Ophthalmology Flashcards
What are risk factors for age related macular degeneration?
Increasing age
Smoking
Family history
HTN
What are the two types of age related macular degeneration?
Dry and wet
Dry = most common
Dry = presence of drusen (yellow round spots)
Wet = more acute, neovascularisation, presents with a sudden deterioration in vision
How does age related macular degeneration present?
Gradual worsening of central field loss (Central scotoma)
Reduction of visual acuity (particularly near field objectives)
Difficulty seeing at night
Flashing lights
Distortion of line perception (crooked/wavy appearance)
Difficulty recognising faces
What is seen on fundoscopy in age related macular degeneration?
Dry = drusen (yellow areas of pigment deposition)
Wet = red patches (vascularisation)
How can age related macular degeneration be managed?
Wet = Intravitreal Anti-VEGF
Avoid smoking
Control BP
What is primary open angle glaucoma and how does it present?
Optic nerve damage due to raised intraocular pressure
Peripheral visual field loss –> Tunnel vision
Decreased visual acuity
What are risk factors for primary open angle glaucoma?
Increasing age
Family history
Myopia (short-sightedness)
Hypertension
Diabetes
Corticosteroid use
What is seen on fundoscopy in primary open angle glaucoma?
Optic disc cupping
Optic disc pallor
Bayoneting of vessels
Cup notching
Disc haemorrhage
How can primary open angle glaucoma be investigated?
Applanation tonometry - measures pressure
Slit lamp examination
Fundoscopy
Gonioscopy
How is primary open angle glaucoma managed?
1st line = Prostaglandin analogue eye drops (Latanoprost)
2nd line = Beta blocker eye drops (Timolol)
3rd line = Dorzolamide
4th line = Pilocarpine
What are side effects of Latanoprost eyedrops?
Brown pigmentation of iris
Increased eyelash length
What are side effects of Pilocarpine eyedrops?
Constricted pupil
Headache
Blurred vision
What is acute angle closure glaucoma and how does it present?
Aqueous humour can’t drain and intraocular pressure continues to increase - ophthalmological emergency
Acute onset severe pain
Nausea and vomiting
Decreased visual acuity
Hard firm eyeball
Red eye
Fixed dilated pupil
Haloes around light
What are risk factors/triggers for acute angle closure glaucoma?
Long sightedness (hypermetropia)
Increasing age
Family history
Female
Medication - noradrenaline, Anticholinergics (e.g. oxybutynin), tricyclic antidepressants
Mydratic drops (dilating drops)
Watching TV in a dark room
What is the emergency management of acute angle closure glaucoma? What is the definitive management?
Emergency management
Pilocarpine eyedrops - 2% for blue eyes and 4% for brown eyes
Beta blocker eyedrops - Timolol
IV Acetazolamide
Definitive management= laser peripheral iridotomy of both eyes
Which glaucoma medication increase uveoscleral outflow?
Prostaglandin analogue (Latanoprost)
Pilocarpine
Which glaucoma medications reduce aqueous humour production?
Beta blockers
Alpha agonists
Acetazolamide/Dorzolamide
What is a cataract and how does it present?
Lens of the eye becomes cloudy
Gradual loss of Generalised reduced vision
Faded colour vision
Glare
Haloes around light
What is the key finding in cataracts?
Loss of red reflex
How are cataracts managed?
Non-surgical = glasses
Surgery if affecting quality of life to replace lens
What are the four types of diabetic retinopathy?
Mild non-proliferative = 1 or more microaneurysm
Moderate non-proliferative = microaneurysms, blot haemorrhages, hard exudates, cotton wool spots, venous bleeding
Severe non-proliferative = blot haemorrhages/microaneurysms in 4 quadrants, or venous bleeding in 2 or more quadrants
Proliferative = retinal neovascularisation. this can lead to vitreous haemorrhage.
How is diabetic retinopathy managed?
Anti-VEGF intravitreal injections
Panretinal photocoagulation
What are the four stages of hypertensive retinopathy?
Stage 1 = arteriolar narrowing, increased light reflex (silver wiring)
Stage 2 = Arteriovenous nipping
Stage 3 = Cotton wool spots, flame haemorrhages, blot haemorrhages
Stage 4 = Papilloedema
What is a vitreous haemorrhage and how does it present?
Bleeding into the vitreous humour
Causes a sudden painless loss of vision
Red hue in the vision
Floaters and dark spots
What are causes of vitreous haemorrhage?
