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Ophthalmology Flashcards

1
Q

What is glaucoma

A

Optic nerve damage due to significant rise in intraocular pressure

Rise in pressure due to blockage of flow of aqueous humour

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2
Q

What are the 2 types of glaucoma

A

Open angle

Closed angle

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3
Q

What are the anterior and posterior chambers of the eye

A

Anterior chamber: between cornea and iris

Posterior chamber: between lens and iris

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4
Q

Describe the path of flow of aqueous humour in the eye

A

Ciliary body (production) –> around lens –> under iris –> through anterior chamber –> through trabecular meshwork –> into canal of Schlemm –> into general circulation

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5
Q

What is normal intraocular pressure

A

10 - 21 mmHg

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6
Q

Explain the pathophysiology of open angle glaucoma

A

Gradual increase in resistance through trabecular meshwork (more difficult for humour to exit eye)

Slow, chronic onset

Increased pressure causes cupping of optic disc (central indentation becomes larger, cup > 0.5 size of disc is abnormal)

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7
Q

What are the risk factors for open angle glaucoma

A

Increasing age

Family history

Black ethnicity

Nearsigntedness (myopia)

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8
Q

How might open angle glaucoma present

A

Often asymptomatic (spotted on routine screening)

Peripheral vision affected first (get tunnel vision)

Fluctuating symptoms (pain, headache, blurred vision, halos around lights)

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9
Q

What are the investigations for open angle glaucoma

A

Non-contact tonometry (puff of air into cornea, measure pressure, not very accurate but useful for screening)

Goldmann applanation tonometry (gold standard, apply pressure directly to cornea)

Fundoscopy (optic disc cupping, general optic nerve health)

Visual field assessment (look for peripheral vision loss)

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10
Q

What is the management for open angle glaucoma

A

Aim to reduce intraocular pressure

Start treatment if pressure > 24 mmHg

Prostaglandin analogue eye drops (latanoprost, increases uveoscleral outflow, side effects: eyelash growth, eyelid/iris pigmentation)

Beta blockers (timolol, reduces aqueous humour production)

Carbonic anhydrase inhibitors (dorzolamide, reduces aqueous humour production)

Sympathomimetics (brimonidine, reduces production, increases flow)

Surgery (trabeculectomy - create new channel for flow)

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11
Q

Explain the pathophysiology of acute angle-closure glaucoma

A

Intraocular pressure very high

Iris bulges forward, seals off trabecular meshwork from anterior chamber

Aqueous humour not drained away

Very high pressure behind iris worsens closure of angle

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12
Q

What are the risk factors for acute angle-closure glaucoma

A

Increasing age

F>M

Family history

East asian ethnicity

Shallow anterior chamber

Medications (anticholinergics, adrenergics, tricyclic antibiotics)

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13
Q

How might acute angle-closure glaucoma present

A

Patient appears unwell

Short history

Severely painful red eye

Blurred vision

Halos around lights

Headaches

Nausea, vomiting

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14
Q

How might the eye appear on examination in acute angle-closure glaucoma

A

Red eye

Teary

Hazy cornea

Decreased visual acuity

Dilated pupil

Fixed pupil size

Firm eyeball on palpation

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15
Q

What is the initial management for acute angle-closure glaucoma

A

Lie on back without pillow

Pilocarpine eye drops (cause pupillary constriction and ciliary muscle contraction - opening up angle)

Oral acetazolamide (reduces aqueous fluid production)

Analgesia

Antiemetics

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16
Q

What is the secondary care management for acute angle-closure glaucoma

A

Pilocarpine (opens up pathway for flow of fluid)

Acetazolamide (reduces production of fluid)

Hyperosmotic agents (increase osmotic gradient between blood and eye)

Timolol (reduces production of fluid)

Dorzolamide (reduces production of fluid)

Brimonidine (reduces production of fluid, opens up angle)

Laser iridotomy (definitive management, make hole in iris for flow of fluid)

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17
Q

What is age-related macular degeneration

A

Degeneration of macula causes progressive deterioration in vision

Most common cause of blindness in the UK

2 types (wet, dry)

