Ophthalmology & Skin - Level 3 Flashcards
1
Q
Definition of uveitis?
A
inflammation of uveal tract (iris, ciliary body and choroid), may also get inflamed retina, optic nerve and vitreous humour
2
Q
Classification of uveitis?
A
o Anterior uveitis – inflammation in anterior segment of eye (iritis – anterior chamber, iridocyclitis – anterior chamber and anterior vitreous)
o Intermediate uveitis – inflammation of ciliary body, pars plana and anterior vitreous
o Posterior uveitis – inflammation of any of: choroid, retina or optic never head
o Panuveitis – inflammation of both anterior and posterior chambers
3
Q
Time frame of uveitis?
A
Acute – sudden onset which resolves within 3 months
o Recurrent – repeated episodes for more than 3 months with periods of inactivity without treatment
o Chronic - persistent >3 months, relapse if treatment discontinued
or 90%
4
Q
Epidemiology of uveitis?
A
- Cause of 10% of people with visual impairment in West
- Women
- Anterior 90%
5
Q
Causes of acute anterior uveitis?
A
o Idiopathic o Systemic disease: Ankylosing spondylitis, juvenile RA, Reiter’s syndrome, IBD Behcet’s disease Psoriasis MS o Infection – HSV, VZV, CMV, toxoplasmosis o Trauma o Neoplasm
6
Q
Risk factors of acute anterior uveitis?
A
o Hx of uveitis
o HLA-B27 marker
7
Q
Symptoms of acute anterior uveitis?
A
o Pain in one or both eyes Worse with ciliary contraction – reading/focussing/accommodation reflex Acute develops over days/hours o Red eye o Blurred vision o Photophobia o Watery eye
8
Q
Signs of acute anterior uveitis?
A
o Visual acuity normal or reduced
o Ciliary injection
o Distorted pupil
o Photophobia
9
Q
Management of acute anterior uveitis - urgent referral for same-day ophthalmology assessment?
A
Acute glaucoma, corneal ulcer/foreign body, anterior uveitis, scleritis, trauma, chemical injuries, neonatal conjunctivitis, contacts lens wearer
10
Q
Management of acute anterior uveitis - indications of serious red eye?
A
Reduced visual acuity, deep pain, unilateral pain, contacts lens, photophobia, trauma, chemical injury, ciliary injection, fluorescein staining, unequal pupils, neonatal conjunctivitis
11
Q
Management of acute anterior uveitis - if chemical injury?
A
Irrigate eye with water/0.9% saline and urgent transfer for ophthalmology assessment
12
Q
Management of acute anterior uveitis - secondary care - investigations?
A
• Bloods – FBC, ESR, ANA, HLA
13
Q
Management of acute anterior uveitis - secondary care - non-infectious uveitis?
A
• Steroids (topically, orally, IV) - prednisolone
o Tapered slowly to avoid relapse
• Cycloplegic-mydriatic (cyclopentolate/atropine)
o Relieve pain and prevents adhesions
- If severe – immunosuppresants (ciclosporin/tacrolimus), TNFi, laser phototherapy, cryotherapy or vitrectomy
- Regular eye clinic follow up – slit lamp monitoring
14
Q
Management of acute anterior uveitis - secondary care - infectious uveitis?
A
- Antimicrobials
- Steroids
- Cycloplegics
15
Q
Complications of acute anterior uveitis?
A
o Visual loss o Band keratopathy o Low intraocular pressure o Macular hole/ischaemia o Retinal detachment o Optic neuropathy/atrophy
16
Q
Prognosis of acute anterior uveitis?
A
o Usually resolves rapidly with treatment
o May progress to chronic uveitis
o Acute anterior uveitis has best visual outcome
17
Q
Definition of ectropion?
A
- Eyelid turns outwards and everts
- Problems arise due to conjunctival and corneal exposure
18
Q
Causes of ectropion?
A
o Involutional ectropion – age related o Paralytic – 7th nerve palsy o Cicatricial – following burns, trauma o Mechanism – mass displaces lid o Congenital
19
Q
Symptoms of ectropion?
