Opthalmology Flashcards
Causes of red eye?
- Acute glaucoma
- Uveitis
- Infective keratitis
- Conjunctivitis
- Scleritis
- Episcleritis
How to explode red eye?
-Painful: acute glaucoma, uveitis, scleritis and corneal abrasion
- VA: glaucoma and possibly uveitis and corneal abrasion
- Photophobia: uveitis and corneal abrasion
- Painless: conjunctivitis and episcleritis
Presentation of acute glaucoma
- Red eye
- Hazy cornea (oedema)
- Loss of vision
- Painful
- Halos
- N&V
- Fixed mid-dilated pupil
- Worse in the dark (pupil dilates causing angle to narrow)
Investigations of acute glaucoma
- Can measure IOP
- At bedside you can look for cupping of the optic disc
Management of acute glaucoma
ED:
- stage 1 is systemic acetazolamide (switch off aqueous production)
- stage 2 is pilocarpine drops (open channel)
- stage 3 is other things such as topical antihypertensives and steroids
Definitive:
-iridotomy
Presentation of uveitis
Inflammatory disease (rarely secondary to systemic infection such as TB or syphilis) ask about joint pain, rashes and bowel habit etc too
- Red eye
- Painful
- Possible blurred vision
- Photophobia
- Lacrimation
- Ciliary flush
- Constricted or non-reactive pupil (inflammatory mediators cause constriction)
- Hypopyon
- Irregular pupil due to synechiae
Management of uveitis
ED:
- seen by ophthalmologists to ensure this isn’t an infective process before starting steroids
Definitive:
- topical steroids (dex) and dilating drops (cyclopentolate)
Presentation of corneal abrasion
- Red eye
- Pain
- Possible loss of vision
- Photophobia
- Foreign body sensation
- Hypopyon
Investigation for corneal abrasion
- fluorescein drops with blue light
Managementof corneal abrasion
ED:
- abx: fluoroquinolones every hour for 48 hours, then QDS for 5 days
-antiviral: 5 x a day for 1-2 weeks
- lubricating eye drops
- opthal review immediately if covering >50% or pupil
Presentation of conjunctivitis
- Red eye
- No pain, photophobia or loss of vision
- Itchy/gritty
- Blepharitis
- Adherent eye lids
- Discharge
Management of conjunctivitis
Clean with cool boiled water and cotton wool
Bacterial self-resolves in a week and viral within 3 weeks
Some may give antibiotics
Antihistamines for allergic, topical or oral
Send neonates (< 28 dys to opthal for review ?chlamydia ?gonnorhoea)
Presentation of scleritis
- Red
- Possible loss of vision
- Pain ON EYE MOVEMENT
- Photophobia
- Congested vessels
- Can be associated with autoimmune disease
Management of scleritis
NSAIDs/steroids/immunosuppression
Presentation of episcleritis
- Red-eye (usually localised)
- Discomfort (not overly painful)
- No photophobia or loss of VA
Management of episcleritis
Self-resolves in two weeks
Analgesia and lubricating eye drops if necessary
What is phenylephrine?
