Ophthalmology 2 Flashcards
What does OCT stand for? What is it?
An Optical Coherence Tomography scan (commonly referred to as an OCT scan) helps us to view the health of your eyes in greater detail, by allowing us to see what’s going on beneath the surface of the eye. It works in a similar way to MRI and ultrasound scans, using light waves to produce a 3D image of your eye.
OCT is useful in diagnosing many eye conditions, including:
macular hole macular pucker macular edema age-related macular degeneration glaucoma central serous retinopathy diabetic retinopathy vitreous traction
What is open-angle glaucoma?
The iris is clear of the meshwork.
Who gets primary open-angle glaucoma?
- 0.5% of people over the age of 40
- prevalance increases with age up to 10% over the age of 80 years
- affects males and females equally
What causes open-angle glaucoma?
- increasing age
- genetics: first degree relatives of an open-angle glaucoma patient have a 16% chance of developing the disease
What are the signs and symptoms of open-angle glaucoma?
Symptoms
- characterised by a slow rise in intraocular pressure: symptomless for a long period
- typically present following an ocular pressure measurement during a routine examination by an optometrist
Signs
- increased intraocular pressure
- visual field defect
- pathological cupping of the optic disc
Case finding:
- optic nerve head damage visible under the slit lamp
- visual field defect
- IOP > 24 mmHg as measured by Goldmann-type applanation tonometry
- if suspected full investigations are performed
How do you diagnose open-angle glaucoma?
Diagnosis:
- Case finding and provisional diagnosis is done by an optometrist
- Referral to the ophthalmologist is done via the GP
- Final diagnosis is done by investigations as below
Investigations:
- automated perimetry to assess visual field
- slit lamp examination with pupil dilatation to assess optic neve and fundus for a baseline
- applanation tonometry to measure IOP
- central corneal thickness measurement
- gonioscopy to assess peripheral anterior chamber configuration and depth
- Assess risk of future visual impairment, using risk factors such as IOP, central corneal thickness (CCT), family history, life expectancy
What’s a gonioscope used for?
To assess the iridocorneal angle.
How do you manage patients with open-angle glaucoma?
The majority of patients with primary open-angle glaucoma are managed with eye drops. These aim to lower intra-ocular pressure which in turn has been shown to prevent progressive loss of visual field.
NICE guidelines:
1. first line: prostaglandin analogue (PGA) eyedrop
2. second line: beta-blocker, carbonic anhydrase inhibitor, or sympathomimetic eyedrop
if more advanced: surgery or laser treatment can be tried2
Reassessment
- important to exclude progression and visual field loss
- needs to be done more frequently if: IOP uncontrolled, the patient is high risk, or there is progression
Surgery in the form of a trabeculectomy may be considered in refractory cases.
What medication can be used to treat open-angle glaucoma?
Prostaglandin analogues (e.g. Latanoprost)
- Increases uveoscleral outflow
- Once daily administration
- Adverse effects include brown pigmentation of the iris
Beta-blockers (e.g. Timolol)
- Reduces aqueous production
- Should be avoided in asthmatics and patients with heart block
Sympathomimetics (e.g. brimonidine, an alpha2-adrenoceptor agonist)
- Reduces aqueous production and increases outflow
- Avoid if taking MAOI or tricyclic antidepressants
- Adverse effects include hyperaemia
Carbonic anhydrase inhibitors (e.g. Dorzolamide)
- Reduces aqueous production
- Systemic absorption may cause sulphonamide-like reactions
Miotics (e.g. pilocarpine, a muscarinic receptor agonist)
- Increases uveoscleral outflow
- Adverse effects included a constricted pupil, headache and blurred vision
What are the risk factors for vitreous haemorrhage?
- Diabetes
- Trauma
- Anticoagulants
- Coagulation disorders
- Severe short sightedness
A mother brings her 8-week-old child in for review. Since birth his right eye has been watering. His symptoms have got worse over the past few days after he picked up a mild viral illness. Clinical examination is unremarkable. What is the most appropriate action?
Teach nasolacrimal duct massage
Symptoms resolve in 95% by the age of one year. Unresolved cases should be referred to an ophthalmologist for consideration of probing, which is done under a light general anaesthetic.
What’s the most common cause of a persistent watery eye in an infant?
Nasolacrimal duct obstruction.
It is caused by an imperforate membrane, usually at the lower end of the lacrimal duct. Around 1 in 10 infants have symptoms at around one month of age
Which eye condition is ankylosing spondylitis associated with and how would it present?
