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Opthalmology Flashcards

1
Q

features of acute angle closure glaucoma

A

severe pain: may be ocular or headache
decreased visual acuity
symptoms worse with mydriasis
hard, red-eye
haloes around lights
semi-dilated non-reacting pupil
corneal oedema results in dull or hazy cornea

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2
Q

causes of acute angle closure glaucoma

A

raised intraocular pressure (IOP) secondary to an impairment of aqueous outflow:

hypermetropia (long-sightedness)
pupillary dilatation
lens growth associated with age

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3
Q

management of acute angle closure glaucoma

A

emergency - urgent ophthalmologist referral

must lower IOP

eye drops
direct parasympathomimetic (pilocarpine) to contract ciliary muscle
beta blocker - timolol to reduce aq humor production
alpha2 agonist -

IV acetazolamide - reduce aq secretions

laser peripheral iridotomy - creates hole in peripheral iris

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4
Q

risk factors for age-related macular degeneration

A

advancing age
smoking
family history
increased risk of ischaemic cardiovascular disease, such as hypertension, dyslipidaemia and diabetes mellitus.

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5
Q

pathophysiology of age related macular degeneration

A

most common cause of blindness in the UK

bilateral degeneration of the central retina (macula)

ARMD is characterised by degeneration of retinal photoreceptors - results in the formation of drusen which can be seen on fundoscopy and retinal photography

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6
Q

features of dry macular degeneration

A

90% of cases
also known as atrophic
characterised by drusen - yellow round spots in Bruch’s membrane

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7
Q

features of wet macular degeneration

A

10% of cases
also known as exudative or neovascular macular degeneration
characterised by choroidal neovascularisation
leakage of serous fluid and blood can subsequently result in a rapid loss of vision
carries the worst prognosis

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8
Q

presentation of age related macular degeneration

A

subacute visual loss with reduced visual acuity - gradual (dry) and subacute (wet)
poor dark adaptation, poor night vision
fluctuant visual disturbance
photopsia
visual hallucinations - charles bonnet syndrome

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9
Q

investigation findings in age related macular degeneration

A

distorted line perception on amsler grid testing
fundoscopy - drusen, yellow areas of pigment deposition in the macular
wet ARMD - well demarcated red patches - intra retinal / sub retinal fluid leakage or haemorrhage

slit-lamp microscopy - identify any pigmentary, exudative or haemorrhagic changes affecting the retina

fluorescin angiography - can guide anti VEGF

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10
Q

treatment of age related macular degeneration

A

zinc + vitamins ACE

anti-VEGF vascular endothelial growth factor
4 weekly injection

laser photocoagulation if new vessel formation present

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11
Q

features of allergic conjunctivitis

A

Bilateral symptoms conjunctival erythema, conjunctival swelling (chemosis)
Itch is prominent
the eyelids may also be swollen
May be a history of atopy
May be seasonal (due to pollen) or perennial (due to dust mite, washing powder or other allergens)

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12
Q

management of allergic conjunctivitis

A

first-line: topical or systemic antihistamines
second-line: topical mast-cell stabilisers, e.g. Sodium cromoglicate and nedocromil

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13
Q

features of anterior uveitis

A

inflammation of the anterior portion of the uvea - iris and ciliary body

acute onset painful red eye
pupil may be small +/- irregular due to sphincter muscle contraction
photophobia (often intense)
lacrimation
ciliary flush: a ring of red spreading outwards
hypopyon; describes pus and inflammatory cells in the anterior chamber
impaired visual acuity and blurriness

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14
Q

associated conditions with anterior uveitis

A

ankylosing spondylitis
reactive arthritis
ulcerative colitis, Crohn’s disease
Behcet’s disease
sarcoidosis: bilateral disease may be seen

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15
Q

management of anterior uveitis

A

urgent review by ophthalmology
cycloplegics (dilates the pupil which helps to relieve pain and photophobia) e.g. Atropine, cyclopentolate
steroid eye drops

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16
Q

features of argyll robertson pupil

A

Accommodation Reflex Present (ARP) but Pupillary Reflex Absent (PRA)

small, irregular pupils
no response to light but there is a response to accommodate

due to diabetes and syphilis

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17
Q

causes of blepharitis

A

meibomian gland dysfunction (common, posterior blepharitis)

seborrhoeic dermatitis/staphylococcal infection (less common, anterior blepharitis)

common in pt with rosacea

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18
Q

features of blepharitis

A

symptoms are usually bilateral
grittiness and discomfort, particularly around the eyelid margins
eyes may be sticky in the morning
eyelid margins may be red. Swollen eyelids may be seen in staphylococcal blepharitis
styes and chalazions are more common in patients with blepharitis
secondary conjunctivitis may occur

