Ophthalmology Flashcards
Signs of retinal vascular disease
Vascular changes: Arteriosclerosis, AV crossing changes, venous tortuosity, cotton wool spots Microaneurysms Haemorrhages Hard exudates Neovascularization
What are microaneurysms and what can they suggest
Little round dots from vessel outpouchings
Need to think about an OCT scan to check for macular oedema
What are the different categories of haemorrhage
Dot and blot
Flame
Pre-retinal
Roth spots
Describe dot and blot haemorrhages
Haemorrhage in the middle retinal layer due to diabetes/HTN
Describe flame haemorrhage
Haemorrhage in the superficial nerve fibre layers due to CRV occlusion
Describe pre retinal haemorrhage
Haemorrhage near the vitreous, between the retina and the posterior hyaloid
Caused by trauma, valsalva, neovascularisation
Describe roth spots
Haemorrhage with central opacity
May be due to seeding of septic emboli (IE), anaemia or haematological diseases
What are hard exudates and what can cause them
Lipid deposition in the outer layer due to abnormal vascular permeability
Ill defined, discrete
Assoc w diabetes
What is a macular star and what causes it?
Star of cream on the macula due to swelling and exudate of the optic nerve head
Due to cat scratch disease or ocular syphilis
What are cotton wool spots and what cause them
Ischaemic infarction in the nerve fiber layer
Assoc with diabetes, HTN, SLE, leukaemia, HIV
What is neovascularization and what causes it
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
What do you do for neovascularization and what risk does it pose?
Treated with laser to prevent further development
Neovascularization increases the risk of new bleeds
What does venous occlusion look like
Dilated venules, haemorrhage, oedema
Increased venous tortuosity
May occur centrally or at a branch
What does arterial occlusion look like
Retinal pallor and oedema arteriole construction column interruption cherry red spots visible emboli retinal pallor
What does retinal degeneration look like and what should you do?
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
What are the types of retinal elevation?
By fluid- retinal detachment
By solid mass- tumour, choroidal neovascularization
Vitreous detachment
Retinal tear
What is cystoid macular oedema
Hard exudates and swelling at the back of the eye
Petalloid appearance on FFA
What does viritis look like
Stranding and tiny cells at the back of the eye
What does multifocal choroiditis look like
Similar to cotton wool spots
Differentiate with lack of diabetes hx and lack of haemorrhages
What does retinitis look like and what causes it
One large cotton wool spot
Likely see vitreous cells in the anterior chamber
Mostly due to toxoplasmosis
What do granulomas look like and what causes them
Pale white spots at the back of the eye
Caused by sarcoid or TB
What is a good exam system for eye trauma
From front to back of eye
Start with visual acuity, end with 5 neuro exams- vision, pupils, visual fields, movement and colour vision
Describe metal trauma to the eye
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
Describe blunt trauma to the eye
Eyelid bruising, subconjunctival haemorrhage (blood between conjunctiva and scleara)
Reassure if otherwise visually intact
What is hyphaema
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
What is orbital blowout fracture
Fracture of bones surrounding eye
May present with poor eye movements due to trapping of muscles in bone shards or inflammation
Describe chemical ocular trauma management
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
Which is worse between acid and alkali burns
Alkali as it causes liquefactive necrosis as opposed to coagulative necrosis
Describe management of UV/IR trauma
Can only give lubricating drops
Describe penetrating/intraocular trauma
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
Describe lid laceration risks and processes
Risk of tear duct dysfunction causing persistent teariness
Risk of poor lid closure
Risk of scar and infection
Requires skilled surgical repair
Describe scleral laceration
May be partial or full thickness of sclera
Pain and blurred vision
Iris may plug hole (like penetrating injury)
Definition of conjunctivitis
Inflammation of the conjunctiva
Causes of conjunctivitis
Viral Bacterial Chlamydial Seasonal/perennial Vernal Atopic
Describe viral conjunctivitis
