Ophthalmology Flashcards
What are the different types of glaucoma?
Primary Open Angle
Primary Closed Acute Angle
Secondary Closed Acute Angle (due to trauma, bleeding etc)
Normal tension
What are the symptoms and clinical features of Acute primary angle closure?
Eye pain
Headache
Visual Halo’s
Nausea and Vomiting
Clinically:
- red eye
- mid-dilated fixed pupil
- Clouding of the cornea
- reduced visual acuity
What type of visual field defect is typically seen in glaucoma?
Arcuate scotoma
List some differentials to sudden vision loss:
Retinal detachment
Wet ARMD
Retinal vein/ artery occlusion
Optic neuritis
Optic neuropathy
Stroke
Give some differentials for gradual vision loss:
Cataract
Glaucoma
Diabetic retinopathy
Dry ARMD
What are the medical terms for long and short sighted?
Myopia
Hypermetropia
Astigmatism
- the cornea is not a smooth shape but is irregular. As such causes blurring off the image
In sudden painless loss of vision there are a set of questions/ investgiations which can be useful to ask to help establish cause - what are these?
HELLP
- Headache - Giant cell arteritis
- ESR level?
- Lights/ flashing - retinal detachment
- Like a curtain - amaurosis fugax
- Poorly controlled DM - Vitreous haemorrhage
What is the term for when fluid accumulates behind the retina causing it to detach? and what are the two most common types?
Rhegmatogenous
- Posterior vitreous detachment
- traumatic retinal detachment
What are the symptoms of retinal detachment? how can you localie the area detached?
the Four F’s:
- Flashes
- Floaters
- Field loss
- Fall in visual acuity
Usually painless
The area detached will reflect in the area of vision lost.
i.e. upper detachment results in lower vision loss
What is the management of retinal detachment?
Rest and body position
- if superior tear lie flat
- if inferior tear sit at 30 degrees
Surgery
- vitrectomy
- laser
- Tamponade
List some differentials for a traumatic and non traumatic red eye:
Traumatic:
- Corneal abrasion
- Subconjunctival Haemorrhage
- Chemical injury
- Penetrating ocular injury
Non-traumatic:
- COnjunctivitis
- Subconjunctival Haemorrhage
- Keratitis (corneal ulcer)
- Iritis
- Episcleritis
- Acute glaucoma
- Cellulitis
Outline some of the findings you would expect to see with bacterial conjunctivitis and what is a serious cause of bacterial conjunctivitis and how does it present?
Unilateral
Sticky purulent discharge
Papillae formation
Chemosis
Gonococcus conjunctivitis - Masked lid swelling - Chemosis - Papillae - Peri-auricular lymphadenopathy \+/- - Keratitis *needs referal to GUM + systemic treatment **most common in neonates <30 days old
How can you differentiate between Gonocal and chlamydial conjunctivitis?
Subacute for Gonocoal
Chlamydia takes about 2-3 weeks to cause infection
What is the most common cause of infective blindness and what is it?
Trachoma
- due to repeated chlamydia infections.
Causes large scarring and inflammation of the conjunctiva
How does a corneal ulcer and abrasion differ?
Abrasion:
- only the surface epithelium is involved/ Stroma
- corneal contour is unchanged
Ulcer
- Entirely through the epithelium squamous and to the Bowman’s layer
- Contour is changed
List some complications for corneal ulceration:
Vision loss
Perforation
Corneal scarring
Endophthalmitis
What is the immediate management of acute closed angle glucoma?
- Immediate referral
- Avoid darkness or anything that dilates the pupil
Timolol
- beta blocker to stop production of aquaous humour
Pilocarpine drops
Acetazolamide IV
Surgery
- peripheral iridectomy (laser or surgical)
What is the gold standard diagnostic test for glaucoma? and list other investigations you would want to do:
Goldman Applanation Tonometry
- visual field testing *peripheral vision loss in accurate scotoma
- Slit lamp investigation
What are the symptoms of optic neuritis?
