Ophthamology - Red eye, Glaucoma, Cataract, Macular degeneration Flashcards
1
Q
Approach to red eye
ddx
A
2
Q
Approach to acute vision loss
A
3
Q
Approach to chronic vision loss
A
4
Q
Approach to ocular pain
A
5
Q
Approach to diplopia
A
6
Q
Approach to ptosis
A
7
Q
Relevant ophthamology history and red flag S/S
A
8
Q
Basic eye examination
A
9
Q
Red eye
Ddx eyelid and adnexa diseases
A
10
Q
Red eye
Ddx conjunctival diseases
A
11
Q
Red eye
Ddx corenal diseases
A
12
Q
Red eye
Ddx scleral and iris diseases
A
13
Q
Red eye
Ddx ocular media diseases
A
14
Q
Red eyes
Red flags for urgent referral
A
15
Q
Red eye
History taking questions
A
16
Q
Red eye
P/E
A
17
Q
Gallery
A
18
Q
Subconjunctival hemorrhage
Cause
S/S
Management
A
19
Q
Infective conjunctivitis
Microbiology
A
20
Q
Bacterial conjunctivitis
S/S
Dx
Mx
A
21
Q
Viral conjunctivitis
S/S
Dx
Mx
A
22
Q
Allergic conjunctivitis
S/S
Dx
Mx
A
23
Q
Degenerative conjunctival diseases
Ddx
S/S
Mx
A
24
Q
Differentiate Stye/ Chodoleum, Chalazion and Blepharitis
A
Stye: (hordeolum): acute painful abscess of eyelid
- Types: external (eyelash follicles) vs internal (Meibomian gland)
- Cause: usually S. aureus, predisposed by pre-existing skin ds (eg. rosacea, seborrheic keratitis), contaminated eye makeup
- May be a/w reactive hyperemia of conjunctiva
- P/E shows tender eyelid lump cf chalazion
Chalazion:
- Chronic inflammation due to obstructed Meibomian (sebaceous) glands
- Initially a/w eyelid swelling and erythema, later becomes a painless, rubbery nodular lesion
Blepharitis
- Chronic infl’n of eyelid margins, a/w acne rosacea and seborrhoeic dermatitis and eczema
- Conjunctival injection a/w hyperemic, crusty, thickened eye margins
- Anterior blepharitis: redness and scaling of lid margins, Collarette debris around lashes, lash detach
- Posterior blepharitis: Meibomian orifice plugging, viscous meibomian secretions, conjunctival infections, dry eyes and punctate keratitis
- Severe cases may extend and involve cornea (blepharokeratitis)
25
Key symptoms and signs of corneal diseases
Symptoms:
- Visual loss not cleared by blinking
- Ciliary flush
- Photophobia
Signs:
- Cornea clouding (epithelial or stroma edema)
- Epithelial erosions (punctate in keratoconjunctivitis si cca or abreasive in chemical or physical trauma)
- Ulcer (deep defect in stroma, infective keratitis)
- Pannus (Subepithelial fibrovascular in-growth, chronic keratitis)
- Stromal infiltrates (focal cellular infiltrate, infective keratitis)
- Anterior chamber reactions: Keratic precipitates, Hypopyon (white cells), Flare (infective keratitis and anterior uveitis)
26
Infectious keratitis
- Typical causative pathogens
- S/S
□ Bacterial: S. aureus, S. epidermidis, S. pneumoniae, P. aeruginosa, G- bacilli (a/w contact lens wearing)
□ Viral: herpes simplex, varicella-zoster (i.e. herpes zoster ophthalmicus)
□ Others: fungal, Acanthamoeba
27
Infective keratitis
Risk factors
Bacterial:
→ Keratoconjunctivitis sicca (dry eye)
→ Breach in corneal epithelium, eg. trauma, surgery
→ Soft contact lens wear (>95% bacterial)
→ Prolonged use of topical steroids
Herpes simplex keratitis: debilitation (eg. systemic illness), immunosuppression
Herpes Zoster Ophthalmicus: reactivation often linked to unrelated systemic illness
Corneal keratitis: exposure Hx, prolonged use of steroids, lack of response to prolong Abx/ indiscriminant use
Acanthamoebic keratitis: contact lens wear in shower or in swimming pool
28
Infective keratitis
Management
STOP contact lens wearing immediately and bring contact lens and box for culture
Offer empirical antimicrobial based on clinical suspicion
- Bacterial: intensive, topical broad-spectrum Abx eyedrops (eg. fluoroquinolones and aminoglycosides)
- Viral: Topical acyclovir for HSV (local) ± systemic (if stromal involvement)/ Oral + topical acyclovir for VZV (systemic) ± gabapentin, amitriptylline for postherpetic neuralgia
- Fungal: amphotericin B (candida) or natamycin (filamentous fungi)
- Amoebic: topical chlorhexidine, polyhexamethylene biguanide (PHMB) and propamidine
Perform corneal scraping for C/ST
→ Add preservative-free anaesthetic before starting
→ Use 15 scalpel blade to scrape edge of ulcer before starting antimicrobial eyedrops
→ Send for bacterial culture, (blood and chocolate agar), Sabouraud medium (fungal) and non-nutrient agar with E. coli (amoeba)
29
Differentiate scleritis with episcleritis
30
Episcleritis and scleritis management
Episcleritis Management: directed to symptomatic relief
□ Topical lubricants, eg. artificial tears if mild discomfort only
□ Topical NSAIDs, eg. diclofenac eyedrops if significant discomfort
□ Topical glucocorticoids, eg. fluorometholone acetate if refractory to NSAIDs
Scleritis:
□ Systemic NSAIDs (eg. indomethacin) for nodular or diffuse forms
