ophthal II Flashcards
What is a key finding associated with macular degeneration in fundoscopy
Drusen (larger and in greater numbers indicate macular degeneration)
Types of age related macular degeneration
Wet and dry (wet carries worse prognosis)
What are drusen
Yellow deposits of proteins and lipids that appear between the retinal pigment epithelium and Bruch’s membrane
Features of wet and dry AMD
Drusen
Atrophy of the retinal pigment epithelium
Degeneration of the photoreceptors
Feature specific to wet AMD
Development of new vessels growing from the choroid layer into the retina due to VEGF
These vessels can leak fluid or blood and cause oedema and more rapid loss of vision
Risk factors for AMD
Age Smoking White or Chinese ethnic origin Family history Cardiovascular disease
Key visual changes in AMD
Gradual worsening central visual field loss
Reduced visual acuity
Crooked or wavy appearance to straight lines
(Wet presents more acutely)
Examination findings in AMD
Reduced acuity using a Snellen chart
Scotoma (a central patch of vision loss)
Fundoscopy. Drusen are the key finding.
Which test can assess for distortion of straight lines in AMD
Amsler grid test
Diagnosis of AMD
Slit-lamp biomicroscopic fundus exam
Optical coherence tomography
Fluorescein angiography
Mx of dry AMD
Ophthal referral
Avoid smoking
Control BP
Vitamin supplementation
Mx of wet AMD
Urgent referral
Anti-VEGF meds(bevacizumab)
Signs of hypertensive retinopathy on fundoscopy
Silver/copper wiring Arteriovenous nipping Cotton wool spots Hard exudates Retinal haemorrhages Papilloedema
What does silver/copper wiring refer to in fudoscopy
the walls of the arterioles become thickened and sclerosed causing increased reflection of the light.
What is arteriovenous nipping
Arterioles cause compression of the veins where they cross. This is again due to sclerosis and hardening of the arterioles.
Classification used for hypertensive retinopathy
Keith-Wagener Classification
Stage 1 - mild narrowing of arterioles
Stage 4 - papillodema
Risk factors for cataracts
Increasing age Smoking Alcohol Diabetes Steroids Hypocalcaemia
Presentation of cataracts
Very slow reduction in vision
Progressive blurring of vision
Change of colour of vision with colours becoming more brown or yellow
“Starbursts” can appear around lights, particularly at night time
Mx of cataracts
Surgery
Potential serious complication of cataracts
Endophthalmitis
It is inflammation of the inner contents of the eye, usually caused by infection
Can lead to vision loss and loss of eye itself
What can cause the pupil to appear as a vertical oval shape
Acute angle closure glaucoma can cause ischaemic damage to the muscles of the iris causing an abnormal pupil shape, usually a vertical oval.
What is rubeosis iridis
(neovascularisation in the iris) can distort the shape of the iris and pupil
This is usually associated with poorly controlled diabetes and diabetic retinopathy.
What is a tadpole pupil and what is associated with
There is spasm in a segment of the iris causing a misshapen pupil. This is usually temporary and associated with migraines.
