Ophthal Flashcards
Q: What is glaucoma?
A: Glaucoma is a group of disorders characterized by optic neuropathy, primarily due to raised intraocular pressure (IOP). However, a minority of patients with raised IOP do not have glaucoma, and vice versa.
Q: What is acute angle-closure glaucoma (AACG)?
A: AACG is a condition where there is a rise in IOP secondary to impairment of aqueous outflow.
Q: What are the factors predisposing to acute angle-closure glaucoma (AACG)?
A: Factors include hypermetropia (long-sightedness), pupillary dilatation, and lens growth associated with age.
Q: What are the common features of acute angle-closure glaucoma (AACG)?
A: Features include severe ocular pain or headache, decreased visual acuity, symptoms worsened by mydriasis (e.g. watching TV in a dark room), hard, red eye, haloes around lights, semi-dilated non-reacting pupil, corneal oedema resulting in a dull or hazy cornea, and systemic upset such as nausea, vomiting, and abdominal pain.
Q: What investigations are used for acute angle-closure glaucoma (AACG)?
A: Tonometry to assess elevated IOP and gonioscopy to visualize the angle using a special slit lamp lens.
Q: What is the management for acute angle-closure glaucoma (AACG)?
A: AACG is an emergency requiring urgent referral to an ophthalmologist, with medical treatment to lower IOP followed by definitive surgical treatment once the acute attack settles.
Q: What is the definitive management for acute angle-closure glaucoma (AACG)?
A: The definitive treatment is laser peripheral iridotomy, which creates a tiny hole in the peripheral iris to allow aqueous humour to flow to the angle.
Q: What is age-related macular degeneration (ARMD)?
A: ARMD is the most common cause of blindness in the UK, characterized by degeneration of the central retina (macula), often bilateral. It involves degeneration of retinal photoreceptors and the formation of drusen visible on fundoscopy and retinal photography.
Q: What are the risk factors for age-related macular degeneration (ARMD)?
A: Risk factors include advancing age, smoking, family history (especially first-degree relatives), hypertension, dyslipidaemia, and diabetes mellitus.
Q: What is the greatest risk factor for developing ARMD?
A: Advancing age is the greatest risk factor, with the risk increasing threefold in patients over 75 years compared to those aged 65-74.
Q: What are the two traditional classifications of macular degeneration?
A: The two traditional forms are dry macular degeneration (90% of cases) and wet macular degeneration (10% of cases). Dry ARMD is characterized by drusen, while wet ARMD involves choroidal neovascularization and fluid leakage.
Q: What are the clinical features of age-related macular degeneration (ARMD)?
A: Clinical features include subacute onset of visual loss (gradual in dry ARMD and subacute in wet ARMD), difficulties with dark adaptation, fluctuating visual disturbances, photopsia (flickering or flashing lights), glare around objects, and visual hallucinations (Charles-Bonnet syndrome).
Q: How is ARMD detected on fundoscopy?
A: On fundoscopy, drusen (yellow areas of pigment deposition) may be seen in the macular area, which may coalesce to form a macular scar in late-stage disease. In wet ARMD, red patches indicating fluid leakage or hemorrhage may be visible.
Q: What investigations are used to diagnose ARMD?
A: Investigations include slit-lamp microscopy, color fundus photography, fluorescein angiography, indocyanine green angiography, and optical coherence tomography (OCT) for detailed 3D visualization of the retina.
Q: What are the treatment options for dry ARMD?
A: The AREDS trial showed that a combination of zinc and antioxidants (vitamins A, C, and E) reduces disease progression by around one-third in dry ARMD, especially in patients with more extensive drusen.
Q: What is the treatment for wet ARMD?
A: Anti-vascular endothelial growth factor (VEGF) agents like ranibizumab, bevacizumab, and pegaptanib are used to limit progression, stabilize, or reverse visual loss. These agents are typically administered via injection every four weeks.
Q: What role does laser photocoagulation play in ARMD treatment?
A: Laser photocoagulation can slow the progression of wet ARMD where new vessel formation is present but carries a risk of acute visual loss, particularly in sub-foveal ARMD, so anti-VEGF therapies are preferred.
Q: What is allergic conjunctivitis?
