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MRCP Part 1 > Ophthalmology > Flashcards

Ophthalmology Flashcards

1
Q

What is glaucoma usually attributed to?

A

Glaucoma is a group of disorders characterised by Optic Neuropathy and is (usually) due to raised intraocular pressure.

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2
Q

What causes the increased intraocular pressure in Acute Angle-Closure Glaucoma (AACG)?

A

Increased intraocular pressure due to an impairment of aqueous outflow.

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3
Q

What 3 factors predispose a patient to Acute Angle-Closure Glaucoma?

A
  • Hypermetropia (long-sightedness)
  • Pupillary dilatation
  • Lens growth associated with age
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4
Q

List the features of Acute Angle-Closure Glaucoma.

A
  • Severe pain: may be ocular or a headache
  • Decreased visual acuity
  • Symptoms worse with mydriasis (dilatation of the pupil) eg. watching TV in a dark room
  • Hard, red eye
  • Haloes around lights
  • Semi-dilated non-reacting pupil
  • Corneal oedema results in a dull or hazy cornea
  • Systemic upset may be seen eg. nausea, vomiting, abdominal pain.
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5
Q

What is the management of a patient with Acute Angle-Closure Glaucoma?

A
  • Urgent referral to an Ophthalmologist
  • Acetazolamide: Reduces aqueous secretions
  • Topical Pilocarpine: induces pupillary constriction
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6
Q

What is the mode of action of Pilocarpine?

A

Muscarinic receptor agonist.

Pilocarpine is used in patients with Acute Angle-Closure Glaucoma. It increases Uveoscleral outflow by constricting the pupil (thereby decreasing intraocular pressure).

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7
Q

List 4 features of Horner’s syndrome.

A
  • Miosis (small pupil)
  • Ptosis
  • Enophthalmos (sunken eye) **
  • Anhydrosis (loss of sweating on one side)

** in reality, the appearance is due to a narrow palpebral aperture rather than true enophthalmos.

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8
Q

How would you know when a patient has congenital Horner’s syndrome?

A

Heterochromia (difference in iris colour) is seen in congenital Horner’s.

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9
Q

A central lesion is causing Horner’s syndrome. Where would you expect to see anhidrosis?

A
  • Face
  • Arms
  • Trunk
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10
Q

A central lesion is causing Horner’s syndrome. List 5 possible differentials for the central lesion.

A
  • Stroke
  • Syringomyelia
  • Multiple Sclerosis
  • Tumour
  • Encephalitis
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11
Q

A pre-ganglionic lesion is causing Horner’s syndrome. Where would you expect to see anhidrosis?

A
  • Face
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12
Q

A pre-ganglionic lesion is causing Horner’s syndrome. List 4 possible differentials for the pre-ganglionic lesion.

A
  • Pancoast’s Tumour
  • Thyroidectomy
  • Trauma
  • Cervical rib
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13
Q

A post-ganglionic lesion is causing Horner’s syndrome. Where would you expect to see anhidrosis?

A

No anhidrosis.

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14
Q

A post-ganglionic lesion is causing Horner’s syndrome. List 4 possible differentials for the lesion.

A
  • Carotid artery dissection
  • Carotid aneurysm
  • Cavernous sinus thrombosis
  • Cluster headache
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15
Q

Describe a ‘Relative Afferent Pupillary Defect (RAPD)’.

What is the name given to a RAPD pupil?

A

RAPD: when the affect and normal eye appear to dilate when light is shoe on the affected eye.

Marcus-Gunn pupil.

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16
Q

What causes a Relative Afferent Pupillary Defect?

A

RAPD: caused by a lesion anterior to the Optic Chiasm ie. Optic Nerve or Retina

  • > RAPD is caused by differences between the two eyes in the afferent pathway due to retinal or optic nerve disease.
  • > This leads to reduced constriction (hence appears as dilation) of both pupils when light is shone from the unaffected eye to the affected eye.
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17
Q

How is a Relative Afferent Pupillary Defect identified?

A

Found by the ‘Swinging Light Test’.

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18
Q

What are the i. Retinal and ii. Optic Nerve causes of a Relative Afferent Pupillary Defect?

