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Ophthalmology Flashcards

1
Q

Open Angle Glaucoma

what is a glaucoma

A

refers to the optic nerve damage that is caused by a significant rise in intraocular pressure

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2
Q

Open Angle Glaucoma

what is the raised intraocular pressure caused by in glaucomas

A

blockage in aqueous humour trying to escape the eye

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3
Q

Open Angle Glaucoma

the vitreous chamber of the eye is filled with ___

A

vitreous humour

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4
Q

where is the anterior chamber

A

between the cornea and the iris

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5
Q

where is the posterior chamber

A

between the lens and iris

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6
Q

the anterior and posterior chamber is filled with ___

A

aqueous humour which supplies nutrients to the cornea

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7
Q

what produces the aqueous humour

A

the ciliary body

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8
Q

describe the flow of aqueous humour

A

from the ciliary body

around the lens and under the iris

through the anterior chamber

through the trabecular meshwork

and into the canal of Schlemm

eventually entering the general circulation

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9
Q

what is the normal intraocular pressure

A

10-21 mmHg

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10
Q

how is intraocular pressure created

A

by the resistance to flow through the trabecular meshwork into the canal of Schlemm

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11
Q

Open Angle Glaucoma

pathophysiology

A

gradual increase in resistance through the trabecular meshwork

more difficult for aqueous humour to flow through the meshwork and exit the eye

pressure slowly builds within the eye and this gives a slow and chronic onset of glaucoma

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12
Q

Acute Angle-Closure Glaucoma

pathophysiology

A

the iris bulges forward and seals off the trabecular meshwork from the anterior chamber

preventing aqueous humour from being able to drain away

leading to a continual build-up of pressure

ophthalmology emergency

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13
Q

what causes cupping of the optic disc

A

increased pressure in the eye

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14
Q

what is in the centre of a normal optic disc

A

the optic cup, a small indent in the optic disc less than half the size of the optic disc

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15
Q

what is cupping

A

when there is raised intraocular pressure, the optic cup becomes larger as the pressure in the eye puts pressure on that indent making it wider and deeper

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16
Q

what is an abnormal optic cup size

A

greater than 0.5 the size of the optic disc

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17
Q

Open Angle Glaucoma

RFs (4)

A
  • increasing age
  • FH
  • black ethnic origin
  • myopia (short sighted)
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18
Q

Open Angle Glaucoma

presentation

A
  • asymptomatic for a long period of time
  • affects peripheral vision first
  • gradually peripheral vision closes until they experience tunnel vision
  • gradual onset of fluctuating pain
  • headaches
  • blurred vision
  • halos appearing around lights esp at night
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19
Q

Open Angle Glaucoma

dx

A

routine screening when attending optometry for eye check

Non-contact tonometry

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20
Q

Open Angle Glaucoma

what is non-contact tonometry

A

the commonly used machine for estimating intraocular pressure by opticians

shoots a puff of air at the cornea and measures the corneal response to that air

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21
Q

Open Angle Glaucoma

what is Goldmann applanation tonometry

A

the gold standard way to measure introcular pressure

special device mounted on slit lamp that makes contact with the cornea and applies different pressures to the front of the cornea to get an accurate measurement of what the intraocular pressure is