Decreased vision
- usually a centralised blind spot
Pain on eye movement
Reduced colour vision
- red desaturation
RAPD
What screening must be done to all children <32 weeks and what is the other time this is done?
Retinopahty of prematurity
Screening carried out when:
- <32 weeks
or
- <1.5kg
What are the red flags in the history for ophthalmology?
Floaters / Flashing lights
- retinal detachment
Hoales
- acute angular glaucoma
Headaches
- jaw claudication
- worse when leaning over
Repeated bouts of transient vision loss
- impeting stroke
- vascular pathology
When taking a history for eye complaints, what additional piece of information do you want in the social history? And what is standard for visual acuity?
DVLA history
- are they driver?
- Work for lorries etc
6/12 is the standard
When testing colour desaturation, what first sign indicates there is disease to the optic nerve?
When there is red desaturation
- this appears with the red becoming paler and more pink
What instruments are used to test peripheral field defects?
Golmann Perimetry
Automated perimetry
- gluacoma
*automated is when the machine moves
What is the characteristic sign seen on fundoscopy of the retina in a patient with dry macular degeneration?
Drusen - yellow round spots
What are the grades of hypertensive retinopathy?
Grade 1: Chronic
- Narrowing, sclerosis of vessels
Grade 2: Chronic
- Exaggerated retinal light reflex
- Definite narrowing
Grade 3: Acute
- cotton wool spots
- flamed shaped haemorrohages
- exudates
Grade 4: Acute
- Papilloedema
SAFE
- silver wiring
- AV nipping
- flame haemorrhages
- Edema (papilledema)
The snellen chart can’t always be used for patients, for example they may be illiterate, or a child and unable to speak. What are some alternatives?
E chart - If illiterate
Kay pictures - >2 years
Toys or movements - <2 years
What are some of the opthalmic findings of shaken baby syndrome?
Retinal detachment in all 4 quadrants
Retinoschisis
- separation of retinal layers
Give 3 causes of a leukorocic pupil in a new born:
Retinoblastoma
Congenital cataracts
Retinopathy of prematurity
What is the name of the condition which causes hallucinations in people who are blind or losing sight?
Charles Bonnet Syndrome
- visual hallucinations of usually small people
- due to brain interrupting signals despite no input
- not associatted with delirium, patients are aware the hallucinations are not real
List some complications of contact lenses, and what bacterial is commonly involved in infection?
Contact lens induced red eye reaction:
- inflammatory response to anterior segment of the eye due to contacts
Sensitivities
- mixing of washing material
The most common organism in contact wearers is:
- pseudomonas
*if contact wearers develop keratitis they need same day referral to eye unit due to more severe keratitis developing.
What are some signs of anterior uveitis?
Anterior chamber cells
Posterior Synechiae
Keratic Precipitates
- inflammatory cells within the cornea
Hypopyon
Redness across the sclera
What is the treatment of anterior uveitis?
Topical steroids
Cycloplegics
- paralysis of the iris to prevent it moving anf causing pain.
What are the 5 top things you want to establish from the past medical opthalmic history?
Refractive Status
- myopia
- hypermyopia
Previous episodes
- previous vision loss
- previous uveitis
Previous surgery
Previous laser
Previous amblyopia
List 6 causes of rapid changes in refractive error:
Senile cataract
Diabetes - rapid changes in cataracts
Eye drops
Eye lid bumps
- Astigmatism - by compressing on cornea
Keratoconus
- progressive thinning of the cornea
Lens subluxation
List 6 causes of gradual painless loss of vision:
Refractive error
Cataracts
Macular degeneration
Advance glaucoma
Retinal degeneration
Chronic Optic nerve ischemia
List 5 causes of acute painful loss of vision:
Acute closed angle glaucoma
Optic neuritis
Corneal ulcer
Uveitis
Orbital cellulitis
List 5 features of chronic glaucoma:
Optic disc cupping >0.8
Increased intra ocular pressure
Accurate scotoma peripheral vision loss
Neovascularization
Complete vision loss
List the various medications which can be used in Glaucoma:
Latanoprost - Prostaglandin analogue (1st line)
- increases outflow
Timolol - Beta blocker
Acetazolamide - Carbonic Anhydrase Inhibitor
Brimonidine - Alpha -2 agonist
Pilocarpine - Parasympathetic drops
What are the pupils called that are associated with neurosyphilus? how do they react?
what other condition is it also associated with?
