Opthal Flashcards
subconjunctival haemorrhages - traumatic haemorrhages are most commonly in which region?
Temporal region
Subconjunctival haemorrhage on examination would show what findings of the fundus?
NORMAL fundus
When do subconjunctival haemorrhages warrant investigation?
Recurrent
Bilateral
Traumatic with other eye injury
No obvious border
In age-related macular degeneration, there is degeneration of retinal photoreceptors that results in the formation of…
DRUSEN
which is seen on fundoscopy and retinal photography
What is the most common cause of blindness in the UK
Age related macular degeneration
Two types of age-related macular degeneration - what are they and which one is more common
- Dry macular degeneration (90%)
- Wet macular degeneration
Dry macular degeneration is also known as…
ATROPHIC
Wet macular degeneration is also known as…
EXUDATIVE or NEOVASCULAR macular degeneration
What is wet macular degeneration (10% of ARMD) characterised by?
Choroidal neovascularisation
What is dry macular degeneration (90% of ARMD) characterised by?
Drusen - yellow round spots in Bruch’s membrane
Which type of age related macular degeneration carries the worst prognosis
Wet (exudate, neovascular) macular degeneration
Leaks serous fluid and blood - rapid loss of vision
Distortion of line perception may be noted (i.e. in diseases such as age-related macular degeneration) using what test?
Amsler grid testing
In fundoscopy of in wet ARMD, red patches may be seen which represent …
intra-retinal or sub-retinal fluid leakage or haemorrhage
What is the investigation of choice to identify any pigmentary, exudative or haemorrhagic changes affecting the retina, and age-related macular degeneration?
Slit lamp microscopy
What investigation can be used to guide intervention for neovascular (wet) ARMD to help with anti-VEGF therapy?
Flureoscein angiography
What investigation can be used to visualise retina in 3D - better than microscopy
Optical coherence tomography
Treatment of ARMD
- Zinc, vitamins A, C, E
- Anti-VEGF agents - 4 weekly injection
- Laser photocoagulation for new vessel formation
What is acute angle-closure glaucoma caused by
Increased intra-ocular pressure due to impaired aqueous outflow
If you struggle to see nearby objects, what is this called
HYPERMETROPIA
Long-sightedness
If you struggle to see far away objects, what is this called
MYOPIA
Short-sightedness
What eye condition has a semi-dilated non-reacting pupil?
Acute angle closure glaucoma
What investigations are used for glaucoma
Tonometry - looks for elevated IOP
Gonioscopy - special lens for slit lamp to visual the angle
Acute angle glaucoma management
- Eyedrops (e.g. pilocarpine, timolol, apraclonidine)
- IV acetazolamide - reduces aqueous secretions
- Topical steroids
- Laser peripheral iridotomy
What 3 types of eyedrops are useful in acute angle closed glaucoma
- Direct parasympathomimetic e.g. pilocarpine - contracts ciliary muscles to increase outflow of aqueous humour
- B-blockers e.g. timolol - reduces aqueous production
- Alpha-2 agonist e.g. apraclonidine - decreases aqueous production and increases outflow
Visual loss, eye pain and red desaturation (poor discrimination of colours) are all classical symptoms of
optic neuritis
What are 3 causes of optic neuritis
- multiple sclerosis
- diabetes
- syphilis
Central scotoma is seen in which eye condition
optic neuritis
Investigation of optic neuritis
MRI of brain and orbits with gadolinium contrast
Management of optic neuritis
High dose steroids
recovery usually 4-6 weeks
If MRI brain in optic neuritis shows >3 white matter lesions, what is the 5 year risk of developing multiple sclerosis
50%
What is the leading cause of curable blindness worldwide
Cataract
Cataracts are usually caused by ageing. Other risk factors include smoking, diabetes, steroids, Down’s syndrome and what metabolic imbalance?
HYPO calcaemia
Gradual onset of:
reduced vision
faded colour vision
glare
haloes around lights
defect in red reflex
what is the diagnosis?
cataracts
What investigations are done for cataracts?
