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Phase 4 > Ophthalmology > Flashcards

Ophthalmology Flashcards

1
Q

what is the pathophysiology of acute angle closure glaucoma?

A

iris bulges forwards and seals off trabecular meshwork of anterior chamber, preventing aqueous humour from draining leading to increase in intraocular pressure => leads to further bulging of iris exacerbating angle closure

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2
Q

what are 6 risk factors for acute closed angle glaucoma?

A

Increased age
FHx
Female - 4x than M
Chinese/east asian ethnic origin
shallow anterior chamber
Hypermetropia - long sightedness

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3
Q

what are 3 meds that can precipitate acute closed angle glaucoma?

A

Adrenergic medications - noradrenaline
Anticholinergic meds - oxybutynin, solfenacin
Tricyclic antidepressants - amitryptyline

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4
Q

what are 5 presentations of acute closed angle glaucoma?

A

severe painful red eye

blurred vision

Halos around lights

Headache, nausea and vom

Pain worse on pupil dilation - watching TV in dark room

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5
Q

what are 5 signs of acute closed angle glaucoma on examination?

A

Red eye

Hazy cornea

decreased visual acuity

mid-dilated fixed size pupil

Hard eyeball on gentle palpation

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6
Q

what is the initial management of acute closed angle glaucoma in primary care? (4)

A

Lie patient on back without pillow

Pilocarpine eyedrops - 2% for blue eyes, 4% for brown eyes

Acetazolamide 500mg orally

Analgesia + antiemetics

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7
Q

WHAT IS PILOCARPINE?

A

used in management of acute closed angle glaucoma

acts on muscarinic receptors in sphincter muscle of iris causing pupil constriction (miotic agent) as well as causing ciliary muscle contraction

OPens pathway for flow of aqueous humour from ciliary body into trabecular meshwork

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8
Q

what is acetazolamide?

A

Used in treatment of acute closed angle glaucoma

carbonic anhydrase inhibitor - reduces production of aqueous humour

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9
Q

what is the dose of pilocarpine in blue eyes in acute closed angle glaucoma?

A

2%

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10
Q

what is the dose of pilocarpine in brown eyes in acute closed angle glaucoma?

A

4%

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11
Q

what is the dose of acetazolamide in acute closed angle glaucoma?

A

500mg PO

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12
Q

what is the definitive treatment of acute closed angle glaucoma?

A

laser iridotomy - making hole in iris with laser to allow for aqueous humour to drain from posterior to anterior chamber, relieving pressure

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13
Q

what are 6 secondary care options for management of acute closed angle glaucoma?

A

Pilocarpine drops - parasympathetic agent

Acetazolamide - PO or IV

Hyperosmotic agents - mannitol to increase osmotic gradient between blood and eye

Timolol - B Blocker which reduces production of aqueous humour

Dorzolamide - carbonic anhydrase inhibitor

Brimonidine - sympathomimetic that reduces aqueous humour production and increased uveoscleral outflow

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14
Q

what are 2 investigations for acute closed angle glaucoma?

A

Tonometry for elevated IOP

Gonioscopy - looking at angle

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15
Q

what is blepharitis?

A

inflammation of the eyelid margins

can be associated with dysfunction of meibomian glands or seborrhoeic dermatitis - can lead to styes, chalazions and conjunctavitis

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16
Q

what is the presentation of blepharitis?

A

bilateral, gritty, itchy, dry sensation in eyes worse in morning

Eyes may feel sticky in morning

Eyelid margins may be red/swollen

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17
Q

what is the management of blepharitis?

A

hot compress BD
Lid hygiene with cotton wool dipped in cooled boiled water
Artificial tears for symptom relief

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18
Q

what are the 2 different types of stye?

A

Hordeolum externum - infection of the glands of zeis or glands of moll - sebaceous or sweat glands at base of eyelashes - tender red possibly pussy lump at base of eyelashes

Hordeolum internum - infection of meibomian glands - deeper more painful, may point inwards towards eyeball underneath eyelid

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19
Q

what is the management of styes?

A

hot compress
analgesia

Chloramphenicol - topical ABx - may be considered with coexisting conjunctivitis

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20
Q

what is a chalazion?

A

blocked and swollen meibomian gland also called meibomian cyst

usually non-tender swelling of eyelid

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21
Q

what is the management of a chalazion

A

warm compress and gentle massage towards eyelashes to encourage drainage

rarely needs surgical drainage

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22
Q

what is entropion?

A

when the eyelid turns inwards and the eyelashes press on the eye

can cause corneal damage and ulceration

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23
Q

what is the management of entropion?

