Ophthalmology Flashcards
What are the differential diagnosis for a painless red eye?
Conjunctivitis
Episcleritis
Subconjunctival haemorrhage
What are the differential diagnosis for a painful red eye?
Glaucoma Anterior uveitis Scleritis Corneal abrasions or ulceration Keratitis Foreign body Traumatic or chemical body
What are the red flags for a red eye?
Impaired vision
Pain/photophobia
Lack of ocular discharge
Define conjunctivitis
Inflammation and redness of the conjunctiva
Symptoms of conjunctivitis
Red eyes Unilateral or bilateral Vision unaffected Bloodshot Itchy or gritty sensation Discharge from the eye Does not cause pain, photophobia or reduced visual acuity
Symptoms of bacterial conjunctivitis
Purulent discharge -> pus Eye may be stuck together in the morning Highly contagious Starts in one eye and spreads to other Papillae
What are the causative organisms for bacterial conjunctivitis?
Staphylococcus
Streptococcus
Haemophilus
Neisseria
Symptoms for viral conjunctivitis
Clear discharge (serous)
Dry cough, sore throat, blocked nose
Preauricular lymph nodes (in front of ears)
Recent URTI
Commonest cause of viral conjunctivitis?
Adenovirus -> causes follicles
What type of hypersensitivity is allergic conjunctivis?
Type 1 hypersensitivity
Caused by contact with allergens
Symptoms of allergic conjunctivitis
Most frequent type of conjunctivitis
Watery discharge - serous
Itch
Caused by contact with allergens
Treatment for allergic conjunctivitis
Antihistamines (oral or topical) used to reduce symptoms
Treatment for bacterial conjunctivitis
Chloramphenicol
Fuscidic acid
General treatment for conjunctivitis
Reassurance (resolves after 1-2 weeks)
Good hygiene
Define ophthalmia neonatorum
Conjunctivitis in the first 3 weeks of life
Purulent discharge
Causes of ophthalmia neonatorum
Chlamydia
Herpes simplex
Gonorrhoea
Staphylococcus/streptococcus
Treatment for chlamydia
Erythromycin
Azithromycin
Treatment for gonorrohoea
Cefotaxime and chloramphenicol
Define episcleritis
Thin vascular layer between sclera and conjunctiva
Symptoms of episcleritis
Common, benign Acute onset Unilateral (bilateral in 30%) Typically not painful Segmental redness Dilated episcleral vessels Watering of eye No discharge Visual acuity is normal
Treatment for episcleritis
Self-limiting and will recover in 1-4 weeks
Artificial tears
Topical or systemic NSAIDs (e.g. naproxen)
Define subconjunctival haemorrhage
Small blood vessel within the conjunctiva ruptures and releases blood into the space between the sclera and the conjunctiva
When is a subconjunctival haemorrhage likely to occur?
After episodes of strenous activity such as heavy coughing, weight lifting or straining when constipated
Causes of subconjunctival haemorrhage
Hypertension
Whooping cough
Trauma
Medications (Warfarin, NOAC’s antiplatelets)
Bleeding disorders (e.g. thrombocytopenia)
Symptoms of subconjunctival haemorrhage
Sudden onset
Painless - does not affect vision
Bright red covering white section
Management of subconjunctival haemorrhage
Resolves spontaneously roughly two weeks
Define scleritis
Inflammation of the full thickness of the sclera
More serious than episcleritis
Rare
What is the most serious type of scleritis?
Necrotising scleritis
Can cause visual impairment and perforation of the sclera
What conditions are associated with scleritis?
