Ophthalmology Flashcards
What is the main bacterial cause of infective conjunctivitis?
Staph aureus
Staph epidermis
Chlamydia
What are the symptoms of conjunctivitis?
Red eye
Irritation/grittiness/discomfort
Sticky/purulent discharge
When should you refer a patient for conjunctivitis?
Lots of discharge
Neonatal patient
Refractory
What is the usual treatment for infective conjunctivitis?
Conservative treatment such as lid hygiene
Topical chloramphenicol
What is the treatment for allergic conjunctivitis?
Topical antihistamine (antazoline) Topical sodium cromoglycate
What is the difference between anterior and posterior uveitis?
Inflammation of the uveal tract, specifically the iris (anterior) or the choroid (posterior)
Which type of uveitis is more likely to be bilateral?
Posterior
What are two risk factors for uveitis?
Autoimmune disease
HLA-B27 positivity
What are four causes of uveitis?
Intraocular lymphoma Trauma Sarcoidosis Ischaemic HSV
What are the main symptoms of anterior uveitis?
Painful red eye
Photophobia and diplopia
What are the main symptoms of posterior uveitis?
Gradual visual loss
Diplopia and floaters
Posterior uveitis is suggested by inflammatory cells where?
In the vitreous
Why is the aqueous hazy in anterior uveitis?
Inflamed vessels leak protein
If the retina appears yellow-white on examination, what does this suggest?
Retinitis, either in isolation or associated with uveitis
In uveitis, what happens to the optic disc, optic nerve, and IOP on examination?
Optic disc - oedema, cupping
Optic nerve - oedema
IOP - decreased as decreased production of aqueous
What is seen on slit lamp examination in uveitis?
Cornea - Keratic precipitates (KPs) - cluster of inflammatory cells
Ciliary flush
Cell and flare - hazy aqueous
Hypopyon
What is the management of a suspected uveitis patient?
Refer within 24h
Cyclopentolate 1%
Corticosteroids (topical/PO/IV depending on severity)
How does cyclopentolate 1% work?
It is a cycloplegic-mydriatic drug
Paralyses the ciliary body, relieves pain, and prevents adhesions
What drug is added if uveitis is persisting?
Ciclosporin
Name three complications of uveitis.
Secondary cataract
Cystoid macular oedema
Retinal detachment
What are the two types of episcleritis?
Simple (vascular congestion on an even surface)
Nodular (discrete elevated area of inflamed episclera)
What is the cause of episcleritis?
Idiopathic
What are the symptoms of episcleritis?
Mild pain/discomfort
Redness, watering, and mild photophobia
Is visual acuity normal in episcleritis?
Yes
How long does episcleritis last before spontaneously resolving?
7-10 days
What is the most common form of scleritis?
Anterior - 90%
Name six risk factors for scleritis.
Rheumatoid arthritis GPA/CTDs Female Ocular surgery Local infections Sarcoidosis
Describe the pain of scleritis.
Severe, boring
Radiates to forehead/brow/jaw
Worse with movement and at night
What are the other symptoms of scleritis?
Red eye
Gradual decrease in vision
Diplopia in posterior disease
What are the signs of scleritis?
Reduced visual acuity
Bluish tinge to sclera and tender globe
Scleral, episcleral, and conjunctival vessels all inflamed causing redness
What percentage of scleritis patients have a systemic vasculitis?
15%
What are the treatment steps for anterior, nodular, and posterior scleritis?
PO NSAIDs
PO prednisolone
Methotrexate/azathioprine
What is the main treatment difference for necrotizing scleritis?
Skip the oral NSAIDs and go straight to oral prednisolone
What are the complications of scleritis?
Raised IOP
Retinal detachment
Uveitis
Cataracts
What are the three causes of blepharitis?
Staphylococcal
Seborrhoeic
Meibomian
What is the cause of seborrheic blepharitis?
Reaction to malassezia furfur
What are two risk factors for blepharitis?
Keratoconjunctivitis sicca
Skin disease
What is the management of blepharitis?
Regular eyelid hygiene including warmth, massage, and cleansing
Artificial tears
What are three complications of blepharitis?
Chalazion
Stye
Conjunctivitis
What does the uveal tract consist of?
Iris, ciliary body, choroid
What is intermediate uveitis?
