Ophthalmological Conditions Flashcards
Acute chlamydial conjunctivitis (presentation, cause, diagnosis, treatment)
Presentation: Acute or subacute unilateral conjunctivitis with mucopurulent discharge or as a chronic conjunctivitis.
Cause: Exposure to STI (mother-to-child transmission, accidental transmission, or sexual abuse).
Diagnosis: Chlamydia PCR.
Treatment: Systemic treatment.
● > 1 month old - azithromycin 1 g (child 20 mg/kg) PO STAT
● Neonate - azithromycin 20 mg/kg PO for 3 days
Bacterial keratitis (symptoms, examination, management)
Epidemiology: 95% secondary to contact lens infection
Symptoms: Usually begin within 24 hours of infection.
● Red eye
● Reduced visual acuity
● Pain
● Eyelid swelling
● Photophobia
Examination: Corneal epithelial defect highlighted on fluorescein staining (common). Other - yellow or white stromal
infiltrates, corneal oedema.
Management:
● Immediate referral for corneal scraping and initiation of topical treatment is essential
● If referral is delayed or vision is threatened, start topical treatment ASAP.
○ Ciprofloxacin 0.3% eye drops 1-2 drops every 15 minutes for 6 hours, then hourly for 48 hours,
then every 4 hours until healed.
Cataracts (definition, terminology, RF, presentation, Ex, management)
Definition: Opacity of the lens that may cause blurred or distorted vision, glare problems or in advanced cases,
blindness.
Terminology:
● Immature cataract = view of the retina and transmission of red reflex still present.
● Mature cataract = red reflex is lost.
Risk factors: age, smoking, alcohol, sunlight, diabetes, systemic high-dose corticosteroids.
Presentation: problems with night driving, short-sighted.
Examination: Ensure eye is dilated for fundoscopy.
Cataract surgery: low-risk procedure. Indicated in interferes with ADLs.
● Optimise BP control
● Aspiring or anticoagulants can be continued for most patients
Complications: Risk for intraoperative floppy iris syndrome in patients on duodart or some antipsychotics (i.e. inform
surgeon).
Post-operative: Review by surgeon at 1 week and 1 month post-surgery. Minimal evidence for restriction of physical
activity.
71M, barber, presenting with difficulty driving at night because of the glare from street lights and oncoming headlights.
Associated with decline in vision. O/E: Bilateral visual loss especially distance vision, red reflexes diminished, view
limited on fundoscopy. What is the likely diagnosis?
Cataracts
Chalazion (cause, prognosis, presentation, examination, management)
Cause: Obstruction of Zeis or meibomian glands.
Prognosis: Small ones resolve without intervention over days or weeks.
Presentation: Plainless localised eyelid swelling.
Examination: Non-tender rubbery nodule of the inner eyelid.
Management:
● Warm compresses for 15 minutes about 4 times a day.
● Refer to an ophthalmologist if persistent.
Conjunctivitis (types)
Viral
- Red, irritated eyes with gritty sensation
- May have follicular appearance
- History of URTI, rapid progression over days, presence of mucopurulent discharge
Bacterial
- Redness and purulent discharge (follicle formation rare)
- Discharge appears at the lid margins and corners of eyes
- More often appears within minutes of wiping discharge
Allergic
- Red, irritated, itchy eyes
- Often have associated atopy, eczema, hay fever or asthma
Hypersensitivity
- Exposure to drugs, eye cosmetics, soaps or other chemicals
Allergic conjunctivitis (general advice, medication options)
General advice: Do not rub eyes, discontinue the use of contact lenses during symptomatic periods, apply cool
compresses, liberally use refrigerated artificial tears during the day, avoidance of allergens.
Medication options: antihistamine and mast cell stabilisers.
- Combination: Olopatadine (Patanol) 0.1% BD
- Antihistamine: Levocabastine 0.05% 2-4 times a day
- Mast cell stabilisers: Lodoxamide 0.1% QID
** Vasoconstrictor eye drops are not recommended because extended use can cause rebound ocular redness.
Episcleritis (key points, prognosis, presentation, management)
Key points
● Majority do not have an underlying infectious (rheumatic disease, herpes zoster) or systemic inflammatory
disease (rheumatoid arthritis, inflammatory bowel disease, vasculitis, systemic lupus erythematosus)
Prognosis: Good. Minimal discomfort, self-resolving after a few weeks.
Presentation: Aching or awareness (not usually pain).
Management: NSAIDs
Gonococcal conjunctivitis (presentation, diagnosis, complications, management)
Key point
● Requires advice from ophthalmologist urgently
Causative agent: Neisseria gonorrhoea
Presentation:
● Adult - Acute onset of copious, purulent discharge
● Neonate - As above ~ 2-5 days after birth
Diagnosis: Gonorrhoea PCR
Complications: Ulceration and perforation of the cornea
Management: Treat concurrently for Chlamydia
> 1 month = Ceftriaxone 1g (child 50 mg/kg) IM STAT
Plus Azithromycin 1 g (child 20 mg/kg) PO single dose
Neonates = Cefotaxime 100 mg/kg IM as a single dose
Plus Azithromycin 20 mg/kg PO for 3 days
Herpes simplex keratitis (key point, ocular manifestations, significance, examination, treatment)
Key point
● Prompt referral to ophthalmologist is recommended with suspected herpes simplex keratitis.
Ocular manifestations: blepharitis, conjunctivitis, keratitis, iritis and retinitis.
Significance: can result in corneal scarring and loss of vision.
