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Clinical Medicine > Ophthalmology > Flashcards

Ophthalmology Flashcards

1
Q

Signs of retinal vascular disease

A 
Vascular changes:  Arteriosclerosis, AV crossing changes, venous tortuosity, cotton wool spots
Microaneurysms
Haemorrhages
Hard exudates
Neovascularization
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2
Q

What are microaneurysms and what can they suggest

A

Little round dots from vessel outpouchings

Need to think about an OCT scan to check for macular oedema

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3
Q

What are the different categories of haemorrhage

A

Dot and blot
Flame
Pre-retinal
Roth spots

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4
Q

Describe dot and blot haemorrhages

A

Haemorrhage in the middle retinal layer due to diabetes/HTN

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5
Q

Describe flame haemorrhage

A

Haemorrhage in the superficial nerve fibre layers due to CRV occlusion

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6
Q

Describe pre retinal haemorrhage

A

Haemorrhage near the vitreous, between the retina and the posterior hyaloid
Caused by trauma, valsalva, neovascularisation

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7
Q

Describe roth spots

A

Haemorrhage with central opacity

May be due to seeding of septic emboli (IE), anaemia or haematological diseases

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8
Q

What are hard exudates and what can cause them

A

Lipid deposition in the outer layer due to abnormal vascular permeability
Ill defined, discrete
Assoc w diabetes

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9
Q

What is a macular star and what causes it?

A

Star of cream on the macula due to swelling and exudate of the optic nerve head
Due to cat scratch disease or ocular syphilis

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10
Q

What are cotton wool spots and what cause them

A

Ischaemic infarction in the nerve fiber layer

Assoc with diabetes, HTN, SLE, leukaemia, HIV

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11
Q

What is neovascularization and what causes it

A

Hypoxia leading to vasoformative factors and neovascularization
May occur in the retina, optic disc, iris or angle
Caused by diabetes, RVO, retrolental fibroplasia (of prematurity), sickle cell disease and inflammatory diseases

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12
Q

What do you do for neovascularization and what risk does it pose?

A

Treated with laser to prevent further development

Neovascularization increases the risk of new bleeds

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13
Q

What does venous occlusion look like

A

Dilated venules, haemorrhage, oedema
Increased venous tortuosity
May occur centrally or at a branch

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14
Q

What does arterial occlusion look like

A 
Retinal pallor and oedema
arteriole construction
column interruption
cherry red spots
visible emboli
retinal pallor
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15
Q

What does retinal degeneration look like and what should you do?

A

Atrophy, pigmentation and scarring of retina
Presence of drusen- collection of material in pigment layer of retina
If present, get an OCT to check for macular oedema

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16
Q

What are the types of retinal elevation?

A

By fluid- retinal detachment
By solid mass- tumour, choroidal neovascularization
Vitreous detachment
Retinal tear

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17
Q

What is cystoid macular oedema

A

Hard exudates and swelling at the back of the eye

Petalloid appearance on FFA

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18
Q

What does viritis look like

A

Stranding and tiny cells at the back of the eye

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19
Q

What does multifocal choroiditis look like

A

Similar to cotton wool spots

Differentiate with lack of diabetes hx and lack of haemorrhages

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20
Q

What does retinitis look like and what causes it

A

One large cotton wool spot
Likely see vitreous cells in the anterior chamber
Mostly due to toxoplasmosis

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21
Q

What do granulomas look like and what causes them

A

Pale white spots at the back of the eye

Caused by sarcoid or TB

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22
Q

What is a good exam system for eye trauma

A

From front to back of eye

Start with visual acuity, end with 5 neuro exams- vision, pupils, visual fields, movement and colour vision

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23
Q

Describe metal trauma to the eye

A

Often secondary to grinding metal
Presents with red, sore and irritated eye
Fluoroscein shows scratches
Can sometimes see foreign body in eye or inner upper eyelid
Use a small needle to flick out of eye unless over pupil

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24
Q

Describe blunt trauma to the eye

A

Eyelid bruising, subconjunctival haemorrhage (blood between conjunctiva and scleara)
Reassure if otherwise visually intact

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25
Q

What is hyphaema

A

Anterior chamber haemorrhage between cornea and iris
Blocks angle, risks increase of pressure and angle crisis
Compresses, steroid drops, 1/52 off work
Continue to assess for risk of rebleeding

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26
Q

What is orbital blowout fracture

A

Fracture of bones surrounding eye

May present with poor eye movements due to trapping of muscles in bone shards or inflammation

