Ophthalmology Flashcards

Question

Corneal abrasions -give 5 features

Answer 1

Corneal abrasions refer to any defect of the corneal epithelium and most commonly come about from a recent history of local trauma (e.g. fingernails, branches). Features -eye pain -lacrimation -photophobia -foreign body sensation and conjunctival injection -decreased visual acuity in the affected eye

Answer 2

Investigation fluorescein staining examination typically reveals a yellow-stained abrasion (representative of the de-epithelialized surface) which is usually visible to the naked eye visualisation is enhanced by the use of a cobalt blue filter (available on an ophthalmoscope) or a Wood's lamp Management a topical antibiotic is recommended for these patients in order to prevent secondary bacterial infection.

Answer 3

A corneal ulcer describes a defect in the cornea, typically secondary to an infective cause. The term corneal abrasion is typically used for corneal defects secondary to physical trauma. Risk factors -contact lens use -vitamin A deficiency: a particular problem in the developing world

Answer 4

Features -eye pain -photophobia -watering of the eye -focal fluorescein staining of the cornea

Answer 5

Keratitis describes inflammation of the cornea. Microbial keratitis is not like conjunctivitis - it is potentially sight threatening and should therefore be urgently evaluated and treated.

Answer 6

Causes bacterial -typically Staphylococcus aureus -Pseudomonas aeruginosa is seen in contact lens wearers fungal amoebic acanthamoebic keratitis -accounts for around 5% of cases -increased incidence if eye exposure to soil or contaminated water -pain is classically out of proportion to the findings parasitic: onchocercal keratitis ('river blindness') Remember, other factors may causes keratitis: -viral: herpes simplex keratitis -environmental photokeratitis: e.g. welder's arc eye exposure keratitis -contact lens acute red eye (CLARE)

Answer 7

Features -red eye: pain and erythema -photophobia -foreign body, gritty sensation -hypopyon may be seen

Answer 8

Referral contact lens wearers assessing contact lens wearers who present with a painful red eye is difficult an accurate diagnosis can only usually be made with a slit-lamp, meaning same-day referral to an eye specialist is usually required to rule out microbial keratitis

Answer 9

Management -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 Complications may include: -corneal scarring -perforation -endophthalmitis -visual loss

Answer 10

Herpes simplex keratitis most commonly presents with a dendritic corneal ulcer. Features -red, painful eye -photophobia -epiphora -visual acuity may be decreased -fluorescein staining may show an epithelial ulcer

Answer 11

Management -immediate referral to an ophthalmologist -topical aciclovir

Answer 12

Features -eye pain -foreign body sensation -photophobia -watering eye -red eye

Answer 13

Indications for referral to ophthalmology -Suspected penetrating eye injury due to high-velocity injuries (e.g. drilling, lawn moving or hammering) or sharp objects (e.g. as glass, knives, pencils or thorns) -Significant orbital or peri-ocular trauma has occurred. -A chemical injury has occurred (irrigate for 20-30 mins before referring) -Foreign bodies composed of organic material (such as seeds, soil) should be referred to ophthalmology as these are associated with a higher risk of infection and complications -Foreign bodies in or near the centre of the cornea -Any red flags e.g. severe pain; irregular, dilated or non-reactive pupils; significant reduction in visual acuity.

Answer 14

Herpes zoster ophthalmicus (HZO) describes the reactivation of the varicella-zoster virus in the area supplied by the ophthalmic division of the trigeminal nerve. It accounts for around 10% of case of shingles. Features -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

Answer 15

Management 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 -topical antiviral treatment is not given in HZO topical corticosteroids may be used to treat any secondary inflammation of the eye ocular involvement requires urgent ophthalmology review

Answer 16

Complications -ocular: conjunctivitis, keratitis, episcleritis, anterior uveitis -ptosis -post-herpetic neuralgia

Answer 17

Hyphema (blood in the anterior chamber of the eye) - especially in the context of trauma warrants urgent referral to an ophthalmic specialist for assessment and management. The main risk to sight comes from raised intraocular pressure which can develop due to the blockage of the angle and trabecular meshwork with erythrocytes. Strict bed rest is required as excessive movement can redisperse blood that had previously settled; therefore high-risk cases are often admitted. Even isolated hyphema will require daily ophthalmic review and pressure checks initially as an outpatient.

