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Opthalmology Flashcards

1
Q

what is the anterior chamber in the eye

A

the space between the cornea and the iris - it is filled with aqueous humour

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2
Q

what is the posterior chamber in the eye

A

it is the space between the iris and the lens - it is filled with aqueous humour

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3
Q

where does aqueous humour get produced and where does it drain?

A

it is produced by the ciliary body and it flows around the lens under the iris, through the anterior chamber, through the trabecular meshwork and into the canal of Schlemm where it enters general circulation

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4
Q

describe the pathophys of open angle glaucoma

A
  • gradual resistance through the trabecular meshwork
  • aqueous humour slowly builds up in anterior and posterior chambers
  • intraocular pressure builds, giving slow and chronic onset of glaucoma
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5
Q

describe the pathophys of acute angle glaucoma

A
  • the iris bulges forward and seals of the trabecular meshwork from the anterior chamber
  • this prevents aqueous humour from draining
  • this is a continual build up of pressure
  • opthalmology emergancy
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6
Q

what happens to the optic nerve in glaucoma

A
  • increased intraocular pressure causes cupping of the optic disc
  • in the centre of a normal optic disc is an optic cup
    • usually less than half the size of the optic disc
  • in glaucoma the optic cup enlarges due to pressure
  • this is called cupping
  • an optic cup greater than 0.5 the size of the optic disc is abnormal
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7
Q

risk factors for open angle glaucoma

A

increasing age

family history

black ethnic origin

nearsightedness (myopia)

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8
Q

presentation of open angle glaucoma

A
  • rise in pressure is asymptomatic for a long time so often diagnosed by routine screening during eye checks
  • affects peripheral vision first gradually until tunnel vision
  • can present with gradual onset of
    • fluctuating pain
    • headaches
    • blurred vision
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9
Q

how do you measure intraocular pressure

A
  • non contact tonometry
    • puff of air
    • less accurate but gives helpful estimate for screening
  • goldmann applanation tonometry
    • gold standard
    • device on end of slip lamp that makes contact with cornea and applies pressure
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10
Q

diagnosis of open angle glaucoma

A

goldmann applanation tonometry

fundoscopy

visual field assessment

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11
Q

management of open angle glaucoma

A
  • prostaglandin analogue eye drops are first line
    • latanoprost
  • other options
    • beta blockers
      • timolol
    • carbonic anhydrase inhibitors
      • dorzolamide
    • sympathomimetics
      • brimonodine
  • trabeculectomy surgery if eye drops are ineffective
    • creates a bleb under the conjunctiva where aqueous humour can be reabsorbed
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12
Q

risk factors for acute angle glaucoma

A

increasing age

female sex

family history

chinese and east asian ethnic origin

rare in black people

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13
Q

which medications can precipitate acute angle-closure glaucoma

A
  • adrenergic medications
    • e.g. noradrenaline
  • anticholinergic medications
    • e.g. oxybutynin
  • tricyclic antidepressants
    • e.g. amitryptyline
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14
Q

presentation of acute angle glaucoma

A

severely painful red eye

blurred vision

halos around lights

associated headache nausea and vomiting

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15
Q

examination findings in acute angle glaucoma

A

red eye

teary

hazy cornea

decreased visual acuity

dilatation of the affected pupil

fixed pupil size

firm eyeball on palpation

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16
Q

initial management of acute closed-angle glaucoma

A
  • ambulance
  • lie patient on back without a pillow
  • pilocarpine eye drops
    • constricts pupil and causes ciliary muscle contraction
    • opens pathway of flow of aqueous humour to trabecular meshwork
  • oral acetazolamide
    • reduces production of aqueous humour
  • analgesia and antiemetic if required
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17
Q

secondary care of acute closed-angle glaucoma

A
  • pilocarpine
  • oral acetazolamide
  • timolol
    • beta blocker reduces production
  • dorzolamide
    • reduces production
  • brimonidine
    • reduces production and increases uveoscleral flow
  • laser iridotomy is usually required
    • makes hole in iris to facilitate flow
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18
Q

what is the most common cause of blindness in the UK

A

age related macular degeneration

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19
Q

what is the key finding seen during fundoscopy in macular degeneration

A

drusen

these are yellow deposits of proteins and lipids

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20
Q

what are the types of age related macular degeneration and which is more common and which has the worse prognosis