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22
Q

Open Angle Glaucoma

dx and inx

A

Goldmann applanation tonometry: intraocular pressure

Fundoscopy: optic disc cupping and optic nerve health

Visual field assessment: peripheral vision loss

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23
Q

Open Angle Glaucoma

aim of mnx

A

reduce intraocular pressure

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24
Q

Open Angle Glaucoma

when is treatment started

A

when intraocular pressure is 24 mmHg or above

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25
Open Angle Glaucoma first line mnx
Prostaglandin analogue eye drops eg. latanoprost
26
Open Angle Glaucoma how does latanoprost work
prostaglandin analogue eye drops increase uveoscleral outflow
27
Open Angle Glaucoma prostaglandin analogue eye drop SEs eg. latanoprost
- eyelash growth - eyelid pigmentation - iris pigmentation (browning)
28
Open Angle Glaucoma other mnx options apart from latanoprost
- BB e.g. timolol - carbonic anhydrase inhibitors e.g. dorzolamide - sympathomimetics e.g. brimonidine Trabeculectomy
29
Open Angle Glaucoma how do BB work
reduce the production of aqueous humour
30
Open Angle Glaucoma how do carbonic anhydrase inhibitors work
reduce the production of aqueous humour
31
Open Angle Glaucoma how do sympathomimetics work
reduce the production of aqueous fluid and increase uveoscleral outflow
32
Open Angle Glaucoma when is a trabeculectomy indicated
where eye drops are ineffective
33
Open Angle Glaucoma what is involved in a trabeculectomy
creating a new channel from the anterior chamber, through the sclera to a location under the conjunctiva it causes a 'bleb' under the conjunctiva where the aqueous humour drains it is then reabsorbed from this bleb into the general circulation
34
Acute Angle Close Glaucoma cause
when the iris bulges forward and seals off the trabecular meshwork from the anterior chamber, preventing aqueous humour from being able to drain away continual build up of pressure in the eye, esp in the posterior chamber which causes pressure behind the iris and worsens the closure of the angle
35
Acute Angle Close Glaucoma RFs (5)
- increasing age - 4F:1M - FH - Chinese + East Asian ethnic origin - shallow anterior chamber
36
Acute Angle Close Glaucoma what medications can precipitate acute angle-closure glaucoma
- Adrenergics: noradrenalin - Anticholinergics: oxybutynin + solifenacin - TCA: amitriptyline, which have anticholinergic effects
37
Acute Angle Close Glaucoma presentation
- generally unwell in themselves - severely painful red eye - blurred vision - halos around lights - headache, N+V
38
Acute Angle Close Glaucoma examination findings (7)
- red eye - teary - hazy cornea - decreased visual acuity - dilatation of the affected pupil - fixed pupil size - firm eyeball on palpation
39
Acute Angle Close Glaucoma initial mnx
same day assessment by opthalmologist while waiting for an ambulance: - lie pt on their back without a pillow - pilocarpine eye drops - PO acetazolamide 500mg - analgesia + antiemetic PRN
40
Acute Angle Close Glaucoma initial mnx: if blue eyes what % pilocarpine do you give
2%
41
Acute Angle Close Glaucoma initial mnx: if brown eyes what % pilocarpine do you give
4%
42
Acute Angle Close Glaucoma how does pilocarpine act?
Miotic agent: acts on the muscarinic receptors in the sphincter muscles in the iris and causes constriction of the pupil also causes ciliary muscle contraction these 2 effects cause the pathway for the flow of aq humour from the ciliary body, around the iris and into the trabecular meshwork to open up
43
Acute Angle Close Glaucoma how does Acetazolamide work
carbonic anhydrase inhibitor. This reduces the production of aq humour
44
Acute Angle Close Glaucoma secondary care mnx to reduce the pressure
- Pilocarpine - Acetazolamide (oral or IV) - Hyperosmotic agents: glycerol, mannitol - Timolol - Dorzolamide - Brimonidine
45
Acute Angle Close Glaucoma how do hyperosmotic agents like glycerol or mannitol work
they increase the osmotic gR between the blood and fluid in the eye
46
Acute Angle Close Glaucoma how does Timolol work
BB: reduces production of the aq humour
47
Acute Angle Close Glaucoma how does Dorzolamide work
carbonic anhydrase inhibitor: reduces the production of aq humour
48
Acute Angle Close Glaucoma how does Brimonidine work
sympathomimetic: reduces the production of aq fluid and increases uveoscleral outflow
49
Acute Angle Close Glaucoma definitive trx
laser iridotomy
50
Acute Angle Close Glaucoma what does laser iridotomy involve
using a laser to make a hole in the iris to allow the aq humour to flow from the posterior chamber into the anterior chamber this relieves pressure that was pushing the iris against the cornea and allow the humour to drain
51
Age Related Macular Degeneration what is it
a condition where there is degeneration in the macula that cause a progressive deterioration in vision
52
in the UK, what is the most common cause of blindness
Age Related Macular Degeneration
53
Age Related Macular Degeneration key finding
drusen seen during fundoscopy
54
Age Related Macular Degeneration what are the 2 types
wet (10%) - worse prognosis | and dry
55
Age Related Macular Degeneration what are the 4 key layers of the macula
bottom: choroid layer Bruch's membrane Retinal pigment epithelium Top: photoreceptors
56
Age Related Macular Degeneration what does the choroid layer of the macular contain
blood vessels that provide blood supply to the macula
57
Age Related Macular Degeneration what are drunsen
yellow deposits of proteins and lipids that appear between the retinal pigment epithelium and Bruch's membrane
58
Larger and greater numbers of drusen can be an early sign of ____
macular degeneration
59
Age Related Macular Degeneration common features of both wet and dry AMD (2)
- atrophy of the retinal pigment epithelium | - degeneration of the photoreceptors
60
Age Related Macular Degeneration pathophysiology of wet AMD
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
61
Age Related Macular Degeneration name a key chemical that stimulates the development of new vessels
vascular endothelial growth factor (VEGF)
62
Age Related Macular Degeneration RFs (5)
- age - smoking - white or chinese ethnicity - FH - CVS disease
63
Age Related Macular Degeneration presentation (3)
- gradual worsening central visual field loss - reduced visual acuity - crooked or waxy appearance to straight lines
64
Age Related Macular Degeneration difference in presentation of wet and dry AMD
wet is more acute loss of vision over days and progress to full loss of vision over 2-3 years. often progresses to bilateral disease.
65
Age Related Macular Degeneration examination + inx findings
- Snellen chart: reduced acuity - Scotoma: central patch of vision loss - Amsler grid test: distortion of straight lines - Fundoscopy: drusen - Slit-lamp biomicroscopic fundus examination - Optical coherence tomography - Fluorescein angiography
66
