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MRCP Part 1 > Ophthalmology #2 > Flashcards

Ophthalmology #2 Flashcards

1
Q

A 68yo male with a history of T2DM presents with worsening eye sight. Mydriatic drops are applied and fundoscopy reveals pre-proliferative diabetic retinopathy. 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?

A

Acute angle closure glaucoma.

Mydriatic drops are a known precipitant of acute angle closure glaucoma.

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2
Q

A 74yo male presents to Ophthalmology clinic after seeing his optician. They have noticed a raised Intra-ocular pressure and decreased peripheral vision.
His past medical history includes Asthma and T2DM.
What is the most appropriate treatment, given the likely diagnosis?

A

Primary Open-Angle Glaucoma.

Treatment: Latanoprost
A prostaglandin analogue.

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3
Q

Describe how glaucomas can be classified.

A
  • Is the peripheral iris covering the trabecular meshwork?
    (This is important in the drainage of aqueous humour from the anterior chamber of the eye).

In open-angle glaucoma, the iris is clear of the meshwork. The trabecular network functionally offers an increased resistance to aqueous outflow, causing increased intra-ocular pressure.

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4
Q

Describe the epidemiology of Primary Open Angle Glaucoma.

A
  • Affects 0.5% of people over the age of 40.
  • Prevalence increases with age up to 10% over the age of 80.
  • Affects males and female equally.
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5
Q

What are the causes of Primary Open Angle Glaucoma?

A
  • Increasing age

- Genetics: first degree relatives of an open-angle glaucoma patient have a 16% chance of developing the disease.

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6
Q

What are the symptoms of Primary Open Angle Glaucoma?

A
  • Characterised by a slow rise in intra-ocular pressure -> asymptomatic for a period.
  • Typically present following an ocular pressure measurement during a routine examination by an optometrist.
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7
Q

What are the signs of Primary Open Angle Glaucoma?

A
  • Increased Intra-ocular pressure
  • Visual field defect
  • Pathological cupping of the optic disc
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8
Q

What would you see on examining the eyes of a patient with Primary Open Angle Glaucoma?

A
  • Optic nerve head damage visible under the slit lamp
  • Visual field defect
  • Intraocular pressure > 24 mmHg as measured by Goldmann-type applanation tonometry
  • If suspected, full investigations are performed.
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9
Q

What should you do on diagnosing a patient with Primary Open Angle Glaucoma?

A
  • Referral to ophthalmologist
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10
Q

A patient is diagnosed with Primary Open Angle Glaucoma. Which investigations should be conducted?

A
  • Autonomated perimetry to assess visual field
  • Slit lamp examination with pupil dilatation to assess optic nerve and fungus for baseline
  • Applanation tonometry to measure intraocular pressure
  • Central corneal thickness (CCT) measurement
  • Gonioscopy to assess peripheral anterior chamber configuration and depth.
  • Assess risk of future visual impairment, using risk factors such as IOP, CCT, family history, life expectancy.
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11
Q

Describe the management of a patient with Primary Open Angle Glaucoma.

A

Eye drops aim to lower intraocular pressure, which has been shown to prevent progressive loss of visual field.

First line: Prostaglandin analogue (PGA) eyedrops eg. Latanoprost

Second line: Beta-blocker, Carbonic Anhydrase inhibitor, or sympathomimetic eyedrops.

If more advanced: surgery or laser treatment can be tried.

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12
Q

Why should you re-assess someone with Primary Open Angle Glaucoma?

A
  • Important to exclude progression of visual field loss

- Needs to be done more frequently if: IOP uncontrolled, the patient is high risk, or there is progression.

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13
Q 
Prostaglandin analogues (PGA)  are first line treatment for Primary Open Angle Glaucoma.  
Give an example of a PGA, describe its mode of action and any patient counselling advice you would need to consider.
A

PGA: Latanoprost
- Increases uveoscleral flow

Patient advice:

  • Once daily administration
  • Adverse effects include brown pigmentation of the iris, increased eyelash length.
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14
Q

Beta-blockers are a 2nd line treatment for Primary Open Angle Glaucoma.
Give an example, describe its mode of action, and list any patient advice you should consider.

A

eg. Timolol, Betaxolol
- Reduces aqueous production

Patient advice:
- Should be avoided in asthmatics and patients with heart block.

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15
Q

Sympathomimetics are a 2nd line treatment for Primary Open Angle Glaucoma.
Give an example, describe its mode of action, and list any patient advice you should consider.

A

eg. Brimonidine (an alpha 2-adernoceptor agonist)
- Reduces aqueous production and increases outflow.

Patient advice:

  • Avoid if taking MAOI or tricyclic antidepressants
  • Adverse effects include hyperaemia
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16
Q

Carbonic Anhydrase inhibitors are a 2nd line treatment for Primary Open Angle Glaucoma.
Give an example, describe its mode of action, and list any patient advice you should consider.

A

eg. Dorzolamide
- Reduces aqueous production

Patient advice:
- Systemic absorption may cause sulphonamide-like reactions

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17
Q

Miotics are a treatment for Primary Open Angle Glaucoma.

Give an example, describe its mode of action, and list any patient advice you should consider.

A

eg. Pilocarpine (a muscarinic receptor agonist)
- Increases uveoscleral outflow.

Patient advice:
- Adverse effects include a constricted pupil, headache and blurred vision.

18
Q

When might surgery be considered for patients with Primary Open Angle Glaucoma?

A

Surgery may be considered in refractory cases.

