Ophthalmology Flashcards
1
Q
Layers of the retina
A
Neural - inner, contains photoreceptors
Pigmented - outer, continuous with whole inner surface of eye
2
Q
Most eye surgery take place in which part of the eye?
A
Anterior chamber - 3mm depth
3
Q
Ophthalmic artery arises from..
A
The internal carotid artery
4
Q
Vascular supply to retina
A
Central artery of the retina, arises from ophthalmic artery
5
Q
Flow of vitreous humor
A
Posterior chamber TO
Anterior chamber TO
Canal of Schlemm TO
Trabecular meshwork
6
Q
Function of Levator Palpebrae Superioris
A
Elevates upper eyelid
7
Q
Nerve supply to Levator Palpebrae Superioris
A
CN III
8
Q
Extraocular muscles supplied by CN III
A
Medial, Superior and inferior recti
Inferior obliques
9
Q
Extraocular muscles supplied by CN IV
A
Superior obliques
10
Q
Extraocular muscles supplied by CN VI
A
Lateral recti
11
Q
Deviation of the eye seen in CN III palsy
A
‘Down and out’
Lateral rectus pulls laterally, superior oblique pulls down
12
Q
Movement of the eye caused by superior oblique
A
Down and in
13
Q
Movement of the eye caused by inferior oblique
A
Up and in
14
Q
Movement of the eye caused by inferior rectus
A
Down and out
15
Q
Movement of the eye caused by superior rectus
A
Up and out
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
17
Q
Myopia
A
Short sighted, large eye
18
Q
Hypermetropia
A
Long sighted, small eye
19
Q
Astigmatism
A
Refractive power is different between the two eyes
20
Q
Features of Mild Nonproliferative Diabetic Retinopathy
A
1 or more microaneurysms (dot haemorrhages)
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)
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
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)
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
25
Management of Severe Nonproliferative Diabetic Retinopathy
Panretinal photocoagulation
If Clinically Significant Macular oedema:
Intravitreal anti VEGF therapy +/- macular laser therapy +/- panretinal photocoagulation
26
Features of proliferative diabetic retinopathy
New vessels
+/- dot and blot haemorrhages
+/- venous beading
+/- cotton wool spots
27
Management of proliferative diabetic retinopathy
Urgent panretinal photocoagulation + intravitreal anti VEGF therapy +/- macular laser therapy
Vitrectomy if severe
28
Features of maculopathy
Any retinal abnormality in the macular area. Any changes in this area are potentially serious and can affect visual acuity.
29
Management of diabetic maculopathy
Anti VEGF for any clinically significant macular oedema
30
Cotton wool spots Vs Exudates
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.
31
Referral guidelines for diabetic retinopathy
Proliferative - urgent referral
Severe NPDR - routine referral
Macular oedema - routine referral
Early NPDR can be managed in primary care.
32
Within 1 week of eye surgery, patient experiences:
↓ visual acuity
Eye ache
Eyelid oedema
Corneal oedema
Endophthalmitis
33
Management of endophthalmitis
Immediate referral to ophthalmology (within 24 hours)
| 'Tap and inject' - aqueous/vitreous sample sent for cultures, intravitreal injection of broad spectrum antibiotics
34
Internuclear ophthalmoplegia
On voluntary gaze to one side, there is impaired adduction of one eye with horizontal nystagmus of contralateral eye.
35
Blepharitis
Inflammation of eyelid margins due to Meibomian gland dysfunction
36
Meibomian Glands
Glands which secrete oil onto eye surface to prevent rapid evaporation of tear film.
37
Presentation of blepharitis
Bilateral, grittiness and discomfort of the eyes.
Eyes may be sticky in the mornings with red margins.
+/- Styes and chalazions
38
Management of blepharitis
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)
39
Stye
Infection of eyelid glands
40
Hordeolum externum
Type of stye caused by staph infection of sebum or sweat glands
41
Hordeolum internum
Type of stye caused by infection of meibomian glands.
