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Ophthalmology Flashcards

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1
Q

What are the key features of age-related macular degeneration?

A

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

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2
Q

What is the management for wet AMD?

A

Refer urgently to ophthalmology
Fluorescein angiogram to confirm
Intravitreal VEGF injections

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3
Q

Which sight disorders predispose you to which types of glaucoma?

A 
Myopia = open angle glaucoma
Hypermetropia = closed angle glaucoma
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4
Q

What visual field defect is associated with open angle glaucoma?

A

Upper, outer scotoma which progresses to tunnel vision

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5
Q

How should you investigate suspected glaucoma?

A

Optic disk examination for signs of pathological cupping
Goldmann’s tonometry
Gonioscopy to confirm angle patency/closure

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6
Q

What is the treatment for open angle glaucoma?

A

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

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7
Q

What are the symptoms of acute angle closure glaucoma?

A 
Acutely painful eye
Loss of vision
Headache, nausea, vomiting
Seeing haloes around lights
Photophobia and eye watering
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8
Q

How is acute closed angle glaucoma managed?

A

Lie flat and give pilocarpine drops
IV or oral acetazolamide +/- mannitol
Pressure lowering eye drops: timolol, pilocarpine, apraclonidine
Laser iridotomy

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9
Q

What are the symptoms of cataracts?

A 
Clouding of the cornea
Loss of contrast in colour
Increased glare
Blurring of vision- change in eye refraction
Double vision
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10
Q

How are cataracts managed?

A

Surgery to remove lens and replace with prosthetic

- ability to accommodate is lost so all patients become hypermetropic

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11
Q

What ocular emergency is associated with cataract surgery?

A

Infective endophthalmitis

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12
Q

What are the signs of cranial nerve 3 palsy?

A

Horizontal and vertical diplopia
Down and out pupil
Ptosis
Mydriasis (dilation) on the affected side (loss of efferent limb of pupil reflex)

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13
Q

What are the signs of cranial nerve 4 palsy?

A

Diplopia- especially when looking down and in e.g. reading, walking down stairs
Inability to adduct eye
Head tilt
Eye rolled up slightly

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14
Q

What are the signs of cranial nerve 6 palsy?

A

Inability to abduct affected eye
Horizontal diplopia
Head tilt (move head to face affected side)

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15
Q

What are the features of blow-out fractures?

A

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

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16
Q

How are blowout fractures managed?

A

Cover the eye
Do not blow nose
Broad spectrum antibiotics
Max fax surgical referral

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17
Q

What are the symptoms of conjunctivitis?

A

Eye irritation/grittiness
Conjunctival injection
Conjunctival discharge- may be purulent
Surrounding erythema

No pain, photophobia, change in vision or pupil reactivity

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18
Q

How should conjunctivitis be managed?

A

Eye lubricants
Cold compress
No contact lenses
Topical chloramphenicol in bacterial causes

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19
Q

How should you treat chlamydial eye disease?

A

Same as treatment for general chlamydia

Oral azithromycin or doxycycline

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20
Q

What are the symptoms of herpes simplex keratitis?

A 
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

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21
Q

What is the key sign of HS keratitis and on which test does it present?

A

Dendritic ulcers

Fluorescein staining and slit lamp

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22
Q

How is HS keratitis managed?

A

14 day course of topical aciclovir drops
Apply 5 times a day
Analgesia, cold compress, topical lubricant, no contacts

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23
Q

What is the most common bacterial cause of keratitis?

A

Staphylococcus epidermidis

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24
Q

What are the symptoms of bacterial keratitis?