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
Treatment of viral conjunctivitis
Meticulous hygeine, compresses, lubricants, swabs
Describe bacterial conjunctivitis
Soreness, pain, heat, tightness Normal vision unless excess swelling Purulent discharge Red and boggy conjunctiva, follicles and papillae Normal pupils
Treatment of bacterial conjunctivitis
Swab for culture, hygeine, chloramphenicol
Describe chlamydial conjunctivitis
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
Treatment of chlamydial conjunctivitis
Tetracycline abx, treat parents and sexual partners
Describe allergic conjunctivitis
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
Treatment for allergic conjunctivitis
Systemic antihistamines are firstline
Describe vernal conjunctivitis
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
Treatment for vernal conjunctivitis
Remove fibrovascular pannus
Most children grow out of vernal, give antihistamines,steroids
Define keratitis
Inflammation of the cornea
Causes of keratitis
Infection Trauma Dry eyes UV Contact lenses
Symptoms of keratitis
Foreign body feeling Photophobia Teariness Reduced vision Watery/purulent discharge Pain Limbus hyperaemia Corneal opacification
Appearance of keratitis
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
Management of keratitis
Corneal scrape and gram stain, culture and sensitivitiy Urgent ABX if bacterial Antivirals if viral Close follow up NOT STEROIDS
Complications of keratitis
Persistent inflammation can lead to scarring
Corneal perforation may require eye removal
Describe scleritis
Less common Severe pain deep vessel injection Assoc with HZO, RA Must be treated with steroids Blindness can occur
Describe episcleritis
More common Uncomfortable not painful Superficial vessel injection No systemic assocs Symptom management only
Define acute angle closure crisis
Increased intraocular pressure due to obstruction of aqueous outflow by partial/total closure of peripheral iris angle- usually spontaneous
AKA iris meets lens
Risk factors for AACC
Short eye
Narrow angle
Thick lens (age)
Symptoms of AACC
Intense eye pain and headache Nausea and vomiting Photophobia Premonitory symptoms (fatigue, yawning, cravings) Hypermetrope (blurred near vision) Ciliary flush
Describe pupils and vision with AACC
Vision blurred due to corneal oedema
Fixed, mid dilated pupil due to iris ischaemia
Appearance and signs of AACC
Circumcorneal injection
Hazy cornea
ON swelling and atrophy if prolonged
Increased intraocular pressure- feels rock hard compared to normal eye
Management of AACC
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
Complications of AACC
Loss of vision due to ON death
Define anterior uveitis/iritis
Inflammation of uveal tissue- iris
Causes of ant. uveitis
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
Symptoms of ant uveitis
Deep aching pain Redness Photophobia Blurred vision Pain on accommodation
Signs of ant uveitis
Reduced acuity Circumcorneal injection Cells and flare on slit lamp Keratic precipitates Iris nodules Severe- see hypopyon
Management of ant uveitis
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
Complication of ant uveitis
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
Definition of posterior uveitis
Inflammation of uveal tissue- choroid/ciliary body
Causes of post uveitis
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
Symptoms of posterior uveitis
Less painful than anterior
Floaters
Blurred vision
Signs of posterior uveitis
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
Management of posterior uveitis
Orbital floor steroid injection Post subtenons steroid injection ABX, Anti-TB therapy (if necessary) Antivirals if viral Immunosuppression if choritis, HSV/HZV
Define subconjunctival haemorrhage
Unilateral bleed under the conjunctiva
Causes of subconjunctival haemorrhage
Severe cough HTN Straining Valsalva Anticoagulation
Symptoms/signs of subconj haemorrhage
Painless, focal blotchy redness
Management of subconj haemorrhage
Self resolving
Causes of floaters
Posterior vitreous detachment
Bleeding due to neovascularization/torn retina
Inflammatory cells- retinitis
History to take from floaters
Onset Flashers Vision Any field loss (makes retinal detach more likely than tear) PMHx POHx
What do retinal tear and post vitreous detachment floaters look like
Retinal tear- tiny black dots if haemorrhage