42
Presentation of Stye
H. externum - thin walled cyst on lid margin, containing clear fluid
H. internum - cyst on lid margin containing sebum
43
Management of a stye
Primary care management
Hot compress and analgesia
44
Chalazion
Cyst of meibomian gland
45
Presentation of Chalazion
Firm, painless lump on eyelid
| Slowly enlarging
46
Management of a Chalazion
No referral required
| Usually resolve spontaneously. Some require surgical drainage.
47
Entropion
In-turning of eyelids, causing eyelashes to abrade the eyeball.
Due to ageing, conjunctival scarring of spasm of orbicularis oculi
48
Presentation of entropion
Foreign body type sensation
Reflex watering
Increased risk of bacterial corneal infection and ulceration
49
Management of entropion
Routine referral for surgery
| Botox may help with blepharospasm
50
Ectropion
Out-turning of eyelids
Due to ageing, facial nerve palsy, eyelid skin scarring, bulky eyelid tumours
51
Presentation of ectropion
Exposure of conjunctiva on lower eye lid
Inflammation and keratinisation of conjunctiva
Eye watering
52
Management of ectropion
Routine referral for surgery.
Surgery not required if CN VII palsy is considered to be reversible.
53
Herpes Zoster Ophthalmicus
Reactivation of VZV in the area supplied by the ophthalmic division of CN V.
Accounts for 10% of all cases of shingles.
54
Features of Herpes Zoster Ophthalmicus
Vesicular rash around the eye
Hutchinson's sign - rash on tip or side of nose, indicating nasociliary involvement. Strong risk factor for eye involvement.
55
Management of Herpes Zoster Ophthalmicus
Oral aciclovir for 7-10 days, within 72 hours
Oral corticosteroids
Urgent ophthalmology review if ocular involvement (within 1-3 days)
56
Complications of Herpes Zoster Ophthalmicus
Ocular: conjunctiv/kerat/episcler/anterior uveitis
Ptosis
Post-herpetic neuralgia
57
Horner's syndrome
Oculosympathetic paresis:
Miosis - anisocoria is more marked in the dark, since there is limited dilatation in the affected eye
Ptosis
Anhidrosis
58
PICA Syndrome
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
```
59
Second order Horner's syndrome is due to pathology affecting the...
Sympathetic trunk
e.g. Trauma or surgery, thoracic outlet, lung apex malignancy
60
Painful Horner's should immediately be suspected as:
Carotid Artery Dissection (until proven otherwise!)
61
A patient presents with painful Horner's syndrome. Which investigations are important to determine whether or not there is a Carotid Artery Dissection?
Neck MRI
| MRI of cavernous sinus
62
Stage I Hypertensive Retinopathy
Arteriolar narrowing and tortuosity i.e. silver wiring
63
Stage II Hypertensive Retinopathy
Arteriolar narrowing and tortuosity i.e. silver wiring
| Arteriovenous nipping
64
Stage III Hypertensive Retinopathy
```
Arteriolar narrowing and tortuosity i.e. silver wiring
Arteriovenous nipping
Cotton Wool Spots
Retinal Haemorrhages
Exudates
```
65
Stage IV Hypertensive Retinopathy
```
Arteriolar narrowing and tortuosity i.e. silver wiring
Arteriovenous nipping
Cotton Wool Spots
Retinal Haemorrhages
Exudates
Papilloedema
```
66
Appearance of papilloedema on fundoscopy
```
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
```
67
Common Differentials for Papilloedema
```
Space occupying lesion: neoplastic or vascular
Malignant hypertension
Idiopathic intracranial hypertension
Hydrocephalus
Hypercapnia
```
68
Management of Hypertensive retinopathy
Optimise blood pressure control using conservative +/- pharmacological methods.
With good control, changes may regress.
