Opthalmology Flashcards
What are the main symptoms of Horner’s syndrome?
Ptosis
Miosis
Anhidrosis (loss of sweating on one side)
Pseudo-enophthalmos (looks like eye has sunken back into the skull)
What are the main causes of Horner’s syndrome?
Central – stroke, MS, Syringomyelia
Pre-ganglionic – Pancoast tumour (apex of the lung), thyroidectomy, cervical rib
Post-ganglionic – carotid artery dissection (sympathetic nerve plexus formed around the carotid artery), cavernous sinus thrombosis, cluster headaches
Anhydrosis:
(first order neurone): Central - head, arm trunk
(second order neurone): Pre-ganglionic - just on face
(third order neurone): Post-ganglionic - no anhydrosis
What is the normal route for the passage of fluid through the eye (that does not function correctly in glaucoma)?
- The ciliary epithelium produce aqueous humour into the posterior chamber which provides nutrition for the lens
- This then passes through a narrow passage to the anterior chamber and reabsorbed by the trabecular meshwork
- When this drainage system is blocked pressure builds in all chambers of the eye and causes intraocular HTN
- The optic nerve may become damaged, leading to vision loss
What is the normal interocular pressure range?
11-21mmHg
What are the three characteristic examination findings in Glaucoma?
1) High IOP
2) Enlargement of the optic disc cup (cup should be less than half the diameter of the optic disc)
3) Progressive loss of visual fields
1 + 2 + 3 = glaucoma
1 only = ocular hypertension
2 + 3 only = normal pressure glaucoma
How does tunnel vision develop in Glaucoma?
Arcuate scotomas (semi-circles) begin
These join up to produce ring scotomas
These extend to produce tunnel vision
Eventually central vision is lost (visual acuity remains good until very late)
What are the three main investigations for Glaucoma?
- Screening by IOP – tonometry
- Visual fields testing
- Identification by cupping – slit-lamp fundoscopy
What are the medical treatment options in Glaucoma?
Observation (mainly just for ocular hypertension)
Medical: eye drops
• Prostaglandin analogues (latanoprost)
• B-blockers (timolol)
• Carbonic anhydrase inhibitors (dorzolamide)
• Alpha agonists (brimonidine)
What do prostaglandin analogues do and what is the main SE?
o Increase uveoscleral outflow
o SE: increased eyelash length
What do B blockers do in Glaucoma and in who do you need to be careful of prescribing them?
o Reduce aqueous production
o SE: careful in asthmatics + heart block
What are the surgical options for Glaucoma?
- Create a drainage route for aqueous humour, end up with a cystic structure above cornea called a ‘bleb’
- Other: Laser surgery – e.g. laser trabeculoplasty, ciliary body laser, laser iridotomy
In who should you consider screening for Glaucoma and from when?
Those with a positive family history should be screened annually from aged 40 years
RFs for Glaucoma?
age, black, hypertension, FH, myopia
What are the symptoms of a sudden rise in IOP in acute glaucoma?
- Acute loss of vision/blurred (classically with haloes around lights) -> Occurs d/t corneal oedema
- Severe periocular pain
- Nausea + vomiting
What would the pupil look like in acute glaucoma and what would the IOP be?
Fixed and dilated
IOP: 40-80
Would findings would you see on inspection of the eye in glaucoma?
Oval pupil
Loss of the red light reflex
Inability to visualise the fundus (back of the eye)
What is the management of acute angle glaucoma?
Urgent referral to ophthalmology
Analgesics + anti-emetics
Reduce aqueous secretion (acetazolamide PO – carbonic anhydrase inhibitor) and induce pupillary constriction (topical pilocarpine)
What are you at risk of if acute glaucoma is left untreated?
central retinal artery occlusion
Causes of papiloedema?
space-occupying lesion: neoplastic, vascular malignant hypertension idiopathic intracranial hypertension hydrocephalus hypercapnia
What is episcleritis and what are the main symptoms?
Uncommon but not that serious cause of red eye
• Inflammation of episclera (outermost layer of the sclera)
• Often seen with a nodule
• Wedge shape of engorged vessels seen on sclera that can be moved over the sclera
• May get dull ache, NO PAIN
• Acuity usually okay
What causes episcleritis?
No cause found in 70% - complication of a systemic disease in a small proportion
How to treat episcleritis?
Rx symptomatic relief with artificial tears and topical/systemic NSAIDs
What are the symptoms of optic neuritis?
