Ophthalmolgy Flashcards
Open Angle Glaucoma
- Raised intraocular pressure caused by blockage in aqueous humour draining from the eye
- Raised pressure causes cupping of the optic disc and optic nerve damage
Acute Close Angle Glaucoma
- Ophthalmological emergency
- The iris bugles forward, sealing off the trabecular meshwork from the anterior chamber and preventing aqueous humour from draining
- Pressure builds in the posterior chamber, pushing the iris forward and exacerbating the angle closure
Blepharitis
- Blepharitis is inflammation of the eyelid margins.
- It may due to either meibomian gland dysfunction (common, posterior blepharitis) or seborrhoeic dermatitis/staphylococcal infection (less common, anterior blepharitis). Blepharitis is also more common in patients with rosacea
Stye
- An infection of the glands of Zeis or glands of Moll.
- The glands of Moll are sweat glands at the base of the eyelashes.
Chalazion
- A chalazion occurs when a Meibomian gland becomes blocked and swells.
- It is often called a Meibomian cyst.
Entropion
Entropion refers to when the eyelid turns inwards with the lashes pressed against the eye.
Ectropion
- Refers to when the eyelid turns outwards, exposing the inner aspect.
- It usually affects the bottom lid. This can result in exposure keratopathy, as the eyeball is exposed and not adequately lubricated and protected.
Trichiasis
- Trichiasis refers to inward growth of the eyelashes.
- It results in pain and can cause corneal damage and ulceration.
Cataracts
A progressively opaque eye lens which reduces the light entering the eye and visual acuity
Central retinal arterial occlusion
- A relatively rare cause of sudden unilateral visual loss.
- It is due to thromboembolism (from atherosclerosis) or arteritis (e.g. temporal arteritis)
Central retinal vein occlusion
Blockage of a retinal vein causes venous congestion in the retina.
Increased pressure results in fluid and blood leaking into the retina, causing macular oedema and retinal haemorrhages.
This results in retinal damage and vision loss.
Can be ischaemic or non-ischaemic
Chronic glaucoma
- This type of glaucoma is painless and usually discovered by checks during routine sight tests made by your optician.
- The pressure of the fluid (aqueous) in the eye damages the sensitive optic nerve which carries visual information to your brain enabling you to see.
- This causes vision damage which is irreversible.
Conjunctivitis
- Inflammation of the conjunctiva
- A thin layer of tissue that covers the inside of the eyelids and the sclera
Diabetic eye disease
- Damage to the retinal blood vessels due to prolonged high blood sugar levels
- Increased vascular permeability
- Yellow-white deposits of lipids and proteins in the retina
- Microaneurysms
- Venous beading
- Damage to the nerve fibres in the retina causes fluffy white patches called cotton wool spots to form on the retina
- Intraretinal microvascular abnormalities (IRMA)
- Neovascularisation
Infective keratitis
Inflammation of the cornea
Iritis (anterior uveitis )
- Inflammation of the anterior uvea. - The uvea consists of the iris, ciliary body and choroid.
- The anterior chamber becomes infiltrated by neutrophils, lymphocytes and macrophages.
- One of the important differentials of a red eye
Macular degeneration
- A progressive condition affecting the macula, it is the most common cause of blindness in the UK and is often unilateral but may be bilateral
There are 2 types - Wet (neovascular) 10% of cases
- Dry (non-neovascular) 90% of cases
Optic neuritis
- The most common presentation of MS
- Involves the demyelination of the optic nerve with unilateral reduced vision developing over hours to days
- Central scotoma (an enlarged central blind spot)
- Pain with eye movement
- Impaired colour vision
- Relative afferent pupillary defect
Periorbital cellulitis
- An infection of the soft tissues anterior to the orbital septum
- This includes the eyelids, skin and SC tissue of the face but not the contents of the orbit
- Orbital includes infection of the orbital septum and is a much more serious condition
Orbital cellulitis
- The result of an infection affecting the fat and muscles posterior to the orbital septum, within the orbit but not involving the globe.