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27
Q

Describe chemical ocular trauma management

A

Irrigate eye under tap until at hospital, then use bags of saline attached to Morgan lens- several litres will be needed
Assess limbus as this is stem cell site and may influence need for corneal transplant
Complication- anaesthetic cornea with conjunctiva overgrowing

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28
Q

Which is worse between acid and alkali burns

A

Alkali as it causes liquefactive necrosis as opposed to coagulative necrosis

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29
Q

Describe management of UV/IR trauma

A

Can only give lubricating drops

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30
Q

Describe penetrating/intraocular trauma

A

Usually a result of high speed metal such as bullet
Comes complaining of eye pain and blurring
Can see part of iris prolapsing to plug hole (teardrop pupil) or opacification of the lens causing an absent red reflex. There may also be a vitreous bleed
Management is usually surgical

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31
Q

Describe lid laceration risks and processes

A

Risk of tear duct dysfunction causing persistent teariness
Risk of poor lid closure
Risk of scar and infection
Requires skilled surgical repair

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32
Q

Describe scleral laceration

A

May be partial or full thickness of sclera
Pain and blurred vision
Iris may plug hole (like penetrating injury)

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33
Q

Definition of conjunctivitis

A

Inflammation of the conjunctiva

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34
Q

Causes of conjunctivitis

A 
Viral
Bacterial
Chlamydial
Seasonal/perennial
Vernal
Atopic
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35
Q

Describe viral conjunctivitis

A

History of previous URTI, pre-auricular lymphadenopathy
Painless, tight, swollen and uncomfortable eyes
Normal vision unless excess swelling
Watery discharge
Scleral and eyelid reddness, follicles
Normal pupils

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36
Q

Treatment of viral conjunctivitis

A

Meticulous hygeine, compresses, lubricants, swabs

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37
Q

Describe bacterial conjunctivitis

A 
Soreness, pain, heat, tightness
Normal vision unless excess swelling
Purulent discharge
Red and boggy conjunctiva, follicles and papillae
Normal pupils
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38
Q

Treatment of bacterial conjunctivitis

A

Swab for culture, hygeine, chloramphenicol

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39
Q

Describe chlamydial conjunctivitis

A

History of urethritis if assoc with reiter’s syndrome
Symptoms: If type ABC it’s eyelid inflammation (trachoma)
If type D-K it’s long term lower eyelid conjunctivitis
Vision normal if conjunctivitis, eventual blindness if trachoma
Mucopurulent discharge
Hyperaemic vessels and follicles
Normal pupils

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40
Q

Treatment of chlamydial conjunctivitis

A

Tetracycline abx, treat parents and sexual partners

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41
Q

Describe allergic conjunctivitis

A

History of atopy, allergy, contact lens wear
Itching, red eyes, lid swelling, URT symptoms
Normal vision unless excess swelling, mucoid discharge
Redness often sectorial, sometimes diffuse
Papillae
Normal pupils

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42
Q

Treatment for allergic conjunctivitis

A

Systemic antihistamines are firstline

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43
Q

Describe vernal conjunctivitis

A

Occurs in 9-19 year olds, in boys more than girls
Itch, mucus, redness and photophobia
Tarsal or limbal papillae
Lipid deposits from leaky vessels (pseudogerontoxon)
Peripheral fibrovascular pannus
Shield ulcer

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44
Q

Treatment for vernal conjunctivitis

A

Remove fibrovascular pannus

Most children grow out of vernal, give antihistamines,steroids

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45
Q

Define keratitis

A

Inflammation of the cornea

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46
Q

Causes of keratitis

A 
Infection
Trauma
Dry eyes
UV
Contact lenses
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47
Q

Symptoms of keratitis

A 
Foreign body feeling
Photophobia
Teariness
Reduced vision
Watery/purulent discharge
Pain
Limbus hyperaemia
Corneal opacification
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48
Q

Appearance of keratitis

A 
Bacterial- white hazy opacifications due to WBC infiltrate
Hypophion- pus level in front of iris
If HSV- dendritic ulcers on fluoroscopy
May also have geographic ulcers
Dilated or N pupils
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49
Q

Management of keratitis

A 
Corneal scrape and gram stain, culture and sensitivitiy
Urgent ABX if bacterial
Antivirals if viral
Close follow up
NOT STEROIDS
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50
Q

Complications of keratitis

A

Persistent inflammation can lead to scarring

Corneal perforation may require eye removal

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51
Q

Describe scleritis

A 
Less common
Severe pain
deep vessel injection
Assoc with HZO, RA
Must be treated with steroids
Blindness can occur
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52
Q

Describe episcleritis

A 
More common
Uncomfortable not painful
Superficial vessel injection
No systemic assocs
Symptom management only
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53
Q