A

wet and dry

90% of cases are dry

10% of cases are wet

wet has the worse prognosis

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21
Q

three features common in both wet and dry AMD

A

atrophy of retinal pigment epithelium

degeneration of the photoreceptors

drusen

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22
Q

pathophys of wet amd

A

new vessels grow from choroid layer to the retina

these leak fluid and cause oedema

more rapid loss of vision

caused by vascular endothelial growth factor

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23
Q

risk factors for amd

A

age

smoking

white or chinese ethnic origin

family history

cvd

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24
Q

presentation of AMD

A

gradual worsening of central visual field

reduced visual acuity

crooked or wavy appearance of straight lines

wet can present more acutely with symptoms coming on over days and progress to full vision loss by 2-3 years

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25
Q

amd findings on examination

A

reduced acuity on snellen chart

scotoma (central patch of vision loss)

fundoscopy - drusen

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26
Q

management of dry amd

A
  • no specific treatment
  • manage lifestyle factors
    • avoid smoking
    • control blood pressure
    • vitamin supplementation slows progression
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27
Q

management of wet amd

A
  • anti-vegf medications
    • ranibizumab
    • bevicizumab
    • pegaptanib
  • these injected into vitreous chamber once a month
  • need to be started within 3 months of symptom onset to be beneficial
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28
Q

pathopys of diabetic retinopathy

7 features

A
  • hyperglycaemia leads to damage of the retinal small vessels
  • blot haemorrhages
  • hard exudates of lipids on retina
  • microanueurysms
  • venous beading
    • wein walls no longer straight and look like string of sausages
  • cotton wool spots
    • nerve fibre damage on retina causes these fluffy white patches
  • intraretinal microvascular abnormalities (IMRA)
    • dilated capillaries that act as shunt between arterial and venous vessels
  • neovascularisation
    • due to growth factors
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29
Q

how do you classify diabetic retinopathy broadly

A
  • depending on whether new blood vessels have developed it is either:
    • proliferative
      • neovascularisation
      • vitrious haemorrhage
    • non-proliferative
      • can develop into proliferative
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30
Q

how do you classify non proliferative diabetic retinopathy based on severity

A
  • mild:
    • microaneurysms
  • moderate:
    • microaneurysms
    • blot haemorrhages
    • hard exudates
    • cotton wool spots
    • venous beading
  • severe
    • blot haemorrhages
    • microaneurysms in 4 quadrants
    • venous beading in 2 duadrants
    • IMRA in any quadrant
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31
Q

complications of diabetic retinopathy

A
  • retinal detatchment
  • vitreous haemorrhage
    • bleeding into vitreous humour
  • rebeosis iridis
    • new blood vessel formation in the iris
  • optic neuropathy
  • cataracts
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32
Q

management of diabetic retinopathy

A

laser photocoagulation

anti-vegf medications such as ranibizumab and bevacizumab

vitreoretinal surgery may be required in severe disease

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33
Q

signs associated with hypertensive retinopathy

A
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34
Q

hypertensive retinopathy signs

6 things

A
  • silver wiring or copper wiring
    • walls of arterioles thickened and sclerosed increasing light reflection
  • arteriovenous nipping
    • arterioles compress veins where they cross
  • cotton wool spots
    • ischaemia and infarction of the retina causes damage to nerve fibres
  • hard exudates
    • caused by damaged vessels leaking lipids into the retina
  • retinal haemorrhages
    • damaged vessels rupture
  • papilloedema
    • ischaemia to the optic nerve results in swelling and blurring of the disc margins
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35
Q

what is the classification system for hypertensive retinopathy

A
  • keith wagener classification
    • stage 1: mild narrowing of the arterioles
    • stage 2: focal constriction of blood vessels and AV nicking
    • stage 3: cotton-wool patches exudates and haemorrhages
    • stage 4: papilloedema
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36
Q

