Ophthalmology Flashcards
1
Q
Most common cause of blindness in 35-65 y/o?
A
Diabetic retinopathy
2
Q
Diabetic retinopathy classification?
A
- Non-proliferative (NPDR)
- Proliferative (PDR)
- Maculopathy
3
Q
NPDR classification?
A
- Mild
- Moderate
- Severe
4
Q
Mild NPDR?
A
1 or more microaneurysms
5
Q
Moderate NPDR?
A
- Microaneurysms
- Blot haemorrhages
- Hard exudates
- Soft exudates = cotton wool spots (areas of retinal infarction), venous beading/looping and intraretinal microvascular abnormalities (IRMA) less severe than in severe NPDR
6
Q
Severe NPDR?
A
- Blot haemorrhages and microaneurysms in 4 quadrants
- Venous beading in at least 2 quadrants
- IRMA in at least 1 quadrant
7
Q
Proliferative DN?
A
- Retinal neovascularisation - may lead to vitrous haemorrhage
- Fibrous tissue forming anterior to retinal disc
- More common in Type I DM, 50% blind in 5 years
8
Q
Diabetic maculopathy?
A
- Based on location rather than severity, anything is potentially serious
- Hard exudates and other ‘background’ changes on macula
- Check visual acuity
- More common in T2DM
9
Q
Diabetic retinopathy all pts Rx
A
- Optimise glycaemic control, BP and hyperlipidaemia
- Regular review by ophthalmoplegia
10
Q
Diabetic maculopathy Rx?
A
If there is change in visual acuity –> Intravitreal VEGF inhibitor
11
Q
Diabetic NPR Rx?
A
- Regular observation
- If severe/very severe consider panretinal laser photocoagulation
12
Q
Diabetic PR Rx?
A
- Panretinal laser photocoagulation
- Intravitreal VEGF inhibitors = often used in combination with PRLP, e.g. ranibizumab
- If severe or vitreous haemorrhage –> vitreoretinal surgery
13
Q
Iritis AKA?
A
Anterior uveitis
14
Q
Anterior uveitis definition?
A
Inflammation of the anterior portion of the uvea - the iris and ciliary body
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
16
Q
Anterior uveitis features?
A
- Acute onset
- Ocular discomfort and pain (may increase with use)
- Pupil may be small +/- irregular due to sphincter muscle contraction
- Photophobia (often intense)
- Blurred vision, red eye, lacrimation
- Ciliary flush = a ring of red spreading outwards
- Hypopyon = pus and inflammatory cells in the anterior chamber, often resulting in a visible fluid level
- Visual acuity initially normal –> impaired
17
Q
Anterior uveitis Rx?
A
- Urgent ophthalmology review
- Cycloplegics (dilates the pupil which helps to relieve pain and photophobia) = atropine, cyclopentolate
- Steroid eye drops
18
Q
Most common cause of blindness in the UK?
A
Age-related macular degeneration (ARMD)
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.
20
Q
ARMD RFs?
A
- Age
- Smoking
- FHx
- IHD = HTN, lipids, DM
21
Q
ARMD classification?
A
- Dry = 90%, AKA atrophic, drusen (yellow round spots in Bruch’s membrane)
- 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
22
Q
ARMD updated classification?
A
- Early ARMD (non-exudative, age-related maculopathy): drusen and alterations to the retinal pigment epithelium (RPE)
- Late ARMD (neovascularisation, exudative)
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
24
Q
ARMD signs?
A
- Distortion of line perception may be noted on Amsler grid testing
- Fundoscopy = drusen, may become confluent in late disease to form a macular scar
- In wet ARMD well demarcated red patches may be seen which represent intra-retinal or sub-retinal fluid leakage or haemorrhage
25
ARMD Ix?
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
26
ARMD Rx?
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
27
Anti-VEGF agents?
Usually administered by 4 weekly injection
1. Ranibizumab
2. Bevacizumab
3. Pegaptanib
28
Amsler grid testing?
ARMD - distortion of line perception
29
Holmes-Adie pupil mushkies?