Define acute angle closure crisis

A

Increased intraocular pressure due to obstruction of aqueous outflow by partial/total closure of peripheral iris angle- usually spontaneous
AKA iris meets lens

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54
Q

Risk factors for AACC

A

Short eye
Narrow angle
Thick lens (age)

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55
Q

Symptoms of AACC

A 
Intense eye pain and headache
Nausea and vomiting
Photophobia
Premonitory symptoms (fatigue, yawning, cravings)
Hypermetrope (blurred near vision)
Ciliary flush
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56
Q

Describe pupils and vision with AACC

A

Vision blurred due to corneal oedema

Fixed, mid dilated pupil due to iris ischaemia

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57
Q

Appearance and signs of AACC

A

Circumcorneal injection
Hazy cornea
ON swelling and atrophy if prolonged
Increased intraocular pressure- feels rock hard compared to normal eye

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58
Q

Management of AACC

A

IOP reduction- alpha agonists, beta blockers, mitotics (all topical)
- Carbonic anhydrase inhibitors, osmotics (systemic)
Surgical management- Peripheral laser iridotomy for new aqueous channel
clear lens extraction/trabeculotomy

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59
Q

Complications of AACC

A

Loss of vision due to ON death

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60
Q

Define anterior uveitis/iritis

A

Inflammation of uveal tissue- iris

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61
Q

Causes of ant. uveitis

A

Idiopathic
Assoc with HLA B27- IBD, reiter’s syndrome, ank spond, psoriatic arthritis
Juvenile chronic arthritis
Bechets syndrome
Sarcoidosis
Collagent vascular issues- SLE, polyarteritis nodosa, wegener’s granulomatosis
Infection- HSV, HZV, HIV, CMV, candida, toxoplasmosis
Trauma- in sympathetic ophthalmia, the immune system targets all uveal tissue to contain damage, but ends up harming both eyes

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62
Q

Symptoms of ant uveitis

A 
Deep aching pain
Redness 
Photophobia
Blurred vision
Pain on accommodation
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63
Q

Signs of ant uveitis

A 
Reduced acuity
Circumcorneal injection
Cells and flare on slit lamp
Keratic precipitates
Iris nodules
Severe- see hypopyon
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64
Q

Management of ant uveitis

A

Subdue inflammation with corticosteroids NOT IF INFECTIVE
Cycloplegics to prevent post synechiae
If increased IOP give ocular hypotensives like timolol
Antivirals
Injected or systemic corticosteroids if necessary

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65
Q

Complication of ant uveitis

A

Post synechiae (risk of angle closure crisis)
Seclusio/occlusio pupillae
Iris bombe- 360 degrees of synechiae
Glaucome secondary to trabecular inflammation, steroid or pupil block
Sectorial iris atrophy secondary to HZO- iris looks moth eaten
Reduced IOP
Cataracts
Cystoid macular oedema
Neovascularisation

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66
Q

Definition of posterior uveitis

A

Inflammation of uveal tissue- choroid/ciliary body

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67
Q

Causes of post uveitis

A

Idiopathic
Assoc with HLA B27- IBD, reiter’s syndrome, ank spond, psoriatic arthritis
Juvenile chronic arthritis
Bechets syndrome
Sarcoidosis
Collagent vascular issues- SLE, polyarteritis nodosa, wegener’s granulomatosis
Infection- HSV, HZV, HIV, CMV, candida, toxoplasmosis
Trauma- in sympathetic ophthalmia, the immune system targets all uveal tissue to contain damage, but ends up harming both eyes

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68
Q

Symptoms of posterior uveitis

A

Less painful than anterior
Floaters
Blurred vision

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69
Q

Signs of posterior uveitis

A

Visible inflammatory products (vitritis)
Inflammatory focus on choroid/retina- commonly toxoplasmosis
Inflammatory sequelae
- Cystoid macular oedema
- Vascular sheathing/occlusion- seen with fluroscein
- Optic disc swelling

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70
Q

Management of posterior uveitis

A 
Orbital floor steroid injection
Post subtenons steroid injection
ABX, Anti-TB therapy (if necessary)
Antivirals if viral
Immunosuppression if choritis, HSV/HZV
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71
Q

Define subconjunctival haemorrhage

A

Unilateral bleed under the conjunctiva

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72
Q

Causes of subconjunctival haemorrhage

A 
Severe cough
HTN
Straining
Valsalva
Anticoagulation
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73
Q