See drusen on fundoscopy

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18
Q

Explain wet age-related macular degeneration

A

Associated features: atrophy of retinal pigment layer, degeneration of photoreceptors

Development of new vessels from choroid layer (due to VEGF, leak fluid and blood, get oedema, rapid loss of vision)

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19
Q

What are the layers of the macula (bottom to top)

A

Choroid (contains blood vessels)

Bruch’s membrane

Retinal pigment epithelium

Photoreceptors

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20
Q

What are drusen

A

Yellow deposits of protein and lipids

Between retinal pigment epithelium and Bruch’s membrane

Abnormal if large and numerous

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21
Q

What are the risk factors for age-related macular degeneration

A

Age

Smoking

White/east asian ethnicity

Family history

Cardiovascular disease

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22
Q

How might age-related macular degeneration present

A

Gradual central visual field loss

Reduced visual acuity

Crooked or wavy appearance to straight lines

Wet: more acute, loss of vision over days, full vision loss in 2-3 years, can be bilateral

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23
Q

What are the investigations for age-related macular degeneration

A

Reduces visual acuity on Snellen chart

Scotoma (central patch of vision loss)

Ambler grid test (assess distortion of straight lines)

Fundoscopy (see drusen)

Slit-lamp biomicroscopic fundus examination (get cross-sectional view of retina)

Fluorescein angiography (get detailed picture of oedema and neovascularisation)

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24
Q

What is the management for age-related macular degeneration

A

Refer to ophthalmology

Dry: no specific treatment, lifestyle improvement to slow progression

Wet: anti-VEGF medications (injected directly into vitreous chamber once a month)

