Ophthalmology (again lol) Flashcards
afferent pupillary defect
Features
• No direct response but intact consensual response
• Cannot initiate consensual response in contralateral
eye.
• Dilatation on moving light from normal to abnormal eye
Causes
• Total CN II lesion
RAPD
Relative Afferent Pupillary Defect • = Marcus-Gunn Pupil Features • Minor constriction to direct light • Dilatation on moving light from normal to abnormal eye. • RAPD = Marcus Gunn Pupil Causes • Optic neuritis • Optic atrophy • Retinal disease
efferent eye defect
Efferent Defect
Feature
• Dilated pupil does not react to light
• Initiates consensual response in contralateral pupil
• Ophthalmoplegia + ptosis
Cause
• 3rd nerve palsy
§ The pupil is often spared in a vascular lesion
(e.g. DM) as pupillary fibres run in the periphery
ddx fixed dilated pupil
Differential of a fixed dilated pupil • Mydriatics: e.g. tropicamide • Iris trauma • Acute glaucoma • CN3 compression: tumour, coning
Holmes Adie pupil
Holmes-Adie Pupil
Features
• Young woman ¯c sudden blurring of near vision
• Initially unilateral and then bilateral pupil dilatation
§ Dilated pupil has no response to light and
sluggish response to accommodation.
§ A “tonic” pupil
Ix
• Iris shows spontaneous wormy movements on slit-lamp
examination
§ Iris streaming
Cause
• Damage to postganglionic parasympathetic fibres
• Idiopathic: may have viral origin
Holmes-Adie Syndrome
• Tonic pupil + absent knee/ankle jerks + ↓ BP
Horner’s syndrome and cauess
Features: PEAS • Ptosis: partial (superior tarsal muscle) • Enophthalmos • Anhydrosis • Small pupil Causes • Central § MS § Wallenberg’s Lateral Medullary Syndrome • Pre-ganglionic (neck) § Pancoast’s tumour: T1 nerve root lesion § Trauma: CVA insertion or CEA • Post-ganglionic § Cavernous sinus thrombosis § Usually 2O to spreading facial infection via the ophthalmic veins § CN 3, 4, 5, 6 palsies
Argyll Robertson pupil
Argyll Robertson Pupil Features • Small, irregular pupils • Accommodate but doesn’t react to light • Atrophied and depigmented iris Cause • DM • Quaternary syphilis
optic neuropathy signs
Features • ↓ acuity • ↓colour vision (esp. red) • Central scotoma • Pale optic disc • RAPD
optic neuropathy ddx
commonest MS glaucoma congenital Alcohol and Other Toxins • Ethambutol • Lead • B12 deficiency Compression • Neoplasia: optic glioma, pituitary adenoma • Glaucoma • Paget’s Vascular: DM, GCA or thromboembolic Inflammatory: optic neuritis – MS, Devic’s, DM Sarcoid / other granulomatous Infection: herpes zoster, TB, syphilis Oedema: papilloedema Neoplastic infiltration: lymphoma, leukaemia
taking a red eye hx
Vision • Blurred • Distorted • Diplopia • Field defect / Scotoma • Floaters, Flashes Sensation • Irritation • Pain • Itching • Photophobia • FB Appearance • Red: ?distribution • Lump • Puffy lids Discharge • Watering • Sticky • Stringy
Qs to ask o/e for red eye and serious disease signs
Key Examination Questions • Inspect from anterior to posterior • Is acuity affected? • Is the globe painful? • Pupil size and reactivity? • Cornea: intact, cloudy? Use fluorescein Signs of Serious Disease • Photophobia • Poor vision • Corneal fluorescein staining • Abnormal pupil
acute glaucoma vs anterior uveitis vs conjunctivitis
acute glaucoma: most painful, no photophobia, reduced acuity, cornea hazy/cloudy, large pupil, raised IOP
anterior uveitis: medium painful, most photophobia, reduced acuity, normal cornea, small pupil, normal IOP
conjunct: may not have pain, photophobic mildly, rest normal
acute glaucoma
acute glaucoma: most painful, no photophobia, reduced acuity, cornea hazy/cloudy, large pupil, raised IOP
anterior uveitis