A
- Asymptomatic or symptoms of:
o Irritation and pain at front of eye
o Watery eye
o Redness to eye - If untreated:
o Conjunctival keratinisation
20
Q
Assessment of ectropion?
A
- Lower lid seen coming away from globe
- Fluorescein staining and slit lamp examination
21
Q
Management of ectropion - referral?
A
o If features of serious or life-threatening cause – same day ophthalmology assessment
Acute glaucoma, corneal ulcer, anterior uveitis, scleritis, trauma
Reduced visual acuity, deep pain, unilateral pain, contact lens use, photophobia, high-velocity/chemical injuries, unequal pupils
o If no features of serious cause – routine referral to ophthalmology
22
Q
Management of ectropion - treatments?
A
o Lubricating eye ointment
o Taping lids overnight whilst waiting for surgical repair
o Surgery – ectropion repair
23
Q
Definition of entropion?
A
- Eyelid turns towards eye, eyelashes then rub against cornea
24
Q
Causes of entropion?
A
o Older people
o Weakness of small muscles around eye
o Trachoma – infection in tropical countries
25
Symptoms of entropion?
```
- Sudden onset:
o Irritation and pain at front of eye
o Watery eye
o Redness to eye
- If untreated:
o Corneal abrasion and ulcer
```
26
Management of entropion - referral?
o If features of serious or life-threatening cause – same day ophthalmology assessment
o If no features of serious cause – routine referral to ophthalmology
27
Management of entropion - treatment?
o Lubricating eye ointment
o Taping eyelid to cheek
o Injecting botulinum toxin into eyelid muscles
o Surgery – entropion repair
28
Definition of blepharitis?
- Chronic inflammatory condition affecting margin of eyelids – usually bilateral
29
Categories of blepharitis?
o Anterior blepharitis – inflammation of base of eyelashes (anterior margin of eyelid)
Caused by – bacteria (Staph), seborrheic dermatitis
o Posterior blepharitis – inflammation of meibomian glands (set of glands running along posterior eyelid margin, produce lipid layer of tear film)
30
Associated conditions with blepharitis?
o Dry eye disease
o Seborrhoeic dermatitis
o Rosacea
o Medications - isotretinoin
31
How common is blepharitis?
- 5% of eye presentations in primary care
| - Usually middle age
32
Symptom of blepharitis?
```
o Burning, itching and/or crusting of eyelids
Symptoms worse in morning
Both eyes affected
o Sore, gritty eye
o Changes to eye lashes
```
33
Signs of blepharitis?
o Anterior staphylococcal blepharitis – hyperaemia and telangectasia around lid margin, crusting on base of eyelids
o Anterior seborrheic blepharitis – erythema, hyperaemia and greasy appearance of lid margin, less inflammation
o Posterior blepharitis – Meibomian glands covered in oil, dilated or visibly obstructed
34
Management of blepharitis - general advice?
o Eyelid hygiene
Wetting a cloth or cotton bud with 1:10 baby shampoo cleanser and wiping along lid margins to clear debris
• Clean twice daily, then once daily as symptoms improve
Eye lubricants used
o Warm Compresses
Applied 5-10 minutes
Then gentle eyelid massage
o Avoid eye makeup when possible
35
Management of blepharitis - if general advice ineffective?
o For anterior blepharitis:
Topical antibiotic (chloramphenicol) rubbed into margin
o For posterior blepharitis:
Oral doxycycline
36
Management of blepharitis - when to refer?
o Same-day assessment if:
Symptoms of corneal disease (pain, blurred vision)
Rapid visual loss
Cellulitis suspected
```
o Routine Ophthalmology if:
Eyelid asymmetry or deformity
Gradual deterioration of vision
Underlying cause – Sjogrens
Treatment in primary care has failed
```
37
Prognosis of blepharitis?
o Chronic condition that remits and relapses
38
Complications of blepharitis?
o Meibomian cyst
o External stye
o Changes to eyelashes – loss, misdirection, depigmentation
o Contact lens intolerance
39
Definition of episcleritis?
