Opthalmology Flashcards
Features of mydriatic and cycloplegic drops
Dilate pupils for visualisation of the retina
Paralyse accommodation in management of children with amblyopia
Used in refraction of children for the prescription of glasses
Features of Atropine
1-2 drops - 0.5-1%
Antimuscarinic - blocks response of iris sphincters muscles and accommodative muscles of ciliary body
Lasts 1-2 weeks
CI - HTN, untreated narrow angle glaucoma
Features of Cyclopentolate
1-2 drops - 0.5-1%
Antimuscarinic - blocks response of iris sphincter muscles and accommodative muscles of ciliary body
Effect in 25-75 mins, recovery over 6-24 hours
CI - untreated narrow angle glaucoma, allergy
Features of Tropicamide
1-2 drops of 1%
Antimuscarinic - blocks response of iris sphincter muscles and accommodative muscles of ciliary body
Effect in 15-20 mins, recovery over 4-8 hours
CI - allergy, untreated narrow angle glaucoma
Features of Phenylephrine
1-2 drops 2.5/10%
Sympathetic agonist - stimulation of iris dilation muscle
Effect 3-6 hours
CI - avoid in children, untreated narrow angle glaucoma
Side effects of mydriatic and cyloplegic drops
Whitening of eyelids due to vasoconstriction - resolves as drops wear off
Atropine can cause redness of face and warm sensation to touch
Sting the eyes for few seconds
Patients cannot drive until blurring worn off
Features of Fluorescein drops
Orange die - used to highlight defects or foreign bodies in the corneal epithelium
- can be used when measuring IOP
Check for allergy
Side effects of Fluorescein drops
Skin discolouration - lasts 6-12 hours
Staining of clothes
Discolour contact lenses
Define Blepharitis
Inflammation of the eyelid margins
Symptoms of Blepharitis
Gritty, itch, dry sensation in the eyes
Eyes sticking together in morning
Symptoms worse in mornings
Recurrent hordeolum
Mx of Blepharitis
Warm compress
Cleaning the margins of the eye with a cotton bud + sterilised water + baby shampoo
Lubricating eye drops can remove symptoms
- hypromellose - least viscous, lasts 10 mins
- polyvinyl alcohol - normal starting choice
- carbomer - most viscouse, lasts 30-60 mins
Avoid eye makeup
DDx for eyelid inflammation
Meibomian cyst or stye Infection Psoriasis Dermatitis Tumours Connective tissue disorders Trauma
Define Hordeolum
Stye Acute localised infection or inflammation of eyelid margin External - appears on eyelid margin - causes by eyelash follicle Internal - Meibomian - occurs on conjunctival surface of eyelid - infection of Meibomian gland
Clinical presentation of a stye
Acute-onset painful localised swelling near eyelid margin
- over several days
- usually unilateral
- eye may water excessively (epiphora)
Mx of a stye
Warm compress
Advise to not attempt to puncture stye
Avoid eye makeup or contact lenses
Define Meibomian cyst
Inflammation of Meibomian gland
Mx of Meibomian cyst
Hot compress
Analgesia
Define Entropion
Eyelid turns inwards with lashes against the eyeball
- can lead to corneal damage and ulceration
- painful
Mx of entropion
Tape down eyelid to prevent from turning inward
- regular drops prevent the eye from becoming dry
Surgical management
Define ectropion
Eyelid turns outwards with inner aspect of eyelid exposed
Usually affects the bottom lid
- can result in exposure keratopathy - eyeball not not adequately lubricated or protected
Mx of ectropion
Mild cases don’t require treatment
Regular lubricating eye drops
Surgical intervention
Define peri-orbital cellulitis
Infection of eyelid and area around the eye
Define orbital cellulitis
Infection of orbital soft tissues
Presentation of orbital cellulitis
Lid oedema Fever Painful swelling of eyelids - impairs vision and prevents eye from opening Shiny and red eyelids Systemically unwell Bulging eyes
