Ophthalmology Flashcards
Name and explain the stages of diabetic retinopathy?
Diabetic retinopathy
- Background
- Microaneurysms (dots) and haemorrhages (dot and blot)
- Hard exudates (more severe) - Maculopathy
- odema/other changes covering 1/3 of the macula - Pre proliferative
- Soft exudates (cotton wool spots- ischemia of nerves) - Proliferative
- new vessel formation
How would maculopathy present?
visual acuity and colour vision loss
How do you treat diabetic retinopathy?
Diabetic retinopathy
- Manage diabetes
- LASER PHOTOCOAGULATION
- anti-VEGF injections to prevent new vessel formation
- Virectomy (only if vitreous bleed)
Name and explain the stages of hypertensive retinopathy?
LOOK FOR VESSEL CHANGES IN HYPERTENSIVE (veins are darker and fatter) Stage 1 -Tortuosity of arteries -Narrowing of arteries
Stage 2
- AV nipping (artery nips vein)
- Silver copper wiring
Stage 3
- Soft exudates (cotton wool spots- ischemia of nerves)
- Hard exudates
- Flame and splinter haemorrhages
Stage 4
-Papilodema (poorly defined margins of optic disk and vessels dont come from clear place)
cupping>atropphy (>80%)
What is the treatment for hypertensive retinopathy?
Treatment for hypertensive retinopathy is controlling BP
What are the different types of conjunctivitis? What is the discharge like for each?
Bacterial - mucopurulent and STICKY
Viral - watery and intermittently ITCHY
Chlamydial - watery
Allergic - stringy and ITCHY
What is the main treatment for bacterial conjunctivitis?
1st line with CI and 2nd line
Antibiotic eye drops
1st line: Chloramphenicol - risk of aplastic anaemia
(CI: pregnant/breastfeeding or personal or FH of aplastic anaemia)
2nd line: Fusidic acid
When would you suspect gonoccocal/chlamydial conjunctivitis?
Treatment of gonoccoal / chlamydial conjunctivitis?
Suspect gonoccocal/chlamydial conjunctivitis when fails to respond to treatment (plus STI risk factors)
Treat as per SYSTEMIC ILLNESS
- Chalmydia: Doxycycline 7 days (azithromycin if pregnant)
- Gonococcal: IM injection of CEFTRIAXONE
Whats the most common cause of bacterial conjunctivitis? Most common cause of viral?
Bacterial conjunctivitis
- Strep pneumoniae
- Staph aureus
- H. influenzae
Viral=most commonly adenovirus
How does allergic conjunctivitis present?
Allergic conjunctivitis
- Itching and watering
- Swollen lids and conjunctiva
- Bilateral (viral more often spreads between eyes/people)
*typically seasonal/history of atopy
What the management of allergic conjunctivitis?
Management:
1. Remove exposure 2. Cool compress 3. Oral/topical antihistamine (Emedastine or cetirizine hydrochloride) 4. Topical mast-cell stabilisers (both antihistamine and mast stabilisers)
How does blepharitis present?
Blepharitis
- Red, swollen and itchy eyelids
- Gunking = secretions from Meibomian glands
- Burning feeling
- Bilateral gritty eyes (if unilateral-think malignancy)
- Crusting = staph infection
- Loss of eyelashes
- Frothy tears
What is the treatment of blepharitis?
‘LID HYGIENE’
Warmth: hot compress
Massage: cotton buds
Clean: baby shampoo
Artificial tears for gritty eye symptoms
Differentiate between entropion and ectropion?
Entropion = inversion of eyelids caused by lower lid laxity so orbicularis muscle overrides tarsal plate
- Red, itchy, sore, gritty, uncomfortable eyes
- Irritation from eyelashes can cause corneal ulcer
Ectropion = eversion of eyelids due to laxity causing exposure of tarsal conjunctiva
- Dryness, redness
- Frequently discharging
Managment of entropian/ectropian?
Entropian
- tape the eyelid
- artificial tears (drops for day, ointment for night)
What is a chalazion?
Chalazion
- Meibomian cyst
- Blockage of gland > traps sebaceous secretions> chronic granulomatous inflammation
Whats the difference between a sty and chalazion?
