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FINALS > Opthalmology > Flashcards

Opthalmology Flashcards

1
Q

Contact lens wearer with red painful eye?

A

Refer to opthalmology to exclude microbial keratitis

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2
Q

Management of children with squint?

A

Refer to ophthalmology

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3
Q

What is seborrhoeic dermatitis associated with?

A

Blepharitis

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4
Q

fixed dilated pupil with conjunctival injection

A

acute closed angle glaucoma

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5
Q

How to manage patient who presents with new-onset flashes or floaters?

A

Urgent referral by opthalmology for ?vitreous detachment

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6
Q

What is myopia (near-sightedness) a risk factor for?

A

Retinal detachment

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7
Q

Bacterial vs viral keratitis?

A

Viral would have contact with herpes infection or recurrent episodes triggered by stress, immunosuppression or trauma

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8
Q

central scotoma and red patches on the retina on fundoscopy in an older person?

A

Wet age-related MD

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9
Q

Mydriatic drops precipitate what?

A

Acute angle closure glaucoma

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10
Q

Metamorphopsia (wavy distortion of straight lines) is the initial symptoms of what?

A

Choroidal neovascularisation

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11
Q

Hutchinson’s sign (rash on the tip of the nose) is a predictor for what in HZO?

A

Ocular involvement

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12
Q

Ankylosing spondylitis is associated with what?

A

Anterior uveitis

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13
Q

Side effects of prostaglandin analogues e.g latanoprost?

A

increased eyelash length, iris pigmentation and periocular pigmentation

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14
Q

How does latanoprost work?

A

increasing uveoscleral outflow

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15
Q

Management of patients with organic foreign body in their eye?

A

Refer to ophthalmology for same day assessment

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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

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17
Q

How is diabetic maculopathy managed?

A

if there is a change in visual acuity then intravitreal vascular endothelial growth factor (VEGF) inhibitors

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18
Q

Management of dry MD?

A

High dose of beta-carotene, vitamins C and E, and zinc

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19
Q

Investigations for acute angle-closure glaucoma?

A

Both tonometry (assess elevated IOP) and gonioscopy (look at the angle)

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20
Q

Glaucoma?

A

Group of conditions characterised by optic neuropathy mainly due to raised intraocular pressure (IOP)

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21
Q

Acute angle-closure glaucoma (AACG)?

A

rise in IOP secondary to impairment of aqueous flow

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22
Q

Factors predisposing to AACG?

A

hypermetropia, pupillary dilation, lens growth associated with age

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23
Q

Hypermetropia

A

long-sightedness

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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
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25
Q

In AACG, symptoms worsen with what?

A

Mydriasis eg. watching tv in dark room

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26
Q

In AACG why do you get dull or hazy cornea?

A

Coreneal oedema

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27
Q

AACG Mx?

A

Emergency, urgent referral to opthalmologist. Need to lower IOP once acute attack settled.

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28
Q

AACG inital medical emergency Mx?

A
  • combination of eye drops eg. pilocarpine (direct parasympathomimetic), timolol (BB) and apraclonidine (alpha-2 agonist)
    • IV acetazolamide
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29
Q

AACG definitive Mx?

A

laser peripheral iridotomy

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30
Q

night blindness and tunnel vision?

A

Retinitis pigmentosa

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31
Q

What is Holmes-Adie pupil?

A

A benign dilated pupil seen in young women

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32
Q

How does Holmes-Adie pupil present?

A
  • Unilateral dilated pupil
  • Slow reactive to accommodation and poorly to light
  • Associated with Holmes-Adie syndrome where ankle/knee reflexes are absent
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33
Q

What is Argyll Robertson pupil?

A
  • Small irregular pupil, usually bilateral
  • No response to light
  • Responds to accommodation
  • Associated with neurosyphilis and DM
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34
Q

What is the most common complication following laser photocoagulation?

A

Reduction of the visual field - especially night vision

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35
Q

Which eye condition is associated with IBD?

A

Anterior uveitis

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36
Q

Conjunctivitis vs orbital cellulitis?

A

Conjunctivitis would not cause any orbital swelling

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37
Q

Dense shadow that starts peripherally progresses towards the central vision/A veil or curtain over the field of vision?

