Ophthalmology Flashcards
Hordeolum (“stye”)
Acute inflammation of the tear gland or eyelash follicles
Dacryocystitis
Acute or chronic infection resulting in inflammation of the lacrimal sac
Blepharitis
Chronic/recurrent inflammation of the eyelids.
Characterized by red, swollen eyelids, irregular eyelid margins with crusty, scaly plaques on the lid margin and eyelashes
Chalazion
A focal granulomatous swelling of the meibomian gland.
Presents as a chronic, slow-growing nodule on the eyelid that is often better seen on eversion of the eyelid.
Role of the choroid
Vascular - blood and oxygen supply to the eye
Role of the fovea
Sharp central vision
Role of the ciliary body
Produces aqueous/ vitreous humour
Conjunctivitis
Inflammation of the conjunctiva (covering of the sclera)
Bacterial v Viral v Allergic conjunctivitis
Bacterial - purulent
Viral - serous/ mucoid
Allergic - mucoid
Acute Iritis - features
pain, photophobia, blurred vision, small pupil
Keratitis
Corneal ulcer
+ pain, photophobia, may have blurry vision
What is the cornea?
Outermost part of the lens
Herpes simplex keratitis
HSV
Painful red eye, photophobia, watery discharge
Fluorescein staining - dendritic ulcers on cornea
Mx:
urgent referral ophthalmologist
TOP/ PO antivirals
What is the value on Snellen for legal blindess
20/200
Exophthalmos (proptosis)
Causes (5)
Anterior displacement of the eye
(distinguish from lid retraction)
Causes:
Graves’
Orbital cellulitis
Orbital tumour
Orbital retrobulbar haemorrhage
Cavernous sinus thrombosis
Enophthalmos
Causes (4)
Posterior displacement (retraction) of the globe
Causes:
Trauma
Fat atrophy
Congenital
Metastatic disease
Orbital Cellulitis
Emergency
Not always distingushable from preseptal cellulitis
Systemically unwell
Red flag symptoms -
loss of visual acuity
exophthalmos
RAPD
painful eye movements
diplopia
Complications of orbital cellulitis
optic nerve inflammation
cavernous sinus thrombosis
brain abscess
Treatment of orbital cellulitis
IV antibx - ceftriaxone + vanc
surgical drainage of abscess
Dry eye syndrome (keratoconjunctivitis sicca)
- aqueous deficient
- evaporative
Aqueous deficient
- Sjogren’s
- lacrimal gland scarring
- CN VII palsy, medications
Evaporative
- Meibomian gland dysfunction
- vitamin a deficiency
- eyelid abnormalities
- contact lenses / allergic
What condition does cherry red spot indicate?
Central retinal artery occlusion
Causes of optic neuritis? (3)
- Multiple sclerosis
- Diabetes
- Syphilis
What is Hutchinson’s sign?
Rash on the tip or side of nose (herpes zoster ophthalmicus)
Affecting trigeminal nerve
Treatment of conjunctivitis in pregnancy?
TOP fusidic acid BD
Visual field defect in prolactinoma?
Bi-temporal hemianopia
Signs of malignant eyelid tumour? (4)
- Distortion of the eyelid
- Loss of eyelashes
- Ulceration
- Bleeding
2WW
Condition with flame shaped retinal haemorrhages?
Central retinal vein occlusion
Features of diabetic retinopathy? (6)
- Microaneurysms
- Hard exudates
- Cotton wool spots
- Neovascularization
- Roth spots
- Haemorrhages
Causes of lens dislocation? (3)
- Ehlers-Danlos syndrome
- Marfan’s syndrome
- homocystinuria
HLA allele associated with anterior uveitis?
HLA B27
Nerve affected causing fixed dilated pupil?
Oculomotor nerve (CN III)
Condition associated with white-grey patch on cornea?
Keratitis
Drug causing amaurosis fugax?
Quinine
Rare side affect of sertraline? (SSRI’s)
Acute angle glaucoma
Dacryocystitis
Inflammation of the lacrimal sac
Mx: warm compress, top antibiotics
Dacryoadenitis
Inflammation of the lacrimal gland
Affecting the upper outer third of the eye
Supportive treatment
Stye versus chalazion
Stye are due to infectious aetiology and chalazions are granulomatous tissue
Hordeolum (stye) - clinical features and management
Acute inflammation of eyelid gland
Painful, red swelling of the lid
Mx: hot compress, lid care, I+D if not resolving
Chalazion
Inflammation of the Meibomian gland
Recurrent lesion may be biopsied to rule out malignancy.