Diabetic retinopathy
Posterior vitreous detachment
Ocular trauma
What is posterior vitreous detachment and how does it present?
Separation of the vitreous membrane from the retina
RF: Short-sightedness and ageing.
Presents with sudden appearance of floaters and flashes
Spots of vision loss
Blurred vision
Weiss ring on Fundoscopy
What is seen on fundoscopy in posterior vitreous haemorrhage?
Weiss ring
How is posterior vitreous detachment treated?
No treatment needed
Symptoms will improve over around 6 months
How does retinal detachment present?
New onset flashers and floaters
Painless, progressive peripheral vision loss
Curtain/shadow progressing to the centre
Straight lines appear curved
How is retinal detachment treated?
Urgent referral to ophthalmology for slit lamp assessment
How does retinal vein occlusion present?
Sudden painless loss of vision
Usually unilateral
What are risk factors for retinal vein occlusion?
Increasing age
Glaucoma
Polycythaemia
What is seen on fundoscopy in retinal vein occlusion?
Severe retinal haemorrhages - flame and blot
Optic disc oedema
Macular oedema
In which eye condition is a Weiss ring seen?
Posterior vitreous detachment
How does central retinal artery occlusion present and how is it seen on fundoscopy?
Sudden onset painless loss of vision
Relevant afferent pupillary defect
Central = Pale retina with cherry red spot
BRanch = pale patch on retina
Which vasculitis is associated with retinal artery occlusion?
Temporal arteritis
What is a relevant afferent pupillary defect?
Both unaffected and affected pupil constrict when light shone in unaffected eye
However when light shone in affected eye - neither pupil constrict
What is the most common cause of retinal artery occlusion?
Atherosclerosis
What is endopthalmitis and how is it managed?
Inflammation of the interior cavity of the eye, usually caused by infection
Complication of intraocular surgery
Red eye, pain and vision loss after intraocular surgery
Managed with intravitreal vancomycin
What are the two types of squint and what is the difference?
Concomitant and paralytic
Concomitant = imbalance of extraocular muscles (common)
Paralytic = paralysis of extra ocular muscles (rare)
What is an Argyll-Robertson pupil? Which condition does it present in?
A pupil which accommodates but does not react
Meaning pupil constricts when focusing on a nearby object but does not constrict when exposed to light
Specific finding in Neurosyphilis
What is a Holmes Adie pupil?
Unilateral dilated pupil
Sluggish response to light, and slow to re-dilate
Benign condition mostly seen in women
Due to damage to post-ganglionic parasympathetic fibres
What occurs in a third nerve palsy?
Ptosis
Dilated pupil (if surgical third nerve palsy)
Down and out
What is Horner syndrome?
Miosis
Ptosis
Anhidrosis (lack of sweating)
sometimes: Exopthalmos
How can you determine the site of the lesion in Horner syndrome?
Look at the location of the anhidrosis
Face+arm+trunk = central lesion -> stroke, syringomyelia, multiple sclerosis
Face only = pre-ganglionic lesion -> thyroidectomy, trauma, pancoast tumour
NO Anhidrosis = post-ganglionic lesion -> carotid artery dissection, carotid aneurysm, cluster headache
What is periorbital cellulitis and how does it present?
Infection of the eyelid/skin around the eye
Acute onset
Red, swollen, painful eye
Erythema + oedema of the eyelids
What are the most common causative organism of periorbital cellulitis?
Staph aureus
What is the antibiotic of choice for periorbital cellulitis?
Oral co-amoxiclav
Should be started by a specialist - urgent referral to ophthalmology required
How can you differentiate between periorbital cellulitis and orbital cellulitis?
Head CT with contrast
What is orbital cellulitis and how does it present?
Infection of the orbit
Usually due to a spreading URTI
Redness and swelling around the eye
Severe ocular pain
Visual disturbance
Exophthalmos (bulging of globe)
Pain on eye movement
How is orbital cellulitis managed?
Urgent referral to ophthalmology
Admission for IV Abx
How does conjunctivitis present and how can you differentiate between bacterial, viral and allergic?
Red bloodshot eyes
Itchy/gritty sensation
Discharge from the eye
No pain
If discharge is purulent - think bacterial, if discharge is clear think viral.
In viral conjunctivitis - will often be other signs of a viral URTI
Allergic - bilateral, may be seasonal, history of atopy
How is bacterial, viral and allergic conjunctivitis treated?