Opthalmoscopy - normal fundus and optic nerve
Slit lamp - visible cataract
What are the 4 types of cataract that they be classified into
- Nuclear - old age, change lens refractive index
- Polar - localised, inherited
- Subcapsular - due to steroid use
- Dot opacities - DM, myotonic dystrophy
Management of cataracts
- Non-surgical - glasses, optimise vision
- Surgery - removal of cloudy lens and replacing it with artificial one
4 complications following cataract surgery
- Posterior capsule opacification - thickened lens capsule
- Retinal detachment
- Posterior capsule rupture
- Endopthalmitis - inflammation of humour
Watery eyes in babies are usually caused by
delayed development of the nasolacrimal ducts
What condition presents with absent red reflex
Retinoblastoma
Management of nasolacrimal duct obstruction
- teach parents to massage the lacrimal duct
- 95% resolves by age of 1 year
- unresolved cases have probing under GA with opthalmologist
what is Hutchinson’s sign in Herpes zoster opthalmicus
Shingles rash on tip/side of nose
Indicates nasociliary + ocular involvement
Treatment for shingles
Oral acyclovir for 7-10 days
ideally start within 72 hours
topical steroids for eye
ocular involvement needs urgent opthal review
Anterior uveitis is associated with which 5 conditions
- ankylosing spondylitis
- reactive arthritis
- inflammatory bowel disease/UC/CD
- Behcet’s
- Sarcoidosis
Painful
Blurred vision
Red eye
Lacrimation
Ciliary flush
Hypopyon (pus in anterior chamber)
Small and irregular, oval, constricted pupil
What is the diagnosis
Anterior uveitis
if a patient has blurred vision, and pinhole occluder improves their vision - what is the likely cause
needs glasses!
- refractive error
Treatment for anterior uveitis
- urgent review by opthalmology
- cycloplegics e.g. atropine - dilates pupil
- steroid eye drops
Those with a positive family history of glaucoma should be screened annually from what age
40 years
Primary open angle glaucoma may present slowly. What 4 signs on fundoscopy are shown?
- Optic disc cupping
- Optic disc pallor (atrophy)
- Vessels break, bayonette
- Cup notching / haemorrhages
Peripheral visual field loss (tunnel vision)
Decreased visual acuity
Optic disc cupping
Slow progression
what is the diagnosis
primary open angle gaucoma
Who makes diagnosis usually of primary open angle glaucoma
Optometrist
GP refers to opthalmologist
Investigations for primary open angle glaucoma
Automated perimetry - assess visual field
Slit lamp exam
Tonometry - measures IOP
Gonioscopy - checks angle
Diabetic retinopathy 3 classifications
Non-proliferative diabetic retinopathy
Proliferative retinopathy
Maculopathy
Within Non-proliferative diabetic retinopathy, what is mild NPDR
1 or more microaneurysm
Within Non-proliferative diabetic retinopathy, what 4 factors are in moderate NPDR
microaneurysms
blot haemorrhages
hard exudates
cotton wool spots
Within Non-proliferative diabetic retinopathy, what 3 factors are in severe NPDR
blot haemorrhages and microaneurysms in 4 quadrants
venous beading in at least 2 quadrants
IRMA in at least 1 quadrant
What 3 key features are part of Proliferative diabetic retinopathy
retinal neovascularisation - may lead to vitrous haemorrhage
fibrous tissue forming anterior to retinal disc
more common in Type I DM, 50% blind in 5 years
what 4 key features are part of maculopathy (diabetic retinopathy)
based on location rather than severity
hard exudates and other ‘background’ changes on macula
check visual acuity
more common in Type II DM
treatment for maculopathy
if there is a change in visual acuity then VEGF inhibitors
treatment for non-proliferative retinopathy
regular observation
if severe then panretinal laser photocoagulation
treatment for proliferative retinopathy
panretinal laser photocoaghulation
intravitreal VEGF inhibitors +/- panretinal laser photocoagulation
if severe or haemorrhage then vitreoretinal surgery
red eye
painful
watering and photophobia
GRADUAL decrease in vision
full thickness inflammation
what is the diagnosis?
scleritis
treatment for scleritis
same day assessment by opthalmologist
oral NSAIDs
oral glucocorticoids for more severe
immunosuppressants for resistant cases
4 risk factors for scleritis
- rheumatoid arthritis
- SLE
- sarcoidosis
- granulomatosis with polyangiitis
how should a patient lie with acute closed angle glaucoma when they are waiting for treatment
ask the patient to lie flat, face up with their head unsupported by pillows to relieve pressure on the angle
herpes simplex keratitis commonly presents with…
dendritic corneal ulcer
management of herpes simplex keratitis (dendritic corneal ulcer)
immediate referral to opthalmologist
topical aciclovir
in-turning of the eyelids is called
entropion
out-turning of the eyelids is called
ectropion
infection of the glands of the eyelids is called
stye
inflammation of the eyelid margins typically leading to a red eye is called
blepharitis
Meibomian cyst is also called
chalazion
2 types of stye
- external (hordeolum externum): infection (usually staphylococcal) of the Zeis or Moll sebum/sweat glands
- internal (hordeolum internum): infection of Meibomian glands. May leave a residual chalazion (Meibomian cyst)
Management of stye
hot compresses and analgesia
CKS only recommend topical antibiotics if there is an associated conjunctivitis
chalazion (Meibomian cyst) is a retention cyst of the Meibomian gland. It presents as a firm painless lump in the eyelid. what is treatment
most resolve themselves
some need surgical drainage
Which is painful vs painless:
(a) scleritis
(b) episcleritis
(a) scleritis - painful
(b) episcleritis - painless
5 ocular manifestations of rheumatoid arthritis
- keratoconjunctivitis sicca
- episcleritis
- scleritis
- corneal ulceration
- keratitis
Blood in anterior chamber of eye is called
hyphema
treatment of hyphema in context of trauma
urgent same day referral to opthalmology
strict bed rest
they will assess for orbital compartment syndrome
Management of orbital compartment syndrome (e.g. secondary to retrobulbar haemorrhage - eye pain, proptosis, rock hard eyelids, RAPD)
Lateral canthotomy to decompress the orbit
Corneal foreign body - refer to opthalmology if
- sharp object
- suspected eye injury due to high velocity injury
- chemical injury (irrigate for 30min first)
- organic material foreign body
- in or near the centre of cornea
- red flags e.g. severe pain, dilated/non-reactive pupils, reduced visual acuity
Blepharitis is inflammation of..
