Ophthalmology conditions Flashcards
Papilloedema - definition
Optic disc swelling secondary to raised ICP Subarachnoid space (which surrounds optic nerve) has excess CSF
Papilloedema - cause
Accumulation of CSF or inadequate drainage of CSF which leads to a raised ICP
Brain tumour
Head injury
Papilloedema - clinical features
Headache Nausea/vomiting Blurred vision Decreased colour perception Transient black outs of vision Loss of vision Painless
Papilloedema - opthalmoscopy
Poorly defined disc contour
Optic disc elevated above retinal surface
Very swollen optic disc
No central cup
Swollen nerve fibres
Enlarged optic disc
Acute phase: cotton wool spots, haemorrhages
Horner’s syndrome - causes
Sympathetic innervation gets compressed and so the innervation is impaired
- root of neck trauma
- carotid dissection
- IJV enlargement
- pancoast tumour
Horner’s syndrome - clinical features of pupil
Miosis
- small pupils
- excess constriction of the pupils as the sympathetics aren’t working to dilate the pupils
Horner’s syndrome - additional clinical features
Ptosis
- drooping of eyelid
Reduced sweating
Increased warmth and redness
Chemosis (acute allergic conjunctivitis) - definition
Swelling of the conjunctiva
Chemosis (acute allergic conjunctivitis) - clinical features
Eye is very inflammed
Watery discharge
Itchy
Puffy swollen eyes
Chemosis (acute allergic conjunctivitis) - cause
Type 1 hypersensitivity reaction
- release of inflammatory mediators cause symptoms
Hydrocephalus - cause
Accumulation of CSF
Subsequent enlargement of the ventricles and an increase in ICP
Hydrocephalus - who gets it
Young babies
Hydrocephalus - clinical features
Bones of developing skull move apart and the head may enlarge significantly
Optic neuritis - who gets it
People with MS
Most commonly females
Optic neuritis - clinical features
Pain on eye movements
Progressive unilateral vision loss
Colour vision defect
Optic neuritis - definition
Inflammation of the optic nerve
Optic neuritis - ophthalmoscopy
Disc is very pale
Loss of blood vessels
CRAO - definition
Central retinal artery occlusion
This artery supplies the inner 2/3rds of the retina
It is an end artery, so if blocked there is no blood supply to the majority of the retina. this causes swelling in the retina.
CRAO - causes
Atherosclerosis
Hypertension
Aneurysm
Stroke
CRAO - clinical features
Sudden loss of vision Painless Very profound loss of vision - won't be able to read top line of snellen chart - won't be able to count your fingers
CRAO - ophthalmoscopy
Retina is pale and milky due to oedema
Retinal nerve fibre layer becomes swollen
Cherry red spot at macula
Cup is very dense and bright white
Blood is struggling to get through circulation - follow an artery and it may disappear
CRAO - management
If it presents within 24 hours of onset then try and ocular massage
- aim to push the embolus further down the vascular tree to a retinal branch artery instead of central retinal artery
Anti-platelet therapy
Branch retinal artery occlusion - clinical features
Bottom half of vision is lost
Branch retinal artery occlusion - ophthalmoscopy
Only the top half of the retina looks pale
Amaurosis fugax - definition
Short lasting CRAO
Amaurosis fugax - clinical features
Short lasting vision loss (5 mins)
Painless
Darkness/blackness coming down from vision like a set of dark curtains
Amaurosis fugax - ophthalmoscopy
No abnormalities
Amaurosis fugax - management
Urgent referral to stroke clinic
Aspirin
CRVO - definition
Central retinal vein occlusion
Blood travels in with no problems but the blood becomes trapped and can’t get back out
CRVO - causes
Atherosclerosis
Hypertension
Hyperviscosity
Raised IOP
CRVO - clinical features
Sudden onset loss of vision
Painless
