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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
Bacterial keratitis features
Staph, strep, pseudemonas, H.influenzae in kids Painful red eye Loss of vision, blurry Discharge Photophobia
26
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
27
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)
28
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
29
Risk factors for AACG
Pupillary dilatation Lens growth associated with age Hypermetropia (long-sighted)
30
Cause of AACG
Rise in intraocular pressure secondary to impairment of aqueous outflow
31
Ocular manifestations of rheumatoid arthritis
Keratoconjunctivitis sicca (most common) Episcleritis (erythema) Scleritis (erythema and pain) Corneal ulceration Keratitis
32
Features of Horner's syndrome
Miosis (small pupil) Ptosis Anhydrosis Enopthalmos (due to narrow palpebral aperture)
33
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)
34
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
35
Causes of subconjunctival haemorrhage
Benign: Drugs - NSAIDs, steroids, warfarin Valsalva (coughing, wretching) HTN Trauma - orbital fracture IC haemorrhage - proptosis, black eye
36
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
37
Causes of anterior uveitis
``` HLA-B27 in 50% of cases Inflammation Infection Neoplasia Ischaemia Trauma Idiopathic ```
38
What conditions is anterior uveitis associated with
HLA-B27 conditions RA Ankylosing spondilitis IBD
39
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) ```
40
Management of anterior uveitis
Refer Steroid Cyclopentolate/atropine (paralyses ciliary body, dilates pupil and reduces pain) Treat any infection
41
Scleritis features
Diffuse red eye Mild-mod pain - worse on movement or waking at night Immobile non-blanching vessels Tender
42
Scleritis investigations and management
Autoimmune screen, fluorescein angiography Mx: 1. oral NSAID 2. oral prednisolone 3. topical/sub-conjunctival steroid 4. referral to rheum for methotrexate
43
Fungal and protozoal causes of keratitis
Aspergillous, candida (AIDs) Acanthamoeba (in contact lens users)
44
Classical features of keratitis
Foreign body sensation (grittiness) Pain Epithelial defect White cell infiltrate
45
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
46
Complications of keratitis
Extension into the sclera Perforation of cornea Endophthalmitis (anterior and posterior chamber) Panophthalmitis (entire eye)
47
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
48
Features of retinitis pigmentosa and investigation
Night blindness Tunnel vision (loss of peripheral retina, but keep central vision) Family history Investigation: visual fields
49
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
50
Argyll-Robertson pupil features
Syphilis history Bilateral small irregular pupils Respond to accommodation but not light
51
Swollen optic disc (no distinct border), flame haemorrhages and cotton wool spots - diagnosis?
Anterior ischaemic optic neuropathy
52
Fundoscopy findings in central retinal artery occlusion
Pallor of the retina Cherry red spot Loss of connections between arteries
53
Unilateral scattered haemorrhages and cotton wool spots on fundoscopy?
Central retinal vein occlusion
54
What palsy would a posterior communicating aneurysm cause?
3rd nerve palsy (presses on the nerve)
55
Third nerve palsy features
Down and out Pupil dilated Ptosis
56
Signs and symptoms of cataracts
Reduced vision Halos around lights Reduced colour vision Glare (lights appear brighter) Red reflex defect
57
Investigations for cataracts
Ophthalmoscopy: fundus and optic disc normal Slit-lamp examination: shows cataracts in lens
58
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
59
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
60
Complications of cataracts surgery
Posterior lens opacification (thickening of lens) Retinal detachment Posterior capsule rupture Endophthalmitis
61
Management of stye
Warm compress and analgesia | Abx only if associated conjunctivitis
62
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
63
Investigations of open angle glaucoma
Visual fields Tonometry Slit lamp (optic nerve assessment) Central corneal thickness
64
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
65
Vitreous detachment features
Flashers and floaters in peripheral field
66
Retinal detachment features
``` Dense shadow starting peripherally and closing in Veil or curtain Spiderweb flashing lights Straight lines appear curved Central vision loss ```
67
Chalazion features
Hard, painless lump of the meibomian duct | Self-resolving
68
Management of childhood squint
Corneal light reflection test Eye patch Referral to secondary care
69
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 ```
70
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
71
Differentiating preseptal from orbital cellulitis
Preseptal won't present with visual disturbance, proptosis or ophthalmoplegia
72
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
73
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
74
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
75
Macular degeneration risk factors
Age Family history Smoking HTN, cholesterol, diabetes
76
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
77
Macular degeneration investigations
Slit lamp exam (exudates, haemorrhages etc) Fluroscein angiography (neovascularisation) Ocular coherence tomography
78
Management of macular degeneration
Dry: anti-oxidant vitamins with zinc Wet: anti-VEGF agents including ranibizumab, bevacizumab and pegaptanib
79
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
80
Vitreous haemorrhage risk factors and features
RF: short-sighted, anticoagulants, diabetes, trauma, coagulation disorder Dark spots, cobwebs/floaters and red-tinged vision
81
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
82
What is the commonest complication of hyphema (pooling of blood inside anterior chamber)?
Glaucoma (due to raised intraocular pressure)
83
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
84
What are the features of mild NPDR?
1 or more microaneurysm
85
What are the features of moderate NDPR?
``` Microaneurysms Blot haemorrhages Hard exudates Cotton wool spots Venous beading/looping Intraretinal microvascular abnormalities ```
86
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
87
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
88
When to start glaucoma screening for a patient with a family history?
Annually from 40
89
Management of newborn with crusty eyelids and purulent discharge
Immediate swabs for microbiological investigations | Treat for gonococcal infection until results
90
Possible causes of cataracts?
``` T2DM Hypocalcaemia Uveitis Down's Syndrome Long-term steroid use ```
91
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)
92
Causes of ptosis
Horner's Myaesthenia gravis Age Third nerve palsy
93
Four causes of abnormally dilated pupil
Third nerve palsy Acute glaucoma Medication (Holmes Adie)
94
Relative afferent pupillary defect - what is the lesion affecting?
Optic nerve (suspect optic neuritis)
95
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

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