Ophthalmology Flashcards
1
Q
What is acute angle closure glaucoma?
A
Sight threatening opthalmic emergency with a rapid rise in intraocular pressure due to sudden obstruction of aqueous humour outflow
2
Q
Epidemiology of acute angle closure glaucoma?
A
More common in those with shallow anterior chamber, narrow iridocorneal angle and thick peripheral iris
More common in females and those of asian descent
3
Q
Pathophysiology of acute angle closure glaucoma?
A
Pupillary block when lens and iris come into close apposition and obstruct the flow of aqueous humour
Primary angle closure osccurs when the iris blocks the drainage angle causing a rise in IOP and subsequent optic nerve damage
4
Q
Epidemiology of acute angle closure glaucoma?
A
Older people
0.4% of people over 40 years in the UK
5
Q
Risk factors for acute angle closure glucoma?
A
Hyperopia
Age
Ethnicity; asian/ inuit populations
Pupillary dilation; habitual use of dim lit settings, use of mydriatics
6
Q
Symptoms of acute angle closure glaucoma?
A
Pain; extreme ocular pain that develops rapidly
Blurred vision; can progress to vision loss
Haloes; coloured halos around lights
Systemically unwell; nausea, vomiting
7
Q
Signs of acute angle closure glaucoma?
A
Red eye – ciliary flush with a hazy cornea
Mid-dilated or fixed pupil
Closed iridocorneal angles on gonioscopy
Corneal oedema
Raised IOP (defined as >21 mmHg) – the globe may feel hard on palpation
8
Q
Differentials for acute angle closure glaucoma?
A
Open angle glaucoma
Acute anterior uveitis
Retinal detachment
9
Q
Investigations to diagnose acute angle closure glaucoma?
A
Gonioscopy; assess angle between iris and cornea
Tonometry; measure intraocular pressure
Ophthalmological examination
10
Q
Management of acute angle closure glaucoma?
A
IOP lowering agents; beta blockers, pilocarpine, IV acetazolamide, mannitol,
Analgesia and antiemetics
Peripheral iridotomy
Surgical iridectomy
11
Q
What is age related macular degeneration?
A
Leading cause of blindness presenting with subacute loss and/ or distortion of central visual field
Degeneration of photoreceptors in central retina that leads to formation of drusen
12
Q
Risk factors for ARMD?
A
Age
Male sex
Smoking
Family history
CVD risk factors; hypertension, diabetes, coagulopathy, dyslipidaemia
13
Q
Types of ARMD?
A
Dry; 85-90% of cases, slow progression over decades, drunsen, macular thinning
Wet; 10-15% of cases, rapid progression over months with poor prognosis, neovascularisation, bleeding, leakage of fluid
14
Q
Symptoms of ARMD?
A
Reduced visual acuity, worse for near vision and central vision (patients may say they struggle seeing faces)
Variability in visual disturbance from day to day is characteristic
Poor vision at night
Photopsia – perceived flickering of lights
Glare
15
Q
Signs of ARMD?
A
Visual distortion
Drunsen in Dry ARMD
16
Q
Differentials for ARMD?
A
Diabetic macular oedema
Retinal vein occlusion
Central serous chorioretinopathy
17
Q
Investigations to diagnose ARMD?
A
Slit lamp biomicroscopy; identify exudative pigmentary or haemorrhagic changes in retina
Colour fundus photography; done at each assessment to monitor progression
Fluorescein angiography; identify neovascular ARMD to guide anti-VEGF therapy
Ocular coherence tomography; all layers of retina and identification of disease not visible by slit lamp biomicroscopy
18
Q
Management of ARMD?
A
Dry ARMD;
Zinc, antioxidant A,C,E supplements
Warm ARMD;
Anti- VEGF monthly injections
19
Q
What is amblyopia?
A
Developmental defect of cortical visual processing resulting from abnormal visual stimulation during early childhood leading to visual impairment
20
Q
Pathphysiology of amblyopia?
A
Central visual pathways develop until 8-10 years, if vision in either or both eyes is less than perfect it can lead to vision loss in affected eyes
21
Q
Aetiology of amblyopia?
A
Anything that can reduce visual stimulation in eye
Squint
Unequal refractive error
Congenital cataract
Tumours blocking visual axis
22
Q
Signs and symptoms of amblyopia?
A
Symptoms;
Reduced visual acuity
Blurred or cloudy vision
Double vision
Poor depth perception
Squinting or closing of one eye
Eye fatigue
Strabismus
Signs;
Decreased depth perception
Suppression
Reduced contrast sensitivity
Anisometropia
23
Q
Management of amblyopia?
A
Early treatment before the age of 8 years
Patching of the strong eye to allow weaker eye to develop
Atropine eye drops to reduce acuity in good eye
24
Q
What is bacterial keratitis?
A
Bacterial infection of the cornea
25
Epidemiology of bacterial keratitis?
Associated with minor trauma to the cornea, contact lens use or ocular surgery
26
Aetiology of bacterial keratitis?
In contact lens wearers; pseudomonas aeruginosa
27
What ocular problems can pseudomonas aeruginosa cause?
Corneal opacification and melting within 24 hours of infection
28
Signs and symptoms of bacterial keratitis?
Pain
Foreign body sensation
Tearing or purulent discharge
Red eye
Corneal ulcer – this may be visible with fluorescein staining
29
Investigations to diagnose bacterial keratitis?
Corneal scrape
Culture of contact lens solution
Slit lamp examination; epithelial defects, infiltrates and presence of pus, estimate depth and size of corneal ulcer
Confocal microscopy; high resolution images of cornea's cellular and structural
Ultrasound biomicroscopy; used when visulisation of corneal layers is limited
30
Management of bacterial keratitis?
Cessation of contact lens use
Topical and oral quinolone antibiotics
Cyclopentolate for pain relief
Consider hospital admission for monitoring and treatment
31
What is basal cell carcinoma of the eyelid?
Skin cancer commonly affecting lower eyelid characterised by pearly sheen, rolled edges and ulcerated centre
32
Epidemiology of BCC of eyelid?
Most prevalent eyelid tumour; 90% of eyelid malignancies
Do not metastasise but can cause complications through local invasion
33
Risk factors for BCC of the eyelid?