Symptoms/signs of subconj haemorrhage

A

Painless, focal blotchy redness

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74
Q

Management of subconj haemorrhage

A

Self resolving

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75
Q

Causes of floaters

A

Posterior vitreous detachment
Bleeding due to neovascularization/torn retina
Inflammatory cells- retinitis

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76
Q

History to take from floaters

A 
Onset
Flashers
Vision
Any field loss (makes retinal detach more likely than tear)
PMHx POHx
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77
Q

What do retinal tear and post vitreous detachment floaters look like

A

Retinal tear- tiny black dots if haemorrhage
Post vit detachment- little gray line
Flashers at the edge of the tear
Treat with laser

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78
Q

What does retinal detachment look like to patients

A

Floaters and flashers plus field loss

Curtain like effect

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79
Q

What does vitreous haemorrhage look like

A

Blurred vision and floaters
May be with attached or detached vitreous
May be due to neovascularization
If blood clouds the vitreous may need vitrectomy

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80
Q

Define blepharitis

A

Diffuse lash follicle inflammation

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81
Q

Causes of blepharitis

A

Usual staph aureus

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82
Q

Symptoms of blepharitis

A 
Gritty sensation
Tenderness
Lid debris
Red thick lid margins
Mild conjunctival infection
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83
Q

Management of blepharitis

A

Lid scrubs with warm water and baby shampoo

Topical erythromycin ointment

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84
Q

Define orbital cellulitis

A

Infection of lids and orbital tissue

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85
Q

Causes of orbital cellulitis

A

Spread from blocked or infected sinuses (paeds)
Spread from trauma or bite or stye
Compromised adults- consider fungus

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86
Q

Symptoms of orbital cellulitis

A 
Diffuse swelling and lid discoloration
Pain
Lid tenderness
Conjunctival engorgement
Proptosis
Reduced eye movements
Diplopia
Reduced vision if cellulitis is post-septal- ON may be compromised
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87
Q

Management of orbital cellulitis

A

Orbital imaging- rule out sinusitis, subperiosteal abscess, tumour
If paeds ethmoid sinusitis is the cause, IV ABX
May require drainage if no improvement or abscess
At risk adults may need a sinonasal biopsy to diagnose fungal infection

88
Q

Define glaucoma

A

Optic neuropathy with axonal loss

May be associated with increased IOP or visual field loss

89
Q

How does aqueous movement occur

A

Ciliary body secretes aqueous humour
This is drained by the trabecular meshwork through the angle of the eye into the anterior chamber
It is drained by episcleral vein

90
Q

What causes open angle glaucoma

A

Resistance in the trabecular meshwork
Primary- the angle is smaller than usual
Secondary- cells or inflammatory mediators cause a clog

91
Q

What causes closed angle glaucoma

A

Lens touches the iris so there is nowhere for the aqueous to move
Primary- narrow anterior chamber angle
Secondary- tumour, synechiae

92
Q

What are risk factors for glaucoma

A 
Age
FHx
Increased IOP
Myopia
Steroids
HTN
African ethnicity
Migraines
93
Q

Symptoms of open angle glaucoma

A

Often asymptomatic

May have visual loss

94
Q

Signs of open angle glaucoma

A

Increased IOP
Optic disc cupping
Crookenberg spindle- brown spots on the lens as iris rubs off cells onto it
Visual field loss if advanced

95
Q

Ix for open angle glaucoma

A

Tonometry- may have elevated IOP

Gonioscopy- mirrored lens to look at angle of eye

96
Q

Symptoms of closed angle glaucoma

A

Rapid onset pain, redness and blurriness

Mid dilated fixed pupil

97
Q

Signs of closed angle glaucoma

A 
Increased IOP
Optic disc cupping
Indentation of ON head
Peripheral vision loss
Pathological blind spot spread
Grants haemorrhage- bleeding on or around disc
98
Q

Investigations for closed angle glaucoma

A

IOP will be elevated

99
Q

Sx of infantile glaucoma

A

Haxy cornea
Watering
Photophobia
Buphthalmos- enlarged eye

100
Q

Management of glaucoma

A

If mild signs and OK nerve, watch and wait
Otherwise
- Local eyedrops- mitotics, prostaglandins, alpha agonists, CAI inhibitors, osmotic agents
- Surgery- Peripheral iridotomy, shunts/iStent, xen gel stent, cyclocryotherapy to ciliary body, goniotomy/trabeculotomy if paeds