Inflammation of the vitreous, posterior ciliary body, and peripheral retina
What are some imaging techniques used to qualify eye inflammation?
Fundus fluorescein angiography
Optical coherence tomography
What is glaucoma?
Damage to the optic nerve head with progressive loss of retinal ganglion cells and their axons
What is glaucoma commonly associated with?
Raised intraocular pressure
Define raised IOP.
> 21mmHg on two consecutive occasions in the absence of any glaucomatous change
What is the end stage of glaucoma?
Absolute glaucoma
No vision, no pupillary reflex, eye has a stony appearance. Very painful
What part of the eye produces aqueous humour?
The ciliary body
What is the anterior chamber angle?
The junction of the iris and the cornea at the periphery of the anterior chamber
What is primary open angle glaucoma?
Chronic degenerative obstruction of aqueous flow through the trabecular meshwork.
What is closed angle glaucoma?
Acutely raised IOP with a physically obstructed iridocorneal angle
What causes pressure build up in closed angle glaucoma?
Aqueous humour cannot flow from the posterior to the anterior chamber. Rapid build up of fluid is painful
What are the symptoms of the early and late stages of glaucoma?
Early - peripheral visual fields affected
Late - foveal vision and acuity affected
What are six risk factors for glaucoma?
Raised IOP particularly >26mmhg Women - shallow anterior chambers Eye trauma/uveitis/other eye conditions Family history Myopia Steroids
What are the symptoms of closed angle glaucoma?
Suddenly painful red eye
Blurred vision rapidly progressing to visual loss
What are the extra symptoms of acute angle closure glaucoma (10%)?
Coloured halos around lights
Nausea and vomiting
Very severe pain
What are the symptoms of open angle glaucoma?
Asymptomatic
Peripheral visual loss
What investigation measures the iridocorneal angle to test whether the glaucoma is closed or open angle?
Which investigation measures intraocular pressure?
Gonioscopy
Tonometry
Examination of what in glaucoma is a direct marker of disease progression?
Optic disc
What suggests glaucoma when examining the optic disc?
Increased diameter of cup compared to overall disc size, with time
What is seen on examination in CAG?
CAG - marked redness, hazy cornea, hard globe, non reactive dilated pupil, shallow anterior chambers, closed iridocorneal angles and corneal epithelial oedema
What is the treatment of CAG?
Topical IOP lowering drug with IV acetazolamide
What are the possible surgical options for CAG?
Peripheral iridotomy
Surgical iridectomy
Trabeculoplasty
Name some IOP lowering drugs, used for both OAG and CAG.
Topical BB: timolol Topical PG analogue: Travaprost Topical parasympathomimetics: pilocarpine IV acetazolamide IV mannitol
What is the aim of OAG treatment with IOP lowering drugs?
Stall progression of glaucoma but not reverse it
What are some second line treatment options in glaucoma?
Argon/selective laser trabeculoplasty
Trabeculectomy
What are some causes of keratoconjunctivitis sicca?
Sjogren's syndrome Lacrimal gland insufficiency Meibomian gland dysfunction (blepharitis, isotretinoin) Reflex hyposecretion Blink disorders e.g. Parkinsons Lagophthalmos
What are some causes of reflex hyposecretion in keratoconjunctivitis sicca?
Contact lens wear Diabetes Corneal surgery Anticholinergic medication Antidepressants
What are some risk factors for keratoconjunctivitis sicca?
Vitamin A deficiency Older age Contact lenses Preservatives in topical drops Post menopausal oestrogen therapy
What are the symptoms of keratoconjunctivitis sicca?
Gritty irritation and burning/mild pain aggravated by air con, prolonged reading, computer work.
Symptoms worse at end of the day
What tests can confirm keratoconjunctivitis sicca?
Slit lamp examination
Schirmer’s test
Rose Bengal staining
What are some complications of keratoconjunctivitis sicca?
Conjunctivitis
Keratitis
Corneal ulceration
What is macular degeneration?
Ageing changes in the macula (centre of the retina) causing visual loss
What are the two types of macular degeneration?
Wet - choroidal neovascularisation
Dry - atrophy and changes to pigmentation of retinal pigment epithelium (RPE)
What are three risk factors for macular degeneration, apart from age?
Smoking
Family history
Prior history of AMD
How does macular degeneration present?