Sun exposure
Immunosuppression
Inherited syndromes; xeroderma pigmentosa, gorlin-goltz syndrome
34
Signs and symptoms of BBC of the eyelid?
Pearly sheen layer on skin
Rolled edges and ulcerated centre
35
Differentials for BCC of the eyelid?
Squamous cell carcinoma
Melanoma
36
Investigations to diagnose BCC of the eyelid?
Examination of eye
Biopsy
2WW referral
37
Management of BCC of eyelid?
Wide local excision
Cryotherapy
Iquimoid cream
Mohs micrographic surgery
38
Aetiology of eyelid lesions?
Sqaumous papillomas; HPV
Seborrheic keratosis
Styes and chalazion
Molluscum contagiosum
Dacryocystitis
39
Presentation of eyelid pathologies?
Squamous papilloma: Typical papillary shape with keratinised surface
Seborrhoeic keratosis: Well-demarcated, warty plaques
Stye: Tender, swollen, red; may involve infection of the upper or lower eyelid at the eyelashes
Chalazion: Initially painful but resolves to leave a non-tender lump
Naevus: Well-demarcated, pigmented lesion; may be raised
Xanthelasma: Soft yellow lesion(s)
Molluscum contagiosum: Small, waxy nodules
Hidrocystoma/cystadenoma: Cystic lesion occurring due to blocked sweat glands
Epidermoid cyst: Inflamed/infected hair follicle
Dacryocystitis: Cystic lesion caused by blockage of the nasolacrimal gland
40
What is Blepharitis?
Conditions that cause chronic inflammation in eyelid margins
41
Aetiology of blepharitis?
Staphylococcus aureus
HSV
VZV
Meibomian gland dysfunction
Seborrheic dermatitis
Rosacea
42
Symptoms of blepharitis?
Painful, gritty, itchy eyes
Eyelids sticking together upon waking
Dry eye symptoms
Symptoms associated with the causative condition (e.g., seborrhoeic dermatitis, acne rosacea)
43
Signs of blepharitis?
Erythema of the eyelid margins
Crusting or scaling at the eyelid margin
Visibly blocked Meibomian gland orifices
44
Differentials for Blepharitis?
Keratoconjunctivitis sicca
Allergic conjunctivitis
Conjunctivitis
Meibomian gland dysfunction
Ocular rosacea
Stye
Chalazion
45
Management of blepharitis??
Lid hygiene
Avoid contact lenses during flare up
46
What is a carotid cavernous fistula?
Abnormal communication between carotid artery and cavernous sinus
47
Aetiology of carotid cavernous fistulas?
Spontaneous; associated with hypertension, atherosclerosis
Trauma
48
Signs and symptoms of carotid cavernous fistula?
Pulsatile proptosis
Bruit
Injected conjunctiva
Cranial nerve impairment
49
Differentials for carotid cavernous fistula?
Orbital cellulitis
Graves disease
Sinus thrombosis
50
Investigations to diagnose carotid cavernous fistula?
Angiography
MRI/ CT scan
51
Management of carotid cavernous fistula?
Endovascular treatment; coil embolisation, balloon occlusion
Surgical repair
Reduce inflammation
52
What is cataracts?
Opacity in the lens which is caused by denaturation of lens portiens
53
Epidemiology of cataracts?
Associated with advancing age
75% of individuals aged over 65 years
54
Risk factors for developing cataracts?
Increasing age
Smoking
Diabetes mellitus
Systemic corticosteroid use
Alcohol consumption
UV exposure
Trauma
Previous eye surgery
Radiation exposure
55
Symptoms of cataracts?
Gradual painless loss of vision
Difficulty reading/watching television
Difficulty recognizing faces
Haloes around lights, particularly at night
In children, cataracts may present with a squint
56
Signs of cataracts?
Loss of red reflex
Brown/ white appearance of lens on slit lamp biomicroscopy
57
Differentials for cataracts?
ARMD
Diabetic retinopathy
58
Investigations to diagnose cataracts?
Slit lamp biomicroscopy
59
Management of cataracts?
Pseudophakia; removal of lens and replacement with artificial lens
60
What is the most common technique of cataract surgery?
Phacoemulsification
61
Complications of cataracts?
Endophthalmitis; severe pain and loss of vision
Posterior lens capsule opacification
62
What is central retinal artery occlusion?
Sudden painless loss of vision due to occlusion of central retinal artery
63
Epidemiology of central retinal artery occlusion?
Less common than retinal vein occlusion
Associated with rapid vision deterioration
64
What is the blood supply to the retina?
Central retinal artery; enters the eye at the optic disc and branches in superior, inferior, nasal and temporal subdivision supplying each quadrant of the retina
Choriocapillaries; capillaries of the choroid which are branches of the ciliary artery supply peripheral retina
65
Pathophysiology of central retinal artery occlusion?
Worse effect on vision the more proximal the occlusion
66
Aetiology of central retinal artery occlusion?
Atherosclerosis – roughly 80% of cases
Embolism – carotid, cardiac or aortic
Inflammatory (e.g. GCA, SLE)
Thrombophilia (e.g. protein S or C deficiency, antiphospholipid syndrome)
67
Signs and symptoms of central retinal artery occlusion?
Sudden onset painless loss of vision, over seconds
On examination a cherry red spot is seen
68
Risk factors for central retinal artery occlusion?
Carotid bruits
Hypertension
Atrial fibrillation
Diabetes mellitus
Smoking
Hyperlipidaemia
69
Differentials for central retinal artery occlusion?
Retinal vein occlusion
Retinal detachment
Optic neuritis
Ischaemic optic neuropathy
70
Investigations to diagnose central retinal artery occlusion?
Fundoscopy
OCT scan
Fluorescein angiography
71
Management of central retinal artery occlusion?
Timely treatment is essential; if after 90-100 mins vision is unlikely to improve
Ocular massage
Vasodilation; isosorbide dinitrate
Anterior chamber paracentesis; reduce IOP
Long term secondary prevention
72
Prognosis of central retinal artery occlusion?
Poor, only 30% have some improvement in vision after presentation
73
What is branch retinal artery occlusion?
When only some of the visual field is lost as retinal blood supply becomes occluded
74
What is central retinal vein occlusion?