Post vit detachment- little gray line
Flashers at the edge of the tear
Treat with laser
What does retinal detachment look like to patients
Floaters and flashers plus field loss
Curtain like effect
What does vitreous haemorrhage look like
Blurred vision and floaters
May be with attached or detached vitreous
May be due to neovascularization
If blood clouds the vitreous may need vitrectomy
Define blepharitis
Diffuse lash follicle inflammation
Causes of blepharitis
Usual staph aureus
Symptoms of blepharitis
Gritty sensation Tenderness Lid debris Red thick lid margins Mild conjunctival infection
Management of blepharitis
Lid scrubs with warm water and baby shampoo
Topical erythromycin ointment
Define orbital cellulitis
Infection of lids and orbital tissue
Causes of orbital cellulitis
Spread from blocked or infected sinuses (paeds)
Spread from trauma or bite or stye
Compromised adults- consider fungus
Symptoms of orbital cellulitis
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
Management of orbital cellulitis
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
Define glaucoma
Optic neuropathy with axonal loss
May be associated with increased IOP or visual field loss
How does aqueous movement occur
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
What causes open angle glaucoma
Resistance in the trabecular meshwork
Primary- the angle is smaller than usual
Secondary- cells or inflammatory mediators cause a clog
What causes closed angle glaucoma
Lens touches the iris so there is nowhere for the aqueous to move
Primary- narrow anterior chamber angle
Secondary- tumour, synechiae
What are risk factors for glaucoma
Age FHx Increased IOP Myopia Steroids HTN African ethnicity Migraines
Symptoms of open angle glaucoma
Often asymptomatic
May have visual loss
Signs of open angle glaucoma
Increased IOP
Optic disc cupping
Crookenberg spindle- brown spots on the lens as iris rubs off cells onto it
Visual field loss if advanced
Ix for open angle glaucoma
Tonometry- may have elevated IOP
Gonioscopy- mirrored lens to look at angle of eye
Symptoms of closed angle glaucoma
Rapid onset pain, redness and blurriness
Mid dilated fixed pupil
Signs of closed angle glaucoma
Increased IOP Optic disc cupping Indentation of ON head Peripheral vision loss Pathological blind spot spread Grants haemorrhage- bleeding on or around disc
Investigations for closed angle glaucoma
IOP will be elevated
Sx of infantile glaucoma
Haxy cornea
Watering
Photophobia
Buphthalmos- enlarged eye
Management of glaucoma
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
Explain how mitotics work for glaucoma
Increase aqueous outflow by constricting pupil
Eg. pilocarpine
Explain how prostaglandin analogues work for glaucoma + se
Increase aqueous outlow through the uveosclera eg. xalatan
Cause browning of blue irises, eyelash growth and eye sinking
Explain how b blockers work for glaucoma + se
Reduce aqueous production eg. timoptol
Bradycardia, heart block, HF, SOB, infant apnea, confusion, fatigue, nightmares, mask hypoglycaemia
Explain how CAIs work for glaucoma + se
Reduce aqueous production eg. azopt
Stinging, conj. hyperaemia, eyelash crust, bitter taste
Explain how a agonists work for glaucoma + se
Reduce aqueous production eg. Iopidine
Hypokalaemia, renal issues, allergy, fatigue, somnolence, HTN, dry mouth, taste change
Explain how osmotic agents work for glaucoma + se
Reduce vitreous volume via osmosis eg. mannitol, glycerol
What structures can diabetes affect in the eye (aside from the retina and macula)
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
What are risk factors for diabetic retinopathy
Age DM duration glycaemic control Smoking Obesity Pregnancy BP Lipids Anaemia Alcohol PMHx Ethnicity
What are signs of diabetic retinopathy and maculopathy
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
How do we classify diabetic retinopathy
Pre-proliferative
Neovascular proliferative
Fibrovascular proliferative
May be with or without maculopathy
What is pre-proliferative change
Microaneurysms, dot blot haemorrhage, exudate
Indicate leakage from arterioles
What is neovascular proliferative change
New blood vessels, suggests, chronic retinal ischaemia
What is fibrovascular proliferative change
Pre-retinal fibrovascular stalk
Indicates severe retinal ischaemia
What are risks to vision in proliferative retinopathy?
