Ophthalmology Flashcards
what is the most common cause of blindness in the UK
age related macular degeneration
which condition presents with ‘‘red desaturation’’
Optic neuritis
what is the management of a patient who presents to the GP with signs of Scleritis ?
Urgent referral to an ophthalmologist
how would you distinguish scleritis from episcleritis
scleritis : painful, episcleritis : not painful
which condition presents with a cherry red spot
central retinal artery occlusion
what is the management of wet ARMD? what is its mechanism
Vascular endothelial growth factor.
what is Amslers grid ? what condition does it test for ?
it checks for distortion of line perception. It may be useful in testing in patients with suspected age related macular degeneration.
what are the 4 key features of Horner’s syndrome ?
Miosis
Ptosis
Enophthalmos - sunken eye
anihydrosis - loss of sweating
which condition presents with Drusen formation
Dry age related macular degeneration
___________ presents with fixed dilated pupil with conjunctival injection
acute closed angle glaucoma
what is the definitive management of acute closed angle glaucoma
laser peripheral iridotomy
what is the diagnostic investigation for optic neuritis
MRI of brain and orbits with gadolinium contrast
give 4 differentials for a red eye
acute angle closure glaucoma
anterior uveitis
scleritis
conjunctivitis
subconjunctival haemorrhage
which condition presents with a small, fixed oval pupil and ciliary flush
anterior uveitis
which condition presents with sudden painless loss of vision and severe retinal haemorrhages on fundoscopy
central retinal vein occlusion
____________ is characterised by a dense shadow starting peripherally and progressing centrally
Retinal detachment
give 4 causes of sudden loss of vision
central retinal vein occlusion
central retinal artery occlusion
vitreous haemorrhage
retinal detachment
what is the management of orbital cellulitis
admission to hospital for IV antibiotics
which condition is associated with pus in the anterior chamber
anterior uveitis
how would you distinguish periorbital from orbital cellulitis
absence of :
painful movements
diplopia
visual impairment
in periorbital celluliitis
which investigation should be performed to assess for orbital cellulitis
Contrast enhanced CT of the orbits, sinuses and brain
what is the medical management of anterior uveitis
cyloplegics such as atropine and steroids drops
what is the management of a stye
regular warm steaming or soaking with a warm flannel
name 4 differentials for sudden painless loss of vision
central retinal vein occlusion
central retinal artery occlusion
vitreous haemorrhage
retinal detachment
give 3 management options for retinal detachment
Vitrectomy
scleral buckling
pneumatic retinopexy
which condition presents with a dense shadow that starts peripherally and progresses towards the central vision ?
retinal detachment
how would you distinguish dry macular degeneration from wet macular degeneration ?
-dry macular degeneration : drusen ( yellow round spots in Bruch’s membrane)
-Wet macular degeneration ( Choroidal neovascularization)
give 4 features of optic neuritis
Central Scotoma
Red saturation - colour vision affected
Acuity * decreased
Pain on eye movements
what is the management of proliferative retinopathy
Panretinal laser photocoagulation
what is Hutchinson’s sign? What condition does it present in ?
Rash on the tip / side of the nose indicating nasociliary involvement and strong RF for ocular involvement in Herpes Zoster Opthalmicus
what is the most serious complication of scleritis ?
Perforation of the sclera
which medications can precipitate acute angle closure glaucoma
adrenergic medications : Noradrenaline
Anti-cholinergic medications : Oxybutynin and Solifencin
TCA - Amitryptiline
what is the mechanism of acetazolamide
carbonic anhydrase inhibitor
what eye drops can be used in the management of acute angle closure glaucoma
Pilocarpine eye drops
__________ is a beta blocker that reduces the production of aqueous humour in acute angle closure glaucoma
Timolol
what produces aqueous humour?
Ciliary body
what drains the aqueous humour
trabecular meshwork
what is the normal intra-ocular pressure ?
10-21 mm Hg
how does visual loss in open angle glaucoma present
slow peripheral loss of vision leading to tunnel vision
name 2 ways to measure intra ocular pressure ? which one is gold standard
- Non contact tonometry
goldmann applanation tonometry ( gold standard)
what is amblyopia ? when does it occur ?
it is known as a lazy eye. It occurs when a squint ( exotropia) goes uncorrected
why has someone with open angle glaucoma got increased eyelash length
due to the use of prostaglandins such as latanoprost in the management of open angle glaucoma
name 3 side effects of prostaglandin analogues post management of open angle glaucoma
increased eyelash length
iris pigmentation
periocular pigmentation
what condition is likely when patient presents with bilateral grittiness and itchiness of the eyes
Blepharitis
in _________ the injected vessels are mobile when gentle pressure is applied on the sclera
episcleritis
what is the mechanism of vascular endothelial growth factor?
