Ophthalmology Flashcards
cardinal features of Horner’s Syndrome?
PEAS
Ptosis: partial (superior tarsal muscle)
Enophthalmos
Anhydrosis
Small pupil (miosis) - due to loss of sympathetic dilatation
causes of horner’s syndrome?
Central:
MS, Wallenberg’s Lateral medullary syndrome
Pre-ganglionic (Neck):
Pancoast tumour
trauma: carotid artery aneurysm/ ICA dissection
Post-ganglionic:
cavernous sinus thrombosis
features of an argyll robertson pupil?
small, irregular pupils
accommodate but dont react to light
atrophied and depigmented iris
cause of argyll robertson pupil?
highly specific sign of neurosyphilis
can also be a sign of diabetic neuropathy
features of an afferent defect of the pupil?
no direct response but intact consensual response
cannot initiate consensual response in contralateral eye
dilatation on moving light from normal to abnormal eye
causes: total CN II lesion
What is a relative afferent pupillary defect?
minor constriction to direct light
dilatation on moving light from normal to abnormal eye
RAPD = Marcus Gunn pupil
The affected eye still senses the light and produces pupillary sphincter constriction to some degree, albeit reduced.
causes of marcus gunn pupil / Relative afferent pupillary defect?
optic neuritis
optic atrophy
retinal disease
lesion of optic nerve
features of an efferent defect of the pupil?
dilated pupil does not react to light (no constriction)
initiates consensual response in contralateral pupil
opthalmoplegia + ptosis
cause of efferent defect of pupil
CN III nerve palsy
differential of a fixed dilated pupil?
mydriatics: e.g. tropicamide
iris trauma
acute glaucoma
CN3 compression: tumour, coning
features of Holmes-Adie pupil?
Dilated pupil has no response to light but sluggish response to accommodation
Initially unilateral and then bilateral pupil dilatation
Young woman w sudden blurring of near vision
ix of holmes adie pupil?
Iris shows spontaneous wormy movements on slit-lamp examination
what is holmes -adie syndrome?
tonically dilated pupil + absent knee/ ankle jerks + low BP
cause of holmes adie pupil?
damage to postganglionic parasympathetic fibres
idiopathic: may have viral origin
features of optic neuropathy/ atrophy?
decreased acuity
decreased colour vision (esp red)
central scotoma
pale optic disc
RAPD
causes of optic atrophy/ neuropathy?
congenital:
alcohol/ toxins
Compression: Glaucoma, pituitary adenoma
vascular: DM, GCA, thromboembolic
inflammatory: optic neuritis -MS, DM, Devic’s
Sarcoid
infection: herpes zoster, TB, syphilis
oedema: papilloedema
Neoplastic: lymphoma, leukaemia
visual history?
vision:
blurred, distorted, diplopia, visual defect/ scotoma, floaters
sensation:
pain, irritation, itching, photophobia
appearance:
red, puffy lids
discharge:
watery, sticky, stringy
symptoms of acute glaucoma?
severe pain
decreased visual acuity
hazy/ cloudy cornea
large pupil
increased IOP
prodrome: rainbow haloes around lights at night time
features of anterior uveitis?
pain
photophobia
decreased visual acuity
small pupil
conjunctivitis features?
pain
photophobia
acute closed angle glaucoma
pathophysiology?
blocked drainage of aqueous humour from anterior chamber via the canal of Schlemm
pupil dilatation (esp at night) worsens the blockage
IOP rises from 15-20 -> 60 mmHg
risk factors for acute closed glaucoma?
hypermetropia
shallow ant chamber
female
FH
increased age
drugs: anticholinergics, sympathomimetics, TCAs, anti-histamines
examination findings of acute closed angle glaucoma?
cloudy cornea with circumcorneal injection
fixed, dilated, irregular pupil
Increased IOP makes eye feel hard
ix of acute closed angle glaucoma?
tonometry: raised IOP
(usually > 40 mmHg)
acute mx of acute closed angle glaucoma?
refer to ophthalmologist
pilocarpine 2-4% drops stat: miosis opens blockage
topical BB (e.g. timolol): decrease aqueous formation
Acetazolamide 500mg IV stat: decrease aqueous formation
analgesia and antiemetics
long term mx of acute closed angle glaucoma?
bilateral YAG laser peripheral iridotomy once IOP decreased medically
what is the uvea?
pigmented part of eye and includes: iris, ciliary body and choroid.
what is anterior uveitis?
