Ophthalmology Flashcards
Name the condition:
- small, irregular pupils
- Accommodation reflex present (ARP)
- Pupillary reflex absent (PRA) (no response to light)
Causes (2)
Argyll-Robertson pupil
Causes
- Syphillis
- Diabetes
- Dilated pupil
- Unilateral
- Slowly reactive to accommodation
- Minimal if at all response to light
- Once pupil constricted it remains small for an abnormally long time
Holmes-Adie pupil
Benign condition common in women
What is Holmes-Adie syndrome?
Association of Holmes-Adie pupil with absent ankle/knee reflexes
Glaucoma types (3) Caused by?
- Closed angle/ angle closure glaucoma
- Opened angle glaucoma
- Normal-tension
Caused by raised intraocular pressure secondary to impairment of aqueous flow
Closed angle/ angle closure glaucoma (8)
Insidious vs sudden Pain or no pain Red or not red Sight Dilated or restricted Other features (2) Worse with restricted or dilated pupils
Raised IOP due to narrow angle between iris and cornea, passage for outflow of aq. humour is too narrow. Due to lens being pushed against iris.
Features
- Sudden onset eye/ head pain
- Hard, red eye
- Haloes
- Decreased visual acuity
- Semi-dilated non reacting pupil
- Worse with mydriaisis
- Systemic upset e.g N&V, AP
- Corneal oedema, dull/ hazy cornea
What does hypermetropia mean?
What does mydriasis mean?
What does myopia mean?
To be long sighted
Dilated pupils
Short/near sighted
Closed angle/ angle closure
Predisposing factors
- Hypermetropia
- Pupillary dilatation
- Lens growth associated with age
Closed angle/ angle closure
Mx
Emergency - refer to ophthalmologist
- Pilocarpine (increased outflow of the aqueous humour))
- BB (e.g. timolol, decreases aqueous humour production)
- alpha-2 agonist (e.g. apraclonidine, dual mechanism, decreasing aqueous humour production and increasing uveoscleral outflow)
- intravenous acetazolamide (reduces aqueous secretions)
Post acute attack
1. Laser peripheral iridotomy
Creates a tiny hole in the peripheral iris → aqueous humour flowing to the angle
Primary open angle glaucoma
RFs (6)
- HTN
- DM
- Steroids
- FH
- Black
- Myopia
Primary open angle glaucoma
Features (3)
- Insidious onset
- Peripheral visual field loss/ tunnel vision/ scotomas
- Optic disc cupping
Fundoscopy signs of primary open-angle glaucoma (5)
- Optic disc cupping
- Optic disc pallor
- Bayonetting of vessels
- Cup notching (usually inferior where vessels enter disc)
- Disc haemorrhages
Primary open angle glaucoma
Mx
First line
1. prostaglandin analogue (PGA) eyedrops
Second line
2. BB, carbonic anhydrase inhibitor, or sympathomimetic eye drops
If more advanced
3. surgery or laser treatment can be tried
What is transient monocular visual loss (TVML)
Name four causes:
Visual loss lasting less than 24 hours Causes 1. ischaemic/vascular (e.g. thrombosis, embolism, temporal arteritis etc). e.g. occlusion of central retinal vein/artery 2. vitreous haemorrhage 3. retinal detachment 4. retinal migraine
Dense shadow that starts peripherally progresses towards the central vision
A veil or curtain over the field of vision
Straight lines appear curved
Central visual loss
Retinal tear
Retinal detachment
features include afferent pupillary defect, ‘cherry red’ spot on a pale retina
Due to thromboembolism
Central retinal artery occlusion
severe retinal haemorrhages are usually seen on fundoscopy
causes: glaucoma, polycythaemia, hypertension
=
Central retinal vein occlusion
causes: diabetes, bleeding disorders, anticoagulants
features may include sudden visual loss, dark spots
=
Vitreous haemorrhage
Flashes of light (photopsia) - in the peripheral field of vision
Floaters, often on the temporal side of the central vision
=
Posterior vitreous detachment
Herpes zoster ophthalmicus
Mx
- PO antivirals for 7-10 to be started within 72 hours of rash - IV if immunocompromised or very severe
- Topical steroids in any inflammation of the eye
If eye involvement –> ophth review
Features of herpes zoster opthalmicus
- vesicular rash around the eye, which may or may not involve the actual eye itself
- Hutchinson’s sign
What is Hutchinson’s sign?