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
30
Holmes-Adie syndrome?
Association of Holmes-Adie pupil with absent ankle/knee reflexes
31
Blepharitis?
Inflammation of the eyelid margins.
32
Causes of blepharitis?
1. Meibomian gland dysfunction = common, posterior blepharitis
2. Seborrheoic dermatitis/staphylococcal infection (less common, anterior blepharitis)
33
Blepharitis association?
Rosacea
34
Meibomian gland function?
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
35
Blepharitis features?
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
36
Blepharitis Rx?
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
37
How to differentiate scleritis from episcleritis?
Scleritis is painful
38
Scleritis features?
1. Red eye
2. Classically painful, but sometimes only mild pain/discomfort is present
3. Watering and photophobia common
4. Gradual decrease in vision
39
Fixed dilated pupil with conjunctival injection?
Acute closed-angle glaucoma
40
Glaucoma definition?
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
41
Acute angle-closure glaucoma (AACG) definition?
Rise in IOP secondary to an impairment of aqueous outflow
42
AACG predisposing factors?
1. Hypermetropia (long sightededness)
2. Pupillary dilatation
3. Lens growth associated with age
43
AACG features?
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
44
AACG Rx Principles?
Emergency, refer to ophthalmologist, need to lower IOP acutely with more definitive surgical Rx once acute attack has settle
45
AACG Acute Rx?
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
46
AACG Definitive Rx?
Laser peripheral iridotomy = creates tiny hole in the peripheral iris --> aqueous humour flowing to the angle
47
Chorioretinitis which test must be done?
HIV
48
Chorioretinitis causes?
1. Syphilis
2. CMV
3. Toxoplasmosis
4. Sarcoidosis
5. TB
49
Orbital cellulitis definition?
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.
50
Periorbital cellulitis definition?
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.
51
Orbital cellulitis RFs?
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
52
Orbital cellulitis presentation?
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)
53
Differentiating orbital from preseptal cellulitis?
Reduced visual acuity, proptosis, ophthalmoplegia/pain with eye movements are NOT consistent with preseptal cellulitis
54
Orbital cellulitis Ix?
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
55
Most common bacterial causes of orbital cellulitis?
Strep, Staph A, HiB
56
Orbital cellulitis Rx?
Admission for IV Abx
57
Orbital compartment syndrome Rx?
Immediate canthotomy
58
Hyphaema?
Blood in the anterior chamber of the eye
59
Hyphema Rx?
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)
60
Orbital compartment syndrome cause?
E.g. Retrobulbar haemorrhage
61
Orbital compartment syndrome featrues?
1. Eye pain/swelling
2. Proptosis
3. Rock-hard eyelids
4. RAPD
62
B-scan US?
Imaging technique to look at posterior compartment of the eye, helpful for retinal detachment or posterior vitreous haemorrhage
63
Immediate IV acetazolamide used for?
AACG
64
Sore, red eyes with sticky discharge?
Conjunctivitis - either viral or bacterial
65
Bacterial conjunctivitis features?
Purulent discharge, eyes may be 'stuck together' in the morning
66
Viral conjunctivitis features?
Serious discharge, recent URTI, preauricular lymph nodes
67
Infective conjunctivitis Rx?
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
68
Optic neuritis causes?
1. MS (most common associated disease)
2. DM
3. Syphilis
69
Optic neuritis features?
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
70
Red desaturation?
Optic neuritis
71
Optic neuritis Ix?
MRI brain and orbits with gadolinium contrast
72
Optic neuritis Rx?
1. High dose steroids
2. Recovery usually takes 4-6 weeks
73
Optic neuritis prognosis?
MRI: If >3 white matter lesions, 5 year risk of developing MS is 50%
74
Most common cause of a persistent watery eye in an infant?
Nasolacrimal duct obstruction
75
Nasolacrimal duct obstruction cause?
Imperforate membrane, usually at the lower end of the lacrimal duct. 1/10 have symptoms at 1m/o.
76
Nasolacrimal duct obstruction Rx?
