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Ophthalmology Flashcards

1
Q

Most common cause of blindness in 35-65 y/o?

A

Diabetic retinopathy

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2
Q

Diabetic retinopathy classification?

A
  1. Non-proliferative (NPDR)
  2. Proliferative (PDR)
  3. Maculopathy
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3
Q

NPDR classification?

A
  1. Mild
  2. Moderate
  3. Severe
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4
Q

Mild NPDR?

A

1 or more microaneurysms

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5
Q

Moderate NPDR?

A
  1. Microaneurysms
  2. Blot haemorrhages
  3. Hard exudates
  4. Soft exudates = cotton wool spots (areas of retinal infarction), venous beading/looping and intraretinal microvascular abnormalities (IRMA) less severe than in severe NPDR
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6
Q

Severe NPDR?

A
  1. Blot haemorrhages and microaneurysms in 4 quadrants
  2. Venous beading in at least 2 quadrants
  3. IRMA in at least 1 quadrant
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7
Q

Proliferative DN?

A
  1. Retinal neovascularisation - may lead to vitrous haemorrhage
  2. Fibrous tissue forming anterior to retinal disc
  3. More common in Type I DM, 50% blind in 5 years
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8
Q

Diabetic maculopathy?

A
  1. Based on location rather than severity, anything is potentially serious
  2. Hard exudates and other ‘background’ changes on macula
  3. Check visual acuity
  4. More common in T2DM
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9
Q

Diabetic retinopathy all pts Rx

A
  1. Optimise glycaemic control, BP and hyperlipidaemia
  2. Regular review by ophthalmoplegia
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10
Q

Diabetic maculopathy Rx?

A

If there is change in visual acuity –> Intravitreal VEGF inhibitor

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11
Q

Diabetic NPR Rx?

A
  1. Regular observation
  2. If severe/very severe consider panretinal laser photocoagulation
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12
Q

Diabetic PR Rx?

A
  1. Panretinal laser photocoagulation
  2. Intravitreal VEGF inhibitors = often used in combination with PRLP, e.g. ranibizumab
  3. If severe or vitreous haemorrhage –> vitreoretinal surgery
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13
Q

Iritis AKA?

A

Anterior uveitis

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14
Q

Anterior uveitis definition?

A

Inflammation of the anterior portion of the uvea - the iris and ciliary body

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15
Q

Anterior uveitis association?

A

HLA-B27 linked conditions
1. Ankylosing spondylitis
2. Reactive arthritis
3. IBD
4. Behcet’s disease
5. Sarcoidosis: bilateral disease

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16
Q

Anterior uveitis features?

A
  1. Acute onset
  2. Ocular discomfort and pain (may increase with use)
  3. Pupil may be small +/- irregular due to sphincter muscle contraction
  4. Photophobia (often intense)
  5. Blurred vision, red eye, lacrimation
  6. Ciliary flush = a ring of red spreading outwards
  7. Hypopyon = pus and inflammatory cells in the anterior chamber, often resulting in a visible fluid level
  8. Visual acuity initially normal –> impaired
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17
Q

Anterior uveitis Rx?

A
  1. Urgent ophthalmology review
  2. Cycloplegics (dilates the pupil which helps to relieve pain and photophobia) = atropine, cyclopentolate
  3. Steroid eye drops
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18
Q

Most common cause of blindness in the UK?

A

Age-related macular degeneration (ARMD)

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19
Q

ARMD mushkies?

A

Degeneration of the central retina (macula) is the key feature with changes usually bilateral. ARMD is characterised by degeneration of retinal photoreceptors that results in the formation of drusen which can be seen on fundoscopy and retinal photography. It is more common with advancing age and is more common in females.

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20
Q

ARMD RFs?

A
  1. Age
  2. Smoking
  3. FHx
  4. IHD = HTN, lipids, DM
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21
Q

ARMD classification?

A
  1. Dry = 90%, AKA atrophic, drusen (yellow round spots in Bruch’s membrane)
  2. Wet = 10%, AKA exudative/neovascular, characterised by choroidal neovascularisation, leakage of serous fluid and blood can subsequently result in a rapid loss of vision, carries the worst prognosis
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22
Q

ARMD updated classification?

A
  1. Early ARMD (non-exudative, age-related maculopathy): drusen and alterations to the retinal pigment epithelium (RPE)
  2. Late ARMD (neovascularisation, exudative)
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23
Q

ARMD features?

A

Subacute onset of visual loss with:
1. Reduction in visual acuity, particularly for near field objects (gradual in dry ARMD, subacute in wet ARMD)
2. Difficulty in dark adaptation with an overall deterioration in vision at night
3. Fluctuations in visual disturbance which may significantly vary from day to day
4. Photopsia = a perception of flickering or flashing lights, and glare around objects
5. Charles Bonnet syndrome

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24
Q

ARMD signs?

