Ophthalmology Flashcards
What to ask in an ophthalmology hx?
Ask about pain, redness, watering, change in appearance of the eye, altered vision, and if the problem is unilateral/ bilateral, distinguish between blurred and double vision Trauma, previous similar episodes, systemic illness, eye disease in the family, if using medication, take a drug history(including eye drops)
How to measure visual acuity?
Test + record central vision of each eye separately for near and distance vision with glasses on- cover the non-test eye carefully
If can’t read the 6/9 line, use a pinhole to improve refraction
Near vision= checked using a near-vision testing card/ newspaper
Examination of the eye?
Eyelids should be symmetrical- check skin around the eyelids, position, eyelashes of, and any inflammation, crusting, or swelling of the lid/ lid margin
Bright light for eye surface- bright and shiny?, if indication of corneal damage= use fluorescein stain
Note any redness
Examining the ocular media?
Darken the room and check you have good batteries in the ophthalmoscope
Check the red reflex
Examine the disc- hand on forehead and support lid with thumb, look for shape, colour and size of the cup
Follow each of 4 main vessels–> periphery
Examine macula by asking patient to look directly at light
Examine peripheral retina by asking patient to look up, down
Dilating pupils with a short-acting mydriatic e.g. 0.5-1% tropicamide makes examination easier, but patients may have what?
Temporarily blurred vision- should not drive home
What other 3 things to examine?
Visual fields in each 4 quadrants
If complains of double vision- move an object to the nine positions of gaze- tell you which increases double vision
Pupils- round, central, of equal size, respond equally to light and accomodation, abnormalities: Horner’s syndrome, fixed dilated pupil(trauma, mydriatic drops, acute glaucoma, 3rd nerve palsy,) afferent pupillary defect(optic neuritis, retinal disease,) Argyll Robertson pupil(DM, neurosyphilis,) Holmes- Adie pupil(unilaterally in young adults)
Things warranting emergency eye referral(A&E or emergency eye clinic)?
Sudden loss of vision, acute glaucoma, perforating injury/ intraocular foreign body, chemical burns, retinal detachment, corneal ulcer, sudden onset diplopia/ squint+ pain, temporal arteritis with visual symptoms
Things warranting same-day eye referral(<24 hours)?
Hyphema/ vitreous haemorrhage, orbital fracture, sudden onset of ocular inflammation e.g. iritis/ ophthalmic herpes zoster, corneal foreign bodies/ abrasions
Things warranting an urgent <2 week referral?
Central visual loss, sinister ‘floaters,’ flashing lights without a field defect, chronic glaucoma with pressure>35mmHg
Things warranting a routine referral?
Gradual loss of vision, chronic glaucoma(unless pressure>35mmHg,) chronic red eye conditions, painless diplopia/ squint, chalazion/ stye/ cyst, ptosis
Things to ask/ do for eye trauma?
Take a careful history; establish the nature of the trauma, measure acuity and examine both eyes carefully recording your findings, try to instill local anaesthetic drops + then examine, unable–> assess in casualty, encourage accident prevention, e.g. wearing protective goggles
Things to ask/ do for corneal abrasion? Important differential dx?
Take a careful history to exclude high-speed particles that could cause penetrating injury, if severe pain- apply a few drops of local anaesthetic e.g. proxymetacaine 0.5% before examining, use fluorescein stain, with cobalt blue light illumination to detect abrasion- stains green, evert the upper lid to ensure no foreign body is left in the eye, advise chloramphenicol 0.5% eye drops QDS until healing is complete
Herpes keratitis- needs antiviral eye drops
If metal or a penetrating injury is suspected, refer to who? Superficial foreign bodies removed how? After removal, treat how? If left >12 hours, what may form?
Eye casualty
With a corner of clean card after instilling local anaesthetic
Topical ABx e.g. chloramphenicol 0.5% drops 2-hourly for 3d, then QDS for 4d
A rust ring may form around a metal foreign body- refer to eye casualty for removal
Symptom of arc eye? Seen in who? Due to what? Management?
Severe eye pain, watering, blepharospasm a few hours after exposure
Welders, sunbed users, skiers, mountaineers, and sailors who don’t use adequate eye protection
Corneal epithelial damage as result of exposure to UV light
Pad eye, analgesics and cyclopentolate 1% eye drops BD, recovery<24 hours, if not refer, advise protective wear for future exposure
Blunt injury from what? Globe rupture presentation? More minor injuries? Refer urgently if what?