□ Systemic steroids + immunosuppressant for necrotizing or post. forms (prednisolone 1mg/kg/d + rituximab or cyclophosphamide )
31
Scleritis
Complications
Scleral complications:
- Scleromalacia (scleral thinning) ± perforation (purplish uvea exposed), causing ↓IOP and risk of choroidal detachment or fissure
- Scleral melting due to ischaemia (in necrotizing subtypes)
Extension to other ocular structures:
- Cornea: peripheral ulcerative keratitis (PUK) ± corneal melt
- Uveal tract: anterior uveitis (up to 40%) ± glaucoma formation
- Lens: cataract
- Posterior segment: vitreitis, cystoid macular oedema, exudative retinal detachment (in posterior scleritis)
32
Endophthalmitis
Cause
S/S
Dx
Mx
Cause: severe intraocular infection (a type of uveitis)
Exogenous (majority) from external source
→ Post-operative: most classically 2o to cataract surgery
→ Post-intravitreal injection, eg. anti-VEGF injections
→ Filtration bleb-related after glaucoma filtration surgery
→ Post-traumatic
Endogenous infection from internal source: e.g. UTI, abscess, IE, IVDU...etc
S/S: most ≤1-2w
□ Symptoms: ↓vision, red, painful eye (25% painless)
□ Signs: ↓VA, hypopyon, hazy media, cells and flare
Dx:
→ USG shows ↑echogenicity of vitreous
→ C/ST of aqueous or vitreous needle aspirate
→ Blood/ vitrous vulture
→ USG Liver (Liver abscess most common internal source, esp. Klebsiella)
Mx:
→ Intravitreal Abx: vancomycin + ceftazidime/amikacin → ± vitrectomy in severe infection
33
Uveitis
- Types
- Causes
Types:
- Anterior uveitis (75%): presence of leukocytes in anterior chamber of eye, i.e. iritis and anterior cyclitis
- Posterior uveitis: active chorioretinal inflammation, i.e. choroiditis, retinitis
- Panuveitis: involve active chorioretinal inflammation
Causes:
- Idiopathic
- Infective: atypical bacteria (syphilis, TB, Brucella...), Viral, Protozoan
- Systemic inflammation: Spondyloarthritis, JIA, SLE, Sjogren's Behcet's, IBD, MS...etc
- Isolated ocular syndromes: eg. pars planitis, symphathetic ophthalmia
34
Uveitis
- Compare presentation of anterior and posterior uveitis
Anterior uveitis:
→ Ocular pain + photophobia
→ Variable blurring of vision
→ Ciliary flush (circumlimbal conj. injection)
→ Signs of anterior chamber inflammation
- Cells and flares due to WBC and protein (early feature)
- Hypopyon due to pus (late feature)
- Keratitic precipitates due to cellular debris on corneal endothelium (late feature) Eg. mutton-fat KPs
→ granulomatous cause
→ Miotic pupils due to iris spasm
Posterior/intermediate uveitis:
→ More likely to be painless and w/o redness
→ Characterized by non-specific visual changes, eg. floaters, ↓VA, photopsia, scotoma
→ Vitreous abnormalities in intermediate uveitis, eg. haze, cells, subhyaloid precipitates
→ Retinitis: blurred white lesions
→ Choroiditis: deeper yellow-white lesions ± exudative retinal detachment
35
Uveitis
Dx and Mx
Dx
- Slit-lamp examination for anterior uveitis
- Dilated fundus examination for posterior uveitis
Mx
Treat infection accordingly if infectious
Steroid therapy
- Topical eyedrops (eg. 1% prednisolone acetate solution)in anterior uveitis
- Intraocular/periocular injections in intermediate/posterior uveitis
- Oral steroids if refractory
Relief of discomfort in anterior uveitis
- Topical cycloplegics (eg. 1% cyclopentolate)
- Oral analgesics (eg. paracetamol)
36
Causes of unilateral vs bilateral ptosis
37
Eyelash disorders
Ddx
S/S
Management
38
Stye
Types
Cause
Management
Complication
39
Chalazion
Cause
S/S
Mx
40
Belpharitis
Causes
S/S
Management
41
Dry eyes
Causes
S/S
Evaluation
Management
42
Tear duct obstruction
Causes
S/S
Evaluation/ Ix
Mx
43
Approach to vision loss
44
P/E for vision loss
45
Ddx transient vision loss
46
Acute vision loss
Ddx ocular media disorder
47
Acute vision loss
Ddx retinal disorder
48
Acute vision loss
Ddx optic nerve disorder
49
Chronic vision loss ddx
50
Chronic vision loss
Ddx lens/ media disorders
51
Chronic vision loss
Ddx retinal disorders
52
Chronic vision loss
Ddx optic nerve disorders
53
Glaucoma
Cause
Classification
54
Primary open angle Glaucoma
Clinical features
55
Primary open angle Glaucoma
Diagnosis
Management
56
Primary open angle Glaucoma
Medical managment
57
Primary open angle claucoma
Surgical treatment options
58
Primary angle closure glaucoma
Clinical features
59
Primary angle closure glaucoma
Management
60
Catatract
Causes
61
Cataract
Clinical presentation
Management
Management:
Cataract surgery:
- Extraction by phacoemulsification or Extracapsular cataract extraction
- Intraocular lens implantation +/- suture for ECCE
62
Age-related macular degeneration
Classification
63
Age-related macular degeneration
Clinical presentation
64
Age-related macular degeneration
Mangement