- A medical emergency requiring hospital admission and urgent senior review
Posterior vitriol detachment
The neurosensory layer of the retina (containing photoreceptors and nerves) separating from the retinal pigment epithelium (base layer attached to the choroid)
Vitreous haemorrhage
- Bleeding into the vitreous humour
- One of the most common causes of sudden painless loss of vision
- Can cause disruption to vision to a variable degree, ranging from floaters to complete vision loss
Squint
- Strabismus is characterised by misalignment of the visual axes
- Can be divided into
- Concomitant (common)
- Paralytic (rare)
Retinal detachment
The neurosensory layer of the retina (containing photoreceptors and nerves) separating from the retinal pigment epithelium (base layer attached to the choroid)
Scleritis
Inflammation of the sclera, the outer layer of the connective tissue surrounding most of the eye (excluding the cornea). It forms the visible white part of the eye
Thyroid eye disease
- Thought to be an autoimmune response against an autoantigen, possibly the TSH receptor → retro-orbital inflammation
- Inflammation results in glycosaminoglycan and collagen deposition in the muscles
Thyroid eye disease includes
Exophthalmos
Conjunctival oedema
Optic disc swelling
Ophthalmoplegia
Inability to close the eyelids may lead to sore, dry eyes
If severe and untreated patients can be at risk of exposure keratopathy (disease of the cornea)
Corneal abrasion
A small scratch on the cornea, the clear window at the front of the eye. They are generally a result of trauma (injury) to the surface of the eye
Retinitis pigmentosa
Progressive degenerative disorder that primarily affects the peripheral retina resulting in tunnel vision
Episcleritis
Episcleritis is describes the acute onset of inflammation in the episclera of one or both eyes.
Adie syndrome
Holmes-Adie pupil is a benign condition most commonly seen in women. It is one of the differentials of a dilated pupil.
Proliferative retinopathy
- Proliferative diabetic retinopathy is a severe form of diabetic eye disease that occurs when blood vessels in the retina close, preventing adequate blood flow.
- The retina responds by growing new blood vessels, which are fragile and can bleed easily.
- These new vessels can cause serious vision problems if not treated promptly.
Holmes-Adie pupil
- A benign condition most commonly seen in women
- Unilateral in 80% of cases
- Dilated pupil once the pupil has constricted it remains small for an abnormally long time slowly reactive to accommodation but very poorly (if at all) to light
Conditions that can present with a red eye ?
Acute angle closure glaucoma
Anterior uveitis
Scleritis
Conjunctivitis
Subconjunctival haemorrhage
Endophthalmitis
DD’s of sudden vision loss ?
Ischaemic/vascular
- Viterous haemorrhage
- Retinal detachment
- Retinal migraine
- Central retinal vein occlusion
- Central retinal artery occlusion
How does Acute Angle Closure Glaucoma typically present ?
Red eye
Severe pain (may be ocular or headache)
Decreased visual acuity, patient sees haloes
Semi-dilated pupils
Hazy cornea
Acute onset !
Patient may be generally unwell
How does Anterior Uveitis typically present ?
Red eye
Acute onset
Pain, blurred vision and photophobia
Small, fixed oval pupil, ciliary flush
How does Scleritis typically present ?
Red eye
Severe pain (may be worse on movement) and tenderness
May be underlying autoimmune disease e.g. RA
How does Conjunctivitis typically present ?
Purulent discharge if bacterial, clear if viral
Red eye
How does Subconjunctival haemorrhage typically present ?
Hx of trauma, coughing, sneezing, HTN or anticoagulation
Red eye - red patch on conjunctiva
Pain less
Vision normal
How does endophthalmitis typically present ?
Red eye, pain and visual loss following intraocular surgery
Primary open-angle glaucoma signs on fundoscopy ?
- Optic disc cupping - cup-to-disc ratio >0.7 (normal = 0.4-0.7), occurs as loss of disc substance makes optic cup widen and deepen
- Optic disc pallor - indicating optic atrophy
- Bayonetting of vessels - vessels have breaks as they disappear into the deep cup and re-appear at the base
- Additional features - Cup notching (usually inferior where vessels enter disc), Disc haemorrhages
How does primary open-angle glaucoma typically present ?
Peripheral visual field loss - nasal scotomas progressing to ‘tunnel vision’
Decreased visual acuity
Optic disc cupping
Pain, headaches, blurred vision and halos
Presenting signs of acute angle-closure glaucoma ?
Red eye
Hazy cornea
Decreased visual acuity
Mid-dilated pupil
Fixed-sized pupil
Hard eyeball on gentle palpation
How does Blepharitis typically present ?
Inflammation of the eyelid margin
How does Stye typically present ?
A tender red lump along the eyelid that may contain pus
How does Chalazion typically present ?
A firm painless lump in the eyelid
How does Entropion typically present ?
Eyelid will be turned inwards with the lashes pressed against the eye
How does Ectropion typically present ?
The eyelid is turned outwards exposing the inner aspect
Usually affects the bottom lid
How does Trichiasis typically present ?
- The inward growth of eyelashes resulting in pain and can cause corneal damage and ulceration
- Can cause keratopathy as the eye is not adequately lubricated and protected
How does Periorbital Cellulitis typically present ?