eyelid margins
Blepharitis is more common in patients who suffer from
rosacea
Bilateral grittiness/discomfort
Eyes sticky in morning
Eyelid margins may be red
Styes + chalazions are more common
What is diagnosis
Blepharitis
Blepharitis treatment
- hot compresses
- lid hygiene - baby shampoo, cooled boiled water, sodium bicarbk
- artificial tears
keratitis is inflammation of the ..
cornea
Causes of keratitis
- Bacterial - Staph, Psuedomonas in contact lens
- Fungal
- Amoebic - acanthamoebic (5%) with soil or water contimated
- Parasitic - onchocercal (river blindness)
- Viral - HSV
- Environmental - photokeratitis (welder’s arc eye), contact lens acute red eye (CLARE)
contact lens wearers who present with a painful red eye require what referral
same-day referral to an eye specialist is usually required to rule out microbial keratitis
management of keratitis
- stop using contact lens
- topical Abx
- cycloplegic for pain relief e.g. cyclopentolatec
4 complications of keratitis
- corneal scarring
- perforation
- endopthalmitis
- visual loss
If suspecting age-related macular degeneration, referral to opthalmology urgently within ..
1 week
Children with viral conjunctivitis school exclusion period
no exclusion
Purulent discharge
Eyes stuck together in morning
Bacterial or viral conjunctivitis?
Bacterial
Serous discharge
Recent URTI
Preauricular lymph nodes
Bacterial or viral conjunctivitis?
Viral
Infective conjunctivitis treatment
- Self-limiting within 1-2 weeks
- Topical Abx e.g. chloramphenicol
- Topical fusidic acid for pregnant women
- Contact lens users - topical fluorescein stain to identify any corneal issue. Stop using contacts
- Do not share towels
- Can continue going to school
management of subconjunctival haemorrhage
reassure
AND CHECK BLOOD PRESSURE
if immediate admission is not possible for acute closed angle glaucoma, emergency treatment should be started in primary care which includes
oral acetazolamide
topical pilocarpine
What is the name for an infection of the lacrimal sac, secondary to obstruction of the nasolacrimal duct
dacryocystitis
What patients with blepharitis should be referred for same day opthalmology assessment
Corneal disease symptoms
e.g. pain and blurred vision
acute angle closure glaucoma is associated with hypermetropia
what is primary open-angle glaucoma associated with?
myopia
what eyedrops increase eyelash length
latanoprost
Papilloedema describes optic disc swelling caused by
increased intracranial pressure
5 causes of papilloedema
- space occupying lesion
- malignant hypertension
- idiopathic intracranial hypertension
- hydrocephalus
- hypercapnia
treatment of herpes simplex keratitis
aciclovir eye ointment
Retinitis pigmentosa main symptoms
Night blindness
Tunnel vision
fundoscopy: black bone spicule-shaped pigmentation in the peripheral retina, mottling of the retinal pigment epithelium
what condition is this
retinitis pigmentosa
episcleritis 2 associated conditions
inflammatory bowel disease
rheumatoid arthritis
what eyedrops can be used to differentiate between episcleritis and scleritis
phenylephrine
blanches conjunctival and episcleral vessels, but not the scleral vessels
management of episcleritis
conversative
artificial tears may be used
who can certify patients as blind or partially sighted
consultant opthalmologist
children with a squint management
referral to opthalmology
NICE advises to arrange a 2-week wait referral if a malignant eyelid tumour is suspected, for example, if the meibomian cyst has an atypical appearance such as …
distortion of eyelid margin
loss of eyelashes
ulceration
bleeding
or it recurs in the same location
corneal ulcer risk factors
contact lens
vitamin A def
organism causes of corneal ulcer
- bacterial keratitis
- fungal keratitis
- viral keratitis - HSV, herpes zoster
- acanthamoeba keratitis - a/w contact lenses
the most common 4 causes of sudden painless loss of vision
- ischaemic/vascular (VTE, GCA)
- vitreous haemorrhage
- retinal detachment
- retinal migraine
ischaemic/vascular causes of sudden losses of vision may respresent a form of TIA. what should the treatment be?
