Ophthalmology Flashcards
Eye with
- Reduced vision
- Pain
- Corneal opacity + epithelial erosion
- Hyperaemia
- Hypolacrimation
+/- mucopurulent discharge, hypopyon
Diagnosis, causes:
Keratitis
neurotropic keratopathy, rheumatoid arthritis, dry eye, corneal infection (Staph, Strep, HSV, VZV, EBV, CMV), FB/contact lens abrasion
Eye with:
- Pain - not relieved with tetracaine
- Photophobia
- Decreased vision
- Watery discharge
- Hyperaemia
- Miosis
Diagnosis, causes, slit lamp findings, management:
Iritis/Anterior uveitis
Blunt trauma, syphilis, herpesvirus, TB, VZV, toxoplasmosis, spondyloarthropathies (HLA-B27), sarcoid, juvenile RA, ulcerative colitis, Kawasaki, Behcet, Reiter’s
- Ciliary/perilimbal injection
- Cells and flare
- Hypopyon
- Keratic precipitates
Discuss with opthlamology - steroid and dilating drops
Consider bloods: CBC, ANA, HLA-B27, ESR, syphilis screen, chlamydia/gonorrhoea
Eye with:
- Violaceous hue
- Globe tender to touch
- Focal scleral injection
- Referred piercing pain to jaw/forehead
+/- corneal ulcers
Diagnosis, cause
Scleritis
Idiopathic, HSV, TB, syphilis, collagen vascular diseases, Wegener’s granulomatosis, sarcoidosis, RA, reactive arthritis, IBD
Eye with:
- Mild pain
- Isolated mild focal injection
- Acute onset
- Normal visual acuity
Diagnosis, cause
Episcleritis
Idiopathic, may be associated with collagen vascular disease
Eye with:
- well demarcated bright red patch on sclera
- Normal vision
- No corneal involvement
Diagnosis, cause
Subconjunctival haemorrhage
Trauma, valsalva, coughing, bleeding disorder, HTN, Kaposi sarcoma
Differentiating between allergic, viral, bacterial conjunctivitis
Management
Allergic - Atopy/hayfever, itch, grittiness, watery discharge
Viral - preceding URTI, watery discharge
Bacterial - Mucopurulent discharge
Cold compress
Artificial tears
Good hand hygiene
If bacterial - antibacterial drops if still ongoing after 2-3 days good hand hygiene
High risk conjunctivitis and treatment
Neonates <28 days
- Suspect maternal STI, acute referral to paeds, treat with erythromycin or azithromycin
- Possible pneumonia with neonatal chlamydia
Chlamydia conjunctivitis (suspect if pre auricular lymph node swelling)
- Opthalmology advice, treat with doxycycline, contact tracing
- Risk for trachoma
Gonorrhoea conjunctivitis (suspect if acute onset profuse purulent discharge)
- Acute ophthalmology referral, contact tracing
Acute referral for all with corneal involvement
Preseptal vs orbital cellulitis symptoms + management
Orbital septum - tissue from orbital rim to eyelids
Preseptal cellulitis - redness, minimal eyelid swelling
Staphylococcus aureus, Streptococcus pyogenes, Haemophilus influenzae - augmentin
Orbital cellulitis - redness, eyelid swelling, painful ocular movement, ptosis, proptosis, diplopia, pupillary changes, visual changes in late stage
- Acute ophthalmology referral
Herpes zoster ophthalmicus symptoms
Flu-like prodrome 1/52
Rash on forehead - erythema macules > papules and vesicles > pustules
Photophobia suggests corneal involvement
Hutchinson’s sign - vesicular lesions on tip of nose
Eye - blepharitis + ptosis, reduced visual acuity, redness (episcleritis)
Secondary bacterial infection
Cornea - punctate epithelial keratitis (day 1-2) > dendritic keratitis (1/52) > anterior stromal keratitis (weeks) > deep stromal keratitis (months) > neurotropic keratopathy (years)
Uveitis (2 weeks-years)
Acute retinal necrosis, optic neuritis, oculomotor palsy
Management of herpes zoster ophthalmicus
Ophthalmology advice
Analgesia
Valaciclovir 1g tds
- in immunocompromised until 2 days after last lesion crusted
Avoid contact with pregnant women, immunocompromised people, children naive to chickenpox until last lesion has crusted
Risks for acute angle closure glaucoma
Increasing age
Female
Hypermetropia
Asian
FHx angle closure glaucoma
Anticholinergics
Symptoms + signs of acute angle closure glaucoma
**Acute onset unilateral painful red eye
**Decreased vision
Nausea and vomiting
First onset at low lighting
Unilateral headache
Halos around vision
Photophobia
**Mid dilated, poorly reactive pupil
Rock hard globe + increased IOP (normal 12-21mmHg)
**Hazy cornea
Management of acute angle closure glaucoma
Urgent ophthalmology referral
Sit upright to reduce IOP
Well lit room to prevent pupil dilation
Ophthalmology management:
Acetazolamide 500mg PO/IV
500mL Mannitol 15% IV
Topical beta-blocker + cholinergic
Laser iridotomy
High risk mechanisms for penetrating eye injury
Exposure to fast projectile, sharp, penetrating objects
Metal on metal exposure (hammering, grinding)
MVA
Fall while holding sharp object
Airguns/firearms
Slit lamp signs of penetrating eye injury
Uveal/retinal prolapse
Vitreous extrusion
Hyphaema
Irregular/peaked pupil shape
Deep or shallow anterior chamber
Subconjunctival haemorrhage
Seidel positive
Management of penetrating eye injury
Refer acutely
Do no apply pressure
- Apply rigid protective cover
Do no apply eye drops
Do not force eyelid open
Do no attempt FB removal
Oral analgesia
Antiemetic
Update tetanus
NBM
Consider abx if delayed transfer
Injuries in blunt eye trauma
Hyphaema - gross/microscopic
Traumatic iritis
Traumatic mydriasis (damage to pupillae sphincter muscles)
Eyelid, lacrimal apparatus injury
Orbital blow out fracture
Globe rupture
Retrobulbar haematoma
Retinal detachment
Iridodialysis - tear of iris root
Lens dislocation
Vitreous haemorrhage
Commotio retinae (traumatic retinopathy) - oedema in retina
Structures injured in medial eye lid lacerations
How to investigate?