- Inflammation of superficial, episcleral layer of eye
| - Common, benign and self-limiting
40
Anatomy of sclera?
o Blood vessels of episclera not usually seen in non-inflamed eye
o Three plexuses:
Bulbar conjunctival – superficial, fine vessels overlying and freely moveable over episcleral. If inflamed, bright red
Episcleral plexus – straight, radially arranged vessels in superficial episcleral, slightly moveable. Inflamed – salmon pink colour
Deep episcleral plexus – closely applied criss-cross vessels to sclera. Inflamed – bluish-red and immobile
41
Types of episcleritis?
o Simple – vascular congestion on even surface
| o Nodular – discrete elevation of inflamed sclera
42
Epidemiology of episcleritis?
- Usually no cause
- Women 70%
- Bilateral 30%
- Can be recurrent, typically every few months
43
Symptoms of episcleritis?
o Mild tenderness, localised eye pain
Acute-onset
Focal, cone-shaped wedge (thin end towards pupil)
o Redness of eye – extends radially
o Grittiness
o Bilateral in 30%
o Rarely, associated diseases – IBD, hyperuricaemia, RA, SLE, granulomatosis, infections, foreign body
44
Signs of episcleritis?
o Segmental redness – episcleral vessels mobile
| o Normal visual acuity, pupil reactions and no corneal staining
45
Investigations of episcleritis?
- Clinical diagnosis
| - If suspicion then refer
46
Management of red eye in GP - when to urgently refer for same-day eye clinic?
Acute glaucoma, corneal ulcer/foreign body, anterior uveitis, scleritis, trauma, chemical injuries, neonatal conjunctivitis, contacts lens wearer
47
Management of red eye in GP - indications of serious red eye disease?
Reduced visual acuity, deep pain, unilateral pain, contacts lens, photophobia, trauma, chemical injury, ciliary injection, fluorescein staining, unequal pupils, neonatal conjunctivitis
48
Management of episcleritis?
o Usually self-limiting – lasts for 7-10 days
o PRN topical or systemic analgesia (NSAIDs)
o Lubricating eye drops
o Follow up – 1 week
49
Management of recurrent or severe episcleritis?
Topical steroids if severe
50
Definition of scleritis?
- Vasculitis of entire thickness of sclera
| - Generalised inflammation with oedema of conjunctiva and scleral thinning
51
Classification of scleritis?
- Anterior (98%)
o Diffuse – most common, widespread inflammation of anterior sclera. Mild and tends to resolve
o Nodular – erythematous, tender, fixed nodules in sclera. May progress
o Necrotising – extreme pain and scleral damage
- Posterior (2%)
o Back of eye, difficult to diagnose
52
Epidemiology of scleritis?
- Women
- Older age
- Associated with RA, granulomatosis, SLE, IBD
53
Symptoms of scleritis? What disease is scleritis commonly associated with?
```
o Severe, deep, boring eye pain
Gradual Onset
Radiates to forehead, brow and jaw
Wakes patient up from sleep
o Red eye, watering
o 50% bilateral
o Commonly, associated with systemic disease
RA, granulomatosis, SLE, ankylosing spondylitis, gout, syphilis, Churg-Strauss syndrome, infections
```
54
Signs of scleritis?
o Reduced visual acuity
o Painful ocular movements
o Diplopia (posterior disease)
o Abnormal pupil reactions
55
Detection of underlying cause in eye clinic of scleritis?
```
o Bloods
FBC, CRP, ESR
RF, Anti-CCP
Syphilis screen
ANCA
o Urine dipstick
o Imaging
```
56
Management of scleritis - diffuse and nodular?
o Refer to ophthalmology
```
o Diffuse and nodular
Oral NSAIDs
Oral high-dose prednisolone
Immunosuppression if steroids not effective – methotrexate, azathioprine, cyclophosphamide
Biologics – infliximab, adalimumab
```
57
Management of scleritis - necrotising?
Oral steroids (prednisolone)
Immunosuppression if steroids not effective – methotrexate, azathioprine, etc
Biologics – infliximab, adalimumab
58
Complications of scleritis?