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19
Q

management of blepharitis

A

hot compresses twice a day

‘lid hygiene’

artificial tears

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20
Q

causes of blurred vision

A

refractive error: most common
cataracts
retinal detachment
age-related macular degeneration
acute angle closure glaucoma
optic neuritis
amaurosis fugax

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21
Q

testing for blurred vision

A

visual acuity with a Snellen chart
if the blurring improves with a pinhole occluder then likely cause is a refractive error
visual fields
fundoscopy

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22
Q

causes of cataract

A

lens of the eye gradually opacifies

Normal ageing process: most common cause
Smoking, alcohol
Trauma
Diabetes mellitus
Long-term corticosteroids
Radiation exposure
Myotonic dystrophy
Metabolic disorders: hypocalcaemia

more common in women

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23
Q

presentation of cataracts

A

a gradual onset of:
Reduced vision
Faded colour vision: making it more difficult to distinguish different colours
Glare: lights appear brighter than usual
Halos around lights

defective red reflex - due to cataracts preventing light from getting to the retina

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24
Q

classification of cataracts

A

Nuclear: change lens refractive index, common in old age
Polar: localized, commonly inherited, lie in the visual axis
Subcapsular: due to steroid use, just deep to the lens capsule, in the visual axis
Dot opacities: common in normal lenses, also seen in diabetes and myotonic dystrophy

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25
Q

management of cataracts

A

surgery - to remove cloudy lens and replace with artificial one

consider side effects
Posterior capsule opacification: thickening of the lens capsule
Retinal detachment
Posterior capsule rupture
Endophthalmitis: inflammation of aqueous and/or vitreous humour

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26
Q

features of central retinal artery occlusion

A

rare cause of sudden unilateral visual loss - due to thromboembolism or arteritis

sudden, painless unilateral visual loss
relative afferent pupillary defect
‘cherry red’ spot on a pale retina

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27
Q

features of central retinal vein occlusion

A

sudden, painless reduction or loss of visual acuity, usually unilaterally

fundoscopy
widespread hyperaemia
severe retinal haemorrhages - ‘stormy sunset’

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28
Q

features of branch retinal vein occlusion

A

when a vein in the distal retinal venous system is occluded and is thought to occur due to blockage of retinal veins at arteriovenous crossings - more limited area of fundus is affected

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29
Q

management of central retinal vein occlusion

A

conservative

indications for treatment - macular oedema - antiVEGF
retinal neovascularisation - laser photocoagulation

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30
Q

indications for referral to ophthalmology in corneal foreign body

A

suspected penetrating eye injury due to high velocity injury
significant orbital/periocular trauma
chemical injury (irrigate 20-30min before referring)
organic material
neare centre of cornea
red flags e.g. severe pain; irregular, dilated or non-reactive pupils; significant reduction in visual acuity.

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31
Q

risk factors and causes of corneal ulcers

A

defect in cornea 2* to infective cause (usually)

RF - contact lenses, vitamin A deficiency

abacterial keratitis
fungal keratitis
viral keratitis: herpes simplex, herpes zoster - may lead to a dendritic ulcer
Acanthamoeba keratitis: associated with contact lens use

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32
Q

features of corneal ulcers

A

eye pain
photophobia
watering of the eye
focal fluorescein staining of the cornea

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33
Q

pathophysiology of diabetic retinopathy

A

damage to cells due to increased blood flow and abnormal metabolism in retinal vessel walls –> increased vascular permeability - exudates on fundoscopy

can be non-proliferative or proliferative

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34
Q

features of non-proliferative diabetic retinopathy

A

microaneurysms
blot haemorrhages
hard exudates
cotton wool spots ‘soft exudates’ - retinal infarction

severe NPDR
blot haemorrhages and microaneurysms in 4 quadrants
venous beading in at least 2 quadrants
IRMA in at least 1 quadrant

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35
Q

features of proliferative diabetic retinopathy

A

retinal neovascularisation - may lead to vitrous haemorrhage

fibrous tissue forming anterior to retinal disc
more common in Type I DM, 50% blind in 5 years

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36
Q

management of diabetic retinopathy

A

optimise glycaemic control, blood pressure and hyperlipidemia
regular review by ophthalmology

Non-proliferative retinopathy
regular observation
if severe/very severe consider panretinal laser photocoagulation

Proliferative retinopathy
panretinal laser photocoagulation
intravitreal VEGF inhibitors - if change in visual acuity
severe or vitreous haemorrhage: vitreoretinal surgery