Mx of orbital cellulitis
Iv abx
Presentation of pre-orbital cellulitis
Lid oedema
No visual loss, conjunctival oedema or protrusion of eyeball
Afebrile and systemically well
Tender, erythematous swollen eyelids
Mx of pre-orbital cellulitis
Oral abx
Causes of ptosis
Mechanical - lid pulled down due to gravity of large mass/scar
Aponeurotic - defect in levator aponeurosis
- senile
- post-op
Myogenic - myopathy of levator muscle or NMJ
- myasthenia gravis
- myotonic dystrophy
- congenital
Neurogenic - innervational defect
- CN III nerve palsy
- Horner syndrome - partial
Define presbyopia
Lens hardening and flattening due to increasing age
- impaired ability to accommodate
- reduction in close up vision/accommodation
- noticeable around age 40
How is intraocular pressure maintained
Aqueous humour - balance between rate of production and drainage - secreted from ciliary epithelium - drainage through posterior chamber, into anterior chamber, through trabecular meshwork into Schlemm's cells Alpha-2 receptors - reduce IOP - reduce aqueous production - increase uveoscleral drainage Beta-2 receptors - increase IOP - increase aqueous production
Measurement of IOP
Non-contact tonometry
- shoots puff of air at cornea and measures corneal response
Goldmann applanation tonometry
- gold standard
- device mounted on slit lamp which makes contact with cornea and applies different pressure to front of cornea
- more accurate
Normal IOP
11-21 mmHg
- high IOP does not equate to glaucoma
Drug mx of high IOP
Beta blockers - Timolol - decrease aqueous production Alpha agonists - Apraclonidine - Dipivefrin - decrease production and increase drainage Prostaglandin analogues - Latanoprost - increase uveoscleral outflow Carbonic-anhydrase inhibitors - Dorzolamine - decrease production Parasympathomimetic - Pilocarpine - increase outflow by constricting iris
Define keratitis
Inflammation of cornea
Causes of keratitis
Viral - herpes simplex Bacterial - pseudomonas - staphylococcus Fungal - candida - aspergillus Contact lens acute red eye Exposure - inadequate eyelid cover - ectropion
Presentation of keratitis
Painful red eye Photophobia Vesicles around eye - herpes Foreign body sensation Watering eye Reduced visual acuity
Complications of keratitis
Stromal keratitis - inflammation of upper layer of iris - stromal necrosis - vascularisation - scarring Corneal scarring Blindness
Ix for keratitis
Staining with fluorescein show dendritic corneal ulcer
Slit lamp
Corneal swabs or scrapings - isolate virus
Mx of keratitis
Same day referral to ophthalmologist Topical/oral acyclovir Ganciclovir eye gel Topical steroids - stromal keratitis Corneal transplant - corneal scarring
Define conjuctivitis
Inflammation of cornea
Types of conjunctivitis
Bacterial - purulent discharge - worse in mornings - highly contagious - easily spreads to other ye Viral - clear, watery discharge - coryzal symptom may be present - tender periauricular lymph nodes Allergic - allergen exposure and hx - swelling of conjunctival sac and eyelid - significant watery discharge and itchiness
Presentation of conjunctivitis
Red eyes
Bloodshot
Itchy/gritty sensation
Discharge
Mx of conjunctivitis
Usually resolves spontaneously in 1-2 weeks Good hygiene to avoid spreading - avoid towel sharing - wash hands Avoid contact lenses Bacterial - abx eye drops - chloramphenicol - fusidic acid Allergic - antihistamines Under 1 month old - urgent ophthalmology review as maybe gonococcal infection
Define corneal abrasion
Scratches or damage to cornea
Causes of corneal abrasion
Contact lenses
Fingernails
Eyelashes/foreign bodies
Entropion
Presentation of corneal abrasion