Anterior uveitis
- painful eye
- mild photophobia
- red eye
What’s the most common eye problem presenting to primary care?
Conjunctivitis
What are the features of infective conjunctivitis?
- sore, red eyes associated with a sticky discharge
Bacterial conjunctivitis
- Purulent discharge
- Eyes may be ‘stuck together’ in the morning)
Viral conjunctivitis
- Serous discharge
- Recent URTI
- Preauricular lymph nodes
How do you manage infective conjunctivitis?
- normally a self-limiting condition that usually settles without treatment within 1-2 weeks
- topical antibiotic therapy is commonly offered to patients, e.g. Chloramphenicol. Chloramphenicol drops are given 2-3 hourly initially where as chloramphenicol ointment is given qds initially
- topical fusidic acid is an alternative and should be used for pregnant women. Treatment is twice daily
- contact lens should not be worn during an episode of conjunctivitis
- advice should be given not to share towels
- school exclusion is not necessary
What’s the condition?
bilateral grittiness that is worse in the mornings along with sticking eyelids
blepharitis
What’s the condition?
bilateral grittiness that is worse in the evenings, pain may be present
Dry eye syndrome
What is blepharitis?
Inflammation of the eyelid margins.
It may due to either meibomian gland dysfunction (common, posterior blepharitis) or seborrhoeic dermatitis/staphylococcal infection (less common, anterior blepharitis).
In which patients is blepharitis more common in?
Rosacea
What are the features of blepharitis?
- symptoms are usually bilateral
- grittiness and discomfort, particularly around the eyelid margins
- eyes may be sticky in the morning
- eyelid margins may be red. Swollen eyelids may be seen in staphylococcal blepharitis
- styes and chalazions are more common in patients with blepharitis
- secondary conjunctivitis may occur
What’s the management for blepharitis?
- softening of the lid margin using hot compresses twice a day
- 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*
- artificial tears may be given for symptom relief in people with dry eyes or an abnormal tear film
*an alternative is sodium bicarbonate, a teaspoonful in a cup of cooled water that has recently been boiled
Can you do an LP if someone has papilloedema?
No, it indicates raised ICP
What would be observed during fundoscopy with papilloedema?
- venous engorgement: usually the first sign
- loss of venous pulsation: although many normal patients do not have normal pulsation
- blurring of the optic disc margin
- elevation of optic disc
- loss of the optic cup
- Paton’s lines: concentric/radial retinal lines cascading from the optic disc
What are the causes of papilloedema?
- space-occupying lesion: neoplastic, vascular
- malignant hypertension
- idiopathic intracranial - hypertension
- hydrocephalus
- hypercapnia
Rare causes include
- hypoparathyroidism and hypocalcaemia
- vitamin A toxicity
Following an uneventful pregnancy, a 19-year-old woman delivers a male child vaginally. At assessment one week later the child is noted to have purulent discharge and crusting of the eyelids. What is the next step in the management of the child?
Take urgent swabs of the discharge for microbiological investigation
Although minor conjunctivitis with encrusting of the eyelids is common and often benign, a purulent discharge may indicate the presence of a serious infection (for example, with chlamydia or gonococcus).In babies with a purulent eye discharge swab samples should be taken urgently for microbiological investigation, using methods that can detect chlamydia and gonococcus. While the guidance is to start systemic antibiotic treatment for possible gonococcal infection while awaiting the swab microbiology results, swabs must be taken first.
What’s the most common cause of blindness in the UK?
Age-related macular degeneration
What are the two forms of macular degeneration?
Dry (90% of cases, geographic atrophy) macular degeneration: characterised by drusen - yellow round spots in Bruch’s membrane.
Wet (10% of cases, exudative, neovascular) macular degeneration: characterised by choroidal neovascularisation. Leakage of serous fluid and blood can subsequently result in a rapid loss of vision. Carries worst prognosis.
Recently there has been a move to a more updated classification:
- early age-related macular degeneration (non-exudative, age-related maculopathy): drusen and alterations to the retinal pigment epithelium (RPE)
- late age-related macular degeneration (neovascularisation, exudative)
What’s the m:f ratio of ARMD?
1:2
What’s the average age of presentation of ARMD?
Over 70
What are the risk factors for ARMD?
- Advancing age itself is the greatest risk factor for ARMD. The risk of ARMD increases 3 fold for patients aged older than 75 years, versus those aged 65-74.
- Smoking is another key risk factor in the development of ARMD, current smokers are twice as likely as non-smokers to have ARMD related visual loss, and ex-smokers have a slightly increased risk of developing the condition, (OR 1.13).
