Ophthamology Flashcards
What is it called when the red reflex is white in kids and what could it be due to?
Leuccocoria
Retinoblastoma or congenital cataracts *
Retinal detachement, retinopathy of prematurity, uveitis
How might Retinoblastoma present?
at 12 months if hereditary, 24 months if sporadic
Loss of red reflex (leuccocoria), strabismus, reduced vision, red eye
Knudsens 2 hit hypothesis
Tumour of retinoblasts
Why must congenital cataracts be managed urgently?
Can cause Amblyopia - halting of central vision development
What is the most common cause of conjuntivitis in neonates?
Chlamydia trachomatis
What is conjuntivitis/ sticky eye(s) in the first month of life called? What are some causes?
Ophthalmia neonatorum
Gonococcal - 1-3 days (risk of blindness)
Chalymidial - 4 - 24 days - most common
Bacteria, HSV
When is myelination of the optic nerve complete?
24 months
When is the eye structurally completely developed?
3 years
What is amblyopia?
Halting of central visual development due to poor vision before ~8 years old
What is Retinopathy of prematurity?
In premature babies, the peripheral retina is not vascularised at birth. There is growth of new blood vessels and scarring. 5 stages in classification
What classes you as partially sighted?
Acuity of 6/60 or worse or 6/60 or better but with visual field restriction
What classes you as blind?
Acuity of 3/60 or worse with a full visual field or 3/60 or better with substantial visual field loss
What is blepharitis?
Inflammation of the eyelid margin secondary to blockage of the meibomian glands (oil secreting) and infection with staph aureus
Redness and irritation of the eye and lid ± marginal keratitis
What is a chalazion and what is a stye?
Chalazion is a swollen blocked meibomian gland. It is hard and non-tender
Stye is a infection of the glands of moll (sweat) or glands of zeis (sebaceous) and it is tender and red
What is lagophthalmos?
Inability to close the eyelids
What is the difference between Periorbital and orbital cellultius and how can you differentiate?
Periorbital - eyelid skin in front of oribital spetum
Orbital - tissue behind orbital septum involved
Orbital is sight and life threatening - CT scan
Orbital Sx - pain on eye movement, changes in vision, abnormal pupillary reactions, proptosis *
Give some examples of sudden and gradual vision loss.
Sudden - Retinal detachement, Wet ARMD, retinal artery or vein occlusion, optic neuritis (central scotoma)
Gradual - cataracts, glaucoma, dry ARMD, diabetic retinopathy
Give some examples of sudden painless vision loss.
Anterior ischaemic optic neuropathy Retinal vein or artery occulsion Wet ARMD Retinal detachement Vitreous haemorrhage Severe uveitis
Give some examples of sudden painful vision loss.
Acute glaucoma, Severe uveitis, optic neuritis, endophthamlitis, severe corneal pathology
What part of your vision does glaucoma affect?
Peripheral
What is normal Intra-ocular pressure?
10-24mmHg
Measured using a Tonometer (goldmann’s)
Explain what an Acute angle closure glaucoma is?
Emergency.
There is a sudden increased in IOP (>/= 30mmHg) due to blockage of the trebecular meshwork where aqueous humorous should drain, due to the iris pressing forward and blocking it. This casues increased pressure that pushes back on the eye causing death of axones at the periphery first (works in like until left with tunnel vision) –> Increased cup:disc ratio
How might a patient with Acute angle closure glaucoma present?
Generally unwell with N&V, onset hr-days Severely painful red eye Blurred vision Halos around lights at night Headcache
What signs might a Acute angle closure glaucoma patient have?
Reduced VA, red eye, corneal haze, mid-dilated and fixed pupil, high IOP digitally, closed iridocorneal angle on goniscopy
For AACG you can give Pilocarpine, what does this do?
Constricts the sphincter muscles of the iris and so the pupil. This helps open the angle and so allows for better drainage
What is Open angle glaucoma?
Chronic due to gradual increase in resistance in the trabecular meshwork causing reduced outflow
Usually asymptomatic and diagnosed by routine screening
What drugs can be used to lower the aqueous humour production in Glaucoma?
Beta blockers (timolol) SE - bradycardia, bronchoconstriction
Carbonic anhydrase inhibitors (Brinzolaminde) SE - malaise, metallic taste
Alpha 1 agonist (Brimonidine) SE - allergy, dry mouth
What drugs can be used to reduce the uveoscleral outflow in glaucoma?
Alpha 1 agonist (Brimonidine) SE- allergy, dry mouth Prostaglandin anagloue (Latanoprost) SE - eyelash growth, iris pigmentation
What is retinal detachement?
When the retinal separates from the choroid
Usually due to a retinal tear allowing vitreous fluid into the space
How might a patient with retinal detachment present?
4 F’s
Floaters and flashed, fall in acuity, field loss
(peripheral vision loss, like a shadow coming across vision. Painless)
tx - surgery
What causes Retinal artery occulsion?