Answer 18

An assessment should also be made for orbital compartment syndrome, e.g. secondary to retrobulbar haemorrhage. This is true ophthalmic emergency features -eye pain/swelling -proptosis -'rock hard' eyelids -relevant afferent pupillary defect management -urgent lateral canthotomy (before diagnostic imaging) to decompress the orbit

Answer 19

Sudden loss is a frightening symptom for patients. It may represent an ongoing issue or only be temporary. The term transient monocular visual loss (TMVL) describes a sudden, transient loss of vision that lasts less than 24 hours.

Answer 20

The most common causes of a sudden painless loss of vision are as follows: -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

Answer 21

Ischaemic/vascular -often referred to as 'amaurosis fugax' wide differential including large artery disease (atherothrombosis, embolus, dissection), small artery occlusive disease (anterior ischemic optic neuropathy, vasculitis e.g. temporal arteritis), venous disease and hypoperfusion -may represent a form of transient ischaemic attack (TIA). It should therefore be treated in a similar fashion, with aspirin 300mg being given a-ltitudinal field defects are often seen: 'curtain coming down' -ischaemic optic neuropathy is due to occlusion of the short posterior ciliary arteries, causing damage to the optic nerve

Answer 22

Central retinal vein occlusion -incidence increases with age, more common than arterial occlusion -causes: glaucoma, polycythaemia, hypertension -severe retinal haemorrhages are usually seen on fundoscopy

Answer 23

Central retinal vein occlusion (CRVO) is a differential for sudden painless loss of vision. Risk factors -increasing age -hypertension -cardiovascular disease -glaucoma -polycythaemia

Answer 24

Features -sudden, painless reduction or loss of visual acuity, usually unilaterally fundoscopy -widespread hyperaemia -severe retinal haemorrhages - 'stormy sunset' A key differential is branch retinal vein occlusion (BRVO) - this occurs when a vein in the distal retinal venous system is occluded and is thought to occur due to blockage of retinal veins at arteriovenous crossings. It results in a more limited area of the fundus being affected.

Answer 25

Management -the majority of patients are managed conservatively indications for treatment in patients with CRVO include: -macular oedema - intravitreal anti-vascular endothelial growth factor (VEGF) agents -retinal neovascularization - laser photocoagulation

Answer 26

Central retinal artery occlusion -due to thromboembolism (from atherosclerosis) or arteritis (e.g. temporal arteritis) -features include afferent pupillary defect, 'cherry red' spot on a pale retina, sudden, painless unilateral visual loss

Answer 27

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.

Answer 28

Vitreous haemorrhage causes: diabetes, bleeding disorders, anticoagulants features may include sudden visual loss, dark spots Vitreous haemorrhage is bleeding into the vitreous humour. It is one of the most common causes of sudden painless loss of vision. It causes disruption to vision to a variable degree, ranging from floaters to complete visual loss. The source of bleeding can be from disruption of any vessel in the retina as well as the extension through the retina from other areas. Once the bleeding stops, the blood is typically cleared from the retina at an approximate rate of 1% per day.

