Opthalmology Flashcards
1
Q
Contact lens wearer with red painful eye?
A
Refer to opthalmology to exclude microbial keratitis
2
Q
Management of children with squint?
A
Refer to ophthalmology
3
Q
What is seborrhoeic dermatitis associated with?
A
Blepharitis
4
Q
fixed dilated pupil with conjunctival injection
A
acute closed angle glaucoma
5
Q
How to manage patient who presents with new-onset flashes or floaters?
A
Urgent referral by opthalmology for ?vitreous detachment
6
Q
What is myopia (near-sightedness) a risk factor for?
A
Retinal detachment
7
Q
Bacterial vs viral keratitis?
A
Viral would have contact with herpes infection or recurrent episodes triggered by stress, immunosuppression or trauma
8
Q
central scotoma and red patches on the retina on fundoscopy in an older person?
A
Wet age-related MD
9
Q
Mydriatic drops precipitate what?
A
Acute angle closure glaucoma
10
Q
Metamorphopsia (wavy distortion of straight lines) is the initial symptoms of what?
A
Choroidal neovascularisation
11
Q
Hutchinson’s sign (rash on the tip of the nose) is a predictor for what in HZO?
A
Ocular involvement
12
Q
Ankylosing spondylitis is associated with what?
A
Anterior uveitis
13
Q
Side effects of prostaglandin analogues e.g latanoprost?
A
increased eyelash length, iris pigmentation and periocular pigmentation
14
Q
How does latanoprost work?
A
increasing uveoscleral outflow
15
Q
Management of patients with organic foreign body in their eye?
A
Refer to ophthalmology for same day assessment
16
Q
How does diabetic maculopathy present?
A
based on location rather than severity, anything is potentially serious
hard exudates and other ‘background’ changes on macula
check visual acuity
more common in Type II DM
17
Q
How is diabetic maculopathy managed?
A
if there is a change in visual acuity then intravitreal vascular endothelial growth factor (VEGF) inhibitors
18
Q
Management of dry MD?
A
High dose of beta-carotene, vitamins C and E, and zinc
19
Q
Investigations for acute angle-closure glaucoma?
A
Both tonometry (assess elevated IOP) and gonioscopy (look at the angle)
20
Q
Glaucoma?
A
Group of conditions characterised by optic neuropathy mainly due to raised intraocular pressure (IOP)
21
Q
Acute angle-closure glaucoma (AACG)?
A
rise in IOP secondary to impairment of aqueous flow
22
Q
Factors predisposing to AACG?
A
hypermetropia, pupillary dilation, lens growth associated with age
23
Q
Hypermetropia
A
long-sightedness
24
Q
Features of acute angle-closed glaucome
A
- severe pain (ocular/headache)
- decreased visual acuity
- hard, red-eye
- haloes around light
- semi-dilated non-reacting pupil
- dull or hazy cornea
- N&V
25
In AACG, symptoms worsen with what?
Mydriasis eg. watching tv in dark room
26
In AACG why do you get dull or hazy cornea?
Coreneal oedema
27
AACG Mx?
Emergency, urgent referral to opthalmologist. Need to lower IOP once acute attack settled.
28
AACG inital medical emergency Mx?
- combination of eye drops eg. pilocarpine (direct parasympathomimetic), timolol (BB) and apraclonidine (alpha-2 agonist)
- + IV acetazolamide
29
AACG definitive Mx?
laser peripheral iridotomy
30
night blindness and tunnel vision?
Retinitis pigmentosa
31
What is Holmes-Adie pupil?
A benign dilated pupil seen in young women
32
How does Holmes-Adie pupil present?
- Unilateral dilated pupil
- Slow reactive to accommodation and poorly to light
- Associated with Holmes-Adie syndrome where ankle/knee reflexes are absent
33
What is Argyll Robertson pupil?
- Small irregular pupil, usually bilateral
- No response to light
- Responds to accommodation
- Associated with neurosyphilis and DM
34
What is the most common complication following laser photocoagulation?
Reduction of the visual field - especially night vision
35
Which eye condition is associated with IBD?
Anterior uveitis
36
Conjunctivitis vs orbital cellulitis?
Conjunctivitis would not cause any orbital swelling
37
Dense shadow that starts peripherally progresses towards the central vision/A veil or curtain over the field of vision?
Retinal detachment
38
Localised headache, neck pain and neuro signs e.g Horner's suggests what?
Cartoid artery dissection
39
red eye, haloes, hazy cornea?
Acute glaucoma
40
blurred vision, haloes?
Acute glaucoma
41
MD vs primary open angle glaucoma?
MD - central visual field loss
Open angle glaucoma - peripheral visual field loss
42
What is a possible complication of corneal transplant surgery?
Corneal graft rejection -> requires urgent assessment by ophthalmologist with topical steroids
43
Wet vs Dry MD?
Wet develops over months whereas dry develops over years
44
Dendritic ulcer?
Herpes simplex keratitis
45
AV nipping ?
Hypertensive retinopathy
46
What is Keratoconjunctivitis sicca a complication of?
Bells palsy
47
What should not be affected in conjunctivitis?
Visual acuity
48
Which organisms cause conjunctivitis?
Viral - adenoviruses, herpes
Bacterial - staph aureus, h influenzae, staph epidermidis
49
What can occur after facial trauma?
Orbital blow out fractures
50
When treating acute glaucoma, what should be treated?
BOTH eyes
51
A 56-year-old patient presents complaining of a red eye. On examination, you notice that the patient's left conjunctiva is severely injected and that the left eye is displaced forwards. Additionally, when you ask the patient to look left you notice that only right eye is able to do so
Carotid cavernous fistula - complication of conjunctivitis/trauma
52
What is an complication of CRVO?
