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Yr4 - Neuro + SS > Opthalmology > Flashcards

Opthalmology Flashcards

1
Q

Features of mydriatic and cycloplegic drops

A

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

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2
Q

Features of Atropine

A

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

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3
Q

Features of Cyclopentolate

A

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

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4
Q

Features of Tropicamide

A

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

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5
Q

Features of Phenylephrine

A

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

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6
Q

Side effects of mydriatic and cyloplegic drops

A

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

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7
Q

Features of Fluorescein drops

A

Orange die - used to highlight defects or foreign bodies in the corneal epithelium
- can be used when measuring IOP
Check for allergy

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8
Q

Side effects of Fluorescein drops

A

Skin discolouration - lasts 6-12 hours
Staining of clothes
Discolour contact lenses

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9
Q

Define Blepharitis

A

Inflammation of the eyelid margins

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10
Q

Symptoms of Blepharitis

A

Gritty, itch, dry sensation in the eyes
Eyes sticking together in morning
Symptoms worse in mornings
Recurrent hordeolum

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11
Q

Mx of Blepharitis

A

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

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12
Q

DDx for eyelid inflammation

A 
Meibomian cyst or stye
Infection 
Psoriasis
Dermatitis
Tumours
Connective tissue disorders
Trauma
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13
Q

Define Hordeolum

A 
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
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14
Q

Clinical presentation of a stye

A

Acute-onset painful localised swelling near eyelid margin

  • over several days
  • usually unilateral
  • eye may water excessively (epiphora)
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15
Q

Mx of a stye

A

Warm compress
Advise to not attempt to puncture stye
Avoid eye makeup or contact lenses

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16
Q

Define Meibomian cyst

A

Inflammation of Meibomian gland

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17
Q

Mx of Meibomian cyst

A

Hot compress

Analgesia

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18
Q

Define Entropion

A

Eyelid turns inwards with lashes against the eyeball

  • can lead to corneal damage and ulceration
  • painful
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19
Q

Mx of entropion

A

Tape down eyelid to prevent from turning inward
- regular drops prevent the eye from becoming dry
Surgical management

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20
Q

Define ectropion

A

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

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21
Q

Mx of ectropion

A

Mild cases don’t require treatment
Regular lubricating eye drops
Surgical intervention

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22
Q

Define peri-orbital cellulitis

A

Infection of eyelid and area around the eye

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23
Q

Define orbital cellulitis

A

Infection of orbital soft tissues

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24
Q

Presentation of orbital cellulitis

A 
Lid oedema
Fever
Painful swelling of eyelids
- impairs vision and prevents eye from opening
Shiny and red eyelids
Systemically unwell
Bulging eyes
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25
Q

Mx of orbital cellulitis

A

Iv abx

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26
Q

Presentation of pre-orbital cellulitis

A

Lid oedema
No visual loss, conjunctival oedema or protrusion of eyeball
Afebrile and systemically well
Tender, erythematous swollen eyelids

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27
Q

Mx of pre-orbital cellulitis

A

Oral abx

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28
Q

Causes of ptosis

A

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

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29
Q

Define presbyopia

A

Lens hardening and flattening due to increasing age

  • impaired ability to accommodate
  • reduction in close up vision/accommodation
  • noticeable around age 40
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30
Q

How is intraocular pressure maintained

A 
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
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31
Q

Measurement of IOP

A

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

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32
Q

Normal IOP

A

11-21 mmHg

- high IOP does not equate to glaucoma

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33
Q

Drug mx of high IOP

A 
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
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34
Q

Define keratitis

A

Inflammation of cornea

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35
Q

Causes of keratitis

A 
Viral
- herpes simplex
Bacterial
- pseudomonas
- staphylococcus
Fungal
- candida
- aspergillus
Contact lens acute red eye
Exposure
- inadequate eyelid cover - ectropion
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36
Q

Presentation of keratitis

A 
Painful red eye
Photophobia
Vesicles around eye - herpes
Foreign body sensation
Watering eye
Reduced visual acuity
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37
Q