Other causes: seborrheic dermatitis, rosacea
Blepharitis
Inflammation of the lid margin.
S/S: itching, tearing, foreign body sensation, crusting, discharge with pressure on lids “toothpaste sign”
Mx: warm compresses, lid massage, lid washing, consider antibiotics
Complications of blepharitis
Recurrent stye
Conjunctivitis
Keratitis
Corneal ulceration and neovascularization
Subconjunctival haemorrage
Blood beneath the conjunctiva.
No other symptoms.
Risk factors: trauma, HTN, bleeding disorders, anticoagulation
Mx: reassurance, self-limiting
Conjunctivitis - clinical features
Red eye
Itching
Foreign body sensation
Discharge
Crusting of the lid margin in the morning
Lid oedema
Allergic conjunctivitis
Associated with atopy and is often seasonal
Mx: avoid allergens, cool compress, antihistamines
Atopic conjunctivitis
peak age 30-50yr
intense ocular itching, tearing, burning, redness, swelling of eyelids, conjunctival hyperemia
Mx: tacrolimus (calcineurin inhibitor ointment), cyclosporine and corticosteroid eye drops
Giant papillary conjunctivitis
Immune reaction due to mucus debris in contact lens users
Mx: corticosteroid drops, change or discontinue contact lenses
Viral Conjunctivitis
Pink eye
Lid pain and swelling, serous discharge, sub-epithelial corneal infiltrates
Mx: normally self limiting
Main causative microbe in pink eye?
Adenovirus
Trachoma
Caused by chlamydia trachomatis
Severe keratoconjunctivitis leading to blindness
Mx: PO azithromycin and TOP tetracycline
Episcleritis
Discomfort, pain, redness
Self-limiting
Ix: blanched vessels with phenylephrine
Associated with: collagen vascular diseases, infection, IBD, rosacea, atopy
Scleritis
Anterior or posterior –> posterior can cause rapidly progressive blindness
S/S: severe pain, photophobia, red eye, decreased vision
Mx: treat underlying aetiology (collagen disorders, granulomatous conditions, infection, chemical or physical agents)
NSAIDs, steroids, immunomodulators
Functions of the cornea? (3)
Transmission of light
Refraction of light
Barrier
Corneal abraision
Causes: trauma, foreign body, contact lenses
Clinical features: pain, redness, photophobia, de-epithelialized area when stained with fluorescein
Mx: topical antibiotic, conservative management
Corneal ulcer - investigation and management
Ix: Seidel test - fluorescein stain under blue filter
Tx: urgent ophthalmology referral, culture, TOP antibiotics
Herpes zoster ophthalmicus
Dermatitis in the dermatomal distribution of CN V1
May have Hutchinson’s sign
Mx: oral antiviral, topical steroid
Keratoconus
Bulging and thinning of the cornea
Tx: corrective glasses/ lenses, surgery
Munson’s sign
Bulging of the eye lid and cornea when looking downwards
Positive for keratoconus
Kayser-Fleischer Ring
Brown/yellow/green pigment in peripheral cornea due to copper deposition
Does not cause any symptoms or eye complications, treat underlying condition (Wilson’s disease)
Anterior uveitis
Clinical features: photophobia, ciliary flush, pain, tenderness, lacrimation
Associated with: IBD, arthritis, syphilis, sarcoidosis
Treatment: mydriatics, steroids, systemic analgesia
Posterior uveitis
PAINLESS
Cataracts - risk factors
Risk factors: DM, homocystinuria, Wilson’s disease, hypocalcaemia, steroid use, high myopia
Posterior vitreous detachment - clinical features
Floaters and flashes of light
Vitreous haemorrhage
Bleeding into the vitreous cavity
Clinical features: sudden loss of visual acuity, preceding floaters or flashes
Mx: expectant or surgical (vitrectomy)
Central retinal artery occlusion
Causes: emboli from carotid arteries, thrombus, GCA/ temporal arteritis
Clinical features: sudden, painless loss of vision, RAPD, cherry red spot on fundoscopy
Mx: decrease IOP - timolol, IV acetazolamide, laser embolectomy
Central retinal vein occlusion
Clinical features: sudden, painless loss of vision, +/-RAPD, flame haemorrhages on fundoscopy