A: Allergic conjunctivitis is an eye condition often associated with hay fever, characterized by conjunctival erythema, conjunctival swelling (chemosis), and itchiness.
Q: What are the common features of allergic conjunctivitis?
A: Features include bilateral conjunctival erythema, conjunctival swelling, prominent itching, swollen eyelids, and a possible history of atopy. It may be seasonal (due to pollen) or perennial (due to dust mites, washing powder, or other allergens).
Q: What are the possible causes of seasonal and perennial allergic conjunctivitis?
A: Seasonal allergic conjunctivitis is typically triggered by pollen, while perennial allergic conjunctivitis can be caused by dust mites, washing powder, or other allergens.
Q: What is the first-line treatment for allergic conjunctivitis?
A: The first-line treatment for allergic conjunctivitis is topical or systemic antihistamines.
Q: What is the second-line treatment for allergic conjunctivitis?
A: Second-line treatment includes topical mast-cell stabilizers like Sodium cromoglicate and nedocromil.
Q: What is anterior uveitis (iritis)?
A: Anterior uveitis is inflammation of the anterior portion of the uvea (iris and ciliary body), often referred to as iritis. It is an important differential diagnosis for a red eye and is associated with HLA-B27.
Q: What are the common features of anterior uveitis?
A: Features include acute onset, ocular discomfort and pain (which may increase with use), small and possibly irregular pupil, photophobia (often intense), blurred vision, red eye, lacrimation, ciliary flush (a ring of red spreading outwards), hypopyon (pus and inflammatory cells in the anterior chamber), and initially normal visual acuity that may become impaired.
Q: What is hypopyon?
A: Hypopyon refers to the presence of pus and inflammatory cells in the anterior chamber of the eye, often forming a visible fluid level.
Q: What conditions are associated with anterior uveitis?
A: Anterior uveitis is commonly associated with HLA-B27-linked conditions such as ankylosing spondylitis, reactive arthritis, ulcerative colitis, Crohn’s disease, Behcet’s disease, and sarcoidosis (which may cause bilateral disease).
Q: What is the management for anterior uveitis?
A: Management involves urgent referral to ophthalmology, use of cycloplegics (e.g. atropine, cyclopentolate) to relieve pain and photophobia by dilating the pupil, and steroid eye drops.
Q: What is the Argyll-Robertson pupil (ARP)?
A: The Argyll-Robertson pupil is a classic pupillary syndrome, often seen in neurosyphilis, characterized by small, irregular pupils that do not respond to light but do respond to accommodation.
Q: What is a mnemonic for remembering the characteristics of the Argyll-Robertson pupil?
A: The mnemonic is “Accommodation Reflex Present (ARP) but Pupillary Reflex Absent (PRA),” which highlights the response to accommodation but absence of the pupillary light reflex.
Q: What are the key features of Argyll-Robertson pupil?
A: Features include small, irregular pupils with no response to light but a response to accommodation.
Q: What are the common causes of Argyll-Robertson pupil?
A: Common causes include diabetes mellitus and syphilis.
Q: What is blepharitis?
A: Blepharitis is inflammation of the eyelid margins, caused by either meibomian gland dysfunction (posterior blepharitis) or seborrhoeic dermatitis/staphylococcal infection (anterior blepharitis). It is more common in patients with rosacea.
Q: What are the common features of blepharitis?
A: Features include bilateral grittiness and discomfort around the eyelid margins, eyes being sticky in the morning, red eyelid margins, swollen eyelids (in staphylococcal blepharitis), increased occurrence of styes and chalazions, and possible secondary conjunctivitis.
Q: What is the management for blepharitis?
Softening the lid margin with hot compresses twice a day.
‘Lid hygiene’ to mechanically remove debris from lid margins, using cotton wool buds dipped in a mixture of cooled boiled water and baby shampoo, or sodium bicarbonate in cooled boiled water.
Artificial tears for symptom relief in patients with dry eyes or abnormal tear film.
Q: What is blurred vision?
A: Blurred vision is defined as a loss of clarity or sharpness of vision. It can be caused by various conditions, and it is important to assess for associated symptoms such as visual loss, double vision, and floaters.
Q: What are the most common causes of blurred vision?
