Ophthalmology Flashcards
Conjunctivitis
inflammation of the conjunctiva (thin layer of tissue that covers the inside of the eyelids and the sclera of the eye)
Conjunctivitis signs/symptoms
Unilateral or bilateral Red eyes Bloodshot Itchy or gritty sensation Discharge from the eye NO PAIN, PHOTOPHOBIA OR REDUCED VISUAL ACUTITY
Bacterial Conjunctivitis signs/symptoms
- Purulent discharge
- Inflamed conjunctiva (red eye)
- worse in the morning when the eyes may be stuck together.
- It usually starts in one eye and then can spread to the other
Bacterial Conjunctivitis Mx
Swab before or after
Topical antibiotic usually chloramphenicol qds (Drops vs ointment)
- Chloramphenicol 0.5% drops: treats most bacteria except Pseudomonas aeruginosa
- Fusidic acid: treats Staph. aureus
- Gentamicin: treats most Gram negative bacteria including coliforms, Pseudomonas aeruginosa
Chlamydial conjunctivitis - signs/symptoms
bilateral conjunctivitis in young adults
Follicular appearance – little grains of rice
Eventually becomes sub tarsal scars if not treated – chronic scarring of the lid
• May or may not have symptoms of urethritis, vaginitis
Chlamydial conjunctivitis Mx
Topical oxytetracycline but adults may also need oral azithromycin treatment (now doxycycline) for genital chlamydia infection
Viral conjunctivitis signs/symptoms
Clear discharge e.g. watery eye
Associated with other symptoms of a viral infection such as dry cough, sore throat and blocked nose.
You may find tender preauricular lymph nodes (in front of the ears).
viral conjunctivitis Mx
supportive unless ramsay-hunt syndrome: aciclovir
allergic conjunctivitis Mx
Antihistamines (oral or topical) can be used to reduce symptoms e.g. emedastine or olopatadine
Topical mast-cell stabilisers can be used in patients with chronic seasonal symptoms e.g. sodium cromoglicate
Keratitis causes
Viral infection with herpes simplex and adenovirus
Bacterial infection with pseudomonas or staphylococcus
Fungal infection with candida or aspergillus
Contact lens acute red eye (CLARE)
Exposure keratitis is caused by inadequate eyelid coverage (e.g. eyelid ectropion)
Keratitis signs/symptoms
Painful red eye (needle like and severe)
Photophobia
Opacity
Vesicles around the eye
Foreign body sensation
Watering eye (Epiphora (excess lacrimation))
Reduced visual acuity. This can vary from subtle to significant.
Bacterial keratitis signs/symptoms
Specific signs/symptoms: Hypopyon (inflammatory cells in the anterior chamber of the eye): White and risk of perforation if allowed to continue
Bacterial keratitis Mx
A 4-quinolone (Ofloxacin)
Gentamicin and cefuroxime
Viral keratitis
Dendritic ulcer
Very painful
Can be recurrent
Recurrences eventually result in reduced corneal sensation
Viral keratitis Ix
Fluorescence and slit lamp: dendritic corneal ulcer
Corneal swabs or scrapings can be used to isolate the virus using a viral culture or PCR.
Viral keratitis Mx
Aciclovir (topical or oral)
Ganciclovir eye gel
Topical steroids may be used alongside antivirals to treat stromal keratitis. Be careful not to cause corneal melt
Adenoviral keratitis – subepithelial infiltrates
Think it is immune mediated reaction – not an actual virus in their eye
Fungi keratitis signs/symptoms and Mx
Often corneal lesions more defined than its bacterial counterpart
Hypopyon
those who were outside
Mx:
Topical anti-fungals (natamycin amphotericin)
Keratitis– contact lenses
Acanthamoeba (protozoa)
extremely painful
Orbital Cellulitis
Orbital cellulitis is inflammation of eye tissues behind the orbital septum.