69
Differentials for Painless, gradual visual loss
Macular Degeneration
Primary open angle glaucoma
Diabetic and hypertensive retinopathy
Cataracts
70
Differentials for Sudden, Painful visual loss
Optic Neuritis
Arteritic Anterior Ischaemic Optic Neuropathy
Acute Angle Closure Glaucoma
71
Differentials for Sudden, Painless visual loss
Retinal vein or artery occlusion
Non arteritic Ischaemic Optic Neuropathy
Exudative Macular Degeneration
Retinal Detachment
Vitreous haemorrhage
72
Risk factors for Age-related Macular Degeneration
```
Age > 55 years
Smoking
Family history
Caucasian
High cumulative UV exposure
Female
CVD
```
73
Features of age-related macular degeneration
Reduced visual acuity “blurred vision” (central vision affected first)
Distortion “Straight lines appear crooked/wavy”
Central scotomas
74
Dry age-related macular degeneration
Progressive atrophy of retina
75
Wet age-related macular degeneration
Leakage of exudate into macula due to new vessels
76
Wet or dry age-related macular degeneration has the worst prognosis?
Wet
77
Management of age-related macular degeneration
Urgent referral - within 1-3 days
Smoking cessation
Referral to low vision services
Anti-VEGF and steroid injections may be useful for wet AMD.
78
Pathology of Open Angle Glaucoma
Slow clogging of aqueous humor causing atrophy of optic disc from the outside in.
79
Presentation of open angle glaucoma
Gradual, painless visual loss (peripheral then central i.e. tunnel vision)
Nasal scotomas
Optic disc cupping and pallor
80
Pathology of acute angle closure glaucoma
Lens pushing against iris, blocking flow of aqueous humor
81
Presentation of acute angle closure glaucoma
```
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
Risk Factors for Primary open angle glaucoma
```
Family history
Black
Myopia (near-sightedness)
Hypertension
Diabetes mellitus
```
83
Risk Factors for Acute Angle Closure Glaucoma
```
Female
Asian or Inuit
Previous history of AACG
Age (Lens growth)
Family History
Hypermetropia (small eyes, long sighted)
Pupillary dilatation
```
84
Management of Primary open angle glaucoma
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
Management of Primary Open Angle Glaucoma in a patient who has not improved with medical management
Trabeculectomy
86
Management of acute angle closure glaucoma
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
Cataracts
Opacification of the lens. Most common cause of decreased vision globally.
88
Risk Factors for Cataracts
Diabetes Mellitus
| Corticosteroid therapy
89
Signs and symptoms of cataract
Blurred vision
Faded colour perception
Poor night vision and glare
Monocular diplopia
Reduced VA
Obscured red reflex
Lens opacification
90
Management of cataracts
Symptomatic: Mydriatic drops and sunglasses
Surgery: if restricting lifestyle (unable to meet driving requirements) - intraocular lens implant
91
Vitreous haemorrhage
Blood occupying the vitreous space
92
Causes of vitreous haemorrhage
Spontaneous bleeding from fragile new vessels e.g. proliferative DR, wet AMD
Trauma
Retinal tears or detachments
Neovascular AMD
93
Presentation of vitreous haemorrhage
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
Examination findings in vitreous haemorrhage
Reduced visual acuity
| Obscured red reflex
95
Management of vitreous haemorrhage
Urgent referral if diabetic (proliferative DR)
Usually spontaneously absorbed but vitrectomy can be done if dense haemorrhage
96
Investigations for suspected Vitreous haemorrhage
HbA1c or BM
Slit lamp - to visualise haemorrhage and potentially underlying cause in posterior segment.
B scan - to identify site of bleed.
97
Pathology of retinal detachment
Neurosensory layer of retina is pulled away from the underlying retinal pigment epithelium.
Causes accumulation of subretinal fluid and loss of retinal function.
98
Types of retinal detachment
Rhegmatogenous
Exudative
Tactional
99
Pathology of rhegmatogenous retinal detachment
Tear or hole in the retina which leads to detachment.
