Ophthalmology Flashcards
1
Q
What is the most common cause of blindness in the UK?
A
Age Related Macular Degeneration.
2
Q
What is Age Related Macular Degeneration?
A
Degeneration of the central retina with changes bilaterally.
Degeneration of the retinal photoreceptor cells which results in formation of drusen (yellow patches-atrophy) which can be seen on fundoscopy and retinal photography.
3
Q
What is the macula?
A
Central vision, containing a high concentration of photoreceptor cells.
4 layers
- Bottom is the choroid layer
- Above is Bruch’s membrane (blood vessels that supply macula)
- Above is retinal pigment epithelium
- Above are the photoreceptors
4
Q
What are the risk factors for ARMD?
A
Female
Advancing age
Smoking
FHx
Ischaemic CVD (HTN/DM/dyslipidaemia)
5
Q
What are the types of ARMD?
A
DRY
- 90%
- Atrophy of retinal pigment epithelium
- Drusen (lipid that appears between retinal pigment epithelium and Bruch’s membrane)
- Long time course
WET
- 10%
- Choroidal neovascularisation (growth of new blood vessels which originate from the choroid, through a break in the Bruch Membrane into the sub-retinal pigment epithelium. VEGF stimulates this. Can easily rupture resulting in sub-retinal haemorrhages and fast deterioration in vision)
- Worst prognosis
-Decreasing vision then sudden deterioration
- Central scotoma
6
Q
What is blepharitis?
A
Inflammation of the eyelid margins
7
Q
In which patients is blepharitis more common?
A
Patients with rosacea
Ankylosing Spondylitis
UC/Crohn’s
RA
Behcet’s Disease
8
Q
What are the different types of blepharitis?
A
Posterior blepharitis (more common)
- Due to meibomian gland dysfunction
Anterior blepharitis
- Due to Seborrhoeic dermatitis/Staph Aureus
9
Q
What is the pathophysiology of blepharitis?
A
Meibomian glands usually secrete oil onto the tear film. to prevent it from drying out.
Therefore if these aren’t working properly then your eye becomes dry and feels gritty. Sometimes it gets watery because there is increased tear production to compensate for this.
10
Q
What are the features of blepharitis?
A
- Dry, gritty eyes
- Foreign body sensation
- Watery eyes
- Swollen/red lids
11
Q
What investigation do you do for blepharitis?
A
Fluroscein staining
12
Q
How do you manage blepharitis?
A
Hot compress 2x a day
Lid hygiene (removing debris)
Artificial tears
Abx ointment if all other options fail
It is a chronic condition
13
Q
What is the pathophysiology of cataract?
A
Gradual opacification of the lens (cloudy).
The cloudiness makes it harder for light to reach the retina, therefore causing reduced/blurred vision.
14
Q
In whom is cataract more common?
A
Females
Advancing age
15
Q
What are the causes of cataract?
A
- DM
- Trauma
- Advancing age (normal)
- Smoking
- Increased alcohol consumption
- Hypocalcaemia
- Myotonic dystrophy
- Long term corticosteroid use
- Radiation exposure
16
Q
What does cataract present with?
A
Gradual onset
- Reduced vision
- Faded colour vision
- Glare
- Haloes around lights
- Absent red reflex
17
Q
What are the classification of cataract?
A
Nuclear: change in lens refractive index (old age)
Polar: localised, inherited, lie in visual axis
Subcapsular: due to steroid use, deep to lens capsule, in visual axis
Dot opacities: seen in diabetes and myotonic dystrophy
18
Q
What investigations would you like to do if you suspect cataract?
A
Ophthalmoscopy (after pupil dilation, normal fundus and optic nerve)
Slit lamp examination (visible cataract)
19
Q
How do you manage cataract?
A
- Increase prescription and ensure bright lighting to improve vision
- Surgery when the worst eye gets to 6/12 (Phacoemulsification: remove old lens to put an artificial lens in) (referral to surgery based on visual impairment, impact on QoL, patient choice)
20
Q
What are the complications following cataract surgery?
