Ophthalmology Flashcards
presentation of acute glaucoma
unwell w/ short history
- severely painful red eye
- blurred vision
- halo around lights
- associated headache, nausea, vom
presentation of acute glaucoma in examination
- Red-eye
- Teary
- Hazy cornea
- Decreased visual acuity
- Dilatation of the affected pupil
- Fixed pupil size
- Firm eyeball on palpation
Ix for primary angle closure glaucoma
measuring intraocular pressure
ophthalmological exam
presentation of cute glaucoma
62 yo woman with a one day hx of pain around her right eye. She feels nauseated and has vomited once. On examination her right eye is red
open angle glaucoma develops insidiously, how does it first present
peripheral field loss –> tunnel vision
what eye conditions present with pain
anterior uveitis (acute painful red eye w/ photophobia & reduced visual acuity)
bacterial/viral conjunctivitis (sore red eye w purulent/ serous discharge)
scleritis (subacute red eye, w. pain, exacerbated by eye movement)
orbital cellulitis ( ocular pain & pain on mvmt w/ redness & swelling around eye )
what differentiates scleritis from episcleritis
episcleritis - painless ( has p in it)
what group of people are most commonly affected by episcleritis
young, middle-aged adults
with inflammatory coinditions ( RA, IBD)
presentation of episcleritis
segmental redness (a patch, not diffuse)
non painful( or mild) w/ foreign body sensation
dilated vessels
watery eye
no discharge
cause: not typically infective
Mx episcleritis
self-limiting ( recovers 1-4wks)
mild- no tx necessary
Symptomatic:
- lubricating eye drops
- simple analgesia
- scold compress
more severe
- systemic NSAID
- topical steroid eye drops
presentation of scleritis
like episcleritis, but: redness is diffuse (not segmental) eye mvmt painful, photophobia
- Severe pain
- Pain with eye movement
- Photophobia
- Eye watering
- Reduced visual acuity
- Abnormal pupil reaction to light
- Tenderness to palpation of the eye
what is necrotising scleritis
most severe type of scleritis
presents: visual impairment , painless
complication: sclera perforation
what conditions are associated with scleritis
RA*, SLE, IBD, Sarcoidosis, Granulomatosis with polyangiitis
*RA is most commonly associated
Mx scleritis
secondary care - same day assessment
1st line NSAIDs ( topical/systemic)
2nd line steroids (oral glucocorticouids -topical/systemic)
immunosuppression according to underlying condition
what investigation is used to dx wet age-related macular degeneration
fluorescein angiography - used to capture images of bloodflow in retina & choroid. macular neovascularisation = wet AMD
most common cause of blindness ( UK )
age-related macular degeneration
what are the types of age-related macular degeneration
dry (90%) - better prognosis
wet (10%) - worse prognosis
what are the 4 layers of the macular
photoreceptors ( top most)
retinal pigment epithelium
bruchs membrane
choroid ( contains blood supply) - bottom layer
drusen are found in what condition
age-related macular degeneration
drusen - yellow (protein& lipid) deposits between retinal pigment epithelium & Bruch’s membrane
features of normal drusen
- small (< 63 micrometres)
- hard.
Larger & greater numbers of drusen - early sign of macular degeneration.
3 features in both wet & dry AMD
drusen ( large, more than normal)
atrophy of retinal pigment epithelium (2nd layer of macular)
degeneration of photoreceptors ( 1st layer of macular)
gradual reduction in vision- blindness
what differentiates wet AMD from dry
wet
- new vessels grow from choroid into retinna –> leak fluid/blood –> oedema —> more rapid vision loss
in both
- drusen
- atrophy of retinal pigment epithelium
- degeneration photoreceptors
what protein is associated with neovascularisation into the retina in wet AMD
VEGF - vascular endothelial growth factor
risk factors of macular degeneration
age
white/ chinese
FHx
smoking
CVD
key features in presentation of AMD
gradual worsening CENTRAL visual field loss ( peripheral - open-angle glaucoma)
reduced visual acuity
lines appear crooked/wavy
wet
- more acute presentation
- loss of vision over days –> full loss in 2–3 yrs
- progresses to bilateral disease
findings on examination in AMD
- Reduced acuity -Snellen chart
- Scotoma (central patch of vision loss)
- Amsler grid test - distortion of straight lines
- Fundoscopy - Drusen
Ix used in AMD
- Dx
- initial Ix for wet MD
- second line Ix for wet MD
Dx: slit-lamp biomicroscopic fundus exam
wet
-1st line: optical coherence tomography ( cross-sectional view of retina layers) - 2nd line: blood supply & oedema in retina)
Mx in AMD
- general
- dry
- wet
general - ophtho referral
dry: avoid smoking, BP control, Vit supplements
wetL anti-VEF meds (ranibizumab, bevacizumab, pegaptanib )
what artery does the central retinal artery branch off?
ophtalmic artery
internal carotid –> ophthalmic –> central retinal
causes of central arterial occlusion (x2)
atherosclerosis ( most common)
GCA - vasculitis of ophthalmic/ central retinal
risk factors for central renal aerterial occlusion
risk factors from atherosclerosis, and GCA
presentation of central retinal arterial occlusion
sudden painless vision loss
afferent pupillary defect (more constriction in affected pupil when light is shone in it
appearance of central retinal arterial occlusion
Ix - fundoscopy
appearance
- pale retina/ retinal opacification ( lack of perfusion)
- cherry -red spot ( macula) - thinner surface shows red coloured choroid
Mx in central retinal artery occlusion
immediate optho referral
- GCA suspected, test ( ESR & temporal artery biopsy) & tx ( 60mg pred)
- thrombus: o Ocular massage
o Removing fluid from the anterior chamber (reduce intraocular pressure.)
