Ophthalmology Flashcards
1
Q
causes of afferent pupil defect?
A
CNII lesion
2
Q
causes of RAPD defect /marcus gunn
A
optic neuritis
optic atrophy
retinal disease
3
Q
causes of efferent defect?
A
3rd nerve palsy
4
Q
causes of fixed and dilated pupil?
A
mydriatrics
iris trauma
acute glaucoma
CNIII compression
5
Q
causes of horners syndrome?
A
central: MS, lateral medullary syndrome
pre-ganglionic: pan coast tumour, CVA insertion
post-ganglionic: cavernous sinus thrombus, CN3-6 palsy
6
Q
what causes holmes adie pupil?
A
viral/bacterial infection of ANS
7
Q
what causes argyll-robertson pupil?
A
DM
syphilis
8
Q
what causes hutchinsons pupil?
A
compressed 3rd nerve
intracranial mass/raised ICP head trauma
9
Q
features of optic atrophy?
A
reduced acuity reduced colour vision central scotoma pale optic disc RAPD
10
Q
causes of optic atrophy?
A
commonly MS or glacuoma
CAC VISION
Congenital Alcohol/toxins Compression Vascular Inflammatory - DM, GCA,stroke Sarcoid infection - VZV,TB, Syphilis Oedema Neoplastic infiltration
11
Q
Ix acute closed angle glaucoma?
A
fundsocopy (cloudy cornea, fixed dilated pupil)
tonometry (high IOP)
GOLD STANDARD: GONIOSCOPY with slit lamp
12
Q
Mx acute closed angle glaucoma?
A
- reduce aqueous formation
- mitosis -> open outflow
REFERRAL
meds: acetazolamide, timolol, pilocarpine (ATP)
laser peripheral iridotomy
lens extraction
13
Q
what is the uvea?
A
iris, ciliary body, choroid
anterior uvea = iris + ciliary
14
Q
S/S anterior uveitis?
A
acute pain
photophobia
blurred vision/reduced acuity
hypopyon (pus in anterior chamber)
15
Q
Ix anterior uveitis?
A
fundoscopy (irregular and small pupil)
circumcorneal injection
hypopyon
16
Q
Mx anterior uveitis?
A
prednisolone drops cyclophentolate drops (mydriatrics/cycloplegics - dilate and prevent adhesions between iris and lens)
17
Q
what is episcleritis?
A
subconjuctival haemorrhage - typically non painful and associated with trauma or coughing bouts
inflammation below conductiva in episcleral layer
18
Q
S/S episcleritis?
A
asymptomatic, associated with RhA, SLE or idiopathic
different from scleritis as NO PAIN
19
Q
Ix episcleritis?
A
blanches vessel on pressure
(scleritis does not blanche)
phenylephrine drops - episcleritis goes white
20
Q
Mx episcleritis?
A
topical/systemic NSAIDS
21
Q
What is scleritis?
A
vasculitis of sclera
22
Q
S/S scleritis?
A
severe pain, worse on eye movement
23
Q
Associations scleritis?
A
GPA, RhA, SLE, vasculitis
24
Q
complications scleritis?
A
scleromalacia (thinning of sclera) - perforation of globe
25
Ix scleritis?
fundoscopy (conjunctival oedema more diffuse than episcleritis)
phenylephrine drops - scleritis stays red
26
Mx scleritis?
REFERRAL URGENTLY <24h
| corticosteroids/immunosuppressants, phenylephrine
27
S/S conjunctivitis?
viral - watery unilateral
bacterial - sticky unilateral
allergic - pruritic bilateral
28
bacteria commonly causing viral conjunctivitis?
adenovirus
29
bacteria commonly causing bacterial conjunctivitis?
staph
strep
HiB
30
Ix conjuctivitis
history
if contact lens wearer refer for same day ophthalmic review as difficult to determine between conjunctivitis and microbial keratitis
31
What is a corneal abrasion?
epithelial breech without keratitis
32
S/S corneal abrasion?
pain, photophobia
blurred vision
visible defect
33
Ix corneal abrasion?
slit lamp fluorescing staining defect green
34
Mx corneal abrasion?
infection prophylaxis (chloramphenicol ointment)
35
causes of keratitis?
