Ophthalmology 18/05/20 Flashcards
symptoms of blepharitis
- usually bilateral - due to meibomian body dysfunction or infection
- gritty, burny eyes
- often eyelid margin redness, swelling suggestive of infection (most common = S epidermidis)
- change in eyelashes (ingrowth/loss)
- association with ROSACEA and increased chance of developing styes/chalazia
management of blepharitis
Lid hygiene: - remove any debris - chloramphenicol ointment to eyelash bases - lid massage with warm compress - artificial tears for dry eyes ~ Treat rosacea ~
COMMON causes of conjunctivitis
VIRAL - systemic illness/sore throat/lymphadenopathy
ALLERGIC - acute allergy/hay fever/topical medication
BACTERIAL - usually staph, consider neisseria/chlamydia in neonates
symptoms of conjunctivitis (ALLERGIC)
- bilateral chemosis and watery
- prominent itch
- may be atopy/seasonal history
symptoms of conjunctivitis (VIRAL)
- biateral chemosis and watery
- recent URTI/systemic illness
- lymphadenopathy (pre-auricular LNs)
symptoms of conjunctivitis (BACTERIAL)
- purulent discharge
- eyes stuck together in mornings
treatment of conjunctivitis
- history (allergic)
- topical/systemic antihistamines (sodium cromoglicate if unresponsive to AHs in allergy)
- viral usually self-limiting (1-2 wks) - don’t share towels, school excl not necessary
- chloramphenicol as an antibiotic topically (fusidic acid in preg)
what produces lipid layer of tear film?
meibomian glands
what produces aqueous layer of tear film?
lacrimal glands
what produces mucin layer of tear film?
goblet cells
episcleritis symptoms
- UNILATERAL
- mild irritation
- no pain
- intense localised redness (confused with haemorrhage)
- self-resolving within 2 wks
scleritis symptoms
- UNILATERAL
- darker red area (due to deeper layer than EPIscleritis)
- typically painful (can be mild-severe)
REFERRAL REQUIRED as can lead to loss of vision
treatment of stye
- self-limiting but often recurrent
- warm compress
- lash removal/stye drainage
- topical antibiotic if necessary
treatment of chalazion
- warm compress
- lid massage
- referral if chronic
common causes of GRADUAL vision disturbance
- cataracts
- chronic glaucoma
- optic nerve compression
common causes of SUDDEN vision disturbance
- VASCULAR (e.g. thrombosis, embolism, temporal arteritis, including CRA/CRV occlusion)
- vitreous haemorrhage
- papilloedema
- retinal detachment
- acute glaucoma
VARIABLE ONSET vision disturbance causes
- optic/retrobulbar neuritis
- diabetic retinopathy
optic/retrobulbar neuritis symptoms/signs
progressive over days
- pain worse on eye movement
- RAPD
- colour (red) desaturation
- central scotoma
- other symptoms of demyelination (association with MS)
management of optic neuritis
- treat underlying cause, commonly MS so high dose steroids
symptoms of vitreous haemorrhage
smaller bleed = - cobwebs/shadows/floaters/hazy vision - may be redness to vision - usually unilateral moderate bleed = - multiple dark spots big bleed = - can cause sudden total visual disturbance
symptoms of retinal detachment
- peripheral shadow that progressively moves centrally (sudden onset floaters commonly)
- flashes of light (photopsia)
- straight lines appearing curved
symptoms of cataracts
gradual onset of:
- reduced vision (faded colour vision)
- glare and halos around lights
- NO red reflex
fundoscopy findings in primary open angle glaucoma (chronic simple)
- Optic disc cupping - cup-to-disc ratio >0.7 (normal = 0.4-0.7)
- Optic disc pallor - indicating optic atrophy
- Bayonetting of vessels - vessels have breaks as they go into the deep cup and re-appear at the base
RFs for primary open angle glaucoma
- age
- genetics
- ethnicity (black population at increased risk)
- myopia (near-sightedness)
- diabetes
- hypertension
RFs for ACUTE ANGLE CLOSURE glaucoma
- age
- hypermetropia (long-sightedness)
- pupillary dilation (eg. 3rd nerve palsy)
symptoms of chronic simple glaucoma
often insidious, picked up on routine optometry
- peripheral visual field loss - nasal scotomas progressing to ‘tunnel vision’
- decreased visual acuity
- optic disc cupping
