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Clinical Medicine > Ophthalmology > Flashcards

Ophthalmology Flashcards

1
Q

Layers of the retina

A

Neural - inner, contains photoreceptors

Pigmented - outer, continuous with whole inner surface of eye

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2
Q

Most eye surgery take place in which part of the eye?

A

Anterior chamber - 3mm depth

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3
Q

Ophthalmic artery arises from..

A

The internal carotid artery

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4
Q

Vascular supply to retina

A

Central artery of the retina, arises from ophthalmic artery

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5
Q

Flow of vitreous humor

A

Posterior chamber TO
Anterior chamber TO
Canal of Schlemm TO
Trabecular meshwork

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6
Q

Function of Levator Palpebrae Superioris

A

Elevates upper eyelid

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7
Q

Nerve supply to Levator Palpebrae Superioris

A

CN III

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8
Q

Extraocular muscles supplied by CN III

A

Medial, Superior and inferior recti

Inferior obliques

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9
Q

Extraocular muscles supplied by CN IV

A

Superior obliques

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10
Q

Extraocular muscles supplied by CN VI

A

Lateral recti

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11
Q

Deviation of the eye seen in CN III palsy

A

‘Down and out’

Lateral rectus pulls laterally, superior oblique pulls down

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12
Q

Movement of the eye caused by superior oblique

A

Down and in

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13
Q

Movement of the eye caused by inferior oblique

A

Up and in

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14
Q

Movement of the eye caused by inferior rectus

A

Down and out

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15
Q

Movement of the eye caused by superior rectus

A

Up and out

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16
Q

Edinger-Westphal nucleus connects which 2 cranial nerves

A

CN II and III.

CN II senses light, passes information onto CN III to cause bilateral pupillary constriction

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17
Q

Myopia

A

Short sighted, large eye

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18
Q

Hypermetropia

A

Long sighted, small eye

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19
Q

Astigmatism

A

Refractive power is different between the two eyes

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20
Q

Features of Mild Nonproliferative Diabetic Retinopathy

A

1 or more microaneurysms (dot haemorrhages)

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21
Q

Management of Mild Nonproliferative Diabetic Retinopathy

A

Observation only.

Optimise blood pressure and glycaemia.

Intravitreal anti VEGF +/- macular laser therapy if clinically significant macular oedema (CSMO)

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22
Q

Features of Moderate Nonproliferative Diabetic Retinopathy

A

Microaneurysms (dot haemorrhages
Blot haemorrhages
Hard exudates/lipid deposits
Cotton wool spots, Venous beading or looping & intraretinal microvascular abnormalities

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23
Q

Management of Moderate Nonproliferative Diabetic Retinopathy

A

Observation only.

Optimise blood pressure and glycaemia.

Intravitreal anti VEGF +/- macular laser therapy if clinically significant macular oedema (CSMO)

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24
Q

Features of severe Nonproliferative Diabetic Retinopathy

A

Dot and blot haemorrhages in 4 quadrants
Venous beading in at least 2 quadrants
Intraretinal microvascular abnormalities in 1 quadrants

+/- Cotton wool spots

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25
Q

Management of Severe Nonproliferative Diabetic Retinopathy

A

Panretinal photocoagulation

If Clinically Significant Macular oedema:

Intravitreal anti VEGF therapy +/- macular laser therapy +/- panretinal photocoagulation

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26
Q

Features of proliferative diabetic retinopathy

A

New vessels

+/- dot and blot haemorrhages
+/- venous beading
+/- cotton wool spots

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27
Q

Management of proliferative diabetic retinopathy

A

Urgent panretinal photocoagulation + intravitreal anti VEGF therapy +/- macular laser therapy

Vitrectomy if severe

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28
Q

Features of maculopathy

A

Any retinal abnormality in the macular area. Any changes in this area are potentially serious and can affect visual acuity.

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29
Q

Management of diabetic maculopathy

A

Anti VEGF for any clinically significant macular oedema

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30
Q

Cotton wool spots Vs Exudates

A

Cotton wool spots are areas of ischaemia - will obscure superficial vasculature

Exudates are areas of fluid leakage due to damaged pericytes - overlying vasculature is visible.

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31
Q

Referral guidelines for diabetic retinopathy

A

Proliferative - urgent referral
Severe NPDR - routine referral
Macular oedema - routine referral

Early NPDR can be managed in primary care.