A
Retinal detachment
Endophthalmitis (inflammation of the aqueous/vitreous humour)
Posterior capsule opacification (thickening of lens capsule)
Posterior capsule rupture
21
Q
What is blepharitis?
A
Inflammation of the lid margins.
22
Q
What causes central retinal artery occlusion?
A
Thromboembolism (atherosclerosis)
Temporal arteritis
23
Q
What are the features of central retinal artery occlusion?
A
Rare cause of sudden unilateral visual loss.
- Painless unilateral visual loss
- Pale retina
- Cherry red spot
- Relative Afferent Pupillary Defect (RAPD)
24
Q
What is the management of central retinal artery occlusion?
A
Difficult and poor prognosis
- Treat underlying cause e.g. IV steroids for temporal arteritis
- Intra-arterial thrombolysis
25
What is open angle glaucoma?
Iris is clear from the trabecular meshwork.
There is resistance of the trabecular meshwork, preventing the flow of aqueous humour resulting in increased intra-ocular pressure.
26
What are the risk factors for open angle glaucoma?
DM
HTN
Increasing age
Myopia
Corticosteroids
Afro-carribean
Genetics
27
What are the features of open angle glaucoma?
Insidious onset (detected on optometry tests)
- Peripheral visual field loss
- Reduced VA
- Optic disc cupping (>0.7, normal is 0.4-0.7)
- Bayonetting of vessels
- Disc haemorrhages
- Pale optic disc
- Cup notching
28
What investigations would you do for open angle glaucoma?
- Automated perimetry (visual field testing)
- Slit lamp examination with dilation
- Application tonometry (IOP >24 mmHg)
- Gonioscopy (assess drainage angle)
- Assess risk of future visual impairment
- Central corneal thickness measurement
29
How do you manage open angle glaucoma?
Selective Laser Trabeculoplasty (SLT) first line for people with IOP>24.
Drops to lower IOP which prevents progressive visual field loss.
1. Prostaglandin analogues (lantoprost)
2. Beta-blockers (timolol), carbonic anhydrase inhibitors (dorzolamide), sympathomimetics (brimiodine- alpha 2 agonist)
Surgery (trabeculectomy) can be done in severe cases.
Reassess: to exclude progression and visual field loss
30
What is the screening programme for glaucoma?
If you have a positive family history for glaucoma
- Screening annually after 40yo
31
What is an example of a prostaglandin analogue?
Latanoprost
32
What is the action of prostaglandin analogues?
Increased uveoscleral outflow
33
What are the side effects of prostaglandin analogues?
Brown pigmentation of the iris
Increased eyelash length
34
What are examples of beta blockers?
Timolol
Betaxolol
35
What is the MOA of beta blockers?
Reduces aqueous production
36
In whom are beta blockers avoided?
Asthmatics
Heart block patients
37
What are some examples of sympathomimetics (alpha 2 agonists)?
Brimonidine (open angle)
Apraclonidine (closed angle)
38
What is the MOA of sympathomimetics?
Reduces aqueous production
&
Increases uveoscleral outflow
39
In whom are sympathomimetics contraindicated?
If taking
- Tricyclic antidepressants (amitriptyline)
- MAOs (selegiline)
40
What is a side effect of sympathomimetics?
Hyperaemia (increased blood flow)
41
What is an example of a carbonic anhydrase inhibitor?
Acetazolamide (closed angle)
Dorzolamide (open angle)
42
What is the MOA of carbonic anhydrase inhibitors?
Reduces aqueous production
43
What are the side effects of carbonic anhydrase inhibitors?
Asthma
Rhinitis
(Sulphonamide like reactions)
44
What is an example of a miotic (parasympathomimetic: pupil constricts) drops?
Pilocarpine (muscarinic receptor agonist)
45
What is the MOA of miotics?
Increases uveoscleral outflow.
46
What are the side effects of miotics?
Constricted pupil
Headache
Blurred vision
47
What is the leading cause of blindness in 35-65 yos?
Diabetic retinopathy
48
What is the pathophysiology of diabetic retinopathy?
Hyperglycaemia causes increased retinal blood flow, and abnormal metabolism in the retinal vessel walls. Leading to damage to epithelial cell and pericytes.
