Ophthalm Presentations Flashcards
What could cause a red eye? What are the key buzzwords for each
Conjunctivitis - Dicharge can be purulent or serous
Blepharitis - Crusts
Subconjunctival haemorrhage
Uveitis - small fixed oval pupil, perilibical injection
Epicleritis - blanch with phenylephrine
Scleritis
Corneal abrasion - visible with fluoroscein
Corneal ulcer (infectious keratitis) - ulcer (dendritic = herpes)
Acute closed angle glaucoma - semi dilated pupil, hazy cornea
Entropion - visible lash involvement
What can cause gradual vision loss?
Macular Degeneration Diabetic retinopathy Open angle glaucoma Cataract Refractive error Optic nerve pathology Drugs
What can cause sudden vision loss?
Retinal vessel occlusion Closed angle glaucoma Retinal detachment Vitreous haemorrhage Ischaemia
What does painful loss of vision indicate?
Serious pathology - malignancy or inflammatory process
What does loss of red reflex mean?
Problem with cornea, lens or vitreous
Where is the lesion likely to be if a patient has monocular blindness?
Ipsilateral optic nerve
Where is the lesion likely to be if a patient has a homonymous hemianopia?
Contralateral optic tract
Where is the lesion likely to be if a patient has a bitemporal hemianopia?
Optic chiasm
Where is the lesion likely to be if a patient has a superior quadrantanopia?
Contralateral temporal lobe or inferior optic radiation
Where is the lesion likely to be if a patient has a inferior quadrantanopia?
Contralateral parietal lobe or superior optic radiation
What does a homonymous hemianopia with macula sparing suggest?
Occipital love damage due to posterior cerebral artery infarct
Occipital pole supplied by middle cerebral artery
What can cause double vision?
Microvascular problems Squint Trauma Myasthenia gravis Thyroid eye disease
What is the difference between monocular and binocular diplopia?
Monocular - double vision remain on occlusion of uninvolved eye
Binocular - double vision corrected when either eye is occluded
What causes monocular diplopia?
Refractive error
Cataracts
Dislocated lens
Retinal detachment
What causes binocular diplopia?
Intermittent - myasthenia gravis
Constant - CN palsy, orbital disease (thyroid), post surgery or trauma
What does a unilateral large pupil indicate?
Pupil is poorly constricted in well lit room
Trauma 3rd nerve palsy Rubeosis Iridis Holmes-adie Pharmacological dilation
What causes a unilateral small pupil?
Poorly dilated in low lit room
Uveitis
Horner’s
Argyll Robertson
Pharmacological constriction
What is a Holmes Adie pupil?
Benign condition due to damage to ciliary ganglion or post ganglionic parasympathetics
Once pupil constricted, remain for long time
Pupil accommodate but slow to react to light
What is an Argyll Robertson pupil?
Bilateral sign of neurosyphilis
Damage to midbrain nuclei
Accommodate but slow to react to light
What can cause a relative afferent pupillary defect?
Defect in pupillary response - issue with optic nerve/retina
Optic neuritis Giant cell arteritis Retinal detachment Unilateral glaucoma Retinal artery disease Optic nerve tumour/infections
What can a fixed dilated pupil be indicative of?
Post traumatic iridocyclitis Intracranial pathology CNIII injury Brainstem injury Post. communicating artery aneurysm
What drugs cause dilation of a pupil?
Topical -
Sympathomimetics (adrenaline)
Antimuscarinics
Systemic - Adrenaline Atropine TCA's Amphetamines and ecstasy
What drugs cause pupillary constriction?
Muscarinic agonists (pilocarpine) Opiates
What can cause ptosis?
CN3 palsy Bells palsy Horners syndrome Myasthenia gravis Thyroid eye disease MS Trauma, infection or lesion
What is optic atrophy?
Loss of some or all of the nerve fibres within the optic nerve
How does optic atrophy present?
Loss of vision - type depend on cause
How does optic atrophy appear on Fundoscopy?
Pale retina
Well demarcated disc
Fewer small vessels crossing surface
What is the aim of management of optic atrophy?
Stop progression - optic nerve can’t regenerate
What can bilateral optic atrophy commonly be caused by?
Intracranial neoplasm
> 40 - vascular
What are the causes for optic atrophy?
Primary - MS, Raised IOP, Trauma
Secondary - papilloedema, giant cell arteritis, non arteritis ischaemia
Retinal - artery occlusion
Toxins - quinine, methanol, arsenic
Vitamin B1,2,6,12 deficiency
What is myopia/hypermetropia?
Myopia = short sightedness
Hypermetropia = long sightedness
What are the risks of myopia?
Retinal detachment
Macular degeneration
What are the risks of hypermetropia?
Acute closed angle glaucoma
Convergent squint
Why may hypermetropia be picked up late?
