Ophth 2 Flashcards
Define hypopion
Pus in anterior chamber
Due to corneal ulcer
Treatment of hypopion
Hourly antibiotic drops in eye
(OFLOXACIN, bacteriocidal)
Avoid contact lenses
Send the contacts off for MC&S
What is the worst case scenario after a hypopion
Corneal ulcer perforates
Iris prolapses
Endopthlamitis and loss of eye
What is fluorescin used to diagnose?
- Corneal ulcers
- Dendritic (herpetic) ulcers
- Corneal abrasion
- Dry eye (pin pricks)
3 types of cataract
Green/yellow, common: Nuclear sclerosis
Steroid use, diabetes: Posterior subcapsular
Spokes of opacity: Cortical
Symptoms of cataracts
- May improve near sight
- Decreased contrast
- Glare
- Duller colours
Name 3 complications of cataract surgery
- Endophthalmitis
- Iris prolapse
- Uveitis
What is used to see whether someone’s vision is distorted?
Amsler chart
Grid patter
Close one eye, focus on black central dot
What is an Amsler chart?
Diagnoses distortion
Close one eye, focus on black central dot.
Grid pattern.
What does wet AMD look like on fundoscopy?
Haemorrhage and exudate (creamy) and fluid are confined to macula
No disc swelling, vessels are not tortuous
Name the bones that make up the orbit
Frontal Maxilla Zygomatic Sphenoid Palatine Ethmoid Lacrimal
Where in the orbit is most at risk from blunt trauma?
Medial wall and floor (thinner with sinuses beneath them)
If someone comes in after a tennis ball to the orbit, what do you do?
Loss of consciousness? (witness collateral history). Mechanism of injury? Other injuries? Previous ocular/medical/drug history. Tetanus prophylaxis.
• Visual acuity
• Gentle exam of lid, orbit, eye (don’t press due to perforation)
• Eye movements
• Note extent of other injuries (eg max fax)
Xrays and CT scans to identify fractures
What does an eye examination entail?
- Lid
- Conj
- Cornea
- Anterior chamber
- Iris/pupil
- Lens
- Intraocular pressure
- Vitreous
- Retina
If blood is seen in anterior chamber, where did it come from? What can it lead to? What is it called?
Hyphema
Usually from iris vessels
Can lead to ocular hypertension due to blockage of filtering system
Define iridodialysis
Disinsertion of the iris root, iris comes away from ciliary body. Pupil becomes misshapen.
What does a traumatic cataract look like?
Traumatic cataracts occur secondary to blunt or penetrating ocular trauma.
Cataracts caused by blunt trauma classically form stellate- or rosette-shaped posterior axial opacities that may be stable or progressive, whereas penetrating trauma with disruption of the lens capsule forms cortical changes that may remain focal if small or may progress rapidly to total cortical opacification.
What can happen to the retina after blunt trauma?
Commotio retinae:
Yellowish sheen on retina, sheer effect due to trauma.
Define choroidal rupture
Breaks in the choroid, the Bruch membrane, and the retinal pigment epithelium (RPE) that result from blunt ocular trauma
White concentric lines of rupture due to torsion around optic nerve
What will perforation of the eye look like?
Tear drop pupil with iris poking out
If there is hx of high velocity injury, what investigation is needed?
Xray to pick up metal in back of eye
What happens if metal is not found and stays in back of eye?
Siderosis: iris colour changes, pupil becomes sluggish. Due to metal foreign body.
What is seen in diabetic retinopathy
- Microaneurysms
- Leakage (hard exudates, haemorrhage)
- Occlusion
- VEGF-> Angiogenesis-> proliferative retinopathy
Treatment of proliferative diabetic retinopathy?
Pan retinal photocoagulation in peripheries
Anti-VEGF intravitreal injections
Steroid injections
Complications of proliferative diabetic retinopathy? (2)
- Ring of fibrous tissue grows with new blood vessels, contracts and can dislodge the retina
- Blood vessels can grow towards iris, can block drainage of fluid
What is seen in anterior uveitis?
Keratitic precipitates
Iris adheres to cornea or lens
Acute uveitis is associated with___
- Can be autoimmune (HLA B27 related, psoriatic arthritis)
- IBD
- Collection of inflammatory cells
Chronic uveitis is associated with__
- Mutton fat keratitic precipitates
- Juvenile idiopathic arthritis
- TB, syphilis, herpes, sarcoidosis
What can cause retinitis?
toxoplasmosis, CMV, candida (in immunosuppression)
Signs and causes of posterior uveitis
- Cells in vitreous: clouding
- Headlight in the fog
- Choroidal granuloma/sarcoidosis
What can corticosteroid treatment do to the eye?