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32
Q

Within 1 week of eye surgery, patient experiences:

↓ visual acuity
Eye ache
Eyelid oedema
Corneal oedema

A

Endophthalmitis

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33
Q

Management of endophthalmitis

A

Immediate referral to ophthalmology (within 24 hours)

‘Tap and inject’ - aqueous/vitreous sample sent for cultures, intravitreal injection of broad spectrum antibiotics

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34
Q

Internuclear ophthalmoplegia

A

On voluntary gaze to one side, there is impaired adduction of one eye with horizontal nystagmus of contralateral eye.

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35
Q

Blepharitis

A

Inflammation of eyelid margins due to Meibomian gland dysfunction

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36
Q

Meibomian Glands

A

Glands which secrete oil onto eye surface to prevent rapid evaporation of tear film.

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37
Q

Presentation of blepharitis

A

Bilateral, grittiness and discomfort of the eyes.
Eyes may be sticky in the mornings with red margins.
+/- Styes and chalazions

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38
Q

Management of blepharitis

A

Managed in primary care.

Softening of lid margin using hot compresses BD

Mechanical removal of debris using cotton wool buds, boiling water and baby shampoo

+/- Artificial tears (symptom relief)

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39
Q

Stye

A

Infection of eyelid glands

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40
Q

Hordeolum externum

A

Type of stye caused by staph infection of sebum or sweat glands

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41
Q

Hordeolum internum

A

Type of stye caused by infection of meibomian glands.

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42
Q

Presentation of Stye

A

H. externum - thin walled cyst on lid margin, containing clear fluid

H. internum - cyst on lid margin containing sebum

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43
Q

Management of a stye

A

Primary care management

Hot compress and analgesia

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44
Q

Chalazion

A

Cyst of meibomian gland

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45
Q

Presentation of Chalazion

A

Firm, painless lump on eyelid

Slowly enlarging

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46
Q

Management of a Chalazion

A

No referral required

Usually resolve spontaneously. Some require surgical drainage.

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47
Q

Entropion

A

In-turning of eyelids, causing eyelashes to abrade the eyeball.

Due to ageing, conjunctival scarring of spasm of orbicularis oculi

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48
Q

Presentation of entropion

A

Foreign body type sensation
Reflex watering
Increased risk of bacterial corneal infection and ulceration

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49
Q

Management of entropion

A

Routine referral for surgery

Botox may help with blepharospasm

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50
Q

Ectropion

A

Out-turning of eyelids

Due to ageing, facial nerve palsy, eyelid skin scarring, bulky eyelid tumours

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51
Q

Presentation of ectropion

A

Exposure of conjunctiva on lower eye lid
Inflammation and keratinisation of conjunctiva
Eye watering

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52
Q

Management of ectropion

A

Routine referral for surgery.

Surgery not required if CN VII palsy is considered to be reversible.

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53
Q

Herpes Zoster Ophthalmicus

A

Reactivation of VZV in the area supplied by the ophthalmic division of CN V.
Accounts for 10% of all cases of shingles.

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54
Q

Features of Herpes Zoster Ophthalmicus

A

Vesicular rash around the eye
Hutchinson’s sign - rash on tip or side of nose, indicating nasociliary involvement. Strong risk factor for eye involvement.

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55
Q

Management of Herpes Zoster Ophthalmicus

A

Oral aciclovir for 7-10 days, within 72 hours
Oral corticosteroids
Urgent ophthalmology review if ocular involvement (within 1-3 days)

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56
Q

Complications of Herpes Zoster Ophthalmicus

A

Ocular: conjunctiv/kerat/episcler/anterior uveitis
Ptosis
Post-herpetic neuralgia

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57
Q

Horner’s syndrome

A

Oculosympathetic paresis:

Miosis - anisocoria is more marked in the dark, since there is limited dilatation in the affected eye
Ptosis
Anhidrosis

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58
Q

PICA Syndrome

A

AKA Wallenberg or Lateral Medullary Syndrome

Results from blockage in Posterior Inferior Cerebellar Artery

Horner's syndrome (miosis, ptosis, anhidrosis)
Vertigo and ataxia
Hoarseness
Sensory loss
Dysphagia
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59
Q

Second order Horner’s syndrome is due to pathology affecting the…

A

Sympathetic trunk

e.g. Trauma or surgery, thoracic outlet, lung apex malignancy

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60
Q

Painful Horner’s should immediately be suspected as:

A

Carotid Artery Dissection (until proven otherwise!)

