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Phase 3b > Ophthalmology > Flashcards

Ophthalmology Flashcards

1
Q

Blepharitis signs and symptoms

A

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

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2
Q

Causes of blepharitis

A

Meibomian gland dysfunction (common, posterior)

Seborrhoeic dermatitis (constant sx that wax and wane)

Staph infection (sudden exacerbations with remission sometimes lasting months)

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3
Q

Role of the meibomian glands?

A

Secretion of oil to prevent rapid evaporation of tear film

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4
Q

Management of blepharitis

A

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)

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5
Q

Differences between bacterial and viral conjunctivitis

A

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

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6
Q

Management of conjunctivitis

A

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

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7
Q

Allergic conjunctivitis features

A

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)

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8
Q

Allergic conjunctivitis management

A
  1. Topical or systemic antihistamines

2. Topical mast cell stabilisers (sodium cromoglicate, nedocromil)

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9
Q

Causes of eyelid infections

A

Viral:
Herpes simplex/zoster
Papilloma

Bacterial: stye, impetigo

Infestation (nits and lice)

Lid malposition (ectropion or entropion)

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10
Q

Herpes simplex infection features

A

Vesiculo-bullous eruption

Preceded by pain and erythema

Lid oedema

Oral herpes lesion

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11
Q

Herpes simplex and zoster treatment

A

Oral and topical antivirals (acyclovir)

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12
Q

Herpes zoster ophthlamicus features

A

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

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13
Q

Causes of ectropion and features to look for

A

Lid laxity in the elderly or a facial nerve palsy

Palsy: eye closure, corneal sensation, Bell’s phenomenon (eye rolling up when closure attempted)

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14
Q

Sub-conjunctival haemorrhage features and management

A

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

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15
Q

What might be causing recurrent bacterial conjunctivitis?

A

Secondary to nasolacrimal duct obstruction, especially in children

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16
Q

What are the three types of chlamydial infection?

A

Trachoma (third world countries)

Adult inclusion conjunctivitis

Neonatal conjunctivitis

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17
Q

Trochoma features and management

A

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

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18
Q

Adult inclusion conjunctivitis features and management

A

GU infection from chlamydia

Causes follicular conjunctivitis (usually one eye)

Corneal inflammation

Treat underlying infection - SYSTEMIC ERYTHROMYCIN

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19
Q

Opthalmia neonatorum definition and causes

A

Conjunctivitis in first 3 weeks of life picked up from mother as passing through birth canal

Chlamydia, herpes simplex, gonorrhoea (loss of vision), staph

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20
Q

Types of allergic conjunctivitis

A

Acute type 1 hypersensitivity

Chronic allergic conjunctivitis (atopic)

Allergy to eye drops

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21
Q

Chronic allergic conjunctivitis (verneal keratoconjunctivitis) features and treatment

A

Children

Sticky mucous discharge

Large papillae on eyelids

Ulcerated cornea

Treatment: topical steroids, specialist care

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22
Q

Management of chemical conjunctivitis

A

Irrigate until pH normal

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23
Q

What corneal disorders can cause red eye

A

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)

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24
Q

Features of herpes simplex keratitis

A

Dendritic ulcer (stained with fluorescein)

Foreign body sensation

Photophobia

Watery discharge/epiphora

Mx: REFERRAL and antiviral (acyclovir)

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25
Q

Bacterial keratitis features

A

Staph, strep, pseudemonas, H.influenzae in kids

Painful red eye

Loss of vision, blurry

Discharge

Photophobia

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26
Q

Marginal keratitis features and treatment

A

Painful red eye

Normal vision

White lesion at periphery of cornea associated with area of redness

Tx: topical steroid (after specialist advice), resolves spontaneously

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27
Q

Acute Angle-Closure Glaucoma features

A

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)

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28
Q

Acute Angle Closure Glaucoma management

A

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

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29
Q

Risk factors for AACG

A

Pupillary dilatation

Lens growth associated with age

Hypermetropia (long-sighted)

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30
Q

Cause of AACG

A

Rise in intraocular pressure secondary to impairment of aqueous outflow

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31
Q

Ocular manifestations of rheumatoid arthritis

A

Keratoconjunctivitis sicca (most common)

Episcleritis (erythema)

Scleritis (erythema and pain)

Corneal ulceration

Keratitis

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32
Q

Features of Horner’s syndrome

A

Miosis (small pupil)
Ptosis
Anhydrosis
Enopthalmos (due to narrow palpebral aperture)

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33
Q

How can you distinguish between causes of Horner’s syndrome?

