Ophthalmology Flashcards
What is glaucoma?
Refers to the optic nerve damage caused by a rise in intraocular pressure.
Raised intraocular pressure is caused by a blockage in aqueous humour trying to escape the eye.
What are the two types of glaucoma?
Open-angle glaucoma
Acute angle-closure glaucoma
What is the normal intraocular pressure?
10-21mmHg
What is the pathophysiology of open-angle glaucoma?
There is a gradual increase in resistance to flow through the trabecular meshwork.
How does open-angle glaucoma present?
Affects the peripheral vision first –> gradual onset of peripheral vision loss (tunnel vision)
- Fluctuating pain
- Headaches
- Blurred vision
- Halos around lights, particularly at night
How do you measure intraocular pressure?
Non- contact tonometry
Goldmann applanation tonometry
What is recommended by NICE guidelines for all patients needing treatment for open-angle glaucoma?
360º selective laser trabecularplasty
What is the first line medical treatment for open-angle glaucoma?
Prostaglandin analogue (e.g., latanoprost) which increase uveoscleral outflow.
What medications could precipitate acute angle-closure glaucoma?
Adrenergic medications (e.g., noradrenaline)
Anticholinergic medications (e.g., oxybutynin and solifenacin)
Tricyclic antidepressants (e.g., amitriptyline) which have anticholinergic effects
What is the presentation of acute angle-closure glaucoma?
- Severely painful red eye
- Blurred vision
- Halos around light
- Associated headache, nausea and vomiting
What signs would you see on examination with acute angle-closure glaucoma?
- Red eye
- Hazy cornea
- Decreased visual acuity
- Mid-dilated pupil
- Fixed size pupil
- Hard eyeball on gentle palpation
What is the initial management of acute angle-closure glaucoma?
- Lying the patient on their back without a pillow
- Pilocarpine eye drops (2% for blue and 4% for brown eyes)
- Acetazolamide 500mg orally
- Analgesia and an antiemetic if required
What is the definitive treatment for acute angle-closure glaucoma?
Laser iridotomy which involves making a hole in the iris using a laser, which allows the aqueous humour to flow directly from the posterior chamber to the anterior chamber.
What is the management of a patient with signs and symptoms of anterior uveitis?
Urgent ophthalmology review (same day)
What conditions are associated with anterior uveitis?
Ankylosing spondylitis
Reactive arthritis
UC/CD
Behcet’s disease
Sarcoidosis: Bilateral disease may be seen
What is the treatment for orbital cellulitis?
Requires admission to hospital for IV antibiotics due to risk of cavernous sinus thrombosis and intracranial spread
How do you differentiate orbital from preseptal cellulitis?
Reduced visual acuity, proptosis, opthelmoplegia/pain with eye movements are NOT consistent with preseptal cellulitis
What is scleritis?
It is full-thickness inflammation of the sclera. It generally has a non-infective cause and typically causes a red, painful eye.
What is the most commonly associated condition with scleritis?
Rheumatoid arthritis
Also: SLE, Sarcoidosis and granulomatosis with polyangiitis
What is the management for Scleritis?
Urgent assessment and management by ophthalmologist with:
- NSAIDS
- Steroids
- Immunosuppression
What are some common causes of vitreous haemorrhage?
Proliferative diabetic retinopathy (over 50%)
Posterior vitreous detachment
Ocular trauma: The most common cause in children and young adults
What is Glaucoma?
Refers to optic nerve damage caused by a rise in intraocular pressure.
What is the cause of raised intraocular pressure in Glaucoma?
Blockage in the aqueous humour trying to escape the eye
What is the pathophysiology of open-angle glaucoma?
Gradual increase in resistance to flow through the trabecular meshwork. The pressure slowly builds within the eye.
What is the pathophysiology of acute angle-closure glaucoma?
The iris bulges forward and seals off the trabecular meshwork from the anterior chamber, preventing aqueous humour from draining.
Risk factors for open-angle glaucoma?
- Increasing age
- Family history
- Black ethnic origin
- Myopia (nearsightedness)
What is the presentation of Glaucoma?
Affects the peripheral vision first, resulting in gradual onset of peripheral vision loss (tunnel vision).
It can also cause:
- Fluctuating pain
- Headaches
- Blurred vision
- Halos around lights, particularly at night
What is the goldstandard way to measure intraocular pressure?
Goldmann applanation tonometry
When is treatment started for Glaucoma?
When the intraocular pressure is 24mmHg or above
What is the interventional treatment recommended for Open-Angle Glaucoma?
360 degree selective laser trabeculoplasty.
May delay or prevent the need for eye drops.
What is the first line medical treatment for open-angle glaucoma?