Uvea is pigmented part of eye and included: iris, ciliary body and choroid.
Iris + ciliary body = anterior uvea
Iris inflammation involves ciliary body too.
symptoms of acute uveitis?
acute pain and photophobia
blurred vision
examination findings of anterior uveitis?
Small pupil initially, irregular later
Circumcorneal injection
Hypopyon: pus in anterior chamber
White (keratic) precipitates on back of cornea
Talbots test: ↑pain on convergence
mx of anterior uveitis?
Refer to ophthalmologist
Prednisolone drops
Cyclopentolate drops: dilates pupil and prevents
adhesions between iris and lens (synechiae)
what is episcleritis?
characterized by the abrupt onset of painless eye redness.
The episclera is a thin layer of tissue that lies between the conjunctiva and sclera
benign, self-limiting inflammatory disease
presentation of episcleritis?
Localised reddening: can be moved over sclera
Painless / mild discomfort
Acuity preserved
mx of episcleritis?
topical or systemic NSAIDs
what is scleritis?
vasculitis of the sclera
associated with Wegener’s, rheumatoid arthritis, lupus
presentation of scleritis?
severe pain: worse on eye movement
Generalised scleral inflammation (vessels wont move over sclera)
Conjunctival oedema
mx of scleritis?
refer to specialist
most need corticosteroids / immunosuppression
complications of scleritis?
thinning of sclera (scleromalacia) -> globe perforation
causes of conjunctivitis?
viral: adenovirus
bacterial: staph, chlamydia, gonococcus
allergic
presentation of conjunctivitis?
often bilateral with purulent discharge
(bacterial: sticky/ viral: watery)
discomfort
conjunctival injection (vessels may move over the sclera)
acuity, pupil responses and cornea are unaffected
tx of bacterial conjunctivitis?
chloramphenicol 0.5% ointment
mx of allergic conjunctivitis?
antihistamine drops e.g. emedastine
symptoms of corneal abrasion?
pain
red eyes
photophobia
blurred vision
ix of corneal abrasion?
slit lamp: fluorescein stains defect green
mx of corneal abrasion?
chloramphenicol ointment for infection prophylaxis
Mx of corneal ulcer + keratitis?
refer immediately to specialist who will
- take smears and cultures
- abx drops, oral/topical aciclovir
- cycloplegics/ mydriatics ease photophobia
- steroids may worsen symptoms: professionals only
risk factors of corneal ulcer + /- keratitis?
contact lens wearers
ix of corneal ulcer +/- keratitis?
slit lamp: fluorescein stains green
complications of corneal ulcer +/- keratitis?
scarring and visual loss
presentation of corneal ulcer +/- keratitis?
pain, photophobia
conjunctival hyperaemia (excess of blood)
decreased acuity
white corneal opacity
what is opthalmic shingles?
variceller zoster reactivation of CN V1
presentation of opthlamic shingles?
pain in CNV1 dermatome precedes blistering rash
40% -> keratitis, iritis
Hutchinson’s sign: nose-tip zoster due to involvement of nasociliary branch (increased chance of globe involvement as nasociliary nerve also supplies globe)
opthalmic involvement: keratitis + corneal ulceration (fluoresceins stain)
+/- iritis
Sudden loss of vision
key questions?
Headache associated: GCA?
Eye movements hurt: optic neuritis
Lights/ flashes preceding visual loss: detached retina
like curtain descending: TIA, GCA
Poorly controlled DM: vitreous bleed from new vessels
What is anterior ischaemic optic neuropathy (AION)?
optic nerve damaged if posterior ciliary arteries blocked by inflammation or atheroma
pale/ swollen optic disc
causes of Anterior ischaemic optic neuropathy?