Stye
- Lid margin infection
- on the eye lid
- Painful ‘spot’
Chalazion
- blokced gland not infection ‘hard’
- within the eye lid
- not usually painful
What is the management of chalazion?
- Usually self limiting
- Hot compresses
- Massage
- If not resolved: Incision + curettage to drain
What can cause ptosis?
Age-related degeneration of levator muscle aponeurosis
CNIII palsy/Horner’s syndrome
Myasthenia gravis/muscular dystrophy
What most commonly causes a corneal ulcer?
Contact lenses
Bacteria
Viruses
Acanthamoeba (live in water)
Fungi (immunocompromised)
How does a corneal ulcer present?
What is the investigation?
What is the managment?
CONTACT LENS USER
- Redness+ Pain
- Photophobia
- Watering
Investigation
- Fluorescein dye (can see epithelial damage)
- Appears green in blue light
- Check for foreign body
Managment
Topical Abx, Local, Eye clinic
What is the managment of corneal foreign body?
Corneal foreign body
- lose foreign body can be irrigated with saline
- can be removed with cotton bud/blunt tip needle
- DO FLUROSCEIN DYE to check for corneal abrasion
- consider chloranphenicol eye drops if risk of infection
What is anterior uveitis/iritis?
What conditions is this assosiated with?
Anterior uveitis/iritis?
-Inflammatory of iris and ciliary body
Autoimmune associations
- Strongly associated with HLA-B27 (70%)
- Rheumatoid/Bechets/Ank spond/Psoriasis/IBD/sarcoidosis
Infective associations
- Toxoplasmosis/HIV/TB
- Herpetic keratitis
- Recent intraocular surgery
Symptoms of anterior uveitis?
Anterior uveitis
- PAIN
- -deep, boring pain
- -↑with accommodation/movements
- -photophobia
- Blurred vision (because not accommodating properly-think of camera lens)
- May have small pupil
How will the eye look in anterior uveitis?
Anterior uveitis
- red eye (perilimbal ciliary injection)
- IRREGULAR SHAPED PUPIL may be small (synechiae),
- may have hypopyon (leukocyte exudate in the anterior chamber)
How do you manage uveitis?
- Analgesia + Urgent ophthalmology assessment
- Opthalmology: Prednisolone 1% eye drops + cycloplegic (e.g. atropine/cyclopentolate) to temporarily paralyse cilary body
How would scleritis present?
- Deep boring pain
- -Wakes patient up from sleep
- -Radiates to forehead
- -Worse on eye movements (muscles)
- -Tender to touch
- Red eye
- Vision may decrease
What is the treatment for scleritis?
Scleritis=systemic treatment. HIGH DOSE SYSTEMIC STEROIDS
*investigat underlying cause
How can you tell the difference between scleritis and episcleritis?
PHENYLEPHRINE EYE DROPS
branching of vessels=episcleritis (superior blood supply)
blueness or persistent redness after 5 mins=scleritis
Episcleritis vs Scleritis
symptoms, treatment, assosiations
Scleritis= deep pain. Episcleritis=little/no pain + watering
Scleritis=visual changes Episcleritis=no visual changes
Scleritis=systemic steroids. Episcleritis=self limiting (topical NSAIDS)
Scleritis=HLA-B27 conditions. Episcleritis=IBD
Define glaucoma
Death of optic nerve due to raised intraocular pressure (>21mmHg), optic disc cupping and progressive visual loss
What type of glaucoma is most common? How does it present?
Open angle glaucoma
Bilateral peripheral visual loss (can be asymptomatic)
What are the risk factors for open angle glaucoma?
Family history
Hypertension
Diabetes
Myopia = short sighted
Explain what happens in closed angle glaucoma present?
- Lens pushes against iris > aqueous can’t drain from posterior to anterior chamber
- Trabecular meshwork also blocked >aqueous cannot drain from ant. chamber
- RAISED intraocular pressure >sight-threatening
Risk factors for closed angle glaucoma ?
Hyperopia (long-sighted) – smaller eyes-easily blocked Low light (dilates pupil) Drugs: sympathomimetics, anticholinergics (dilate pupil) (inhalers)
How would closed angle glaucoma present?