37
Q

pathophysiology of episcleritis

A

acute onset of inflammation in the episclera of one or both eyes

usually idiopathic
inflammatory bowel disease
rheumatoid arthritis

38
Q

features of episcleritis

A

red eye
50% bilateral
mild pain/irritation
watering and mild photophobia may be present

episcleritis - injected vessels are mobile when gentle pressure - blanched by phenylephrine
scleritis - vessels are deeper, dont move

39
Q

common eyelid problems

A

blepharitis: inflammation of the eyelid margins typically leading to a red eye

stye: infection of the glands of the eyelids

chalazion (Meibomian cyst)

entropion: in-turning of the eyelids

ectropion: out-turning of the eyelids

40
Q

types of stye

A

external (hordeolum externum): infection (usually staphylococcal) of the glands of Zeis (sebum producing) or glands of Moll (sweat glands)

internal (hordeolum internum): infection of the Meibomian glands. May leave a residual chalazion (Meibomian cyst)

41
Q

common presentations of herpes simplex keratitis

A

dendritic corneal ulcer

Features
red, painful eye
photophobia
epiphora
visual acuity may be decreased
fluorescein staining may show an epithelial ulcer

42
Q

management of herpes simplex keratitis

A

immediate referral to an ophthalmologist
topical aciclovir

43
Q

features of herpes zoster ophthalmicus

A

Herpes zoster ophthalmicus (HZO) - reactivation of the varicella-zoster virus in the area supplied by the ophthalmic division of the trigeminal nerve

vesicular rash around the eye - may involve the actual eye itself
Hutchinson’s sign: rash on the tip or side of the nose. Indicates nasociliary involvement and is a strong risk factor for ocular involvement

44
Q

management of herpes zoster ophthalmicus

A

oral antiviral treatment for 7-10 days

start <within 72 hours
IV antivirals if severe or immunocompromised

topical corticosteroids - to treat any secondary inflammation of the eye

ocular involvement requires urgent ophthalmology reviewV

45
Q

features of holmes-adie pupil

A

benign condition in females - unilateral dilated pupil
slowly reactive to accomodation

46
Q

features of horner’s sydrome

A

miosis (small pupil)
ptosis
enophthalmos* (sunken eye)
anhidrosis (loss of sweating one side)

47
Q

sites of lesions causing horners and subsequent effects

A

central lesions - anhidrosis of face, arm, trunk
stroke, syringomyelia, MS
tumour, encephalitis

pre-ganglionic - anhidrosis of face
pancoast tumour, thyroidectomy, trauma, cervical rib

post-ganglionic lesions - no anhidrosis
carotid artery/aneurysm, cavernous sinus thrombosis, cluster headache

48
Q

classification of hypertensive retinopathy

A

I Arteriolar narrowing and tortuosity
Increased light reflex - silver wiring

II Arteriovenous nipping

III Cotton-wool exudates
Flame and blot haemorrhages
These may collect around the fovea resulting in a ‘macular star’

IV Papilloedema

49
Q

bacterial vs viral conjunctivitis

A

common eye problem- sore, red eyes with sticky discharge

Bacterial conjunctivitis Purulent discharge
Eyes may be ‘stuck together’ in the morning)

Viral conjunctivitis Serous discharge
Recent URTI
Preauricular lymph nodes

50
Q

management of infective conjunctivitis

A

normal self-limiting condition
topical antibiotic therapy e.g., chloramphenicol

topical fusidic acid for women

51
Q

causes of keratitis

A

inflammation of the cornea

bacterial - Staphylococcus aureus, Pseudomonas aeruginosa in contact lens wearers

fungal

amoebic - acanthamoebic keratitis

parasitic: onchocercal keratitis (‘river blindness’)

viral - herpes simplex keratitis

environmental - photokeratitis, exposure keratitis, contact lens acute red eye

52
Q

clinical features of keratitis

A

red eye: pain and erythema
photophobia
foreign body, gritty sensation
hypopyon may be seen

53
Q

management of keratitis

A

stop using contact lenses
topical antibiotics - quinolones
cycloplegic - for pain relief

54
Q

causes of mydriasis

A

third nerve palsy
Holmes-Adie pupil
traumatic iridoplegia
phaeochromocytoma
congenital

topical mydriatics: tropicamide, atropine
sympathomimetic drugs: amphetamines, cocaine
anticholinergic drugs: tricyclic antidepressants

55
Q

features of nasolacrimal duct obstruction

A

most common cause of a persistent watery eye in an infant.