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61
Q

A patient presents with painful Horner’s syndrome. Which investigations are important to determine whether or not there is a Carotid Artery Dissection?

A

Neck MRI

MRI of cavernous sinus

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62
Q

Stage I Hypertensive Retinopathy

A

Arteriolar narrowing and tortuosity i.e. silver wiring

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63
Q

Stage II Hypertensive Retinopathy

A

Arteriolar narrowing and tortuosity i.e. silver wiring

Arteriovenous nipping

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64
Q

Stage III Hypertensive Retinopathy

A 
Arteriolar narrowing and tortuosity i.e. silver wiring 
Arteriovenous nipping 
Cotton Wool Spots
Retinal Haemorrhages 
Exudates
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65
Q

Stage IV Hypertensive Retinopathy

A 
Arteriolar narrowing and tortuosity i.e. silver wiring 
Arteriovenous nipping 
Cotton Wool Spots
Retinal Haemorrhages 
Exudates 
Papilloedema
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66
Q

Appearance of papilloedema on fundoscopy

A 
Venous engorgement 
Blurring of optic disc margin
Elevation of optic disc 
Loss of optic cup
Paton’s lines - concentric/radial lines cascading from optic disc
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67
Q

Common Differentials for Papilloedema

A 
Space occupying lesion: neoplastic or vascular 
Malignant hypertension 
Idiopathic intracranial hypertension
Hydrocephalus 
Hypercapnia
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68
Q

Management of Hypertensive retinopathy

A

Optimise blood pressure control using conservative +/- pharmacological methods.
With good control, changes may regress.

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69
Q

Differentials for Painless, gradual visual loss

A

Macular Degeneration

Primary open angle glaucoma

Diabetic and hypertensive retinopathy

Cataracts

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70
Q

Differentials for Sudden, Painful visual loss

A

Optic Neuritis

Arteritic Anterior Ischaemic Optic Neuropathy

Acute Angle Closure Glaucoma

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71
Q

Differentials for Sudden, Painless visual loss

A

Retinal vein or artery occlusion

Non arteritic Ischaemic Optic Neuropathy

Exudative Macular Degeneration

Retinal Detachment

Vitreous haemorrhage

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72
Q

Risk factors for Age-related Macular Degeneration

A 
Age > 55 years 
Smoking 
Family history 
Caucasian 
High cumulative UV exposure 
Female 
CVD
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73
Q

Features of age-related macular degeneration

A

Reduced visual acuity “blurred vision” (central vision affected first)
Distortion “Straight lines appear crooked/wavy”
Central scotomas

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74
Q

Dry age-related macular degeneration

A

Progressive atrophy of retina

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75
Q

Wet age-related macular degeneration

A

Leakage of exudate into macula due to new vessels

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76
Q

Wet or dry age-related macular degeneration has the worst prognosis?

A

Wet

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77
Q

Management of age-related macular degeneration

A

Urgent referral - within 1-3 days

Smoking cessation
Referral to low vision services

Anti-VEGF and steroid injections may be useful for wet AMD.

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78
Q

Pathology of Open Angle Glaucoma

A

Slow clogging of aqueous humor causing atrophy of optic disc from the outside in.

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79
Q

Presentation of open angle glaucoma

A

Gradual, painless visual loss (peripheral then central i.e. tunnel vision)
Nasal scotomas
Optic disc cupping and pallor

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80
Q

Pathology of acute angle closure glaucoma

A

Lens pushing against iris, blocking flow of aqueous humor

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81
Q

Presentation of acute angle closure glaucoma

A 
Sudden, painful visual loss
Reduced visual acuity, worse on dilatation e.g. watching TV in a dark room
Red eye 
Halos around lights 
Fixed mid-dilated, non-reacting pupil
Dense cataract
Hazy cornea (corneal oedema)
Systemic upset e.g. N&V, abdo pain
82
Q

Risk Factors for Primary open angle glaucoma

A 
Family history
Black
Myopia (near-sightedness)
Hypertension
Diabetes mellitus
83
Q

Risk Factors for Acute Angle Closure Glaucoma

A 
Female 
Asian or Inuit 
Previous history of AACG
Age (Lens growth)
Family History 
Hypermetropia (small eyes, long sighted)
Pupillary dilatation
84
Q

Management of Primary open angle glaucoma

A

PG analogue e.g. Latanoprost (ADR: brown pigmented iris)
Beta adrenergic receptor antagonists e.g. Timolol
Carbonic anhydrase inhibitors e.g. Acetazolamide
Alpha adrenergic agonists e.g. Brimonidine (Avoid with MAO-I or TCAs)

A combination of the above treatments can be tried 2nd line.