101
Q

Explain how mitotics work for glaucoma

A

Increase aqueous outflow by constricting pupil

Eg. pilocarpine

102
Q

Explain how prostaglandin analogues work for glaucoma + se

A

Increase aqueous outlow through the uveosclera eg. xalatan

Cause browning of blue irises, eyelash growth and eye sinking

103
Q

Explain how b blockers work for glaucoma + se

A

Reduce aqueous production eg. timoptol

Bradycardia, heart block, HF, SOB, infant apnea, confusion, fatigue, nightmares, mask hypoglycaemia

104
Q

Explain how CAIs work for glaucoma + se

A

Reduce aqueous production eg. azopt

Stinging, conj. hyperaemia, eyelash crust, bitter taste

105
Q

Explain how a agonists work for glaucoma + se

A

Reduce aqueous production eg. Iopidine

Hypokalaemia, renal issues, allergy, fatigue, somnolence, HTN, dry mouth, taste change

106
Q

Explain how osmotic agents work for glaucoma + se

A

Reduce vitreous volume via osmosis eg. mannitol, glycerol

107
Q

What structures can diabetes affect in the eye (aside from the retina and macula)

A

Tear film- reduced quantity and stability
Cornea- decreased sensitivity, risking fungal and viral infection, erosions, persistent defects and punctate keratitis
Iris- mitotic pupil, neovascularisation, cataract

108
Q

What are risk factors for diabetic retinopathy

A 
Age
DM duration
glycaemic control
Smoking
Obesity
Pregnancy
BP
Lipids
Anaemia
Alcohol
PMHx
Ethnicity
109
Q

What are signs of diabetic retinopathy and maculopathy

A 
Microaneurysm- unique to diabetes
Dot and blot and flame haemorrhage
Cotton wool spots
Druse
Hard exudate
Pigment
Vascular changes- sausaging, intra-retinal microvascular anomalies (pre-proliferative)
Vascular growth- new disc and retinal vessels (proliferative changes)
Macular oedema
110
Q

How do we classify diabetic retinopathy

A

Pre-proliferative
Neovascular proliferative
Fibrovascular proliferative
May be with or without maculopathy

111
Q

What is pre-proliferative change

A

Microaneurysms, dot blot haemorrhage, exudate

Indicate leakage from arterioles

112
Q

What is neovascular proliferative change

A

New blood vessels, suggests, chronic retinal ischaemia

113
Q

What is fibrovascular proliferative change

A

Pre-retinal fibrovascular stalk

Indicates severe retinal ischaemia

114
Q

What are risks to vision in proliferative retinopathy?

A
  1. Neovascualrization
  2. Vessel size
  3. Vessel location- worse if near macula
  4. Haemorrhage
115
Q

How do we classify maculopathy

A

Focal- leakage from small microaneurysms. Shows yellow ring (circinate exudate)
Ischaemic- capillaries underlying fovea are occluded, increased vessel tortuosity
Diffuse- all leak

116
Q

How do we manage diabetic retinopathy

A

Laser treatment for blockage
Focal laser for leaks
Avastin to decrease macular oedema and neovascularization
General measures- BP and glycaemic control, lipids, renal monitoring

117
Q

What can cause age related macular degeneration

A

Uncertain- exacerbated by smoking though!

118
Q

Symptoms of wet ARMD

A

Vision loss, usually unilateral
Distorted vision
Macular discolouration
Serum and blood leakage

119
Q

Symptoms of dry ARMD

A

Pigment degeneration in fovea
Drusen
Vision loss
Distorted vision

120
Q

Management of ARMD

A

Periodic VEGF injection
Smoking cessation
Vitamin tablets
Refer to ophthalm if new vision loss

121
Q

What do you examine with pupils

A

Size and shape, symmetry
Near and light reflexes
RAPD

122
Q

What is anisocoria

A

Difference in pupil size- a problem if more tha 1mm difference and different reaction to light

123
Q

Causes of anisocoria

A

Medicines- mydriatics, mitotics, atropine
Trauma- surgery, post synechiae
Disease- uveitis, glaucoma (compression may stun iris into dilating), syphillis
Systemic meds- narcotics, opioids
Syndromes- horners, CNIII palsy

124
Q

What can cause small anisocoria

A

Horner syndrome

Argyll Robertson syndrome

125
Q

Causes of horner’s syndrome

A

Sympathetic pathway disruption so

  • Brainstem disease
  • Spinal cord tumour
  • Carotid dissection (pain)
  • Lung apex tumour
  • Neck lesion
126
Q

Symptoms of horners syndrome

A 
Unilateral
Miosis
Ptosis
Enophthalmos (eye sinking)
Cutaneous anhydrosis
Scleral redness
127
Q

Investigation for Horners syndrome

A

Topical cocaine- normal pupil dilates, abnormal won’t due to loss of noradrenaline at junction
Apraclonidine- see reverse effect
Imaging to determine cause

