Ophthal 2 Flashcards
1
Q
Left congruous homonymous hemianopia visual field defect - where is the lesion?
If it’s incongruous?
A
Right optic radiation or, occipital cortex (esp if there’s macula sparing)
Incongruous: Right optic tract
2
Q
Inferior homonymous quadrantanopia - where is the lesion?
A
Parietal lobe
3
Q
Superior homonymous quadrantanopia - where is the lesion?
A
Temporal lobe
4
Q
Congruous (complete or symmetrical) visual defect - where is the lesion?
Incongruous visual defect - where is the lesion?
A
Congruous: optic radiation or occipital cortex
Incongruous: optic tract lesion
5
Q
Bitemporal hemianopia where the upper quadrant defect > lower quadrant defect?
A
Inferior compression of the optic chiasm - e.g. pituitary tumour
6
Q
Bitemporal hemianopia where the lower quadrant defect > upper quadrant defect?
A
Superior compression of the optic chiasm - e.g. craniopharyngioma
7
Q
What is infection of the lacrimal sac i.e. watering eye with swelling & erythema at the inner canthus?
Rx?
A
Dacrocystitis
- systemic Abx, IV if periorbital cellulitis
8
Q
Eye drops that reduce aqueous production?
A
- beta-blockers
- sympathomimetics (also increase outflow)
- carbonic anhydrase inhibitors
9
Q
Eye drops that increase uveoscleral outflow?
A
- prostaglandin analogues
- sympathomimetics (also reduce aqueous production)
- miotics
10
Q
Eye drops administered once daily that increase uveosacral outflow but can cause brown pigmentation of the iris?
A
prostaglandin analgues eg Latanoprost
11
Q
Eye drops that reduce aqueous production but should be avoided in asthmatics & pts with heart block?
A
beta blockers eg timolol
12
Q
Eye drops that should be avoided if taking MAO-I or TCAs and can cause hyperaemia?
A
Sympathomimetics e.g. Brimonidine (alpha2 agonist)
- reduce aqueous production & increase outflow
13
Q
Eye drops that reduce aqueous production and if systemically absorbed can cause sulphonamide-like reactions?
A
carbonic anhydrase inhibitors eg Dorzolamide
14
Q
Eyedrops that increase uveoscleral outflow but can cause headache, blurred vision, and a constricted pupil?
A
Miotics eg Pilocarpine, a muscarinic agonist
15
Q
How to classify glaucomas? (optic neuropathies usually ass with raised IOP)
A
- peripheral iris is covering the trabecular meshwork (important in the drainage of aqueous humour from anterior chamber of the eye)
- Open-angle glaucoma: iris is clear of the meshwork. the trabecular network functionally offers an increased RESISTANCE to aqueous outflow, causing increased IOP
16
Q
Open-angle glaucoma: Sx & signs?
Case finding?
A
- aSx for a while when slow rise in IOP, presents after its measured by optometrist
- increased IOP
- visual field defect
- pathological cupping of the optic disc
- optic nerve head damage visible under slit lamp
- visual field defect
- IOP>24mmHg
- provisional Dx/case finding by optometrist
- ophthal referral by GP
17
Q
Dx/Ix of 1ry open angle glaucoma?
A
- automated perimetry to assess visual field
- slit lamp exam with pupil dilatation to assess optic nerve & fundus for a baseline
- applanation tonometry to measure IOP
- central corneal thickness measurement
- gonioscopy to assess peripheral anterior chamber configuration & dephth
- assess risk of future visual impairment (IOP, central corneal thickness, FHx, life expectancy etc)
18
Q
1ry open angle glaucoma: 1st line Rx?
2nd?
if more advanced?
reassessment?
A
1st: PROSTAGLANDIN ANALOGUE
2nd: beta-clocker, carbonic anhydrase inhibitor or sympathomimetic
if more advances consider surgery/laser Rx
- important to exclude progression & visual field loss - do more frequently if IOP uncontrolled, pt is high risk, or there is progression
- surgery eg trabeculectomy if refractory
19
Q
Central lesion (1st order neutron) causes of Horner’s syndrome?
A
Stroke Syringomyelia MS Tumour Encephalitis - anhidrosis of face, arm, trunk
20
Q
Pre-ganglion lesion (2nd order neutron) causes of Horner’s syndrome?
A
- anhidrosis of face Pancoasts tumour Thyroidectomy Trauma Cervical rib
21
Q
Post-ganglionic lesion (3rd order neutron) causes of Horner’s syndrome?
