Ophthalmology Flashcards
Blepharitis signs and symptoms
Red eyelid, swollen if staph
Grittiness and discomfort
Sticky in the mornings
More at risk of styes and chalazions
Poor closure of eyelids
Flaky material (keratin squames) in eyebrows
Secondary conjunctivitis
Causes of blepharitis
Meibomian gland dysfunction (common, posterior)
Seborrhoeic dermatitis (constant sx that wax and wane)
Staph infection (sudden exacerbations with remission sometimes lasting months)
Role of the meibomian glands?
Secretion of oil to prevent rapid evaporation of tear film
Management of blepharitis
Lubricants: help with poor tear film
Lid hygiene - baby shampoo to clean staph from eyelids
Hot spoon bathing: helps meibomian glands empy and prevent chalazion
Topical Abx: chloramphenicol ointment
Oral Abx: sometimes for a few months
Medicated shampoo for scalp to treat dandruff (caused by chronic pityrosporum fungus)
Differences between bacterial and viral conjunctivitis
Bacterial: purulent discharge, eyes stuck together in the mornings, often starts in one eye
Viral: watery/sticky discharge, follicles (raised white lesions), recent URTI, preauricular lymphadenopathy, systemic symptoms [ADENOVIRUS]
Both can cause bloody discharge in severe cases (diphtheria)
VISION NOT AFFECTED
Management of conjunctivitis
Usually self-limiting, resolves after 1-2 weeks
If contact lens wearer - refer for assessment as risk of keratitis
Chloramphenicol ointment (every 2-3 hours) or drops (qds)
Topical fusidic acid BD for pregnant women
Don’t share towels or use contact lenses
No need to exclude from school
Allergic conjunctivitis features
History of atopy, hayfever
Nasal symptoms
Bilateral conjunctival erythema and swelling (chemosis)
Itchy
Papillae (red lesions from capillary dilatation)
Swelling of eyelids
Watery discharge
May be seasonal (pollen) or perennial (dust mite, washing powder)
Allergic conjunctivitis management
- Topical or systemic antihistamines
2. Topical mast cell stabilisers (sodium cromoglicate, nedocromil)
Causes of eyelid infections
Viral:
Herpes simplex/zoster
Papilloma
Bacterial: stye, impetigo
Infestation (nits and lice)
Lid malposition (ectropion or entropion)
Herpes simplex infection features
Vesiculo-bullous eruption
Preceded by pain and erythema
Lid oedema
Oral herpes lesion
Herpes simplex and zoster treatment
Oral and topical antivirals (acyclovir)
Herpes zoster ophthlamicus features
Vesicular rash around the eye
Involvement of nose (Hutchinson’s sign), upper lid and forehead
Caused by varicella-zoster virus
Eye can become involved - corneal inflammation (keratitis/uveitis) with vascularisation, clouding and thinning - REFER TO EYE DEPARTMENT
Causes of ectropion and features to look for
Lid laxity in the elderly or a facial nerve palsy
Palsy: eye closure, corneal sensation, Bell’s phenomenon (eye rolling up when closure attempted)
Sub-conjunctival haemorrhage features and management
Sudden onset bright red eye
Blood can extend to cover the whole globe
Can be spontaneous in the elderly
No treatment, but aways check for orbital or ocular injury if following trauma
What might be causing recurrent bacterial conjunctivitis?
Secondary to nasolacrimal duct obstruction, especially in children
What are the three types of chlamydial infection?
