NSS Flashcards
Ophthal ✔ Neuro - ENT - derm -
What two blood tests will support a diagnosis of a seizure after a fall?seizure
Serum lactate
Serum prolactin
How can red eye be divided into categories, and what are the causes?
Painless- conjunctivitis, episcleritis, subconjunctival haemorrhage
Painful- acute glaucoma, anterior uveitis, scleritis, corneal ulcer or abrasion, keratitis, foreign body, trauma/chemicals
Vision loss- Corneal ulceration, glaucoma
What are the causes of painful vision loss?
Acute closed angle glaucoma
Corneal abrasion
What are the causes of painless vision loss?
Cataracts
AMD
Retinal detachment
Retinal vein occlusion
Central retinal artery occlusion
Retinitis pigmentosa
Vision loss is described as a painless shadow/ curtain coming across vision. What are the likely dx? How can you tell the difference o/e?
Retinal detachment or Central retinal artery occlusion (will have RAPD)
Vision loss is described as painless gradual loss of central vision. What is the likely dx?
AMD
What conditions are associated with anterior uveitits?
Autoimmune conditions:
-Seronegative spondyloarthropathies, e.g. ankylosing spondylitis, psoriatic arthritis and reactive arthritis
-Inflammatory bowel disease
-Sarcoidosis
-Behçet’s disease
What is the first line management for anterior uveitis?
Steroids
Cycloplegics e.g. cyclopentolate or atropine
How do cycloplegics work?
They dilate the pupil and reduce pain associated with ciliary spasm by paralysing the ciliary muscles. They reduce the action of the iris sphincter muscles and ciliary muscles.
Symptoms:
Painful red eye
Reduced visual acuity
Photophobia
Excessive lacrimation
What is the diagnosis?
Scleritis or Anterior uveitis
What are the signs of anterior uveitis?
Ciliary flush
Miosis
Abnormal shape pupil - due to synechiae
Hypopyon
What is the definitive management of cataracts?
Phacoemulsification
What is the main complication of phacoemulsification?
Endophthalmitis
Symptoms:
Severely painful red eye
Blurred vision
Halos around lights
Associated headache, nausea and vomiting
What is the likely diagnosis?
Acute closed angle glaucoma
What can be done to manage acute closed angle glaucoma, before reaching hospital?
Lying the pt on their back
Pilocarpine eye drops
Acetazolamide
Analgesia and anti emetic
What is the definitive management of acute closed angle glaucoma?
Laser iridotomy
What examination is done to diagnose keratitis, and what does it show?
Slit lamp examination with fluorescein staining, showing a dendritic corneal ulcer
What are the risks with posterior vitreous detachment?
Retinal tears
Retinal detachments
What are the risk factors for retinal detachment?
Lattice degeneration/thinning of retina
PVD
Trauma
Diabetic retinopathy
Retinal malignancy
Family history
Symptoms:
Peripheral vision loss- shadow coming across vision
Blurred or distorted vision
Flashes and floaters
What is the likely diagnosis?
Retinal detachment
What are the options for reattaching the retina in retinal detachment?
Vitrectomy
Scleral buckling
Pneumatic
What are the most common causes of central retinal artery occlusion? And what are the risk factors for them?
GCA:
White ethnicity
Older
Female
PMR
Atherosclerosis:
Smoking
Hypertension
Diabetes
Hyperlipidaemia
What does a pale retina and cherry red spot suggest on fundoscopy?
Central retinal artery occlusion
What are the risk factors for retinal vein occlusion?
HTN
Hyperlipidaemia
DM
Smoking
High plasma viscosity e.g. myeloma
Myeloproliferative disorders
Inflammatory conditions e.g. SLE
What are the fundoscopy findings of retinal vein occlusion?
‘Blood and thunder’ appearance
Dilated tortuous retinal veins
Flame and blot haemorrhages
Retinal oedema
Cotton wool spots
Hard exudates
How is orbital compartment syndrome managed?
Urgent lateral canthotomy
What is the finding of dry AMD on fundoscopy?
Drusen
What can cause optic neuritis?
MS most common
Living at high altitude
Autoimmune disorders
Infectious conditions
What is the classic triad of optic neuritis?
Vision loss- central plus red green colour blind
Periocular pain
Dyschromatopsia
What is first line management of optic neuritis?
IV methylprednisolone
What is the most definitive way to diagnose optic neuritis?
MRI of the brain and orbits with gadolinium contrast
What are the risk factors for cataracts?
Increasing age
Smoking
Alcohol
DM
Steroids
Hypocalcaemia
What are the risk factors for AMD?
Age
Smoking
Caucasian
CVD, HTN
Light iris
Hyperopia
FMH- genetic component linked to drusen formation
What are the stages of dry AMD? Describe them
Early - few medium drusen
Intermediate- one or more large drusen, or many medium. Global atrophy not affecting macular centre.
Advanced- Drusen and global atrophy extend to the macular centre. May have gradual vision loss.
What is worse, soft or hard drusen? Why?
Soft is worse as it can lift the RPE away from Bruch’s membrane. Can result in inflammation and hypoxic state.