- Neovascualrization
- Vessel size
- Vessel location- worse if near macula
- Haemorrhage
How do we classify maculopathy
Focal- leakage from small microaneurysms. Shows yellow ring (circinate exudate)
Ischaemic- capillaries underlying fovea are occluded, increased vessel tortuosity
Diffuse- all leak
How do we manage diabetic retinopathy
Laser treatment for blockage
Focal laser for leaks
Avastin to decrease macular oedema and neovascularization
General measures- BP and glycaemic control, lipids, renal monitoring
What can cause age related macular degeneration
Uncertain- exacerbated by smoking though!
Symptoms of wet ARMD
Vision loss, usually unilateral
Distorted vision
Macular discolouration
Serum and blood leakage
Symptoms of dry ARMD
Pigment degeneration in fovea
Drusen
Vision loss
Distorted vision
Management of ARMD
Periodic VEGF injection
Smoking cessation
Vitamin tablets
Refer to ophthalm if new vision loss
What do you examine with pupils
Size and shape, symmetry
Near and light reflexes
RAPD
What is anisocoria
Difference in pupil size- a problem if more tha 1mm difference and different reaction to light
Causes of anisocoria
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
What can cause small anisocoria
Horner syndrome
Argyll Robertson syndrome
Causes of horner’s syndrome
Sympathetic pathway disruption so
- Brainstem disease
- Spinal cord tumour
- Carotid dissection (pain)
- Lung apex tumour
- Neck lesion
Symptoms of horners syndrome
Unilateral Miosis Ptosis Enophthalmos (eye sinking) Cutaneous anhydrosis Scleral redness
Investigation for Horners syndrome
Topical cocaine- normal pupil dilates, abnormal won’t due to loss of noradrenaline at junction
Apraclonidine- see reverse effect
Imaging to determine cause
Cause of argyll robertson pupil
Neurosyphillis
Sx of argyll robertson pupil
Small irregular pupils
Normal near reflex, absent light reflex
What can cause large pupils
Adie’s pupil
CNIII palsy
What can cause Adies pupil
Postganglionic parasympathetic denervation
- Idiopathic, diabetes, viral, traumatic
Symptoms of adie’s pupil
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
Investigations for adie’s pupil
Hypersensitivity to pilocarpine- abnormal pupil will construct due to upregulated neurotransmitter receptors
Causes of CNIII palsy
Compressive: aneurysm, tumour, tentorial herniation
Non-compressive: Diabetes, HTN, atherosclerosis
Sx of CNIII palsy
Unilateral Pupil dilation IF compressive lesion Eyes down and out Limited down, up and adduction movements Normal abduction Ptosis
Management of CNIII palsy
Removal of compressive lesion
Scan to exclude compressive lesions
What is RAPD
Pupil response to consensual light but not direct
Causes of RAPD
ON compression or inflammation Chiasma compression Retinal detachment Large unilateral macular lesion Unilateral glaucoma
Investigation for RAPD
Swinging light test
Associations of atopic keratoconjunctivitis
Eczema and opportunistic infection
Where can atopic keratoconjunctivitis manifest
Papillary
Periorbital
Deep cornea
Symptoms of atopic keratoconjunctivitis
Itch
Photophobia
Watering
Redness
Management of mild atopic keratoconjunctivitis
Avoid allergens and rubbing Cold compresses Topical and systemic antihistamines Mast cell stabilisers for prevention NSAIDs, patanol
Management of severe atopic keratoconjunctivitis
Topical corticosteroids- high then tail off quickly
Cyclosporine
Immunosuppressants
Surgery- papilla excision/keratectomy
Complications of atopic keratoconjunctivitis
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
Symptoms of HSO
Blepharo-conjunctivitis
Keratititis in 50%
Dendritic ulcer on fluroscopy
Management of HSO
50% self resolve
Acyclovir
Risk of recurrence is 25% in 5 years
Complications of HSO
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
Symptoms of giant cell arteritis
Unilateral headache
Weight loss
Amaurosis fugax
Investigations for GCA
CRP and ESR
Temporal artery biopsy
Ophthalmoscopy findings for GCA
Unilateral pale, swollen disc with flame haemorrhages
Management of GCA
Immediate steroids
Definition of cataracts
Clouding of the lens
Causes of cataracts
Age related- most common Gongenital Diabetes Toxic- corticosteroids Traumatic- radiation Secondary such as to anterior uveitis
Symptoms of cataract
Progressive blurring is affected eye
Can improve with pinholes
Investigations for cataracts
Slit lamp- can determine location and grade
Ophthalmoscopy- lose the red reflex
Visual acuity
Management of cataracts
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!