Orbital Cellulitis signs/symptoms
- Sudden onset of unilateral swelling of conjunctiva and lids
- Painful – especially on eye movements
- Proptosis – pushing eye forward
- Often associated with paranasal sinusitis
- Pyrexia and severe malaise
- Sight threatening – if pressing on optic nerve
- Relative afferent pupillary defect
pre-orbital vs orbital
pain on eye movement, reduced eye movements, changes in vision, abnormal pupil reactions and forward movement of the eyeball (proptosis).
Orbital cellulitis Mx
Orbital Medical Emergency: Transfer to hospital immediately and refer to ENT and/or Ophthalmology.
- Ceftriaxone IV 2g bd + Flucloxacillin IV 2g qds + Metronidazole IV 500mg tds (Penicillin allergy: seek advice)
- Step down to Co-amoxiclav PO 625mg tds (10-14 days total)
Surgery
Periorbital cellulitis
Periorbital cellulitis (also known as preorbital cellulitis) is an eyelid and skin infection in front of the orbital septum (in front of the eye).
Periorbital cellulitis Mx
Co-amoxiclav PO 625mg tds or IV 1.2g tds (pencillin allergy: Clindamycin*) Duration: 7-10 days
Endophthalmitis
Devastating infection inside of the eye (Immune system finds it hard to cross the barrier)
Post-surgical e.g. post cataract surgery (breached blood-retina barrier and taken pathogen in) or endogenous (septicaemia)
- most common is staph epidermidis
Endophthalmitis signs/symptoms
- Painful +++, with decreasing vision
- Very red eye
- Sight threatening
- Eye op, eye pain and reducing vision
Endophthalmitis Mx
Intravitreal amikacin/ ceftazidime/ vancomycin and topical antibiotics
Chorioretinitis
inflammation of the choroid (thin pigmented vascular coat of the eye) and retina of the eye.
Chorioretinitis Causes
o CMV in AIDS
o Toxoplasma gondii
o Toxocara canis (worm)
Toxoplasmosis Mx
Requires systemic treatment if sight threatening (clindamicin/azithromycin +/-steroids)
Cataracts
opacifications within the lens (cloudiness of lens)
Age related cataracts
degenerative change of the fibres resulting in opacifications due to the mesh work of fibres.
Cumulative UVB damage can increase likelihood of cataracts
Diabetic cataract
change to osmotic pressures and altering of fluid content in lens damages epithelial cells and fibres
- Increased sugar content in lens
- Conversion of glucose to sorbitol
- Altered osmotic gradients
Nuclear cataract
This is the most common type of age-related cataract, caused primarily by the hardening and yellowing of the lens over time. “Nuclear” refers to the gradual clouding of the central portion of the lens, called the nucleus; “sclerotic” refers to the hardening, or sclerosis, of the lens nucleus.
Posterior subcapsular cataract
posterior subcapsular cataract starts as a small, opaque area that usually forms near the back of the lens, right in the path of light.
Christmas tree cataract (aka polychromatic cataract)
- Reflective, polychromatic, iridescent crystalline deposits deep in the lens
- May progress to posterior subcapsular cataract or complete cortical opacification
- In patients without myotonic dystrophy, cholesterol deposits may cause the cataract
Congenital cataracts
lens opacity present at birth. Congenital cataracts cover a broad spectrum of severity: whereas some lens opacities do not progress and are visually insignificant, others can produce profound visual impairment. Congenital cataracts may be unilateral or bilateral.
No red light reflex
cataracts risk factors
age smoking alcohol diabetes steroids (systemic) Hypocalcaemia
cataracts signs/symptoms
Eye is opaque and cloudy
Very slow reduction in vision
Progressive blurring of vision
Change of colour of vision with colours becoming more brown or yellow
“Starbursts”
loss of the red reflex
Cataracts Mx
surgery
Open angle Glaucoma
optic nerve damage (progressive optic neuropathy) that is caused by a significant rise in intraocular pressure
Normal pressure is 10-21
Open angle Glaucoma risk factors
Increasing age
Family history
Black ethnic origin
myopia
Open angle glaucoma signs/symptoms
1) Asymptomatic: affects peripheral vision first until tunnel vision
2) It can present with gradual onset of fluctuating pain, headaches, blurred vision and halos appearing around lights, particularly at night time.