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25
What is diabetic retinopathy
Blood vessels in retina damaged due to prolonged exposure to high blood sugars Progressive deterioration in health of retina
26
Explain the pathophysiology of diabetic retinopathy
Increased vascular permeability (get leaky blood vessels, blot haemorrhages, formation of hard exudates) Microaneurysms (weakness in vessel walls, get small bulges) Venous beading (walls of vessels not straight) Cotton wool spots (due to damage to nerve fibres, fluffy white patches on retina) Intraretinal microvascular abnormalities (dilated and tortuous capillaries in retina, act as shunts) Neurovascularisation
27
What are the classifications of diabetic retinopathy
Based on fundoscopy Non-proliferative: - No new blood vessel development - Can become proliferative - Mild, moderate, or severe Proliferative: - New blood vessel development - Vitreous haemorrhages Diabetic maculopathy: - Macular oedema - Ischaemic maculopathy
28
What is the management for diabetic retinopathy
Laser photocoagulation Anti-VEGF medications Viteoretinal surgery (for severe disease)
29
What are the complications of diabetic retinopathy
Retinal detachment Vitreous haemorrhage (bleeding into vitreous fluid) Rubeosis iridis (new blood vessel formation in iris) Optic neuropathy Cataracts
30
What is hypertensive retinopathy
Damage to small blood vessels due to systemic hypertension (systemic or malignant)
31
What are the fundoscopy signs of hypertensive retinopathy
Silver wiring/copper wiring (walls of arterioles thickened and sclerosed, get increased refraction) Arteriovenous nipping (arterioles cause compression of veins that they cross) Cotton wool spots (due to ischaemia and infarction of retina) Hard exudates (due to damaged vessels leaking lipids into retina) Retinal haemorrhage (release of blood into retina) Papilloedema (optic disc swelling, blurring of optic disc margins)
32
What is the Keith-Wagner classification of hypertensive retinopathy
Stage 1 - mild narrowing of arterioles Stage 2 - focal constriction of blood vessels and AV nicking Stage 3 - cotton wool spots, exudates, haemorrhages Stage 4 - papilloedema
33
What is the management for hypertensive retinopathy
Control blood pressure Control lipid levels Stop smoking
34
What are cataracts
Lens becomes cloudy and opaque Reduced visual acuity (less light entering eye) Most in older age Can be congenital (screen for red reflex in neonatal examination)
35
What are the risk factors for cataracts
Increasing age Smoking Alcohol Diabetes Steroid (especially eye drops) Hypercalcaemia
36
How might cataracts present
Usually asymmetrical Very slow reduction in vision Progressive blurring of vision Changes in colour vision (colours become more brown/yellow) 'Starbursts' around lights (especially at night) Loss of red reflex (lens grey/white) Glare
37
What is the management for cataracts
Is manageable, no intervention needed Surgery (drill, break lens into pieces, remove pieces, implant artificial lens)
38
What are the complications of cataracts
Endophthalmitis: - Complication of eye surgery - Inflammation of inner contents of eye - Usually due to infection - Treat with intravitreal antibiotics - Can lead to loss of vision/eye Posterior capsule opacification: - Build-up of debris on capsule - Treated with lasers
39
What are the causes of abnormal pupil shape
Trauma to sphincter muscles Anterior uveitis Acute angle-closure glaucoma Rubeosis iridis (neurovascularisation of iris) Coloboma (congenital malformation of eye) Tadpole pupil (usually temporary, associated with migraines)
40
What are the features of 3rd nerve palsy
Ptosis Dilated, non-reactive pupil Divergent strabismus (squint) 'Down and out' position
41
Which eye muscles does CN 3 supply
All extraocular muscles except LR and SO Levator palpebrae superioris (lifts eyelid) Sphincter muscles of iris
42
What are the causes of 3rd nerve palsy
Idiopathic If pupil spared, usually microvascular cause If full 3rd nerve palsy: compression of nerve (idiopathic, tumour, trauma, aneurysms, raised ICP)
43
What are the features of Horner syndrome
Ptosis Miosis Anhidrosis May have enopthalmos (sunken eyes) Light and accommodation reflexes normal
44
What are the causes of Horner syndrome
Central lesions (stroke, multiple sclerosis, tumours) Pre-ganglionic (tumours, trauma, thyroidectomy, cervical rib) Post-ganglionic (carotid aneurysms, cluster headaches) Congenital (associated with heterochromia)
45
What is the management for pupil disorders due to Horner syndrome
Cocaine eye drops (stop noradrenaline re-uptake) Low concentration adrenaline eye drops
46
What is a Holmes Adie pupil
Unilateral dilated pupil Sluggish to react to light Slow dilation following constriction Pupil gets smaller over time Also have absent ankle and knee reflexes
47
What is a Argyll-Robertson pupil