Hx of foreign body Painful red eye Foreign body sensation Watering eye Blurred vision Photophobia
Ix for corneal abrasion
Fluorescein stain - collects in abrasions/ulcers highlighting them
Slit lamp exam
Mx of corneal abrasion
Simple analgesia
Lubricating eye drops
Abx eye drops
Follow up in 1 week to check healing
Define hyphema
Blood in anterior chamber
Causes of hyphema
Trauma
Intraocular surgery
Neovascularisation - due to posterior segment ischaemia
Spontaneous - bleeding disorders, antiplatelets, iris melanoma
Presentation of hyphema
Blurred vision
Ocular distortion - kaleidoscope vision
Pain, headache and photophobia is IOP raise
Ix for hyphema
Slit-lamp examination Full ophthalmic examination o Visual acuity o Pupillary examination o Intraocular pressure o Gonioscopy – condition of the angle and the trabecular meshwork o Measure the height of the hyphema from the inferior limbus o Measure IOP
Mx of hyphema
Uncomplicated - eye shield - limited activity - head elevation Monitor eye closely in first few days - high risk of further bleeding Avoid NSAIDs
Complications of hyphema
Obstruction of trabecular meshwork -> increased IOP
Peripheral anterior synechiae - iris adheres to lens
Posterior synechia - iris adheres to cornea
Corneal bloodstaining
Rebleeding
Define endophthalmitis
Inflammation of one or more coats of the eye with contagious cavity inflammation
Causes of endophthalmitis
Intraocular surgery
Penetrating trauma
Draining a glaucoma bleb
Types of endophthalmitis
Acute - staph epidermis - staph aureus - strep - pseudomonas Chronic - propionibacterium acnes - staph epidermis - fungi Trauma - staph epidermis - strep - fungi - gram-neg bacteria Bled-related - strep
Prestation of endophthalmitis
Very painful red eye
Hypopyon present - leukocytic exudate in anterior chamber of eye
Mx of endophthalmitis
Aqueous and vitreous tap
Intravitreal abx - vancomycin
Topical/oral ciprofloxacin
Define cataracts
Opacification of the crystalline lens
Causes of cataracts
Normal aging Smoking Increased alcohol Trauma DM Long term corticosteroids Radiation exposure Myotonic dystrophy Hypocalcaemia
Presentation of cataracts
Reduced vision Faded colour vision Glare - lights appear brighter than usual Halos around lights Altered red light reflex
Ix for cataracts
Ophthalmoscopy
- normal fundus and optic nerve
Slit lam examination
- visible cataract
Classification of cataracts
Nuclear - change lens refractive index - common in old age Polar - localised, lie in visual axis - commonly inherited Subcapsular - due to steroid use - deep to lens capsule, in visual axis Dot opacities - common in normal lenses - seen in diabetes and myotonic dystrophy
Mx of cataracts
Non-surgical - prescribe stronger glasses - use brighter lights Surgical - remove cloudy lens and replace with artificial lens
Stages of cataract removal
Eyedrops to dilate pupil + local anaesthetic
Remove cataract
- phacoemulsification - probe inserted via incision and USS used to break up cataract
- laser to make incisions and soften cataract for removal
- extracapsular cataract extraction - larger incision made and cataract removed whole
Complications of cataract surgery
Posterior capsule opacification - thickening of lens capsule
Retinal detachment
Posterior capsule rupture
Endophthalmitis - inflammation of aqueous /vitreous humour
Define glaucoma
Optic nerve damage caused by significant rise in IOP
- secondary to blockage of aqueous humour leaving anterior chamber
Define primary open angle glaucoma
Gradual increase in resistance through the trabecular meshwork
- decreasing drainage of aqueous humour
Increased pressure causes cupping of optic disc
Glaucoma screening
Annual screening for those over 40 with 1st degree relative that had glaucoma .
