Opthalmology Flashcards
MILD non-proliferative diabetic retinopathy (NPDR)
1+ microaneurysm
MODERATE NPDR
microaneurysms, blot haemorrhages, hard exudates, cotton wool spots, venous looping
SEVERE NPDR
blot haemorrhages and microaneurysms in 4 quadrants, venous bleeding in 2 quadrants
Proliferative retinopathy
retinal neovascularisation - may lead to vitreous haemorrhages
Diabetic Retinopathy treatment
Control DM and BP
Anti- VEGF injections
Photocoagulation
Diabetic Maculopathy
Macular oedema
Ischaemic maculopathy
Complications of Diabetic Retinopathy
Retinal detachment
Vitreous haemorrhage (bleeding in to the vitreous humour)
Rebeosis iridis (new blood vessel formation in the iris)
Optic neuropathy
Cataracts
Hypertensive retinopathy classification system
Keith-Wagener
Keith Wagener classification grades
Hypertensive Retinopathy
1 - Mild generalized retinal arteriolar narrowing
2 - Definite focal narrowing and arteriovenous nipping
3 - -Signs of grade 2 plus retinal haemorrhages, exudates and cotton wool spots
4 - Severe grade three plus papilledema
Hypertensive retinopathy management
Management is focused on controlling the blood pressure and other risk factors such as smoking and blood lipid levels.
Hypertensive retinopathy signs
Silver wiring Hard exudates Arteriovenous nipping Papilloedema Retinal haemorrhages Cotton wool spots
Congenital cataracts - screening
Red reflex at neonatal examination
Cataracts rf
Increasing age Smoking Alcohol Diabetes Steroids Hypocalcaemia
Cataracts presentation
Very slow reduction in vision
Progressive blurring of vision
Change of colour of vision with colours becoming more brown or yellow
“Starbursts” can appear around lights, particularly at night time
Key sign of cataracts
Loss of red reflex
Distinctive signs - Cataracts vs glaucoma vs macular degeneration
Cataracts - reduced visual acuity, starbursts around light
Glaucoma - peripheral visual loss and halos around lights
Macular degeneration - Central loss of vision and crooked/wavy straight lines
Cataracts management
if needed, artificial lens
Phacoemulsification
What is Endophthalmitis and mx
comp. of cataract surgery - requires intravitreal antibiotics
Types of cataracts
Nuclear - old age
Cortical - wedge shaped spokes
Posterior subcapsular - steroid use
Inv for cataract
slit lamp
Glaucoma definition
optic neuropathy secondary to increased intra-ocular pressure (IOP) (>21mmHg)
open angle Glaucoma ivx
Perimetry
- Slit lamp biomicroscopy “cupping”
- Goldmann tonometry or non-contact Tonometry (pressures)
- Gonioscopy (visualise iridoangle)
OA glaucoma treatment
Prostaglandin analogues like latanoprost (decrease uveoscleral outflow, increased eyelash length)
Beta blockers like timolol (reduced aqueous production, bad for asthmatics)
CO glaucoma risk fators
Dilation, cataracts, hypermetropia
AAC glaucoma treatment
IV acetazolamide (reduce aqueous production) Pilocarpine drops (pupil constrict) Iridotomy (allow flow) Analgesia/antiemetic
Pupil constriction mechanism
Parasympathetic
Acetylcholine (muscarinic receptors)
Oculomotor nerve (third nerve)
Miosis
Pupil dilation mechanism
Sympathetic, adrenaline,
mydriasis
Causes of mydriasis
Third nerve palsy Holmes-Adie syndrome Raised intracranial pressure Congenital Trauma Stimulants such as cocaine Anticholinergic
Causes of Miosis
Horners syndrome Cluster headaches Argyll-Robertson pupil (in neurosyphilis) Opiates Nicotine Pilocarpine
Third Nerve Palsy
Ptosis (drooping upper eyelid)
Dilated non-reactive pupil
Divergent strabismus (squint) in the affected eye.