Complications of cataract surgery
Iris prolapse or trauma
Anterior capsule tear
Dropped nucleus
Why is corneal transplant more straightforward and how long does it take to work
It is avascular so few rejections and no immunosuppression needed
12-18mos for optimal vision
Indications for corneal transplants
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
Types of corneal transplant
Penetrating- whole cornea
Anterior laminal- host endothelium remains
Endothelial- only endothelium transplanted
Definition of dry eye
Multifactorial evaporative or aqueous defect of the tears and ocular surface, exacerbated by contact lenses and environmental conditions
Symptoms of dry eye
Dryness
Grittiness
Irritation
Burning
Definition of sjogren syndrome
A chronic, systemic, inflammatory autoimmune disorder characterised by lymphocytic infiltration of the exocrine organs (Aqueous deficient in nature)
Symptoms of sjogren syndrome
Xerophthalmia (dry eye) Xerostomia (dry mouth) Parotid enlargement Arthralgia Reynauds RA Lymphoma Eating or speaking difficulties
Causes of sjogren syndrome
Genetic
Environmental
Sex hormones
Viral trigger sometimes
Classification of sjogren syndrome
Primary- dry eye and mouth with no rheumatoid issues
Secondary- dry eye, mouth and rheumatoid
Pathophysiology of sjogren syndrome
Gland changes lead to reduced aqueous, hyperosmolar tears, inflammation, cytokine invasion, epithelial damage and then more gland changes
Signs of eye sjogren syndrome
Ocular redness Corneal dullness Blepharitis Meibomian dysfunction Mucous trands on cornea Poor tear film stability
Investigations for eyes with sjogren syndrome
Schrimmer test- wets less than 5mm of card touching sclera in 5m
fluroscein- stains epithelial loss
Rose bengal- stains dead or uncovered cells
Oral signs of sjogren syndrome
Tongue sticks to depressor Dental caries Periodontal disease Predisposition to candida Parotid enlargement
Signs of rheum sjogren
Arthritis- symmetrical and polyarticular
Ix for rheum sjogren and oral sjogren
RF positive ANA positive Anti Ro positive in primary Anti La positive in almost half of primary Salivary gland biopsy
Treatment of eye sjogren level 1
Symptoms mild and with no signs- tear supplements and environmental changes
Treatment of eye sjogren level 2
Moderate symptoms, mild signs- as for 1 plus tear gel nocte, short course of topical steroids, cyclosporine A, nutritional supplements
Treatment of eye sjogren level 3
Severe symptoms with marked signs: 2 plus tetracyclines, serum tears, punctal occlusion, acetylcystine (which breaks mucus strands)
Treatment of eye sjogren level 4
Extreme symptoms, severe signs: Systemic anti inflammatories, topical vitamin A, moisture chamber glasses
Other treatments for sjogren syndrome
Cholinergic parasympathetic mimetics
DMARDs (hydroxychloroquine)
Immunosuppression
Multidisciplinary care
Define strabismus
Misaligned eyes
Causes of strabismus
Brain, cranial nerves, NMJ or extraocular muscle dysfunction
Symptoms of strabismus
Diplopia if reported
Often based on parental report- not fixing/following/full eye movement
Types of strabismus
Phoria- present when eyes dissociated
Tropia- present with binocular vision
Positional categories of strabismus
Eso/exotropia- adduction/abduction
Hyper/hypotropia- superior/inferior deviation
Examination of strabismus
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