Giant cell arteritis
HTN, DM, high lipids, smoking
symptoms of optic neuritis?
unilateral loss of acuity over hours- days
decreased colour discrimination
eye movements may hurt
signs of optic neuritis
decreased acuity
decreased colour vision
enlarged blind spot
optic disc may be: normal, swollen, blurred
afferent defect
mx of optic neuritis?
high dose methylprednisolone IV for 72 h
then oral pred for 11 days
what is a vitreous haemorrhage?
extravasation of blood into or around the areas of the vitreous humour of the eye
e.g. new vessels - DM
retinal tears/ detachment/ trauma
presentation of vitreous haemorrhage?
small bleeds -> small black dots/ ring floaters
large bleed can obscure vision-> no red reflex, retina cant be visualized
mx of vitreous haemorrhage?
undergoes spontaneous absorption
vitrectomy may be performed in dense VH
presentation of central retinal artery occlusion?
dramatic unilateral visual loss in seconds
afferent pupil defect (may recede retinal changes)
pale retina w cherry red macula
causes of central retinal artery occlusion?
GCA
thromboembolism: clot, infection, tumour
Mx of central retinal artery occlusion?
if seen within 6 h aim is to increase retinal blood flow by decreasing IOP
- ocular massage
- surgical removal of aqueous humour
- anti-hypertensives (local and systemic)
causes of transient visual loss?
vascular: TIA, migraine
MS
subacute glaucoma
papilloedema
what is retinal detachment?
Holes/tears in retina allow fluid to separate sensory retina from retinal pigmented epithelium
May be 2O to cataract surgery, trauma, DM
presentation of retinal detachment?
4Fs
floaters: numerous, acute onset, ‘spiders web’
flashes
field loss
faill in acuity
painless
appearance of fundus in retinal detachment?
grey, opalescent retina, ballooning forwards
mx of retinal detachment?
urgent surgery
vitrectomy + gas tamponade with laser coagulation to secure the retina
presentation of occlusion of branch of retinal vein?
unilateral visual loss
causes of central retinal vein occlusion?
atherosclerosis, HTN, DM, polycythaemia
presentation of central retinal vein occlusion?
sudden unilateral visual loss with RAPD
fundus appearance with central retinal vein occlusion?
stormy sunset appearance
tortuous dilated vessels
haemorrhages
cotton wool spots
complications of central retinal vein occlusion?
glaucoma
neovascularisation
complications of occlusion of a branch of retinal vein?
retinal ischaemia -> VEGF release and neovascularisation
(tx: laser photocoagulation)
common causes of gradual vision loss?
diabetic retinopathy
age related macular degeneration
cataracts
open angle glaucoma
commonest cause of blindness in the elderly?
age related macular degeneration
risk factors of age related macular degeneration?
smoking
increasing age
genetic factors
presentation of age related macular degeneration?
elderly pt
with central visual loss
what is dry age related macular degeneration?
small white or yellowish deposits, called drusen, form on the retina, beneath the macula, causing it to deteriorate or degenerate over time.
What is wet age related macular degeneration?
Wet age-related macular degeneration (AMD) develops when abnormal blood vessels grow into the macula.
-> Leak blood or fluid which leads to scarring of the macula and rapid loss of central vision.
ix of wet age related macular degeneration?
Fundoscopy shows macular haemorrhage -> scarring
- Slit lamp: identify any pigmentary, exudative or haemorrhagic changes affecting the retina
amsler gird detects distortion
fluorescein angiography -> can guide intervention with anti-VEGF therapy
OCT: optical coherence tomography gives high resolution images of the retina
Mx of wet age related macular degeneration?
photodynamic therapy
intravitreal VEGF inhibitors
- bevacizumab, ranibizumab
antioxidant vitamins (C, E) + zinc may help early ARMD
what is tobacco-alcohol amblyopia?
Due to toxic effects of cyanide radicals when combined with thiamine deficiency.
Optic atrophy, loss of red/green discrimination, scotomata
pathogenesis of chronic simple (open angle) glaucoma?
trabecular meshwork dysfunction
IOP > 21 mmHg -> decreased blood flow and damage to optic nerve -> optic disc atrophy (pale) + cupping
presentation of chronic open angle glaucoma?