```
bacteria (S.aureus, P.aeruginosa)
fungi
amoeba (Acanthamoeba keratitis)
Virus (herpes simplex) - 'dendritic ulcer'
Environmental (contact lenses)
```
36
S/S keratitis?
```
pain
photophobia
blurred vision
visible defect/grittiness
white corneal opacity
```
37
Complications of keratitis?
scarring
visual loss
EMERGENCY
38
Ix keratitis?
slit lamp-> fluorescin staining defect green
| done by ophthalmologist
39
Mx keratitis?
referral
topical Abx/aciclovir
cycloplegics/mydriatics
40
what is ophthalmic shingles/herpes zoster ophthalmicus?
CNV1 reactivation of VZV (10% all shingles)
41
S/S of ophthalmic shingles?
pain
blistering rash
40% associated keratitis/uveitis
42
Ix ophthalmic shingles
fundoscopy
slit lamp fluorescin staining
Hutchinson's sign = nose tip zoster, ophthalmic involvement
- ophthalmic involvement = keratitis +/- corneal ulceration +/- iritis
43
Mx ophthalmic shingles?
```
referral
oral acyclovir (7-10 days) +/- topical corticosteroids if inflammation
```
44
Cx ophthalmic shingles?
ptosis
post-herpetic neuralgia
ocular (conjunctivitis, keratitis, episcleritis, anterior uveitis)
45
When should you refer for urgent ophthalmology assessment?
```
anyone with red eye and loss of visual acuity:
Acute glaucoma
Corneal ulcer, foreign body
Contact lens related red eye
Anterior uveitis
Scleritis
Trauma, chemical injuries
Neonatal conjunctivitis
```
46
what is anterior ischaemic optic neuropathy?
aion
| optic nerve damage from posterior ciliary artery blockage (inflammation or atheroma)
47
Types of AION?
Arteritic (caused by GCA)
| Non-arteritic? (DM, HTN, hypercholesterolaemia, smoking)
48
S/S AION?
Visual loss
RAPD
visual fiel defect
49
Ix AION?
fundoscopy (pale, swollen optic disc, peripheral micro aneurysms)
ESR - raised in aAION, normal in naAION
50
S/S optic neuritis?
```
CRAP
Central scotoma
RAPD
Acuity loss (central and colour vision)
Pain on movement
```
optic disc normal, swollen or blurred
51
Causes optic neuritis?
MS
DM
drugs (ethambutol, chloramphenicol)
infection (VZV, lyme)
52
Mx optic neuritis?
methylprednisolone IV for 72 hours
| prednisolone oral for 11 days
53
S/S vitrous haemorrhage?
small bleed - small black dots/floaters
| large bleed - loss of red reflex, retina not visualised
54
Causes of vitreous haemorrhage?
angiogenesis (DM accounts for 50%)
retinal tear, detachment or trauma
warfarin
55
Ix vitreous haemorrhage?
B scan (brightness scan) ultrasonography
56
Mx vitreous haemorrhage?
smaller - spontaneous reabsorption
| larger - vitrectomy
57
causes of retinal detachment?
cataract surgery
trauma
DM
58
S/S retinal detachment?
```
4Fs
floaters (numerous, acute onset, spiders webs)
flashes
field loss
fall in acuity
```
PAINLESS
59
Ix retinal detachment
grey, opalescent retina ballooning forwards
60
Mx retinal detachment?
urgent surgery
| vitrectomy + gas tamponade with laser coagulation
61
What causes retinal artery occlusion?
thrombo-embolic
| nb any hx amaurosis fugax
62
Ix retinal artery occlusion?
CVS RF hx (echo, carotid dopplers)
temporal artery biopsy
ESR
63
Mx retinal artery occlusion?
eyeball massage
| carbon therapy, haemodilution, vasodilators, decrease intraocular pressure
64
S/s in central retinal artery occlusion?
sudden painless total loss of vision + RAPD
| cherry red macula
65
S/S branch retinal artery occlusion?
sudden painless partial loss of vision - RAPD
66
S/S cilioretinal artery occlusion?
painless central vision loss
| EQUALLY if CRA present and CRAO occurs then central vision may be retained
67
What causes retinal vein occlusion?