Endothelial dysfunction leads to increased vascular permeability.
Pericyte dysfunction leads to micro aneurysms.
Neovascualrisation occurs due to the growth factors being released in response to retinal ischaemia.
49
What are the types of diabetic retinopathy?
NON-PROLIFERATIVE
Mild
- 1 or more micro aneurysms
Moderate
- Cotton wool spots (soft exudates due to retinal infarction)
- Hard exudates (lipid, due to increased permeability)
- Blot haemorrhages (permeability)
- Microaneurysms
- Venous beading
- IRMA (intraretinal microvascular abnormalities): tortuous/dilated capillaries
Severe
- Micro aneurysms and blot haemorrhages in all 4 quadrants
- IRMA in at least 1 quadrant
- Venous beading in at least 2 quadrants
PROLIFERATIVE
- Retinal neovascularisation (can lead to vitreous haemorrhage)
- Fibrous tissue
- More common in T1
MACULA
- Hard exudates and changes to the macula
- More common in T2
50
How do you manage diabetic retinopathy?
Optimise glycemic control, BP, and hyperlipidaemia
Annual retinal screening
Non-proliferative
- Regular observation
- If severe= pan retinal laser photocoagulation
Proliferative
- Pan retinal laser photocoagulation
- Intravitreal VEGF inhibitors (ranibizumab)
- Vitreoretinal surgery if vitreous haemorrhage
Macular
- VEGF inhibitors if reduced VA
51
What are the complications of diabetic retinopathy?
Retinal detachment
Optic neuropathy
Cataract
Rebeosis iris (new blood vessel formation in the iris, this increases IOP and puts you at risk of glaucoma)
52
What is the purpose of VEGF inhibitors?
Slow progression
Improve VA
53
What is a side effect of pan retinal laser photocoagulation?
Reduced visual fields due to scarring
54
What is a hyphema?
Blood within the anterior chamber of the eye.
If associated with trauma it is an ocular emergency- urgent referral
55
What is the main risk of a hyphema?
Risk of increased IOP which can lead to glaucoma.
Due to the build up of blood blocking the drainage of aqueous humour.
56
How do you manage a hyphema?
Strict bed rest, as excessive movement can redisperse blood.
57
What indicates orbital compartment syndrome secondary to a retrobulbar haemorrhage?
Proptosis
Rock hard eyelids
Eye pain
Swelling
RAPD
58
How do you manage orbital compartment syndrome?
Urgent lateral canthotomy to decompress the orbit
59
What is the most common cause of persistent watery eye in an infant?
Nasolacrimal duct obstruction
(recurrent discharge)
60
What is the pathophysiology of a nasolacrimal duct obstruction?
Imperforate membrane.
Usually at the lower end of the duct.
61
How do you manage a nasolacrimal duct obstruction?
Massage nasolacrimal duct.
Should resolve by 1yo.
If not resolved then refer to ophthalmology for probing.
62
What is scleritis?
Non-infective inflammation of the full thickness of the sclera.
63
What are the risk factors for scleritis?
RA
SLE
Sarcoidosis
Granulomatosis with polyangitis
64
What are the features of scleritis?
Red eye (deeply injected vessels)
Watery
Photophobia
Painful (unlike episcleritis)
Gradual decrease in vision
65
What is the management of scleritis?
Urgent referral to ophthalmology.
Oral NSAIDs
Oral glucocorticoid in severe cases
Immunosuppressive drugs in drug resistant cases.
66
How do you differentiate scleritis from episcleritis?
Injected vessels are mobile when pressure is applied in episcleritis.
67
How do you differentiate anterior uveitis from scleritis?
Anterior uveitis: more painful when moving the eye and there is ciliary flush present.
68
What are some common causes of sudden loss of vision?
Retinal detachment
Retinal migraine
Vitreous haemorrhage
Ischaemic/vascular (thrombosis, embolism, arteritis)
69
What is blurred vision?
Loss of clarity or sharpness of vision
70
What are some causes of red eye?
