Ophthalmology Flashcards
What are the key features of age-related macular degeneration?
Drusen on examination
Neovascularisation of the retina= wet ADM
Central scotoma- progressive loss of central vision
Blurring and curving of straight lines
Peripheral vision preserved
No pain in the eye
Wet AMD= faster progressing
Dry AMD= slow progressing
What is the management for wet AMD?
Refer urgently to ophthalmology
Fluorescein angiogram to confirm
Intravitreal VEGF injections
Which sight disorders predispose you to which types of glaucoma?
Myopia = open angle glaucoma Hypermetropia = closed angle glaucoma
What visual field defect is associated with open angle glaucoma?
Upper, outer scotoma which progresses to tunnel vision
How should you investigate suspected glaucoma?
Optic disk examination for signs of pathological cupping
Goldmann’s tonometry
Gonioscopy to confirm angle patency/closure
What is the treatment for open angle glaucoma?
1st line- prostaglandin analogue e.g. latanoprost
Additional: Pilocarpine B-blocker - timolol Carbonic anhydrase inhibitor- acetazolamide a-blocker- doxazosin
Laser trabeculectomy to improve aqueous flow
What are the symptoms of acute angle closure glaucoma?
Acutely painful eye Loss of vision Headache, nausea, vomiting Seeing haloes around lights Photophobia and eye watering
How is acute closed angle glaucoma managed?
Lie flat and give pilocarpine drops
IV or oral acetazolamide +/- mannitol
Pressure lowering eye drops: timolol, pilocarpine, apraclonidine
Laser iridotomy
What are the symptoms of cataracts?
Clouding of the cornea Loss of contrast in colour Increased glare Blurring of vision- change in eye refraction Double vision
How are cataracts managed?
Surgery to remove lens and replace with prosthetic
- ability to accommodate is lost so all patients become hypermetropic
What ocular emergency is associated with cataract surgery?
Infective endophthalmitis
What are the signs of cranial nerve 3 palsy?
Horizontal and vertical diplopia
Down and out pupil
Ptosis
Mydriasis (dilation) on the affected side (loss of efferent limb of pupil reflex)
What are the signs of cranial nerve 4 palsy?
Diplopia- especially when looking down and in e.g. reading, walking down stairs
Inability to adduct eye
Head tilt
Eye rolled up slightly
What are the signs of cranial nerve 6 palsy?
Inability to abduct affected eye
Horizontal diplopia
Head tilt (move head to face affected side)
What are the features of blow-out fractures?
Surgical emphysema around the orbit
Bruising around the orbit
Loss of sensation beneath the orbital rim
Subconjunctival haemorrhage
Limited eye movement- often trapping of inferior rectus meaning that hardest to look down and up
Vertical diplopia
Eye recession or depression
How are blowout fractures managed?
Cover the eye
Do not blow nose
Broad spectrum antibiotics
Max fax surgical referral
What are the symptoms of conjunctivitis?
Eye irritation/grittiness
Conjunctival injection
Conjunctival discharge- may be purulent
Surrounding erythema
No pain, photophobia, change in vision or pupil reactivity
How should conjunctivitis be managed?
Eye lubricants
Cold compress
No contact lenses
Topical chloramphenicol in bacterial causes
How should you treat chlamydial eye disease?
Same as treatment for general chlamydia
Oral azithromycin or doxycycline
What are the symptoms of herpes simplex keratitis?
Painful eye- incl pain on movement Photophobia Eye watering Blurring of vision Red eyes Fever
May have vesicular lesions on the eyelids or pre-auricular lymphadenopathy
What is the key sign of HS keratitis and on which test does it present?
Dendritic ulcers
Fluorescein staining and slit lamp
How is HS keratitis managed?
14 day course of topical aciclovir drops
Apply 5 times a day
Analgesia, cold compress, topical lubricant, no contacts
What is the most common bacterial cause of keratitis?
Staphylococcus epidermidis
What are the symptoms of bacterial keratitis?
Eye pain and redness Photophobia Pain on eye movement Eye watering Purulent discharge +/- hypopyon Corneal ulcers
What is the biggest risk factor for bacterial keratitis?
Wearing contact lenses
What treatment is contraindicated in bacterial keratitis?
Steroid eye drops
What sign suggests herpes zoster ophthalmicus?
What are the other features?
Hutchinson’s sign: vesicles on the end of the nose
Vesicles in distribution of ophthalmic division of trigeminal nerve Photophobia Eyelid swelling Keratitis/iritis General malaise and fever Pre-auricular lymphadenopathy
How is herpes zoster ophthalmicus managed?
