Ophthalmology Flashcards
What is acute closed angle glaucoma ?
In Acute closed angle glaucoma, it is often caused by a blockage in aqueous humor trying to escape the eye. The iris bulges forward and seals off trabecular meshwork from the anterior chamber preventing aqueous humor from being able to drain away. Pressure builds up mainly in the posterior chamber. Ophthalmological emergency.
How does acute angle closure glaucoma present ?
- Severe painful red eye
- Blurred vision
- nausea and vomiting
- Headache
- Sudden and short history
- Halos around lights
What will be present on examination in patients with acute angle closure glaucoma ?
- Red eye
- Teary
- Hazy cornea
- Decreased visual acuity
- Firm eyeball on palpation
- Hyperaemia
- Fixed dilated pupil
What will occur to the pupil in acute angle closure glaucoma ?
Fixed dilated pupil
What are the risk factors for acute closed angle glaucoma ?
- Increasing age
- Females
- FHX
- Chinese and east Asian ethnic origin
- Shallow anterior chamber
- Adrenergic medications– Noradrenalin
- Anticholinergics– Oxybutynin
- TCAs like amitriptyline and glasses (positive glasses prescription = hypermetropic/long sighted)
What vision problems are at a higher risk of developing acute angle closure glaucoma ?
+ perscription
- Hypermetropic (long sighted)
What investigation can be undertaken to confirm diagnosis of acute angle closure glaucoma ?
- Goldmans tonometry to measure the IOP
What is the definitive management of acute angle closure glaucoma ?
peripheral laser iridectomy. Usually performed bilaterally as the other eye is at risk
In AACG, why is peripheral laser iridectomy performed bilaterally ?
As the other eye is at risk
What can be given in hospital to a patient presenting with AACG ?
Patients should be started on BB ( to reduce aq production, pilocarpine (to increase uvoscleral outflow) and IV acetazolamide to constrict the pupil and increase trabecular outflow . In primary care before referral, they can give patients topical pilocarpine in order to constrict the pupil and increase trabecular outflow
A patient presents to A and E with suspected AACG, what is the management ?
- Topical pilocarpine and IV acetazolamide and BB potentially
- Urgent refferal to opthalmology
How does CRAO present ?
- Sudden, painless loss of vision.
- Relative afferent pupillary defect
What is a RAPD
– Pupil in the affected eye constricts more when light is shone in the other eye compared to the affected eye.
How to diagnose CRAO ?
Fundoscopy ?
What will be present on fundoscopy in CRAO ?
- Pale retina
- Cherry red spot
How is CRAO managed ?
- Immediate referral to ophthalmology
- Occular massage, IV acetazolomide to remove fluid from the anterior chamber to reduce IOP
- Inhalation of carbogen to dilate artery
How is CRAO managed long term ?
- Treating reversible RF like GCA and cardiovascular disease
- GCA – Testing with ESR and temporal artery biopsy and treatment is with high dose steroids.
What are the most common causes of CRAO ?
GCA and atheroscleroscleoris
What are the risk factors for CRAO ?
- Atherosclerosis (carotid bruits)
- Hypertension
- AF
- Smoking
- hyperlipidaemia/hypercholesterolaemia
-APLS
What is anterior uveitis ?
Inflammation of the anterior uvea (choroid, ciliary body and choroid). Anterior chamber of the eye becomes infiltrated by neutrophils, lymphocytes and macrophages. Caused by an autoimmune process.
What group of conditions is anterior uveitis associated with ?
HLA B27 genes
What conditions is anterior uveitis associated with ?
- Acute – HLA B27 (AS, bechets, Reactive arthritis) as well as MS, SLE, IBD granulomatosis and polyangiitis.
- Chronic – Sarcoidosis, syphilis, Lyme disease, TB, HZV
- Can also be associated with Trauma, infection, ischemia or malignancy.
How does anterior uveitis present ?
- Unilateral and spontaneous
- PMH of one of the associated conditions
- Dull aching painful red eye
- Worsens over days
- Floaters and flashes
- Photophobia
-Pain on movement
What is present on examination in patients with anterior uveitis ?
- Miosis
- Cilary flush
- Pupil irregularity
- Increased lacrimation
- Hypopyon
- RED
- Cloudy Aqueous humour and inflammatory proteins
How is anterior uveitis managed initially ?
- Cycloplegic mydriatic drops- Dilation of the pupil.
- Corticosteroids - initially hourly regime
- Analgesia
Urgent ophthalmology refferal and investigation of underlying cause
How can chronic uveitis be managed ?
systemic steroid sparing immunosuppressants like methotrexate.
What is optic neuritis ?
Inflammation of the optic nerve
What are the clinical features of optic neuritis ?