Argyll - Robertson Pupils
- small pupils and
- accommodation reflex is present, light reflex is not
Also associatedwith diabetic retinopathy
Give 5 features of Horner’s syndrome:
Miosis Ptosis Anhidrosis Enophthalmos Iris Heterochromia
What are the diagnostic investigations into glaucoma?
Goldmann Tanometry
Visual field testing
Central corneal thickness measurement
Slitlamp
- assess the optic nerve
Gonioscopy
What signs may be present in macular degeneration - age related and what investigations should be carried out:
Distortion of line perception
- via Amsler grid testing
Drusen/ yellow areas on the macula
- seen via fundoscopy
Investigations:
- slit lamp
- Fluorescein Angiography if Wet ARMD is suspected
- OCT
**OCT is definitive test for diagnosis
List some risk factors for ARMD:
Advancing age Female Smoking Caucasian Hypermetropia Cardiovascular disease
Refractive erros can be associatted with glaucoma, what are they?
Primary open angle glaucoma:
- Myopia
Acute closed angle glaucoma
- Hypermyopia
Other than raised ICP, what else may cause papilledema?
Hypercapnia
*in the emergency room you can induce hyperventilation to reduce the papiloedma
Malignant hypertension
Idiopathic hypertension
Which type of cataracts is most associated with steroid use?
Subcapsular cataracts
Give 5 causes of homologous hemianopia:
Stroke Migraine Tumour Trauma Demyelinating disease
List 3 major causes of a RAPD:
Neuritis / MS
Extensive retinal damage - vein occlusion/ advance diabetic retinopathy
Dense macular lesion
The ocular nerve as well carrying parasympathetic fibres, also carries sympathetic fibres, what do these innervate?
Levator Palpebrae Superioris
What are the characteristic findings in a 4th nerve palsy?
diplopia on upwards gaze
Failure to look at nose
Head tilt
*job is look inwards and look downwards
What are the characteristics of a 6th nerve palsy?
Failure to converge
Diplopia horizontal when abducting
What are the features of acute closed angle glaucoma?
Blurred vision halos
Severe pain with headache and vomiting
Cloudy cornea
Dilated fixed pupil
Hard feeling eye - as the pressure is fixed
What are the causes of exophthalmos?
Thyroid eye disease
Carotid Cavernous sinus fistula
Cavernous sinus thrombosis
Orbital tumour
Orbital cellulitis
List some common causes of ptosis:
Horner’s syndrome
3rd nerve palsy
Senile
Myasthenia gravis
Congenital
What are clinical features of orbital cellulitis?
Lid erythema
Exophthalmoses
Conjunctival injection/ chemosis
Visual disturbance
Diplopia/ reduced eye movement
Describe the stages of diabetic retinopathy:
- Background Diabetic retinopathy
- flame haemorrhages - Pre-proliferative
- blots
- dots
- hard exudates
- cotton wool spots - Proliferative
- angiogenesis
- neovascularization - Retinal detachment
- Macula oedema
* macula oedema can occur at any stage
What are the risk factors for diabetic retinopathy to progress?
Poor glycaemic control
Hypertension
Hyperlipidemia
Pregnancy
Long standing diabetes
List some causes for optic disc swelling:
Raised ICP
Neuritis
Ophthalmic vein occlusion
Vasculitis
Orbital cellulitis
What are the most common causes of leukocoria
Cataracts
Retinoblastoma
retinopathy of prematurity
Which patient group are at risk of vitreous haemorrhage?
Diabetics
What are the signs of retinitis pigmentosa?
Night blindness
Tunnel vision formation
- peripheral vision is lost
Mottling of the retinal pigmental epithelium