Peripheral visual field defect: superior nasal first
Central field is intact. acuity maintained until late
Presentation delayed until optic N. damage is irreversible
Ix of chronic open angle glaucoma?
Tonometry: IOP >21 mmHg
Fundoscopy: cupping of optic disc
Visual field assessment: peripheral loss
mx of chronic open angle glaucoma?
eye drops to decrease IOP to baseline
1st line: BB
e.g. timolol, betaxolol to decrease aqueous production
(caution in asthma, HF)
prostaglandin analogues: to increase uveoscleral outflow
e.g. latanoprost, travoprost
a-agonists:
to decrease aqueous production and increase uveoscleral outflow
e.g. brimonidine, apraclonidine
carbonic anhydrase inhibitors:
dorzolamide drops, acetazolamide PO
miotics: pilocarpine
surgical mx of chronic open angle glaucoma?
laser trabeculoplasty
surgery (trabeculectomy) is used if drugs fail
- new channel allows aqueous to flow into conjunctival bleb
how does DM increase risk of cataracts?
DM accelerates cataract formation
lens absorbs glucose which is converted to sorbitol by aldose reductase
-> sorbitol forms deposits within lens
What is diabetic retinopathy?
too much sugar in your blood can lead to the blockage of the tiny blood vessels that nourish the retina, cutting off its blood supply. As a result, the eye attempts to grow new blood vessels. But these new blood vessels don’t develop properly and can leak easily.
microangiopathy -> occlusion
new vessel formation bleed -> vitreous haemorrhage
-> retinal detachment
Occlusion also -> cotton wool spots (ischaemia)
vascular leakage -> oedema and lipid exudates
Rupture of microaneurysms -> blot haemorrhage
eye screening for diabetics?
all diabetics should be screened annually
fundus photography
refer those w maculopathy etc to ophthalmologist
ix of diabetic retinopathy
fluorescein angiography
mx of diabetic retinopathy?
good BP and glycaemic control
tx concurrent disease: HTN, dyslipidaemia, renal disease, smoking, anaemia
Laser photocoagulation:
maculopathy- focal or grid
Proliferative disease: pan retinal (macula spared)
Cranial nerve palsies due to diabetes?
CNIII and CNVI palsies
due to damage to the small blood vessels that feed the nerve
In diabetic CN III palsy the pupil may be spared as its nerve fibres run peripherally and receive blood from pial vessels.
presentation of cataracts?
increasing myopia
blurred vision -> gradual visual loss
esp difficult in bright lights/ sunshine
monocular diplopia
ix of cataracts?
visual acuity
dilated fundoscopy
Slit lamp: to visualize cataract
tonometry
blood glucose to exclude DM
conservative mx of cataracts?
glasses
encouraging the use of brighter lighting to improve vision
surgical mx of cataracts?
consider if symptoms affect lifestyle or driving
day case surgery under LA
- phacoemulsification + lens implant
post op capsule thickening is common: easily tx w laser capsultomy
post op eye irritation is common and requires drops
What is Retinitis Pigmentosa?
most prevalent inherited degeneration of the macula
involve a breakdown and loss of cells in the retina—which is the light sensitive tissue that lines the back of the eye.
presentation of retinitis pigmentosa?
night blindness
loss of peripheral vision -> tunnel vision
most are registrable blund by mid 30s
Fundoscopy findings of retinitis pigmentosa?
pale optic disc: optic atrophy
peripheral retina pigmentation: spares the macula
signs of retinoblastoma?
strabismus
leukocoria (white pupil) -> no red reflex
mx of retinoblastoma
depends on size
chemo/ radio/ enucleation
what is a stye?
aka hordeolum externum
a bacterial infection of an oil gland in the eyelid
(usually staph aureus)
mx of stye?
hot compresses and analgesia
local abx e.g. fusidic acid if there is an associated conjunctivitis
what is hordeolum internum/ chalazion?