risk factors for cateracts

A

increasing age

smoking

alcohol

diabetes

steroids

hypocalcaemia

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37
Q

presentation of cateracts

A
  • symptoms usually asymmetrical as both eyes are affected seperately
    • slow reduction in vision
    • progressive visual blurring
    • starbursts around light
  • loss of red reflex
    • lens appears grey or white when testing red reflex
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38
Q

name a complication of cateract surgery

A

endopthalmitis - inflammation of the inner contents of the eye normally caused by infection

treated with intravitreal abx injected into the eye

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39
Q

causes of mydriasis

A
  • 3rd nerve palsy
  • holmes adie syndrome
  • raised ICP
  • congenital
  • trauma
  • stimulants such as cocaine
  • anticholinergics
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40
Q

causes of miosis

A

horner’s syndrome

cluster headaches

argyll-robertson pupil (neurosyphilis)

opiates

nicotine

pilocarpine

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41
Q

third nerve palsies cause

A

ptosis (supplies levator palpebrae superioris)

dilated non-reactive pupil (contains parasympathetic fibres that innervate sphincter muscles of iris)

divergent strabismus (down and out)

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42
Q

causes of third nerve palsy

A
  • full third nerve palsy (caused by compression therefore referred to as surgical third)
    • idiopathic
    • tumour
    • trauma
    • cavernous sinus thrombosis
    • posterior communicating artery aneurysm
    • raised ICP
  • if pupil is spared it’s because parasympathetic fibres are spared and suggests a microvascular cause
    • diabetes
    • hypertension
    • ischaemia
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43
Q

what is horner’s syndrome

A

ptosis

miosis

anhidrosis

enopthalmos

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44
Q

what causes horner’s syndrome

A
  • damage to the sympathetic nervous system supplying the face
  • depending on the anhidrosis then the location of the damage can be identified
    • central lesions cause anhidrosis of the arm and trunk as well as face
    • pre-ganglionic lesions cause anhidrosis of the face
    • post-ganglionic lesions do not cause anhidrosis
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45
Q

what is the journey of the sympathetic nerves that supply the head

A
  • arise from spinal cord in chest as pre-ganglionic nerves
  • enter sympathetic ganglion at base of neck
  • exit as post-ganglionic nerves
  • post-ganglionic nerves travel to the head running alongside the internal carotid
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46
Q

causes of central, pre and post ganglionic causes of horner’s

and how to remember this

A
  • 4S for Sentral
    • Stroke
    • multiple Sclerosis
    • Swelling (tumours)
    • Syringomyelia (cyst on spinal cord)
  • 4T for Torso (pre-ganglionic)
    • Tumour (pancoast)
    • Trauma
    • Thyroidectomy
    • Top rib (cervical rib growing above the clavicle
  • 4C for Cervical (post-ganglionic)
    • Carotid aneurysm
    • Carotid artery dissection
    • Cavernous sinus thrombosis
    • Cluster headache
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47
Q

what is argyll robertson pupil

A

specific finding in neurosyphilis

constricted pupil that accomodates when focussing nearby object

does not react to light

often irregularly shaped

“accomodates but does not react” made it known as prostitutes pupil also due to it’s relation to syphilis

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48
Q

what is blepharitis

A

inflammation of the eyelid margins - can be associated with dysfunction of the meibomian glands

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49
Q

management of blepharitis

A
  • hot compresses and gentle cleaning
  • lubricating eye drops
50
Q

what is a stye

how are they treated

A
  • hordeolum externum
    • infection of glands of Zeis
      • sebacious glands at the base of eyelashes
    • or infection of glans of Moll
      • sweat glands at the base of the eyelashes
  • hordeolum internum
    • infection of meibomian glands - tend to be deeper
    • may be under eyelid
  • treated with hot compresses and analgesia
  • consider chloramphenicol topically if associated with conjunctivitis or persistent
51
Q
A
52
Q

what is a chalazion

how is it treated

A
  • aka meibomian cyst
  • this is when a meibomian gland becomes blocked and swells up
  • typically not tender but can be tender and red
  • treated with hot compress and analgesia
  • consider chloramphenicol if acutely inflamed
  • rarely, surgical drainage may be necessary
53
Q