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
77
Eyelid problems?
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
78
What is a Chalazion/Meibomian cyst?
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
79
Stye classification?
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
80
Stye Rx?
1. Hot compresses and analgesia
2. Topical Abx only if associated conjunctivitis
81
Transient monocular visual loss (TMVL)?
Sudden, transient loss of vision that lasts less than 24 hours
82
Most common causes of sudden painless loss of vision?
1. Ischaemic/vascular
2. Vitreous haemorrhage
3. Retinal detachment
4. Retinal migraine
83
Ischaemic/vascular visual loss?
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
84
Ischaemic optic neuropathy cause?
Occlusion of short posterior ciliary arteries
85
CRVO?
1. Incidence increases with age, more common than CRAO
2. Causes = glaucoma, polycythaemia, hypertension
3. Severe retinal haemorrhages on fundoscopy
86
CRAO?
1. Due to thromboembolism (from atherosclerosis) or arteritis (temporal arteritis)
2. Features include RAPD, 'cherry red' spot on pale retina
87
Cherry red spot on pale retina?
CRAO
88
Vitreous haemorrhage?
1. Causes = DM, bleeding disorders, anticoagulants
2. Features may include sudden visual loss, dark spots
89
Retinal detachment?
Features of vitreous detachment, which may precede retinal detachment, include flashes of light or floaters
90
Differentiating between posterior vitreous detachment, retinal detachment and vitreous haemorrhage?
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
91
CRAO features?
1. Sudden, painless unilateral visual loss
2. RAPD
3. Cherry red spot on pale retina
92
CRAO Rx?
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
93
Severe retinal haemorrhages on fundoscopy?
CRVO
94
Cheese and tomato pizza?
CRVO
95
CRVO risk factors?
1. Age
2. HTN
3. CVD
4. Glaucoma
5. Polycythaemia
96
Stormy sunset?
CRVO
97
CRVO features?
1. Sudden, painless reduction or loss of visual acuity, usually unilaterally
2. Fundoscopy = widespread hyperaemia, severe retinal haemorrhages (stormy sunset)
98
Key CRVO differential?
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
CRVO Rx?
1. Conservatively usually
2. Indications for Rx
a. Macular oedema = Intravitreal VEGF
b. Retinal neovascularisation = laser photocoagulation
100
Blurring of vision years after cataract surgery?
Posterior capsule opacification
101
Cataract definition?
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
Leading cause of curable blindness worldwide?
Cataracts
103
Cataracts epidemiology?
1. W > M
2. Ag
104
Most common cause of cataracts?
Age
105
Other causes of cataracts?
1. Smoking
2. EtOH
3. Trauma
4. DM
5. Steroids
6. Radiation
7. Myotonic dystrophy
8. Metabolic disorders = hypocalcaemia
106
Cataracts features?
1. Reduced vision
2. Faded colour vision
3. Glare = lights appear brighter than usual
4. Haloes around lights
107
Cataracts signs?
Defect in red reflex
108
Cataracts Ix?
1. Ophthalmoscopy = done after pupil dilation, normal fundus and optic nerve
2. Slit lamp examination = visible cataract
109
Cataract classification?
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
Cataract Rx?
1. Non-surgical = stronger glasses
2. Surgical = 85-90% achieve 6/12 vision post-op
111
Complications following cataract surgery?
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
RAPD strongly associated with?
Optic neuritis
113
Causes of mydriasis?
1. 3rd nerve palsy
2. Holmes-Adie
3. Traumatic iridoplegia
4. Phaeochromocytoma
5. Congenital
114
Drug causes of mydriasis?
1. Topical mydriatics = tropicamide, atropine
2. Sympathomimetic drugs = amphetamines, cocaine
3. Anticholinergics = TCAs
115
Argyll-Robertson Ppuil mnemonic?
ARP PRA (Small, irregular pupils)
Accommodation reflex present
Pupillary reflex absent
116
Causes of Argyll-Robertson pupil?
1. DM
2. Syphilis
117
Marcus-Gunn pupil AKA/
AKA
118
RAPD lesion location?