Fists, squash balls etc
A wound and severely reduced vision
Subconjunctival haemorrhage/ corneal abrasion
Visual acuity affected, double vision, lacerated conjunctiva, hyphaema, unable to see posterior limit of subconjunctival haemorrhage(may indicate orbital fracture,) persistent pupil dilation(may indicated torn iris,) signs of retinal damage(oedema, choroidal rupture,) cannot assess the eye
Presentation of ‘blow out’ fracture of the orbit? From what? Refer for what?
Blurred/ double vision, pain on moving the eye, enophthalmos, infraorbital nerve loss, inability to look upwards due to trapping of inferior rectus muscle
Blunt trauma e.g. squash ball injury
XR and assessment of eye trauma via A&E
Refer to what if penetrating injury is a possibility? What can confirm diagnosis? S+S? Do not do what?
Eye casualty i.e. hx of flying object/ working with hammers, drills, lathes, or chisels where a metal fragment may fly off
XR/ CT scan
Wound may be tiny, eye is painful and waters, vision may be normal initially/ be very poor(depending on size of foreign body,) photophobia, hyphaema, and/ or pupil distortion
Remove large foreign bodies(dart/ knife)- support with padding whilst transferring the patient supine to casualty/ A&E, cover the other eye to prevent damage from conjugate movement
Use what before examining chemical burns? What causes great damage? Refer where? Tx how?
Topical anaesthetic e.g. proxymetacaine 0.5% before examining
Alkali injuries
Eeye casualty
Hold the lids open, brush out any powder, and irrigate with large amounts of clean saline/ water
Consider what conditions with pain? Gritty eye discomfort? Pain on moving the eye? Referred pain? Photophobia?
Corneal foreign body, keratitis, iritis, scleritis, acute glaucoma, ophthalmic shingles, arc eye
Conjunctivitis, entropion, trichiasis, dry eye, episcleritis
Optic neuritis
Tension headache, migraine, refractive error, trigeminal neuralgia, ophthalmic shingles, GCA, ocular muscle imbalance, increased ICP
Conjunctivitis and migraine
Causes of papilloedema? Refer to who?
Intracranial SOL, encephalitis, SAH, benign IC HTN, malignant HTN, optic neuritis, disc infiltration, ischaemic optic neuropathy, retinal venous obstruction, metabolic causes e.g. hypocalcaemia
Same-day specialist medical opinion
Bilateral causes of exophthalmos? Unilateral? What is microphthalmios? Ass with what?
Graves’ disease
Graves’ disease, orbital disease, vascular disease e.g. cavernous sinus thrombosis, carotid- cavernous fistula; sinus disease
Small eyes- Down’s syndrome + other genetic abnormalities
Preseptal/ periorbital cellulitis causes what? Cause? Typically affects who? What can be used to differentiate it from orbital cellulitis? Tx how? Can progress to what?
Swelling + redness + hot skin around the eye, children following mild trauma- normally unilateral
H.influenzae/ s.pneumoniae
Infection= localised to the skin and superficial tissues
CT scan
Tx as localised cellulitis- oral/ IV ABx e.g. flucloxacillin, admission for observation may be required
Orbital cellulitis
Orbital cellulitis typically from what? Presents? Severe cases can lead to what? If suspected refer to who for what?
Infection spread from the paranasal sinuses- involves tissues behind the orbital septum
Usually pain, double/ blurred vision, and general malaise, signs= fever, eyelid swelling, proptosis, and inability to move the eye
Severe= can lead to septicaemia, meningitis and cavernous sinus thromboses- CT + LP to exclude meningitis
Ophthalmology for IV antibiotics/ surgical drainage- cefotaxime
Features differentiating orbital cellulitis to periorbital cellulitis?
Pain on eye movement, reduced eye movements, changes in vision, abnormal pupil reactions and forward movement of the eyeball
S+S of orbital tumours? If suspected, refer for?
Unilateral proptosis, orbital pain- in rapidly growing malignant tumours especially, lid swelling/ distortion, limitation of eye movements +/- diplopia, reduced visual acuity if involvement of optic nerve, retina, or vascular supply
Urgent ophthalmology opinion
Orbital tumours may be what 3 things?