Age Related Macular Degeneration dx with what
Slit-lamp biomicroscopic fundus examination by a specialist
67
Age Related Macular Degeneration what is Optical coherence tomography
a technique used to gain a cross-sectional view of the layers of the retina. can be used to diagnose wet AMD.
68
Age Related Macular Degeneration what is Fluorescein angiography
involves giving a fluorescein contrast and photographing the retina to look in detail at the blood supply to the retina useful to show up any oedema and neovascularisation used 2nd line to diagnose wet AMD
69
Age Related Macular Degeneration mnx of dry AMD
refer to ophthalmologist - Avoid smoking - Control blood pressure - Vitamin supplementation
70
Age Related Macular Degeneration mnx of wet AMD
Anti-VEGF medications: ranibizumab, bevacizumab and pegaptanib block VEGF and slow the development of new vessels need to be started within 3m to be beneficial
71
Age Related Macular Degeneration how often are Anti-VEGF medication injected
once a month injected directly into the vitreous chamber
72
Diabetic Retinopathy what is it
condition where the blood vessels in the retina are damaged by prolonged exposure to high blood sugar levels causing a progressive deterioration in the health of the retina
73
Diabetic Retinopathy pathophysiology : hyperglycaemia leads to...
hyperglycaemia --> damage to retinal small vessels + endothelial cells
74
Diabetic Retinopathy pathophysiology: increased vascular permeability leads to ....
leakage from blood vessels, blot haemorrhages and the formation of hard exudates (yellow/white deposits of lipids in the retina)
75
Diabetic Retinopathy pathophysiology: damage to blood vessel walls lead to
microaneurysms: weakness in the wall causes small bulges and venous beading: walls of the veins are no longer straight and parallel and look more like a string of beads or sausages
76
Diabetic Retinopathy pathophysiology: damage to nerve fibres in the retina causes..
cotton wool spots: fluffy white patches formed on the retina
77
Diabetic Retinopathy pathophysiology: what is intraretinal microvascular abnormalities (IMRA)
where there are dilated and tortuous capillaries in the retina these can act as a shunt between the arterial and venous vessels in the retina
78
Diabetic Retinopathy pathophysiology: what is neovascularisation
when growth factors are released in the retina causing the development of new blood vessels
79
Diabetic Retinopathy how can diabetic retinopathy be split into
- non-proliferative - proliferative - diabetic maculopathy depending on whether new blood vessels have developed
80
Diabetic Retinopathy mild non-proliferative diabetic retinopathy
microaneurysms
81
Diabetic Retinopathy moderate non-proliferative diabetic retinopathy
- microaneurysms - blot haemorrhages - hard exudates - cotton wool spots - venous beading
82
Diabetic Retinopathy severe non-proliferative diabetic retinopathy
- blot haemorrhages + microaneurysms in 4 quadrants - venous beading in 2 quadrants - intraretinal microvascular abnormality (IMRA) in any quadrant
83
Diabetic Retinopathy proliferative diabetic retinopathy (2)
- neovascularisation | - vitreous haemorrhage
84
Diabetic Retinopathy diabetic maculopathy (2)
- macular oedema | - ischaemic maculopathy
85
Diabetic Retinopathy complications (5)
- retinal detachment - vitreous haemorrhage - Rebeosis iridis - Optic neuropathy - Cataracts
86
Diabetic Retinopathy complications: what are vitreous heamorrhages
bleeding into the vitreous humour
87
Diabetic Retinopathy complications: what is Rebeosis iridis
new blood vessel formation in the iris
88
Diabetic Retinopathy mnx
- laser photocoagulation - anti-VEGF meds: ranibizumab, bevacizumab - vitreoretinal surgery: keyhole surgery on the eye may be required in severe disease
89
Cataracts what is it
where the lens becomes cloudy and opaque this reduces visual acuity by reducing the light that enters the eye
90
Cataracts what is the lens' function
to focus light coming into the eye onto the retina at the back of they eye
91
Cataracts what is the lens held in place by
suspensory ligaments attached to the ciliary body
92
Cataracts how does the lens thicken
when the ciliary body contracts it releases tension on the suspensory ligaments and the lens thicken
93
Cataracts how does the lens narrow
when the ciliary body relaxes it increases the tension in the suspensory ligaments and the lens narrows
94
Cataracts how is the lens nourished
by the surrounding fluid, it doesn't have a blood supply
95
Cataracts how is congenital cataracts screened for
using the red reflex during the neonatal examination
96
Cataracts RFs (6)
- increasing age - smoking - alcohol - diabetes - steroids - hypocalcaemia
97
Cataracts presentation
- usually asymmetrical - very slow reduction in vision - progressive blurring of vision - change in colour of vision: colours more brown or yellow - 'starbursts' can appear around lights esp at night
98
Cataracts key sign
loss of the red reflex
99
Cataracts mnx if symptoms are manageable
no intervention
100
Cataracts mnx
cataract surgery
101
Cataracts what does cataract surgery involve
drilling and breaking the lens into pieces, removing the pieces then implanting an artificial lens into the eye
102
Cataracts why might the pt still have poor visual acuity after cataract surgery
other pathology may be detected after surgery as cataracts can prevent the detection beforehand
103
Cataracts what is a rare but serious complication of cataract surgery
Endophthalmitis
104
Cataracts what is endophthalmitis
rare but serious complication of cataract surgery inflammation of the inner contents of the eye, usually caused by infection
105
Cataracts how can endophthalmitis be treated
with intravitreal antibiotics injected into the eye
106
Conjunctivitis what is the conjunctiva
a thin layer of tissues that covers the inside of eyelids and the sclera of the eye
107
Conjunctivitis what are the 3 types
- bacterial - viral - allergic
108
Conjunctivitis presentation
- unilateral or bilateral - red eyes - bloodshot - itchy or gritty sensation - discharge from the eye
109
Conjunctivitis does it cause pain, photophobia or reduced visual acuity?
NO
110
Conjunctivitis how does bacterial conjunctivits present
purulent discharge inflamed conjunctiva worse in morning when eyes may be stuck together starts in 1 eye and spread to other
111
Conjunctivitis how does viral conjunctivitis present
clear discharge other sx of a viral infection tender preauricular lymph nodes
112
Ddx for painless red eye
- conjunctivitis - episcleritis - subconjunctival haemorrhage
113
Ddx for painful red eye
- glaucoma - anterior uveitis - scleritis - corneal abrasions or ulceration - keratitis - foreign body - traumatic or chemical injury
114
Conjunctivitis mnx
usually resolves within 1-2w good hygiene: avoid sharing towels, wash hands, avoid contacts, clean eyes with hot water
115
Conjunctivitis when can antibiotic eye drops be considered
in bacterial conjunctivitis: chloramphenicol and fuscidic acid
