Opthal Flashcards
Primary open angle glaucoma pneuonic for symptoms and whats seen on fundoscopy? Which visual field lost first?
OPENs
-Optic dis atrophy
-Pressure >21mmHg -> Optic disc cupping (increased cup:disc ratio [>0.7]). Pallor also seen
-Emerging vessles from optic disc
-Nasal + superior visual fields lost first
Most common type of glaucoma - affects both eyes ?
Primary open angle glaucoma
Aute painful red eye. Long-sighted, episodes of blurred vision, headaches, nausea, halos around lights … which glaucoma? How does it look on exam?
Acute angle closure glaucoma
Semi diated with a fixed pupil, decreased acuity and may be hard on palpation
men or women primary angle closure glaucoma
women - 2:1
What is raised IOP cut off?
> 21mmHg
Which receptors increase secretion of aqueous humour
B2
[A2 inhibit]
Who gets screened in glaucoma
> 60 Screened every 2 years. >70 annually
> 40 annually with 1st degree family member with OAG
> 40 black african annually
Rx of open angle glaucoma
Open Lovers Touch Bums
Topical prostaglandin analouge - eg latanoprost [increases aqueous outflow]
Topical B blocker eg timolol [decreases aqueous humour production]
Topical carbonic anhydrase inhibitor eg Brinzolamide [decreases aqueous formation]
[Usually latanoprost then add timolol. Second line therapies include pilocarpine (cholinergic agonist) and brimonidine (A2 agonist) ]
First thing you do with acute angle closure glaucoma
Lie patient flat
Rx of acute angle closure glaucoma? Long term?
Lie down PAL
Lie patient flat
Pilocarpine eye drops
Acetazolomide (IV/PO) or Dorozolamide drops
[analgesia, antiemetic, timolol]
Peripheral Lazer irodotomy
Open angle glaucoma may also get laser therapy (Trabeculoplasty) or what
Shunt formation
[teeny lil one]
Inform DVLA with glaucoma
Dont need to if affects one eye
Do need to if affects both
Asymmetric diabetic retinopathy need which 2 investigations ? Why?
Carotid doppler
Fluorescein angiography
Raises suspicion of ocular ischemic syndrome which is usually due to atherosclerosis [usually >90% stenosed on affected side]
Which CN does oblique movements ? horizontal?
SO4 - Superior oblique = trochlear CN IV
LR6 - lateral rectus = abducens CN VI
If diplopia slowly gets worse through day - what needs excluded ?
myasthenia gravis
Painless sudden loss of vision in 1 eye is likely? Seen on fundoscopy / exam?
Central retinal artery occlusion
pale oedematous retina with ‘cherry red spot’
RAPD
[If only part of vision lost - may be branch artery occlusion]
Outcomes of retinal artery occulsion are poor. Even with prompt management only 1/3 of people have any improvement.
What can you do?
Decrease IOP - Eg IV acetazolomide / b blockers
Dilate renital artery - sublingual isosorbide dinitrate, hyperbaric oxygen
Chronic hyperglycaemia -> diabetic retinopathy. Sight loss is due to neovascularisation. What is the mainstay of treatment (bar addressing factors eg Glycaemic control/BP/Lipids…)
for macular oedema?
Proliferative retinopathy?
Focal laser therapy
Intra vitreal injection of Vascular endothelial growth factor
Pan retinal photocoagulation
Diabetic retinopathy
Microanneursyms, exudates, haemorrhages, sight not affected? Symptoms? Rx?
Background diabetic retinopathy
Asx
Annual screening
Control of factors eg glucose / lipids / BP
Diabetic retinopathy
widespread changes in retina - cotton wool spots, venous changes, multiple haemorrhages? Symptoms? Rx?
Pre-proliferative
ASx
-> routine opthal referral
-> 6 monthly check up
Diabetic retinopathy
Neovascularisation, vitreous haemorrhage? Symptoms?
Proliferative
Floaters, blurred vision
Diabetic retinopathy
Retinopathy in the macular region? Symptoms?
Diabetic maculopathy
Blurred vision with darkened / distorted vision
What is the earliest clinical sign of diabetic retinopathy? How do they appear?