128
Q

Cause of argyll robertson pupil

A

Neurosyphillis

129
Q

Sx of argyll robertson pupil

A

Small irregular pupils

Normal near reflex, absent light reflex

130
Q

What can cause large pupils

A

Adie’s pupil

CNIII palsy

131
Q

What can cause Adies pupil

A

Postganglionic parasympathetic denervation

- Idiopathic, diabetes, viral, traumatic

132
Q

Symptoms of adie’s pupil

A

Light and near reflexes sluggish
Eventual pupil tonicity
Can see vermiform movements as parts of pupillary sphincter are re-innervated
If coupled with reduced reflexes- Holmes Adie syndrome

133
Q

Investigations for adie’s pupil

A

Hypersensitivity to pilocarpine- abnormal pupil will construct due to upregulated neurotransmitter receptors

134
Q

Causes of CNIII palsy

A

Compressive: aneurysm, tumour, tentorial herniation

Non-compressive: Diabetes, HTN, atherosclerosis

135
Q

Sx of CNIII palsy

A 
Unilateral
Pupil dilation IF compressive lesion
Eyes down and out
Limited down, up and adduction movements
Normal abduction
Ptosis
136
Q

Management of CNIII palsy

A

Removal of compressive lesion

Scan to exclude compressive lesions

137
Q

What is RAPD

A

Pupil response to consensual light but not direct

138
Q

Causes of RAPD

A 
ON compression or inflammation
Chiasma compression
Retinal detachment
Large unilateral macular lesion
Unilateral glaucoma
139
Q

Investigation for RAPD

A

Swinging light test

140
Q

Associations of atopic keratoconjunctivitis

A

Eczema and opportunistic infection

141
Q

Where can atopic keratoconjunctivitis manifest

A

Papillary
Periorbital
Deep cornea

142
Q

Symptoms of atopic keratoconjunctivitis

A

Itch
Photophobia
Watering
Redness

143
Q

Management of mild atopic keratoconjunctivitis

A 
Avoid allergens and rubbing
Cold compresses
Topical and systemic antihistamines
Mast cell stabilisers for prevention
NSAIDs, patanol
144
Q

Management of severe atopic keratoconjunctivitis

A

Topical corticosteroids- high then tail off quickly
Cyclosporine
Immunosuppressants
Surgery- papilla excision/keratectomy

145
Q

Complications of atopic keratoconjunctivitis

A

Marginal keratitis- pale inside of iris due to staph toxins
Rosacea/blepharitis- assoc with contact lens wear
If adenovirus- pseudomembranes and scarring which need to be peeled.
Corneal subepithelial infiltrates- degrade vision but settle on their own

146
Q

Symptoms of HSO

A

Blepharo-conjunctivitis
Keratititis in 50%
Dendritic ulcer on fluroscopy

147
Q

Management of HSO

A

50% self resolve
Acyclovir
Risk of recurrence is 25% in 5 years

148
Q

Complications of HSO

A

Amoeboid ulcer if given steroids without acyclovir coverage
Disciform keratitis- keratitis leads to endothelitis leads to oedema leads to pot belly cornea on slit lamp
Anaesthetic, scarred and vascularised cornea

149
Q

Symptoms of giant cell arteritis

A

Unilateral headache
Weight loss
Amaurosis fugax

150
Q

Investigations for GCA

A

CRP and ESR

Temporal artery biopsy

151
Q

Ophthalmoscopy findings for GCA

A

Unilateral pale, swollen disc with flame haemorrhages

152
Q

Management of GCA

A

Immediate steroids

153
Q

Definition of cataracts

A

Clouding of the lens

154
Q

Causes of cataracts

A 
Age related- most common
Gongenital
Diabetes
Toxic- corticosteroids
Traumatic- radiation
Secondary such as to anterior uveitis
155
Q

Symptoms of cataract

A

Progressive blurring is affected eye

Can improve with pinholes

156
Q

Investigations for cataracts

A

Slit lamp- can determine location and grade
Ophthalmoscopy- lose the red reflex
Visual acuity

157
Q

Management of cataracts

A

Intracapsular lens extraction- lens and capsule, zonules dissolved
Extracapsular extraction- lens removed, leaving capsule- requires large incision
Phacoemulsification- high frequency US to emulsify cataract using tiny incision- preferred!
Intraocular lenses- placed into capsule or clipped to iris- allows tiny incisions- adjunct to others!