Complications of keratitis

A 
Stromal keratitis
- inflammation of upper layer of iris
- stromal necrosis
- vascularisation
- scarring
Corneal scarring
Blindness
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38
Q

Ix for keratitis

A

Staining with fluorescein show dendritic corneal ulcer
Slit lamp
Corneal swabs or scrapings - isolate virus

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39
Q

Mx of keratitis

A 
Same day referral to ophthalmologist
Topical/oral acyclovir
Ganciclovir eye gel
Topical steroids - stromal keratitis
Corneal transplant - corneal scarring
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40
Q

Define conjuctivitis

A

Inflammation of cornea

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41
Q

Types of conjunctivitis

A 
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
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42
Q

Presentation of conjunctivitis

A

Red eyes
Bloodshot
Itchy/gritty sensation
Discharge

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43
Q

Mx of conjunctivitis

A 
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
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44
Q

Define corneal abrasion

A

Scratches or damage to cornea

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45
Q

Causes of corneal abrasion

A

Contact lenses
Fingernails
Eyelashes/foreign bodies
Entropion

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46
Q

Presentation of corneal abrasion

A 
Hx of foreign body
Painful red eye
Foreign body sensation
Watering eye
Blurred vision
Photophobia
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47
Q

Ix for corneal abrasion

A

Fluorescein stain - collects in abrasions/ulcers highlighting them
Slit lamp exam

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48
Q

Mx of corneal abrasion

A

Simple analgesia
Lubricating eye drops
Abx eye drops
Follow up in 1 week to check healing

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49
Q

Define hyphema

A

Blood in anterior chamber

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50
Q

Causes of hyphema

A

Trauma
Intraocular surgery
Neovascularisation - due to posterior segment ischaemia
Spontaneous - bleeding disorders, antiplatelets, iris melanoma

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51
Q

Presentation of hyphema

A

Blurred vision
Ocular distortion - kaleidoscope vision
Pain, headache and photophobia is IOP raise

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52
Q

Ix for hyphema

A 
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
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53
Q

Mx of hyphema

A 
Uncomplicated 
- eye shield
- limited activity
- head elevation
Monitor eye closely in first few days - high risk of further bleeding
Avoid NSAIDs
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54
Q

Complications of hyphema

A

Obstruction of trabecular meshwork -> increased IOP
Peripheral anterior synechiae - iris adheres to lens
Posterior synechia - iris adheres to cornea
Corneal bloodstaining
Rebleeding

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55
Q

Define endophthalmitis

A

Inflammation of one or more coats of the eye with contagious cavity inflammation

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56
Q

Causes of endophthalmitis

A

Intraocular surgery
Penetrating trauma
Draining a glaucoma bleb

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57
Q

Types of endophthalmitis

A 
Acute
- staph epidermis
- staph aureus
- strep
- pseudomonas
Chronic
- propionibacterium acnes
- staph epidermis
- fungi
Trauma
- staph epidermis
- strep
- fungi
- gram-neg bacteria
Bled-related
- strep
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58
Q

Prestation of endophthalmitis

A

Very painful red eye

Hypopyon present - leukocytic exudate in anterior chamber of eye

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59
Q

Mx of endophthalmitis

A

Aqueous and vitreous tap
Intravitreal abx - vancomycin
Topical/oral ciprofloxacin

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60
Q

Define cataracts

A

Opacification of the crystalline lens

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61
Q

Causes of cataracts

A 
Normal aging
Smoking
Increased alcohol
Trauma
DM
Long term corticosteroids
Radiation exposure
Myotonic dystrophy
Hypocalcaemia
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62
Q

Presentation of cataracts

A 
Reduced vision
Faded colour vision
Glare - lights appear brighter than usual
Halos around lights
Altered red light reflex
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63
Q

Ix for cataracts

A

Ophthalmoscopy
- normal fundus and optic nerve
Slit lam examination
- visible cataract

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64
Q

Classification of cataracts

A 
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
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65
Q

Mx of cataracts

A 
Non-surgical
- prescribe stronger glasses
- use brighter lights
Surgical
- remove cloudy lens and replace with artificial lens
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66
Q