Posterior subcapsular cataract
2º glaucoma
Which antimalarial drugs can cause eye problems?
Chloroquine-> maculopathy
Quinine-> Optic atrophy, arteriolar narrowing
Treatment of giant cell arteritis?
Urgent steroids
Which eye muscles adduct?
Medial rectus
Inferior and superior recti
Which eye muscles abduct?
Lateral rectus
Inferior and superior oblique
What is left esotropia?
Left pupil too adducted
What is right hypertropia?
Right pupil too superior
What is the difference between a tropia and a phoria?
Tropia: misalignment always there, even when both eyes are open and attempting to work together
Phoria: latent squint, misalignment only occurs sometimes, eg in cover test
Difference between incomitant and cocomitant
Is the deviation the same magnitude regardless of gaze position? Yes: concomitant
6 causes of an incomitant strabismus
Mechanical Restrictions a) Muscle (e.g. contracture) b) Bone (e.g. fracture) c) Connective Tissue (e.g inflammation) d) Mass (e.g. tumour) Innervational Abnormalities a) Underaction (e.g. palsy) b) Overaction (e.g. inferior oblique)
Definition of amblyopia
Commonly known as lazy eye, is the eye condition noted by reduced vision not correctable by glasses or contact lenses and is not due to any eye disease. The brain, for some reason, does not fully acknowledge the images seen by the amblyopic eye.
Causes of amblyopia
Anything that interferes with clear vision in either eye during the critical period (birth to 6 years of age) can result in amblyopia
- Constant strabismus (constant turn of one eye)
- Anisometropia (different vision/prescriptions in each eye)
- Blockage of an eye due to trauma, lid droop
Treatment of amblyopia
Correct vision (improve lid drop, correct refractive errors, patch over good eye) Maximum benefit of amblyopia treatment is up to age 7
Define nystagmus
Rapid rhythmic repetitious involuntary (uncontrollable) eye movements.
Can be horizontal, vertical or rotary and can effect one or both eyes.
5 causes of acquired nystagmus
• Inner ear disorders (labyrinthitis or Meniere’s disease)
• Toxic- drugs, medication (such as anti-seizure medications and sedating meds), alcohol intoxication
• Head injury
• Stroke (blood vessel blockage
in the brain)
• Diseases of the brain…multiple sclerosis or brain tumours
Signs of Horner’s syndrome
Interruption of sympathetics Miosis (constricted pupil) Anhydrosis (decreased sweating) Ptosis (drooping eyelid) Enophthalmos (Inset eyeball)
If Horner’s syndrome is painful, what needs to be excluded?
Carotid dissection
Define amaurosis fugax
- Transient monocular visual loss or dimming
- May last from 2-3 minutes to 30 minutes or more • Due to decrease blood flow to the eye
- Causes:
- Carotid atheroma
- Cardiac valve disease
- Atrial myxoma
- Retinal migraine
- Giant cell arteritis
- Hyperviscosity syndromes
Name the muscles of the eye
Levator palpebrae superioris (skeletal)
Muller’s muscle (sympathetic innervation)
Orbicularis oculi
Describe sclera
Tough white shell starting from the limbus and extends all around the eye
Gets nutrients from episclera and choroid
Describe parasympathetic action on iris
Sphincter pupillae muscle contracts
Pupil size decreases (miosis)
Function of ciliary body
Produces aqueous humour in anterior chamber
2 treatments of dry eye
Lubricating eye drops, punctal plugs
Define chalazion
Treatment?
Focal swelling of the eyelid as a hard and painless nodule, due to inflammation and blockage of the sebaceous glands. Lid massage with steroid drops if not cleared within a month. Incision and drainage if infected. If sebaceous gland carcinoma is suspected send fluid for screening. If parasitic, nocturnal ointment will smother them.
Name the common infectious agents causing conjunctivitis
Viral is most common: adenovirus, herpes simplex virus, varicella zoster
Bacterial: Staphylococcus, streptococcus, corynebacterium, haemophilus influenza, pseudomonas
Signs and symptoms of allergic eye
Erythema, itching, burning, watering of eyes, oedema of eyelids.
Papillary hyperplasia
Causes of sticky eye in infant
Infant’s nasolacrimal ducts are narrower so it is normal for them to become slightly blocked and cause a watery/sticky eye. Resolves on its own.