It is caused by an imperforate membrane, usually at the lower end of the lacrimal duct.

Around 1 in 10 infants have symptoms at around one month of age

56
Q

causes of optic neuritis

A

multiple sclerosis: the commonest associated disease
diabetes
syphilis

57
Q

features of optic neuritis

A

unilateral decrease in visual acuity over hours or days
poor discrimination of colours, ‘red desaturation’
pain worse on eye movement
relative afferent pupillary defect
central scotoma

58
Q

management of optic neuritis

A

high-dose steroids
recovery usually takes 4-6 weeks

59
Q

pathophysiology of orbital cellulitis

A

infection affecting the fat and muscles posterior to the orbital septum, within the orbit but not involving the globe

caused by a spreading URTI from the sinuses and carries a high mortality rate

a medical emergency requiring hospital admission and urgent senior review

60
Q

risk factors for orbital cellulitis

A

Childhood - mean age of hospitalisation 7-12 years
Previous sinus infection
Lack of Haemophilus influenzae type b (Hib) vaccination
Recent eyelid infection/ insect bite on eyelid (periorbital cellulitis)
Ear or facial infection

61
Q

presentation of orbital cellulitis

A

Redness and swelling around the eye
Severe ocular pain
Visual disturbance
Proptosis
Ophthalmoplegia/pain with eye movements
Eyelid oedema and ptosis
Drowsiness +/- Nausea/vomiting in meningeal involvement (Rare)

differentiating orbital from preseptal cellulitis - reduced visual acuity, proptosis, ophthalmoplegia/pain with eye movements are NOT consistent with preseptal cellulitis

62
Q

fundoscopy findings in papilloedema

A

venous engorgement: usually the first sign
loss of venous pulsation: although many normal patients do not have normal pulsation
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

63
Q

causes of papilloedema

A

space-occupying lesion: neoplastic, vascular
malignant hypertension
idiopathic intracranial hypertension
hydrocephalus
hypercapnia

64
Q

describe posterior vitreous detachment

A

separation of the vitreous membrane from the retina due to natural changes to the vitreous fluid of the eye with ageing

common condition, does not cause any pain or loss of vision.

may sometimes lead to tears and detachment of the retina.

must rule out retinal tears or retinal detachment in anyone with suspected posterior vitreous detachment, as they may result in permanent loss of vision.

65
Q

risk factors of posterior vitreous detachment

A

As people age, the vitreous fluid in the eye becomes less viscous, and thus, does not hold its shape as well. Therefore, it pulls the vitreous membrane away from the retina towards the centre of the eye.
Highly myopic (near-sighted) patients are also at increased risk of developing posterior vitreous detachment earlier in life. This is because the myopic eye has a longer axial length than an emmetropic eye.

66
Q

features of posterior vitreous detachment

A

The sudden appearance of floaters (occasionally a ring of floaters temporal to central vision)

Flashes of light in vision
Blurred vision
Cobweb across vision

The appearance of a dark curtain descending down vision (means that there is also retinal detachment)

67
Q

management of posterior vitreous detachment

A

examination by an ophthalmologist within 24hours to rule out retinal tears or detachment.

Posterior vitreous detachment alone does not cause any permanent loss of vision. Symptoms gradually improve over a period of around 6 months and therefore no treatment is necessary.
If there is an associated retinal tear or detachment the patient will require surgery to fix this.

68
Q

management of primary open angle glaucoma

A

prostaglandin analogues - latanoprost - increase uveoscleral outflow

beta blockers - timolol - reduce aq production

sympathomimetics - brimoniodine - reduce aq production, increases outflow

carbonic anhydrase inhibitors - dorzolamide - reduce aq production

miotics - pilocarpine - increase uveoscleral outflow

69
Q

fundoscopy of primary open angle glaucome

A
  1. Optic disc cupping - cup-to-disc ratio >0.7 (normal = 0.4-0.7), occurs as loss of disc substance makes optic cup widen and deepen
  2. Optic disc pallor - indicating optic atrophy
  3. Bayonetting of vessels - vessels have breaks as they disappear into the deep cup and re-appear at the base
  4. Additional features - Cup notching (usually inferior where vessels enter disc), Disc haemorrhages
70
Q

investigation findings in primary open angle glaucoma

A

automated perimetry to assess visual field

slit lamp examination

applanation tonometry to measure IOP

central corneal thickness measurement

gonioscopy

71
Q

describe a relative afferent pupillary defect

A

Marcus-Gunn pupil, caused by a lesion anterior to the optic chiasm

the affected and normal eye appears to dilate when light is shone on the affected eye

causes
retina: detachment
optic nerve: optic neuritis e.g. multiple sclerosis

71
Q

causes of red eye

A

Acute angle closure glaucoma

Anterior uveitis

Scleritis

Conjunctivitis

Subconjunctival haemorrhage

Endophthalmitis

72
Q

pathway of pupillary light reflex

A

afferent: retina → optic nerve → lateral geniculate body → midbrain
efferent: Edinger-Westphal nucleus (midbrain) → oculomotor nerve