Painless scotoma esp. for near vision
Reduced acuity and contrast sensitivity
Abnormal dark adaptation
Photopsia and light glare
What tool is used to test visual acuity in macular degeneration?
Amsler grid
What is seen on fundoscopy in macular degeneration?
Macular drusen and scarring
Dry - Changes in pigmentation to the RPE
Wet - intraretinal, subretinal, or sub RPE haemorrhages
What is the cause of wet/neovascular AMD?
New blood vessels grow from the choriocapillaris and spread around the RPE. They are fragile and leak easily, causing disciform scarring
Name three differentials, apart from AMD, for painless loss of vision.
Cataracts
Primary open angle glaucoma
Retinal detachment
What drug class is used to prevent progression of wet AMD?
Anti-vascular endothelial growth factor (anti-VEGF)
Intraviteal injections
How do anti-VEGFs work and give an example.
Decreases angiogenesis and vascular permeability
Ranibizumab
What is the pathophysiology of strabismus?
Misalignment of the eyes resulting in the retinal image not being in corresponding areas of both eyes
What does strabismus result in?
Adults - diplopia
Children - Amblyopia
What prefixes are used in describing strabismus?
Eso - inward ocular deviation
Exo - outward ocular deviation
Hypo - downward deviation
Hyper - upward deviation
What is the name of an inward-turning squint?
Esotropia
Hypertropic/hypotropic squints are commonly due to what?
Superior oblique paresis
What is the leading cause of strabismus in adults?
Stroke
What are the symptoms of strabismus in adults?
Diplopia
Asthenopia
Pulling sensations
How is strabismus investigated?
Bruckner and cover tests
Hirschburg’s test (corneal reflection test)
How is strabismus treated in a patient less than 8 years old
Eye patching and cycloplegic drops
What is blepharospasm?
A focal dystonia of the orbicularis oculi muscle resulting in an increased lid closure frequency
What is the first line treatment of blepharospasm?
Botulinum toxin A into orbicularis oculi.
What is the triad of features in optic neuritis?
Visual loss
Eye pain worse on movement
Dyschromatopsia especially red desaturation
What is the most common cause of optic neuritis?
Multiple sclerosis
What are some other causes of optic neuritis?
GCA
Sarcoidosis, SLE, Behcet’s
Post infection
Lyme disease
What are the signs of optic neuritis?
Decreased pupillary light reflex
RAPD
Arcuate defects/scotoma/papillitis
How is optic neuritis diagnosed?
Clinical diagnosis
Fundoscopy - pale optic disc
MRI - demyelinating plaque
What is the treatment of optic neuritis?
1g methylprednisolone 3 days
What features of optic neuritis suggest a cause other than MS?
Patient aged <12 or >50
Bilateral
Absent or extremely severe pain
Lack of RAPD
What are risk factors for diabetic retinopathy?
Pregnancy
DM diagnosed before 30
HTN and other CV risk factors, renal disease
How is diabetic retinopathy classified?
Non-proliferative (mild, mod, severe)
Proliferative (non high risk to high risk)
What is seen on fundoscopy in diabetic retinopathy?
Microaneurysms
Hard exudates and cotton wool spots
Neovascularisation
Intra-retinal haemorrhages
How does diabetic retinopathy present?
Painless reduction in central vision
Dark painless floaters (from haemorrhage)
What is primary prevention of diabetic retinopathy?
Optimal glycaemic control (HbA1c<7%)
A minority of patients with diabetic retinopathy undergo intervention such as…
Laser treatment
Intravitreal steroids
Vitrectomy
What is the gold standard investigation for diabetic retinopathy?
Dilated retinal photography
What is a cataract?
Lens opacity
What are risk factors for cataracts?
Female, age, smoking, DM, systemic corticosteroids
What are the symptoms of cataracts?
Depends on the size and location of the opacity
Gradual painless loss of
vision.
May have halos surrounding light sources
What are the four types of cataract?
Nuclear sclerosis
Cortical
Posterior subcapsular
Paediatric
What are the signs of cataracts?
Defects in the red reflex
Brown or white lens
What is the surgical intervention of cataracts?
Lens extraction and replacement.
What is retinal detachment?
The neurosensory layer of the retina separates from the underlying retinal pigment epithelium
How are retinal detachments classified?