Causes of a full (surgical) Third Nerve Palsy
Idiopathic Tumour Trauma Cavernous sinus thrombosis Posterior communicating artery aneurysm Raised intracranial pressure
Third nerve palsy sparing pupil causes
Diabetes
Hypertension
Ischaemia
Horner syndrome triad
Ptosis
Miosis
Anhidrosis
Location of lesion in horners
Anhidrosis in face - pre-ganglion
Anhidrosis in face and trunk - central
No anhidrosis - post-glanglionic
Congenital Horner syndrome
heterochromia
Horner’s treatment
adrenalin eye drop
cocaine eyedrop
Holmes Adie Pupil
unilateral dilated pupil that is sluggish to react to light with slow dilation of the pupil following constriction.
post-ganglionic parasympathetic fibres. The exact cause is unknown but may be viral.
Argyll-Robertson Pupil
neurosyphilis. It is a constricted pupil that accommodates
does not react to light
Lubricating eye drops
Hypromellose is the least viscous. The effect lasts around10 minutes.
Polyvinyl alcohol is the middle viscous choice. It is worth starting with these.
Carbomer is the most viscous and lasts 30 – 60 minutes.
Blepharitis
inflammation of the eyelid margins.
comp styes and chalazions.
Stye
Hordeolum externum
Stye Tx
Styes are treated with hot compresses and analgesia. Consider topic antibiotics (i.e. chloramphenicol) if it is associated with conjunctivitis or persistent.
Chalazion
Meibomian cyst
Entropion
Entropion is where the eyelid turns inwards with the lashes against the eyeball.
corneal damage and ulceration.
A same-day referral to ophthalmology is required if there is a risk to sight.
Ectropion
where the eyelid turns outwards
exposure keratopathy
Trichiasis
Trichiasis is inward growth of the eyelashes.
pain and corneal damage and ulceration
Periorbital Cellulitis mx
differentiate it from orbital cellulitis, which is a sight and life threatening emergency. CT scan
Periorbital Cellulitis tx
h systemic antibiotics (oral or IV). Preorbital cellulitis can develop into orbital cellulitis
Orbital Cellulitis presentation and mx
pain on eye movement, reduced eye movements, changes in vision, abnormal pupil reactions and forward movement of the eyeball (proptosis).
admission and IV antibiotics. They may require surgical drainage if an abscess forms.
Painless acute red eye differentials
Painless Red Eye
Conjunctivitis
Episcleritis
Subconjunctival Haemorrhage
Painful acute red eye differentials
Glaucoma Anterior uveitis Scleritis Corneal abrasions or ulceration Keratitis Foreign body Traumatic or chemical injury
Bacterial conjunctivitis treatment
Chloramphenicol and fuscidic acid
neonatal conjunctivitis
Patients under the age of 1 month of age with conjunctivitis need urgent ophthalmology review
gonococcal infection and can cause loss of sight and more severe complications such as pneumonia.
Anterior uveitis acute causes
Acute anterior uveitis is associated with HLA B27 related conditions:
Ankylosing spondylitis
Inflammatory bowel disease
Reactive arthritis
Chronic anterior uveitis is associated with:
Sarcoidosis Syphilis Lyme disease Tuberculosis Herpes virus
Anterior uveitis symptoms
Dull, aching, painful red eye
Ciliary flush
Reduced visual acuity
Floaters and flashes
miosis
Photophobia
Pain on movement
(lacrimation)
Abnormally shaped pupil
hypopyon
Anterior uveitis management
Same day ophthalmologist referral
Steroids (oral, topical or intravenous)
Cycloplegic-mydriatic medications such as cyclopentolate or atropine eye drops.
Immunosuppressants such as DMARDS and TNF inhibitors
Laser therapy, cryotherapy or surgery (vitrectomy) are also options in severe cases.
Episcleritis associations
rheumatoid arthritis and inflammatory bowel disease.
Episcleritis presentation
Typically not painful but there can be mild pain Segmental redness (rather than diffuse). There is usually a patch of redness in the lateral sclera.
Foreign body sensation
Dilated episcleral vessels
Watering of eye
No discharge
Episcleritis management
If in doubt about the diagnosis, refer to ophthalmology.
Episcleritis is usually self limiting and will recover in 1-4 weeks. In mild cases no treatment is necessary. Lubricating eye drops can help symptoms.