Occlusion of central retinal vein
75
Risk factors for central retinal vein occlusion?
Atherosclerotic; age, smoking, obesity, HTN, diabetes
Haematological; protein S deficiency , protein C deficiency, antithrombin deficiency, factor V leiden, multiple myeloma, glaucoma, antiphopsholipid syndrome
76
Signs and symptoms of central retinal vein occlusion?
Sudden painless loss of vision
Reduced visual acuity of 6/60 or worse
77
Appearance on fundoscopy in central retinal vein occlusion?
Stormy sunset
Numerous flame haemorrhages
Dot and blot haemorrhages
Cotton wool spots
Retinal oedema
Dilated or tortuous retinal veins
Visual field defects, depending on the site of the occlusion
78
Differentials for central retinal vein occlusion?
Diabetic retinopathy
Hypertensive retinopathy
Ocular ischaemic syndrome
Retinal artery occlusion
Retinal detachment
Macular hole
Optic neuropathy
79
Investigations to diagnose central retinal vein occlusion?
Fundoscopy; macular oedema, optic nerve head oedema, flame haemorrhage, venous tortuosity, cotton wool spots
FBC, CRP, ESR, clotting, U+E, LFT, TFT
80
Management of central retinal vein occlusion?
Laser photocoagulation
Intravitreal anti-VEGF injections
Corticosteroids
81
Complications of central retinal vein occlusion?
Neovascularisation
Vitreous haemorrhage
Hyphaema
82
What is chronic open angle glaucoma?
Optic neuropathy characterised by death of optic nerve fibres with or without rise in IOP which leads to changes in visual field
83
Epidemiology of chronic open angle glaucoma?
Most prevalent form of glaucoma worldwide
Incidence increases with age and is leading cuase of irreversible blindness in over 60s
84
Risk factors for chronic open angle glaucoma?
Raised IOP – key modifiable risk factor
Hypertension
Diabetes mellitus
Corticosteroids
Myopia
Afro-Caribbean ethnicity
Increasing age
Genetics
85
Pathophysiology of chronic open angle glaucoma?
Impaired aqueous humour drainage through trabecular meshwork causing raised IOP
Pressure gradually damages optic nerve and leads to peripheral visual field loss
Chronic nature is due to structural and vascular factors
86
Symptoms of chronic open angle glaucoma?
No visual symptoms due to chronic nature
Diagnosis is clinical
87
Signs of chronic open angle glaucoma?
Loss of peripheral visual fields
Fundoscopy and slit lamp assessment may show;
Pale optic disc
Optic disc cupping cup: disc ratio >0.7 suggests cupping
Retinal vessel bayonetting; vessels appear to have a break
88
Investigations to diagnose chronic open angle glaucoma?
Goldmann applanation tonometry- gold standard
Central corneal thickness measurement
Automated visual field assessment?
89
Management of chronic open angle glaucoma?
Surgical; 360 degree selective laser trabeculoplasty
Medical;
Latanoprost; prostaglandin analogues (inc uveoscleral outflow)
Timolol; beta blocker (reduces aqueous production)
Dorzolamide; carbonic anhydrase inhibitors (reduces aqueous production)
Brimonidine, apraclonidine; sympathomimetics (reduces aqueous production and inc uveoscleral outflow)
Pilocarpine; miotics (inc uveoscleral outflow)
90
What is conjunctivitis?
Inflammation and infection of the conjunctiva, the membrane that lines the eyelid and covers the white parts of the eye
91
Epidemiology of conjunctivitis?
Spreads rapidly
Very common in children
92
Aetiology of conjunctivitis?
Allergic conjunctivitis; Type 1 hypersensitivity reaction
Viral conjunctivitis; adenovirus, HSV
Bacterial conjunctivitis; staphylococcus aureus, staphylococcus epidermidis, streptococcus pneumoniae, haemophilus influenzae
93
Signs and symptoms of conjunctivitis?
Eye redness
Itching
Irritation
Excessive tearing
Discharge from the eyes, which can vary in consistency based on the cause. For example viral aetiologies produce a more watery discharge, wheres bacterial causes produce purulent discharge.
Photophobia, which suggests corneal involvement (keratoconjunctivitis)
No effect on visual acuity
94
Red flag symptoms of conjunctivitis?
Reduced visual acuity
Marked eye pain, headache, photophobia
Red sticky eye in a neonate
History of trauma or foreign body
Rapidly progressive discharge
Infection with herpes virus
Contact lens use
Pupil abnormalities or pain on constriction
Loss of red reflex
Blood or pus in the anterior chamber
95
Differentials for conjunctivitis?
Dry eyes
Corneal abrasion
Uveitis
Glaucoma
96
Investigations to diagnose conjunctivitis?
History and examination
Swabs
97
Management of conjunctivitis?
Allergic conjunctivitis; artificial tears, topical antihistamines, sodium cromoglycate
Viral conjunctivitis; self limiting, hygiene
Bacterial conjunctivitis; chloramphenicol, fusidic acid
98
What is corneal arcus?
Deposition of lipids in the periphery of the cornea resulting in visible white, blue or grey opaque ring
99
Epidemiology of corneal arcus?
Common in elderly
If under 40 may be indicative of lipid metabolism disorders
100
Aetiology of corneal arcus?
Lipid (cholesterol and phospholipids) deposition in peripheral corneal region
101
Presentation of corneal arcus?
Visible white, blue or grey opaque ring in the periphery of the cornea
102
Differentials for corneal arcus?
Corneal dystrophy
Keratoconus
Pinguecula
103
Investigations to diagnose corneal arcus?
Slit lamp examination
Lipid profile
104
Management of corneal arcus?
Treat hyperlipidaemia/ hypercholestrolaemia
105
What is corneal graft rejection?
Immediate complication after corneal transplant as a result of immune reaction
106
Clinical presentation of corneal graft rejection?
Oedema
Iritis
Redness
Pain
Visual loss
107
Differentials for corneal graft rejection?
Endophthalmitis
Corneal infection
Graft vs Host disease
108
Pathophysiology of corneal graft rejection?
Immune reaction against graft tissue which can be triggered by genetic incompatibility, inadequate immunosuppression, surgical complications, infection
109
Investigations to diagnose corneal graft rejection?
