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Year 4 M&M > Ophthalmology > Flashcards

Ophthalmology Flashcards

1
Q

What is the maximum human eye acuity?

What is meant by 6/6 visual acuity?

A
  • Maximum human eye acuity = 6/4.5 to 6/3.5
  • Lower limit of normal/screening cut off
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2
Q

What do the following deal with in terms of visual acuity?

Refractive errors

Eye problems

A
  • Refractive errors – Opticians
  • Eye problems – Opthalmologists
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3
Q

What is the function of the eyelids?

Which muscles open/close the eyelids?

A
  • Protect the eye from injury + Excessive light
  • Distribute tears
  • Contribute to facial expression

Muscles

  • Open – Levator palpebrae superioris + Mullers muscle
  • Closed – Orbicularis Oculi
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4
Q

What produces the lacrimal secretions?

A
  • Mucin from goblet cells in the conjunctiva
  • Aqueous tears from lacrimal glands in supero-temporal orbit & Conjunctiva
  • Oil from meibomian glands in eyelids
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5
Q

How are lacrimal secretions/tears drained?

A
  • Pool in the lacrimal ducts
  • Superior fornix via Puncta
  • Into lacrimal sac
  • Nasolacrimal duct
  • Nasal inferior meatus
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6
Q

What are the conjunctiva?

What is the function?

A
  • Thin mucous membrane lining the eyelids
  • Reflected at superior and inferior fornices onto surface of eye

Produce tears – Carrying nutrients + immune proteins onto the cornea

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7
Q

Label the following diagram of the eye

A
    1. Optic disc/Blind spot
    1. Optic nerve & Retinal blood vessels
    1. Macula lutea + Fovea centralis (Central depression)
    1. Retina
    1. Choroid
    1. Sclera
    1. Ciliary body & Muscle + Suspensory ligaments
    1. Cornea
    1. Iris
    1. Pupil
    1. Lens
    1. Vitreous body + Vitreous humor
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8
Q

What are the layers of the eye?

A

Sclera + Cornea (Outer)

  • Cornea = Transparent, Sclera = White
  • Composed of collagen
  • Avascular – Derives nutrients from tear film + Aqueous humour
  • Refractory component of eye

Choroid (Middle)

  • Vascular layer

Retina (Inner)

  • Neurosensory layer of the eye
  • Continous with the optic nerve
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9
Q

What is found in the anterior chamber?

What is found in the posterior chamber?

A

Anterior chamber

  • B/w cornea and the iris
  • Filled with aqueous humour - Produced by ciliary body
  • Drained by trabecular meshwork of angle of anterior chamber

Posterior chamber

  • Behind the lens
  • Filled with vitreous humour
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10
Q

What are the parts of the visual pathway?

A
  • Retina
  • Optic chiasm (Deccusation)
    • Nasal fibres Decussate (Temporal fields)
  • Optic tracts (R + L)
  • Lateral geniculate nucleus (Thalamus)
    • Afferent limb of pupillary reflex leaves here
  • Optic radiations - In temporal lobe + Parietal lobe
  • Visual cortex in Occipital lobe(Contralateral)
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11
Q

What is found in the retina?

A

Inner neurosensory layer (Lens side)

  • Continous with optic nerve
  • Rods + Cones + Interconnecting bipolar cells + Ganglion cells
    • Rods – Night vision + peripheral movement
    • Cones – Daylight + Central vision

Outer pigmented plexiform layer (Choroid & Sclera side)

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12
Q

What are the extra-occular muscles?

A
  • Superior oblique - CN 4
  • Superior rectus - CN 3
  • Medial rectus - CN 3
  • Inferior rectus - CN3
  • Inferior oblique - CN 3
  • Lateral rectus - CN 6
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13
Q

How is pupil function controlled?

A

Afferent limb

  • Optic nerve - Chiasm - Optic tract - Edinger Westphal nucleus

Efferent limb

  • Inferior division of CN 3 via ciliary ganglion - Constrictor muscle of iris

Nervous control

  • SNS stimulation – Pupillary dilation + Upper & Lower lid retraction
  • PNS stimulation – Constriction + Upper & Lower lid opening
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14
Q

You are asked to take a Hx from a patient presenting with eye problems. How would you go about this?

A

[PC/HPC]

  • Has your vision been affected?
  • Are your eyes uncomfortable at all?
  • Are your eyes actually painful, enough that would consider taking pain medication or are they just sore?
  • If patient reports visual field loss
  • Was the onset sudden/rapid/slow?
  • Where is the field loss? - If what you see is like a TV screen where is the bit that is missing?
  • Does it affect one/both eyes?
  • What does it look like to you?
  • Do you tend to bump into people or things?

[PMHx]

  • Any Hx of previous ophthalmic disease/surgery?
  • Any Hx of ocular injury?
  • How did this happen?
  • Any Hx of ambylopia (Lazy eye)?
  • With glasses on has one eye always been weaker than the other since childhood?
  • Any Hx of glasses/contact lens wear?

[DHx]

  • Any medications?
    • Prescribed
    • OTC
    • Herbal/Alternative
  • Any allergies?
  • Drugs that are toxic to the eyes:
    • Tamoxifen
    • Cholorquine
    • Chlorpromazine
    • Interferon

[FHx]

  • Is there a Hx of eye disease or vision loss in your family?
  • Thyroid eye disease

[SHx]

  • Hx of tobacco use?
  • Alcohol intake?
  • Sexual Hx - HIV/Neurosyphilis
  • Occupation - Determine if vision is required for the job
  • Does the patient drive?
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15
Q

What is the significance of the following symptom/sign?

  • Grittiness/dryness eyes feel tired/want to close
  • Sharp/stabbing pain “like needles”
  • Dull ache, like toothache
A
  • Grittiness/dryness eyes feel tired/want to close -> Most often dry eye
  • Sharp/stabbing pain “like needles” -> Occular surface problems
  • Dull ache, like toothache -> Uveitis/raised eye pressure/Scleritis
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16
Q

What eye conditions are associated with the following?

DM

Thyroid disease

HTN

A

DM

  • Diabetic retinopathy/Diabetic macular oedema/Occular ischaemia/CN 3 or 6 palsy/Retinal vein occlusion

Thyroid disease

  • Exopthalmos/Opthalmoplegia/Red eye

HTN

  • Retinal vein occlusion/Retinal artery occlusion/Occipital lobe infarction
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17
Q

Which eye conditions are associated with the following conditons?

AF

MS

Atopy

IBD/RA

AS

A

AF

  • Embolic retinal artery occlusion/Occipital lobe infarction

MS

  • Optic neuritis/CN 6 palsy/Bilateral internuclear paresis

Atopy

  • Allergic eye disease

IBD/RA

  • Episcleritis/Scleritis

AS

  • Recurrent anterior uveitis
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18
Q

What are the DVLA Rules on eyesight?

A
  • MUST wear glasses/contact lenses every time you drive if you need them to meet standards of vision for driving
  • Must tell DVLA if you have a problem with your eyesight that affects both of your eyes
  • Not included if Long/short sighted or Colour blind

Standards

  • Must be able to read with glasses/contact lenses - car number plate from 20m
  • VA must be at least 6/12 with glasses if required
  • Must have adequate field of vision

Professional drivers

  • Must have VA of at least 6/7.5 in best eye, and 6/60 in the other eye
  • Acceptable if this can be reached using glasses/contact lenses with corrective power NOT >+8 D
  • No limit for contact lenses
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19
Q

You are asked to perform an eye exam, what does this involve?