Neovascular gaucoma -> develops over a few months
53
painful red eye, blurring of vision and photophobia with hypopyon?
Anterior uveitis
54
Anterior uveitis is important differential of what?
A red eye
55
What is anterior uveitis (iritis)?
Inflam of anterior portion of uvea- iris and ciliary body
56
What is the genetic association of anterior uveitis?
HLA-B27
57
Features of anterior uveitis?
acute onset; ocular pain; small pupil; photophobia; blurred vision; red eye; ciliary flush; hypopyon; visual acuity initially normal then impaired.
58
Pupil/cornea in anterior uveitis?
Small fixed oval pupil, ciliary flush
59
Hypopyon?
pus and inflam cells in anterior chamber of uvea, resulting in visible fluid level
60
Ciliary flush?
ring of red spreading outwards around cornea
61
Anteroir uveitis asssociated conditions?
Ankylosing spondylitis; IBD; reactive arthritis; sarcoidosis
62
Anterior uveitis Mx
Urgent review by opth. Cycloplegics eg. atropine and steroid eye drops.
63
How do cycloplegics eg. atropine work?
Dilate pupil which helps relieve pain and photophobia
64
First line treatment for chronic glaucoma?
Prostaglandin analogues e.g. latanoprost
65
Lid lag is a sign of?
Thyroid eye disease
66
How enlarged should the optic disc: cup ratio be to diagnose open angle glaucoma?
>0.7
67
Complication of untreated squint?
Amblyopia- lazy eye
68
Most common risk factor for CRVO?
HTN
69
What should be given for corneal abrasion?
Topical Abx
70
Elderly female with painless loss of vision with scalp tenderness/headaches/jaw claudication?
Think arthritic ischaemic optic neuropathy caused by GCA
71
Long sightedness is a risk factor for what?
Acute glaucoma - smaller eyeball therefore iris-cornea angle is smaller
72
Orbital vs preorbital cellulitis?
Preorbital will have no proptosis, no pain on eye movements, no swelling on conjunctiva and normal optic nerve function
73
What are examination findings for cataracts?
- Clouding of lens
- Absent red reflex
- reduced visual acuity
74
What is the name of cataract surgery?
Phacoemulsification
75
What is an early and late complication of cataract surgery?
Early - posterior capsule rupture
Late - posterior capsule opacification
76
Only effective Mx of cataracts?
Surgery. In early stages can manage conservatively eg. glasses but will eventually need surgery.
77
Referral for cataract surgery should be dependent on what?
visual impairment? impact on quality of life? patient choice? risks and benefits?
78
What is used to measure intraocular pressure and what is the normal upper limit?
Tonometry - 21
79
What is gonioscopy?
Measurement of the iridocorneal angle -> distinguishes between open-angle and closed-angle
80
What investigations should be done when suspecting macular degeneration?
Amsler chart, fundoscopy, OCT, fluorescein angiography
81
What are the management options for wet ARMD?
- Photodynamic therpay
- Laser photocoagulation
- anti-VEGF
82
What causes the blurred vision in acute closed angle glaucoma?
Corneal oedema
83
What can cause resolution of acute glaucoma symptoms upon going to bed?
Pupil constricts which pulls iris out of the angle
84
What is the immediate management of central retinal artery occulsion?
High dose steroids
85
Retinal artery occlusion?
Rare cause of sudden unilateral visual loss but to thromboembolism or arteritis.
86
3 features of central retinal artery occlusion
- sudden painless unilateral visual loss
- relative afferent pupillary defect
- 'cherry red' spot on pale retina
87
What agent is used to visualise any ulceration of the cornea?
Fluorescein
88
What should be examined in the eye in someone with ophthalmic shingles?
Corneal sensation due to risk of corneal ulceration
89
Contact lens wearer who swims?
Acanthanoeibc keratitis
90
What are Amsler grids and Snellen charts used for?
Amsler - tests for distortion of line perceptions
Snellen - tests visual acuity
91
What are signs of orbital compartment syndrome?
- Blood in anterior chamber
- Proptosis
- Stiff eyelid
- RAPD
92
How should orbital compartment syndrome be managed?
Immediate canthotomy to reduce pressure then can do imaging like CT
93
What is the finding of a RAPD?
Affected and normal eye dilated when light is shone on the affected -> usually optic nerve/retina affected
94
What is papilledema?
Blurring of the optic disc margin on fundoscopy
95
What screening test can be done for squints in children?
Hirschberg test - corneal light reflection test
96
Vitreous hemorrhage?
Bleeding into vitreous humour
97
Source of bleeding in vitreous haemorrhage?
any vessel in retina and the extension through the retina from other areas
98
In vitreous haemorrhage, once the bleeding stops, what rate is the blood typically cleared from the retina?
1% a day
99
CP of vitreous hameorrage
Acute or subacute onset; painless visual loss or haze; red hue in vision; floaters or shadows/dark spots in vision.
Signs: decreased visual acuity; visual field defect if severe haemorrhage
100
red-tinged vision along with dark spots
Vitreous haemorrhage
101
What are risk factors for vitreous haemorrhage?
- Proliferative diabetic retinopathy
- Ocular trauma
- Anticoag/coagulation disorders
- posterior vitreous detachment
102
Ix for vitreous haemorrhage?
- dilated fundocopy: ?haemorrage in vitreous cavity
- slit-lamp exam: red blood cells in anterior V
- US: rule out retinal T/D and if haemorrhage obscures retina
- fluorescein angiography: identify neovascularisation
- orbital CT: if open globe injury
103
What is the management of vitreous haemorrhage?