Risk factors for primary open angle glaucoma
Increasing age
FHx
Black ethnic origin
Nearsightedness (myopia)
Presentation for primary open angle glaucoma
Often rise in IOP asymptomatic
Affects peripheral vision first then turns to tunnel vision
Fluctuating pain, headaches, blurred vision and halos around light
Mx of primary open angle glaucoma
Prostaglandin analogue eyedrops - latanoprost - increase uveoscleral outflow Betablockers - timolol - reduce production of aqueous humour Carbonic anhydrase inhibitors - dorzolamide - reduced production of aqueous humour Alpha-2-agonist - brimonidine - reduce production of aqueous humour - increase uveoscleral outflow Trabeculectomy surgery when drops ineffective - new channel underneath conjunctiva - forms a bled
Side effects of prostaglandin analgogues
Eyelash growth
Eyelid pigmentation
Iris pigmentation
Define acute angle closure glaucoma
Ophthalmological emergency
Occurs when iris bulges forward and seals off trabecular network
- prevents aqueous humor form draining away
Pressure build up in posterior chamber
Risk factors for acute angle closure glaucoma
Increasing age Female FHx Chinese and east Asian ethnicity Shallow anterior chamber Medications - noradrenaline - oxybutynin - amitriptyline - steroids
Presentation of acute angle closure glaucoma
Severely painful eye Blurred vision Halos around light Associated headache, N+V Epiphora - excessive eye watering Hazy cornea Decreased visual acuity Fixed and dilated affected pupil Firm eyeball on palpation
Mx of acute angle closure glaucoma
Initial steps - lay patient on back without pillow - Pilocarpine eye drops - Acetazolamide 500mg orally - analgesia and antiemetic Secondary - laser iridotomy - creates hole in iris to allow aqueous humour to flow from posterior chamber to anterior
Pathophysiology of diabetic retinopathy
Hyperglycaemia leads to damage of retinal small vessels and endothelial cells
Increased vascular permeability leads to leakage from blood vessels, blot haemorrhages and formation of hard exudates
Damage to vessel walls leads to microaneurysms and venous bleeding
Damage to nerve fibres causes cotton wall spots
Intraretinal microvascular abnormalities (dilated and torturous capillaries in retina) shunt between arterial and venous vessels
Classification of diabetic retinopathy
Non-proliferative
- no neovascularisation
Proliferative
- presence of neovascularisation
Fundus findings of diabetic eye disease
Non-proliferative diabetic retinopathy - mild = microaneurysms - moderate = microaneurysms, blot haemorrhages, hard exudates, cotton wool spots, venous bleeding - severe = blot haemorrhages, microaneurysms in 4 quadrants, venous bleeding in 2 quadrants, IMRA in any quadrant Proliferative diabetic retinopathy - neovascularisation - vitreous haemorrhage Diabetic maculopathy - macular oedema - ischaemic maculopathy
Complications of diabetic eye disease
Retinal detachment Vitreous haemorrhage Rubeosis iridis - new blood vessel formation in iris Optic neuropathy Cataracts
Mx of diabetic eye disease
Laser photocoagulation Anti-VEGR mutations - ranibizumab - bevacizumab Vitreoretinal surgery
Pathophysiology of central retinal vein occlusion
Thrombus in retinal vein blocks the drainage of blood from retina
Pooling of blood in retina
- leakage of fluid and blood causing macular oedema and retinal haemorrhages
Leads to loss of vision
Neovascularisation stimulated by VEGF release
Risk factors for central retinal vein occlusion
Hypertension High cholesterol DM Smoking Glaucoma SLE
Presentation of central retinal vein occlusion
Sudden painless loss of vision
Ix for central retinal vein occlusion
Fundoscopy - flame and blot haemorrhages - optic disc oedema - macular oedema FBC - leukaemia ESR - inflammatory disorders BP BM
Mx of central retinal vein occlusion
Referred immediately Treat macular oedema and prevent neovascularisation Laser photocoagulation Intravitreal steroids - dexamethasone Anti-VEGF therapies
Define hypertensive retinopathy
Damage to retinal blood vessels relating to systemic hypertension
Presentation of hypertensive retinopathy
Silver/copper wiring - walls of arterioles become thickened and sclerosed causing increased light reflection
Arteriovenous nipping - arterioles cause compression of veins
Cotton wool spots - nerve ischaemia