A

[Introduction]

  • Wash hands & Introduce self
  • Ask patient name & DOB & Age
  • What I am going to be doing today is an examination of your eyes, so i’m going to be having a look at the eye and the pupil, and then ask you to do a few movements, and finally have a look inside the eye using some equipment. As part of the exam I will have to get very close to you in order to carry it out properly
    • Does that all sound ok?
  • The examiner will act as a chaperone for this exam
  • Do you have any pain at the moment? Have you had any discharge from your eye recently?
    • Can you please remove eye patch/glasses?
  • For this exam I will need you sat in a chair, and I will need to turn off the lights in the room at some point also

[Inspection]

  • Examine the eyes
    • Ptosis
    • Proptosis (Forward bulging of eyeball)
    • Lid lag
      • Follow upper eyelid movement with the downward movement of the eye
      • Lid lag -> Thyroid eye disease
    • Eyelids
      • May require inversion
  • Assess for:
    • Redness
    • Swelling
    • Lacerations
    • Lumps/Bumps
    • Rashes
    • Ulcerations
    • Ill-defined shape of eyelids
    • Eyelashes
  • Puncta (Tear ducts)
    • Size & Shape
    • Any swelling medial to the tear duct
  • Conjunctiva
    • May require inversion
    • Assess
      • Colour
      • Cysts
      • Ulceration
      • Laceration
      • Oedema
      • Sclera
  • Cornea
    • Hazy (Generalised/localised)
    • White dots
  • Pupils
    • Size
    • Shape

[Vision]

  • Visual acuity Test using Snellen chart or equivalent at 6 metres
    • Can also have the chart at 3m with patient facing a mirror = 6m
  • Test each eye individually with glasses/contact lenses in
    • Can you cover your R/L eye with your hand and tell me which line you can read and read it out
    • Record as distance from chart/number next to lowest line read
    • If they are unable to see the top line then move the patient forward to 1/2 distance and repeat
    • If severe dysfunction - Patient may only be able to count fingers/hand movement/light
  • If patient has refractory error - tell patient to try again using Pin-holes to correct for refractory error

Near vision

  • Test near vision using near vision chart and hold it at normal reading distance
  • Ask patient to read the paragraph that they can read clearly
  • N8 - Newsprint

Colour vision

  • Ishihara plates can be used to formally assess colour vision

Visual fields

  • Look at my nose
  • spread arms out
  • Ask patient to point out which hand is moving - move R and then L hand and check what patient sees
    • Exclude obvious field defect

Ask patient to cover L eye with palm of L hand

  • I will cover my R eye
    • Is any part of my face missing?
  • Keep looking at my face and tell me when you notice my fingers come into view
    • Move fingers in slowly from all 4 corners of the visual field toward the centre of vision ensuring fingers remain equidistant b/w me and patient
  • Compare my visual field with the patients
  • Repeat for R eye - Cover your R eye with your R hand
    • I will cover my L eye

Blind spot

  • Offer
  • Ask patient to cover their L eye with their L hand
    • Close or cover my own R eye
  • Keep looking at my face - I am going to bring a red hat pin in to view
    • Tell me when the red tip of it appears to vanish
    • Move red pin slowly in an arc at pupil height and equidistant between myself and patient
    • Blind spot -> typically at 15deg and should be compared to my blind spot

[Pupils]

Direct and consensual

  • Ask patient to look into the distance
  • Warn them that you are going to shine a light in their eye
  • Bring in light from the side to avoid accommodation reflex
  • Check both eyes for direct and consensual reflexes

Swinging light test

  • Ask patient to concentrate on a spot on the wall
  • Swing the light back and forth between the 2 pupils
  • Shine it in each eye for about 2s
  • Normally both pupils should constrict -> then relax a little each time the light is shown
  • In RAPD - Both pupils dilate when the light is swung across to the affected side

Accommodation

  • Ask patient to focus on a distant object
  • Hold object approx 15cm in front of them and ask them to focus on this
  • Pupils should constrict and eyes converge (Accomodation)

[Eye movement]

  • Now I am going to be checking your eye movements
  • What I would like you to do, is to follow my finger with your eyes, but keep your head still
  • Hold finger approx 50cm away b/w me and patient
  • Let me know if you get pain or double vision whilst looking at my finger
  • Move finger in H pattern or union flag shape, assess for:
    • Nystagmus
    • Opthalmoplegia

If patient notes double vision, identify if it is:

  • Maximum/Vertical/Horizontal/Tilted
  • Does closing one eye make the double vision better?

[Fundoscopy]

  • Darken the room
  • Take the fundoscope and tell patient: I’m going to be having a look into the back of your eye. I’ll have to get very close to your face and will put my hand on your shoulder to steady myself.
    • Is that ok?
    • Start at lens at 0
      • Small spot of light -> Small pupils
      • Large spot of light -> Large pupils
  • Examine the eye:
    • Look for red reflex at arms length then move in closer
    • If no red reflex -> Significant problem
  • Look for a vessel - follow the vessel nasally to the optic disc
    • Disc
    • Cup
    • Colour
    • Contour
  • Follow the 4 vascular arcades
  • Check for peripheral changes Ask patient to look Up/Down/Left/Right
  • Check Macula - asking patient to look directly into the light

[Complete exam]

  • Thank patient & Wash hands
  • “This is patient x who is a x year old Male/Female with the following findings”
  • I would take a full Hx + examine any other relevant systems
  • I would consider the differentials
  • I would order relevant investigations
    • Observations
    • Bloods
    • Imaging
  • I would initiate management of the most likely differential
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20
Q

How is visual acuity measured?

A

Record as distance from chart/number next to lowest line read

  • If they could read the top line at 6m then this is recorded as 6/6
  • If they are unable to see the top line then move the patient forward to 1/2 distance and repeat
    • If only read at 3m then record as 3/6
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21
Q

You are asked to administer some eye drops, how would you go about this?

A

[Introduction]

  • Wash hands & Introduce self
  • Ask patient name & DOB & Age
  • Check:
    • Right drug
    • Right dose
    • Right time
    • Right route
    • Correct eye
  • Check for allergies - Do you have any allergies that you are aware of?

[Procedure]

  • Wash hands & wear gloves
  • Patient sat back with head leaning backwards
  • Clean eyelids with moist sterile swabs if required
    • If patient has crusting/discharge
  • Ask patient to look up and carefully pull down skin just below lower eye lid with clean tissue
    • Expose the conjunctival sac
  • Instill the prescribed number of drops or apply a thin stream of ointment along the inner conjunctiva
  • Ask patient to keep eye closed for 1 min to allow absorption
  • Wipe off any excess
  • Wash hands
  • Document administration
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22
Q

You are asked to perform eyelid eversion, how would you go about this?

A

[Introduction]

  • Wash hands & Introduce self
  • Ask patient name & DOB & Age
  • Check:
    • Right drug
    • Right dose
    • Right time
    • Right route
    • Correct eye
  • Check for allergies - Do you have any allergies that you are aware of?

[Procedure]

  • Indications for this:
    • Inspection for foreign bodies/pathology
    • Irrigation
  • Wash hands
  • Patient seated
  • Warn patient it may feel strange
  • Ask them to look down (Elongate eyelid)
  • Place cotton bud tip across top of tarsal plate of upper eyelid
  • Using eyelashes - flip the lid back over itself
    • Removing cotton bud
    • Hold the everted lid in place
  • Inspect under the eyelid
    • Remove any foreign body using cotton bud/irrigation
  • When finished ask patient to
    • Look up and blink
    • Should flip eyelid back in place
      • If not - replace eyelid manually
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23
Q

A patient presents with central field loss, what are the differentials to be considered?

A
  • Age related macular degeneration
  • Optic neuropathy
  • Optic atrophy
  • Cone dystrophies
  • Retinal artery occlusion
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24
Q

A patient presents with peripheral field loss, on examination. What differentials would you be considering?

A
  • Glaucoma – Closed/Open angle
  • Retinal detachment
  • Retinitis pigmentosa
  • Chorioretinitis
  • Branch retinal artery occlusion
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25
Q

A patient presents with the following pattern of visual field loss, where is the lesion?

  • Total blindness of one eye
  • Bipolar hemaniopia
  • Nasal hemaniopia
  • Homonymous hemaniopia
  • Homonymous inferior quadrantanopia
  • Homonymous superior quadrantanopia
A
  • Total blindness of one eye – Lesion of optic nerve on ipsilateral side
  • Bipolar hemaniopia – Midline lesion in the optic chiasm
  • Nasal hemaniopia – Lesion involving ipsilateral perichiasmal area
  • Homonymous hemaniopia – Lesion/pressure on contralateral optic tract/occipital lobe
  • Homonymous inferior quadrantanopia – Lower contralateral optic radiation
  • Homonymous superior quadrantanopia – Upper contralateral optic radiation
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26
Q

What are cataracts?

What can cause them?