Slit lamp examination
Intraocular pressure measurement
Ophthalmic imaging; OCT
110
Management of corneal graft rejection?
Urgent referral to ophthalmologist
Intensive topical steroid
Follow up and consider re-grafting
111
What is dacryocystitis?
Infection of lacrimal sac as a result of obstruction in nasolacrimal duct
112
Aetiology of dacryocystitis?
Blockage of nasolacrimal duct prevents normal drainage of tears from eye, stagnant tear fluid then becomes breeding ground for bacteria resulting in infection
113
Signs and symptoms of dacryocystitis?
Pain and tenderness over medial canthus
Watering of the eye
Potential purulent discharge
114
Differentials for dacryocystitis?
Conjunctivitis
Orbital cellulitis
Other eye infections
115
Investigations to diagnose dacryocystitis?
Clinical diagnosis
USS, CT scan
116
Management of dacryocystitis?
Oral antibiotics
Analgesia
Close monitoring to look out for spread of infection to conjunctiva/ orbit
117
Severity levels of non proliferative diabetic retinopathy?
Mild NPDR: Microaneurysms and dot haemorrhages on fundoscopy.
Moderate NPDR: Microaneurysms, dot and blot haemorrhages, cotton-wool spots, and hard exudates.
Severe NPDR: Beaded veins, intraretinal microvascular abnormalities (IRMA), and extensive retinal hemorrhages.
118
What is diabetic retinopathy?
Sight threatening complication of diabetes mellitus due to poor glycaemic control leading to vascular occlusion and leakage from capillaries supplying the retina causing ischaemia, neovascularisation
119
Pathophysiology of diabetic retinopathy?
Chronic hyperglycaemia causes structural changes to retinal capillaries, thickening of basement membrane and loss of pericytes
This results in capillary occlusion and leakage leading to retinal ischaemia and formation of new fragile vessels
120
Signs and symptoms of diabetic retinopathy?
Floaters or dark spots in the vision
Blurred or distorted vision
Difficulty seeing at night
Sudden loss of vision
121
Differentials for diabetic retinopathy?
ARMD
Retinal vein occlusion
Hypertensive retinopathy
122
Investigations to diagnose diabetic neuropathy?
Fundoscopy;
Signs of mild disease; microaneurysm, hard exudates, blot haemorrhage
Severe disease; engorged tortuous veins, large blot haemorrhage
In proliferative disease neovascularisation can be seen
Optical coherence tomography
Fluorescein angiography
123
Management of diabetic retinopathy?
Optimise blood glucose control
Laser photocoagulation for proliferative diabetic retinopathy
Intravitreal injections of anti- VEGF
Vitrectomy
124
Complications of diabetic retinopathy?
Vitreous haemorrhage
Tractional retinal detachment
Macular oedema
Neovascular glaucoma
Blindness
125
Questions to ask when assessing red eye?
Is acuity affected?
Is the eye painful?
Are pupil reflexes affected?
126
Diagnoses to rule out when presenting with red eye?
Acute angle closure glaucoma
Anterior uveitis
Scleritis
127
Sight threatening visual problems?
Acute angle closure glaucoma
Corneal ulcer
Infectious keratitis
Scleritis
Endophthalmitis
Hyphema
Uveitis
Retinal detachement
Orbital cellulitis
Acute retinal ischaemia
Acute optic neuritis
Ocular tumours
128
Non sight threatening conditions?
Subconjunctival haemorrhage
Conjunctivitis
Allergic conjunctivitis
Dry eye syndrome
Pinguecula
Corneal abrasion
Iritis
Episcleritis
Contact lens related irritation
Foreign body
Chemical exposure
Sub tenon's haemorrhage
129
Causes of gradual vision loss?
Cataracts
Dry age related macular degeneration
Wet age related macular degeneration
Chronic open angle glaucoma
Diabetic maculopathy
Retinitis pigmentosa; leber's optic atrophy, syphilis, choroiditis
130
Aetiology of diplopia?
CN III palsy; posterior communicating aneurysm, MS
CN IV palsy; ocular trauma, Diabetes mellitus
CN VI palsy; diabetic neuropathy, stroke infection, MS
131
Signs of CN III palsy?
Eye looks down and out
Ptosis, proptosis, fixed dilation
132
Signs of CN IV palsy?
Upwards and inward deviation of affected eye
Patient may tilt head to compensate
133
Signs of CN VI palsy?
Fails to abduct eye
Medial deviation
134
Differentials for CN palsies?
Myasthenia gravis
Strabismus
Thyroid eye disease
135
Investigations to diagnose cause of diplopia?
Ophthalmic examination
Neuro- imaging such as CT/ MRI
Blood tests
Lumbar puncture
Nerve conduction studies
136
Management of diplopia?
Strabismus surgery
Blood sugar control
Immunosuppression
Cause dependent management
137
What is endophthalmitis?
Severe inflammation of the interior of the eye as a result of infection
138
Epidemiology of endophthalmitis?
Serious complication of ocular surgery
Can lead to significant visual loss
139
Aetiology of endophthalmitis?
Bacterial contamination, especially during cataracts surgery
Most common causative agent is gram positive bacteria, staphylococcus
140
Presentation of endophthalmitis?
Redness of the eye
Eye pain
Decreased visual acuity
Photophobia
Floaters
Hypopyon (pus collection within anterior chamber)
141
Differentials for endophthalmitis?
Uveitis
Keratitis
Retinitis
142
Investigations to diagnose endophthalmitis?
Detailed ocular examination
Cultures of vitreous and aqueous humour
143
Management of endophthalmitis?
Intravitreal administration of Abx (commonly vancomycin)
Vitrectomy
144
What is scleritis?
Inflammation of the sclera
Episcleritis is inflammation of the episclera
145
Aetiology of scleritis?
Systemic illness
Rheumatoid arthritis
Granulomatosis with polyangitis
146
Presentation of slceritis?
Red eye
Severe pain in the orbit
Pain on eye movement
Bluish tinge to the white of the eye in severe or necrotising scleritis
Systemic symptoms in ~50% of patients
147
Presentation of episcleritis?