DM
HTN
Hypercoagulable state
glaucoma
68
Ix retinal vein occlusion?
fluorescin angiography (ischemic vs non ischemic CRVO)
69
Mx retinal vein occlusion?
only ischaemic CRVO
| pan-retinal photocoagulation
70
S/S central retinal vein occlusion (CRVO)
ISCHAEMIC - sudden painless total loss of vision + RAPD
- stormy sunset on fundscopy
- haemorrhages
- cotton wool spots
- macular and papilloedema
Non-ischaemic - subacute mild-moderate loss of vision - RAPD
-haemorrhages in all 4 quadrants
71
S/S branch retinal vein occlusion ?
asymptomatic unless involving macula
| haemorrhage confide to retinal quadrants
72
Causes of gradual vision loss?
Common: DM, open angle glaucoma, ARMD (most common cause >60), cataracts
Rare: retinitis pigments, HTN, optic atrophy
73
RFs ARMD?
increased age
smoking
FHx
74
S/S of ARMD?
central visual loss
old age
blurring of small words
straight lines appearing curvy
75
types of ARMD?
wet - sub retinal neovascularisation
| dry (90%) - geographic atrophy
76
Features of dry ARMD?
Drusen white fluffy spots around the macula - fat deposits under retina
Degeneration of macula with slow decline over 1-2years
77
Features of wet ARMd?
Aberrant vessel grow into the retina from the choroid and lead to haemorrhage
rapid visual decline with distortion and macular haemorrhage
78
Ix wet ARMD?
Amsler grid
| fundoscopy
79
Mx wet ARMD?
```
Photodynamic therapy
VEGF inhibitors (intravitreal) e.g. bevacizumab
antioxidant vitamins (A,C,E,zinc)
```
80
Ix ARMD?
Urgent referral ophthalmology
1. slit lamp microscopy
wet ARMD -fluorescin angiography
optical coherence tomography
81
Mx ARMD?
Stop smoking (slows degeneration)
dry: zinc + vitamin A, C, E
wet: anti-VEGF
82
What are the drugs for chronic glaucoma?
BAC (reduce aqueous production)
beta blokcer
alpha 2 agonist
carbonic anhydrase inhibitor
PP (reduce uveoscleral outflow)
pilocarpine
prostaglandin analogue
83
what are the S/S of tobacco-alcohol amblyopia?
optic atrophy
loss of red/green discrimination
scotoma
84
MX tobacco-alcohol amblyopia?
vitamins may help
85
Pathophysiology of chronic simple open angle glaucoma?
increase IOP >21, blood flow, damaged optic nerve, optic disc atrophy and cupping
86
S/S of open angle glaucoma?
peripheral field loss (central vision maintained)
87
RF open angle glaucoma?
myopia, FHx
88
Ix open angle glaucoma?
those with strong FH have screening from 40
screening: >35, afro-carribean, FHx, steroid, DM, HTN, migraines, myopia
tonometry (>21mmHg), fundoscopy (cupped optic disc), visual fields
89
Mx open angle glaucoma?
1st line: beta blocker (timolol), prostaglandin analogue (latanoprost)
2nd line: topical alpha 2 agonist (brimonidine tartrate), carbonic anhydrase inhibitor (acetazolamide), topical miotic (pilocarpine)
surgical: laser trabeculoplasty [new can be used 1st line if desired]
90
SEs of prostaglandin analogies in eye?
iris pigmentation and eyelash growth
91
Pathogenesis of diabetes mellitus in the eye?
cataracrts
| retinopathy- microangiopathic vessel disease (occlusion + fragile neovascularisation)
92
Screening for eye in diabetes?
annual screening + funds photography + fluorescin staining
93
Management of diabetic retinopathy?
C: BP and glycaemic control
Proliferative retinopathy -> pan-retinal photocoagulation
Maculopathy -> grid/focal retinal photocoagulation
94
Stages of diabetic retinopathy?