A

Lens opacities, caused by excess crystallins - which can block light & obstruct vision

Causes:

  • Ageing – Lens is continually growing
  • Malnutrition
  • Acute dehydrating illnesses
  • Excess UV exposure
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27
Q

What are the different types of cataract?

A

Acquired:

  • Normal ageing process - Most common
  • Trauma/Metabolic disorder/medications

Congenital:

  • Usually bilateral & symmetrical
  • Due to transient toxic influences during lens development or autosomal dominant inheritance
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28
Q

Who classically gets cataracts?

A
  • >65yrs
  • Women > Men
  • Smokers
  • Patients with DM
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29
Q

What are the classical symptoms & signs of cataracts?

A
  • Gradual painless loss of vision
  • Difficulties reading/watching TV
  • Diplopia in one eye
  • Haloes
  • Problems with glare when driving
  • Defect in red reflex
  • Lens may appear brown/white when bright light is shone on eye
  • Visual acuity not improved with pinhole
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30
Q

What is the most common cause of congenital cataracts in children?

A
  • Rubella infection
  • Measles
  • Chicken pox
  • CMV
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31
Q

A patient presents with the following Hx, what is the most likely diagnosis? What are the differential diagnoses?

A 65-year-old man presents with generally decreased vision and difficulty driving at night due to glare from oncoming headlights. He describes having trouble reading the small print on his television screen. He is healthy and has no history of any other eye problems. His best corrected visual acuity is noted to be 20/50 in the right eye and 20/40 in the left eye. On examination, a yellowish opacification of the lens in the left eye is noted. On ophthalmoscopy, the red reflex in the left eye is obscured centrally, and the details of the fundus are indistinct. No other abnormalities are found.

A
  • Cataracts
  • Macular degeneration
  • Presbyopia
  • Retinal disease
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32
Q

A patient presents with the following Hx, what is the most likely diagnosis? What are the differential diagnoses?

A 27-year-old man presents following an incident where he was struck in the left eye with a paint ball. He notices a sudden decrease in vision in the left eye, from 20/20 before the accident, to counting-fingers vision after the accident. On examination, the left pupil appears whitish, and visual acuity is greatly decreased. The patient does not have any history of other medical problems. On dilated eye examination, the lens in the left eye appears whitish anteriorly, with a spoke-like pattern. On direct ophthalmoscopy, the red reflex is diminished and retinal details are indistinct.

A
  • Cataracts
  • Macular degeneration
  • Presbyopia
  • Retinal disease
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33
Q

A patient presents with the following Hx, suggestive of cataracts. What investigations would you order?

A 27-year-old man presents following an incident where he was struck in the left eye with a paint ball. He notices a sudden decrease in vision in the left eye, from 20/20 before the accident, to counting-fingers vision after the accident. On examination, the left pupil appears whitish, and visual acuity is greatly decreased. The patient does not have any history of other medical problems. On dilated eye examination, the lens in the left eye appears whitish anteriorly, with a spoke-like pattern. On direct ophthalmoscopy, the red reflex is diminished and retinal details are indistinct.

A
  • Opthalmoscope exam
    • Opacity seen O/E
  • Dilated fundus examination – Fundus + Optic nerve normal
  • Measurement of intraoccular pressure – Normal
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34
Q

How are cataracts managed?

A

No functional visual impairment

  • No treatment required
  • Annual eye exam

Functional visual impairment

  • Surgical removal of cataract
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35
Q

What is Glaucoma?

A
  • Damage to the optic nerve head
  • Progressive loss of retinal ganglion cells + axons
  • Progressive loss of visual field
  • Raised Intraoccular pressure

Can be open/closed angle

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36
Q

What is Occular HTN?

A
  • Where IOP is >21 mmHg on >2 occasions
  • No Glaucoma damage
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37
Q

You are asked to explain to Prostaglandin eye drops - Latanoprost + Bimatoprost, How would you go about this?

A

[Introduction]

  • Check what the patient knows
  • Brief history
  • Do they know what the drug is?
  • Indication & Action of the drug
  • Side effects
  • How to take it
  • Monitoring requirements

[Indication & Action of the drug]

Indication:

  • Lower intraocular pressure in open angle glaucoma and Ocular HTN
  • Preferred over topical beta blockers

Action:

  • Glaucoma = progressive optic nerve damage -> with visual field loss and eventual blindness
  • Associated with intraocular pressure (Ocular HTN)
  • Lowering intraocular pressure reduces glaucoma progression
  • Analogues of prostaglandin reduce intraocular pressure by increasing outflow of aqueous humour via uveoscelral pathway

[Side effects]

Few systemic SE

Locally can cause:

  • Blurred vision
  • Conjunctival redenning (Hyperaemia)
  • Ocular irritation and pain
  • Permanent change of eye colour - increasing melanin in stromal melanocytes of the iris

[Complications & CI]

Caution in:

  • When the lens is absent - Aphakia
  • When the lens is artificial - Pseudoaphakia
  • Patients with or at risk of Iritis/Uveitis/Macular oedema

[How to take it]

  • 1 drop administered to affected eye(s) once daily
  • Contact lenses should be removed before instilling the drops
  • Reinstated 15mins later
  • Compress the medial canthus (Nasal corner) of eye for about 1 min -> To reduce drainage through lacrimal duct - lowering systemic absorption of the drug
  • Best to administer in the evening

[Monitoring requirements]

  • Aim of the treatment is to reduce the risk of sight loss
  • Review regularly by specialist
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38
Q

What is close angle glaucoma?

A

Where there is reversible/adhesional closure of the anterior chamber angle – Increased IOP

Acute

  • IOP rises rapidly due to sudden blocking of the trabecular meshwork, due to iris being pushed back and closing the angle

Chronic

  • Develops after acute angle closure where the is adhesional closure of the angle
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39
Q

What are the causes of closed angle glaucoma?

A
  • Thick cataractous lens
  • Ectopic lens
  • Neovascularisation of the angle secondary to diabetic retinopathy/occular ischaemia
  • Tumours
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40
Q

Who commonly gets closed angle glaucoma?

A
  • Older patients >60yrs
  • Common amongst southeast asian/chinese populations
  • Females > Males
  • FHx
  • Patients with an already narrowed anterior chamber
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41
Q

What are the classical symptoms/signs of closed angle glaucoma?

A
  • Pain - Severe & Rapidly progressive
  • Frontal/Generalised headache
  • Blurred vision
  • Coloured haloes around lights
  • Nausea & Vomiting
  • Systemically unwell

O/E:

  • Red eye - marked around periphery of cornea
  • Hazy cornea
  • Non-reactive/Mildly dilated pupil
  • Hard on palpation of the globe
  • Raised IOP
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42
Q

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 50-year-old woman, who has no eye symptoms, is found during routine ophthalmic examination to have elevated intraocular pressure of 42 mmHg in both eyes. Funduscopy shows that the optic nerve head appears normal, with no evidence of glaucomatous neuropathy. Gonioscopy shows that the anterior chamber angles are closed for almost the full circumference.

A
  • Close angle glaucoma – Emergency!
  • Traumatic glaucoma
  • Anterior uveitis
  • Scleritis
  • Endopthalmitis
  • Optic neuritis
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43
Q

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 64-year-old woman presents to the emergency department with severe pain around her right eye of 4-hour duration, accompanied by blurred vision in that eye. She is also nauseated. Examination shows a red right eye with oedematous cornea and a wide pupil that is unresponsive to light. Intra-ocular pressure is extremely elevated (60 mmHg), only in the right eye. The anterior chamber angle is closed in both eyes.

A
  • Close angle glaucoma – Emergency!
  • Traumatic glaucoma
  • Anterior uveitis
  • Scleritis
  • Endopthalmitis
  • Optic neuritis
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44
Q

A patient presents with the following Hx suggestive of closed angle glaucoma, what investigations should be ordered?

A 64-year-old woman presents to the emergency department with severe pain around her right eye of 4-hour duration, accompanied by blurred vision in that eye. She is also nauseated. Examination shows a red right eye with oedematous cornea and a wide pupil that is unresponsive to light. Intra-ocular pressure is extremely elevated (60 mmHg), only in the right eye. The anterior chamber angle is closed in both eyes.