Wait 1 year before considering surgical intervention
What is a Fresnal prism?
Used to correct diplopia (double vision). 1mm thick
Occlusive lens
Patch
Symptoms of a corneal ulcer
Erythema of eyelid and conjunctiva, mucopurulent discharge,
foreign body sensation, blurred vision, light sensitivity, pain
Causes of keratitis
Rheumatoid arthritis (autoimmune), bacterial infection (contact lens use or post-surgery), UV light
Difference between myopia and presbyopia
Myopia (nearsightedness): lens refracts wrongly so can’t see distant objects
Presbyopia (farsightedness): Can’t see up-close, usually age related
Difference between phakia and aphakia
Aphakia: absence of lens (congenital, surgical removal, perforating wound or ulcer)
Phakia: presence of the natural lens of the eye
3 causes of iritis
Inflammation of the iris
Injury (blunt force trauma, penetrating injury, burn)
Shingles (herpes zoster) infection, TB, syphilis
Juvenile rheumatoid arthritis
Presenting symptoms of diabetic eye disease
Blurred vision
Painless gradual reduction in central vision
Sudden onset of dark, painless floaters
What does a fluorescein angiogram assess?
Highlights retinal blood vessels, looking for Av nipping, haemorrhages, aneurysms, neovascularisation
Define drusen
Deposits of lipid under the retina
Define floaters
Grey/black lines/specks/cobwebs seen infront of eyes. They move when the patient moves their eyes and drift when the eyes stop/start moving. Usually fragments of vitreous jelly coming loose
Define retinal detachment
Presentation
Separation of the neural layer from the underlying pigment epithelial layer
Floaters, flashes, curtain over field of vision
Difference between raised intraocular pressure and glaucoma
Glaucoma is a multifactorial disease of optic nerve damage and visual field loss.
Raised intraocular pressure is usually seen in glaucoma but raised IOP can be present without glaucoma
Normal intraocular pressure?
10-21mmHg
2 types of visual field assessment
Confrontation visual field testing and automated perimetry.
Humphries & Goldmann’s
What does asymmetrically cupped discs mean?
Suggests early simple glaucoma and optic disk ischaemia, esp if unilateral
Define papilloedema
Optic disc swelling caused by raised intracranial pressure
Give a reason for small and unreactive pupils and a reason for small and reactive pupils
Small and unreactive: opiate overdose, posterior synaechiae
Small and reactive: Overactive parasympathetic system/Horner’s syndrome
Give a reason for large and unreactive pupils and a reason for large and reactive pupils
Large and non reactive: third nerve palsy, dilating drops
Large and reactive: Adie syndrome (slow reaction, damage to dilator pupilae)
What are the signs of a direct carotid-cavernous fistula?
Ocular pulsations, optic disc swelling, intraretinal haemorrhage +/- tinnitus, bruit over eye
Normal cup:disc ratio
< 0.5 normal
How is vision tested in young children?
Most children can cooperate for a vision test by naming or matching pictures from years old. Until that age, assessment of vision is objective e.g. by observing reactions to covering either eye or by comparing the fixation behaviour of either eye when toys or special targets (gratings) are presented to the infant.
Forced choice preferential looking test
Naming/matching pictures/letters
When should squints in children be referred?
Any constant squint (misalignment of the eyes), convergent or divergent, in a baby or child should be referred to an ophthalmolgist a.s.a.p.
Any intermittent squint after the age of 4 months in a baby should be referred a.s.a.p.
R 4th nerve palsy presentation
The right eye will tend to be elevated – this could be a manifest or a latent vertical squint. There may be an associated horizontal deviation.
The right eye will demonstrate an under action when looking down to the left.
A head tilt is often present which helps to control the vertical squint.
R 6th nerve palsy presentation
The right eye will demonstrate an esotropia when looking in the distance and will not move fully into abduction i.e. out to the right.
Describe optic neuritis
- Young
- Rapid vision loss over days (colour washed out first)
- RAPD
- Disc swollen and hyperaemic
Define en/ex tropion
Entropion: eyelid folded in
Lashes rub on eye, very painful
Ectropion: eyelid folded out
Define ptergium
Conjunctival overgrowth over cornea. Needs surgical excision.
Sun exposure is a risk factor.
Describe viral conjunctivitis
Redder conjunctiva, subconjunctival haemorrhage. Lubricating eye drops initially. Start steroids if cornea is involved.
Signs of chlamydial conjunctivitis
Chlamydial: stickier discharge than viral, less than bacterial. Corneal involvement, pale follicles present.