Trachoma (third world countries)
Adult inclusion conjunctivitis
Neonatal conjunctivitis
Trochoma features and management
Caused by chlamydia trachomatis and passed from eye to eye by flies
Conjunctival scarring
dry eyes
in-growing eyelashes
corneal scarring
Management:
Surgery to treat blinding stage (trachomatous trichiasis)
Abx
Facial cleanliness
Adult inclusion conjunctivitis features and management
GU infection from chlamydia
Causes follicular conjunctivitis (usually one eye)
Corneal inflammation
Treat underlying infection - SYSTEMIC ERYTHROMYCIN
Opthalmia neonatorum definition and causes
Conjunctivitis in first 3 weeks of life picked up from mother as passing through birth canal
Chlamydia, herpes simplex, gonorrhoea (loss of vision), staph
Types of allergic conjunctivitis
Acute type 1 hypersensitivity
Chronic allergic conjunctivitis (atopic)
Allergy to eye drops
Chronic allergic conjunctivitis (verneal keratoconjunctivitis) features and treatment
Children
Sticky mucous discharge
Large papillae on eyelids
Ulcerated cornea
Treatment: topical steroids, specialist care
Management of chemical conjunctivitis
Irrigate until pH normal
What corneal disorders can cause red eye
Trauma/foreign bodies
Infection (keratitis): viral, bacterial, acanthamoeba (contact lens with fresh water swimming, pain out of proportion)
Allergic: marginal keratitis, immunological keratitis (peripheral ulcerative keratitis)
Features of herpes simplex keratitis
Dendritic ulcer (stained with fluorescein)
Foreign body sensation
Photophobia
Watery discharge/epiphora
Mx: REFERRAL and antiviral (acyclovir)
Bacterial keratitis features
Staph, strep, pseudemonas, H.influenzae in kids
Painful red eye
Loss of vision, blurry
Discharge
Photophobia
Marginal keratitis features and treatment
Painful red eye
Normal vision
White lesion at periphery of cornea associated with area of redness
Tx: topical steroid (after specialist advice), resolves spontaneously
Acute Angle-Closure Glaucoma features
Unilateral severe pain and red eye
Semi-dilated, non-reacting pupil
Blurred vision
Symptoms worse with mydriasis (e.g. watching TV in dark room)
Haloes around lights
Ciliary flush around the iris
GI upset
Corneal oedema (hazy or dull)
Acute Angle Closure Glaucoma management
Referral
Slit lamp exam and gonioscopy (closed IC angle)
Topical drops with beta blockers (e.g. timalol)
IV acetazolamide
Prednisolone
Topical pilocarpine - induces papillary constriction
Peripheral iridotomy
Risk factors for AACG
Pupillary dilatation
Lens growth associated with age
Hypermetropia (long-sighted)
Cause of AACG
Rise in intraocular pressure secondary to impairment of aqueous outflow
Ocular manifestations of rheumatoid arthritis
Keratoconjunctivitis sicca (most common)
Episcleritis (erythema)
Scleritis (erythema and pain)
Corneal ulceration
Keratitis
Features of Horner’s syndrome
Miosis (small pupil)
Ptosis
Anhydrosis
Enopthalmos (due to narrow palpebral aperture)
How can you distinguish between causes of Horner’s syndrome?
Heterochromia (difference in iris colour) - congenital
Anhidrosis of face, arms and trunk - central lesion (stroke, MS, syringomyelia, tumour, encephalitis)
Anhidrosis of face - pre-ganglionic lesion (Pancoast tumour, thyroidectomy, trauma, cervical rib)
No anhidrosis - post-ganglionic (carotid artery dissection, carotid aneurysm, cluster headache, cavernous sinus thrombosis)
Episcleritis features
Red eye, PAINLESS (may have mild pain)
Lacrimation and mild photophobia
Injected vessels are mobile with pressure (e.g. cotton bud), whereas immobile in scleritis
If phenylephrine drops improves redness then episcleritis (not scleritis)
Mx: self-limiting, artificial tears may be used
Causes of subconjunctival haemorrhage
Benign:
Drugs - NSAIDs, steroids, warfarin
Valsalva (coughing, wretching)
HTN
Trauma - orbital fracture
IC haemorrhage - proptosis, black eye
Features and management of subconjunctival haemorrhage
Bleeding that can spread and change colour (yellow)