100
Pathology of exudative retinal detachment
Inflammation or vascular problem leads to build up of fluid under retina
101
Pathology of tractional retinal detachment
Fibrous or neovascular tissue pulls retina away from retinal pigment epithelium
102
Risk factors for retinal detachment
```
Rhegmatogenous:
Myopes (exceeding -8)
Hx of cataract surgery
Previous retinal detachment
Recent severe eye trauma
```
Non Rhegmatogenous:
DM
Intraocular tumour
AMD
103
Presentation of retinal detachment
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
Investigations required in suspected retinal detachment
Visual acuity testing
Slit lamp
B-scan if unable to visualise fundus
CT/MRI orbit if history of trauma
105
Management of Retinal Detachment
Urgent referral (within 24 hours)
Surgical reattachment.
106
Which form of retinal detachment is a greater emergency?
Macula-on or macula-off
Macula-on
Once the macula has become detached it cannot be saved.
107
Pathology of Arteritic Anterior Ischaemic Optic Neuropathy
Optic nerve damage due to inflammation of posterior ciliary arteries
108
Presentation of Arteritic Anterior Ischaemic Optic Neuropathy
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
Criteria for diagnosis with Arteritic Anterior Ischaemic Optic Neuropathy
```
> 50 yrs
Headache
Scalp tenderness or jaw claudication
ESR > 60
+ve biopsy
```
110
Management of Arteritic Anterior Ischaemic Optic Neuropathy
IV methylprednisolone
+ Gastric protection
+ Bone protection
+ 75mg aspirin
+ BM and BP monitoring
111
Pathology of Non Arteritic Anterior Ischaemic Optic Neuropathy
Occlusion of posterior ciliary artery and therefore damage to optic nerve. Usually due to atherosclerosis
112
Risk Factors for Non Arteritic Anterior Ischaemic Optic Neuropathy
```
Hypertension
Hypercholesterolaemia
DM
Smoking
Small optic nerve head
Obstructive sleep apnoea
Drugs for erectile dysfunction
```
113
Presentation of Non Arteritic Anterior Ischaemic Optic Neuropathy
Gradual, painless loss of vision (over hours to days)
+/- systemic features
114
Management of Non Arteritic Anterior Ischaemic Optic Neuropathy
Urgent referral < 24 hours
Manage underlying risk factors to protect the fellow eye.
Incrementally reduce blood pressure to prevent further damage.
115
Pathology of optic neuritis
Inflammation of the optic nerve. Usually demyelinating disease with or without MS.
116
Causes of optic neuritis
```
Multiple sclerosis
Neurosyphilis
Devic’s disease
Leber’s Optic Atrophy
Diabetes
Vitamin Deficiency
Lyme disease
```
117
Risk factors for optic neuritis
```
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
Presentation of optic neuritis
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
Management of Optic Neuritis
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
Pathology of retinal vein occlusion
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
Risk factors for retinal vein occlusion
```
Hypertension
DM
Atherosclerosis
Glaucoma
Hypercoagulability and vasculitis (in younger patients)
```
122
Presentation of retinal vein occlusion
Sudden, painless loss of vision
Affecting 1 quadrant if branch of retinal vein
Affecting whole visual field if retinal vein.
