Normal vs Abnormal Flashcards
What is the referral urgency for POAG?
Routine
What are the signs for POAG?
Optic disc cupping - vertical size changes, not following ISNT
Reproducible VF defect consistent with disc appearance
IOP >21mmHg
What are the symptoms for POAG?
Usually asymptomatic until significant VF loss
What are the signs of POAG at the optic disc?
Loss of ISNT rule
Asymmetrical discs >0.2
Vertical enlargement
CD >0.7 (changed since last visit or new px)
Focal narrowing or notching of NRR
Concentric/generalised atrophy
Peripapillary Atrophy (PPA)
Sharpened nasal edge
Visible lamina cribosa
Pallor
Saucerisation
Baring of circumlinear vessels
Bayonetting (vessels entering at 90 degrees)
Collaterals
Disc haem (flame-shaped at rim)
RNFL thinning
What are the risk factors for POAG?
Increasing age
Female
OHT
FH for first degree relative
Thin CCT
Myopia >4D
Diabetes
Systemic hypertension
West African or African-Caribbean ethnicity (onsets at younger age)
What are the differential diagnoses for POAG?
OHT
Tilted discs
Physiological cupping
Disc drusen
Anterior ischaemic optic neuropathy
Secondary glaucoma
Optic atrophy
Glaucomatous VF defect from another condition
What are the signs of OHT?
IOP >21mmHg with no other glaucomatous signs or sxs
What is the referral urgency for OHT?
Routine
What are the RFs for OHT?
HBP
Afro-Caribbean race
Increasing age
What are the differential diagnoses for OHT?
POAG
PACG
Secondary OAG
What is the referral urgency for NTG?
Routine
What are the signs of NTG?
IOP consistently <21mmHg
Glaucomatous VF defect
Glaucomatous optic disc
Peripheral vasospasm
What are the symptoms of NTG?
Migraines
Otherwise asymptomatic
What are the differential diagnoses for NTG?
POAG
Intermittent ACG
Secondary OAG
Ischaemic optic neuropathy
What are the RFs for NTG?
Hypotension
Thin cornea
Female
Glaucomatous discs
What is the referral urgency for Acute ACG?
Emergency (same day)
What are the signs of Acute ACG?
Dilated limbal/conjunctival vessels - hyperaemia
V high IOP (40-80mmHg)
Corneal epithelial/stromal oedema
Descemet’s folds due to oedema
Shallow or flat AC
Fixed, mid dilated, oval pupil which doesn’t react to light (RAPD present)
Iris bombe
Peripheral anterior synechiae
What are the symptoms of Acute ACG?
Reduced vision
Haloed lights
Headache
Pain
Nausea and/or vomiting
What are the risk factors for Acute ACG?
FH of AACG
Hyperopia
Chinese ethnicity
40-50 years old
Female
What are the differential diagnoses for Acute ACG?
Acute conjunctivitis
Uveitis
Keratitis
Trauma
Inflammation
Neovascular glaucoma
Secondary ACG
What is the referral urgency for optic neuritis?
Urgent
What causes optic neuritis?
Inflammatory or demyelinating disorder of the optic nerve head unilaterally
What are the symptoms of optic neuritis?
Rapid vision loss in one eye
Retro-orbital pain
Ocular pain
Visual loss worse in heat or during exercise
What are the signs of optic neuritis?
RAPD
VA loss
Central scotoma
Severely impaired colour vision
Fundus normal but blurred disc margins
Swollen veins
What are the RFs for optic neuritis?
Younger age
Female
MS
Viral infections
Tuberculosis
Syphilis
What are the differential diagnoses for optic neuritis?
Arteritic anterior ischaemic optic neuropathy
Non-arteritic anterior ischaemic optic neuropathy
Papilloedema
What is papilloedema?
Swelling of the optic nerve - inflammatory or demyelinating bilaterally
What are the mechanical signs of papilloedema?
ONH elevation
Blurred optic disc margin
Physiological cup filling in
Peripapillary RNFL oedema
Retinal and/or choroidal folds
What are the vascular signs of papilloedema?
Disc hyperaemia
Loss of spontaneous venous pulsation and venous congestion
Papillary/peripapillary haem
Hard exudates
Cotton wool spots
Enlarged blind spot on VF
Diplopia due to CN VI palsy
What is the referral urgency for papilloedema?
Urgent
What can cause papilloedema?
Brain tumours
Meningitis
Hydrocephalus
Pseudo-tumour cerebri (raised intracranial pressure with no other intracranial pathology)
What are the symptoms of papilloedema?
Severe headaches
Nausea
Explosive vomiting
Amaurosis fugax (transient blanking of vision - otherwise normal)
What are the differential diagnoses for papilloedema?
