Ophthalmology Flashcards

Question

Uveitis | Complications (3)

Answer 1

Prolonged visual loss in 2/3 22% meet criteria for blindness Cystoid macular oedema and cataracts

Answer 2

Primary: anatomical predisposition Secondary: arises from pathological processes eg. traumatic haemorrhage pushing the posterior chamber forwards

Answer 3

Normally, aqueous humour is produced by the ciliary body and flows through the pupil and empties out at the drainage angle through the canal of Schlemm Any structural change to this angle will block the flow and raise intra-ocular pressure (normal is 15-20)

Answer 4

Shallow anterior chamber Thick lens Thin iris Hypermetropic eye

Answer 5

Generally unwell with nausea and vomiting Uniocular attack of headache and painful red eye Often preceded by blurred vision or haloes around lights at night

Answer 6

Urgent gonioscopy (must avoid eye patches or dark rooms which will worsen the angle closure by pupillary dilatation)

Answer 7

Triad of B-blockers + pilocarpine + acetazolamide B-blocker: timolol to suppress aqueous humour production (drops) Pilocarpine: to induce miosis and open blocked, closed drainage angle (drops) Acetazolamide: reduce aqueous formation (oral/IV) Analgesia + anti-emetics Laser/surgical peripheral iridectomy: do once IOP is controlled, a piece of iris is removed at 12 o'clock in both eyes to allow aqueous flow

Answer 8

Visual loss Central retinal artery/vein occlusion Repeated episodes in either eye

Answer 9

Allergic conjunctivitis most frequent | Contact lens wearers may develop reaction

Answer 10

Non-herpetic viral (serous discharge), most common, 80% are adenoviruses Bacterial (purulent discharge)

Answer 11

``` Conjnctiva red and inflamed Hyperaemic vessels may be moved over the sclera by gentle pressure on the globe Acuity, pupillary responses unaffected Eyes, itch, burn and lacrimate Often bilateral Discharge sticks lids together ```

Answer 12

Conjunctival cultures only needed if suspect gonococcal/chlamydial infection, neonatal conjunctivitis or recurrent disease not responding to therapy

Answer 13

Most cases are viral and only need symptomatic relief with artificial tears and topical antihistamines, viral conjunctivitis is highly contagious Bacterial tends to be self-limiting but topical antibiotics reduce duration and transmission (chloramphenicol) For allergic, try antihistamine drops

Answer 14

Trauma Contact lenses Previous corneal disease

Answer 15

Pain Photophobia May have reduced visual acuity Lacrimation

Answer 16

Fluorescein drops and blue light- abrasions stain green | Check for foreign bodies

Answer 17

Local anaesthetic drops eg/ tetracaine | Send home with analgesics, chloramphenicol ointment for lubrication and compression pads

Answer 18

Bacterial Herpetic Fungal Vasculitic eg. in RA

Answer 19

Eye pain Photophobia Eye watering

Answer 20

Antibiotic drops

Answer 21

Optic neuropathies (usually monocular vision loss with a central scotoma and afferent defect) Anterior ischaemic optic neuropathy (optic nerve damage when posterior vascular supply to it is blocked by inflammation/atheroma) Giant cell arteritis (may be transient- amaurosis fugax, before permanent) Optic neuritis (affects colour vision, afferent defect, often a precursor to MS) Central retinal artery occlusion (uncommon, dramatic loss within seconds, type of stroke, retina white with cherry red spot at macula) Retinal vein occlusion (central or branch) Vitreous haemorrhage Retinal detachment

Answer 22

2nd most common cause of blindness from retinal vascular disease (diabetic neuropathy is 1st)

Answer 23

Arteriosclerosis High BP Diabetes Glaucoma

Answer 24

If the whole central retinal vein is thrombosed, there is visual loss Less sudden than central retinal artery occlusion Visual loss may be perceived as sudden by patient but the mechanism of visual loss is due to the development of ischaemia and macular oedema

Answer 25

Fundus fluorescein angiogram determines the degree of ischaemia and to give pan-retinal photcoagulation is given to prevent/treat neovascularisation

Answer 26

1st anti-VEGF 2nd dexamethasone implant or intravitreal triamcinolone acetonide Photocoagulation if retinal neovascularisation has started to develop

Answer 27

Occurs at level of optic nerve and will present with sudden onset painless blurred vision in one eye (never asymptomatic)

Answer 28

Non-ischaemic: more common, better acuity and prognosis but 30% convert to ischaemic Ischaemic: with cotton wool spots, swollen optic nerve, macular oedema and risk of neovascularisation

Answer 29

Can be asymptomatic if the macula isn't affected, but most complain of visual deficits corresponding to the area of occlusion

Answer 30

Arise from neovascularisation (DM, branch retinal/central retinal vein occlusion), retinal tears, retinal detachment or trauma Small extravasations of blood produce vitreous floaters

Answer 31

Sudden, painless loss of vision or haze Floaters Shadows/dark spots in vision Decreased visual acuity depending on size, location and degree

Answer 32

Usually spontaneously absorbs | If dense, vitrectomy to remove blood if retinal tear or detachment

Answer 33