Mild irritation
Mx:
conservative, CT if trauma
DON’T give aspirin or NSAIDs
topical lubricant
Refer:
persistent, bilateral or recurrent
Causes of anterior uveitis
HLA-B27 in 50% of cases Inflammation Infection Neoplasia Ischaemia Trauma Idiopathic
What conditions is anterior uveitis associated with
HLA-B27 conditions
RA
Ankylosing spondilitis
IBD
Anterior uveitis features
Progressive red eye and pain Photophobia Irregular pupil (oval) Blurred vision Lacrimation Ciliary flush Hypopyon (inflammatory cells in anterior chamber resulting in fluid level)
Management of anterior uveitis
Refer
Steroid
Cyclopentolate/atropine (paralyses ciliary body, dilates pupil and reduces pain)
Treat any infection
Scleritis features
Diffuse red eye
Mild-mod pain - worse on movement or waking at night
Immobile non-blanching vessels
Tender
Scleritis investigations and management
Autoimmune screen, fluorescein angiography
Mx:
- oral NSAID
- oral prednisolone
- topical/sub-conjunctival steroid
- referral to rheum for methotrexate
Fungal and protozoal causes of keratitis
Aspergillous, candida (AIDs)
Acanthamoeba (in contact lens users)
Classical features of keratitis
Foreign body sensation (grittiness)
Pain
Epithelial defect
White cell infiltrate
Investigations and management of keratitis
Corneal scrapings
Culture contact lens accessories
Mx:
Antimicrobials or antivirals
If HSV - avoid steroids
Refer if >1.5mm infiltrate, hypopyon, other complications
Complications of keratitis
Extension into the sclera
Perforation of cornea
Endophthalmitis (anterior and posterior chamber)
Panophthalmitis (entire eye)
Management of herpes zoster ophthalmicus
oral antiviral 7-10 days (IV if severe or immunocompromised)
NOT TOPICAL
Topical steroids for secondary ocular inflammation
Urgent referral if ocular involvement
Features of retinitis pigmentosa and investigation
Night blindness
Tunnel vision (loss of peripheral retina, but keep central vision)
Family history
Investigation: visual fields
Homes-Aide pupil features
Unilateral midriatic pupil (dilated)
Slowly reactive to accommodation, little reaction to light
When constricted, stays constricted for abnormally long time
Associated with with absent knee/ankle reflexes
Argyll-Robertson pupil features
Syphilis history
Bilateral small irregular pupils
Respond to accommodation but not light
Swollen optic disc (no distinct border), flame haemorrhages and cotton wool spots - diagnosis?
Anterior ischaemic optic neuropathy
Fundoscopy findings in central retinal artery occlusion
Pallor of the retina
Cherry red spot
Loss of connections between arteries
Unilateral scattered haemorrhages and cotton wool spots on fundoscopy?
Central retinal vein occlusion
What palsy would a posterior communicating aneurysm cause?
3rd nerve palsy (presses on the nerve)
Third nerve palsy features
Down and out
Pupil dilated
Ptosis
Signs and symptoms of cataracts
Reduced vision
Halos around lights
Reduced colour vision
Glare (lights appear brighter)
Red reflex defect
Investigations for cataracts
Ophthalmoscopy: fundus and optic disc normal
Slit-lamp examination: shows cataracts in lens
Types of cataracts
Nuclear: change in lens refractive index, old age
Polar: commonly inherited, localised
Subcapsular: due to steroid use
Dot opacities: common in normal lens, also in diabetes and myotonic dystrophy
Management of cataracts
Conservative: stronger glasses, encourage brighter lighting (surgery inevitable)
Surgery: take into account patient choice, presence of visual impairment and impact on quality of life. Advise on use of eye drops and eye wear and what to do if vision changes
Complications of cataracts surgery
Posterior lens opacification (thickening of lens)
Retinal detachment
Posterior capsule rupture
Endophthalmitis
Management of stye
Warm compress and analgesia
Abx only if associated conjunctivitis
Features of open angle glaucoma
Gradual increased ocular pressure >24mmHg
Often symptomless incidental finding!