A

surgery

should have same day referral to ophthalmology if risk to sight

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24
Q

what is an eye ectropian?

A

when eyelid turns outwards exposing inner aspect

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25
Q

what can be a complication of an eye ectropion?

A

exposure keratopathy as the eyeball is exposed to air and not properly lubricated and protected

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26
Q

what is the management of eye ectropion?

A

regular lubricating eye drops

may require surgery - same day referral if risk to sight

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27
Q

what is trichiasis?

A

inward growth of the eyelash resulting in pain - can cause corneal damage and ulceration

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28
Q

what is the management of trichiasis?

A

removal of affected eyelashes

if recurrent may require electrolysis, cryotherapy or laser treatment to prevent regrowth

same day referral to ophthalmology if risk to sight

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29
Q

what is periorbital cellulitis?

A

eyelid and skin infection of orbital septum in front of eye
red, swollen hot skin around eye and eyelid

can progress to orbital cellulitis

should be seen in secondary care

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30
Q

what is the management of periorbital cellulitis in adults?

A

1 - Co-amoxiclav 500/125mg TDS for 7 days PO

Pen allergy -
Clarithromycin 500mg BD 5-7 days
PLUS Metronidazole 400mg TDS for 7 days

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31
Q

what is the management of periorbital cellulitis in children?

A

<30 days - r/f ophthalmology

Co-amoxiclav 0.25ml/kg of 125/31 oral suspension
OR
12-17 years - 25-/125mg TDS PO tablets

Clarithromycin in allergy

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32
Q

what is orbital cellulitis?

A

infection around the eyeball involving tissues behind orbital septum

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33
Q

what are 7 presentations of orbital cellulitis?

A

Redness and swelling around eye

severe ocular pain

visual disturbance

Proptosis

Pain with eye movements - ophthalmoplegia

Eyelid oedema and ptosis

Symptoms of meningeal involvement

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34
Q

what imaging can be used for orbital cellulitis?

A

CT with contrast to distinguish orbital and periorbital cellulitis - for all patients suspected

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35
Q

what are the 3 of the most common organisms causing orbital cellulitis?

A

Streptococcus
Staphylococcus Aureus
Haemophilus influenzae B

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36
Q

what is the management of orbital cellulitis?

A

Admission for IV Abx - as per local guidelines - Cefotaxime + flucloxacillin

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37
Q

what are the 4 most common causative organisms for preorbital cellulitis?

A

Staph Aureus
Staph Epidermis
Streptococci
Anaerobes

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38
Q

what age group are most affected be periorbital/orbital cellulitis?

A

children - <10

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39
Q

what is primary open angle glaucoma?

A

a chronic progressive optic neuropathy characterised by degeneration of retinal ganglion cells and their axons leading to irreversible visual field loss due to chronic raised intraocular pressure and subsequent stress on the optic nerve head

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40
Q

what is normal intraocular pressure?

A

10-21mmHg

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41
Q

what are 7 risk factors for chronic open angle glaucoma?

A

Increased age
FHx
Black ethnic origin
Myopia
HTN
DM
Corticosteriods

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42
Q

what 5 presentations of chronic open angle glaucoma?

A

Gradual onset of peripheral vision loss - tunnel vision

Fluctuating pain
Headaches
Blurred vision
Halos around lights particularly at night

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43
Q

what are 2 ways to measure intraocular pressure?

A

non contact tonometry - puff of air
goldmann applanation tonometry - GOLD STANDARD - device mounted on sit lamp that applies various pressures to eye

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44
Q

what 4 things can be seen on fundoscopy in chronic open angle glaucoma?

A

increased optic cup to disc ratio >0.7
optic disc pallor - due to optic atrophy
bayonetting of vessels
cup notching and disc haemorrhages

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45
Q

what are 5 tools for diagnosis of chronic open angle glaucoma?

A

Goldmann applanation tonometry - for intraoccular pressure
Slit lap assessment of retinal health
Visual field assessment - peripheral vision loss
Gonioscopy - assess angle between iris and cornea
Central corneal thickness assessment

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46
Q

At what pressure is treatment for chronic open angle glaucoma usually started?

A

> 24mmHg

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47
Q

what is the 1st line management of chronic open angle glaucoma?

A

360 degree selective laser trabeculoplasty

laser directed at trabecular meshwork to improve drainage and delay need for eye drops

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48
Q

what is the 1st line medical treatment for chronic open angle glaucoma?

A

Prostaglandin analogues - latanoprost

increase uveoscleral outflow

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49
Q

what are 3 side effects of prostaglandin analogues?

