ophthalmology Flashcards
what is retinitis pigmentosa
inherited condition causing retinal degeneration. most common
primarily affects the peripheral retina
presentation retinitis pigmentosa
tunnel vision
night blindness often initial sign
fundoscopy of retinitis pigmentosa
black bone spicule-shaped pigmentation in the peripheral retina, mottling of the retinal pigment epithelium
(looks like black bits around the edges)
what nerve is affected in loss of corneal reflex
CN V1 (trigeminal)
- ophthalmic branch
CN III (oculomotor) palsy
ptosis
‘down and out’ eye
dilated, fixed pupil
as III controls MR, IO, SR, I
CN IV (trochlear) palsy
defective downward gaze → vertical diplopia
as IV controls SO
CN VI (abducens) palsy
defective abduction → horizontal diplopia
eye deviates inwards
as VI controls LR
what is glaucoma
optic nerve damage caused by a significant increase in intraocular pressure
what is acute angle-closure glaucoma
iris bulges forward + seals off trabecular meshwork from anterior chamber preventing the aqueous humour from being able to drain
-> continual build up of pressure in eye (particularly in posterior chamber which in turn worsens angle closure)
risk factors for acute angle-closure glaucoma
chinese/east-asian
increased age
female
FHx
shallow anterior chambre
pupil dilation
catacracts
hypermetropia (long sited)
meds that can increase risk of acute angle-closure glaucoma
adrenergic e.g. noradrenaline
anticholinergic e.g. oxybutynin
tricyclic antidepressants
presentation of acute angle-closure glaucoma
severely painful red eye
blurred vision
halos around lights
assoc headache, N&V
clinical examination in acute angle-closure glaucoma
red eye
hazy cornea
teary
fixed, dilated pupil
decreased visual acuity
firm eyeball on palpation
tx acute angle-closure glaucoma
same day ophthalmology assessment - med emergency as can lose vision
lie px back - no pillow
PILOCARPINE eye drops (causes pupil to contract)
acetazolamide 500mg oral (decreases production of aqueous humour), can be given IV
definative tx = Laser peripheral iridotomy
what is open angle glaucoma
where there is a gradual increase in resistance through the trabecular meshwork making it more diff for aqueous humour to flow through + exit eye
slow + chronic onset
RFs open angle glaucoma
age
FHx
black
nearsighted (myopia)
presentation open angle glaucoma
asx for a long time
ofen found at routine screening in eye checks
affects peripheral vision first -> tunnel vision
pain, headaches, blurred, halos
ix of intraocular pressure
goldmann applanation tonometry GS
non-contact tonometry
mx open angle glaucoma
Latanoprost - prostaglandin analogue eye drops
- increase uveoscleral outflow
- increases eyelash length
B-blocker eye drops - timolol
- reduces aqueous production
- CI asthma, heart block
SEs of prostaglandin analogue eye drops e.g. latanoprost
eyelash growth
eyelid pigmentation
iris pigmentation (browning)
most common cause of blindness in UK
age-related macular degeneration
findings assoc w age-related macular degeneration
drusen seen in fundoscopy (paler dots) - espesh around macular in DRY
neovascularisation in WET
atrophy of retinal pigment epithelium
degeneration of photoreceptors
what happens in wet age-related macular degeneration
neovascularisation
dev of new vessels growing from the choroid layer of macular into the retina. These can leak -> oedema -> vision loss
RFs age-related macular degeneration
age
smoking
white or chinese
FHx
CVD
presentation of age-related macular degeneration
gradual worsening of central visual field loss
reduced visual acuity
crooked/wavy appearance to straight lines
wet is more acute than dry
what test is used to dx age-related macular degeneration
slit-lamp biomicroscopic fundus exam
tx wet age-related macular degeneration
refer all age-related macular degeneration to opthal
anti-VEGF meds - inject to eye monthly
Rfs for retinal detachment
posterior vitreous detachment
diabetic retinopathy
trauma to eye
retinal malignancy
older age
FHx
presentation of retinal detachment
painless
peripheral vision loss - sudden, SHADOW coming across vision
blurred vision
flashes + floaters
how does GCA cause vision loss
Ischaemia to the anterior optic nerve
what is positive afferent pupillary defect
pupils respond differently to light
what is scotoma
visual field abnormality, or a blind spot
causes of optic neuritis
multiple sclerosis: the commonest associated disease
diabetes
syphilis
optic neuritis presentation
unilateral decrease in visual acuity over hrs/days