A 
Eye pain and redness
Photophobia
Pain on eye movement
Eye watering
Purulent discharge +/- hypopyon
Corneal ulcers
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25
What is the biggest risk factor for bacterial keratitis?
Wearing contact lenses
26
What treatment is contraindicated in bacterial keratitis?
Steroid eye drops
27
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 ```
28
How is herpes zoster ophthalmicus managed?
Oral course of aciclovir | Topical steroids
29
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
30
What conditions are most strongly associated with anterior uveitis?
Ankylosing spondylitis and other inflammatory Ulcerative Colitis TB
31
How is anterior uveitis managed?
Steroid eyedrops Dilate pupil to relieve ciliary spasm and break adhesions (atropine or cytopentolate) Management of systemic condition
32
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
33
What are the features of background retinopathy (R1)
Microaneurysms Blot haemorrhages Exudates Venous loops
34
What are the features of pre-proliferative retinopathy (R2)?
``` Intra-retinal microvascular anomalies Blot haemorrhages Cotton wool spots Flame haemorrhages Venous beading ```
35
What are the features of proliferative retinopathy (R3)?
Venous malformation Retinal proliferative neovascularisation Pale macula + macular oedema Hard exudates
36
What are the potential complications of diabetic retinopathy?
Vitreous haemorrhage Retinal detachment Cataracts Optic neuropathy
37
How is diabetic retinopathy managed?
Optimisation of glycemic control Anti-VEGF injections Intra-vitreal steroid injections Pan-retinal photocoagulation
38
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
39
How is CRAO managed?
IV acetazolamide Digital massage Hyperventilation Surgical/laser embolectomy Steroids if caused by GCA/temporal arteritis
40
What is amaurosis fugax?
transient, fleeting loss of vision due to passing of fibrin embolus through CRA
41
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
42
How is CRVO managed?
Pan-retinal photocoagulation Anti-VEGF agents Management of increased coagulation
43
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
44
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 ```
45
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
46
How is orbital cellulitis managed?
Oral/IV co-amoxiclav = first line IV ceftriaxone in severe infection May need surgical drainage of any abscesses
47
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
48
How should infective endophthalmitis be managed?
Urgent sampling of aqueous and vitreous fluid | Concurrent intra-vitreal injection of broad spectrum antibiotics (vanc, Ceph)
49
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 ```
50
How is retrobulbar haemorrhage managed?
Lateral canthotomy ASAP to decompress pressure on optic nerve Surgical evacuation of haematoma <2hrs of onset
51
What is the inheritance pattern of inherited retinoblastoma?
Autosomal dominant | RB1 gene
52
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 ```
53
What are differentials for leukocoria in a child?
Retinoblastoma Congenital cataracts Retinopathy of prematurity
54
What are the risk factors for retinopathy of prematurity?
Babies born < 31 weeks Birthweight <1500g These should have screening at 4-7 weeks
55
How is retinopathy of prematurity managed?
Laser photocoagulation
56
What is amblyopia?
Lazy eye
57
Which medications can precipitate closed angle glaucoma?
Adrenergic medication e.g. noradrenaline Anticholinergic medication e.g. oxybutynin TCAs e.g. amitriptyline
58
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
59
Which branch of the nervous system is responsible for pupil constriction?
Parasympathetic | CN3 - hence palsy causes mydriasis on affected side
60
What are the causes of mydriasis?
``` Third nerve palsy Holmes-Adie syndrome Raised ICP Congenital Trauma Stimulants such as cocaine, MDMA Anticholinergic ```
61
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
62
Causes of miosis
``` Horner's syndrome Cluster headaches Argyll-Robertson pupil (syphillis) Opiates Nicotine Pilocarpine ```
63
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
64
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
65
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
66
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
67
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
68
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
69
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
70
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.
71
What are differentials for painless red eye?
Conjunctivitis Episcleritis Subconjunctival haemorrhage
72
What are differentials for painful red eye?
``` Glaucoma Anterior uveitis Scleritis Keratitis Corneal abrasion or ulceration Foreign body Traumatic or chemical injury ```
73
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.
74
How is allergic conjunctivitis managed?
Antihistamines - topical or oral | Topical mast cell stabilisers
75
What conditions are often associated with episcleritis?
Rheumatoid arthritis | Inflammatory bowel disease
76
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 ```
77
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.
78
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 ```
79
How should scleritis be managed?
Referral for same day assessment by an ophthalmologist. NSAIDs Steroids Immunosuppression for underlying condition
80
How are corneal abrasions diagnosed?
Fluorescein staining and slit lamp examination

Finals Revision (23 decks)

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