A
  1. Distortion of line perception may be noted on Amsler grid testing
  2. Fundoscopy = drusen, may become confluent in late disease to form a macular scar
  3. In wet ARMD well demarcated red patches may be seen which represent intra-retinal or sub-retinal fluid leakage or haemorrhage
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25
Q

ARMD Ix?

A
  1. Slit-lamp = 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
  2. Fluorescein angiography = used 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
  3. Ocular 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
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26
Q

ARMD Rx?

A
  1. Zinc with Vitamins A,C,E reduce disease progression by 1/3rd
  2. Anti-VEGF for wet ARMD, within first 2m of diagnosis if possible
  3. Laser photocoagulation does slow progression, but risk of acute visual loss after treatment, therefore anti-VEGF therapies usually preferred
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27
Q

Anti-VEGF agents?

A

Usually administered by 4 weekly injection
1. Ranibizumab
2. Bevacizumab
3. Pegaptanib

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28
Q

Amsler grid testing?

A

ARMD - distortion of line perception

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29
Q

Holmes-Adie pupil mushkies?

A
  1. Benign condition most commonly seen in women
  2. Dilated pupil, once the pupil has constricted it remains small for an abnormally long time
  3. Slowly reactive to accommodation but very poorly (if it all) to light
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30
Q

Holmes-Adie syndrome?

A

Association of Holmes-Adie pupil with absent ankle/knee reflexes

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31
Q

Blepharitis?

A

Inflammation of the eyelid margins.

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32
Q

Causes of blepharitis?

A
  1. Meibomian gland dysfunction = common, posterior blepharitis
  2. Seborrheoic dermatitis/staphylococcal infection (less common, anterior blepharitis)
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33
Q

Blepharitis association?

A

Rosacea

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34
Q

Meibomian gland function?

A

Secrete oil onto 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

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35
Q

Blepharitis features?

A
  1. Usually bilateral grittiness and discomfort, particularly around eyelid margins
  2. Eyes may be sticky in the morning
  3. Eyelid margins may be red, swollen eyelids may be seen in staphylococcal blepharitis
  4. Styes and chalazions are more common in pts with blepharitis
  5. Secondary conjunctivitis may occur
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36
Q

Blepharitis Rx?

A
  1. Softening of lid margins using hot compresses BD
  2. 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
  3. Artificial tears may be given for symptom relief in people with dry eyes or an abnormal tear film
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37
Q

How to differentiate scleritis from episcleritis?

A

Scleritis is painful

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38
Q

Scleritis features?

A
  1. Red eye
  2. Classically painful, but sometimes only mild pain/discomfort is present
  3. Watering and photophobia common
  4. Gradual decrease in vision
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39
Q

Fixed dilated pupil with conjunctival injection?

A

Acute closed-angle glaucoma

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40
Q

Glaucoma definition?

A

Glaucoma is a group of disorders characterised by optic neuropathy due, in the majority of patients, to raised intraocular pressure (IOP). It is now recognised that a minority of patients with raised IOP do not have glaucoma and vice versa

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41
Q

Acute angle-closure glaucoma (AACG) definition?

A

Rise in IOP secondary to an impairment of aqueous outflow

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42
Q

AACG predisposing factors?

A
  1. Hypermetropia (long sightededness)
  2. Pupillary dilatation
  3. Lens growth associated with age
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43
Q

AACG features?

A
  1. Severe pain = may be ocular or headache
  2. Decreased visual acuity
  3. Symptoms worse with mydriasis (e.g. watching TV in dark room)
  4. Hard, red-eye
  5. Haloes around lights
  6. Semi-dilated non-reacting pupil
  7. Corneal oedema results in dull or hazy cornea
  8. Systemic upset may be seen e.g. N&V and even abdominal pain
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44
Q

AACG Rx Principles?

A

Emergency, refer to ophthalmologist, need to lower IOP acutely with more definitive surgical Rx once acute attack has settle

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45
Q

AACG Acute Rx?

A

Combination of eye drops:
1. Pilocarpine = direct sympathomimetic, contraction of the ciliary muscle → opening the trabecular meshwork → increased outflow of the aqueous humour
2. Timolol = BB, decreases aqueous humour production
3. Apraclonidine = A2 agonist, dual mechanism, decreases aqueous humour production and increases uveoscleral outflow

Also: IV Acetazolamide = reduces aqueous secretions

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46
Q

AACG Definitive Rx?

A

Laser peripheral iridotomy = creates tiny hole in the peripheral iris –> aqueous humour flowing to the angle

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47
Q

Chorioretinitis which test must be done?

A

HIV

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48
Q

Chorioretinitis causes?

A
  1. Syphilis
  2. CMV
  3. Toxoplasmosis
  4. Sarcoidosis
  5. TB
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49
Q

Orbital cellulitis definition?

A

An infection affecting the fat and muscles posterior to the orbital septum, within the orbit but not involving the globe. It is usually caused by a spreading upper respiratory tract infection from the sinuses and carries a high mortality rate. Orbital cellulitis is a medical emergency requiring hospital admission and urgent senior review.