- A red, swollen, painful eye of acute onset
- Fever
- Erythema and oedema of the eyelids, which can spread onto the surrounding skin
- Partial or complete ptosis of the eye due to swelling
- Orbital signs (pain on movement of the eye, restriction of eye movements, proptosis, visual disturbance, chemosis, RAPD) must be absent in preseptal cellulitis - their presence would indicate orbital cellulitis
Signs of Periorbital Cellulitis ?
- Erythema and oedema of the eyelids which can spread to surrounding skin
- Partial or complete ptosis of the eye due to swelling
- Orbital signs are absent e.g. pain on movement
How does Orbital Cellulitis typically present ?
- Pain with eye movement, reduced eye movements, vision changes, abnormal pupil reactions and proptosis
- Eyelid oedema and ptosis
- Drowsiness +/- nausea/vomiting in meningeal involvement (rare)
Important to distinguish from Per– - - Orbital Cellulitis a non-emergency
How does Posterior Vitreous Detachment typically present ?
Floaters, flashing lights and blurred vision
How does Cataracts typically present ?
- Slow reduction in visual acuity
- Progressive blurring of the vision
- Colours becoming more faded, brown or yellow
- Starbursts can appear around lights, partially at night
- Loss of red reflex
- Lens can appear grey or white when using ophthalmoscope
How does Retinal Vessel Occlusion typically present ?
- Painless blurred vision or vision loss
- The loss of vision corresponds to the affected area of the retina
- E.g. when the branch draining the macula is affected then central vision is lost
How does Retinal Vessel Occlusion typically present on fundoscopy ?
- Dilated and tortuous retinal veins
- Flame and blot haemorrhages
- Retinal oedema
- Cotton wool spots
- Hard exudate
How does Central Retinal Artery Loss typically present ?
Sudden, painless unilateral vision loss
Relative afferent pupillary defect
‘Cherry red’ spot on a pale retina
How does Chronic Glaucoma typically present ?
Gradual and painless loss of vision
Peripheral vision is lost first and gradually progresses inwards
How does Conjunctivitis typically present ?
Red, bloodshot but painless eye
Itchy and gritty sensation
Discharge which may cause temporarily blurry vision
Purulent discharge = bacterial, clear = viral
DD’s of acute red eye that is painful
Acute angle-closure glaucoma
Anterior uveitis
Scleritis
Corneal abrasions or ulceration
Keratitis
Foreign body
Traumatic or chemical injury
DD’s of acute red eye that is not painful
Conjunctivitis
Episcleritis
Subconjunctival haemorrhage
How does background findings of diabetic retinopathy typically present on fundoscopy ?
Microaneurysms, retinal haemorrhages, hard exudates and cotton wool spots
How does pre-proliferative findings of diabetic retinopathy typically present on fundoscopy ?
Venous beading, multiple blot haemorrhages and intra retinal microvascular abnormality
How does proliferative findings of diabetic retinopathy typically present on fundoscopy ?
Neovascularisation and vitreous haemorrhage
How does Infective Keratitis typically present ?
- Primary infection often involves mild symptoms of blepharoconjunctivitis (inflammation of the eyelid margins and conjunctiva)
- Recurrent infections (MCC herpes simplex) present with painful red eye, photophobia, fluid filled blisters (vesicles), foreign body sensation, watery discharge and reduced visual acuity
How does Macular Degeneration typically present ?
(Tend to be) unilateral with gradual central vision loss, reduced visual acuity and crooked or wavy appearance of straight lines
Wet presents more acutely than dry and vision loss can develop and progress to complete vision loss within 2-3 years and can progress to bilateral disease
How does Optic Neuritis typically present ?
- Unilateral decrease in visual acuity over hours to days
- Poor discrimination of colours ‘red desaturation’
- Central scotoma (enlarged central blind spot)
- Pain worse on eye movement
- Relative afferent pupillary defect
How does Vitreous Haemorrhage typically present ?
- Painless visual loss or haze
- Red hue in vision
- Floaters or shadows/dark spots in vision
- Visual field defect if severe haemorrhage
How does Squint typically present ?
Eyes will look in different directions due to the permanent deviation in the direction of the gaze of one eye.
How does Retinal Detachment typically present ?
Peripheral vision loss often sudden and described as a shadow coming across the vision
Blurred or distorted vision
Flashes or floaters
How does Scleritis typically present ?