123
Management of Retinal vein occlusion
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
Central retinal artery occlusion is most commonly due to
Carotid Artery Atherosclerosis
125
Causes of central retinal artery occlusion
Carotid Artery Atherosclerosis
Temporal arteritis
Thromboembolism (AF, infective endocarditis)
Atherosclerosis
126
Presentation of central retinal artery occlusion
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
Management of central retinal artery occlusion
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
Ocular manifestations of Sjogren's syndrome
Keratoconjunctivitis Sicca
129
Management of Keratoconjunctivitis Sicca
Artificial tears +/- pilocarpine
| Management of Sjogren's syndrome
130
Ocular manifestations of Temporal Arteritis
Arteritic Anterior Ischaemic Optic Neuropathy (affects ⅕ of patients with Temporal arteritis)
131
Ocular manifestations of Ankylosing spondylitis
Acute Anterior Uveitis (affects ⅓ of patients with Ankylosing Spondylitis)
132
Ocular manifestations of Psoriatic Arthritis
Uveitis
133
Ocular manifestations of Rheumatoid Arthritis
Episcleritis
Scleritis
Scleromalacia - holes in sclera
Sjogren’s syndrome → Keratoconjunctivitis Sicca
134
Eye conditions requiring immediate referral, within 24 hours
```
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
Eye conditions requiring urgent referral, within 1-3 days
```
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
Eye conditions requiring non urgent referral
```
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
Periorbital cellulitis
Inflammation and infection of the superficial eyelid.
138
Orbital cellulitis
Infection within orbital soft tissues. Associated with ocular dysfunction
139
Source of infection in periorbital cellulitis
Superficial - may follow trauma
140
Source of infection in orbital cellulitis
Paranasal sinus infection - Usually Haemophilus influenzae in children, Streptococcus pneumoniae, Anaerobes
141
Presentation of periorbital cellulitis
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
Presentation of orbital cellulitis
Severe redness and swelling of eyelid
```
Proptosis
Reduced eye movement
Ocular pain
Reduced visual acuity
Headache
Elevated intraocular pressure
```
143
Imaging required to distinguish periorbital and orbital cellulitis
CT sinus and orbits with contrast.
144
Management of periorbital cellulitis
Determine whether orbital or periorbital
Empirical IV antibiotics for 2-5 days.
Oral if reliable daily follow up
145
Management of orbital cellulitis
Immediate referral - seen within 24 hours
Empirical IV antibiotics
ENT referral if sinusitis for sinus drainage
146
Corneal abrasions are...
Breach of corneal epithelium, usually due to trauma
147
Features of Corneal abrasion
```
Painful Red eye
Watering
Foreign body sensation
Photophobia
Blurred vision
```
Reduced visual acuity
Can be visualised under blue light with fluorescein drops
148
Management of corneal abrasion
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
What is keratitis?
Inflammation of cornea.
There may be an opaque or white patch on cornea due to aggregation of inflammatory cells
150
Causes of keratitis
Recent trauma
Severe dry eyes
Ingrown eyelashes
Poor eyelid function
151
Organisms associated with viral keratitis
HSV, VZV, Adenovirus
152
Organisms associated with bacterial keratitis
Gram positive: Staph. aureus, Strep pneumoniae/epidermidis
Gram negative: Pseudomonas aeruginosa, Enterobacter
153
Organisms associated with Protozoan Keratitis
Acanthamoeba (associated with contact lens use - extended wear, poor hygiene and swimming)
154
Features of Keratitis
Painful, red eye
Blurred vision
Lacrimation (Epiphora)
155
Dendritic ulcers on fluorescein examination are associated with
HSV Keratitis
156
Management of Keratitis
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
Conjunctivitis
Inflammation of conjunctiva
158
Features of viral conjunctivitis
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
Features of bacterial conjunctivitis
Red eye with discomfort (grittiness, irritation)
Purulent discharge
May cause eyes to stick together
Normal visual acuity, pupillary reflexes and corneal lustre
160
Features of allergic conjunctivitis
```
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
Management of viral conjunctivitis
Managed in primary care. No treatment
Symptomatic relief - topical lubricants +/- steroids
Hand washing advice as viral conjunctivitis is high contagious
162
Management of bacterial conjunctivitis
Topical chloramphenicol 4-6 hourly
163
Management of allergic conjunctivitis
Avoidance of triggers and eye protection
| Topical antihistamines +/- steroids
164
Subconjunctival haemorrhage
Bleeding into the subconjunctival space.
| Usually benign and self limiting
165
Causes of subconjunctival haemorrhage
```
Valsalva manoeuvre
Trauma
Hypertension
Bleeding disorders
Anticoagulation
```
166
Features of subconjunctival haemorrhage
```
Red patch with normal surrounding sclera.
