Opthalmology Flashcards
What would defect be if there is lesion in the optic nerve prior to the optic chiasm
Complete blindness in that eye
What is anatomy of visual nerve pathway
Optic nerve leaves eye going to the optic chiasm
From optic chiasm it goes to the lateral geniculate nucleus via optic tract
From lateral geniculate nucleus it goes to visual cortex via optic radiations
What do you get if lesion in the optic tract
Sided homonymous hemianopia
What is optic nerve function
Carries visual information to the brain
What are 3 main functions of CN 3
Supply the levator palpabrae to lift eyelid
Parasympathetic innervation to constrict eyelid
Control muscles of eye
What muscles in eye does CN 3 innervate
Inferior rectus
Superior rectus
Medial rectus
Inferior oblique
What see in CN 3 palsy
Dilated pupil
Eye down and out
Ptosis
Difference between surgical and medical third nerve palsy in terms of presentation
In surgical you see mydriasis before down and out palsy as parasympathic supply on outside of nerve bundle which will be seen first however in ischaemia it affects centre of bundle first so there is muscle problem before mydriasis
What is function of abducens nerve
Supplies lateral rectus
What get in a 6th nerve palsy
Eye adducted
What is function of trochlear nerve
Supplies superior oblique
What is presentation of 6th nerve palsy
Double vision horizontally on gaze towards affected side
Presentation of 3rd nerve palsy (vision wise)
Multidirectional diplopia
What gives pain in eye with white corneal infiltrate in a contact lens user
Corneal ulcer
Management of corneal ulcer
Moxifloxacin drops
What is in horners syndrome
Miosis
Ptosis
Anhidrosis
Enopthalmos
What is enopthalmos
When eye sinks into socket
How to determine site of lesion in horners
Look at where the anhidrosis is
- on face, arm and trunk= central lesion
- just on face= preganglionic cervical area lesion
- absent= post gangionic carotid area
Causes of central horners
Stroke
MS
Encephalitis
Causes of preganglionic horners
Pancoasts tumour
Thyroidectomy
Cervical rib
Trauma
Causes of postganglionic horners
Carotid artery dissection
Carotid aneurysm
Presentation of vitreous haemorrhage
Seeing floaters
Reddish hue to vision
Sudden painless loss of vision
What is most common cause of vitreal haemorrhage
Proliferative diabetic retinopathy
Painless loss of vision in diabetic
Vitreous haemorrhage
Fundoscopy finding in dry age related macular degeneration
Drusen- lipid and protein debris
Yellow spots in bruchs membrane
Fundoscopy finding in wet age related macular degeneration
Choroidal neovascularisation
Difference in presentation of wet and dry ARMD
Wet can be more acute due to leakage of serous fluid
Main changes in vision seen in ARMD
Usually unilateral
- Difficulty in dark adaptation
- Central vision affected
- Small words appearing blurry
- Straight lines appearing curvy (metamorphopsia)
What do cotton wool spots indicate
Areas of retinal infarction
AKA soft exudate
What are 3 types of diabetic retinopathy
Non-proliferative
Proliferative
Maculopathy
What makes a diabetic retinopathy, proliferative
Presence of retinal neovascularisation
What is diabetic maculopathy
Diabetic changes over macula
- hard exudates
Macula oedema
Management of non-proliferative retinopathy
Regular observation
Severe- panretinal laser photocoagulation
Management of maculopathy
If visual acuity change then intra vitreal vascular endothelial growth factor inhibitor
Management of proliferative retinopathy
Panretinal laser photocoagulation
Intravitreal VEGF inhibitors
Presentation of acute angle closure glaucoma
Severe pain
Reduced visual acuity
Red eyes
Dilated
Haloes
Non reactive
Systemically unwell- abdo pain, nausea
What is used to determine pressure in the ocular
Tonoscopy
What is used to visualise the angle in AACG
Gonioscopy- lens added to slit lamp test
Management of acute angle closure glaucoma
Initial medical treatment- combination of drops including pilocarpine, timolol and brimonidine
IV acetazolamide
Once settled can do peripheral laser iridotomy
What is use of pilocarpine in glaucoma