Soft drusen is more likely to promote progression to advanced AMD.
How is dry AMD managed?
Self monitoring using Amsler grid
Inc dietary or supplementary vit A
Protect eyes from sunlight
Avoid smoking
What protein plays a key role in converting dry AMD into wet AMD?
VEGF-A
How is wet AMD managed?
Anti VEGF medication injections, monthly:
Ranibizumab
Aflibercept
Bevacizumab
What treatment can be given to differentiate between scleritis and episcleritis?
Phenylephrine eye drops- will blanch the episcleral vessels, but will not affect episcleritis
What is episcleritis and what conditions is it associated with?
Inflammation of the episclera, the outermost layer of the sclera (just beneath the conjunctiva)
Associated with inflammatory conditions e.g. RA, IBD.
How can you differentiate scleritis from episcleritis from history and examination?
Scleritis has symptoms in addition to the red sclera and congested vessels:
Severe pain, and pain with eye movement
Photophobia
Epiphora
Reduced visual acuity
Tenderness to palpation of the eye
What are the causes of scleritis
Idiopathic
Underlying systemic condition, like:
-RA
-Vasculitis e.g. granulomatosis with polyangiits
Infection
How is scleritis managed?
Urgent assessment by ophthal
NSAIDs
Steroids
Immunosuppression for underlying condition
Antibiotics if infectious scleritis
What is the most severe type of scleritis?
Necrotising scleritis
Can lead to perforation of the sclera
How is episcleritis managed
Self limiting condition, in 1-2 weeks
Analgesia and lubricating eye drops.
What is the pathophysiology of diabetic retinopathy?
Hyperglycaemia damages small retinal vessels and endothelial cells
Inc vasc permeability= blot haemorrhages and hard exudates (lipids and proteins)
Damage to the blood vessel walls= microaneurysm and venous beading
Damage to nerve fibres causes cotton wool spots
Tortuous capillaries form AV malformations
Growth factors are released causing neovascularisation
What are the treatment options for proliferative diabetic retinopathy?
Pan retinal photocoagulation
Anti VEGF intravitreal injections
Surgery e.g. vitrectomy
What are the grades of diabetic retinopathy, based on the findings on fundus examination?
Background- microaneurysms, retinal haemorrhages, hard exudates and cotton wool spots
Pre-proliferative – venous beading, multiple blot haemorrhages, AV malformation
Proliferative- neovascularisation and vitreous haemorrhage
Also, can be classified depending on if there is macular oedema/involvement or not.
What are the features on fundoscopy of hypertensive retinopathy?
Silver wiring
AV nipping
Cotton wool spots
Hard exudates
Retinal haemorrhages
Papilloedema - ischaemia to the optic nerve
What is the Keith Wagener classification?
HTN retinopathy:
1- mild arteriole narrowing
2- AV nipping
3- cotton wool patches, exudates, haemorrhages
4- papilloedema
What can cause painless peripheral vision loss?
Open angle glaucoma
Retinitis pigmentosa
What is the name of the condition whereby visual hallucinations occur due to significant vision loss?
Charles Bonnet syndrome
What are the risk factors for open angle glaucoma?
Myopia- short sightedness
Increasing age
Black ethnic origin
FMHx
What are the ways in which we can measure intraocular pressures?
Non contact tonometry
Goldmann applanation tonometry
What is the normal intraocular pressure, and at what pressure is treatment needed for glaucoma?
Normal is 10-21
Treatment at 24mmHg or above
What is the key finding on fundoscopy in open angle glaucoma?
Disk cupping:
The optic cup is more than 50% of the optic disk
What is the most common cause of normal pressure glaucoma, and how is it investigated?
Over treating HTN causes hypotension and optic nerve ischaemia at night
24 hour BP is done
What are the side effects of latanoprost?
Eyelash growth
Eyelid pigmentation
Iris pigmentation
What are the medical management options for open angle glaucoma? What is their MoA? Which is first line?
Prostaglandin eye drops increase the uveoscleral outflow, and are first line. E.g. Latanoprost.
B-blocker timolol reduces aqueous humour production.
Carbonic anhydrase inhibitor dorzolamide reduced aqueous humour production.
Sympathomimetic brimonidine reduces aqueous humour production and increases uveoscleral outflow
What are the surgical management options for open angle glaucoma?
Trabeculotomy- creates a channel from the anterior chamber through the sclera to just under the conjunctiva. Forms a bleb under the conjunctiva.
Laser iridotomy- more for emergencies
What is the normal route and physiology of aqueous humour?
Provides nutrients to the cornea.
Produced in the ciliary body. Flows through the posterior chamber and around the iris to the anterior chamber. Drains through the trabecular meshwork to the canal of Schlemm. Re-enters circulation.
What symptoms can be caused by closed angle glaucoma?
Peripheral vision is affected first. Gradual tunnel vision develops.
Intermittent pain
Headaches
Blurred vision
Halos around lights
What are the risk factors for closed angle glaucoma?
Increasing age
FMH
Female
Chinese or east asian
Hyperopia
Medications- adrenergic, anticholinergic, tricyclic antidepressants