Primary(benign/ malignant)- any orbital structure may be involved, due spread from adjacent structures, due to blood-borne metastases
What is trichiasis? What is needed?
Ingrowing lashes–> irritable feeling +/- recurrent infection, severe–> corneal damage + ulceration
Eyelash removal (epilation,) electrolysis, cryotherapy/ laser tx
Same day ophthalmology referral if risk to sight
What is madarosis? Tx?
Loss of eyelashes- usually due to blepharitis(condition usually bilateral + ass w/ other S+S of blepharitis,) other causes= plucking/ rubbing(unilateral/ bilateral,) alopecia areata and discoid lupus(scarring madarosis)
Tx the cause
What is poliosis? Usually a what? Associated with what?
Depigmentation of the eyelases
Family hx, AI disease e.g. thyroid and Vogt- Koyanagi-Harada syndrome
What is entropion? Most commonly affects what? Increases with? Temporary relief method? Can cause what if untreated? Refer for what?
In-turning of the eyelids due to degenerative changes/ secondary to scarring, lower eyelid
Age- rare<40 y/o
Eyelashes rub on cornea and irritate the eye
Taping lower lid–> the cheek
Corneal vascularisation, ulceration, and infection
Rapid surgical correction, same-day referral if risk to sight
What is ectropion? Can result in? Causes? Most common? Refer for?
Turning out of the lower eyelid, exposure keratopathy
Watering and eye irritation
Elderly/ those with facial nerve palsy
Surgery, mild= no tx, regular lubricating eye drops, risk to sight= same-day referral–> ophthalmology
How to assess ptosis(drooping of the upper eyelid)? Lid margin should move how much? In severe ptosis? Tx what? How to determine the cause?
Look downwards as far as possible and then upwards as far as possible
>8mm, <4mm in severe
The cause
Look at the pupil: dilated= 3rd nerve palsy, refer–> neuro/ constricted= Horner’s syndrome/ normal= old age, congenital, MG, muscular dystrophy, myopathy, botulism
Congenital ptosis causes what? Children may compensate by doing what? 50% have associated what? Refer for what as obstructing vision may cause what?
Unilateral/ bilateral weakness of the levator muscle
Tilting their heads upwards to see better
Superior rectus muscle weakness
Surgical correction- amblyopia
Neurological causes of ptosis? Muscular and mechanical causes of ptosis?
3rd nerve palsy- often complete if pupil is dilated(refer urgently to neurology to exclude cerebral haemorrhage/ tumour)
Horner’s syndrome
Tabes dorsalis secondary to syphilis
Senile- most common, due to age-related changes in the levator muscle, refer if causing problems
MG, muscular dystrophy e.g. myotonic/ oculopharyngeal dystrophy, myopathy e.g. Graves’, mechanical- due to allergy/ mass effect of tumour
Causes of localised eyelid swelling? 2 forms of stye(common eyelid infection)?
Stye, chalazion, papilloma, xanthelasma, sebaceous cyst, marginal cyst of Zeis/ Moll, dermoid cyst- usually upper inner and outer angles of the orbit, BBC usually lid margin, lacrimal gland + lacrimal sac disorders
External(hordeolum externum) + internal (“ internum)
Most common form of stye? Infection of a lash follicle/ associated gland of Moll/ Zeis usually by what organism? Confined to what? Always points where? Tx how?
External stye (hordeolum externum)- s.aureus
The skin- outwards
Hot compresses + oral/ topical Abx e.g. chloramphenicol ointment
Internal stye is an abscess of what? Often causes less what than an external stye? May point where? Tx how?
Meibomian gland
Swelling
Inwards onto the conjunctiva(red patch with yellow centre before it bursts) or outwards through the skin
Same as external stye- hot compresses + oral/ topical ABx
What is a marginal cyst of Zeis or Moll? Tx?
Non-infected swellings of the glands of Zeis/ Moll
No tx unless troublesome then refer
RFs for styes? Symptoms typically resolve within how long once the stye has been what? Possible complications?
Chronic blepharitis + acne rosacea
5-7 days- spontaneously ruptured/ drained
Infective conjunctivitis, Meibomian cyst formation/ periorbital/ orbital cellulitis
Assessment + examination for suspected stye? Refer to who if malignant eyelid tumour suspected?
