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Ophthalmology Flashcards

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USMLE® Step 1 flashcards
1
Q

Conjunctivitis

A

inflammation of the conjunctiva (thin layer of tissue that covers the inside of the eyelids and the sclera of the eye)

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2
Q

Conjunctivitis signs/symptoms

A 
Unilateral or bilateral
Red eyes
Bloodshot
Itchy or gritty sensation
Discharge from the eye
NO PAIN, PHOTOPHOBIA OR REDUCED VISUAL ACUTITY
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3
Q

Bacterial Conjunctivitis signs/symptoms

A
  • 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
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4
Q

Bacterial Conjunctivitis Mx

A

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
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5
Q

Chlamydial conjunctivitis - signs/symptoms

A

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

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6
Q

Chlamydial conjunctivitis Mx

A

Topical oxytetracycline but adults may also need oral azithromycin treatment (now doxycycline) for genital chlamydia infection

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7
Q

Viral conjunctivitis signs/symptoms

A

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).

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8
Q

viral conjunctivitis Mx

A

supportive unless ramsay-hunt syndrome: aciclovir

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9
Q

allergic conjunctivitis Mx

A

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

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10
Q

Keratitis causes

A

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)

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11
Q

Keratitis signs/symptoms

A

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.

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12
Q

Bacterial keratitis signs/symptoms

A

Specific signs/symptoms: Hypopyon (inflammatory cells in the anterior chamber of the eye): White and risk of perforation if allowed to continue

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13
Q

Bacterial keratitis Mx

A

A 4-quinolone (Ofloxacin)

Gentamicin and cefuroxime

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14
Q

Viral keratitis

A

Dendritic ulcer
Very painful
Can be recurrent
Recurrences eventually result in reduced corneal sensation

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15
Q

Viral keratitis Ix

A

Fluorescence and slit lamp: dendritic corneal ulcer

Corneal swabs or scrapings can be used to isolate the virus using a viral culture or PCR.

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16
Q

Viral keratitis Mx

A

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

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17
Q

Adenoviral keratitis – subepithelial infiltrates

A

Think it is immune mediated reaction – not an actual virus in their eye

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18
Q

Fungi keratitis signs/symptoms and Mx

A

Often corneal lesions more defined than its bacterial counterpart

Hypopyon

those who were outside

Mx:
Topical anti-fungals (natamycin amphotericin)

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19
Q

Keratitis– contact lenses

A

Acanthamoeba (protozoa)

extremely painful

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20
Q

Orbital Cellulitis

A

Orbital cellulitis is inflammation of eye tissues behind the orbital septum.

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21
Q

Orbital Cellulitis signs/symptoms

A
  • 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
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22
Q

pre-orbital vs orbital

A

pain on eye movement, reduced eye movements, changes in vision, abnormal pupil reactions and forward movement of the eyeball (proptosis).

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23
Q

Orbital cellulitis Mx

A

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

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24
Q

Periorbital cellulitis

A

Periorbital cellulitis (also known as preorbital cellulitis) is an eyelid and skin infection in front of the orbital septum (in front of the eye).

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25
Q

Periorbital cellulitis Mx

A

Co-amoxiclav PO 625mg tds or IV 1.2g tds (pencillin allergy: Clindamycin*) Duration: 7-10 days

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26
Q

Endophthalmitis

A

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
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27
Q

Endophthalmitis signs/symptoms

A
  • Painful +++, with decreasing vision
  • Very red eye
  • Sight threatening
  • Eye op, eye pain and reducing vision
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28
Q

Endophthalmitis Mx

A

Intravitreal amikacin/ ceftazidime/ vancomycin and topical antibiotics

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29
Q

Chorioretinitis

A

inflammation of the choroid (thin pigmented vascular coat of the eye) and retina of the eye.

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30
Q

Chorioretinitis Causes

A

o CMV in AIDS
o Toxoplasma gondii
o Toxocara canis (worm)

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31
Q

Toxoplasmosis Mx

A

Requires systemic treatment if sight threatening (clindamicin/azithromycin +/-steroids)

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32
Q

Cataracts

A

opacifications within the lens (cloudiness of lens)

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33
Q

Age related cataracts

A

degenerative change of the fibres resulting in opacifications due to the mesh work of fibres.

Cumulative UVB damage can increase likelihood of cataracts

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34
Q

Diabetic cataract

A

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
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35
Q

Nuclear cataract

A

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.

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36
Q

Posterior subcapsular cataract

A

posterior subcapsular cataract starts as a small, opaque area that usually forms near the back of the lens, right in the path of light.

