Ophthalmology Flashcards
Causes of blepharitis
- Idiopathic
- Bacterial infection
- Viral infection e.g. HSV dermatitis, ZVZ
- Allergies
Symptoms of blepharitis
- Symptoms generally worse in the morning
- Scaly eyelid
- Red eyelid
- Burning/itching/gritty sensation in the eye
- Increased lacrimation
- Crusting/sticking of the eyelids
- Photophobia
- Blurred vision
Investigations to consider in a patient with suspected blepharitis
- Slit lamp examination
- Tear break-up time
Management of blepharitis
- Eyelid hygiene - heat compress, eyelid massage, eyelid scrubs
- Topical antibiotics
- Topical steroids
Conjunctivitis is inflammation of the … layer in the sclera
Conjunctival vessels
Causes of conjunctivitis
Bacterial:
- Staphylococcus
- Streptococcus
- Haemophilus
Viral:
- Adenovirus
- HSV
- Enterovirus
Allergic:
- Pollen
- Perfumes, cosmetics
- Smoke
- Dust mites
- Eye drops
Symptoms of bacterial conjunctivitis
- Unilateral but may quickly spread to other eye
- Rapid onset of symptoms
- Conjunctival redness
- Eyelid swelling
- Sticky discharge and crusting of eye
- Gritty/scratchy feeling
Symptoms of viral conjunctivitis
- Associated URTI
- Usually begins in one eye then spreads to the other
- Fine, diffuse redness in eye
Symptoms of allergic conjunctivitis
- Usually bilateral
- Increased itching
- Redness
- Swelling of conjunctiva
- Increased lacrimation
Investigations required for a patient with suspected conjunctivitis
- Usually none
- Swab for bacterial culture if bacterial cause suspected and no response to topical antibiotics
- Viral cultures in epidemic cases
- Patch test in allergic
Management of conjunctivitis
Usually none required
Episcleritis is inflammation of the … layer of the sclera
Superficial episcleral plexus
Symptoms/signs of episcleritis
- Symptoms are usually bilateral
- Redness (may be sectoral)
- Discomfort (mild-moderate)
- Grittiness
- Photophobia
- Normal visual acuity
Investigations required in suspected episcleritis
None
Management of episcleritis
Usually none required
Can consider topical/oral NSAID +/- weak topical steroid
Causes of keratitis
Non-infectious:
- Exposure
- Photo-keratitis
- Allergic
- Autoimmune
- Post-LASIK surgery
Bacterial:
- Pseudomonas
Viral:
- HSV
- VZV
Fungal:
- Candida
- Aspergillus
Protozoal:
- Acanthomoeba
Management of non-infectious keratitis
Analgesia and treatment of cause
Infectious keratitis is an ocular emergency (T/F)
True - it is a major cause of blindness worldwide
Complications of keratitis
- Corneal scarring
- Corneal perforation
- Endopthalmitis (vitreal humour infection)
Risk factors for bacterial keratitis
- Trauma
- Contact lenses
- Severe dry eyes
- Immunocompromise
- History of autoimmune disease
- Previous eye surgery
- Poor lid function
Risk factors for viral keratitis
- Trauma
- Contact lenses
- Severe dry eyes
- Immunocompromise
- History of autoimmune disease
- Topical steroids
- Previous HSV/VZV infection
Risk factors for fungal keratitis
- Trauma
- Contact lenses
- Severe dry eyes
- Immunocompromise
- History of autoimmune disease
- Topical steroids
- Ocular trauma with plant matter
Risk factors for protozoal keratitis
- Trauma
- Contact lenses
- Severe dry eyes
- Immunocompromise
- History of autoimmune disease
- Contaminated water exposure
Symptoms/signs of bacterial keratitis
- Pain
- Photophobia
- Blurred vision
- Lid oedema
- Red eye
- Increased lacrimation
- Decreased visual acuity
- Corneal ulcers
Symptoms/signs of viral keratitis
- Pain
- Photophobia
- Blurred vision
- Lid oedema
- Red eye
- Increased lacrimation
- Decreased visual acuity
- Dendritic corneal ulcer, raised IOP (HSV)
- Dermatomal rash (VZV)
Symptoms/signs of fungal keratitis
- Pain
- Photophobia
- Blurred vision
- Lid oedema
- Red eye
- Increased lacrimation
- Decreased visual acuity
- Satellite lesions
Symptoms/signs of protozoal keratitis
- Pain
- Photophobia
- Blurred vision
- Lid oedema
- Red eye
- Increased lacrimation
- Decreased visual acuity
- Prominent nerves
- Ring abscess
Investigations to consider in a patient with suspected keratitis
- Corneal scraping for microscopy and culture
- Bloods: FBC (?infection), HIV screen (?immunosuppression)
- Visual acuity
- Slit lamp examination