Rheumatoid arthritis SLE Inflammatory bowel disease Sarcoidosis Wegener's granulomatosis
Symptoms of scleritis
Constant, severe dull ache Severe pain Pain with eye movement Eye watering -> no discharge Photophobia Reduced visual acuity Headache Abnormal pupil reaction to light Tenderness to palpation of the eye
Management of scleritis
Urgent referral within 24 hours
Oral NSAIDs
Oral high-dose prednisolone
Treat underlying condition - Methotrexate for rheumatoid arthritis
Define anterior uveitis (iritis)
Inflammation in the anterior uvea (comprises the iris and ciliary body)
Posterior uvea contains the choroid (inflammation here is termed choroiditis)
Causes of anterior uveitis
Ankylosing spondylitis Inflammatory bowel disease Reactive arthritis Sarcoidosis Syphilis Lyme disease TB Herpes simplex Behcet's disease
Symptoms of anterior uveitis
Unilateral Dull, aching painful red eye Ciliary flush (ring of red spreading from the cornea outwards) Reduced visual acuity - blurred vision Photophobia Pain on movement Lacrimation (excessive tear production) Floaters and flashes Miosis (constricted pupil) Abnormally shaped pupil due to posterior synechiae (adhesions)
Questions to ask when suspecting anterior uveitis?
Headaches Mouth ulcers (Behcet's disease) Joint problems Chest and skin disease GU symptoms
Investigations for anterior uveitis
Slit lamp with dilated pupil to visualise inflammatory cells (leucocytes), measure IOP too
Fundus fluorescein and indocyanide green-angiography
Treatment for anterior uveitis
Urgent same day referral to ophthalmologist
Topical prednisolone
Cyclopentolate or atropine -> to dilate the pupil
DMARDs or TNF inhibitors for immunosuppression
Laser therapy/surgery (vitrectomy) in severe cases
Define keratitis
Inflammation of the cornea
Causes of keratitis
Viral = herpes simplex Bacterial = psuedomonas or staphylococcus Fungal = candida or aspergillus
Symptoms of herpes simplex keratitis
Painful red eye Photophobia Vesicles around the eye Watery discharge Foreign body sensation Reduced visual acuity
Investigations for viral keratitis
Staining with fluorescein - shows dendritic corneal ulcer
Slit lamp examination
Corneal swabs or scrapings
Management for viral keratitis
Same day urgent referral to ophthalmologist
Aciclovir (topical or oral)
Don’t use steroids without expert opinion
Symptoms of bacterial keratitis
Painful red eye
Loss of vision
Signs: Hazy cornea with central abscess
Management of bacterial keratitis
Requires specialist
Intense antibiotics
Define corneal abrasions
Scratches or damage to the cornea
Causes of corneal abrasions
Contact lenses - may have psuedomonas infection Foreign bodies Finger nails Eyelashes Entropian (inward turning eyelid)
Symptoms of corneal abrasions
History of contact lenses/foreign body Painful red eye Foreign body sensation Watering eye Blurring vision Photophobia
Investigations for corneal abrasions
Staining with fluorescein -> yellow/orange colour
Slit lamp examination
Management for corneal abrasions
Same day referral to ophthalmologist Analgesia - paracetamol Lubricating eye drops Antibiotic eye drops - chloramphenicol Cyclopentolate eye drops - dilate pupil and improves photophobia
Usually heal over 2-3 days
Define keratoconjunctivitis sicca
Dry eyes
What are the components of tears?
Watery layer (main, middle) - lacrimal glands Oily layer (thin outer) - meibomian glands Mucus layer (inner) - conjunctiva
Causes of dry eyes
Old age
Medications (beta blockers, antihistamines, antidep, diuretics)
Systemic illness (RA, sarcoidosis, Sjogren’s)
Blepharitis (decreased tear production)
Allergic conjunctivitis
Increased evapouration
Symptoms of dry eyes
Irritation
Sight blurring
Photophobia - discomfort when looking at bright lights
Investigations for dry eyes
Schirmer’s test - strip of filter paper
Slit lamp
Assessment of corneal damage - fluorescein stain
Treatment for dry eyes
Artificial tears
Drops
Gels
Define blepharitis
Inflammation of the eyelids
Symptoms of blepharitis
Gritty, irritable eyes Itching Dry sensation Loss of eyelashes Thick, red, inflamed eyelids Watery discharge
What can blepharitis lead to?
Styes and chalazions
Treatment for blepharitis
Eyelid hygiene - baby shampoo
Oral antibiotics - erythromycin
Hot spoon bathing
Lubricants
What are the two types of styes?
Hordeolum externum - Staphylococcus infection of the glands of Zeis or gland of Moll.
