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Ophthalmology Flashcards

1
Q

Define cataract

A

any opacity (clouding) in the lens that reduces transparency of lens

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2
Q

List the risk factors for cataracts?

A 
elderly age
congenital in children (common in Downs)
smoking *
sunlight exposure of UVB*
systemic diseases - diabetes*, myotonic dystrophy, HIV, neurofibromatosis 3, atopic dermatitis 
corticosteroids use**
radiotherapy
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3
Q

How can cataracts be prevented?

A

wear good eye protection/ sunglasses in the sun
smoking cessation
anti oxidants

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4
Q

What are the sub classifications for cataracts?

A
  1. nuclear cataracts - common in old age, changes lens refractive index and dulls colours
  2. cortical cataracts - spoke like wedge opacities which have milder effects on vision
  3. sub capsular cataracts - common in steroid use, progress faster and deep to lens capsule
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5
Q

How do cataracts present?

A 
blurring/ misting of vision
painless gradual loss of vision 
glare -> difficulty driving at night, dazzle in sunlight
faded colour visions
halos around lights
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6
Q

how do cataracts present in babies/ children?

A 
reduced vision 
white/ grey pupil 
nystagmus
squint
sensitivity to light
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7
Q

What are the signs on examination of a cataract?

A

reduced visual acuity on snellen chart
ophthalmoscope : opacity in the lens
reduced red reflex

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8
Q

How are cataracts managed?

A

SURGERY - phacoemulsification
- offered to anyone with reduced QoL and only cure
- small incisional surgery and change intraocular lens
95% have 6/12 vision after

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9
Q

what are the complications of cataract surgery?

A

early - posterior capsule rupture
late - posterior capsule opacification

also: still have glare/ dazzle , retinal detachment , macular degeneration, bleeding , glaucoma, intraocular infection

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10
Q

Describe how diabetic retinopathy is caused?

A
  1. hyperglycaemia causes increased retinal blood flow and abnormal metabolism in retinal vessel wall
  2. damage to pericytes and endothelial cells
  3. increased vascular permeability and micro aneurysm
  4. leads to vascular occlusions and leakage
    - occlusions lead to cotton wool spots
    - leakage causes oedema, hard exudates and rupture of microaneuryms causing flame shaped haemorrhages
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11
Q

How is diabetic retinopathy classified?

A
  1. non proliferative *
  2. proliferative
    more common in T1DM
    neovascularisations in optic disc that can cause vitreous haemorrhages
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12
Q

Describe the characteristic changes in non proliferative diabetic retinopathy

A 
blot / flame shaped haemorrhages (late sign)
micro aneurysm (early sign)
hard exudates 
enlarged tortuous veins 
cotton wool spots (from occlusions)
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13
Q

How are diabetics screened for retinopathy?

A

refer to ophthalmology when first diagnosed and then there is a NHS retinopathy screening plan annually

use dilated fundus photography** and ophthalmoscope**

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14
Q

How is diabetic retinopathy managed?

A
  1. good glycemic control of diabetes
  2. control BP
  3. photocoagulation by laser (proliferative)
  4. ANTI VEGF (proliferative)
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15
Q

Explain the pathology of age related macular degeneration?

A
  1. drusens (which are collections of lipid and protein) form beneath the retinal pigment epithelium and within Bruch membranes
  2. causes retinal atrophy and bilateral central retinal (macular) degeneration
  3. loss of central vision
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16
Q

What are the risk factors for macular degeneration?

A 
age **
family history
smoking
CV disease
previous catract surgery
dyslipidaemia
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17
Q

how does macular degeneration present?

A
  1. blurring of CENTRAL vision and reduced visual acuity
  2. distortion of images and lines
  3. difficulty with night time vision, reading and making out faces
  4. visual fluctuation
  5. glare and photopsia (flickering of lights)
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18
Q

What are the complications of macular degeneration?

A

irreversible visual loss and blindness
depression
falls and fractures
reduced QoL

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19
Q

What are the differences between the two types of macular degeneration?

A
  1. WET ARMD- choroidal neovascularisation and EXUDATIVE

2. DRY ARMD (90%) - DRUSEN (yellow spots in bruchs membrane) and changes in macula/ retinal pigment epithelium

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20
Q

What are the signs of wet ARMD?

A

rapid visual loss
red patches and fluid exudate O/E
localised detachment of pigment

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21
Q

what are the signs of dry ARMD?

A

yellow round spots (drusen) on Bruch membrane using slit lamp microscopy
distortion of line perception in Amsler grid test

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22
Q

How is dry macular degeneration treated?

A

anti oxidant vitamins (A,C,E, Z) supplements

+/- intraocular injections of anti angiogenic drugs

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23
Q

How is wet ARMD treated?