Usually gradual onset
Can be uni or bilateral
Red inflamed sclera (localised or diffuse)
Severe pain and pain on movement
Congested vessels
Photophobia
Epiphora (excessive tear production)
Reduced visual acuity
Tenderness on palpation of the eye
How does Thyroid Eye Disease typically present ?
(Can be either hypo or hyper)
Exophthalmos
Conjunctival oedema
Optic disc swelling
Ophthalmoplegia
Inability to close the eyelids may lead to sore, dry eyes
If severe and untreated patients can be at risk of exposure keratopathy (disease of the cornea)
How does Corneal Abrasion typically present ?
Maybe Hx of trauma
Eye pain and photophobia
Epiphora (excessive year production)
Foreign body sensation
Blurred vision
How does a Corneal Ulcer typically present ?
Contact lens use (RF)
Eye pain and photophobia
Watering of the eye
Focal fluorescein staining of the cornea
How does Corneal Foreign Body typically present ?
Eye pain and photophobia
Foreign body sensation
Watering and red eye
How does Retinitis Pigmentosa typically present ?
Progressive
Night blindness (inital sign)
Tunnel vision due to loss of peripheral retina
Funoscopy: Black bone spicule-shaped pigmentation in the peripheral retina, mottling of the retinal pigment epithelium
How does Episcleritis typically present ?
Red but not painful eye (compared to scleritis which is painful)
Watering and mid-photophobia may be present
Injected vessels are mobile when gentle pressure is applied on the sclera (in scleritis the vessels are deeper and hence do not move)
~50% of cases are bilateral
How can one differentiate between scleritis and episcleritis ?
Scleritis is painful
Injected vessels are mobile when gentle pressure is applied on the sclera (in scleritis the vessels are deeper and hence do not move)
Phenylephrine blanches the conjunctival and episcleral vessels but not the scleral vessels if the eye redness improves after phenylephrine a diagnosis of episcleritis can be made
How does Holmes-Adie Pupil typically present ?
Dilated pupil
Once pupil has constricted it will remain small for an abnormally long time
Slowly reactive to accommodation but very poorly (if at all) to direct light
How is primary open-angle glaucoma managed ?
Management starts if intraocular pressure if 24mmHg or above
1st line = 360 selective laser trabeculoplasty
2nd line = prostaglandin analogues e.g. latanoprost
3rd line = beta blockers, carbonic anhydrase inhibitors or sympathomimetic eye drops
How is Ocular trauma treated ?
Coming soon
What eye drops are available 3rd line for open-angle glaucoma ?
Beta blockers e.g. timolol
Carbonic anhydrase inhibitors e.g. dorzolamide
Sympathomimetic eye drops e.g. brimonidine
How do prostaglandin analogues work in the treatment of open-angle glaucoma ?
Latanoprost = increase uveoscleral outflow
How do beta blocker eye drops work ?
Timolol = Reduce aqueous production
How do carbonic anhydrase inhibitors work ?
Dorzolamide = reduces aqueous production
How is acute angle-closure glaucoma initially managed ?
Immediate admission
Pilocarpine eye drops (2% blue and 4% brown eyes)(muscarinic agonist)
Acetazolamide 500mg (carbonic anhydrase inhibitor)
Analgesia and antiemetic
What is definitive management of acute angle-closure glaucoma ?
Laser iridotomy
Making a hole in the iris allowing the aqueous humour to flow directing from the posterior to the anterior chamber
What medications can be given in acute angle-closure glaucoma ?
Pilocarpine eye drops
Acetazolamide (oral or IV)
Timolol
Dorzolamide (CAi)
Brimonidine (sympathomimetic)
How is blepharitis managed ?
Warm compressed and gentle cleaning of the eyelid margins to remove debris
How is a stye treated ?
Hot compresses and analgesia
Topical Abxs may be considered if associated with conjunctivitis
How is a chalazion managed ?
Warm compresses and gentle massage towards the eyelashes
Rarely surgical drainage may be required
How is an entropion managed ?
Initial = taping eyelid down to prevent it from turning inward
Same day ophthalmology referral if there is a risk to sight
Lubricating eye drops required if taped to prevent eye from drying out
How is an ectropion managed ?
Mild cases do not require treatment
Regular lubricating eye drops to protect surface of the eye
If risk to sight then same day referral
How is trichiasis managed ?
Removing the affected eyelashes
Recurrent may require electrolysis, cryotherapy or laser treatment to prevent regrowth
Same fay referral if risk to sight
How is Cataracts managed ?
No intervention if symptoms are manageable
Surgery to remove lens and replace with artificial lens
How is Central retinal arterial occlusion managed ?