- Laser photocoagulation
- Anti VEGF injections
- Vitrectomy
104
Main causes of tunnel vision
- Papilloedema
- Glaucoma
- Choroidoretinits
105
Management of proliferative diabetic retinopathy?
Intravitreal VEGF injections + pan retinal photocoagulation laser. If severe or vitreous haemorrgae= vitreoretinal surgery
106
Congruous vs Incongruous loss of vision?
Congruous - complete/symmetrical visual field loss -> optic radiation lesion/occipital cortex
Incongruous - incomplete/asymmetrical visual field loss -> optic tract lesion
107
Initial management of glaucoma?
1. Direct parasympathomimetic e.g. pilocarpine (increase AH outflow)
2. Beta blocker e.g timolol (decrease AH production)
3. alpha-2 agonist e.g Apraclonidine (decrease AH production + improve outflow)
4. IV Acetazolamide (reduce secretions)
108
Proliferative vs Non proliferative diabetic retinopathy on fundoscopy?
Proliferative - new vessel formation/haemorrhages
109
Untreated Proliferative vs treated proliferative diabetic retinopathy?
Treated - dark circular scars around peripheries -> pan retinal photocoagulation / yellow spots/holes all over the fundus -> laser therapy
110
Mild vs Moderate vs Severe NPDR?
Mild - microaneurysms
Moderate - blot haemorrhages, hard exudates, cotton wool spots
Severe - venous beading, blot haemorrhages and microaneurysms in all 4 quadrants
111
What metabolic disorder can cause cataracts?
Hypocalcaemia
112
What is associated with subcapsular cataracts?
Steroids
113
Painful red eye with photophobia + watery eye?
Herpes keratitis
114
What may fluorescein staining in herpes simplex keratitis show?
epithelial ulcer
115
What does herpes simplex keratitis commonly present with?
Dendritic corneal ulcer
116
Mx of herpes simplex keratitis?
immediate opthal referal; topical aciclovir.
117
HTN retinopathy vs DM retinopathy?
DM will have choroidal neovascularisation
118
Acute vs chronic glaucoma
Acute - hypermetropia (far sightedness)
Chronic - myopia (near sightedness)
119
What can cause worsening of eye disease in Graves?
Radioiodine treatment
120
Cotton wool spots represent what?
Area of pre capillary arteriolar occlusion/infarction
121
What mineral can cause band keratopathy?
Calcium
122
What does superior rectus do?
Move eye up and out + inward rotation
123
Green central disc with spoke like projections?
Wilsons disease
124
What is the earliest feature which can be seen in anterior uveitis?
Aqueous flare
125
What does inferior oblique move eye in?
Down, in and outward
126
Risk factors for AAG
- Hypermetropia
- Shallow anterior chamber
- Thicker lens
- Smaller corneal diameter
127
Care advice for someone with bacterial conjunctivitis?
- Avoid touching eyes
- Avoid sharing towels
- Wash hands using drops
- Return if persists
128
Allergic vs bacterial conjunctivitis
Allergic will have itchy eyes, watery discharge
129
What are risk factors for cataracts?
- Age
- Sunlight
- Eye trauma
- Recurrent uveitis
- corticosteroid use
- women
- smoking
- DM
- hypocalcaemia
130
Cataracts?
opacity (cloudy area) that forms within the lens of an eye that can reduce transparency of lens. May be one or both eyes, most common >60yrs
131
Untreated congenital cataracts in babies cause what?
Deprivation amblyopia- lifelong visual impairment.
132
CP of cataracts
Glare (diff seeing in presence of bright light); gradual and painless reduction in visual acuity.
Babies/children= leukocoria, nystagmous, strabismus
133
What is leukocoria?
white or grey pupil
134
Strabismus?
Squint
135
Which dermatome is affected in herpes zoster opthalmicus?
Ophthalmic division of trigeminal nerve
136
Scleritis?
Full-thickness inflamm of sclera. Non-infective cause and causes red painful eye.
137
What are risk factors for scleritis?
- Autoimmune eg. RA
- SLE
- Sarcoidosis
- TB
- Syphilis
- Trauma
138
Scleritis CP?
red eye; PAINFUL (can be mild)and tender; watering; photophobia; gradual decrease in vision, pain may be worse on movement.
139
Scleritis Mx?
- same day opthal assessment
- oral NSAIDs 1st
- severe: oral glucocorticoids
- resistant: immunosupressive drugs
140
What are examination findings for scleritis?
- Inflammation involving full thickness of sclera
- Anterior uveitis
- Scleral thinning
- Corneal thinning
141
Episcleritis vs Scleritis?
Episcleritis - fast onset, no pain, superficial inflammation, self limiting
Scleritis - gradual, painful, watery discharge, visual disturbances, topical steroids to treat
142
Risk factors for orbital cellulitis?
- URTI
- Retained foreign body
- Post surgery
- Systemic infection
- childhood
- previous sinus infection
- lack of Hib vaccine
- ear or facial infection
143
Orbital cellulitis?
Infection affecting the fat and muscles posterior to the orbital septum within the orbit but not invl. the globe.
144
What is orbital cellulitis usually caused by?
spreading URTI from the sinuses; high mortality rate
145
Periorbital (preseptal) cellulitis?
Less serious that orbital; superficial infection anterior to orbital septum resulting from superficial tissue injury (chalazion, insect bite ect). Incl. eyelids, skin and subcut tissues of face but not contents of orbit.