A

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)

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34
Q

Episcleritis features

A

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

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35
Q

Causes of subconjunctival haemorrhage

A

Benign:
Drugs - NSAIDs, steroids, warfarin
Valsalva (coughing, wretching)
HTN

Trauma - orbital fracture
IC haemorrhage - proptosis, black eye

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36
Q

Features and management of subconjunctival haemorrhage

A

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

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37
Q

Causes of anterior uveitis

A 
HLA-B27 in 50% of cases 
Inflammation 
Infection 
Neoplasia 
Ischaemia 
Trauma 
Idiopathic
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38
Q

What conditions is anterior uveitis associated with

A

HLA-B27 conditions
RA
Ankylosing spondilitis
IBD

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39
Q

Anterior uveitis features

A 
Progressive red eye and pain
Photophobia 
Irregular pupil (oval)
Blurred vision 
Lacrimation 
Ciliary flush 
Hypopyon (inflammatory cells in anterior chamber resulting in fluid level)
40
Q

Management of anterior uveitis

A

Refer
Steroid
Cyclopentolate/atropine (paralyses ciliary body, dilates pupil and reduces pain)
Treat any infection

41
Q

Scleritis features

A

Diffuse red eye
Mild-mod pain - worse on movement or waking at night
Immobile non-blanching vessels
Tender

42
Q

Scleritis investigations and management

A

Autoimmune screen, fluorescein angiography

Mx:

  1. oral NSAID
  2. oral prednisolone
  3. topical/sub-conjunctival steroid
  4. referral to rheum for methotrexate
43
Q

Fungal and protozoal causes of keratitis

A

Aspergillous, candida (AIDs)

Acanthamoeba (in contact lens users)

44
Q

Classical features of keratitis

A

Foreign body sensation (grittiness)

Pain

Epithelial defect

White cell infiltrate

45
Q

Investigations and management of keratitis

A

Corneal scrapings
Culture contact lens accessories

Mx:
Antimicrobials or antivirals
If HSV - avoid steroids

Refer if >1.5mm infiltrate, hypopyon, other complications

46
Q

Complications of keratitis

A

Extension into the sclera

Perforation of cornea

Endophthalmitis (anterior and posterior chamber)

Panophthalmitis (entire eye)

47
Q

Management of herpes zoster ophthalmicus

A

oral antiviral 7-10 days (IV if severe or immunocompromised)

NOT TOPICAL

Topical steroids for secondary ocular inflammation

Urgent referral if ocular involvement

48
Q

Features of retinitis pigmentosa and investigation

A

Night blindness

Tunnel vision (loss of peripheral retina, but keep central vision)

Family history

Investigation: visual fields

49
Q

Homes-Aide pupil features

A

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

50
Q

Argyll-Robertson pupil features

A

Syphilis history

Bilateral small irregular pupils

Respond to accommodation but not light

51
Q

Swollen optic disc (no distinct border), flame haemorrhages and cotton wool spots - diagnosis?

A

Anterior ischaemic optic neuropathy

52
Q

Fundoscopy findings in central retinal artery occlusion

A

Pallor of the retina
Cherry red spot
Loss of connections between arteries

53
Q

Unilateral scattered haemorrhages and cotton wool spots on fundoscopy?

A

Central retinal vein occlusion

54
Q

What palsy would a posterior communicating aneurysm cause?

A

3rd nerve palsy (presses on the nerve)

55
Q

Third nerve palsy features

A

Down and out
Pupil dilated
Ptosis

56
Q

Signs and symptoms of cataracts

A

Reduced vision
Halos around lights
Reduced colour vision
Glare (lights appear brighter)

Red reflex defect

57
Q

Investigations for cataracts

A

Ophthalmoscopy: fundus and optic disc normal

Slit-lamp examination: shows cataracts in lens

58
Q

Types of cataracts

A

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

59
Q

Management of cataracts

A

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

60
Q

Complications of cataracts surgery

A

Posterior lens opacification (thickening of lens)
Retinal detachment
Posterior capsule rupture
Endophthalmitis

61
Q

Management of stye

A

Warm compress and analgesia

Abx only if associated conjunctivitis

62
Q

Features of open angle glaucoma

A

Gradual increased ocular pressure >24mmHg

Often symptomless incidental finding!