infection / abscess of the meibomian gland (oil gland of the eyelid) which points inwards onto conjunctiva
resolve spontaneously but some require surgical drainage
May leave a residual chalazion (Meibomian cyst): firm painless lump
what is blepharitis?
inflammation of eyelid margins
e.g. due tomeibomian gland dysfunction or staph, seborrhoeic dermatitis
meibomian glands secrete oil on to the eye surface to prevent rapid evaporation of the tear film. Any problem affecting the meibomian glands (as in blepharitis) can hence cause drying of the eyes which in turns leads to irritation
features of blepharitis?
red eyes
gritty/ itchy sensation
eyes may be sticky in the morning
scales on lashes
often assoc w rosacea
symptoms are usually bilateral
eyelid margins may be red. Swollen eyelids may be seen in staphylococcal blepharitis
mx of blepharitis?
clean crusts of lashes with warm soaks
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
what is entropion?
lid inversion -> corneal irritation
typically caused by muscle spasm or by inflammation or scarring of the conjunctiva (as in diseases such as trachoma)
what is an ectropion?
low lid eversion -> watering and exposure keratitis
assoc w ageing and facial n palsy
what is lagophthalmos?
Difficulty in lid closure over the globe which may →exposure keratitis
Causes: exophthalmos, facial palsy, injury
mx of lagophthalmos?
Lubricate eyes w liquid paraffin ointment
Temporary tarsorrhaphy may be needed if corneal ulcers develop.
what is pinguecula?
yellowish, slightly raised thickening of the conjunctiva on the white part of the eye (sclera), close to the edge of the cornea.
what is a pterygium?
benign growth of the conjunctiva or mucous membrane that covers the white part of your eye over the cornea
-> decreased vision
assoc w dusty, windblown life styles, sun exposure
mx of orbital cellulitis?
IV abx
e.g. cefuroxime
presentation of orbital cellulitis?
inflammation of orbit + lid swelling
pain and decreased range of eye movement
exophthalmos
systemic signs e.g. fever
+/- tenderness over the sinuses
complications of orbital cellulitis?
local extension -> meningitis and cavernous sinus thrombosis
blindness due to optic n pressure
myopia
pathophysiology?
eye is too long (AP diameter)
distant objects are focused in front of the back of the eye
mx of myopia?
concave lenses
astigmatism
pathophysiology?
Cornea or lens doesn’t have same degree of curvature in horizontal and vertical planes.
Image of object is distorted longitudinally or vertically
solution: correcting lenses
hypermetropia
pathophysiology?
eye is too short
when eye is relaxed and not accommodating, objects are focussed behind the retina
contraction of ciliary muscles to focus image -> tiredness of gaze and possibly a convergent squint in children
mx of hypermetropia?
convex lenses
presbyopia pathophysiology?
long-sightedness caused by loss of elasticity of the lens of the eye
(around 40->60)
use convex lenses
what is esotropia?
convergent squint
commonest type in children
may be idiopathic or due to hypermetropia
what is exotropia?
divergent squint
diagnosis of non-paralytic squint?
corneal reflection test
(Hirschberg test): to see if light reflects off corneas symmetrically
cover test: covering unaffected eye causes movement of affected eye
mx of non paralytic squint
optical: correct refractive errors
Operations - of eye muscles to help alignment
Patching good eye encourages use of squinting eye
paralytic squint
features?
diplopia greatest on looking in direction of pull of paralysed muscle
eye wont move to centre on covering
cover each eye in turn: whichever eye sees the outer image is malfunctioning
CNIII palsy squint presentation?
ptosis (LPS weakness)
Fixed dilated pupil (no parasympathetic)
eye down and out
CN IV paralytic squint features?
diplopia especially on going down stairs
test: cant depress eyes in adduction
head tilt
CNVI paralytic squint features?
diplopia in horizontal plane
eye medially deviated and cannot abduct
Eye trauma
what to do??