- Globe perforation
- Scleral thinning
- Ischaemia of globe
- Raised intra-ocular pressure
- Retinal detachment
- Uveitis
- Cataracts
- Globe Atrophy
59
Definition of squint?
- A squint (strabismus) is a misalignment of the visual axes. That is, both eyes are not directed at an object at the same time
60
Definition of pseudosquint?
- A pseudo squint is the impression of misaligned eyes when no squint is present. For example, prominent epicanthic fold
61
Aetiology of squint?
o Idiopathic
o Refractive error
o Visual loss
Retinoblastoma, cataract, ocular movements, optic neuropathy
o Cerebral palsy
o Abnormal extra-ocular muscles of innervation
o Cranial III, IV, VI palsies
62
Risk factors of squint?
```
o Low birth weight
o Prematurity
o Smoking
o Anisometropia, hypermetropia
o FHx
```
63
What is manifest squint?
o A manifest squint (a 'tropia')
A squint present when eyes are open and being used so that when one eye views the object of interest, the other eye is deviated
This may be constant, or intermittent when the squint is present only some of the time
64
What is latent squint?
o A latent squint (a 'phoria')
A squint that is present only when the use of the two eyes together is interrupted ('dissociated')
For example, by covering one eye
65
Description of direction of squints?
o Horizontal deviation
Esotropia or esophoria (convergent squint), or exotropia or exophoria (divergent squint).
o Vertical deviation
Hypertropia (upward squint) or hypotropia (downward squint)
o Combined
66
Description of squints in relation to eye position?
```
o Comitant (concomitant) squint
Degree of deviation does not vary with the direction of gaze
This is typical of most childhood squints
This equates to no paralysis or limitation of eye movements but the balance between the muscles in the two eyes has been lost.
```
```
o Incomitant (non-comitant) squint
The degree of deviation varies with the direction of gaze
This may indicate an acquired neurological or muscular disease-causing paresis or paralysis of one or more of the extra-ocular muscles resulting in limitation of eye movements
```
67
Description of squints in relationship to accomodation?
o Accommodative
A squint that occurs, or is more obvious, when the child is accommodating and focusing on an object
The child is typically hypermetropic (long-sighted) and the squint can be reduced or corrected if the refractive error is corrected with glasses
o Non-accommodative
A squint where either there is no significant hypermetropia, or if hypermetroia is present there is no change in the angle of the squint with appropriate glasses.
68
Assessment of squints?
- General inspection
o Look for any asymmetry in eye position and ocular abnormalities
- Corneal light reflex
o Pen-torch held at 30cm, light reflection should appear in same position in two pupils
o If not, a squint is present
- Red reflex test
o Using ophthalmoscope, visualise red reflex from 30cm and should be identical in shape, size and colour
- Cover Test
o Ask child to fix on object, cover the good eye and watch squinting eye fix
o Done at 33cm and 6m
o As the cover is introduced over one eye, watch the uncovered eye for any movement. Then repeat, covering the other eye. In a manifest squint when the straight eye is covered, the squinting eye will have to move to align with the fixation objection
o If no manifest squint is found then proceed to look for a latent squint.
- Uncover Test/Alternate Cover Test
o As the child fixes on the toy, cover one eye for about three seconds, then remove the cover and watch for any movement of the eye that has just been uncovered
o Repeat, covering the other eye. In latent squint the eye will drift under the cover, on removing the cover the eye will straighten to regain binocular vision, and the examiner will see this movement
- Cranial Nerve Exam
o Ocular movements
o Check visual acuity
o Fundoscopy
69
Management of any child with squint?
- Refer any child with a suspected or confirmed squint to the local paediatric eye service
- Must refer:
o Divergent
o Paralytic
o Persistent beyond age of 2mths
- The earlier treatment for a squint can be initiated, the better the outcome to prevent amblyopia
70
Management options in squint?
```
o Corrective Glasses
o Occlusion of normal eye
With patch or occlusive glasses
Penalisation alternative where normal eye blurred by atropine drops
o Eye exercises
o Surgery
Altering point of insertion of an extra-ocular muscle into sclera, or by shortening an extra-ocular muscle
o Botulinum Toxin
```
71
Definition of actinic (solar) keratosis?