Vessels will disappear if in the episcleral layers
Another cause of red eye to know about
Sub-conjunctival haematoma
Often due to valsava, not serious and self-resolve in a few weeks
Check no warfarin use etc
Causes of sudden vision loss
- RAO
- CRVO
- Optic neuritis
- Vitreous haemorrhage
- Retinal detachment
- GCA
Presentation of RAO
Sudden unilateral painless loss of vision like a curtain or shadow
Full, hemi or quadrant
RAPD (CRA supplies optic nerve)
Cherry red spot on a pale retina
RAO management
Stroke/TIA clinic for workup
Presentation of CRVO
Sudden painless unilateral loss of vision
CVD RFs
Ischemia or non-ischemic: ischemic has worse outcomes an typically has worse visions, RAPD, new vessel formation and high pressure
Shows retinal haemorrhages (stormy sunset)
Management of CRVO
Seen by opthal and conservative
Macular oedema - anti VEGF
Neovascularisation - PC
Presentation of optic neuritis
Central scotoma
Pain in eye movement
Red desaturation
RAPD
Progresses across a week or so, then plateaux and resolves over months
?MS ?SLE ?Sarcoidosis ?Syphyllis ?MM ?Lyme disease
Management of optic neuritis
Everyone gets an MRI - can see ON lesion but also check for other MS lesions
Steroids
Vitreous haemorrhage
Varying loss of vision from floater to quite significant blurriness
Some people report a red tinge
No RAPD or pain, obscure fundal exam
Can be secondary to ocular trauma, diabetic eye disease or retinal tear/detachment
Management of vitreous haemorrhage
Resolves in 6 to 8 weeks. If not then vitrectomy
Can do USS to rule out retinal detachment
Presentation of retinal detachment
- Peripheral loss of vision like a shadow over hours to days
- Flashers and floaters
- Blurriness
- Near sighted/trauma
(PVD is basically the same except you don’t get peripheral vision loss)
Management of retinal detachment
Tear-cryotherapy/laser therapy to form adhesions
Detachment - vitrectomy, scleral buckling and pneumatic retinopexy
Presentation of orbital cellulitis
Pre-septal cellulitis is in front of the eye i.e., confined to the eyelid
Very difficult to differentiate from orbital cellulitis
- Peri-ocular redness
- Ptosis
- Proptosis
- Loss of vision
- Stye/chalazion
- High IOP
- Headache
If they have proptosis, change of vision, lack of pupil reflex or pain in movement then treat as orbital. Ask about tooth abscesses, sinusitis
Management of orbital/pre-orbital cellulitis
Orbital - imaging and IV abx and consider need for lateral epi canthotomy
Pre-septal - 7 days of co-amoxiclav, often secondary to chalazion
Other eyelid disorders
Blepharitis - inflammation of the eyelid margins; feels gritty, itchy and dry (warm compress and washing)
Stye - inflammation of eyelid gland such as either glands of Zeis (sebum) or glands of Moll (sweat), known as hordeolum externum, or of the Meibomian glands (oil), know as hordeolum internum; red lump at the base of the eyelash, if more internal/inwards/painful then it is internum (warm compress and analgesia, abx may be considered if persistent)
Chalazion - blocked Meibomian gland; more on the eyelid (warm compress and massage towards eyelash)
Presentation of chronic glacuoma
- gradual onset tunnel vision (loss of peripheral vision)
- fluctuating pain
- headaches
- blurred vision
- halos; particularly at night
Glaucoma investigations
Measure IOP
- non-contact tonometry
- Goldman applanation tonometry is gold standard
Slit lamp, visual fields and IOP
Management of chronic glaucoma
Treatment starts after an IOP of 24
- NICE now recommend 360 degrees selective laser trabeculoplasty
- Prostaglandin eye drops e.g. latanoprost
- Other drops if necessary e.g. beta blocker, CAi or symphanometics
- trabeculectomy may be considered
Acute VS Chronic Glaucoma
Open-angle is due to the gradual increase in resistance of the trabecula meshwork, causing a gradual increase in IOP
Closed-angle is due to the iris bulging forward and closing off the anterior chamber from the trabecula meshwork
Presentation of cataracts
- usually asymmetrical
- a gradual reduction in VA
- a gradual blurring
- colours are faded; more brown and yellow
- starbursts!!
- loss of red reflex
Management of cataracts
Surgery
Presentation of age-related macular degeneration
Unilateral loss of central vision
Reduced VA
Crooked or wavy appearance of straight lines (metamorphopsia)
Investigations for AMD
Fundoscopy
VA
Amsler grid testing
Slit lamp
OCT - optical coherence tomography
Fluorescein angiography
Type of AMD
Wet - neovascular (10%)
Dry - non-neovascular (90%)
Management of AMD
Dry: no specific treatment
- stop smoking
- control BP
- vitamin supplementation (Zinc and vit ACE)
Wet:
- anti VEGF intravitreal injections