Answer 29

Epidemiology -Spontaneous vitreous haemorrhage has an incidence of around 7 cases per 100000 patient-years -Incidence by age and sex varies according to the incidence of the underlying causes Common causes (collectively account for 90% of cases): -proliferative diabetic retinopathy (over 50%) -posterior vitreous detachment -ocular trauma: the most common cause in children and young adults

Answer 30

Patients typically present with an acute or subacute onset of: -painless visual loss or haze (commonest) -red hue in the vision -floaters or shadows/dark spots in the vision Signs: -decreased visual acuity: variable depending on the location, size and degree of vitreous haemorrhage -visual field defect if severe haemorrhage

Answer 31

Investigations: -dilated fundoscopy: may show haemorrhage in the vitreous cavity -slit-lamp examination: red blood cells in the anterior vitreous -ultrasound: useful to rule out retinal tear/detachment and if haemorrhage obscures the retina -fluorescein angiography: to identify neovascularization -orbital CT: used if open globe injury

Answer 32

May precede retinal detachment Posterior vitreous detachment Flashes of light (photopsia) - in the peripheral field of vision Floaters, often on the temporal side of the central vision

Answer 33

-Dense shadow that starts peripherally progresses towards the central vision -A veil or curtain over the field of vision -Straight lines appear curved -Central visual loss

Answer 34

Retinal detachment occurs when the neurosensory tissue that lines the back of the eye comes away from its underlying pigment epithelium. It is a reversible cause of visual loss, provided it is recognised and treated before the macula is affected. If left untreated and symptomatic, retinal detachment will inevitably lead to permanent visual loss.

Answer 35

Risk factors -diabetes mellitus occurs as a result of breaks in the retina due to traction by the vitreous humour these tears may proceed to detachment if left untreated -myopia -age -previous surgery for cataracts (accelerates posterior vitreous detachment) -eye trauma e.g. boxing

Answer 36

Features -new onset floaters or flashes, as these indicate pigment cells entering the vitreous space or traction on the retina respectively -sudden onset, painless and progressive visual field loss, described as a curtain or shadow progressing to the centre of the visual field from the periphery should also raise suspicion of detachment -if the macula is involved, central visual acuity and visual outcomes become much worse -peripheral visual fields may be reduced, and central acuity may be reduced to hand movements if the macula is detached -the swinging light test may highlight a relative afferent pupillary defect if the optic nerve is involved fundoscopy -the red reflex is lost and retinal folds may appear as pale, opaque or wrinkled forms -if the break is small, however, it may appear normal

Answer 37

Management any patients with new onset flashes and floaters should be referred urgently (<24 hours) to an ophthalmologist for assessment with a slit lamp and indirect ophthalmoscopy for pigment cells and vitreous haemorrhage

Answer 38

Risk factors Advancing age itself is the greatest risk factor for ARMD -the risk of ARMD increases 3 fold for patients aged older than 75 years, versus those aged 65-74. -smoking current smokers are twice as likely as non-smokers to have ARMD related visual loss, and ex-smokers have a slightly increased risk of developing the condition, (OR 1.13). -family history is also a strong risk factor for developing ARMD first degree relatives of a sufferer of ARMD are thought to be four times more likely to inherit the condition. other risk factors for developing the condition include those associated with an increased risk of ischaemic cardiovascular disease, such as hypertension, dyslipidaemia and diabetes mellitus.

Answer 39

Traditionally two forms of macular degeneration are seen: dry macular degeneration 90% of cases also known as atrophic characterised by drusen - yellow round spots in Bruch's membrane wet macular degeneration 10% of cases also known as exudative or neovascular macular degeneration characterised by choroidal neovascularisation leakage of serous fluid and blood can subsequently result in a rapid loss of vision carries the worst prognosis Recently there has been a move to a more updated classification: early age-related macular degeneration (non-exudative, age-related maculopathy): drusen and alterations to the retinal pigment epithelium (RPE) late age-related macular degeneration (neovascularisation, exudative)

Answer 40

Patients typically present with a subacute onset of visual loss with: -a reduction in visual acuity, particularly for near field objects -gradual in dry ARMD -subacute in wet ARMD -difficulties in dark adaptation with an overall deterioration in vision at night fluctuations in visual disturbance which may vary significantly from day to day -they may also suffer from photopsia, (a perception of flickering or flashing lights), and glare around objects -visual hallucinations may also occur resulting in Charles-Bonnet syndrome

Answer 41

Signs: -distortion of line perception may be noted on Amsler grid testing -fundoscopy reveals the presence of drusen, yellow areas of pigment deposition in the macular area, which may become confluent in late disease to form a macular scar. -in wet ARMD well demarcated red patches may be seen which represent intra-retinal or sub-retinal fluid leakage or haemorrhage.