anterior uveitis: medium painful, most photophobia, reduced acuity, normal cornea, small pupil, normal IOP
conjuncitviits
conjunct: may not have pain, photophobic mildly, rest normal
acute closed angle glaucoma risk factors and presentation
Acute Closed Angle Glaucoma • Blocked drainage of aqueous from anterior chamber via the canal of Schlemm. • Pupil dilatation (e.g. @ night) worsens the blockage. • Intraocular pressure rises from 15-20 → >60mmHg Risk Factors • Hypermetropia • Shallow ant. chamber • Female • FH • ↑age • Drugs § Anti-cholinergics § Sympathomimetics § TCAs § Anti-histamines Symptoms • Prodrome: rainbow haloes around lights at night-time. • Severe pain ¯c n/v • ↓ acuity and blurred vision
inv and management acute closed angle glaucoma
Examination
• Cloudy cornea c¯ circumcorneal injection
• Fixed, dilated, irregular pupil
• ↑ IOP makes eye feel hard
Ix
• Tonometry: ↑↑ IOP (usually >40mmHg)
Acute Mx: Refer to Ophthalmologist
• Pilocarpine 2-4% drops stat: miosis opens blockage
• Topical β-B (e.g. timolol): ↓ aqueous formation
• Acetazolamide 500mg IV stat: ↓ aqueous formation
• Analgesia and antiemetics
Subsequent Mx
• Bilat YAG peripheral iridotomy once IOP ↓ medically
path, symp, o/e anterior uveitis
Pathophysiology • Uvea is pigmented part of eye and included: iris, ciliary body and choroid. • Iris + ciliary body = anterior uvea • Iris inflammation involves ciliary body too. Symptoms • Acute pain and photophobia • Blurred vision (aqueous precipitates) Examination • Small pupil initially, irregular later • Circumcorneal injection • Hypopyon: pus in anterior chamber • White (keratic) precipitates on back of cornea • Talbots test: ↑pain on convergence
anterior uveitis assoc + treat
Associations (most have no systemic associations)
• Seronegative arthritis: AS, psoriatic, Reiter’s
• Still’s / JIA
• IBD
• Sarcoidosis
• Behcet’s
• Infections: TB, leprosy, syphilis, HSV, CMV, toxo
Mx
• Refer to ophthalmologist
• Prednisolone drops
• Cyclopentolate drops: dilates pupil and prevents
adhesions between iris and lens (synechiae)
episcleritis
Episcleritis • Inflammation below conjunctiva in the episclera Presentation • Localised reddening: can be moved over sclera • Painless / mild discomfort • Acuity preserved Causes • Usually idiopathic • May complicate RA or SLE Rx: Topical or systemic NSAIDs
scleritis
Scleritis • Vasculitis of the sclera Presentation • Severe pain: worse on eye movement • Generalised scleral inflammation § Vessels won’t move over sclera • Conjunctival oedema (chemosis) Causes • Wegener’s • RA • SLE • Vasculitis Mx • Refer to specialist • most need or corticosteroids or immunosuppressants Complications: • Scleromalacia (thinning) → globe perforation
conjunctivitis
Conjunctivitis
Presentation
• Often bilateral ¯c purulent discharge
§ Bacterial: sticky (staph, strep, Haemophilus)
§ Viral: watery
• Discomfort
• Conjunctival injection
§ Vessels may be moved over the sclera
• Acuity, pupil responses and cornea are unaffected.
Causes
• Viral: adenovirus
• Bacterial: staphs, chlamydia, gonococcus
• Allergic
Rx
• Bacterial: chloramphenicol 0.5% ointment
• Allergic: anti-histamine drops: e.g. emedastine
corneal abrasion
Corneal Abrasion • Epithelial breech w/o keratitis • Cause: trauma Symptoms • Pain • Photophobia • Blurred vision Ix • Slit lamp: fluorescein stains defect green Rx • Chloramphenicol ointment for infection prophylaxis
corneal ulcer + keratitis
Corneal Ulcer + Keratitis (corneal inflam)
Causes: bacteria, herpes, fungi, protozoa, RA
• Dendritic ulcer = Herpes simplex
• Acanthamoeba: protazoal infection affecting contact
lens wearers swimming in pools.