A

i. Retinal: Detachement

ii. Optic Nerve: Optic Neuritis eg. Multiple Sclerosis

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19
Q

Describe the pathway of pupillary light reflex.

Afferent and Efferent

A

Afferent: Retina -> Optic Nerve -> Lateral Geniculate Body -> Midbrain

Efferent: Edinger-Westphal nucleus (midbrain) -> Oculomotor Nerve

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20
Q

List the ocular manifestations of Rheumatoid Arthritis and some differentiating features.

A
  • Keratoconjunctivitis sicca (most common)
  • Episcleritis (erythema)
  • Scleritis (erythema + pain)
  • Corneal ulceration
  • Keratitis
21
Q

List the iatrogenic ocular problems a person with Rheumatoid Arthritis might encounter.

A
  • Steroid-induced cataracts

- Chloroquine retinopathy

22
Q

Which feature differentiates scleritis from episcleritis?

A

Scleritis = PAINFUL

Episcleritis = is not painful

23
Q

Describe 4 features of Keratoconjunctivitis sicca.

A
  • Usually bilateral
  • Dry eyes
  • Burning
  • Itchy
24
Q

Roughly what percentage of people with Rheumatoid Arthritis experience eye problems?

A

25%

25
Q

What would you expect to see on fundoscopy of a patient with Retinitis Pigmentosa?

A

Black bone spicule-shaped pigmentation in the peripheral retina

26
Q

What visual changes are associated with Retinitis Pigmentosa?

A
  • Night blindness (often the initial sign)
  • Tunnel vision (due to loss of the peripheral retina)

On fundoscopy: black bone spicule-shaped pigmentation in the peripheral retina, and mottling of the retinal pigment epithelium

27
Q

Which diseases are associated with Retinitis Pigmentosa?

A
  • Refsum disease: cerebellar ataxia, peripheral neuropathy, deafness, ichthyosis
  • Usher syndrome
  • A-beta-lipoproteinemia
  • Lawrence-Moon-Biedl syndrome
  • Kearns-Sayre syndrome
  • Alport’s syndrome
28
Q

A 71yo male with T2DM and hypertension is complaining of a sensation of lights flashing in his right eye. Symptoms have been present for 2 days and seem to occur more at the periphery of his vision. There is no pain or redness in the affected eye.
Corrected visual acuity is measured as 6/9 in both eyes.
What is the most likely diagnosis?

A

Vitreous detachment

Flashers and floaters are symptoms of vitreous detachment. The patient is at risk of retinal detachment and should be referred urgently to an Ophthalmologist.

29
Q

What are the most common causes of sudden, painless loss of vision?

A
  • Ishcaemic / vascular: eg. thrombosis, embolism, temporal arteritis). This include syndromes such as Occlusion of central retinal vein and Occlusion of central retinal artery.
  • Vitreous haemorrhage
  • Retinal detachment
  • Retinal migraine
30
Q

What are the differentials for sudden painless loss of vision with an ischaemic / vascular cause?

A
  • ‘Amarosis fugax’
  • Atherothrombosis
  • Embolus
  • Dissection
  • Small artery occlusive disease eg. Anterior ishcaemic optic neuropathy, vasculitis (temporal arteritis)
  • Venous disease
  • Hypoperfusion
  • May represent a form of Transient Ischaemic Attack
31
Q

What causes Ischaemic Optic Neuropathy?

A
  • Occlusion of the short posterior ciliary arteries

- Causes damage to the Optic Nerve

32
Q

For Central Retinal Vein Occlusion, describe the following:

i. Incidence
ii. Causes
iii. What you’d see on fundoscopy.

A

Central Retinal Vein Occlusion

i. Incidence increases with age. More common that arterial occlusion.
ii. Causes: Glaucoma, Polycythaemia, Hypertension
iii. Fundoscopy: Severe retinal haemorrhages

33
Q

For Central Retinal Artery Occlusion, describe the following:

i. Cause
ii. Features

A

Central Retinal Artery Occlusion

i. Cause: due to thromboembolism (from atherosclerosis) or arteritis (eg. temporal arteritis)

ii. Features:
- Afferent pupillary defect
- ‘Cherry red’ spot on a pale retina

34
Q

For Vitreous Haemorrhage, describe the:

i. Causes
ii. Features

A

Vitreous Haemorrhage

i. Causes: Diabetes, Bleeding Disorders, Anticoagulants
ii. Features: sudden visual loss, dark spots

35
Q

How would you identify Posterior Vitreous Detachment from a patient’s symptoms?

