Ophthalmology Flashcards
Anti-ccp
Rheumatoid arthritis marker
Rheumatoid factor
Rheumatoid arthritis marker
Diclofenac
Nsaid
Heberdens nodes
DIP joint swelling in OA
Allopurinol
1st line prophylactic treatment for gout
Methotrexate given with
Folic acid
Sulfalazine
DMARD – good for fertile women
Monosodium urate crystals
Build up in joints leads to gout
Leflunomide
DMARD
Colchicine
2nd line in gout if nsaids are CI becoz of renal impairment
Hydroxychloroquine
DMARD
Bouchards nodes
PIP joint swelling in OA
Volar displacement
Displacement of the distal radius towards the palm of the hand #
Colles fracture
Fracture of the head of the radius with dorsal displacement – towards back of the hand
Weber classification
Classifies based on the location of distal fibula fracture relative to the syndesmosis
Calcium pyrophosphate crystals
A = distal, B = at same level, C= proximal
The 4 Rs of fractures
Pseudogout
Closed reduction
Resuscitation, Reduction, Restriction (immobilisation), Rehabilitation
Susceptible nerve in elbow fracture
Bones realigned without surgery
Susceptible nerve in humeral neck fracture
Ulnar nerve
Susceptible nerve in humeral mid shaft fracture
Axillary nerve
Negatively birefringent, needle shape crystals
Radial nerve
Weakly positive birefringent, rhomboid shaped crystals
Monosodium urate = gout
Pre-patellar bursitis
Calcium pyrophosphate = pseudogout
5 common malignancies that spread to bone
Housemaids knee – able to flex and relatively pain free
Chondrocalcinosis
Thyroid, lung, breast, renal, prostate
Fat pad
Radiographic feature of pseudogout – calcifications in the joint space
Mason classification
Signe up blood and fat in the joint capsule
Tension band wire
Classifies radial head fracturs
Monteggia fracture
1=undisplaced 2 = displaced 3=comminuted
Galeazzi fracture
Surgical method to fix olecranon #s
Volar tilt
of proximal ulna with dislocation of the radial head
Radial inclination
of distal radius with dislocation of the distal radio-ulnar joint
Smith’s fracture
Normal wrist has 10 degrees volar tilt
Carpal bones
Normal wrist has 25 degrees radial inclination
FOOSH
Volar displacement of radius head
Clinical signs of scaphoid fracture
Bones of the wrist
Swan neck deformity
Scaphoid, lunate, triquetral, pisiform
Boutonnieres deformity
Trapezium, trapezoid, capitate, hamate
Z shaped thumb
Fall on out stretched hand
Ulnar deviation
Pain in anatomical snuff box on palpation, pain on palpation of scaphoid tubercle, pain on telescoping of the thumb
Garden classification
Sign of RA
Intertrochanteric # treatment
Hyperflexed DIPJ and hyperextended PIPJ
Intracapsular# treatment
Sign of RA
Management of hip OA
Hyperextended DIPJ and hyperflexed PIPJ
Commonest hip replacement
Sign of RA
The fibula lies on the _______ side
MCPJ flexion and IPJ extension
Schatzker classification
At the MCP joints
Ankle joint bones
Might develop to subluxation
Pilon #
For NOF#
Foot bones
1 – incomplete fracture, not displaced
Hallux valgus
2- complete fracture not displaced
Jones fracture
3 – complete fracture partially displaced
Odontoid peg
4- complete fracture completely displaced
Bamboo spine
Dynamic hip screw
Syndesmophytes
Cannulated screws for non-displaced fractures
Things that make diabetic retinopathy more likely
Long duration of diabetesType of diabetes (more common in type 1)Poor glycemic controlIncreased BPPresence of macro or microalbuminuriaIncreased serum cholesterol levelsPregnancyCigarette smokingGenetic factors
Screening for diabetic retinopathy
All diabetics need annual screening Children screened after five years if have type 1Increased checks if pregnantPhotographs taken - 2 photos of each eye. Disc centred and macula centred, Slit lamps used
Why can diabetes lead to blindness
MaculopathyNew vessel formation CataractsCVA with field loss
Stages of diabetic eye disease0123
0- no retinopathy 1- microaneurysms, any exudate, venous loops2- any microvascular changes, venous beading, multiple blot haemorrhage 3- proliferative disease
What is glaucoma
Chronic progressive optic neuropathyThinning of neuroretinal rim of the optic disc results in characteristic cupping of optic nerve head and visual field loss
Risks for primary open angle glaucoma
AgeIOPraceFamily history High myopiaCorneal thicknessDiabetes Vascular factors eg CV disease, vasospasms, systemic hypotension
Normal intraocular pressure
10-21 mmHg15.5 average
Optic changes in glaucoma
Enlargement of optic cupLoss of disc rimVascular changesPeripappillary atrophy
Treatment of primary open angle glaucoma
Control the IOPOptions:Prostaglandin analogues eg latanoprost. These increase outflow Beta blockers eg timolol. Decrease productionCarbonic anyhydrase inhibitors eg dorzolamide. Decrease productionAlpha agonists decrease production Cholinergic agonists eg pilocarpine. Increase trabecular outflow.