Anterior uveitis
- acute
- pain
- blurred vision
- photophobia
- small, fixed, oval pupil
- ciliary flush
Scleritis
- severe pain
- tenderness
- underlying autoimmune disease
Conjunctivitis
- purulent discharge= bacterial
- clear discharge= viral
Subconjunctival haemorrhage
- Hx of trauma/coughing
Endophthalmitis
- red eye
- pain
- visual loss
- following intraocular surgery
Acute angle glaucoma
- haloes
- severe pain
- hazy cornea
- semi-dilated pupil
- decreased VA
71
What are the 4 things associated with acute optic neuropathy?
1. Monocular visual field defect (central scotoma)
2. Reduced colour vision (Reduced Ishihara plate score)
3. RAPD
4. Optic disc swelling or pallor
72
What are the 4 things associated with acute optic neuropathy?
1. Monocular visual field defect (central scotoma)
2. Reduced colour vision (Reduced Ishihara plate score)
3. RAPD
4. Optic disc swelling or pallor
73
What is another term for dry eye?
Keratoconjunctivitis sicca
(SE of Bell's palsy)
74
Where is the most likely source of an infection for orbital cellulitis?
Ethmoid sinus
75
What blood test do you want to do to rule in temporal arteritis as the cause for central retinal artery occlusion?
ESR
76
What is Sjogren's Syndrome?
Inflammation mediated destruction of the lacrimal and salivary glands.
Anti-Ro and Anti-La antibodies are specific to this condition.
77
What is Sjogren's Syndrome?
Inflammation mediated destruction of the lacrimal and salivary glands.
Anti-Ro and Anti-La antibodies are specific to this condition.
78
What is a corneal arcus?
Blue ring around the cornea.
Due to hyperlipidaemia.
79
What are the signs of 4th nerve palsy?
Trochlear Nerve Palsy- normally supplies the superior oblique
Signs
- eye deviated upwards and outwards
- head tilt
- defective downward gaze
- vertical diplopia
80
What is a kertoacanthoma?
Rapidly growing skin tumour, with a centralised keratinous plug.
Not malignant
81
What is leukocoria?
White pupillary reflex rather than a red one
Seen in retinoblastomas
82
What is orbital cellulitis?
Infection affecting the fat and muscles posterior to the orbital septum, involving the orbit but not the globe itself.
Caused from URTI spread via sinuses (ethmoid).
Medical emergency- high mortality
83
What is periorybital cellulitis?
Less severe than orbital cellulitis.
Superficial infection anterior to the orbital septum resulting from a superficial tissue injury (chalazion/insect bite)
Can progress to orbital.
84
What are the risk factors for orbital cellulitis?
Childhood
Lack of HiB vaccination
Previous sinus infection
Recent insect bite/chalazion
85
What is the presentation of orbital cellulitis?
Proptosis
Severe ocular pain
Eyelid oedema & ptosis
Ophthalmoplegia/pain when moving the eye
Visual disturbances
Redness/swelling near eye
Ear/facial infection
Drowsiness +/-N&V in meningeal involvement
86
How do you differentiate orbital from pre-septal cellulitis?
Orbital presents with:
- proptosis
- reduced VA
- ophthalmoplegia/pain when moving the eye
Whereas pre-septal does not
87
What investigations do you do if you suspect orbital cellulitis?
FBC (inflammatory markers)
Clinical examination
CT with contrast (inflammation of the tissues and muscles behind the orbital septum)
Blood cultures and microbiology swabs (Step, Staph Aureus, HiB)
88
How do you manage orbital cellulitis?
Admission for IV cefotaxime
(prevent cavernous sinus thrombosis & intracranial spread)
89
What are the causes of optic neuritis?
MS (MRI first line, LP for oligoclonal bands)
DM
Syphilis
90
What are the features of optic neuritis?
Reduced VA (acutely)
Colour desaturation
Pain on eye movements
Central scotoma
RAPD
91
What investigation do you do if you suspect optic neuritis?
MRI brain and orbit with gadolinium contrast
92
How do you manage optic neuritis?
High dose steroids
Should improve in 4-6 weeks
93
What is episcleritis?
Acute inflammation of the episclera
94
What causes episcleritis?
Idiopathic
IBD
RA
95
What are the features of episcleritis?