Causes of mydriasis
Third nerve palsy Holmes-Adie syndrome Raised ICP Congenital Trauma Stimulants Anticholinergics
Causes of miosis
Horners syndrome Cluster headaches Argyll-Robertson pupil (in neurosyphilis) Opiates Nicotine Pilocarpine
What can cause compression of oculomotor nerve
Cavernous sinus thrombosis and a posterior communicating artery aneurysm
What does a third nerve palsy with sparing of the pupil indicate
microvascular cause as the parasympathetic fibres are spared
Causes of CN III palsy with pupil sparing
Diabetes
Hypertension
Ischaemia
Causes of CN III palsy without pupil sparing
Idiopathic Tumour Trauma Cavernous sinus thrombosis Posterior communicating artery aneurysm Raised intracranial pressure
(Called a surgical third)
Causes of horner’s syndrome
Stroke MS Pancoast's Trauma Carotid aneurysm
What is congenital horner syndrome associated with
Heterochromia
What can be used to test for horner syndrome
Cocaine eye drops (no pupil reaction on administration)
What is a Holmes Adie pupil
unilateral dilated pupil that is sluggish to react to light with slow dilation of the pupil following constriction
caused by damage to the post-ganglionic parasympathetic fibres
What is argyll-robertson pupil
Specific finding in neurosyphilis. It is a constricted pupil that accommodates when focusing on a near object but does not react to light
What is blepharitis
gritty, itchy, dry sensation in the eyes. It can be associated with dysfunction of the Meibomian glands
Mx of blepharitis
hot compresses and gentle cleaning of the eyelid margins(sterilised water and baby shampoo)
Lubricating eye drops
Types of stye
Hordeolum external - sweat glands at base of eyelashes tender red lump along eyelid
Hordeolum internum - meibomian glands - deeper infection
Mx of stye
hot compresses and analgesia
Topical antibiotics(chloramphenicol) if conjunctivitis present
What is a chalazion
Meibomian gland becomes blocked and swells up
Mx of chalazion
Treatment is with hot compress and analgesia. Consider topic antibiotics (i.e. chloramphenicol) if acutely inflamed.
What is an entropion
eyelid turns inwards with the lashes against the eyeball
Results in corneal damage and ulceration
Mx of entropion
taping the eyelid down to prevent it turning inwards
Definitive mx is surgical intervention (same day referral required if risk to sight)
What is an ectropion
Ectropion is where the eyelid turns outwards with the inner aspect of the eyelid exposed. It usually affects the bottom lid.
What can ectropion result in
exposure keratopathy as the eyeball is exposed and not adequately lubricated and protected
Mx of ectropion
Mild cases may not require treatment. Regular lubricating eye drops are used to protect the surface of the eye. More significant cases may require surgery to correct the defect.
Same day referral if risk to sight
What is trichiasis
inward growth of the eyelashes
can result in corneal damage and ulceration
Mx of trichiasis
Management by a specialist is to remove the eyelash (epilation).
Recurrent cases may require electrolysis, cryotherapy or laser treatment to prevent the lash regrowing.
Same day referral may be required if risk to sight
What is periorbital cellulitis
eyelid and skin infection in front of the orbital septum (in front of the eye). It presents with swelling, redness and hot skin around the eyelids and eye.
How can periorbital cellulitis be differentiated from orbital cellulitis
CT scan
Treatment of periorbital cellulitis
Systemic antibiotics(oral or IV)
What is orbital cellulitis
Orbital cellulitis is an infection around the eyeball that involves tissues behind the orbital septum.
Orbital vs periorbital cellulitis
Key features that differentiate this from periorbital celluitis is pain on eye movement, reduced eye movements, changes in vision, abnormal pupil reactions and forward movement of the eyeball (proptosis).
Mx of orbital cellulitis
medical emergency that requires admission and IV antibiotics. They may require surgical drainage if an abscess forms.
Presentation of retinal vein occlusion
Sudden painless loss of vision
Macula oedema
Retinal haemorrhages
Neuovascularisaiton
Risk factors for retinal vein occlusion
Hypertension High cholesterol Diabetes Smoking Glaucoma SLE
Mx of retinal vein occlusion
Immediate referral
Laser photocoagulation
Intravitreal steroids(dexamethasone)
Anti-VEGF therapies
Causes of central retinal artery occlusion
Atherosclerosis
Giant cell arteritis
Risk factors for retinal artery occlusion
Older age FHx Smoking Alcohol HTN Diabetes
Presentation of central retinal artery occlusion
Sudden painless loss of vision
RAPD
what might fundoscopy show in CRAO
Pale retina with cherry red spot(pale due to lack of perfusion and cherry-red spot is macula)
General mx of CRAO
Immediate referral
IX for GCA
Acute mx of CRAO
Ocular massage
Removal of fluid from anterior chamber
Carbogen
Sublingual isosorbide dinitrate