- Pre-malignant crumbly white/yellow scaly crusts on sun-exposed skin
- From dysplastic intra-epidermal proliferation of atypical keratinocytes
- Progression to SCC <1 in 1000/year
72
Epidemiology of actinic (solar) keratosis?
- Prevalence increases with age
73
Risk factors of actinic (solar) keratosis?
```
o Elderly
o Fair-skinned
o Blue eyed
o Ginger/Blonde hair
o Burn easily
```
74
Symptoms and signs of actinic (solar) keratosis?
- Background of sun damaged skin
- Erythematous, scaly plaques on sun-exposed area
o Common – forearms, backs of hands, face, ears, scalp and lower legs
o Rough to touch
- Asymptomatic, sore or itchy
75
Diagnosis of actinic (solar) keratosis?
- Clinical diagnosis
| - Biopsy if uncertain
76
Management of actinic (solar) keratosis - when to refer?
- Refer from GP to GPwSI or consultant dermatologist
o Diagnostic uncertainty
o More widespread/severe actinic damage
o If suspicious – 2 week wait
77
Management of actinic (solar) keratosis - general advice?
o Protect skin from further skin damage (sun hats, long sleeves, sunscreen >SPF 30)
o Some resolve spontaneously
o Moisturisers useful
78
Management of actinic (solar) keratosis - treatments?
o Cryotherapy
o Creams – 5-FU, imiquimod or Ingenol gel
o Surgical removal
o Photodynamic therapy
79
Description of keloid scar?
- Irregular hypertrophy of vascularised collagen (type 3) forming raised edges at sites of previous scars that extend outside scar
- Does not regress and recurs after excision
80
Epidemiology of keloid scar?
- Common in dark skin – African-Americans, Hispanic, Chinese
- Peak age 20-30 years
- More likely in burns, acne and infected wounds
81
Causes of keloid scar?
- Cause unknown
| - 50% have positive FHx
82
Symptoms and scar of keloid scar?
- Commonly, sternum, shoulder, earlobe and cheek
- Scar
o Grown beyond original line
o Red at early stages, then becomes brown or pale with age
o No hair follicles or sweat glands
o May be tender, painful or itch
- History of scar, trauma or surgery
83
Diagnosis of keloid scar?
- Clinical diagnosis
- If uncertain then biopsy can be taken
Differential
o Hypertrophic scars – red and prominent but do not extend beyond wound border
84
Management of keloid scar?
Difficult to treat
Intralesional steroid injection
o Triamcinolone
o Every 2-6 weeks until improvement
o Steroid tape and creams are options
Occlusive dressings with silicone
Surgery
o Has high recurrence rates and scar can be larger than before
o Radiotherapy can be given after to reduce chance of recurrence
Cryotherapy and laser treatment possible
85
Prevention of keloid scar?
o Avoid piercings, tattoos and unnecessary incisions if family history
o Treat acne thoroughly
86
Definiton of ganglion?
- Smooth, multilocular swellings containing jelly-like fluid in communication with joint capsules or tendon sheaths
- Can fluctuate in size
- Fluid inside is thicker synovial fluid
87
Epidemiology of ganglion?
- Commonest cause of lump on hand or wrist
- More common in women
- Young to middle-aged adults
88
Symptoms and signs of ganglion?
- Found throughout arms and legs
o Commonly back or front of wrist, by nails of fingers or palm of the finger or top of foot
- Often asymptomatic
- Present as visible lump under the skin
o Smooth, round
o Sore, painful to touch
o Compress a nerve – weakness, pain, limitation of movement
89
Diagnosis of ganglion?
- Usually clinical diagnosis
| - Can perform USS or MRI if needed
90
Management of ganglion - observation?
o Treatment not needed unless causing pain, affecting daily life or pressure (e.g. on nerves)
o May disappear spontaneously
91
Management of ganglion - aspiration?
o With needle and syringe
o Removes fluid from cyst
o Does not remove the sac or stem of ganglion and often fluid returns
92
Management of ganglion - surgical management?
