Ophthalmology Flashcards
Features of anterior uveitis (6)
Anterior uveitis = iritis = iridocyclitis
- acute onset
- irregular pupil
- photophobia
- red eye
- lacrimation
- flares and cells in anterior chamber
Associates conditions to anterior uveitis (4)
Ankylosing spondylitis
Reactive arthritis
Ulcerative colitis
Crohn’s disease
What eye condition is associated with rheumatoid arthritis?
Scleritis
Management of anterior uveitis
Urgent ophthal review
1.Cycloplegics - cyclopentate
=dilates pupil to prevent adhesion between lens and iris
= relieves pain and photophobia
2.prednisolone drops - reduce inflammation
Atropine
Anterior uveitis vs acute angle closure glaucoma (AACG)
AU = marked photophobia Cells + flares in anterior chamber Irregular* pupil - distorted , sluggish reaction Variable IOP Keratitis precipitates on cornea
AACG = Mild photophobia, shallow anterior chamber w/ hard globe on palpating Fixed semi-dilated oval pupil High IOP Hazy/cloudy dull cornea Nausea + vomiting +**dark room.
Treatment of AACG
Pilocarpine Acetazolamide Beta blockers - timolol Steroids Analgesics Antiemetic Surgery - peripheral iridotomy
Stages of diabetic retinopathy
- Non proliferative
- Pre proliferative
- Proliferative
Non proliferative retinopathy features
Dots + blots + hard exudates
Pre - proliferative retinopathy features
Dots + blots + hard exudates + cotton wool spots *
Proliferative retinopathy features
Dots+ blots + hard exudates + Cotton wool spots
+ neovascularisation**
Treatment of proliferative retinopathy
Laser photo coagulation
Hypertensive retinopathy on fundoscopy
Macular oedema + hard exudates + dots + blots
AV nipping + copper/silver wiring +flame shaped haemorrhage
Management of hypertensive retinopathy
Control HTN
What eye condition is associated to multiple sclerosis
Optic neuritis
Features of optic neuritis
Swollen pale optic disc
Eye pain esp on movement
Reduced vision
Reduced colour vision * RED first
Affected structure in optic neuritis
Management
Optic nerve
Corticosteroids
Management of multiple sclerosis
Acute
Long term
Acute = initial methyl pred oral or IV
Long term = Glatiramer acetate or interferon beta
Central retinal artery occlusion CRAO
Features
CRA - branch of ophthalmic - branch of Internal carotid a.
Sudden painless unilateral loss of vision
Fundo - pale/white retinue + cherry red spot at macula + vessel attenuation
Treatment of CRAO
<100 mins of symptoms = firm ocular massage to dislodge occlusion
+ refer
CRAO is associated with?
Giant cell arteritis / temporal arteritis
CRVO features
Sudden painless loss of vision
Hemorrhagic retina - flame shaped
Swollen macula
Engorged tortuous veins
RF for cataracts
High myopia
Long term ORAL steroid use - asthma , COPD, RA, DM
Significant exposure to UV light
Eye trauma
Features of cataracts
Glare at night - lights appear brighter
Dazzling halos
Frequent change of glasses - refraction changes
Fundoscopy of cataract
Dense opacities - cloudy lens
Features of viral conjunctivitis
Commonest organism
Treatment
Redness , no pain
No discharge or serous discharge
Commonly after URTI
Adenovirus
Reassure + supportive (artificial tears)
Treatment of bacterial conjunctivitis
Self care , clean
If longer than week - topical antibiotics = chloramphenicol drops Fusidic acid ( choice for pregnant women )
Features + Treatment of allergic conjunctivitis
Bilateral redness + chemo sis + itching
Swollen eyelids/conjuctiva
Topical antihistamines
Transient loss of vision , sudden + painless
“Curtain falling down”
Dx?
Amaurosis fugax - transient occlusion of central retinal a.
Resolves in 5-30 mins
Sudden painless loss of vision + curtain fall + grey opaque retina ballooning forwards
Dx?
Tx?
Retinal detachment
- flashers. Floaters , visual field loss
Tx - scleral buckling.
Tilt head backwards , surgical/mechanical reattachment
Night blindness + peripheral vision loss (tunnel vision)
Hereditary
Dx?
Next step?