85
Q

Management of Primary Open Angle Glaucoma in a patient who has not improved with medical management

A

Trabeculectomy

86
Q

Management of acute angle closure glaucoma

A

Urgent referral (<24 hours)

Reduce intraocular pressure - Acetazolamide (Carbonic anhydrase inhibitors) and topical Pilocarpine to induce pupil constriction.

Antiemetics and analgesia

Peripheral iridectomy (hole in iris) - to prevent future attacks

87
Q

Cataracts

A

Opacification of the lens. Most common cause of decreased vision globally.

88
Q

Risk Factors for Cataracts

A

Diabetes Mellitus

Corticosteroid therapy

89
Q

Signs and symptoms of cataract

A

Blurred vision
Faded colour perception
Poor night vision and glare
Monocular diplopia

Reduced VA
Obscured red reflex
Lens opacification

90
Q

Management of cataracts

A

Symptomatic: Mydriatic drops and sunglasses
Surgery: if restricting lifestyle (unable to meet driving requirements) - intraocular lens implant

91
Q

Vitreous haemorrhage

A

Blood occupying the vitreous space

92
Q

Causes of vitreous haemorrhage

A

Spontaneous bleeding from fragile new vessels e.g. proliferative DR, wet AMD
Trauma
Retinal tears or detachments
Neovascular AMD

93
Q

Presentation of vitreous haemorrhage

A

Sudden, Painless loss of vision
Unilateral visual loss

Multiple small floaters if small amount of blood
Complete loss of vision if lots of blood.

94
Q

Examination findings in vitreous haemorrhage

A

Reduced visual acuity

Obscured red reflex

95
Q

Management of vitreous haemorrhage

A

Urgent referral if diabetic (proliferative DR)

Usually spontaneously absorbed but vitrectomy can be done if dense haemorrhage

96
Q

Investigations for suspected Vitreous haemorrhage

A

HbA1c or BM
Slit lamp - to visualise haemorrhage and potentially underlying cause in posterior segment.
B scan - to identify site of bleed.

97
Q

Pathology of retinal detachment

A

Neurosensory layer of retina is pulled away from the underlying retinal pigment epithelium.
Causes accumulation of subretinal fluid and loss of retinal function.

98
Q

Types of retinal detachment

A

Rhegmatogenous
Exudative
Tactional

99
Q

Pathology of rhegmatogenous retinal detachment

A

Tear or hole in the retina which leads to detachment.

100
Q

Pathology of exudative retinal detachment

A

Inflammation or vascular problem leads to build up of fluid under retina

101
Q

Pathology of tractional retinal detachment

A

Fibrous or neovascular tissue pulls retina away from retinal pigment epithelium

102
Q

Risk factors for retinal detachment

A 
Rhegmatogenous:
Myopes (exceeding -8)
Hx of cataract surgery
Previous retinal detachment 
Recent severe eye trauma

Non Rhegmatogenous:
DM
Intraocular tumour
AMD

103
Q

Presentation of retinal detachment

A

Sudden, painless visual loss

Flashes and floaters
Fall in acuity (central > peripheral)

NB Macula-on RD has normal visual acuity. Macula-off RD has reduced visual acuity.

104
Q

Investigations required in suspected retinal detachment

A

Visual acuity testing
Slit lamp
B-scan if unable to visualise fundus
CT/MRI orbit if history of trauma

105
Q

Management of Retinal Detachment

A

Urgent referral (within 24 hours)

Surgical reattachment.

106
Q

Which form of retinal detachment is a greater emergency?

Macula-on or macula-off

A

Macula-on

Once the macula has become detached it cannot be saved.