3) Cupping of optic disc (greater than 0.5 of the optic disc) – loss of retinal ganglion cells
Glaucoma Ix
Non-contact tonometry
Goldmann applanation tonometry
Fundoscopy assessment
Visual field assessment
Open angle glaucoma Mx
Start around 24mmHg
1st: : Prostaglandin analogue/prostanoids eyedrops (e.g. latanoprost, travoprost or tafluprost): increase uveoscleral outflow
2nd:
- Beta blockers e.g. timolol, betaxolol, levobunolol carteolol reduce aqueous humour
- Carbonic anhydrase inhibitors (e.g. topical: dorzolamide (Trusopt) or systemic: acetazolamide (Diamox)) reduce the production of aqueous humour
- sympathomimetics/Alpha2 adrenergic agonist (e.g. brimonidine) reduce the production of aqueous fluid and increase uveoscleral outflow
- Parasympathomimetic (mitotics) – pilocarpine – miosis pulls the iris away from the trabecular meshwork to allow improved drainage of aqueous humour.
Trabeculectomy
Dry Age-related Macular Degeneration
degeneration in the macular that cause a progressive deterioration in vision.
Larger greater numbers of drusen
Dry Age-related Macular Degeneration signs/symptoms with Ix
Gradual worsening central visual field loss – Scotoma
Reduced visual acuity – Snellen chart
Crooked or wavy appearance to straight lines – amsler grid test
Fundoscopy – drusen and atrophic patches of retina
Slit-lamp biomicroscopic fundus examination by a specialist can be used to diagnose AMD.
Dry Age-related Macular Degeneration Mx
Management focuses on lifestyle measure that may slow the progression:
- Avoid smoking
- Control blood pressure
- Vitamin supplementation has some evidence in slowing progression
Use vision aids such as magnifier glass and social support
Diabetic Retinopathy
where the blood vessels in the retina are damaged by prolonged exposure to hyperglycaemia causing a progressive deterioration in the health of the retina.
lose their vision from retinal oedema affecting the fovea, vitreous haemorrhage and scarring/ tractional retinal detachment
Chronic hyperglycaemia glycosylation of protein/basement membrane loss of pericytes microaneurysm
Diabetic Retinopathy pathology
1) Damage causes increased vascular permeability which leads to leakage from the blood vessels, blot haemorrhages and the formation of hard exudates (yellow/white deposits of lipids)
2) Damage to the blood vessel walls leads to microaneurysms and venous beading.
- Microaneurysms are where weakness in the wall causes small bulges.
- Venous beading is where the walls of the veins are no longer straight and parallel and look more like a string of beads or sausages.
3) Cotton wool spots: Damage to nerve fibres in the retina causes fluffy white patches
4) Intraretinal microvascular abnormalities (IMRA) is where there are dilated and tortuous capillaries in the retina acting as a shunt between the arterial and venous vessels in the retina.
5) Neovascularisation is when growth factors are released in the retina causing the development of new blood vessels.