Asking about the timescale of symptoms; previous episodes; associated eye symptoms; any RFs/ triggers
Typical clinical features- eversion of the lower + upper eyelids; signs of a complication; signs of an alternative diagnosis inc atypical features suggesting a malignant eyelid tumour(rare)
Urgently to an ophthalmologist
When does a chalazion occur? Tx? If recurrent infection/ chronic cyst, refer to who to ophthalmology for what? Refer early if what and why?
Following an internal stye- the Meibomian gland may become blocked forming a cyst–> swelling typically not tender, can be tender and red
May resolve spontaneously, but often become infected- tx with topical ABx and/ or chronic
Hot compress and analgesia, consider topical ABx i.e. chloramphenicol if acutely inflamed
Surgical drainage= rarely if conservative fails
Incision and curettage, <7 y/o as large cysts can affect refraction and generate amblyopia
What is a squamous cell papilloma? Refer for what?
Benign skin tumour, may form a horn-like lesion
Excision/ curettage
What is blepharitis? Causes what sensation? Ass with what leading to what? Tx? Lubricating eye drops that can relieve symptoms(over 2-3 months with regular eye car 3x/ week)?
Inflammation of the eyelid margins
Gritty, itchy, dry sensation in the eyes
Dysfunction of the Meibomian glands(secrete oil onto the eye surface,)–> styes and chalazions
Hot compresses + gentle cleaning of the eyelid margins to remove debris using cotton wool dipped in sterilised water + baby shampoo
Hypromellose= least viscous- lasts around 10 minutes
Polyvinyl alcohol= worth starting with
Carbomer= most viscous, lasts 30-60 minutes
Tx blepharitis exacerbations with what? What may be useful for patients not responding to lid care and topical ABx? Tx dry eye symptoms with what?
Topical ABx
Oral ABx e.g. doxycycline 50mg OD for 3 months
Preservative- free tear supplements e.g. Liquifilm Tears
What does anterior blepharitis refer to? Can be caused by what? Posterior blepharitis? What can occur? Sx commonly worse when? Commonly ass with what conditions? DDx? Referral indicated when?
Inflammation of the base of the eyelashes- bacteria(staphylococcal,) or seborrheic
Inflammation of the Meibomian glands
Mixed anterior + posterior blepharitis
In the mornings- dry eye syndrome, seborrheic dermatitis + rosacea(tx with metronidazole)
Malignant tumours of the eyelid, eczema, infection, infestation + AI disease
Sx of corneal disease/ becomes painful and/ or red, loss of vision, orbital/ pre-septal cellulitis suspected, persistent localised disease/ eyelid asymmetry, underlying conditions needing secondary tx, ongoing sx despite tx in primary care, uncertain diagnosis
What is dry eye syndrome(keratoconjunctivitis sicca)? Commonly ass with what? Causes? Tx? Refer to ophthalmology when? Longer acting drops do what and short-acting drops only give relief for how long?
Tear secretion reduces with age–> eye irritation + redness which is often worse in centrally heated buildings + as the day goes on, the eye feels gritty, vision is occasionally blurred, reflex watering in severe cases
Blepharitis
Reduced tear production(Sjogren’s,) increased evaporation (e.g. exposure keratitis)
Artificial tears- preservative- free drops, if one doesn’t work- use another, treat associated lid disease e.g. blepharitis, if simple med fails try combined short- and long-acting drops
Continuing symptoms despite tx, serious/ underlying condition suspected, abnormal lid anatomy/ function, diagnostic uncertainty
Blur vision for a time, 30 minutes- may need frequent application
How is dry eye syndrome categorised? Ddx? Who is it more common in? Complications? Ix?
Aqueous tear deficiency- reduced secretion from lacrimal glands, evaporative tear deficiency- increased tear film evaporation often due to a deficient lipid layer in the tear film
Meibomian gland dysfunction, blepharitis, lacrimal gland deficiency, low blink rate, malposition of eyelids, contact lens wear, corneal refractive surgery, medication, Sjogren’s, diabetes mellitus
Aged>50 y/o, females had refractive surgery
Keratinisation of the ocular surface, corneal scarring, thinning, ulceration/ neovascularisation; visual loss
Slit lamp exam of cornea + tear film + Schirmer’s test to rule out Sjogren’s- optometry/ ophthalmology referral may be needed
What is epiphoria? Acute dacryocystitis? Tx? Chronic dacryocystitis seen in who? Presents? Refer for what?