Unilateral vision loss over hrs -> days (central scotoma)
Poor discrimination of colours, red seems ‘washed-out’
Pain worse on eye movements
Relative afferent pupillary defect
What is the treatment of optic neuritis?
high-dose steroids, usually recover in 4-6 weeks
What is the macula for and where in the eye is it found?
part of the retina where visual acuity is at its highest
Found 3mm temporal to the optic disc (2 disc diameters)
What is found in the centre of the macula?
fovea centralis (containing only cone photoreceptors)
RFs for macular degeneration?
AGE ++ , DM, smoking, CVD, FH, cataracts surgery
What does good visual acuity rely on?
- Functioning photoreceptors
- Healthy retinal pigment epithelium (RPE)
- Choroid perfusion by capillaries
What occurs in and are the symptoms of dry macular degeneration?
ATROPHY of RPE, choroid and retina
Patient develops central scotoma
Patient retains good peripheral vision
What occurs in wet macular degeneration?
Choroidal neo-vascularisation Leaking vessels below retina Localised retinal detachment which leads to distorted central vision and eventually a central scotoma Exudates and haemorrhage Retinal scarring
What are the symptoms of wet macular degeneration?
Patients notice a more rapid change in vision – objects become distorted or smalling in size (micropsia). Patients are given a grid in clinic to take home + keep looking at and to return if the grid changes at all. Amsler grid.
Also poor night time vision
May notice flickering lights/halos
Symptoms fluctuate day to day
Investigations in macular degeneration?
Slit-lamp - to look at back of eye
Fluorescein angiography - to see if new vessels
What is the management of wet macular degeneration?
Reversible if you act promptly, but carries a worse prognosis than dry
Intravitreal injections (monthly) of anti-VEGF are now standard treatment for wet AMD
Laser photodynamic therapy can be used by caries risks
Provide glasses etc
Treatment for dry macular degeneration?
For dry: stop smoking, balanced diet, beta carotene, Vit C + E, zinc
GP: ‘Stop smoking, BCEZ you’ll be seeing the specialist in a week’
Beta-carotine in smokers increases your risk of lung cancer
What is the most common cause of blindness in the UK?
Age-related macular degeneration
What causes retinal detachment and what occurs when the retina detaches?
When the retina detaches it takes its blood supply with it
Most retinal breaks are caused by posterior vitreous detachment, or trauma
What are the symptoms of retinal detachment?
Symptoms of vitreous detachment often occur first –
• Flashing lights
• Floaters (fine dots, cobwebs, veils)
When the retina detaches, patients usually describe a dark “curtain” coming across
- Can take hours-weeks for curtain to cover full vision
- Painless
May also see retinal tears on fundoscopy (holes with bright red choroid shining through)
What would you see on examination of the eye in retinal detachment?
- Loss of red reflex
- Retinal detachment near the macula can be seen
- Detached retina may be pale, opaque + wrinkled with absent normal choroidal pattern
May see relative afferent pupillary defect
What is the management of retinal detachment?
Immediate referral
Surgical repair is the only Tx option: laser photocoagulation or cryotherapy
Three most common causes of vitreous haemorrhage?
Proliferative diabetic retinopathy
Posterior vitreous detachment
Ocular trauma (most © cause in children)
What are the symptoms of vitreous haemorrhage?
Painless vision loss or haze
Red hue in the vision
Floaters or shadows/dark spots
How to investigate a vitreous haemorrhage?
Dilated fundoscopy – may be able to visualise the haemorrhage
Slit-lamp exam – RBCs in the anterior vitreous
USS – useful to rule out retinal tear/detachment
Fluorescein angiography – to identify neovascularisation
Orbital CT – used if open global injury
Treatment of vitreous haemorrhage?
Can spontaneously resolve, but if large may need surgery – photocoagulation
Symptoms specific to posterior vitreous detachment?
Sudden appearance of floaters (occasionally a ring of floaters temporal to central vision)
Flashes of light
Blurred vision
Cobweb across vision
Management of posterior vitreous detachment?
All patients with suspected vitreous detachment should be examined by an ophthalmologist within 24hours to rule out retinal tears or detachment
Mx – symptoms will improve over 6m
No permanent vision loss
If there are retinal tears/detachment, need Tx
What is Holmes-Adie pupil?
Benign condition, more common in women
Causes one dilated pupil
Symptoms of Holmes-Adie pupil?
unilateral in 80% of cases
dilated pupil
once the pupil has constricted it remains small for an abnormally long time
slow to accommodation
very poorly (if at all) reactive to light
Affected pupil is initially larger -> then becomes smaller over time and remains constricted
What other clinical finding on examination is associated with Holmes-Adie pupil?
absent ankle/knee reflexes
What are the possible causes of conjunctivitis?