Retinitis pigmentosa - X linked
Referral (routine) to ophthalmologist
- progressive - eventually ends in central blindness
HIV + visual deterioration + retinal haemorrhage and white -yellow **exudates
Dx?
CMV retinitis
Treatment of orbital cellulitis
Admit
IV antibiotics
What nerve is involved in herpes zoster ophthalmicus
Trigeminal (5) - ophthalmic branch
Features of herpes zoster ophthalmicus
Treatment
Complications
Conjunctivitis + keratitis
Pain around eye + painful vesicles/rash
Acyclovir
C- keratitis - dendritic corneal ulcer = treat with topical acyclovir
Fundoscopy findings of retinitis pigmentosa
Black bone spicule shaped pigmentation
Mottling of retinal pigment epithelium
What is papilloedema?
Causes
First sign
Optic disc swelling caused by raised ICP
Almost always bilateral
Space occupying lesions , malignant HTN
1st sign = venous engorgement
Affected part in papilloedema
Optic DISC
Risk factors of retinal detachment
Myopia
Extraction of cataracts surgically
History of trauma
Opportunistic infections in HIV positive
CD4 > 200
(4)
Thrush - Candida albicans
Shingles - herpes zoster
Hairy leukoplakia - EBV
Kaposi sarcoma - HHV-8 human herpes virus 9
Opportunistic infections in HIV positive
CD4 <200 cells/mm3
(4)
Pneumocystis jirovecii (Carini) pneumonia
Cerebral toxoplasmosis
Oesophageal candidiasis - C. Albicans
CMV retinitis - esp if CD4 < 50
Subconjunctival hemorrhage
Features
Management
No symptoms
Small bleed - spontaneous or post trauma
Check BP. - R/O systemic HTN
if on anticoagulant - check INR
If spontaneous, no trauma = reassure
Eye signs of graves
Most appropriate investigation
Lid lag Lid retraction Exophthalmos Diplopoda Ophtlamoplegia
TFT!
3rd nerve palsy features
Investigation of choice
Diplopoda
Ptosis
Mydriasis - fixed dilated pupil
Out + down deviation
Ct angio
What is a Marcus Gunn pupil
RAPD - relative afferent pupillary defect
Caused by lesion anterior to optic chiasm e.g. optic n, retina
Light to intact eye = both constrict
Light to affected eye - both dilate
Cause of RAPD
Retinal detachment
Optic neuritis
Optic neuritis with RAPD
Type of visual field loss?
Monocular visual field loss
(Also seen in amaurosis fugax)
**usually optic neuritis associated with central scotoma
Where is central scotoma seen?
Optic neuritis
Macular degeneration
Vision loss in acromegaly and pituitary adenoma
Bitemporal hemianopia
What kind of halos are seen in AACG
Coloured halos
Schirmers test < 10 mm
Dx?
Tx?
Keratoconjunctivitis sicca
Artificial tears - hypromellose /NaCl / sodium hyaluroanate
Treatment of acute dacryocystitis
Systemic antibiotics
IV if there’s associated periorbital cellulitis
CRAO vs BRAO
CRAO - complete loss of vision + other features
BRAO - no complete loss of vision , areas of loss correspond with affected branch
Fundoscopy - wedge shaped area of pallor, rest of retina spared
Treatment for BOTH is firm ocular massa
Cause of glaucoma
Risk factors
Impaired aqueous outflow - increased IOP
RF - hypermetropia + pupillary dilatation
Medical management of Glaucoma (AACG)
IV acetazolamide - reduces aqueous secretions
Pilocarpine - pupillary constrictions
Beta blocker (timolol)
, steroids , analagesia
Once stable — refer urgently to ophthalmologist
Surgical management of AACG
Peripheral iridotomy
Surgical iridectomy
Management of cluster headache
Acute phase
Prophylaxis
Acute phase - 100% Oxygen 10 -20 mins
Sumatriptan - nasal or subcutaneous
If 1st time - refer to specialist for CT to r/o other ddx
P- verapamil (calcium channel blocker)
Preseptal vs orbital cellulitis
Preseptal - no reduced VA, proptosis to ophthalmoplegia/pain with eye movements
Ddx for seeing halos
Cataract - dazzling halos
AACG - coloured halos
Commonest eye association in rheumatoid arthritis
Keratoconjunctivitis sicca
What happens when the following nerves are affected
3rd, 4th, 6th
3rd - occulomotor
Same side - dilated pupils +ptosis
4th - trochlear
Opp Side, Diplopia on downgaze
6th - Abducens
Same side - diplopia later gaze
Progressive decrease in VA + peripheral field vision in elderly short sighted person
Dx?