Sectoral redness
Tenderness over the inflamed area
Milder pain compared to scleritis
Episcleral vessels move or blanch when pressed with a cotton bud
148
Investigations to diagnose scleritis?
Urine dip
FBC, CRP, U+E, LFT,; identify anaemia of chronic disease, neutrophilia, renal function
Autoimmune serology
Phenylephrine eye drops
149
Management of scleritis?
NSAIDs such as fluriprofen 100mg TDS
Corticosteroids
150
Management of episcleritis?
Supportive therapy
Artificial tears
151
Prognosis of scleritis?
5% of patients lose useful vision
25% of patients vision deteriorates
Some develop cataracts
152
What is herpes simplex keratitis?
Severe eye infection caused by herpes simplex virus affecting the cornea leading to discomfort, visual distortion and blindness
153
Epidemiology of herpes simplex keratitis?
Most prevalent form of corneal blindness in developed world
Reactivation of HSV1 in trigeminal nerve ganglion
154
Aetiology of HSV keratitis?
HSV1 lies dormant in trigeminal nerve ganglion. Reactivation leads to inflammation
155
Signs and symptoms of HSV keratitis?
Acute pain
Photophobia
Epiphora
156
Differentials for HS keratitis?
Bacterial keratitis
Fungal keratitis
Acanthamoeba keratitis
157
Investigations to diagnose HSV1 keratitis?
Gold standard; slit lamp with fluoroscein staining
Viral culture
PCR
Immunofluorescence assay
158
What is herpes zoster ophthalmicus?
Infection caused by reactivation of VZV affecting ophthalmic division of the trigeminal ganglion, virus invades cornea leading to inflammation, pain and possible vision loss
159
Epidemiology of Herpes zoster ophthalmicus?
Affects older adults, immunocompromised individuals
160
Signs and symptoms of herpes zoster ophthalmicus?
Painful red eye
Fever
Malaise
Headache
Erythematous vesicular rash over the trigeminal division of the ophthalmic nerve
Hutchinson's sign: a skin lesion on the tip or side of the nose, indicative of nasociliary nerve involvement indicates there is high risk of ocular involvement and so patients with this sign should have an urgent Ophthalmology review
161
Differentials for Herpes zoster ophthalmicus?
Bacterial conjunctivitis
Uveitis
Keratitis
162
Investigations to diagnose Herpes zoster ophthalmicus?
Ophthalmic examination
Viral culture and PCR
163
Management of herpes zoster ophthalmicus?
Hutchinson's sign; urgent review
Systemic antiviral therapy
Topical steroids
164
What is hypertensive retinopathy?
Disease of retina and retinal vasculature due to uncontrolled hypertension
Damage arises from arteriolar vasoconstriction and leakage
165
Pathophysiology of hypertensive retinopathy?
Prolonged hypertension leads to damage to retinal vasculture, changes in arteriolar structure leading to vasoconstriction and leakage
166
Signs and symptoms of hypertensive retinopathy?
Blurred vision
Sudden vision loss
Floaters in the visual field
167
Grades of hypertensive retinopathy?
Grade I – Vascular attenuation (or narrowing of the retinal arteries)
Grade II – Above + AV nipping
Grade III – Above + retinal haemorrhages, hard exudates and cotton wool spots
Grade IV – Above + optic nerve oedema + silver wiring (increased arteriole light reflex due to sclerosis)
168
Differentials for hypertensive retinopathy?
Diabetic retinopathy
Retinal vein occlusion
Age related macular degeneration
169
Investigations to diagnose hypertensive retinopathy?
Fundus photograph
Fluorescein angiography
OCT scan
170
Management of hypertensive retinopathy?
Laser photocoagulation
VEGF inhibitors
171
Presentation of intra- ocular foreign body?
Sudden decrease in vision
Pain in the eye
Presence of blood in the eye
Visible foreign body in the eye
172
Differentials for intra- ocular foreign body?
Corneal abrasion
Retinal detachment
Uveitis
173
What is ischaemic optic retinopathy?
Optic nerve damage due to lack of blood flow
174
Epidemiology of ischaemic optic neuropathy?
Anterior is more common than posterior
More common in those over 50 years
175
What are Kayser- Fleischer rings?
Copper coloured rings around periphery of the cornea due to copper deposition
Seen in wilsons disease, cholestasis, primary biliary cirrhosis
176
What is a keratoacanthoma?
Rapidly growing skin lesion which develops from hair follicles in skin exposed to sun
177
Appearance of keratoacanthoma?
Well demarcated raised papule, surrounded by normal skin
178
What is light near dissociation?
Pupils constricts on convergence or focusing on a near object
It does not constrict in response to direct light exposure
179
Signs and symptoms of light near dissociation?
Abnormal pupillary response
No constriction in response to direct light exposure
180
Differentials for light near dissociation?
Meningitis
Alcoholism
Argyll- Robertson pupil
Adie syndrome
Pinealoma
181
Investigations to diagnose light near dissociation?
Neuroimaging
Bloods; infection, systemic consitions
Lumbar puncture of meningitis is suspected
Serological tests
182
Management of light near dissociation?
Treat underlying cause
Antibiotics for meningitis or neurosyphilis
Detoxification and rehabilitation programs for alcoholism
Symptomatic treatment for Adie syndrome
Surgery or radiation therapy for tectal lesions like pinealomas
183
Most common ocular infection in HIV patients?
CMV retinitis
184
Aetiology of HIV ocular disease?
CMV, HSV, VZV, mycobacterium tuberculosis
Kaposi's sarcoma
185
Signs and symptoms of HIV ocular disease?
CMV Retinitis: Reduced visual acuity; fundoscopy reveals a classic "pizza pie" appearance
HSV Infection: May affect the anterior or posterior segment of the eye; involvement of the central area of the cornea can result in permanent vision impairment
VZV Infection: Can cause multiple ophthalmic disorders including red and swollen eyelids (herpes zoster ophthalmicus), keratitis, uveitis, progressive outer retinal necrosis, and cerebral vasculitis
Tuberculosis: Can cause uveitis or discrete ocular granulomas within the retina
Kaposi's Sarcoma: Discrete lesions found on the eyelid or growing within the conjunctiva
Molluscum contagiosum: Small painless lesions, typically on both eyelids
186
Investigations to diagnose HIV ocular disease?