``` Cataract Macular degeneration Glaucoma (primary open angle) Diabetic retinopathy Optic atrophy Slow retinal detachment ```

Answer 34

``` Pigment drusen (signifies optic nerve-head axonal degeneration and calcium deposits) and sometimes bleeding at the macula Over time it progresses to retinal atrophy and central retinal degeneration which causes a loss of central vision ```

Answer 35

``` Age Smoking Cardiovascular disease Family history Cataract surgery ```

Answer 36

Initially there is no deterioration in visual acuity but difficulty making out images due to failing contrast Difficulty with reading and making out faces Difficulty with night vision and changing light conditions Visual fluctuation (some days it is ok) Metamorphosia (distortion of visual images)

Answer 37

Pathological choroidal neovasular membranes develop under the retina, they can leak fluid and blood causing a central disciform scar Vision deteriorates rapidly and distortion is a key feature (over months) Ophthalmoscopy shows fluid exudation, localised detachment of the pigment Treat with anti-VEGF, laser photocoagulation, intravitreal steroids

Answer 38

Much slower, progressive visual loss (over decades) Ophthalmoscopy shows mainly drusen and changes at the macula Treatment: preventive and mineral supplements

Answer 39

Pale discs

Answer 40

``` Increased intraocular pressure (glaucoma) Retinal damage (choroiditis, retinitis pigmentosa) Ischaemia (retinal artery occlusion) ```

Answer 41

Optic neuropathy with death of many retinal ganglion cells and their optic nerve axons, often with a raised IOP

Answer 42

Loss of disc substance which makes the cup look larger As damage progresses, the disc pales (atrophies) and the cup widens and deepens, so vessels emerge from the disc appear to have breaks as they disappear into the cup and are then seen at the base again As cupping develops, the disc vessels are displaced nasally so nasal + superior fields are lost first (temporal last) and central vision is maintained

Answer 43

``` >35 (typical patient is 60) +ve family history Afro-Caribbean Myopia Diabetic/thyroid eye disease Screening for high risk groups ```

Answer 44

Asymptomatic until visual fields impaired High IOP Slowly progressive, usually bilateral, peripheral visual field impairment (tunnel vision) Optic disc paleness Cupping and haemorrhage

Answer 45

IOP measurement using tonometry Central corneal thickness measurement Peripheral anterior chamber configuration and depth assessments using gonioscopy Visual field measurement Optic nerve assessment with slit lamp + cup:disc ratio (shows high C:D ratio, disc haemorrhages, nasal displacement of vessels, disc pallor)