Rhegmatogenous
Non-rhegmatogenous (exudative/tractional)
What are most RDs preceded by?
Posterior vitreous detachment which causes traction on the retina and a retinal tear
What are risk factors for RD?
Age RD in the contralateral eye Marfan syndrome FH Myopia Previous eye injury/surgery/infection
What is lattice degeneration?
The peripheral retina becomes thinned/atrophic in a lattice pattern, and is prone to breaks or tears which may further progress to RD.
How does RD present?
New onset floaters
New onset photopsia
Painless sudden visual loss
Name some things seen on examination in RD.
Tobacco dust
Visual field defects
RAPD
Billowing sensory retina, and the tear, on fundoscopy
How is RD treated?
Cryotherapy/laser photocoagulation
What is a hyphaema and how is it treated?
Blood in the anterior chamber
Evacuation
How is eye trauma/foreign body managed?
Tetracaine 1% drops allow examination
Pad the unaffected eye to prevent damage from conjugate movement
X-Ray the orbit, not MRI, as foreign bodies may be magnetic
After removal: chloramphenicol 0.5% drops
Apart from papilloedema, what are the causes of optic disc swelling?
Optic neuritis
GCA
Retinal vein occlusion
What are the causes of papilloedema and raised ICP?
Tumour
Cerebral trauma, haemorrhage, infection, or inflammation
Idiopathic intracranial hypertension
What is absent on examination if the optic disc is swollen?
Spontaneous venous pulsation
What is usually an important investigation in a patient with papilloedema?
Urgent MRI with gadolinium enhancement
Why does papilloedema suggest raised ICP?
The optic nerve sheath is continuous with the sub arachnoid space so increased ICP is transmitted to SA space surrounding the optic nerve
What is seen on examination in papilloedema?
Blurred optic margins
Disc swelling
Venous engorgement
Paton’s lines - radial retinal lines
What are the risk factors for primary open angle glaucoma?
FH Afro-Caribbean Myopia Hypertension DM Corticosteroids
How can the red eye of glaucoma be distinguished from uveitis?
Glaucoma: severe pain, haloes, semi-dilated pupil, dull/hazy cornea from oedema
Uveitis: small, fixed oval pupil, ciliary flush, blurred vision and photophobia
What is the triad of Horner’s syndrome?
Partial ptosis (eyelid drooping) Miosis (pupil constriction) leading to anisocoria Hemifacial anhidrosis
What are four causes of Horner’s syndrome?
Pancoast’s tumour
Stroke/MS
Herpes Zoster
Cluster headaches/migraine
What are the key side effects of prostaglandin analogues used to treat glaucoma?
Increased eyelash length
Iris pigmentation
Periocular pigmentation
What is the classification system for hypertensive retinopathy?
Keith-Wagener
Describe the Keith Wagener system for hypertensive retinopathy.
1: silver wiring
2: arteriovenous nipping
3: Cotton wool exudates and flame haemorrhages
4: papilloedema
Name four causes of tunnel vision.
Papilloedema
Glaucoma
Retinitis pigmentosa
Choroidoretinitis
Which cranial nerves supply the extraocular muscles?
Oculomotor - MR, SR, IR, IO
Trochlear - SO
Abducens - LR
What is a Holmes-Adie pupil?
Dilated pupil that shows delayed and incomplete constriction to light, but better response to accommodation
What is Holmes-Adie syndrome?
Young females
Holmes-Adie pupil
Reduced deep tendon reflexes
Pilocarpine test
What is retinitis pigmentosa?
Inherited condition presenting in young adulthood
Loss of rod photoreceptor cells
First symptoms: loss of night vision, loss of peripheral vision
How can you differentiate viral conjunctivitis from other types?
Tarsal follicles
What are the symptoms of keratitis?
Painful red eye
Purulent discharge if bacterial
Hypopyon - pus in anterior chamber
White opacity of corneal ulcer
How can you differentiate corneal ulcers from corneal abrasions?
Ulcers - corneal oedema, blurred vision
Abrasions - normal vision, no oedema
What is the only treatment of dry AMD?
Vitamin supplementation - C, E, beta-carotene, and zinc.
How is retinal detachment with vitreous haemorrhage diagnosed?
USS B scan of the globe
What is microbial keratitis and a risk factor?
Corneal ulcer
Steroid eye drops/contact lenses