116
Conjunctivitis why do pts <1y need urgent ophthalmology review
neonatal conjunctivits can be associated with gonococcal infection and can cause loss of sight and more severe complications such as pnuemonia
117
Conjunctivitis what is allergic conjunctivitis caused by
contact with allergens
118
Conjunctivitis what does allergic conjunctivitis present as
- swelling of conjunctival sac and eye lid | - significant watery discharge and itch
119
Conjunctivitis trx for allergic conjunctivitis
oral or topical antihistamines topical mast-cell stabiliser if chronic seasonal sx
120
Conjunctivitis how do mast-cell stabiliser work
preventing mast cells releasing histamine
121
Anterior Uveitis what is it
inflammation in the anterior part of the uvea aka iritis
122
Anterior Uveitis what does the uvea involve
- iris - ciliary body - choroid
123
Anterior Uveitis what is the choroid
the layer between the retina and sclera all the way around the eye
124
Anterior Uveitis pathophysiology
- inflammation and immune cells in the anterior chamber of the eye - the anterior chamber of the eye becomes infiltrated by neutrophils, lymphocytes and macrophages - usually caused by an autoimmune process but can be due to infection, trauma, ischaemia or malignancy
125
Anterior Uveitis what causes floaters in the pt's vision
inflammatory cells in the anterior chamber
126
Anterior Uveitis what types are there
acute or chronic
127
Anterior Uveitis difference between acute and chronic
chronic: more granulomatous (has more macrophages) and has a less severe and longer duration of symptoms, lasting >3m
128
Anterior Uveitis what is acute anterior uveitis associated with
HLA B27 conditions: - ankylosing spondylitis - IBD - Reactive arthritis
129
Anterior Uveitis what is chronic anterior uveitis associated with
- sarcoidosis - syphilis - lyme disease - TB - herpes virus
130
Anterior Uveitis presentation
- unilateral - may occur with a flare of reactive arthritis - dull, aching, painful red eye - ciliary flush - miosis - photophobia - pain on movement - lacrimation - abnormally shaped pupil - hypopyon
131
Anterior Uveitis | what is ciliary flush
a ring of red spreading from the cornea outwards
132
Anterior Uveitis what causes miosis
sphincter muscle contraction
133
Anterior Uveitis what causes photophobia
ciliary muscle spasm
134
Anterior Uveitis what causes an abnormal shaped pupil
posterior synechiae (adhesions) pulling the iris into abnormal shapes
135
Anterior Uveitis what is hypopyon
a collection of WBCs in the anterior chamber, seen as a yellowish fluid collection settled in front of the lower iris with a fluid level
136
Anterior Uveitis NICE guidelines on pts with potentially sight threatening causes of red eye
refer for same day assessmentt by ophthalmologist full slit lamp assessment and intraocular pressures
137
Anterior Uveitis trx choices
- steroids (PO, top, IV) - cycloplegic-mydriatic meds: cyclopentolate or atropine eye drops - immunosuppresants: DMARDS and TNF inhibitors - laser therapy, cryotherapy, vitrectomy for severe cases
138
Anterior Uveitis what does cycloplegic mean
paralysing the ciliary muscles
139
Anterior Uveitis | what does mydriatic mean
dilating the pupils
140
Anterior Uveitis how do cyclopentolate and atropine work
antimuscarinics that block the action of iris sphincter muscles and ciliary body these dilate the pupil and reduce pain associated with ciliary spasm by stopping the action of the ciliary body
141
Retinal Detachment what is it
where the retina separates from the choroid underneath usually due to a retinal tear that allows vitreous fluid to get under the retina and fill the space between the retina and choroid
142
Retinal Detachment what makes it a sight-threatening emergency
the outer retina relies on the blood vessels of the choroid for its blood supply
143
Retinal Detachment RFs(6)
- posterior vitreous detachment - diabetic retinopathy - trauma to the eye - retinal malignancy - older age - FH
144
Retinal Detachment presentation (3)
- peripheral vision loss. Often sudden and like a shadow coming across the vision - blurred or distorted vision - flashes and floaters
145
Retinal Detachment presents with painless flashes and floaters. Mnx?
detailed assessment of retina to detect retinal tears or detachment immediately refer to ophthalmology
146
Retinal Detachment mnx of retinal tears
aim to create adhesions between the retina and choroid to prevent detachment - laser therapy - cryotherapy
147
Retinal Detachment mnx options for reattaching the retina
- vitrectomy - scleral buckling - pneumatic retinopexy
148
Retinal Detachment what does vitrectomy involve
removing the relevant parts of the vitreous body and replacing it with oil or gas
149
Retinal Detachment what does scleral buckling involve
using a silicon 'buckle' to put pressure on the outside of the eye (the sclera) so that the outer indents bring the choroid inwards and into contact with the detached retina
150
Retinal Detachment what does pneumatic retinopexy involve
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.
151
Blepharitis what is it
inflammation of the eyelid margins
152
Blepharitis presentation
gritty, itchy, dry sensation in the eyes
153
Blepharitis what can it be associated with
dysfunction of the Meibomian glands, which are responsible for secreting oil onto the surface of the eye can lead to styes and chalazions
154
Blepharitis mnx
- hot compresses - gentle cleaning of the eyelid margins to remove debris using cotton wool dipped in sterilised water + baby shampoo - lubricating eye drops to relieve symptoms
155
Blepharitis what lubricating eye drop is usually started with
Polyvinyl alcohol the middle viscous choice
156
Blepharitis which lubricating eye drop is the least viscous and how long does it last for
Hypromellose least viscous lasting around 10 min
157
Blepharitis which lubricating eye drop is the most viscous and how long does it last for
Carbomer most viscous and lasts 30-60min
158
Stye what is Hordeolum externum
an infection of the glands of Zeis or glands of Moll
159
Stye what are the glands of Zeis
sebaceous glands at the base of the eyelashes
160
Stye what are the glands of Moll
sweat glands at the base of the eyelashes
161
Stye presentation
tender red lump along the eyelid that may contain pus
162
Stye what is Hordeolum internum
infection of the Meibomian glands deeper, more painful may point inwards towards the eyeball underneath the eyelid
163
Stye trx
hot compresses and analgesia consider topical abx (i.e. chloramphenicol) if assc w/ conjunctivitis or persistent
164
Chalazion when does it occur
when a Meibomian gland becomes blocked and swells up
165
Chalazion aka?
Meibomian cyst
166
Chalazion presentation
swelling in the eyelid typically not tender but can be tender and red
167
Chalazion trx
hot compress and analgesia consider topical abx (i.e. chloramphenicol) if acutely inflamed surgical drainage may be required
168
Entropion what is it
where the eyelid turns inwards with the lashes against the eyeball