- Grow on disc, periphery or on iris if severe
Classification of diabetic retinopathy
Non-proliferative
- Mild: microaneurysms
- Moderate: microaneurysms, blot haemorrhages, hard exudates, cotton wool spots and venous beading
- Severe: blot haemorrhages plus microaneurysms in 4 quadrants, venous beading in 2 quadrates, intraretinal microvascular abnormality (IMRA) in any quadrant
Proliferative:
- Neovascularisation and Vitreous haemorrhage
diabetic maculopathy classification
Macular oedema and Ischaemic maculopathy
- observable maculopathy
- referable maculopathy – too close to comfort to the centre of the macula
- clinically significant maculopathy
diabetic Retinopathy/maculopathy Mx
good management of diabetes
Laser photocoagulation: Panretinal (peripheral) or macular grid (cauteruse vessels near macula)
Anti-VEGF medications such as ranibizumab and bevacizumab
Vitreoretinal surgery (keyhole surgery on the eye) may be required in severe disease
Diabetic retinopathy complications
retinal detachment vitreous haemorrhage rebeosis irdis optic neuropathy cataracts
Myopia - what is it and Mx
short sighted (in front of retina) and concave lens
Hypermetropia and lens
long sighted and behind the lens and convex lens
Astigmatism
irregular corneal curvature
Presbyopia
Loss of accommodation with ageing
Closed angle glaucoma
optic nerve damage that is caused by a significant rise in intraocular pressure, therefore visual loss.
Iris bulges forward and seals of trabecular meshwork from anterior chamber preventing aqueous humour being able to drain away. Continual build up of pressure particularly in posterior chamber and this puts more pressure on the iris and worsens angle
acute closed angle glaucoma signs/symptoms
Patient will not be systemically well Severely painful red eye Blurred vision Halos around lights Associated headache, nausea and vomiting Rapid visual acuity red`uction/sudden visual loss Teary Hazy cornea Dilatation of the affected pupil and a fixed pupil size Firm eyeball on palpation
acute closed angle glaucoma Mx
same day assessment
lie patient on back without pillow
- give pilocarpine drops (muscarinic agonist: constriction of pupil and ciliary muscle contraction - open up flow)
- acetazolamide 500mg orally - reduce aq humour production
- analgesia and anti-emetic
2nd: Hyperosmotic agents such as glycerol or mannitol increase the osmotic gradient between the blood and the fluid in the eye
- timolol
- dorzolamide
- brimonidine
definitive: Laser iridotomy
Wet age related macular degeneration pathology
development of new vessels growing from the choroid layer into the retina. These vessels can leak fluid or blood and cause oedema and more rapid loss of vision. The key chemical that stimulates the development of new vessels is vascular endothelial growth factor (VEGF) and this is the target of medications to treat wet AMD
Eventually causes scarring
Wet ARMD signs/symptoms and Ix
- Reduced visual acuity using a Snellen chart
- Metamorphopsia: Crooked or wavy appearance to straight lines - Amsler grid test can be used to assess distortion of straight lines
- Wet age related macular degeneration presents more acutely.
- Loss of central vision over days – scotoma
- Dhrusen, haemorrhage and exudate – fundoscopy
- Slit-lamp biomicroscopic fundus examination used to diagnose AMD.
- Wet AMD: Optical coherence tomography is a technique used to gain a cross sectional view of the layers of the retina
- Fluorescein angiography involves giving a fluorescein contrast and photographing the retina to look in detail at the blood supply to the retina. It is useful to show up any oedema and neovascularisation.
Wet ARMD Mx
Anti-VEGF: e.g. ranibizumab, bevacizumab and pegaptanib
Central retinal artery occlusion and cause
central retinal artery supplies the blood to the retina. It is a branch of the ophthalmic artery, which is a branch of the internal carotid artery.
- atherosclerosis
- carotid artery disease embolus
- cardioembolic
- giant cell arteritis
Central retinal artery occlusion signs/symptoms
Sudden painless loss of vision
Relative afferent pupillary defect
Fundoscopy: pale retinal nerve layer (lack of perfusion with blood) with a cherry red spot (macula which has thinner surface showing red coloured choroid below)
Central retinal artery occlusion Mx
Giant cell: ESR, temporal artery biopsy and prednisolone 60mg
- ocular massage
- removing fluid from anterior chamber
- inhaling carbogen
- sublingual isosorbide
Long term: treat reversible risk factors and prevent secondary CVD
Branch retinal artery occlusion
Going to be less damage as it is not central – can see a paler section only
Part of the vision has disappeared
Amaurosis fugax and Mx
transient painless visual loss
‘like a curtain coming down’
lasts~5mins with full recovery
Mx: refer to stroke team
Central Retinal Venous occlusion
blood clot (thrombus) forms in the retinal veins and blocks the drainage of blood from the retina. Causes pooling of blood in the retina. This causes leakage of fluid and blood causing macular oedema and retinal haemorrhages.