aspirin 300mg
what type of conditions would cause sudden loss of vision ‘curtain coming down’
Retinal detachment
- dense shadow that starts peripherally and progresses towards central vision
- straight lines appear curved
3 causes of central retinal vein occlusion
Glaucoma
Polycthaemia
Hypertension
Central retinal artery occlusion causes
VTE (from atherosclerosis)
Arteritis e.g. GCA
RAPD
sudden visual loss
painless
unilateral
cherry red spot on a PALE retina
what is the diagnosis
central retinal artery occlusion
Flashes of light/floaters
Sudden loss of vision
What are the two conditions that can cause this?
Vitreous or retinal detachment
Causes of vitreous haemorrhage (sudden painless visual loss, floaters/dark spots)
Diabetes
Posterior vitreous detachment
Bleeding disorders
Anticoagulants
straight lines appear curved in which 2 conditions
retinal detachment
age related macular degeneration
What eye condition is related to syphilis (Trepnoema pallidum)
Argyll-Robertson pupil
also caused by diabetes
What are the pupils like in Argyll-Robertson?
Small and irregular
Accommodate but do not react to light
(ARP = accommodation reflex present, PRA = pupillary reflex absent!)
Hypertensive retinopathy - what stage?
Arteriolar narrowing + tortuosity
Increased light reflex - silver wiring
Stage 1
Hypertensive retinopathy - what stage?
AV nipping
Stage 2
Hypertensive retinopathy - what stage?
Cotton wool exudates
Flame + blot haemorrhages
Stage 3
Hypertensive retinopathy - what stage?
Papilloedema
Stage 4
Horner’s syndrome 4 features
Miosis (small pupil)
Ptosis
Enopthalmos (sunken eye)
Anhidrosis
Congenital horner’s versus horner’s - what is different
heterochromia - difference in iris colour in congenital
the location of anhidrosis in Horner’s syndrome can help distinguish where the lesion is. where is the lesion for:
(a) anhidrosis of face, arm and trunk
(b) anhidrosis of face
(c) no anhidrosis
(a) face, arm and trunk - central lesion e.g. the ‘S’ - Stroke, Syringomelia, multiple Sclerosis, tumourS
(b) face - the ‘T’ - pancoast Tumour, Thyroidectomy, Trauma
(c) no anhidrosis - the ‘C’ - carotid dissection, carotid aneurysm, cluster headache, cavernous sinus thrombosis
what is the usual first line treatment for childhood squint after referral to paeds team
occlusion therapy of normal eye with eye patch
what is the medical term for squint
strabismus
how can squints be categorised
- concomitant - due to imbalance in extraocular muscles. covergent > divergent
- paralytic - due to paralysis of muscles
Why are squints important to detect and correct
Uncorrection can lead to amblyopia (brain favours one eye > other for inputs)
How to detect a squint
Corneal light reflection test
hold light source 30cm from child’s face to see if light reflects symmetrically on pupils
6 causes of tunnel vision
- papilloedema
- glaucoma
- retinitis pigmentosa
- choroidoretinitis
- optic atrophy secondary to tabes dorsalis
- hysteria
management of central retinal artery occlusion
- treat cause e.g. IV steroids for GCA
- if they present acutely then can attempt intra-arterial thrombolysis
What is the diagnosis
Sudden painless loss of vision
Unilateral
Fundoscopy shows:
severe retinal haemorrhages (stormy sunset)
widespread hyperaemia (redness)
Central retinal vein occlusion
Holmes-Adie pupil
Is it constricted or dilated
And what does it react/not react to?
Dilated
Slowly reactive to accommodation
Very poorly (if at all) to light
Holmes-Adie pupil - dilated pupil
Is it unilateral/bilateral in most cases?
Unilateral 80%
Holmes-Adie is associated with what reflexes
Absent ankle/knee reflexes
5 causes of mydriasis (dilated large pupil)
- 3rd nerve palsy
- Holmes-Adie pupil
- Trauma
- Phaeochromocytoma
- Congenital
What two eye drops can cause dilated large pupil (mydriasis)
Tropicamide
Atropine