A

Slit lamp examination

  • Shallow anterior chamber
  • Large optic cup
  • Splinter haemorrhages

Examination of anterior chamber angle – Diagnostic

  • Trabecular meshwork not visible
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45
Q

How is close angle glaucoma managed?

A
  • Refer immediately – Opthalmic emergency!
  • Lay patient supine
  • Systemic analgesia ± Antiemetics
  • Topic medication – Beta blocker/Steroids/Pilocarpine
  • IV Acetazolamide

No response:

  • Systemic hyperosmotics e.g. Mannitol

Surgical:

  • Peripheral iridotomy – Treat both eyes
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46
Q

What are the complications that can arise from close angle glaucoma?

A
  • Permanent loss of vision
  • Repitition of acute attack
  • Attack in the opposite eye
  • Central retinal artery/vein occlusion
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47
Q

What is open angle glaucoma?

A
  • Progressive chronic condition where IOP is increased
  • Reduced flow through the trabecular meshwork, with chronic degenerative obstruction
  • There is an open iridocorneal angle
  • Glaucomatous optic neuropathy
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48
Q

Who classically gets open angle glaucoma?

A
  • Most common form of glaucoma
  • Increased prevalence with age typically >70yrs
  • FHx
  • More common in black people
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49
Q

What are the classical symptoms/signs of open angle glaucoma?

A
  • Typically asymptomatic – Visual loss is usually compensated by other eye
  • Visual loss noticed when severe + permanent damage has occured
  • Visual field loss
  • Normal/Increased IOP

If glaucomatous changes:

  • Increase in cupping
  • Notching of optic nerve cup
  • Retinal haemorrhage
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50
Q

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 50-year-old man presents for a routine eye examination with no symptoms. He has elevated intra-ocular pressure of 25 mmHg in the right eye and 30 mmHg in the left eye. On dilated examination, the cup-to-disc ratio is 0.5 in the right eye and 0.8 in the left eye. Corneal thickness and gonioscopy are normal. Subsequent automated testing of visual fields demonstrates peripheral visual field loss greater in the left eye than in the right. Repeated automated visual field testing shows that the visual field defects are reproducible.

A
  • Open angle glaucoma
  • Normal tension glaucoma
  • Closed angle glaucoma
  • Occular HTN
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51
Q

A patient presents with the following Hx suggestive of open angle glaucoma, what investigations would you order?

A 50-year-old man presents for a routine eye examination with no symptoms. He has elevated intra-ocular pressure of 25 mmHg in the right eye and 30 mmHg in the left eye. On dilated examination, the cup-to-disc ratio is 0.5 in the right eye and 0.8 in the left eye. Corneal thickness and gonioscopy are normal. Subsequent automated testing of visual fields demonstrates peripheral visual field loss greater in the left eye than in the right. Repeated automated visual field testing shows that the visual field defects are reproducible.

A

Tonometry – Measure IOP

  • May be raised/normal

Opthalmoscopy

  • Cup to disc ratio >0.6
  • Flame haemorrhages

Visual field testing

  • Scotoma

Visualisation of anterior chamber

  • No obstruction of angle, rule out closed angle glaucoma
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52
Q

How is open angle glaucoma managed?

A
  • If disease is obvious + advanced - Start treatment immediately
  • Set target IOP
  • Patient education - Irreversible condition, adherence to medications is essential
    • Patient needs to inform DVLA for assesment
  • Topical eye drop – Beta blocker/Prostaglandin analogue
    • Treatment to 1 or both eyes

If urgent IOP reduction required:

  • IV Mannitol or Acetazolamide

If resistant to >2 treatments:

  • Surgery – Trabeculoplasty
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53
Q

What are the complications of open angle glaucoma?

A
  • Progressive condition
  • Treatment side effects
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54
Q

What is Age related macular degeneration?

A
  • Ageing changes that occur in the central area of retina (Macula) in people >55yrs
  • Progressive chronic disease

Types:

  • Wet AMD – Drusen in the macula + Choroidal neovascularisation
  • Dry AMD – Drusen in macula + Geographic atrophy
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55
Q

What is dry AMD?

A
  • Most common form of AMD
  • Soft drusen
  • Changes in pigmentation (Hypo/Hyper-pigmentation) of the retinal pigment epithelium
  • End stage – Whole macula affected, visual loss
56
Q

What is wet AMD?

A
  • New blood vessels grow in from choriocapillaris under retina
  • Spread under/above retinal pigment epithelium
  • Fragile + Leak easily

Leads to:

  • Haemorrhage
  • Scar formation
  • Severe visual impairment if left untreated
57
Q

How is AMD classified?

A
  • No AMD – None/few drusen
  • Early AMD – Multiple small/intermediate drusen + Abnormalities of the retinal pigment epithelium
  • Intermediate AMD – Extensive intermedate or large drusen ± geographic atrophy not involving the fovea
  • Advanced AMD – Geographic atrophy involving the fovea ± any features of wet AMD
58
Q

Who classically gets AMD?

A
  • Most common cause of visual impairment in the developing world
  • Dry AMD is most common
  • More common in white people
  • Women > Men
  • FHx
  • Smoking
  • Hx of CVD/HTN
  • High BMI
59
Q

What is the classical symptoms/signs of AMD (Wet/Dry)?

A

Wet AMD

  • Painless rapid deterioration of central vision
  • Person age >55yrs
  • Reduced visual acuity, particularly near vision
  • Photopsia – Perception of flickering/flashing lights
  • Charles Bonnet syndrome – Visual hallucinations
  • O/E:
    • Drusen (Yellow deposits) in macula
    • Macular scar
    • Well demarcated red patches (haemorrhages/fluid)
    • Patchy pigmentation

Dry AMD

  • Painless gradual deterioration of central vision
  • Person age >55yrs
  • Reduced visual acuity, particularly near vision
  • Photopsia – Perception of flickering/flashing lights
  • Charles Bonnet syndrome – Visual hallucinations
  • O/E:
    • Drusen (Yellow deposits) in macula
    • Macular scar
    • Hypopigmentation/Hyperpigmentation of peripheral retina
60
Q

A patient presents with the following symptoms, what is the most likely diagnosis?

What are the differentials?

A 75-year-old woman presents with new-onset distortion in one eye. Vision is 20/80 in the involved eye. She has a family history of AMD and has smoked 20 cigarettes a day for most of her adult life.

A
  • Age related macular degeneration
  • Refractive error
  • Cataract
  • Posterior viterous detachment
  • Retinal artery/vein occlusion
  • Stroke
61
Q

A patient presents with the following Hx, suggestive of AMD. What investigations should be ordered?

A
  • Fundoscopy
    • Drusen
    • Red patches - Haemorrhages/fluid
  • Slit lamp exam
    • Drusen
    • Atrophic changes the macula
  • Fluorescein angiography
    • Neovascular AMD diagnosis
62
Q

How is AMD managed?

A
  • Urgent referral for further assesment - within 1 week
  • If worsening symptoms - Urgent Eye casualty

Dry AMD

  • No treatment to prevent progression
  • Slow progression with lifestyle changes
  • Patient education
  • Smoking cessation/visual rehab/Nutritional supplements
  • Manage co-existing visual impairment
  • Register as sight impaired for support
  • Inform DVLA

Wet AMD

  • Patient education
  • Smoking cessation/visual rehab/Nutritional supplements
  • Manage co-existing visual impairment
  • Register as sight impaired for support
  • Inform DVLA
  • Intravitreal injections of anti-VEGF (MAB)
63
Q

What are the complications of AMD?

A
  • Serous retinal detachment
  • Haemorrahge
  • Visual impairment/Blindness
64
Q

What is diabetic retinopathy?

A
  • chronic progressive, potentially sight-threatening disease of the retinal microvasculature
  • associated with the prolonged hyperglycaemia of DM, hypertension

Types:

  • Non-proliferative diabetic retinopathy (NPDR)
    • early stage of the disease and is less severe - Haemorrhages may lead to blurred vision
  • Proliferative diabetic retinopathy (PDR)
    • more advanced form of the disease – Neovascularisation + haemorrhages leads to vision loss + scarring of the retina
65
Q

What features are often found in Diabetic retinopathy?

A
  • Microaneurysms – predisposed to leaks
  • Hard exudates – Lipoprotein deposits
  • Haemorrhages
  • Cotton wool spots
  • Neovascularisation
66
Q

Who classically gets diabetic retinopathy?

