Ophthalmology Flashcards
How does retinitis pigmentosa present?
Retinitis pigmentosa - night blindness + tunnel vision
How does Horner’s syndrome present?
Horner’s syndrome, also known as oculosympathetic paresis, is a rare condition characterised by a triad of ptosis (drooping eyelid), miosis (constricted pupil), and anhidrosis (lack of sweating) on the affected side of the face.
How does Argyll-Robertson pupil present?
bilateral small pupils that constrict when the patient focuses on a near object but do not react to direct or consensual light stimulation. They are often referred to as ‘prostitute’s pupils’ because they ‘accommodate but do not react’. It is seen primarily in patients with neurosyphilis, which does not fit with the presented case.
How does sixth nerve palsy present?
A sixth cranial nerve palsy would present with horizontal double vision that increases when looking towards the affected side due to paralysis of the lateral rectus muscle, which abducts the eye.
How does third nerve palsy present?
third nerve palsy is incorrect as it typically presents with drooping of the eyelid (ptosis), dilation of the pupil (mydriasis), upward and outward deviation of the eye (‘down & out’ appearance) and inability to move eye inward and downward due to paralysis of the medial rectus and inferior rectus muscles respectively.
How does Holmes-Adie pupil present?
This condition presents with a unilateral dilated pupil that reacts poorly to light but shows slow constriction on accommodation. It may be associated with absent reflexes elsewhere in the body such as the ankle-jerk reflex. Holmes-Adie syndrome doesn’t cause ptosis which was observed in our patient.
How does Herpes Zoster Ophthalmicus present?
This condition presents with a painful, blistering rash in the distribution of the ophthalmic division of the trigeminal nerve. It is caused by reactivation of latent varicella-zoster virus (the same virus that causes chickenpox) within the sensory ganglion. The patient’s age and presentation with a burning sensation around his right eye followed by an erythematous blistering rash are typical features of this condition.
Where do you see drusen?
Drusen = Dry macular degeneration
What is the biggest risk factor for macular degeneration?
Smoking
How does fundoscopy differ in retinal central vein vs artery occlusion?
Artery - fundoscopic findings of a pale and opaque retina with a cherry-red spot are classic features of central retinal artery occlusion (CRAO)
Vein - diffuse retinal haemorrhages (‘blood and thunder’ appearance), venous dilation and tortuosity
How does optic neuritis present?
Colour vision is affected in optic neuritis and typically there is periocular pain associated with eye movement. Visual field defects can also occur, most commonly in the form of a central scotoma. There is typically a relative afferent pupillary defect if the other eye is uninvolved.
What is amsler grid testing?
Amsler grid testing (to check for distortion of line perception) may be useful in testing patients with suspected age related macular degeneration
How do we treat herpes zoster ophthalmicus?
Oral steroids
How does keratitis present?
red eye, photophobia and gritty sensation
How do episcleritis and scleritis differ?
Episcleritis is typically asymptomatic or presents with a mild grittiness sensation, but scleritis usually presents with frank pain and tenderness.
Where do you see bone-spicule pigmentation on fundoscopy?
Retinitis pigmentosa classically presents with black bone-spicule pigmentation on fundoscopy
Which kind of eye drops can be used to differentiate scleritis and episcleritis?
Phenylephrine 10% eye drops can be used to distinguish between episcleritis and scleritis. It blanches the redness in episcleritis but doesn’t in scleritis.
What is Hutchinson’s sign?
Seen in herpes zoster ophthalmicus, Hutchinson’s sign: rash on the tip or side of the nose. Indicates nasociliary involvement and is a strong risk factor for ocular involvement
How does anterior uveitis present?
Anterior uveitis is characterised by symptoms of a painful red eye with photophobia. Visual loss is more variable and can include reduced visual acuity, blurred vision, or reduced peripheral fields. Anterior uveitis is associated with a constricted pupil. Patients with a history of HLA-B27 positivity or autoimmune conditions are more likely to develop anterior uveitis.
What is chorioretinitis?
Chorioretinitis is an inflammatory condition affecting the choroid and retina of the eye. This dual inflammation can be precipitated by infectious or autoimmune aetiologies, leading to the potential for significant visual impairment if not promptly and effectively managed.
Where would you see pizza pie appearance on fundoscopy?
When the moon hits your eye like a big pizza pie that’s chorioretinitis
Why do you see an irregular pupil in anterior uveitis?
An irregular pupil is found in anterior uveitis because of the formation of posterior synechiae due to inflammation within the eye and they stick the iris to the anterior lens surface causing irregularity of the pupil.