107
Q

Pathology of Arteritic Anterior Ischaemic Optic Neuropathy

A

Optic nerve damage due to inflammation of posterior ciliary arteries

108
Q

Presentation of Arteritic Anterior Ischaemic Optic Neuropathy

A

Sudden, painful visual loss

Malaise
Jaw claudication
Tender scalp +/- temporal arteries
Thickened or absent temporal pulses

On examination:

  • Reduced visual acuity
  • RAPD
  • Visual field loss
  • Reduced colour vision
  • Swollen, pale optic nerve on fundoscopy
109
Q

Criteria for diagnosis with Arteritic Anterior Ischaemic Optic Neuropathy

A 
> 50 yrs 
Headache
Scalp tenderness or jaw claudication
ESR > 60 
\+ve biopsy
110
Q

Management of Arteritic Anterior Ischaemic Optic Neuropathy

A

IV methylprednisolone

+ Gastric protection
+ Bone protection
+ 75mg aspirin
+ BM and BP monitoring

111
Q

Pathology of Non Arteritic Anterior Ischaemic Optic Neuropathy

A

Occlusion of posterior ciliary artery and therefore damage to optic nerve. Usually due to atherosclerosis

112
Q

Risk Factors for Non Arteritic Anterior Ischaemic Optic Neuropathy

A 
Hypertension
Hypercholesterolaemia 
DM
Smoking 
Small optic nerve head 
Obstructive sleep apnoea 
Drugs for erectile dysfunction
113
Q

Presentation of Non Arteritic Anterior Ischaemic Optic Neuropathy

A

Gradual, painless loss of vision (over hours to days)

+/- systemic features

114
Q

Management of Non Arteritic Anterior Ischaemic Optic Neuropathy

A

Urgent referral < 24 hours

Manage underlying risk factors to protect the fellow eye.
Incrementally reduce blood pressure to prevent further damage.

115
Q

Pathology of optic neuritis

A

Inflammation of the optic nerve. Usually demyelinating disease with or without MS.

116
Q

Causes of optic neuritis

A 
Multiple sclerosis 
Neurosyphilis 
Devic’s disease 
Leber’s Optic Atrophy 
Diabetes 
Vitamin Deficiency
Lyme disease
117
Q

Risk factors for optic neuritis

A 
White > black 
Age 30-50
Females 
HLA DR(2)15 mutation
Presence of autoimmune disease - PMH and FH
Exposure to Lyme Disease and Syphilis
118
Q

Presentation of optic neuritis

A

Gradual (painful) visual loss (over hours to days)
Unilateral

Potential loss of colour vision
Painful eye movement

On examination: RAPD, reduced visual acuity, red desaturation, optic disc may be swollen

119
Q

Management of Optic Neuritis

A

Urgent referral 1-3 days

Steroids - accelerate visual recovery in acute phase.

Adjuvants:
Gastric protection
Bone protection

NB Steroids do not improve long term outcome so should only be offered if bilateral.

120
Q

Pathology of retinal vein occlusion

A

Occlusion of a branch or central retinal vein. More common than retinal artery occlusion.

Usually branches (BRVO) of the retinal vein, rather than the vein itself (CRVO) are affected.

Usually associated with arteriosclerosis

121
Q

Risk factors for retinal vein occlusion

A 
Hypertension 
DM
Atherosclerosis
Glaucoma 
Hypercoagulability and vasculitis (in younger patients)
122
Q

Presentation of retinal vein occlusion

A

Sudden, painless loss of vision
Affecting 1 quadrant if branch of retinal vein
Affecting whole visual field if retinal vein.

123
Q

Management of Retinal vein occlusion

A

Urgent referral 1-3 days

Observation if uncomplicated with management of risk factors/comorbidities.

Ischaemic?
More regular monitoring due to risk of neovascularisation
Panretinal photocoagulation if neovascularisation

Macula oedema?
Intravitreal steroid injections +/-
Anti VEGF (ranibizumab, aflibercept)

124
Q

Central retinal artery occlusion is most commonly due to

A

Carotid Artery Atherosclerosis

125
Q

Causes of central retinal artery occlusion

A

Carotid Artery Atherosclerosis
Temporal arteritis
Thromboembolism (AF, infective endocarditis)
Atherosclerosis

126
Q

Presentation of central retinal artery occlusion

A

Sudden, painless loss of vision
Unilateral

On examination:

  • Pale fundus
  • Cherry red spot at the macula
  • RAPD (ischaemic retina cannot convert light to neural signal)
  • Reduced visual acuity - rarely able to count fingers
127
Q

Management of central retinal artery occlusion

A

Urgent ophthalmic review (<24 hours)

Reduction in intraocular pressure (potentially, the embolus will dislodge and move further down the vessel, limiting the damage)
Conservative - ocular massage
Medically - IV Acetazolamide
Invasively - ‘paracentesis’ i.e. fluid removed from anterior chamber

Prevention of recurrent vascular events by treating underlying cause e.g. anticoagulation, carotid endarterectomy.