A: The most common causes of blurred vision include refractive error, cataracts, retinal detachment, age-related macular degeneration, acute angle-closure glaucoma, optic neuritis, and amaurosis fugax.
Q: How is blurred vision assessed?
Visual acuity testing with a Snellen chart.
Use of a pinhole occluder to check if the blurred vision improves (indicating a refractive error).
Visual field testing.
Fundoscopy to assess the retina and other structures.
Q: What is the significance of a pinhole occluder in blurred vision assessment?
A: A pinhole occluder is used to check if the blurred vision improves, which would suggest that the cause is likely a refractive error. If it does not improve, other causes should be considered.
Q: What is the management of blurred vision?
If there is gradual onset, improvement with a pinhole occluder, and no associated symptoms, an optician review is recommended.
If there are associated symptoms like visual loss or pain, the patient should be referred urgently to ophthalmology.
Q: What is a cataract?
A: A cataract is a condition where the lens of the eye becomes cloudy, which makes it difficult for light to reach the retina, causing reduced or blurred vision. It is the leading cause of curable blindness worldwide.
Q: What are the common causes of cataracts?
A: The most common cause of cataracts is the normal ageing process. Other possible causes include smoking, increased alcohol consumption, trauma, diabetes mellitus, long-term corticosteroid use, radiation exposure, myotonic dystrophy, and metabolic disorders like hypocalcaemia.
Q: What are the typical symptoms of cataracts?
A: Symptoms include gradual onset of reduced vision, faded color vision, glare (brighter lights), and halos around lights.
Q: What is the significance of a red reflex defect in cataracts?
A: A red reflex defect occurs when cataracts prevent light from reaching the retina, making it impossible to see the normal reddish-orange reflection during ophthalmoscopy.
Q: What are the main types of cataracts?
Nuclear: Common in old age, changes the lens refractive index.
Polar: Localized, inherited, lies in the visual axis.
Subcapsular: Due to steroid use, located just deep to the lens capsule in the visual axis.
Dot opacities: Common in normal lenses, seen in diabetes and myotonic dystrophy.
Q: What is the management for cataracts?
A: Early management involves prescribing stronger glasses/contact lenses and encouraging the use of brighter lighting. Surgery is the only effective treatment, involving removal of the cloudy lens and replacement with an artificial lens.
Q: What factors should be considered before cataract surgery?
A: Prior to surgery, factors such as the presence of visual impairment, the impact on quality of life, patient choice, whether both eyes are affected, and the potential risks and benefits should be considered.
Q: What are the complications following cataract surgery?
A: Complications include posterior capsule opacification (thickening of the lens capsule), retinal detachment, posterior capsule rupture, and endophthalmitis (inflammation of the aqueous and/or vitreous humor).
Q: What is central retinal artery occlusion (CRAO)?
A: CRAO is a rare cause of sudden unilateral visual loss, often caused by thromboembolism (from atherosclerosis) or arteritis (such as temporal arteritis).
Q: What are the key features of central retinal artery occlusion?
A: Features include sudden, painless unilateral visual loss, relative afferent pupillary defect, and a “cherry red” spot on a pale retina.
Q: What is the management for central retinal artery occlusion?
A: Management is difficult, and the prognosis is poor. Any underlying conditions (e.g., temporal arteritis) should be treated, such as with intravenous steroids. In acute cases, intra-arterial thrombolysis may be attempted, but trial results are mixed.
Q: What is central retinal vein occlusion (CRVO)?
A: CRVO is a condition that causes sudden painless loss of vision and is considered a differential diagnosis for such cases.
Q: What are the risk factors for central retinal vein occlusion?
A: Risk factors include increasing age, hypertension, cardiovascular disease, glaucoma, and polycythaemia.
Q: What are the key features of central retinal vein occlusion?
A: Features include sudden, painless reduction or loss of visual acuity (usually unilateral), widespread hyperaemia on fundoscopy, and severe retinal haemorrhages, often described as “stormy sunset.”
Q: What is the difference between central retinal vein occlusion and branch retinal vein occlusion (BRVO)?
A: BRVO occurs when a vein in the distal retinal venous system is occluded due to blockage at arteriovenous crossings, leading to a more limited area of the fundus being affected, unlike the widespread impact seen in CRVO.
Q: What is the management for central retinal vein occlusion?