Ocular muscles and innervation
Medial rectus- adduction. Third cranial nerveLateral rectus- abduction. Fourth cranial nerveSuperior rectus- up. ThirdInferior rectus- down. ThirdSuperior oblique- fourthInferior oblique- third
Horizontal Diplopia cause
Sixth nerve palsy as lateral rectus not working - could be trauma, neoplasms, ischamia, demyelination. Autoimmune disorders
Vertical diplopia
Fourth or third cranial nerve palsy- superior oblique or superior rectus
Causes of a mechanical restriction in eye movement
Trauma leading to orbital floor fracture leading to vertical Diplopia usuallyThyroid eye disease
How to test for RAPD
Swinging light testDetects if there is paradoxical dilatation of the pupil when light is shone into it due to an afferent defectDetects an optic neuritis
Causes of optic neuritis
MS or neuromyelitis optica
Blindness by age group16-6465-7475-84 85+
16-64 diabetic retinopathy, macular disorders, optic atrophy, hereditary 65-74 AMD75-84 glaucoma 85+ cataracts
What eye diseases is smoking linked to?
Cataracts Macular degenerationThyroid eye diseaseRetinal vein occlusionRetinal artery occlusion
How do you perform a visual acuity test?
Corrective lenses should be wornTest each eye individually Should be 6m away with snellen or 3m with a 3m snellenNumber on chart says distance at which most people can read itRecord as distance from chart over number on chart Test near vision and colour vision
Charts to measure visual acuity
SnellenLogmar
Eye symptoms history questions
Has vision been affected When did it startSudden or gradualAre the eyes uncomfortable Pain?Grittiness, dryness, feel tired- dryness problemSharp or stabbing pain- ocular surface problems Dull ache- uveitis, raised IOP, scleritisRednessPrevious eye history or surgeryFHsmoking, alcohol, job, driver
Total blindness of right eye- where is lesion
Right optic nerve
Bitemporal hemianopia- where lesion
Optic chiasm- think pituitary tumour
Left visual field loss
Right occipital lobe- could be posterior circulation stroke
Peripheral field loss- what’s the problem
Could be glaucoma
Left homonymous inferior quadrantanopia
Right parietal lobe lesion or stroke
Right homonymous superior quadrantanopia
Left temporal lobe lesion or stroke
What are you looking for on optic disc
CupColour- should be orange with pale centre. Can be pale in optic atrophy eg optic neuritis advanced glaucomaContour- circle should be well defined, if not then could be papilloedema
Cataracts
Common cause of visual loss in the elderlyGradual blurring of distant then near vision If cataracts is posterior in the lens then they experience glare and vision is better out of sunlight Correct with surgery and intraocular implant
Younger patients with cataracts
Diabetes, steroid use, chronic uveitis, FH
Primary open angle glaucoma How does it presentWho is at risk
Progressive painless visual field lossRisk factor include Afro Caribbean, family history, hypertensionOften picked up by opticians or at glaucoma screening
What are changes in ARMD?
Central visionReading, faces and fine detail affected. Colour is also affected
Dilating agents
TropicamideCyclopentolatePhenylephrine
Absent red reflex
Cataracts Retinoblastoma (rare)
Drusen
Lipid deposits Think ARMD
Flat retina- means not
Not glaucoma as this causes cupping
Retinal haemorrhages
Hypertension Retinal vein occlusion Diabetes In baby could be shaken baby
Retinal elevation
Retinal detachment
Dry ARMD
Gradual loss of central visionRisk factors- female, smoking, HTN, previous cataracts surgery
Side effects of latanoprost
Blurred vision, stinging, long eyelashes, foreign body sensation, hyperaemia
Eyes and the DVLAAcuityGlaucoma ARMDCataractsOptic neuritis Diplopia
Must have at least 6/12 vision If glaucoma need to inform DVLA so they can do tests to see if safeMacular degeneration- inform if both eyes affectedCataracts- don’t need to tell DVLA if still over 6/12Optic neuritis- tell DVLA Diplopia- can drive once adaptations of once settled. HGV drivers can’t even with prisms
What is wet macular degeneration
Fluid and or blood develops in the retinaSudden loss of central vision Needs instant referral for anti VEGFV injections
Blurred vision Red eye Nausea and vomiting Headache Differential?
