Ophthalmology Flashcards
what is affected in Holmes-Adie pupil?
the ciliary ganglion
can be because of infection
is the pupil constricted or dilated in Holmes-Adie?
dilated
causes of dilated pupil [5]
Holmes-Adie
Oculomotor nerve palsy
Cocaine, Amphetamines
atropine, tropicamide
Phaeochromocytoma
does Horner’s cause a constricted or dilated pupil?
constricted
[when you are horny, you aim for the constricted hole]
features of optic neuritis [5]
- unilateral decrease in visual acuity over hours or days
- poor discrimination of colours, ‘red desaturation’
- pain worse on eye movement
- relative afferent pupillary defect
- central scotoma
or CRAP
- central scotoma
- RAPD
- acuity loss
- painful eye movement
investigation for optic neuritis
MRI of the brain and orbits with gadolinium contrast
features of mild non proliferative diabetic retinopathy
1 or more microaneurysm
features of moderate non proliferative diabetic retinopathy [5]
- microaneurysms
- blot haemorrhages
- hard exudates
- cotton wool spots (‘soft exudates’ - represent areas of retinal infarction), - venous beading/looping
- intraretinal microvascular abnormalities (IRMA) less severe than in severe NPDR
features of severe non proliferative diabetic retinopathy
- blot haemorrhages and microaneurysms in 4 quadrants
- venous beading in at least 2 quadrants
- IRMA in at least 1 quadrant
features of proliferative diabetic retinopathy [3]
- retinal neovascularisation - may lead to vitrous haemorrhage
- fibrous tissue forming anterior to retinal disc
- more common in Type I DM, 50% blind in 5 years
treatment of maculopathy
VEGF inhibitors
treatment of proliferative diabetic retinopathy [3]
- panretinal laser photocoagulation
- VEGF inhibitors
- vitreoretinal surgery
complications of retinal photocoagulation [4]
- MAIN: decreased night vision (reduced rods in the periphery)
- macular oedema
- visual field reduction
- decreased visual acuity
causes of anhidrosis of face, arms and trunk [5]
where is the lesion?
central lesions
Stroke
Syringomyelia
Multiple sclerosis
Tumour
Encephalitis
causes of anhidrosis of the face [4]three Ts
where is the lesion?
preganglionic lesions
Pancoast’s tumour
Thyroidectomy
Trauma
Cervical rib
causes of postganglionic lesions that don’t cause anhidrosis [4C]
Carotid artery dissection
Carotid aneurysm
Cavernous sinus thrombosis
Cluster headache
Differentiating orbital from preseptal cellulitis [3]
- reduced visual acuity
- proptosis
- ophthalmoplegia/pain with eye movements
are NOT consistent with preseptal cellulitis
Main imaging for orbital cellulitis
CT with contrast of orbits, sinuses, brain
complications of orbital cellulitis [2]
cavernous sinus thrombosis and intracranial spread and abscess
what structures are affected in orbital cellulitis
result of an infection affecting the fat and muscles posterior to the orbital septum, within the orbit but not involving the globe.
features of vitreous haemorrhage [3]
- PAINLESS visual loss or haze (commonest)
- red hue in the vision
- floaters or shadows/dark spots in the vision
patient risk factors in vitreous haemorrhage [3]
- proliferative diabetic retinopathy (over 50%)
- posterior vitreous detachment
- ocular trauma: the most common cause in children and young adults
cause of sudden vision loss in diabetics
vitreous haemorrhage
how is a squint (strabismus) detected
corneal light reflection test
how is a squint in a child managed
referral to ophthalmologist
what condition is treated with an eye patch
amblyopia (lazy eye)
key feature on fundoscopy of central retinal artery occlusion [3]
- cherry red spot at fovea
- atheromatous plaques
- globally pale retina
differential for sudden painless loss of vision [6] NEEDS EDIT
CRVO
CRAO
vitreous haemorrhage
retinal detachement
ischaemic optic neuropathy
occipital stroke
ischaemic/vascular (e.g. thrombosis, embolism, temporal arteritis etc). This includes recognised syndromes e.g. occlusion of central retinal vein and occlusion of central retinal artery
vitreous haemorrhage
retinal detachment
retinal migraine
how long does amaurosis fugax last
resolves spontaneously in minutes
features on fundoscopy in central retinal vein occlusion [6]
ischaemic:
* extensive, severe flame haemorrhages- ‘stormy sunset’
* cotton wool spots
* widespread hyperaemia
* tortuous dilated vessels
* retinal oedema
* hard exudates
non-ischaemic
* haemorrhage in all 4 quadrants
MoA of prostaglandin analogues e.g. latanoprost in the treatment of glaucoma
increases uveoscleral outflow