Anterior to the optic chiasm i.e. optic nerve or retina
119
RAPD finding?
Affected and normal eye appear to dilate when light shone on the affected
120
RAPD causes?
1. Retina = detachment
2. Optic nerve = optic neuritis e.g. MS
121
Pupillary reflex afferent pathway?
Retina --> Optic nerve --> LGN --> Midbrain
122
Pupillary reflex efferent pathway?
Edinger-Westphal nucleus (midbrain) --> Oculomotor nerve
123
Subconjunctival haemorrhage definition?
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
Subconjunctival haemorrhage epidemiology?
1. Women > Men
2. Newborns, elderly
3. Incidence 2.6%
125
Subconjunctival haemorrhage risk factors?
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
Subconjunctival haemorrhage symptoms?
1. Red eye, usually unilateral
2. Usually asymptomatic, however mild irritation may be present
127
Subconjunctival haemorrhage signs?
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
Subconjunctival haemorrhage Ix?
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
Subconjunctival haemorrhage Rx?
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
Subconjunctival haemorrhage prognosis?
Mild, self-limiting illness and should resolve on it's own in 2-3 weeks
131
Peripheral visual field floaters?
Vitreous detachment
132
Pizza pie on fundoscopy?
Chorioretinitis
133
Chorioretinitis is a form of?
Posterior uveitis
134
Red eye, photophobia, gritty sensation?
Keratitis
135
Keratitis definition?
Inflammation of the cornea. Microbial keratitis is not like conjunctivitis - it is potentially sight threatening and should therefore be urgently evaluated and treated
136
Keratitis causes?
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
Keratitis clinical features?
1. Red eye = pain and erythema
2. Photophobia
3. Foreign body, gritty sensation
4. Hypopyon may be seen
138
Keratitis referral?
Contact lens wearers, an accurate Dx needs slit-lamp, so same day referral to eye specialist
139
Keratitis Rx?
1. Stop using contact lens until symptoms fully resolved
2. Topical Abx = quinolones
3. Cycloplegic for pain relief = cyclopentolate
140
Keratitis complications?
1. Corneal scarring
2. Perforation
3. Endophthalmitis
4. Visual loss
141
Hutchinson's sign?
Vesicles extending to the tip of the nose, strongly associated with ocular involvement in shingles
142
Herpes zoster ophthalmicus definition?
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
HZO features?
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
HZO Rx?
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
HZO complications?
1. Ocular = conjunctivitis, keratitis, episcleritis, anterior uveitis
2. Ptosis
3. Post-herpetic neuralgia
146
Primary Open-Angle Glaucoma (POAG) definition?
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
POAG risk factors?
1. Age
2. Genetics
3. Afro-Caribbean
4. Myopia
5. HTN
6. DM
7. Corticosteroids
148
POAG features?
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
Fundoscopy signs of POAG?
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
POAG Dx?
1. Case finding and provisional Dx done by optometrist
2. Referral to ophthalmologist done via GP
3. Final Dx done by Ix below
151
POAG Ix?
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
Young person with tunnel vision?
Retinitis pigmentosa
153
Retinitis pigmentosa features?
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
Retinitis pigmentosa associated diseases?
1. Refsum disease, Usher syndrome
2. Abetalipoproteinemia
3. Lawrence-Moon-Biedl syndrome
4. Kearns-Sayre syndrome
5. Alport's syndrome
155
Black bone-spicule pigmentation on fundoscopy?
Retinitis pigmentosa
156
Fixed dilated pupil with conjunctival injection?
Acute closed-angle glaucoma
157
Haloes around lights?
Acute closed-angle glaucoma
158
Corneal ulcer features?
1. Eye pain
2. Photophobia
3. Watering of eye
4. Focal fluorescein staining of the cornea
159
Pain relief for corneal ulcers?
Oral analgesics
160
Iritis AKA?
Anterior uveitis
161
Squint definition?
Misalignment of the visual axes
162
Squint classification?