Damages retina and VEGF is released
Central Retinal Venous occlusion signs/symptoms
- Sudden painless visual loss
- Range of visual loss: need to determine degree of ischaemia
- Fundoscopy:
o Flame and blot haemorrhages
o Dilated tortuous veins
o Optic disc oedema (swelling)
o Macula oedema (swelling)
Other tests to look for associated conditions
o Full medical history
o FBC for leukaemia
o ESR for inflammatory disorders
o Blood pressure for hypertension
o Serum glucose for diabetes
Central Retinal Venous occlusion Mx
Aims to treat macular oedema and prevent complications such as neovascularisation of the retina and iris and glaucoma.
- Pan retinal Laser photocoagulation
- Intravitreal steroids (e.g. a dexamethasone intravitreal implant)
- Anti-VEGF therapies (e.g. ranibizumab, aflibercept or bevacizumab)
Ischaemic optic neuropathy (ION)
damage of the optic nerve caused by a blockage of its blood supply.
Occlusion of optic nerve head circulation
Posterior ciliary arteries become occluded, resulting in infarction of the optic nerve head
Optic disc in ION
Pale swollen disc
Vitreous Haemorrhage causes
1) Bleeding occurs from abnormal vessels e.g. retinal ischaemia in diabetes or retinal vein occlusion causes abnormal, fragile new blood vessels to form
2) Bleeding occurs from normal retinal vessels e.g. bridging a retinal tear, retinal detachment
Vitreous Haemorrhage signs/symptoms
Loss of vision
Floaters
Loss of red reflex
Haemorrhage on fundoscopy
Vitreous Haemorrhage Mx
Vitrectomy - remove blood in vitreous if retina is torn or detached or patient needs treatment for new blood vessels
Diabetes: photocoagulation
Retinal detachment
retina separates from the choroid underneath. Due to a retinal tear allowing vitreous fluid to get under the retina. Outer retina relies on the blood vessels of the choroid for its blood supply. This makes retinal detachment a sight threatening emergency unless quickly recognised and treated.
Retinal detachment risk factors
- Posterior vitreous detachment
- Diabetic retinopathy
- Trauma to the eye
- Retinal malignancy
- Older age
- Family history
Retinal detachment signs/symptoms Ix
Painless
Peripheral vision loss. This is often sudden and like a shadow coming across the vision.
Blurred or distorted vision
Sudden onset of Flashes and floaters
Signs: RAPD or tear on ophthalmoscopy
Retinal detachment Mx
Mx retinal tears: create adhesions between the retina and the choroid to prevent detachment.
- Laser therapy
- Cryotherapy
Mx retinal detachment: reattach the retina and reduce any traction or pressure that may cause it to detach
- Vitrectomy involves removing the relevant parts of the vitreous body and replacing it with oil or gas.
- Scleral buckling involves using a silicone “buckle” to put pressure on the outside of the eye (the sclera) so that the outer eye indents to bring the choroid inwards and into contact with the detached retina.
- Pneumatic retinopexy involves injecting a gas bubble into the vitreous body and positioning the patient so the gas bubble creates pressure that flattens the retina against the choroid and close the detachment.
Hypertensive retinopathy
the damage to the small blood vessels in the retina relating to systemic hypertension. (chronic or malignant)
Features of hypertensive retinopathy
- Attenuated blood vessels-copper or silver wiring: walls of the arterioles become thickened and sclerosed causing increased reflection of the light.