poor discrimination of colours (red desaturation)
pain worse on eye movement
relative afferent pupillary defect
central scotoma
optic neuritis ix
MRI of brain + orbits w gadolinium contrast
mx optic neuritis
high dose steroids
4-6 wks recovery
what happens in central retinal artery occlusion
sudden painless loss of vision due to blockage of BF to the retina
how does anterior uveitis present
unilat sx starting spontan
acute onset redness
pain (increasing w movement of eye)
photophobia
decreased vision
floaters + flashes
miosis, abnormally shaped pupil
pus in AC
lacrimation
ciliary flush - ring of red spreading out
hypopyon - pus + inflam cells in anterior chamber -> visible fluid level
what is anterior uveitis
inflammation affecting the anterior portion of the uvea (iris, ciliary body + choroid)
usually an AI process
also called iritis
difference between acute and chronic anterior uveitis
chronic is more granulomatous (more macrophages)
less severe
+ longer duration of > 3 mths
what is acute anterior uveitis assoc w
HLA B27 related conditions
ie Ankylosing spondylitis
Inflammatory bowel disease
Reactive arthritis
what is chronic anterior uveitis assoc w
Sarcoidosis
Syphilis
Lyme disease
Tuberculosis
Herpes virus
mx anterior uveitis
urgent same day assessment w opthlamologist
cycloplegics (dilate pupil) - atropine, cyclopentolate
steroid eye drops
causes of central retinal artery occlusion
atherosclerosis (most common)
GCA
RFs central retinal artery occlusion
same as for CVD:
Older age
Family history
Smoking
Alcohol consumption
Hypertension
Diabetes
Poor diet
Inactivity
Obesity
GCA risk:
>50
females
prev
polymyalgia rheumatica
what pupil defect in central retinal artery occlusion
relative afferent pupillary defect
- where the pupil in the affected eye constricts more when light is shone in the other eye compared to when it is shone in the affected eye
(This occurs because the input is not being sensed by the ischaemic retina when testing the direct light reflex but is being sensed by the normal retina during the consensual light reflex.)
fundoscopy in central retinal artery occlusion
pale retina with a cherry red spot
(pale as lack of blood perfusion, spot is macula)
mx central retinal artery occlusion
immediate referral to ophthalmology
older px tested + tx for GCA (IV steroids)
what is a cataract
progressively opaque (cloudy) eye lens reducing light entering eye + visual acuity
screening for congenital cataracts
red reflex
(If no red reflex, or a weak one, is seen, it may mean there’s cloudiness in the lens.)
Rfs cataracts
Increasing age
Smoking
Alcohol
Diabetes
Steroids
Hypocalcaemia
Downs syndrome
presentation cataracts
usually asymmetrical, eyes affected separately
- slow reduction in visual acuity
- progressive vision blurring
- colours becoming more faded/brown/yellow
- starbursts can appear around lights (espesh at night)
key exam finding in cataracts
Loss of the red reflex
The lens can appear grey or white using an ophthalmoscope
mx cataracts
no mx if sx ok
surgery - drilling + breaking lens, artificial lens = phacoemulsification
what is endophthalmitis
inflam of inner contents of the eye
rare complication of cataract surgery
tx intravitreal abx
what is scleritis
inflam of full thickness of the sclera (white bit)
most signif comp of scleritis
necrotising scleritis -> sclera perforation
systemic conditions assoc w scleritis
RA
SLE
IBD
sarcoidosis
granulomatosis with polyangiitis
scleritis presentation
acute onset
50% bilateral
pain -w movement
photophobia
eye watering
reduced visual acuity
abnormal pupil reaction to light
tender to eye palpation
red /blue sclera
mx scleritis
same-day assessment by an ophthalmologist
oral NSAIDs are typically used first-line
oral glucocorticoids may be used for more severe presentations
immunosuppressive drugs for resistant cases
what is episcleritis
self-limiting inflammation of the episclera, the outermost layer of the sclera.
The episclera is situated just underneath the conjunctiva.
episcleritis presentation
acute onset unilateral symptoms:
Typically not painful but there can be mild pain
Segmental redness (rather than diffuse like scleritis). There is usually a patch of redness in the lateral sclera.
Foreign body sensation
Dilated episcleral vessels
Watering of eye
No discharge
mx episcleritis
If in doubt about the diagnosis, refer to ophthalmology.
Episcleritis is usually self limiting and will recover in 1-4 weeks. In mild cases no treatment is necessary. Lubricating eye drops can help symptoms.