Management and prognosis is poor
Manage underlying condition e.g. IV steroids for temporal arteritis
If acute presentation then consider thrombolysis
How is Central retinal vein occlusion managed ?
Immediate referral
Then to treat macular oedema and prevent neovascularisation
Anti-VEGF therapies e.g. ranibizumab
Dexamethasone intravitreal implant
Laser photocoagulation
How is Conjunctivitis managed ?
Usually resolves in 1-2 weeks without needing treatment.
Cleaning eyes with cooled boiled water and cotton wool can help with discharge
ABx eye drops such as Chloramphenicol or fusidic acid eye drops if necessary
How is conjunctivitis managed in neonates ?
Urgent ophthalmological assessment
Gonococcal infection can cause permanent vision loss
How is allergic conjunctivitis managed in neonates ?
Antihistamines (oral or topical)
Topical mast-cell stabilisers if chronic seasonal symptoms
How is Diabetic eye disease managed ?
Non-proliferative = monitor
Proliferative =
Pan-retinal photocoagulation (PRP)
Anti-VEGF intravitreal injections
Surgery e.g. vitrectomy in severe disease
How can macular oedema be managed in diabetic eye disease or associated with retinal vein occlusions ?
intravitreal implant releasing dexamethasone
How is Infective keratitis managed ?
Urgent ophthalmologist assessment
Topical or oral antivirals e.g. aciclovir
Corneal transplant if permanent scarring or vision loss
How is Iritis (anterior uveitis ) managed ?
Urgent ophthalmology review
Cycloplegics e.g. atropine to relieve pain and photophobia
Steroid eye drops
How is dry Macular degeneration managed ?
No specific treatment
Reduce risk of progression by avoiding smoking, controlling BP and taking vitamin supplementation
How is wet macular degeneration managed ?
Anti-vascular endothelial growth factor (VEGF) e.g. ranibizumab which blocks the development of new vessels
Injections directly into vitreous chamber of the eye usually once a month
How is Optic neuritis managed ?
High dose steroids
Usually takes 4-6 weeks to recover
How is Periorbital cellulitis managed ?
All cases should be referred to secondary care for assessment
Oral Abxs usually co-amoxiclav
Children may require admission for observation
How is Orbital cellulitis managed ?
Admission to hospital for IV antibiotics
Cefotaxime or ceftriaxone plus flucloxacillin
How is Posterior vitriol detachment managed ?
No treatment is necessary symptom may improve over time
But can predispose to retinal tear and detachment and thus should be excluded
How is Vitreous haemorrhage managed ?
Depends on the underlying cause but
Anti-VEGF or a vitrectomy can be useful if due to neovascularisation
How is Squint managed ?
Referral to secondary care
Eye patches may help prevent amblyopia
How is Retinal tear managed ?
Aim of treatment is to create adhesions between the retina and the choroid so either
Laser therapy or cryotherapy are used
How is retinal detachment treated ?
Vitrectomy
Scleral buckle
Pneumatic retinopexy
How is Scleritis managed ?
Refer for urgent assessment of both the eye and underlying systems
NSAID (oral)
Steroids (topical or systemic)
Immunosuppression appropriate if underlying systemic conditions e.g. methotrexate for RA.
How is Thyroid eye disease managed ?
Smoking cessation
Topical lubricants may be needed to help prevent corneal inflammation caused by exposure
Steroids
Radiotherapy
Surgery
How is Corneal abrasion managed ?
Topical ABxs e.g. Chloramphenicol or fusidic acid
Simple analgesia
Removal or foreign bodies
How is corneal foreign body managed ?
Referral if
Penetrating injury due to high velocity mechanism, sharp objects
Significant orbital or peri-ocular trauma
Chemical injury (irrigate 20-30 mins)
Foreign body composed of organic material
Foreign bodies in or near the centre of the cornea
Eye trauma red flags
Severe pain
Irregular or dilated or non-reactive pupils
Significant reduction in visual acuity
How is Retinitis pigmentosa
Referral to an ophthalmologist for assessment, diagnosis and follow-up
Genetic counselling
Vision aids
Sunglasses to protect the retina from accelerated damage
Driving limitations and informing the DVLA
How is Episcleritis managed ?
Conservative
Artificial tears may sometimes be used
Consequence of retinal ischemia
Release of vascular endothelial growth factor (VEGF)
Causes of Iritis
An autoimmune process usually causes it, but it can be due to infection, trauma, ischaemia or malignancy.
What is a Hypopyon ?
- Seen in Iritis
- A Hypopyon refers to a fluid collection containing inflammatory cells seen at the bottom of the anterior chamber on inspection.