Parasymphamomimetic- increased outflow of fluid
What is use of timolol in glaucoma
Decreases fluid production
What is use of actazolamide in glaucoma
Reduces secretions
Management of blepharitis
Hot compress
What is holmes adie pupil
Unilateral dilated pupil in women
Slowly reactive to light and accomodation
What is holmes adie syndrome
Holmes adie pupil with contaminant absent ankle and knee reflexes
Risk factors for cataracts
Age
Smoking
Alcohol
Long term steroid use
Presentation of cataracts
Faded colour vision
Glare- bright lights become very bright
Halos around lights
Absent red reflex
How visualise a cataract
Slit lamp examination
Management of cataracts
In early stages to prevent progression improve glasses and contact lens, use brighter lights
To cure it can use surgery which replaces the lens
- only do if severe impairment, impact on life
Most common cause of optic neuritis and 2 other causes
MS
DM and syphilis also causes
How image optic neuritis
MRI of brain and orbits with gadolinium contrast
Management of optic neuritis
IM corticosteroids
MRI of brain and orbits with contrast
Presentation of optic neuritis
Pain on movement of eyes
Scotoma
Relative afferent pupillary defect
Poor discrimination of colours (red desaturation)
What is herpes zoster opthalmicus
Reactivation of herpes zoster in the area supplied by opthalmic division of the trigeminal nerve
Effectively shings of V1
Presentation of herpes zoster opthalmicus
Eruption of vesicular rash around the eyes
Rash can be on top of the nose or side of nose
Management of herpes zoster opthalmicus
Urgent opthal referral
Oral aciclovir for 10 days
Presentation of episcleritis
Acute onset red eye localised to one area
Painless
Lacrimation
Presentation of scleritis
Painful red eye
Lacrimation
Worse when move eye
Violet or blue discolouration of eye
Can get blurred vision
What is scleritis vs episcleritis
Scleritis- Full thickness inflammation of the sclera
Episcleritis- Inflammation of the episclera- a membrane which lies on the sclera
Causes of episcleritis and scleritis versus anterior uveitis
Episcleritis
- RA
- SLE
- Vasculitis
Anterior uveitis
- HLS-B27 conditions
- behcets
- sarcoid
Management of episcleritis and scleritis
Urgent opthal referral
- NSAIDS orally most commonly
- may use steroid drops if refractory
What is keratitis
Inflammation of the cornea
What is conjunctivitis
Inflammation of the conjuntiva which is a layer over the cornea
What are pathogenic causes of keratitis
Bacterial
- staphylococcus
- pseudomona
Acanthamoeba
HSV
What pathogen can cause keratitis in contact lens wearers
Pseudomonas
How can you get acanthamoeba keratitis
Swimming in contaminated water
How can keratitis present
Red eye
Photophobia
Pain
Feel like smt in the eye
Management of keratitis if contact lens wearer
Same day opthal referral
- Stop wearing them until it clears
- Topical quinolone
- cyclopegic
How assess keratitis in a contact lens wearer
Slit lamp test
What is anterior uveitis
Inflammation of the iris
What is a hypopyon
Presence of inflammatory cells and pus in the anterior chamber of the eye
What are cyclopegics
Drugs which dilate the pupil
Antimuscarinic activty- atropine
What is the purpose of cyclopegics
Dilate the pupil which relieves pain and photophobia
Presentation of anterior uveitis
acute onset
ocular discomfort & pain
photophobia
blurred vision
red eye
What is management of anterior uveitis
Urgent opthal referral
- cyclopegics
- steroid eye drops
What is seen in argylle robertson pupil
Small constricted pupils
React to accomadation reflex BUT NOT LIGHT
How does central retinal vein occlusion present
Painless loss of vision in the eye
Widespread haemorrhage present in eye
How does papilloedema appear on fundoscopy
Blurring of optic disc
Paton’s lines: concentric/radial retinal lines cascading from the optic disc (see in picture)
Causes of acute vision loss
Ischaemic
- TIA
- retinal artery occlusion
- retinal vein occlusion
Vitreal haemorrhage
Retinal detachment
Vitreal detachment
Migraine
Sudden loss of vision with curtain coming down
Ischaemic cause
Rfs for vitreous haemorrhage
DM
Anticogulants