Painless
Red eye
Watery eye
Photophobia
Injected vessels move when pressure applied (as not deep)
Phenyephrine drops blanch episcleral vessels but not scleral vessels
96
What is the management of episcleritis?
Conservative
Artificial tears may be given
97
What is a corneal ulcer?
Microbial keratitis
Inflammation of the cornea secondary to an infective process.
98
What is a corneal abrasion?
Corneal defects secondary to physical trauma
99
What are the risk factors for corneal ulcers?
Contact lens wearers
Vitamin A deficiency (developing world)
100
What is the pathophysiology/different types of corneal ulcers?
Bacterial keratitis= Staph Aureus/Pseudomonas aeruginosa in contact lens wearers
Viral keratitis= herpes simplex/zoster (dendritic)
Fungal keratitis= caused by steroid drops
Acanthomoeba keratitis= contact lens wearers, pain out of proportion, due to contact with soil or contaminated waters
Parasitic keratitis= river blindness
Photokeratitis= mechanics (no forge in body sensation)
101
What are the features of a corneal ulcer?
Watery eye
Eye pain
Photophobia
Hypopyon
Gritty
Focal fluroscein staining of the cornea
102
How do you manage a corneal ulcer?
Urgent medical referral same day if contact lens wearer
Stop wearing contact lens until symptoms have resolved.
- Drops targeting the organism
- Cycloplegic drops to relieve pain (atropine/cyclopentate)
103
What are the complications of a corneal ulcer?
Corneal scarring
Visual loss
Endophthalmitis
Perforation
104
What are some causes of mydriasis (large pupil)?
Phaechromocytoma
3rd Nerve Palsy
Traumatic iridoplegia
Holmes-Adie pupil
Congenital
Topical mydriatics (atropine)
Sympathomimetic drugs (cocaine, amphetamines)
Anticholingeric drugs (TCAs)
Aniscoria can result in apparent mydriasis due to difference with other pupil
105
When is aniscoria pathological?
When aniscoria is worse in bright light, it implies there is a problem with the dilated pupil.
This is due to decreased parasympathetic innervation (ciliary ganglion)
106
What is the most common cause of sudden painless loss of vision?
Vitreous haemorrhage
107
What is vitreous haemorrhage?
Bleeding into the vitreous humour
108
What are the causes of vitreous haemorrhage?
Proliferative diabetic retinopathy
Posterior vitreous detachment
Ocular trauma (most common cause in young people)
109
What are the features of vitreous haemorrhage?
Sudden painless loss of vision/haze
Red hue to vision
Floaters/dark spots/ shadows in vision
Reduced VA
Visual field defects
110
How do you investigate a vitreous haemorrhage?
Slit lamp examination (RBC in anterior vitreous)
Fundoscopy with dilation (haemorrhage in vitreous)
Fluroscein angiography (neovascularisation)
USS (retinal teat/detachment)
CT orbit (openglobe injury)
111
What causes optic disc swelling?
Raised ICP
Always bilateral
112
What are the features of papilloedema?
Venous engorgement (1st sign)
Loss of venous pulsation
Elevation of the optic disc
Loss of optic cup
Blurring of the edges of the optic disc
Paton's Lines- cascading retinal lines cascading from the disc
113
What are the causes of papilloedema?
SOL
Hypercapnia
Hypocalcaemia
Hypoparathyroidism
Hydrocephalus
IIH
Malignant HTN
Vitamin A toxicity
114
What does it suggest if papilloedema is unilateral?
There is a local structure increasing pressure in the eye
e.g. optic nerve tumour
115
What investigation can you not do if you have raised ICP?
Lumbar puncture
Due to risk of coning
116
What is a stye?
Infection of the glands in the eye
117
What is a chalazion?
Meibomian gland cyst
Painless firm lump in the eyelid
Usually self-resolves, sometimes needs surgical drainage
118
What is entropion?
In-turning of the eyelids
119
What is ectropion?
Out-turning of the eyelids
120
What are the types of stye?
External
- Infection (staph) of the Zeis Glands (sebum) or the Moll glands (sweat)
Internal
- Infection of the meibomian glands
- May leave residual chalazion
121
How do you manage a stye?