Fundoscopy: Particularly useful in identifying CMV retinitis and other retinal diseases
Culture and Sensitivity: For bacterial infections
PCR: Useful in identifying viral infections such as CMV, HSV, and VZV
Biopsy: of lesions suggestive of Kaposi's sarcoma/malignancy
187
Management of HIV ocular disease?
CMV Retinitis: Intraocular injections of ganciclovir and systemic oral valganciclovir
HSV Infection: Topical aciclovir
VZV Infection: Systemic antiviral therapy
Tuberculosis: Regular TB treatment
Kaposi's Sarcoma: Primarily responds to cART`
188
Differentials to rule out for patient presenting with ocular pain?
Acute angle closure glaucoma
Anterior uveitis
Scleritis
Corneal ulcer
189
Differentials for ocular pain?
Acute angle closure glaucoma
Anterior uveitis
Scleritis
Corneal ulcer
Cluster headache
Optic neuritis
Corneal abrasion
Keratitis
190
Primary ocular tumours?
Retinoblastoma
Ocular melanoma
Intra-ocular lymphoma
Conjunctival melanoma
Eyelid carcinoma
Lacrimal gland tumour
191
Causes of secondary ocular tumour?
Breast cancer
Lung cancer
Kidney, thyroid, prostate
192
Investigations to diagnose ocular tumours?
Ophthalmic examination
Imaging; OCT, MRI
Biopsy
Systemic evaluation
193
Management of ocular tumours?
MDT
Surgery, radiation, chemotherapy, immunotherapy
Visual preservation
Regular monitoring
Supportive care and patient education
194
What is onchocerciasis?
Chronic disease affecting skin and eyes due to parasitic worm onchocerca volvulus transmitted through bite by an infected blacklfy
195
Epidemiology of onchocerciasis?
More common in intertropical zone; latin america, arab peninsula
196
Aetiology of onchocerciasis?
Onchocerca volvulus worm transmitted by bite of infected black fly
197
Signs and symptoms of onchocerciasis?
Ocular presentation;
Itchy eyes
Ocular pain
Photophobia
Blurred vision
Glaucoma
Night blindness
Progression to blindness
Skin presentation;
Rashes
Nodules
198
Differentials for onchocerciasis?
Allergic conjunctivitis
Dry eye syndrome
Dermatitis
Parasitic infection
199
Investigations to diagnose onchocerciasis?
Microscopy; skin shavings, excised nodules
200
Management of onchocerciasis?
Ivermectin
Supportive management
201
What is ophthalmia neonatorum?
Neonatal conjunctivitis within first 28 days of life
202
Aetiology of ophthalmia neonatorum?
Gonococcal conjunctivitis
Chlamydia conjunctivitis
203
Signs and symptoms of ophthalmia neonatorum?
Hyperaemia
Swollen eyelids
Conjunctival discharge
Chemosis
204
Management of ophthalmia neonatorum?
IV antibiotics
Topical antibiotics
205
What is optic disc pallor?
Sign of optic atrophy
206
Signs and symptoms of optic disc pallor?
Decreased visual acuity
Changes in the field of vision
Changes in colour vision
Potential loss of peripheral vision
Possible photopsia
207
Differentials for optic disc pallor?
Glaucoma
Retinitis pigmentosa
Choroiditis
Central retinal artery occulsion
Multiple sclerosis
Leber's optic atrophy
Syphilis
208
Investigations to diagnose optic disc pallor?
Comprehensive ophthalmic evaluation
Visual field testing
Optical coherence tomography (OCT)
209
Management of optic disc pallor?
Intraocular pressure reduction for glaucoma
Immunosuppressive or immunomodulatory therapy for conditions like multiple sclerosis
Antimicrobial treatment for infections such as syphilis
Gene therapy or vitamin supplementation for conditions like Leber's hereditary optic neuropathy
Low vision aids and counselling for conditions leading to irreversible vision loss.
210
What is papilloedema?
Optic disc swelling due to raised ICP
211
Aetiology of papilloedema?
Unilateral;
Diabetes, central retinal vein occlusion, uveitis, sarcoidosis, Herpes, toxoplasmosis, optic neuritis, multiple sclerosis, lymphoma
Bilateral;
Raised ICP, space occupying lesion, idiopathic intracranial hypertension, malignant hypertension, hydrocephalus, ethambutol, lymphoma
212
Symptoms of papilloedema?
Headache; worse on coughing or standing
Increased hypermetropia
Transient vision loss; particularly when standing
213
Signs of papilloedema?
Blurring of optic disc margin
Absent venous pulsation on fundoscopy
Haemorrhage near optic disc
Diplopia
214
Differentials for papilloedema?
Optic neuritis
Nonarteric ischaemic optic neuropathy
Intracranial pathology
215
Investigations to diagnose papilloedema?
Frisen scale
CT/ MRI of head
Fundoscopy
216
What is optic neuritis?
Inflammatory condition of optic nerve resulting in visual impairement and ocular pain
217
Epidemiology of optic neuritis?
Most common presentation is in MS
More commonly affects adult women
218
Aetiology of optic neuritis?
Multiple sclerosis
Neuromyelitis optica
Autoimmune disorders: lupus, sarcoidosis
Viral/ bacterial infections
219
Clinical presentation of optic neuritis?
Acute painful vision loss
Periocular pain
Dyschromatopsia
220
Differentials for optic neuritis?
Optic neuropathy
Retinal disorders
CNS infections
Tumours
221
What is orbital cellulitis?
Inflammation of the structures behind the orbital Septum
Sight and life threatening condition
222
What is preseptal cellulitis?
Infection of tissue interior to orbital septum
223
Epidemiology of orbital cellulitis?
Pre-septal is more common; 80% of cases
Most cases occur in under 10 years
224
Risk factors for orbital cellulitis?
Trauma
Surgical; ocular, adnexal or sinus
Sinusitis
Dental infection
225
Signs of orbital cellulitis?
Periocular pain and swelling
Fever
Malaise
Erythematous, swollen and tender eyelid
Chemosis
Proptosis
Restricted eye movements +/– diplopia
226
Findings that suggest pre-septal cellulitis over orbital cellulitis?