A
- no anhydrosis Carotid dissection Carotid aneurysm Cavernous sinus thrombosis Cluster headache
22
Q
Degeneration of retinal photoreceptors leading to Drusen - yellow round spots in Bruchs membrane, alteration to reinal-pigment epithelium
Dx?
A
Dry AMD or early
23
Q
Degeneration of retinal photoreceptors leading to choroidal neovasculisation with leakage of serous fluid & blood that can rapidly cause loss of vision i.e. neovascularisation, exudative. Dx?
A
Wet AMD
- late
24
Q
RFs of AMD?
Sx & signs?
A
- age
- smoking
- male 2:1
- FHx
- CVD RFs
- reduced visual acuity esp near field objects or at night
- difficulties in dark adaptation
n- fluctuations in visual disturbance - photopsia & glare
- distortion of line perception on Amsler grid testing
- duress which may become a macular scar
- well demarcated red patches which represent intra-retinal or sub-retinal fluid leakage or haemorrhage (wet AMD)
25
Ix in AMD?
Slit-lamp: pigment, exudate, haemorrhage etc, with colour fundus photo for baseline
Fluoresceine angiography: if neovascular suspected, to guide anti-VEGF Rx, may be complemented with indocyanine green angio to visualise changes in choroidal circulation
Ocular coherence tomography: visualise retina in 3 dimensions
26
Rx of dry & wet AMD?
Dry: antioxidants can help esp with most extensive drusen, c/i in smoking
Wet: anti-VEGF can stabilise/limit progression/reverse, within first 2months of Dx e.g. Ranibizumab, Bevacizumab, Pegaptanib. 4wkly injection
(Laser photocoag can slow progression where there is novas but risk of acute visual loss after Rx, esp in sub-foveal AMD)
27
RFs for 1ry open angle glaucoma?
- age
- genetics/FHx
- myopia ie SHORT sightedness
- black pts
- HTN
- DM
- corticosteroids
28
Features of 1ry open angle glaucoma?
| what is seen on fundoscopy?
- peripheral visual field loss where nasal scooters progress to tunnel vision
- decreased visual acuity
- optic disc cupping
- increased cup to disc ration >0.7 (loss of disc substance makes optic cup widen & deepen)
- pallor of disc (atrophy)
- Bayonetting of vessels (vessels have breaks as they disappear into deep cup & re-appear at the base)
- Cup notching, usually inferior, Disc haemorrhages
29
Rx of herpes zoster ophthalmicus?
- oral antivirals/aciclovir 7-10days within 72h
- urgent ophthal review
(oral steroids may reduce duration of pain but not incidence of neuralgia post-herpetic)
30
Flashers (photopsia) in peripheral vision & floaters in temporal side of central vision
Dx?
Posterior vitreous detachment
| - ophthal review to assess risk of progressing to retinal detachment
31
dilated pupil that reacts slowly to accommodation and once constricted remains small for an abnormally long time
- v poorly if at all to light
- can be ass with absent ankle/knee reflexes
- 80% are unilateral
Holmes-Adie pupil
32
Pathology in diabetic retinaopathy?
hyperglycaemia -> increased retinal blood flow & abnormal metabolism in retinal vessel walls -> precipitating damage to endothelial cells & pericytes
Endothelial dysfunction -> increased vascular permeability -> exudates
Pericyte dysfunction -> predisposes to microaneurysm formation
Retinal ischaemia -> growth factors -> neovascularisation
33
Diabetic retinopathy:
| - mild non-proliferative DR?
1+ microaneurysm
34
Diabetic retinopathy:
| - moderate non-proliferative DR?
- microanuerysms
- blot haemorrhages
- hard exudates
- cotton wool spots, venous beading/looping & intraretinal microvascular abnormalities (IRMA) less severe than in severe NPDR
35
Diabetic retinopathy:
| - severe non-proliferative DR?
- blot haemorrhages & micro aneurysms in 4 quadrants
- venous beading in at least 2 quadrants
- IRMA: intra-retinal microvascular abnormalities in at least 1 quadrant
36
Diabetic retinopathy:
| - proliferative?
- retinal neovascularisation - may lead to vitreous haemorrhage
- fibrous tissue forming anterior to retinal disc
- more common in type 1 DM, 50% blind in 5years
37
Diabetic retinopathy:
| - maculopathy?