A

vascular endothelial growth factor (VEGF) inhibitors e.g. ranibizumab, bevacizumab

laser photocoagulation

photodynamic therapy

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24
Q

how is ARMD investigated?

A 
slit lamp microscopy **
colour fundus photography 
fluorescin angiography (dilates blood vessels in the back of the eye)- for WET ARMD
optical coherence tomography
Ampler grid
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25
Define glaucoma?
optic neuropathy with or without raised intraocular pressure
26
explain the normal drainage system of aqueous humour in the eye
1. aqueous humour is made in the ciliary epithelium 2. travels through narrow space in posterior chamber 3. flows into anterior chamber 4. aqueous humour then passes through trabecular network into canal of sclemm 5. drained into aqueous veins
27
Describe the pathology of glaucoma?
1. drainage system in eye is blocked 2. fluid builds up in the anterior chamber 3. causes arises intraocular hypertension (>21 mmHg) 4. damages optic nerve 5. visual loss
28
describe the pathology behind chronic open angle glaucoma
drainage system slowly gets clogged so there is a slow increase in pressure bending the eye and damages optic nerve first causes outer rim atrophy of nerve so pt presents with peripheral visual loss continued damage to nerve causes central visual loss
29
Describe the pathology behind acute closed angle glaucoma
when angle between iris and cornea is too small so aqueous humour passage is too narrow and there is a rapid build up of pressure and sudden damage to optic nerve RF: elderly, pupil dilatation, hypermetropia (long sighted), traumatic haemorrhage
30
How does acute closed angle glaucoma present?
``` sudden eye pain and redness headache visual halos decreased PERIPHERAL visual acuity nausea and vomiting, systemic upset photophobia ```
31
How does open angle glaucoma present?
** peripheral visual field loss **-> central visual loss decreased visual acuity mostly asymptomatic and picked up by opticians
32
Describe the risk factors for open angle glaucoma
``` age family history hypertension diabetes corticosteroids ocular hypertension myopia ```
33
List your examination findings for open angle glaucoma?
1. tonometer: elevated intraocular pressure >21mmHg 2. fundoscopy: pallor of optic disc**, optic disc cupping **(caused by atrophy of nerve, loss of neurones, normal disc:cup ratio <0.5), notching, disc haemorrhage 3. automated perimetry: peripheral visual field defect, leads to tunnelling of vision 4. gonioscopy: measures the iridocorneal angle to distinguish between open and closed angle
34
List the medical management options to lower intraocular pressure?
1st line = prostaglandin analogue eye drops e.g. latanoprost (increases aqueous humour outflow) 2nd line = beta blocker drops (timolol), (reduce aqueous production), carbonic anhydrase inhibitors drops (dorzolamide), alpha 2 agonist drops (brimonidine) if advanced: laser therapy or surgery (trabeculomty)
35
List the differentials for red eyes
``` conjunctivitis scleritis corneal abrasions acute uveitis acute glaucoma trauma subconjunctival haemorrhage ```
36
Describe the symptoms of corneal ulceration
pain, red eye, foreign body sensation, reduced visual acuity
37
How are corneal ulcerations caused?
trauma - surface epithelium is sloughed off
38
Define acute uveitis / iritis?
inflammation of the anterior uvea (contains iris, choroid and ciliary body)
39
How is acute uveitis caused and its associations?
``` HLA-B27 diseases e.g. ankylosing spondylitis , psoaritic arthritis, reactive arthritis UC and crohns sarcoidosis Behcets malignancy - lymphoma, retinoblastoma HIV, syphilis, TB ```
40
describe the symptoms of scleritis?
= inflammation of the sclera | severe brain, lacrimation, photophobia, gradual reduction in vision
41
How is scleritis treated?
NSAIDs or oral prednisolone if severe
42
What are subconjunctival haemorrhages?
diffuse or localised collection of blood under conjunctiva | asymptomatic and resolve in 10-14 days
43
What are the causes of subconjunctival haemorrhages?
``` trauma idiopathic coughing sneezing hypertension aspirin ```
44
What are the main causes of conjunctivitis?
1. allergic **- IgE mediated hypersensitivity reaction (history of atopy- caused by pollen, dust mite, cleaning products) 2. infectious - bacterial (staph aureus, strep pneumonia) or viral (adenovrius, herpes )
45
How does bacterial caused conjunctivitis present?
unilateral initially and then spread to bilateral sticky discharge - eyes stuck together in morning red, sore, gritty
46
How does allergic caused conjunctivitis present?
bilateral conjunctival oedema and conjunctival swelling itchy ** oedema - swollen eyelids
47
How is infective conjunctivitis treated?