rash on the tip or side of the nose. Indicates nasociliary involvement and is a strong risk factor for ocular involvement
Seen in herpes zoster opthalmicus
RA ocular manifestations (5)
Iatrogenic ocular manifestations (2)
- keratoconjunctivitis sicca (most common)
- episcleritis (erythema)
- scleritis (erythema and pain)
- corneal ulceration
- keratitis
Iatrogenic
steroid-induced cataracts
chloroquine retinopathy
Scleritis
Features (4)
- red, watery eye
- classically painful (in comparison to episcleritis)
- photophobia
- gradual decrease in vision
How to differentiate between scleritis and episcleritis
Mx episcleritis
Sclertitis painful, episcleritis isn’t
phenylephrine drops can be used to differentiate between the two. If eye redness improves after phenylephrine –> episcleritis
Mx artificial tears
What is keratitis?
Common bacteria (2)
Inflammation of the cornea
Microbial keratitis is potentially sight threatening and should therefore be urgently evaluated and treated
- Staph A
- Pseudomonas aeruginosa is seen in contact lens wearers
Keratitis
Features (4)
- red eye: pain and erythema
- photophobia
- foreign body, gritty sensation
- hypopyon may be seen
Painful red eye in a contact lens wearer
Diagnostic test
Mx
Keratitis Slit lamp Mx 1. Topical quinolone 2. Cycloplegic for pain relief
Age Related Macular Degeneration (ARMD)
Features (5)
Speed of visual loss What type of sight is lost first? (2) Other features (2)
- Subacute visual loss
- Near field loss
- Deterioration at night
- Photopsia, (a perception of flickering or flashing lights),
- Crooked or wavy appearance to straight lines
ARMD
Ix including fundoscopy findings (5)
Fundoscopy findings in wet ARMD
- Amsler grid testing - distortion of line perception
- Fundoscopy: drusen + central scotoma
- slit-lamp microscopy + colour fundus photography
- fluorescein angiography (wet ARMD)
- ocular coherence tomography (wet ARMD)
Fundoscopy- wet ARMD well demarcated red patches may be seen which represent intra-retinal or sub-retinal fluid leakage or haemorrhage
ARMD types
Dry 90% of cases
Wet 10% of cases
- worse prognosis
What is the role of vascular endothelial growth factor (VEGF) in ARMD?
VEGF stimulates new vessel growth in wet ARMD which leads to oedema and more rapid loss of acuity.
ARMD
Mx
Dry
Wet
- Dry ARMD zinc with anti-oxidant vitamins A,C and E
2. Wet ARMD anti-VEGF agents, e.g ranibizumab, bevacizumab and pegaptanib - 4 weekly injection.
Define: Blepharitis Stye Chalazion Entropion Ectropion
blepharitis: inflammation of the eyelid margins typically leading to a red eye, grittiness and discomfort
stye: infection of the glands of the eyelids
chalazion = Meibomian cyst
entropion: in-turning of the eyelids
ectropion: out-turning of the eyelids
What is a chalazion?
Mx
Retention cyst of the Meibomian gland. It presents as a firm painless lump in the eyelid. Resolve spontaneously some require surgical drainage
What is a stye? How does it differ from a chalazion?
Chalazion are cysts of the meibomian gland/ oil glands deep in the eye lid (internal)
Stye’s are usually an infected an eyelash caused by Staph Aureus (external)
Mx hot compresses and analgesia, only give abx if assoc. conjunctivitis
Blepharitis features (4)
Rx
- Usually bilateral
- grittiness and discomfort, particularly around the eyelid margins
- eyes may be sticky in the morning
- eyelid margins may be red and swollen
Rx
- Hot compress BD
- Lid hygiene
- Artificial tears
Anterior uveitis Genetics Features (5) Acute/ insidious Restricted or dilated pupil Other (3)
Is visual acuity affected?