158
Q

Complications of cataract surgery

A

Iris prolapse or trauma
Anterior capsule tear
Dropped nucleus

159
Q

Why is corneal transplant more straightforward and how long does it take to work

A

It is avascular so few rejections and no immunosuppression needed
12-18mos for optimal vision

160
Q

Indications for corneal transplants

A

Keratoconus following failure of hard lens correction- cornea protruding, thin and distorted
Keratopathy or oedema- painful blisters and scars secondary to surgery or glaucoma
Dystrophy- genetic disorders and ageing
Infection causing ulcers
Trauma- chemical or physical
Pterygium
Melanoma

161
Q

Types of corneal transplant

A

Penetrating- whole cornea
Anterior laminal- host endothelium remains
Endothelial- only endothelium transplanted

162
Q

Definition of dry eye

A

Multifactorial evaporative or aqueous defect of the tears and ocular surface, exacerbated by contact lenses and environmental conditions

163
Q

Symptoms of dry eye

A

Dryness
Grittiness
Irritation
Burning

164
Q

Definition of sjogren syndrome

A

A chronic, systemic, inflammatory autoimmune disorder characterised by lymphocytic infiltration of the exocrine organs (Aqueous deficient in nature)

165
Q

Symptoms of sjogren syndrome

A 
Xerophthalmia (dry eye)
Xerostomia (dry mouth)
Parotid enlargement 
Arthralgia
Reynauds
RA
Lymphoma
Eating or speaking difficulties
166
Q

Causes of sjogren syndrome

A

Genetic
Environmental
Sex hormones
Viral trigger sometimes

167
Q

Classification of sjogren syndrome

A

Primary- dry eye and mouth with no rheumatoid issues

Secondary- dry eye, mouth and rheumatoid

168
Q

Pathophysiology of sjogren syndrome

A

Gland changes lead to reduced aqueous, hyperosmolar tears, inflammation, cytokine invasion, epithelial damage and then more gland changes

169
Q

Signs of eye sjogren syndrome

A 
Ocular redness
Corneal dullness
Blepharitis
Meibomian dysfunction
Mucous trands on cornea
Poor tear film stability
170
Q

Investigations for eyes with sjogren syndrome

A

Schrimmer test- wets less than 5mm of card touching sclera in 5m
fluroscein- stains epithelial loss
Rose bengal- stains dead or uncovered cells

171
Q

Oral signs of sjogren syndrome

A 
Tongue sticks to depressor
Dental caries
Periodontal disease
Predisposition to candida
Parotid enlargement
172
Q

Signs of rheum sjogren

A

Arthritis- symmetrical and polyarticular

173
Q

Ix for rheum sjogren and oral sjogren

A 
RF positive
ANA positive
Anti Ro positive in primary
Anti La positive in almost half of primary
Salivary gland biopsy
174
Q

Treatment of eye sjogren level 1

A

Symptoms mild and with no signs- tear supplements and environmental changes

175
Q

Treatment of eye sjogren level 2

A

Moderate symptoms, mild signs- as for 1 plus tear gel nocte, short course of topical steroids, cyclosporine A, nutritional supplements

176
Q

Treatment of eye sjogren level 3

A

Severe symptoms with marked signs: 2 plus tetracyclines, serum tears, punctal occlusion, acetylcystine (which breaks mucus strands)

177
Q

Treatment of eye sjogren level 4

A

Extreme symptoms, severe signs: Systemic anti inflammatories, topical vitamin A, moisture chamber glasses

178
Q

Other treatments for sjogren syndrome

A

Cholinergic parasympathetic mimetics
DMARDs (hydroxychloroquine)
Immunosuppression
Multidisciplinary care

179
Q

Define strabismus

A

Misaligned eyes

180
Q

Causes of strabismus

A

Brain, cranial nerves, NMJ or extraocular muscle dysfunction

181
Q

Symptoms of strabismus

A

Diplopia if reported

Often based on parental report- not fixing/following/full eye movement

182
Q

Types of strabismus

A

Phoria- present when eyes dissociated

Tropia- present with binocular vision

183
Q

Positional categories of strabismus

A

Eso/exotropia- adduction/abduction

Hyper/hypotropia- superior/inferior deviation

184
Q

Examination of strabismus

A

Corneal light reflex test- should be just nasal of pupil but is displaced in misaligned eye
Cover test- deviated eye will move to fix once good eye is covered
Uncover test- look for deviation as cover is removed
Alternate cover test- as eyes switch cover they both move- can measure degree of strabismus
Prism cover testing- prism over deviated eye to neutralize alternate cover movement- allows determination of surgery