A

Retinal detachment

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38
Q

Localised headache, neck pain and neuro signs e.g Horner’s suggests what?

A

Cartoid artery dissection

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39
Q

red eye, haloes, hazy cornea?

A

Acute glaucoma

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40
Q

blurred vision, haloes?

A

Acute glaucoma

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41
Q

MD vs primary open angle glaucoma?

A

MD - central visual field loss
Open angle glaucoma - peripheral visual field loss

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42
Q

What is a possible complication of corneal transplant surgery?

A

Corneal graft rejection -> requires urgent assessment by ophthalmologist with topical steroids

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43
Q

Wet vs Dry MD?

A

Wet develops over months whereas dry develops over years

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44
Q

Dendritic ulcer?

A

Herpes simplex keratitis

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45
Q

AV nipping ?

A

Hypertensive retinopathy

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46
Q

What is Keratoconjunctivitis sicca a complication of?

A

Bells palsy

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47
Q

What should not be affected in conjunctivitis?

A

Visual acuity

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48
Q

Which organisms cause conjunctivitis?

A

Viral - adenoviruses, herpes
Bacterial - staph aureus, h influenzae, staph epidermidis

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49
Q

What can occur after facial trauma?

A

Orbital blow out fractures

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50
Q

When treating acute glaucoma, what should be treated?

A

BOTH eyes

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51
Q

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

A

Carotid cavernous fistula - complication of conjunctivitis/trauma

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52
Q

What is an complication of CRVO?

A

Neovascular gaucoma -> develops over a few months

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53
Q

painful red eye, blurring of vision and photophobia with hypopyon?

A

Anterior uveitis

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54
Q

Anterior uveitis is important differential of what?

A

A red eye

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55
Q

What is anterior uveitis (iritis)?

A

Inflam of anterior portion of uvea- iris and ciliary body

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56
Q

What is the genetic association of anterior uveitis?

A

HLA-B27

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57
Q

Features of anterior uveitis?

A

acute onset; ocular pain; small pupil; photophobia; blurred vision; red eye; ciliary flush; hypopyon; visual acuity initially normal then impaired.

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58
Q

Pupil/cornea in anterior uveitis?

A

Small fixed oval pupil, ciliary flush

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59
Q

Hypopyon?

A

pus and inflam cells in anterior chamber of uvea, resulting in visible fluid level

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60
Q

Ciliary flush?

A

ring of red spreading outwards around cornea

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61
Q

Anteroir uveitis asssociated conditions?

A

Ankylosing spondylitis; IBD; reactive arthritis; sarcoidosis

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62
Q

Anterior uveitis Mx

A

Urgent review by opth. Cycloplegics eg. atropine and steroid eye drops.

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63
Q

How do cycloplegics eg. atropine work?

A

Dilate pupil which helps relieve pain and photophobia

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64
Q

First line treatment for chronic glaucoma?

A

Prostaglandin analogues e.g. latanoprost

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65
Q

Lid lag is a sign of?

A

Thyroid eye disease

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66
Q

How enlarged should the optic disc: cup ratio be to diagnose open angle glaucoma?

A

> 0.7

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67
Q

Complication of untreated squint?

A

Amblyopia- lazy eye

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68
Q

Most common risk factor for CRVO?

A

HTN

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69
Q

What should be given for corneal abrasion?

A

Topical Abx

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70
Q

Elderly female with painless loss of vision with scalp tenderness/headaches/jaw claudication?

A

Think arthritic ischaemic optic neuropathy caused by GCA

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71
Q

Long sightedness is a risk factor for what?

A

Acute glaucoma - smaller eyeball therefore iris-cornea angle is smaller

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72
Q

Orbital vs preorbital cellulitis?

A

Preorbital will have no proptosis, no pain on eye movements, no swelling on conjunctiva and normal optic nerve function

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73
Q

What are examination findings for cataracts?

A
  • Clouding of lens
  • Absent red reflex
  • reduced visual acuity
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74
Q

What is the name of cataract surgery?

A

Phacoemulsification

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75
Q

What is an early and late complication of cataract surgery?

A

Early - posterior capsule rupture
Late - posterior capsule opacification

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76
Q

Only effective Mx of cataracts?

A

Surgery. In early stages can manage conservatively eg. glasses but will eventually need surgery.