Oral course of aciclovir
Topical steroids
What are the symptoms of anterior uveitis?
Painful, red eyes- pain on eye movement
Photophobia and mitosis
Blurred vision
Eye watering
May have pupil distortion due to posterior adhesions
Ciliary injection- from the cornea outwards
Floaters
What conditions are most strongly associated with anterior uveitis?
Ankylosing spondylitis and other inflammatory
Ulcerative Colitis
TB
How is anterior uveitis managed?
Steroid eyedrops
Dilate pupil to relieve ciliary spasm and break adhesions (atropine or cytopentolate)
Management of systemic condition
What is the diabetic retinopathy screening programme?
Annual checks: visual acuity, full eye exam, retinal photography
Children screened after having suffered for 5 years
Additional screening in pregnancy
What are the features of background retinopathy (R1)
Microaneurysms
Blot haemorrhages
Exudates
Venous loops
What are the features of pre-proliferative retinopathy (R2)?
Intra-retinal microvascular anomalies Blot haemorrhages Cotton wool spots Flame haemorrhages Venous beading
What are the features of proliferative retinopathy (R3)?
Venous malformation
Retinal proliferative neovascularisation
Pale macula + macular oedema
Hard exudates
What are the potential complications of diabetic retinopathy?
Vitreous haemorrhage
Retinal detachment
Cataracts
Optic neuropathy
How is diabetic retinopathy managed?
Optimisation of glycemic control
Anti-VEGF injections
Intra-vitreal steroid injections
Pan-retinal photocoagulation
What are the symptoms of CRAO?
What would you see on fundoscopy?
Sudden painless loss of vision
Poor direct pupil response but brisk indirect
Pale macula with cherry red spot
Weeks later, atrophic and pale disk
How is CRAO managed?
IV acetazolamide
Digital massage
Hyperventilation
Surgical/laser embolectomy
Steroids if caused by GCA/temporal arteritis
What is amaurosis fugax?
transient, fleeting loss of vision due to passing of fibrin embolus through CRA
What are the symptoms of CRVO?
What would you see on fundoscopy?
Sudden, painless loss of vision
Less acute than CRAO
May only be partial loss of vision
May have blurring initially
Swollen, tortuous veins
Swollen optic disk
Neovascularisation
How is CRVO managed?
Pan-retinal photocoagulation
Anti-VEGF agents
Management of increased coagulation
What are symptoms of retinal detachment?
Floaters and flashing lights
Progressive development of a visual field defect- like a curtain coming down
Reduced visual acuity, especially if macula affected
What are the symptoms of orbital cellulitis?
Periorbital swelling and erythema Inability to open eye Painful eye movements + gaze restriction Raised IOP Diplopia RAPD Eye discharge Proptosis Fever
What investigations should be done in orbital cellulitis?
Swabs of the eyes
Sepsis 6 / blood cultures
CT / MRI orbit WITH contrast to look for any collections behind the eye
Continual checks on visual acuity
How is orbital cellulitis managed?
Oral/IV co-amoxiclav = first line
IV ceftriaxone in severe infection
May need surgical drainage of any abscesses
What are the symptoms of infective endopthalmitis?
Hypopyon/fluid level in the eye
Painful, red eye
Reduced visual acuity
Loss of red reflex and pupil reactivity
How should infective endophthalmitis be managed?
Urgent sampling of aqueous and vitreous fluid
Concurrent intra-vitreal injection of broad spectrum antibiotics (vanc, Ceph)
What are the symptoms of retrobulbar haemorrhage?
Severely painful, proposed eye Subconjunctival haemorrhage Periorbital swelling and haematoma Loss of vision Reduced eye movements RAPD N&V
How is retrobulbar haemorrhage managed?
Lateral canthotomy ASAP to decompress pressure on optic nerve
Surgical evacuation of haematoma
<2hrs of onset
What is the inheritance pattern of inherited retinoblastoma?
Autosomal dominant
RB1 gene
What are the symptoms of retinoblastoma?
Leukocoria Strabismus Vision problems- complaining of blurred/reduced vision Loss of pupil reactivity May have eye pain, bleeding or proptosis
What are differentials for leukocoria in a child?
Retinoblastoma
Congenital cataracts
Retinopathy of prematurity
What are the risk factors for retinopathy of prematurity?
Babies born < 31 weeks
Birthweight <1500g
These should have screening at 4-7 weeks
How is retinopathy of prematurity managed?
Laser photocoagulation
What is amblyopia?
Lazy eye
Which medications can precipitate closed angle glaucoma?