Answer 42

Investigations: -slit-lamp microscopy is the initial investigation of choice, to identify any pigmentary, exudative or haemorrhagic changes affecting the retina which may identify the presence of ARMD. This is usually accompanied by colour fundus photography to provide a baseline against which changes can be identified over time. -fluorescein angiography is utilised if neovascular ARMD is suspected, as this can guide intervention with anti-VEGF therapy. This may be complemented with indocyanine green angiography to visualise any changes in the choroidal circulation. -optical coherence tomography is used to visualise the retina in three dimensions because it can reveal areas of disease which aren't visible using microscopy alone.

Answer 43

Treatment the AREDS trial examined the treatment of dry ARMD in 3640 subjects. It showed that a combination of zinc with anti-oxidant vitamins A,C and E reduced progression of the disease by around one third. Patients with more extensive drusen seemed to benefit most from the intervention. Treatment is therefore recommended in patients with at least moderate category dry ARMD. vascular endothelial growth factor (VEGF) -VEGR is a potent mitogen and drives increased vascular permeability in patients with wet ARMD -a number of trials have shown that use of anti-VEGF agents can limit progression of wet ARMD and stabilise or reverse visual loss -evidence suggests that they should be instituted within the first two months of diagnosis of wet ARMD if possible -examples of anti-VEGF agents include ranibizumab, bevacizumab and pegaptanib,. The agents are usually administered by 4 weekly injection. laser photocoagulation does slow progression of ARMD where there is new vessel formation, although there is a risk of acute visual loss after treatment, which may be increased in patients with sub-foveal ARMD. For this reason anti-VEGF therapies are usually preferred.

Answer 44

Diabetic retinopathy is the most common cause of blindness in adults aged 35-65 years-old. Pathophysiology Hyperglycaemia is thought to cause increased retinal blood flow and abnormal metabolism in the retinal vessel walls. This precipitates damage to endothelial cells and pericytes Endothelial dysfunction leads to increased vascular permeability which causes the characteristic exudates seen on fundoscopy. Pericyte dysfunction predisposes to the formation of microaneurysms. Neovasculization is thought to be caused by the production of growth factors in response to retinal ischaemia

Answer 45

Patients are typically classified into those with non-proliferative diabetic retinopathy (NPDR), proliferative retinopathy (PDR) and maculopathy.

Answer 46

Mild NPDR -1 or more microaneurysm Moderate NPDR -microaneurysms -blot haemorrhages -hard exudates -cotton wool spots ('soft exudates' - represent areas of retinal infarction), venous beading/looping and intraretinal microvascular abnormalities (IRMA) less severe than in severe NPDR Severe NPDR -blot haemorrhages and microaneurysms in 4 quadrants -venous beading in at least 2 quadrants -IRMA in at least 1 quadrant

Answer 47

Key features -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

Answer 48

Key features -based on location rather than severity, anything is potentially serious -hard exudates and other 'background' changes on macula -check visual acuity -more common in Type II DM

Answer 49

All patients optimise glycaemic control, blood pressure and hyperlipidemia regular review by ophthalmology

Answer 50

Maculopathy -if there is a change in visual acuity then intravitreal vascular endothelial growth factor (VEGF) inhibitors Non-proliferative retinopathy -regular observation -if severe/very severe consider panretinal laser photocoagulation