- hard exudates and other background changes on macula
- anything potentially serious
- check visual acuity
- mose common in type 2 DM
38
Diabetic retinopathy:
| - background?
- microaneurysms - dots
- blots haemorrhages upto 3
- hard exudates
39
Diabetic retinopathy:
| - pre-proliferative?
- cotton wool spots soft exudates - ischaemic nerve fibres
- >3 blots
- venous beading/looping
- deep/dark cluster haemorrhages
- more common in type 1 DM, treat with laser photocoag
40
Floaters then numerous dark spots then sudden painless visual loss?
Vitreous haemorrhage
(small bleed -> moderate -> large)
- often retinal novas in diabetes leads to this
41
```
Dense shadow starting peripherally progresses towards central vision
veil/curatin over field of vision
straight lines appear curved
central visual loss
Painless
Dx?
```
Retinal detachment
42
Painless visual loss with afferent pupillary defect, cherry red spot on a pale retina?
Central retinal artery occlusion
43
Painless visual loss seen in glaucoma, polycythaemia, hypertension with severe retinal haemorrhages on fundoscopy?
Central retinal vein occlusion
| commoner than arterial
44
What is a cataract?
| RFs/causes?
- lens opacification, making it more difficult for light to reach back of eye, causing reduced/blurred vision
- Age, more common in women
- smoking, etoh
- trauma
- DM, long-term steroids
- radiation exposure
- metabolic disorders
- Downs syndrome
- uveitis
45
Sx & signs of cataracts?
- reduced vision
- faded colour vision
- glare (lights appear brighter than usual)
- haloes around lights
- Defect in red reflex
46
Ix in cataract on fundoscopy & slit lamp?
- after pupil dilation, normal funds & optic nerve (providing no other disease)
- visible cataract on slit lamp
47
Classification of cataract?
1. Nuclear: change lens refractive index, common in old age
2. Polar: localised, commonly inherited, lie in visual axis
3. Subcapsular: Steroid use, just deep to lens capsule, in visual axis
4. Dot opacities: common in normal lenses, also in diabetes & myotonic dystrophy
48
Rx of cataracts?
Non-surgical: conservatively if early but won't slow progression, no medicine
Surgery: remove cloudy lens, replace with artificial one\- referral for surgery depends on visual impairment, impact on ADLs, 1 ro both eyes, risks & benefits etc
Pre-op: give info on refractive implications of various types of intraocular lenses
Post-op: info on eye drops, eyewear, what to do if vision changes, Rx of other ocular problems
- high success rate
49
Post-op complications of cataract surgery?
- posterior capsule opacification: thickening of lens capsule
- retinal detachment
- posterior capsule rupture
- endophthalmitis: inflammation of aqueous &/or vitreous humour
50
Features of keratitis = inflammation of cornea?
Infective & environmental causes?
- painful red eye with erythema
- photophobia
- foreign body, gritty sensation
- hypopyon may be seen
- viral HSC
- bacterial staph aureus, pseudomonas
- fungal
- amoebic acanthomoebic keratitis
- parasitic onchocercal keratitis river blindness
- photokeratitis welders arc eye
- exposure keratitis
- CLARE: contact lens acute red eye
51
Factors predisposing to acute angle closure glaucoma?
- rise in IOP 2ry to impairment of aqueous outflow
- hypermetropia (LONG sightedness)
- pupil DILATATION
- lens growth with age
52
Features of acute angle closure glaucoma?
- severe pain: ocular/headache
- decreased visual acuity
- Sx worse with mydriasis e.g. watching tv in a dark room
- hard, red eye
- haloes around lights
- semi-dilated non-reacting pupil
- corneal oedema results in dull/hazy cornea
- systemic upset may be seen
53
Rx of acute angle closure glaucoma?
Urgent ophthal referral
Acetazolamide (reduce Aqueous secretions)
Pilocarpine, topical to induce Pupillary constriction
54
Drugs which may precipitate acute glaucoma? i.e. mydriatics
- anticholinergics, Tricyclics
- top mydriatics: tropicamide, atropine
- sympathomimetics: amphetamines, cocaine
55
Acute red eye with small fixed oval pupil, ciliary flush?
anterior uveitis
56
Features & Rx of herpes simplex keratitis?
- dendritic corneal epithelial ulcer on fluorescein stain
- red, painful eye, photophobia, epiphora, decreased visual acuity
- immediate ophthal referral
- topical aciclovir
57
Ocular manifestations in RA?
| Iatrogenic?