Adrenergic medication e.g. noradrenaline
Anticholinergic medication e.g. oxybutynin
TCAs e.g. amitriptyline
What are the signs of hypertensive retinopathy?
Silver/copper wiring
AV nipping
Cotton wool spots (Ischaemia and infarction)
Hard exudates
Retinal haemorrhages
Papilloedema- indicates end stage disease and ischaemia to the optic nerve
Which branch of the nervous system is responsible for pupil constriction?
Parasympathetic
CN3 - hence palsy causes mydriasis on affected side
What are the causes of mydriasis?
Third nerve palsy Holmes-Adie syndrome Raised ICP Congenital Trauma Stimulants such as cocaine, MDMA Anticholinergic
What is Holmes-Adie syndrome?
Loss of direct pupil reflex
Accommodation in-tact
Slightly oval-shaped pupil
Absent or sluggish deep tendon reflexes
Can sometimes cause blurred vision/photophobia
Causes of miosis
Horner's syndrome Cluster headaches Argyll-Robertson pupil (syphillis) Opiates Nicotine Pilocarpine
How do you differentiate between Horner’s syndrome and CN 3 palsy?
Horner’s - pupil constriction
CN3 palsy- pupil dilation
Down + out pupil in CN3
Anhydrosis in Horner’s + facial flushing
What are the causes of Horner syndrome?
4 Ss, 4Ts, 4Cs
Central Stroke MS Swelling (tumours) Syringomelia
Peripheral Tumour (Pancoast) Trauma Thyroidectomy Top rib (cervical rib)
Carotid aneurysm
Carotid artery dissection
Cluster headache
Cavernous Sinus Thrombosis
What is an Argyll-Robertson pupil?
Associated with neurosyphilis
Constricted pupil which does not react to light but will accommodate on focusing.
Often irregularly shaped
What is Blepharitis?
Inflammation of the eyelid margins
Causes itchy, gritty, dry sensation in the eyes and can lead to styes and chalazions.
Management is with hot compresses and gentle cleaning of the eyelid margins to remove debris.
Lubricating eye drops can also be useful in management
What is a stye?
Infection of the glands of Zeis/Moll on the lash line
This causes a tender red lump along the eyelid which may contain puss and can be painful
Managed with hot compresses and analgesia.
Consider chloramphenicol if associated with conjunctivitis
What is a chalazion?
Occurs when a meibomian gland becomes blocked and swells up
Causes swelling of the eyelid that is not usually tender- but can become tender and red
What is an entropion?
Where eyelid turns in on itself with the lashes against the eyeball.
This can cause corneal damage and ulceration. Requires SAME DAY referral to ophthalmology.
Initially: tape eyelid down to prevent it turning inwards + lubricating eye drops
Definitive mamagement = surgical intervention
What is an ectropion?
Eyelid turns out, with the inner aspect of the eyelid exposed.
This usually affects the bottom lid, and can result in exposure keratopathy if not managed.
Mild: regular lubricating eye drops
More severe: may require surgical correction
Same-day referral to ophthalmology required if there is a risk to sight.
What are differentials for painless red eye?
Conjunctivitis
Episcleritis
Subconjunctival haemorrhage
What are differentials for painful red eye?
Glaucoma Anterior uveitis Scleritis Keratitis Corneal abrasion or ulceration Foreign body Traumatic or chemical injury
Why is neonatal conjunctivitis more urgent?
If <1 month and presenting with conjunctivitis, babies should have an urgent ophthalmology review. Can be associated with gonococcal infection and can cause loss of sight, pneumonia etc.
How is allergic conjunctivitis managed?
Antihistamines - topical or oral
Topical mast cell stabilisers
What conditions are often associated with episcleritis?
Rheumatoid arthritis
Inflammatory bowel disease
How does episcleritis usually present?
Usually not painful Segmental redness of the sclera Foreign body sensation Dilated episcleral vessels Watering of the eye No discharge
How is episcleritis managed?
Usually self limiting within 1-4 weeks
Lubricating eyedrops can help symptoms
Simple analgesia, COLD compresses and safety netting.
More severe cases may benefit from systemic NSAIDs or topical steroids.
How does scleritis usually present?
50% bilateral, 50% unilateral
Severe eye pain Redness of the whole eye Pain with eye movement Photophobia Eye watering Reduced visual acuity Abnormal pupil reactivity Tenderness to palpation
How should scleritis be managed?
Referral for same day assessment by an ophthalmologist.
NSAIDs
Steroids
Immunosuppression for underlying condition
How are corneal abrasions diagnosed?
Fluorescein staining and slit lamp examination