146
Can periorbital cellulitis progress to orbital cellulitis
yes
147
CP of orbital cellulitis
Redness & swelling around the eye
Severe ocular pain
Visual disturbance
Proptosis
Ophthalmoplegia/pain with eye movements
Eyelid oedema and ptosis
Drowsiness +/- N&V in meningeal involvement (Rare)
148
Differentiate orbital from periorbital (preseptal cellulitis)
reduced visual acuity, proptosis, opthalmoplegia/pain with eye movement NOT consistent with preseptal cellulitis
149
Ix for orbital cellulitis?
- FBC (WBC raised, raised CRP&ESR)
- clinical exam
- CT with contrast (inflam of orbital tissues deep to septum, sinusitis)
- blood cultures and microbio swab
150
Clinical examination of orbital cellulitis?
Decreased vision, afferent pupillary defect, proptosis, dysmotility, oedema, erythema.
151
Most common bacterial causes of orbital cellulitis?
Streptococcus, Staphylococcus aureus, Haemophilus influenzae B.
152
Mx for orbital cellulitis?
Hospital admission for IV ABx
153
Where does the infection for preseptal (periorbital) cellulitis come from typically?
From nearby sites eg. breaks in skin or local infections eg. sinusitis or resp tract infections
154
Most frequent causative organism in periorbital (preseptal) cellulitis?
Staph. aureus, Staph. epidermidis, streptococci and anaerobic bacteria.
155
RFs for preseptal (periorbital) cellulitis?
Children, esp <10
Winter
156
CP of periorbital (preseptal) cellulitis?
red, swollen painful eye, acute onset, symp assoicated with fever.
Signs: erythema and oedema of eyelids +/- surrounding skin; ptosis; orbital signs ABSENT
157
Ix for periorbital (preseptal) cellulitis?
- bloods (raised CRP&ESR)
- swab of discharge
- contrast CT of orbit in all pts suspected to have orbital cellulitis
158
Mx of periorbital (preseptal) cellulitis?
- refer all cases to secondary care
- co-amoxiclav
- may admit children for observation
159
Cx of periorbital (preseptal) cellulitis?
may spread to orbit= orbital cellulitis (more serious)
160
Recurrent watery/sticky eye in neonates?
Tear duct obstruction -> self resolves by 1 year
161
What is the prognosis of herpes zoster opthalmicus?
Complete resolution with no complications
162
Causes of lack of red reflex
- Retinoblastoma
- Cataracts
- Retinal dysplasia
- Corneal opacity
163
What are the 2 layers of retina?
- Neurosensory layer which has ganglion cells and photoreceptors
- Retinal pigment epithelium
164
Timolol (beta blockers) is C/I when?
- Asthma and heart block
165
What is leukocoria?
White pupillary reflex - absence of red reflex -retinoblastoma
166
What is ophthalmia neonatorum?
Neonatal conjunctivitis contracted within the first 28 days of birth
Commonly gonococcal in first 5 days and chlamydia after 5 days
167
What are the 4 stages of HTN retinopathy?
1 - silver wiring, arteriolar narrowing
2 - AV nipping
3 - Cotton wool spots, flame haemorrhages
4 - Papilledema
168
Scleritis vs anterior uveitis
Scleritis would not have any pupillary signs i.e. irregularly shaped pupil
169
What is the fluorescein eye drop test used for?
Identify any defects in the corneal epithelium
170
What is the management of endophthalmitis?
Intravitreal Abx
Vitrectomy in severe cases
171
dense shadow that starts peripherally and moves to the patient’s central vision on a background of new onset floaters and flashes
Retinal detachment
172
What is the name given to blood in the anterior chamber of the eye following trauma?
Hyphema
173
What should be done when thinking about any corneal abrasions (Ix)?
Fluorescein staining: yellow-stained abrasion (de-epithelialised surface) visible to naked eye
174
Corneal abrasion?
Any defect of corneal epithelium, most commonly due to local trauma eg. fingernails, branches
175
CP of corneal abrasion?
eye pain, lacrimation, photophobia, foreign body sensation, conjunctival injection, decreased visual acuity
176
Blunt ocular trauma with associated hyphema
High risk for raised IOP -> secondary glaucoma?
177
Herpes zoster opthalmicus is caused by what?
Varicella zoster
178
What is a carotid cavernous fistula?
Abnormal communication between carotid artery and the cavernous sinus
179
What causes carotid cavernous fistulas?
Secondary to trauma e.g. head injuries, surgery
180
How does carotid cavernous fistulas present?
- Pulsatile proptosis
- Bruit
- Severe conjunctivitis
- Cranial nerve involvement
181
What is the gold standard for carotid cavernous fistulas?
- Cerebral Angiography
182
How is carotid cavernous fistulas managed?
Coil embolization or balloon occlusion
183
Which cranial nerves are in cavernous sinus?
3,4,6,5 - opthalmic and maxillary
184
"pizza pie" appearance on fundoscopy?
CMV retinitis -> HIV patient
185
Horners is loss of innervation to what?
Sympathetic chain
186
How to tell right vs left 4th nerve palsies?
Vision improves when head tilts towards the unaffected side
187
Age-related macular degeneration?
Changes in the central area of the retina (macula) in people >50yrs.
188
Changes that occur in age-related macular degeneration?
- Drusen
- RPE abnormalities- hyper or hypopigmentation
- Geographic atrophy
- Neovascular (exudative) AMD: development of new blood vessels in choroid that easily leak blood constituents resulting in distorsion and scarring of the retina
189
How is age-related macular degeneration classified?
- Early AMD: low, medium or high risk of progression
- Late AMD: intermediate, wet active, dry, or wet inactive
190
Commonest cause of severe visual impairment in older adults?