- Arteriovenous nipping:
- cotton wool spots: ischaemia and infarction in the retina causing damage to nerve fibres.
- hard exudates:
- retinal haemorrhage
- optic disc oedema: ischaemia to the optic nerve resulting in optic nerve swelling (oedema) and blurring of the disc margins.
Papilloedema
‘Optic disc swelling’ means disc swelling secondary to ANY cause
‘Papilloedema’ is a specific term meaning bilateral optic disc swelling secondary to raised intracranial pressure (ICP)
Subconjunctival Haemorrhage
one of the small blood vessels within the conjunctiva ruptures and release blood into the space between the sclera and the conjunctiva.
can be caused by: hypertension, bleeding disorders (thrombocytopenia), whooping cough, medications (anti-coags) and NAI
Subconjunctival Haemorrhage signs/symptoms
bright red blood underneath the conjunctiva and in front of the sclera covering the white of the eye.
It is painless and does not affect vision.
There may be a history of a precipitating event such as a coughing fit or heavy lifting.
Blepharitis
inflammation of the eyelid margins
Blepharitis anterior types
Seborrhoeic (squamous) scales on the lashes
- Dandruff
- No ulceration and lashes unaffected
Staphylococcal – infection involving the lash follicle
- Lashes distorted, loss of lashes, ingrowing lashes - trichiasis
- Styes, ulcers of lid margin
- corneal staining, marginal ulcers (due to exotoxin)
Lid margin redder than deeper part of lid
Blepharitis posterior signs
- Meibomian gland dysfunction (M.G.D.)
- Redness is in deeper part of lid. Lid margin often quite normal looking
- Lid margin skin and lashes unaffected
- M.G. openings pouting & swollen
- Inspissated (dried) secretion at gland openings
- Meibomian Cysts (chalazia)
- Associated with Acne Rosacea (50%)
Blepharitis anterior Mx
Hot compresses and gentle cleaning of the eye lid
Lubricating eye drops can be used to relieve symptoms:
o Hypromellose
o Polyvinyl alcohol (start with)
o Carbomer
Blepharitis posterior Mx
brief gentle eyelid massage following the use of a warm compress
For posterior blepharitis associated with meibomian gland dysfunction and rosacea consider prescribing oral antibiotics (such as doxycycline [off-label] or tetracycline [contraindicated in pregnancy, lactation and in children under 12 years]): 2-3 months
Episcleritis
benign and self-limiting inflammation of the episcleral, the outermost layer of the sclera (just underneath sclera)
episcleritis signs/symptoms
Typically not painful but there can be mild pain
Segmental redness (rather than diffuse): patch of redness in the lateral sclera.
Foreign body sensation
Dilated episcleral vessels
Watering of eye
No discharge
episcleritis Mx
- usually self-limiting and will recover in 1-4 weeks.
- In mild cases no treatment is necessary. - Lubricating eye drops can help symptoms.
- Simple analgesia, cold compresses and safety net advice are appropriate.
- More severe cases may benefit from systemic NSAIDs (e.g. naproxen) or topical steroid eye drops.
Scleritis
inflammation of the full thickness of the sclera
associated conditions
- RA, SLE, IBD, sarcoidosis, GPA
Scleritis signs/symptoms
- Severe pain
- Pain with eye movement
- Photophobia
- Eye watering
- Reduced visual acuity
- Abnormal pupil reaction to light
- Tenderness to palpation of the eye
- Injection of deep vascular plexus – ‘violaceous hue’
Scleritis Mx
Phenylephrine test: wont blanch
NSAIDS
steroids
Immunosuppression
Anterior Uveitis (iritis)
inflammation in the anterior part of the uvea.