Microaneurysms
small red dots in superficial layers
Cotton wool spots are? When might these affect vision ?
Arteriole occlusion
If in fovea
Who gets diabetic retinopathy screening
All with diabetes > 12
What are aflibercept and ranibizumab?
VEGF inhibitors
What is triamcinolone
Intra vitreal Steroid used in proliferative retinopathy / macular oedema
Surgical rx of proliferative retinopathy? Macular oedema
Proliferative - pan-retinal photocoagulation
Macular - focal laser therapy
Surgical Rx if lots of blood in vitreous/aggressive proliferative retinopathy? Why? What is it?
Vitrectomy - reduce risk of retinal detachment
Cloudy vitreous is replaced with saline
-Often day case under local anaesthetic
What does a posterior communicating artery aneurysm lead to?
CN III palsy
(Fixed dilated pupil facing down and out)
+/- SAH
CNIII palsy but painless and sparing of the pupil?
Diabetic/hypertensive microangiopathy.
[Due to pupillary fibres on the peripheral surface of nerve and having own vascular supply]
Why aye abduction in CN III palsy?
due to unopposed action of Lateral rectus
How does vitreous haemorrhage present? How does it appear on fundoscopy? What is needed?
Loss of vision
Hazy/limited fundal view
US scan to check for retinal detachment
The usual cause of CRVO vs BRVO? How does it look on fundoscopy?
Central - thrombus
Branch - compression from an adjacent artery
Retinal haemorrhages, cotton wool spots, dilated vessels/tortuosity. Swollen optic disc
Rx of RVO? if macular oedema ?
VEGF inhibitors - aflibercept / ranibizumab
intravitreal steroids
focal laser coagulation if macular oedema in BRVO
Which eye condition usually in sarcoidosis ? Usual sarcoid presentation?
Anterior uveitis
Bihalar lymphadenopathy and erythema nodosum [+ fever, arthalgia]
What eye condition might be associated with complete heart block and a gradual reduction in eye movements + poor night vision
Retinitis pigmentosa
Rx of thyroid eye disease
High dose IV steroids
Surgical decompression may be required
Optic neuropathy (eg in thyroid eye disease) typically presents with….
loss of colour vision and reduced acuity
When do you see cells in the anterior chamber?
Uveitis or inflamation
CMV eye infection looks like?
‘brush fire’ (rapidly spreading outwards)
Vasculitis and haemorrhages
VZV and HSV eye infections cause
Actute retinal necrosis
Arteriole narrowing, Arterovenous nipping, hard exudates and flame haemorrhages?
Hypertensive retinopathy
Rosacea. What seen in eye
keratitis
Why would patient with rosecea end up getting cataracts
Secondly to steroid treatment for keratitis
Vitamin deficiency -> keratitis
Vit A
What gives a dendritic ulcer
HSV keratitis
Contact use then swimming -> which protozoal infection
Acathamoeba
Key thing to not give people with bacterial / viral keratosis
Topical corticosteroids
Diabetic + unilateral painless visual loss -> with vitreous haemorrhage on fundoscopy. Whats happened
Neovascularisation -> haemorrhage
(proliferative diabetic retinopathy)
What is supranuclear gaze palsy?
Doll’s eye
[dont follow movements up but will continue to focus on object despite head turning]
[Due to a leision between cortex and ocular motor nuclei]
Eye feels firm - IE increased IOP. It can be due to many things such as trauma which may cause hyphema (bleeding in iris). First line RX to reduce the pressure
Carbonic anhydrase inhibitor (acetazolamide)
[or topical B blockers]
Most common side effect of carbonic anhydrase inhibitor eg. cetazolamide, methazolamide, dorzolamide, brinzolamide
Finger tingling
Which condition always gets optic neuritis in questions? Which type of optic neuritis
MS
Retrobulbar neuritis
How long is the presentation of optic neuritis
Usually few days - 2 weeks. IE sub acute
Optic neuritis presents how?
Pain
Decreased acuity
Colour desaturation [USUALLY RED]
RAPD
Main investigation in optic neuritis
Gadolinium enhanced MRI
Acute optic neuritis management
High dose Mpred
Eg 1000mg IV for 3 days
Heavy smoker with unilateral ptosis and constricted pupil? What is this describing? why?