It stimulates the development of new blood vessels in the retina.
what is RAPD
relative afferent pupillary defect is when the affected and normal eye appear to dilate when the light is shone on the affected eye in the swinging light test
what are the causes of mydriasis ( large pupil)
third nerve palsy
Holmes Adie pupil
traumatic idroplegia
phaeochromocytoma
congenital
what is argyll robertson pupil and how does it present
clasic pupillary syndrome seen in neurosyphilis. The pupil typically accommodates but does not react.
Accommodation reflex present but Pupillary reflex absent
syphilis= prostitute who accommodates but doesnt react like argyll robertson
what is a holmes adie pupil
one of the differentials for a dilated pupil.
unilateral dilated pupil.
D for dilated. once the dilated pupil goes home it stays constricted.
once the pupil has constricted it remains small for an abnormally long time
slowly reactive to accommodation / very poorly to light
what are some features of adie’s tonic pupil
aniscoria( one pupil bigger than the other) is greater in bright light thus there is an issue with the dilated pupil and its a bility to constrict
what is the management of herpes zoster ophthalmicus
oral antivirals ( 7-10 days)
how do you manage anterior uveitis
urgent review by ophthalmology
cycloplegic eye drops ( atropine, cyclopentolate)
steroid eye drops
3 most common associations of optic neuritis
MS
Diabetes
syphilis
is glaucoma hereditary? how is that managed
strong hereditary component . annual glaucoma screening from 40 should be commenced
proliferative diabetic retinopathy is associated with which condition
T1DM
what is the management for herpes simplex keratitis
topical acicylovir
what do cotton wool spots represent in diabetic retonipathy
pre capillary arteriolar occlusion or retinal infarction
how to distinguish posterior vitreous detachment and retinal detachment
no loss of vision in posterior vitreous detachment
what is the most common bacterial cause of keratitis in contact lens wearers
pseudomonas aeroginosa
when would you refer someone for corneal foreign body to opthalmology
- suspicion of penetrating eye injury
-significant orbital / periocular trauma - chemical injury ( irrigation for 20-30 mins prior to referral)
organic component
red flags
what are the 4 stages of hypertensive retinopathy
- Arteriolar narrowing and tortuosity
Increased light reflex - AV nipping
- Cotton wool exudate, flame and blot haemorrhages
macular star - papilloedema
which conditions are blepharitis associated with
dry eye syndrome
seborrhoeic dermatitis
acne rosacea
what is a stye ?
It is an infection of the glands of the eyelids. it is an infection of the glands of zeis or glands of moll and presents as a painful swelling of upper eyelid and is managed with analgesia and hot compress.
Topical antibiotics are recommended if there is an associated conjunctivitis.
what is the most common underlying cause of a vitreous haemorrhage?
what are other causes
Proliferative diabetic retinopathy - most common
posterior vitreous detachment
ocular trauma
what investigations are performed for vitreous haemorrhage
dilated fundoscopy : may show haemorrhage in vitreous cavity
slit lamp examination : RBC’s in anterior vitreous
ultrasound : to rule out retinal tear/ detachment
fluorescein angiography : identification of neovascularization
Orbital CT: if there is open globe injury
what are the risk factors for retinal detachment
damn my eye aches constantly
diabetes mellitus
myopia
eye trauma
age
cataract surgery
which ocular conditions can herpes zoster opthalmicus cause
conjunctivitis
keratitis
episcleritis
anterior uveitis
what condition can affect swimmers wearing contact lenses
acanthamoeba keratitis
what medications are used in the management of open angle glaucoma and what is their mechanism
latanoprost - prostaglandin analogue
beta-blocker : reduces aqueous production
carbonic anhydrase inhibitors : reduce aqueous production
miotics ( pilocarpine) -muscarinic receptor agonist
what is the step-wise management of open angle glaucoma
- trabeculoplasty to those with IOP >- 24 mmHg
- prostaglandin analogues
- beta blockers
- carbonic anhydrase inhibitor eyedrops
what is the key presenting feature of anterior uveitis
small fixed oval pupil with ciliary flush
what is a severe complication of proliferative diabetic retinopathy
vitreous haemorrhage
what are the complications of pan retinal laser photocoagulation
noticeable reduction in visual fields
decrease in night vision
how would you distinguish between NPDR and PDR
NPDR : presents with micro-aneurysms, blot haemorrhage and cotton wool spots
PDR : retinal neovascularisation
what is the most common cause of a watery eye in an infant ? How does it present and how is it managed ?