o Inhaling carbogen (a mixture of 5% CO2 & 95% O2) to dilate the artery
o Sublingual isosorbide dinitrate (dilate the artery)
long term - Mx reversible risk factors
cause of central retinal vein occlusion
thrombus
thrombus –> no drainage –> blood pooling in retina –> leakage of fluid & blood –> macular oedema & retinal haemorrhages –> damaged tissue –> vision loss
presentation of central retinal vein occlusion
sudden painless loss of vision
risk factors for central retinal vein occlusion
thrombus risk factors
glaucoma
systemic inflammatory conditions e.g. SLE
Appearance of central retinal vein occlusion on funduscopy
flame & blot haemorrhages
optic disc oedema
macula oedema
Mx central retinal vein occlusion
laser photocoagulation
intravitreal steroids (dex)
anti-VEGF - ranibizumab aflibercept, bevacizumab
cause of orbital cellulitis
URTI (from sinuses)
preseptal ( periorbital ) cellulitis which progressed to orbital celllulitis
how does cataracts affect vision
reduces vision
blurs vision
a pt presents with worsening redness and swelling around her right eye for the past 2 days.
On examination of the child, there is tenderness and erythema over the right eyelid and during the assessment of her eye movements, she complains of pain and ‘seeing double’. Her temperature is 38°C
is this preseptal cellulitis or orbital cellulitis
orbital as
- reduced visual acuity (diplopia)
-proptosis
- pain w/ eye movement
painful eye movements and visual disturbance (‘seeing double’ referring to diplopia) in the context of a red, swollen, tender eye is concerning for orbital cellulitis
Mx orbital cellulitis
IV cefotaxime / clindamycin
Mx presptal cellulitis
oral co-amox
risk factors for orbitak cellulitis (5)
Childhood (7-12 years)
Hx sinus infection
No Hib vaccination
Recent eyelid infection/ insect bite on eyelid (periorbital cellulitis)
Ear or facial infection
how does orbital cellulitis present
Redness and swelling around the eye
Severe ocular pain
Visual disturbance
Proptosis
Ophthalmoplegia/pain with eye movements
Eyelid oedema and ptosis
most common bacterial causes of orbital cellulitis ( 3)
Streptococcus
Staph. aureus
HiB.
give one potential complication fof preseptal cellulitis
devloping into orbital cellulitis
so Adx for observation in severe cases/ vulnerable pts (e.g. children)
most common causative organisms of preseptal cellulitis
Staph. aureus, Staph. epidermidis, streptococci and anaerobic bacteria.
presentation of preseptal cellulitis
- Erythema and oedema of the eyelids, which can spread onto the surrounding skin
- Partial or complete ptosis of the eye (swelling)
- Orbital signs (pain on movement of the eye, restriction of eye movements, proptosis, visual disturbance, chemosis, RAPD) - ABSENT
light and accommodation reflex findings in Horners syndrome
not affected
the location of Horners syndrome can be determined by the anhidrosis. what is the presentation of anhidrosis in
- central lesions (spinal cord )
- preganglionic lesions ( chest)
- Postganglionic lesions ( base of neck)
central lesions (e.g. stroke) - anhidrosis of arm, trunk & face
Pre-ganglionic (e.g. pancoast’s tumour) - anhidrosis of face)
post-ganglionic (e.g. carotid artery dissection) - no anhidrosis
causes of central ( x4), pre-ganglionic (x4) and post-ganglionic (x4) Horners
4Ss (Sentral) , 4Ts (Torso - pre-), 4Cs (Cervical post-)
Sentral ( anhidrosis face, arm, trunk)
S-Stroke,
S- multiple Sclerosis
S- Swelling ( tumour)
S- syringomyelia (cyst in spinal cord)
Torso ( anhidrosis of face)
T- tumour (panoast’s tumour)
T-Trauma
T-Thyroidectomy
T - Top rib ( cervical rib growing above clavicle)
Post-ganglionic lesion ( 4Cs)
C- Carotid aneurysm
C - Carotid artery dissection
C - Cavernous sinus thrombosis
C - Cluster headache
what eye finding is associated with congenital Horner syndrome
heterochromia
what eye drops can be used to test for Horners
Cocaine eye drops
- cocaine stops noradrenaline re-uptake in NMJ
- so in normal eye: dilate
- Horners: no noradrenal being released anyway, so no pupillary change
Low conc adrenalin eye drop (0.1%)
- Normal pupil: won’t dilate
- Horner syndrome: pupil dilates
apart from miosis, ptosis, anhidrosis, hat other finding is associated with horners
enophthalmos* (sunken eye)
mx in diabetic retinopathy
laser photocoagulation
anti-VEGF meds ( ranibizumab, bevacizumab)
Vitreoretinal surgery
unilateral eye pain, photophobia and ciliary congestion suggest which condition?
anterior uveitis
Red eye - glaucoma or uveitis?
glaucoma: severe pain, haloes, ‘semi-dilated’ pupil
uveitis: small, fixed oval pupil, ciliary flush