Stages of cataract removal

A

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

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67
Q

Complications of cataract surgery

A

Posterior capsule opacification - thickening of lens capsule
Retinal detachment
Posterior capsule rupture
Endophthalmitis - inflammation of aqueous /vitreous humour

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68
Q

Define glaucoma

A

Optic nerve damage caused by significant rise in IOP

- secondary to blockage of aqueous humour leaving anterior chamber

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69
Q

Define primary open angle glaucoma

A

Gradual increase in resistance through the trabecular meshwork
- decreasing drainage of aqueous humour
Increased pressure causes cupping of optic disc

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70
Q

Glaucoma screening

A

Annual screening for those over 40 with 1st degree relative that had glaucoma .

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71
Q

Risk factors for primary open angle glaucoma

A

Increasing age
FHx
Black ethnic origin
Nearsightedness (myopia)

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72
Q

Presentation for primary open angle glaucoma

A

Often rise in IOP asymptomatic
Affects peripheral vision first then turns to tunnel vision
Fluctuating pain, headaches, blurred vision and halos around light

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73
Q

Mx of primary open angle glaucoma

A 
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
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74
Q

Side effects of prostaglandin analgogues

A

Eyelash growth
Eyelid pigmentation
Iris pigmentation

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75
Q

Define acute angle closure glaucoma

A

Ophthalmological emergency
Occurs when iris bulges forward and seals off trabecular network
- prevents aqueous humor form draining away
Pressure build up in posterior chamber

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76
Q

Risk factors for acute angle closure glaucoma

A 
Increasing age
Female
FHx
Chinese and east Asian ethnicity
Shallow anterior chamber
Medications
- noradrenaline
- oxybutynin
- amitriptyline
- steroids
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77
Q

Presentation of acute angle closure glaucoma

A 
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
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78
Q

Mx of acute angle closure glaucoma

A 
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
79
Q

Pathophysiology of diabetic retinopathy

A

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

80
Q

Classification of diabetic retinopathy

A

Non-proliferative
- no neovascularisation
Proliferative
- presence of neovascularisation

81
Q

Fundus findings of diabetic eye disease

A 
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
82
Q

Complications of diabetic eye disease

A 
Retinal detachment
Vitreous haemorrhage
Rubeosis iridis - new blood vessel formation in iris
Optic neuropathy
Cataracts
83
Q

Mx of diabetic eye disease

A 
Laser photocoagulation
Anti-VEGR mutations 
- ranibizumab
- bevacizumab
Vitreoretinal surgery
84
Q

Pathophysiology of central retinal vein occlusion

A

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

85
Q

Risk factors for central retinal vein occlusion

A 
Hypertension 
High cholesterol
DM
Smoking
Glaucoma
SLE
86
Q

Presentation of central retinal vein occlusion

A

Sudden painless loss of vision

87
Q

Ix for central retinal vein occlusion

A 
Fundoscopy
- flame and blot haemorrhages
- optic disc oedema
- macular oedema
FBC
- leukaemia
ESR
- inflammatory disorders
BP
BM
88
Q

Mx of central retinal vein occlusion

A 
Referred immediately
Treat macular oedema and prevent neovascularisation
Laser photocoagulation
Intravitreal steroids - dexamethasone
Anti-VEGF therapies
89
Q

Define hypertensive retinopathy

A

Damage to retinal blood vessels relating to systemic hypertension

90
Q

Presentation of hypertensive retinopathy

A

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

91
Q

Classification of hypertensive retinoapthy

A

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
92
Q

Mx of hypertensive retinopathy

A

Controlling BP and other risk factors

93
Q

Define central retinal artery occlusion

A

Branch of ophthalmic artery which arises from internal carotid artery

94
Q

Causes of central retinal artery occlusion

A

Atherosclerosis

Giant cell arteritis -> vasculitis

95
Q

Risk factors for central retinal artery occlusion

A 
Older age
Fhx
Smoking
Alcohol consumption
Hypertension
Diabetes
Poor diet
Inactivity
Obesity
96
Q

Presentation of central retinal artery occlusion

A

Sudden painless loss of vision
RAPD
Pale retina with cherry red spot (macula)