A: Most patients are managed conservatively. Treatment is indicated in cases of macular oedema (treated with intravitreal anti-VEGF agents) and retinal neovascularization (treated with laser photocoagulation).
Q: What is a corneal abrasion?
A: A corneal abrasion is any defect in the corneal epithelium, commonly caused by trauma such as fingernails or branches.
Q: What are the key features of a corneal abrasion?
A: Features include eye pain, lacrimation, photophobia, foreign body sensation, conjunctival injection, and decreased visual acuity in the affected eye.
Q: How is a corneal abrasion investigated?
A: Investigation involves fluorescein staining, which reveals a yellow-stained abrasion. This can typically be seen with the naked eye and is enhanced with a cobalt blue filter or a Wood’s lamp.
Q: What is the management for a corneal abrasion?
A: Management involves using a topical antibiotic to prevent secondary bacterial infection.
Q: What are the key features of a corneal foreign body?
A: Features include eye pain, foreign body sensation, photophobia, watering eye, and red eye.
Q: When should a patient with a corneal foreign body be referred to ophthalmology?
A: Referral is indicated for suspected penetrating eye injury (from high-velocity injuries or sharp objects), significant orbital or peri-ocular trauma, chemical injuries (after irrigation), foreign bodies made of organic material (such as seeds or soil), foreign bodies near the center of the cornea, or any red flags such as severe pain, irregular or non-reactive pupils, or significant reduction in visual acuity.
Q: What is a corneal ulcer?
A: A corneal ulcer is a defect in the cornea, typically secondary to an infectious cause. Corneal abrasions refer to corneal defects caused by physical trauma.
Q: What are the risk factors for corneal ulcer?
A: Risk factors include contact lens use and vitamin A deficiency (especially in the developing world).
Q: What are the different types of keratitis that can lead to corneal ulcers?
A: Types include bacterial keratitis, fungal keratitis, viral keratitis (such as herpes simplex and herpes zoster, which may lead to a dendritic ulcer), and Acanthamoeba keratitis (associated with contact lens use).
Q: What are the key features of a corneal ulcer?
A: Features include eye pain, photophobia, watering of the eye, and focal fluorescein staining of the cornea.
Q: What is diabetic retinopathy?
A: Diabetic retinopathy is the most common cause of blindness in adults aged 35-65 years and results from hyperglycaemia causing retinal damage.
Q: What is the pathophysiology of diabetic retinopathy?
A: Hyperglycaemia causes increased retinal blood flow and abnormal metabolism in retinal vessels, leading to endothelial dysfunction, increased vascular permeability, and microaneurysms. Neovascularisation occurs in response to retinal ischaemia.
Q: How is diabetic retinopathy classified?
A: It is classified into non-proliferative diabetic retinopathy (NPDR), proliferative diabetic retinopathy (PDR), and maculopathy.
Q: What are the stages of non-proliferative diabetic retinopathy (NPDR)?
Mild NPDR: 1 or more microaneurysms
Moderate NPDR: Microaneurysms, blot haemorrhages, hard exudates, cotton wool spots, venous beading, and intraretinal microvascular abnormalities (IRMA)
Severe NPDR: Blot haemorrhages and microaneurysms in 4 quadrants, venous beading in 2 quadrants, IRMA in 1 quadrant
Q: What are the features of proliferative diabetic retinopathy (PDR)?
A: PDR features retinal neovascularisation, fibrous tissue forming anterior to the retinal disc, and a higher risk of vitreous haemorrhage. It is more common in Type 1 diabetes and can cause blindness in 50% of patients within 5 years.
Q: What are the key features of maculopathy in diabetic retinopathy?
A: Maculopathy is based on location, often involving hard exudates and background changes on the macula. It is more common in Type II diabetes.
Q: What is the management of diabetic retinopathy?
Optimise glycaemic control, blood pressure, and hyperlipidemia.
Regular ophthalmology reviews.
Maculopathy: Intravitreal VEGF inhibitors if visual acuity changes.
Non-proliferative retinopathy: Regular observation; consider panretinal laser photocoagulation for severe/very severe cases.
Proliferative retinopathy: Panretinal laser photocoagulation, intravitreal VEGF inhibitors (e.g., ranibizumab), and vitreoretinal surgery for severe cases or vitreous haemorrhage.