169
Entropion what does it result in
pain and corneal damage and ulceration
170
Entropion initial mnx
tape eyelid down to prevent it turning inwards + regular lubricating eye drops to prevent eye drying out
171
Entropion definitive mnx
surgical intervention
172
Entropion when to refer to ophthalmology same day
if there is a risk to sight
173
Ectropion what is it
where the eyelid turns outwards with the inner aspect of the eyelid exposed usually affects the bottom lid
174
Ectropion what can it lead to and why
exposure keratopathy as the eyeball is exposed and not adequately lubricated and protected
175
Ectropion trx
mild: none regular lubricating eye drops severe: surgery
176
Trichiasis what is it
inward growth of the eyelashes results in pain, corneal damage and ulceration
177
Trichiasis mnx
epilation (remove eyelash)
178
Trichiasis recurrent cases mnx
electrolysis, cryotherapy or laser trx to prevent the lash regrowing
179
Periorbital Cellulitis what is it
eyelid and skin infection in the front of the orbital septum (in front of the eye)
180
Periorbital Cellulitis presentation
swelling, redness and hot skin around the eyelids and eye
181
Periorbital Cellulitis Ddx
orbital cellulitis ! a sight and life threatening emergency
182
Periorbital Cellulitis how to distinguish between periorbital and orbital cellulitis
CT scan
183
Periorbital Cellulitis trx
systemic abx (PO or IV) vulnerable pts or sever may require admission as can develop into orbital cellulitis
184
Orbital Cellulitis what is it
infection around the eyeball that involves tissues behind the orbital septum.
185
Orbital Cellulitis key features that differentiate this from periorbital cellulitis
- pain on eye movement - reduced eye movements - changes in vision - abnormal pupil reactions - proptosis (forward movement of the eyeball)
186
Orbital Cellulitis mnx
medical emergency that requires admission and IV antibiotics may require surgical drainage if an abscess forms.
187
Subconjunctival Haemorrhage what is it
one of the small blood vessels within the conjunctiva ruptures and release blood into the space between the sclera and the conjunctiva
188
Subconjunctival Haemorrhage what activities may it occur after
episodes of strenuous activity such as heavy coughing, weigh lifting or straining when constipated or trauma to the eye
189
Subconjunctival Haemorrhage what conditions may have contributed to it
- HTN - bleeding disorders (e.g. thrombocytopenia) - whooping cough - medications (warfarin, NOACs, antiplatelets) - non-accidental injury
190
Subconjunctival Haemorrhage presentation
- patch of bright red blood underneath the conjunctiva and in front of the sclera covering the white of the eye - painless, doesn't affect vision
191
Subconjunctival Haemorrhage dx
hx and examination
192
Subconjunctival Haemorrhage mnx
2w to resolve spontaneously possible causes: HTN, bleeding disorders may need further inx
193
Subconjunctival Haemorrhage if there is a foreign body sensation, what can help
lubricating eye drops
194
Retinal Vein Occlusion where does the central retinal vein run through
the optic nerve
195
Retinal Vein Occlusion what is the central retinal vein responsible for
draining blood from the retina
196
Retinal Vein Occlusion what is central retinal vein occlusion
thrombus forms in the retinal veins and blocks the drainage of blood from the retina
197
Retinal Vein Occlusion how many branched veins come together to form the central retinal vein
4
198
Retinal Vein Occlusion what does blockage of one of the branched vein cause
problems in the area drained by that branch
199
Retinal Vein Occlusion what does blockage in the central vein cause
problems with the whole retina
200
Retinal Vein Occlusion symptom
sudden painless loss of vision
201
Retinal Vein Occlusion what inx is diagnostic
fundoscopy
202
Retinal Vein Occlusion what does fundoscopy show
- flame and blot haemorrhages - optic disc oedema - macula oedema
203
Retinal Vein Occlusion why is there macula oedema and retinal haemorrhages
blockage of retinal vein causes pooling of blood in the retina this results in leakage of fluid and blood
204
Retinal Vein Occlusion what do macula oedema and retinal haemorrhages lead to
damage to the tissue in the retina and loss of vision also leads to the release of VEGF which stimulates the development of new blood vessels (neovascularisation)
205
Retinal Vein Occlusion RFs (6)
- HTN - high cholesterol - diabetes - smoking - glaucoma - SLE
206
Retinal Vein Occlusion inx to check for possible associated conditions
- full medical hx - FBC: leukaemia - ESR: inflammatory disorders - BP - serum glucose
207
Retinal Vein Occlusion should you refer
yes if suspected, refer immediately to ophthalmologist
208
Retinal Vein Occlusion mnx
- laser photocoagulation - intravitreal steroids (dexamethasone intravitreal implant) - anti-VEGF therapies (ranibizumab, aflibercept or bevacizumab)
209
Retinal Vein Occlusion what is the aim of mnx
to treat macular oedema and prevent complications such as neovascularisation of the retina and iris and glaucoma
210
Central Retinal Artery Occlusion what supplies the blood to the retina
the central retinal artery
211
Central Retinal Artery Occlusion what is the central retinal artery a branch of
the ophthalmic artery, which is a branch of the internal carotid artery
212
Central Retinal Artery Occlusion most common cause
atherosclerosis | can also be caused by GCA
213
Central Retinal Artery Occlusion how does giant cell arteritis cause it
vasculitis affecting the ophthalmic or central retinal artery causes reduced blood flow
214
Central Retinal Artery Occlusion RFs
the same for CVD: - older age - FH - Smoking - alcohol - hypertension - diabetes - poor diet - inactivity - obesity
215
Central Retinal Artery Occlusion main presentation
sudden painless loss of vision
216
Central Retinal Artery Occlusion what is relative afferent pupillary defect
the pupil in the affected eye constricts more when light is shone in the other eye compared when it is shone in the affected eye
217
Central Retinal Artery Occlusion why does relative afferent pupillary defect occur
because the input is not being sensed by the ischaemic retina when testing the direct light reflex but is being sensed by the normal retina during the consensual light reflex
218
Central Retinal Artery Occlusion what will fundoscopy show
a pale retina | with a cherry-red spot
219
Central Retinal Artery Occlusion | why is the retina pale
due to a lack of perfusion with blood
220
Central Retinal Artery Occlusion what is the cherry-red spot on fundoscopy
the macula, which has a thinner surface that shows the red coloured choroid below and contrasts with the pale retina
221
Central Retinal Artery Occlusion mnx
refer immediately if suspecting GCA: ESR, temporal artery biopsy , high dose steroids
222
Central Retinal Artery Occlusion immediate mnx
- ocular massage - remove fluid from anterior chamber to reduce intraocular pressure - inhale carbogen (5% CO2 + 95% O2) to dilate artery - sublingual isosorbide dinitrate to dilate the artery