Horners syndrome - Ptsosis (drooping eyelid), miosis (constricted pupil) and anhydrosis (decreased sweating)
Pancoast tumour
The location of anhydrosis lets you work out where the lesion causing horners syndrome is.
Face arm and trunk? [1st order]
Face only? [2nd order]
No anhydrosis? [3rd order]
Face arm and trunk = MS / encephalitis / brain tumours…1st order [central]
Face only - Thoracic/thyroid carcinomas including Pancoast, Thoracic AAA, Trauma … 2nd order [pre ganglionic]
No anhydrosis - cluster headache, carotid dissection/aneursym, cavenous sinus thrombosis. 3rd order [post ganglionic]
finding only in congenital horners syndrome?
Heterochromia iridis
[Different coloured bits of iris. ie one blue one brown eye or just in a section]
Cocaine test in horners?
Cocaine drops in the eye -> block the reuptake of NA which makes pupil dilate
-In horners lack of NA causes a failure of the pupil to dilate (remains constricted)
[Can also use apraclonidine hydrochloride / adrenaline (beta adrenic receptor test) - this test the affected pupil is the one to dilate)
How to differentiate between a 3rd order (post ganglionic horners and a 1st/2nd] other than the lack of anhydrosis
Hydroxyamphetamine test
If pupil dilation occurs it is a 1st/2nd order
no dilation is a 3rd
NF type 1. Seen in the eye?
lisch nodules on iris
Who gets ash leaf spots on trunk
Tuberous sclerosis
Best test to look for diabetic retinopathy
Fluorescein angiography [ to visualise the micro aneurysms
Visual field defects with lesions :
Before chiasm
At chiasm
After chiasm
Biltemporal hemaniopia from below? Above?
Homonymous superior quadrantanopia Top right/left quarter?
Homonymous inferior quadrantanopia?
Before chiasm - Ipsilateral eye
At chiasm - bitemporal homonymous hemaniopia [lateral fibres cross]
After chiasm - Homonymous contralateral
Eg right occipital = left side of both eyes
Biltemporal hemaniopia from below = cause from above Eg Pit tumour
Above = lesion from below eg Craniopharyngioma
Homonymous upper quadratic? Temporal lesion
Homonymous inferior quadratic? Parietal
Older person with neovascularisation and leakage at macula only on fundoscopy =? 3 key risks factors? which is most important?
Wet macular degeneration
Smoking - most important
Hypertension
Cataract surgery
Which macular degeneration is there a Rx for?
Wet
VGEF inhibitors
Differentiate wet and dry macular degeneration? What do they both have
Both have
Drussen: Protein/lipid under retinal pigement epithelium (RPE)
RPE - hypo/hyperpigmentation
Only wet has neovascularisation and exudate / haemorrhages
Early, intermediate and advanced macular degeneration
Early - numerous drussen / mild RPE abnormalities
Intermediate - drussen >125um
-Geographic atrophy NOT involving fovea
Advanced - Atrophy involving fovea
Neovascularisation
What do drussen look like ? What does geographical atrophy look like?
Yellow deposits in retina
Hypopigmentation of retina
What test is required for diagnosis of wet AMD and for monitoring treatment
Ocular coherence tomography
Intermediate AMD usual therapy
Vitamin supplements
Control of risk factors
Painful 3rd nerve palsy age 50. Most likely cause
PCA Aneurysm
[MS would present earlier]
Aortic regurg and Aphakic glassess = ? What eye thing?
Marfans
Ectopia lentis [dislocation of lens]
-Aphakia means not having a lens inside your eye. The glasses are big jam jar ones which do the work of the lens
Hereditary ectopia lentis. What Ix?
homocysteine levels
Same day review by opthal in?
Corneal ulcer
Acute glaucoma
Endopthalmitis
Foreign body stuck
Trauma / chemical injury
Drug causes of closed angle glaucoma
A’s
Antidepresents (tricyclics)
Antipsychotics
Antihistamine
Anti-parkinsons
(sulphonamides)
What is hypopyon. Symptoms associated
‘level’ of inflammatory cells in anterior chamber.