Specific to neurosyphilis Constricted pupil that accommodates when focussing on near objects, but no reaction to light
48
Give an overview of blepharitis
Inflammation of eyelid margin Gritty, itchy, dry eye Associated with dysfunction of Meibomian glands Can get styes or chalazions Management: hot compress, gentle cleaning, lubricating eye drops (hypromellose, polyvinyl alcohol, carbomer)
49
Give an overview of styes
Hordeolum externum: infection of glands of Zeis/Mill (at base of eyelashes), tender red lump, may point outwards Hordeolum internum: infection of Meibomian glands (deep), painful, may point inwards Management: hot compresses, analgesia, consider topical antibiotics (if persistent/have conjunctivitis)
50
Give an overview of chalazion
When Meibomian glands become blocked and swell up Swollen eyelid Not tender Red Management: hot compress, analgesia, consider topical antibiotics (if inflamed), may need surgical drainage
51
Give an overview of entropion
Eyelid turned inwards Lashes against eyeball Pain Can get corneal damage/ulceration Management: tape eyelid down, lubricating eye drops, surgery (definitive) Same-day ophthal referral if risk to sight
52
Give an overview of ectropion
Eyelid turned outwards Inner part of eyelid exposed Can get exposure keratopathy Management: none for mild cases, lubricating eye drops, may need surgery Same-day ophthal referral if risk to sight
53
Give an overview of trichiasis
Inward growth of eyelashes Pain Can get corneal damage/ulceration Management: remove eyelashes (epilation), electrolysis, cryotherapy, laser treatment Same-day ophthal referral if risk to sight
54
Give an overview of periorbital cellulitis
Eyelid and skin infection in front of orbital septum Swelling Redness Hot skin around eyelid/eye Use CT to differentiate from orbital cellulitis Management: systemic antibiotics, admit vulnerable patients (may develop orbital cellulitis)
55
Give an overview of orbital cellulitis
Infection around eyeball Involves tissues behind orbital septum Pain on eye movement Reduced eye movements Changes in vision Abnormal pupil reaction Proptosis (eyeball sitting forward) A medical emergency Admit, give IV antibiotics May need surgical drainage (if abscess forms)
56
What is conjunctivitis
Inflammation of the conjunctiva (thin layer of tissue covering inside of eyelid and sclera) May be bacterial, viral, or allergic
57
How might conjunctivitis present in general
Unilateral or bilateral Red eyes Bloodshot Itchy/gritty sensation Discharge from eye Not painful No photophobia No changes to visual acuity
58
How might bacterial conjunctivitis present
Purulent discharge Inflamed conjunctiva Worse in morning (eye stuck together) Starts in one eye, may spread to the other Highly contagious
59
How might viral conjunctivitis present
Clear discharge Associated with other symptoms of viral infection Pre-auricular lymph nodes may be tender Contagious
60
What are the painless red eye conditions
Conjunctivitis Episcleritis Subconjunctival haemorrhage
61
What are the painful eye conditions
Glaucoma Anterior uveitis Scleritis Corneal abrasions and ulceration Keratitis Foreign body Traumatic/chemical injury
62
What is the management for conjunctivitis
Usually spontaneously resolves in 2 weeks Advise on good hygiene If bacterial, consider antibacterial eye drops Babies < 1 month: urgent ophthalmology review, neonatal conjunctivitis associated with gonococcal infection can cause loss of sight
63
What is allergic conjunctivitis
Due to exposure to allergens Swelling of conjunctival sac and eyelid Significant watery discharge and itching Management: antihistamines (topical/oral)
64
What is anterior uveitis
Inflammation of interior part of uvea Uvea involves: iris, ciliary body, choroid Get inflammation and immune cells in anterior chamber Causes: autoimmune, infection, trauma, ischaemia, malignancy Get 'floaters' in vision (due to immune cells)
65
What conditions are associated with acute anterior uveitis
Ankylosing spondylitis Inflammatory bowel disease Reactive arthritis
66
What conditions are associated with chronic anterior uveitis
Sarcoidosis Syphilis Lyme disease TB Herpes More macrophages, less severe, > 3 months
67
How might anterior uveitis present
Unilateral Spontaneous onset Dull, aching, painful red eye Ciliary flush (ring of red spreading out from cornea) Reduced visual acuity Floaters, flashes Miosis Photophobia Pain on eye movements Abnormal pupil shape Hypopyon (yellow fluid in front of iris)
68
What is the management for anterior uveitis
Refer for same day ophthalmology review Steroids Cycloplegic-mydriatic medications (antimuscarinics - block iris sphincters and ciliary body) Immunosuppressants (DMARDs, TNF inhibitors) Laser therapy Cryotherapy Surgery
69
What is episcleritis
Benign and self-limiting inflammation of episclera Episclera: outermost layer of sclera Common in young and middle-aged adults Usually due to inflammatory disorders (rheumatoid arthritis, inflammatory bowel disease)