Superior/inferior lacrimal punctums and lacrimal canals
Lacrimal sac and nasolacrimal canal
Instill fluorescein in eye, look for dye in the wound
What to avoid in suturing of lid laceration?
Removal of sutures time?
Patient advice?
Avoid vertical tension - risk of lid retraction, ectropion, lagophthalmos (inability to close eyelids completely)
Lid sutures - 4-6 days
Lid margins + periorbital skin - 5-7 days
Limit sun + water exposure
No makeup 2-3 weeks
Referral criteria for lid lacerations
Within 6-8mm of medial canthus, or medial to punctum
Involving inner surface
Involving lid margin
Deep to tarsal plate
Tissue avulsion
Ptosis (levator palpebrae involvement)
Orbital fat exposure (orbital septum, levator palpebrae)
Management of chemical ocular burns
Alkali worse than acidic
Oral analgesia + repeated tetracaine
Irrigate ASAP - deterioration within seconds
At least 1L Hartmanns > NaCl/sterile water
Evert eyelid, sweep fornices
Ophthalmology advice
Urgent assessment for alkali burns, hazy cornea, corneal defects
UV keratoconjunctivitis
Cause, presentation, management
Excess UV-B and UV-C light exposure to eye
30mins-24hrs post exposure - photophobia, FB sensation, watering, conjunctivitis, blurred vision
Punctate epithelial staining on fluroescein
Self-limiting 24-48 hours - cold compress, sunglasses
Causes of transient bilateral vision loss
Papilloedema
- Elevated ICP, haemorrhages, tumours, venous obstruction, infection, hydrocephalus.
- Refer for neuroimaging/LP
Vertebrobasilar insufficiency
- Reduced posterior cerebral blood flow
- embolic disease, atherosclerosis, hypercoagulability, hyperviscosity, vasculitis
- Good control of cardiac/vascular risk factors
Migraine
- Retinal vasospasm
- Headache within 60 mins of vision loss
- Do not use triptans, ergots, beta blockers
Management of transient unilateral vision loss
Amaurosis fugax
Carotid artery disease, atherosclerosis, embolic disease, hypercoagulability, hyperviscosity, arteritis, cocaine
Manage as TIA
Refer acutely for USS carotids, MRA/CTA of neck, echocardiogram
Management of cardiac risk factors
3 types of retinal detachment
Symptoms - flashes, floaters, reduced peripheral vision, blurred vision
Rhegmatogenous (most common)
- vitreoretinal traction
- Risks - age, myopia, trauma, cataract surgery
- Surgical management
Tractional
- Fibrosis from prev retinal tears, surgery, trauma, proliferative retinopathy
- Surgical excision of fibrosis
Exudative (serous)
- Inflammation (sarcoid uveitis), severe acute HTN, neoplasm
- Manage underlying condition
2 causes of painless unilateral persistent vision loss, various severity
Retinal artery occlusion
- Embolism atherosclerosis, giant cell arteritis, hypercoagulability, collagen vascular disease
Retinal vein occlusion
- venous stasis > oedema, haemorrhage, ischaemia
- Embolism, atherosclerosis, hypercoagulability, collagen vascular disease, glaucoma
Manage HTN, hyperlipidaemia, smoking cessation, diabetes.
Progressive unilateral vision loss over days, pain with eye movements, reduced light intensity and colour brightness
Diagnosis? Cause?
Optic neuritis
Middle aged women
Demyelinating disease (MS), infection (syphilis, Lyme, viral), granulomatous (sarcoidosis)
Refer acutely for neuro-imaging, IV steroids
Painless vision loss, altitudinal visual defect, reduced colour vision
2 types that can cause these symptoms?
Anterior ischaemic optic neuropathy
- Unilateral
- Idiopathic, nocturnal hypotension, abnormal autoregulation of optic nerve blood flow.
- Giant cell arteritis
- Risk factors - atherosclerosis, HTN, smoking, diabetes, sleep apnoea, amiodarone, phosphodiesterase inhibitors (sildenafil)
Posterior ischaemic optic neuropathy
- Unilateral or bilateral
- Intraoperative hypotension, anaemia, prolonged Trendelenburg, lengthy abdominal/cardiac/spine surgeries
- Risks - atherosclerosis