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50
Q

Periorbital cellulitis definition?

A

A less serious superficial infection anterior to the orbital septum, resulting from a superficial tissue injury (chalazion, insect bite etc…). Periorbital cellulitis can progress to orbital cellulitis.

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51
Q

Orbital cellulitis RFs?

A
  1. Childhood = mean age of hospitalisation 7-12 years
  2. Previous sinus infection
  3. Not HiB vaccinated
  4. Recent eyelid infection/insect bite on eyelid (periorbital cellulitis)
  5. Ear or facial infection
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52
Q

Orbital cellulitis presentation?

A
  1. Redness and swelling around the eye
  2. Severe ocular pain, visual disturbance, proptosis
  3. Ophthalmoplegia/pain with eye movements
  4. Eyelid oedema and ptosis
  5. Drowsiness +/- N&V in meningeal involvement (rare)
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53
Q

Differentiating orbital from preseptal cellulitis?

A

Reduced visual acuity, proptosis, ophthalmoplegia/pain with eye movements are NOT consistent with preseptal cellulitis

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54
Q

Orbital cellulitis Ix?

A
  1. FBC
  2. Clinical examination involving complete ophthalmological assessment = decreased vision, RAPD, proptosis, dysmotility, oedema, erythema
  3. CT with contrast = Inflammation of the orbital tissues deep to the septum, sinusitis
  4. Blood culture and swab to determine causative organism
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55
Q

Most common bacterial causes of orbital cellulitis?

A

Strep, Staph A, HiB

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56
Q

Orbital cellulitis Rx?

A

Admission for IV Abx

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57
Q

Orbital compartment syndrome Rx?

A

Immediate canthotomy

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58
Q

Hyphaema?

A

Blood in the anterior chamber of the eye

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59
Q

Hyphema Rx?

A

Urgent referral to ophthalmology (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)

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60
Q

Orbital compartment syndrome cause?

A

E.g. Retrobulbar haemorrhage

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61
Q

Orbital compartment syndrome featrues?

A
  1. Eye pain/swelling
  2. Proptosis
  3. Rock-hard eyelids
  4. RAPD
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62
Q

B-scan US?

A

Imaging technique to look at posterior compartment of the eye, helpful for retinal detachment or posterior vitreous haemorrhage

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63
Q

Immediate IV acetazolamide used for?

A

AACG

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64
Q

Sore, red eyes with sticky discharge?

A

Conjunctivitis - either viral or bacterial

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65
Q

Bacterial conjunctivitis features?

A

Purulent discharge, eyes may be ‘stuck together’ in the morning

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66
Q

Viral conjunctivitis features?

A

Serious discharge, recent URTI, preauricular lymph nodes

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67
Q

Infective conjunctivitis Rx?

A
  1. Usually self-limiting 1-2 weeks
  2. Chloramphenicol drops 2-3h or ointment QDS
  3. Topical fusidic acid BD for pregnant women
  4. Contact lens users = topical fluorescein to identify any corneal staining, lenses should not be work
  5. Don’t share towels
  6. School exclusion not necessary
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68
Q

Optic neuritis causes?

A
  1. MS (most common associated disease)
  2. DM
  3. Syphilis
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69
Q

Optic neuritis features?

A
  1. Unilateral decrease in visual acuity over hours or days
  2. Poor discrimination of colours, ‘red desaturation’
  3. Pain worse on eye movement
  4. RAPD
  5. Central scotoma
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70
Q

Red desaturation?

A

Optic neuritis

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71
Q

Optic neuritis Ix?

A

MRI brain and orbits with gadolinium contrast

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72
Q

Optic neuritis Rx?

A
  1. High dose steroids
  2. Recovery usually takes 4-6 weeks
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73
Q

Optic neuritis prognosis?

A

MRI: If >3 white matter lesions, 5 year risk of developing MS is 50%

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74
Q

Most common cause of a persistent watery eye in an infant?

A

Nasolacrimal duct obstruction

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75
Q

Nasolacrimal duct obstruction cause?

A

Imperforate membrane, usually at the lower end of the lacrimal duct. 1/10 have symptoms at 1m/o.

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76
Q

Nasolacrimal duct obstruction Rx?

A
  1. Teach parents to massage lacrimal duct
  2. Symptoms resolve in 95% by 1 y/o, unresolved cases should be referred to an ophthalmologist for consideration of probing, which is done under a light general anaesthetic
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77
Q

Eyelid problems?

A
  1. Blepharitis = inflammation of the eyelid margins typically leading to a red eye
  2. Stye = infection of the glands of the eyelids
  3. Chalazion = Meibomian cyst
  4. Entropion = in-turning of the eyelids
  5. Ectropion = out-turning of the eyelids
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78
Q

What is a Chalazion/Meibomian cyst?

A

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

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79
Q

Stye classification?