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37
Q

Christmas tree cataract (aka polychromatic cataract)

A
  • 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
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38
Q

Congenital cataracts

A

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

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39
Q

cataracts risk factors

A 
age
smoking
alcohol 
diabetes 
steroids (systemic)
Hypocalcaemia
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40
Q

cataracts signs/symptoms

A

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

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41
Q

Cataracts Mx

A

surgery

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42
Q

Open angle Glaucoma

A

optic nerve damage (progressive optic neuropathy) that is caused by a significant rise in intraocular pressure

Normal pressure is 10-21

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43
Q

Open angle Glaucoma risk factors

A

Increasing age
Family history
Black ethnic origin
myopia

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44
Q

Open angle glaucoma signs/symptoms

A

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

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45
Q

Glaucoma Ix

A

Non-contact tonometry
Goldmann applanation tonometry
Fundoscopy assessment
Visual field assessment

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46
Q

Open angle glaucoma Mx

A

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

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47
Q

Dry Age-related Macular Degeneration

A

degeneration in the macular that cause a progressive deterioration in vision.

Larger greater numbers of drusen

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48
Q

Dry Age-related Macular Degeneration signs/symptoms with Ix

A

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.

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49
Q

Dry Age-related Macular Degeneration Mx

A

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

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50
Q

Diabetic Retinopathy

A

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

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51
Q

Diabetic Retinopathy pathology

A

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

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52
Q

Classification of diabetic retinopathy

A

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

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53
Q

diabetic maculopathy classification

A

Macular oedema and Ischaemic maculopathy

  • observable maculopathy
  • referable maculopathy – too close to comfort to the centre of the macula
  • clinically significant maculopathy
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54
Q

diabetic Retinopathy/maculopathy Mx

A

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

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55
Q

Diabetic retinopathy complications

A 
retinal detachment 
vitreous haemorrhage 
rebeosis irdis 
optic neuropathy 
cataracts
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56
Q

Myopia - what is it and Mx

A

short sighted (in front of retina) and concave lens

57
Q

Hypermetropia and lens

A

long sighted and behind the lens and convex lens

58
Q

Astigmatism

A

irregular corneal curvature

59
Q

Presbyopia

A

Loss of accommodation with ageing

60
Q

Closed angle glaucoma

A

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

61
Q

acute closed angle glaucoma signs/symptoms

A 
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
62
Q

acute closed angle glaucoma Mx

A

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

63
Q

Wet age related macular degeneration pathology

A

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

64
Q

Wet ARMD signs/symptoms and Ix

A
  • 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.
65
Q

Wet ARMD Mx

A

Anti-VEGF: e.g. ranibizumab, bevacizumab and pegaptanib

66
Q

Central retinal artery occlusion and cause

A

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
67
Q

Central retinal artery occlusion signs/symptoms

A

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)

68
Q

Central retinal artery occlusion Mx

A

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

69
Q

Branch retinal artery occlusion

A

Going to be less damage as it is not central – can see a paler section only

Part of the vision has disappeared

70
Q

Amaurosis fugax and Mx

A

transient painless visual loss
‘like a curtain coming down’
lasts~5mins with full recovery

Mx: refer to stroke team

71
Q

Central Retinal Venous occlusion

A

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

72
Q

Central Retinal Venous occlusion signs/symptoms

A
  • 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
73
Q

Central Retinal Venous occlusion Mx

A

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)
74
Q

Ischaemic optic neuropathy (ION)

A

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

75
Q

Optic disc in ION

A

Pale swollen disc

76
Q

Vitreous Haemorrhage causes

A

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

77
Q

Vitreous Haemorrhage signs/symptoms

A

Loss of vision
Floaters
Loss of red reflex
Haemorrhage on fundoscopy

78
Q

Vitreous Haemorrhage Mx

A

Vitrectomy - remove blood in vitreous if retina is torn or detached or patient needs treatment for new blood vessels

Diabetes: photocoagulation

79
Q

Retinal detachment

A

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.

80
Q

Retinal detachment risk factors

A
  • Posterior vitreous detachment
  • Diabetic retinopathy
  • Trauma to the eye
  • Retinal malignancy
  • Older age
  • Family history
81
Q

Retinal detachment signs/symptoms Ix

A

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

82
Q

Retinal detachment Mx

A

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.
83
Q

Hypertensive retinopathy

A

the damage to the small blood vessels in the retina relating to systemic hypertension. (chronic or malignant)

84
Q

Features of hypertensive retinopathy

A
  • 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.
85
Q

Papilloedema

A

‘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)

86
Q

Subconjunctival Haemorrhage

A

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

87
Q

Subconjunctival Haemorrhage signs/symptoms

A

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.

88
Q

Blepharitis

A

inflammation of the eyelid margins

89
Q

Blepharitis anterior types

A

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

90
Q

Blepharitis posterior signs

A
  • 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%)
91
Q

Blepharitis anterior Mx

A

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

92
Q

Blepharitis posterior Mx

A

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

93
Q

Episcleritis

A

benign and self-limiting inflammation of the episcleral, the outermost layer of the sclera (just underneath sclera)

94
Q

episcleritis signs/symptoms

A

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

95
Q

episcleritis Mx

A
  • 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.
96
Q

Scleritis

A

inflammation of the full thickness of the sclera

associated conditions
- RA, SLE, IBD, sarcoidosis, GPA

97
Q

Scleritis signs/symptoms

A
  • 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’
98
Q

Scleritis Mx

A

Phenylephrine test: wont blanch
NSAIDS
steroids
Immunosuppression

99
Q

Anterior Uveitis (iritis)

A

inflammation in the anterior part of the uvea.