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77
Q

Referral for cataract surgery should be dependent on what?

A

visual impairment? impact on quality of life? patient choice? risks and benefits?

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78
Q

What is used to measure intraocular pressure and what is the normal upper limit?

A

Tonometry - 21

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79
Q

What is gonioscopy?

A

Measurement of the iridocorneal angle -> distinguishes between open-angle and closed-angle

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80
Q

What investigations should be done when suspecting macular degeneration?

A

Amsler chart, fundoscopy, OCT, fluorescein angiography

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81
Q

What are the management options for wet ARMD?

A
  • Photodynamic therpay
  • Laser photocoagulation
  • anti-VEGF
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82
Q

What causes the blurred vision in acute closed angle glaucoma?

A

Corneal oedema

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83
Q

What can cause resolution of acute glaucoma symptoms upon going to bed?

A

Pupil constricts which pulls iris out of the angle

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84
Q

What is the immediate management of central retinal artery occulsion?

A

High dose steroids

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85
Q

Retinal artery occlusion?

A

Rare cause of sudden unilateral visual loss but to thromboembolism or arteritis.

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86
Q

3 features of central retinal artery occlusion

A
  • sudden painless unilateral visual loss
  • relative afferent pupillary defect
  • ‘cherry red’ spot on pale retina
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87
Q

What agent is used to visualise any ulceration of the cornea?

A

Fluorescein

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88
Q

What should be examined in the eye in someone with ophthalmic shingles?

A

Corneal sensation due to risk of corneal ulceration

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89
Q

Contact lens wearer who swims?

A

Acanthanoeibc keratitis

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90
Q

What are Amsler grids and Snellen charts used for?

A

Amsler - tests for distortion of line perceptions
Snellen - tests visual acuity

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91
Q

What are signs of orbital compartment syndrome?

A
  • Blood in anterior chamber
  • Proptosis
  • Stiff eyelid
  • RAPD
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92
Q

How should orbital compartment syndrome be managed?

A

Immediate canthotomy to reduce pressure then can do imaging like CT

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93
Q

What is the finding of a RAPD?

A

Affected and normal eye dilated when light is shone on the affected -> usually optic nerve/retina affected

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94
Q

What is papilledema?

A

Blurring of the optic disc margin on fundoscopy

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95
Q

What screening test can be done for squints in children?

A

Hirschberg test - corneal light reflection test

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96
Q

Vitreous hemorrhage?

A

Bleeding into vitreous humour

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97
Q

Source of bleeding in vitreous haemorrhage?

A

any vessel in retina and the extension through the retina from other areas

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98
Q

In vitreous haemorrhage, once the bleeding stops, what rate is the blood typically cleared from the retina?

A

1% a day

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99
Q

CP of vitreous hameorrage

A

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

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100
Q

red-tinged vision along with dark spots

A

Vitreous haemorrhage

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101
Q

What are risk factors for vitreous haemorrhage?

A
  • Proliferative diabetic retinopathy
  • Ocular trauma
  • Anticoag/coagulation disorders
  • posterior vitreous detachment
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102
Q

Ix for vitreous haemorrhage?

A
  • 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
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103
Q

What is the management of vitreous haemorrhage?

A
  • Laser photocoagulation
  • Anti VEGF injections
  • Vitrectomy
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104
Q

Main causes of tunnel vision

A
  • Papilloedema
  • Glaucoma
  • Choroidoretinits
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105
Q

Management of proliferative diabetic retinopathy?

A

Intravitreal VEGF injections + pan retinal photocoagulation laser. If severe or vitreous haemorrgae= vitreoretinal surgery

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106
Q

Congruous vs Incongruous loss of vision?

A

Congruous - complete/symmetrical visual field loss -> optic radiation lesion/occipital cortex
Incongruous - incomplete/asymmetrical visual field loss -> optic tract lesion

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107
Q

Initial management of glaucoma?

A
  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)
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108
Q

Proliferative vs Non proliferative diabetic retinopathy on fundoscopy?

A

Proliferative - new vessel formation/haemorrhages

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109
Q

Untreated Proliferative vs treated proliferative diabetic retinopathy?