What cause of vision loss presents with curtain coming in, seeing spider webs and floaters
Retinal detachment
What cause of sudden vision loss presents with flashing lights
Posterior vitreous detachment
Causes of blepharitis
Seborrheic dermatitis
Staph infections
What is a chalazion
A blocked oil gland which presents as a painless lump
What is a stye
Infection of the root of a hair follicle or oil gland in eyelid
Difference between a chalazion and a stye
Chalazion is painless and firm
Styes due to infection are painful and tender
Viral conjunctivitis causes
Adenovirus most commonly
HSV
VZV
Bacterial conjunctivitis causes
Staph aureus
HIB
Strep pneumoniae
Presentation of viral conjunctivitis
Recent URTI
Red eyes
Clear discharge
Preauricular lymph node swelling
Presentation of bacterial conjunctivitis
Eyes stuck together
Red eyes
Prurulent dishcarge
Management of conjunctivitis
Viral
- reassure
- avoid sharing towels etc
- avoid contact lens
Bacterial
- watch and wait
- chloramphenicol drops if needs be
How does corneal abrasion present
Reduced acuity in eye
Photophobia
Pain
How is corneal abrasion visualised
Using fluorescein in slit lamp test
Management of corneal abrasion
Antibiotic eye drops to cover possible bacterial superinfection
Management of age related macular degeneration
Both require opthal assessment and management
Dry
- vitamin supplementation- High-dose beta-carotene and vitamins C and E alongside zinc are
Wet
- Intravitreal anti-VEGF agents
What is seen here
Hypertensive retinopathy
What is AV nipping
arteriole is seen crossing a venule, which results in the compression of the vein with bulging on either side of the crossing.
What can cause an acute deterioration in dry ARMD
Progression to wet ARMD- get central vision impaired and demarcated red patches on the retina
How to differentiate between central and branch retinal vein occlusion
In central the bleeding would be widespread, in branching it is confined to 1 area
How does herpes keratitis present
Red eye
Pain
Photophobia
Crusted lesions/ulcers on face
What is a dendritic ulcer on cornea
Herpes keratitis
Appears with abnormal shape as opposed to normal corneal ulcers
What factors demonstrate orbital cellulitis
reduced visual acuity
proptosis
pain with eye movements
any visual problem
What acute red eye presents with small, fixed oval pupil, ciliary flush
Anterior uveitis
Presentation of retinal detachment
Floaters and flashing
Painless loss of vision- curtain coming across vision
RAPD
What is management of posterior vitreous detachment
Conservative but requires urgent referral
What is definition of glaucoma
Group of eye diseases which may damage the optic nerve due to increased intraocular pressure
What is first line for primary open angle glaucoma
Laser trabeculoplasty
Which drugs for glaucoma reduce production of aqueous fluid
Carbonic anhydrase inhibitors
Beta blockers
Alpha adrenergic agonists
Which drugs for glaucoma increase outflow of fluids
Muscarinic agonists
Prostaglandin analogues
Alpha agonists
Which acute cause of vision loss presents with poor colour differentiation
optic neuritis
What can cause unilateral papilloedema
Something compressing on optic nerve in that eye like a tumour
GCA
Presentation of open angle glaucoma
Reduced peripheral vision
Reduced acuity
Insidious onset
Which glaucoma drug can increase eyelash length and increase pigmentation in the eye
Prostaglandin analogues
What is entropion vs ectoprion of eyelids
Entropion= in curling of eyelids
Extroption= out curling
What is miopia
Short sightednesss where objects close are clear but those farther away can be very blurry
What is hyperopia
Long sightedness where objects close are blurry but ones far away are clear
How test for refractive errors
Check visual acuity with snellen chart, then use a pin hole occluder to see if this improves the acuity. If improves then requires optician review
What is first investigation for blurred vision
Test visual acuity with a snellen chart then use a pinhole occluder to check if this improves it. If so need glasses so optician review
What is hyphema
Blood in the anterior chamber of the eye
