Ophthalmology Brief Flashcards
what is the anterior chamber in the eye
the space between the cornea and the iris - it is filled with aqueous humour
what is the posterior chamber in the eye
it is the space between the iris and the lens - it is filled with aqueous humour
where does aqueous humour get produced and where does it drain?
it is produced by the ciliary body and it flows around the lens under the iris, through the anterior chamber, through the trabecular meshwork and into the canal of Schlemm where it enters general circulation
describe the pathophys of open angle glaucoma
- gradual resistance through the trabecular meshwork
- aqueous humour slowly builds up in anterior and posterior chambers
- intraocular pressure builds, giving slow and chronic onset of glaucoma
describe the pathophys of acute angle glaucoma
- the iris bulges forward and seals of the trabecular meshwork from the anterior chamber
- this prevents aqueous humour from draining
- this is a continual build up of pressure
- opthalmology emergancy
what happens to the optic nerve in glaucoma
- increased intraocular pressure causes cupping of the optic disc
- in the centre of a normal optic disc is an optic cup
- usually less than half the size of the optic disc
- in glaucoma the optic cup enlarges due to pressure
- this is called cupping
- an optic cup greater than 0.5 the size of the optic disc is abnormal
risk factors for open angle glaucoma
increasing age
family history
black ethnic origin
nearsightedness (myopia)
presentation of open angle glaucoma
- rise in pressure is asymptomatic for a long time so often diagnosed by routine screening during eye checks
- affects peripheral vision first gradually until tunnel vision
- can present with gradual onset of
- fluctuating pain
- headaches
- blurred vision
how do you measure intraocular pressure
- non contact tonometry
- puff of air
- less accurate but gives helpful estimate for screening
- goldmann applanation tonometry
- gold standard
- device on end of slip lamp that makes contact with cornea and applies pressure
diagnosis of open angle glaucoma
goldmann applanation tonometry
fundoscopy
visual field assessment
management of open angle glaucoma
- prostaglandin analogue eye drops are first line
- latanoprost
- other options
- beta blockers
- timolol
- carbonic anhydrase inhibitors
- dorzolamide
- sympathomimetics
- brimonodine
- beta blockers
- trabeculectomy surgery if eye drops are ineffective
- creates a bleb under the conjunctiva where aqueous humour can be reabsorbed
risk factors for acute angle glaucoma
increasing age
female sex
family history
chinese and east asian ethnic origin
rare in black people
which medications can precipitate acute angle-closure glaucoma
- adrenergic medications
- e.g. noradrenaline
- anticholinergic medications
- e.g. oxybutynin
- tricyclic antidepressants
- e.g. amitryptyline
presentation of acute angle glaucoma
severely painful red eye
blurred vision
halos around lights
associated headache nausea and vomiting
examination findings in acute angle glaucoma
red eye
teary
hazy cornea
decreased visual acuity
dilatation of the affected pupil
fixed pupil size
firm eyeball on palpation
initial management of acute closed-angle glaucoma
- ambulance
- lie patient on back without a pillow
- pilocarpine eye drops
- constricts pupil and causes ciliary muscle contraction
- opens pathway of flow of aqueous humour to trabecular meshwork
- oral acetazolamide
- reduces production of aqueous humour
- analgesia and antiemetic if required
secondary care of acute closed-angle glaucoma
- pilocarpine
- oral acetazolamide
- timolol
- beta blocker reduces production
- dorzolamide
- reduces production
- brimonidine
- reduces production and increases uveoscleral flow
- laser iridotomy is usually required
- makes hole in iris to facilitate flow
what is the most common cause of blindness in the UK
age related macular degeneration
what is the key finding seen during fundoscopy in macular degeneration
drusen
these are yellow deposits of proteins and lipids
what are the types of age related macular degeneration and which is more common and which has the worse prognosis
wet and dry
90% of cases are dry
10% of cases are wet
wet has the worse prognosis
three features common in both wet and dry AMD
atrophy of retinal pigment epithelium
degeneration of the photoreceptors
drusen
pathophys of wet amd
new vessels grow from choroid layer to the retina
these leak fluid and cause oedema
more rapid loss of vision
caused by vascular endothelial growth factor
risk factors for amd
age
smoking
white or chinese ethnic origin
family history
cvd
presentation of AMD
gradual worsening of central visual field
reduced visual acuity
crooked or wavy appearance of straight lines
wet can present more acutely with symptoms coming on over days and progress to full vision loss by 2-3 years
amd findings on examination
reduced acuity on snellen chart
scotoma (central patch of vision loss)
fundoscopy - drusen
management of dry amd
- no specific treatment
- manage lifestyle factors
- avoid smoking
- control blood pressure
- vitamin supplementation slows progression
management of wet amd
- anti-vegf medications
- ranibizumab
- bevicizumab
- pegaptanib
- these injected into vitreous chamber once a month