97
Q

Mx of central retinal artery occlusion

A

Refer immediately to ophthalmology
Treat underlying cause
Mx of risk factors

98
Q

Features of age-related macular degeneration

A 
Most common cause of blindness in UK
Two types 
- wet 10%
- dry 90%
Wet carries worse prognosis
99
Q

Pathophysiology of age-related macular degeneration

A

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

100
Q

Risk factors for ARMD

A 
Increasing age
Smoker
White or Chinese ethnic origin
FHx
CVS disease
101
Q

Presentation of ARMD

A

Gradual worsening central visual field loss
Reduced visual acuity
Crooked or wavy appearance of straight lines
Wet presents more acutely

102
Q

Examination features of ARMD

A

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

103
Q

Mx of ARMD

A

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

104
Q

Define posterior vitreous detachment

A

Vitreous humour maintains surface structure of the eye and keeps retina pressed onto choroid
Detachment occurs when vitreous humour comes away from retina

105
Q

Presentation of PVD

A

Painless
Spots of vision
Floaters
Flashing lights

106
Q

Mx of PVD

A

Improves over time as brain adjusts

Predisposes patient to retinal tears and detachment - important to assess retina

107
Q

Define retinal detachment

A

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

108
Q

Risk factors for retinal detachement

A 
Posterior vitreous detachment
Diabetic retinopathy
Trauma to eye
Retinal malignancy
Older age
Fhx
109
Q

Presentation of retinal detachement

A

Sudden peripheral vision loss
Blurred or distorted vision
Flashes and floaters

110
Q

Mx of retinal detachment

A

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

111
Q

Mx of retinal tear

A

Laser or cryotherapy to create adhesions between retina and choroid

112
Q

Define uveitis

A

Inflammation of one or all parts of uvea

  • iris
  • ciliary body
  • choroid
  • retina
113
Q

Types of uveitis

A

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

114
Q

Presentation of anterior uveitis

A 
Pain - burning
Red eye
Blurred vision
Photophobia
Dilated ciliary vessels
Cells in anterior chamber
Headaches 
Keratic precipitates
115
Q

Presentation of posterior uveitis

A 
Floaters
Blurred vision
Photopsia
Vasculitis
Optic disc swelling
116
Q

Ix for uveitis

A 
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 test
117
Q

Mx of uveitis

A

Cycloplegic drops - atropine
- pain relief
- prevent posterior synechiae
Steroid drops

118
Q

Define herpes zoster ophthalmicus

A

Reactivation of varicella zoster virus in the area supplied by the ophthalmic division of CN V

119
Q

Presentation of herpes zoster ophthalmicus

A

Vesicular rash around eye
Hutchinson’s sign
- rash on tip or side of nose indicated nasociliary involvement
- strong risk factor for ocular involvement

120
Q

Mx herpes zoster ophthalmicus

A

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

121
Q

Define giant cell artertis

A

Systemic vasculitis of medium and large arteries

- typically temporal

122
Q

Risk factors for temporal arteritis

A

Female
White
Over 50
Polymyalgia rheumatia

123
Q

Presentation of giant cell arteritis

A 
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
124
Q

Ix for temporal arteritis

A

CRP raised
Temporal artery biopsy - multinucleated giant cells
FBC - normocytic anaemia and thrombocytosis
LFTs - raised ALP
Duplex USS of temporal artery - hypoechoic halo sign

125
Q

Mx of temporal arteritis

A 
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
126
Q

Compilations of temporal arteritis

A 
Early
- visual loss
- stroke
Late
- replases
- steroid side effects
- stroke
- aortitis - leading to aortic aneurysm and aortic dissection
127
Q

Define scleritis

A

Full thickness inflammation of sclera

128
Q

Causes of sclertitis

A 
Not usually infection
Associated with
- RA
- SLE
- IBD
- sarcoidosis
- granulomatosis with polyangiitis
129
Q

Presentation of sclertitis

A 
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
130
Q

Mx of scleritits

A

Consider underlying systemic conditions
NSAIDs
Steroids
Immunosuppression

131
Q

Features of RA

A

Scleritis
Peripheral corneal thinning - perforation
Episcleritis
Keratoconjunctivitis sicca - dry eyes