Hot compress & analgesia
Avoid antibiotics unless there is associated conjunctivitis
122
What is the management of viral keratitis?
Immediate referral
Topical aciclovir
123
What is retinal detachment?
Neurosensory tissue that lines the back of the eye comes away from its underlying pigment epithelium
Reversible cause of painless visual loss if macula not yet involved
If untreated and symptomatic it will result in permanent visual loss
124
What are the risk factors for retinal detachment?
DM
Myopia
Eye trauma
Previous surgery for cataract
Increasing age
125
What are the features of retinal detachment?
Floaters/flashers
Curtain/progressive loss of vision from outside inwards
Macula involvement: central VA loss
RAPD if optic nerve involved
Fundoscopy
- Absent red reflex
- Pale retina, opaque/wrinkled/folded
126
What is the management of retinal detachment?
Urgent assessment by ophthalmologist within 24 hours
127
What is esotropia?
Towards the nose
128
What is exotropia?
Temporally
129
What is hypertropia?
Superiorly
130
What is hypotropia?
Inferiorly
131
What is strabismus?
Squint
Misalignment of the visual axis
132
What are the types of squint?
Concomitant (common)
- imbalance in the extra-ocular muscles
- convergent more common than divergent
Paralytic
- paralysis of extra-ocular muscles
133
What can strabismus lead to?
Amblyopia (lazy eye)
Brain fail to fully process input from one eye and over time favours the other eye
134
How do you investigate strabismus?
Corneal Leith Reflection test (hold light 30m away from face and look at reflection of light to see if symmetrical)
Cover test (identify nature of squint)
- focus on object
- cover one eye
- observe movement from uncovered eye
- cover other eye and repeat
135
What is the management of strabismus?
Referral to secondary care (assess type and severity, address causes and refractive error)
Eye patch to prevent amblyopia
136
What are the different types of infective conjunctivitis?
Bacterial
- Purulent discharge
- Eyes stuck together
Viral
- Recent URTI
- Serous
- pre-auricular nodes
137
What are the features of infective conjunctivitis?
Sore red eye
Discharge
138
How do you manage infective conjunctivitis?
Self limiting in 1-2 weeks
Topical chloramphenicol (2-3hrly)
Topical fusidic acid in pregnant women (BD)
Contact lens wearers, remove. Fluroscein staining
Avoid sharing towels
No school exclusion
139
What happens if a baby appears to have conjunctivitis?
Swab urgently to microbiology to test for chlamydia and gonorrhoea.
Start systemic abx whilst awaiting results
140
What is posterior vitreous detachment?
Separation of the vitreous membrane from the retina.
Due to natural changes to the vitreous fluid due to ageing.
141
What are the risk factors for vitreous detachment?
Age
Highly myopic
Female
142
What are the symptoms of vitreous detachment?
Sudden appearance of floaters
Flashes of light
Blurred vision
Cobweb across vision
Dark curtain means retinal detachment (it can lead to tears/detachment of retina)
No pain
Weiss ring on fundoscopy (detachment of vitreous membrane around optic nerve forming a ring shaped floater)
143
What is the management of vitreous detachment?
Seen within 24 hours to rule out tears/detachment
Symptoms improve in 6 months so no treatment
If tear/detachment surgery is required
144
What are the risk factors for central retinal vein occlusion?
Age
HTN
CVD
PCV
Glaucoma
145
What are the features of central retinal vein occlusion?
Sudden painless off of vision, unilaterally
Widespread hyperaemia (excess blood vessels) and severe retinal haemorrhages (stormy sunset)
146
What is the management of central retinal vein occlusion?
Conservative
Macular oedema: anti-VEGF
Retinal neovascularisation: laser photocoagulation
147
What is branch retinal vein occlusion?
Severe retinal haemorrhages confined to a limited areas of the retina
148
How do you classify hypertensive retinopathy?
Keith-Wagener Classification
1.
- arteriolar narrowing and tortuosity
- increased light reflex- silver wiring
2.
- arteriovenous nipping
3.
- cotton wool exudates
-flame and blot haemorrhages (may collect around fovea forming a macula star)
4.