What are the symptoms/signs?

A
  • T1DM after approx 5yrs + T2DM patients
  • HTN
  • Renal disease - Diabetic nephropathy
  • Poor glycaemic control

Symptoms/Signs:

May be asymptomatic with normal eyesight

  • painless gradual reduction of central vision
  • Haemorrhages result in the sudden onset of dark, painless floaters which may resolve over several days – vitreous haemorrhage and vitreous degeneration
    • Severe haemorrhage – Painless visual loss + acuity (Acute)
  • Spots in red reflex - suggest vitreous haemorrhage
  • Opthalmoscope:
    • little red dots (dot haemorrhages or small aneurysms)
    • irregular notching (venous beading)
    • any new vessels (these tend to be thinner and more disorganised than pre-existing vessels)
    • well-demarcated creamy/yellow lesions often appearing like clusters of spots (hard exudates)
    • paler lesions with less well-defined edges (cotton wool spots)
67
Q

A patient presents with the following Hx, what is the most likely diagnosis? what are the differentials?

A 55-year-old Hispanic man with a 15-year history of type 2 diabetes mellitus attends his optometrist with visual loss in his right eye, which cannot be corrected with eyeglasses. He is obese and hypertensive and has poor glycaemic control with an HbA1c of 82 mmol/mol (9.6%). Visual acuity is 20/100 right eye and 20/20 left eye. Retinal examination reveals microaneurysms, hard exudates, and thickening at the right macula, indicating right clinically significant macular oedema.

A
  • Diabetic Retinopathy
  • Occular ischaemic syndrome
  • Radiation neuropathy
  • Retinal venous occlusion
  • HTN
68
Q

A patient presents with the following Hx suggestive of diabetic retinopathy, what investigations would you order? How is it managed?

A 55-year-old Hispanic man with a 15-year history of type 2 diabetes mellitus attends his optometrist with visual loss in his right eye, which cannot be corrected with eyeglasses. He is obese and hypertensive and has poor glycaemic control with an HbA1c of 82 mmol/mol (9.6%). Visual acuity is 20/100 right eye and 20/20 left eye. Retinal examination reveals microaneurysms, hard exudates, and thickening at the right macula, indicating right clinically significant macular oedema.

A

Investigations:

  • diagnosis is dilated retinal photography with accompanying ophthalmoscopy
  • Fundus examination

Management:

  • Glycaemic control
  • Blood pressure control - target: 140/80 mm Hg or lower
  • Lipid control
  • Smoking cessation
  • Usually no treatment

If severe:

  • Laser treatment – induce regression of neovascularisation and reduce macular thickening
  • Doesnt restore lost vision
  • Either Focal treatment (Specific areas - Maculopathy) or Panretinal photocoagulation (Entire periphery of retina)
  • Fluocinolone acetonide intravitreal implant – Steroid anti-inflammatory + VEGF
  • vitrectomy (removal of the vitreous) may be required following an intravitreal bleed in proliferative DR
69
Q

How is Diabetic retinopathy screening carried out? Who is offered it?

A
  • Arrange or perform eye screening at or around the time of diagnosis for adults with type 1 or type 2 diabetes
    • repeat of structured eye screening annually
  • Monitoring for DR should begin at 12 years of age for both type 1 and type 2 diabetes
70
Q

What are the emergency/red flags for diabetic retinopathy?

A

Arrange emergency review by an ophthalmologist for:

  • Sudden loss of vision.
  • Rubeosis iridis (Blood vessels on iris)
  • Pre-retinal or vitreous haemorrhage.
  • Retinal detachment.

Arrange rapid review by an ophthalmologist for new vessel formation

71
Q

What are the complications of diabetic retinopathy?

A

visual loss secondary to:

  • Macular oedema.
  • Macular ischaemia.
  • Vitreous haemorrhage.
  • Tractional retinal detachment
  • Cataract – Rare, but snowflake opacities
72
Q

What is Central Retinal Artery occlusion?

What causes it?

A
  • ophthalmic emergency
  • more common causes of severe visual impairment in elderly patients

Causes:

  • Embolism is the most common cause
  • Local atherosclerotic plaques and vasculitis may cause vaso-obliteration
  • vascular compression
73
Q

What is the blood supply of the retina?

A
  • central retinal artery (CRA) is a branch of the ophthalmic artery, which is the first branch of the ICA
    • divides into two main branches (superior and inferior)
    • these divide into temporal and nasal branches, which supply blood to the four quadrants of the retina
  • outer retina is supplied by the choriocapillaries of the choroid that branches off the ciliary artery
74
Q

What is the significance of the location of retinal artery occlusion?

A
  • more proximal ophthalmic artery occlusion will have the most devastating effect, as all layers of the entire retina lose their blood supply (CRAO)
  • Occlusion of a distal end branch of the retinal artery will only affect the inner neural retina of that part of the retina, sparing the photoreceptors and limiting visual loss (BRAO)
75
Q

Who classically gets central retinal artery occlusion?

What are the symptoms/signs?

A
  • majority of patients are aged >60 years
  • Men > Women

Symptoms/Signs:

  • unilateral acute painless loss of vision
  • vision is usually reduced to counting fingers (worse suggests that the ophthalmic artery may also be affected)
  • may be a history of amaurosis fugax
  • afferent pupillary defect and a pale retina with attenuation of the vessels
  • segmentation of the blood column in the arteries (‘cattle-trucking’)
  • centre of the macula (supplied by the intact underlying choroid) stands out as a cherry-red spot
  • carotid auscultation for bruits, heart sounds for murmurs, radial pulse for atrial fibrillation and blood pressure
76
Q

What differentials should be considered in a patient with a Hx of central retinal artery occlusion?

A
  • Central Retinal artery occlusion
  • Giant cell arteritis
  • Retinal detachment
  • Vitreous haemorrhage
  • Retinal vein occlusion
  • Acute glaucoma
  • Acute optic neuritis
77
Q

A patient presents with a Hx suggestive of central retinal artery occlusion. What investigations would you order, how would you manage it?

A

Investigations:

  • Diagnosis is usually clinical and investigations are aimed at ruling out underlying diseases
  • rule out giant cell arteritis – Urgent ESR and CRP
  • fluorescein angiography and optical coherence tomography

Management:

ocular emergency

  • reperfuse ischaemic tissue as quickly as possible
  • presents within 90-100 minutes of onset of symptoms
    • firm ocular massage (repeatedly massaging the globe over the closed lid for ten seconds with five-second interludes) may dislodge the obstruction.
  • Lowering intraocular pressure with anterior chamber paracentesis + acetazolamide
  • Dilatation of the artery (eg, sublingual isosorbide dinitrate, inhaled carbogen or hyperbaric oxygen).
  • Intra-arterial fibrinolysis through local injection of urokinase into the proximal part of the ophthalmic artery
  • Carotid endartectomy

Ophthalmic follow-up in the eye department

  • Referral to low vision aid clinics
  • Driver and Vehicle Licensing Agency (DVLA) notification - if there is complete loss of vision in one eye (lacking even light perception), the DVLA may need to be notified
78
Q

What is Retinal detachment?

A
  • neurosensory layer of the retina separating off from the underlying retinal pigment epithelium (RPE)
    • Sub-retinal fluid accumulates, and the retina temporarily loses its function
  • Most are preceded by a posterior vitreous detachment (PVD), which causes traction on the retina and, potentially, a retinal tear
  • Opthalmic emergency
79
Q

What are the different types of retinal detachment?

A
  • Rhegmatogenous RD (Most common):
    • usually resulting from age-related degenerative liquefaction and shrinkage of the vitreous
  • Exudative (or serous) RD:
    • results from the accumulation of serous and/or haemorrhagic fluid in the subretinal space
  • Tractional RD:
    • occurs via mechanical forces on the retina
80
Q

Who classically gets retinal detachment?

What are the symptoms/signs of retinal detachment?