- need to be started within 3 months of symptom onset to be beneficial
pathopys of diabetic retinopathy
7 features
- hyperglycaemia leads to damage of the retinal small vessels
- blot haemorrhages
- hard exudates of lipids on retina
- microanueurysms
- venous beading
- wein walls no longer straight and look like string of sausages
- cotton wool spots
- nerve fibre damage on retina causes these fluffy white patches
- intraretinal microvascular abnormalities (IMRA)
- dilated capillaries that act as shunt between arterial and venous vessels
- neovascularisation
- due to growth factors
how do you classify diabetic retinopathy broadly
- depending on whether new blood vessels have developed it is either:
- proliferative
- neovascularisation
- vitrious haemorrhage
- non-proliferative
- can develop into proliferative
- proliferative
how do you classify non proliferative diabetic retinopathy based on severity
- mild:
- microaneurysms
- moderate:
- microaneurysms
- blot haemorrhages
- hard exudates
- cotton wool spots
- venous beading
- severe
- blot haemorrhages
- microaneurysms in 4 quadrants
- venous beading in 2 duadrants
- IMRA in any quadrant
complications of diabetic retinopathy
- retinal detatchment
- vitreous haemorrhage
- bleeding into vitreous humour
- rebeosis iridis
- new blood vessel formation in the iris
- optic neuropathy
- cataracts
management of diabetic retinopathy
laser photocoagulation
anti-vegf medications such as ranibizumab and bevacizumab
vitreoretinal surgery may be required in severe disease
signs associated with hypertensive retinopathy
hypertensive retinopathy signs
6 things
- silver wiring or copper wiring
- walls of arterioles thickened and sclerosed increasing light reflection
- arteriovenous nipping
- arterioles compress veins where they cross
- cotton wool spots
- ischaemia and infarction of the retina causes damage to nerve fibres
- hard exudates
- caused by damaged vessels leaking lipids into the retina
- retinal haemorrhages
- damaged vessels rupture
- papilloedema
- ischaemia to the optic nerve results in swelling and blurring of the disc margins
what is the classification system for hypertensive retinopathy
- keith wagener classification
- stage 1: mild narrowing of the arterioles
- stage 2: focal constriction of blood vessels and AV nicking
- stage 3: cotton-wool patches exudates and haemorrhages
- stage 4: papilloedema
risk factors for cateracts
increasing age
smoking
alcohol
diabetes
steroids
hypocalcaemia
presentation of cateracts
- symptoms usually asymmetrical as both eyes are affected seperately
- slow reduction in vision
- progressive visual blurring
- starbursts around light
- loss of red reflex
- lens appears grey or white when testing red reflex
name a complication of cateract surgery
endopthalmitis - inflammation of the inner contents of the eye normally caused by infection
treated with intravitreal abx injected into the eye
causes of mydriasis
- 3rd nerve palsy
- holmes adie syndrome
- raised ICP
- congenital
- trauma
- stimulants such as cocaine
- anticholinergics
causes of miosis
horner’s syndrome
cluster headaches
argyll-robertson pupil (neurosyphilis)
opiates
nicotine
pilocarpine
third nerve palsies cause
ptosis (supplies levator palpebrae superioris)
dilated non-reactive pupil (contains parasympathetic fibres that innervate sphincter muscles of iris)
divergent strabismus (down and out)
causes of third nerve palsy
- full third nerve palsy (caused by compression therefore referred to as surgical third)
- idiopathic
- tumour
- trauma
- cavernous sinus thrombosis
- posterior communicating artery aneurysm
- raised ICP
- if pupil is spared it’s because parasympathetic fibres are spared and suggests a microvascular cause
- diabetes
- hypertension
- ischaemia
what is horner’s syndrome
ptosis
miosis
anhidrosis
enopthalmos
what causes horner’s syndrome
- damage to the sympathetic nervous system supplying the face
- depending on the anhidrosis then the location of the damage can be identified
- central lesions cause anhidrosis of the arm and trunk as well as face
- pre-ganglionic lesions cause anhidrosis of the face
- post-ganglionic lesions do not cause anhidrosis
what is the journey of the sympathetic nerves that supply the head
- arise from spinal cord in chest as pre-ganglionic nerves
- enter sympathetic ganglion at base of neck
- exit as post-ganglionic nerves
- post-ganglionic nerves travel to the head running alongside the internal carotid
causes of central, pre and post ganglionic causes of horner’s
and how to remember this
- 4S for Sentral
- Stroke
- multiple Sclerosis
- Swelling (tumours)
- Syringomyelia (cyst on spinal cord)
- 4T for Torso (pre-ganglionic)
- Tumour (pancoast)
- Trauma
- Thyroidectomy
- Top rib (cervical rib growing above the clavicle
- 4C for Cervical (post-ganglionic)
- Carotid aneurysm
- Carotid artery dissection
- Cavernous sinus thrombosis
- Cluster headache
what is argyll robertson pupil
specific finding in neurosyphilis
constricted pupil that accomodates when focussing nearby object
does not react to light
often irregularly shaped
“accomodates but does not react” made it known as prostitutes pupil also due to it’s relation to syphilis
what is blepharitis
inflammation of the eyelid margins - can be associated with dysfunction of the meibomian glands