Viral = no treatment needed
Bacterial = Chloramphenicol eye drops / Chloramphenicol ointment / Fusidic acid eye drops. If infant less than 1 year of age = referral to paeds
Allergic = topical/systemic antihistamines
What is anterior uveitis and how does it present?
Acute onset
Ocular pain
Red eye - red ring from the cornea spreading outwards (ciliary flush)
Small, irregular-shaped pupil
Hypopyon
Blurred vision
Photophobia
How is anterior uveitis managed?
Urgent referral to ophthalmology
For cycloplegics + steroid
(e.g. Cylopentolate + Prednisolone)
Which HLA-B27 conditions are associated with anterior uveitis?
Ankylosing spondylitis
Reactive arthritis
UC/Crohn’s
Behcet’s
Eye presentation: acute onset painful red eye with irregular pupil and hypopyon. What is it and how is it managed?
Anterior uveitis
Urgent ophthalmology referral for cycloplegics + steroid
What inflammatory conditions are associated with episcleritis and scleritis?
Rheumatoid arthritis
SLE
IBD
Sarcoidosis
GPA (Wegener’s)
What is the difference between episcleritis and scleritis?
Both acute onset red eye
Episcleritis = not painful, segmental red eye (not diffuse)
Scleritis = severe pain, reduced visual acuity, diffuse redness
What eyedrops can be given to differentiate episcleritis and scleritis?
Phenylephrine drops
If redness improves -> episcleritis
How is a corneal abrasion diagnosed?
Fluorescin stain shows vertical line defect in corneal epithelium
What are the different causes of keratitis?
Bacterial - usually staph aureus but in contact lens wearers, pseudomonas
Acanthamoebic keratitis in swimmers (esp if wearing contact lenses)
Can also be viral - herpes keratitis (treated w/ oral Aciclovir)
How does keratitis present?
Painful red eye
Photophobia
Gritty sensation
If herpes keratitis - vesicles around eye
How is keratitis managed?
Urgent ophthalmology referral
Usually treated with topical quinolone e.g. Ciprofloxacin
Herpes keratitis - topical Aciclovir
Which type of keratitis is common in HIV patients? What is seen on fundoscopy? How is it treated?
- Cytomegalovirus keratitis
- Retinal haemorrhages, necrosis. Termed ‘pizza retina’
- IV Ganciclovir
- What is retinitis pigmentosa?
- How does it present?
- What is seen on fundoscopy?
- How is it managed?
- Congenital inherited condition causing degeneration of the rods and cones in the retina
- first symptom = night blindness, also loss of peripheral vision
- Bone-spicule pigmentation
- Ophthalmology referral
How is papilloedema seen on fundoscopy?
Venous engorgement
Loss of venous pulsation
Blurring of optic disc margins
Elevation of optic disc
Loss of optic cup
Paton’s lines - concentric/radial retinal lines
What is herpes zoster ophthalmicus? How does it present? How is it managed?
Reactivation of the varicella zoster virus in the ophthalmic division of the trigeminal nerve
Vesicular rash around eye
Hutchinson’s sign - Rash on the tip/side of nose -> risk factor for ocular involvement -> urgent ophthalmology referral needed
If no indication of ocular involvement - oral aciclovir
What is Hutchinson’s sign?
Presence of vesicles on tip/side of nose in herpes zoster ophthalmicus
Indicates need for urgent referral
What is optic neuritis and what is the most common cause?
Inflammation of the optic nerve
Most common cause = multiple sclerosis
How does optic neuritis present?
Visual loss
Poor discrimination of colours - esp. red desaturation
Central scotoma - blind spot in line of sight
Relative afferent pupillary defect
Periocular pain
Pain on eye movement
Optic disc swelling
What is seen on fundoscopy in optic neuritis?
Pale optic disc
Optic disc swelling
What is seen on fluorescin stain in herpes keratitis?
Dendritic corneal ulcer
What is the definitive diagnostic test for diagnosing acute angle closure glaucoma?
Gonioscopy
Which organism most commonly causes keratitis in people who wear contact lenses?
Psuedomonas/Acanthamoeba (from water)
Causes of absence of red reflex?
Cataracts
Retinoblastoma
Who should get annual glaucoma screening?
Anyone >40 with family history of glaucoma
Diabetics
How to investigate primary open angle glaucoma?
Gonioscopy
Slit lamp exam
Applanation tonometry
How to investigate age related macular degeneration?
Amsler grid testing - wavy lines
Fundoscopy
Failure to correct a childhood squint - what are they at risk of in the future?
Amblyopia