A

lash growth
eyelid pigmentation
iris pigmentation - browning

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50
Q

what are 3 alternative medical therapies for chronic open angle glaucoma?

A

B Blockers - timolol - reduce production of aqueous humour

Carbonic anhydrase inhibitors - dorzolamide - reduce production of aqueous humour

Sympathomimetics - brimonidine - reduce production of aqueous fluid and increase uveoscleral outflow

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51
Q

what is the definitive management of chronic open angle glaucoma if other treatment fails?

A

Surgical trabeculectomy to create new channel from anterior chamber for humour resorption

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52
Q

what are 3 side effects of miotics (pilocarpine)?

A

constricted pupil
headache
blurred vision

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53
Q

what is an example of a prostaglandin analogue?

A

Latanoprost

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54
Q

what is latanoprost used for?

A

Prostaglandin analogue 1st line in medical management of chronic open angle glaucoma

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55
Q

what is the most common cause of blindness is in the UK?

A

Age related macular degeneration

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56
Q

what are 4 risk factors for age related macular degeneration?

A

Advanced Age - 3x risk >75 years
Smoking - 2x more likely
FHx - 4x risk
Risk of ischaemic cardiovascular disease increases risk of ARMD

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57
Q

What are the 2 classifications of age related macular degeneration?

A

Dry and Wet

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58
Q

what is the macula?

A

area in the centre of the retina that generates high def colour vision in the central visual field

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59
Q

what are the 4 layers of the macula?

A

Choroid layer - blood vessels
Brusch membrane
Retinal pigment epithelium
Photoreceptors - at surface

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60
Q

what are drusen?

A

yellowish deposits of proteins and lipids between retinal pigment epithelium and Bruch membrane in macula. Frequent and large druses can be a sign of macular degeneration

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61
Q

what are 3 retinal signs of macular degeneration?

A

Drusen
Atrophy of retinal pigment epithelium
Degeneration of photoreceptors

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62
Q

what is the difference between wet and dry macular degeneration?

A

Macular degeneration is caused by the degeneration of retinal photoreceptors

In wet macular degeneration there is neovascularisation from the choroid layer into the retina causing oedema and faster vision loss

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63
Q

Is wet or dry macular degeneration more common?

A

Dry - 90%
Wet - 10%

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64
Q

what chemical stimulates neovascularisation in wet macular degeneration?

A

vascular endothelial growth factor

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65
Q

what is the presentation of macular degeneration?

A

gradual loss of central vision
reduced visual acuity
crooked or wavy appearance of straight lines - metamophopsia

often present with gradually worsening ability to read small text

Wet AMD can develop within days and progress to complete vision loss in a few years

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66
Q

what are 4 findings on examination for macular degeneration?

A

reduced visual acuity with snellen chart
scotoma - enlarged central area of vision loss
ambler grid test for straight lines
Drusen on fundoscopy

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67
Q

what are 2 ways of visualising macular degeneration?

A

Optical coherence tomography - gives cross section of layers of retina

Fluorescein angiography - flurorescein contrast and photographing the retina to assess the blood supply showing oedema and neovascularisation in wet AMD

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68
Q

what medications are used in wet age related macular degeneration and what are their names?

A

anti-vascular endothelial growth factor medications - injected into vitreous chamber usually once a month

E.g. - Ranibizumab, aflibercept, bevacizumab

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69
Q

what is the management of dry macular degeneration?

A

monitoring and reducing risk - stop smoking, control BP, vitamin supplements

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70
Q

what are 6 risk factors for cataracts?

A

Increased age
smoking
Alcohol
Diabetes
Steroids
Hypocalcaemia

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71
Q

what is cataracts?

A

progressive opacity of the lens of the eye reducing light entering the eye and decreasing visual acuity

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72
Q

what is the role of the lens and how does it work?

A

Lens focuses light onto the retina

held in place by suspensory ligaments attached to ciliary body which contracts and relaxes to change shape of lens

No blood supply but is nourished by aqueous humour

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73
Q

what are 4 presentations of cataracts?

A

Asymetical
Slow reduction in visual acuity
Progressive blurring of vision
Colours become more faded, brown or yellow
Stardust’s spear around lights especially at night

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74
Q

what is a key examination finding in cataracts?

A

Loss of red reflex

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75
Q

what is a rare but serious complication of cataracts surgery?

A

Endophthalmitis - inflammation of inner contents of eye usually caused by infection - can lead to vision loss

Tx with intravitreal Abx injected directly into eye

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76
Q

what are 6 common causes of loss of red reflex?