- Family history is also a strong risk factor for developing ARMD. First degree relatives of a sufferer of ARMD are thought to be four times more likely to inherit the condition.
- Other risk factors for developing the condition include those associated with increased risk of ischaemic cardiovascular disease, such as hypertension, dyslipidaemia and diabetes mellitus.
How would a patient present with ARMD?
Patients typically present with - a subacute onset of visual loss with:
a reduction in visual acuity, particularly for near field objects
- difficulties in dark adaptation with an overall deterioration in vision at night
- fluctuations in visual disturbance which may vary significantly from day to day
- they may also suffer from photopsia, (a perception of flickering or flashing lights), and glare around objects
Signs:
- distortion of line perception may be noted on Amsler grid testing
- fundoscopy reveals the presence of drusen, yellow areas of pigment deposition in the macular area, which 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.
What investigations are done for ARMD?
- slit-lamp microscopy is the initial investigation of choice, to 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.
- fluorescein angiography is utilised 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.
- 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.
What are the treatments for ARMD?
- the AREDS trial examined the treatment of dry ARMD in 3640 subjects. It showed that a combination of zinc with anti-oxidant vitamins A,C and E reduced progression of the disease by around one third. Patients with more extensive drusen seemed to benefit most from the intervention. Treatment is therefore recommended in patients with at least moderate category dry ARMD.
- Vascular endothelial growth factor, (VEGF) is a potent mitogen and drives increased vascular permeability in patients with wet ARMD. A number of trials have shown that use of anti-VEGF agents can limit progression of wet ARMD and stabilise or reverse visual loss. Evidence suggests that they should be instituted within the first two months of diagnosis of wet ARMD if possible. Examples of anti-VEGF agents include ranibizumab, bevacizumab and pegaptanib,. The agents are usually administered by 4 weekly injection.
- Laser photocoagulation does slow progression of ARMD where there is new vessel formation, although there is a risk of acute visual loss after treatment, which may be increased in patients with sub-foveal ARMD. For this reason anti-VEGF therapies are usually preferred.
What are the stages of hypertensive retinopathy?
I
- Arteriolar narrowing and tortuosity
- Increased light reflex - silver wiring
II
- Arteriovenous nipping
III
- Cotton-wool exudates
- Flame and blot haemorrhages
IV
- Papilloedema
What is posterior subcapsular cataracts associated with?
- diabetes
- steroids
- hypermetropia
- often present with glare from bright lights
- central granular lens opacity on examination
- fast progression
What is nuclear cataracts associated with?
- myopia
- ocular trauma is usually associated with nuclear cataracts with a ‘stellate’ morphology but depend on the trauma mechanism
Are cataracts more common in women or men?
Women
What causes cataracts?
Normal ageing process: most common cause
Other possible causes
- Smoking
- Increased alcohol consumption
- Trauma
- Diabetes mellitus
- Long-term corticosteroids
- Radiation exposure
- Metabolic disorders
What’s the typical presentation of a patient with cataracts?
- Reduced vision
- Faded colour vision: making it more difficult to distinguish different colours
- Glare: lights appear brighter than usual
- Halos around lights
Signs:
A Defect in the red reflex: the red reflex is essentially the reddish-orange reflection seen through an ophthalmoscope when a light is shone on the retina. Cataracts will prevent light from getting to the retina, hence you see a defect in the red reflex.
What investigations and results would you expect for a patient with cataracts?
- Ophthalmoscopy: done after pupil dilation. Findings: normal fundus and optic nerve
- Slit lamp examination. Findings: visible cataract
What are the different types of cataracts?
- Nuclear: change lens refractive index, common in old age
- Polar: localized, commonly inherited, lie in the visual axis
- Subcapsular: due to steroid use, just deep to the lens capsule, in the visual axis
- Dot opacities: common in normal lenses, also seen in diabetes and myotonic dystrophy
How do you manage cataracts?
Non-surgical: In the early stages, age-related cataracts can be managed conservatively by prescribing stronger glasses/contact lens, or by encouraging the use of brighter lighting. These options help optimise vision but do not actually slow down the progression of cataracts, therefore surgery will eventually be needed.