Watering eyes- due to overproduction/ outflow obstruction, caused by corneal irritation, iritis, acute glaucoma, ectropion, blocked tear duct
Acute infection of the tear sac- can spread to surrounding tissues, Abx- flucloxacillin, abscess–> refer for surgical drainage
Middle-aged + elderly, watery eye discharges mucus regularly–> syringing of the lacrimal system/ surgery
What is infantile dacryocystitis(blocked tear duct)? Swab to exclude chlamydia when? Tx? % fail to clear by 1 year, refer to who and tx?
Delay in canalisation/ obstruction of the lacrimal duct causing persistent watering/ sticky eyes in 20% babies
Vision= normal + is no conjunctival inflammation, if lower lid conjunctiva= reddened
Bathe with cooled boiled water
Avoid ABx eye drops unless clear infection
Spontaneous resolution= the norm
4%, paediatric ophthalmologist- probing the duct to clear it
‘Red flags’ for potentially dangerous red eye? Refer to specialist to be seen how soon?
Reduced visual acuity, pain deep in the eye- not surface irritation as with conjunctivitis, absent/ sluggish pupil response, corneal damage on fluorescein staining, hx of trauma
On the same day
Ddx if inflammation of the orbit? Lid disease? Scleral inflammation? Conjunctival disease? Corneal disease? Uveal/ iris inflammation? Other causes?
Thyroid eye disease/ exomphalos, tumour, orbital cellulitis
Stye, chalazion, blepharitis, allergic eye disease
Scleritis/ episcleritis, post-op inflammation
Viral/ bacterial infection, chlamydial infection, allergy, subconjunctival haemorrhage
Foreign body/ trauma, corneal ulceration, corneal abrasion, dry eye, arc eye, ophthalmic shingles
Anterior uveitis, posterior uveitis/ toxoplasma
Acute glaucoma, post-op endophthalmitis
Types of conjunctivitis? General sx? Red flags?
1) Viral= most common, likely adenovirus, tx= reassurance(likely to get sore throat, dry cough, blocked nose and clear eye discharge, possible tender pre-auricular lymph nodes)
2) Allergic- acute allergy, meds, hayfever, clear mucus eye discharge, tx= antihistamine eye drops/ oral antihistamines, chronic seasonal symptoms= mast-cell stabilisers
3) Bacterial- normally s.aureus/ s.pneumoniae + h.influenzae, can be STD- related, tx= ABx drops. contact lens wearers + immunocompromised= greatest risk of comps e.g. keratitis
(Typically worse in the morning, usually starts in one eye + can then spread to the other)
Conjunctival blood vessel dilation, vision can be affected but resolves after a blink, unilateral/ bilateral, itchy/ gritty sensation, eye discharge- NO PAIN/ PHOTOPHOBIA/ REDUCED VISUAL ACUITY
Tx of conjunctivitis? What is hyperacute conjunctivitis? Ophthalmia neonatorum?
Good hygiene + avoid contact lenses, cleaning eyes with cooled boiled water + cotton wool, bacterial= topical chloramphenicol qds for 5d + fusidic acid eye drops if sx not improving in 3-5 days
Rapidly developing severe conjunctivitis typically caused by infection with n.gonorrhoeae
Conjunctivitis within the 1st 4 weeks of life- can be infectious/ non-infectious
Painless vs painful red eye?
Conjunctivitis, episcleritis, subconjunctival haemorrhage
Glaucoma, anterior uveitis, scleritis, corneal abrasions/ ulceration, keratitis, foreign body, traumatic/ chemical injury
Urgent ophthalmology referral for infective conjunctivitis if?
Red flag indicating serious cause of red eye, ophthalmia neonatorum, suspected gonococcal/ chlamydial conjunctivitis, possible herpes infection, suspected periorbital/ orbital cellulitis, corneal ulceration/ significant keratitis/ pseudomembrane presence, hx of recent intraocular surgery, conjunctivitis ass w/ severe RA/ immunocompromise, corneal involvement ass w/ soft contact lens use
Discussion with/ referral to ophthalmology if what for infective conjunctivitis?