Can cause tender red lump along the eyelid that may contain pus
Hordeolum internum - Infection of Meibomian glands. They are deeper, tend to be more painful and may point inwards
Management of styes
Hot compression
Analgesia
Define Chalazion
Occurs when a Meibomian gland (may develop from hordeolum internum) becomes blocked and swells
It is typically not tender and hard
Management of Chalazion
Hot compression
Consider topic antibiotics (Chloramphenicol) if inflamed
Define entropian
The eyelid (usually lower lid) turns inwards with the lashes against the eyeball
Management for an entropian
Tape the eyelid down
Definitive treatment is with surgical intervention
Define ectropian
Outward turning of the eyelid, with the inner aspect of the eyelid exposed
It usually affects the bottom eyelid
Symptoms of an ectropian
Watering
Exposure keratitis
Eye irritation
Associations with an ectropian
Old age
Facial palsy
Management of an ectropian
Lubricating eye drops
Surgical correction
Define trichiasis
Inward growth of the eyelashes
Symptoms of trichiasis
Pain, corneal damage and ulceration
Management of trichiasis
Remove eyelash - epilation
Recurrent cases - electrolysis, cryotherapy, laser treatment
Define acute closed-angle glaucoma
Optic nerve damage as a result of a raised intraocular pressure. This raised IOP is caused by a blockage in aqueous humour trying to escape the eye.
Aqueous has to escape through the lens and the cornea, when the iris comes into contact with the lens the humour cannot pass through.
Fluid and pressure then builds up the in the posterior chamber
Acute closed-angle glaucoma is an ophthalmology emergency
What is a raised intraocular pressure?
> 30 mmHg
Normal = 10-21 mmHg
Risk factors for acute closed-angle glaucoma
Increasing age (40-60 years old) Female 4x more likely Family history Chinese and Asian Medications (Adrenergic - noradrenalin, anticholinergic - oxybutynin, tricyclic antidepressants - amitryptyline)
Symptoms of acute closed-angle glaucoma
Headache Nausea and vomiting Painful red eye Halos around lights Blurred vision Decreased visual acuity Dilated pupil Photophobia
Investigations for acute closed-angle glaucoma
Slit lamp - large cup and nerve fibre loss
Static perimetry - visual field loss
Gonioscopy - trabecular meshwork not visible
Treatment for acute closed-angle glaucoma
Pilocarpine drops - constrict the pupil
Acetazolamide (carbonic anhydrase inhibitor) - reduces the production of aqueous humour
Timolol (beta blocker) - suppress aqueous humour production
Mannitol
Laser iridotomy - piece of iris removed - definitive, prevents recurrence
Define open angle glaucoma
A gradual increase in resistance through the trabecular meshwork - difficult for aqueous humour to flow through. Pressure slowly builds.
Slow and chronic onset.
Increased pressure causes a cupping of the optic disc. A small indent in the optic disc. An optic cup greater than 0.5 the size of the optic disc is abnormal.
Risk factors for open angle glaucoma
Increasing age Family history Black ethnicity Nearsightedness Hypertension Diabetes
Symptoms of open angle glaucoma
Often asymptomatic Peripheral vision lost first -> tunnel vision then lost Fluctuating pain Headaches Blurred vision Halos appearing around lights
Triad for open angle glaucoma
Raised IOP (>21 mmHg) Abnormal disc - cup:disc ratio asymmetry - severe cupping Visual field defect
Investigations for open angle glaucoma
Goldmann applanation tonometry - measures IOP
Fundoscopy - checks optic disc cupping and optic nerve health
Visual field assessment
Management for open angle glaucoma
Prostaglandin analogues e.g. Latanoprost - 1st line
Beta blockers e.g. Timolol
Carbonic anhydrase inhibitors e.g. Dorzolamide
Alpha agonists e.g. Brimonidine
Laser therapy - trabeculoplasty
What prostaglandin analogues do? and their side effects?
Increase uveoscleral outflow
SE: eyelash growth, iris pigmentation, bronchospasm
What do beta blockers do, side effects and contraindications?
Block production of aqueous humour
SE: dry eyes, bronchospasm, bradycardia, heart block, hyptension
CI: Asthma/COPD, Heart failure
What do carbonic anhydrase inhibitors do, side effects and contraindications?