what is an entropian

how is it managed

A
  • where eyelid turns inwards with lashes agains eyeball
  • can result in corneal damage
  • initial management
    • tape down to stop it turning inwards
    • essential to use regular lubricating eye drops
  • difinitive management
    • surgery
54
Q

what is an opthalmic ectropian

A
  • eyelid turns outwards with the inner aspectof the eyelid exposed
  • can lead to exposure keratopathy
  • mild cases may not need treatment
  • regular lubricating eye drops may be needed
  • surgery may be needed for severe cases
55
Q

what is trichiasis

A
  • inward growth of eyelashes
  • can lead to corneal damage
  • management by epilation
  • recurrent cases may need electrolysis or laser treatment
56
Q

what is periorbital cellulitis

A
  • skin infection in front of the eye
  • swelling redness and hot skin around the eyelids and eyes
  • treatment with IV or oral abx
    • can develop into orbital cellulitis so vulnerable people may need admission
  • NOT THE SAME AS ORBITAL CELLULITIS which is sight and life threatening
    • CT can be used to differentiate
57
Q

what is orbital cellulitis

A
  • infection around the eyeball that involves the orbital septum
  • medical emergency that requires
    • admission
    • IV antibiotics
    • maybe surgical drainage if there is an abscess
58
Q

how to differentiate orbital and periorbital cellulitis

A
  • orbital cellulitis has these features that periorbital cellulitis does not
    • pain on eye movement
    • reduced eye movement
    • changes in vision
    • abnormal pupil reacctions
    • proptosis
59
Q

what are the three types of conjunctivitis

A

bacterial

viral

allergic

60
Q

causes of painless red eye

A

conjunctivitis

episcleritis

subconjunctival haemorrhage

61
Q

causes of painful red eye

A

glaucoma

anterior uveitis

scleritis

corneal abrasions or ulcerations

keratitis

foreign body

traumatic or chemical injury

62
Q

how long does it normally take conjunctivitis to resolve

A

normally resolves without treatment in 1-2 weeks

63
Q

what is the uvea

A

involves the iris, ciliary body and choroid

64
Q

what is anterior uveitis

A
  • inflammation and immune infiltration of the anterior chamber of the eye
  • usually autoimmune
  • can be acute or chronic
  • chronic is more granulomatous (has more macrophages)
  • chronic if lasting more than 3 months
65
Q

what conditions is acute anterior uveitis associated with

A
  • HLA B27 related conditions
    • ankylosing spondylitis
    • inflammatory bowel disease
    • reactive arthritis
66
Q

chronic anterior uveitis is associated with

A

sarcoidosis

syphilis

lyme disease

tuberculosis

herpes virus

67
Q

anterior uveitis presentation

A
  • dull aching painful red eye
  • pain on movement
  • ciliary flush
  • reduced visual acuity
  • floaters
  • photophobia
  • pain on movement
  • excessive lacrimation
  • hypopyon
    • collection of white blood cells in the anterior chamber
    • seen as yellowish fluid collection settled in front of the lower iris
68
Q

managment of anterior uveitis

A
  • same day assessment by an opthalmologist
    • steroids
    • immunosuppressants
    • DMARDs
69
Q

what is episcleritis

A

benign and self-limiting inflammation of the episclera

70
Q

presentation of episcleritis

A
  • typically not painful but there may be mild pain
  • segmental redness
  • foreing body sensation
  • watering of eye
  • no discharge
71
Q

management of episcleritis

A
  • usually self-limiting and recovers in 1-4 weeks
  • simple analgesia
  • safetynetting advice
72
Q

what is scleritis

A

inflammation of the full thickness of the sclera

more serious than episcleritis

not usually caused by infection

most severe type is called necrotising scleritis which can lead to perforation of the sclera

73
Q

systemic conditions associated with scleritis

A
  • associated systemic condition in around 50% of patients presenting with scleritis
    • rheumatoid arthritis
    • systemic lupus erythematosus
    • inflammatory bowel disease
    • sarcoidosis
    • granulomatosis with polyangiitis
74
Q

presentation of scleritis

A

severe pain

pain with eye movement

photophobia

eye watering

reduced visual acuity

abnormal pupil reaction

tenderness to palpation of the eye

75
Q

if a corneal abrasion is associated with the use of contact lense there may be infection with _______