A

Treated - dark circular scars around peripheries -> pan retinal photocoagulation / yellow spots/holes all over the fundus -> laser therapy

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110
Q

Mild vs Moderate vs Severe NPDR?

A

Mild - microaneurysms
Moderate - blot haemorrhages, hard exudates, cotton wool spots
Severe - venous beading, blot haemorrhages and microaneurysms in all 4 quadrants

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111
Q

What metabolic disorder can cause cataracts?

A

Hypocalcaemia

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112
Q

What is associated with subcapsular cataracts?

A

Steroids

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113
Q

Painful red eye with photophobia + watery eye?

A

Herpes keratitis

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114
Q

What may fluorescein staining in herpes simplex keratitis show?

A

epithelial ulcer

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115
Q

What does herpes simplex keratitis commonly present with?

A

Dendritic corneal ulcer

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116
Q

Mx of herpes simplex keratitis?

A

immediate opthal referal; topical aciclovir.

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117
Q

HTN retinopathy vs DM retinopathy?

A

DM will have choroidal neovascularisation

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118
Q

Acute vs chronic glaucoma

A

Acute - hypermetropia (far sightedness)
Chronic - myopia (near sightedness)

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119
Q

What can cause worsening of eye disease in Graves?

A

Radioiodine treatment

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120
Q

Cotton wool spots represent what?

A

Area of pre capillary arteriolar occlusion/infarction

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121
Q

What mineral can cause band keratopathy?

A

Calcium

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122
Q

What does superior rectus do?

A

Move eye up and out + inward rotation

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123
Q

Green central disc with spoke like projections?

A

Wilsons disease

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124
Q

What is the earliest feature which can be seen in anterior uveitis?

A

Aqueous flare

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125
Q

What does inferior oblique move eye in?

A

Down, in and outward

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126
Q

Risk factors for AAG

A
  • Hypermetropia
  • Shallow anterior chamber
  • Thicker lens
  • Smaller corneal diameter
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127
Q

Care advice for someone with bacterial conjunctivitis?

A
  • Avoid touching eyes
  • Avoid sharing towels
  • Wash hands using drops
  • Return if persists
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128
Q

Allergic vs bacterial conjunctivitis

A

Allergic will have itchy eyes, watery discharge

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129
Q

What are risk factors for cataracts?

A
  • Age
  • Sunlight
  • Eye trauma
  • Recurrent uveitis
  • corticosteroid use
  • women
  • smoking
  • DM
  • hypocalcaemia
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130
Q

Cataracts?

A

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

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131
Q

Untreated congenital cataracts in babies cause what?

A

Deprivation amblyopia- lifelong visual impairment.

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132
Q

CP of cataracts

A

Glare (diff seeing in presence of bright light); gradual and painless reduction in visual acuity.
Babies/children= leukocoria, nystagmous, strabismus

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133
Q

What is leukocoria?

A

white or grey pupil

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134
Q

Strabismus?

A

Squint

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135
Q

Which dermatome is affected in herpes zoster opthalmicus?

A

Ophthalmic division of trigeminal nerve

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136
Q

Scleritis?

A

Full-thickness inflamm of sclera. Non-infective cause and causes red painful eye.

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137
Q

What are risk factors for scleritis?

A
  • Autoimmune eg. RA
  • SLE
  • Sarcoidosis
  • TB
  • Syphilis
  • Trauma
138
Q

Scleritis CP?

A

red eye; PAINFUL (can be mild)and tender; watering; photophobia; gradual decrease in vision, pain may be worse on movement.

139
Q

Scleritis Mx?

A
  • same day opthal assessment
  • oral NSAIDs 1st
  • severe: oral glucocorticoids
  • resistant: immunosupressive drugs
140
Q

What are examination findings for scleritis?

A
  • Inflammation involving full thickness of sclera
  • Anterior uveitis
  • Scleral thinning
  • Corneal thinning
141
Q

Episcleritis vs Scleritis?

A

Episcleritis - fast onset, no pain, superficial inflammation, self limiting
Scleritis - gradual, painful, watery discharge, visual disturbances, topical steroids to treat

142
Q

Risk factors for orbital cellulitis?

A
  • URTI
  • Retained foreign body
  • Post surgery
  • Systemic infection
  • childhood
  • previous sinus infection
  • lack of Hib vaccine
  • ear or facial infection
143
Q

Orbital cellulitis?