A

Cataracts
Corneal Scars
Vitreous Haemorrhage
Retinoblastoma
Macular degeneration
Diabetic retinopathy

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77
Q

what is the name for a white red reflex?

A

leukocoria - commonly seen in retinoblastoma, also seen in congenital cataracts

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78
Q

what are 4 ways to investigate loss of red reflex?

A

Ophalmic USS - can visualised intraocular structures and detect masses, retinal derangement and vitreous haemorrhage

MRI

Serology - for infective causes
Cytology and Histopathology for masses

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79
Q

what are 2 intraoperative complications of cataracts surgery?

A

Capsular tear - causes vitreous loss or dislocation of lens fragments into vitreous cavity

Zonular dehiscence

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80
Q

what are 4 postoperative complications of cataracts surgery?

A

Posterior capsule opacification - most frequent - lens epithelial cells proliferate and migrate onto posterior capsule - YAG laser capsulotomy required for treatment

Cystoid macular oedema - fluid accumulation in macula - Tx steroid and NSAIDs

Endophthalamitis

Intraocular lens dislocation - surgery required to correct

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81
Q

where does the central retinal artery branch from?

A

Internal carotid artery branches to ophthalmic artery which branches to central retinal artery

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82
Q

what are 2 causes of central retinal artery occlusion?

A

Atherosclerosis - most common
Giant cell arteritis

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83
Q

what are 7 Risk factors for central retinal artery occlusion?

A

RF for CVD - HTN, Smoking, Diabetes, raised cholesterol

RF for GCA - White, Older age, female, polymyalgia rheumatic

84
Q

what is relative afferent pupillary defect?

A

when pupil in affected eye constricts more when light is shone in other eye than when it is shone in affected eye

85
Q

what is the clinical presentation of central retinal artery occlusion?

A

Sudden painless loss of vision

86
Q

what 2 things will be seen on fundoscopy in central retinal artery occlusion?

A

Pale retina - due to lack of perfusion
Cherry red spot on retina - thinned fovea showing red choroid below

87
Q

what are 4 differentials for sudden (acute) painless vision loss?

A

Retinal detachment
Central retinal artery occlusion
Vitreous Haemorrhage
Retinal detachment

Amaurosis fugal describes a temporary loss of vision caused by interruption to blood flow

88
Q

what are 3 differentials for visual loss over hours to days?

A

Anterior ischaemic optic neuropathy
Central retinal vein occlusion
Glaucoma - acute angle close

89
Q

what are 2 differentials for visual loss over days to weeks?

A

Optic neuritis
Wet macular degeneration

90
Q

what are 4 differentials for visual loss over months to years?

A

Glaucoma - open angle
Dry age related macular degeneration
diabetic retinopathy
cataracts

91
Q

what is the management of central retinal artery occlusion?

A

GCA Tx if cause - High doe steroids

Ocular massage

Intra-arterial thrombolysis - urokinase administered directly though ophthalmic artery catheterisation

Vasodilatory therapy -I nhaled Carbogen, ublingual isosorbide dinitrate, oral pentoxifylline

Reduction of intraocular pressure - anterior chamber paracentesis, medications

92
Q

what is the secondary prevention of central retinal artery occlusion?

A

Carotid source of emboli - carotid enartectomy if stenosis >50%

Cardiac source of emboli - long term anticoagulant

uncertain aetiology - anti platelets and atherosclerosis risk factor modifications

93
Q

where do the retinal veins drain?

A

Drain into central retinal vein which runs through optic nerve then into either superior ophthalmic vein or cavernous sinus

94
Q

what is retinal vein occlusion?

A

blockage of retinal vein cabin venous congestion in retina and increased pressure leading to blood leakage into retina causing macula oedema and retinal haemorrhages leading to retinal damage and vision loss

95
Q

what are 7 risk factors for retinal vein occlusion?

A

HTN
High cholesterol
Diabetes
Smoking
High plasma viscosity
Myeloproliferative disorders
Inflammatory conditions

96
Q

what is the presentation of retinal vein occlusion?

A

painless blurred vision or vision loss

97
Q

what is seen on fundoscopy in retinal vein occlusion? 6

A

Dilated tortuous retinal veins
Flame/Blot haemorrhages - stormy sunset appearance
Retinal oedema
Cotton wool spots
Hard exudates

98
Q

what is the management of retinal vein occlusion?

A

treatment of macular oedema and prevention of neovascularisation using anti-VEGF therapies, Intravitreal dexamethasone and laser photocoagulation of new vessels

99
Q

what is the sclera?

