Ophthalmology Flashcards
Ophthalmoscopy | Pathology
Increased cup:disc ratio; glaucoma
Pale optic disc; optic atrophy
Blurry contour; papilloedema in raised ICP
AMD | Clinical features
Gradual loss of vision
Painless
Central vision only, peripheral vision spared
Wet AMD; sudden central vision loss, distortion
AMD | Types
Dry AMD, 90%; drusen, RPE atrophy
Wet AMD, 10%; haemorrhage, exudate, neovascularisation, pigment epithelial detachment
AMD | Management
Dry AMD; observation, RF modification
Wet AMD; urgent ophthalmology referral, intravitreal antiVEGF injections, RF modification
Primary open angle glaucoma | Clinical features
History
Triad
Gradual loss of vision Painless Peripheral vision Haloes, eye ache Scotoma
- Visual field defect
- Abnormal disc
- Raised IOP
Glaucoma | Investigations
Goldmann tonometry; for IOP
Normal range 10-20mmHg Ocular hypertension (OHT) >21mmHg AACG >40mmHg
Primary open angle glaucoma (POAG) | Management
Medical
Implications for driving
SEs
Patient counselling
[Medical]
Topical prostaglandin analogues; travoprost
Topical beta-blockers; timolol
Topical carbonic anhydrase inhibitors; acetazolamide
Topical alpha2-adrenergic agonists
[Implications for driving]
Inform of driving standards
If glaucoma affects both eyes, must inform DVLA
[Patient counselling] Effect of drops SEs Importance of compliance Probability of lifetime treatment That they will not notice any day-to-day benefit
AMD | RFs
Age >50yrs
Smoking
FH +ve
Acute angle closure glaucoma (AACG) | Clinical features
History
Signs
Sudden onset loss of vision Painful Eye redness Fixed semi-dilated pupil Corneal oedema; cloudy appearance due to waterlogged cornea
Deep, dull, periorbital headache
Nausea/vomiting
Haloes around lights
Acute angle closure glaucoma (AACG) | RFs
Female Hypermetropia; long-sighted, smaller eye, shallower anterior chamber, more likely to occlude Cataracts; thicker lens, shallow chamber Previous AACG in fellow eye Asian ethnicity
Acute angle closure glaucoma (AACG) | Management
PLAN
Medical
Surgical
[PLAN]
Admit patient to hospital
Check IOP hourly until under adequate control
[Medical] TOPICAL Carbonic anhydrase inhibitors + beta-blockers 1. Dorzolamide + timolol drops 2. + pupil contstriction (Brinzolamide) (Timolol 0.5% 1 drop BD)
SYSTEMIC carbonic anhydrase inhibitors
1. IV/PO acetazolamide
[Surgical]
Laser peripheral iridotomy (LPI)
Prophylaxis of contralateral eye with LPI
Cataract surgery, artificial ‘pseudophakic’ lens thinner allowing deepening of anterior chamber
Occular emergencies
Acute angle closure glaucoma (AACG)
Central retinal artery occlusion (CRAO)
Retinal detachment
Wet AMD
Orbital cellulitis
Postoperative infective endophthalmitis
Central retinal artery occlusion (CRAO) | Clinical features
History
Signs
Sudden onset loss of vision
Painless
Unilateral
RAPD
Cherry red spot in the macula
Pale swollen retina
Emboli
Central retinal artery occlusion (CRAO) | RFs
Atherosclerotic
Embolic
Inflammatory
[Atherosclerotic]
HTN, DM
Hypercholesterolaemia
Smoking
[Embolic]
Carotid artery disease; TIA/stroke
Arrhythmias; AF
Valve vegetations; infective endocarditis
[Inflammatory]
Vasculitis; GPA, giant cell arteritis (GCA)
Central retinal artery occlusion (CRAO) | Investigations
BP, FBC, BM, blood cultures
Lipid profile
Coagulation profile
MUST r/o GCA in >50yrs; FBC, CRP, ESR, temporal artery biopsy
Carotid Doppler USS; carotid artery plaques/stenosis
Vasculitis autoantibodies; ANA, ANCA, DNA, RF
To r/o infective endocarditis; ECG, echocardiogram, blood cultures
Central retinal artery occlusion (CRAO) | Management
PLAN
Medical
Urgent ophthalmology referral within hours; retinal ischaemia similar to ‘stroke’, may restore vision
[Medical]
IV acetazolamide
Retinal detachment | Clinical features
History
Signs
Sudden onset loss of vision
Painless
Preceded by flashes of light, floaters, or ‘curtain’ visual field defect
If macula is involved central vision is affected, otherwise peripheral loss
Demarcation lines ‘high tide marks’ / tear
Retinal thinning
Pale detached retina
Loss of RPE peripheral markings
Retinal detachment | RFs
Myopia
Trauma
Previous ophthalmic surgery
Retinal detachment | Management
Surgery
[Surgery]
Vitrectomy within 24hrs
Orbital cellulitis | Clinical features
Paediatric ocular pain Loss of vision Painful limited EOM Proptosis Periorbital erythema, swelling/oedema, warmth, tenderness Unilateral