Presentation
• Pain, photophobia
• Conjunctival hyperaemia
• ↓ acuity
• White corneal opacity
Risk factors: contact lens wearers
Ix: green ¯c fluorescein on slit lamp
Rx: refer immediately to specialist who will
• Take smears and cultures
• Abx drops, oral/topical aciclovir
• Cycloplegics/mydriatics ease photophobia
• Steroids may worsen symptoms: professionals only
Complications
• Scarring and visual loss
ophthalmic shingles
Ophthalmic Shingles • Zoster of CNV1 • 20% of all Shingles (only commoner in thoracic dermatomes) Presentation • Pain in CNV1 dermatome precedes blistering rash • 40% → keratitis, iritis • Hutchinson’s sign § Nose-tip zoster due to involvement of nasociliary branch. § ↑ chance of globe involvement as nasociliarry nerve also supplies globe • Ophthalmic involvement § Keratitis + corneal ulceration (fluorescein stains) § ± iritis
sudden vision loss Qs
Key Questions
• Headache associated: GCA
• Eye movements hurt: optic neuritis
• Lights / flashes preceding visual loss: detached retina
• Like curtain descending: TIA, GCA
• Poorly controlled DM: vitreous bleed from new vessels
optic neuritis
Optic Neuritis Symptoms • Unilateral loss of acuity over hrs – days • ↓ colour discrimination (dyschromatopsia) • Eye movements may hurt Signs • ↓ acuity • ↓ colour vision • Enlarged blind-spot • Optic disc may be: normal, swollen, blurred • Afferent defect Causes • Multiple sclerosis (45-80% over 15yrs) • DM • Drugs: ethambutol, chloramphenicol • Vitamin deficiency • Infection: zoster, Lyme disease Rx • High-dose methyl-pred IV for 72h • Then oral pred for 11/7
vitreous haemmorhage
Vitreous Haemorrhage Source • New vessels: DM • Retinal tears / detachment / trauma Presentation • Small bleeds → small black dots / ring floaters • Large bleed can obscure vision → no red reflex, retina can’t be visualised Ix • May use B scan US to identify cause Mx • VH undergoes spontaneous absorption • Vitrectomy may be performed in dense VH
central retinal artery occlusion
Central Retinal Artery Occlusion
Presentation
• Dramatic unilateral visual loss in seconds
• Afferent pupil defect (may precede retinal changes)
• Pale retina ¯c cherry-red macula
Causes
• GCA
• Thromboembolism: clot, infective, tumour
Rx
• If seen w/i 6h aim is to ↑ retinal blood flow by ↓ IOP
§ Ocular massage
§ Surgical removal of aqueous
§ Anti-hypertensives (local and systemic)
I think peripheral would be less dramatic with blurring
central retinal vein occlusion
Retinal Vein Occlusion Central • Commoner than arterial occlusion • Causes: arteriosclerosis, ↑BP, DM, polycythaemia • Pres: sudden unilat visual loss ¯c RAPD • Fundus: Stormy Sunset Appearance § Tortuous dilated vessels § Haemorrhages § Cotton wool spots • Complications § Glaucoma § Neovascularisation • Prognosis: possible improvement for 6mo-1yr
check pics
branch retinal vein occlusiono
Branch
• Presentation: unilateral visual loss
• Fundus: segmental fundal changes
• Comps: retinal ischaemia → VEGF release and
neovascularisation (Rx: laser photocoagulation)
check pics
retinal detachement presentation o/e traetment
Retinal Detachment
• Holes/tears in retina allow fluid to separate sensory
retina from retinal pigmented epithelium
• May be 2O to cataract surgery, trauma, DM
Presentation: 4 F’s
• Floaters: numerous, acute onset, “spiders-web”
• Flashes
• Field loss
• Fall in acuity
• Painless
Fundus: grey, opalescent retina, ballooning forwards
Rx
• Urgent surgery
• Vitrectomy + gas tamponade ¯c laser coagulation to
secure the retina
causes transient visual loss
Causes of transient visual loss • Vascular: TIA, migraine • MS • Subacute glaucoma • Papilloedema
causes gradual vision loss
Causes Common • Diabetic retinopathy • ARMD • Cataracts • Open-angle Glaucoma Rarer • Genetic retinal disease: retinitis pigmentosa • Hypertension • Optic atrophy`
age related macular degeneration
Age-Related Macular Degeneration (ARMD) • Commonest cause of blindness >60yrs • 30% of >75yrs will have dry AMD Risk Factors • Smoking • ↑ age • Genetic factors Presentation • Elderly pts. • Central visual loss
dry age related mac degen
Dry ARMD: Geographic Atrophy
• Drusen: fluffy white spots around macula
• Degeneration of macula
• Slow visual decline over 1-2yrs
wet age related mac degen
Wet ARMD: Subretinal Neovascularisation
• Aberrant vessels grow into retina from choroid and →
haemorrhage
• Rapid visual decline (sudden / days / wks) ¯c distortion
• Fundoscopy shows macular haemorrhage → scarring
• Amsler grid detects distortion
treat age mac degen
Ix • OCT: optical coherence tomography § Gives high resolution images of the retina Mx for Wet AMRD • Photodynamic therapy • Intravitreal VEGF inhibitors § Bevacizumab (Avastin) § Ranibizumab (Lucentis) • Antioxidant vitamins (C,E) + zinc may help early ARMD
can’t treat dry
FYITobacco-Alcohol Amblyopia
• Due to toxic effects of cyanide radicals when
combined with thiamine deficiency.