A
  1. External = hordeolum externum = infection (usually staphylococcal) of the glands of Zeis (sebum producing) or glands of Moll (sweat glands)
  2. Internal = hordeolum internum = infection of the Meibomian glands, may leave a residual chalazion
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80
Q

Stye Rx?

A
  1. Hot compresses and analgesia
  2. Topical Abx only if associated conjunctivitis
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81
Q

Transient monocular visual loss (TMVL)?

A

Sudden, transient loss of vision that lasts less than 24 hours

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82
Q

Most common causes of sudden painless loss of vision?

A
  1. Ischaemic/vascular
  2. Vitreous haemorrhage
  3. Retinal detachment
  4. Retinal migraine
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83
Q

Ischaemic/vascular visual loss?

A
  1. AKA Amaurosis fugax
  2. 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
  3. May represent a form of TIA, so Rx with 300mg aspirin
  4. Altitudinal field defects often seen e.g. curtain coming down
  5. Ischaemic optic neuropathy is due to occlusion of the short posterior ciliary arteries, causing damage to the optic nerve
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84
Q

Ischaemic optic neuropathy cause?

A

Occlusion of short posterior ciliary arteries

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85
Q

CRVO?

A
  1. Incidence increases with age, more common than CRAO
  2. Causes = glaucoma, polycythaemia, hypertension
  3. Severe retinal haemorrhages on fundoscopy
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86
Q

CRAO?

A
  1. Due to thromboembolism (from atherosclerosis) or arteritis (temporal arteritis)
  2. Features include RAPD, ‘cherry red’ spot on pale retina
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87
Q

Cherry red spot on pale retina?

A

CRAO

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88
Q

Vitreous haemorrhage?

A
  1. Causes = DM, bleeding disorders, anticoagulants
  2. Features may include sudden visual loss, dark spots
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5
Perfectly
89
Q

Retinal detachment?

A

Features of vitreous detachment, which may precede retinal detachment, include flashes of light or floaters

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90
Q

Differentiating between posterior vitreous detachment, retinal detachment and vitreous haemorrhage?

A
  1. PVD = flashes of light and floaters
  2. RD = Dense shadow starts peripherally and progresses towards central vision
  3. VH = sudden visual loss, numerous dark spots
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91
Q

CRAO features?

A
  1. Sudden, painless unilateral visual loss
  2. RAPD
  3. Cherry red spot on pale retina
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92
Q

CRAO Rx?

A

Rx is difficult and prognosis is poor
1. Underlying conditions should be identified and treated e.g. IV Steroids for temporal arteritis
2. If presents acutely then intraarterial thrombolysis may be attempted but currently trials show mixed results

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93
Q

Severe retinal haemorrhages on fundoscopy?

A

CRVO

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94
Q

Cheese and tomato pizza?

A

CRVO

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95
Q

CRVO risk factors?

A
  1. Age
  2. HTN
  3. CVD
  4. Glaucoma
  5. Polycythaemia
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96
Q

Stormy sunset?

97
Q

CRVO features?

A
  1. Sudden, painless reduction or loss of visual acuity, usually unilaterally
  2. Fundoscopy = widespread hyperaemia, severe retinal haemorrhages (stormy sunset)
98
Q

Key CRVO differential?

A

Branch retinal vein occlusion (BRVO) - 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

99
Q

CRVO Rx?

A
  1. Conservatively usually
  2. Indications for Rx
    a. Macular oedema = Intravitreal VEGF
    b. Retinal neovascularisation = laser photocoagulation
100
Q

Blurring of vision years after cataract surgery?

A

Posterior capsule opacification

101
Q

Cataract definition?

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

102
Q

Leading cause of curable blindness worldwide?

103
Q

Cataracts epidemiology?

104
Q

Most common cause of cataracts?

105
Q

Other causes of cataracts?

A
  1. Smoking
  2. EtOH
  3. Trauma
  4. DM
  5. Steroids
  6. Radiation
  7. Myotonic dystrophy
  8. Metabolic disorders = hypocalcaemia
106
Q

Cataracts features?

A
  1. Reduced vision
  2. Faded colour vision
  3. Glare = lights appear brighter than usual
  4. Haloes around lights
107
Q

Cataracts signs?

A

Defect in red reflex

108
Q

Cataracts Ix?

A
  1. Ophthalmoscopy = done after pupil dilation, normal fundus and optic nerve
  2. Slit lamp examination = visible cataract
109
Q

Cataract classification?

A
  1. Nuclear: change lens refractive index, common in old age
  2. Polar: localized, commonly inherited, lie in the visual axis
  3. Subcapsular: due to steroid use, just deep to the lens capsule, in the visual axis
  4. Dot opacities: common in normal lenses, also seen in diabetes and myotonic dystrophy
110
Q

Cataract Rx?

A
  1. Non-surgical = stronger glasses
  2. Surgical = 85-90% achieve 6/12 vision post-op
111
Q

Complications following cataract surgery?

A
  1. Posterior capsule opacification = thickening of lens capsule
  2. Retinal detachment
  3. Posterior capsule rupture
  4. Endophthalmitis = inflammation of aqueous and/or vitreous humour
112
Q

RAPD strongly associated with?