Visual field defect
Pathological cupping of optic disc
Slit lamp: optic nerve head damage
Investigations of open angle glaucoma
Visual fields
Tonometry
Slit lamp (optic nerve assessment)
Central corneal thickness
Treatment of open angle glaucoma
Prostaglandin analogues - increase aqueous outflow (latanoprost)
Beta blockers - reduce aqueous production (timolol)
Alpha-2-adrenoreceptor agonists - both mechanisms
Carbonic anydrase inhibitors - reduce aqueous prodcution (dorzolamide)
Pilocarpine/muscarinic agonists - increase outflow
Vitreous detachment features
Flashers and floaters in peripheral field
Retinal detachment features
Dense shadow starting peripherally and closing in Veil or curtain Spiderweb flashing lights Straight lines appear curved Central vision loss
Chalazion features
Hard, painless lump of the meibomian duct
Self-resolving
Management of childhood squint
Corneal light reflection test
Eye patch
Referral to secondary care
Optic neuritis features
Over the course of hours or days: Visual loss Painful eye worse on movement Impaired coloured vision (red saturation) Relative afferent pupillary defect Central scotoma
Features of orbital cellulitis
Swelling around the eye Fever Painful eye movement Reduced visual acuity depending on severity Proptosis Eyelid oedema and ptosis
Drowsiness +/- nausea and vomiting if meningeal involvement
Differentiating preseptal from orbital cellulitis
Preseptal won’t present with visual disturbance, proptosis or ophthalmoplegia
Investigations and management of orbital cellulitis
FBC
Eye examination (decreased vision, afferent pupillary defect)
CT scan: inflammation of orbital tissues
Blood cultures (Strep, Staph aureus, HiB)
HOSPITAL ADMISSION AND IV ABX
Marcus Gunn pupil features
Relative afferent pupillary defect
Diagnosed with swinging light test - affected and normal eye appear to dilate when light is shone in affected eye
Caused by retinal detachment or optic neuritis
Difference between wet and dry macular degeneration
Dry: drusen (yellow round spots), most common and best prognosis
Wet: exudates, neovascularisation, rapid loss of vision, worst prognosis
Macular degeneration risk factors
Age
Family history
Smoking
HTN, cholesterol, diabetes
Macular degeneration signs
Reduced visual acuity, particular near field objects
Photopsia - flickering or flashing lights and glare around objects
Reduced vision at night
Distortion of line perception
Macular degeneration investigations
Slit lamp exam (exudates, haemorrhages etc)
Fluroscein angiography (neovascularisation)
Ocular coherence tomography
Management of macular degeneration
Dry: anti-oxidant vitamins with zinc
Wet: anti-VEGF agents including ranibizumab, bevacizumab and pegaptanib
Most common cause of persistent watery eye in an infant? How would you manage it?
Nasolacrimal duct obstruction
Mx: lacrimal duct massage - should resolve by one year
Refer to ophthalmologist for probing if not resolved
Vitreous haemorrhage risk factors and features
RF: short-sighted, anticoagulants, diabetes, trauma, coagulation disorder
Dark spots, cobwebs/floaters and red-tinged vision
Painful rash on tip of the nose - what is this sign and what does it suggest?
Hutchinsons sign - suggests orbital involvement in herpes zoster infection
What is the commonest complication of hyphema (pooling of blood inside anterior chamber)?
Glaucoma (due to raised intraocular pressure)
Management of optic neuritis
High dose steroids
Resolution in 4-6 weeks
MRI: if >3 white matter lesions then 50% risk of MS in next 5 years
What are the features of mild NPDR?
1 or more microaneurysm
What are the features of moderate NDPR?
Microaneurysms Blot haemorrhages Hard exudates Cotton wool spots Venous beading/looping Intraretinal microvascular abnormalities
What are the features of severe NDPR?
Blot haemorrhages and microaneurysms in 4 quadrants
Venous beading in at least 2 quadrants
Intraretinal microvascular abnormalities in at least 1 quadrant
What are the features of proliferative retinopathy?
retinal neovascularisation - may lead to vitreous haemorrhage
Fibrous tissue forming anterior to retinal disc
More common in T1 diabetes, 50% blind in 5 years
When to start glaucoma screening for a patient with a family history?
Annually from 40
Management of newborn with crusty eyelids and purulent discharge
Immediate swabs for microbiological investigations
Treat for gonococcal infection until results
Possible causes of cataracts?
T2DM Hypocalcaemia Uveitis Down's Syndrome Long-term steroid use
Man just started on mydriatic drops has sudden onset pain in one eye and decreased visual acuity?
Acute angle closure glaucoma (increased risk due to mydriatic drops)
Causes of ptosis
Horner’s
Myaesthenia gravis
Age
Third nerve palsy
Four causes of abnormally dilated pupil
Third nerve palsy
Acute glaucoma
Medication
(Holmes Adie)
Relative afferent pupillary defect - what is the lesion affecting?
Optic nerve (suspect optic neuritis)
What is a hyphaema? What is the most serious complication?
Blood forming a layer in the anterior chamber
Complication: can cause a secondary haemorrhage leading to raised IOP and secondary glaucoma