Optic disc drusen
Malignant hypertension
Pseudopapilloedema
CRVO
Anterior ischaemic optic neuropathy
Optic neuropathy
What is the referral urgency for hypertensive retinopathy?
Emergency
What are the signs of hypertensive retinopathy?
Focal arteriolar narrowing
Arteriosclerotic changes
Flame haem on nerve fibres
Cotton wool spots
Disc oedema
Macular star
What are the symptoms of hypertensive retinopathy?
Headache
Blurred vision
Altered conscious state
Palpitations
Chest pain
What are the differential diagnoses for hypertensive retinopathy?
Diabetic retinopathy (esp if less sxs)
CRVO
Radiation retinopathy
What are the signs of CRVO?
Haem in all quadrants (deep and dark) due to ishchaemia
Dilated, tortuous veins
RAPD
Multiple cotton wool spots due to ischaemia
Macular oedema
Poss rubeosis iridis (iris neovasc)
Neovasc (disc or elsewhere - NVD or NVE)
What is the referral urgency for CRVO?
Urgent
What are the symptoms of CRVO?
Sudden vision loss (<6/36)
No pain
What are the RFs for CRVO?
Smoking
Diabetes
Hypertension
Hyperlipidaemia
Hyperviscosity of blood
What are the differential diagnoses for CRVO?
POAG
BRVO
Hypertensive retinopathy
Diabetic retinopathy
What are the signs for BRVO?
Flame, dot and blot haem next to dilated and tortuous vein
Only in one area of retina, not usually crossing horizontal midline
Exudates
Occlusion at A/V crossing (arteriole anterior to vein)
What are the symptoms for BRVO?
Often asymptomatic unless affecting large area of retina or the macula
What is the referral urgency for BRVO?
Urgent
What are the RFs for BRVO?
Hypertension
Cardiovascular disease
Lipid abnormality
What are the differential diagnoses for BRVO?
CRVO
Hypertensive retinopathy
Diabetic retinopathy
What are the signs of CRAO?
VA = LP or worse
RAPD
Poss visible emboli in vessel
Narrowed vessels
Pale retina
Macula cherry red spot
Optic disc pallor (paler as NFs degenerate)
What is the referral urgency for CRAO?
Emergency
What are the symptoms of CRAO?
Severe, sudden, painless loss of vision unilaterally
Poss previous amaurosis fugax (transient loss of vision)
What are the differential diagnoses for CRAO?
Macular haem
Retinal detachment
Anterior ischaemic optic neuropathy
What are the signs of BRAO?
Areas of retinal infarction (whitening)
Narrowed vessels
(Size of affected area and likelihood of macular oedema dependant on location of occlusion)
What is the referral urgency for BRAO?
Urgent - if no macular involvement
Emergency - of foveal involvement and recent onset
What are the symptoms of BRAO?
Unilateral, no pain
Poss previous amaurosis fugax (transient loss of vision)
Loss of vision if macula involved
What are the differential diagnoses for BRAO?
Hypertensive retinopathy
Diabetic retinopathy
What are the signs of Arteritic Anterior Ischaemic Optic Neuropathy (AAION)?
Sudden, profound, permanent vision loss (preceded by amaurosis fugax attacks)
Swollen, pale optic disc
Peripapillary haemorrhages
Cupping (late stage)
Temporal artery thick and pulseless
What is the referral urgency for AAION?
Emergency
What are the symptoms of AAION?
Headache
Pain in temple/neck
Scalp tenderness
Pain while chewing
Weight loss
Fatigue
Neck stiffness
What are the differential diagnoses for AAION?
Non-AAION
Optic neuropathy
CRAO
CRVO
What causes AAION?
Occlusion of posterior ciliary artery
Associated with Giant cell arteritis
What causes Non-Arteritic Anterior Ischaemic optic neuropathy (Non-AAION)?
Atherosclerosis
What are the signs of Non-AAION?
Sudden, painless vision loss (not severe, altitudinal hemianopia)
Reduced colour vision
Pale or oedematous optic disc
Fellow eye’s cup is small or absent
What is the referral urgency for Non-AAION?
Urgent
What are the symptoms of Non-AAION?
No systemic symptoms
Vision loss
What are the differential diagnoses for Non-AAION?
AION
Optic neuropathy
CRVO
Tumour
Hypertensive retinopathy
What are the signs of Background Diabetic Retinopathy?
Microaneurysms
Retinal Haemorrhages
Venous loop
Hard exudates and Cotton Wool Spots (if other signs present)
What are the symptoms of Background Diabetic Retinopathy?
None
What is the referral urgency for Background Diabetic Retinopathy?
Refer via GP to diabetic eye screening service (if not already attending)
What are the signs of Pre-proliferative Diabetic Retinopathy?
Background DR signs +
Venous beading
Venous reduplication
Multiple deep, round haem or blot haem
Intraretinal microvascular abnormality (IRMA): dilated capillaries
What is the referral urgency for Pre-proliferative Diabetic Retinopathy?