Acute angle closure glaucoma
Why blurred vision in AACG
IOP increases leading to oedema of cornea and it becomes cloudy Therefore affects vision
Who does AACG affect
Long sighted Female
Treatment of acute angle closure glaucoma
Reduce pressure with drops- acetazolamidePeripheral iridotomy to restore aqueous flow Treat other eye prophylactically
Cherry red spot with pale retina
Central retinal artery occlusion
Why does central retinal artery occlusion happen
Non inflammatory vascular problems Raised cholesterol, HTN, atherosclerosis, diabetesAlongside angina and TIAGet smoking Hx, CV exam, routine bloods
Sudden onset of floaters
Most likely to be retinal detachment
Risk factors for retinal detachment
Trauma eg high velocity Myopia is also a risk
Treatment for retinal detachment
Surgery! Vitreous removed. Flatten retina with gas or oil
Child with eye pain, oedema, erythema, chemosis (swelling of conjunctiva), restricted eye movement, systemically unwell
Orbital cellulitis!
Once identified or suspected orbital cellulitis, what is next step
True emergency! Get senior! May need referral to oculoplastic team or ENT.Investigation- blood cultures, swabs, orbital scan, FBCCephalosporins or penicillin IV. If abscess present may need surgery Check obs and visual acuity hourly
Common organisms causing orbital cellulitis
Usually a bacterial infection spread from paranasal sinuses. Commonly staphylococcus aureus, strep pneumoniae, h influenzae. Could be fungal in severely immunosuppressed.
What is a hypopyon?
Red eye, fluid level in anterior chamber of the eye, this indicates an accumulation of WBCCan be a sign of bacterial keratitis. Leads to a risk of corneal perforationTreat with broad spec antibiotics
Red eye, pain and reduced vision
Refer!
Questions with query conjunctivitis
Contact lensesSexually active (could be chlamydial) URTI recently (indicates probably viral cause)Any contact with people with red eyesAllergies
Symptoms of conjunctivitis
Redness of conjunctivaNormal visual acuityReactive pupilsMucoid discharge
Tests in conjunctivitis
Swabs- bacterial, viral, chlamydial
Treatment of conjunctivitis
Usually bacterial usually self limiting. 60% resolve in five days without treatment. Chloramphenicol drops. Ointments and gel provide a higher concentration for longer periods than drops but daytime use is limited because of blurred vision. Cold compressesLubricantsIf allergic conjunctivitis then remove trigger. Antihistamines.
If conjunctivitis does not go away after chloramphenicol…
PCR may be required as more likely to be viral or chlamydial
Fluoroscein eye drops would help reveal..
Corneal abrasion, dendritic ulcers and microbial keratitis
Dendritic ulcers
When herpes simplex infects corneal epithelium Treat with Aciclovir drops
Young male with red eye
Conjunctivitis? Anterior uveitis? Ask about back painAsk about IBD
Investigation into Diplopia
HistoryTests to measure squintAssess range of eye movements Use Hess chartDo bloods and head scans to determine cause of eye palsy (could be aneurysm, SOL, could be microvascular infarcts)
Treatment of eye palsy
80% of palsies due to microvascular infarct resolve in 6 months. Therefore symptom treatment eg temporary plastic prism can be fitted to patients glasses then Botox into medial rectus muscle to reduce size of squint
Ptosis, eye divergent and depressed. Large pupil
The pupil involvement suggests pressure on nerve rather than microvascular cause
Causes of Diplopia
Poor blood supply, direct pressure on nerve (aneurysm), tumour, head injury, inflammation near nerve
Presence of large pupil as well as nerve palsy, treatment
Indicates Pressure on nerve. Therefore is a medical emergency! This could be dangerous swelling of blood supply in the brain (posterior communicating artery). Imaging required! Go from there.
Trauma to eye area
Could lead to inferior orbital floor fracture. Orbital fat and muscle can get stuck in fracture and lead to diplopia. Get max fax involved, prescribe broad spec antibiotic. Do not blow nose! Ask about loss of sensation below orbit
Variable or progressive weakness of eyelid and ocular muscle
Think myasthenia gravis
Symptoms of optic neuritis
Sudden vision lossDecreased contrast and colour sensitivity Pain with eye movement RAPD
Child with white pupil
Retinoblastoma!Congenital cataracts
Retinopathy of prematurity
Underdeveloped Retina. The retina is susceptible to the high oxygen that premature babies are often exposed to.Babies born on or before 31 weeks gestation, under 1500g. Laser photocoagulation is the treatment of choice.