1. hard exudates, micro aneurysms, blot haemorrhages (conservative)
2. pre-proliferative: cotton wool spots, soft exudates (pan-retinal photocoagulation)
3. proliferative: angiogenesis (pan-retinal photocoagulation)
4. maculopathy: hard exudates heart macula (grid-retinal-photocoagulation)
95
HTN retinopathy stages (Keith-Wagener)
Grade 1: silver wiring, arteriole tortuosity
Grade 2: AV nipping
Grade 3: Flame haemorrhages, cotton wool exudates
Grade 4: papilloedema
96
S/S cataracts?
increasing myopia + blurred vision
dazzling bright lights, night vision loss
halos
97
Causes of cataracts?
```
age (30% >65yo have cataracts)
steroids
smoking
DM
uveitis
hypocalcaemia
congenital: idiopathic, rubella infection, wilson's, Alpert's, galactoseamia, myotonic dystrophy, Downs
```
98
Ix cataracts?
tonometry
fundoscopy (darkened red reflex)
acuity testing
BMs
99
Mx cataracts?
C: Glasses and sunglasses, glycemic control
M: mydriatic eye drops (tropicamide)
S: cataract surgery
100
Complications of cataract surgery?
```
posterior capsular opacification (decreased acuity) -> laser surgery
posterior capsule rupture
retinal detachment glaucoma
endophthalmitis
anterior uveitis
vitreous haemorrhage
```
101
What is the anatomy of the retina?
outer pigmented layer in contact with choroid
inner sensory layer in contact with vitreous
fovea at centre
102
what is retinitis pigmentosa?
most common inherited degeneration of the macula
103
inheritance of retinitis pigmentosa?
most common - AR
best prognosis - AD
worse prognosis - X linked
104
S/S retinitis pigmentosa?
night blindness
tunnel vision
blind by mid 30s
105
Associations retinitis pigmentosa?
Friedrich's ataxia
Kearns-Sayre syndrom
Refsum's disease
Usher's syndrome
106
Ix retinitis pigmentosa?
fundoscopy (pale optic disc/atrophy, macula sparing peripheral retinal pigmentation)
107
What is the commonest intraocular tumour in children?
retinoblastoma
108
S/S Retinoblastoma?
strabismus
| leukocoria (white in eye with no red reflex)
109
Associations retinoblastoma?
pineal tumours
osteosarcoma
rhabdomyosarcoma
110
Ix retinoblastoma?
fundoscopy
111
Mx retinoblastoma?
enucleation
chemotherapy
radiotherapy
depends on size
112
Causes of blepharitis?
seborrhoea dermatitis
| staphylococcus
113
S/S blepharitis?
gritty itchy eyes with scales on the lashes
114
Mx blepharitis?
compresss and clean +/- topical chloramphenicol
115
what is entropion and ectropion?
```
entropion = eyelid inversion - corneal irritation
ectropion = lower lid eversion - watering and exposure keratitis associated w ageing, CN7 palsy
```
116
What is lagophthalmos?
difficulty closing the lid over the globe - exposure keratitis
117
Causes of lagophthalmos?
exophthalmos, facial palsy
118
Mx lagophthalmos?
lubrication (liquid paraffin)
| tarrsorrhaphy
119
What are pinguecula?
yellow vascular nodules either side of the cornea
120
what are pterygium?
yellow vascular nodules growing over the cornea - decreased vision
benign growth of the conjunctiva
associations with dusty, wind blown lifestyles and sun exposure
121
what can cause orbital cellulitis?
staphylococcus
pneumococcus
GAS
122
S/S orbital cellulitis?
```
inflammation of orbit
lid swelling
pain on movement of eyes
systemic symptoms
exophthalmos
```
n.b. periorbital does not have pain on eye movement, no systemic symptoms, no proptosis, no vision loss
123
Ix orbital cellulitis?
CT scan w/contrast (orbits, sinuses and brain; assess for posterior spread
124
Mx orbital cellulitis?
```
referral to ophthalmology
IV Abx (cefuroxime)
```
125
Complications orbital cellulitis?
local extension (meningitis, cavernous sinus thrombosis), optic nerve damage
126
What is a carotid cavernous fistula?
carotid aneursym rupture leading to reflux of blood into cavernous sinus
127
Causes of cavernous fistula?
spontaneous rupture or trauma?