Advanced AMD
191
RFs for age-related macular degeneration?
old age, smoking, FHx, genetic factors
192
Complications of age-related macular degeneration?
visual impairments and blindness, visual hallucinations, depression, falls and fractures, reduced quality of life
193
Early and intermediate AMD is not associated with what?
disturbances of central visual function
194
Advanced AMD can cause...
severe visual impairment
195
Geographic atrophy in AMD tends to progress...
slowly
196
uncreated neovascular AMD can progress within...
weeks or months- severe visual loss
197
CP of age-related macular degeneration?
- metamorphopsia
- painless loss or blurring of central/near-central vision
- scotoma
- difficulty reading, driving
- photopsia
- difficulty adjusting from bright to dim light
- visual hallucinations
198
Scotoma?
black or grey patch affecting central field of vision
199
Photopsia?
flickering or flashing lights
200
Metamorphopsia?
distorsion of vision (straight lines=wavy)
201
Age-related macular degeneration examination signs?
- visual acuity may be normal or reduced
- fundoscopy= drusen (early stages); pigmentary, exudate, haemorrhagic or atrophic changes affecting the macula
202
Age-related macular degeneration Ix?
Refer urgently to opthalmologist for diagnosis:
slit-lamp biomicroscopy, colour fundus photography, fluorescein angiography
203
If AMD affects both eyes, what should the patient do?
Inform DVLA
204
Age-related macular degenration: Mx for geographic atrophy?
limited: counselling, smoking cessation, visual rehab
205
Age-related macular degenration: Mx for neovascular AMD?
- anti-VEGF (vascular endothelial growth factor) eg. ranibizumab intravitreal injection monthly for 3ms then variable after.
206
Blepharitis?
Inflam of eyelid margins.
207
What is blepharitis due to?
- Posterior blepharitis= common, meibomian gland dysfunction
- Anterior= seborrhoeic dermatitis/staph infection
208
Blepharitis is more common in pts with what?
Rosacea
209
What do the meibomian glands do?
Secrete oil onto eye surface to prevent rapid evaporation of tear film. Any problem with meibomian glands eg. in blepharitis causes drying of eyes & irritation.
210
CP of blepharitis?
burning, itching,erythema and crusting of eyelids, worse in morning. Chronic, relapses and exacerbations common.
211
Mx of blepharitis?
- hot compress twice a day to soften lid margin
- lid hygiene: cotton buds dipped in cooled boiled water and baby shampoo twice daily then once daily when no symptoms
- artificial tears
212
When to refer a pt with blepharitis?
- symp of corneal disease eg. pain and blurred vision
- rapid onset visual loss
- suspect orbital or pre-septal cellulitis
- localised disease or eyelid asymmetry (?malignancy)
- ongoing symp despite Mx
213
Pathophysiology of diabetic retinopathy?
hyperglyc- increased retinal blood flow and abnorm metabolism in retinal vessel wall -> damages endothelial cells -> increased vascular permaebility causing exudates on fundoscopy. Formation of microaneuryms and production of growth factors in response to retinal ischaemia.
214
Classification of diabetic retinopathy?
1) non-proliferative diabetic retinopathy (NPDR)
2) proliferative retinopathy (PDR)
3) maculopathy
215
Non-proliferative diabetic retinopathy?
1) mild= 1+ microaneurysm
2) moderate= microaneurysms, blot haemorrages, hard exudates, cotton wool spots, venous bleeding and intraretinal microvascular abnorm (IRMA) not v. severe.
3) severe= blot haemorr and microan in 4 quadrants, venous bleeding in at least 2 quadrants and IRMA in at least 1 quadrant.
216
NPDR: cotton wool spots?
Soft exudates that represent areas of retinal infarction
217
Proliferative diabetic retinopathy?
Retinal neovascularisation- may lead to vitrous haemorrhage; fibrous tissue forming anterior retinal disc; common in DMT1, 50% blind in 5yrs
218
Diabetic retinopathy: maculopathy?
based on location rather than severity; hard exudates and other 'background' changes on macula; check visual acuity; common in DMT2
219
Mx of all diabetic retinopathy?
optimise glycaemia control, BP and hyperlipidaemia; regular review by opthal.
220
Mx of non-proliferative retinopathy?
Regular observation; if severe then consider panretinal laser photocoagulation.
221
Keratitis?
inflam of cornea
222
Why should microbial keratitis be urgently evaluated and Mx?
not like conjunctivitis, it's potentially sight threatening
223
Causes of keratitis?
- bacterial
- fungal
- amoebic
- parasitic
- viral
- environmental: photokeratitis (welder's arc eye) , exposure keratitis, contact lens acute red eye (CLARE)
224
Bacterial causes of keratitis?
staph aureus
pseudomonas aeruginosa in contact lens wearers
225
Amoebic causes of keratitis?
acanthamoebic keratitis
increased incidence in eye exposure to soil or contam water, pain out of proportion to findings
226
Parasitic causes of keratitis?
Onchocercal keratitis (river blindness)
227
Viral causes of keratitis?
Herpes simplex keratitis
228
Features of keratitis?
red eye (pain and erythema), photophobia, foreign body (gritty sensation), hypopyon
229
Referral for keratitis?
Contact lens wearers= accurate diagnosis only from a slit-lamp so need same day referral to eye specialist to rule out microbial keratitis
230
Keratitis Mx
stop contact lens until full resolved; topical quinolones; cyclopentolate for pain relief
231
Cx of keratitis?
corneal scaring, perforation, endophthalmitis, visual loss
232
Causes of optic neuritis?