Seen in inflammation Eg anterior uveitis
Pain + photophobia + reduced acuity
[IBD…]
Ehlers-danlos sudden painless loss of vision in 1 eye. Normal anterior chamber. What has happened?
Retinal detachement
[Anterior chamber would not be normal if lens dislocation]
Superior homonymous hemianopia
Temporal lobe lesion
Right eye superior visual field loss
Branch retinal artery / vein occulsion
Cough, sore lesions on face with facial swelling. Facial palsy. CSF high protein?
If there was uveitis and fever?
Neurosarcoid
Heerfordt-waldenstrom syndrome
[Parotid enlargement, uveitis, fever, cranial nerve palsies]- type of neuro sarcoid
seizing 10 mins with 2x 10mg rectal diazepam. What next?
IV phenytoin loading
Essential tremor. 1st line 2 options? Second line and key side effect
Propranolol / topiramate
Primidone - drowsiness
[Deep brain stimulation can also be used]
Most common cause of viral meningitis ? CSF findings
Enterovirus (echovirus/coxsakie)
Mild raised protein, Normal glucose, lymphocytosis
When is CSF glucose very low? (2)
TB
Fungal
Myasthenia gravis which receptor
Nicotinic Ach 90%
MuSK - 10%
[Muscle specific tyrosine kinase]
What is key assoc with myasthenia gravis
Thymus abnormalities 75% (10% thymus Ca)
Myasthenic crisis Rx
IV Ig
Plasmapheresis
+/- ventilate
Myasthenia gene risks. Which is specific for ocular
HLA DR3 / B8
HLA DR1 - specific for ocular myasthenia
Myasthenia crisis triggered by infection or which class of drug? Other classes to avoid generally
Amino-glycosides - gentamicin, neomycin
other -mycin types
-cyclines
B blockers
Antipsychotics
Bedside test with 90% sensitivity in MG
Ice test
-Ice in glove.
Put on ptosis and it will improve temporary
Bar Anti-Ach what tests for MG
Anti-MuSK
TFTs
EMG
CT/MRI brain / thymus
Why is the edrophonium test no longer done? other name?
Tensilon test for MG
No longer done due to severe brady / arrest
Rx MG usual drug?
What else initially?
Which -mab?
Surgical
Pyridostigmine - cholinesterase inhibitor
Steroids (+ steroid sparing)
Rituximab (think Thymus and T cell driven attack)
Thymectomy
Differentiate L5 and S1 lesions. Movement
L5 Largest of 5 - dorsiflexion - dorsiflex foot and it will have big toe at top
S1 - Small 1
Plantar flex and lil toe will be bottom
Impaired adduction and contralateral nystagmus. Normal accommodation. Where is lesion
Medial longitudinal fasiculus
[If R sided adduction issues its on R side]
Ipsilateral horners. Facial numbess, horse voice and contralateral limb numbness. [May get nystagmus / limb ataxia]
Called? Lesion is where?
Wallenberg syndrome
Lateral medulla
Most common type of nystagmus in kids ? Direction
Sensory deprivation nystagmus (90%)
Bi - horizontal
Vertical nystagmus Upwards - lesion in
Medulla (stroke often)
Vertical downbeat nystagmus in?
Arnold-chiari malformation
- lesion in foramen magnum
Acute vs chronic horizontal nystagmus
Acute - away from lesion
Chronic - towards lesion
Nystagmus with hearing loss / tinitus =
Usually peripheral cause
-Trauma
-Menniers
-CN8 lesion
Nystagmus that varies with head position
BPPV
partial dislocation of lens (ectopia lentis), quivering (iridodonesis) of (iris), nearsightedness (myopia). Long arms and legs
Cyststhione beta synthase deficiency
(Hereditary homocystineuria)
Unilateral visual loss and pain with RAPD
Optic neuritis
GCA causes anterior ischemic optic neuritis. What is most common thing seen on fundoscopy
Optic disk swelling
[occlusive vasculitis -> ischemia of optic nerve which then manifests as swelling visible on exam]
Amiodarone deposits in eye sometimes termed?
cornea verticillata
vortex keratopathy
What are
Band keratopathy?
Hudson -stahli lines?
band - Calcium deposition due to chronic hyper Ca
Hudson - iron deposition in normal ageing