A
  • Older age >60yrs
  • Men = Women
  • Traumatic cause more common in younger pts
  • Increased risk with Myopia/FHx/Previous RD

Symptoms/Signs:

  • New onset of floaters (perception of mobile dots, lines, or haze due to blood and pigment cells entering the vitreous cavity casting shadows on the retina)
  • New onset of flashes (seen as recurrent, brief flashes, often more noticeable in low light conditions, caused by traction on the retina as the vitreous pulls away)
  • Sudden-onset painless, usually progressive, visual field loss (dark curtain or shadow)
  • RAPD typically occurs if the macula is detached or if at least two quadrants of the non-macular retina have detached
  • altered red reflex, with a grey or folded appearance
  • poor visual acuity suggests that the macula has already become detached
  • Confrontational visual field testing may reveal gross visual defects corresponding to the area of detached retina
81
Q

A patient presents with the following Hx, what is the most likely diagnosis? what are the differentials?

A 67-year-old man presents with a 2-day history of sudden visual loss in his right eye. He is slightly myopic and had successful cataract extraction with intraocular lens implantation 3 years earlier. He does not remember this eye ever having been injured. No pain was associated with the vision loss, and his blood pressure is normal with medication. The patient describes the loss of vision as a veil covering the visual field.

A
  • Retinal detachment
  • PVD - which may lead to RD.
  • Atypical/ocular migraine.
  • Optic nerve pathology - eg, optic neuritis.
  • Cerebrovascular event/transient ischaemic attacks
  • Vitreous haemorrhage
  • Age-related macular degeneration
82
Q

A patient presents with the following Hx, what is the most likely diagnosis? what are the differentials?

A 71-year-old woman presents after accidentally discovering that she has no vision in her left eye. She covered her right eye as she was scratching her eyelid, and noticed that the left eye was ‘blind’. She has been moderately myopic (-5 D) for decades but has no other significant history.

A
  • Retinal detachment
  • PVD - which may lead to RD.
  • Atypical/ocular migraine.
  • Optic nerve pathology - eg, optic neuritis.
  • Cerebrovascular event/transient ischaemic attacks
  • Vitreous haemorrhage
  • Age-related macular degeneration
83
Q

A patient presents with the following Hx suggestive of PD, how would you investigate & manage the condition?

A 67-year-old man presents with a 2-day history of sudden visual loss in his right eye. He is slightly myopic and had successful cataract extraction with intraocular lens implantation 3 years earlier. He does not remember this eye ever having been injured. No pain was associated with the vision loss, and his blood pressure is normal with medication. The patient describes the loss of vision as a veil covering the visual field.

A

Investigations:

  • slit-lamp examination
  • Ultrasound or optical coherence tomography may be used to assess the type and extent of the detachment
  • full systemic examination

Management:

  • If there is a visual field defect but visual acuity is good, referral is urgent, as it is likely to be a ‘macula-on’ RD (the macula is still adherent to the underlying RPE)
  • ‘macula-off’ detachment (where surgery is a rescue procedure rather than a protective one)
  • If there are new-onset flashes and/or floaters, refer them immediately if there are signs of threat to sight, such as:
    • Visual field loss (such as a dark curtain or shadow), or distorted or blurred vision.
    • Fundoscopic signs of RD or vitreous haemorrhage

Medical management

  • Treated with cryotherapy or laser photocoagulation – permanent adhesion between the retina and RPE
  • Topical antibiotics and corticosteroids are prescribed postoperatively
84
Q

What is Orbital cellulitis?

A
  • infection of the soft tissues behind the orbital septum
    • originates from locally spreading infection
  • potentially sight-threatening and life-threatening (but uncommon) ophthalmic emergency
  • characterised by:
    • eyelid oedema
    • erythema and chemosis
    • with orbital signs (such as proptosis, gaze restriction and blurred or double vision)
    • systemic signs (such as fever)
  • Commonly caused by:
    • Streptococcus pneumoniae
    • Staphylococcus aureus
    • Streptococcus pyogenes
    • Haemophilus influenzae
85
Q

What is Pre-orbital cellulitis?

A
  • more common and less serious infection anterior to the orbital septum
  • common in young children
  • eyelid oedema in the absence of orbital signs such as gaze restriction and proptosis
  • Upper respiratory infection and sinusitis are the most important predisposing factors for periocular infection in children.

Caused by:

  • Streptococcus spp.
86
Q

Who classically gets orbital cellulitis?

What are the symptoms/signs?

A
  • Orbital cellulitis is much less common than preseptal cellulitis
  • no predilection for gender or race
  • orbital cellulitis more frequently affects those aged 7-12 years, whereas preseptal cellulitis occurs at younger ages

Symptoms/Signs:

  • Acute onset of unilateral swelling of conjunctiva and lids.
  • Oedema, erythema, pain, chemosis
  • decreased visual acuity, proptosis and external ophthalmoplegia.
  • Temperature greater than 37.5°C and leukocytosis resulting in fever
  • Diplopia.
  • Relative afferent pupillary defect (RAPD)
87
Q

What are the symptoms/signs of preseptal cellulitis?

A
  • Acute onset of swelling, redness, warmth and tenderness of the eyelid.
  • Eyelid oedema in the absence of orbital signs such as gaze restriction and proptosis.
  • Fever, malaise, irritability in children.
  • Ptosis
88
Q

A patient presents with the following Hx, what is the most likely diagnosis? what are the differentials?

A 9-year-old boy is brought to the emergency department with redness and swelling around his eye that has been present for 1 day. His left eyelid is red, tender to touch, and swollen. It will not open fully and he has a slightly decreased confrontational visual field in the left eye superiorly. He is afebrile and vital signs are normal. He denies any decrease in vision or double vision and his examination is significant for best corrected vision of 20/25 (right eye) and 20/25 (left eye). He has full motility of both eyes, has no afferent pupillary defect, and has eye pressures of 16 mmHg (right eye) and 18 mmHg (left eye). His conjunctiva and sclera are within healthy limits and the anterior chamber is deep and quiet. Fundus findings are normal in the left eye and the rest of his examination is within healthy limits. No masses are palpable. CT of orbits and sinus revealed absence of orbital fat stranding and sub-periosteal abscess. Patient had opacified ethmoid and frontoethmoidal recess on the left side.

A
  • Orbital/preseptal cellulitis.
  • Necrotising fasciitis.
  • Chalazion.
  • Allergic lid swelling.
  • Severe viral conjunctivitis.
89
Q

A patient presents with the following Hx suggestive of orbital cellulitis, how would you investigate + manage the condition?

A 9-year-old boy is brought to the emergency department with redness and swelling around his eye that has been present for 1 day. His left eyelid is red, tender to touch, and swollen. It will not open fully and he has a slightly decreased confrontational visual field in the left eye superiorly. He is afebrile and vital signs are normal. He denies any decrease in vision or double vision and his examination is significant for best corrected vision of 20/25 (right eye) and 20/25 (left eye). He has full motility of both eyes, has no afferent pupillary defect, and has eye pressures of 16 mmHg (right eye) and 18 mmHg (left eye). His conjunctiva and sclera are within healthy limits and the anterior chamber is deep and quiet. Fundus findings are normal in the left eye and the rest of his examination is within healthy limits. No masses are palpable. CT of orbits and sinus revealed absence of orbital fat stranding and sub-periosteal abscess. Patient had opacified ethmoid and frontoethmoidal recess on the left side.

A

Investigations:

  • Clinical diagnosis
  • FBC frequently shows a leukocytosis
  • Blood culture
  • Any discharge from skin breaks should be swabbed and sent to microbiology
  • CT of the sinuses and orbit ± brain is indicated for children and if orbital cellulitis is suspected in an adult

Management:

  • Emergency referral
  • Preseptal cellulitis
    • Children are initially admitted to hospital
    • Oral co-amoxiclav may be used both for adults and for children as long as there is no allergy to penicillin
    • IV ceftriaxone until response is seen
  • Orbital cellulitis
    • Hospital admission is mandatory, usually under the joint care of ophthalmologists and the ENT surgeons
    • IV ABx (eg, cefotaxime and flucloxacillin) with addition of metronidazole in patients over 10 years of age with chronic sinonasal disease
    • Clindamycin plus a quinolone are used where there is penicillin sensitivity
  • Surgery is indicated where there is CT evidence of an orbital collection
90
Q

What is Endopthalmitis?