The uvea involves the iris, ciliary body and choroid
Inflammation and immune cells
Anterior Uveitis (iritis) signs/symptoms
Unilateral symptoms Inflammatory cells in the anterior chamber cause floaters in the patient’s vision. Flashes Dull, aching, painful red eye Ciliary flush (a ring of red spreading from the cornea outwards) Reduced visual acuity Miosis Photophobia due to ciliary muscle spasm Pain on movement Excessive lacrimation
Abnormally shaped pupil due to posterior synechiae (adhesions) pulling the iris into abnormal shapes
Anterior Uveitis Mx
Steroids (oral, topical or intravenous): Pred Forte 1% Hourly Tapering over 4-8 weeks
Cycloplegic-mydriatic medications such as cyclopentolate or atropine eye drops
Investigate other systemic causes
Immunosuppressants such as DMARDS and TNF inhibitors
Laser therapy, cryotherapy or surgery (vitrectomy) are also options in severe cases.
Infectious uveitis: appropriate antimicrobial drug as well as corticosteroids and cycloplegics.
Corneal abrasion
defect in the corneal epithelium as a result of mechanical trauma; fingernails, foreign bodies and contact lenses (might be an infection with pseudomonas) are common culprits
also entropion and eyelashes
Corneal abrasion Ix
- Fluorescein stain
* Slit lamp examinations
Corneal abrasion Mx
Simple analgesia (e.g. paracetamol)
Lubricating eye drops can improve symptoms
Antibiotic eye drops (i.e. chloramphenicol)
- Chloramphenicol ointment, applied 4 times daily in conjunction with a mydriatic
- Cyclopentolate
VI nerve palsy
Lateral rectus
- abduction failure
- diplopia on horizontal vision (looking to that side)
- esotropia (inwards)
- patients compensate by turning head to side
VI nerve palsy causes
Medical: diabetes and hypertension
Surgical: ICP (main), tumour, congenital
IV nerve palsy
Superior oblique
- failure of eye depression (depression in adduction)
- hypertropia
- vertical diplopia worse on looking down
IVth nerve palsy causes
congenital (Most common)
microvascular
tumour
bilateral - head trauma
CN III controls
SR, IF, MR, IO, Sphincter pupillae and levator palpebrae superioris
CN III signs/symptoms
abduction and depression: resting state
- ptosis
- dilated non reactive pupil
- divergent strabismus
CN III causes
sparing of pupil (diabetes and hypertension and ischaemia)
Surgical - posterior communicating artery aneurysm o Idiopathic o Tumour o Trauma o Cavernous sinus thrombosis
Horners syndrome
damage to the sympathetic nervous system supplying the face.
- Central lesions cause anhidrosis of the arm and trunk as well as the face.
- Pre-ganglionic lesions cause anhidrosis of the face.
- Post-ganglionic lesions do not cause anhidrosis.
Horners syndrome signs/symptoms
Ptosis
Miosis
Anhidrosis
Light and accommodation reflexes are not affected
Horners syndrome Ix
Apraclonidine can be used to confirm a Horner’s pupil: topical apraclonidine is an alpha-1 receptor agonist which causes pupillary dilation in the Horner’s pupil due to denervation hypersensitivity, however, normal pupil remain unaffected
Argyll-Robertson pupil
specific finding in neurosyphilis
focusing on a near object but does not react to light. They are often irregularly shaped.
It is commonly called “prostitutes’ pupil” due to the relation to neurosyphilis and because “it accommodates but does not react“.
Inter-nuclear Ophthalmoplegia and medial longitudinal fasciculus
medial longitudinal fasciculus links the three main nerves which control eye movements, i.e. the oculomotor, trochlear and the abducent nerves, as well as the vestibulocochlear nerve
Causes : MS, Vascular and mass
Optic nerve defects (causes)
Ischaemic optic neuropathy
- optic neuritis (MS)
- Tumours (meningioma and glioma)
Optic chiasm causes
Pituitary tumour
Craniopharyngioma (inferior)
Tuberculum sellae meningioma
Causes bitemporal hemianopia
Optic tracts and radiation causes
Tumours (primary or secondary) e.g. meningioma
- demyelination
- vascular anomalies
Optic tract visual loss
Contralateral homonymous hemianopia
Optic radiations eye deficiencies
Temporal radiations:
o Contralateral superior homonymous quadrantanopia “pie in sky”.
