Opthalmology Flashcards
Which drugs used in the management of primary open angle glaucoma increase uveoscleral outflow?
- Prostaglandin analogues (e.g. latanoprost)
- Miotics (e.g. pilocarpine)
Which drugs used in the management of primary open angle glaucoma reduce aqueous production?
- Beta-blockers (e.g. timolol, betaxolol)
- Carbonic anhydrase inhibitors (e.g. dorzolamide)
Which drug type used in the management of primary open angle glaucoma reduces aqueous production and increases uveoscleral outflow?
Sympathomimetics (e.g. brimonidine, an alpha2-adrenoceptor agonist)
What are the adverse effects of latanoprost?
- Brown pigmentation of the iris
- Increased eyelash length
When would timolol be contraindicated?
Asthmatics and patients with heart block
When would brimonidine be contraindicated?
Avoid if taking MAOI or tricyclic antidepressants
What are the adverse effects of brimonidine?
Hyperaemia
What are the adverse effects of dorzolamide?
Systemic absorption may cause sulphonamide-like reactions
What are the adverse effects of pilocarpine?
Adverse effects included a constricted pupil, headache and blurred vision
Describe the clinical features of Horner’s syndrome
- Miosis (small pupil)
- Ptosis
- Enophthalmos (sunken eye)
- Anhidrosis (loss of sweating one side)
Describe the clinical features of an Argyll-Robertson pupil
- Typically presents with bilateral irregularly shaped pupils that constrict poorly to light but accommodate well to near vision
- Associated with neurosyphilis
Describe the clinical features of a third nerve palsy
- Usually results in a dilated pupil and ptosis
- Also causes other ocular motor abnormalities such as diplopia (double vision) and inability to move the eye upward, downward or inward
Describe the clinical features of a Holmes-Adie pupil
- Characterised by a large, irregularly shaped pupil that reacts slowly to light stimulation but constricts well upon accommodation
- This condition is more commonly seen in young women and can be associated with absent tendon reflexes
Which of the following is NOT a cause of a mydriatic pupil?
* Third nerve palsy
* Atropine
* Holmes-Adie pupil
* Argyll-Robertson pupil
* Traumatic iridoplegia
Argyll-Robertson pupil
What is the main risk of hyphema?
The main risk to sight comes from raised intraocular pressure which can develop due to the blockage of the angle and trabecular meshwork with erythrocytes
Following ocular trauma, what opthalmic emergency should be assessed for?
Orbital compartment syndrome
Describe the management of orbital compartment syndrome
Urgent lateral canthotomy (before diagnostic imaging) to decompress the orbit
When should patients with a positive family history of glaucoma be screened?
Annually from 40 years
Describe the management of herpes zoster ophthalmicus
Urgent ophthalmological review and 7-10 days of oral antivirals
Name a screening test for childhood squints
The corneal light reflection test
What is the first line management of bacterial conjunctivitis
Topical chloramphenicol
In a patient with Horner’s syndrome, anhydrosis of the head, arm and trunk indicates a lesion at what level?
Central lesion: stroke, syringomyelia
In a patient with Horner’s syndrome, anhydrosis of the just the face indicates a lesion at what level?
Pre-ganglionic lesion: Pancoast’s, cervical rib
In a patient with Horner’s syndrome, no anhydrosis indicates a lesion at what level?
Post-ganglionic lesion: carotid artery
What is the most likely diagnosis associated with this fundoscopy?
Branch retinal vein occlusion
Fundoscopy shows severe retinal haemorrhages (red patches) confined to a limited area of the retina, making the diagnosis branch retinal vein occlusion
Why would a lumbar puncture be contraindicated in a patient with blurring of the optic disc margin on fundoscopy?
Papilloedema indicates raised intracranial pressure and thus would contraindicate an LP
A 3-year-old child is brought to surgery as her mother has noticed that she is ‘cross-eyed’. The corneal light reflection test confirms this. What is the most appropriate management?
Refer to opthalmology
Name 2 examination findings associated with optic neuritis
- Relative afferent pupillary defect
- Central scotoma
List some of the causes of cataract formation
- Normal ageing process: most common cause
- Smoking
- Increased alcohol consumption
- Trauma
- Diabetes mellitus
- Long-term corticosteroids
- Radiation exposure
- Myotonic dystrophy
- Metabolic disorders: hypocalcaemia
Describe the clinical features of chronic open-angle glaucoma
- Peripheral vision defect
- Increased cup-to-disc ratio
- Tonometry can be normal
Name a common cause of suddenonset visual loss in diabetics
Vitreous haemorrhage
What is the most likely diagnosis associated with this fundoscopy?
Optic nerve tumour
Demonstrates papilloedema, characterised by the blurring of the optic disc edges and enlargement of the surrounding veins. There are small haemorrhages (patches of red) surrounding the optic disc which are also seen in papilloedema
Flashes + floaters are most commonly associated with what condition?
Posterior vitreous detachment
What is the gold-standard investigation for suspected optic neuritis?
Contrast MRI of the brain and orbits
What is the most appropriate management of orbital cellulitis?
Admission to hospital for IV antibiotics due to the risk of cavernous sinus thrombosis and intracranial spread
How would you differentiate between preseptal and orbital cellulitis?
Reduced visual acuity, proptosis, ophthalmoplegia/pain with eye movements are NOT consistent with preseptal cellulitis
What is the most appropriate management for proliferative diabetic retinopathy?
Intravitreal VEGF inhibitors + pan-retinal photocoagulation laser
A 24-year-old woman presents with visual disturbance. On examination, you swing the penlight from eye to eye quickly and note that the right pupil and left pupil dilate when light is shone into the right eye.
Where is the most likely site of the lesion?