Prostaglandin analogue eye drops (e.g. latanoprost).
They increase uveoscleral outflow
What is the most common type of age-related macular degeneration?
Dry (also called non-neovascular) accounts for 90% of cases and wet is the other 10%
What are Drusen and what do they indicate?
Drusen are yellowish deposits of proteins and lipids between the retinal pigment epithelium and Bruch’s membrane.
A few small Drusen can be normal in Older patients.
Frequent and larger drusen can be an early sign of macular degeneration.
What are some of the risk factors for AMD?
- Older age
- Smoking
- Family History
- Cardiovascular disease (e.g. hypertension)
- Obesity
- poor diet, low in vitamins and high in fat
Presentation of AMD?
Visual changes of AMD tend to be unilateral with:
- Gradual loss of central vision
- Reduced visual acuity
- Crooked or wavy appearance to straight lines (metamorphopsia)
Which presents more acutely Wet or Dry AMD?
Wet AMD presents more acutely than dry AMD.
Vision loss can develop within days and progress to complete vision loss within 2-3 years. It often progresses to bilateral disease
What examination findings would you expect in AMD?
- Reduced visual acuity
- Scotoma (enlarged area of vision loss)
- Amsler grid test can be used to assess for the distortion of straight lines seen in AMD
- Drusen may be seen during fundoscopy
What is the management for dry AMD?
- No specific treatment
- Management involves monitoring and reducing the risk of progression by avoiding smoking, controlling BP and giving vitamin supplementation
What is the management of Wet AMD?
Anti-VEGF medications are used to treat wet AMD.
Vascular endothelial growth factor (VEGF) stimulates the development of new blood vessels in the retina.
What are some complications of diabetic retinopathy?
- Vision loss
- Retinal detachment
- Vitreous haemorrhage
- Rubeosis iridis (new blood vessel formation in the iris)
An elderly female smoker presents with reduced visual acuity, complaining of ‘blurred’ vision. On examination there is a central scotoma and fundoscopy reveals multiple drusen is a stereotypical history of:
Macular Degeneration
Cause of central retinal rein occlusion?
Glaucoma, Polycythaemia, Hypertension
What are the causes of central retinal artery occlusion?
Due to thromboembolism (from atherosclerosis) or artertits (e.g. Temporal arteritis)
What are the features of central retinal artery occlusion?
Includes an afferent pupillary defect and a ‘cherry red’ spot on a pale retina
What are the causes of vitreous haemorrhage?
Diabetes, Bleeding disorders, anticoagulants
What are the features of vitreous haemorrhage?
Sudden visual loss, dark spots
An elderly short-sighted man presents with flashing lights which are worse on eye movement and are located in the temporal visual field. He also describes some upper visual field loss ‘like a curtain coming down’ is a typical history of?
Retinal detachment
A young man presents with an acute, painful red eye associated with photophobia and blurred vision. On examination the pupil is small and irregular is a stereotypical history of?
Anterior uveitis
How does Herpes simplex keratitis most commonly present?
Most commonly presents with a dendritis corneal ulcer
- Red, painful eye
- Photophobia
- Epiphora
- Visual acuity may be decreased
- Fluorescein staining may show an epithelial ulcer
What are the features of Retinitis pigmentosa?
Features
- Night blindness is often the initial sign
- Tunnel vision due to loss of the peripheral retina (occasionally referred to as funnel vision)
- Fundoscopy: black bone spicule-shaped pigmentation in the peripheral retina, mottling of the retinal pigment epithelium
A woman is noted to have a unilateral mydriatic pupil which is minimally reactive to light is a stereotypical history of:
A Holmes-Adie pupil
A man who has a history of syphilis presents with bilateral small, irregular pupils which respond to accommodation but not to light. This is a stereotypical history of:
Argyll-Robertson pupil
What is the treatment of amblyopia?
To patch or penalise the good eye.
Treatment is often not effective after the age of 8
What is a cataract?
Characterized by an opacity in the lens which is typically caused by the denaturation of lens proteins
What are the risk factors for developing cataracts?
- Age
- Smoking
- Diabetes Mellitus
- Systemic Corticosteroid use
Others include: Alcohol consumption, UV exposure, trauma, previous eye surgery and radiation exposure
What are the symptoms of cataracts?
- Gradual painless loss of vision
- Difficulty reading/watching television
- Difficulty recognizing faces
- Haloes around lights, particularly at night
- In children, cataracts may present with a squint
What are the signs of cataracts?
- Loss of red reflex
- Brown/White appearance of the lens upon slit-lamp biomicroscopy
What is the first-line investigation for cataracts?
- Slit-lamp biomicroscopy
What is the management of Cataracts?