Viral –
• Adenovirus ©, HSV, Herpes zoster ophthalmicus, molluscum contagiosum
Bacterial –
• Staphlococcus, strep. Pneumoniae, H. influenzae, Chlamydial
Allergic © –
• Seasonal allergic conjunctivitis (recurring at the same time of the year)
• Perennial allergic conjunctivitis (daily, often on waking)
• Giant papillary conjunctivitis (often in those wearing contact lenses or following eye surgery)
• Contact dermatoconjunctivitis (associated with use of eye drops)
Infestation – E.g. Lice
What are the symptoms of conjunctivitis?
• Red eye (often bilateral, usually generalised)
• Irritation, grittiness and discomfort
• Discharge
(Photophobia: suggests corneal involvement)
What are the causes of anterior uveitis?
- Idiopathic
- Autoimmune – HLA B27, chronic Reiter’s disease, sarcoidosis, UC, crohns, juvenile rheumatoid arthritis
- Infections – syphilis, TB, herpes simplex
- Malignancy – retinoblastoma, leukaemia, lymphoma
- Other – trauma, retinal detachment
What are the symptoms of anterior uveitis?
- Unilateral red eye
- Pain/photophobia
- POORLY REACTIVE pupil (d/t iris adhesion to the anterior lens)
Hypophon may be seen
Horner’s syndrome - which are first, second and third order neurones?
First - travels from the brain to the spinal cord
Second - from the spinal cord to the ganglion
Third - from the ganglion to the eye
What eye drops are used and what will happen in first, second and third order neurone dysfunction causing corners syndrome?
A normal pupil is dilated by cocaine and hydroxyamphetamine
In Horner’s:
4% cocaine eyedrops fail to dilate the pupil
Central + pre-ganglionic lesions (first and second order) hydroxyamphetamines cause dilation
Post-ganglionic lesions (third order) adrenaline causes dilation
Symptoms of central retinal vein occlusion?
Sudden painless vision loss
Treatment of central retinal vein occlusion?
Anti-VEGF, then dexamethasone implants (to treat the swelling)
Photocoagulation to prevent/treat neovascularisation
Symptoms of central retinal artery occlusion?
Cherry red spots in the macula
Sudden complete loss of vision
Treatment of central retinal artery occlusion?
drop IOP with acetazolamide
vigorous ocular massage
Manage with stroke protocols
What is seen on fundoscopy in optic atrophy?
pale, well demarcated disc
Usual symptom of optic atrophy?
usually bilateral and causes a gradual loss of vision
Which conditions are associated with optic atrophy?
MS papilloedema (longstanding) raised IOP (e.g. glaucoma, tumour) retinal damage ischaemia toxins: tobacco amblyopia, quinine, methanol, arsenic, lead nutritional: vitamin B1, B2, B6 and B12 deficiency B+Q MALT
What is a Marcus-Gunn pupil?
Relative afferent pupillary defect
When light is shone into the affected size (and the normal side is in the dark) - both pupils dilate
What will you see in an Argyll-Robinson pupil and what are the two main causes?
Will accommodate but not react
caused by neurosyphilis and DM
What is the mode of the action of pilocarpine and what type of receptor does it work at?
Muscarinic receptor agonist
Constricts the pupil - increased uveoscleral flow
Name two examples of anti-VEGF?
Bevacizumab, ranibizumab
What is the journey of the afferent nerve used in pupillary light reflex?
retina → optic nerve → lateral geniculate body → midbrain
What is the journey of the efferent nerve used in pupillary light reflex?
Edinger-Westphal nucleus (midbrain) → oculomotor nerve to the pupil
Two main symptoms of retinitis pigmentosa?
Night blindness
Tunnel vision
What causes blepharitis?
Meibomian gland dysfunction
Seborrheic dermatitis
Staph infection
What are the symptoms for blepharitis?
Bilateral
Grittiness and discomfort
Red eyelid margins
Eyes may be sticky in the morning
Management of blepharitis?
Lid hygiene
Warm compress
Artificial tears
What is the role of VEGF?
promotes new vessel growth + proliferation, also makes them leaky
Therefore anti-VEGF works to prevent this
Causes of cataracts?
- Increasing age (usual onset from 5th decade)
- Sunlight
- Diabetes, Downs
- Smoking/alcohol, steroid-use, hypocalcaemia
Visual symptoms experienced with cataracts?
- Reduced vision
- Faded colour vison
- Glare – bright lights
- Haloes around lights
Complications and prognosis of cataracts?
sight-threatening = endophthalmitis (inflammation within the eye), retinal detachment/tear, choroidal haemorrhage
© intra-operative complication = posterior capsule rupture with vitreous loss
© post-operative complication = posterior capsule opacification, intraocular lens dislocation
• Outcome: 92% pts attain best-corrected visual acuity (BCVA) >6/12 within 3 months
What is a hypophon?