A

pseudomonas

76
Q

how do you diagnose corneal abrasions

A

fluorescein stain collects in abrasions and ulcers showing up yellow/orange

77
Q

management of corneal abrasions

A

simple analgesia e.g. paracetamol

lubricating eye drops

chloramphenicol eye drops if infection suspected

safetynetting

78
Q

what is keratitis

A

inflammation of the cornea

79
Q

what are the different causes of keratitis

A
  • viral: herpes simplex
  • bacterial: pseudomonas or staphylococcus
  • fungal: candida or aspergillus
  • contact lense acute red eye (CLARE)
  • exposure keratitis
80
Q

what is the most common cause of keratitis

A

herpes simplex keratitis

81
Q

diagnosis of keratitis

A

fluorescein staining will show a dendritic corneal ulcer

slit lamp examination

swabs and scrapings can be used to isolate the virus using viral culture or PCR

82
Q

managment of herpes keratitis

A

aciclovir - topical or oral

ganciclovir eye gel

corneal transplant may be needed after infection has resolved to treat scarring

83
Q

what may cause a subconjunctival haemorrhage

A
  • strenuous activity such as heavy coughing, weight lifting or straining when constipated.
  • can also be caused by trauma to eye
  • most are idiopathic but there are some risk factors to ask about
    • hypertension
    • bleeding disorders (thrombocytopenia)
    • whooping cough
    • medications (warfarin, NOACs, antiplatelets)
    • NAI
84
Q

management of subconjunctival haemorrhage

A

harmless and resolve without any treatment in 2 weeks

investigate any predisposing features

85
Q

what happens in retinal detatchment

A

retina seperates from choroid underneith

usually due to a retinal tear that allows vitreous fluid to get under the retina and fill the space between the retina and the choroid

because the retina relies on the vessels of the choroid for its blood supply this is a sight threatening emergency

86
Q

risk factors for retinal detatchment

A
  • posterior vitreous attachment
  • diabetic retinopathy
  • trauma to the eye
  • retinal malignancy
  • older age
  • family history
87
Q

presentation of retinal detatchment

A

painless

peripheral vision loss - sudden

blurred vision

flashes and floaters

88
Q

management of retinal detatchment

A
  • patients with painless flashes and floaters should have a detailed assessment of the retina by someone with the appropriate skillset
  • three options to reattach retina
    • vitrectomy
      • replace vitreous body with oil or gas
    • scleral bulking
      • silicone buckle in sclera causes outer eye to indent and bring choroid in to meet retina
    • pneumatic retinopexy
      • inject a gas bubble into vitreous body and position so retina flattens against choroid
89
Q

what happens in retinal vein occlusion

A
  • the central retinal vein runs through the optic nerve and is responsible for draining blood from the retina
  • four branches come together to form the central retinal vein
  • thrombosis in of one of these causes problems in that area
  • thrombosis in the central retinal vein causes problems with the whole retina
  • blood will pool in the retina causing:
    • macular oedema
    • retinal haemorrhages
    • VEGF release –> neovascularisation
90
Q

presentation of retinal vein occlusion

A

sudden painless loss of vision

91
Q

risk factors for retinal vein occlusion

A

hypertension

high cholesterol

diabetes

smoking

glaucoma

systemic inflammatory conditions such as SLE

92
Q

diagnosis of retinal vein occlusion

A
  • fundoscopy has characteristic findings:
    • flame and blot haemorrhages
    • optic disc oedema
    • macula oedema
93
Q

management of retinal vein occlusion

A
  • immediate referral to opthalmologist
  • laser photocoagulation
  • intravitreal steroids
    • dexamethasone intravitreal implant
    • anti-VEGF therapies (e.g. ranibizumab, bevacizumab)
94
Q

in diabetic retinopathy, cotton wool spots represent areas of:

A

retinal infarction

95
Q

what are the stages of non-proliferative diabetic retinopathy

A
  • Mild NPDR
    • 1 or more microaneurysm
  • Moderate NPDR
    • microaneurysms
    • blot haemorrhages
    • hard exudates
    • cotton wool spots, venous beading/looping and intraretinal microvascular abnormalities (IRMA) less severe than in severe NPDR
  • Severe NPDR
    • blot haemorrhages and microaneurysms in 4 quadrants
    • venous beading in at least 2 quadrants
    • IRMA in at least 1 quadrant
96
Q

what is the marcus-gunn pupil

A
  • relative afferent pupillary defect
  • the affected and normal eye appear to dilate when the torch is moved from the unaffected eye to the affected eye
  • causes
    • lesion anterior to the optic chiasm
      • retinal detachment
      • optic neuritis
97
Q

what are the pathways of the pupillary light reflex

A
  • afferent
    • retina –> optic nerve –> lateral geniculate body –> midbrain
  • efferent
    • edinger-westphal nucleus (midbrain) –> oculomotor nerve
98
Q

how does glaucoma affect vision

A

starts in the peripheries leading to tunnel vision

acuity can be affected but this is less common

99
Q

young woman with high BMI, headache and visual symptoms:

A

think idiopathic intracranial hypertension

100
Q

eye pain out of proportion with clinical presentation, contact lens and recent freshwater swimming - which is the causative organism

A

acanthamoeba

accounts for 5% of cases

101
Q

what is central scotoma

A

a blind spot in the centre of your vision

102
Q

three diseases associated with optic neuritis

A

MS - most common

diabetes

syphilis

103
Q

what is hutchinson’s sign

A

a shingles rash on the tip or the root of the nose - representing the dermatome of the nasociliary nerve - strongly associated with ocular involvement

104
Q

what test can differentiate episcleritis and scleritis

A

phenylepherine drops blanch conjunctival and episcleral vessels but not scleral ones

therefore if the redness improves after phenylepherine, a diagnosis of episcleritis can be made

105
Q

how is anterior uveitis treated

A

steroid eye drops and cycloplegic eye drops such as atropine

cycloplegic means paralysis of ciliary muscles of eyes

106
Q

bilateral gritty eyes - think:

A

blepharitis

107
Q

is there screening for glaucoma

A

there is a strong hereditary component of glaucoma

those with a first degree relative should have annual screening from the age of 40

108
Q

how do you manage a patient in GP with an organic foreign body in their eye e.g. grass seed

A

refer immediately to opthalmology due to infection risk

109
Q

what are the features of papilloedema

A
  • venous engorgement: usually the first sign
  • blurring of the optic disc margin
  • elevation of optic disc
  • loss of the optic cup
  • Paton’s lines: concentric/radial retinal lines cascading from the optic disc
110
Q

what is papilloedema

A

Papilloedema describes optic disc swelling that is caused by increased intracranial pressure. It is almost always bilateral.

111
Q

causes of tunnel vision

A
  • papilloedema
  • glaucoma
  • retinitis pigmentosa
  • choroidoretinitis
112
Q

4 most common causes of sudden painless loss of vision

A
  • ischaemic/vascular
    • includes:
      • occlusion of central retinal artery
      • occlusion of central retinal vein
  • vitreous haemorrhage
  • retinal detatchment
  • retinal migraine
113
Q

what is hyphema

A

pooling or collection of blood inside the anterior chamber of the eye

114
Q

what is the most serious complication of hyphema

A

blood blicking drainage of aqueous humour and leading to glaucoma

115
Q

what’s mydriasis

A

dilation of the pupil

116
Q

central renal artery occlusion

A
  • sudden unilateral visual loss
  • thromboembolism from atherosclerosis or temporal arteritis
  • features
    • afferent pupillary defect
    • cherry red spot
    • pale retina
117
Q

management of dry armd

A

zinc and anti-oxidant vitamin therapy

that’s it

118
Q

treatment for wet armd

A

anti-VEGF agents such as ranibizumab, bevicizumab and pegaptanib

119
Q

what is hypermetropia

A

long sightedness

120
Q

use the words HYPERMETROPIA and MYOPIA to fill these spaces

acute angle glaucoma is associated with _______

primary open angle glaucoma is associated with _____

A

acute angle glaucoma is associated with HYPERMETROPIA

primary open angle glaucoma is associated with MYOPIA

121
Q
A

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