1. hygiene / self care - do not wear contact lenses, do not share towels, bathing eyelid, cool compress, lubrication 2. chloramphenicol 0.5% drops (topical fusidic acid if pregnant)
48
How is allergic conjunctivitis treated?
1. hygiene/ education - regualar handwashing, do not share towels, warm compress 2. 1st line = topical anti histamines 3. 2nd line = topical mast cell stabilisers e.g. sodium cromoglicate
49
What are the main emergencies in opthalmology?
1. ACUTE GLAUCOMA 2. CHEMICAL INJURY WITH ALKALINE SOLUTION 3. POSTERIOR CIRCULATING ARTERY ANEURYSM
50
What is the cause of acute glaucoma?
sudden acute rise in intraocular pressure causing damage to optic nerve
51
How does acute glaucoma present?
``` headache - severe pain over eye hard red eye semi dilated non reactive pupil corneal oedema systemic upset - fever, unwell visual halos ```
52
How is acute glaucoma treated?
mannitol to reduce pressure | oral carbonic anhydrase inhibitors e.g. acetazolamide (reduce aqueous humour secretions)
53
What are the symptoms of a posterior communicating artery aneurysm?
``` headache double vision vertical diplopia difficulty focussing increased intraocular pressure vomiting ```
54
How is a posterior communicating artery aneurysm managed?
1. MRI | 2. refer to neurosurgeons
55
List the differentials for dry eyes?
sjogrens syndrome drugs - NSAIDs, diuretics, sulfonylureas, vasodilators diabetes long term contact lens wear age related dry eye lacrimal gland infiltration e.g. sarcodiosis, lymphoma, AIDS
56
How are dry eyes treated?
artificial tear drops - treat cause
57
What are the differentials for vascular causes of sudden visual loss?
central retinal vein occlusions central retinal artery occlusion anterior ischaemic optic neuropathy amaurosis fugax (TIA)
58
How are central artery occlusions caused?
atherosclerosis or emboli from carotid artery or heart GCA RF: thrombosis, GCA, AF, diabetes, valvular disease, smoking
59
How does central artery or vein occlusions present?
artery: sudden total unilateral loss of vision vein: blurring mild-severe visual loss, field defect
60
what are the signs O/E of central retinal artery occlusions
fundoscopy: "cherry red" spot on pale optic disc | Marcus Gunn pupil (= relative afferent pupillary defect)
61
what are the signs O/E of central retinal vein occlusions?
fundoscopy: flame haemorrhages in region of occlusion, cotton wool spots, swollen optic nerve, macular oedema
62
How is central retinal artery occlusion managed?
secondary prevention of stroke : aspirin, control BP, statin, diabetes control, smoking cessation, exercise, reduce alcohol consumption give aspirin immediately have 6 hour window to save eyesight
63
What are the inflammatory causes of sudden visual loss?
optic neuritis e.g. MS, diabetes, syphilis temporal arteritis - + headache, scalp tenderness, amaurosis fugax, jaw claudication
64
Describe the symptoms of optic neuritis
``` unilateral reduced visual acuity red eye pain on eye movements difficulty distinguishing colour relative afferent pupillary defect ```
65
List the differentials for sudden visual loss
``` central retinal vein occlusion central retinal artery occlusion TIA - amaurosis fugax optic neuritis GCA vitreous haemorrhage retinal detachment ```
66
Describe the pathology in retinal detachment
fluid can enter in the space between photoreceptors and retinal pigment epithelium and cause the retina to lift and detach from the retinal pigment epithelium
67
How is retinal detachment caused?
trauma, vitreous detachment precedes | myopia more at risk (due to thinning of retina as it is stretched over larger area)
68
what are the symptoms of retinal detachment?
``` painless loss of central vision F - floaters F- flashes F- fall in acuity F - field loss ```
69
How is retinal detachment diagnosed?
1. B- scan USS *** - flying angel sign 2. ophthalmoscopy - Schaffens sign 3. slit lamp microscopy - grey retina, retina peeling away
70
How is retinal detachment managed?
rest urgent referral to ophthalmology laser therapy and urgent surgery (cryotherapy, vitrectomy)
71
how does vitreous detachment present?
floaters | field loss
72
List the differentials of eye lid lumps?
chalazion stye cancer - BCC*, squamous cell Ca, malignant melanoma blepharitis
73
what is a chalazion?
hard inflamed lump on eyelid - chronic granulomatous inflammation affecting the meibombian gland
74
what is a stye?
infection of the lash follicle by staph aureus infection
75
how are styes or chalazion treated?
1. warm compress | 2. chloramphenicol ointment
76
what is blepharitis?
"chronic lid margin disease" - inflammation of the eyelid
77
how is blepharitis caused?
1. bacterial infection (staph aureus) -> anterior inflammation 2. meibomianitis -> posterior inflammation associated with roseacea and seborrhoeic dermatitis
78