1. Concomitant (common)
2. Paralytic (rare)
163
Amblyopia definition?
Brain fails to fully process inputs from one eye and over time favours the other eye
164
Concomitant squint?
1. Due to imbalance in extraocular muscles
2. Convergent is more common than divergent
165
Paralytic squint?
1. Due to paralysis of extraocular muscles
166
How to test for squint?
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
Test for the nature of a squint?
Cover test
168
Squint Rx?
Referral to secondary care = eye patches may help prevent amblyopia
169
Papilloedema definition?
Optic disc swelling caused by increased ICP, almost always bilateral
170
Papilloedema on fundoscopy?
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
Causes of papilloedema?
1. SoL = neoplastic, vascular
2. Malignant HTN
3. IIH
4. Hydrocephalus
5. Hypercapnia
172
Rare causes of papilloedema?
1. Hypoparathyroidism and hypocalcaemia
2. Vitamin A toxicity
173
Episcleritis causes?
1. Idiopathic (majority)
2. IBD
3. RhA
174
Episcleritis features?
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
What drops to differentiate between episcleritis and scleritis?
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
Episcleritis Rx?
1. Conservative
2. Artificial tears may sometimes be used
177
Ocular pain, tearing and photophobia in association with corneal uptake of fluorescein?
Corneal ulcer
178
Dense shadow starting peripherally and progressing centrally?
Retinal detachment
179
Most common RhA ocular manifestation?
Keratoconjunctivitis sicca
180
What % of RhA pts have ocular mnifestations?
25%
181
Ocular manifestations of RhA?
1. Keratoconjunctivitis sicca (most common)
2. Episcleritis (erythema)
3. Scleritis (erythema and pain)
4. Corneal ulceration
5. Keratitis
182
Iatrogenic RhA ocular manifestations?
1. Steroid-induced cataracts
2. Chloroquine retinopathy
183
Anterior uveitis Rx?
Steroid + cycloplegic (mydriatic) drops
184
Cycloplegic eye drop examples?
Atropine, cyclopentolate
185
Intermittent squint in newborns <3m old?
Normal
186
Definitive AACG Rx?
Laser peripheral iridotomy
187
AACG acute eye drops?
1. Pilocarpine
2. Timolol
3. Brimonidine
188
Commonest cause of orbital cellulitis in children?
Infection of the ethmoidal sinus due to relatively thin medial wall of the orbit
189
Overall deterioration in vision at night?
ARMD
190
Entropion Rx?
1. Interim = eye lubricants and tape to pull eyelid outwards
2. Definitive = surgery
191
Corneal abrasion definition?
Any defect of the corneal epithelium and most commonly come about from a recent history of local trauma
192
Corneal abrasion Ix?
Fluorescein examination typically reveals a yellow stained abrasion (representative of the de-epithelialized surface) which is usually visible to the naked eye
193
Corneal abrasion Rx?
Topical Abx to prevent bacterial superinfection
194
Pus in anterior chamber (hypopyon)?
Anterior uveitis
195
Meibomian gland dysfunction?
Symptoms that are worse on wakening, eyelids sticking together on waking, and redness of the eyelids
196
Rx of dry eyes?
Eyelid hygeine
197
Dry eyes fluorescein stain?
Punctate fluorescein staining
198
Ciliary flush?
Anterior uveitis
199
Fixed oval pupil?
Anterior uveitis
200
Semi dilated pupil?
AACG
201
Hazy cornea?
AACG
202
Primary open angle glaucoma (POAG) causes?
1. Age
2. Genetics
203
Cupping of the optic disc?
POAG
204
POAG Rx?
1. 1st line = Prostaglandin analogue
2. 2nd line = BB, Carbonic anhydrase inhibitor, sympathomimetic eyedrop
3. If more advanced: surgery or laser treatment
205
Prostaglandin analogue mushkies?
1. Latonoprost
2. Increases uveoscleral outflow
3. OD
4. S/e = brown pigmentation of iris, increased eyelash length
206
Beta blocker mushkies?