Fever, malaise
Orbital cellulitis | RFs
Children, male
Recent sinusitis; H. influenzae
Lack of HiB vaccination
Recent eyelid surgery
Orbital cellulitis | Management
PLAN
Medical
[PLAN]
Admit to hospital
Urgent referral to oculoplastics/ENT
[Medical]
Abx; IV cefuroxime/ceftriaxone
Post-operative infective endophthalmitis | Clinical features
History triad
Sudden onset loss of vision
Painful
Inflamed red eye; injected conjunctiva
Hypopyon; pus in anterior chamber
Fixed unreactive pupil
Abnormal red reflex
- Painful sudden vision loss
- Recent ocular surgery within 1/52 ago
- Poorly controlled DM; immunocompromised
Post-operative infective endophthalmitis | Investigations & Management
PLAN
Medical
Vitreous tap; intraocular fluid sample
PLAN
Immediate referral to ophthalmology
Intravitreal abx injection
Conjunctivitis | Clinical features
Bacterial
Viral
Allergic
Chlamydial
HSV-1
Fungal
Bacterial; red, sticky, mucopurulent, gritty
Gonococcus
Viral; red, watery, gritty
Recent cold/flu-like sx
Adenovirus
Allergic; red, itchy, swelling, watery/mucoid, bilateral
Chlamydial; red, persistent mucopurulent discharge, unilateral
Neonates
HSV-1; dendritic ulcer
Fungal; immunocompromised
Conjunctivitis | Investigations
Conjunctival swabs; Gram-stain, culture, PCR
PCR; unresponsive chlamydial/viral infection
Corneal scrape
Fluorescein staining; dendritic ulcers, corneal abrasion, bacterial keratitis (severe may increase risk of corneal perforation)
Conjunctivitis | Management
Non-pharmacological
Pharmacological
[Non-pharmacological]
Self-limiting, resolve within 5/7
Bathing/cleaning eye with clean water/sterile wipes
Avoid contact lens wear with topical treatment
Contact lens wear should be discontinued until at least 48hrs after complete resolution of sx
Reduce risk of transmission; good hand hygiene, avoid sharing towels
[Pharmacological] Bacterial; topical chloramphenicol Viral; topical acyclovir Chlamydial/gonococcal; immediate referral to ophthalmology as risk of corneal scarring Allergic; topical/PO antihistamine
Anterior uveitis | Clinical features & RFs
Sudden onset loss of vision Painful Red eye Photophobia Without discharge (watery)
RFs; HLA-B27 gene association, IBD, psoriasis, spondyloarthritides (PsA, AS, JIA)
Anterior uveitis | Management
Referral to ophthalmology
Topical corticosteroid; topical prednisolone 1%
Pupillary dilation if synechiae; topical cyclopentolate
Abducens palsy, CN6 | Clinical features, Investigations & Management
Horizontal diplopia
Worse on ipsilateral gaze and in the distance
Limited abduction of ipsilateral eye
Inv; CT/MRI head to r/o head injury, raised ICP, or compressive lesions (SOL)
Tx; referral to orthoptics, fresnel prism
Occulomotor palsy, CN3 | Clinical features, Investigations & Management
Horizontal and vertical diplopia Unilateral ptosis Fixed dilated pupils; complete loss of parasympathetic supply 'Down and out' gaze Limited EOM up and inwards
[Investigations]
CT/MRI; to r/o trauma, aneurysm, SOL, stroke
Dilation implies external compression of parasympathetic nerve; PCA aneurysm
If supply is spared, indicates vascular cause
Tx; ?neurosurgery depending on underlying cause
Trochlear palsy, CN4 | Clinical features & Management
Vertical diplopia
Worse with near vision
Torsion of images
Tx; referral to orthoptics, prisms, surgical correction
‘Blowout’ fracture | Clinical features & Management
Periorbital bruising, oedema, haemorrhage, pain
Upward gaze diplopia
Limited upward gaze
Enopthalmos
[Management]
Advise not to blow their nose, communication with sinuses may cause orbital infection
PO abx
Maxillofacial surgery
Myasthenia gravis | Clinical features, Investigations & Management
Variable and fatiguable sx
Diplopia
Ptosis
Inv; antiACh antibodies, edrephonium test, CT/MRI
CXR; thymoma, thyroid disease
Tx; referral to neurology to assess extent of systemic involvement
Anticholinesterases
Paediatric ophthalmology | Conditions
RB
Congenital cataract
ROP
[Retinoblastoma] Leukocoria Abnormal red reflex Raised mass involving macula Tx; urgent ophthalmology referral
[Congenital cataract] Leukocoria Abnormal red reflex Amblyopia Tx; urgent paediatric cataract surgery
[Retinopathy of prematurity]
Vitreous haemorrhage
Retinal detachment
Inv; ROP postnatal screening at 4-7wks of age
Laser photocoagulation
