Opthalmology Flashcards
Marcus-Gunn pupil?
Minor constriction to direct light
Dilatation on moving light from normal to abnormal eye
RAPD
Causes of Marcus Gunn Pupil?
Optic neuritis
Optic atrophy
Retinal disease
Horner’s syndrome features and causes?
Ptosis
Anhidrosis
Miosis
Causes: Central (MS, Lateral Medullary Syndrome)
Pre-ganglionic (Pancoast tumour, CVA insertion)
Post-ganglionic (cavernous sinus thrombus, CN 3-6 palsy)
Causes of fixed and dilated pupil?
Mydriatics (i.e. tropicamide)
Iris trauma
Acute glaucoma
CN III compression (surgical)
Holmes-Adie pupil?
Dilated pupil [“Holmes has a dilated personality”]
- no response to light
- sluggish accommodation
Causes of Holmes-Adie pupil?
Viral/bacterial infection of ANS
Argyll-Robertson pupil?
Small, irregular pupil
Sluggish response to light
Accommodation intact
Causes of Argyll-Robertson pupil?
DM
Syphilis (quaternary)
Hutchinson’s pupil?
Compressed 3rd nerve
Unilaterally dilated pupil
Unresponsive to light
- [1] ipsilateral pupil constricts (PNS irritation)
- [2] ipsilateral pupil dilates (PNS inhibited)
- [3] contralateral pupil constricts (PNS irritation)
- [4] contralateral pupil dilates (poor prognosis)
Causes of Hutchinson’s pupil?
Intracranial mass / raised ICP head trauma
Mx of vitreous haemorrhage?
Vitrectomy
Main cause of vitreous haemorrhage?
DM
Tx for optic neuritis?
Methylprednisolone for 72 hours. Prednisolone for 11 days
Treatment for keratitis?
o Mx: referral topical ABx/aciclovir drops, cycloplegics/mydriatics (cyclopentolate)
- Scleritis tx?
o Mx: referral urgently (<24 hours) corticosteroids/immunosuppressants, phenylephrine
- Episcleritis tx?
o Mx: topical/systemic NSAIDs
Cherry red spot on macular is seen in what condition?
Retinal artery artery occlusion
Causes of gradual vision loss?
DM, open-angle glaucoma, ARMD, cataracts
o Signs & symptoms of age-related macular degeneration?
Central visual loss, old age, blurring of small words, straight lines appearing curvy
Features of dry ARMD?
Drusen - white fluffy spots around the macula – fat deposits under the retina)
* Degeneration of macula with slow decline over 1-2 years
Is dry or wet ARMD more common?
Dry
Wet ARMD features?
subretinal neovascularisation
* Aberrant vessels grow into the retina from the choroid and lead to haemorrhage
* Rapid visual decline (days-weeks) with distortion and macular haemorrhage
AMRD Ix:?
- Investigations: Amsler grid, fundoscopy
(urgent referral to ophthalmology):
1st = slit-lamp microscopy (picks up pigmentary, haemorrhagic, exudative changes)
Wet ARMD = fluorescein angiography (detects abnormal neovascularisation)
Mandatory = Optical Coherence Tomography (OCT) – high-res images of the retina
Mx of wet ARMD?
o Photodynamic therapy
o VEGF inhibitors (intravitreal) – i.e. bevacizumab
o Antioxidant vitamins (A, C, E) and Zinc
Mx of dry ARMD?
stop smoking (best to slow degeneration); dry: zinc + vitamin A, C, E;
Mx of wet ARMD?
anti-VEGF
Chronic Simple (Open Angle) Glaucoma features?
Increased IOP (>21mmHg), reduced blood flow, damaged optic nerve, optic disc atrophy and cupping
o Signs & symptoms peripheral field loss (central vision maintained); RF: myopia, FHx
Glaucoma pattern of vision loss?
Peripheral vision loss first and moves is (tunnel vision)
RF for Chronic Simple (Open Angle) Glaucoma?