73
Q

describe retinal detachment

A

occurs when the neurosensory tissue that lines the back of the eye comes away from its underlying pigment epithelium

reversible cause of visual loss if recognised and treated before the macula is affected

f left untreated and symptomatic, retinal detachment will inevitably lead to permanent visual loss.

74
Q

risk factors for retinal detachment

A

diabetes mellitus
myopia
age
previous surgery for cataracts (accelerates posterior vitreous detachment)
eye trauma e.g. boxing

75
Q

features of retinal detachment

A

new onset floaters or flashes

sudden onset, painless and progressive visual field loss - a curtain, or shadow progressing to the centre of the visual field from the periphery

if macula is involved = central visual acuity, visual outcomes become much worse

reduced peripheral visual fields

76
Q

fundoscopy findings in retinal detachment

A

the red reflex is lost and retinal folds may appear as pale, opaque or wrinkled forms
if the break is small, however, it may appear normal.

77
Q

features of retinitis pigmentosa

A

primarily affects the peripheral retina resulting in tunnel vision

night blindness is often the initial sign
tunnel vision due to loss of the peripheral retina (occasionally referred to as funnel vision)
fundoscopy: black bone spicule-shaped pigmentation in the peripheral retina, mottling of the retinal pigment epithelium

78
Q

ocular manifestations of rheumatoid arthritis

A

keratoconjunctivitis sicca (most common)
episcleritis (erythema)
scleritis (erythema and pain)
corneal ulceration
keratitis

79
Q

risk factors of scleritis

A

rheumatoid arthritis: the most commonly associated condition
systemic lupus erythematosus
sarcoidosis
granulomatosis with polyangiitis

80
Q

causes and types of strabismus

A

Squint (strabismus) = misalignment of the visual axes.

concomitant (common) - due to imbalanced extraocular muscles, convergent>divergent

paralytic (rare) - due to paralysis of extra-ocular muscles

uncorrected may lead to amblyopia (the brain fails to fully process inputs from one eye and over time favours the other eye).

81
Q

features of scleritis

A

scleritis = full thickness inflammation of sclera, causes red, painful eye

red eye
classically painful (in comparison to episcleritis), but sometimes only mild pain/discomfort is present
watering and photophobia are common
gradual decrease in vision

82
Q

investigation of squint

A

corneal light reflection test - holding a light source 30cm from the child’s face to see if the light reflects symmetrically on the pupils

The cover test is used to identify the nature of the squint
ask the child to focus on an object
cover one eye
observe movement of uncovered eye
cover other eye and repeat test

83
Q

causes of sudden vision loss

A

ischaemic/vascular (e.g. thrombosis, embolism, temporal arteritis etc). This includes recognised syndromes e.g. occlusion of central retinal vein and occlusion of central retinal artery
vitreous haemorrhage
retinal detachment
retinal migraine

84
Q

causes of tunnel vision

A

due to concentric diminution of the visual fields

papilloedema
glaucoma
retinitis pigmentosa
choroidoretinitis
optic atrophy secondary to tabes dorsalis
hysteria

85
Q

features of vitreous haemorrhage

A

painless visual loss or haze (commonest)

red hue in the vision

floaters or shadows/dark spots in the vision

decreased visual acuity: variable depending on the location, size and degree of vitreous haemorrhage

visual field defect if severe haemorrhage

86
Q

causes of vitreous haemorrhage

A

proliferative diabetic retinopathy (over 50%)
posterior vitreous detachment
ocular trauma

87
Q

investigation findings in vitreous haemorrhage

A

dilated fundoscopy: may show haemorrhage in the vitreous cavity
slit-lamp examination: red blood cells in the anterior vitreous
ultrasound: useful to rule out retinal tear/detachment and if haemorrhage obscures the retina
fluorescein angiography: to identify neovascularization
orbital CT: used if open globe injury

88
Q

management of corneal foreign body

A

suspected penetrating eye injury due to high-velocity injuries

Significant orbital or peri-ocular trauma

chemical injury - irrigate 20-30mins
organic foreign bodies

red flag sx

Finals (27 decks)

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