Usually due to an emboli or GCA*
How might a patient with retinal artery occlusion present?
Sudden painless loss of vision
RAPD
Pale retina with a cherry red fovea
What does Central retinal vein occlusion look like on fundoscopy?
Flame or blot haemorrhages, Macular oedema, optic disc oedema
What might indicate Anterior ischaemic optic neuropathy on fundoscopy?
Pale, swollen optic disc
What might be the underlying cause for a vitreous haemorrhage?
Retinal tears or detachment
Trauma
Neovascularisation (2’ RVO or diabetic retinopathy)
What is the most common type of non-paralytic squint?
Convergent or Esotropic (eye(s) turned in)
What tests can you do to check for a squint?
Cover test and Corneal reflection test
What does a paralytic squint present like?
Diplopia in looking the direction of the pull of the paralysed muscles
3 types - CN 3, 4, 6
What type of diplopia is seen in CN 4 palsy and CN 6 palsy?
CN 4 - vertical diplopia
CN 6 - horizontal diplopia
What are the 4 layers of the macula?
Choroidal blood vessels, Bruch’s membrane, RPE, photoreceptors
What are some age-related changes that occur to the eye?
Colour becomes more yellow Light transmission reduces Eye becomes more hard Loss of accommodation - Presbyopia Protein aggregation - Lens opacification
During a fundoscopy, Drusen was noted. What condition could this be?
ARMD
How might a patient with ARMD present?
Loss of central vision or distorsion of central vision
Kinks in straight lines - Amsler grid
How does cataracts occur?
Proteins accumulate in the lens
They obstruct the light and cause a haziness
What is the commonest type of cataracts?
Nuclear sclerotic cataracts
What are some post-op complications of cataract surgery?
Endophthalmitis - 3-5d post-op. Inflammation of the inner contents of the eye
Posterior capsular opacification
How might Endophthalmitis (inflammation of the inner contents of the eye) present?
Rapidly progressive pain, red eye, ocular discharge and blurring. Reduced VA, lid swelling, hypopyon, dulling of red reflex
What are the causes of anterior uveitis?
~50% idiopathic
Trauma, neoplastic
Acute - Ankylosing spondylitis, reactive arthritis, IBD, HLA-B27 associated conditions
Chronic - HSV, Sarcoidosis, TB, HIV, syphilis (more granulomatous, >3months)
When should you refer to the eye clinic in suspected Uveitis?
Urgently
Should be seen within 24 hours
What are some sight-threatening causes of red eye?
AACG Corneal ulcer / abrasion Penetrating eye injury Scleritis Anterior Uveitis
What are some features of diabetic retinopathy?
Non-proliferative: Micro-aneurysms, dot or blot haemorrhages, hard exudates, macular oedema
Pre-proliferative: Cotton wool spots (from vessel infarction), intraretinal microvascular changes
Proliferative: neovascularisation
What are the stages of HTN retinopathy?
Grade 1: Retinal arteriole narrowing
Grade 2: Above + AV nipping and copper wiring
Grade 3: Above + retinal haemorrhage, macular start, cotton wool spots, hard exudates
Grade 4: Above + papilloedema
How does anterior blepharitis present?
Gritty eyes, Eyes sticking together when they wake in the morning
Eyes feel itchy.
crusty, FB sensation
Inflammation of the eyelid margin due to seborrheci dermatitis
Tx - hot compresses, good hygiene, artificial tears
What is posterior blepharitis?
inflammation of the eyelid marging Due to meibomian gland dysfunction
Tx - hot compresses, good hygiene, artificial tears
How do you manage a stye?
Warm compresses ± antibiotics
How do you manage a chalazion?
Warm compresses ± surgical drainage
What is the median age of periorbital cellulitis?
21 months
Red, swollen painful eye lids
tx - PO co-amox
How might a patient with orbital cellulitis present?
Red swollen eyes with deep ocular pain, proptosis, diplopia, reduced VA, RAPD, reduced colour vision, Sx worsen on eye movements**, associated with fever and malaise
Tx - admit + IV ceftriaxone + flucloxacillin
What Ix would you do in suspected periorbital or orbital cellulitis?
Contracts CT head and orbit, swabs, FBC
How might chlamydia infection present in the eyes?
Mucucopurulent discharge* (s.aureus just pus discharge)
Unilateral, sexual history, subacute
tx - topical chloramoehnicol
maintain good hygiene, avoid contact lenses
How does allergic conjunctiviits present?
Bilateral, red, itchy, swelling, chemosis, watery discharge, hx of atopy, papillae
Tx - antihistamine
maintain good hygiene, avoid contact lenses
How would you treat a corneal ulcer (keratitis)?
Corneal scrape**
- as long as an ulcer is their it can potentially cause visual damage
What might a FB in the eye leave when removed?
Rust ring - oxidised metallic object
Ix - XR? MRI
tx - remove FB + topical chloraphenicol
What can help relieve symptoms of photophobia?