- Surgical dissection – least recurrence
93
Description of salmon patch?
Flat red or pink patches that can appear on a baby's eyelids, neck or forehead at birth
They're the most common type of vascular birthmark and occur in around half of all babies
Most salmon patches will fade completely within a few months, but if they occur on the forehead they may take years
Often more noticeable when a baby cries because they fill with blood and become darker
94
Description of Port-Wine Stain?
Deep pink or red patch present at birth and grows as the child grows
May darken to purple, is flat; the overlying skin is normal. Later in life more papular lesions can occur within the patch
Present for life and has no tendency toward involution
Usually unilateral with a clear demarcation at the midline
If Sturge-Weber syndrome is suspected, MRI scan of the brain is required
Optical coherence tomography
Regular ophthalmic checks to exclude glaucoma should be carried out in the first three years of life
Refer as young as possible, usually around 1 year old, to a centre which has the laser and anaesthetic facilities
Tunable pulsed dye laser (PDL)
Surgical excision with or without cosmetic reconstruction may be required for lesions resistant to laser therapy
95
Description of angioma?
benign tumour formed by the dilation of blood vessels or the formation of new ones by the proliferation of endothelial cells
96
Description of infantile proliferative haemangioma?
Proliferates in the first few weeks of life, followed by involution later in childhood
o Red to purple papules or plaques with a normal epithelial surface
o Compression leads to partial emptying and the colour becomes less prominent
o Haemangiomas are common, particularly in girls, and affect around 5% of babies soon after birth
o If they get bigger rapidly, or those that interfere with vision or feeding may need treatment
97
Description of cherry angioma?
adult onset, common degenerative lesions, usually multiple
98
Description of angiokeratoma?
acquired scaly angiomas, usually on vulva or scrotum, or in association with Fabry disease
99
Description of telangiectasia?
- Prominent cutaneous blood vessels can be physiological or pathological.
• Blood vessels feeding a tumour such as basal cell carcinoma
• A common sign of rosacea
100
Description of spider telangiectasia?
consists of central arteriole and radiating capillaries. Very common in healthy individuals, but more arise in response to oestrogen, often in pregnancy, liver disease
101
Description of angiosarcoma?
idiopathic or secondary to chronic lymphoedema or radiation. Often aggressive, it mostly presents in elderly people with spreading purple patches and plaques that may bleed and ulcerate.
102
Definition of Kaposi's Sarcoma?
- Spindle-cell tumour, derived from capillary endothelial cells or from fibrous tissue - caused by HHV-8
103
Risk factors of Kaposi's Sarcoma?
o Men
o MSM
o Immune deficient – HIV, transplant
104
Cause of Kaposi's Sarcoma?
human herpes virus (HHV-8)
105
Types of Kaposi's Sarcoma?
o Classic KS (on legs)
o Endemic KS (African)
o KS in immunosuppression (e.g. organ transplant patients)
o AIDS-related KS (often multi-organ)
106
Symptoms and signs of Kaposi's Sarcoma?
- Purple papules (0.5-1cm) or plaques on skin and mucosa
o Most commonly located in mouth, nose and throat
- Bleeding, inflamed lesions can occur
- Metastasizes to nodes
107
Organs involved in Kaposi's Sarcoma?
o N&V, difficulty swallowing, abdominal pain – GI involvement
o Cough, SOB and chest pain – lung involvement
108
Investigations of Kaposi's Sarcoma?
- Biopsy
o Spindle cells
o Highly vascular
- Latency-associated nuclear antigen (LANA) confirms diagnosis
109
Management of Kaposi's Sarcoma - if HIV positive?
o Not curable
o Optimize HAART
o Radiotherapy for palliative symptom control
110
Management of Kaposi's Sarcoma - local and systemic treatment?
- Local treatment
o Intralesional chemotherapy, cryotherapy, laser and photodynamic therapy
o Excision
- Systemic Treatment
o Interferon-Alpha or chemotherapy