Answer 46

Prostaglandin analogues to increase uveoscleral outflow B-blockers reduce aqueous production to reduce IOP A-adrenergic agonists to reduce production of aqueous and increase uveoscleral outflow Laser therapy (trabeculoplasty) increases aqueous outflow so reduces IOP Surgery (trabeculectomy)

Answer 47

Any opacity in the lens | Leading cause of blindness

Answer 48

``` Age (75% of >65s) Genetics Diabetes Smoking Alcohol excess Sunlight exposure Trauma Radiotherapy ```

Answer 49

Immature cataracts- red reflex occurs Dense cataracts- no red reflex, or visible fundus Nuclear cataracts- change the lens refractive index and dulls colours, common in old age Cortical cataracts- spoke-like wedge-shaped opacities, milder effects on vision Posterior subcapsular cataracts- progresses faster, cause the classic glare from bright sunlight and lights whilst driving at night, even if little effect on visual acuity

Answer 50

Blurred vision- gradual painless loss of vision Dazzle (especially in sunlight) Monocular diplopia Haloes

Answer 51

Mydriatic drops Sunglasses Surgery: phacoemulsion and intraocular lens (IOL) implant (ocular biometry done pre op to measure for suitable implant) Post-op capsule thickening is common

Answer 52

Holes/tears in the retina allow fluid to separate the sensory retina from the retinal pigment epithelium

Answer 53

Rhegmatogenous retinal detachment: tear in retina causes fluid to pass from the vitreous space into the subretinal space between the sensory retina and the retinal pigment epithelium, typically caused by trauma Exudative retinal detachmentL the retina detaches without a tear eg. hypertension, vasculitis, macular degeneration Tractional retinal detachment: pulling on the retina eg. proliferative retinopathy, more common in myopic eyes

Answer 54

Floaters Flashes Field loss Fall in acuity (painless and may be as a curtain falling over the vision-field defects indicate position and extent of the detachment ie. superior detachment = inferior field loss) Ophthalmoscopy: grey opalescent retina, ballooning forward

Answer 55

Rest: if superior detachment lie flat, if inferior detachment lie 30 degrees head up Laser photocoagulation Surgery: vitrectomy + gas tamponade, scleral silicone implants, cryotherapy/laser to secure retina

Answer 56

The macula is an area 5.5mm across, just lateral to the optic disc In the middle of the macula is a 1.5mm pit, the fovea (fovea centralis- no ganglion cells)

Answer 57

A small break in the macular region of the retinal tissue, it involves the fovea therefore affecting the visual acuity causing blurred + distorted central vision

Answer 58

With ageing, the vitreous starts to lose some of the 80% water content, which causes it to shrink causing traction on the retinal tissue

Answer 59

Distorted vision with visual loss Tiny punched-out area in the centre of the macula, there may be yellow-white deposits at the base Hole typically surrounded by a grey halo of detached retina

Answer 60

Some will spontaneously resolve (if impending hole seen as a yellow spot on the fovea) Vitrectomy

Answer 61

Arteriopathic: arteries nip veins where they cross-share the same connective tissue sheath Hypertensive: arteriolar vasoconstriction and leakage producing hard exudates, macular oedema, haemorrhages and rarely papilloedema

Answer 62

Thick, shiny arterial walls appear like wiring Narrowing of arterioles leads to infarction of the superficial retina seen as cotton wool spots and flame haemorrhages Leaks from these appear as hard exudates /- macular oedema or papilloedema

Answer 63

There is reduced tear formation, producing a gritty feeling in the eyes Decreased salivation also gives a dry mouth (xerostomia) Occurs in association with collagen diseases

Answer 64

Pilocarpine and cevimeline help features | Topical ciclosporin helps moderate/severe dry eye

Answer 65

30% of adults have ocular problems when diabetes presents but vast majority remain asymptomatic until advanced disease takes hold

Answer 66

DM causes ocular ischaemia, which can cause new blood vessel forming on the iris (rubeosis) and if these block the drainage of aqueous fluid, glaucoma may result Formation of age-related cataract is accelerated in DM

Answer 67

Causes ischaemia +/- new vessel formation (ie. proliferative retinopathy) which bleed (vitreous haemorrhage) Causes cotton wool spots (ischaemic nerve fibres) Causes retraction of fibrous tissue running with new vessels heightens risk of retinal detachment

Answer 68