Cycloplegics/mydratics - dilates the pupil and reduces ciliary spams
What can alkaline chemical injury to the eye cause?
Liquefactive necrosis allowing it to penetrate the eye more
Damage to limbal system - conjunctivalisation
tx - irrigation, pH
What can cause keratitis?
Bacteria (pseudomonas aeruginosa, s. aueus) (biggest risk factor contact lenses), acanthamoebic (contact lens users), fungal, HSV, onchocercal
How would you differentiate between episcleritis and scleritis?
Episcleritis is painLESS, can move the episcleral vessels around with pressure.
Scleritis is painFUL - deep severe pain and constant dull ache, wakes patient up at night), SIGHT THREATENING. Cannot moves episcleral vessels
How would you manage scleritis?
Necrotising: NSAIDs + Steroids
Non-necrotising: Steroids + immunosuppressants (methotrexate, infliximab, cyclophosphamide)
How long must you have stopped warfarin for before performing surgery?
Stop 5 days before surgery
Can give prothrombin complex in an emergency
How would you manage the different causes of conjunctivitis?
Bacterial (papillae) - topical abx (chloramphenicol)
Allergic (papillae) - Topical antihistamines
Gonococcal (papillae) - Topical abx, systemic tx and refer to GUM
Viral (follicular) - Lubricants
Chlamydia (follicular) - Topical abx, systemic tx, refer to GUM
Papillae - cobble stoning, red with pale base
Follicle - lymphoid hyperplasia, pale with red base
What is the most common cause of blindness due to infection?
Trachoma
Repeated infections with chlamydia trachomatis leads to sever conjunctival inflammation, scarring and potentially blinding in-turned eyelashes (trichiasis or ectropion) in later life
How might you tell the difference between a corneal abrasion and a corneal ulcer (keratitis)?
Fluorescein eye drops and the blue slit lamp
Abrasion - translucent, only epithelium
Ulcer - opaque, stroma is involved –> Sight threatening, needs urgent referral if suspected
How might you manage a patient with corneal abrasion?
Lubricant eye drops, analgesia, chloramphenicol ointment ± cycloplegics/mydratics
Review in 1 week
How might you manage a corneal ulcer/keratits?
Urgent referral to ophthalmology*
Corneal scrap ± send lenses, contact solution for culture or viral PCR?
Start broad spec abx before culture back.
Cephalosporins (Cefuroxime), gentamicin, fluroquinoloines
Cyloplegics (cyclopentolate, atropine)
What might you think is happening in a patient with a red eye who wears contacts?
Keratitis - refer for same day ophthalmology review
What signs might indicate a posterior uveitis and how would you manage it?
Snowballs, vitreous haze, retinitis Systemic steroids (after ruling out infection)
How would you diagnose anterior uveitis and what signs would be present?
Slit lamp
Circumcorneal limbal injection (ciliary flush)
Posterior synechiae (adhesions between lens and pos iris)
Hypopyon - WBC and yellow fluid with a fluid level in front of iris
Keratitic percipitates
Anterior chamber cells and flare
Management of anterior Uveitis?
Urgent referral to ophthamology within 24 hours
- Topical steroids - prednisolone or dexamethasone
- Topical cyloplegics/mydratics - atropine or cyclopentolate
- ?Immunosupressants - DMARDs, TNFi
- ? Laser therapy, cryotherapy, vitrectomy
Acyclovoir if HSV the cause
What is the most common ocular presentation of herpes simplex?
Keratitis
If it affects the stroma - stromal keratitis - can lead to stromal necrosis and blindness due to scarring
What key feature may make you think HSV keratits?
Painful red eye, photophobia, lacrimation, FB sensation, reduced acuity
Dendritic ulcer on slit lamp with fluorescein drops
What are causes of primary and secondary acute angle closure glucoma?
Primary - anatomical predisposition - ?smaller, narrower eye
Secondary - traumatic hemorrhage, chinese/east asian, hypermetropic
What is the management in AACG?
Urgent referral!
Beta blocker - timolol - reduce aqueous humour
Pilocarpine - constrict pupil to reduce angle
Acetazolamide PO 500mg - CAI - reduces AH
Analgesia, antiemetics
?Laser iridotomy once IOP reduced
How would you manage open angle glucoma?
B-CAP
Beta blockers - Timolol
Carbonic anhydrase inhibitor - brinzolamide
Alpha 1 agonist (sympathomimmetic)- Brimonidine
1st line - Prostaglandin analogue - Latanoprost
What medication for glaucoma gives a metallic taste?
Carbonic anhydrase inhibitor - brinzolamide
What medication for glucoma can increase eyelash growth and cause iris hyperpigmetation?
Prostaglandin analogue - Latanoprost
What Medication for glaucoma causes a dry mouth/allergy?
Alpha 1 agonist - Brimonidine
How might Herpes zoster virus present?
Hutchinson’s sign: vesicles extending to the tip of the nose. This is strongly associated with ocular involvement in shingles (nasociliary involvement)