Answer 51

Proliferative retinopathy Panretinal laser photocoagulation -following treatment around 50% of patients develop a noticeable reduction in their visual fields due to the scarring of peripheral retinal tissue -other complications include a decrease in night vision (rods are predominantly responsible for vision in low light conditions, the majority of rod cells are located in the peripheral retina), a generalised decrease in visual acuity and macular oedema intravitreal VEGF inhibitors often now used in combination with panretinal laser photocoagulation examples include ranibizumab strong evidence base suggests they both slow progression of proliferative diabetic retinopathy and improve visual acuity if severe or vitreous haemorrhage: vitreoretinal surgery

Answer 52

The table below shows the Keith-Wagener classification of hypertensive retinopathy Stage Features I Arteriolar narrowing and tortuosity Increased light reflex - silver wiring II Arteriovenous nipping III Cotton-wool exudates Flame and blot haemorrhages These may collect around the fovea resulting in a 'macular star' IV Papilloedema

Answer 53

Glaucomas are optic neuropathies associated with raised intraocular pressure (IOP). They can be classified based on whether the peripheral iris is covering the trabecular meshwork, which is important in the drainage of aqueous humour from the anterior chamber of the eye. In primary open-angle glaucoma (POAG), the iris is clear of the meshwork. The trabecular network functionally offers an increased resistance to aqueous outflow, causing increased IOP. It is now recognised that a minority of patients with raised IOP do not have glaucoma and vice versa.

Answer 54

Risk factors: increasing age -affects < 1'5 in individuals under 55 years of age -but up to 10% over the age of 80 years genetics -first degree relatives of an open-angle glaucoma patient have a 16% chance of developing the disease Afro Caribbean ethnicity myopia hypertension diabetes mellitus corticosteroids

Answer 55

POAG may present insidiously and for this reason is often detected during routine optometry appointments. Features may include -peripheral visual field loss - nasal scotomas progressing to 'tunnel vision' -decreased visual acuity -optic disc cupping

Answer 56

Fundoscopy signs of POAG 1. Optic disc cupping - cup-to-disc ratio >0.7 (normal = 0.4-0.7), occurs as loss of disc substance makes optic cup widen and deepen 2. Optic disc pallor - indicating optic atrophy 3. Bayonetting of vessels - vessels have breaks as they disappear into the deep cup and re-appear at the base 4. Additional features - Cup notching (usually inferior where vessels enter disc), Disc haemorrhages

Answer 57

Diagnosis: -Case finding and provisional diagnosis is done by an optometrist -Referral to the ophthalmologist is done via the GP -Final diagnosis is done by investigations as below Investigations: -automated perimetry to assess visual field slit lamp examination with pupil dilatation to assess optic nerve and fundus for a baseline -applanation tonometry to measure IOP -central corneal thickness measurement -gonioscopy to assess peripheral anterior chamber configuration and depth -Assess risk of future visual impairment, using risk factors such as IOP, central corneal thickness (CCT), family history, life expectancy

Answer 58

NICE guidelines 1: offer 360° selective laser trabeculoplasty (SLT) first-line to people with an IOP of ≥ 24 mmHg NICE -360° SLT can delay the need for eye drops and can reduce but does not remove the chance they will be needed at all -a second 360° SLT procedure may be needed at a later date 2: prostaglandin analogue (PGA) eyedrops should be used next-line NICE 3:the next line of treatments includes: -beta-blocker eye drops -carbonic anhydrase inhibitor eye drops -sympathomimetic eye drops 4: surgery in the form of a trabeculectomy may be considered in refractory cases.