Hard exudates - leaking lipids
Retinal haemorrhages
Papilloedema
Classification of hypertensive retinoapthy
Keith-Wagener classification
- stage 1 = anterior narrowing and tortuosity, increased light reflex
- stage 2 = arteriovenous nipping
- stage 3 = cotton-wool exudates, flame and blot haemorrhages
- stage 4 = papilloedema
Mx of hypertensive retinopathy
Controlling BP and other risk factors
Define central retinal artery occlusion
Branch of ophthalmic artery which arises from internal carotid artery
Causes of central retinal artery occlusion
Atherosclerosis
Giant cell arteritis -> vasculitis
Risk factors for central retinal artery occlusion
Older age Fhx Smoking Alcohol consumption Hypertension Diabetes Poor diet Inactivity Obesity
Presentation of central retinal artery occlusion
Sudden painless loss of vision
RAPD
Pale retina with cherry red spot (macula)
Mx of central retinal artery occlusion
Refer immediately to ophthalmology
Treat underlying cause
Mx of risk factors
Features of age-related macular degeneration
Most common cause of blindness in UK Two types - wet 10% - dry 90% Wet carries worse prognosis
Pathophysiology of age-related macular degeneration
Wet and Dry
- large number of Drusen - yellow deposits of protein and lips between retinal pigment epithelium and Bruch’s membrane
Atrophy of retinal pigment epithlium
Degeneration of photoreceptors
Wet
- development of new vessels growing from choroid layer in retina
- can leak fluid causing oedema
Risk factors for ARMD
Increasing age Smoker White or Chinese ethnic origin FHx CVS disease
Presentation of ARMD
Gradual worsening central visual field loss
Reduced visual acuity
Crooked or wavy appearance of straight lines
Wet presents more acutely
Examination features of ARMD
Reduced acuity using Snellen chart
Scotoma - blind spot
Amsler grid test - assess distortion of straight lines
Fundoscopy/slip lamp - drusen
Optical Coherence Tomography - diagnose wet ARMD
Fluorescein angiography - shows oedema and neovascularisation
Mx of ARMD
Dry
- no specific treatment
- focus on lifestyle measures - avoid smoking, control BP
- vitamin supplementation to slow measures
Wet
- anti-VEGF medications injected into vitreous chamber
Define posterior vitreous detachment
Vitreous humour maintains surface structure of the eye and keeps retina pressed onto choroid
Detachment occurs when vitreous humour comes away from retina
Presentation of PVD
Painless
Spots of vision
Floaters
Flashing lights
Mx of PVD
Improves over time as brain adjusts
Predisposes patient to retinal tears and detachment - important to assess retina
Define retinal detachment
Retina separates from choroid
Usually due to retinal tear allowing vitreous fluid to get under retina
Outer retina relies on blood vessels from choroid for blood supply - sight threatening emergency
Risk factors for retinal detachement
Posterior vitreous detachment Diabetic retinopathy Trauma to eye Retinal malignancy Older age Fhx
Presentation of retinal detachement
Sudden peripheral vision loss
Blurred or distorted vision
Flashes and floaters
Mx of retinal detachment
Vitrectomy
- remove relevant parts of vitreous body and replacing with oil or gas
Scleral buckling
- forces pressure from outside of eye so choroid indents and makes contact with retina
Pneumatic retinopexy
- injecting gas bubble into vitreous body to create pressure that forces retina onto choroid
Mx of retinal tear
Laser or cryotherapy to create adhesions between retina and choroid
Define uveitis
Inflammation of one or all parts of uvea
- iris
- ciliary body
- choroid
- retina
Types of uveitis
Anterior
- iris and ciliary body
- common in ankylosing spondylitis, Reiters syndrome, RA, IBD, SLE
- often HLA-B27 +
Posterior
- choroid, retina and retinal vasculature
- often seen in sarcoidosis, MS, TB, herpetic eye disease
- classified by duration, age of onset or presence of granulomas
Presentation of anterior uveitis
Pain - burning Red eye Blurred vision Photophobia Dilated ciliary vessels Cells in anterior chamber Headaches Keratic precipitates
Presentation of posterior uveitis
Floaters Blurred vision Photopsia Vasculitis Optic disc swelling
Ix for uveitis
Ocular
- fluorescein angiogram
- OCT
- intravitreal tap
- endophthalmitis culture and sensitivity
- cytology
- toxoplasmosis and CMV PCR
Blood tests
- routine
- immunologial