128
Q

Ocular manifestations of Sjogren’s syndrome

A

Keratoconjunctivitis Sicca

129
Q

Management of Keratoconjunctivitis Sicca

A

Artificial tears +/- pilocarpine

Management of Sjogren’s syndrome

130
Q

Ocular manifestations of Temporal Arteritis

A

Arteritic Anterior Ischaemic Optic Neuropathy (affects ⅕ of patients with Temporal arteritis)

131
Q

Ocular manifestations of Ankylosing spondylitis

A

Acute Anterior Uveitis (affects ⅓ of patients with Ankylosing Spondylitis)

132
Q

Ocular manifestations of Psoriatic Arthritis

A

Uveitis

133
Q

Ocular manifestations of Rheumatoid Arthritis

A

Episcleritis
Scleritis
Scleromalacia - holes in sclera
Sjogren’s syndrome → Keratoconjunctivitis Sicca

134
Q

Eye conditions requiring immediate referral, within 24 hours

A 
Central Retinal Artery Occlusion
Branch Retinal Artery Occlusion 
Ischaemic Optic Neuropathy 
Retinal detachment or tear 
Vitreous haemorrhage in diabetics 
Acute angle closure glaucoma 
Corneal ulcer with infiltrates 
Chemical burns 
Penetrating trauma/globe rupture 
Trauma 
Endophthalmitis 
Orbital cellulitis 
Hypopyon or hyphema 
Any problems following corneal graft
135
Q

Eye conditions requiring urgent referral, within 1-3 days

A 
Optic neuritis 
Age related macular degeneration
Amaurosis Fugax - TIA pathway
New onset floaters with reduced VA
Acute Dacryocystitis 
Foreign body 
Acute iritis 
Corneal abrasion (large)
Cranial nerve palsy
Herpetic ulcer 
Episcleritis or scleritis 
Papilloedema 
Herpes Zoster Ophthalmicus
136
Q

Eye conditions requiring non urgent referral

A 
Chronic, progressive visual loss
Chronic or recurrent floaters 
Dry eye failing to respond 
Diplopia 
Chronic conjunctivitis 
entropion/ectropion/trichiasis 
Severe dry eye 
Squints 
Cataract
Field defects
137
Q

Periorbital cellulitis

A

Inflammation and infection of the superficial eyelid.

138
Q

Orbital cellulitis

A

Infection within orbital soft tissues. Associated with ocular dysfunction

139
Q

Source of infection in periorbital cellulitis

A

Superficial - may follow trauma

140
Q

Source of infection in orbital cellulitis

A

Paranasal sinus infection - Usually Haemophilus influenzae in children, Streptococcus pneumoniae, Anaerobes

141
Q

Presentation of periorbital cellulitis

A

Redness around the eyelid.

May have an insect bite on the eyelid or surrounding area.
May have a stye or chalazion on the eyelid.

142
Q

Presentation of orbital cellulitis

A

Severe redness and swelling of eyelid

Proptosis 
Reduced eye movement 
Ocular pain 
Reduced visual acuity 
Headache 
Elevated intraocular pressure
143
Q

Imaging required to distinguish periorbital and orbital cellulitis

A

CT sinus and orbits with contrast.

144
Q

Management of periorbital cellulitis

A

Determine whether orbital or periorbital

Empirical IV antibiotics for 2-5 days.

Oral if reliable daily follow up

145
Q

Management of orbital cellulitis

A

Immediate referral - seen within 24 hours

Empirical IV antibiotics

ENT referral if sinusitis for sinus drainage

146
Q

Corneal abrasions are…

A

Breach of corneal epithelium, usually due to trauma

147
Q

Features of Corneal abrasion

A 
Painful Red eye 
Watering 
Foreign body sensation 
Photophobia 
Blurred vision

Reduced visual acuity
Can be visualised under blue light with fluorescein drops

148
Q

Management of corneal abrasion

A

Urgent referral if large (1-3 days)

Topical antibiotic (First line: Chloramphenicol) for 7 days 
Avoid contact lens use until completely healed and antibiotics stopped for 24 hours
149
Q

What is keratitis?