No proptosis
Normal eye movements
No chemosis
Normal optic nerve function
227
Investigations to diagnose orbital cellulitis?
FBC, CRP, inflammatory markers
Microscopy, cultures and sensitivities
CT orbit- gold standard
228
Management of orbital cellulitis?
Admission for IV antibiotics
Close monitoring
ENT and ophthalmology
229
Management of preseptal cellulitis?
If young and systemically unwell then admit for IV antibiotics
Oral antibiotics and daily outpatient review
230
What is an orbital blowout fracture?
Fracture in orbital wall due to sudden increase in intra-orbital pressure from the impact
231
Epidemiology of orbital fracture?
Common in facial trauma
Most common mechanism includes trauma from assaults, car accidents and sporting injuries
232
Aetiology of orbital fracture?
Involve orbital floor/ medial wall as these are the weakest points
Occur due to sudden increase in orbital pressure caused by blunt force impact
233
Signs and symptoms of orbital fractures?
Pain, particularly on eye movement
Swelling and bruising around the eye
Visual disturbances such as diplopia
Decreased eye movement
Numbness in the distribution of the infraorbital nerve
Vertical diplopia and restriction of upgaze - can occur due to entrapment the inferior rectus muscle
234
Differentials for orbital fractures?
Orbital cellulitis
Orbital tumours
Sinusitis
235
Investigations to diagnose orbital fractures?
CT scan
236
Management of orbital fractures?
Close ophthalmology follow-up to monitor the fracture and the patient's vision
Possible use of antibiotics to prevent infection
Surgery may be used in severe cases or if the fracture does not improve with conservative management
237
What is posterior vitreous detachment?
When vitreous gel separates from the retina
238
Epidemiology of posterior vitreous detachment ?
Associated with natural ageing process
More common in those over 60 years
239
Aetiology of posterior vitreous detachment?
Ageing; vitreous gel shrinks over time and separate from retina
Eye trauma; injuries can cause vitreous gel to separate from retina
Severe myopia
240
Signs and symptoms of posterior vitreous detachment?
Photopsia
Floaters
241
Differentials for posterior vitreous detachment?
Retinal detachment
242
Signs and symptoms of retinal detachment?
Flashes of light in peripheral vision (Photopsia)
Floaters in the vision
A shadow or curtain over a portion of the visual field, often progressing towards the centre
243
Investigations to diagnose posterior vitreous detachment?
Fundoscopy
244
Management of posterior vitreous detachment?
Serial fundus checks to monitor
Can lead to retinal tears and detachment
245
What is pterygium?
Pathological overgrowth of the conjunctiva onto cornea surface
246
Epidemiology of pterygium?
More common in those who live in warm climates
UV radiation and sunlight exposure contributes
247
Aetiology of pterygium?
Associated with high levels of UV exposure
Dust and wind exposure
248
Signs and symptoms of pterygium?
Reduced visual acuity
Eye irritation
Presence of a visible white fibrous opacity over the cornea, continuous with the conjunctiva
249
Differentials for pterygium?
Pinguecula
Limbal dermoid
250
Investigations to diagnose pterygium?
Ophthalmic examination
Slit lamp examination
251
Management of pterygium?
Artificial tears
Corticosteroid eye drops
Surgical resection
252
What is retinal detachement?
Separation of the retina from the retinal pigment epithelium
253
Aetiology of retinal detachment?
Trauma
Severe myopia
Previous eye surgery
Diabetes, sickle cell disease
Age related ocular changes
254
Signs and symptoms of retinal detachment?
Floaters
Photopsia (flashes of light)
Progressive and rapidly reduced visual acuity and visual field loss
Painlessly in most cases
255
Differentials for retinal detachment?
Posterior vitreous detachment
Age related macular degeneration
Vitreous haemorrhage
256
Investigations to diagnose retinal detachment?
Fundoscopy
Ultrasound
OCT scan
257
Management of retinal detachment?
Laser therapy
Cryotherapy
Vitrectomy
Scleral buckling
Pneumatic retinopexy
258
What is retinitis pigmentosa?
Inherited disorders that cause progressive peripheral vision loss and night blindness due to degeneration of rod photoreceptors
259
Aetiology of retinitis pigmentosa?
Genetic mutation that affects functioning of rod photoreceptor cells in retina inherited in an AD, AR, X-linked pattern
260
Signs and symptoms of retinitis pigmentosa?
Present at a young age
Tunnel vision due to damage to the peripheral retina
Reduced visual acuity in dim light (night blindness)
Difficulty adapting to low light conditions
Loss of central vision in later stages
261
Differentials for retinitis pigmentosa?
Glaucoma
Optic neuropathies
Cone- rod dystrophies
262
Investigations to diagnose retinitis pigmentosa?
Fundoscopy
Electroretinography
Genetic testing
263
Management of retinitis pigmentosa?
Visual aids: to help with low vision
Vitamin A supplementation: may slow disease progression in some patients
Genetic counselling: for patients and families
Research is ongoing into potential treatments including retinal implants and gene therapy
264
What is retinoblastoma?
Malignant neoplasm originating from retina and is most prevalent intraocular tumour in paediatric population
265
Epidemiology of retinoblastoma?
50-60 cases in UK per year
3% of cancers diagnose in under 15 years
266
Aetiology of retinoblastoma?
Hereditary; germline mutation in RB1 gene
Non hereditary caused by somatic mutations in RB1 gene
267
Presentation of retinoblastoma?
Deteriorating vision
Strabismus
Failure to thrive
Leukocoria
268
Differentials for retinoblastoma?
Congenital cataracts
Congenital toxoplasmosis
Congenital rubella syndrome
Persistent hyperplastic primary vitreous
Retinopathy of prematurity
269
What is an external hordeolum?
An abscess at an eyelash follicle, commonly caused by staphylococcus.
269
Prognosis of retinoblastoma?
5 year survival of 90-95%
269
Investigations to diagnose retinoblastoma?
Ophthalmoscopy under anaesthesia
Systemic examination
USS, CT, MRI
270
Management of retinoblastoma?
Surgery, radiotherapy, chemotherapy
271
What is an internal hordeolum?
An abscess of the Meibomian gland, which can lead to a chalazion if the gland becomes blocked.