1. Timolol, betaxolol
2. Reduces aqueous production
3. Should be avoided in asthmatics and heart block
207
Sympathomimetics mushkies?
1. Brimonidine = alpha2 adrenoreceptor agonist
2. Reduces aqueous production and increases outflow
3. Avoid taking MAOI or TCA
4. S/e = hyperaemia
208
Carbonic anyhdrase inhibitor mushkies?
1. Dorzolamide
2. Reduces aqueous production
3. Systemic absorption may cause sulphonamide-like reactions
209
Miotics mushkies?
1. Pilocarpine, a muscarinic receptor agonist
2. Increases uveoscleral outflow
3. S/e = constricted pupil, headache, blurred vision
210
POAG surgery?
Trabeculectomy may be considered in refractory cases
211
Allergic conjunctivitis features?
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
Allergic conjunctivitis Rx?
1. 1st line = topical or systemic antihistamines
2. 2nd line = topical mast-cell stabilisers = sodium cromoglicate and nedecromil
213
When to give topical Abx for stype?
If associated conjunctivitis
214
Hypertensive retinopathy classification?
Keith-Wagener classification
215
Keith-Wagener classification for hypertensive retinopathy?
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
Horner's features?
1. Miosis
2. Ptosis
3. Enophthalmos
4. Anhidrosis
217
Distinguishing between causes of Horner's?
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
Differentiating causes of Horners based on anhidrosis?
1. Face, arm and trunk = Central lesions, SSSTe
2. Face = Pre-ganglionic lesions, TTTC
3. None = post-ganglionic lesions, CCCC
219
Central horners lesions?
1. Stroke
2. Syringomyelia
3. MS
4. Tumour
5. Encephalitis
220
Pre-ganglionic Horners lesions?
1. Tumour (Pancoasts)
2. Thyroidectomy
3. Trauma
4. Cervical rib
221
Post-ganglionic Horners lesions?
1. Carotid artery dissection
2. Carotid aneurysm
3. Cavernous sinus thrombosis
4. Cluster headache
222
Mydriatics given before fundoscopy and then reduced visual acuity and eye pain?
AACG
223
Metabolic cause of cataracts?
Hypocalcaemia
224
Herpes simplex keratitis usually presents with?
Dendritic corneal ulcer
225
Herpes simplex keratitis features?
1. Red, painful eye
2. Photophobia
3. Epiphora
4. Visual acuity may be decreased
5. Florescein staining may show an epithelial ulcer
226
Herpes simplex keratitis?
1. Immediate referral to ophthalmologist
2. Topical aciclovir
227
Night blindness and tunnel vision?
Retinitis pigmentosa
228
Fixed oval pupil?
Anterior uveitis
229
Red eye causes?
1. AACG
2. Anterior uveitis
3. Scleritis
4. Subconjunctival haemorrhage
5. Conjunctivitis
6. Endophthalmitis = red eye, pain and visual loss following intraocular surgery
230
Sudden loss of vision causes?
1. Ischaemic/vascular (incl. CRAO, CRVO)
2. Vitreous haemorrhage
3. Retinal detachment
4. Retinal migraine
231
Tunnel vision causes?
1. Papilloedema
2. Glaucoma
3. Retinitis pigmentosa
4. Choroidoretinitis
5. Optic atrophy secondary to tabes dorsalis
6. Hysteria
232
Feathery fluorescein uptake?
Herpes simplex keratitis
233
Red desaturation?
Optic neuritis
234
ARMD ophthalmology referral speed?
Within 1 week to get a formal diagnosis because if wet can receive anti-VEGF injections
235
Red eye, pain and visual loss following intraocular surgery?
Endophthlamitis
236
Endophthalmitis mushkies?
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
Lens dislocation causes?
1. Marfans = upwards
2. Homocytinuria = downwards
3. Ehlers Danlos
4. Trauma
5. Uveal tumours
6. Autosomal recessive ectopia lentis
238
Stye definition?
Infection of the glands of the external eyelid
239
Stye definition?
Infection of the glands of the external eyelid