MS, diabetes, syphilis
233
Features of optic neuritis?
unilateral decrease in visual acuity over hrs/days; poor discrimination of colours (red desaturation); pain worse on eye movement; relative afferent pupillary defect; central scotoma
234
What is relative afferent pupillary defect?
condition in which pupils respond differently to light stimuli shone in one eye at a time due to unilateral or asymmetrical disease of the retina or optic nerve
235
Ix for optic neuritis?
MRI of brain and orbits with gadolinium contrast
236
Mx of optic neuritis?
high-dose steroids; recovery usually 4-6w
237
Prognosis of optic neuritis
MRI: if > 3 white-matter lesions, 5-year risk of developing multiple sclerosis is c. 50%
238
Characteristics of glaucoma?
visual field defects
changes to optic nerve head eg. pathological cupping or pallor of optic disc
239
Ocular HTN?
consitent/recurrently raised IOP but no signs of glaucoma- may progress to glaucoma so needs monitoring
240
how is glaucoma classified?
- age of onset
- cause: primary (unknown) or secondary
- rate of onset
- the anterior chamber angle between the iris and cornea: being open or closed
241
Most common type of glaucoma?
primary open angle glaucoma (POAG)
242
Mx of all types of glaucoma with IOP of 24mmHg or more, PACG and risk of visual impairment?
360° selective laser trabeculoplasty.
243
Main Cx of glaucoma?
irreversible loss of vision (partial or complete)
244
Primary open-angle glaucoma (POAG)?
iris is clear of the trabecular meshwork (used in draining aqueous humour from anterior chamber of eye) so increased resistance to aqueous outflow causing increased IOP
245
RFs for POAG?
age, FHx, afro-caribbean, myopia, HTN, DM, corticosteroids
246
POAG CP?
insidious onset, chronic, affects both eyes, peripheral visual field loss (tunnel vision), decreased visual acuity, optic disc cupping. Often detected at routine appointment.
247
Fundoscopy signs of POAG?
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
248
Ix of POAG?
- automated perimetry to assess visual field
- slit lamp examination with pupil dilatation to assess optic nerve and fundus for a baseline
- applanation tonometry to measure IOP
- central corneal thickness measurement
- gonioscopy to assess peripheral anterior chamber configuration and depth
- Assess risk of future visual impairment, using risk factors such as IOP, central corneal thickness (CCT), family history, life expectancy
249
Aim of POAG treatment?
Lower IOP to prevent progressive loss of visual field
250
Mx for POAG?
1st line= 360° selective laser trabeculoplasty (SLT) first-line to people with an IOP of ≥ 24 mmHg
2nd if can't do procedure= prostaglandin analogue (PGA) eyedrops eg. latanoprost
3rd= beta-blocker eye drops, carbonic anhudrase inhibitor eye drops or sympathomimetric eye drops
251
Most of action and adverse effects of prostaglandin analogues eg. latanoprost for POAG?
Increases uveoscleral outflow; once daily.
Brown pigmentation of iris, increased eyelash length.
252
Retinal attachment?
separation of inner neurosensory retina from underlying retinal pigment epithelium resulting in progressive loss of vision and can lead to permanent visual loss in affected eye
253
What does the retinal pigment epithelium allow?
Vitreous fluid to accumulate in subretinal space
254
3 types of retinal detachment?
- rhegmatogenous detachment (most common)
- exudative detachment
- tractional detachment
255
What is Rhegmatogenous detachment?
As the vitreous shrinks and partly separates from the retinal surface, a retinal tear or break may develop. Continuing traction by the vitreous on the retinal surface allows fluid to enter the subretinal space, causing retinal detachment.
256
What is exudative detachment caused by?
leakage of fluid into the subretinal space, often due to inflammation or malignancy
257
What is tractional detachment caused by?
common in proliferative diabetic retinopathy, where abnormal vasculature causes contraction of the vitreous, which then pulls on the underlying retina.
258
RFs for retinal detachment?
men, eye trauma, myopia, FHx, DM, cataract surgery
259
Cx of retinal detachment?
permanent loss of vision- prompt referral to allow prompt surgical repair before macula is detached
260
When to suspect retinal detachment?
- new onset floaters
- new onset flashes
- sudden onset painless and progressive visual field loss
- reduced acuity, blurred or distorted vision
261
Mx of retinal detachment?
new onset flashes and floaters should be referred urgently (<24 hours) to an ophthalmologist for assessment with a slit lamp and indirect ophthalmoscopy for pigment cells and vitreous haemorrhage.
Surgery or laser therapy/cryotherapy.
262
Advise for pt with retinal detachment?
wear eye protection when doing at-risk sports to reduce risk of future eye injury
263
Left homonymous hemianopia?
Visual defect to the left ie. lesion of right optic tract
264
Homonymous quadrantanopias?
PITS (Parietal-Inferior, Temporal- Superior)
265
Incongruous defect causes?
Optic tract lesion; congruous defects= optic radiation lesion or occipital cortex
266
Congruous defect?
Complete or symmetrical visual field loss
267
Incongruous defect?
Incomplete or asymmetric visual field loss
268
Homonymous hemianopia: incongruous defect is due to a lesion of what?
Optic tract
269
Homoymous hemianopia: congruous defect is due to lesion of what?
Optic radiation or occipital cortex
270
Homonymous hemianopia with macula sparing: lesion of..
Occipital cortex
271
Homonymous quadrantanopias: superior?
lesion of the inferior optic radiations in the temporal lobe (Meyer's loop) (PITS)
272
Homonymous quadrantanopias: inferior?
lesion of the superior optic radiations in the parietal lobe (PITS)
273
Bitemporal hemianopia is caused by a lesion where?