70
How might episcleritis present
Acute onset Unilateral Usually not painful Segmental redness (patch of redness in lateral sclera) Foreign body sensation Dilated episcleral vessels Watery eye No discharge
71
What is the management for episcleritis
If in doubt, refer to ophthalmology Usually self-limiting (resolves in 1-4 weeks) Lubricating eye drops Simple analgesia Cold compress Severe cases: systemic NSAIDs, topical steroid eye drops
72
What is scleritis
Inflammation of full thickness of sclera Not usually due to infection
73
What is necrotising scleritis
Severe form of scleritis Have visual impairment No pain Can get perforation of sclera Significant complication
74
What conditions are associated with scleritis
Rheumatoid arthritis SLE Inflammatory bowel disease Sarcoidosis Glanulomatosis with polyangiitis
75
How might scleritis present
Acute onset Can be unilateral/bilateral Severe pain Pain with eye movements Photophobia Eye watering Reduced visual acuity Abnormal pupil reaction to light Tenderness on palpation of eye
76
What is the management for scleritis
Refer for same-day ophthalmology review Manage underlying condition NSAIDs Steroids Immunosuppressants
77
What is a corneal abrasion
Scratch or damage to cornea Chemical abrasions can cause severe damage and loss of vision
78
What are the common causes of corneal abrasions
Contact lenses Foreign bodies Fingernails Eyelashes Entropion (inward turning eyelid)
79
How might corneal abrasions present
History of contact lenses/foreign body Painful red eye Foreign body sensation Watery eye Blurred vision Photophobia
80
What are the investigations for corneal abrasion
Fluorescein stain (collects in abrasions/ulcers) Slit lamp examination (for significant abrasions)
81
What is the management for corneal abrasions
If significant, refer for ophthalmology review Remove foreign body Simple analgesia Lubricating eye drops Antibiotic eye drops Follow-up after 24 hours Cyclopentolate eye drops (dilate pupil, help relieve symptoms) Chemical abrasions: immediate irrigation for 20-30 mins, urgent ophthalmology referral If uncomplicated, usually heal over 2-3 days
82
What is keratitis
Inflammation of cornea Causes: herpes (most common), bacterial, fungal, contact lenses, exposure keratitis
83
What is stromal keratitis
Herpes keratitis that is affecting the stromal layer Associated with: stromal necrosis, vascularisation, scarring, corneal blindness
84
How might keratitis present
Painful red eye Photophobia Vesicles around eye Foreign body sensation Watery eye Reduced visual acuity
85
What are the investigations for keratitis
Fluorescein staining (show dendritic corneal ulcers) Slit lamp examination (for diagnosis of keratitis) Corneal swab/scraping (isolate causative virus)
86
What is the management for keratitis
Refer for urgent ophthalmology review Aciclovir Ganciclovir eye gel Topical steroids If have significant corneal scarring: corneal transplant
87
What is a subconjunctival haemorrhage
Relatively common Rupture of small blood vessel in conjunctiva Release of blood into space between sclera and conjunctiva Due to: strenuous exercise, heavy coughing, weight lifting, straining, trauma
88
How might a subconjunctival haemorrhage present
Bright red blood covering white of the eye Painless Does not affect vision History of precipitating event
89
What is the management for subconjunctival haemorrhage
Resolve spontaneously in 2 weeks If foreign body sensation, lubricating eye drops
90
What is posterior vitreous detachment
Vitreous body comes away from retina Very common (especially in elderly)
91
How might a posterior vitreous detachment present
Painless Spots of vision loss Floaters Flashing lights
92
What is the management for posterior vitreous detachment
No treatment needed (symptoms improve as brain adjusts) Can predispose to: retinal tears, retinal detachment
93
What is retinal detachment
Retina separates from choroid Usually due to retinal tears (vitreous fluid gets under retina) Sight-threatening emergency (outer retina relies on blood vessels from choroid for blood supply)
94
What are the risk factors for retinal detachment
Posterior vitreous detachment Diabetic retinopathy Trauma to eye Retinal malignancy Older age Family history
95
How might retinal detachment present
Painless Peripheral vision loss (often sudden, like 'shadow coming across eye') Blurred/distorted vision Floaters Flashing
96
What is the management for retinal detachment
Immediate referral to ophthalmology Manage retinal tears: laser, cryotherapy Manage retinal detachment: aim to reattach retina, vitrectomy (remove part of vitreous body), scleral buckling (use silicone buckles to put pressure on outside of eye), pneumatic retinopexy (injection of gas bubble into vitreous body)
97
What is retinal vein occlusion