Answer 59

Prostaglandin analogues (e.g. latanoprost) Increases uveoscleral outflow Once daily administration Adverse effects include brown pigmentation of the iris, increased eyelash length

Answer 60

Beta-blockers (e.g. timolol, betaxolol) Reduces aqueous production Should be avoided in asthmatics and patients with heart block

Answer 61

Sympathomimetics (e.g. brimonidine, an alpha2-adrenoceptor agonist) Reduces aqueous production and increases outflow Avoid if taking MAOI or tricyclic antidepressants Adverse effects include hyperaemia

Answer 62

Carbonic anhydrase inhibitors (e.g. Dorzolamide) Reduces aqueous production Systemic absorption may cause sulphonamide-like reactions

Answer 63

Miotics (e.g. pilocarpine, a muscarinic receptor agonist) Increases uveoscleral outflow Adverse effects included a constricted pupil, headache and blurred vision

Answer 64

Causes -multiple sclerosis: the commonest associated disease -diabetes -syphilis Features -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

Answer 65

Investigation MRI of the brain and orbits with gadolinium contrast is diagnostic in most cases Management high-dose steroids recovery usually takes 4-6 weeks Prognosis MRI: if > 3 white-matter lesions, 5-year risk of developing multiple sclerosis is c. 50%

Answer 66

Also known as the Marcus-Gunn pupil, a relative afferent pupillary defect is found by the 'swinging light test'. It is caused by a lesion anterior to the optic chiasm i.e. optic nerve or retina Finding the affected and normal eye appears to dilate when light is shone on the affected

Answer 67

Causes retina: detachment optic nerve: optic neuritis e.g. multiple sclerosis

Answer 68

Pathway of pupillary light reflex afferent: retina → optic nerve → lateral geniculate body → midbrain efferent: Edinger-Westphal nucleus (midbrain) → oculomotor nerve

Answer 69

Argyll-Robertson pupil is one of the classic pupillary syndrome. It is sometimes seen in neurosyphilis. A mnemonic used for the Argyll-Robertson Pupil (ARP) is Accommodation Reflex Present (ARP) but Pupillary Reflex Absent (PRA) Features small, irregular pupils no response to light but there is a response to accommodate Causes diabetes mellitus syphilis

Answer 70

Holmes-Adie pupil is a benign condition most commonly seen in women. It is one of the differentials of a dilated pupil. Overview unilateral in 80% of cases dilated pupil once the pupil has constricted it remains small for an abnormally long time slowly reactive to accommodation but very poorly (if at all) to light Holmes-Adie syndrome association of Holmes-Adie pupil with absent ankle/knee reflexes

Answer 71

Horner's syndrome Features -miosis (small pupil) -ptosis -enophthalmos* (sunken eye) -anhidrosis (loss of sweating one side)

Answer 72

Spinal cord lesion above T1: stroke / tumours syringmyelia/MS/encephalitis Damage to 2nd order neurone: pancoast tumour/thyroidectomy/trauma/cervical rib Damage to 3rd order neurone: dissection of internal carotid artery/carotid aneurysm/cavernous sinus thrombosis/cluster headache

Answer 73

Distinguishing between causes -heterochromia (difference in iris colour) is seen in congenital Horner's -anhidrosis -pharmacologic tests can be useful to confirm the diagnosis of Horner syndrome and localise the lesion apraclonidine drops (an alpha-adrenergic agonist) can be used: causes pupillary dilation in Horner's syndrome due to denervation supersensitivity but produces mild pupillary constriction in the normal pupil by down-regulating the norepinephrine release at the synaptic cleft

Answer 74

Central lesions i.e. spinal cord - anhydrosis of face,arm and trunk Pre-ganglionic lesions - anhydrosis of face Post-ganglionic lesions - no anhydrosis

Answer 75

Causes of mydriasis (large pupil) third nerve palsy Holmes-Adie pupil traumatic iridoplegia phaeochromocytoma congenital Drug causes of mydriasis topical mydriatics: tropicamide, atropine sympathomimetic drugs: amphetamines, cocaine anticholinergic drugs: tricyclic antidepressants Anisocoria may result in apparent mydriasis, due to the difference with the other pupil.