Optic chiasm
274
Bitemporal hemianopia: upper quadrant defect > lower quadrant defect?
inferior chiasmal compression, commonly pituitary tumour
275
Bitemporal hemianopia: lower quadrant defect > upper quadrant defect?
superior chiasmal compression, commonly a craniopharyngioma
276
Causes of absent red reflex?
cataracts; retinoblastoma; corneal scarring; vitreous haemorrhage.
277
Ocular trauma: hyphema?
Blood in anterior chamber of eye
278
What to do in ocular trauma with hyphema?
urgent referral to opthal speicalist
279
What causes the risk to sight if a pt presents with hyphema following ocular trauma?
Raised IOP due to blockage of angle and trabecular meshwork with erythrocytes
280
Ocular trauma: hyphema Mx?
strict bed rest, XS movement can redisperse settled blood so high risk cases admitted; isolated hyphema requires daily opthal review and pressure checks as outpt.
281
If a pt presents with hyphema following ocular trauma, an assessment for what should be made?
orbital compartment syndrome as may require immediate decompression prior to imaging
282
Features of orbital compartment syndrome?
EMERGENCY.
Eye pain/swelling, proptosis, 'rock hard' eyeballs; relevent afferent pupillary defect
283
Mx of orbital compartment syndrome?
Urgent lateral canthotomy (before imaging) to decompress orbit
284
Orbital compartment syndrome?
elevation of intra-orbital pressure that exceeds the vascular perfusion pressure of the ophthalmic artery. It can result in ischemia and irreversible vision loss.
285
What do subconjunctival haemorrhages result from?
Bleeding of blood vessels into subconjunctival space. Vessels usually responsible for supplying the conjunctiva or episclera.
286
Are subconjunctival haemorrhages serious?
Rarely indicator of anything sinister
287
RFs of subconjunctival haemorrhage?
- trauma
- contact lens usage
- idiopathy
- newborn, elderly
- valsalva manoeuvre eg. coughing, straining
- aspirin, NSAIDs, anticoag
- HTN
- DM
- bleeding disorders
288
Symptoms of subconjunctival haemorrhage?
- red eye
- unilateral usually
- most asymptomatic
- mild irritation
289
Signs of sunconjunctival haemorrhage?
- flad red patch on conjunctiva, well-defined edges and normal conjunctiva surrounding, can be whole conjunctiva
- vision normal
- fundus normal
290
Most common area of conjunctiva affected in subconjunctival haemorrhage?
inferior
291
Subconjunctival haemorrhage Ix?
- clinical
- no trauma= check BP
- on wardarin= check INR
- whole border not clear or full extent of haemorrhage unclear= CT head as may be intracranial bleed or orbital roof fracture
- recurrent, spontaneous or bilateral= Ix bleeding disorders
292
Mx for subconjunctival haemorrhage?
- reassure, will resolve on own 2-3w. Colour of patch may change to yellow/green
- traumatic cause= ?refer opthal in case eye damage
- mild irritation= artifical tears
- recurrent= consult GP ?bleeding disorder
293
Posterior vitreous detachment?
Separation of vitreous membrane from retina due to natural changes to vitreous fluid of eye with ageing.
294
Cx of posterior vitreous detachment?
Common, doesn't cause pain or loss of vision. Can rarely lead to tears and detachment of retina so rule this out as may result in permanent loss of vision.
295
RFs of posterior vitreous detachment?
- 75% people >75yrs
- female
- highly myopic (myopic eye has longer axial length than emmetropic eye)
296
Why can posterior vitreous detachment happen as people age?
vitreous fluid in eye becomes less viscous so doesn't hold shape well; it pulls the vitreous membrane away from retina towards centre of eye
297
CP of posterior vitreous detachment?
- sudden appearance of floaters (occassionally ring of floaters temporal to central visison)
- flashes of light
- blurred vision
- cobweb across vision
- appearance of dark curtain descending down vision (means also retinal detachment)
298
Signs of posterior vitreous detachment on opthalmoscopy?
Weiss ring: detachment of vitreous membrane around optic nerve to form a ring-shaped floater
299
Posterior vitreous detachment Ix?
all should be examined by othal within 24hrs to rule out retinal tears/detachment
300
Posterior vitreous detachment Mx?
doesn't cause permanent loss of vision and symptoms gradully improve over 6m so no Mx needed.
301
Corneal foreign body features?
eye pain, foreign body sensation, photophobia, watering eye, red eye
302
Indications for referral if corneal foreign body?
- ?penetrating injury
- signif orbital/peri-ocular trauma
- chemical injury
- foreign body= organic material eg. seeds, soil as higher risk of infection and Cx
- near or in centre of cornea
- red flags
303
Corneal foreign body red flags?
Severe pain, irregular, dilated or non-reactive pupils, signif reduction in visual acuity, hyphema, hypopyon, corneal opacities
304
What to do before referal if the corneal foreign body is chemical injury?
Irrigate for 20-30mins with water or normal saline
305
Mx for corneal foreign body?
- loose superfical removed in primary care
- analgesia and ocular lubricants offered
- topical ABx eg. chloramphenicol if ?infection
- avoid rubbing or touching eye
- arrange follow up in 24hrs, seek urgent medical review if worsen or new features develop
306
Blurred vision?
Loss of clarity or sharpness of vision. Important to assess for visual loss, double vision and floaters.
307
Vast majority of pts with blurred vision have what?