- auto-antibody screen
- HLA testing
- syphilis
- HIV test
- toxoplasmosis
X-rays
- CXR - sarcoidosis, TB
- Lumbosacral spine - ankylosing spondylitis
- MRI brain and optic nerve - MS
Mantoux testMx of uveitis
Cycloplegic drops - atropine
- pain relief
- prevent posterior synechiae
Steroid drops
Define herpes zoster ophthalmicus
Reactivation of varicella zoster virus in the area supplied by the ophthalmic division of CN V
Presentation of herpes zoster ophthalmicus
Vesicular rash around eye
Hutchinson’s sign
- rash on tip or side of nose indicated nasociliary involvement
- strong risk factor for ocular involvement
Mx herpes zoster ophthalmicus
Oral antiviral treatment for 7-10 days
IV antiviral in immunocompromised or severe infection
Topical corticosteroids to treat secondary inflammation of eye
Ocular involvement requires urgent ophthalmology review
Define giant cell artertis
Systemic vasculitis of medium and large arteries
- typically temporal
Risk factors for temporal arteritis
Female
White
Over 50
Polymyalgia rheumatia
Presentation of giant cell arteritis
Severe unilateral headache - temporal and forehead Scalp tenderness - notice when brushing hair Jaw claudication - can lead to weight loss Blurred or double vision Irreversible painless sight loss
Ix for temporal arteritis
CRP raised
Temporal artery biopsy - multinucleated giant cells
FBC - normocytic anaemia and thrombocytosis
LFTs - raised ALP
Duplex USS of temporal artery - hypoechoic halo sign
Mx of temporal arteritis
Prednisolone 40-60 mg - continue till symptoms stop then slowly wean Don't STOP advice - don't stop abruptly - adrenal crisis - sick day rules - double dose - treatment card - osteoporosis prevention - bisphosphonates and supplemental calcium and vit D - PPI Aspirin 75mg daily Referrals - vascular surgeons - biopsy - rheumatology - diagnosis + mx - ophthalmology - review same day if symptoms get worse
Compilations of temporal arteritis
Early - visual loss - stroke Late - replases - steroid side effects - stroke - aortitis - leading to aortic aneurysm and aortic dissection
Define scleritis
Full thickness inflammation of sclera
Causes of sclertitis
Not usually infection Associated with - RA - SLE - IBD - sarcoidosis - granulomatosis with polyangiitis
Presentation of sclertitis
Acute onset to symptoms - 50% bilateral Severe pain Pain on eye movement Photophobia Eye watering Reduced visual acuity Abnormal pupil reaction to light Tenderness to palpation of eye
Mx of scleritits
Consider underlying systemic conditions
NSAIDs
Steroids
Immunosuppression
Features of RA
Scleritis
Peripheral corneal thinning - perforation
Episcleritis
Keratoconjunctivitis sicca - dry eyes
Features of SLE
Scleritis Peripheral corneal thinning Eyelid erythema Keratoconjunctivitis sicca Retinopathy - primary or secondary due to hypertension
Pathophysiology of thyroid eye disease
Orbital tissues including extra-ocular muscles infiltrated by inflammatory cells
- increased pressure in orbit
IgG mediated
Associated with thyrotoxicosis
Aqueous humour outflow obstruction from eye may lead to secondary glaucoma
Stages of thyroid eye disease
Acute inflammatory - risk of sight loss - lasts 12-18 months - causes proptosis - can cause obstructive optic neuropathy Chronic fibrotic - leads to restrictive myopathy and diplopia
Risk factors for thyroid eye disease
Female
Smoking
Symptoms of thyroid eye disease
Asymptomatic Grittiness - superior limbic keratoconjunctivits Redness Eyelid swelling Diplopia Bulging eyes Visual loss
Examination findings of thyroid eye disease
Lid retraction - due to fibrotic contracture of levator
Lid lag on down gaze
Ix for thyroid eye disease
CT orbit
- proptosis - 2/3 of globe should lie within orbit
- extraocular muscle infiltration and enlargement
TFTs
- Graves disease = suppressed TSH, elevated T3 and T4
Mx of thyroid eye disease
Manage thyroid dysfunction
Ocular lubricants - for corneal exposure
Glaucoma topical meds - secondary glaucoma
Systemic corticosteroids
Orbital radiotherapy
Diplopia - squint surgery, prisms, botox
Cosmetic - orbital decompression, lid surgery
Define retionblastoma
Malignant tumour
Develops from immature cells of retina
45% inherited - mutations of RB1 on chromosome 13
Presentation of retinoblastoma
Leukocoria - abnormal white reflection from retina
May lack red reflex