• Pres: Optic atrophy, loss of red/green discrimination,
scotomata
• Rx: vitamins may help
chronic open angle glaucoma presentatin
Chronic Simple (Open-Angle) Glaucoma
Pathogenesis
• Depends on susceptibility of pt’s. retina and optic
nerve to ↑ IOP damage.
• IOP >21mmHg → ↓blood flow and damage to optic
nerve → optic disc atrophy (pale) + cupping
Presentation
• Peripheral visual field defect: superior nasal first
• Central field is intact \ acuity maintained until late
§ Presentation delayed until optic N. damage is
irreversible
screening and inv open angle glaucoma
Screen if High Risk • >35yrs • Afro-Caribbean • FH • Drugs: steroids • Co-morbidities: DM, HTN, migraines • Myopia Ix • Tonometry: IOP ≥21mmHg • Fundoscopy: cupping of optic disc • Visual field assessment: peripheral loss
management chronic open angle glaucoma
Mx • Life-long f/up Eye-drops to ↓ IOP to baseline • 1st line: β-blockers § Timolol, betaxolol § ↓ aqueous production § Caution in asthma, heart failure • Prostaglandin analogues § Latanoprost, travoprost § ↑ uveoscleral outflow • α-agonists § Brimonidine, apraclonidine § ↓ aqueous production and ↑ uveoscleral outflow • Carbonic anhydrase inhibitors § Dorzolamide drops, acetazolamide PO • Miotics § Pilocarpine Non-medical Options • Laser trabeculoplasty • Surgery (trabeculectomy) is used if drugs fail § New channel allows aqueous to flow into conjunctival bleb
commonest worldwide causes of blindness
Commonest Causes of Blindness Worldwide • Trachoma • Cataracts • Glaucoma • Keratomalacia: vitamin A deficiency • Onchocerciasis • Diabetic Retinopathy
diabetes and eye trouble
Cataract
• DM accelerates cataract formation
• Lens absorbs glucose which is converted to sorbitol by
aldose reductase.
Retinopathy
• Microangiopathy → occlusion
• Occlusion → ischaemia → new vessel formation in
retina
§ Bleed → vitreous haemorrhage
§ Carry fibrous tissue ¯c them → retinal
detachment
• Occlusion also → cotton wool spots (ischaemia)
• Vascular leakage → oedema and lipid exudates
• Rupture of microaneurysms → blot haemorrhage
Screening
• All diabetics should be screened annually
• Fundus photography
• Refer those ¯c maculopathy, NPDR and PDR to
ophthalmologist
§ 30% NPDR develop PDR in 1y
inv and management diabetic eye diseas
Ix • Fluorescein angiography Mx • Good BP and glycaemic control • Rx concurrent disease: HTN, dyslipidaemia, renal disease, smoking, anaemia • Laser photocoagulation § Maculopathy: focal or grid § Proliferative disease: pan-retinal (macula spared)
background diabetic retionopathy
Background Retinopathy: Leakage
• Dots: microaneurysms
• Blot haemorrhages
• Hard exudates: yellow lipid patches
pre proliferative diabetic retinopathy
Pre-proliferative Retinopathy: Ischaemia • Cotton-wool spots (infarcts) • Venous beading • Dark Haemorrhages • Intra-retinal microvascular abnormalities
diabetic proliferative retinopathy
Proliferative Retinopathy
• New vessels
• Pre-retinal or vitreous haemorrhage
• Retinal detachment
diabetic maculopathy
Maculopathy
• Caused by macular oedema
• ↓ acuity may be only sign
• Hard exudates w/i one disc width of macula
cataracts presentation and cause
Cataracts Presentation • Increasing myopia • Blurred vision → gradual visual loss • Dazzling in sunshine / bright lights • Monocular diplopia Causes • ↑Age: 75% of >65s • DM • Steroids • Congenital § Idiopathic § Infection: rubella § Metabolic: Wilson’s, galactosaemia § Myotonic dystrophy
cataracts inv and manage