A
  • Flashes of light (photopsia) in the peripheral field of vision
  • Floaters, often on the temporal side of the central vision
36
Q

How would you identify Retinal Detachment from a patient’s symptoms?

A
  • Dense shadow that starts peripherally and progresses towards the central vision
  • A veil or curtain over the field of vision
  • Straight lines appear curved
  • Central visual loss
37
Q

How would you identify a Vitreous Haemorrhage from a patient’s symptoms?

A
  • Large bleeds cause sudden visual loss
  • Moderate bleeds may be described as numerous dark spots
  • Small bleeds may cause floaters.
38
Q

What is ‘Posterior Vitreous Detachment’?

A

The separation of the vitreous membrane from the retina.
This occurs due to natural changes to the vitreous fluid of the eye with ageing.
- A common condition which does not cause any pain or loss of vision.

39
Q

Which condition is it important to rule out in a patient with Posterior Vitreous Detachment?

A

Rule out Retinal tears or Retinal Detachment as this may result in permanent loss of vision.

-> separation of the vitreous membrane can lead to tears and detachment of the retina.

40
Q

What is ‘Hutchinson’s sign’? What does it predict?

A

The presence of a vesicular rash on the tip of a patient’s nose.
Predicts ocular involvement eg. consider Herpes Zoster Ophthalmicus.

41
Q

Which virus causes Herpes Zoster Ophthalmicus?

A

Varicella-Zoster Virus

Reactivation of VZV in the area supplied by the ophthalmic division of the trigeminal nerve.

42
Q

What are the features of Herpes Zoster Ophthalmicus?

A
  • Vesicular rash around the eye, which may or may not involve the actual eye itself.
  • Hutchinson’s sign: rash on the tip or side of the nose. Indicates nasociliary involvement and is a strong risk factor for ocular involvement.
43
Q

Describe the management of Herpes Zoster Ophthalmicus.

A
  • Oral antiviral treatment for 7-10 days
    > Ideally started within 72 hours
    > IV antivirals may be given for very severe infection or if the patient is immunocompromised.
    > Topical antiviral treatment is NOT given in HZO.
  • Topical corticosteroids may be used to treat any secondary inflammation of the eye
  • Ocular involvement requires urgent ophthalmology review.
44
Q

What are the complications of Herpes Zoster Ophthalmicus?

A
  • Ocular: conjunctivitis, keratitis, episcleritis, anterior uveitis
  • Ptosis
  • Post-herpetic neuralgia
45
Q

What is Blepharitis?

A

Inflammation of the eyelid margins.

46
Q

What causes Blepharitis?

A
  • Posterior blepharitis is caused by Meibomian gland dysfunction (this is most common)
  • Anterior blepharitis (less common) is caused by seborrhoea dermatitis / staphylococcal infection.
  • Blepharitis is also more common in patients with rosacea.
47
Q

How do problems affecting the Meibomian glands lead to blepharitis?

A
  • Meibomian glands secrete oil onto the eye surface to prevent rapid evaporation of the tear film.
  • Any problem affecting the Meibomian glands (as in Blepharitis) can hence cause drying of the eyes which in turn leads to irritation.
48
Q

What are the features of Blepharitis?

A
  • Symptoms are usually bilateral
  • Grittiness and discomfort, particularly around the eyelid margins
  • Eyes may be sticky in the morning
  • Eyelid margins may be red. Swollen eyelids may be seen in staphylococcal blepharitis
  • Styes and chalazions are more common in patients with blepharitis
  • Secondary conjunctivitis may occur
49
Q

Describe the management of a patient with Blepharitis.

A
  • Softening of the lid margin using hot compresses twice a day
  • ‘Lid hygiene’: mechanical removal of debris from lid margins
    > cotton wool buds dipped in a mixture of cooled boiled water and baby shampoo
    > OR a teaspoonful for sodium bicarbonate in cooled water that has recently been boiled.
  • Artificial tears may be given for symptom relief in people with dry eyes or an abnormal tear film.

MRCP Part 1 (16 decks)

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