Ophthalmology Flashcards
What are causes of blepharitis, or what types of conditions can contribute to blepharitis?
5 answers
Rosacea
Staphylococcal infection
Contact dermatitis
Seborrhoeic Dermatitis
Infestation by the Dermodex mite
What is this?
Right lower eyelid anterior Blepharitis
What is the general treatment for Blepharitis?
3 parts
Warm compressors applied to the eyelids (with closed eyes) for 2-5 minutes to soften the crusts followed by …
gentle scrubbing of the eye lashes with a sodium bicarb solution, baby shampoo solution or proprietary eyelid solutions.
If conservative management fails then
Topical chloramphenicol for anterior blepharitis and oral doxycycline for posterior blepharitis
What is the potential pharmacological management for this?
(anterior blepharitis)
chloramphenicol 1% eye ointment topically, applied to the eyelid margin of both eyes, twice daily for 1 to 2 weeks.
How could you pharmacologically treat this?
(posterior blepharitis)
Adult
Doxycycline 100mg, oral, daily until improvement and then 50mg oral, daily for a minimum of 8 weeks
review at 8 weeks
What is this? how is it treated?
This is a stye (hordeolum) it is a lesion on the eyelid margin.
Treated with warm compressors
Antibiotics are not needed
Incision and Drainage may be needed for persistent lesions
What is this? How is it treated?
This is a Chalazion. It is usually associated with blepharitis. Occurs on the eyelid, not the margin. Due to the blocked Meibomian gland.
Treated with warm compressors.
Antibiotics NOT indicated.
If signs of periorbital cellultis then yes antibiotics.
May need Incision and Drainage if persistent.
After a corneal abrasion, is there an indication for chloramphenicol eye drops?
No there is no clinical benefit
But can consider
chloramphenicol eye drops 0.5%, 1 drop into affected eye, four times a day until healed.
What is the most important step in management with this condition?
Patient wears soft contact lenses
(3)
(bacterial keratitis)
Answer: urgent referral to an ophthalmologist to prevent visual loss
Also not to wear contact lenses
Ideally specialist would do a corneal scraping for MCS. However
If referral is delayed, you can start ciprofloxacin eye drops
What are the ocular manifestations of an HSV outbreak? Which of them require an urgent referral?
(5)
Conjunctivitis
iritis
blepharitis
retinitis
keratitis (urgent ophthal referral)
How does one get Herpes Zoster Opthalmicus? and what is the most important step in treatment?
Herpes zoster ophthalmicus occurs when the varicella-zoster virus is reactivated in the ophthalmic division of the trigeminal nerve
Consult an ophthalmologist in all cases of HZ ophthalmicus.
Should get ORAL antiviral therapy within 72 hours. however can begin later if there are still active vesicles present
A. What condition is this?
B. What is the feature present on staining?
C. how is it treated? (dosing not needed)
- herpes keratitis
- Dendritic ulcer
- Acyclovir eye ointment
Steps in examination for keratitis?
(5)
- Visual acquity, each eye
- Inspect the eyelids and invert
- Inspect the conjunctiva. diffuse injection is more likely to be keratitis
- Inspect the cornea, note any defects
- Enhance any defects with staining and use of cobalt blue light
what is this and how is it treated?
Acute vs chronic
Dacrocysitis.
Acute: cephalexin 500mg (12.5mg/kg) , orally, 6 hourly (not sure how long, assume until clear)
Chronic: no role for Abx. Likely need surgical management.
Explain the difference between a hordeolum and chalazion
Chalazion is a blockage of a meibomian gland - which are glands at the edge of the eyelid.
A hordeolum ( a stye ) is an inflammation near the eyelid margin. they are external or internal. Internal ones are an acute infection of the meibomian gland
These images represent how a person with ____(A)_____ see the world.
B. What would you call these changes? (3)
C. How is this treated?
A. Cataract
B. Discoloured, hazy, double vision or ghosting.
C. Surgery- 3 different types
Name changes you would find in hypertensive retinopathy?
- Arteriovenous nicking
- Copper wiring
- Flame shaped haemorrhages
- Cotton wool spots
- Yellow hard exudates
- optic disc oedema
- Ateriolar constriction
NFC
Nicking Flame Haemorrhages Copper wiring.
What percentage of people with diabetes have a retinopathy?
25%-50%
What are the two mechanisms that lead to visual loss and blindness with diabetic retinopathy?
- Mostly macular oedema. Blood retinal barrier breaks down with subsequent blood leakage and retinal thickening.
- Proliferative diabetic retinopathy. New abnormal vessels are formed due to ischemia. this causes bleeding.
List some of the changes you’d expect to see in a diabetic retina?
Mainly
- microaneurysms
- neovascularisation
also
-Exudates
-Cotton wool spots
-Oedema
What medication can be used to treat diabetic retinopathy?
Fenofibrate. The dosing changes because of different potencies with different capsules.
What is first line and second line medical treatment for Herpes Zoster Ophthalmicus?
valaciclovir 1gram orally, 8 hourly for 7 days
second
Famciclovir 500mg, orally, 8 hourly for 7 days
What organism is responsible for this?
This is trachoma. it is a chronic conjunctivitis.
Caused by non genital strains of Chlamydia
Which communities are defined as at risk for trachoma and what is done about this?
At risk communities are those where >5% of the children aged 5-9 have trachoma in aboriginal or Torre Strait islander communities.
A screening program is put into place
How do you diagnose trachoma?