A

Optic neuritis

113
Q

Causes of mydriasis?

A
  1. 3rd nerve palsy
  2. Holmes-Adie
  3. Traumatic iridoplegia
  4. Phaeochromocytoma
  5. Congenital
114
Q

Drug causes of mydriasis?

A
  1. Topical mydriatics = tropicamide, atropine
  2. Sympathomimetic drugs = amphetamines, cocaine
  3. Anticholinergics = TCAs
115
Q

Argyll-Robertson Ppuil mnemonic?

A

ARP PRA (Small, irregular pupils)
Accommodation reflex present
Pupillary reflex absent

116
Q

Causes of Argyll-Robertson pupil?

A
  1. DM
  2. Syphilis
117
Q

Marcus-Gunn pupil AKA/

118
Q

RAPD lesion location?

A

Anterior to the optic chiasm i.e. optic nerve or retina

119
Q

RAPD finding?

A

Affected and normal eye appear to dilate when light shone on the affected

120
Q

RAPD causes?

A
  1. Retina = detachment
  2. Optic nerve = optic neuritis e.g. MS
121
Q

Pupillary reflex afferent pathway?

A

Retina –> Optic nerve –> LGN –> Midbrain

122
Q

Pupillary reflex efferent pathway?

A

Edinger-Westphal nucleus (midbrain) –> Oculomotor nerve

123
Q

Subconjunctival haemorrhage definition?

A

Subconjunctival haemorrhages result from the bleeding of blood vessels into the subconjunctival space. The vessels that bleed are usually the ones responsible for supplying the conjunctiva or episclera. The cause is most commonly traumatic followed by spontaneous idiopathic cases, Valsalva manoeuvres and several systemic diseases. Subconjunctival haemorrhages can look dramatic and cause worry to patients, however they are rarely an indicator of anything sinister.

124
Q

Subconjunctival haemorrhage epidemiology?

A
  1. Women > Men
  2. Newborns, elderly
  3. Incidence 2.6%
125
Q

Subconjunctival haemorrhage risk factors?

A
  1. Trauma and contact lens usage (68%)
  2. Idiopathic
  3. Valsalva
  4. HTN
  5. Bleeding disorders
  6. Aspirin, NSAIDs, anticoagulants
  7. DM
  8. Arterial disease and hyperlipidaemia
126
Q

Subconjunctival haemorrhage symptoms?

A
  1. Red eye, usually unilateral
  2. Usually asymptomatic, however mild irritation may be present
127
Q

Subconjunctival haemorrhage signs?

A
  1. Flat, red patch on the conjunctiva. It will have well-defined edges and normal conjunctiva surrounding it. Patches can vary in size depending on the size of the bleed, and can involve the whole conjunctiva
  2. Traumatic haemorrhages are most common in the temporal region (40.5%), with the inferior conjunctiva as the next most commonly affected area
  3. Vision should be normal, including acuity, visual fields and range of eye movements
  4. Fundus should be normal
128
Q

Subconjunctival haemorrhage Ix?

A
  1. Dx is clinical
  2. BP, INR
  3. Recurrent/spontaneous/bilateral –> bleeding diatheses
  4. Cannot see whole border of haemorrhage may be associated with intracranial bleed or orbital roof fracture –> CN exam, CT head, d/w senior
129
Q

Subconjunctival haemorrhage Rx?

A
  1. Usually resolves in 2-3 weeks
  2. If traumatic consider referral to ophthalmologist
  3. Contact GP if recurrent
  4. Artificial tears for a few weeks if there is any mild irritation
130
Q

Subconjunctival haemorrhage prognosis?

A

Mild, self-limiting illness and should resolve on it’s own in 2-3 weeks

131
Q

Peripheral visual field floaters?

A

Vitreous detachment

132
Q

Pizza pie on fundoscopy?

A

Chorioretinitis

133
Q

Chorioretinitis is a form of?

A

Posterior uveitis

134
Q

Red eye, photophobia, gritty sensation?

135
Q

Keratitis definition?

A

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

136
Q

Keratitis causes?

A
  1. Bacterial = S. aureus, Pseudomonas in contact lens wearers
  2. Fungal
  3. Amoebic = acanthamoebic keratitis, accounts for 5% cases, increased incidence if eye exposure to soil or contaminated water, pain is classically out of proportion to findings
  4. Parasitic = onchocercal keratitis (river blindness)
  5. Viral = Herpes simplex
  6. Environmental = Photokeratitis (welder’s arc eye), exposure keratitis, contact lens acute red eye (CLARE)
137
Q

Keratitis clinical features?

A
  1. Red eye = pain and erythema
  2. Photophobia
  3. Foreign body, gritty sensation
  4. Hypopyon may be seen
138
Q

Keratitis referral?

A

Contact lens wearers, an accurate Dx needs slit-lamp, so same day referral to eye specialist

139
Q

Keratitis Rx?