MoA of beta blockers in the treatment of glaucoma
reduces aqueous production
MoA of carbonic anhydrase inhibitors in the treatment of glaucoma
Reduces aqueous production
MoA of sympathomimetics e.g brimonidine in the treatment of glaucoma
Reduces aqueous production and increases outflow
MoA of miotics e.g. pilocarpine in the treatment of glaucoma
Increases uveoscleral outflow
first line treatment for glaucoma with an IOP of ≥ 24 mmHg
360° selective laser trabeculoplasty (SLT
2nd line treatment of primary open angle glaucoma
prostaglandin analogues e.g. latanoprost
3rd line treatment of primary open angle glaucoma [3]
beta-blocker eye drops
carbonic anhydrase inhibitor eye drops
sympathomimetic eye drops
treatment of refractory glaucoma
trabeculectomy
example of sympathomimetic
MoA
brimonidine
alpha2-adrenoceptor agonist
example of Prostaglandin analogue
latanoprost
example of carbonic anhydrase inhibitor [2]
- Dorzolamide
- Acetozolamide
example of miotic
MoA
pilocarpine
muscarinic agonist
which part of the visual field does glaucoma affect most
peripheral
leads to tunnel vision
what eyesight is at risk of primary open angle glaucoma
myopia
what happens to the optic disc in primary open angle glaucoma [2]
optic disc cupping and pallor
what sort of eyesight is at risk of retinal detachment
myopia
how should a patient with a new onset of flashers and floaters be managed
referred urgently (<24 hours) to an ophthalmologist for assessment with a slit lamp and indirect ophthalmoscopy for pigment cells and vitreous haemorrhage
what does Amsler grid testing show in age related macular degeneration
distortion of line perception
compare the reduction of visual acuity in the two types of age related macular degeneration
gradual in dry ARMD, fluctuating quality of vision
subacute in wet ARMD
key feature in dry ARMD
drusen (yellow spots under the retinaantioxidant)
key feature in wet ARMD
neovascularisation
difference in symptoms between scleritis and episcleritis
no pain in episcleritis
treatment of acute angle-closure glaucoma [4]
- a direct parasympathomimetic (e.g. pilocarpine, causes contraction of the ciliary muscle → opening the trabecular meshwork → increased outflow of the aqueous humour)
- a beta-blocker (e.g. timolol, decreases aqueous humour production)
- an alpha-2 agonist (e.g. apraclonidine, dual mechanism, decreasing aqueous humour production and increasing uveoscleral outflow)
- intravenous acetazolamide
definitive treatment of acute angle-closure glaucoma
laser peripheral iridotomy
causative agent in contact lens keratitis
Pseudomonas
causative agent in keratitis
staph aureus
amoebic cause of keratitis
acanthamoebic keratitis
increased incidence if eye exposure to soil or contaminated water
4 features of keratitis [4]
red eye: pain and erythema
photophobia
foreign body, gritty sensation
hypopyon may be seen
management of keratitis [3]
- stop using contact lens until the symptoms have fully resolved
- topical antibiotics: typically quinolones are used first-line
- cycloplegic for pain relief e.g. cyclopentolate
Mydriatic drops are a known precipitant of…
acute angle-closure glaucoma
cause of flashers and floater [2]
vitreous haemorrhage
vitreous detachment (which often precedes retinal detachment)
cause of central scotoma
optic neuritis
metabolic cause of cataract
hypocalcaemia
what eye sight is at risk of acute angle closure glaucoma
hypermetropia
what happens to the cup to disc ration in chronic open angle glaucoma
increased
which eye drops put you at risk of corneal ulcer
steroid
what is seen on fundoscopy in CRVO
widespread haemorrhages, well demarcated red patches
are vein occlusions associated with flashes and floaters
NO
triad of Horner’s syndrome
miosis (small pupil)
ptosis (right lid lag)
enophthalmos (a sunken eye appearance due to narrowing of the palpebral fissure)
+/- anhydrosis
what MSK symptom can a Pancoast tumour present with
shoulder pain
bilateral grittiness cause
blepharitis
management of blepharitis
- softening of the lid margin using hot compresses twice a day
- ‘lid hygiene’ - mechanical removal of the debris from lid margins
- cotton wool buds dipped in a mixture of cooled boiled water and baby shampoo is often used
- an alternative is sodium bicarbonate, a teaspoonful in a cup of cooled water that has recently been boiled
- artificial tears may be given for symptom relief in people with dry eyes or an abnormal tear film
what is Hutchinson’s sign and what is it predictive of
rash on the tip or side of the nose.