Nasolacrimal duct obstruction presenting with an imperforate membrane. Mostly self resolving - some referred to ophthalmologist for probing
what is blepharitis? How does it present? How is it managed?
inflammation of the eyelid margins due to Meibomian gland dysfunction or seborrheic dermatitis / staphylococcus infection.
presents with bilateral grittiness and discomfort with sticky eyes in the morning and styes and chalazions
management includes hot compresses and lid hygiene which is the mechanical removal of debris from the lid margins.
cotton wool buds/ sodium bicarbonate
what are the risk factors for vitreous haemorrhage
CATS and Dogs
Coagulation disorders
Anti-coagulation
Trauma
Severe short sightedness
Diabetes
What are the risk factors for central retinal vein occlusion?
glaucoma
polycythaemia
HTN
what is the management of dry macular degeneration
high doses of beta-carotene, vitamin C and E and zinc
what are the risk factors for age related macular degeneration ?
advancing age - greatest risk factor
smoking
family history
what are the classical features of dry and wet ARMD
there is a gradual reduction of vision in dry ARMD whereas there is a more subacute reduction of vision in wet ARMD
difficulty in dark adaptation
visual hallucinations if Charles Bonnet syndrome is present
what are the signs of ARMD
There is distortion of line perception that can be noted on the Amsler grid
Drusen = dry ARMD on fundoscopy
red patches = wet ARMD on fundoscopy
what is the most important risk factor in Horner’s syndrome
smoking
how does a Pancoast tumour present ?
Horner’s syndrome + shoulder and arm pain due to brachial plexus invasion
what is the most common eye problem presenting to primary care? How does it present ? What are its types?
Conjunctivitis - presents with red sore eyes associated with a sticky discharge.
bacterial conjunctivitis presents with purulent discharge and eyes stuck together.
Viral conjunctivitis presents with serous discharge usually preceded by a viral URTI. Periauricular lymph nodes may be swollen.
how is infective conjunctivitis managed ?
generally self limiting (1-2 weeks)
chloramphenicol eye drops can be given / topical fusidic acid in pregnant women.
what advice should be given to contact lens users surrounding infective conjunctivitis
topical Fluoresceins
dont wear contact lenses
how should purulent eye discharge be associated in neonates
urgent eye discharge swabs to rule out chlamydia and gonococcus
what is associated with Holmes Adie syndrome
absent ankle/ knee reflexes associated with Holmes Adie pupil
how would you distinguish Argyll Robertson pupil from Holmes Adie pupil
Argyll Robertson pupil is generally small and often irregular and bilateral + associated with neuro-syphilis.
Holmes Adie is generally a unilateral dilated pupil.
what is the management of viral conjunctivitis
conservative management with cold compresses and good eye hygiene.
what is papilledema ? Is it unilateral or bilateral?
Optic disc swelling that is caused by increased ICP. It is almost always bilateral.
how does papilloedema present on fundoscopy
there is venous engorgement, blurring of the optic disc margin and loss of venous pulsation
Paton’s lines - concentral/radial retinal lines cascading from the optic disc
what are the causes of papilloedema?
space-occupying lesion: neoplastic, vascular
malignant hypertension
idiopathic intracranial hypertension
hydrocephalus
hypercapnia
what are the causes of central retinal artery occlusion?
thromboembolism ( from atherosclerosis)
arteritis ( temporal arteritis)
how is central retinal artery occlusion managed?
IV steroids - if temporal arteritis
complex management
what are the aims of treatment of acute angle glaucoma ?
reducing aqueous secretion and inducing pupillary constriction
what are the causes of tunnel vision
glaucoma
papilloedema
choroidoretinitis
retinitis pigmentosa
how does orbital cellulitis present ? How is it managed?
redness and swelling
severe ocular pain
visual disturbances
proptosis
ophthalmoplegia / painful eye movements
what are the risk factors for orbital cellulitis ?
childhood
previous sinus infection
lack of Hib vaccination
recent eyelid infection / insect bite
ear / face infection
what are the most common bacterial causes of orbital cellulitis
streptococcus
staphylococcus aureus
HiB
what is the management of orbital cellulitis
IV Abx
what is the diagnostic investigation for ARMD if neovascularisation is suspected
Fluorescein angiography
what is the initial investigation for ARMD
Slit lamp microscopy
what are the 2 key symptoms that patients complain of in vitreous haemorrhage
sudden painless loss of vision
dark spots in vision
red hue in vision
how is blurred vision investigated?
visual acuity with a Snellen chart
Pinhole occluders to check for refractive errors
what is a chalazion and how does it present
retention cyst of Meibomian gland presenting as a firm painless lump in the eyelid.
what is the difference between entropion and ectropion?
entropion : in turning of the eyelids
ectropion : out turning of the eyelids
how does herpes simplex keratitis present? What are its features? How is it managed ?
dendritic corneal ulcer
red painful eye
photophobia
decreased visual acuity
fluorescein stain : epithelial ulcer
management : urgent referral to ophthalmology
topical acyclovir
what are the risk factors for scleritis ?