A
  1. Stop using contact lens until symptoms fully resolved
  2. Topical Abx = quinolones
  3. Cycloplegic for pain relief = cyclopentolate
140
Q

Keratitis complications?

A
  1. Corneal scarring
  2. Perforation
  3. Endophthalmitis
  4. Visual loss
141
Q

Hutchinson’s sign?

A

Vesicles extending to the tip of the nose, strongly associated with ocular involvement in shingles

142
Q

Herpes zoster ophthalmicus definition?

A

HZO describes 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.

143
Q

HZO features?

A
  1. Vesicular rash around the eye, which may or may not involve eye itself
  2. Hutchinson’s sign: rash on the tip or side of the nose. Indicates nasociliary involvement and is a strong risk factor for ocular involvement
144
Q

HZO Rx?

A
  1. Oral antiretrovirals 7-10 days, start within 72h, IV if severe/immunocompromised, topicals not given
  2. Topical corticosteroids may be used to treat secondary inflammation of the eye
  3. Ocular involvement requires urgent ophthalmology review
145
Q

HZO complications?

A
  1. Ocular = conjunctivitis, keratitis, episcleritis, anterior uveitis
  2. Ptosis
  3. Post-herpetic neuralgia
146
Q

Primary Open-Angle Glaucoma (POAG) definition?

A

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.

147
Q

POAG risk factors?

A
  1. Age
  2. Genetics
  3. Afro-Caribbean
  4. Myopia
  5. HTN
  6. DM
  7. Corticosteroids
148
Q

POAG features?

A
  1. Peripheral visual field loss - nasal scotomas progressing to ‘tunnel vision’
  2. Decreasing visual acuity
  3. Optic disc cupping
  4. Presents insidiously, often detected during routine optometry
149
Q

Fundoscopy signs of POAG?

A
  1. Optic disc cupping = cup to disc ratio > 0.7
  2. Optic disc pallor = optic atrophy
  3. Bayonetting of vessels
  4. Cup notching, disc haemorrhages
150
Q

POAG Dx?

A
  1. Case finding and provisional Dx done by optometrist
  2. Referral to ophthalmologist done via GP
  3. Final Dx done by Ix below
151
Q

POAG Ix?

A
  1. Automated perimetry to assess visual field
  2. Slit lamp examination with pupil dilatation to assess optic nerve and fundus for a baseline
  3. Applanation tonometry to measure IOP
  4. Central corneal thickness measurement
  5. Gonioscopy to assess peripheral anterior chamber configuration and depth
  6. Assess risk of future visual impairment, using risk factors such as IOP, central corneal thickness (CCT), family history, life expectancy
152
Q

Young person with tunnel vision?

A

Retinitis pigmentosa

153
Q

Retinitis pigmentosa features?

A
  1. Night blindness often initial sign
  2. Tunnel vision due to loss of peripheral retina
  3. Fundoscopy = black bone spicule-shaped pigmentation in the peripheral retina, mottling of the retinal pigment epithelium
154
Q

Retinitis pigmentosa associated diseases?

A
  1. Refsum disease, Usher syndrome
  2. Abetalipoproteinemia
  3. Lawrence-Moon-Biedl syndrome
  4. Kearns-Sayre syndrome
  5. Alport’s syndrome
155
Q

Black bone-spicule pigmentation on fundoscopy?

A

Retinitis pigmentosa

156
Q

Fixed dilated pupil with conjunctival injection?

A

Acute closed-angle glaucoma

157
Q

Haloes around lights?

A

Acute closed-angle glaucoma

158
Q

Corneal ulcer features?

A
  1. Eye pain
  2. Photophobia
  3. Watering of eye
  4. Focal fluorescein staining of the cornea
159
Q

Pain relief for corneal ulcers?

A

Oral analgesics

160
Q

Iritis AKA?

A

Anterior uveitis

161
Q

Squint definition?

A

Misalignment of the visual axes

162
Q

Squint classification?

A
  1. Concomitant (common)
  2. Paralytic (rare)
163
Q

Amblyopia definition?

A

Brain fails to fully process inputs from one eye and over time favours the other eye

164
Q

Concomitant squint?

A
  1. Due to imbalance in extraocular muscles
  2. Convergent is more common than divergent
165
Q

Paralytic squint?

A
  1. Due to paralysis of extraocular muscles
166
Q

How to test for squint?

A

Corneal light reflection test - holding a light source 30cm from the child’s face to see if the light reflects symmetrically on the pupils

167
Q

Test for the nature of a squint?

A

Cover test

168
Q

Squint Rx?

A

Referral to secondary care = eye patches may help prevent amblyopia

169
Q

Papilloedema definition?

A

Optic disc swelling caused by increased ICP, almost always bilateral

170
Q

Papilloedema on fundoscopy?