Indicates nasociliary involvement and is a strong risk factor for ocular involvement
Herpes zoster ophthalmicus complications [3]
ocular: conjunctivitis, keratitis, episcleritis, anterior uveitis
ptosis
post-herpetic neuralgia
treatment of HZO
oral antiviral treatment for 7-10 days
ideally started within 72 hours
intravenous antivirals may be given for very severe infection or if the patient is immunocompromised
review by ENT if ocular involvement
what is an entropion
in turning of eye lid
what is an ectropion
out turning of eye lid
adverse effect of prostaglandin analogues [2]
brown iris pigmentation
eye lash elongation
which patients should avoid taking sympathomimetics [2]
Avoid if taking MAOI or tricyclic antidepressants
adverse effect includes hyperaemia
adverse effects of miotics like pilocarpine [3]
Adverse effects included a constricted pupil, headache and blurred vision
Keith-Wagener classification of hypertensive retinopathy: stage 1
Arteriolar narrowing and tortuosity
Increased light reflex - silver wiring
Keith-Wagener classification of hypertensive retinopathy: stage 2
Arteriovenous nipping
Keith-Wagener classification of hypertensive retinopathy: stage 3 [3]
Cotton-wool exudates
Flame and blot haemorrhages
These may collect around the fovea resulting in a ‘macular star’
Keith-Wagener classification of hypertensive retinopathy: stage 4
Papilloedema
what is seen in Marcus Gunn pupil (RAPD)
the affected and normal eye appears to dilate when light is shone on the affected
where is the lesion in RAPD
anterior to optic chiasm i.e. optic nerve or retina
what is a Holmes Adie Pupil associated with [2]
most commonly seen in women
reduced lower limb reflexes
3 causes of RAPD
optic neuritis
optic atrophy
retinal disease
cause of afferent pupil defect
optic nerve lesion
cause of efferent pupil defect
3rd nerve palsy
causes of fixed and dilated pupil [4]
acute glaucoma
surgical third nerve palsy
iris trauma
mydriatics e.g. tropicamide
which pupillary defect has a sluggish accomodation
Holmes Adie
which pupillary defect is seen in syphilis and DM
argyll-robertson
which ocular muscles are innervated by CNVI and CNIV
SO4
LR6
red flag symptoms for red eyes [4]
photophobia
poor vision
fluorescein staining
abnormal pupil
treatment of anterior uveitis [2]
urgent review by ophthalmology
prednisolone and cyclopentolate
treatment of scleritis
urgent referral <24 hours
oral NSAIDs are typically used first-line
oral glucocorticoids may be used for more severe presentations
immunosuppressive drugs for resistant cases (and also to treat any underlying associated diseases)
differential for sudden vision loss [5]
- anterior ischaemic optic neuropathy
- optic neuritis
- vitreous haemorrhage
- retinal detachment
- retinal vessel occlusion
what causes anterior ischaemic optic neuropathy
optic nerve damage due to posterior ciliary artery blockage
3 features of AION
visual loss
RAPD
visual field defect
3 features on fundoscopy in AION
pale
swollen optic disc
peripheral microaneurysm
management of optic neuritis
methylprednisolone IV 72 hours
investigation of vitreous haemorrhage
B-scan US
treatment of large vitreous haemorrhage
victrectomy
smaller ones–> spontaneous reabsorption
main risk factor for vitreous haemorrhage
diabetes
aetiology of retinal detachment
holes in the retinal allow fluid to separate the retina from the pigmented epithelium
3 causes of retinal detachment
Diabetes
cataract surgery
trauma
4 signs of retinal detachment
- flashers
- floaters
- field loss (veil down)
- fall in acuity
all painless
fundoscopy features in retinal detachment
grey, opalescent retina
balloons forward
difference in visual loss between central retinal artery and branch retinal artery occlusion [2]
total vs partial loss of vision
RAPD +ve vs RAPD -ve
management of arterial retinal occlusion
eyeball massage
aetiology of venous retinal vessel occlusion [4]
diabetes
hypertension
hypercoaguable state
glaucoma
different between central retinal vein and branch retinal vein occlusion
total/moderate loss of vision +/- RAPD
vs
asymptomatic unless macula involved, vision loss in affected area only
investigation of venous retinal vessel occlusion
fluorescein angiography
common and rare causes of gradual loss of vision
common:
diabetes
open-angle glaucoma
ARMD
cataracts
rare:
retinitis pigments
hypertension
optic atrophy
investigations of ARMD
Amsler grid and fundoscopy looking for neovascularisation
slit lamp microscopy upon referral
fluoroscein angio for wet ARM