These groups can get screening
Myopia, >35yo, Afro-Caribbean, FHx, steroid tx, DM, HTN, migraines,
Fundoscopy in open angle glaucoma?
Cupping of optic disc
SEs of prostaglandin analogue?
Iris pigmentation, eyelash growth
Management (life-long follow-up) for open angle glaucoma?
Medical (eye-drops to decrease IOP):
* 1st line (one - the other - a combination of both):
o Beta-blocker (reduces) aqueous production: timolol, betaxolol
o Prostaglandin analogue (increases) uveoscleral outflow: latanoprost
- 2nd line:
o Topical alpha-2 agonist (reduces)aqueous production brimonidine tartrate
o Carbonic anhydrase-I (reduces) aqueous production acetazolamide
o Topical miotic (M3 agonist) (increases) uveoscleral outflow pilocarpine - Surgical (can be used 1st line over medical if desired laser trabeculoplasty
Mx of Proliferative retinopathy?
Pan-retinal photocoagulation
Medical mx of cataracts?
o Medical mydriatic eye drops (tropicamide)
Ix of cataracts?
- Investigation: tonometry, fundoscopy (darkened red reflex), acuity testing, BMs
Retinitis pigmentosa:
o Most common (1 per 2,000) inherited degeneration of the macula
o Inheritance (variable):
Most common AR
Best prognosis AD
Worst prognosis X-linked
o S/S: night blindness, tunnel vision, blind by mid-30s
Associations: Friedrich’s ataxia, Kearns-Sayre syndrome, Refsum’s disease, Usher’s syndrome
o Ix: fundoscopy (pale optic disc / atrophy, macula-sparing peripheral retinal pigmentation)
Retinoblastoma:
o Commonest (1 in 15,000) intraocular tumour in children
o Inheritance (variable):
Hereditary vs. non-hereditary
AD mutation in RbP gene (a TSG)
One mutant allele in every retinal cell acquire +1 mutation and a retinoblastoma develops
o S/S: strabismus, leukocoria (white eye with no red reflex)
Associations: pineal tumours (5%), osteosarcoma, rhabdomyosarcoma
o Ix: fundoscopy
o Mx (depends on size): enucleation, chemotherapy, radiotherapy
- Inflammatory lid swelling mx?
Warm compresses
- Blepharitis?
chronic eyelid inflammation - not curable but can be maintained:
o Causes: seborrhoeic dermatitis, staphylococcus
o S/S: red, gritty/itchy eyes with scales on the lashes (like conjunctivitis)
o Mx: compress and clean (warm compress BD, warm water cleaning BD) ± topical ABx (chloramphenicol)
What is Entropion?
Eyelid inversion - can lead to corneal irritation
- Pterygium?
Yellow vascular nodules growing over the cornea - leads to decreased vision:
o Benign growth of the conjunctiva
o Associations with dusty, wind-blown lifestyles and sun exposure (i.e. desert dwellers)
Mx of peri-orbital cellulitis?
Referral to ophthalmology, IV ABx (cefuroxime)
Ix for peri-orbital cellulitis?
o Ix: CT scan w/ contrast (orbits, sinuses and brain; assess for posterior spread)
Carotid cavernous fistula:
o Aetiology: carotid aneurysm rupture leading to reflux of blood into cavernous sinus
o Causes: spontaneous rupture or trauma
o Signs & symptoms:
Engorgement of eye vessels
Lid and conjunctival oedema
Pulsatile exophthalmos
Eye bruit
o Mx: endovascular treatment
Types of cranial nerve palsy?
CN III palsy S/S: ptosis, fixed/dilated pupil, ‘down and out’
* Medical DM, MS, infarction
* Surgical ( ICP) cavernous sinus thrombosis, PCA aneurysm
CN IV palsy S/S: diplopia going downstairs
* Peripheral DM (30%), trauma (30%), compression
* Central MS, SOL, vascular
CN VI palsy S/S: diplopia in horizontal plane; Mx: botulinum toxin
* Peripheral DM (30%), trauma (30%), compression
* Central MS, SOL, vascular
Describe the two types of strabismus
o Concomitant (common) – imbalance in extraocular muscles
o Paralytic (rare) – paralysis of extraocular muscles
Squint classifications?
o …the nose = esotropia (convergent squint)
Commonest type in children
Causes: idiopathic, hypermetropia
o …temporally = exotropia (divergent squint)
Older children
Often intermittent
o …superiorly = hypertropia
o …inferiorly = hypotropia
Management of strabismus?