RA
SLE
Sarcoidosis
Granulomatosis with polyangiitis
what are the features of scleritis ? How would you distinguish this from episcleritis ?
classically painful red eye
watering and photophobia
gradual decrease in vision
Injected vessels are generally mobile in episcleritis unlike scleritis and episcleritis is painless
how is a squint management
referral to ophthalmology where eye patch may be recommended
what is a suitable screening test for childhood squints?
corneal light reflection test
what are the 2 types of squints?
concomitant : imbalance in extra-ocular muscles leading to convergence
Paralytic : paralysis of extra-ocular muscles.
How does retinitis pigmentosa present ?
night blindness and tunnel vision
what points to a diagnosis in chronic open angle glaucoma
increased cup to disc ratio
what is the pathophysiology of cataract?
lens of the eye gradually opacifies and becomes cloudy which makes it difficult for the light to reach the back of the eye ( retina) causing blurred vision.
what is the most common cause of cataract? What are the other risk factors?
most common cause : ageing
other risk factors include :
smoking
alcohol
trauma
diabetes
steroids
hypocalcaemia
what are the signs and symptoms of cataract
reduced vision
faded colour vision
glare and halos
defect in red reflex
what is the management of cataract
non surgical : conservative/ glasses
surgical : dependent on patient choice and visual impairment
what are the complications of cataract surgery
Posterior capsule opacification: thickening of the lens capsule
Retinal detachment
Posterior capsule rupture
Endophthalmitis: inflammation of aqueous and/or vitreous humour
how does corneal abrasion present? How is it investigated and management?
eye pain
lacrimation
photophobia
foreign body sensation
decreased visual acuity
investigations : Fluorescein staining
management : topical antibiotic ( chloramphenicol_)
what is the action of latanoprost
increases uveoscleral outflow
what is the action of brimonidine ? what are its contraindications and adverse effects
Reduces aqueous production and increases outflow
Avoid if taking MAOI or tricyclic antidepressants
Adverse effects include hyperaemia
what is the action of carbonic anhydrase inhibitors ? What are its adverse effects
Reduces aqueous production
Systemic absorption may cause sulphonamide-like reactions
what is the action of miotics like pilocarpine? What are its adverse affects ?
increases uveoscleral outflow
Adverse effects included a constricted pupil, headache and blurred vision
what are three key features of central retinal artery occlusion
sudden, painless unilateral visual loss
relative afferent pupillary defect
‘cherry red’ spot on a pale retina
what is the main complication of ocular trauma
raised intra-ocular pressure causing risk to sight
what are the features of orbital compartment syndrome
eye pain/swelling
proptosis
‘rock hard’ eyelids
relevant afferent pupillary defect
what is the management of orbital compartment syndrome
urgent lateral canthotomy
what 2 investigations can be used to investigate acute angle closure glaucoma
tonometry and gonioscopy
what complications are those with scleritis most at risk of
Perforation of the globe
what are the risk factors for primary open angle glaucoma
Age
genetics
Afro-Caribbean ethnicity
myopia
HTN
diabetes mellitus
corticosteroids
what are the medications used in the management of acute angle closure glaucoma
pilocarpine, timolol, apraclonidine and IV Acetazolamide
how does endophthalmitis present
Painful, red eye following cataract surgery
what is normally the most common bacterial cause of keratitis
staph. aureus
how is keratitis generally managed
topical abx and cycloplegics like cyclopentolate
what is an example of anti vegf
bevacizumab and pegaptanib
how does anhydrosis determine site of lesion in Horner’s syndrome
head, arm, trunk = central lesion: stroke, syringomyelia
just face = pre-ganglionic lesion: Pancoast’s, cervical rib
absent = post-ganglionic lesion: carotid artery
what is diabetic maculopathy?
progressive eye disease due to diabetes affecting the macula - based on location causing blurred vision / blind spot
what type of cataract are the following associated with?
subcapsular : steroid use , allopurinol bit less
myotonic dystrophy : dot cataracts
myopia : nuclear cataracts
ocular trauma : nuclear cataract