Reduce production of aqueous humour
SE: Burning/tearing, blepharoconjunctivitis
CI: Renal/liver failure
What do alpha agonists do?
Reduce production of aqeuous humour and increase uveoscleral outflow
Define cataract
When the lens in the eye becomes cloudy and opaque
Risk factors for a cataract
Increasing age Smoking Alcohol Diabetes Steroid use Hypocalcaemia
What are different types of cataracts?
Nuclear
Cortical
Posterior subcapsular
Symptoms of a cataract
Asymmetrical Blurred vision - diplopia Reduction in vision - reduced acuity Colours become more yellow/brown 'Starbursts' can appear around lights Loss of red reflex White colour of pupil (leucocoria)
Management for a cataract
Cataract surgery - day case, under local anaesthetic
Process of phacoemulsification, an intraocular lens implant and removal of the current lens
Complications for cataracts
Endophthalmitis - red, painful, loss of vision/eye itself
Treat with intravitreal antibiotics
Define age related macular degeneration (ARMD)
Degeneration in the macular
Drusen and sometimes blood is found at the macula during fundoscopy
Chief cause of registrable blindness
Risk factors for age related macular degeneration
Increasing age Smoking Cardiovascular disease Family history White or chinese ethnicity
What are the four layers of the macula?
Photoreceptors
Retinal pigment epithelium
Bruch’s membrane
Choroid layer
What degeneration occurs to the macula in both wet and dry ARMD?
Drusen - between retinal pigment epithelium and Bruch’s membrane
Atrophy of retinal pigment epithelium
Degeneration of the photoreceptors
Symptoms of ARMD
Reduced visual acuity
Gradual worsening central visual field loss
Visual fluctuation
Metamorphopsia (distortion of visual images)
Wavy appearance to straight lines
Symptoms of wet ARMD
Presents more acutely Development of new vessels Loss of vision over days -> progresses to full vision loss over 2/3 years Progress to bilateral disease Distortion Linked with VEGF
Define dry ARMD
Much slower (over decades)
Investigations for ARMD
Snellen chart - reduced acuity
Scotoma
Fundoscopy - drusen
Slit lamp
Investigations for a wet ARMD
Optical coherence tomography - diagnoses wet ARMD
Fluorescien angiography
Management for wet ARMD
VEGF inhibitors - decrease formation of new blood vessels, increase acuity. E.g. bevacizumab, ranibizumab
Stop smoking
Diet rich in green vegetables
PHotodynamic laser therapy
Management for dry ARMD
Vitamin supplementation (Vit A/E/zinc) Stop smoking
Define myopia
Short sight The eyeball is too long, only close objects focus the retina Genetic causes (chromosome 18p and 12q) Treatment = concave contact lenses
Define hypermetropia
Long sight
The eye is too short
Corrected with convex lens
Define retinal vein occlusion
Less sudden visual loss than retinal artery occlusion
Much more common than retinal artery occlusion
Occlusion occurs when a blood clot forms in the retinal veins and blocks off the drainage of blood
Causes macular oedema and retinal haemorrhage
Also the release of VEGF - formation of new blood vessels
Risk factors for retinal vein occlusion
Incidence increases with age Hypertension High cholesterol Diabetes Smoking Glaucoma SLE
Central retinal vein occlusion symptoms
Sudden onset
Painless blurred vision in one eye
Never asymptomatic
Blood spread out and not as dark
Branch retinal vein occlusion symptoms
Can be asymptomatic
Blurring of vision
Blood concentrated in one area (that branch vein)
Investigations for retinal vein occlusions
Fundoscopy - flame and blot haemorrhages, macular oedema, optic disc oedema
Fluoresein angiography
BP - for hypertension
Treatment for retinal vein occlusions
Immediate referral to ophthalmologist
VEGF inhibitors - ranibizumab, bevacizumab
Laser photocoagulation
Intravitreal steroids - dexamethasone implants
Define central retinal artery occlusion
Visual loss within seconds
Occurs when something blocks the flow of blood through the central retinal artery
Less common than retinal vein occlusion
Risk factors for central retinal artery occlusion