(4 O’s):
o Ophthalmological review
o Optical (correct refractive errors)
o Orthoptic (eye patches to the good eye to prevent amblyopia)
o Operations (resection of rectus muscles)
Ambylopia = impaired or dim vision without obvious defect or change in the eye.
Orbital blowout fracture mx?
Mx: maxilla-facial/ophthalmology referral, fracture reduction / muscle release
- Giant Papillary Conjunctivitis (GPC):
o Iatrogenic FBs (contact lenses, prostheses, sutures)
o S/S: giant papillae on tarsal conjunctivae
o Mx: removal of FB, mast cell stabilisers
Treatment of trachoma?
o Mx: tetracycline
Progressively causes blindness
- Onchocerciasis (river blindness) treatment?
o Mx: ivermectin
- Xerophthalmia and Keratomalacia: what is it and how to treat?
Keratomalacia [manifestation of vitamin A deficiency]:
o S/S: night blindness, dry conjunctiva, corneal ulceration/perforation
o Mx: vitamin A
Macular degeneration tx?
Amsler grid, fundoscopy → dry - antioxidants (zinc + vitamins A, C and E), wet - anti-VEGF injections
Bilateral gradual painless vision loss peripherally to centrally, impaired adaptation to darkness, halos around lights, headaches?
Primary open-angle glaucoma
Primary open-angle glaucoma risk factors?
myopia (short-sighted, African)
Treatment for Primary open-angle glaucoma
prostaglandin analogue eye drops to increase uveoscleral outflow (latanoprost)
Tx of diabetic retinopathy?
Tx: NPDR mild - observation, NPDR moderate/severe - focal laser photocoagulation, PDR pan-retinal photocoagulation + anti-VEGF injections
Diabetic retinopathy
Classification is non-proliferative (NPDR), proliferative (PDR) or maculopathy
NPDR mild - ≥1 microaneurysm, moderate - cotton-wool exudates, flame and blot haemorrhages, hard exudates, severe - involvement of all 4 quadrants
Hypertensive retinopathy>?
I - AV narrowing and tortuosity (silver wiring)
II - AV nipping
III - cotton-wool exudates, flame and blot haemorrhages
IV - papilloedema
Sx: unilateral acute painful vision loss, hard red eye, halos around lights, headaches, N&V, cloudy cornea, semi-dilated unresponsive pupil = what condition?
Acute closed angle glaucoma
Treatment for acute closed angle glaucoma?
Tx: pilocarpine eye drops + acetazolamide
Vitreous detachment
floaters (cobwebs) and flashes (photopsia)
Vitreous haemorrhage
Floaters and flashes, blurry vision, red hue to vision
Retinal detachment sx?
Unilateral sudden acute painless vision loss like a curtain or black shadow moving across vision with preceding floaters and flashes
‘pale retina with cherry-red spot in fovea’
Central retinal artery occlusion (CRAO)
Central retinal vein occlusion (CRVO) sign?
cheese and tomato pizza’
unilateral acute or gradual visual loss often causing scotomas, red desaturation, pain on eye movements
Optic neuritis
Temporal arteritis can lead to what?
CRAO
Sx of keratitis?
Sx: unilateral or bilateral acute painful red eye, blurry vision, photophobia, epiphora (watering)
Important to refer contact lens wearers
Sx: unilateral acute painful red eye, blurry vision, photophobia, epiphora (watering), hypopyon?
Uveitis
Associated with rheumatoid arthritis
Treatment of subarachnoid haemorrhage?
Aneurysm - coil
Vasospasm - nimodipine
Hydrocephalus - extraventricular drain