What is the definitive treatment for acute angle closure glaucoma?
Laser peripheral iridotomy is the definitive treatment for acute angle-closure glaucoma. Produces an extra pathway in the iris for aqueous to flow from the posterior chamber into the anterior chamber in order to be drained into the angle.
How do we treat herpes simplex keratitis?
Topical aciclovir
Where do you see a central scotoma?
Optic neuritis
What is a hypopyon?
pus in the anterior chamber
A 68-year-old man with a history of type 2 diabetes mellitus presents with worsening eye sight. Mydriatic drops are applied and fundoscopy reveals pre-proliferative diabetic retinopathy. A referral to ophthalmology is made. Later in the evening whilst driving home he develops pain in his left eye associated with decreased visual acuity. What is the most likely diagnosis?
Acute angle closure glaucoma
Where would you see positive Chvostek and Trousseau signs
Hypocalcaemia
Which ophthalmological condition is associated with hypocalcaemia
Cataracts
How does herpes simplex keratitis present?
Features
red, painful eye
photophobia
epiphora
visual acuity may be decreased
fluorescein staining may show an epithelial ulcer
What is the Keith-Wagener classification for hypertensive retinopathy?
First they start to twist and turn [silver wiring] (I), then they nip about the place [AV nipping] (II), afterwards they play with cotton wool and fire [cotton wool spots, flame and blot haemorrhages] (III), finally they swell up [papilloedema] (IV).
What is Marcus-Gunn pupil?
Relative afferent pupillary defect, seen during the swinging light examination of pupil response. The pupils constrict less and therefore appear to dilate when a light is swung from unaffected to affected eye. Most commonly caused by damage to the optic nerve or severe retinal disease.
What is a hordeolum externum?
A type of stye
What is a chalazion?
A chalazion is also called meibomian cyst and is typically on the internal eyelid.
How do we manage corneal abrasion?
Corneal abrasion: topical antibiotics should be given to prevent secondary bacterial infection e.g. chloramphenicol
How do we distinguish scelritis and episcleritis?
Scleritis is painful
How does acute angle closure glaucoma present/
Acute angle closure glaucoma: ocular pain, decreased visual acuity, worse with mydriasis, haloes around lights
How do we manage AACG initially?
Pilocarpine (cholinergic), timolol (beta-blocker), and brimonidine (alpha-agonist) are all used to reduce intra-ocular pressure (IOP), which is compromising the optic nerve.
What is the definitive mx for AACG?
laser peripheral iridotomy
How does keratitis present?
Keratitis is the correct answer. The typical presentation usually involves a red eye, photophobia, pain and gritty sensation. Wearing contact lenses is a known risk factor.
Where do you see cotton wool spots?
In diabetic retinopathy, cotton wool spots represent areas of retinal infarction
How does orbital lymphoma present?
Orbital lymphoma could present like a chronic unilateral conjunctivitis resistant to treatment
How does vitreous detachment present?
Flashes and floaters - vitreous/retinal detachment
Retinal detachment can occur following vitreous detachment and is typically referred to in questions as a ‘dense shadow’ that progresses from the peripheral towards central vision, appearing as a veil or curtain.
Does Holmes-Adie pupil affect both eyes or just one/
80% of cases unilateral
What is the most common cause of Argyll-Robertson pupil in the UK?
Diabetes mellitus - not neurosyphilis!
Which one of the following is the most common ocular manifestation of rheumatoid arthritis?
Keratoconjunctivitis sicca, also known as dry eye syndrome, which affects approximately 15-25% of rheumatoid arthritis (RA) patients. This condition occurs due to autoimmune-mediated inflammation of the lacrimal glands, leading to reduced tear production and subsequent ocular surface damage.
When do we give antibiotics in tx of stye?
Topical antibiotics are only recommended for stye if associated conjunctivitis
How does anterior uveitis present?
acutely painful red eye, which is associated with photophobia, lacrimation and reduced visual acuity.
How do we treat anterior uveitis?
Anterior uveitis is most likely to be treated with a steroid + cycloplegic (mydriatic) drops
Which test must be do in chorioretinitis?
HIV test
How does orbital compartment syndrome present?
blood in the anterior chamber, proptosis, stiff eyelid, and a relative afferent pupillary defect. Orbital compartment syndrome is an ophthalmic emergency and can lead to irreversible vision loss if not treated promptly.
What causes orbital compartment syndrome?
It is caused by an increase in volume within the orbit, either by bleeding behind the globe or oedema of the globe itself. This could be due to iatrogenic surgical trauma, or external trauma, such as a squash ball hitting the orbit.