Atherosclerosis Old age Family history Smoking Alcohol Hypertension Diabetes Poor diet - cholesterol Obesity/inactivity
Symptoms of central retinal artery occlusion
Sudden painless loss of vision
Total loss of vision = central retinal artery
Top half or bottom half visual loss = branch retinal artery
Afferent pupillary defect
Investigations for central retinal artery occlusion
Fundoscopy - pale, white retina. Cherry red spot at the macula, thin retinal arteries
Treatment for central retinal artery occlusion
Immediate referral to ophthalmologist Ocular massage Removal of fluid to reduce IOP Inhaling carbogen - to dilate the artery Sublingual isosorbide dinitrate - to dilate the artery
Long term management for central retinal artery occlusion
Treat risk factors: stop smoking
cholesterol
Hypertension
Define giant cell arteritis
Medium to large vessel systemic vasculitis (rupture or stenosis of blood vessels)
Typically seen in patients >70 years old
Rapid onset e.g. <1 month
Symptoms of giant cell arteritis
Headache
Jaw claudication (chewing pain)
Scalp and temporal artery tenderness (when combing hair)
Neck pain
Sudden blindness, typically in one eye -> amaurosis fugax
Hip and shoulder morning stiffness (polymyalgia rheumatica)
Investigations for giant cell arteritis
ESR >50 mm/hr
CRP raised
Temporal artery biopsy - shows skip lesions - do within one week of starting prednisolone
Treatment for giant cell arteritis
Prednisolone (60mg) - high dose for two years
Define optic neuritis
Unilateral loss of acuity occurs over hours or days
Colour vision is affected (dyschromatopsia): red appears less red
Eye movements hurt
Afferent defect
Associated with multiple sclerosis
Treatment for optic neuritis
High-dose methylprednisolone (then prednisolone)
Full recovery over 2-8 weeks
Define retinal detachment
Where the retina separates from the choroid underneath, this is usually due to a retinal tear that allows vitreous fluid to get under the retina and fill the space between the retina and the choroid
Sight threatening emergency
The outer retina relies on the blood vessels of the choroid for its blood supply
Risk factors for retinal detachment
Trauma to the eye Posterior vitreous detachment Diabetic retinopathy Retinal malignancy Older age Family history
Symptoms of retinal detachment
4 F’s: Flashes and floaters (vitreous haemorrhage), Field loss (blurred or distorted vision), fall in acuity (peripheral vision loss) - like a shadow coming across
Management of retinal detachment
Virectomy (removal of vitreous fluid)
Scleral buckling
Pneumatic retinopathy
Management of retinal tears: Laser therapy, cyrotherapy
Define vitreous haemorrhage
Arises from: retinal neovascularization (diabetes & retinal vein occlusions), retinal tears, retinal detachment, trauma
Symptoms of vitreous haemorrhage
Vitreous floaters (small bleeds) - small black dots Sudden vision loss in large bleeds
Investigations for vitreous haemorrhage
B-scan US
Ophthalmoscopy
Treatment for vitreous haemorrhage
Virectomy - removes blood
Define posterior vitreous detachment
The vitreous body is the gel which keeps the retina pressed on the choroid. With age it becomes less firm and less able to maintain its shape.
Posterior vitreous detachment is where the gel comes away from the retina
Common in the elderly
Symptoms of posterior vitreous detachment
Painless
Flashing lights (photopsia) in peripheral vision
Floaters - in temporal side of vision
Spots of vision loss
Management for posterior vitreous detachment
Over time symptoms improve
Can cause retinal tears and detachment
Define retinal pigmentosa
Congenital inherited condition where there is degeneration of the rods and cones in the retina
Rods degenerate more than cones, leading to night blindness
Onset 10-30 years old
What time of inheritance is retinal pigmentosa?
It can be autosomal dominant, recessive or x-linked
Symptoms of retinal pigmentosa
Night blindness - 1st symptom
Peripheral vision loss -> followed by central vision loss
Investigations for retinal pigmentosa?