185
Q

Management of strabismus

A

Surgical- weaken strong muscle, strengthen weak muscle, reposition muscles

186
Q

Pseudoesotropia

A

Medial sclera is buried with lateral gaze so eyes look crossed
Normal on exam- child will grow out of it

187
Q

Infantile esotropia

A 
Onset up to 2 months of age secondary to poor fusion
Other motility issues such as nystagmus 
Need to manage amblyopia
Surgery at 6-12 months
50% need another surgery too
188
Q

Refractive esotropia

A

Onset 18mo-5y
Shows hyperopia, accommodation stimulates convergence
Often corrects with hyperopic glasses but may require surgery

189
Q

Intermittent exotropia

A

Onset at 2-5y of age worse with distance vision
May close eye in bright light
Surgery for depth perception and cosmesis
May improve, progress to constant or stay stable without intervention

190
Q

SO palsy

A

Congenital or acquired
Ipsilateral hypertrope worse with contralateral gaze and ipsilateral tilt
Surgery- IO weakening or SO tuck

191
Q

Define amblyopia

A

Poor visual cortex development secondary to blurred visual input- ie. problem is in BRAIN not EYE

192
Q

Causes of amblyopia

A

Refractive- anisometropia goes to astigmatism goes to hyperopia goes to myopia
Strabismus
Stimulus deprivation

193
Q

Management of amblyopia

A

Patching- good eye is occluded for 2-6h per day

Good eye blurring with atropine- but beware toxicity (red, mad, hot)

194
Q

Causes of abnormal red reflex in children

A

Retinoblastoma
Congenital cataract
Congenital glaucoma

195
Q

Describe retinoblastoma

A

RB1 gene mutation with high survival with treatment
Risk of other malignancies if inherited
Presents as red reflex loss, poor vision, eye misalignment
Can treat with cryo, laser, radiation and chemo

196
Q

Describe congenital cataract

A

20% aare inherited showing a loss of the red reflex

Surgery needs to take place at 4-6 weeks of age with an IOL at 6 months

197
Q

Describe congenital glaucoma

A

Abnormal drainage angle requiring surgery

Photophobia, teariness, hazy cornea and buphthalmos

198
Q

Describe retinopathy of prematurity

A

Fibrovascular retinal proliferation in pre term infants- worry about potential retinal detachment
Watch and wait- if there are issues, do laser photocoagulation

199
Q

Describe neurofibromatosis

A

Autosomal dominant disorder

Lisch nodules show up as tan lumps on the iris, increase with age

200
Q

Describe abusive head trauma

A

Multiple retinal haemorrhages often extending to the periphery
Check for other injuries including external ocular and brain

201
Q

Describe lens subluxation

A

Assoc with marfan syndrome, haemocystinuria

202
Q

Describe blue sclera

A

Assoc with osteogenesis imperfecta secondary to type I collagen deficiencey

203
Q

Describe findings of congenital ptosis

A

Fair or poor LPS action with lack of lid crease

There may also be lag on down gaze with or without upgaze problems

204
Q

What are types of acquired ptosis

A

Involutional
Neurogenic
Myogenic
Mechanical

205
Q

Causes and presentation of involutional ptosis

A

due to aponeurotic dehisence- CL wearers often
Shows good LPS action, high lid crease and no lid lag on down gaze
Frontalis may be overactive as it tries to raise the eyebrows to compensate

206
Q

Causes of neurogenic ptosis

A

CNIII palsy, horners

207
Q

Causes of myogenic ptosis

A

Chronic progressive external ophthalmoplegia, myaesthenia gravis

208
Q

Causes of mechanical ptosis

A

Upper lid tumours, trauma, surgery

209
Q

Causes of lid retraction

A

Congenital

Acquired- midbrain lesion, thyroid eye disease

210
Q

Pathophysiology of thyroid eye disease

A

Lymphocytic infiltration leading to msucle and fat becoming oedematous and expanding
Doposition of hyaluronic acid and GAGs

211
Q

Signs of thyroid eye disease

A

Thick extraocular muscles
Max eye diameter outside orbital rim
Tenting of optic neuritis

212
Q

Management of thyroid eye disease

A

Watch for signs of corneal exposure

Optic nerve if compressed may need surgical decompression

213
Q

Define ectropion

A

Eyelid margin is away from the globe

214
Q

Involutional ectropion

A

Laxity of canthal tendon of eye

215
Q

Cicatricial ectropion

A

Scar at cheek pulling lid down

216
Q

Paralytic ectropion

A

CNVII palsy due to orbicularis oculi as in bells palsy, parotid excision, accoustic neuroma

217
Q

Mechanical ectropion

A

Lower eyelid oedema

Clinical Medicine (5 decks)

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