Visual outcome is variable - might not loose complete vision
CRVO - ophthalmoscopy
Congested fundus Dilated, torturous veins Cotton wool spots (areas of ischaemia) Widespread haemorrhage Can be difficult to see the optic disc
CRVO - investigations
OCT scan
- where the fovea dip is usually present, there is a ‘hill’ due to intra-retinal fluid build up over the fovea
CRVO - management
Laser treatment
Anti VEGF injections
Occlusion of optic nerve head circulation - definition
Posterior ciliary arteries (which supply optic nerve head) become occluded
Occlusion of optic nerve head circulation - types
Giant cell arteritis
Atherosclerosis
Occlusion of optic nerve head circulation - clinical features
Sudden, profound vision loss
Occlusion of optic nerve head circulation - ophthalmoscopy
Swollen disc
Pale disc
Margins are fluffy and not well defined
Vitreous haemorrhage - definition
Bleeding into the vitreous cavity
Vitreous haemorrhage - clinical features
Sudden loss of vision
Floaters in the eye
Loss of red reflex
Vitreous haemorrhage - ophthalmoscopy
Red areas
Vitreous haemorrhage - management
Identify cause of haemorrhage
Retinal detachment - clinical features
Painless
Sudden loss of vision
Sudden onset flashes and floaters
Retinal detachment - ophthalmoscopy
Retinal tear
Retinal detachment - management
Usually surgical
wet ARMD - definition
Age related macular degeneration
New blood vessels grow under the retina and macula
This causes a break in the choroid layer and leakage causes a build up of fluid/blood which lifts the macula up from its normally flat position
Wet ARMD - clinical features
Sudden vision loss
Central visual loss
Dark spots in the centre of pts vision due to blood/fluid under the macula
Symptoms are often unilateral to begin with but always end up bilateral
Wet ARMD - ophthalmoscopy
Retinal oedema
Localised elevation
Exudates in and around macula
Detachment of retinal pigment epithelium
Wet ARMD - management
Dietary supplements
Anti-VEGF injections
- stops new blood vessels from growing
Dry ARMD - definition
Dry age related macular degeneration
Build up of waste products (drusen) below the retinal pigment epithelium which causes the retina to be pulled away from the choroid
There is no leakage of fluid and no blood
Dry ARMD - clinical features
Gradual decline in vision
Central vision gets lost gradually (scotoma)
Dry ARMD - ophthalmoscope
Yellow/white deposits
Dry ARMD - management
Supportive treatment
Low vision aids (magnifiers)
Cataract - definition
Clouding of the lens in the eye which leads to a decrease in vision
Cataract - causes
Age related Trauma Diabetes Obesity Drug induced - SE of steroids
Cataract - clinical features
Gradual decline in vision Hazy, blurred vision Faded colours Halos around light Trouble with bright light Trouble seeing at night
Cataract - management
Surgical removal of lens with intra-ocular lens implant (if pt symptomatic)
Diabetic retinopathy - types
Non proliferative
Proliferative
Non proliferative diabetic retinopathy - definition
Early stage
Tiny blood vessels within the retina leak blood or fluid.
This causes retina to swell or deposits to form
Non proliferative diabetic retinopathy - ophthalmoscopy
Micro-aneurysm Dot and blot haemorrhages Hard exudates (yellow) Cotton wool patches Abnormalities of venous calibre Intra-retinal microvascular abnormalities (IRMA)
Proliferative diabetic retinopathy - definition
New vessel formation - may grow on disc (NVD) - may grow elsewhere in retina (NVE) Fibrosis Scarring (which shrinks the retina and pulls it off)
Proliferative diabetic retinopathy - ophthalmoscopy
New vessel formation
- grows into the vitreous
Smal dot haemorrhages in macula
White/black laser scars
Why do new vessels form in proliferative diabetic retinopathy?