Management of strabismus
Surgical- weaken strong muscle, strengthen weak muscle, reposition muscles
Pseudoesotropia
Medial sclera is buried with lateral gaze so eyes look crossed
Normal on exam- child will grow out of it
Infantile esotropia
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
Refractive esotropia
Onset 18mo-5y
Shows hyperopia, accommodation stimulates convergence
Often corrects with hyperopic glasses but may require surgery
Intermittent exotropia
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
SO palsy
Congenital or acquired
Ipsilateral hypertrope worse with contralateral gaze and ipsilateral tilt
Surgery- IO weakening or SO tuck
Define amblyopia
Poor visual cortex development secondary to blurred visual input- ie. problem is in BRAIN not EYE
Causes of amblyopia
Refractive- anisometropia goes to astigmatism goes to hyperopia goes to myopia
Strabismus
Stimulus deprivation
Management of amblyopia
Patching- good eye is occluded for 2-6h per day
Good eye blurring with atropine- but beware toxicity (red, mad, hot)
Causes of abnormal red reflex in children
Retinoblastoma
Congenital cataract
Congenital glaucoma
Describe retinoblastoma
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
Describe congenital cataract
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
Describe congenital glaucoma
Abnormal drainage angle requiring surgery
Photophobia, teariness, hazy cornea and buphthalmos
Describe retinopathy of prematurity
Fibrovascular retinal proliferation in pre term infants- worry about potential retinal detachment
Watch and wait- if there are issues, do laser photocoagulation
Describe neurofibromatosis
Autosomal dominant disorder
Lisch nodules show up as tan lumps on the iris, increase with age
Describe abusive head trauma
Multiple retinal haemorrhages often extending to the periphery
Check for other injuries including external ocular and brain
Describe lens subluxation
Assoc with marfan syndrome, haemocystinuria
Describe blue sclera
Assoc with osteogenesis imperfecta secondary to type I collagen deficiencey
Describe findings of congenital ptosis
Fair or poor LPS action with lack of lid crease
There may also be lag on down gaze with or without upgaze problems
What are types of acquired ptosis
Involutional
Neurogenic
Myogenic
Mechanical
Causes and presentation of involutional ptosis
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
Causes of neurogenic ptosis
CNIII palsy, horners
Causes of myogenic ptosis
Chronic progressive external ophthalmoplegia, myaesthenia gravis
Causes of mechanical ptosis
Upper lid tumours, trauma, surgery
Causes of lid retraction
Congenital
Acquired- midbrain lesion, thyroid eye disease
Pathophysiology of thyroid eye disease
Lymphocytic infiltration leading to msucle and fat becoming oedematous and expanding
Doposition of hyaluronic acid and GAGs
Signs of thyroid eye disease
Thick extraocular muscles
Max eye diameter outside orbital rim
Tenting of optic neuritis
Management of thyroid eye disease
Watch for signs of corneal exposure
Optic nerve if compressed may need surgical decompression
Define ectropion
Eyelid margin is away from the globe
Involutional ectropion
Laxity of canthal tendon of eye
Cicatricial ectropion
Scar at cheek pulling lid down
Paralytic ectropion
CNVII palsy due to orbicularis oculi as in bells palsy, parotid excision, accoustic neuroma
Mechanical ectropion
Lower eyelid oedema