Surgery: Surgery is the only effective treatment for cataracts. This involves removing the cloudy lens and replacing this with an artificial one. NICE suggests that referral for surgery should be dependent upon whether a visual impairment is present, impact on quality of life, and patient choice. Also whether both eyes are affected and the possible risks and benefits of surgery should be taken into account. Prior to cataract surgery, patients should be provided with information on the refractive implications of various types of intraocular lenses. After cataract surgery, patients should be advised on the use of eye drops and eyewear, what to do if vision changes and the management of other ocular problems. Cataract surgery has a high success rate with 85-90% of patients achieving 6/12 corrected vision (on a Snellen chart) postoperatively.
What are the complications of cataract surgery?
- Posterior capsule opacification: thickening of the lens capsule
- Retinal detachment
- Posterior capsule rupture
- Endophthalmitis: inflammation of aqueous and/or vitreous humour
What does optic atrophy look like on fundoscopy?
pale, well demarcated disc
What type of vision loss does optic atrophy cause?
Usually bilateral, gradual visual loss
What are the causes of optic atrophy?
Acquired causes
- multiple sclerosis
- papilloedema (longstanding)
- raised intraocular pressure (e.g. glaucoma, tumour)
- retinal damage (e.g. choroiditis, retinitis pigmentosa)
- ischaemia
- toxins: tobacco amblyopia, quinine, methanol, arsenic, lead
- nutritional: vitamin B1, B2, B6 and B12 deficiency
Congenital causes
- Friedreich’s ataxia
- mitochondrial disorders e.g. Leber’s optic atrophy
- DIDMOAD - the association of cranial Diabetes Insipidus, Diabetes Mellitus, Optic Atrophy and Deafness (also known as Wolfram’s syndrome)
What are the causes of horner’s syndrome?
Central lesions
- Anhidrosis of the face, arm and trunk
- Stroke
- Syringomyelia
- Multiple sclerosis
- Tumour
- Encephalitis
Pre-ganglionic lesions
- Anhidrosis of the face
- Pancoast’s tumour
- Thyroidectomy
- Trauma
- Cervical rib
Post-ganglionic lesions
- No anhidrosis
- Carotid artery dissection
- Carotid aneurysm
- Cavernous sinus thrombosis
- Cluster headache
What’s another name for relative afferent pupillary defect?
Marcus Gunn pupil
What causes RAPD?
- retina: detachment
- optic nerve: optic neuritis e.g. multiple sclerosis
What’s the diagnosis?
severe pain, haloes, ‘semi-dilated’ pupil
Glaucoma
What’s the diagnosis?
small, fixed oval pupil, ciliary flush (bloodshot eye)
Uveitis
Eye pain worse on movement is characteristic of what?
Optic neuritis
What causes optic neuritis?
- multiple sclerosis
- diabetes
- syphilis
What are the features of optic neuritis?
- unilateral decrease in visual acuity over hours or days
- poor discrimination of colours, ‘red desaturation’ ( red color appears “washed out,” pink, or orange when viewed with the affected eye)
- pain worse on eye movement
- relative afferent pupillary defect
- central scotoma
How do you treat optic neuritis?
- high-dose steroids
- recovery usually takes 4-6 weeks
What’s the prognosis if someone has optic neuritis?
MRI: if > 3 white-matter lesions, 5-year risk of developing multiple sclerosis is c. 50%
What’s the name for flashes of light?
Photopsia
What’s the diagnosis?
older age, gradual loss of vision, blurring of small words and straight lines appearing ‘curvy’
Age-related macular degeneration
A 6-year-old boy presents 2 days after sustaining a laceration to his right upper eyelid. He is febrile and generally unwell. The eyelid is now acutely swollen, erythematous, and hot and tender on palpation. There is also notable ptosis. However, there is no proptosis, visual impairment or pain on eye movements.
Which of the following is the most likely diagnosis?
Periorbital cellulitis
Periorbital (preseptal) vs Orbital cellulitis: Absence of painful movements, diplopia and visual impairment indicates the former
Which organisms most frequently cause periorbital cellulitis?
- Staph. aureus
- Staph. epidermidis
- Streptococci
- Anaerobic bacteria.
Epidemiology of preseptal cellulitis
- Preseptal cellulitis occurs most commonly in children - 80% of patients are under 10 and the median age of presentation is 21 months
- It is more common in the winter due to the increased prevalence of respiratory tract infections.
What are the signs and symptoms of periorbital/preseptal cellulitis?
Symptoms
- a red, swollen, painful eye of acute onset
- fever
Signs
- Erythema and oedema of the eyelids, which can spread onto the surrounding skin
- Partial or complete ptosis of the eye due to swelling
Orbital signs (pain on movement of the eye, restriction of eye movements, proptosis, visual disturbance, chemosis, RAPD) must be absent in preseptal cellulitis - their presence would indicate orbital cellulitis
What are the differential diagnoses for preseptal/periorbital cellulitis?