- Papilloedema
149
What is retinitis pigmentosa?
Affects the peripheral retina resulting in tunnel vision
150
What are the features of retinitis pigmentosa?
Night blindness
Tunnel vision
Fundoscopy: Black bone spicule shaped pigmentation in the peripheral retina, mottling of the retinal pigment epithelium
151
What is acute angle closure glaucoma?
Rise in IOP secondary to impairment of aqueous flow.
Iris bulges forwards and seals off the trabecular meshwork from the anterior chamber preventing the drainage of aqueous humour leading to increased IOP.
152
What are the predisposing factors for acute angle closure glaucoma?
Hypermetropia
Pupillary dilation
Lens growth associated with increased age
153
What are the features of acute angle closure glaucoma?
Corneal oedema= hazy
Severe pain (ocular/headache)
Hard, red eye
Reduced VA
Semi-dilated fixed pupil
Haloes
Symptoms worse with mydriasis (pupil dilation)
Systemic upset
154
How do you manage acute angle closure glaucoma?
Medical emergency.
Emergency treatment to lower IOP, then definitive surgical treatment once attack has settled.
Eye drops
- Pilocarpine (parasympathomimetic= increased uveoscleral outflow)
- IV acetazolamide (carbonic anhydrase inhibitor= decreased humour production)
- Apraclonidine (alpha-2 agonist/sympathomimetic= decreases humour production & increases uveoscleral outflow)
- Timolol (beta-blocker= decreases humour production)
Definitive
- Laser peripheral iridotomy
155
What are the features and signs of ARMD?
Subacute onset of visual loss with:
- reduction in VA, particularly for near objects (subacute- wet, gradual-dry)
- difficulties in dark adaptation with deterioration of vision at night
- fluctuations in visual disturbance
- Photopsia (flickering/flashing of lights) and glare
- Visual hallucinations (Charles-Bonnet Syndrome)
Distortion of the line of perception (Amsler Grid Testing)
Fundoscopy reveals drusen (may become confluent to produce a macula scar)
Wet= demarcated red patches
156
What investigations would you do if you suspect ARMD?
Slit lamp microscopy (see any pigmentary/haemorrhagic changes and get a baseline picture)
Fluorescein angiography (if neovascular suspected, guides anti-VEGF therapy)
OCT (ocular coherence tomography)
157
How do you treat ARMD?
DRY
- combination of zinc and anti-oxidant vitamins (A, C, E)
- stop smoking
WET
- Anti-VEGF (vascular endothelial growth factor) within 2 months of diagnosis e.g. ranibizumab
- Laser photocoagulation (risk of acute visual loss)
158
In what condition is allergic conjunctivitis usually seen in?
Hay fever
159
What are the features of allergic conjunctivitis?
Bilateral symptoms
Conjunctival erythema
Chemosis
Itchy
Swollen eyelids
Hx of atopy
Seasonal/perennial
160
What is the management of allergic conjunctivitis?
1st line
- topical/systemic antihistamines (antazoline)
2nd line
- topical mast cell stabilisers (sodium cromoglicate)
161
What is anterior uveitis?
Red eye. Also called iritis.
Inflammation of the anterior portion of the urea (iris and ciliary body)
162
What are the features of anterior uveitis?
Acute
Ocular discomfort and pain
Ciliary flush
Small, irregular pupil
Photophobia
Blurred vision
Lacrimation
Hypopyon
Impaired VA
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What conditions is anterior uveitis associated with?
HLA-B27
Ankylosing Spondylitis
UC/Crohns
RA
Behcet's disease
Sarcoidosis
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How do you manage anterior uveitis?
Urgent review
Cycloplegics- dilate pupil to help with pain (atropine/cyclopentolate)
Steroid eye drops
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In what condition is Argyll Robertson pupil seen in?
Neurosyphilis
DM
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What are the features of Argyll Robertson pupil?
Small, irregular pupils
Accommodation reflex present
Pupillary reflex absent (no response to light)
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What are the features of 3rd nerve palsy?
Oculomotor nerve
Ptosis
Down and out eye
Dilated fixed pupil (surgical)