Clinical. Turned in eyelashes, eyelid contraction, in-turned eyelid margin. painful corneal scarring, corneal opacity
Lab tests are not recommended
How to do you treat acute Chlamydia Trachomatis Conjunctivitis?
Or chronic chlamydia trachomatis
azithromycin 1 g (child: 20 mg/kg up to 1 g) orally, as a single dose.
In areas of prevalent trachoma, what is recommended?
Regular facial cleansing (this may mean having to address access to water and not sharing items used on the face with other household members)
Treatment of the entire household.
Community wide treatment might be needed if it is endemic.
What is acute angle closure glaucoma?
What are the symptoms?
This is when there is blockage of aqueous drainage. Causing a build up intraocular pressure.
Headache
Extreme ocular pain
Blurred vision
Severe nausea and vomiting
What are signs on examination of acute angle closure glaucoma?
(3)
Hazy cornea
Red eye
Mildly dilated pupil
This is obviously an ophthalmological emergency and needs referral
How to approach chemical injury to the eyes?
Acids are form protein coagulants and usually prevent further damage whereas alkalis break down the corneal barriers and are actually more dangerous.
- ideally irrigate eye with eye buffering solution. or normal saline. tap water can be used if patient is ringing up and wants advice.
- Can apply local anaesthetic drops
- Do a litmus test on the affected eye versus the normal eye first, so you know what to aim for
- Call an ophthalmologist
Where is the sclera and episclera, and what is the management of scleritis ?
The sclera is a fibrous coating around the eye. The episclera is superficial to the sclera on the anterior eye and is continuous with the cornea
Scleritis is an emergency and needs urgent ophthalmological review.
What are causes of scleritis?
How does it present and what does this mean?
Usually autoimmune or connective tissue diseases cause complications with the sclera
e.g. arthritis, sjogrens, IBD, scleroderma, SLE
Usually presents with severe pain and visual loss. Hence it is an emergency
Is episcleritis a medical emergency?
Usually not.
There usually isn’t visual loss, there is a bright red colour, and usually is not painful.
It has similar causes/associations as scleritis. ie. autoimmune/connective tissue disorders.
if painful + visual loss then suspect scleritis which is an emergency.
What is this?
Not painful. no visual loss.
How is it different from conjunctivitis?
What if there was pain or visual loss?
what is the management?
- Episcleritis
- Conjuctivitis has more of a diffuse injection
- Consider scleritis.
- NSAIDs, eye lubricants and if persistent over a week then a mild topical steroid.
What are questions to ask if someone presents with visual failure? (points of interest)
These questions will directly guide your differential diagnosis.
- Sudden onset?
- Is vision through a pinhole normal?
- Is the visual loss transient?
- Is the red reflex normal. Keep in mind red reflex is not always red across different ethnicities.
- Is there an associated headache?
- Is the pupillary reflex normal?
A 50 year old patient comes in with chronic visual loss, there is no headaches or neurology.
Using a pinhole doesn’t improve the vision much, and there is no red reflex on the left eye.
- What diagnosis is most important to consider?
- What is the most likely diagnosis?
- Retinoblastoma
- Cataract
what are risk factors for cataract development?
(5)
- Age (>40, definitely >80)
- Family history of cataract
- Smoking
- Diabetes (**causes early cataract)
- Time in sun without protection.
What differentials should you consider with a sudden loss of vision that is prolonged, not corrected by pinhole, and normal pupillary reflex?
Retinal Detachment
Viterous Hemorrhage
Central retinal vein occlusion
CVA
posterior vitreous attachment
What symptoms to those with retinal detachment present with?
(4)
Loss of vision
Or sudden flashes
Or sudden appearance of multiple floaters
A cloud or web over their vision
Vision like this is related to what condition?
what do you call this?
Age related macular degeneration
“central scotoma” seen in image
what combination of supplements modestly reduces the progression of AMD? (in a subgroup of patients) (5)
How else do you manage DRY AMD? (4)
AMD- age related macular degeneration
Zince + Copper + Vitamin A + Vitamin c + beta carotene
Lifestyle management
-smoking cessation
-healthy diet
-exercise
-sun protection (for the eyes)
what is the other name for chronic simple glaucoma?
open angle glaucoma
How is chronic simple glaucoma usually detected?
It has a gradual onset visual disturbance, maybe fuller vision loss.
Usually if no other symptoms it will be detected by an optometrist when testing intraocular pressures.
sudden and painful visual loss is acute angle closure glaucoma and is a medical emergency
what is the treatment for chronic simple glaucoma/open angle glaucoma?
- Surgery
- eye drops
a. prostaglandins eg. lantanoprost (increase OUTFLOW of fluid)
b. beta blockers e.g timolol (to reduce fluid production)
c. alpha adrengergic agonists e.g brimonidine
d. carbonic anhydrase inhibitors (to reduce aqueous production)
e. rho-kinase inhibitors (reduce fluid production)
f. miotic or cholinergic agents (reduce fluid production0
who is at risk of Glaucoma?
what should be done?
Those with a first degree relative with glaucoma
Caucasian and asian patients > 50
Those of African decent > 40
Action: refer for ocular exam 5-10 years before relative with glaucoma had their diagnosis.
Who is at highest risk of glaucoma? (1) + (5)
What should be done?
Those aged over 50 and have
- diabetes
- myopia
- migraine and peripheral vasospasm
- hypertension
- long term steroid use
Refer to optometrist for examination of optic nerve and intra-ocular pressures and visual field assessment