A
  1. Venous engorgement = usually the first sign
  2. Loss of venous pulsation
  3. Blurring of optic disc margin
  4. Elevation of optic disc
  5. Loss of optic cup
  6. Paton’s lines = concentric/radial retinal lines cascading from the optic disc
171
Q

Causes of papilloedema?

A
  1. SoL = neoplastic, vascular
  2. Malignant HTN
  3. IIH
  4. Hydrocephalus
  5. Hypercapnia
172
Q

Rare causes of papilloedema?

A
  1. Hypoparathyroidism and hypocalcaemia
  2. Vitamin A toxicity
173
Q

Episcleritis causes?

A
  1. Idiopathic (majority)
  2. IBD
  3. RhA
174
Q

Episcleritis features?

A
  1. Red eye
  2. Classically not painful (in comparison to scleritis), but mild pain/irritation is common
  3. Watering and mild photophobia may be present
  4. In episcleritis, injected vessels are mobile when gentle pressure is applied on the sclera (in scleritis, vessels are deeper, hence do not move)
  5. Phenylephrine drops may be used to differentiate between episcleritis and scleritis
175
Q

What drops to differentiate between episcleritis and scleritis?

A

Phenylephrine drops = blanches the conjunctival and episcleral vessels but not the scleral vessels, if the eye redness improves after phenylephrine a diagnosis of episcleritis can be made

176
Q

Episcleritis Rx?

A
  1. Conservative
  2. Artificial tears may sometimes be used
177
Q

Ocular pain, tearing and photophobia in association with corneal uptake of fluorescein?

A

Corneal ulcer

178
Q

Dense shadow starting peripherally and progressing centrally?

A

Retinal detachment

179
Q

Most common RhA ocular manifestation?

A

Keratoconjunctivitis sicca

180
Q

What % of RhA pts have ocular mnifestations?

181
Q

Ocular manifestations of RhA?

A
  1. Keratoconjunctivitis sicca (most common)
  2. Episcleritis (erythema)
  3. Scleritis (erythema and pain)
  4. Corneal ulceration
  5. Keratitis
182
Q

Iatrogenic RhA ocular manifestations?

A
  1. Steroid-induced cataracts
  2. Chloroquine retinopathy
183
Q

Anterior uveitis Rx?

A

Steroid + cycloplegic (mydriatic) drops

184
Q

Cycloplegic eye drop examples?

A

Atropine, cyclopentolate

185
Q

Intermittent squint in newborns <3m old?

186
Q

Definitive AACG Rx?

A

Laser peripheral iridotomy

187
Q

AACG acute eye drops?

A
  1. Pilocarpine
  2. Timolol
  3. Brimonidine
188
Q

Commonest cause of orbital cellulitis in children?

A

Infection of the ethmoidal sinus due to relatively thin medial wall of the orbit

189
Q

Overall deterioration in vision at night?

190
Q

Entropion Rx?

A
  1. Interim = eye lubricants and tape to pull eyelid outwards
  2. Definitive = surgery
191
Q

Corneal abrasion definition?

A

Any defect of the corneal epithelium and most commonly come about from a recent history of local trauma

192
Q

Corneal abrasion Ix?

A

Fluorescein examination typically reveals a yellow stained abrasion (representative of the de-epithelialized surface) which is usually visible to the naked eye

193
Q

Corneal abrasion Rx?

A

Topical Abx to prevent bacterial superinfection

194
Q

Pus in anterior chamber (hypopyon)?

A

Anterior uveitis

195
Q

Meibomian gland dysfunction?

A

Symptoms that are worse on wakening, eyelids sticking together on waking, and redness of the eyelids

196
Q

Rx of dry eyes?

A

Eyelid hygeine

197
Q

Dry eyes fluorescein stain?

A

Punctate fluorescein staining

198
Q

Ciliary flush?

A

Anterior uveitis

199
Q

Fixed oval pupil?

A

Anterior uveitis

200
Q

Semi dilated pupil?

201
Q

Hazy cornea?

202
Q

Primary open angle glaucoma (POAG) causes?

A
  1. Age
  2. Genetics
203
Q

Cupping of the optic disc?

204
Q

POAG Rx?

A
  1. 1st line = Prostaglandin analogue
  2. 2nd line = BB, Carbonic anhydrase inhibitor, sympathomimetic eyedrop
  3. If more advanced: surgery or laser treatment
205
Q

Prostaglandin analogue mushkies?

A
  1. Latonoprost
  2. Increases uveoscleral outflow
  3. OD
  4. S/e = brown pigmentation of iris, increased eyelash length
206
Q

Beta blocker mushkies?

A
  1. Timolol, betaxolol
  2. Reduces aqueous production
  3. Should be avoided in asthmatics and heart block
207
Q

Sympathomimetics mushkies?

A
  1. Brimonidine = alpha2 adrenoreceptor agonist
  2. Reduces aqueous production and increases outflow
  3. Avoid taking MAOI or TCA
  4. S/e = hyperaemia
208
Q

Carbonic anyhdrase inhibitor mushkies?