- RED and PAINFUL EYE
- Systemic: nausea, vomiting, headache, abdo pain
- ‘Halos’ around lights (often in eve-dilation of pupils)
- Reduced aquity
How would pupil look in closed angle glaucoma ? (3)
- Red
- Hazy cornea
- MID DILATED PUPIL UNREACTIVE TO LIGHHT
Treatment of closed angle glaucoma?
- Opiate analgesia & antiemetic (Oromorph + Ondansetron)
- IV acetazolamide (carbonic anhydrase inhibitor) - reduces aqueous production and ↓IOP
- Pilocarpine 1% drops (after 1hr)
(Topical miotic>constrict the pupil and allows drainage)
- **Emergency ophthalmic review for DEFINITIVE treatment -Laser peripheral iridotomy
- Makes an alternate flow for aqueous
What is keratitis?
How would this present?
Inflammation of cornea – often after trauma (contact lenses, lupus, syphilis)
Potentially sight-threatening
Presentation
- Pain
- loss of vision
- purulent discharge (somethings on the eye and its trying to remove)
Managment of keratitis?
Management
Same day ophthalmology referral
Stop using contact lens!
Antibiotics (topical +/- IV)
Causes of subconjunctival heamorrage?
Treatment?
Raise in IOP (sneezing/coughing)
Aspirin (check coag if taking other anticoags)
Trauma
HTN (check BP)
Reassure: Will take 2-3wks to resolve
What eye sign may suggest ocular trauma?
What is the management of ocular trauma?
-Hyphema may suggest blunt trauma (blood in ant chamber)
Managment (more serious than SCheamorrage)
- Requires regular ophthalmic review and rest
- IF PENETRATING GIVE ORAL ANTIBIOTICS and SURGERY
How can you tell the difference between Periorbital (pre-septal) cellulitis and orbital cellulitis?
Orbital cellulitis (infection of eye mussels/fat
- Reduced visual acuity
- Proptosis
- Ophthalmoplegia / pain
- Red eye
Pre septal is just an infection of the skin and soft tissues so wont have these
Different managment for Periorbital (pre-septal) cellulitis and orbital cellulitis?
Periorbital (pre-septal) cellulitis: Refer to hospital and Oral co-amoxiclav (but rule out orbital)
Orbital cellulitis: Admit for IV abx
CEFOTAXIME + FLUCLOXACILLIN
(may also need surgery)
Investigation of choice for orbital cellulitis?
contrast CT head if orbital cellulitis is suspected (there is high mortality with orbital cellulitis)
What organisms most commonly cause preseptal and orbital cellulitis? How do you treat each?
Preseptal
- Staph aureus
- Abx: co-amoxiclav 10 days
Orbital
- Strep pneumoniae
- Abx: flucloxacillin/ceftriaxone IV
What are the main complications of orbital cellulitis?
Blindness
Meningitis
Cavernous sinus thrombosis
Whats the treatment for open angle glaucoma
Latanoprost (prostaglandin analogue) - increases outflow
Timolol (beta-blocker) - reduces aqueous
What are the side effects of latanoprost?
Thicker, darker, longer lashes
Darker iris + skin around eyes
What can cause a painful loss of vision?
Acute angle closure glaucoma Giant cell arteritis Optic neuritis Uveitis, slceritis, keratitis Shingles Orbital cellulitis
What can cause a painless loss of vision?
Cataracts Retinal detachment Retinal vessel occlusion Diabetic retinopathy Age-related macular degeneration Optic nerve compression (Berry aneurysm)
What is amaurosis fugax?
TIA of a retinal artery
Causes transient monocular blindess due to transient retinal ischaemia (preceding central retinal artery occlusion-the MI of the eye)
What are risk factors for cataracts?
- old age
- female
- diabetes
- smoking
- steroids
Classic symptoms of cataracts?
Signs of cataracts (2)
- clouding
- light scattering
- HALOS
- GLARRING AT NIGHT
- obstruction of vision (painless, gradual, worse watching TV/reading)
Signs: loss of red light and opacities
Most common cause of cataract (acquired/congenital)
Aquired: age
Congenital: rubella (also TORCH/EBV/chicken pox))
What are the following tests
Amslers grid test
Tonmetry
Amslers grid test: macular degeneration
Tonmetry: pressure in eye
Presentation of hepatic ulcer?