Parietal radiations:
o Contralateral inferior homonymous quadrantanopia ”pie in floor”.
Occipital cortex causes
Vascular disease (CVA) – occipital infarct
Demyelination
Occipital cortex visual field loss
Occlusion of the calcarine artery of the posterior cerebral artery:
- Contralateral homonymous hemianopia with macular-sparing.
Damage to the tip of the occipital cortex in a posterior head injury:
- Congruous homonymous macular defects.
Dacrocystitis
blockage of the lacrimal system and is treated with broad spectrum antibiotics
Alkali vs Acid burns to eye
Alkali - easy, rapid penetration (right)
- cicatrising changes to conjunctiva and cornea
- penetrates the intra-ocular structures
Acid - coagulates proteins (left)
- little penetration
Chemical burns Mx
Assessment of chemical injury occurs after thorough irrigation
- Quick history
- Nature of chemical, when, irrigation at event…
- Beware Lime / Cement
- Check Toxbase if available
- Check pH
- Irrigate +++ (minimum of 2l saline, or until pH normal)
- Then assess at slit lamp
- Washout chemical burns immediately
Cornea levels
Lipid: water: lipid sandwich at cornea
Epithelium is lipophilic/hydrophobic
Stroma is lipophobic/hydrophilic
Acetate and phosphate on to drugs makes them ….
- Alcohol or acetate makes steroid more hydrophobic (struggle to get into stroma)
- Phosphate makes it more hydrophilic (struggle to get into epithelium)
Topical steroid uses
- post op cataracts: significant systemic inflammatory response after surgery – minimise the immune response with steroids
- uveitis
- prevent corneal graft rejection
- Chorioretinitis
- Temporal arteritis
- Anterior ischaemic neuropathy
Strengths of topical steroids
- FML (fluorometholone)
- Predsol (prednisolone phosphate) – Poor penetration of cornea and acts more on surface (corneal disease)
- Betamathasone
- Dexamethasone/ prednisolone acetate - goes through the lipid and goes into the eye
LA uses
FB removal (foreign body)
Tonometry (IOP measurement)
corneal scraping
comfort Cataract surgery
fluorescein uses
- corneal abrasion
- dendritic ulcer – herpetic keratitis
- identify leaks – trauma to the eye
- tonometry
- diagnosing nasolacrimal duct obstruction
- angiography
Mydriatics
E.g. tropicamide, cyclopentolate
pupil dilation by blocking parasympathetic supply to iris
Cause cycloplegia i.e. stop lens from focus
Cycloplegia is paralysis of the ciliary muscle of the eye, resulting in a loss of accommodation.
Benign essential blepharospasm and Mx
A bilateral idiopathic condition characterized by involuntary contraction of the orbicularis oculi muscle
Artificial tears
First line: Botulinum toxin injection
Sympathetic Ophthalmia
Bilateral granulomatous uveitis (iris, ciliary body and choroid) due to trauma or surgery.
secondary to development of an autoimmune reaction to ocular antigens: exposed during the traumatic or surgical event
Initial wave of infiltrative cells composed of CD4+ helper T cells. Later wave of infiltrative cells are CD8+ cytotoxic T cells
The injured eye is the ‘exciting eye’ and the fellow eye is known as the ‘sympathising eye’. Clinically both eyes appear the same and it is only by history that one can identify which eye is the exciting eye
Sympathetic Ophthalmia Mx
repair globe (stick it back together) ASAP to recover quickly and limit pathogen. If you cannot close eye then you may need to remove eye at early stage to spare the second eye
Ocular cicatricial pemphigoid: which type of hypersensitivity
II
Type of autoimmune conjunctivitis: blistering and scarring of conjunctiva
Autoimmune corneal melting - Type of hypersensitivity
III