Orbital cellulitis
Allergic reaction
What investigations should you do if you suspect preseptal/periorbital cellulitis?
- Bloods - raised inflammatory markers
- Swab of any discharge present
- Contrast CT of the orbit may help to differentiate between preseptal and orbital cellulitis. It should be performed in all patients suspected to have orbital cellulitis
How do you manage periorbital cellulitis?
- All cases should be referred to secondary care for assessment
- Oral antibiotics are frequently sufficient - usually co-amoxiclav
- Children may require admission for observation
A 65-year-old man with a history of primary open-angle glaucoma presents with sudden painless loss of vision in his right eye. On examination of the right eye the optic disc is swollen with multiple flame-shaped and blot haemorrhages. What is the most likely diagnosis?
Occlusion of central retinal vein
Where are the capillaries located within the retina and when bleeds occur what do they look like?
The capillary network in the posterior retina is found in two layers; a superficial one in the nerve fibre layer and a deeper on within the inner nuclear layer.
Haemorrhage within the nerve fibre layer tends to be flame shaped, following the divergence of axons (1).
In the inner layer, haemorrhage is aligned at right angles to the retinal surface and is consequently viewed end-on when using an ophthalmoscope; these haemorrhages appear dot or blot shaped.
What do multiple blot haemorrhages imply?
Significant retinal ischaemia, characteristic of pre-proliferative retinopathy.
What are rings of hard exudate known as?
circinates
What are hard exudates made of?
They are largely made up of extracellular lipid which has leaked from abnormal retinal capillaries, hence there is often associated retinal oedema (which is not visible using direct ophthalmoscopy).
What’s the earliest clinically visible changes of diabetic retinopathy? What do they look like? How does it affect vision?
Microaneurysms
They are localised capillary dilatations which are usually saccular (round).
They appear as small red dots which are often in clusters.
Vision is not affected
How can diaetes lead to retinal detachment?
As the new vessels mature, connective tissue and fibrosis (gliosis) occurs allowing the vitreous to exert traction which may cause retinal detachment.
What is a sub-hyaloid haemorrhage?
New vessels form abnormal adhesions with the vitreous humor and this can lead to haemorrhage. Where there is localised detachment of the vitreous blood can accumulate between the retina and the vitreous adopting the characteristic appearance of a subhyaloid haemorrhage. This is often said to be boat-shaped.
What looks similar to cotton wool spots?
Treatment of diabetic retinopathy by photocoagulation is of proven efficacy for both proliferative retinopathy and diabetic maculopathy. Transpupillary laser is applied so as to produce a retinal burn. Initially these burns appear as small fluffy areas similar to cotton wool spots. Over time these may evolve into large pigmented scars similar in appearance to moon craters.
A 40-year-old female presents to her GP complaining of blurred vision in her right eye. It has become progressively blurrier over the last week, and is associated with pain worse on eye movement. She also feels that colours are dimmer than they should be, and this is affecting her work as a graphic designer.
On examination, a relative afferent pupillary defect is detected. Ophthalmoscopy reveals an elevated optic disc, with blurred margins.
Which underlying condition is most likely to have caused this presentation?
MS
Optic neuritis is associated with relative afferent pupillary defect
A 71-year-old man who has recently been diagnosed with macular degeneration asks for advice regarding antioxidant dietary supplements. Which one of the following may contraindicate the prescription of such supplements?
Current smoker Pernicious anaemia Treated hypertension History of depression Previous episodes of tendonitis
Current smoker
Beta-carotene has been found to increase the risk of lung cancer and hence antioxidant dietary supplements are not recommended for smokers.
What are the causes of tunnel vision?
- papilloedema
- glaucoma
- retinitis pigmentosa
- choroidoretinitis
- optic atrophy secondary to tabes dorsalis
- hysteria
Is hypermetropia associated with open or closed angle glaucoma?
Acute angle closure glaucoma is associated with hypermetropia, where as primary open-angle glaucoma is associated with myopia
What’s the epidemiology of open angle glaucoma?
- affects 0.5% of people over the age of 40
- the prevalence increases with age up to 10% over the age of 80 years
- affects males and females equally
What are the risk factors for open angle glaucoma?
- genetics: first degree relatives of an open-angle glaucoma patient have a 16% chance of developing the disease
- black patients
- myopia
- hypertension
- diabetes mellitus
- corticosteroids
How might open angle glaucoma present?