Diagnostic uncertainty, lack of appropriate equipment to make definitive diagnosis/ recurrent conjunctivitis, persistent, or due to molluscum contagiosum
When does seasonal allergic conjunctivitis occur? Ass with what? Perennial? Vernal keratoconjunctivitis? Atopic keratoconjunctivitis? Giant papillary conjunctivitis?
Periodically and with seasonal allergens e.g. tree/ grass pollen
Non-seasonal environmental allergens often found in the home e.g. house dust mites, mould spores/ animal dander
Most common + severe in hot arid environments
Severe and usually associated with atopic dermatitis of the eyelids
Has a mechanical component and can occur due to chronic micro-trauma e.g. contact lens
Sight-threatening causes of a red eye? Hx and examination?
Acute glaucoma, anterior uveitis, corneal ulcer, contact lens- related red eye + corneal foreign body, neonatal conjunctivitis, trauma, chemical injuries, scleritis, endophthalmitis
Onset + duration of sx, unilateral/ bilateral, associated sx, use of lenses, trauma/ chemical exposure, previous episodes, relevant medical hx + medication
Inspection, visual acuity assessment, fluorescein examination, pupil reactions
Features in red eye hx indicating same-day ophthalmology assessment?
Reduced visual acuity, moderate-severe pain, headache, photophobia, ciliary injection, fluorescein staining of the cornea, unequal/ misshapen pupils/ abnormal pupillary reactions/ painful pupillary constriction, loss of red reflex, corneal defect/ haze, hyphaema/ hypopyon(pus in the anterior chamber), high-velocity injury, foreign body/ penetrating lesion, chemical eye injury, contact lens use, conjunctivitis in infant in first 28 days of life
What is subconjunctival haemorrhage? Common in who? Clears when? Associations? Check what? If severe/ recurrent check what x2? Avoid what? If foreign body sensation, what can help?
Spontaneous painless localised haemorrhage under the conjunctiva- generally unilateral + asymptomatic
The elderly
Spontaneously in 1-2 weeks, but may recur
HTN, clotting disorders, leukaemia, increased venous pressure, whooping cough, medications- warfarin, NOACs, antiplatelets, NAI
BP/ FBC + clotting screen- NSAIDs + aspirin
Lubricating eye drops
What is corneal vascularisation? What if they’re a contact lens wearer? Refer for what?
Growth of blood vessels onto the cornea- in patients with severe lid disease, rosacea/ due to excessive contact lens wear
Advise to remove contact lenses for at least 2 months
To ophthalmology for specialist management to prevent long-term damage
Episcleritis is unilateral in what fraction of cases? Presents how? Tx? Ineffective/ if in doubt, do what? Ass w/?
2/3
Diffuse inflammation of the eye with minimal tenderness and NO discharge, typically NOT painful, segmental redness, watering of the eye
NSAID e.g. ibuprofen 400mg tds/ ketorolac 0.5% eye drops QDS, lubricating eye drops can help, cold compresses, safety netting
Refer to ophthalmology for consideration of steroid tx
Inflammatory disorders e.g. RA + IBD
Is scleritis uni/ bilateral? Peak age? Affects what and can be what? Presents how? May be accompanying what? Ass w/? Tx? Comps?
Either, 40-60 y/o, anterior or posterior segment- diffuse/ nodular/ necrotising(most severe)
Severe pain, pain with eye movement, photophobia, eye watering, reduced visual acuity, abnormal pupil reaction to light, tenderness to palpation of the eye
Uveitis + keratitis
50%= systemic illness(herpes zoster, RA, SLE, polyarteritis nodosa, Wegener’s granulomatosis, trauma, infection/ surgery)
Refer urgently–> ophthalmology, NSAIDs, steroids, immunosuppression appropriate to underlying systemic condition
Cataracts, glaucoma, retinal detachment
What condition likely follows a carotid aneurysm rupture? Aetiology? Presentation? Ix? Tx?
Cortical cavernous fistula–> reflux of blood into the cavernous sinus
Surgery, trauma/ spontaneous
Engorged eye vessels, lid and conjunctival oedema, bilateral proptosis + diplopia
Pulsatile loud bruit over the eye/ sensation of tinnitus
MRI arteriography
Surgery