- HLA B27
Features
- Acute onset, painful red eye
- Pupil irregular and small
- Photophobia
- Blurred vision
- Lacrimation
Visual acuity is initially normal, then becomes impaired
Anterior uveitis
Mx
- urgent review by ophthalmology
- cycloplegics (dilates the pupil which helps to relieve pain and photophobia) e.g. Atropine, cyclopentolate
- steroid eye drops
What is papilloedema?
Optic disc swelling that is caused by increased intracranial pressure.
Bilateral
Papilloedema
Features (6)
- venous engorgement: usually the first sign
- loss of venous pulsation
- blurring of the optic disc margin
- elevation of optic disc
- loss of the optic cup
- Paton’s lines: concentric/radial retinal lines cascading from the optic disc
Name the condition: severe pain (may be ocular or headache) decreased visual acuity, patient sees haloes semi-dilated pupil hazy cornea
Acute angle closure glaucoma
Name the condition: acute onset pain blurred vision and photophobia small, fixed oval pupil, ciliary flush
Anterior uveitis
Name the condition: severe pain (may be worse on movement) and tenderness may be underlying autoimmune disease e.g. rheumatoid arthritis
Scleritis
Name the condition:
purulent discharge if bacterial, clear discharge if viral
Conjunctivitis
Name the condition:
history of trauma or coughing bouts, painless, red eye
Subconjunctival haemorrhage
Name the condition
typically red eye, pain and visual loss following intraocular surgery
Endophthalmitis
Retinitis pigmentosa
Features (2)
Fundoscopy findings
- night blindness
- tunnel vision due to loss of the peripheral retina
Fundoscopy:
- black bone spicule-shaped pigmentation in the peripheral retina
- mottling of the retinal pigment epithelium
- Cherry red spot
- Sudden loss of vision
- Due to thromboembolism
Central retinal artery occlusion
- sudden, painless reduction or loss of visual acuity
- unilaterally
- Fundoscopy: severe retinal haemorrhages
Central retinal vein occlusion
- Reduced vision
- Faded colour vision: making it more difficult to distinguish different colours
- Glare: lights appear brighter than usual
- Halos around lights
Defect in red reflex
Cataracts
Cataracts
Ix (2)
- Fundoscopy: normal fundus and optic nerve
2. Slit-lamp examination. Findings: visible cataract
Complications post cataract op (4)
- Posterior capsule opacification: thickening of the lens capsule
- Retinal detachment
- Posterior capsule rupture
- Endophthalmitis: inflammation of aqueous and/or vitreous humour
Chorioretinitis
Causes (5)
syphilis cytomegalovirus toxoplasmosis sarcoidosis tuberculosis
Fluorescein examination: yellow stained abrasion which is usually visible to the naked eye.
Mx
Corneal abrasion
Topical antibiotic
Corneal ulcers
Common in which type of pt?
Features (4)
Contact lens wearers
- eye pain
- photophobia
- watering of eye
- focal fluorescein staining of the cornea
Diabetic retinopathy
Types
Non proliferative
Proliferative
Non proliferative diabetic retinopathy features
Mild
Moderate
Severe
Mild
=>1 microaneurysm
Moderate
- microaneurysms
- blot haemorrhages
- hard exudates
- cotton wool spots
- venous beading/looping
- intraretinal microvascular abnormalities (IRMA)
Severe
- blot haemorrhages and microaneurysms in 4 quadrants
- venous beading in at least 2 quadrants
- IRMA in at least 1 quadrant
Proliferative diabetic retinopathy
Features
- retinal neovascularisation - may lead to vitrous haemorrhage
- fibrous tissue forming anterior to retinal disc
(more common in T1DM, 50% blind in 5 years)
Diabetic maculopathy
- hard exudates and other ‘background’ changes on macula
More common in T2DM
A patient presents with an acute, painful red eye associated with photophobia and epiphora. Fluorescein staining reveals a ragged area on the cornea
Mx
Herpes simplex keratitis
- Ophth review
- Topical aciclovir
Horner’s syndrome
Features
- miosis (small pupil)
- ptosis
- enophthalmos* (sunken eye)
- anhidrosis (loss of sweating one side)
Congenital Horner’s
heterochromia (difference in iris colour)
Keith-Wagener classification of hypertensive retinopathy
I - Arteriolar narrowing and tortuosity
- Increased light reflex - silver wiring
II - Arteriovenous nipping
III - Cotton-wool exudates
- Flame and blot haemorrhages
IV - Papilloedema
Serous discharge
Recent URTI
Preauricular lymph nodes
=
Viral conjunctivitis
Purulent discharge
Eyes may be ‘stuck together’ in the morning)
Bacterial conjunctivitis
Mx conjunctivitis
Usually settles without treatment within 1-2 weeks
- Topical chloramphenicol - drops every 2-3 hours or ointment QDS
- Topical fusidic acid for pregnant women
What is the most common cause of a persistent watery eye in an infant?