Record acuity of both eyes
Take detailed Hx of event
If unable to open injured eye, instil LA (e.g. tetracaine
1%)
if foreign body suspected: xray orbit
if corneal abrasions? -> fluorescein dye
mx of eye trauma
chloramphenicol drops as infection prophylaxis
eye patch
cycloplegic drugs to decrease pain: tropicamide
what is an orbital blowout fracture?
traumatic deformity of the orbital floor or medial wall,
-> herniation of orbital contents into maxillary sinus
presentation of orbital blowout fracture?
ophthalmoplegia + diplopia
(tethering of inferior rectus and inferior oblique)
loss of sensation to lower lid skin (infraorbital n injury)
ipsilateral epistaxis (damage to anterior ethmoidal artery)
decreased acuity
irregular pupil that reacts slowly to light
Mx of orbital blowout fracture?
fracture reduction and muscle release if necessary
initial investigation of choice for age related macular degeneration?
slit-lamp microscopy
to identify any pigmentary, exudative or haemorrhagic changes affecting the retina which may identify the presence of ARMD
usually + colour fundus photography
what is grade 1 of the Keith Wagener Barker classification of hypertensive retinopathy?
mild generalized retinal arteriolar narrowing
what is grade 2 of the keith wagener barker classification of hypertensive retinopathy?
definite focal narrowing and arteriovenous nipping
what is grade 3 of the keith wagener barker classficiation of hypertensive retinopathy?
grade 2 + Cotton-wool exudates
Flame and blot haemorrhages
what is grade 4 of the keith wagener barker classification of hypertensive retinopathy?
severe grade 3 + papilloedema
what is trachoma?
caused by chlamydia trachomatis (A, B, C)
spread by flies
Inflammatory reaction under lids → scarring → lid distortion → entropion → eyelashes scratch cornea →ulceration → blindness
mx of trachoma?
tetracycline 1% ointment +/- PO
mx of ophthalmic shingles?
oral aciclovir for 7-10 days, ideally started within 72 hours.
oral corticosteroids may reduce the duration of pain but do not reduce the incidence of post-herpetic neuralgia
ocular involvement requires urgent ophthalmology review
what is Hutchinson’s sign?
rash on the tip or side of the nose. Indicates nasociliary involvement and is a strong risk factor for ocular involvement
Anhidrosis in Horner’s syndrome
Anhydrosis of the face, arm and trunk suggests lesion is in?
Central lesion
e.g.
Stroke
Syringomyelia
Multiple sclerosis
Tumour
Encephalitis
Anhidrosis in Horner’s syndrome
Anhidrosis of the face alone suggests lesion is in?
Pre-ganglionic lesions
e.g.
Pancoast’s tumour
Thyroidectomy
Trauma
Cervical rib
Anhidrosis in Horner’s syndrome
no anhidrosis suggests lesion is in?
post-ganglionic lesion
e.g.
Carotid artery dissection
Carotid aneurysm
Cavernous sinus thrombosis
Cluster headache
distinguishing features between acute closed angle glaucoma and anterior uveitis?
anterior uveitis:
acute onset
pain
blurred vision and photophobia
small, fixed oval pupil, ciliary flush
Acute angle closure glaucoma:
severe pain (may be ocular or headache)
decreased visual acuity, patient sees haloes
semi-dilated pupil
hazy cornea
features of papilloedema on fundoscopy?
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 type of visual field defect may arise from glaucoma?
peripheral visual field
in age related macular degeneration, straight lines may be seen as?
curvy
1st line mx of chronic open angle glaucoma?
Topical prostaglandin analogues
e. g. latanoprost
- increases uveoscleral outflow of aqueous humour.
or
Topical BB
e. g. timolol, betaxolol
- decreases aqueour humour production
adverse effects of miotics e.g. pilocarpine?
Adverse effects included a constricted pupil, headache and blurred vision
adverse effect of prostaglandin analogue e.g. latanoprost for glaucoma?
brown pigmentation of iris
features of severe non proliferative diabetic retinopathy?
blot haemorrhages and microaneurysms in 4 quadrants
venous beading in at least 2 quadrants
intraretinal microvascular abnormalities (IRMA) in at least 1 quadrant
features of moderate non proliferative diabetic retinopathy?
microaneurysms
blot haemorrhages
hard exudates
cotton wool spots, venous beading/looping and intraretinal microvascular abnormalities (IRMA) less severe than in severe NPDR
example of miotic?