Bilateral in 1/3 cases
May develop squint
Mx of retinoblastoma
Enucleation of eye
Radiotherapy
Chemotherapy
Define amblyopia
Reduction of corrected visual acuity
Define strabismus
Misalignment of eyes
Causes amblyopia due to competitive interaction between cortical inputs from both eyes
Types of amblyopia
Primary
- develops in child with otherwise normal ocular exam
- due to central developmental anomaly
Secondary
- occurs following ocular disease
- refractive error - difference between two eyes gives one blurred image
- media opacity
Classification of strabismus
Esotropia - convergent squint
Exotropia - divergent squint
Accommodative - focussing on near object results in excessive convergence - completely corrected by glasses
Mixed
Mx of stabismus
Nerve conductions to LGN cease to be plastic after 8 years old
Correction of any significant refractive error with glasses
Removal of any visual obstruction
Amblyopia treatment with patching
Causes of congenital cataracts
Down’s syndrome
Hypoparathyroidism
TORCH - intrauterine infectsions
Mx of congenital cataracts
If severe surgery required in early life to allow for normal development
- risk of open angle glaucoma
Define retinopathy of premature infants
Proliferative vitreoretinopathy affecting pre-term infants with low birth weight
Retinal vessels develop at 4 months gestation, reach nasal periphery at 8 months and temporal periphery 1 month after birth
In preterm infants incompletely vascularized retina susceptible to damage from low or high O2 concentrations
Mx of retinopathy of prematurity
Laser treatment to ablate ischaemic retina
Screening for retinopathy of prematurity
Babies born
- less than 32 weeks
- less than 1500g
Key points of neonatal conjunctivitis
Under 1 month is a notifiable disease Gonococcal - 2-4 day post birth - corneal ulceration and perforation Chlamydial - 5-14 days post birth - most common - treat with topical tetracycline or oral erythromycin
Features of atopic eye disease
Peak age onset 20 years
IgE mediated
Features of seasonal allergic conjuctivitis
Symptoms seasonal and mild
Examination shows small papillae on tarsal conjuctiva
Self-limiting
- antihistamine drops helpful - ketotifen
Features of perennial allergic conjuctivitis
Mild and may persist all year with seasonal exacerbations
Examination shows small papillae on tarsal conjuctiva
Mx = olopatadine - antihistamine and mast cell stabiliser
Features of atopic keratoconjunctivis
Severe pain, redness and reduced vision
Examination shows papillae on conjunctiva
- can causing scaring leading to corneal opacification and neovascularisation
Mx = cidofovir
Define Horner Syndrome
Triad of ptosis, miosis and anhidrosis
Occurs with damage to sympathetic chain
Causes of Horners syndrome
Central lesions - stroke - MS - tumours - syringomyelia Pre-ganglionic lesions - Pancoast tumour - trauma - thyroidectomy - top rib Post-ganglionic - carotid aneurysm - carotid artery dissection - cavernous sinus thrombosis - cluster headache
Define Argyll Robertson Pupil
Specific finding in neurosyphilis but can also be due diabetes
Constricted pupil that accommodates when focussing on near object but doesn’t react to light
Often irregularly shaped
Define Holmes Adies Pupil
Unilateral dilated pupil that is sluggish to react to light - slow dilatation followed by constriction
Over time pupil gets smaller
Due to damage to post-ganglionic parasympathetic fibres
Presentation of 3rd nerve palsy
Ptosis Dilated non-reactive pupil - carries parasympathetic nerve fibres Divergent strabismus - down and out Sparing of pupil suggest microvascular cause
Causes of 3rd nerve palsy
Idiopathic Pupillary sparing - diabetes, hypertension, ischaemia Tumour Trauma Cavernous sinus thrombus Posterior communicating artery aneurysm Raised ICP
Ix for 3rd nerve palsy
BP
BM
CRP
Brain imaging
Mx of 3rd nerve palsy
Correct BP and glucose
Usually resolves over 4-6 months
May require surgery
Features of 4th nerve palsy
Leads to paralysis of superior oblique
Diplopia on depression
Abnormal head posture - head tilt and face turn to unaffected eye
Causes of 4th nerve palsy
Congenital Vascular - diabetes, hypertension Demyelination Tumour Giant cell arteritis Aneurysm
Ix for 4th nerve palsy
Head tilt test - tilting head to ipsilateral side induces upward movement of globe to to unopposed superior rectus action BP BM CRP Brain imaging
