 13

If pan retinal photocoagulation can not be attempted for any reason then what can be attempted?

Answer 13

vitrectomy

Question 14

What is the TEARS mnemonic for management of thyroid eye disease?

Answer 14

• tobacco abstinence
• euthyroid
• artifical tears
• referral to specialist centre
• self help groups

Question 15

What are the characteristic features of thyroid eye disease?

Answer 15

Thyroid eye disease is a condition in which the eye muscles, eyelids, tear glands and fatty tissues behind the eye become inflamed. This can cause the eyes and eyelids to become red, swollen and uncomfortable and the eyes can be pushed forward (‘staring’ or ‘bulging’ eyes).

Question 16

What are the principles of care for raised intracranial pressure?

what are the principles of care for raised intracranial pressure refractory to initial management?

Answer 16

1. Medical management of increased ICP should include sedation, drainage of CSF, and osmotherapy with either mannitol or hypertonic saline.
2. For intracranial hypertension refractory to initial medical management, barbiturate coma, hypothermia, or decompressive craniectomy should be considered.

Question 17

Which way does a 3rd nerve palsy go?

Answer 17

Down and out

Question 18

What is the difference between a medical and a surgical third nerve palsy?

Answer 18

“Medical”: pupil sparing (and painless)

“Surgical”: pupil fixed and dilated

Pathology

Parasympathetic fibres are situated on the periphery of the 3rd nerve trunk and so are the first to be affected by compression resulting in a fixed and dilated pupil.

The classic cause of a “surgical” 3rd nerve palsy is a posterior communicating artery aneurysm. The vaso vasorum which supplies the 3rd nerve starts from the centre and supplies out radially.

In “medical” 3rd nerve palsies the centre of the 3rd nerve is affected first leaving the parasympathetic fibres and therefore pupillary constriction intact until the end.

Question 19

Which way does a 4th and 6th nerve palsy go?

Answer 19

Question 20

Which cranial palsy is sometimes regarded as a false localising sign? Why?

Answer 20

• VI
• As the abducens nerve enters the subarachnoid space, other etiologies may arise resulting in palsy. In these cases, the palsy is primarily because of the increased intracranial pressure. As such, other symptoms such as a headache, nausea, vomiting, and papilledema may be noted

Question 21

What are the clinical features of MS related optic neuritis?

Answer 21

• RAPD
• Loss of central vision
• pain on moving the eye

Question 22

What is the management of MS related optic neuropathy?

Answer 22

Optic neuritis usually improves on its own. In some cases, steroid medications are used to reduce inflammation in the optic nerve. Possible side effects from steroid treatment include weight gain, mood changes, facial flushing, stomach upset and insomnia. Steroid treatment is usually given by vein (intravenously)

Question 23

What eye signs do anterior circulation strokes lead to?

Answer 23

homonymous hemianopia

Question 24

what eye signs do posterior circulation strokes lead to?

Answer 24

Cranial nerve palsies

Question 25

Which two ocular diseases are commonly associated with HIV?

Answer 25

Cytomegalovirus retinitis and mycobacterium-avium complex disease are usually seen in patients with profound reductions of CD4 counts

Question 26

What is the treatment of CMV ocular infection?

Answer 26

Treatment of CMV retinitis is with intravenous ganciclovir administered as an initial, high-dose induction therapy (5 mg/kg twice daily for 2 weeks) followed by long-term maintenance therapy (5 mg/kg once daily).

Question 27

Giant cell arteritis is ________ ______ of the ______ artery that risks blindness through ischaemic optic neuropathy

Answer 27

• granulomatous
• inflammation
• temporal

Question 28

What are the investigations for GCA?

Answer 28

Investigation =CRP ESR, +ve Temporal Artery Biopsy (granulomatous inflammation)

Question 29

What is the management of visually sparing GCA?

What is the management of visually affecting GCA?

Answer 29

1. prednisolone
2. methylprednisolone

Question 30

Which ocular sign is sarcoidosis associated with?

Answer 30

Uveitis

Question 31

Which ocular sign is SLE associated with?

Answer 31

ocular vessel constriction

Question 32

What is the number 1 ocular sign seen in RA?

Answer 32

keratoconunctivitis sicca

Question 33

What two ocular signs are seen in behcets syndrome?

Answer 33

uveitis, and retinal vasculitis