Simple analgesia, cold compresses and safetynet advice are appropriate.
More severe cases may benefit from systemic NSAIDs (e.g. naproxen) or topical steroid eye drops.
Scleritis presentation
Severe pain Pain with eye movement Photophobia Eye watering Reduced visual acuity Abnormal pupil reaction to light Tenderness to palpation of the eye
Scleritis management
Consider an underlying systemic condition
NSAIDS (topical / systemic)
Steroids (topical / systemic)
Immunosuppression appropriate to the underlying systemic condition (e.g. methotrexate in rheumatoid arthritis)
Scleritis ass. conditions
Rheumatoid arthritis Systemic lupus erythematosus Inflammatory bowel disease Sarcoidosis Granulomatosis with polyangiitis
Corneal abrasion inv.
fluorescein stain
slit lamp examination
Corneal keratitis causes
Viral infection with herpes simplex
Bacterial infection with pseudomonas or staphylococcus
Fungal infection with candida or aspergillus
Contact lens acute red eye (CLARE)
Exposure keratitis is caused by inadequate eyelid coverage (e.g. eyelid ectropion)
Herpes keratitis presentation
Painful red eye Photophobia Vesicles around the eye Foreign body sensation Watering eye Reduced visual acuity. This can vary from subtle to significa
Herpes keratitis inv
fluorescein will show a dendritic corneal ulcer
Herpes keratitis
Swabs
Herpes keratitis mx
Aciclovir (topical or oral)
Ganciclovir eye gel
Topical steroids may be used alongside antivirals to treat stromal keratitis
A corneal transplant
Subconjunctival Haemorrhage rf
Hypertension
Bleeding disorders (e.g thrombocytopenia)
Whooping cough
Medications (warfarin, NOACs, antiplatelets)
Non-accidental injury
Posterior vitreous detachment presentation
Painless
Spots of vision loss
Floaters
Flashing lights
It is essential to exclude and assess the risk of a retinal tear or detachment with a thorough assessment of the retina
no treatment necessary
Retinal detachment rf
Posterior vitreous detachment Diabetic retinopathy Trauma to the eye Retinal malignancy Older age Family history
Retinal detachment presentation
Peripheral vision loss. This is often sudden and like a shadow coming across the vision.
Blurred or distorted vision
Flashes and floaters
retinal tear management
Laser therapy
Cryotherapy
retinal detachment mx
Vitrectomy
Pneumatic retinopexy
Scleral buckling
Retinal vein occlusion presentation
sudden painless loss of vision.
Retinal vein occlusion fundoscopy
Flame and blot haemorrhages
Optic disc oedema
Macula oedema
Retinal vein occlusion management
Same day referal
Laser photocoagulation
Intravitreal steroids (e.g. a dexamethasone intravitreal implant)
Anti-VEGF therapies (e.g. ranibizumab, aflibercept or bevacizumab
central retinal artery occlusion presentation
sudden painless loss of vision.
relative afferent pupillary defect
Fundoscopy will show a pale retina with a cherry-red spot.
GCA management
Giant cell arteritis is an important potentially reversible cause.
Testing involves an ESR and temporal artery biopsy and treatment is with high dose steroids
Central retinal artery occlusion mx
Ocular massage
Removing fluid from the anterior chamber to reduce intraocular pressure.
Inhaling carbogen (a mixture of 5% carbon dioxide and 95% oxygen) to dilate the artery
Sublingual isosorbide dinitrate to dilate the artery
Retinitis Pigmentosa presentation
night blindness.
They get decreased central and peripheral vision. (peripheral first)
Retinitis Pigmentosa mx
Referral to an ophthalmologist for assessment and diagnosis
Genetic counselling
Vision aids
Sunglasses to protect the retina from accelerated damage
Driving limitations and informing the DVLA
Regular follow up to assess vision and check for other potentially reversible conditions that may worsen the vision such as cataracts
Dry eyes test
Schirmer - filter paper next to conjunctiva
Dry eyes mx
Artificial tears
Episcleritis vs scleritis dx
phenylnephrine drops - blanches in episcleritis
Cranial nerve defects
3rd - unilateral ptosis
fourth - bilateral look to one side
Sixth unilateral adduction