A

Inflammation of cornea.

There may be an opaque or white patch on cornea due to aggregation of inflammatory cells

150
Q

Causes of keratitis

A

Recent trauma
Severe dry eyes
Ingrown eyelashes
Poor eyelid function

151
Q

Organisms associated with viral keratitis

A

HSV, VZV, Adenovirus

152
Q

Organisms associated with bacterial keratitis

A

Gram positive: Staph. aureus, Strep pneumoniae/epidermidis

Gram negative: Pseudomonas aeruginosa, Enterobacter

153
Q

Organisms associated with Protozoan Keratitis

A

Acanthamoeba (associated with contact lens use - extended wear, poor hygiene and swimming)

154
Q

Features of Keratitis

A

Painful, red eye
Blurred vision
Lacrimation (Epiphora)

155
Q

Dendritic ulcers on fluorescein examination are associated with

A

HSV Keratitis

156
Q

Management of Keratitis

A

Stop contact lens wear

Topical treatment:

  • Aciclovir if viral
  • Broad spectrum antibiotics if bacterial

Urgent referral (1-3 days) if Herpetic Ulcer i.e. HSV

157
Q

Conjunctivitis

A

Inflammation of conjunctiva

158
Q

Features of viral conjunctivitis

A

Red eye with discomfort (grittiness, irritation)
Watery discharge
Lymphoid aggregates (follicles on conjunctiva)
Coryzal illness
Periauricular lymphadenopathy is seen in viral conjunctivitis
Normal visual acuity, pupillary reflexes and corneal lustre

159
Q

Features of bacterial conjunctivitis

A

Red eye with discomfort (grittiness, irritation)
Purulent discharge
May cause eyes to stick together
Normal visual acuity, pupillary reflexes and corneal lustre

160
Q

Features of allergic conjunctivitis

A 
Red eye with discomfort (grittiness, irritation) 
Itchiness
Burning sensation 
Papilla on upper tarsal of conjunctiva 
Longer history

Normal visual acuity, pupillary reflexes and corneal lustre

161
Q

Management of viral conjunctivitis

A

Managed in primary care. No treatment
Symptomatic relief - topical lubricants +/- steroids
Hand washing advice as viral conjunctivitis is high contagious

162
Q

Management of bacterial conjunctivitis

A

Topical chloramphenicol 4-6 hourly

163
Q

Management of allergic conjunctivitis

A

Avoidance of triggers and eye protection

Topical antihistamines +/- steroids

164
Q

Subconjunctival haemorrhage

A

Bleeding into the subconjunctival space.

Usually benign and self limiting

165
Q

Causes of subconjunctival haemorrhage

A 
Valsalva manoeuvre
Trauma
Hypertension
Bleeding disorders
Anticoagulation
166
Q

Features of subconjunctival haemorrhage

A 
Red patch with normal surrounding sclera.
Painless
Unilateral
Asymptomatic - normal vision 
Change to green-yellow over time.
167
Q

Management of subconjunctival haemorrhage

A

No referral

Check blood pressure and investigate for bleeding disorders if unprovoked or recurrent.

Optimise blood pressure control. Discourage use of aspirin and NSAIDs

168
Q

Episcleritis

A

Inflammation of episclera i.e. vascular layer between conjunctiva and sclera

169
Q

Features of episcleritis

A

Red eye with mild discomfort (white sclera is still visible in and around redness)

Photophobia

170
Q

Management of episcleritis

A

Urgent referral 1-3 days
Supportive: reassurance and cold compresses
Topical lubricant/NSAIDs/steroids (rarely)

171
Q

Scleritis

A

Inflammation of sclera

172
Q

Scleritis is associated with which conditions?

A

Rheumatoid arthritis
Ankylosing spondylitis
Infections e.g. TB

173
Q

Features of scleritis

A

Diffuse Red eye - bluish hue if scleral thickening
Painful - deep, constant, boring
Photophobia

174
Q

Patient presents with a painful, red eye.
You apply a topical vasoconstrictor, phenylephrine to distinguish between episcleritis and scleritis - how would the results differ?