A
  1. Dorzolamide
  2. Reduces aqueous production
  3. Systemic absorption may cause sulphonamide-like reactions
209
Q

Miotics mushkies?

A
  1. Pilocarpine, a muscarinic receptor agonist
  2. Increases uveoscleral outflow
  3. S/e = constricted pupil, headache, blurred vision
210
Q

POAG surgery?

A

Trabeculectomy may be considered in refractory cases

211
Q

Allergic conjunctivitis features?

A
  1. Bilateral symptoms = conjunctival erythema and swelling (chemosis)
  2. Itch is prominent
  3. Eyelids may also be swollen
  4. Hx of atopy, may be seasonsal due to pollen or perennial
212
Q

Allergic conjunctivitis Rx?

A
  1. 1st line = topical or systemic antihistamines
  2. 2nd line = topical mast-cell stabilisers = sodium cromoglicate and nedecromil
213
Q

When to give topical Abx for stype?

A

If associated conjunctivitis

214
Q

Hypertensive retinopathy classification?

A

Keith-Wagener classification

215
Q

Keith-Wagener classification for hypertensive retinopathy?

A
  1. Arteriolar narrowing and tortuosity, increased light reflex = silver wiring
  2. AV nipping
  3. Cotton wool exudates and flame and blot haemorrhages (may collect around the fovea resulting in a macular star)
  4. Papilloedema
216
Q

Horner’s features?

A
  1. Miosis
  2. Ptosis
  3. Enophthalmos
  4. Anhidrosis
217
Q

Distinguishing between causes of Horner’s?

A
  1. Heterochromia = congenital HOrner’s
  2. Anhidrisos (see subsequent card)
  3. Pharmacological tests = loaclising 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
218
Q

Differentiating causes of Horners based on anhidrosis?

A
  1. Face, arm and trunk = Central lesions, SSSTe
  2. Face = Pre-ganglionic lesions, TTTC
  3. None = post-ganglionic lesions, CCCC
219
Q

Central horners lesions?

A
  1. Stroke
  2. Syringomyelia
  3. MS
  4. Tumour
  5. Encephalitis
220
Q

Pre-ganglionic Horners lesions?

A
  1. Tumour (Pancoasts)
  2. Thyroidectomy
  3. Trauma
  4. Cervical rib
221
Q

Post-ganglionic Horners lesions?

A
  1. Carotid artery dissection
  2. Carotid aneurysm
  3. Cavernous sinus thrombosis
  4. Cluster headache
222
Q

Mydriatics given before fundoscopy and then reduced visual acuity and eye pain?

223
Q

Metabolic cause of cataracts?

A

Hypocalcaemia

224
Q

Herpes simplex keratitis usually presents with?

A

Dendritic corneal ulcer

225
Q

Herpes simplex keratitis features?

A
  1. Red, painful eye
  2. Photophobia
  3. Epiphora
  4. Visual acuity may be decreased
  5. Florescein staining may show an epithelial ulcer
226
Q

Herpes simplex keratitis?

A
  1. Immediate referral to ophthalmologist
  2. Topical aciclovir
227
Q

Night blindness and tunnel vision?

A

Retinitis pigmentosa

228
Q

Fixed oval pupil?

A

Anterior uveitis

229
Q

Red eye causes?

A
  1. AACG
  2. Anterior uveitis
  3. Scleritis
  4. Subconjunctival haemorrhage
  5. Conjunctivitis
  6. Endophthalmitis = red eye, pain and visual loss following intraocular surgery
230
Q

Sudden loss of vision causes?

A
  1. Ischaemic/vascular (incl. CRAO, CRVO)
  2. Vitreous haemorrhage
  3. Retinal detachment
  4. Retinal migraine
231
Q

Tunnel vision causes?

A
  1. Papilloedema
  2. Glaucoma
  3. Retinitis pigmentosa
  4. Choroidoretinitis
  5. Optic atrophy secondary to tabes dorsalis
  6. Hysteria
232
Q

Feathery fluorescein uptake?

A

Herpes simplex keratitis

233
Q

Red desaturation?

A

Optic neuritis

234
Q

ARMD ophthalmology referral speed?

A

Within 1 week to get a formal diagnosis because if wet can receive anti-VEGF injections

235
Q

Red eye, pain and visual loss following intraocular surgery?

A

Endophthlamitis

236
Q

Endophthalmitis mushkies?

A

Endophthalmitis (infection within the globe) is a rare, sight-threatening complication of intraocular surgery and requires review by ophthalmology as soon as possible. Treatment options include systemic and intravitreal antibiotics

237
Q

Lens dislocation causes?

A
  1. Marfans = upwards
  2. Homocytinuria = downwards
  3. Ehlers Danlos
  4. Trauma
  5. Uveal tumours
  6. Autosomal recessive ectopia lentis
238
Q

Stye definition?

A

Infection of the glands of the external eyelid

239
Q

Stye definition?

A

Infection of the glands of the external eyelid

Focused 1 (25 decks)

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