223
Central Retinal Artery Occlusion long term mnx
treat reversible RFs and secondary prevention of CVD
224
Posterior Vitreous Detachment what is the vitreous body
the gel inside the eye that maintains the structure of the eyeball and keeps the retina pressed on the choroid
225
Posterior Vitreous Detachment what is the vitreous body made of
collagen and water
226
Posterior Vitreous Detachment what is it
the vitreous gel comes away from the retina very common, esp in older pts
227
Posterior Vitreous Detachment presentation
- painless - spots of vision loss - floaters - flashing lights presents similarly to retinal tear/detachment
228
Posterior Vitreous Detachment mnx
none, over time the sx will improve as the brain adjusts
229
Posterior Vitreous Detachment what are pts predisposed to
retinal tears and retinal detachment
230
Herpes Keratitis what is keratitis
inflammation of the cornea
231
causes of keratitis
- viral: herpes simplex - bacterial: pseudomonas or staph - fungal: candida or aspergillus - contact lens acute red eye - exposure karatitis
232
what is the most common cause of keratitis
herpes simplex keratitis
233
Herpes Keratitis what layer does herpes keratitis usually only affect
the epithelial layer of the cornea
234
Herpes Keratitis what is stromal keratitis
if there is inflammation of the stroma (the layer between the epithelium and endothelium)
235
Herpes Keratitis what is stromal keratitis associated with
complications such as stromal necrosis, vascularisation and scarring and can lead to corneal blindness
236
Herpes Keratitis presentation
- painful red eye - photophobia - vesicles around the eye - foreign body sensation - watering eye - reduced visual acuity
237
Herpes Keratitis what will staining with fluorescein show
dendritic corneal ulcer
238
Herpes Keratitis what is required to find and diagnose keratitis
slit lamp Corneal swabs or scrapings can be used to isolate the virus using a viral culture or PCR.
239
Herpes Keratitis mnx
- Aciclovir (topical or oral) - Ganciclovir eye gel - Topical steroids may be used alongside antivirals to treat stromal keratitis
240
Herpes Keratitis trx for corneal scarring caused by stromal keratitis
a corneal transplant may be required
241
Scleritis what is the most severe type
necrotising scleritis: visual impairment but may not have pain
242
Scleritis what is the most significant complication
perforation of the sclera
243
Scleritis what are some associated systemic conditions
- RA - SLE - IBD - Sarcoidosis - Granulomatosis w/ polyangiitis
244
Scleritis presentation
- acute severe pain - pain w/ eye movement - photophobia - eye watering - reduced visual acuity - abnormal pupil reaction to light - tenderness to palpation of the eye
245
Scleritis mnx
- NSAIDs - Steroids - Immunosuppression for underlying systemic condition
246
Episcleritis what is it
benign and self-limiting inflammation of the episclera, the outermost layer of the sclera.
247
Episcleritis whom is it common in
young and middle-aged adults
248
Episcleritis which inflammatory disorders is it associated with
RA and IBD
249
Episcleritis presentation
- acute + unilateral - no pain - segmental redness - foreign body sensation - dilated episcleral vessels - watering of eye - no discharge
250
Episcleritis mnx
- recovers in 1-4w - analgesia - cold compresses - lubricating eye drops
251
Pupil Disorders what causes pupil constriction
parasympathetic nervous system using ACh contracts circular muscles in the iris which cause pupil constriction travels along CN III (oculomotor)
252
Pupil Disorders what causes pupil dilation
dilator muscles stimulated by the sympathetic NS using adrenalin as a neurotransmitter
253
Pupil Disorders what can cause trauma to the sphincter muscles in the iris
cataract surgery and other eye operations causing an irregular pupil
254
Pupil Disorders how can anterior uveitis cause misshapen pupils
can cause adhesions in the iris
255
Pupil Disorders what can cause a vertical oval pupil
Acute angle closure glaucoma can cause ischaemic damage to the muscles of the iris
256
Pupil Disorders what is Rubeosis iridis
neovascularisation in the iris can distort the shape of the iris and pupil. usually associated with poorly controlled diabetes and diabetic retinopathy.
257
Pupil Disorders what is Coloboma
congenital malformation in the eye. This can cause a hole in the iris causing an irregular pupil shape.
258
Pupil Disorders what is tadpole pupil
spasm in a segment of the iris causing a misshapen pupil. usually temporary and associated with migraines.
259
Pupil Disorders causes of mydriasis (dilated pupil)
- 3rd nerve palsy - Holmes-Adie syndrome - raised ICP - congenital - trauma - stimulants: cocaine - anticholinergics
260
Pupil Disorders causes of miosis (constricted pupil)
- Horner's syndrome - cluster headaches - Argyll-Robertson pupil (in neurosyphilis) - opiates - nicotine - pilocarpine
261
Pupil Disorders 3 signs in 3rd nerve palsy
- divergent strabismis: down + out - ptosis - dilated non-reactive pupil
262
Pupil Disorders what does the 3rd nerve (oculomotor) supply
all of the extraocular muscles except the lateral rectus and superior oblique: down + out levator palpebrae superioris: ptosis sphincter muscle of the iris: dilated fixed pupil
263
Pupil Disorders how can a cavernous sinus thrombosis and posterior communicating artery aneurysm cause compression of the 3rd nerve, causing palsy
the oculomotor nerve travels from the brainstem through the cavernous sinus and close to the posterior communicating artery
264
Pupil Disorders what does a 3rd nerve palsy with sparing of the pupil suggest
a microvascular cause as the parasympathetic fibres are spared. May be due to: - DM - HTN - ischaemia
265
Pupil Disorders what is a full 3rd nerve palsy (surgical 3rd) cause
compression of the 3rd nerve inc the parasympathetic fibres
266
Pupil Disorders what is a full 3rd nerve palsy due to
- Idiopathic- - Tumour - Trauma - Cavernous sinus thrombosis - Posterior communicating artery aneurysm - Raised ICP
267
Pupil Disorders Horner syndrome triad
- ptosis - miosis - anhidrosis (loss of sweating)
268
Pupil Disorders Horner syndrome cause
damage to the sympathetic nervous system supplying the face.
269
Pupil Disorders Horner syndrome: journey of the sympathetic nerves
- spinal cord in chest (pre-ganglionic nerves) - enter into the sympathetic ganglion at the base of the neck - exit as post-ganglionic nerves - then travel to the head, running alongside the internal carotid artery.
270
Pupil Disorders location of Horner's syndrome if there is anhidrosis of the arm, trunk and face
central lesions (4 Ss): - Stroke - MS - Swelling (tumour) - Syringomyelia (cyst in the spinal cord)
271
Pupil Disorders location of Horner's syndrome if there is anhidrosis in the face only
Pre-ganglionic lesions (4 Ts): - Pancoast's tumour - Trauma - Thyroidectomy - Top rib: a cervical rib growing above the first rib above the clavicle