Fundoscopy - shows pigmentation, narrowing of arterioles, waxy or pale optic disc
Associated diseases with retinal pigmentosa
Usher’s syndrome
Bassen-Kornzweig syndrome
Refsum’s disease
Management for retinal pigmentosa
Refer to ophthalmologist + genetic counselling
Inform DVLA + wear sunglasses
Vitamin A/Beta carotene supplements
Oral Acetazolamide
Define hypertensive retinopathy
Damage to the small blood vessels in the retina.
Can be as a result of years of chronic hypertension or can develop quickly in response to malignant hypertension
Signs of hypertensive retinopathy
Silver or copper wiring - arteriole walls become thickened Arteriovenous nipping Cotton wool spots Flame haemorrhage Hard exudate Papilloedema
What are the stages in the Keith-Wagener classification for hypertensive retinopathy?
Stage 1 = mild narrowing of arterioles
Stage 2 = focal constriction of blood vessels & AV nicking
Stage 3 = Cotton-wool patches, exudates & haemorrhages
Stage 4 = Papilloedema
Management for hypertensive retinopathy
Control BP- stop smoking, diet, exercise
Define diabetic retinopathy
The blood vessels in the retina are damaged by prolonged exposure to high blood sugar levels (hyperglycaemia) causing retinal damage
Increased vascular permeability leads to leakage from the blood vessels, blot haemorrhages and the formation of hard exudates
Damage to the blood vessel wall leads to microaneurysms and venous bleeding
Damage to nerve fibres in the retina causes cotton wool spots
Neovascularization can occur
What categories can diabetic retinopathy be split into?
Non-proliferative
Proliferative
Diabetic maculopathy
What are the symptoms of non-proliferative diabetic retinopathy?
Mild: Microaneurysms -> dots
Moderate: Microaneurysms, blot haemorrhages, hard exudates, cotton wool spots, venous bleeding
Severe: Microaneurysms, blot haemorrhages, hard exudates, cotton wool spots, venous bleeding + intraretinal microvascular abnormality
Can progress to sight-threatening proliferative
Symptoms of proliferative diabetic retinopathy?
Neovascularization
Vitreous haemorrhage
Symptoms of diabetic maculopathy
Leakage from vessels close to macula
Macular oedema
Ischaemic maculopathy
Retinal thickening and hard exudates
Investigations for diabetic retinopathy
Dilated fundus photography
25% of type 2 diabetes mellitus have retinopathy at diagnosis
Management for diabetic retinopathy
Laser photocoagulation - treats proliferative and maculopathy
Anti VEGF medications e.g. ranibizumab,bevacizumab. SE: endopthalmitis
Vitreoretinal surgery - keyhole surgery on the eye. SE: cataract/haemorrhage
Complications of diabetic retinopathy
Retinal detachment Vitreous haemorrhage Rebeosis iridis (new blood vessel formation in iris) Optic neuropathy Cataracts
Risk factors for diabetic retinopathy
Pregnancy Dyslipidaemia Hypertension Smoking Anaemia Renal disease
Define Horner’s syndrome
Ptosis (drooping of upper eyelid)
Miosis (constriction of the pupil)
Anhydrosis (loss of sweating)
May also have enopthalmos
Caused by damage to sympathetic nervous system
Does not dilate to cocaine eyedrops
Causes of Horner’s syndrome
Stroke
Multiple sclerosis
Swelling (tumours) - Pancoast’s tumour
Syringomyelia (cyst in the spinal cord)
What is Holmes Adie pupil?
Unilateral dilated pupil
Slow responses to light and accommodation
Young female, impaired sweating
Holmes Adie syndrome = absent ankle and knee reflexes
What is Argyll Robertson pupil?
Bilateral Occurs in neurosyphilis Does not react to light Accommodates Bilaterally small
What is third nerve palsy?
Ptosis (eyelid droops)
Divergent strabismus (down and out pupil)
Dilated non-reactive pupil
Causes of third nerve palsy
Idiopathic Tumour Trauma Cavernous sinus thrombosis Posterior communicating artery aneurysm Raised ICP
What is a retinoblastoma
Most common ocular tumour found in children
The average age of diagnosis is 18 months
Signs: Strabismus, absence of red reflex, white pupil (leukocornia), visual problems
Treatment: Enucleation, chemotherapy, radiotherapy, photocoagulation