A

the outer layer of connective tissue surrounding most of the eye excluding the cornea

100
Q

What is a complication of scleritis?

A

can become necrotising scleritis and lead to scleral perforation

101
Q

what is the presentation of scleritis?

A

severe painful red eye
congested vessels
Pain with eye movement
photophobia and watering
reduced visual acuity
tender on palpation

102
Q

what are 3 causes of scleritis?

A

Autoimmune disease - RA, LSE, Vasculitis
Infection
Trauma

103
Q

what are 4 complications of scleritis?

A

Corneal thinning
cataracts
glaucoma
scleral perforation

104
Q

what is the management of scleritis?

A

referral to Ophthalmology

NSAIDs
Steroids
Immunosuppresion - if caused by autoimmune condition
Abx

105
Q

what is episcleritis?

A

Non-paiful inflammation of the outermost layer of the sclera just below the conjunctiva

Common in young and middle aged adults and associated with inflammatory disorders

106
Q

what can be used to differentiate between episcleritis and scleritis?

A

phenylephrine eye drops - causes blanching of episcleral vessels causing redness to disappear in episcleritis

107
Q

what are the 3 most common organisms to cause infective keratitis?

A

pseudomonas aeruginosa - creamy white corneal infiltrates
Staph aureus
herpes simplex virus

Fungi and parasites less commonly

108
Q

what is keratitis?

A

a severe corneal infection caused by pathogens

109
Q

what is the presentation of Infective keratitis? 5

A

painful red eye
photophobia
Reduced visual acuity
Visible corneal infiltrate
eye watering

110
Q

what are 7 complications of infective keratitis?

A

corneal scaring
perforation
endophthalmitis
blindness
cataracts formation
secondary glaucoma
scleritis and episcleritis

111
Q

what are 5 risk factors for infective keratitis?

A

Contact lens use
ocular surface disease - dry eyes, blepharitis, meibomian gland dysfunction
trauma
previous ocular surgery
Impaired immunity

112
Q

what can be used to confirm infective keratitis?

A

corneal scrapings for MCS

113
Q

what antibiotics are used in infective keratitis?

A

Fluoroquinolones - ciprofloxacin, levofloxacin, gemifloxacin

114
Q

what is keratitis?

A

inflammation of the cornea

115
Q

what is the most common microbial cause of keratitis?

A

HSV-1

116
Q

what causes recurrent Herpes simplex keratitis?

A

HSV virus becomes latent in trigeminal ganglion and can reactive

117
Q

what is required to diagnose keratitis?

A

Slit lamp examination

118
Q

what is seen on slit lamp exam in Herpes simplex keratitis?

A

fluorescein staining shows dendritic corneal ulcer - branching ulcer

119
Q

what is the management of Herpes simplex keratitis?

A

topical or oral antivirals - aciclovir PO 200mg 5x a day 5 days or Eye ointment 1cm 5x daily until 3 days after healed

or ganciclovir

120
Q

what is a surgical option to manage keratitis complications?

A

Corneal transplant for scaring and vision loss

121
Q

what can be used to visualise corneal abrasions?

A

Fluorescein eye drops - stains abrasions yellow to naked eye

especially evident under cobalt blue light

122
Q

what are 3 different types of lubricating eye drops?

A

Hypromellose - least viscus - 10 minute effect
Polyvinyl alcohol - middle viscus
Carbomer - most viscus - 30-60 minute effect

123
Q

what are 5 presentations of corneal abrasion?

A

painful red eye
photophobia
foreign body sensation
epiphora - excessive tearing
blurred vision

124
Q

what is hyphema?

A

blood in the anterior chamber of the eye in front of iris

urgent ophthalmology referral

125
Q

what are 4 features of hyphema?

A

eye pain/swelling
proptosis
rockhard eyelids
relevant afferent pupillary defect

126
Q

what is the emergency management of hyphema?

A

lateral canthotomy - surgery to lateral cantos (corner or eye) incision made to relieve fluid pressure and decrease IOC pressure

127
Q

what are 4 risk factors for Subconjunctival haemorrhage?

A

heavy coughing
weight lifting
straining while constipated
trauma to eye

HTN
Bleeding disorders
Whooping cough
Meds - antiplatelets/coagulants
NAI

128
Q

what is the presentation of a subconjuctival haemorrhage?

A

bright red blood under conjunctiva covering white of eye - painless and does not affect vision

129
Q

How long does it take Subconjunctival haemorrhages to resolve?

A

2 weeks

130
Q

what is retinal detachment?