Answer 76

A cataract is a common eye condition where the lens of the eye gradually opacifies i.e. becomes cloudy. This cloudiness makes it more difficult for light to reach the back of the eye (retina), thus causing reduced/blurred vision. Cataracts are the leading cause of curable blindness worldwide. Epidemiology Cataracts are more common in women than in men The incidence of cataracts increases with age. One study found that 30% of individuals aged 65 and over had a visually-impairing cataract in either one or both eyes

Answer 77

Causes Normal ageing process: most common cause Other possible causes Smoking Increased alcohol consumption Trauma Diabetes mellitus Long-term corticosteroids Radiation exposure Myotonic dystrophy Metabolic disorders: hypocalcaemia

Answer 78

Patients typically present with a gradual onset of: -Reduced vision -Faded colour vision: making it more difficult to distinguish different colours -Glare: lights appear brighter than usual -Halos around lights Signs: A Defect in the red reflex: the red reflex is essentially the reddish-orange reflection seen through an ophthalmoscope when a light is shone on the retina. Cataracts will prevent light from getting to the retina, hence you see a defect in the red reflex.

Answer 79

Investigations: -Ophthalmoscopy: done after pupil dilation. Findings: normal fundus and optic nerve -Slit-lamp examination. Findings: visible cataract

Answer 80

Classification -Nuclear: change lens refractive index, common in old age -Polar: localized, commonly inherited, lie in the visual axis -Subcapsular: due to steroid use, just deep to the lens capsule, in the visual axis -Dot opacities: common in normal lenses, also seen in diabetes and myotonic dystrophy

Answer 81

Management Non-surgical: In the early stages, age-related cataracts can be managed conservatively by prescribing stronger glasses/contact lens, or by encouraging the use of brighter lighting. These options help optimise vision but do not actually slow down the progression of cataracts, therefore surgery will eventually be needed. Surgery: Surgery is the only effective treatment for cataracts. This involves removing the cloudy lens and replacing this with an artificial one. NICE suggests that referral for surgery should be dependent upon whether a visual impairment is present, impact on quality of life, and patient choice. Also whether both eyes are affected and the possible risks and benefits of surgery should be taken into account. Prior to cataract surgery, patients should be provided with information on the refractive implications of various types of intraocular lenses. After cataract surgery, patients should be advised on the use of eye drops and eyewear, what to do if vision changes and the management of other ocular problems. Cataract surgery has a high success rate with 85-90% of patients achieving 6/12 corrected vision (on a Snellen chart) postoperatively.

Answer 82

Complications following surgery -Posterior capsule opacification: thickening of the lens capsule -Retinal detachment -Posterior capsule rupture -Endophthalmitis: inflammation of aqueous and/or vitreous humour

Answer 83

Eyelid problems commonly encountered include: -blepharitis: inflammation of the eyelid margins typically leading to a red eye -stye: infection of the glands of the eyelids -chalazion (Meibomian cyst) -entropion: in-turning of the eyelids -ectropion: out-turning of the eyelids

Answer 84

Different types of stye are recognised: -external (hordeolum externum): infection (usually staphylococcal) of the glands of Zeis (sebum producing) or glands of Moll (sweat glands). -internal (hordeolum internum): infection of the Meibomian glands. May leave a residual chalazion (Meibomian cyst) management includes hot compresses and analgesia. CKS only recommend topical antibiotics if there is an associated conjunctivitis

Answer 85

A chalazion (Meibomian cyst) is a retention cyst of the Meibomian gland. It presents as a firm painless lump in the eyelid. The majority of cases resolve spontaneously but some require surgical drainage

Answer 86

Blepharitis is inflammation of the eyelid margins. It may due to either meibomian gland dysfunction (common, posterior blepharitis) or seborrhoeic dermatitis/staphylococcal infection (less common, anterior blepharitis). Blepharitis is also more common in patients with rosacea The meibomian glands secrete oil on to the eye surface to prevent rapid evaporation of the tear film. Any problem affecting the meibomian glands (as in blepharitis) can hence cause drying of the eyes which in turns leads to irritation