128
S/S carotid cavernous fistula?
engorgement of eye vessels
lid and conjunctival oedema
pulsatile exophthalmos
eye bruit
129
Mx carotid cavernous fistula?
endovascular treatment
130
Common causes exophthalmos?
Graves
orbital cellulitis
trauma
131
What is squint/strabismus?
misalignment of visual axes
132
types of squint?
concomitant (common) - imbalance of extra ocular muscles
| paralytic (rare) - paralysis of extra ocular muscles
133
What are the causes of CNIII palsy?
Medical: DM, MS, infarction
Surgical: raised ICP, cavernous sinus thrombosis, PCA aneurysm
134
What are the causes of CNIV palsy?
peripheral: DM, trauma, compression
central: MS, SOL, vascular
135
What are the causes of CNVI palsy?
peripheral: DM, trauma, compression
central: MS, SOL, vascular
136
what is esotropia?
squints where eye deviates towards the nose (common in children)
caused: idiopathic, hypermetropia
137
what is exotropia?
divergent squint
older children
often intermittent
138
ix squint?
corneal light reflection test
| cover test
139
Management of squint?
```
4Os
ophthalmological review
optical - correct refractive errors
orthoptic (eye patches to the good eye to prevent amblyopia)
operations (resection of rectus muscles)
```
140
Ix foreign bodies?
XR eye
| fluorescin
141
Mx foreign bodies?
chloramphenicol drops
eyepatch
mydriatics/cycloplegics
refer to eye emergency - do not try and remove A&E
142
what is hyphaema?
blood in anterior chamber
143
What is the mx of intra-ocular haemorrhage?
small amounts clear spontaneously; large may need evacuation
144
Complications intra-ocular haemorrhage?
acute closed angle glaucoma if restricts outflow
| corneal staining
145
Mx chemical injury?
irrigate
| referral
146
What is the aetiology of orbital blowout fracture?
blunt trauma, sudden increase IOP, orbital content herniate into maxillary/ethmoid sinus
147
S/S orbital blowout fracture?
ophthalmoplegia + diplopia
loss of sensation to lower lid - infraorbital nerve injury
ipsilateral epistaxis - anterior ethmoidal artery rupture
decreased acuity
irregular pupil reacting slowly to light
148
what are floaters?
small dark spots;
| sudden showering one eye may be blood/retinal detachment
149
causes of floaters?
```
retinal detachment
vitreous haemorrhage
diabetic retinopathy/HTN retinopathy
old retinal branch occlusion
syneresis
```
150
types of flashes?
```
intraocular
intracerebral (ie migraine)
```
151
What are some causes of haloes?
haloes - cataract, corneal oedema, acute glaucoma
haloes + eye pain- acute glaucoma
jagged haloes - migraine
152
Mx of trachoma?
tetracycline
153
what causes trachoma?
chlamydia trachomatis
| ulceration and blindness
154
what causes onchocerciasis?
river blindness
microfilariae of nematode onchocerca
corneal opacities and synechiae
155
Mx onchocerciasis?
ivermectin
156
What is xerophthalmia?
manifestation of vitamin A deficiency
night blindness
dry conjunctiva
corneal ulceration/perforation
157
Mx xerophthalmia
vitamin A
158
anterior uveitis associated conditions
```
ankylosing spondylitis
reactive arthritis
ulcerative colitis, Crohn's disease
Behcet's disease
sarcoidosis: bilateral disease may be seen
```
159
Ocular manifestations of rheumatoid arthritis?
```
keratoconjunctivitis sicca (most common)
episcleritis (erythema)
scleritis (erythema and pain)
corneal ulceration
keratitis
```
160
Indications to refer to ophthalmology for foreign body?
- penetrating eye injury due to high-velocity injuries (e.g. drilling, lawn moving or hammering) or sharp objects
- Significant orbital or peri-ocular trauma has occurred
- Chemical injury has occurred (irrigate for 20-30 mins before referring)
- Foreign bodies composed of organic material
- Foreign bodies in or near the centre of the cornea
Any red flags e.g. severe pain; irregular, dilated or non-reactive pupils; significant reduction in visual acuity.
161
Causes of tunnel vision?
papilloedema
retinitis pigmentosa
choroidoretinitis
glaucoma