Mx of 4th nerve plasy
Correct BP and glucose
Usually resolves in 4-6 months
May require surgery
Presentation of 6th nerve palsy
Ipsilateral convergent squint
- due to unopposed medial rectus
Horizontal diplopia
Abnormal head posture
Define Nystagmus
Involuntary repetitive back and forth oscillations of the eye
May be horizonal (most common), vetical or torsional
- description based on fast phase
- if no fast phase = pendular
Features of physiological nystagmus
Caloric testing - warm/cold water put in patient’s ear to induce
Gaze evoked - normal to mild nystagmus on extreme left/right gaze
Features of congenital nystagmus
Seen in children up to 1
Initially horizontal pendular nystagmus - later developing jerk stage
May be inherited - X-linked or autosomal recessive
Indicator of poor vision
Should be monitored for refractive error, amblyopia and strabismus
Causes of acquired nystagmus
Recent trauma Toxicity - alcohol - phenothiazines - Wernicke's encephalopathy Cerebral disease - stroke - MS - tumour
Ix for acquired nystagmus
Full physical exam - including neuro
Toxicity screening
Neurological imaging
Mx of acquired nystagmus
Treatment of any cerebral disease
Botox
Surgery
Nystagmus associated with neuro disease
Convergence retraction - eyes converge and drawn into orbit on upgaze - dorsal midbrain disease Downbeat nystagmus - foramen magnus lesions Upbeat nystgamus - cerebellar lesions See-saw - chiasmal lesion
Define optic neuritis
Inflammation of optic nerve
Presentation of optic neuritis
Reduced visual acuity Abnormal visual fields Peri-orbital pain RAPD Poor colour vision Optic disc swelling
Causes of optic neuritis
Retrobulbar neuritis - disc appears normal in acute phase due to demyelination - early sign of MS Papillitis - disc inflammation - viral infection in young children Ischaemic - GCA, embolic, SLE Compressive Traumatic Toxic - alcohol - B12 deficiency Retinal disease - retinitis pigmentosa
Ix for optic neuritis
ESR - exclude GCA FBC Visual field test Vit B12 and folate levels Autoantibody screen Orbital and brain imaging if compressive suspected Temporal artery biopsy
Define papilloedema
Bilateral disc swelling due to raised ICP
Clinical features of papilloedema
Bilateral swollen hyperaemic discs Disc haemorrhages Absent venous pulsations at disc Optic atrophy Champagne cord appearance if chronic
Causes of papilloedema
Intracranial tumour
Benign idiopathic hypertension
Meningitis
Brain abscess
Ix for papilloedema
Urgent CT head
LP
BP
Unilateral causes of swollen optic disc
Central retinal vein occlusion Uveitis Ocular hypotony Anterior ischaemic optic neuropathy Optic disc infiltration
Define chiasmal disease
Affects junction of optic nerve and optic chiasm
Presentation of chiasmal disease
Blurred vision
Constricted visual fields - bitemporal hemianopia
Headache
See-saw nystagmus
Causes of chiasmal disease
Pituitary tumour - compress from below - supero-temporal vision affected first Meningioma Craniopharyngioma
Red eye DDx
Subjunctival haemorrhage Blepharitis Conjunctivitis Trauma Keratitis Iritis Episcleritis Scleritis Primary angle closure
Causes of gradual changes in vision
Refractive error Cataract Posterior capsule opacification Age-related macular degeneration Retinitis pigmentosa
Causes of monocular diplopia
Corneal opacity/scarring/oedema Iris defects Subluxated natural lens Decentred artificial intraocular lens Uncorrected astigmatism
Causes of binocular diplopia
Horizontal - decompensated pre-existing eso/exo phoria - CN VI palsy - internuclear ophthalmoplegia - medial orbital wall fracture Vertical - decompensated pre-existing hypo/hyper phoria - CN IV palsy - CN III palsy Variable - thyroid eye disease - MG
Causes of sudden changes in vision
Painful
- anterior segment – iritis, scleritis, keratitis, primary angle closure
- optic nerve – optic neuritis, arteritic ischaemic optic neuropathy
- intracranial – migraine, benign intracranial hypertension
Painless
- vitreous – vitritis, vitreous haemorrhage
- retinal (vascular) – retinal vein occlusion, retinal artery occlusion
- retinal (macula) – wet ARMD, diabetic maculopathy
- retinal – retinal detachment, retinitis, retinochoroiditis
- optic nerve – non-arteritic ischaemic optic neuropathy, compressive optic neuropathy
- intracerebral – stroke