Management of hyphema
Strict bed rest as movement can redistribute blood
What concerned about most in ocular trauma
Orbital compartment syndrome
Presentation of orbital compartment syndrome
Eye pain
Proptosis
Rock hard eyelids
RAPD
Management of orbital compartment syndrome
Urgent canthotomy before even imaging
Where make a slit in skin lateral to the eye
What presents with increased cup to disc ratio
Open angle glaucoma
What is important point to remember with glaucoma and intraocular pressure
Not all patients with glaucoma have raised IOP and vice versa
Presentation of blepharitis
Bilateral most commonly
- grittiness feeling
- eyes sticky in morning
- eyelids swollen
What are gritty eyes
Where feel dry and scratchy
Management of allergic conjunctivitis
Topical anti histamine
Management of herpes keratitis
Topical aciclovir
What presents with a pale retina and a cherry red spot
Central retinal artery occlusion
Features of central retinal artery occlusion
Sudden painless visual loss
RAPD
Cherry red spot on a pale background
What is screening process for glaucoma
If a positive family history then should get annual screening from age 40
If childhood squints are not corrected what does it lead to
Lazy eye (amblyopia)
If when apply gentle pressure to the eye, the injected vessels move, what is the cause
Episcleritis
Differentiating between uveitis and glaucoma
Glaucoma= dilated pupil
Uveitis= small and fixed pupil
What is gold standard investigation for wet ARMD
Fluorescein angiography to visualise neovascularisation
What pathophysiologically does a RAPD suggest
Problem with optic disc/nerve
Patient who has had mydriatic drops recently presents with an acutely painful eye and reduced acuity
Acute angle closure glaucoma
What is a richard gunn pupil
Relative afferent pupillary defect
What is it get a red painful eye with reduced vision after a surgery on the eyes
Endopthalmitis
What causes sudden onset vision loss in a quadrant with floaters
Retinal detatchment
What do if acute red eye but reduced visual acuity
Need to refer to opthal ED as shows cornea involved if visual acuity worse
Main side effect of panretinal laser photocoagulation
Decrease in night vision
Reduction in visual field
What is amsler grid useful for testing
Distortion of line perception in ARMD
Signs on examination of anterior uveitis
Hypophyon- inflam cells and pus in anterior chamber of eye
Miosis from constriction of ciliary muscles
Abnormally shaped pupil
Ciliary flush where redness spreads outwards from the pupil
What is retinitis pigmentosa
Genetic condition resulting in degeneration of the rods in retina which are responsible for nighttime vision and peripheral vision
Retinitis pigmentosa on fundoscopy
Spiculated pattern of increased pigmentation in peripheral retina
Management of vitreal haemorrhage
Refer for urgent eye assessment to rule out coexistent retinal detatchment
Management of retinal tear
Need to re-adhere, can do via laser or cryo therapy
Management of retinal detachment
Vitrectomy- remove vitreal fluid then reinject with air or oil to push retina back
What type of drop is brimonidine
Alpha 2 receptor agonist
Definitive management of acute angle closure glaucoma
Peripheral laser iridotomy once medical management settles acute phase
Rfs for AACG
Pupil dilation- can be from mydriatic drops
Long sighted (hypermetropia)
Management of primary open angle glaucoma
Treat if IOP >24, if less than regular follow-up
1st line- Selective laser trabeculoplasty
2nd line if CI- prostaglandin eye drops like latanoprost
3rd line- beta blocker, alpha agonist or carbonic anhydrase
If not having laser trabeculoplasty for primary open angle glaucoma, what is first line eye drop
prostaglandin eye drops like latanoprost
Main side effect of cataracts surgery
Endopthalmitis
Main sign on examination of cataracts
Loss of red reflex
Bacterial conjunctivitis management
Conservative
If no improvement after 5 days then topical chloramphenicol drops
Herpetic conjuntivitis management
Refer to opthalmologist
Uncomplicated- warm compress and eye drops
Complicated- topical aciclovir