optic coherence tomography
management of ARMD [3]
photodynamic therapy
VEGF inhibitors
anti-oxidant vitamins and zinc
management of wet ARMD
anti VEGF
laser photocoagulation does slow progression of ARMD
management of dry ARMD
zinc+ vitamin A,C,E, beta-carotene supplementation (antioxidant)
how to best slow progression of ARMD
stop smoking
drugs that reduce aqueous production
BAC
- beta blocker
- alpha 2 agonists
- carbon anhydrase inhibit
drugs that increase uveoscleral outflow
Ps
- pilocarpine
- prostaglandin analouges
management of proliferative retinopathy
pan-retinal photocoagulation
management of maculopathy
grid/focal retinal photocoagulation
causes of cataracts [4]
age
steroids
diabetes
smoking
investigations for cataracts
tonometry
fundoscopy shows darkened red reflex
acuity test
BMs
complication after cataracts surgery
posterior capsular opacification
treated with laser surgery
conditions with blurred optic disc margin
optic neuritis and papilloedema
inheritance of the most common form of retinitis pigmentosa
which has the best prognosis and the worst prognosis
AR
best: AD
worst: x-linked
features of retinitis pigmentosa
night blindness
tunnel vision
blind by mid-30s
Friedrichs ataxia
features of retinoblastoma
strabismus
leukocoria (white eye with no red reflex)
management of retinoblastoma
depending on size:
- enucleation
- chemo
- radio
where is the abscess in chalazion
Meibomian gland
what makes a ptosis a true ptosis
LPS weakness
causes of blepharitis
seborrhoeic dermatitis
staphylococcus
causes of bilateral ptosis
MG
congenital
myotonic dystrophy
senile
what is lagopthalmos
difficulty closing lid over the globe leading to exposure keratitis
treat with lubrication and tarsorrhaphy
what is pinguecula
yellow vascular nodules on either side of the cornea
what is pterygium
yellow vascular nodes the grow over the cornea affecting vision
management of orbital cellulitis
urgent referal
IV abx e.g. cefuroxime
3 causes of exopthalmos
Graves
orbital cellulits
trauma
2 types of strabismus
Concomitant (common) – imbalance in extraocular muscles
Paralytic (rare) – paralysis of extraocular muscles
what is a carotid cavernous fistula
carotid aneurysm rupture leading to reflux of blood into cavernous sinus
leads to eye bruit, pulsate exophthalmos
treated with endovascular repair
what direction diplopia does a CN IV palsy cause
downwords
what direction diplopia does CN VI cause
horizontal
mx: botulinum toxin
most common type of squint in children
esotropia/convergent
cause: hypermetropia
haloes + eye pain
acute glaucoma
causes of haloes [3]
cataract
corneal oedema
acute glaucoma
1st line treatment of allergic conjunctivitis
2nd line
antihistamine
2nd: topical cromoglycate (mast cell stabiliser)
treatment of trachoma
tetracycline
treatment of onchocerciasis (river blindness)
ivermectin
treatment of xerophthalmia and keratomalacia
vitamin A
this Vit A def
anti muscarinic drugs
examples [2]
what effects do they have
tropicamide (3 hr)
cyclopentolate (24 hr, paeds)
all are mydriatics, cycloplegics paralyse the iris in order to dilate.
effects:
- pupil dilatation
- loss of light reflex
- blurred vision
features of scleritis
red eye
classically painful (in comparison to episcleritis), but sometimes only mild pain/discomfort is present
watering and photophobia are common
gradual decrease in vision
conditions associated with scleritis
RA and SLE
what is anterior uveitis the inflammation of
iris and ciliary body (anterior portion of the uvea)
what is blepharitis
inflammation of the eyelid margins. It may due to either meibomian gland dysfunction
features of anterior uveitis
acute onset
ocular discomfort & pain (may increase with use)
pupil may be small +/- irregular due to sphincter muscle contraction
photophobia (often intense)
blurred vision
red eye
lacrimation
ciliary flush: a ring of red spreading outwards
hypopyon; describes pus and inflammatory cells in the anterior chamber, often resulting in a visible fluid level
visual acuity initially normal → impaired
treatment of central retinal artery occlusion
Management is difficult and the prognosis is poor
any underlying conditions should be identified and treated (e.g. intravenous steroids for temporal arteritis)
if a patient presents acutely then Intraarterial thrombolysis may be attempted but currently, trials show mixed results.
Red eye - glaucoma or uveitis?
glaucoma: severe pain, haloes, ‘semi-dilated’ pupil
uveitis: small, fixed oval pupil, ciliary flush