Q: What is episcleritis?
A: Episcleritis is the acute onset of inflammation in the episclera of one or both eyes, with the majority of cases being idiopathic.
Q: What conditions are associated with episcleritis?
A: Episcleritis is associated with inflammatory bowel disease and rheumatoid arthritis.
Q: What are the key features of episcleritis?
Red eye
Typically not painful (mild irritation or discomfort may occur)
Mild watering and photophobia
The injected vessels are mobile with gentle pressure, differentiating it from scleritis.
Phenylephrine drops can be used to differentiate episcleritis from scleritis. The redness improves with phenylephrine in episcleritis.
Q: How can episcleritis be differentiated from scleritis using phenylephrine?
A: Phenylephrine blanches the conjunctival and episcleral vessels but not the scleral vessels. If the eye redness improves after phenylephrine, the diagnosis is episcleritis.
Q: What is the management of episcleritis?
A: The management is typically conservative. Artificial tears may sometimes be used to relieve symptoms.
Q: What are common eyelid problems?
A: Common eyelid problems include blepharitis, stye, chalazion (Meibomian cyst), entropion, and ectropion.
Q: What is a stye (hordeolum)?
A stye is an infection of the glands of the eyelids, and there are two types:
External (hordeolum externum): infection of the glands of Zeis (sebaceous) or glands of Moll (sweat glands).
Internal (hordeolum internum): infection of the Meibomian glands, which may lead to a residual chalazion (Meibomian cyst).
Q: How is a stye managed?
A: Management includes hot compresses and analgesia. Topical antibiotics are only recommended if there is an associated conjunctivitis.
Q: What is a chalazion (Meibomian cyst)?
A: A chalazion is a retention cyst of the Meibomian gland. It presents as a firm, painless lump in the eyelid. Most cases resolve spontaneously, but some require surgical drainage.
Q: What are entropion and ectropion?
Entropion: in-turning of the eyelids.
Ectropion: out-turning of the eyelids.
Q: What is the most common presentation of Herpes simplex keratitis?
A: The most common presentation is a dendritic corneal ulcer.
Q: What are the features of Herpes simplex keratitis?
Red, painful eye
Photophobia
Epiphora (excessive tearing)
Decreased visual acuity
Fluorescein staining may show an epithelial ulcer.
Q: How is Herpes simplex keratitis managed?
Immediate referral to an ophthalmologist
Topical aciclovir.
Q: What is Herpes zoster ophthalmicus (HZO)?
A: Herpes zoster ophthalmicus (HZO) is the reactivation of the varicella-zoster virus in the area supplied by the ophthalmic division of the trigeminal nerve. It accounts for around 10% of shingles cases.
Q: What are the features of Herpes zoster ophthalmicus?
Vesicular rash around the eye, which may or may not involve the eye itself
Hutchinson’s sign: Rash on the tip or side of the nose, indicating nasociliary involvement and a strong risk factor for ocular involvement.
Q: How is Herpes zoster ophthalmicus managed?
Oral antiviral treatment for 7-10 days, ideally started within 72 hours
Intravenous antivirals for very severe infection or if the patient is immunocompromised
Topical antiviral treatment is not given in HZO
Topical corticosteroids for secondary inflammation of the eye
Urgent ophthalmology review if ocular involvement occurs.
Q: What are the complications of Herpes zoster ophthalmicus?
Ocular: Conjunctivitis, keratitis, episcleritis, anterior uveitis
Ptosis
Post-herpetic neuralgia.
Q: What is Holmes-Adie pupil?
A: Holmes-Adie pupil is a benign condition most commonly seen in women, characterized by a dilated pupil that remains small for an abnormally long time after constriction. It is slowly reactive to accommodation but poorly reactive to light.
Q: What is the common presentation of Holmes-Adie pupil?
A: Holmes-Adie pupil is typically unilateral in 80% of cases and features a dilated pupil that constricts slowly and remains small for an abnormally long time after constriction. It is poorly reactive to light but slowly reactive to accommodation.
Q: What is Holmes-Adie syndrome?
A: Holmes-Adie syndrome refers to the association of Holmes-Adie pupil with absent ankle and knee reflexes.