- peripheral visual field loss - nasal scotomas progressing to ‘tunnel vision’
- decreased visual acuity
- optic disc cupping
What are the fundoscopy signs of open angle glaucoma?
- Optic disc cupping - cup-to-disc ratio >0.7 (normal = 0.4-0.7), occurs as loss of disc substance makes optic cup widen and deepen
- Optic disc pallor - indicating optic atrophy
- Bayonetting of vessels - vessels have breaks as they disappear into the deep cup and re-appear at the base
- Additional features - Cup notching (usually inferior where vessels enter disc), Disc haemorrhages
How is open angle glaucoma diagnosed and investigated?
Diagnosis:
- Case finding and provisional diagnosis is done by an optometrist
- Referral to the ophthalmologist is done via the GP
- Final diagnosis is done by investigations as below
Investigations:
- automated perimetry to assess visual field
- slit lamp examination with pupil dilatation to assess optic neve and fundus for a baseline
- applanation tonometry to measure IOP
- central corneal thickness measurement
- gonioscopy to assess peripheral anterior chamber configuration and depth
- Assess risk of future visual impairment, using risk factors such as IOP, central corneal thickness (CCT), family history, life expectancy
What’s the normal pressure in the eye?
8-22 mmHg
A long history of diabetes mellitus in an elderly presentation along with unilateral blurry vision and halos surrounding light sources are strongly suggestive of?
Cataract
Increased arterial reflex is a feature of?
hypertensive retinopathy
What’s the action of latanoprost in the management of primary open-angle glaucoma?
Increases uveoscleral outflow
How do you assess for demyelination in MS?
An MRI brain would be first-line in assessment for areas of demyelination
Other options:
- Lumbar puncture is a good option and may show oligoclonal bands. But MRI would still be diagnostic first-line
- PET scan has no value in MS
- CT brain is less detailed at ascertaining areas of demyelination and therefore is rarely used when MRI is available.
- X-ray has no value here
You are an FY-2 doctor in ophthalmology. A 58-year-old male presents with a painful right eye. He also has some tearing of the eye and a reduced vision. On examination you identify a corneal ulcer. Which of the following is most likely to have resulted in this developing?
Antibacterial eye drops Steroid eye drops Saline eye drops Anti-fungal eye drops Lubricant eye drops
Steroid eye drops can lead to fungal infections, which in turn can cause corneal ulcers
What’s another name for a corneal ulcer? What causes them?
A corneal ulcer, otherwise known as a microbial keratitis, is an infection of the cornea by a bacteria, fungi or protists.
What’s the diagnosis?
- unilateral in 80% of cases
- dilated pupil
- once the pupil has constricted it remains small for an abnormally long time
- slowly reactive to accommodation but very poorly (if at all) to light
- association with absent ankle/knee reflexes
Holmes-Adie pupil
How do you treat allergic conjunctivitis?
Topical antihistamines are the first-line treatment in this condition. Oral antihistamines may be used if there are other symptoms such as rhinosinusitis.
- first-line: topical or systemic antihistamines
- second-line: topical mast-cell stabilisers, e.g. Sodium cromoglicate and nedocromil
Is hyper or hypocalcemia a risk factor for cataract?
Hypocalcaemia
A 68-year-old gentleman was diagnosed with glaucoma and commenced on treatment. He returned in one month for review, his eye pressures had improved but he complains his eyelashes have increased in length. What medicine is likely to have caused his eyelashes to grow in length?
Key side effects of prostaglandin analogues include increased eyelash length, iris pigmentation and periocular pigmentation
A 25-year-old man is visiting his GP for a new patient check-up. He is fit and well, with no concerns. On enquiry about illnesses that run in the family he reveals that both his mother and grandfather both suffer from glaucoma.
What advice should you give him regarding glaucoma?
Those with a positive family history of glaucoma should be screened annually from aged 40 years
What’s the term for infection inside the eye and how might it come about?
Endophthalmitis
- May be introduced by corneal infection, eye trauma, or eye surgery (“exogenous”)
- May be introduced via blood stream from infected internal source (“endogenous”)
- Unless treated immediately and vigorously, eye will be destroyed
What is ciliary flush?
- hyperemia of conjunctival and episcleral vessels adjacent to the cornea
- can be caused by anterior uveitis
What’s a bacterial infection of lacrimal sac known as?
Dacryocystitis
What’s the bit under the eyelid called?
pre-tarsal sulcus
A vision-threatening delayed complication of central retinal vein occlusion is?
Neovascular glaucoma