Long-term refractive errors
308
Causes of blurred vision?
refractive error: most common
cataracts
retinal detachment
age-related macular degeneration
acute angle closure glaucoma
optic neuritis
amaurosis fugax
309
Ix for blurred vision?
- Visual acuity with Snellen chart
- Visual fields
- Fundoscopy
310
What is a good way to check if blurred vision is due to a refractive error or not?
Pinhole occluders when checking visual acuity; if blurring improves with pinhole occluder then likely to be refractive error
311
Mx for blurred vision?
- gradual, corrected by pinhole and no other symptoms= optician review
- other eg. visual loss or pain= urgent opthal review
312
Optic atrophy?
pale, well demarcated disc on fundoscopy; usually bilateral and causes gradual loss of vision (due to optic neuropathy)
313
Acquired causes of optic atrophy?
- MS
- papilloedema (longstanding)
- raised IOP (e.g. glaucoma, tumour)
- retinal damage (e.g. choroiditis, retinitis pigmentosa)
- ischaemia
- toxins: tobacco amblyopia, quinine, methanol, arsenic, lead
- nutritional: vitamin B1, B2, B6 and B12 deficiency
314
Congenital causes of optic atrophy?
- Friedreich's ataxia
- mitochondrial disorders e.g. Leber's optic atrophy
- DIDMOAD - the association of cranial Diabetes Insipidus, Diabetes Mellitus, Optic Atrophy and Deafness (also known as Wolfram's syndrome)
315
Squint (strabismus)?
Misalignment of visual axes
316
Squint can be divided into what types?
Concomitant (common) and paralytic (rare)
317
Why is it important to detect a squint?
If uncorrected may lead to amblyopia (brain fails to process inputs from one eye and over time favours the other)
318
What causes a concomitant squint?
Due to imbalance in extraocular muscles. Convergent is more common than divergent
319
What causes a parlytic squint?
Paralysis of extraocular muscles
320
Ix for squint?
- Corneal light reflection test (hold light 30cm from face to see if it reflects symmetrically on pupils)
- Nature of squint= cover test (ask child to focus on object, cover one eye, observe movement of uncovered eye, cover other eye and repeat test)
321
Mx for squint?
Refer to secondary care:
- glasses
- occlusion therapy eg. patch
- or atropine drops to blur vision in normal eye and force child to use amblyopic eye
- surgery
322
What may help prevent amblyopia if pt has a squint?
Eye patches
323
Why does a squint develop?
Lack of coordination that prevents the gaze of both eyes being directed at the same point in space
324
Causes of squint?
- refractive errors, poor visual acuity, neurodevelopmental conditions, brain lesions, cranial nerve palsies, low birth weight, prematurity, FHx, hypermetropia
325
Parents often present their children with what if they have a squint?
'turning eye'
326
Causes of red eye?
- AACG
- anterior uveitis
- scleritis
- conjunctivitis
- subconjunctival haemorrhae
- endophthalmitis
327
Cause of conjunctivitis if discharge is purulent?
Bacterial
328
Cause of conjunctivitis if discharge is clear?
Viral
329
In subconjunctival haemorrgae, the patient may have a history of what?
Trauma or coughing bouts
330
Endophthalmitis?
typically red eye, pain and visual loss following intraocular surgery
331
Transient monocular visual loss (TMVL)?
Sudden transient loss of vision that lasts <24hrs
332
Causes of sudden painless loss of vision?
- ischaemic/vascular icl. thrombosis, embolism, arteritis, occlusion of central retinal vein and occlusion of central retinal artery.
- vitreous haemorrhage
- retinal detachment
- retinal migraine
333
Differentials for amaurosis fugax?
large artery disease (artherothrombosis, embolus, dissection); small artery occlusive disease (vasculitis eg. temporal arteritis, anterior ischaemic optic neuropathy); venous disease; hypoperfusion; TIA
334
Immediate Mx for amaurosis fugax?
Aspirin 300mg as may be TIA
335
Amaurosis fugax
Sudden loss of vision; often see curtain coming down (altitudinal field defects)
336
What is ischaemia optic neuropathy due to?
Occlusion of short posterior ciliary arteries, causing damge to optic nerve
337
Central retinal vein occlusion?
Cause of sudden vision loss. Causes: glaucoma, polycythaemia, HTN. Common with age, more common than arterial occlusion. See severe retinal haemorrhages on fundoscopy.
338
Central retinal artery occlusion is due to what?
Thromboembolism (from atherosclerosis) or arteritis
339
Differentiate between posterior vitreous detachment, retinal detachment and vitreous haemorrhage?
1) Posterior vitreous detachment= Flashes of light (photopsia) - in the peripheral field of vision.
Floaters, often on the temporal side of the central vision.
2) Retinal detachment= Dense shadow that starts peripherally progresses towards the central vision. A veil or curtain over the field of vision. Straight lines appear curved. Central visual loss
3) Vitreous haemorrhage= Large bleeds cause sudden visual loss. Moderate bleeds may be described as numerous dark spots. Small bleeds may cause floaters.
340
Ptosis + dilated pupil =?
ptosis + constricted pupil = ?
Ptosis + dilated pupil = third nerve palsy; ptosis + constricted pupil = Horner's
341
Acid vs alkali worse for cornea?
alkali
342
When to worry about conjunctivitis?
neonates
eg. from mother with gonnorhoea
343
Uvea?
iris + CB + choroid
344
Uveitis?
inflam of uveal tract
painful + photophobia
345
Anterior uveitis?
iritis (intermediate)
panuveitis (posterior)
346
When is uveitis silent? (no pain, red eye or photophobia)
Idiopathic juvenille arthritis so screen anyone with this for uveitis