Answer 87

Features -symptoms are usually bilateral -grittiness and discomfort, particularly around the eyelid margins -eyes may be sticky in the morning -eyelid margins may be red. Swollen eyelids may be seen in staphylococcal blepharitis -styes and chalazions are more common in patients with blepharitis -secondary conjunctivitis may occur

Answer 88

Management 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

Answer 89

Dacryocystitis is infection of the lacrimal sac Features watering eye (epiphora) swelling and erythema at the inner canthus of the eye Management is with systemic antibiotics. Intravenous antibiotics are indicated if there is associated periorbital cellulitis Congenital lacrimal duct obstruction affects around 5-10% of newborns. It is bilateral in around 20% of cases Features watering eye (even if not crying) secondary infection may occur Symptoms resolve in 99% of cases by 12 months of age

Answer 90

Nasolacrimal duct obstruction is the most common cause of a persistent watery eye in an infant. It is caused by an imperforate membrane, usually at the lower end of the lacrimal duct. Around 1 in 10 infants have symptoms at around one month of age Management teach parents to massage the lacrimal duct symptoms resolve in 95% by the age of one year. Unresolved cases should be referred to an ophthalmologist for consideration of probing, which is done under a light general anaesthetic

Answer 91

Papilloedema describes optic disc swelling that is caused by increased intracranial pressure. It is almost always bilateral. The following features may be observed during fundoscopy: 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

Answer 92

Causes of papilloedema space-occupying lesion: neoplastic, vascular malignant hypertension idiopathic intracranial hypertension hydrocephalus hypercapnia Rare causes include hypoparathyroidism and hypocalcaemia vitamin A toxicity

Answer 93

Blurred vision may be defined as a loss of clarity or sharpness of vision. The vast majority of patients with blurred vision will have long-term refractive errors. Like a lot of terms, it can mean different things to different patients/doctors, therefore, it's important to assess for associated symptoms such as visual loss, double vision, floaters. Causes refractive error: most common cataracts retinal detachment age-related macular degeneration acute angle closure glaucoma optic neuritis amaurosis fugax

Answer 94

Assessment -visual acuity with a Snellen chart pinhole occluders are a useful way to check for whether the blurred vision is due to a refractive error or not if the blurring improves with a pinhole occluder then likely cause is a refractive error -visual fields -fundoscopy

Answer 95

Squint (strabismus) is characterised by misalignment of the visual axes. Squints may be divided into concomitant (common) and paralytic (rare). It is important to detect as uncorrected may lead to amblyopia (the brain fails to fully process inputs from one eye and over time favours the other eye).

Answer 96

Concomitant: Due to imbalance in extraocular muscles Convergent is more common than divergent Paralytic: Due to paralysis of extraocular muscles

Answer 97

Detection of a squint may be made by the corneal light reflection test - holding a light source 30cm from the child's face to see if the light reflects symmetrically on the pupils The cover test is used to identify the nature of the squint ask the child to focus on an object cover one eye observe movement of uncovered eye cover other eye and repeat test Management referral to secondary care eye patches may help prevent amblyopia

Answer 98

Retinitis pigmentosa primarily affects the peripheral retina resulting in tunnel vision 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

Answer 99

Associated diseases Refsum disease: cerebellar ataxia, peripheral neuropathy, deafness, ichthyosis Usher syndrome abetalipoproteinemia Lawrence-Moon-Biedl syndrome Kearns-Sayre syndrome Alport's syndrome

Answer 100

Ocular manifestations of rheumatoid arthritis are common, with 25% of patients having eye problems Ocular manifestations keratoconjunctivitis sicca (most common) episcleritis (erythema) scleritis (erythema and pain) corneal ulceration keratitis Iatrogenic steroid-induced cataracts chloroquine retinopathy