- Intra-ocular pressure measure
- Fundoscopy
Management of a patient with bacterial keratitis
- URGENT referral
- Topical levofloxacin (+/- topical gentamicin if high risk)
Management of a patient with viral keratitis
- URGENT referral
- Oral and topical aciclovir (high dose if VZV)
Management of a patient with fungal keratitis
- URGENT referral
- Topical anti-fungals
Management of a patient with protozoal keratitis
- URGENT referral
- 6 months topical chlorhexidine, polyhexidine + propamidine
Ocular emergencies
- Acute angle closure glaucoma
- Scleritis
- Infectious keratitis
Scleritis describes inflammation in the … layer of the sclera
Deep vascular plexus
Complications of scleritis
- Keratitis
- Scleromalacia perforans
- Posterior scleritis
Causes of scleritis
- Rheumatoid arthritis
- Granulomatosis with polyangitis
Symptoms/signs of scleritis
- Redness (diffuse, nodular or necrotising)
- Deep severe ocular pain
- Decreased visual acuity
- Photophobia
Investigations to consider in a patient with suspected scleritis
- Bloods: FBC, CRP, rheumatology antibodies
Management of a patient with scleritis
- URGENT referral
- Oral/IV steroids
- Oral NSAIDs
- Cytotoxic therapy
- Scleral graft
Structures affected in anterior uveitis/iritis
- Iris
- Ciliary body
Causes of anterior uveitis/iritis
- Idiopathic (50%)
- Infection e.g. HSV, VZV, TB, syphilis
- Inflammatory conditions e.g. ankylosing spondylitis, IBD< sarcoidosis
- MS
- Trauma
Structure involved in intermediate uveitis
Vitreous humour
Causes of intermediate uveitis
- MS
- Sarcoidosis
- IBD
Structures involved in posterior uveitis
- Choroid
- Retina
Causes of posterior uveitis
- CMV
- Toxoplasmosis
Structures involved in panuveitis
All uveal structures
- iris
- ciliary body
- vitreous humour
- choroid
- retina
Causes of panuveitis
- Sarcoidosis
- Behcet’s disease
Risk factors for uveitis
- Inflammatory disease
- HLA-B27+
- Ocular trauma
- Age 30-40
Symptoms/signs of uveitis
- Ocular pain (posterior uveitis may not be painful)
- Photophobia
- Blurred vision
- Red eye
- Systemic symptoms of inflammation/infection
Investigations to consider in a patient with ?uveitis
- Bloods: FBC, U&Es, LFTs, CRP, serum ACE, ANA, ANCA, RF
- VDLR
- Lyme disease screen
- Bartonella screen
- Toxoplasma titre
- CXR
Management of uveitis
- Referral
- Topical corticosteroids + cyclopentolate
- Treatment of underlying cause
Complications of uveitis
- Ciliary injection (inflammation around the iris)
- Keratin precipitates (inflammatory deposits on the corneal epithelium)
- Hypopon (inflammatory exudate in the anterior chamber)
- Posterior syechiae (adhesions between the pupil margin and the lens capsule)
Causes of cataracts
Ocular causes:
- Uveitis
- Trauma
- High myopia
- Steroid eye drops
- Intraocular tumour
- UV radiation
Systemic causes:
- Diabetes
- Wilson’s disease
- Systemic steroids
- Chlorpromazine
- X-rays
- Congenital rubella
- Atopic dermatitis
- Myotonic dystrophy
- Down syndrome
Risk factors for cataracts
- Age >65
- Smoking
- Long-term UV exposure
- Family history
Symptoms/signs of cataracts
- Progressive painless loss of vision
- Glare
- Change in refraction
- Altered colour perception
- Decreased visual acuity (especially in bright light)
- Difficulty driving at night
- Dark silhouette against red reflex
Management of cataracts
Surgical ultrasonic phacoemulsification with intra-ocular lens implant
Indication for surgical management of cataracts
Cataracts are having a significant impact on quality of life
Complications of cataract surgery
- Iris prolapse
- Posterior capsule opacification
- Endopthalmitis
- Cystoid macular oedema
- Vitreous loss and retinal detachment
A lesion in the left optic nerve would present with …?
Total loss of vision in the left eye
A lesion in the optic chiasm would present with …?
Bitemporal hemianopia
A lesion in the left optic tract would result in …?
Right homonymous hemianopia
A lesion in the right optic radiation in the temporal lobe would result in …?
Left superior quadrantanopia
A lesion in the left optic radiation of the parietal lobe would result in …?
Right inferior quadrantanopia
A lesion in the right posterior tip of the occipital lobe would result in …?