``` Capillaries bulge (microaneurysms) and there is oedema and hard exudates Rupture of microaneurysms at nerve fibre level causes flame-shaped haemorrhages, and when deep in the retina they form blot haemorrhages ```

Answer 69

Non-proliferative: microaneurysms (dots), haemorrhages (flame-shaped or blots), hard exudates (yellow patches), engorged tortuous veins, cotton wool spots and large blot haemorrhages = ischaemia Proliferative: fine new vessels appear on the optic disc, retina and can cause vitreous haemorrhage Maculopathy: leakage from the vessels close to the macula cause oedema and can significantly threaten vision

Answer 70

At the time of diagnosis and at least 1x/year thereafter Dilated fundus retinopathy Lesions mostly at posterior pole Referral for laser photocoagulation if maculopathy, pre-proliferative retinopathy (venous bleeding/loops, blot haemorrhages) or proliferative retinopathy

Answer 71

Target BP <140/80 (<130/80 if end-organ damage) Don't correct refractive errors until controlled diabetes because diabetes causes relative myopia which improves on treatment Laser photocoagulation for maculopathy + proliferative retinopathy Add on anti-VEGF if macular oedema

Answer 72

Swelling of the optic disc caused by raised intracranial pressure, always bilateral but may not be symmetrical

Answer 73

N+V Headache worse in mornings, centred in frontal region + worsened by bending CN XI palsy Transient visual obscurations

Answer 74

MRI to rule out SOL | BP to check for malignant hypertension

Answer 75

Inflammatory lid swellings

Answer 76

Abscess/infection (usually Staph) in a lash follicle Can affect glands of Moll (sweat glands) and of Zeis (sebum-producing gland attached directly to lash follicles) Point outwards Treat with warm compress

Answer 77

Abscesses of Meibomian glands Point inwards Opening to conjunctiva Cause less local reaction but leave a residual swelling called a chalazion or a Meibomian cyst when they subside Residual swellings treated with incision + curettage

Answer 78

Lid inflammation eg. from staphs, seborrhoeic dermatitis or rosacea

Answer 79

Burning, itching red margins | Scales on the lashes

Answer 80

Good eyelid hygiene Baby shampoo diluted 1:10 with warm water In children consider oral erythromycin

Answer 81

``` Lid inturning (typically due to degeneration of lower lid fascial attachments and their muscles) The inturned eyelashes irritate cornea ```

Answer 82

Taping lower eyelids to cheek Botox to lower lid Surgery

Answer 83

Lower lid eversion Eye irritation Watering

Answer 84

Old age | Facial palsy

Answer 85

Plastic surgery | If facial palsy, consider surgical correction with an implant in upper lid to aid closure

Answer 86

Hereditary (autosomal dominant mutation of RB gene located at 13q14) Pineal/other tumour

Answer 87

Strabismus (squint) Leukoconia (white pupil) Absent red reflex

Answer 88

Chemotherapy Enucleation (eye removal) if large or complicated External beam radiotherapy

Answer 89

Herpes zoster ophthalmicus

Answer 90

``` Most common (55%) is the thoracic nerves Second is the ophthalmic branch of trigeminal nerve (20%) ```