Ix • Visual acuity • Dilated Fundoscopy • Tonometry • Blood glucose to exclude DM Mx Conservative • Glasses • Mydriatic drops and sunglasses may give some relief Surgery • Consider if symptoms affect lifestyle or driving (<6/10) • Day-case surgery under LA § Phacoemulsion + lens implant • 1% risk of serious complications § Anterior uveitis / iritis § VH § Retinal detachment § Secondary glaucoma § Endophthalmitis (→ blindness in 0.1%) • Post-op capsule thickening is common § Easily Rx ¯c laser capsulotomy. • Post-op eye irritation is common and requires drops
normal optic disc features and key abnormalities
Optic Disc Colour • Should be pale pink • Paler in optic atrophy Contour • Margins blurred in papilloedema and optic neuritis Cup • Physiological cup lies centrally and should occupy 1/3 of disc diameter • Cup widening and deepening in glaucoma
retinitis pigmentosa
Most prevalent inherited degeneration of the macula
Presentation
• Night blindness
• ↓↓ visual fields → tunnel vision
• Most are registrable blind (<3/60) by mid 30s
Fundoscopy
• Pale optic disc: optic atrophy
• Peripheral retina pigmentation: spares the macula
retinoblastoma
Retinoblastoma
• Commonest intraocular tumour in children
strabismus and loss of red reflex; white pupil
mx: enucleation, C/Rtherapy
stye
Stye or hordeolum externum
• An abscess / infection in a lash follicle which points
outwards.
• Rx: local Abx – e.g. fusidic acid
chalazion
Chalazion or hordeolum internum
• Abscess of the Meibomian glands which points
inwards onto conjunctiva.
§ Sebaceous glands of eyelid
blepharitis
Blepharitis • Chronic inflammation of eyelid • Causes: seborrhoeic dermatitis, staphs • Features § Red eyes § Gritty / itchy sensation § Scales on lashes. § Often assoc. ¯c rosacea • Rx § Clean crusts of lashes ¯c warm soaks § May need fusidic acid drops
entropion and ectropion
Entropion • Lid inversion → corneal irritation • Degeneration of lower lid fascia Ectropion • Low lid eversion → watering and exposure keratitis • Assoc. ¯c ageing and facial N. palsy
ptosis causes
Ptosis • True ptosis is intrinsic LPS weakness • Bilateral § Congenital § Senile § MG § Myotonic dystrophy • Unilateral § 3rd Nerve palsy § Horner’s syndrome (partial) § Mechanical: xanthelasma, trauma
orbital cellullitis presentation
Orbital Cellulitis Pathophysiology • Infection spreads locally: e.g. from paranasal sinuses, eyelid or external eye. • Staphs, pneumococcus, GAS Presentation • Usually a child ¯c inflammation of the orbit + lid swelling • Pain and ↓ range of eye movement • Exophthalmos • Systemic signs: e.g. fever • ± tenderness over the sinuses
orbital cellulitis manage / complic
Rx • IV Abx: Cefuroxime (20mg/kg/8h IV) Complications • Local extension → meningitis and cavernous sinus thrombosis. • Blindness due to optic N. pressure.
carotid cavernous fistula
Carotid-cavernous fistula • May follow carotid aneurysm rupture ¯c reflux of blood into cavernous sinus. • Causes: spontaneous, trauma • Presentation § Engorgement of eye vessels § Lid and conjunctival oedema, § Pulsatile exophthalmos § Eye bruit • Rx: endovascular treatmen
Exophthalmos / Proptosis
• Protrusion of one or both eyes Common Causes • Graves’ Disease § 25-50% § ↑ risk in smoker’s § Anti-TSH Abs → retro-orbital inflammation and lymphocyte infiltration → swelling • Orbital cellulitis • Trauma Other Causes • Idiopathic orbital inflammatory disease • Vasculitis: Wegener’s • Neoplasm § Lymphoma § Optic glioma: assoc. ¯c NF-1 § Capillary haemangioma § Mets • Carotid-cavernous fistula
myopia
Myopia: Short-sightedness The Problem • The eye is too long • Distant objects are focussed too far forward. Causes • Genetic • Excessive close work in the early decades The Solution • Concave lenses
astigmatism
Astigmatism
The Problem
• Cornea or lens doesn’t have same degree of
curvature in horizontal and vertical planes.