A

neurosensory layer of retina with photoreceptors and nerves separates from retinal pigment epithelium usually due to retinal tear allowing vitreous fluid between the two layers

neurosensory layer relies on supply from choroid so detachment can cause permanent damage

131
Q

what are 7 risk factors for retinal detachment?

A

Lattice degeneration
posterior vitreous detachment
trauma
diabetic retinopathy
retinal malignancy
Fhx
Myopia

132
Q

what are 3 presentations of retinal detachment?

A

Painless peripheral vision loss, loss of visual fields - described as shadow coming across vision
Blurred or distorted vision
flashers and floaters

133
Q

what is the management of retinal tears?

A

layer therapy or cryotherapy

134
Q

what is the management of retinal detachment?

A

vitrectomy - keyhole surgery to remove vitreous fluid and fix tear, add gas to hold retina in place

scleral buckle - silicone buckles to put pressure on sclera from outside eye to reconnect layers

pneumatic retinopexy - injecting gas bubbles into vitreous body to press layers back together

135
Q

what are 3 presentations of conjunctivitis?

A

red blood shot painless eyes
itchy/gritty sensation
discharge

136
Q

what is the presentation of bacterial versus viral conjunctivitis?

A

bacterial more purulent discharge worse in morning

viral discharge usually clear and concurrent with other viral illness, raised pre auricular lymph nodes

137
Q

what are 7 causes of an acute painful red eye?

A

Acute angle closure glaucoma
anterior uveitis
scleritis
corneal abrasion/ulceration
keratitis
foreign body
trauma/chemicals

138
Q

what are 3 causes of an acute painless red eye?

A

conjunctivitis
episcleritis
Subconjunctival haemorrhage

139
Q

what can be given manage bacterial conjunctivitis? (same in children and adults)

A

chloramphenicol 0.5% - 1 drop ever 2 hours reducing for 48 hours after healing

Fuscidic acid eye drops 1% - BD - SAFE IN PREGNANCY

140
Q

what advice should be given to contact lens wearers with conjuctivitis?

A

Stop wearing lenses
bathe eyelids with cooled boiled water on cotton wool
Avoid contact lenses till symptoms have cleared

141
Q

What are 7 red flags in a red eye Hx requiring immediate referral to ophthalmology?

A

Reduced visual acuity
Marked eye pain, headache or photophobia
Neonate (<30 days)
Hx of trauma/possible foreign body
Copius rapidly progressive discharge - ?gonorrhoea
Herpes virus infection
Soft contact lens use with corneal symptoms - watering, photophobia

142
Q

what are 4 common bacterial causes of conjunctivitis?

A

S aureus
Strep pneumoniae
Haemophilus influenzae
Mortadella catarrali

143
Q

what is the most common viral cause of conjunctivitis?

A

adenovirus

144
Q

who should be referred to ophthalmology immediately with conjunctivitis?

A

Neonates - ophthalmia neonatorium

Can be due to chlamydia/gonorrhoea infection

145
Q

what is anterior uveitis?

A

inflammation of the anterior uvea which includes iris, ciliary body and choroid

146
Q

what are 5 causes of anterior uveitis?

A

autoimmune - most common
Infection
trauma
ischaemia
malignancy

147
Q

what are 4 autoimmune conditions associated with anterior uveitis?

A

seronegative spondyloarthropathies - HLA-B27
IBD
Sarcoidosis
behcet’s disease

148
Q

what are 4 symptoms of anterior uveitis?

A

Painful red eye - dull achy
Photophobia
Reduced visual acuity
excessive lacrimation

149
Q

what are 4 findings in anterior uveitis?

A

Ciliary flush - red ring from cornea outwards
Miosis
Abnormally shaped pupil due to adhesions
Hypopyon - collection of inflammatory cells as white fluid in anterior chamber

150
Q

what is the management of anterior uveitis?

A

1 - corticosteroids

AND Cycloplegics - Cyclopentolate or atropine 1% eye drops - to dilate pupil and reduce Hilary spasm pain

recurrence may require DMARDS or anti TNF meds

151
Q

what are 5 complications of anterior uveitis?

A

posterior synechiae - adhesions between iris and lens leading to pupil distortion and angle closure glaucoma

Cataracts
glaucoma
Cystoid macular oedema
Band keratopathy

152
Q

what is the presentation of optic neuritis? 6

A

sudden onset vision loss
painful eye movements
changes in colour perceptions - dyschromatopsia
Relative afferent pupillary defect
visual field defects
impaired light adaption

153
Q

what are 2 risk factors for thyroid eye disease?