Visual field defect

Pathological cupping of optic disc

Slit lamp: optic nerve head damage

63
Q

Investigations of open angle glaucoma

A

Visual fields
Tonometry
Slit lamp (optic nerve assessment)
Central corneal thickness

64
Q

Treatment of open angle glaucoma

A

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

65
Q

Vitreous detachment features

A

Flashers and floaters in peripheral field

66
Q

Retinal detachment features

A 
Dense shadow starting peripherally and closing in 
Veil or curtain 
Spiderweb flashing lights 
Straight lines appear curved 
Central vision loss
67
Q

Chalazion features

A

Hard, painless lump of the meibomian duct

Self-resolving

68
Q

Management of childhood squint

A

Corneal light reflection test
Eye patch
Referral to secondary care

69
Q

Optic neuritis features

A 
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
70
Q

Features of orbital cellulitis

A 
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

71
Q

Differentiating preseptal from orbital cellulitis

A

Preseptal won’t present with visual disturbance, proptosis or ophthalmoplegia

72
Q

Investigations and management of orbital cellulitis

A

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

73
Q

Marcus Gunn pupil features

A

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

74
Q

Difference between wet and dry macular degeneration

A

Dry: drusen (yellow round spots), most common and best prognosis

Wet: exudates, neovascularisation, rapid loss of vision, worst prognosis

75
Q

Macular degeneration risk factors

A

Age
Family history
Smoking
HTN, cholesterol, diabetes

76
Q

Macular degeneration signs

A

Reduced visual acuity, particular near field objects
Photopsia - flickering or flashing lights and glare around objects
Reduced vision at night
Distortion of line perception

77
Q

Macular degeneration investigations

A

Slit lamp exam (exudates, haemorrhages etc)

Fluroscein angiography (neovascularisation)

Ocular coherence tomography

78
Q

Management of macular degeneration

A

Dry: anti-oxidant vitamins with zinc

Wet: anti-VEGF agents including ranibizumab, bevacizumab and pegaptanib

79
Q

Most common cause of persistent watery eye in an infant? How would you manage it?

A

Nasolacrimal duct obstruction

Mx: lacrimal duct massage - should resolve by one year

Refer to ophthalmologist for probing if not resolved

80
Q

Vitreous haemorrhage risk factors and features

A

RF: short-sighted, anticoagulants, diabetes, trauma, coagulation disorder

Dark spots, cobwebs/floaters and red-tinged vision

81
Q

Painful rash on tip of the nose - what is this sign and what does it suggest?

A

Hutchinsons sign - suggests orbital involvement in herpes zoster infection

82
Q

What is the commonest complication of hyphema (pooling of blood inside anterior chamber)?

A

Glaucoma (due to raised intraocular pressure)

83
Q

Management of optic neuritis

A

High dose steroids
Resolution in 4-6 weeks
MRI: if >3 white matter lesions then 50% risk of MS in next 5 years

84
Q

What are the features of mild NPDR?

A

1 or more microaneurysm

85
Q

What are the features of moderate NDPR?

A 
Microaneurysms 
Blot haemorrhages 
Hard exudates 
Cotton wool spots 
Venous beading/looping  
Intraretinal microvascular abnormalities
86
Q

What are the features of severe NDPR?

A

Blot haemorrhages and microaneurysms in 4 quadrants
Venous beading in at least 2 quadrants
Intraretinal microvascular abnormalities in at least 1 quadrant

87
Q

What are the features of proliferative retinopathy?

A

retinal neovascularisation - may lead to vitreous haemorrhage

Fibrous tissue forming anterior to retinal disc

More common in T1 diabetes, 50% blind in 5 years

88
Q

When to start glaucoma screening for a patient with a family history?

A

Annually from 40

89
Q

Management of newborn with crusty eyelids and purulent discharge

A

Immediate swabs for microbiological investigations

Treat for gonococcal infection until results

90
Q

Possible causes of cataracts?

A 
T2DM
Hypocalcaemia 
Uveitis 
Down's Syndrome 
Long-term steroid use
91
Q

Man just started on mydriatic drops has sudden onset pain in one eye and decreased visual acuity?

A

Acute angle closure glaucoma (increased risk due to mydriatic drops)

92
Q

Causes of ptosis

A

Horner’s
Myaesthenia gravis
Age
Third nerve palsy

93
Q

Four causes of abnormally dilated pupil

A

Third nerve palsy
Acute glaucoma
Medication
(Holmes Adie)

94
Q

Relative afferent pupillary defect - what is the lesion affecting?

A

Optic nerve (suspect optic neuritis)

95
Q

What is a hyphaema? What is the most serious complication?

A

Blood forming a layer in the anterior chamber

Complication: can cause a secondary haemorrhage leading to raised IOP and secondary glaucoma

Phase 3b (18 decks)

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