Right retina or optic nerve
A relative afferent pupillary defect is when the affected and normal eye appears to dilate when light is shone on the affected eye
In diabetic retinopathy, what is the pathophysiology of cotton wool spots?
Pre-capillary arteriolar occlusion (retinal infarction)
Name a complication of scleritis
Perforation of the globe
List some of the potential causes of papilloedema
- Space-occupying lesion: neoplastic, vascular
- Malignant hypertension
- Idiopathic intracranial hypertension
- Hydrocephalus
- Hypercapnia
- Rare causes include hypoparathyroidism, hypocalcaemia, vitamin A toxicity
A 60-year old man presents with a one month history of worsening visual acuity. He describes blurring of the smaller words in the newspaper and has noticed that straight lines, such as those on the wallpaper in his lounge appear ‘curvy’. He has also started to see a grey patch in his central field of vision. On examination his acuity is 20/30 bilaterally. Ophthalmoscopy demonstrates choroidal neovascularisation. What is the most likely diagnosis?
(Wet) age-related macular degeneration
Describe the findings associated with stage 1 hypertensive retinopathy
Arteriolar narrowing and tortuosity
Increased light reflex - silver wiring
Describe the findings associated with stage 2 hypertensive retinopathy
Arteriovenous nipping
Describe the findings associated with stage 3 hypertensive retinopathy
- Cotton-wool exudates
- Flame and blot haemorrhages; these may collect around the fovea resulting in a ‘macular star’
Describe the findings associated with stage 4 hypertensive retinopathy
Papilloedema
Describe the clinical features of a Marcus-Gunn pupil
- Relative afferent pupillary defect, seen during the swinging light examination of pupil response
- The pupils constrict less and therefore appear to dilate when a light is swung from unaffected to affected eye
- Most commonly caused by damage to the optic nerve or severe retinal disease
Describe the clinical features of a Hutchinson’s pupil
- Unilaterally dilated pupil which is unresponsive to light
- A result of compression of the occulomotor nerve of the same side, by an intracranial mass (e.g. tumour, haematoma)
Describe the management of herpes simplex keratitis (dendritic ulcer)
Topical aciclovir
What is the most likely diagnosis associated with this fundoscopy?
Central retinal artery occlusion
When anisocoria is greater in bright light, this means there is an issue with the dilated/undilated pupil and its inability to constrict
Dilated
Describe the first line management of acute angle-closure glaucoma
- Combination of eyedrops (pilocarpine, timolol, apraclonidine)
- Intravenous acetazolamide
What is the most likely diagnosis associated with this fundoscopy?
Proliferative retinopathy
A 34-year-old man with a history of ankylosing spondylitis presents with a painful right eye associated with mild photophobia. Cycloplegic drops have recently been given. What is the most likely diagnosis?
Anterior uveitis
What is the most common cause of bacterial keratitis in contact lense wearers?
Pseudomonas aeruginosa
What is the most likely diagnosis associated with this fundoscopy?
Papilloedema
Describe the clinical features of carotid artery dissection
- Localised headache
- Neck pain
- Neurological signs (e.g. Horner’s)
An 83-year-old lady is complaining of poor vision, which has been gradually progressing for the last few years. On examination, there are obvious cataracts in both eyes, but best corrected visual acuity is only slightly reduced at 6/9. She has no past ocular history.
What is the most appropriate management?
Referral for cataract surgery
Cataract removal operations should never be rationed on the basis of visual acuity
A 56-year-old woman presents to the GP because she has been experiencing some visual changes. The doctor performs a fundoscopy (pictured). The only previous fundoscopy was three years ago and was normal.
What additional feature would you find on examination?
Hypertension
Describe the clinical features of post-operative endopthalmitis
Painful red eye and visual loss shortly after ocular surgery
A 73-year-old man complains of a sore right eye. What is the diagnosis?
Entropion
Define entropion
In-turning of the eyelids
Define ectropion
Out-turning of the eyelids
What two investigations should be performed in patients with suspected acute angle-closure glaucoma?
Tonometry and gonioscopy
Describe the clinical features of central retinal vein occlusion
- Sudden painless loss of vision
- Severe retinal haemorrhages on fundoscopy
A 67-year-old woman with a history of Addison’s disease presents to the hospital with pain when chewing. This has been the case for the last 5 days. She has subsequently developed a headache in the last two days and feels her sight is slightly out of focus. Fundoscopy is shown.
Given the presentation and background, what is the most appropriate management?
IV methylprednisolone
Suggestive of temporal arteritis
Name a strong risk factor for subcapsular cataracts
Steroid use
How would you differentiate between macular degeneration and primary open-angle glaucoma?
- Macular degeneration is associated with central field loss
- Primary open-angle glaucoma is associated with peripheral field loss
What is the first line treatment for blepharitis?
Hot compresses and mechanical removal of lib debris
What test can be used to identify refractive errors as the cause of blurred vision?
Pin-hole occluder
If decreased visual acuity is caused by refractive error then pin-hole acuity will be better than unaided acuity
How would you differentiate between glaucoma or uveitis in a patient presenting with a red eye?
- Glaucoma: severe pain, haloes, ‘semi-dilated’ pupil
- Uveitis: small, fixed oval pupil, ciliary flush
What is the pathological basis for wet macular degeneration?
Choroidal neovascularisation
What is the first line management for a stye?
Analgesia + warm compresses
Describe the clinical presentation of anterior uveitis
Bilateral red, painful eyes around the corneal limbus, watering, blurry vision, and small, fixed, oval-shaped pupils
Describe the management of anterior uveitis
Anterior uveitis is most likely to be treated with a steroid + cycloplegic (mydriatic) drops
What complication can be associated with panretinal laser photocoagulation?
Descrease in night vision
Describe the clinical features of keratitis
Red eye, photophobia and gritty sensation