Mx: retinal laser photocoagulation, anti-VEGF, corticosteroid injection
Retinal detachment
Clinical features: sudden vision loss, flashes/ floaters, hazy spots in line of vision
Tx: surgical - scleral bulking, laser/cryotherapy for flashes and floaters
Retinitis pigmentosa
Familial degenerative eye disease of retina - mainly AR inheritance
Clinical features: night blindness, decreased peripheral vision, glare, decreased central vision
Ix: fundoscopy - pale optic disc, narrow retinal arterioles, bone-spicule pigment
Age related macular degeneration - dry versus wet
Dry -
slow, progressive vision less
drusen
geographic atrophy
Wet -
less common (10%)
choroidal neovascularization
progresses more to vision loss
ARMD clinical features and management
Clinical features: progressive central vision loss
Ix: Amsler grid, fluorescein angiography
Tx:
Dry - monitor, low vision aids, anti-oxidants (AREDS2)
Wet - anti-VEGF, Verteporfin (Visudyne)
Primary open angle glaucoma
Restriction in aqueous flow –> increased IOP
Clinical features: gradual painless vision loss, mainly peripheral vision
Mx:
1. Increase aqueous flow - latanoprost, topical a2 adrenergics (brimonidine)
2. Decrease aqueous production - carbonic anhydrase inhibitors (acetazolamide)
3. Surgical - trabeculectomy, shunt
Primary angle closure glaucoma
Clinical features: painful, red eye, decreased visual acuity, N+V, abdominal pain, halos, fixed mid-dilated pupil
Mx: aqueous suppressants, IV mannitol, miotics - pilocarpine, surgery
Definitive treatment for primary angle closure glaucoma
Laser iridotomy
Adie’s pupil
Postganglionic nerve damage causes dilation of the pupil and slow reactivity to light
Horner’s pupil
Pupil smaller than normal, does not dilate with light
Argyll-Robertson Pupil
Bilateral small pupils that fail to constrict in response to bright light but exhibit constriction during near vision tasks.
Brisk constriction for near tasks.
Abnormal pupil shape - oval
Seen in tertiary syphilis
CN III palsy
Down and out
CN IV palsy
Up and out
Canadian screening guidelines for diabetic retinopathy (Type 1, Type 2, Pregnancy)
T1DM: annually five years after onset, or annually from over 12 years
T2DM: annually
Pregnancy: ocular exam in 1st trimester
Hypertensive retinopathy
Clinical features: blurred vision, decreased colour vision, central scotoma
Treatment: blood pressure control, steroids for optic neuritis
Classification of hypertensive retinopathy
Modified Scheie classification
0: no changes
1: mild arterial narrowing
2: obvious arterial narrowing with focal abnormalities
3: grade 2 + retinal haemorrhages +/- exudate
4: grade 3 + swollen optic nerve (malignant HTN)
Treatment optic neuritis
IV steroids then taper to PO
TIA/ amaurosis fugax
Sudden transient blindness from vascular compromise
Strabismus
Misalignment between eyes
Refer to ophthalmology
Amblyopia (lazy eye)
Progressive suppression of visual input from eye
Normally unilateral
Most common cause of vision loss in children, half secondary to strabismus
Mx: corrective lenses for strabismus, surgery
Leukocoria
White pupillary reflex (absent red reflex)
URGENT referral to ophthalmology
r/o retinoblastoma
Retinoblastoma
arising from immature cells of the retina
often presents with leukocoria, strabismus, red eye, eye enlargement
Mx: local laser/chemo, genetic counselling
Blow out fracture features
Restricted extraocular movement, diplopia, sunken eye (enophthalmos)
Ethmoid fracture feature
Emphysema of the lid subcutaneously
Hyphema
Blood in the anterior chamber/ around iris
Chorioretinitis
Inflammation of the choroid and retina
Caused by infections: TB, CMV, HIV, autoimmune diseases
Clinical features: blind spots, flashers and floaters, blurred vision
On fundoscopy: “pizza pie” appearance
Management: treat underlying infection/ cause