A

smoking
radioiodine treatment

154
Q

what is the pathophysiology of thyroid eye disease?

A

Autoimmune response against auto antigen on THS receptor expressed on bothy thyroid follicular cells and orbital fibroblasts

Increased production of cytokines and chemokine promoting inflammatory cell infiltration

Inflammation results in glycosaminoglcan and collagen deposit in extra ocular muscles and connective tissues

155
Q

what are 5 presentations of thyroid eye disease?

A

Exophthalmos (proptosis) - eyes bulging out
conjunctival oedema
Optic disc swelling
Ophthalmoplegia - paralysis of eye muscles

may have any thyroid level - eu, hypo, hyper

156
Q

what is the management of thyroid eye disease?

A

topical lubricants
Corticosteroids

radiotherapy
surgery - orbital decompression if there is optic nerve compression due to oedema

157
Q

what are 6 red flags for referral to ophthalmology in thyroid eye disease?

A

Unexplained deterioration in vision
Change in colour vision
eye ‘popping out’ - globe sublaxation
obvious corneal opacity
cornea visible with eyes closed
disc swelling

158
Q

what are 3 complications of thyroid eye disease?

A

Exposure keratopathy - most common due to corneal exposure
Optic neuropathy
Strabismus and diplopia - due to fibrosis of extraoccular muscles

159
Q

what is the usual presentation of a corneal foreign body?

A

pain, tearing, redness, photophobia, foreign body sensation

160
Q

when should corneal foreign body presentations be referred to ophthalmology?

A

Suspected penetrating eye injury/high velocity mechanism
significant oribital/periorbital trauma
Foreign body near centre of cornea
Foreign body composed of organic material - higher infection risk
chemical injury

161
Q

what is the management of corneal foreign body?

A

Topical anaesthesia - proparacaine hydrochlorine 0.5% or tetracaine hydrochloride 1%

Irrigation
Needle technique
Jeweller’s forceps
Buratto technique

Abx prophylaxis - chloramphenicol 0.5% or ofloxacin 0.3%
Cycloplegia (cyclopentolate hydrochloride 1%) for cilliary spasm
Analgesia
Tetanus prophylaxis

162
Q

what is concomitant strabismus?

A

Due to imbalance in extra ocular muscle strength

convergent more common than divergent

163
Q

what is paralytic strabismus?

A

due to paralysis of extra ocular muscle(s)

164
Q

why are eye patches used in squint?

A

to prevent amblyopia - where brain favours use of one eye and fails to process input from other eye

165
Q

what is esotopia?

A

inward positioned squint

166
Q

what is exotropia?

A

outward positioned squint

167
Q

what is hypertropia?

A

upwards moving affected eye in squint

168
Q

what is hypotonia?

A

downward moving affected eye in squint

169
Q

what are 5 causes of squint?

A

Idiopathic
Hydrocephalus
Cerebral palsy
space occupying lesion
trauma

170
Q

what tests can be used to identify squint?

A

Hirschberg’s test - shine pen torch 1m away from patient, observe reflection of light - should be central and symmetrical, deviation indicates squint

cover test to identify type of squint

171
Q

until what age are the visual fields developing?

A

8 years

172
Q

what is the management of squint?

A

occlusive patch to cover good eye
atropine drops in good eye to blur vision

173
Q

What is posterior vitreous detachment?

A

when the vitreous body comes away from retina

Common in older age

174
Q

what are 3 presentations of posterior vitreous detachment?

A

Floaters
Flashing lights
Blurred vision

Can be completely asymptomatic

175
Q

what is the management of posterior vitreous detachment?

A

No treatment necessary - symptoms improve over time as brain adjusts

Predisposes patients to retinal tears and retinal detachment - can present with similar flashers and floaters

176
Q

what are floaters?

A

small, dark shadowy shapes that drift into field of vision

Usually caused by age related changes to vitreous humour

177
Q

what are flashes?

A

brief sensation of light that can occur when the retina receives a non-light induced simulation

Associated with posterior vitreous detachment, retinal breaks and retinal detachment

rarely - optic neuritis, ocular migraines occipital lobe infarct

178
Q

what is monocular diplopia?

A

persists even when one eye is closed
often due to refractive errors, corneal abnormalities, lens dislocation or cataracts

179
Q

what is binocular diplopia?

A

disappears when one eye is closed

usually due to strabismus, CN palsies, thyroid eye disease, Myasthenia graves or orbital lesions

180
Q

what are 3 differentials for monocular diplopia?

A

Keratoconus - corneal disorder

Cataracts - opacities scatter light leading to double vision

Retrobulbar lesions - optic neuritis

181
Q

What are 3 causes of binocular diplopia?