272
Aetiology of styes?
Staphylococcus bacteria
273
Aetiology of chalazions?
Meibomian gland becomes blocked following internal hordeolum
274
Presentation of styes?
Painful, red hot lump on eyelid that points outwards causing localised inflammation
275
Presentation of chalazion?
Initially painful but evolves into a non tender swelling that points inwards
276
Differentials for styes and chalazions?
Blepharitis
Dacryocystitis
Cellulitis
277
Management of styes and chalazions?
Warm compress
OTC pain relief
Topical antibiotics
Surgical intervention
278
Differentials for painless loss of vision?
Central retinal vein occlusion
Central retinal artery occlusion
Ischaemic optic retinopathy
Retinal detachment
Vitreous haemorrhage
279
Epidemiology of thyroid eye disease?
Half of the people with graves develop TED
80% of TED is due to graves disease
279
Pathophysiology of thyroid eye disease?
Autoimmune reaction results in lymphocyte infiltration into orbital tissue triggering inflammatory response
Inflammatory phase lasts 6-24 months resulting in swelling of extra-ocular muscles
After inflammatory phase inactive fibrotic phase occurs
280
Risk factors for thyroid eye disease?
Smoking
FHx
Female sex
Poorly controlled thyroid
281
Signs and symptoms of thyroid eye disease?
Ocular pain – often worse on movement
Dry, red eyes
'Bulging eyes'
Painful eyelids
Proptosis/exophthalmos
Lid retraction and lid lag
Chemosis
Orbital fat prolapse
Exposure keratopathy
282
Management of thyroid eye disease?
Steroids
Immunosuppressants
Surgical orbital decompression
IV corticosteroids
283
Complications of thyroid eye disease?
Exposure keratopathy
Compressive optic neuropathy
Diplopia
284
Indications for steroid eye drops?
Inflammatory eye conditions; uveitis, episcleritis, scleritis
Allergic conjunctivitis
Post operative inflammation
Dry eye syndrome
285
Types of steroid eye drops?
Prednisolone acetate
Dexamethasone
Fluorometholone
Loteprednol etabonate
286
Side effects of steroid eye drops?
Increased IOP
Cataract formation
Delayed wound healing
Ocular surface changes
Superficial fungal/ bacterial infections
Periorbital dermatitis
287
What is trachoma?
Infectious eye condition caused by chlamydia trachomatis presenting as keratoconjunctivitis
288
Epidemiology of trachoma?
More prevalent in resource poor settings
Poor hygiene
Population dense
289
Aetiology of trachoma?
Bacterial infection with chlamydia trachomatis
290
Signs and symptoms of trachoma?
Eye irritation and pruritus
Photophobia
Conjunctival redness and discharge
291
Differentials for trachoma?
Allergic conjunctivitis
Bacterial conjunctivitis
Viral conjunctivitis
292
Investigations to diagnose trachoma?
Clinical examination
Culture/ PCR
293
Management of trachoma?
Oral antibiotics; azithromycin single dose
294
What is uveitis?
Inflammation of the uveal tract, iris, ciliary body, choroid and associated structures in the eye
295
Types of uveitis?
Anterior uveitis
Intermediate uveitis
Posterior uveitis
Panuveitis
296
Aetiology of uveitis?
Autoimmune disease;
Ankylosing spondylitis
Behçet's disease (associated with HLA-B51 positivity)
Juvenile idiopathic arthritis
Multiple sclerosis
Systemic lupus erythematosus (SLE)
Inflammatory bowel disease
Granulomatosis with polyangiitis
Reactive arthritis
Non autoimmune causes;
Infections (e.g., herpes, tuberculosis, syphilis, HIV)
Trauma
Iatrogenic causes (e.g., ocular surgery or medications)
Ischaemic conditions
297
Symptoms of anterior uveitis?
Painful red eye worsening over several days
Photophobia
Blurred vision
Headache
298
Signs of anterior uveitis?
Conjunctival injection
Hypopyon
Keratic precipitates
Posterior synechiae and irregular pupil
Anterior chamber flare
Anterior chamber cells
299
Symptoms of posterior uveitis?
Blurred vision
Progressive vision loss
Flashes or floaters
300
Signs of posterior uveitis?
Yellow/white appearance of the retina
Cystoid macular oedema
301
Differentials for uveitis?
Acute angle closure glaucoma
Conjunctivitis
Keratitis
Scleritis
302
Investigations to diagnose uveitis?
Complete ocular examination
Blood tests and autoimmune markers
Infectious disease screening
303
Management of uveitis?
Cyclopentolate eye drops; cause iris dilation preventing posterior synechiae
Corticosteroids, immunosuppression
Analgesia
304
Prognosis of uveitis?
Relapse in 2 out of 3 patients
305
Presentation of vitamin A deficiency?
Night blindness
Dryness of the conjunctiva and cornea
Keratomalacia, a condition that results in corneal thinning
Bitot's spots, which are irregular foamy patches on the whites of the eyes
Corneal perforation
Dry skin and hair
Brittle nails
Follicular hyperkeratosis, a condition characterized by an excess buildup of keratin in hair follicles
Increased susceptibility to infections
306
Differentials for vitamin A deficiency?
Dry eye syndrome
Keratoconjunctivitis sicca
Xerophthalmia
Sjorgens syndrome
307
What is a vitreous haemorrhage?
Presence of blood in the vitreous humour
308
Aetiology of vitreous haemorrhage?
Proliferative diabetic retinopathy
Retinal tears
Retinal detachment
Ocular trauma
ARMD
Retinal vascular disease
309
Clinical features of vitreous haemorrhage?
Blurred vision
Floaters
Loss of visual acuity
310
Differentials for vitreous haemorrhage?
Retinal detachment
Retinal tear
Macular degeneration
Retinal vein occlusion
311
Investigations to diagnose vitreous haemorrhage?
Fundoscopy
Slit lamp examination
OCT
Fluroscien angiography
Bscan ultrasonography
Orbital CT
312
Management of vitreous haemorrhage?
Observation
Treat underlying cause; blood sugar management
Vitrectomy
313
Complications of vitreous haemorrhage?
Visual impairment
Retinal detachment
Proliferative vitreorretinopathy
314