Common age
Mx
Nasolacrimal duct obstruction
1 month
Mx
Massage the lacrimal duct
Sx resolve in 95% by the age of one year.
If unresolved refer to ophthalmologist for consideration of probing
Optic neuritis causes:
multiple sclerosis
diabetes
syphilis
Optic neuritis
Features (5)
Mx
- unilateral decrease in visual acuity over hours or days
- poor discrimination of colours, ‘red desaturation’
- pain worse on eye movement
- relative afferent pupillary defect
- central scotoma
Mx
high-dose steroids
recovery usually takes 4-6 weeks
Explained the Relative afferent pupillary defect What is it also known as? What is it caused by? How do you test for it? Seen in which conditions?
Marcus-Gunn pupil
‘swinging light test’.
Caused by a lesion anterior to the optic chiasm i.e. optic nerve or retina
Dilatation of the eye when light is shone on the affected eye
MS (optic neuritis)
Retinal detachment
What is the pathway of the pupillary light reflex
Afferent
Efferent
afferent: retina → optic nerve → lateral geniculate body → midbrain
efferent: Edinger-Westphal nucleus (midbrain) → oculomotor nerve
Spreading upper respiratory tract infection from the sinuses 1. reduced visual acuity 2. proptosis 3. ophthalmoplegia/pain with eye movements 4. Redness, swelling 5. Eyelid oedema + ptosis 6. Drowsiness/ nausea/ vomiting Medical emergency --> ADMIT IV abx
Orbital cellulitis
Caused by commonly
Mx
Orbital cellulitis
Ix
Most common organisms (3)
- Bloods - raised infection markers
- Ophthalmological assessment- decreased vision, afferent pupillary defect, proptosis, dysmotility, oedema, erythema.
- CT with contrast – Inflammation of the orbital tissues deep to the septum, sinusitis.
- Blood culture and microbiological swab to determine the organism.
Most common bacterial causes – Streptococcus, Staphylococcus aureus, Haemophilus influenzae B.
Squint
Types
- Concomitant
- Due to imbalance in extraocular muscles
- convergent - Paralytic
- Due to paralysis of extraocular muscles
- divergent
Ix (2)
Mx (2)
- corneal light reflection test - holding a light source 30cm from the child’s face to see if the light reflects symmetrically on the pupils
2. Cover test ask the child to focus on an object cover one eye observe movement of uncovered eye cover other eye and repeat test
Mx
referral to secondary care
eye patches may help prevent amblyopia
Cataracts causes
- Ageing
- Smoking
- Increased alcohol consumption
- Trauma
- Diabetes mellitus
- Long-term corticosteroids
- Radiation exposure
- Myotonic dystrophy
- Metabolic disorders: hypocalcaemia
Severe dry eyes management:
Punctal plugs if there is frequent use of eye drops without features of inflammation
white focal retinitis with overlying vitreous inflammation.
= toxoplasmosis
‘pizza pie’, with retinal spots and flame haemorrhages-
cytomegalovirus
central retinal vein occlusion
Mydriatic drops are a known precipitant of ?
acute angle closure glaucoma
Intermittent squint in newborns less than 3 months
Mx
normal and does not need to be investigated
night blindness + tunnel vision =
Retinitis pigmentosa
Preauricular lymph nodes
bacterial or viral conjunctivitis?
viral
Punctate fluorescein staining of the cornea is common in patients with
dry eyes
Dots + blots + haemorrhages and lipid exudates =
background retinopathy
vision improving with a pin hole =
refractive error