Pilocarpine
surgical mx of different types of glaucoma?
Trabeculoplasty: to open trabecular meshwork
for open angle glaucoma
Iridotomy: for closed angle
example of carbonic anhydrase inhibitor?
dorzolamide, acetazolamide
Reduces aqueous production
in open angle glaucoma
e.g. of alpha agonists
for glaucoma? + mode of action?
e.g. brimonidine, apraclonidine
decreases aqueous humour production +
increases uveoscleral outflow
e.g. of topical antihistamines for eye?
emedastine
antazoline
e.g. lubricants for eyes
hypromellose eye drops - artificial tears
carbomer - viscotears
anaesthetic used to permit examination of painful eye?
tetracaine
mydriatics e.g.s?
tropicamide: half life 3h
cyclopentolate: half life 24h (preferred for paediatric use)
side effects of mydriatics?
ciliary paralysis -> blurred vision due to loss of accommodation
loss of light reflex
caution: may cause acute glaucoma if shallow anterior chamber
indications for mydriatics?
eye exam
prevention of synechiae in anterior uveitis
what is keratoconjunctivitis sicca?
dry eyes due to decreased tear production
+ dry mouth
in sjogrens!
schirmer’s test +ve
mx of keratoconjunctivitis sicca?
artificial tears/ saliva
what are Roth spots?
seen in infective endocarditis
boat shaped haemorrhages w pale centres
kayser-fleischer rings?
wilson’s disease
corneal calcification
what metabolic disease?
hyperparathyroidism
features of CMV retinitis on fundoscopy?
pizza pie fundus + flames
features of HIV retinopathy on fundoscopy?
cotton wool spots
red eye
classically not painful (in comparison to scleritis), but mild pain may be present
watering and mild photophobia may be present
dx?
episcleritis
painless transient loss of vision in one or both eyes
‘black curtain coming down’
amaurosis fugax
red, painful eye
photophobia
dendritic ulcer seen on the slit lamp examination with fluorescein stain
dx?
Herpes simplex keratitis
tx:
immediate referral to an ophthalmologist
topical aciclovir
causes of sudden painless loss in vision?
ischaemic optic neuropathy (e.g. temporal arteritis or atherosclerosis)
occlusion of central retinal vein
occlusion of central retinal artery
vitreous haemorrhage
retinal detachment
tx of dry age related macular degeneration?
no treatment available, but vision aids can help reduce the effect on your life.
lifestyle changes that can help to slow down progression of dry age related macular degeneration?
stop smoking
mx of seasonal allergic conjunctivis?
1st line: topical antihistamines
Oral antihistamines may be used if there are other symptoms such as rhinosinusitis.
Topical mast cell stabilisers (e.g. sodium cromoglycate) may be used
features of allergic conjunctivitis?
Bilateral symptoms conjunctival erythema, conjunctival swelling (chemosis)
Itch is prominent
the eyelids may also be swollen
May be history of atopy
May be seasonal (due to pollen) or perennial (due to dust mite, washing powder or other allergens)
how often should someone get screened if +ve history for glaucoma?
People older than 40 years of age who have a first-degree relative (parent, sibling, or child) with open angle glaucoma should be examined annually
xerophthalmia
what is it?
caused by vitamin A deficiency
pathologic dryness of the conjunctiva and cornea
can lead to corneal ulceration and ultimately to blindness as a result of corneal damage
tx w vit A
keratomalacia
what is it?
results from vitamin A deficiency
ack of vitamin A leads to atrophic changes in the normal mucosal surface, with loss of goblet cells, and replacement of the normal epithelium by an inappropriate keratinized stratified squamous epithelium
- > cornea becomes opaque
- > blindness
what is onchocerciasis?
infection with the parasitic worm Onchocerca volvulus
severe itching, bumps under the skin, and blindness.
Fly bites → microfilariae infection → invade the eye →
inflammation → fibrosis → corneal opacities and synechiae
tx of onchocerciasis?