Simple analgesia, cold compresses and safetynet advice
what is blepharitis
inflam of eyelid margins
can be assoc w dysfunc of meibomian glands (secrete oil to surface of eye)
can lead to styes + chalazions
presentation blepharitis
gritty, itchy, dry sensation in eyes
mx blepharitis
warm compresses and gentle cleaning of the eyelid margins to remove debris
what is a stye
a tender red lump along the eyelid that may contain pus
what is Hordeolum externum
type of stye
infection of the glands of Zeis (sebaceous) or Moll (sweat) (at the base of eyelashes)
what is Hordeolum internum
type of stye
infection of the meibomian glands (oil)
deeper, more painful + may point towards the eyeball under the eyelid
stye tx
Hot compresses and analgesia
Topical antibiotics (e.g., chloramphenicol) may be considered if it is associated with conjunctivitis or if sx are persistent
what is a chalazion
occurs when a meibomian gland becomes blocked + swells
can be called meibomian cyst
chalazion presentation
swelling in the eyelid not typically tender
usually slightly above upper eyelid
tx chalazion
warm compresses + gentle massage towards the eyelashes to encourage drainage
what is entropion
when the eyelid turns inwards with the lashes pressed against the eye
causes pain + can result in corneal damage + ulceration
mx entropion
taping eyelid down (lubricating eye drops)
definitive mx is surgical
same day referral if risk to sight
what is ectropion
when the eyelid turns outwards exposing inner aspect
usually affects bottom lid -> exposure keratopathy
tx ectropion
mild cases nothing
regular lubricating eye drops
surgery
what is trichiasis
inward growth of eyelashes
mx trichiasis
remove affected eyelashes
recurrent cases may need electrolysis, cryotherapy or laser treatment
what is periorbital cellulitis
an eyelid + skin infection in front of the orbital septum (in front of eye)
swollen, red, hot skin around eyelid + eye
tx periorbital cellulitis
(need to differentiate from orbital which is a sight + life threatening emergency)
systemic abx
admit vulnerable px
what is orbital cellulitis
infection around the eyeball involving tissues behind the orbital septum
sx orbital cellulitis
pain w eye movement
reduced eye movements
vision changes
abnormal pupil reactions
proptosis
tx orbital cellulitis
emergency admission under opthalmology + IV abx
what is keratitis
infection of the cornea
causes of keratitis
bacterial
- typically Staphylococcus aureus
- pseudomonas aeruginosa is seen in contact lens wearers
fungal
amoebic
- acanthamoebic keratitis (5%)
- increased incidence if eye exposure to soil or contaminated water
- pain is classically out of proportion to the findings
parasitic: onchocercal keratitis (‘river blindness’)
viral: herpes simplex keratitis
environmental
- photokeratitis: e.g. welder’s arc eye
- exposure keratitis
- contact lens acute red eye (CLARE)
where does herpes keratitis usually affect
the epithelial layer of the cornea
if there is stroma inflam (layer between epithelium + endothelium) = stromal keratitis + has lots of comps
presentation herpes keratitis
Painful red eye
Photophobia
Vesicles around the eye
Foreign body sensation
Watering eye
Reduced visual acuity. This can vary from subtle to significant.
ix herpes keratitis
FLUORESCEIN staining = DENDRITIC CORNEAL ULCER
SLIT-LAMP examination req to find + dx
corneal swabs/scrapings to isolate the virus
mx keratitis
(red-eye say patients with potentially sight-threatening causes of red eye should be referred for same-day assessment by an ophthalmologist
- always refer if they wear contacts)
- Aciclovir (topical or oral)
- Ganciclovir eye gel
- Topical steroids may be used alongside antivirals to treat stromal keratitis
corneal transplant
what is retinal detachment
the retina separates from the choroid underneath
usually due to a retinal tear that allows vitreous fluid to get under the retina
sight-threatening emergency as outer retina relies on BVs of choroid
mx of retinal tears + detachment
Any suspicion requires immediate referral to ophthalmology
Mx of retinal tears aims to create adhesions between retina + choroid:
- Laser therapy
- Cryotherapy
Mx of detachment aims to reattach the retina and reduce any traction or pressure that may cause it to detach again:
- Vitrectomy
- Scleral buckling
- Pneumatic retinopexy
conjunctivitis presentation
Red, bloodshot eye
Itchy or gritty sensation
Discharge (purulent if bacterial, clear if viral + other sx viral infect)
NO pain
NO vision change
NO photophobia
Contagious
list causes of acute painful red eye
Acute angle-closure glaucoma
Anterior uveitis
Scleritis
Corneal abrasions or ulceration
Keratitis
Foreign body
Traumatic or chemical injury
list causes of acute painless red eye
Conjunctivitis
Episcleritis
Subconjunctival haemorrhage
mx conjunctivitis
usually resolves 1-2 wks no tx
hygiene measures to avoid spread
cleaning the eyes with cooled boiled water and cotton wool can help clear the discharge.
Chloramphenicol or fusidic acid eye drops are options for bacterial conjunctivitis if necessary.