Answer 91

Increasing age Trauma to the area Immunocompromised patients

Answer 92

``` Pain and neuralgia in distribution of cranial nerve V1 dermatome precedes a blistering inflamed rash Purulent conjunctivitis Visual loss Episcleritis/scleritis Cranial nerve palsy Iritis ```

Answer 93

Globe is affected in 50% of those with HZO (corneal signs +/- iritis) Nose-tip involvement (Hutchinson's sign) makes it likely the eye will be affected

Answer 94

Oral antivirals | Steroid eye drops

Answer 95

Aetiology: herpes zoster oticus Definition: herpes zoster infection of facial nerve Signs + symptoms: severe otalgia precedes VII cranial nerve palsy (then spreads to other cranial nerves in ascending order), zoster vesicles appear around ear in the deep meatus, may have vertigo/tinnitus/deaf Treatment: aciclovir + prednisolone

Answer 96

Infection of soft tissues posterior to the orbital septum | Spread typically via paranasal sinus infection (typically in a child)

Answer 97

``` Orbital inflammation Fever Lid swelling Reduced eye mobility and painful eye movement Conjunctival swelling ```

Answer 98

Subperiosteal and orbital abscesses Optic neuritis Central retinal vein or artery occlusion Intracranial involvement can result in meningitis, brain abscesses and thrombosis in the dural or cavernous sinuses

Answer 99

Antibiotics | Drain abscesses

Answer 100

Infection of soft tissues anterior to the orbital septum | Commonly caused by sinusitis or facial skin lesions

Answer 101

Acute erythematous swelling of the eyelid | Distinguishing from orbital cellulitis: absence of painful eye movements, diplopia and visual impairment

Answer 102

Amoxicillin

Answer 103

Commonest type in children May be no cause or due to hypermetropia In strabismic amblyopia the brain suppresses the deviated image, the visual pathway doesn't develop normally

Answer 104

Occur in older children | Often intermittent

Answer 105

Usually start in childhood May be constant or not Corneal reflection: reflection from a bright light falls centrally and symmetrically on each cornea if no squint, asymmetrically if squint present Cover test: movement of the uncovered eye to take up fixation as the other eye is covered demonstrates manifest squint; latent squint is revealed by movement of the covered eye as the cover is removed

Answer 106

Optical: assess refractive state after cyclopentolate drops and exclude structural abnormality Orthoptic: patching the good eye encourages use of the one which quints Operations: resection and recession of rectus muscles, help alignment and gives good cosmetic results, botulinum toxin is sometimes good enough

Answer 107

Diplopia is most on looking in the direction of pull of the paralysed muscle When the separation between the 2 images is greatest, the image from the paralysed eye is furthest from the midline and faintest

Answer 108

Ptosis Proptosis (as recti tone decreases) Fixed pupil dilatation Eye looking down and out

Answer 109

Diplopia | Eye looking upward, in adduction and cannot look down and in (superior oblique paralysed)

Answer 110

Diplopia | Eye medially deviated and cannot move laterally from the midline, as the lateral rectus is paralysed

Answer 111

Superior rectus: elevation (adduction and medial rotation)- oculomotor Inferior rectus: depression (adduction and lateral rotation)- oculomotor Medial rectus: adduction- oculomotor Lateral rectus: abduction- abducens Superior oblique: depression, abduction and medial rotation- trochlear Inferior oblique: elevation, abduction + lateral rotation- oculomotor

Answer 112

Nerve impulse from pupil to brain along the optic nerve when a light is shone in that eye

Answer 113

Optic neuritis Optic atrophy Retinal disease

Answer 114

Absent direct response- pupil won't respond to light, but constricts to a beam in the other eye (consensual response) Swinging light test: on beaming light to normal eye, both pupils constrict, if on swining the light to the affected eye the pupil dilates it is a relative afferent pupillary defect Pupils same size

Answer 115

The impulse sent from the midbrain back to both pupils via ciliary ganglion and CNIII causing both pupils to constrict, even though only one eye is being stimulated by the eye

Answer 116

Diabetes, hypertension (pupil often spared in vascular causes) Tumour, aneurysm (pupillary fibres are peripheral and are the first affected by compressive lesions)

Answer 117

Complete ptosis Fixed, dilated pupil Eye looks down and out