132
Q

Features of SLE

A 
Scleritis
Peripheral corneal thinning
Eyelid erythema
Keratoconjunctivitis sicca
Retinopathy - primary or secondary due to hypertension
133
Q

Pathophysiology of thyroid eye disease

A

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

134
Q

Stages of thyroid eye disease

A 
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
135
Q

Risk factors for thyroid eye disease

A

Female

Smoking

136
Q

Symptoms of thyroid eye disease

A 
Asymptomatic
Grittiness - superior limbic keratoconjunctivits
Redness
Eyelid swelling
Diplopia
Bulging eyes 
Visual loss
137
Q

Examination findings of thyroid eye disease

A

Lid retraction - due to fibrotic contracture of levator

Lid lag on down gaze

138
Q

Ix for thyroid eye disease

A

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

139
Q

Mx of thyroid eye disease

A

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

140
Q

Define retionblastoma

A

Malignant tumour
Develops from immature cells of retina
45% inherited - mutations of RB1 on chromosome 13

141
Q

Presentation of retinoblastoma

A

Leukocoria - abnormal white reflection from retina
May lack red reflex
Bilateral in 1/3 cases
May develop squint

142
Q

Mx of retinoblastoma

A

Enucleation of eye
Radiotherapy
Chemotherapy

143
Q

Define amblyopia

A

Reduction of corrected visual acuity

144
Q

Define strabismus

A

Misalignment of eyes

Causes amblyopia due to competitive interaction between cortical inputs from both eyes

145
Q

Types of amblyopia

A

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

146
Q

Classification of strabismus

A

Esotropia - convergent squint
Exotropia - divergent squint
Accommodative - focussing on near object results in excessive convergence - completely corrected by glasses
Mixed

147
Q

Mx of stabismus

A

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

148
Q

Causes of congenital cataracts

A

Down’s syndrome
Hypoparathyroidism
TORCH - intrauterine infectsions

149
Q

Mx of congenital cataracts

A

If severe surgery required in early life to allow for normal development
- risk of open angle glaucoma

150
Q

Define retinopathy of premature infants

A

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

151
Q

Mx of retinopathy of prematurity

A

Laser treatment to ablate ischaemic retina

152
Q

Screening for retinopathy of prematurity

A

Babies born

  • less than 32 weeks
  • less than 1500g
153
Q

Key points of neonatal conjunctivitis

A 
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
154
Q

Features of atopic eye disease

A

Peak age onset 20 years

IgE mediated

155
Q

Features of seasonal allergic conjuctivitis

A

Symptoms seasonal and mild
Examination shows small papillae on tarsal conjuctiva
Self-limiting
- antihistamine drops helpful - ketotifen

156
Q

Features of perennial allergic conjuctivitis

A

Mild and may persist all year with seasonal exacerbations
Examination shows small papillae on tarsal conjuctiva
Mx = olopatadine - antihistamine and mast cell stabiliser

157
Q

Features of atopic keratoconjunctivis

A

Severe pain, redness and reduced vision
Examination shows papillae on conjunctiva
- can causing scaring leading to corneal opacification and neovascularisation
Mx = cidofovir

158
Q

Define Horner Syndrome

A

Triad of ptosis, miosis and anhidrosis

Occurs with damage to sympathetic chain

159
Q

Causes of Horners syndrome

A 
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
160
Q

Define Argyll Robertson Pupil

A

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

161
Q

Define Holmes Adies Pupil

A

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

162
Q

Presentation of 3rd nerve palsy

A 
Ptosis
Dilated non-reactive pupil
- carries parasympathetic nerve fibres
Divergent strabismus - down and out
Sparing of pupil suggest microvascular cause
163
Q

Causes of 3rd nerve palsy

A 
Idiopathic
Pupillary sparing - diabetes, hypertension, ischaemia
Tumour
Trauma
Cavernous sinus thrombus
Posterior communicating artery aneurysm
Raised ICP
164
Q