Refer via GP to diabetic eye screening service (if not already attending)
What are the symptoms of Pre-proliferative Diabetic Retinopathy?
None
What are the differential diagnoses for Pre-proliferative DR?
Hypertensive Retinopathy
CRVO
BRVO
What are the signs of Proliferative Diabetic Retinopathy?
Neovasc (disc and elsewhere)
New pre-retinal haem
New vitreous haem
New pre-retinal fibrosis
New tractional retinal detachment
What is the referral urgency for Proliferative Diabetic Retinopathy?
Urgent
What are the symptoms of Proliferative Diabetic Retinopathy?
Vision loss
May be asymptomatic if macula not involved
What are the differential diagnoses for Proliferative DR?
Hypertensive Retinopathy
CRVO
BRVO
What are the signs of diabetic maculopathy?
Exudate within 1 disc diameter of central fovea
Group of exudates within macula
Macular oedema within 1 disc diameter of central fovea
Microaneurysm or haem within 1 disc diameter of central fovea
What are the symptoms of diabetic maculopathy?
Central vision loss
Metamorphopsia if macular oedema
What is the referral urgency for diabetic maculopathy?
Routine
Urgent if best VA <6/12
What is a retinal break?
Full thickness defect in sensory retina
What is a retinal tear?
Retinal break associated with vitreous traction
What are the symptoms of the retinal break/tear?
Acute: Flashing lights, recent hx of head or ocular trauma
Chronic: may be asymptomatic
What is the referral urgency for a retinal break/tear?
Urgent: if incidental finding, no sxs, no subretinal fluid or pigment change at border of break/tear
Emergency: if subretinal fluid or sxs
What are the signs of a retinal break/tear?
Red lesion
What are the types of retinal break/tear?
Flap/horseshoe
Operculated
Retinal dialysis
Giant tear
Retinal hole
What are the symptoms of a Rhegmatogenous retinal detachment?
Flashes
Floaters
Veil/curtain/spider webs in vision
Wavy/watery vision
Poss asx if no macula involvement
What are the differential diagnoses for Rhegmatogenous retinal detachment?
Retinoschisis
Exudative retinal detachment
Tractional retinal detachment
What is the referral urgency for Rhegmatogenous retinal detachment?
Emergency
What are the signs of Rhegmatogenous retinal detachment?
Elevation of retina from RPE
Full thickness retinal break or tear
Translucent/corrugated appearance of detached retina
No movement of subretinal fluid on eye movements
Shafer’s sign (tobacco dust)
PVD
Vitreous haem
Reduced IOP
RAPD if severe
Line of demarcation at posterior if longstanding
What is a choroidal naevus?
Common, benign choroidal tumour made up of melanocytes
What are the signs of a choroidal naevus?
Flat, pigmented lesion
Diffuse edges
Grey
Subretinal
What are the symptoms of a choroidal naevus?
None unless malignant
What are the signs of malignancy in a choroidal naevus?
Continued growth through adulthood
Over 2mm thick
Subretinal fluid
Orange pigment (lipofuscin)
Edge near optic disc
No drusen on the surface of lesion
Symptoms: flashes, floaters, vision loss
What is the referral urgency for a choroidal naevus?
None if benign
Routine or urgent if suspicious
What are the signs of Dry AMD?
Drusen (small/hard if mild, large/soft if moderate)
Focal pigmentation from RPE
Macular atrophy
What are the symptoms of Dry AMD?
Blurred vision
Slight metamorphopsia
What are the RFs for Dry AMD?
Age
Smoking
What is the differential diagnosis for Dry AMD?
Wet AMD
What’s the management for Dry AMD?
No referral as no treatment available
Advise to look out for change in vision and metamorphopsia (give Amsler chart)
Regular monitoring
Advise to stop smoking, improve diet
What are the signs of Wet AMD?
Choroidal neovascular membrane: grey subretinal distortion
Haem and damage in central fundus due to CNM
Scars within photoreceptor layers
Disciform scarring at macula (late AMD)
What are the symptoms of Wet AMD?
Metamorphopsia
Major central vision loss/impairment
What are the RFs for Wet AMD?
Smoking
Age
Dry AMD
Wet AMD in fellow eye
What are the differential diagnoses for Wet AMD?
Diabetic retinopathy
Vascular occlusion
What is the management for Wet AMD?
Anti-VEGF injections (under HES)
Give Amsler chart
What is the referral urgency for Wet AMD?
Urgent
What is the management for new floaters?
Explain what floaters are and what to watch out for (sxs)
Advise of retinal detachment risk
Give info leaflet
Record discussion on record
What are the signs of a Posterior Vitreous detachment (PVD)?
Weiss ring (full or partial)
Macular oedema if PVD at macula
What are the symptoms of a PVD?