Painless
Unilateral
Asymptomatic - normal vision
Change to green-yellow over time.
```
167
Management of subconjunctival haemorrhage
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
Episcleritis
Inflammation of episclera i.e. vascular layer between conjunctiva and sclera
169
Features of episcleritis
Red eye with mild discomfort (white sclera is still visible in and around redness)
Photophobia
170
Management of episcleritis
Urgent referral 1-3 days
Supportive: reassurance and cold compresses
Topical lubricant/NSAIDs/steroids (rarely)
171
Scleritis
Inflammation of sclera
172
Scleritis is associated with which conditions?
Rheumatoid arthritis
Ankylosing spondylitis
Infections e.g. TB
173
Features of scleritis
Diffuse Red eye - bluish hue if scleral thickening
Painful - deep, constant, boring
Photophobia
174
Patient presents with a painful, red eye.
You apply a topical vasoconstrictor, phenylephrine to distinguish between episcleritis and scleritis - how would the results differ?
Episcleritis - redness resolves
Scleritis - redness does not resolve
175
Management of scleritis
Urgent referral 1-3 days
Topical +/- systemic steroids
Immunosuppression if severe
176
Anterior uveitis
Inflammation of anterior uvea
AKA Iritis (inflammation of iris)
177
Causes of anterior uveitis
Ocular causes: HSV, trauma
Systemic causes: Ankylosing spondylitis, psoriatic arthritis, IBD, sarcoidosis, Behcet's disease, Syphilis
178
Features of anterior uveitis
```
Red eye
Aching pain, worse with reading
Photophobia
Lacrimation
Reduced visual acuity
Miosis (constricted pupil)
```
179
Screening tests for recurrent, bilateral or therapy resistant anterior uveitis
```
ESR
FBC
Serum ACE and CXR (sarcoidosis)
Syphilis serology
HLA typing
Sacroiliac X-ray
TB
Lyme disease
```
180
Management of anterior uveitis
Topical steroids (prednisolone, betamethasone, dexamethasone)
181
Differentials for red eye with reduced visual acuity
Scleritis
Anterior uveitis
Corneal abrasion
182
Features of retinitis pigmentosa
Night-blindness
Tunnel vision
Fundoscopy: black bone spicule-shaped pigmentation in peripheral retina, mottling of the retinal pigment epithelium
183
Retinitis pigmentosa is associated with
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
Strabismus
Misalignment of the eyes
185
Causes of strabismus
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Causes of acquired strabismus:
CN III, IV or VI palsy
Reduced visual acuity
Thyroid eye disease
Myasthenia gravis
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Poorly understood in children - probably genetic
186
Esotropia
Strabismus where one eye points inwards
187
Exotropia
Strabismus where one eye points outwards
188
Hypertropia
Strabismus where one eye points upwards
189
Hypotropia
Strabismus where one eye points downwards
190
Features of strabismus
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
Risk factors for strabismus
Family history
| Prematurity
192
Cover test in strabismus
Ask patient to look at an object then cover one eye.
Positive result - uncovered eye makes a refixation movement
193
Investigations in a patient with acquired strabismus
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
Pseudostrabismus
Patient appears to have a strabismus due to epicanthal folds, wide nasal bridge or eyelid abnormality
195
Management of strabismus
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
What percentage of patients with Graves' disease experience orbitopathy?
20%
Increased risk in smokers. More severe in males.
197
Features of Graves' orbitopathy
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Gritty/foreign body sensation
Lacrimation
Eye or retroocular pain/ache
Blurred vision
Diplopia
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198
Management of Graves' orbitopathy
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
Pathology of RAPD
Unilateral damage to optic nerve or retina
200
Differentials for RAPD
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