Ivermectin
Retinitis Pigmentosa
characterised by triad of arteriolar attenuation, bone specule pigmentation and waxy optic disc pallor
what type of eye drops are a risk factor for development of corneal ulcer?
steroid eye drops
reducing inflammation and thus the immune reaction to an infection, this leads the cornea at risk of infection from a bacteria, fungi or protists.
risk factors for vitreous haemorrhage?
Diabetes
Trauma
Anticoagulants
Coagulation disorders
Severe short sightedness
what alternative tx is used for pregnant women w infective conjunctivitis?
topical fusidic acid is an alternative and should be used for pregnant women. Treatment is twice daily
most common causes of a sudden painless loss of vision?
ischaemic optic neuropathy (e.g. temporal arteritis or atherosclerosis)
occlusion of central retinal vein
occlusion of central retinal artery
vitreous haemorrhage
retinal detachment
causes of papilloedema?
space-occupying lesion: neoplastic, vascular
malignant hypertension
idiopathic intracranial hypertension
hydrocephalus
hypercapnia
features of papilloedema on fundoscopy?
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 is Hutchinson’s sign?
rash on the tip or side of the nose. Indicates nasociliary involvement and is a strong risk factor for ocular involvement in herpes zoster ophthalmicus
ix of age related macular degeneration?
slit-lamp microscopy: initial investigation of choice, to identify any pigmentary, exudative or haemorrhagic changes affecting the retina which may identify the presence of ARMD. Usually accompanied by colour fundus photography to provide a baseline against which changes can be identified over time.
fluorescein angiography: 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: to visualise the retina in three dimensions, because it can reveal areas of disease which aren’t visible using microscopy alone.
branched retinal vein occlusion
central retinal vein occlusion
central retinal artery occlusion
‘cherry red’ spot on a pale retina
Dense shadow that starts peripherally progresses towards the central vision
A veil or curtain over the field of vision
Straight lines appear curved
Central visual loss
retinal detachment
mx of anterior uveitis?
urgent review by ophthalmology
cycloplegics (dilates the pupil which helps to relieve pain and photophobia) e.g. Atropine, cyclopentolate
steroid eye drops
optic disc atrophy (pale) + increased cupping
Chronic glaucoma
visual field defect of chronic glaucoma?
superior arcuate defect
mx of central retinal artery occlusion?
rapid reduction in IOP by ocular massage, or surgical drainage of fluid from the eye by paracentesis, may dislodge an embolus from the central retinal artery into a smaller vessel -> restoration of vision
Causes of central retinal artery occlusion?
GCA (Check ESR)
Thromboembolism: clot, infective, tumour
(check ECG, carotid doppler, echo for IE)
Hyphaema
A hyphema is a pooling or collection of blood inside the anterior chamber of the eye
usually painful
usually caused by trauma to eye
at risk of precipitating secondary glaucoma (due to raised IOP)
features of retinitis pigmentosa?
night blindness
peripheral blindness
family history +veee
dendritic ulcer
HSV keratitis
Hypopyon
- pus deposition from leucocytes in the anterior chamber
tx with topical corticosteroids may reduce inflammation and prevent adhesion formation and visual loss
what organism most commonly causes infection following ocular foreign bodies?
Staphylococcus
What organism is most commonly the cause of infection in contact lens wearers?
pseudomonas
what pH is most damaging to the eye?
alkali - high pH
can penetrate the surface of the eye and cause severe injury to both external structures such as the cornea and internal structures such as the lens
signs of cataracts?
A Defect in the red reflex
Slit lamp examination. Findings: visible cataract
mx of infective conjunctivitis in pregnant woman?
topical fusidic acid
what eye medication causes eyelashes to grow in length?
prostaglandin analogues
e.g latanoprost
signs of chronic open angle glaucoma?
increased intraocular pressure
visual field defect
pathological cupping of the optic disc
mx of primary open angle glaucoma?
1st line: prostaglandin analogue (latanoprost) eyedrop
2nd line: beta-blocker (e.g. timolol), carbonic anhydrase inhibitor (Dorzolamide), or sympathomimetic (e.g. brimonidine) eyedrop
if more advanced: surgery (trabeculectomy) or laser treatment can be tried