Examination: Fluorescein staining. Can be confirmed on PCR.
Treatment:
● Aciclovir 3% eye ointment, 5 times a day, for 10-14 days OR
● Valaciclovir 500mg PO BD for 7-10 days (if ointment nor available)
Herpes zoster ophthalmicus (key points, treatment)
Key point
● Antiviral therapy aims to reduce pain.
● Can be started after 72 hours (ideally <72 hours) if there are active vesicles present or in
immunocompromised or elderly patients to reduce the risk of ocular complications.
● Concerning symptoms include red eye, visual loss and photophobia.
Treatment: Topical acyclovir has no role.
1. Valaciclovir 1g (child 20 mg/kg) PO, 8 hourly for 7 days
Hyphema - significance, management
Significance: Risk of secondary glaucoma.
● Ruptured vessels could fill the anterior chamber with blood, blocking the escape of aqueous humour and
causing a severe secondary glaucoma.
Management: Complete bed rest.
● Exclude penetrating eye injury
● Eye shield over affected eye
● Elevate patient’s head to 30 degrees and main patient at bed rest
● Dilate pupil
● Symptomatic management for nausea and topical pain control
Lens care and use
Length of lens use and wear
● Soft lenses allow only a limited time of safe and health usage
● Prescribed for use during waking hours only and not while sleeping
Monitor for: pain, redness, blurred vision, photophobia.
Complications:
● Increased risk of microbial keratitis with overnight use
● Corneal ulcers
● Corneal abrasions
Macular degeneration (presentation, fundocscopy)
Clinical presentation: Sudden fading of central vision. Others - distortion of vision, straight lines may seem wavy and
objects distorted, peripheral fields normal.
Fundoscopy: white exudates, haemorrhages in retina. Macula may look normal or raised.
** Refer to page 203 of GP Study Notes for picture
Marginal keratitis (cause, association, presentation, management)
Cause: Inflammation of the cornea.
Associated with: Blepharitis.
Presentation: Foreign body sensation or pain, epiphora, photophobia and occasionally reduced visual acuity.
Management: Warm compresses, lid massage, lid scrubs +/- antibiotic and steroid drops or ointments.
Optic neuritis (definition, significance, acute features)
Definition: Inflammatory, demyelinating condition that causes acute (usually monocular) visual loss.
Significance: Occurs in 50% of patients with multiple sclerosis at some point in time.
Acute features: Vision loss over a period of hours to days and eye pain (most common).
● Other - flickering or flashes of light, retrobulbar neuritis, loss of colour vision.
31F, presenting with a sudden appearance of large black spots obstructing central vision of the left eye with some discomfort associated. Fundoscopy normal.
Optic neuritis
Orbital cellulitis (RF, presentation)
Risk factor: Infection from paranasal sinuses. Children under 4 years.
Presentation: Reduced vision, limited or painful eye movements, diplopia, proptosis or chemosis (swelling of the eye
surface membranes because of fluid accumulation).
Periorbital cellulitis (definition, presentation, complications, management)
Definition: Cellulitis involving the soft tissue of the eyelids.
Presentation: Vision and eye movements are normal and the patient is systemically well.
Complications: Children under 4 years are at a higher risk of orbital cellulitis due to incomplete orbital septum.
Management:
1. Investigate for orbital cellulitis if there are systemic symptoms
2. If mild - moderate: Treat with oral antibiotics and review in 48 hours to ensure improvement
● Flucloxacillin 500 mg (child 12.5 mg/kg) 6 hourly for 7 days
3. If severe: Treat with IV antibiotics
Photokeratitis (definition, prognosis, presentation, examination, prevention, treatment)
Definition: Acute syndrome causing severe eye pain 6-12 hours after exposure to ultraviolet light
Prognosis: Resolution of symptoms in 24-72 hours.
Presentation: Foreign body sensation, eye injection and oedema, facial and lid erythema.
Examination: Fluorescein.
Prevention: Protective eyewear.
Treatment: Supportive.
● Antibiotic ointment - chlorsig
● Oral analgesia
** Topical anaesthetics should not be prescribed for ongoing management.
Pinguecula (definition, epidemiology, prognosis, complication, treatment)
Definition: Yellowish elevated nodular growth on either side of the cornea.
Epidemiology: > 35 years.
Prognosis: Generally status and not requiring treatment.
Complication: Pingueculitis (inflammation of the growth).
Treatment:
● Excision is indicated if they are large and uncomfortable.
● If irritating, topical astringent drops such as naphazoline compound drops can give relief.
Posterior vitreous detachment (epidemiology, timeframe, presentation, case)
Epidemiology: 50-75 years.
Timeframe: Usually over one week but can take up to 3 months to completely develop.
Presentation: New onset of cobweb-like floaters and/or increased floaters.
Case: 62F, Aboriginal with T2DM, seeing ants crawling on the toilet that aren’t there. Associated with flashing light in
the same eye. Symptoms worsening.
Pterygium (definition, epidemiology, treatment)
Definition: Overgrowth of the conjunctiva onto the nasal side of the cornea.
Epidemiology: Adults living in dry, dusty, windy areas.
Treatment:
● Excision by specialist indicated if it is likely to interfere with vision or becomes red/uncomfortable/disfiguring.
Red eye - differentials
Conjunctivitis (bacterial, viral, allergic, contact hypersensitivity) Subconjunctival haemorrhage Herpes simplex keratitis Corneal ulcer Scleritis/episcleritis Acute uveitis/iritis Acute glaucoma
** Refer to page 251 of GP Study Notes