272
Pupil Disorders location of Horner's syndrome if no anhidrosis
Post-ganglionic lesions (4 Cs) - Carotid aneurysm - Carotid artery dissection - Cavernous sinus thrombosis - Cluster headache
273
Pupil Disorders what is Congenital Horner syndrome associated with
heterochromia: difference in the colour of the iris on the affected side.
274
Pupil Disorders what test can be used for Horner Syndrome
Cocaine eye drops/Apraclonidine or adrenalin eye drop (0.1%)
275
Pupil Disorders how does cocaine eye drops test for Horner's syndrome
Cocaine acts on the eye to stop noradrenalin re-uptake at the neuromuscular junction normal eye dilates because there is more noradrenalin stimulating the dilator muscles of the iris Horner: the nerves are not releasing noradrenalin to start with so blocking re-uptake does not make a difference and there is no reaction of the pupil
276
Pupil Disorders results of adrenalin eye drop (0.1%) test for Horner's syndrome
normal: won't dilate horner: dilates
277
Pupil Disorders what is Holmes Adie Pupil
unilateral dilated pupil that is sluggish to react to light with slow dilation of the pupil following constriction Over time the pupil will get smaller
278
Pupil Disorders what is Holmes Adie pupil caused by
damage to the post-ganglionic parasympathetic fibres. The exact cause is unknown but may be viral.
279
Pupil Disorders what is Holmes Adie Syndrome
Holmes Adie pupil with absent ankle and knee reflexes.
280
Pupil Disorders what is Argyll-Robertson Pupil
specific finding in neurosyphilis constricted pupil that accommodates when focusing on a near object but does not react to light. They are often irregularly shaped
281
Pupil Disorders what is Argyll-Robertson Pupil often called and why
“prostitutes pupil” due to the relation to neurosyphilis and because “it accommodates but does not react“.
282
Retinitis Pigmentosa what is it
congenital inherited condition degeneration of the rods and cones in the retina
283
Retinitis Pigmentosa when do most cases start
in childhood
284
Retinitis Pigmentosa presentation
1st symptom: night blindness peripheral vision is lost before central vision
285
Retinitis Pigmentosa why is night blindness the first symptom
the rods degenerate more than cones
286
Retinitis Pigmentosa what will fundoscopy show
“bone-spicule” pigmentation
287
Retinitis Pigmentosa what does “bone-spicule” pigmentation mean
spicule: sharp, pointed Bone-spicule is used to refer to the similarity to the networking appearance of bone matrix.
288
Retinitis Pigmentosa associated systemic diseases
- Usher’s Syndrome: hearing loss + retinitis pigmentosa - Bassen-Kornzweig Syndrome: disorder of fat absorption + metabolism causing progressive neuro sxs and retinitis pigmentosa - Refsum’s Disease: metabolic disorder of phytanic acid causing neuro, hearing and skin sxs and retinitis pigmentosa
289
Retinitis Pigmentosa general mnx
- refer to ophthalmologist - genetic counselling - vision aids - sunglasses - inform DVLA - follow up regularly
290
Retinitis Pigmentosa medical mnx which may be considered
- Vitamin and antioxidant supplements - PO acetazolamide - Topical dorzolamide - Steroid injections - Anti-VEGF injections
291
Corneal Abrasions common causes
- contact lenses - foreign bodies - finger nails - eyelashes - entropion (inward turning eyelid)
292
Corneal Abrasions what organism is associated with use of contact lenses
pseudomonas
293
Corneal Abrasions important differential
herpes keratitis: needs antiviral eye drops
294
Corneal Abrasions presentation
- History of contact lenses or foreign body - Painful red eye - Foreign body sensation - Watering eye - Blurring vision - Photophobia
295
Corneal Abrasions dx
fluorescein stain highlights abrasions or ulcers slit lamp for more significant abrasions
296
Corneal Abrasions mnx
- refer immediately if sight threatening cause of red eye - Simple analgesia (e.g. paracetamol) - Lubricating eye drops can improve symptoms - Antibiotic eye drops (i.e. chloramphenicol) - review in 1w to check it has healed - Cyclopentolate eye drops dilate the pupil and improve significant symptoms, particularly photophobia. - Uncomplicated corneal abrasions usually heal over 2-3 days.
297
Hypertensive Retinopathy what is it
damage to the small blood vessels in the retina relating to systemic hypertension
298
Hypertensive Retinopathy cause
- years of chronic hypertension | - or it can develop quickly in response to malignant hypertension
299
Hypertensive Retinopathy signs in the eye
- silver/copper wiring - arteriovenous nipping - cotton wool spots - hard exudates - retinal haemorrhages - papilloedema
300
Hypertensive Retinopathy signs: what is silver or copper wiring
the walls of the arterioles become thickened and sclerosed causing increased reflection of the light
301
Hypertensive Retinopathy signs: what is arteriovenous nipping
sclerosis and hardening of the arterioles cause compression of the veins where they cross.
302
Hypertensive Retinopathy signs: what causes cotton wool spots
ischaemia and infarction in the retina causing damage to nerve fibres
303
Hypertensive Retinopathy signs: what are hard exudates caused by
damaged vessels leaking lipids into the retina
304
Hypertensive Retinopathy signs: what are retinal haemorrhages caused by
damaged vessels rupturing and releasing blood into the retina
305
Hypertensive Retinopathy signs: what is papilledema caused by
ischaemia to the optic nerve resulting in optic nerve swelling (oedema) and blurring of the disc margins
306
Hypertensive Retinopathy Stage 1 Keith-Wagener Classification
Mild narrowing of the arterioles
307
Hypertensive Retinopathy Stage 2 Keith-Wagener Classification
Focal constriction of blood vessels and AV nicking
308
Hypertensive Retinopathy Stage 3 Keith-Wagener Classification
Cotton-wool patches, exudates and haemorrhages
309
Hypertensive Retinopathy Stage 4 Keith-Wagener Classification
Papilloedema
310
Hypertensive Retinopathy mnx
- control BP | - control RFs: smoking, blood lipid levels
311
what is trachoma
a bacterial keratoconjunctivitis caused by Chlamydia trachomatis
312
who is trachoma common in
children and adults with poor hygiene e.g, in resource poor areas of the world.
313
presentation of trachoma
- conjunctival scarring and corneal abrasion
314
trx of trachoma
typically Azithromycin as a one-off dose
315
what is a common finding in acute ischaemic optic neuropathy
swollen optic disc
316
what is ophthalmia neonatorum
aka neonatal conjunctivitis an infection of the conjunctiva contracted by neonates within the first 28 days following birth
317
sx of ophthalmia neonatorum
hyperaemia, swollen eyelids, conjunctival discharge and chemosis
318
what is chemosis
oedema of the conjunctiva
319
what are the 2 most common causes of ophthalmia neonatorum
chlamydia and gonorrhoea
320
difference between chlamydia and gonorrhoea conjunctivitis
Gonococcal: - commonly presents from 0-3d following birth - purulent discharge Chlamydial: - commonly presents from 5d onwards following birth - mucopurulent discharge