A
  • severe inflammation of the anterior and/or posterior chambers of the eye
    • involving the vitreous and/or aqueous humours
  • exogenous and occur after eye surgery (including cataract surgery) or penetrating ocular trauma, or as an extension of corneal infection
  • endogenous, arising from bacteraemic or fungaemic seeding of the eye
  • panophthalmitis = involves all the layers ± the peri-ocular tissues
  • Acute bacterial endophthalmitis is a medical emergency
91
Q

What commonly causes endopthalmitis?

A
  • Staphylococcus aureus
  • Streptococcus spp
92
Q

Who classically gets endopthalmitis?

What are the symptoms/signs?

A
  • Rare condition
  • Endogenous endophthalmitis is even rarer than exogenous endophthalmitis

Symptoms/Signs:

  • acute, with eye pain and decreased vision
  • eyelid may be swollen
  • Hypopyon is a common finding, and the appearance of the eye may be hazy
  • no fever and minimal, if any, peripheral leukocytosis
  • red eye, ocular discharge, and blurring
  • Decreased red reflex.
  • Decreased visual acuity.
93
Q

If you suspect a patient has endopthalmitis, what investigations would you do? How would you manage the patient?

A

Investigations:

  • slit-lamp examination
  • confirmed by taking a sample of vitreous for microbiological culture (diagnostic surgical vitrectomy) – therapeutic procedure if the vitreous is entirely removed (to reduce the infectious load
    • intraocular antibiotics can be administered at the same time
  • FBC
  • blood cultures
    • culture of all indwelling lines and catheters
  • CT or MRI scan of the orbit may help to rule out other ophthalmic conditions

Management:

  • Endophthalmitis is a medical and ophthalmological emergency.
  • Suspected acute endophthalmitis requires emergency admission
  • direct injection of antibiotics into the vitreous, and vitrectomy in more severe cases
94
Q

What is infective conjunctivitis?

A
  • Bacterial conjunctivitis is usually a benign self-limiting illness
    • Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pneumoniae and, in children, Haemophilus influenzae
  • Viral conjunctivitis can be prolonged and can, in some cases, have lasting consequences
    • Adenovirus/HSV
  • herpes viruses can cause significant associated keratitis and uveitis
95
Q

Who classically gets infective conjunctivitis?

What are the symptoms/signs (Bacterial)?

A
  • In adults, viral conjunctivitis is more common than bacterial conjunctivitis
  • In children and the elderly, bacterial conjunctivitis is more common than viral conjunctivitis

Symptoms/Signs:

  • Discomfort - burning or gritty but not sharp.
  • Significant pain suggests a more serious diagnosis.
  • Vision is usually normal, although ‘smearing’, particularly on waking, is common.
  • Discharge tends to be thick rather than watery.
  • There may be mild photophobia.
  • chronic cases consider sexually transmitted infection (STI)
  • Red eye, with uniform engorgement of all conjunctival blood vessels.
  • Typically causes a yellow-white mucopurulent discharge.
  • Eyes may be difficult to open in the morning, with lids glued together by discharge.
  • Bacterial conjunctivitis is usually bilateral (though often sequential).
  • Visual acuity should be normal, other than the mild and temporary blur secondary to the discharge
96
Q

In a patient with infective conjunctivitis which STIs need to be ruled out?

How are they managed?

A
  • Neisseria gonorrhoeae
  • Chlamydia trachomatis – green stringy discharge in the morning

Management:

  • Trachoma: can be treated with oral azithromycin
  • Chlamydia: Topical treatment with tetracycline ointment (qds for six weeks) and systemic doxycycline (100 mg bd for 1-2 weeks) or azithromycin (1 g single dose)
97
Q

How is infective conjunctivitis diagnosed?

How is bacterial conjunctivitis managed?

A
  • Clinical diagnosis

Management:

  • Infective conjunctivitis is a self-limiting illness that usually settles without treatment within 1-2 weeks
  • Clean away infected secretions from eyelids and lashes with cotton wool soaked in water.
  • Wash hands regularly
  • Chloramphenicol is the drug of choice for superficial eye infections
  • Fusidic acid is useful for staphylococcal infections
  • Fluoroquinolones such as ciprofloxacin and ofloxacin are reserved for serious ocular infections
98
Q

What are the symptoms/signs of viral conjunctivitis?

A
  • Symptoms usually begin in one eye, becoming bilateral after a few days.
  • Hx of URTI or of close contact with someone with a red eye.
  • There is a burning or gritty foreign body sensation.
  • Patients notice morning crusting.
  • Discharge is watery and mucoid
  • conjunctiva is typically very red and irritated.
  • There may be pinpoint conjunctival haemorrhages.
  • Eyelid redness and oedema are common.
  • Preauricular lymphadenopathy is a classic sign
99
Q

How is viral conjunctivitis managed?

A
  • Management is essentially supportive.
  • Cool compresses and artificial tears used several times daily may improve comfort.
  • Viral conjunctivitis can last 4-6 weeks and can get worse before it gets better.
  • Contact lenses should not be worn until all symptoms and signs of infection have completely resolved and any treatment has been discontinued for 24 hours.
  • Infected secretions should be cleaned away from eyelids and lashes with cotton wool soaked in water.
  • Patients should be advised to wash hands regularly

Ocular herpes simplex requires urgent referral to ophthalmology for exclusion of uveitis

  • Topical antiviral treatment, such as aciclovir, is the usual treatment.
  • Contact lens wear should be discontinued until symptoms have settled and treatment is complete.

Herpes Zoster (VZV)

  • Start systemic antiviral treatment as soon as the diagnosis is made (eg, aciclovir, valaciclovir or famciclovir) .
  • Refer for ophthalmic review.
100
Q

A patient presents with the following Hx, what is the most likely diagnosis? what are the differentials?

A 6-year-old girl with no significant past medical history presents 4 days after developing a red, irritated left eye. Her mother states that she has been wiping thick whitish-yellow discharge from her eye, and the eye is matted shut in the morning. She denies any exposure to an infected person, upper respiratory tract symptoms, or contact lens use. She also denies any significant pain or light sensitivity. On examination, the patient’s pupils are equal and reactive. She does not have a tender pre-auricular lymph node. Penlight examination does not reveal any corneal opacity, but thick, whitish discharge is seen.

A
  • Bacterial conjunctivitis
  • Viral conjunctivitis
  • Allergic conjunctivitis
101
Q

A patient presents with the following Hx, what is the most likely diagnosis? what are the differentials?

A 14-year-old boy with no significant past medical history presents 3 days after developing a red, irritated right eye that spread to the left eye today. He has watery discharge from both eyes and they are stuck shut in the morning. He reports recent upper respiratory tract symptoms and that several children at his day camp recently had pink eye. He denies significant pain or light sensitivity and does not wear contact lenses. On examination, his pupils are equal and reactive and he has a right-sided, tender pre-auricular lymph node. Penlight examination does not reveal any corneal opacity.

A
  • Viral conjunctivitis
  • Bacterial conjunctivitis
  • Allergic conjunctivitis
102
Q

What are the symptoms/signs of allergic conjunctivitis?

How is it diagnosed?

A

Investigations:

  • Diagnosis is usually made on history and eye examination

Symptoms/Signs:

  • exposure to allergens and irritants such as chemicals, eye drops, potential chemical irritants (including eye make-up)
  • Associated conditions which support an allergic cause include atopy, idiopathic urticaria, non-hereditary angio-oedema, and food allergies
  • Red eyes, usually bilateral, and often with a clear watery discharge.
  • Oedema may be visible in round swellings on the inside of the eyelid.
  • Lid swelling and/or oedema.
  • Conjunctival injection.
  • Discharge, if present, is usually watery
  • Skin irritation may be visible on the lids in contact dermatoconjunctivitis.
103
Q

How is allergic conjunctivitis managed?

A
  • Allergen avoidance
  • Topical mast cell stabilisers – Sodium cromoglycate/lodoxamide/nedocromil
  • Topical antihistamines – antazoline/azelastine/emedastine, provide rapid relief of the symptoms of allergic conjunctivitis.
  • Oral antihistamines such as loratadine or chlorphenamine
104
Q

What is Uveitis?