Open angle glaucoma
Features of open angle glaucoma (7)
Nasal scotoma - Tunnel vision Decreased VA Optic disk cupping ** >60 Family Hx +black people + myopia
What can myopia cause?
Open angle glaucoma
Cataract
Retinal detachment
What can hypermetropia cause ?
AACG
Name the degenerative corneal diseases
Kill The Blue Parrot K - keratoconus T- terrier marginal degeneration B- band keratopathy P- pellucid marginal degeneration
What is mooren’s ulcer
Management
Painful peripheral corneal ulceration + absence of scleritis/ systemic autoimmune disorder
Progressive in nature
Tx - topical corticosteroid , conjunctival resection
D- shaped pupil seen in
Iridodialysis
Management of chalazion
Most resolve spontaneously
Warm compress
If after 4 weeks conservative management it is still present
= refer to ophthalmologist
What ocular side effects do citalopram citalopram and fluoxetine have?
AACG
Citalopram - SSRI
TCA - clomipramine
What is Ramsay hunt syndrome?
Features
Treatment
Herpes zoster oticus
- reactivation of VZV in geniculate ganglion of facial nerve
== ipsilateral facial palsy, loss of taste
- otalgia - 1st symptom, painful rash on auditory canal
Oral acyclovir + corticosteroids + amitriptyline
Most common bacteria causing orbital cellulitis
Streptococcus
Staph aureus
HiB
What is Charles bonnet syndrome?
Initial investigation
Visual hallucinations (only visual) - not real - caused by failing eyesight
Slit lamp exam
What are the 2 types of hallucination in Charles bonnet syndrome
- Simple repeated patterns - grids, shapes, lines
- Complex images of people object and landscapes
Last for few minutes
Left homonymous hemianopia
Where is the lesion?
Right optic tract
Homonymous quadrantopias
Lesions
PITS
Parietal- inferior, temporal-superior
Superior = inferior optic radiations in Meyers loop (temporal lobe) Inferior = superior optic radiations in parietal lobe
Incongruous defects - lesion is on
Optic tract
Incongruous defect = incomplete or asymmetrical visual field loss
Congruous defect - lesion is on
Optic radiation or occipital cortex
Congruous defect = complete or symmetrical visual field loss
Macula sparing homonymous hemianopia
Lesion is -
On the occipital cortex
Bitemporal hemianopia is a lesion on
Optic chiasm
If upper > lower defect - inferior chiasm compression - pituitary tumour
If lower > upper - superior chiasm - craniopharyngioma
Most common cause of blindness in the uk
Features (6)
Age related macular degeneration (irreversible)
> 70 mostly
Loss or visual disturbance - night mostly
Loss of contrast vision
Difficulty recognising faces
Micropsia - objects appear smaller
Metamorphopsia- straight lines appear wavy
Key feature of Age related macular degeneration
Degeneration of the central retina (macula)
Changes are usually bilateral
Degeneration of retinal photoreceptors — drusen formation (seen on fundoscopy)
Initial investigation for age related macular degeneration
Slit lamp
Colour fundus photography - to provide baseline for comparison
Traditional 2 types of macular degeneration
- Dry = 90% — geographic atrophy -DRUSEN (yellow round spots in bruch’s membrane)
- Wet = 10% - exudative, neovascular
- choroid also neovascularisation
- serous fluid + blood leakage — rapid loss of vision - worst prognosis
Updated 2 types of age related macular degeneration
- Early — non exudative
= drusen and alterations to retinal pigment epithelium - Late - exudative, neovascularisation
What do you if tip of nose is involved in herpes zoster ophthalmicus?
What is it called?
+ve Hutchinson sign
Occurs in immunosuppressed , immunocompromised
Admit for IV acyclovir
Dendritic ulcers on cornea sen on fluorescein dye
Dx?
HSV keratitis