- Eye pain worse on movement
- Monocular vision loss
- Impaired colour vision of the eye (red desaturation)
What is present on examination in optic neuritis ?
- Reduced visual acuity
- RAPD on the affected side
- Visual field defect
What condition is optic neuritis closely related with ?
MS
What investigation should all patients with suspected optic neuritis have ?
MRI brain
To look for white matter lesions that can indicate MS diagnosis as well as inflammation of the optic nerve
What can be present on fundoscopy in patients with optic neuritis ?
- Pale optic disk
- Papillodema (swelling of the optic disk)
What is the triad of symptoms associated with optic neuritis ?
- Visual loss
- Periocular pain
- Dyschtomatopsia - Deficiency in the perception of colours
What is the treatment of optic neuritis ?
- First line is IV methylprednisolone and usually self resolves
What is blepharitis ?
Inflammation of the eyelid margins. Chronic lid inflammation.
What are the most common causes of blepharitis ?
Staphylococcus, HSV or VZV, rosacea and seborrheic dermatitis.
What are the symptoms of blepharitis ?
Painful, gritty, itchy eyes. Eyes will stick together on waking, dry eye and symptoms associated with the causative condition like seborrhoeic dermatitis and acne rosacea.
What are the signs of blepharitis ?
Erythema of the eyelid margins. Crusting or scaling at the eyelid margins and visibly blocked glands.
What is the treatment of blepharitis ?
Chronic condition where there is no cure but it can be controlled - Lid hygiene and avoid contact lens use during flares.
How is acute blepheritis managed ?
Conservative
What is severe profound vision loss and pus in the anterior chamber post cateract surgery until proven otherwise ?
Endophthalamitis
A patient with rheumatoid arthritis presents with a sore red eye that is worse on movement and in bright lights. What is the most likley diagnosis and what is the treatment
Scleritis
Oral steroids
Any patient with a squint should be reffered to ???
Opthalmology
What are the signs of papilodema on fundoscopy ?
Blurring of the optic disc margin
Venous enlargement.
Elevation of optic dis
Loss of the optic cup
A patient presenting with oculomotor nerve palsy (CN3) - ptosis, down and out gaze and dilated fixed pupil, should be assumed to have an aneurysm of what artery ?
Left posterior communicating artery.
What are the symptoms of CRVO ?
Sudden painless vision loss of visual field defect
What are the signs of CRVO ?
STORMY SUNSET
- Flume haemorrhages and blot
- Cotton wool spots
-Retinal odema
What is the management of CRVO ?
Usually conservative. Treat the underlying cause like CV or heamotological RF
- Retinal neovascularisation (laser)
- Macular odema - Anti VEGF injections
Macular odema can be treated with ANTI VEGF injections. When are these contraindicated ?
What is given in-staid ?
- MI or stroke within 3 months or pregnancy
Steroids are given instaid.
A 64 year old female presents to Accident & Emergency with visual loss in her right eye. She reports a sudden loss of vision over the space of a minute with no associated pain. Her medical history includes hypertension and diabetes mellitus.
On examination, her visual acuity is reduced to finger counting and you note a relative afferent pupillary defect. On fundoscopy, you observe a disorganized ‘stormy-sunset’ appearance.
Which of the following is the most likely diagnosis?
CRVO
What are the main risk factors for ARMD ?
- Age (1)
- smoking (all patients should be counselled on smoking).
-FhX - Cv risk factors
What are majority of the causes of AMRD
DRY
How does ARMD present ?
decreased visual acuity, worse near vision, variability in visual disturbance, poor vision at night
What is present on fundoscopy in patients with dry ARMD
- Drusen and yellow spots
What is present on fundosocpy in patients with WET ARMD ?
Haemorrhages and red patches around the macula.
What is the treatment of dry ARMD
Zinc + antidoxidants vitamin A/C/E
What is the treatment of wet ARMD
Anti VEGF
What is posterior vitreous attachment ?
Condition where the vitreous gel in the eye separates from the retina.
What are the clinical features of posterior vitreous attachment ?
Common causes = eye trauma or old age, severe myopia is a more significant risk factor
Clinical features = Photopsia (perception of light arising without external light stimulus) and floaters.
How is posterior vitreous detachment managed ?
Normal part of ageing, but all patients should be reffered for fundus checks as in a small proportion, it can cause retinal detachmement.
What palsy causes defective abduction ?
Sixth nerve abducens
What does a dendrite ulcer on slit lamp indicate ?
HSK
Chronic open angle glaucoma - RF ?
- Increased IOP, DM, corticosteroids, HTN, myopia
What are signs on investigation of chronic open angle glaucoma ?
Pale/cupped optic disk.
What is the treatment of chronic open angle glaucoma ?
1st line = selective laser trabeculectomy
2nd = Latanoprost, BB, pilocarpine