Thrombus in retinal vein, blocking drainage of blood from retina Pooling of blood in retina Leakage of blood and fluid (macular oedema, retinal haemorrhage, damage to retinal tissue, loss of vision, release of VEGF)
98
How might retinal vein occlusion present
Sudden, painless loss of vision
99
What are the risk factors for retinal vein occlusion
Hypertension High cholesterol Diabetes Smoking Glaucoma Systemic inflammatory conditions
100
What are the investigations for retinal vein occlusion
Fundoscopy (flame/blot haemorrhages, optic disc oedema, macular oedema) Look for causes of retinal vein occlusion (bloods, glucose, blood pressure)
101
What is the management for retinal vein occlusion
Immediate referral to ophthalmology Aim to treat macular oedema and prevent complications for neovascularisation Laser photocoagulation Intravitreal steroids Anti-VEGF therapy
102
What is central retinal artery occlusion
Central retinal artery: branch of ophthalmic artery (branch of internal carotid), supplies blood to retina Common causes of occlusion: atherosclerosis, giant cell arteritis, vasculitis
103
What are the risk factors for central retinal artery occlusion
Older age Family history Smoking Alcohol consumption Hypertension Diabetes Poor diet Inactivity Obesity
104
How might central retinal artery occlusion present
Sudden, painless loss of vision Relative afferent pupillary defect (pupil more sensitive to light)
105
What are the fundoscopy findings in central retinal artery occlusion
Pale retina with cherry-red spots Pale due to lack of perfusion Spots due to macula showing up more
106
What is the management for central retinal artery occlusion
Immediate referral to ophthalmology Immediate: attempt to dislodge thrombus (ocular massage, remove fluid from anterior chamber, inhaled carbogen, sublingual isosorbide dinitrate) Long-term: treat reversible risk factors, secondary prevention of cardiovascular disease
107
What is retinitis pigmentosa
Congenital inherited condition Degeneration of rods and cones in retina Usually have more rod degeneration Night blindness
108
How might retinitis pigmentosa present
Night blindness Peripheral vision lost before central vision
109
What might you see on fundoscopy in retinitis pigmentosa
Pigmentation ('bone-spicules', mostly in mid-peripheral area of retina) Narrowing of arterioles Waxy/pale optic disc
110
What is the management for retinitis pigmentosa
Refer to ophthalmology for assessment and diagnosis Genetic counselling Vision aids Sunglasses (prevent retina from accelerated damage) Driving limitations Regular follow ups Vitamin/anti-oxidant supplements Oral acetazolamide Steroid injections Anti-VEGF injections Gene therapy may be possible in the future
111
What is the ophthalmology management for facial nerve palsy
Acute eye protection (lubricating eye drops, cross-taping)
112
Which causes of an acute red eye are associated with itching/scratchiness/burning
Allergy Conjunctivitis Corneal disorders Foreign body Trichiasis Dry eye
113
Which causes of an acute red eye are associated with localised eyelid tenderness
Hordeolum Chalazion
114
Which causes of an acute red eye are associated with deep intense pain
Corneal abrasion Scleritis Iritis Acute glaucoma Sinusitis
115
Which causes of an acute red eye are associated with photophobia
Corneal abrasion Iritis Acute glaucoma
116
Which causes of an acute red eye are associated with halo vision
Corneal oedema (acute glaucoma, over-wearing contacts)
117
How do you test low vision
Count fingers Hand movements Perception of light No perception of light
118
Give an overview of 3rd nerve palsy related to eye position
Down and out CN3 supplies: - Superior branch: SR - Inferior branch: MR, IR, IO Classic features: ptosis, dilated and unreactive pupil, diplopia
119
Give an overview of 4th nerve palsy related to eye position
Up and in Often have a head tilt CN4 supplies SO
120
Give an overview of 6th nerve palsy related to eye position
Eye facing in CN6 supplies LR
121
Give an overview of beta blockers as a method of reducing intraocular pressure
Timolol, carteolol Reduce production of aqueous fluid
122
Give an overview of alpha agonists as a method of reducing intraocular pressure
Aorackinidine, brimonidine Reduce production of aqueous fluid Increase drainage of aqueous fluid
123
Give an overview of prostaglandin analogues as a method of reducing intraocular pressure
Latanoprost, bimatoprost Increase uveoscleral outflow of aqueous fluid
124
Give an overview of carbonic anhydrase inhibitors as a method of reducing intraocular pressure
Dorzolamide, brinzolamide Reduce production of aqueous fluid
125
Give an overview of parasympathomimetics as a method of reducing intraocular pressure
Pilocarpine Increase outflow of aqueous fluid (ciliary muscles contract, opening up trabecular meshwork)

Neuro and special senses (4 decks)

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