Surgical intervention also known as pseudophakia
What does Pseudophakia involve?
- Involves the removal of the lens affected by the cataract and its replacement with an artificial lens.
- Most common surgical technique is phacoemulsification which breaks down the lens using ultrasound waves.
What is the imaging modality of choice for orbital cellulitis?
- CT Orbit, sinuses and brain
What is the most serious complication of untreated bacterial keratitis?
- Corneal Perforation
- Corneal scarring
- Endophthalmitis
- Secondary Glaucoma
Which extraocular muscles is most frequently affected in thyroid eye disease?
Levator Palpebrae superioris
Where is the pathology if there is a Relative Afferent Pupillary defect?
- The Retina: Detachment
- The Optic Nerve: Optic Neuritis e.g. MS
What does Anisocoria worse in bright light indicate?
Implies a problem with the dilated pupil
What would you see on Fundoscopy in central retinal vein occlusion?
- Widespread hyperaemia
- Severe Retinal Haemorrhages - ‘stormy sunset’
What does an Argyll-Robertson pupil look like?
Bilateral small pupils which accomodate but do not respond to light.
Occurs due to damage to the Pretectal nuclei in the midbrain that control pupillary light reflex
What are the features of Optic Neuritis?
- Unilateral decrease in visual acuity over hours or days
- Poor Discrimination of colours
- Pain worsens on eye movements
- RAPD
- Central Scotoma
What is the diagnostic test for Optic Neuritis?
MRI of the brain and orbits with Gadolinium contrast is diagnostic in most cases
What is the management of Optic Neuritis
High-dose steroids
What do cotton wool spots represent?
They represent areas of retinal infarction
What is Stage 1 of the Keith-Wagener classification of hypertensive retinopathy?
Arteriolar narrowing and tortuosity
Increased light reflex - silver wiring
What is Stage 2 of the Keith-Wagener classification of hypertensive retinopathy?
Arteriovenous nipping
What is Stage 3 of the Keith-Wagener classification of hypertensive retinopathy?
Cotton-wool exudates
Flame and blot haemorrhages
These may collect around the fovea resulting in a ‘macular star’
What is Stage 4 of the Keith-Wagener classification of hypertensive retinopathy?
Papilloedema
What are cycloplegics?
They dilate the pupil which helps to relive pain and photophobia e.g. Atropine, cyclopentolate
Does Episcleritis or Scleritis blanch with Phenylephrine?
Episcleritis
How would you differentiate between scleritis and episcleritis?
Blanching
Painful/Not
Long-term complication of scleritis?
Catarscts
What is the management of episcleritis?
Self-resolving within 2 weeks can use artifical
What autoimmune condition is linked to scleritis?
RA
What is the difference between orbital and preorbital cellulitis
Orbital is infection of tissue behind the orbital septum whereas preorbital is anterior.
Orbital is more severe.
Proptosis in orbital severe
Reduced visual acuity in orbital
Risk factors for orbital cellulitis
Trauma
Dental Abscess
Facial Surgery
Sinus infection
Eyelashes
What is the Hutchinsons sign?
Tip of the nose involvement in VZV
What is the treatment for Herpes Zoster Ophthalmicus?
Urgent Review
Aciclovir
Topical Steroids
What is the most common type of trauma causing Retinal Detachment?
Rhegmatogenous retinal detachement
What is a Rhegmatogenous retinal detachement
Rhegmatogenous detachments are caused by a hole or tear in the retina that allows fluid to pass through and collect underneath the retina. This fluid builds up and causes the retina to pull away from underlying tissues.
What is the most common risk factor for CRVO?
Hypertension
Name 4 findings on fundoscopy in CRVO?
- Macular oedema
- Optic nerve head oedema
- Flame haemorrhages
- Venous tortuosity
- Cotton wool spots
= STORMY SUNSET
What is the name of the relative afferent pupillary defect seen in advanced CRVO?
Marcus Gunn pupil
Name the treatment for CRVO?
- Ophthalmology review
- Laser photocoagulation
- Intravetrial anti-VEGF injections
What are the features of Horner’s syndrome?
Miosis (small pupil)
Ptosis
Enophthalmos
Anhidrosis
What is the presentation of anterior uveitis?
Acutely painful red eye
Photophobia
Small pupil
Reduced visual acuity
Often associated with pus in the anterior chamber (A hypopyon)
What is the management for anterior uveitis?
Urgent Ophthalmology review
Cycloplegics e.g., atropine, cyclopentolate
Steroid eye drops
What is the presentation of retinal toxicity from hydroxychloroquine?
Development of a scotoma (visual blind spot) along with colour vision loss.