• Image of object is distorted longitudinally or vertically
The Solution
• Correcting lenses
hypermetropia
The Problem
• Eye is too short
• When eye is relaxed and not accommodating, objects
are focussed behind the retina.
• Contraction of ciliary muscles to focus image →
tiredness of gaze and possibly a convergent squint in
children.
The Solution
• Convex lenses
presbyopia
Presbyopia
• With age, lens becomes stiff and less easy to deform.
• Start at about 40yrs and is complete by 60yrs.
• Use convex lenses.
non paralytic squint / lazy eye
Diagnosis
• Corneal reflection: should fall centrally and
symmetrically on each cornea.
• Cover test: movement of uncovered eye to take up
fixation demonstrates manifest squint.
Management: 3 O’s
• Optical: correct refractive errors
• Orthoptic: patching good eye encourages use of
squinting eye.
• Operations: e.g. resection and recession of rectus
muscles – help alignment and cosmesis.
third nerve palsy
CNIII • Ptosis (LPS) • Fixed dilated pupil (no parasympathetic) • Eye looking down and out • Causes § Medical: DM, MS, infarction § Surgical: ↑ ICP, cavernous sinus thrombosis, posterior communicating artery aneurysm
fourth nerve palsy
CNIV • Diplopia especially on going down stairs • Head tilt • Test: can’t depress in adduction • Causes § Peripheral: DM (30%), trauma (30%), compression § Central: MS, vascular, SOL
sixth nerve palsy
CNVI
• Eye is medially deviated and cannot abduct
• Diplopia in the horizontal plane.
• Causes
§ Peripheral: DM, compression, trauma
§ Central: MS, vascular, SOL
• Rx: botulinum toxin can eliminate need for surgery
eye trauma and foreign bodies
Eye Trauma • Record acuity of both eyes • Take detailed Hx of event • If unable to open injured eye, instil LA (e.g. tetracaine 1%) Foreign Bodies • X-ray orbit if metal FB suspected • Fluorescein may show corneal abrasions Mx • Chloramphenicol drops 0.5% prevent infection § Usually coagulase-negative Staphylococcus • Eye patch • Cycloplegic drops may ↓ pain § Tropicamide, cyclopentolate
intra ocular haemorrhage
Intra-ocular Haemorrhage
• Blood in anterior chamber = hyphaema
• Small amounts clear spontaneously, but some may
need evacuation.
• Complicated by corneal staining and glaucoma (pain)
• Keep IOP↓ and monitor
orbital blowout fracture
Orbital Blowout Fracture
• Blunt injury → sudden ↑ in orbital pressure ¯c
herniation of orbital contents into maxillary sinus.
Presentation
• Ophthalmoplegia + Diplopia
§ Tethering of inferior rectus and inferior oblique
• Loss of sensation to lower lid skin
§ Infraorbital nerve injury
• Ipsilateral epistaxis
§ Damage to anterior ethmoidal artery
• ↓ acuity
• Irregular pupil that reacts slowly to light
Mx
• Fracture reduction and muscle release necessary
eye chemical injury
Chemical Injury • Alkaline solutions are particularly damaging • Mx § Copious irrigation § Specialist referral
floaters, causes etc
Floaters • Small dark spots in the visual field • Sudden showers of floaters in one eye may be due to blood or retinal detachment Causes • Retinal detachment • VH • Diabetic retinopathy / Hypertension • Old retinal branch vein occlusion • Syneresis (degenerative opacities in the vitreous)
flashes in eye, causes etdc
Flashes (Photopsia)
• Either from intraocular or intracerebral pathology
• Headache, n/v: migraine
• Flashes and floater: retinal detachment
halos in eye
Usually just diffractive phenomena
• May be caused by hazy ocular media – cataract,
corneal oedema, acute glaucoma
• Haloes + eye pain = acute glaucoma
• Jagged haloes which change shape are usually
migrainous.