A

Episcleritis - redness resolves

Scleritis - redness does not resolve

175
Q

Management of scleritis

A

Urgent referral 1-3 days

Topical +/- systemic steroids

Immunosuppression if severe

176
Q

Anterior uveitis

A

Inflammation of anterior uvea

AKA Iritis (inflammation of iris)

177
Q

Causes of anterior uveitis

A

Ocular causes: HSV, trauma

Systemic causes: Ankylosing spondylitis, psoriatic arthritis, IBD, sarcoidosis, Behcet’s disease, Syphilis

178
Q

Features of anterior uveitis

A 
Red eye 
Aching pain, worse with reading 
Photophobia
Lacrimation
Reduced visual acuity
Miosis (constricted pupil)
179
Q

Screening tests for recurrent, bilateral or therapy resistant anterior uveitis

A 
ESR
FBC
Serum ACE and CXR (sarcoidosis)
Syphilis serology
HLA typing 
Sacroiliac X-ray
TB 
Lyme disease
180
Q

Management of anterior uveitis

A

Topical steroids (prednisolone, betamethasone, dexamethasone)

181
Q

Differentials for red eye with reduced visual acuity

A

Scleritis
Anterior uveitis
Corneal abrasion

182
Q

Features of retinitis pigmentosa

A

Night-blindness
Tunnel vision
Fundoscopy: black bone spicule-shaped pigmentation in peripheral retina, mottling of the retinal pigment epithelium

183
Q

Retinitis pigmentosa is associated with

A

Refsum disease: cerebellar ataxia, peripheral neuropathy, deafness, ichthyosis
Usher syndrome
Abetalipoproteinaemia
Lawrence-moon-biedl syndrome
Kearns-Sayre syndrome
Alport’s syndrome (renal failure in the young, Anti GBM following transplant)

184
Q

Strabismus

A

Misalignment of the eyes

185
Q

Causes of strabismus

A 
Causes of acquired strabismus: 
CN III, IV or VI palsy
Reduced visual acuity
Thyroid eye disease
Myasthenia gravis

Poorly understood in children - probably genetic

186
Q

Esotropia

A

Strabismus where one eye points inwards

187
Q

Exotropia

A

Strabismus where one eye points outwards

188
Q

Hypertropia

A

Strabismus where one eye points upwards

189
Q

Hypotropia

A

Strabismus where one eye points downwards

190
Q

Features of strabismus

A

Binocular Diplopia - horizontal if eso/exotropia, vertical if hyperhypotropia
Ambylopia - CNS suppresses input from one eye, occurs in children < 7 to prevent diplopia
Abnormal eye movements
Asthenopia - eye discomfort due to eye strain

191
Q

Risk factors for strabismus

A

Family history

Prematurity

192
Q

Cover test in strabismus

A

Ask patient to look at an object then cover one eye.

Positive result - uncovered eye makes a refixation movement

193
Q

Investigations in a patient with acquired strabismus

A

Cover test
H test - diplopia? incomplete eye movements?
CT or MRI orbit if associated with trauma
MRI brain if suspected mass lesion
CT chest if myasthenia gravis associated

194
Q

Pseudostrabismus

A

Patient appears to have a strabismus due to epicanthal folds, wide nasal bridge or eyelid abnormality

195
Q

Management of strabismus

A

Routine referral and orthoptic assessment.

First line:
Correct refractive error (glasses), correct diplopia and ambylopia using an eye patch

Second line: Extraocular muscle surgery

Treat underlying cause if acquired.

196
Q

What percentage of patients with Graves’ disease experience orbitopathy?

A

20%

Increased risk in smokers. More severe in males.

197
Q

Features of Graves’ orbitopathy

A 
Gritty/foreign body sensation
Lacrimation
Eye or retroocular pain/ache
Blurred vision
Diplopia
198
Q

Management of Graves’ orbitopathy

A

Optimise hyperthyroidism management

  • Propanolol
  • Carbimazole
  • Radioiodine
  • Thyroidectomy

Smoking cessation

Eye protection - shades, artificial tears, raising head of bed at night

Treatment of inflammation and swelling in periorbital tissues (NSAIDs, steroids)

199
Q

Pathology of RAPD

A

Unilateral damage to optic nerve or retina

200
Q

Differentials for RAPD

A

Optic nerve disorders: Optic neuritis, Ischaemic optic neuropathy (Arteritic or non arteritic), optic atrophy/trauma/malignancy etc.

Retinal disorders: Ischaemic retina (vein or artery occlusion, retinal detachment, retinal infection

Clinical Medicine (9 decks)

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