Floaters (new or increase)
Flashes in temporal peripheral vision
What are the RFs for a PVD?
Age
Myopic
What is the management/referral urgency for a PVD?
Annual review
Emergency referral if signs of retinal detachment or break
What are the signs of anterior uveitis?
Hyperaemia (ciliary injection)
Keratic Precipitates
Aqueous cells
Aqueous flare
Poss raised IOP
Posterior synechiae - may cause pupil block and iris bombe
Iris nodules
What is the referral urgency for anterior uveitis?
Emergency
What are the symptoms of anterior uveitis?
Sudden onset
Unilateral (usually)
Pain (dull/ache), worse on pupil constriction
Photophobia
Redness
Reduced vision
Increased lacrimation
What are the differential diagnoses for anterior uveitis?
ACG
Conjunctivitis
Lens-induced uveitis
Intraocular FB
What are the other forms of uveitis?
Intermediate (posterior ciliary body and anterior choroid)
Posterior (choroid, poss retina, optic disc, retinal vasculature)
Panuveitis (whole uvea inflamed)
What are the signs of episcleritis?
Hyperaemia (episcleral vessels not conjunctival, blanches with vasoconstrictors)
Sectoral or nodular redness
Ant Chamb ok
Cornea ok
Palpebral conj ok
VA ok
What are the symptoms of episcleritis?
Acute onset
Unilateral red eye
Mild ache/burning sensation
Poss tender on palpation
Poss watery
Recurrent
What is the referral urgency for episcleritis?
Refer for investigation at third episode
What are the RFs for episcleritis?
Systemic disorders like rheumatoid arthritis, IBS, systemic lupus erythematous
Gout
Ocular rosacea
Previous episodes
Herpes zoster ophthalmicus
40-50 years old
What are the differential diagnoses for episcleritis?
Conjunctivitis
Scleritis
Anterior Uveitis
What are the signs of scleritis?
Unilateral
Deep hyperaemia (doesn’t blanche with vasoconstrictors)
Poss anterior uveitis also present
Globe tenderness
What are the symptoms of scleritis?
Severe pain (worse on eye movement, may disturb sleep)
Gradual onset
Globe tenderness
Photophobia
Epiphora (watery)
Visual loss
Poss prev episodes
What is the referral urgency for scleritis?
Emergency
What are the RFs for scleritis?
Middle age
Female
Systemic inflammatory disease (rheumatoid arthritis, IBS, syphilis, systemic lupus erythematous, sarcoidosis, TB)
Local causes (trauma, surgery, herpes zoster)
What are the differential diagnoses for scleritis?
Episcleritis
What are the possible complications from scleritis?
Cataract
Glaucoma
Retinal detachment
What are the signs of bacterial conjunctivitis?
Lid crusting
Purulent or mucopurulent discharge
Hyperaemia
Poss mild papillary reaction on tarsal conjunctiva
Cornea ok usually
What are the symptoms of bacterial conjunctivis?
Redness
Discomfort/grittiness
Discharge
Blurred vision due to discharge
Unilateral (often spreads to other eye)
What is the referral urgency for bacterial conjunctivitis?
Only refer is not resolving or corneal involvement
What are the signs of viral conjunctivitis?
Watery discharge
Hyperaemia
Palpebral conjunctiva follicles
Petechial subconjunctival haem
Pre-auricular lymphadenopathy (poss sore throat and fever)
Sometimes corneal involvement
What is the referral urgency for viral conjunctivitis?
No referral usually
Emergency if very severe (significant keratitis - pain, loss of vision)
What are the symptoms of viral conjunctivitis?
Wateriness
Redness
Discomfort
Lids stuck together on waking (no discharge)
Unilateral at first
What are the differential diagnoses for viral conjunctivitis?
Bacterial or allergic conjunctivitis
Chlamydial or herpetic conjunctivitis
AACG
Keratitis
Anterior uveitis
What are the signs of allergic conjunctivitis?
Increased lacrimation
Hyperaemia
Inflammation of tarsal conjunctiva
Lid margin ok
What are the symptoms of allergic conjunctivitis?
Itching
Burning
Watery eyes
Photophobia
Pain
Blurred vision
Mucous discharge
Sneezing
Nasal congestion
What is the referral urgency for allergic conjunctivitis?
No referral unless persistent or px wants referral
What are the differential diagnoses for allergic conjunctivitis?
Atopic bleph
Bacterial or chlamydial conjunctivitis
Corneal abrasions or ulcers
Dry eye
Episcleritis
Marginal and punctate keratitis
Viral infection
Tight lens syndrome
How can allergic conjunctivitis be treated?
Reduced exposure to trigger
Antihistamines
Mast cell stabilisers
Cold compress
Vasoconstrictors
Topical steroids
Immunotherapy