symptoms of acute angle closure glaucoma
- severe pain: may be ocular or headache
- hard, red-eye
- decreased visual acuity
- halos around lights
- semi-dilated non-reacting pupil on RAPD
- corneal oedema results in dull or hazy cornea
- nausea and vomiting
- symptoms worse with mydriasis (e.g. watching TV in a dark room)
common red flag for 3rd nerve palsy
post. communicating artery aneurysm
tumour
features of iritis/anterior uveitis
acute onset
- red, watery eye (with ciliary flush)
- pain
- irregular/small pupil
- photophobia
- blurred vision (visual acuity initially normal → impaired)
- hypopyon; describes pus and inflammatory cells in the anterior chamber, often resulting in a visible fluid level
management of iritis/ant. uveitis
urgent review by ophthalmology
- dilate pupil to relieve acute symptoms eg. atropine
- steroid eye drops
corneal ulcer symptoms (similar presentation to HSV keratitis)
more common in contact lense users - pain and irritation (watery) - photophobia - focal fluorescein staining of the cornea can lead to vision loss if not treated
management of corneal ulcer
- antimicrobials
- steroid eye drops
- cornea transplant if severe scarring/vision loss
entropion/ectropion
- entropion: in-turning of the eyelids
- ectropion: out-turning of the eyelids
(Holmes-)Adie pupil features
benign condition, mostly affecting women
- unilateral in 80% of cases
- dilated pupil - efferent pupil defect
- once the pupil has constricted it remains small for an abnormally long time
- slowly reactive to accommodation but barely to light
management of open-angle glaucoma
- prostaglandin analogue drops (eg. latanoprost)
- can then offer beta-blocker (eg. timolol), carbonic anhydrase inhibitor (eg. acetazolamide) or sympathomimetic eyedrop (eg. brimonidine)
- surgery (trabeculectomy) or laser treatment
- follow up!
explanation of glaucoma management
prostaglandin analogue (eg. latanoprost)
- increased uveoscleral outflow
- AEs = brown pigmentation of iris, extra eyelash length
beta blocker (eg. timolol)
- reduced aqueous production
- avoid in asthmatics/heart block
carbonic anhydrase inhibitors (eg. acetazolamide)
- reduced aqueous production
sympathomimetics (eg. brimonidine - alpha2 adrenoceptor agonist)
- reduced aqueous production
- increased uveoscleral outflow
- avoid in those on MAOIs/TCAs
- AEs = hyperaemia
miotics (eg. pilocarpine - muscarinic recetptor agonist)
- increased uveoscleral outflow
- AEs = constricted pupil, blurred vision, headache
management of acute closed angle glaucoma
urgent referral to ophthalmology
management options include:
- inducing pupillary constriction with topical pilocarpine
- timolol (BB)
- apraclonidine
- reducing aqueous secretions with IV acetazolamide
- laser or surgery
anterior ischaemic optic neuropathy features
risk factors of atheroscerosis increase risk
- sudden, painless loss or blurring of vision in one eye
- usually noticed upon waking from sleep (it is believed that the normal drop in blood pressure during sleep triggers an interruption of blood flow to the optic nerve)
anterior ischaemic optic neuropathy FUNDOSCOPY features
- central flame haemorrhages localised around optic disc
- cotton wool infarcts localised to disc
- peripheral retina clear (if not then consider retinal vein occlusion)
age-related macular degeneration (AMD) features
subacute onset of visual loss with:
- reduced visual acuity, particularly close objects - may have distortion (eg. bent lines)
- night blindness
- day to day fluctuations in visual disturbance
- photopsia (flashing lights/glare)
dry vs wet AMD signs
90% AMD = dry
- dry = geographic atrophy, drusen
- wet = neovascularisation, haemorrhage
retinitis pigmentosa features
associations with various rare diseases, including Alport’s
- night blindness often first
- tunnel vision due to loss of the peripheral retina
- fundoscopy: black bone spicule-shaped pigmentation in the peripheral retina
what is Hutchinson’s sign?
- vesicles extending to the tip of the nose
- this is strongly associated with ocular involvement in shingles (anterior uveitis)