321
'A single, well demarcated white ulcer' what is it
bacterial keratitis
322
'Vertical linear defects in the corneal epithelium' what is it
corneal abrasion represents the damage caused every time the patient blinks due to a foreign object
323
what is the Ishihara plate score
test for determining colour vision deficiency
324
how would acute optic neuropathy present as (4)
1. central scotoma 2. Reduced colour vision 3. Relative afferent pupillary defect 4. Acutely: optic disc swelling; chronically, with death of optic nerve fibres: atrophy (seen as a pale disc)
325
Ddx of optic neuropathy (5)
1. Demyelinating (MS associated) optic neuritis - 2. Ischaemic optic neuropathy (eg GCA) 3. Compression (eg optic nerve glioma, metastatic tumour) 4. Nutrition: B12/folate deficiency, alcohol excess - usually bilateral, symmetrical (thus no RAPD) 5. Raised ICP, malignant hypertension, sarcoid, ethambutol
326
trx of gonococcal conjunctivitis
- IV Ceftriaxone - bacitracin ointment - hourly saline lavage
327
what is ciliary injection
involves branches of the anterior ciliary arteries and indicates inflammation of the cornea, iris, or ciliary body.
328
6-hour history of dull pain in his right eye. O/E: eye appears red, cornea is cloudy and there is evidence of ciliary injection what is it
acute angle closure glaucoma.
329
what is the definitive test for diagnosing acute angle closure glaucoma
Gonioscopy: using goniolens + slit lamp in to gain a view of the angle between the eye's cornea and iris
330
what is a strong indicator of ocular involvement in Herpes Zoster Ophthalmicus
Hutchinson's sign: A skin lesion on the tip or side of the nose
331
Small penetrating objects can often leave a sealed wound and may not be visible clinically. what imaging is required?
urgent CT scan
332
mnx if a foreign body is found on CT scan
urgent surgery to close the wound and remove the foreign body
333
what medication may raise IOP
Topical steroids, steroid eye drops, and systemic steroids
334
causes of Horner's syndrome
Pancoast tumour (affecting sympathetic nerve supply) Stroke Carotid artery dissection (Red flag: neck pain)
335
describe a keratocanthoma
A rapidly growing, well differentiated lesion that is "dome shaped" in appearance central depression and debris within painless can be on eyelid
336
what is a retinoblastoma
a malignant tumour of the retina, and the most common intraocular tumour of childhood
337
presentation of retinoblastoma
- leukocoria (white pupil) - deteriorating vision - strabismus - failure to thrive
338
fundoscopy shows a stormy sunset. What is it
Central retinal vein occlusion
339
difference on examination with Argyll-Robertson pupil or Holmes-Adie tonic pupil
Holmes-Adie: after the patient is asked to accommodate, the dilated pupil tones up, so much so that it becomes smaller compared to the other pupil (ie the anisocoria is reversed) Argyll-Robertson: some constriction will be seen, but the pathological pupil will remain bigger compared to the other
340
mnx of Holmes-Adie
reassure
341
is long sightedness a RF for acute angle glaucoma
yes
342
mnx for idiopathic intracranial hypertension
Acetazolamide | mannitol would cause a fluid shift too rapidly
343
when is contrast used in CT
1. to see if normal blood vessels have become blocked (PE or ischaemic stroke) 2. to see if abnormal structures have developed new blood supplies (ie neovascularisation surrounding a malignancy)
344
``` punched in eye proptosis severe pain restricted eye movement rapid deterioration in vision ``` what is it
retrobulbar haemorrhage, leading to orbital compartment syndrome
345
mnx of orbital compartment syndrome
urgent decompression by lateral canthotomy
346
when would you give anti-VEGF vs photocoagulation in diabetes
anti-VEGF: clinically significant diabetic macular oedema photocoagulation: proliferative diabetic retinopathy
347
most common cause of surgical 3rd nerve palsy
posterior communicating artery aneurysm. Other causes: cavernous sinus lesions (infection, thrombosis, tumour infiltration).
348
which therapy is contraindicated in thyroid eye disease
Radioactive iodine ablation therapy
349
is plasma copper high or low in wilson's disease
low because it quickly accumulates in the liver and the CNS
350
A patient with signs of an oculomotor nerve palsy (cranial nerve 3) with pupillary signs (mydriasis) should be assumed to have?
an aneurysm of their ipsilateral posterior communicating artery until proven otherwise
351
what inx for a retinal tear if cannot view retina because of a vitreous haemorrhage
A B-scan ultrasound will help determine if the retina has detached as it is not possible to view this patient's retina.
352
eye cannot look out away from the nose. What palsy is it
6th nerve palsy
353
eye is upwards and inwards and the patient may present with a tilted head. What palsy is it
4th nerve palsy
354
painful red nodule on her left lower eyelid. lesion has a pearly margin with an ulcerated centre. What is the most likely diagnosis?
Basal cell carcinoma
355
12m old baby has large cream coloured mass in the fundus of both eyes. The red reflex is absent. What is it
Hereditary retinoblastoma
356
Fundoscopy reveals a large yellow lesion at the back of the eye. 40 pack smoker what is it
Ocular metastases
357
6-month-old child with a 5-month history of a rapidly growing bright red lesion on his right upper eyelid. the right upper eyelid bisects the pupil and the lesion blanches on pressure what is it
large haemangioma
358
trx of a large haemangioma obstructing vision
PO propranolol
359
difference between surgical and medical 3rd nerve palsy
surgical: pupil is dilated
360
double vision that is worse particularly when looking down and gets better when tilting his head to the right side. He particularly struggles to walk down stairs. what is it
Left fourth-nerve palsy
361
where is the likely source of infection if she has orbital cellulitis involving the ocular muscles and causing compression of the optic nerve
the ethmoid sinus sits medially to the orbit
362
pain started last night when he accidentally scratched his eye while taking his contact lens out. On examination, you note hyperaemia and a white deposit on the cornea. what is it
Bacterial keratitis
363
which common conditions lead to Charles Bonnet syndrome
age related macular degeneration, followed by glaucoma and cataract.
364
sx of Charles Bonnet syndrome
well formed, vivid, elaborate, and often stereotyped visual hallucinations in a partially sighted person who has insight into the unreality of what he or she is seeing.
365
A 6m child with 5m history of a rapidly growing bright red lesion on his right upper eyelid. right upper eyelid bisects the pupil and the lesion blanches on pressure mnx?
large haemangioma that is obstructing vision | so BB first line
366
which medication can raise IOP
topical steroids, steroid eye drops, and systemic steroids

Finals (47 decks)

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