A

CN palsies - CNIII, IV, VI
Neuromuscular junction disorders - Myasthenia graves, Lambert eaton syndrome
Extraocular muscle disorders - Thyroid eye disease, orbital myositis

182
Q

what is the pathophysiology of diabetic retinopathy?

A

Hyperglycaemia damages retinal small vessels and endothelial cells

increased vascular permeability leads to leaking blood vessels, blot haemorrhages and hard exudates in the retina

damage to blood vessel wall leads to micro aneurysms and venous beading

Damage to nerve fibres in the retina cause fluffy white cotton wool spots in retina

intraretinal microvascular abnormalities - dilated tortuous capillaries in retina - shunt between arterial and venous vessels

Neovascularisation due to vascular endothelial growth factor stimulating new blood vessels

183
Q

what is the grading of diabetic retinopathy?

A

Background - micro aneurysms, retinal haemorrhages, hard exudates and cotton wool spots

Pre-proliferative - venous beading, multiple blot haemorrhages, intraretinal microvascular abnormalities

Proliferative - neovascularisation and vitreous haemorrhage

184
Q

what are 7 complications of diabetic retinopathy?

A

vision loss
retinal detachment
vitreous haemorrhage
rubeosis iris
glaucoma
optic neuropathy
cataracts

185
Q

what is the management of non-proliferative diabetic retinopathy?

A

close monitoring and good diabetic control

186
Q

what is diabetic maculopathy?

A

macular oedema caused by leakage from damaged capillaries

187
Q

what are 7 risk factors for diabetic eye disease?

A

poor glycemic control
longer duration of diabetes
hypertension
dyslipidaemia
nephropathy
smoking
poor diet and obesity

188
Q

what are 5 presenting features of diabetic eye disease?

A

Asymptomatic
Vision changes - blurred, fluctuating
Floaters - due to vitreous haemorrhage from new vessel formation
Sudden visual loss - vitreous haemorrhage
Gradual vision loss

189
Q

what examination findings are seen in diabetic eye disease?

A

fundus
- micro aneurysm
dot and blot haemorrhages
hard exudates
cotton wool spots
venous beading
intraretinal microvascular abnormalities

Macular oedema

new vessel formation

190
Q

what 5 investigations are used assessing diabetic eye disease?

A

Fundus photography
Fluorescein Angiography
Optical coherence tomography
Tonometry - DM increases risk of glaucoma
Hba1c and lipids

191
Q

How often should people with diabetes get their eyes tested?

A

every year after the age of 12 or 5 years since diagnosis for T1DM

Every year from diagnosis in T2DM

192
Q

what is the management of proliferative diabetic eye disease?

A

Pan-retina photocoagulation - laser treatment to suppress new vessels
Anti-VEGF intravitreal medications
Vitreoretinal surgery

193
Q

what blood pressure treatment is used in diabetes?

A

ACEi

194
Q

what is the name of the anti-VEGF medication licensed for diabetic retinopathy?

A

ranibizumab

195
Q

what is a signs of allergic conjunctivitis?

A

bilateral, itchy , sore swollen eyelids

Sign - papillae under lids

196
Q

what isthe management of allergic conjunctivitis?

A

antihistamine drops
mass stell stabilisers
topical steroids

197
Q

what nucleus does the optic tract terminate in and where in the brain is it?

A

Lateral geniculate nucleus

thalamus

198
Q

where is the defect in an ipsilateral monocular blindness?

A

lesion of that sided optic tract pre-optic chiasm

199
Q

what are 5 causes of monocular blindness?

A

Optic neuritis
amaurosis fugax
optic atrophy
retrobulbar optic neuropathy
Trauma

200
Q

where is the defect in a bilateral temporal hemianopia?

A

optic chiasm

201
Q

what are 2 causes of bilateral hemianopia?

A

pituitary adenoma
suprasellar aneurysm

202
Q

where is the defect in an superior (upper) homonymous quadrantanopia?

A

Superior defects = Temporal (myers) optic radiation defects

203
Q

where is the defect in an inferior (lower) homonymous quadrantanopia?

A

inferior = Parietal lobe optic radiation defects

204
Q

How do you remember what optic radiation supplied superior or inferior visual fields?

A

PITS

Parietal
Inferior
Temporal
Superior

205
Q

what is the most common cause of homonymous quadrantinopias?

A

occipital lobe lesions

206
Q

what is a key feature of optic lobe lesion visual field defects?

A

MACULAR SPARING

Phase 4 (22 decks)

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