If neonate = urgent assess (may be gonococcal)
what is allergic conjunctivitis
caused by contact with allergens. It causes swelling of the conjunctival sac and eyelid with itching and a watery discharge.
tx allergic conjunctivitis
Antihistamines
Topical mast-cell stabilisers - need several wks of use b4 benefit
eye drops that dilate pupil
Cyclopentolate
tx for macular oedema
An intravitreal implant containing dexamethasone
what is nasolacrimal duct obstruction
most common cause of a persistent watery eye in an infant
caused by an imperforate membrane, usually at the lower end of the lacrimal duct
1 in 10 infants have symptoms at around one month of age
tx nasolacrimal duct obstruction
teach parents to massage the lacrimal duct
symptoms resolve in 95% by the age of one year- leave it
Unresolved cases should be referred to an ophthalmologist for consideration of probing, which is done under a light general anaesthetic
horner’s syndrome
triad of ptosis (drooping of the upper eyelid), miosis (constricted pupil) and anhidrosis (lack of sweating) on the affected side
what is the macula
the central part of the retina responsible for sharp, detailed vision.
The fovea is a small, central pit located in the macula.
Central retinal vein occlusion
decrease in central vision
typically presents with retinal haemorrhages, venous dilation, and tortuosity (stormy sunset appearance)
diabetic maculopathy
most common cause of vision loss in people with diabetes (often preceded by diabetic retinopathy)
BV changes in the macular (central area of retina) - hard exudates + oedema
fundoscopy features of papilloedema
venous engorgement: usually the first sign
loss of venous pulsation: although many normal patients do not have normal pulsation
blurring of the optic disc margin
elevation of optic disc
loss of the optic cup
Paton’s lines: concentric/radial retinal lines cascading from the optic disc
almost always bilateral
causes of papilloedema
space-occupying lesion: neoplastic, vascular
malignant hypertension
idiopathic intracranial hypertension
hydrocephalus
hypercapnia
features of hypertensive retinopathy
Cotton-wool spots (widespread white-ish areas resulting from ischaemia)
Retinal haemorrhages (red blotches around the centre of the image)
A ‘macular star’ composed of intraretinal lipid exudates (the radial, sunburst pattern of white streaks around the macular)
The optic nerve head is swollen, which is the feature that separates grade 3 and grade 4 hypertensive retinopathy
retinal changes w high BP + dic swelling (papilloedema)
Keith-Wagener classification of hypertensive retinopathy
I = Arteriolar narrowing and tortuosity, Increased light reflex - silver wiring
II = Arteriovenous nipping
III = Cotton-wool exudates, Flame and blot haemorrhages
IV = Papilloedema
When you earn SILVER (1), you get a NIP and tuck (II), then you trade your clothes made of COTTON and WOOL to something more hot/FLAME (III). When you start dressing hot you get a new PAPI (IV)
what is herpes zoster ophthalmicus (HZO)
reactivation of the varicella-zoster virus in the area supplied by the ophthalmic division of the trigeminal nerve
features of herpes zoster ophthalmicus (HZO)
vesicular rash around the eye, which may or may not involve the actual eye itself
Hutchinson’s sign: rash on the tip or side of the nose. Indicates nasociliary involvement and is a strong risk factor for ocular involvement
mx herpes zoster ophthalmicus (HZO)
oral antiviral treatment for 7-10 days
- start within 72 hours
- IV antivirals may be given for v severe infection or if px is immunocompromised
topical corticosteroids may be used to treat any secondary inflammation of the eye
ocular involvement requires urgent ophthalmology review
what is Argyll-Robertson pupil + what causes it
Bilaterally small pupils that accommodate but don’t react to bright light.
neurosyphilis
diabetes mellitus
ix for acute angle closure glaucoma
tonometry to assess for elevated IOP
gonioscopy (literally looking, oscopy, at the angle, gonio): a special lens for the slit lamp that allows visualisation of the angle
Endophthalmitis
typically red eye, pain and visual loss following intraocular surgery
presentation of vitreous haemorrhage
subacute onset:
- painless visual loss or haze (commonest)
- red hue in the vision
- floaters or shadows/dark spots in the vision
most common cause of vitreous haemorrhage
proliferative diabetic retinopathy (over 50%)
in children + young adults: ocular trauma
Key things to remember in eye trauma
Urgent refer to opthal - suspect foreign body in eye
Keep px NMB
NO MRI! Might do CT
Do they need a tetanus shot
Tape plastic shield over eye
myiadratic eye drops + examples
DILATE the eye
e.g. cycloplegic eye drops Atropine, cyclopentolate
what eye drops constrict the eye
pilocarpine
complication of panretinal photocoagulation
decrease in night vision