Due to ischaemia
Proliferative diabetic retinopathy - management
Laser ischaemic tissue - sacrifice some of the peripheral retina in order to save the central retina PRP - pan retino photocoagulation Macular grid
Ablate retina
Surgery
Hypertensive retinopathy - definition
Hypertension must be very severe for this to occur
Hypertensive retinopathy - ophthalmoscopy
Cotton wool spots Hard exudates Retinal haemorrhages Optic disc oedema Weakened blood vessels
Idiopathic intracranial hypertension - BP levels
Normal
Idiopathic intracranial hypertension - ophthalmoscopy
Bilateral disc swelling
No crisp edge to the disc
Glaucoma - definition
Progressive optic neuropathy
- optic nerve gets damaged by the pressure of the fluid inside your eye
Glaucoma - cause
Increased intra-ocular pressure (IOP) causes damage to nerve fibres
This leads to optic nerve dysfunction
Glaucoma - types
Open angle
Closed angle
Glaucoma - ophthalmoscopy
Increased cup size due to loss of nerve fibres
Cup:Disc ratio >0.7
Other features of optic disc should be normal
Glaucoma - management
Eye drops which decrease aqueous humour production (this decreased IOP) e.g. bimatoprost
Prostanoids eg latanoprost
Beta blockers - block ciliary body and therefore reduce aqueous humour production
Carbonic anhydrase inhibitors - block ciliary body and therefore reduce aqueous humour production
Parasympathomometic eg pilocarpine
Laser treatment
Closed angle glaucoma - gradual/sudden vision loss
Sudden
Closed angle glaucoma - definition
Aqueous humour struggles to get through the canal of schlemm and so backs up and builds up.
This pushes the iris forward and the iris further blocks the canal of schlemm
Pressure continues to increase
Plugging of drain as iris has anatomically blocked the drainage canal
Closed angle glaucoma - clinical features
Sudden vision loss Painful, red eye Headache Nausea Vomiting Cloudy cornea
Closed angle glaucoma - examination
Limbus injection of vessels
Cloudy cornea
Pupil mid dilated
Open angle glaucoma - definition
Iridocorneal angle is open but there is clogging up of the canal of schlemm
Aqueous humour is not draining so the pressure increases and damage occurs
Clogged drain
Open angle glaucoma - clinical features
Often asymptomatic
Gradual visual loss
What is the commonest cause of blindness in the western world?
ARMD
Which is more common: Wet or dry ARMD ?
Dry
Anterior uveitis - clinical features
Dull achy pain - pain may be referred to brow red eye (limbus) Reduced vision Photophobia
Anterior uveitis - examination
Ciliary injection around the limbus
Hypopyon (clumps of white inflammatory cells)
Small or irregular pupil
Anterior uveitis - management
Topical steroids
Mydratics - cyclopentolate
Thyroid eye disease - extra ocular features
Proptosis Lid retraction Lid lag Lid pigmentation Swelling of periorbital fat
Thyroid eye disease - ocular features
Chemosis (oedema of conjunctiva)
Glaucoma
Blepharitis - anterior (name the 2 types)
Seborrhoeic
Staphylococcal
Blepharitis - anterior - seborrhoeic
Scales on the lashes
Lid margin is more red than deeper part of lid
No ulceration
Blepharitis - anterior - staphylococcal
Infection involving the lash follicle Lashes are distorted - ingrowing of lashes Can get a sty Ulcers of lid margin
Blepharitis - posterior
Meibomian gland dysfunction - lid margin and lashes unaffected redness is in deeper part of lid Meibomian cysts Assoc with acne rosacea
Episcleritis - associated condition
Gout
Episcleritis - clinical features
Recurrent
Can cause nodular bumps on eye surface
Episcleritis - management
Self limiting
Scleritis - definition
Serious disease
Assoc with serious systemic vasculitides
Scleritis - clinical features
Painful
scleritis - management
Injection of deep vascular plexus
Phenylephrine test
Oral NSAIDs
Oral Steroids