Treatment for herpatic ulcer?
Red eye, extremely painful, no discharge (unlike keratitis) (fluorescein drops)
treatment: topical Aciclovir drops 2 weeks
Treatment for herpes zoster opthalmicus (herpes involving eye)
-ORAL aciclovir and topical steroids
What signs would vitreous haemorrhage give with fundoscopy?
No red reflex
Can’t see retina
(if you can’t see in and patient can’t see out, it is likely vitreous haemorrhage and retinal detachment is the differential)
What causes optic atrophy (big cup)?
Optic neuritis
End stage glaucoma
Tumour compressing optic nerve
What is a central retinal artery occlusion?
How does it present?
- Central retinal artery occlusion is an MI of the eye (caused by thromboembolic disease also in GCA)
- Sudden onset unilateral LOV (time critical)
What does fundoscopy of a retinal artery occlusion look like?
Treatment:
- Pale retina (no blood supply) with oedema
- Cherry-red macula (still okay because double blood supply)
Treatment-URGENT REFERAL
- Masage eye (help with blood supply)
- Nitrates to vasodilate
- Surgical fibrinolytic
What is central retinal vein occlusion?
How does it present?
- PE of the eye (caused by venous thrombosis or nipping by HTN arteries)
- Painless subacute LOV (few days)
- More common that central artery occlusion
What does fundoscopy of a retinal vein occlusion look like?
- Hypertensive signs or arteries (tortuous, nipping)
- Looks like a cheese and tomato pizza -yellow and redness
How do you manage retinal vein occlusion?
anti-VEGF
Vascular endothelial growth factor is released to recruit new blood vessels
How does ARMD present?
Progressive central visual deterioration
Differentiate between dry and wet age-related macular degeneration
Dry
- Atrophic
- Drusen in macula (yellow spots)
Wet
- Exudative
- Neovascularisation
- Subretinal haemorrhages in/around macula
Treatment for ARMD
Wet ARMD
- Anti-VEGF - prevents neovascularisation
- Laser phocoagulation
(no treatment for dry)
Management of optic neuritis?
High dose methylprednisolone for 72hrs (1000mg/24hr IV)
then prednisolone 1mg/kg/d po for 11 days
What is hyperopia vs myopia?
Hyperopia (long sighted) = an image of a distant object becomes focused behind the retina, making objects up close appear out of focus
Myopia (short sighted) = an image of a distant object becomes focused in front of the retina, making distant objects appear out of focus
Name two types of squint
Convergent squint (esotropia) Divergent squint (exotropia)
Which type of squint is more common? What causes it?
Esotropia - either no cause or can be due to hypermetropia
How are squints investigated?
Corneal reflection
Cover test
Describe a corneal reflection test
Reflection from a bright light falls centrally and symmetrically if no squint
Describe a cover test
What is the cover/uncover test
Cover test is used to determine MANIFEST squints (tropias) I.e. squints that are ALWAYS there
-The uncovered eye moves to take up fixation (uncovered eye corrects itself)
Cover/uncover test
- used to look for LATENT squints (phorias)
- the eye will only squint when covered, and when uncovered its fine
What is a paralytic vs a non paralytic squint?
Paralytic (or concomitant) squint is when the squint occurs in all directions of gaze, double vision does not normally occur
Non-paralytic is not constant, occurs when child is tired
management of squint
Glasses for refractive errors
Eye patches
Operation eg resection and recession of rectus muscles to realign
Botulinum injections
Pupil in acute angle closure glaucoma vs anterior uveitis
anterior uveitis
-irregular shape
-may be small
+/- hypopyon
acute angle closure glaucoma
- mid dilated
- unresponsive to light
- hazy cornea
Vitreous heamorrage vs vitreous detachment vs retinal detachment
Vitreous heamorrage
- Large bleeds cause sudden visual loss (morning as blood is more settled)
- Diabetics
Vitreous detachment
-Flashes/floaters
Retinal detachment
- Flashing lights, floaters and loss of vision in the upper outer quadrant of his right eye.
- Dense shadow that starts peripherally progresses towards the central vision
- Straight lines appear curved