Left central homonymous hemianopia with peripheral sparing
A lesion in the left optic radiation in the anterior occipital lobe would result in …?
Right homonymous hemianopia with macular sparing
Leading cause of visual impairment and irreversible blindness in the industrialised world
Age-related macular degeneration
Risk factors for AMD
- Age
- Smoking
- Family history e.g. complement factor H mutation
- Obesity
Symptoms of AMD
- Progressive blurring/distortion of vision
- Progressive central vision loss
Clinical signs of AMD on imaging
- Early: ‘Drusen’ (lipo-proteinaceous deposits under the retinal pigment epithelium)
- Focal areas of macular hypo- and hyper-pigmentation
- Dry AMD: atrophy of the RPE and destruction of the rods and cones
- Wet AMD: neovascularisation of the retinal pigment epithelium
Management of patients with any stage of AMD
- Specialist referral
- High-dose antioxidant and mineral supplementation
- Monitoring with fluorescein angiography and OCT
Additional management of a patient with WET AMD
- Intra-vitreal anti-VEGF
- Photodynamic therapy
Which type of photoreceptors are more likely to be affected in retinitis pigmentosa?
Rods
Clinical features of retinitis pigmentosa
- Progressive night blindness (nyctalopia)
- Decreased peripheral vision
- Decreased central vision
- Glare
Typical appearance of retinitis pigmentosa on imaging
- ‘Bone-spicule’ pigment clumping in the mid-periphery of the retina
Investigations to consider in a patient with suspected retinitis pigmentosa
- Fundoscopy
- Electroretinography
- Electro-oculography
- Family history
Causes of retinal detachment
- Retinal tears/holes
- Tractional detachment e.g. diabetic retinopathy
- Exudative/serous detachment e.g. choroidal tumour, uveitis (posterior), intraocular tumours, central serous retinopathy
- Vitreous humour detachment e.g. old age
Risk factors for retinal detachment
- High myopia
- Ocular trauma
- Family history
- Cataract surgery
Clinical features of retinal detachment
- Floaters and flashing lights
- Peripheral visual field loss which progresses to central visual loss
- Loss of red reflex
- Grey retina which ‘balloons’ forward and retinal blood vessels seen on examination
- Features of any underlying causative diseases
Management of retinal tear/hole and retinal detachment
- Immediate ophthalmology referral
- Surgical repair - indentation of eye wall, vitrectomy, laser or cryotherapy
Clinical features of retinoblastoma
Children with:
- Leukocoria
- Strabismus
- Secondary glaucoma
- White fleshy mass on fundoscopy
Investigations to consider in a child with suspected retinoblastoma
- Fundoscopy
- US, CT and MRI of globe
- Tumour marker blood tests
- Staging scans, LP and bone marrow aspiration
Management of retinoblastoma
Enucleation
Most common primary intra-ocular tumour in adults
Choroidal melanoma
Clinical features of choroidal melanoma
- Age >50
- Flashing lights in vision
- Substantial retinal elevation
- Adjacent exudative retinal detachment
- Orange pigment deposits
- Increasing size
Management options in choroidal melanoma
- Enucleation
- Proton beam radiotherapy, radioactive plaque application, local resection
- Palliative chemotherapy
Common sites of origin for choroid metastasis
- Breast
- Lung
- GI tract
Appearance of choroidal metastasis on fundoscopy
- Pale, shallowly elevated masses
- Often at the posterior pol and often multiple and bilateral
Causes of optic neuropathy
- Ischaemia
- Glaucoma
- Meningioma
- Optic neuritis
- Uveitis
- Retinal vein occlusion
- Optic nerve compression
- Transmission of raised intra-cranial pressure
- Pituitary gland compression
Clinical features of optic nerve disease
- Loss of visual acuity/blurred vision
- Enlargement of the blind spot
- Central scotomata or other visual field defects
- Loss of colour vision
- Relative afferent pupillary defect
Two types of Anterior Ischaemic Optic Neuropathy
1) Arteritic (GCA)
2) Non-arteritic - associated with atherosclerosis, hypertension, smoking and diabetes
Symptoms of anterior ischaemic optic neuropathy
- Sudden onset unilateral sight loss
- May be preceded by transient episodes of visual loss
- Relative afferent pupillary defects
- Altitudinal visual field defects
Fundoscopy results in anterior ischaemic optic neuropathy
- Swollen optic disc
- Haemorrhage
- Cotton wool spots
Clinical features of optic neuritis
- Typically in young women
- Rapidly progressive loss of visual acuity
- Rapidly progressive loss of colour vision
- Pain exacerbated by eye movements
- Central scotomata
- Relative afferent pupillary defect