19
Q

A 34yo female presents complaining of headaches. Examination of her pupils using a light shone alternately in each eye reveals that when the light is shone in the right eye, both pupils constrict. But when the light source immediately moves to the left eye, both eyes appear to dilate.
What is the most likely diagnosis?

A

Left Optic Neuritis.

  • Swinging light test reveals a relative afferent pupillary defect.
  • As there is a defect in the afferent nerve on the left side the pupils constrict less than normal, giving the impression of dilation.

Given her age, Multiple Sclerosis causing Optic Neuritis is the likely underlying diagnosis.

Optic neuritis typically causes a dull ache in the region of the eye which is aggravated by movement.

20
Q

What are the features of a Central Retinal Artery Occlusion?

A
  • Sudden unilateral visual loss
  • Due to thromboembolism (from atherosclerosis) or arteritis (eg. due to temporal arteritis)
  • Features include afferent pupillary defect, ‘cherry red’ spot on a pale retina.
21
Q

List the causes of tunnel vision.

A 
Tunnel vision in the concentric diminution of the visual fields. 
Causes include:
- Papilloedema
- Glaucoma
- Retinitis pigmentosa
- Choroidoretinitis
- Optic atrophy secondary to tabes dorsalis
- Hysteria
22
Q

An 83yo female presents to her GP with complete loss of vision in her right eye, which occurred suddenly. The episode lasted for 10 minutes and she denies any pain in her eye. Her Past Medical History includes hypercholesterolaemia, diet controlled, and Hypertension for which she takes Amlodipine.
Eye examination and fundoscopy are normal. BP is 145/80mmHg.
Which medication are you going to give first?

A

Aspirin 300mg

  • Amaurosis fugax
  • > treat as a TIA

Sudden painless loss of vision with a normal fundoscopy examination is an Amaurosis Fugax and therefore treated as a TIA.

NICE guidance:
300mg Aspirin should be given immediately, and admission if ABCD2 score > 3 or crescendo TIA, otherwise an immediate TIA clinic referral is required.

23
Q

Which disease might you see ‘cotton wool spots’ in?

A

Pre-proliferative retinopathy

24
Q

Why does hyperglycaemia (seen in diabetes) cause retinopathy?

A
  • Hyperglycaemia is thought to cause increased retinal blood flow and abnormal metabolism in the retinal vessel walls.
  • This precipitates damage to endothelial cells and pericytes.
  • Endothelial dysfunction leads to increase vascular permeability which causes the characteristic exudates seen on fundoscopy.
  • Pericyte dysfunction predisposes to the formation of microaneurysms.
  • Neovascularization is thought to be caused by the production of growth factors in response to retinal ischaemia.
25
Q

How would you identify mild Non-proliferative diabetic retinopathy (NPDR)?

A

1 or more microaneurysm.

26
Q

How would you identify moderate NPDR (Non-proliferative diabetic retinopathy)?

A
  • Microaneurysms
  • Blot haemorrhages
  • Hard exudates
  • Cotton wool spots, venous beading / looping and intraretinal microvascular abnormalities (IRMA) less severe than in severe NPDR
27
Q

How would you identify severe NPDR (Non-proliferative diabetic retinopathy)?

A
  • Blot haemorrhages and microaneurysms in 4 quadrants
  • Venous beading in at least 2 quadrants
  • IRMA (intraretinal microvascular abnormalities) in at least 1 quadrant.
28
Q

How might you identify proliferative retinopathy?

A
  • Retinal neovascularisation: may lead to vitreous haemorrhage
  • Fibrous tissue forming anterior to retinal disc
  • More common in Type 1 Diabetes, 50% blind in 5 years
29
Q

How might you identify Maculopathy?

A
  • Based on location rather than severity (anything is potentially serious!)
  • Hard exudates and other ‘background’ changes on macula
  • Check visual acuity
  • More common in Type 2 Diabetes Mellitus
30
Q

List 4 key distinguishing features of Acute Angle Closure Glaucoma.

A
  • Severe pain (may be ocular or headache)
  • Decreased visual acuity, patient sees haloes
  • Semi-dilated pupil
  • Hazy cornea
31
Q

List 4 key distinguishing features of Anterior Uveitis.

A
  • Acute onset
  • Pain
  • Blurred vision and photophobia
  • Small, fixed, oval pupil, ciliary flush
32
Q

List 2 distinguishing features of Scleritis.

A
  • Severe pain (may be worse on movement) and tenderness

- May be underlying autoimmune disease e.g Rheumatoid Arthritis.

33
Q

Give a distinguishing feature of Bacterial vs Viral Conjunctivitis.

A

Purulent discharge if bacterial.

Clear discharge if viral

34
Q

Give a feature of a presentation of a subconjunctival haemorrhage.

A

History of trauma or coughing bouts.

35
Q

Give a distinguishing feature of Endophthalmitis.

A

Typically red eye, pain and visual loss following intraocular surgery

36
Q

What is Dacryocystitis?

A

Inflammation of the lacrimal sac

37
Q

List 2 features of Dacryocystitis.

A
  • Watering eye (epiphora)

- Swelling and erythema at the inner canthus of the eye

38
Q

How would you treat Dacryocystitis?

A
  • Systemic antibiotics.

- IV antibiotics are indicated if there is associated periorbital cellulitis.

39
Q

Describe the epidemiology of Congenital Lacrimal Duct Obstruction.

A
  • Affects 5 - 10% of newborns

- Bilateral in around 20% of cases

40
Q

What are the features of Congenital Lacrimal Duct Obstruction?

A
  • Watering eye (even if not crying)
  • Secondary infection may occur
  • Symptoms resolve in 99% of cases by 12 months of age.

MRCP Part 1 (16 decks)

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