How do we treat orbital compartment syndrome?
immediate decompression is needed, and therefore an immediate canthotomy is the correct answer.
How do we treat dry AMD?
Dry age-related macular degeneration (AMD) is a chronic, progressive disease that primarily affects the central vision. There is currently no cure for dry AMD according to UK guidelines, and management mainly involves monitoring for conversion to wet AMD and supportive measures such as low vision aids and antioxidant supplements in certain cases.
The mother of a 6-month-old boy brings him to your clinic worried about recurrent sticky left eye. She describes constant watering of the left eye which at times becomes sticky but is not yellow or green. He has previously been treated twice with chloramphenicol drops which did not improve symptoms. An eye swab last month was negative. He is otherwise well in himself and has no problems with visual development.
How would you manage this patient?
Congenital tear (lacrimal) duct obstruction is a cause of recurrent watery or sticky eye in neonates and usually, self-resolves by 1 year of age
How may we treat raised intracranial pressure?
Hyperventilation - induces hypocapnia
Can be reversed too
Where would you see Fluorescein staining shows a linear, branching epithelial defect.?
Treatment for herpes simplex keratitis is topical aciclovir
What is entropion?
entropion: in-turning of the eyelids - causes sore right eye
How does chronic open-angle glaucoma present?
often presents with peripheral vision loss that comes on slowly so patients don’t notice it. Glaucoma can occur in patients with normal intraocular pressure. Furthermore, the investigations conducted point toward a diagnosis of glaucoma, especially the increased cup-to-disc ratio. Gonioscopy reveals a normal drainage angle and therefore this is open-angle glaucoma.
What is the difference between bacterial and viral conjunctivitis?
Bacterial conjunctivitis Purulent discharge
Eyes may be ‘stuck together’ in the morning)
Viral conjunctivitis Serous discharge
Recent URTI
Preauricular lymph nodes
How do we treat bacterial conjunctivitis?
topical antibiotic therapy is commonly offered to patients, e.g. Chloramphenicol. Chloramphenicol drops are given 2-3 hourly initially whereas chloramphenicol ointment is given qds initially
How do we treat bacterial conjunctivitis in pregnant women?
Topical fusidic acid should be used to treat bacterial conjunctivitis in pregnant women
How does AACG present?
acute severe ocular pain, patients usually have features of systemic upset such as nausea and vomiting, and visual acuity is reduced from the start, as many patients have blurred vision. Patients may also notice halos around lights and the cornea may appear cloudy on examination
How does primary open-angle glaucoma present, and how is it treated?
This patient’s raised intraocular pressure and decreased peripheral vision suggest that he has glaucoma, likely primary open-angle glaucoma (POAG) given his age. Latanoprost is a prostaglandin analogue which works by increasing the outflow of aqueous humour from the eye, thereby reducing intraocular pressure. Latanoprost is recommended as first-line treatment for POAG in the NICE guidelines.
You suspected age-related macular degeneration.
Which ONE of the following is your next step in management?
Refer to ophth urgently within 1 week - if wet amd can tx with injections and greatly improve long term outcome
How does Pancoast’s syndrome present?
Symptoms are caused by an apical malignant neoplasm of the lung. These include ipsilateral invasion of the sympathetic cervical plexus leading to Horner’s syndrome with shoulder and arm pain due to Brachial Plexus invasion. A smoking history is the most important of the above questions to ask, as 90% of cancers are caused by smoking.
Painless, monocular loss of vision in Marfan’s syndrome may be due to…
Lens dislocation
How does wet AMD present?
Decreasing vision over months with metamorphopsia and central scotoma should cause high suspicion of wet age-related macular degeneration
How does the cornea stain with dry eye?
Dry eye syndrome is a common complication of Bell’s palsy. Punctate fluorescein staining of the cornea is common in patients with dry eyes
What is Horner’s syndrome?
Horner’s syndrome is characterised by a triad of ptosis (drooping of the upper eyelid), miosis (constricted pupil) and anhidrosis (lack of sweating) on the affected side. It occurs due to disruption of the sympathetic nerve pathway, which can be caused by various conditions including lesions within the brainstem or cervical spinal cord, such as those seen in multiple sclerosis.
What is the difference between ptosis + dilated pupils and with constricted pupils?
Ptosis + dilated pupil = third nerve palsy; ptosis + constricted pupil = Horner’s
How do we determine whether someone has severe sight impairment (blindness)
The criteria for the certification of blindness (severely sight impaired) is <3/60 with a full visual field