A
  • inflammation of the uveal tract, with or without inflammation of neighbouring structures (eg, the retina or vitreous)
    • Trauma-related uveitis
    • Infection-related uveitis
    • Autoimmune uveitis

Uveitis may be anterior, intermediate, posterior or panuveitis

  • Anterior uveitis describes inflammation of the iris
  • Intermediate uveitis affects the vitreous and posterior part of the ciliary body
  • Posterior uveitis describes inflammation of the choroid
  • Panuveitis describes inflammation throughout the uveal tract
105
Q

Who classically gets uveitis?

What are the symptoms/signs?

A
  • Anterior uveitis is the most common form

Symptoms/Signs:

  • Symptoms may develop over hours or days (acute uveitis), or onset may be gradual (chronic uveitis)
  • Acute anterior uveitis
  • Usually unilateral.
  • Pain, redness and photophobia are typical.
  • Eye pain is often worse when trying to read.
  • Progressive - occurs over a few hours/days.
  • Blurred vision.
  • There may be excess tear production.
  • Associated headache is common.
  • Visual acuity may be decreased.
  • Extraocular movement: generally normal
106
Q

A patient presents with the following Hx, what is the most likely diagnosis? what are the differentials?

A 40-year-old man presents to the emergency department complaining of red eye without purulent discharge. He also has pain, photophobia, blurred vision, and tearing. On slit-lamp examination, the attending ophthalmologist notices a small irregular pupil, conjunctival injection around the corneal limbus, and WBCs in the anterior chamber.

A
  • Uveitis
  • Intra-occular foreign body
  • Endopthalmitis
  • Posterior segment tumour
  • Occular ischaemia syndrome
107
Q

A patient presents with the following Hx, what is the most likely diagnosis? what are the differentials?

A 30-year-old woman presents with onset of bilateral decreased vision associated with floaters. Slit-lamp examination of the anterior segment shows no abnormality. However, on dilated fundoscopic examination, vitreous cells and a choroiditis are apparent.

A
  • Uveitis
  • Intra-occular foreign body
  • Endopthalmitis
  • Posterior segment tumour
  • Occular ischaemia syndrome
108
Q

A patient presents with the following Hx suggestive of uveitis, how would you investigate and manage?

A

Investigations:

  • A first episode of mild, unilateral non-granulomatous acute uveitis can be diagnosed by history and clinical examination alone

Management:

  • Refer people with suspected uveitis to an ophthalmologist within 24 hours
  • Corticosteroids are used to reduce inflammation and prevent adhesions in the eye
109
Q

What is retinoblastoma?

What is the key sign?

How is it managed?

A

Embryonal tumour of the retina - Most common eye malignancy in children

  • mutation on chromosome 13 (Rb gene)

Sign:

  • Leukocoria – Intermittent white pupillary reflex, rather than red
  • Strabismus

Management:

  • Red reflex test
  • Urgent referral
110
Q

What is Keratitis?

How does it present?

How is it managed?

A

Infection/inflammation of the cornea

Sign/Symptoms:

  • Redness
  • Pain
  • Photophobia
  • Foreign body sensation + Reduced visual acuity

Management:

  • If bacterial – Topical ABx
  • Virus – Referral + Topical antivirals
111
Q

What does the following fundoscopic exam show?

A

Diabetic retinopathy

Non-proliferative

  • Microaneurysms (dots) – only change in mild
  • Haemorrhages (blots)
  • Venous beading
  • Intraretinal microvascular anomalies
  • Hard exudates – lipid deposits (well defined)
  • Cotton wool spots – infarcts (not well defined)
  • Proliferative
  • Any neovascularisation
112
Q

What does the following fundoscopic exam show?

A

Diabetic retinopathy

Proliferative

  • Any neovascularisation
113
Q

What does the following fundoscopic exam show?

A

Panretinal laser photocoagulation scars

  • Hundreds of dots of laser burns across wide area of retina (avoiding major vessels and macula)
114
Q

What does the following fundoscopic exam show?

A

Focal/Grid laser photocoagulation scars

  • Smaller areas of laser burns in dots or grids near macula
115
Q

What does the following fundoscopic exam show?

A

Hypertensive retinopathy

  • flame haemorrhages
  • hard exudates
  • cotton wool spots
  • Arteriolar narrowing
  • AV nicking
  • Papilloedema
116
Q

What does the following fundoscopic exam show?

A

Retinal Artery Occlusion

  • Swollen + Pale + Oedematous retina
  • Cherry red spot (Fovea)
117
Q

What does the following fundoscopic exam show?

A

Retinal vein occlusion

  • Tortous dilated vessels
  • Widespread retinal haemorrhages (Stormy sunset)
118
Q

What does the following fundoscopic exam show?

A

Retinal detachment

  • Gray opalescent retina
  • Ballooning forwards
119
Q

What does the following fundoscopic exam show?

A

Retinitis pigmentosa

  • Peripheral pigmentation
  • Arteriolar narrowing
  • Waxy disc pallor
120
Q

What does the following fundoscopic exam show?

A

Dry macular degeneration

  • Drusen in macula area – Tiny yellow/white deposits
121
Q

What does the following fundoscopic exam show?

A

Wet macular degeneration

  • Subretinal haemorrhages around the macula
  • Localised retinal elevation + retinal oedema
122
Q

What does the following fundoscopic exam show?

A

Optic atrophy

  • Pale + Featureless optic disc (Sun setting)
123
Q

What does the following fundoscopic exam show?

A

Papilloedema

  • Bilateral swollen optic discs (Blurred margins)
124
Q

What does the following fundoscopic exam show?

A

Open angle glaucoma

  • Optic disc cupping (Optic cup > 1/3 of the disc)
  • Optic disc atrophy
125
Q

What does the following fundoscopic exam show?

A

Vitreous haemorrhage

  • No red reflex
  • Difficult/impossible to visualise the retina
126
Q

What does the following fundoscopic exam show?

A

Normal fundoscopy exam

  • Fovea - Darkest area in dark spot
  • Macula - Dark spot
  • Optic disc
  • Optic cup
127
Q

What is Scleritis?

A

Severe inflammation of the sclera - potential for necrosis + perforation

  • Associated with rheumatological disease/vasuculitidies

Symptoms/Signs:

  • Deep + Boring + Severe pain
  • Tenderness

Investigations:

  • Vasculitis screen:
    • ESR
    • RF
    • FBC
    • ANCA

Management:

  • Intensive local/topical steroid
  • NSAIDs
  • Systemic steroids
128
Q

What is a 3rd nerve palsy?

How is it caused?

What are the symptoms?

A
  • Palsy of the occulomotor nerve and associated muscles
  • Caused by Stroke/Increased ICP/Vasculitis/Demyelination

Symptoms:

  • Eye is down and out - due to suppressed elevation + unopposed pull of lateral rectus
  • Ptosis - palsy of levator palpebrae superioris
129
Q

What is a 4th nerve palsy?

How is it caused?

What are the symptoms?

A

Palsy of CN4

  • Caused by: Head trauma/Congenital CN4 palsy/CVD risk factors

Symptoms/Signs:

  • Elevated relative to the fellow eye
  • Unable to look down and in
130
Q

What is a 6th nerve palsy?

How is it caused?

What are the symptoms?

A

Palsy of CN6

  • Caused by increased ICP/Cardiovascular risk factors/Demyelination/Vasculitis

Symptoms/Signs:

  • Eye cannot abduct beyond the midline
131
Q

What are the causes of optic disc swelling (Local + Systemic)?

A

Local:

  • Optic neuritis
  • Optic disc vasculitis (GCA)
  • Disc infarction

Systemic:

  • Intracranial SoL
  • Severe HTN
  • Leukaemic cell infiltration
  • Metastases
132
Q

A child has attended the Emergency Department complaining of severe swelling and pain around their right eye. Vision is reduced and eye movements are both reduced and painful.
They look unwell and have a temperature of 39.2°C

What can you see in this picture?

A
  • Periocular erythema of R eye
  • Periocular swelling R eye
  • Patient cannot elevate R eye
133
Q

What do you see in this image of an eye?

A
  • Injected conjunctiva (Increased blood flow)
  • Pus in anterior chamber - fluid level
134
Q

What do you see in this image of an eye?

A

Bacterial infiltrate (Keratitis)

135
Q

What do you see in this image of an eye?

A

Bacterial keratitis

  • Hypopypon – pus in the anterior chamber

Year 4 M&M (7 decks)

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