The uvea involves the iris, ciliary body and choroid

Inflammation and immune cells

100
Q

Anterior Uveitis (iritis) signs/symptoms

A 
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

101
Q

Anterior Uveitis Mx

A

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.

102
Q

Corneal abrasion

A

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

103
Q

Corneal abrasion Ix

A
  • Fluorescein stain

* Slit lamp examinations

104
Q

Corneal abrasion Mx

A

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
105
Q

VI nerve palsy

A

Lateral rectus

  • abduction failure
  • diplopia on horizontal vision (looking to that side)
  • esotropia (inwards)
  • patients compensate by turning head to side
106
Q

VI nerve palsy causes

A

Medical: diabetes and hypertension

Surgical: ICP (main), tumour, congenital

107
Q

IV nerve palsy

A

Superior oblique

  • failure of eye depression (depression in adduction)
  • hypertropia
  • vertical diplopia worse on looking down
108
Q

IVth nerve palsy causes

A

congenital (Most common)
microvascular
tumour
bilateral - head trauma

109
Q

CN III controls

A

SR, IF, MR, IO, Sphincter pupillae and levator palpebrae superioris

110
Q

CN III signs/symptoms

A

abduction and depression: resting state

  • ptosis
  • dilated non reactive pupil
  • divergent strabismus
111
Q

CN III causes

A

sparing of pupil (diabetes and hypertension and ischaemia)

Surgical 
- posterior communicating artery aneurysm 
o	Idiopathic
o	Tumour
o	Trauma
o	Cavernous sinus thrombosis
112
Q

Horners syndrome

A

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.
113
Q

Horners syndrome signs/symptoms

A

Ptosis
Miosis
Anhidrosis
Light and accommodation reflexes are not affected

114
Q

Horners syndrome Ix

A

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

115
Q

Argyll-Robertson pupil

A

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“.

116
Q

Inter-nuclear Ophthalmoplegia and medial longitudinal fasciculus

A

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

117
Q

Optic nerve defects (causes)

A

Ischaemic optic neuropathy

  • optic neuritis (MS)
  • Tumours (meningioma and glioma)
118
Q

Optic chiasm causes

A

Pituitary tumour
Craniopharyngioma (inferior)
Tuberculum sellae meningioma

Causes bitemporal hemianopia

119
Q

Optic tracts and radiation causes

A

Tumours (primary or secondary) e.g. meningioma

  • demyelination
  • vascular anomalies
120
Q

Optic tract visual loss

A

Contralateral homonymous hemianopia

121
Q

Optic radiations eye deficiencies

A

Temporal radiations:
o Contralateral superior homonymous quadrantanopia “pie in sky”.
Parietal radiations:
o Contralateral inferior homonymous quadrantanopia ”pie in floor”.

122
Q

Occipital cortex causes

A

Vascular disease (CVA) – occipital infarct

Demyelination

123
Q

Occipital cortex visual field loss

A

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.

124
Q

Dacrocystitis

A

blockage of the lacrimal system and is treated with broad spectrum antibiotics

125
Q

Alkali vs Acid burns to eye

A

Alkali - easy, rapid penetration (right)

  • cicatrising changes to conjunctiva and cornea
  • penetrates the intra-ocular structures

Acid - coagulates proteins (left)
- little penetration

126
Q

Chemical burns Mx

A

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
127
Q

Cornea levels

A

Lipid: water: lipid sandwich at cornea

Epithelium is lipophilic/hydrophobic

Stroma is lipophobic/hydrophilic

128
Q

Acetate and phosphate on to drugs makes them ….

A
  • Alcohol or acetate makes steroid more hydrophobic (struggle to get into stroma)
  • Phosphate makes it more hydrophilic (struggle to get into epithelium)
129
Q

Topical steroid uses

A
  • 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
130
Q

Strengths of topical steroids

A
  • 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
131
Q

LA uses

A

FB removal (foreign body)
Tonometry (IOP measurement)
corneal scraping
comfort Cataract surgery

132
Q

fluorescein uses

A
  • corneal abrasion
  • dendritic ulcer – herpetic keratitis
  • identify leaks – trauma to the eye
  • tonometry
  • diagnosing nasolacrimal duct obstruction
  • angiography
133
Q

Mydriatics

A

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.

134
Q

Benign essential blepharospasm and Mx

A

A bilateral idiopathic condition characterized by involuntary contraction of the orbicularis oculi muscle

Artificial tears
First line: Botulinum toxin injection

135
Q

Sympathetic Ophthalmia

A

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

136
Q

Sympathetic Ophthalmia Mx

A

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

137
Q

Ocular cicatricial pemphigoid: which type of hypersensitivity

A

II

Type of autoimmune conjunctivitis: blistering and scarring of conjunctiva

138
Q

Autoimmune corneal melting - Type of hypersensitivity

A

III

Medical Diseases (18 decks)

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