Ix for 3rd nerve palsy

A

BP
BM
CRP
Brain imaging

165
Q

Mx of 3rd nerve palsy

A

Correct BP and glucose
Usually resolves over 4-6 months
May require surgery

166
Q

Features of 4th nerve palsy

A

Leads to paralysis of superior oblique
Diplopia on depression
Abnormal head posture - head tilt and face turn to unaffected eye

167
Q

Causes of 4th nerve palsy

A 
Congenital 
Vascular - diabetes, hypertension
Demyelination
Tumour
Giant cell arteritis
Aneurysm
168
Q

Ix for 4th nerve palsy

A 
Head tilt test - tilting head to ipsilateral side induces upward movement of globe to to unopposed superior rectus action
BP
BM
CRP 
Brain imaging
169
Q

Mx of 4th nerve plasy

A

Correct BP and glucose
Usually resolves in 4-6 months
May require surgery

170
Q

Presentation of 6th nerve palsy

A

Ipsilateral convergent squint
- due to unopposed medial rectus
Horizontal diplopia
Abnormal head posture

171
Q

Define Nystagmus

A

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

172
Q

Features of physiological nystagmus

A

Caloric testing - warm/cold water put in patient’s ear to induce
Gaze evoked - normal to mild nystagmus on extreme left/right gaze

173
Q

Features of congenital nystagmus

A

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

174
Q

Causes of acquired nystagmus

A 
Recent trauma 
Toxicity
- alcohol
- phenothiazines
- Wernicke's encephalopathy
Cerebral disease
- stroke
- MS
- tumour
175
Q

Ix for acquired nystagmus

A

Full physical exam - including neuro
Toxicity screening
Neurological imaging

176
Q

Mx of acquired nystagmus

A

Treatment of any cerebral disease
Botox
Surgery

177
Q

Nystagmus associated with neuro disease

A 
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
178
Q

Define optic neuritis

A

Inflammation of optic nerve

179
Q

Presentation of optic neuritis

A 
Reduced visual acuity
Abnormal visual fields
Peri-orbital pain
RAPD
Poor colour vision
Optic disc swelling
180
Q

Causes of optic neuritis

A 
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
181
Q

Ix for optic neuritis

A 
ESR - exclude GCA
FBC
Visual field test
Vit B12 and folate levels
Autoantibody screen
Orbital and brain imaging if compressive suspected
Temporal artery biopsy
182
Q

Define papilloedema

A

Bilateral disc swelling due to raised ICP

183
Q

Clinical features of papilloedema

A 
Bilateral swollen hyperaemic discs
Disc haemorrhages
Absent venous pulsations at disc
Optic atrophy
Champagne cord appearance if chronic
184
Q

Causes of papilloedema

A

Intracranial tumour
Benign idiopathic hypertension
Meningitis
Brain abscess

185
Q

Ix for papilloedema

A

Urgent CT head
LP
BP

186
Q

Unilateral causes of swollen optic disc

A 
Central retinal vein occlusion
Uveitis
Ocular hypotony
Anterior ischaemic optic neuropathy
Optic disc infiltration
187
Q

Define chiasmal disease

A

Affects junction of optic nerve and optic chiasm

188
Q

Presentation of chiasmal disease

A

Blurred vision
Constricted visual fields - bitemporal hemianopia
Headache
See-saw nystagmus

189
Q

Causes of chiasmal disease

A 
Pituitary tumour
- compress from below
- supero-temporal vision affected first
Meningioma
Craniopharyngioma
190
Q

Red eye DDx

A 
Subjunctival haemorrhage
Blepharitis
Conjunctivitis
Trauma
Keratitis
Iritis
Episcleritis
Scleritis
Primary angle closure
191
Q

Causes of gradual changes in vision

A 
Refractive error
Cataract
Posterior capsule opacification
Age-related macular degeneration
Retinitis pigmentosa
192
Q

Causes of monocular diplopia

A 
Corneal opacity/scarring/oedema
Iris defects
Subluxated natural lens
Decentred artificial intraocular lens
Uncorrected astigmatism
193
Q

Causes of binocular diplopia

A 
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
194
Q

Causes of sudden changes in vision

A

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

Yr4 - Neuro + SS (9 decks)

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