Seen in the anterior of the eye
Collection of WBCs
Symptoms of keratitis?
Painful, red eye
Foreign body sensation
Photophobia
Hypophon may be seen
Treatment of keratitis?
Don’t wear your contacts
Topical abx
Complications of keratitis?
Corneal scarring
Perforation
Endophthalmitis
Visual loss
What might you see on inspection in herpetic keratitis?
Dendritic pattern under blue light
RFs for central retinal vein occlusion?
increasing age
glaucoma
polycythaemia
Two drug classes/types that may precipitate acute angle glaucoma?
anticholinergics and tricyclic antidepressants
What is Herpes zoster ophthalmicus (HZO)?
describes the reactivation of the varicella-zoster virus in the area supplied by the ophthalmic division of the trigeminal nerve. It accounts for around 10% of case of shingles.
What is Hutchinson’s sign?
Rash on the tip or side of the nose seen in herpes zoster ophthalmicus. Indicates nasociliary involvement and is a strong risk factor for ocular involvement
Management of Herpes zoster ophthalmicus (HZO)?
PO antiviral
Topical steroids may be used if eye involvement and needs urgent ophthalmology review
What is herpes zoster oticus?
Ramsay Hunt syndrome (herpes zoster oticus) is caused by the reactivation of the varicella zoster virus in the geniculate ganglion of the seventh cranial nerve.
Symptoms of Ramsay Hunt syndrome?
auricular pain is often the first feature
facial nerve palsy
vesicular rash around the ear
other features include vertigo and tinnitus
Treatment of Ramsay Hunt syndrome?
oral aciclovir and corticosteroids are usually given
What causes diabetic retinopathy?
a multifocal disease of the retinal microvasculature – multiple abnormalities occur in small retinal arteries (haemorrhages/new vessel formation)
What is the prevalence of diabetic retinopathy in T1 and T2?
In T1, retinopathy is rare at Dx but present in >90% after 15yrs
In T2, retinopathy is present in 20% at Dx but only 60% after 15yrs
What might you see on fundoscopy?
Microaneurysms, exudates, cotton wool spots, haemorrhages
Neovascularisation
Macular oedema
What is the main case of severe sight loss in diabetic retinopathy?
Diabetic maculopathy (damage to macula)
What might be seen in non-proliferative diabetic retinopathy and how to treat?
- Microaneurysms
- Small haemorrhages (flame shaped)
- Hard exudates
- Cotton wool spots
- Microinfarcts – interrupted axon flow at site of microvascular occlusion
- Venous beading/loops
Ranges from mild -> severe
Tx: Regular review
if severe/very severe consider panretinal laser photocoagulation
What might be seen in proliferative diabetic retinopathy and how to treat?
• Retinal neovascularisation
Tx:
Anti-VEGF therapies intravitreal
For oedema = steroids
Laser photocoagulation
Causes of sudden vision loss?
Ischaemic/vascular – often amaurosis fugax (vision disappears and then returns) Central retinal artery occlusion Central retinal vein occlusion Vitreous haemorrhage Retinal detachment
Hypertensive retinopathy stages 1-4?
1 – arteriolar narrowing + tortuous vessels, increased light reflex (silver wiring)
2 – arteriovenous nipping (a small artery crosses a small vein -> compression of the vein and bulging either side)
3 – cotton-wool exudates (when axons become damaged and leak fluid), flame and blot haemorrhages
4 – papilledema
Treatment of conjunctivitis?
Viral – most cases are self-limiting and resolve in 1-2 weeks
• Chloramphenicol eye drops – may be used to prevent secondary bacterial infections
• Oral aciclovir – in herpes simplex + varicella zoster
Bacterial – often self-limiting
• General measures – personal hygiene, saline irrigation
• Antibiotics – chloramphenicol, bd for 5 days
Allergic –
• Avoid allergen if known
• Topical antihistamines (not oral) – e.g. antazoline
• Oral corticosteroid therapy – in severe cases with no diagnostic uncertainty
Difference between acute vs chronic anterior uveitis?
Acute – often non-granulomatous
• Characterised by pain, photophobia, redness, lacrimation
Chronic – characterised by granulomata (can get acute exacerbations on top)
• Often white (Alice’s friends Ellie has this)
Treatment of anterior uveitis?
Needs an urgent ophthalmology review
Symptom relief: Systemic analgesics + dark glasses for photophobia
Infectious causes – Tx with antiviral or antimicrobial agents
Non-infectious causes – corticosteroids
Mydriatic (dilating)/cycloplegic agents – can be used to relieve pain and prevent adhesion
Immunosuppressants may be recommended if not responding to above