Describe the symptoms of blepharitis?
burning, gritty, crusting of eyelids itchy worse in morning
79
How is bacterial blepharitis treated?
1. lid hygiene 2. ocular lubricants 3. topical chloramphenicol (abx)
80
How is meibomianitis treated?
1. oral tetracyclines | 2. education of hygiene and chronic , relapsing course of blepharitis
81
How does diabetic retinopathy present?
gradual loss in central vision
82
what are the risk factors of diabetic retinopathy?
``` early/ long term diabetes diagnosis hypertension renal disease with proteinuria pregnancy minority ethnic groups ```
83
What are the complications of diabetic retinopathy?
``` macular oedema macular ischaemic vitreous haemorrhage retinal detachment blindness ```
84
what are the signs on examination of acute closed angle glaucoma?
``` red eye semi dilated fixed pupil (iris sphincter is ischaemic) corneal oedema (causes blurred vision) poor peripheral visual acuity hazy cornea ```
85
how is acute closed angle glaucoma investigated?
Slit lamp examination – showing large cup and nerve fibre loss Gonioscopy - measure's angle Automated perimetry – to assess visual field tonometry: Measure intra-ocular pressure (normal 10-21 mmHg)
86
How is acute closed angle glaucoma managed acutely?
1. urgent referral to ophthalmology 2. Lower the pressure: with Topical carbonic anhydrase inhibitors (dorzolamide) + oral/ IV carbonic anhydrase inhibitor (acetazolamide) 3. constrict pupil: Pilocarpine drops (topical cholinergic agonist) - increases angle between cornea and iris
87
how is acute closed angle glaucoma managed long term?
``` Laser +/- surgery Laser iridotomy (hole in iris) – definitive treatment - stops 2nd attack by providing a bypass for the extra pressure ```
88
What are the signs O/E of optic neuritis?
Marcus-Gunn pupil (RAPD – seen on swinging light test) Central scotoma (areas of depressed vision) Decrease in visual acuity on eye examination
89
how is optic neuritis managed?
high dose steroids (IV methylprednisolone for 72 hours) | +MRI is suspect MS
90
What are the causes of vitreous haemorrhage?
``` Anything which can cause neovascularisation or bleeding risk: Diabetes Bleeding disorders, anti coagulants Retinal tear/detachment Trauma Wet ARMD ```
91
how does vitreous haemorrhage present?
sudden painless loss of vision small = floaters, dark spots large = obscured vision
92
what are the signs on examination of vitreous haemorrhage?
loss of red reflex retina not visible B-scan USS ophthalmoscopy fundoscopy
93
How is vitreous detachment haemorrhage?
referral to ophthalmology | usually resolves spontaneously
94
what are the symptoms of acute uveitis?
``` red eye painful photophobia blurred vision increased lacrimation (no sticky discharge) ```
95
what are the signs of acute uveitis?
irregular pupil size peripheral visual field defect red
96
how is acute uveitis diagnosed?
fluorescein stain with slit lamp microscopy - see lymphocytes in anterior chamber (hypopyon), keratin precipitates, flare
97
How is acute uveitis treated?
topical steroids - prednisolone | topical muscarinic antagonist (cyclopentolate) - dilates the pupils
98
How does amaurosis fugax occur?
embolus from internal carotid artery causing retinal artery occlusion
99
how does amaurosis fugax present?
transient loss of vision "curtain coming down"
100
How is amaurosis fugax investigated?
CT head temporal artery biopsy fundoscopy ESR
101
How does viral conjunctivitis present?
watery discharge, red, unilateral irritation, recent URTI, photophobia
102
what are the signs O/E of viral conjunctivitis?
``` watery discharge red decreased visual acuity pre auricular lymph nodes petechial conjunctival haemorrhage ```
103
Which organism are you worried about in neonatal conjunctivitis?
chlamydia (passed on during birth)
104
what is a cotton wool spot?
ischaemic nerve fibre
105
How is hypertensive retinopathy severity graded?
graded 1-4 grade 2= AV nipping (copper wiring), arteriolar constriction grade 4 = papilloedema
106
what are the signs of hypertensive retinopathy?
``` papilloedema (= elevation of optic disc, absent venous pulsation, blurring of disc margins) cotton wool spot flame haemorrhages AV nipping arteriolar constriction ```
107
List the advice for ARMD?
stop smoking inform DVLA diet rich in green veg only affects central vision
108
If shingles presents with the vesicular rash to the tip of the nose, what is this indicating?
HHV3 virus affecting the nasociliary nerve which can mean corneal involvement with loss of corneal sensation (= Hutchinson's sign)
109
what is used to visualise ulceration of the cornea?
fluoroscein dye
110
what would you find O/E of cornea ophthalmic shingles?
dendritic ulcers | reduced corneal sensation

3b Specialities (7 decks)

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