Accommodation can compensate
Can lead to headaches
What is presbyopia?
Reduction in accommodative ability with age
Lens and capsule less elastic - less able to accommodate
How is presbyopia corrected?
Give convex lens
Bifocals if pre-existing refractive error
What is astigmatism?
Abnormal curvature of the eye - rugby ball
Can cause blurred vision and headaches
What is amblyopia?
Eye functioning normally but dysfunction processing of visual information
How is amblyopia treated?
Correct any causative issues
Patch over good eye
Atropine drops in good eye
Aim to blur good eye so the bad eye has to work
How is amblyopia diagnosed?
Unilateral decrease in visual acuity >2 lines on snellen chart
What are the ocular manifestations of diabetes?
Retinopathy
Rubeosis iridis
Ocular nerve palsies
Maculopathy - complication of retinopathy
How does diabetic retinopathy appear on Fundoscopy?
Mild non proliferative - microaneurysms
Moderate non proliferative - microaneurysms, cotton wool spots, flame haemorrhages, hard exudates, venous beading
Severe non proliferative - as above in more quadrants of eye
Severe proliferative - + neovascularisation and vitreous haemorrhage
What are flame haemorrhages?
Haemorrhages due to weak vessels that track along nerve fibre bundles
What are cotton wool spots?
Build up of axonal debris - poor axonal metabolism in infarcted areas
How is diabetic retinopathy diagnosed?
Dilated retinal photography and ophthalmoscopy
How often are diabetic patients screened for retinopathy?
At diagnosis and annually for patients >12yo
How does diabetic retinopathy present?
Painless reduction in central vision
Dark painless floaters
How is diabetic retinopathy managed?
Prevent
Laser treatment of new vessels
Intravitreal steroids
Vitrectomy
What is diabetic maculopathy?
Macula oedema occurring with retinopathy
Breakdown of blood retinal barrier allow fluid to accumulate
Reduction in central vision
Treat with anti VEGF injections
What are the ocular manifestations of neurofibromatosis?
Lisch nodules
What are the ocular manifestations of shaken baby syndrome?
Intra retinal haemorrhages
What are the ocular manifestations of TIA?
Amaurosis Fugax
What are the ocular manifestations of hyper viscosity syndromes?
Amaurosis fugax, visual loss, retinal vein dilation, haemorrhage, disc oedema
What are the ocular manifestations of sickle cell?
Retinal artery occlusion - peripheral neovascularisation and haemorrhage
What cancers metastasise to the eye and how do they manifest?
Breast and Lung
Creamy white lesion in choroid
Irregular pupil shape
Hyphema
How does papilloedema look on Fundoscopy?
Cupping of optic disc
Blurring of optic disc margin
Venous engorgement
Loss of venous pulsation
What are the types of uveitis?
Granulomatous - blurred vision, mild pain, watering, sarcoid, TB
Non granulomatous - acute pain and photophobia - herpes, ank spond, IBD
What causes retinal vasculitis?
Behcet Sarcoid MS RA SLE Temporal arteritis
How does retinal vasculitis present?
Painless loss of vision - esp. colours
Floaters
Scotomas
How does optic neuritis present?
Reduced vision - exaggerated by heat
Pain on eye movement
Impaired colour vision
Can have socotoma, photopsia, RAPD
How is optic neuritis managed?
V high dose steroids
How does amaurosis fugax present?
Curtain drawing from above
Temporary loss of vision - between seconds to hours
What causes amaurosis fugax?
Emboli or atherosclerosis
Temporary vasospasm
Giant cell arteritis
What can cause hornets syndrome?
Pancoast tumour
Thyroid tumour
Carotid dissection
Cavernous sinus thrombosis
What are the phases of thyroid eye disease?
Active inflammatory - expansion of extra ocular muscles and orbital fat
Inactive fibrotic - lead to sight loss if active phase not treated
How does thyroid eye disease present?
Proptosis Lid retraction Orbital fat prolapse Diplopia Optic neuropathy Exposure keratopathy Decreased ocular mobility
How would you investigate thyroid eye disease?
TSH, free t4, thyroid autoantibodies
MRI
How is thyroid eye disease managed?
Achieve euthyroid state
Smoking cessation
Lubricants, steroids, prisms and surgery can be done/used
What is herpes zoster opthalmicus?
Reactivation of varicella zoster in area supplied by ophthalmic division of trigeminal nerve
How does herpes zoster ophthalmicus present?
Vesicular rash around eye
Hutchinson’s sign - rash on tip or side of nose
How is herpes zoster ophthalmicus managed?
Urgent ophthalmology review
Oral antiviral treatment for 7-10 days (systemic)
Topical corticosteroids can be used
What are the complications associated with herpes zoster ophthalmicus?
Conjunctivitis Keratitis Episcleritis Anterior uveitis Ptosis Post herpetic neuralgia