- commonest is keratoconjunctivitis sicca
- episcleritis (erythema)
- scleritis (erythema & pain)
- corneal ulceration
- keratitis
- steroid cataract
- chloroquine retinopathy
58
Causes of RAPD?
| Pathway?
- lesions anterior to optic chiasm is nerve/retina
- retina: detachment
- optic nerve: optic neuritis eg MS
Afferent: retina -> optic nerve -> lateral geniculate body -> midbrain
Efferent: Edinger-Westphal nucleus (midbrain) -> oculomotor nerve
59
Causes of a large pupil?
```
3rd nerve palsy
Holmes-Adiepupil
traumatic iridoplegia
phaeochromocytoma
congenital
drugs
```
60
small, irregular pupils
no response to light but there is a response to accommodate
Dx?
Argyll-Robertson
- neurosyphilis
- DM
61
Blepharitis causes/ass?
- commonly posterior - Meibomian gland dysfunction
- less commonly anterior - seb derm, staph infection
- rosacea
62
Visual loss over hours/days with poor discrimination of colours and eye pain on movement Dx?
Optic neuritis
63
Fundoscopy findings of papilledema?
- venous engorgement 1st
- loss of venous pulsation
- blurring of optic disc margin
- elevation of optic disc
- loss of optic cup
- Patons lines: concentric/radial retinal lines cascading from the optic disc
64
Causes of papilloedema?
- SOL: neoplastic, vascular
- malignant hypertension
- idiopathic intracranial hypertension
- hydrocephalus
- hypercapnia
- rarely hypoparathyroid, hypocalcaemia, vitamin A toxicity
65
Causes of optic neuritis?
diabetes
MS
syphilis
66
Features of optic neuritis?
| Rx?
- UL decrease in visual acuity over hours-days
- red desaturation, poor discrimination of colours
- pain worse on eye movement
- RAPD
- central scotoma
- high-dose steroids, recovery usually takes 4-6weeks
67
Keith-Wagener classification of hypertensive retinopathy stage I?
- arteriolar narrowing & tortuosity
| - increased light reflex - silver wiring
68
Keith-Wagener classification of hypertensive retinopathy stage II?
- AV nipping
69
Keith-Wagener classification of hypertensive retinopathy stage III?
- cotton-wool exudates
| - flame & blot haemorrhages
70
Keith-Wagener classification of hypertensive retinopathy stage IV?
- papilloedema
71
Features of retinitis pigments?
| Ass diseases?
- NIGHT blindness is often initial sign
- peripheral retina affected -> tunnel vision
- black bone spicule-shaped pigmentation in peripheral retina, with mottling of RPE on fundoscopy
- Alport's syndrome
- abetalipoproteinaemia, Usher syndrome, Larence-Moon-Biedl syndrome, Kearns-Sayre syndrome, Refsum disease: cerebellar ataxia, peripheral neuropathy, deafness, ichthyosis
72
Most important intervention in a poorly controlled diabetic with proliferative retinopathy?
```
LASER THERAPY
(tight glycaemic control will take too long)
```
73
What are angioid retinal streaks?
| Causes?
- irregular dark red streaks radiating from the optic nerve head seen on fundoscopy
- caused by degeneration, calcification & breaks in Bruchs membrane
- sickle cell disease
- Paget's disease
- acromegaly
- Ehler-Danlos syndrome
- pseudoxanthoma elasticum
74
Fundoscopy: pigmented scrambled egg appaearance concentrated around the macula
Dx?
Macular congenital hypertrophy
75
Central irregular pigmentation with bulls eye maculopathy on fundoscopy
Dx?
Chloroquine-ass retinopathy
76
Congenital causes of optic atrophy?
Friedrichs ataxia
mitochondrial disorders eg Lebers optic atrophy
DIDMOAD - ass of cranial DI, DM, OA & deafness
77
Acquired causes of optic atrophy?
- MS
- longstanding papilloedema
- raised IOP e.g. glaucoma, SOL
- retinal damage eg choroiditis, retinitis
- ischaemia
- toxins: tobacco, quinine, methanol, arsenic, lead
- nutritional: bits B1, B2, B6, B12 deficiency
78
Causes of tunnel vision?
```
papilloedema
glaucoma
retinitis pigmentosa
choroidoretinitis
optic atrophy 2ry to tabes dorsalis
hysteria
```