types of allergic eye disease
Seasonal Allergic Conjunctivitis (SAC)
• 50% of allergic eye disease
• Small papillae on tarsal conjunctivae
• Rx
§ Antazoline: antihistamine drops:
§ Cromoglycate: inhibits mast cell degranulation
Perennial Allergic Conjunctivitis (PAC)
• Symptoms all year ¯c seasonal exacerbations
• Small papillae on tarsal conjunctivae
• Rx: olopatadine (antihistamine and mast-cell
stabiliser)
Giant Papillary Conjunctivitis
• Iatrogenic FBs: contact lenses, prostheses, sutures
• Giant papillae on tarsal conjunctivae
• Rx: removal of FB, mast cell stabilisers
manage allergic eye diseae
Management of Allergic Eye Disorders 1. Remove the allergen responsible where possible 2. General measures § Cold compress § Artificial tears 3. Oral antihistamines: loratadine 10mg/d PO 4. Eye drops § Antihistamines: antazoline, azelastine § Mast cell stabilizers: cromoglycate, lodoxamide § Steroids: dexamethasone - Beware of inducing glaucoma § NSAIDs: diclofenac
trachoma FYI
Trachoma Pathophysiology • Caused by Chlamydia trachomatis (A,B,C) • Spread by flies • Inflammatory reaction under lids → scarring → lid distortion → entropion → eyelashes scratch cornea → ulceration → blindness Rx • Tetracycline 1% ointment ± PO Prevention • Good sanitation • Face washing
Xerophthalmia and Keratomalacia FYI
• Manifestations of vitamin A deficiency
Presentation
• Night blindness and dry conjunctivae (xerosis)
• Corneal ulceration and perforation
Rx
• Vitamin A / palmitate reverses early corneal changes
hypertensive retinopathy
Hypertensive Retinopathy
• Keith-Wagener Classification
• Tortuosity and silver wiring
• AV nipping
• Flame haemorrhages and soft / cotton wool spots
• Papilloedema
• Grades 3 and 4 = malignant hypertension
know the stages+look
inflammatory disease and eye signs
Systemic Inflammatory Disease
• Conjunctivitis: SLE, reactive arthritis, IBD
• Scleritis / episcleritis: RA, vasculitis, SLE, IBD
• Iritis : ank spond, IBD, sarcoid
• Retinopathy: dermatomyositis
HIV eye signs
CMV retinitis: pizza-pie fundus + flames
• HIV retinopathy: cotton wool spots
anti muscarinic eye drugs
Anti-Muscarinics • Tropicamide § Duration: 3h • Cyclopentolate § Duration: 24h § Preferred for paediatric use • Pupil dilatation + loss of light reflex • Cycloplegia (ciliary paralysis) → blurred vision
sympthamomimetic eye drugs
Sympathomimetics
• Para-hydroxyamphetamine, phenylephrine
• May be used ¯c tropicamide
• Don’t affect the light reflex or accommodation
Indications
• Eye examination
• Prevention of synechiae in ant. uveitis / iritis
Caution
• May → acute glaucoma if shallow anterior chamber
miotic eye drugs
Miotics Effect • Constrict the pupil Pilocarpine • Muscarinic agonist Use • Acute closed-angle glaucoma
chronic open angle glaucoma treatment summary
Chronic Open-Angle Glaucoma • 1st line: β-blockers § Timolol, betaxolol § ↓ aqueous production § Caution in asthma, heart failure • Prostaglandin Analogues § Latanoprost, travoprost § ↑ uveoscleral outflow • α-agonists § Brimonidine, apraclonidine § ↓ aqueous production and ↑ uveoscleral outflow • Carbonic anhydrase inhibitors § Dorzolamide drops, acetazolamide PO • Miotics: Pilocarpine
vascular occlusion and eye, metabolic syndromes and eye
Vascular Occlusion • Emboli → amaurosis fugax: GCA, carotid atheroemboli • Microemboli → Roth spots: infective endocarditis § Boat-shaped haemorrhage ¯c pale centre Metabolic • Kayser-Fleischer Rings: Wilson’s • Exophthalmos: Graves’ • Corneal calcification: HPT