A

Infection affecting the fat and muscles posterior to the orbital septum within the orbit but not invl. the globe.

144
Q

What is orbital cellulitis usually caused by?

A

spreading URTI from the sinuses; high mortality rate

145
Q

Periorbital (preseptal) cellulitis?

A

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
Q

Can periorbital cellulitis progress to orbital cellulitis

A

yes

147
Q

CP of orbital cellulitis

A

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
Q

Differentiate orbital from periorbital (preseptal cellulitis)

A

reduced visual acuity, proptosis, opthalmoplegia/pain with eye movement NOT consistent with preseptal cellulitis

149
Q

Ix for orbital cellulitis?

A
  • 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
Q

Clinical examination of orbital cellulitis?

A

Decreased vision, afferent pupillary defect, proptosis, dysmotility, oedema, erythema.

151
Q

Most common bacterial causes of orbital cellulitis?

A

Streptococcus, Staphylococcus aureus, Haemophilus influenzae B.

152
Q

Mx for orbital cellulitis?

A

Hospital admission for IV ABx

153
Q

Where does the infection for preseptal (periorbital) cellulitis come from typically?

A

From nearby sites eg. breaks in skin or local infections eg. sinusitis or resp tract infections

154
Q

Most frequent causative organism in periorbital (preseptal) cellulitis?

A

Staph. aureus, Staph. epidermidis, streptococci and anaerobic bacteria.

155
Q

RFs for preseptal (periorbital) cellulitis?

A

Children, esp <10
Winter

156
Q

CP of periorbital (preseptal) cellulitis?

A

red, swollen painful eye, acute onset, symp assoicated with fever.
Signs: erythema and oedema of eyelids +/- surrounding skin; ptosis; orbital signs ABSENT

157
Q

Ix for periorbital (preseptal) cellulitis?

A
  • bloods (raised CRP&ESR)
  • swab of discharge
  • contrast CT of orbit in all pts suspected to have orbital cellulitis
158
Q

Mx of periorbital (preseptal) cellulitis?

A
  • refer all cases to secondary care
  • co-amoxiclav
  • may admit children for observation
159
Q

Cx of periorbital (preseptal) cellulitis?

A

may spread to orbit= orbital cellulitis (more serious)

160
Q

Recurrent watery/sticky eye in neonates?

A

Tear duct obstruction -> self resolves by 1 year

161
Q

What is the prognosis of herpes zoster opthalmicus?

A

Complete resolution with no complications

162
Q

Causes of lack of red reflex

A
  • Retinoblastoma
  • Cataracts
  • Retinal dysplasia
  • Corneal opacity
163
Q

What are the 2 layers of retina?

A
  • Neurosensory layer which has ganglion cells and photoreceptors
  • Retinal pigment epithelium
164
Q

Timolol (beta blockers) is C/I when?

A
  • Asthma and heart block
165
Q

What is leukocoria?

A

White pupillary reflex - absence of red reflex -retinoblastoma

166
Q

What is ophthalmia neonatorum?

A

Neonatal conjunctivitis contracted within the first 28 days of birth
Commonly gonococcal in first 5 days and chlamydia after 5 days

167
Q

What are the 4 stages of HTN retinopathy?

A

1 - silver wiring, arteriolar narrowing
2 - AV nipping
3 - Cotton wool spots, flame haemorrhages
4 - Papilledema

168
Q

Scleritis vs anterior uveitis

A

Scleritis would not have any pupillary signs i.e. irregularly shaped pupil

169
Q

What is the fluorescein eye drop test used for?

A

Identify any defects in the corneal epithelium

170
Q

What is the management of endophthalmitis?

A

Intravitreal Abx
Vitrectomy in severe cases

171
Q

dense shadow that starts peripherally and moves to the patient’s central vision on a background of new onset floaters and flashes

A

Retinal detachment

172
Q

What is the name given to blood in the anterior chamber of the eye following trauma?

A

Hyphema

173
Q

What should be done when thinking about any corneal abrasions (Ix)?

A

Fluorescein staining: yellow-stained abrasion (de-epithelialised surface) visible to naked eye

174
Q

Corneal abrasion?

A

Any defect of corneal epithelium, most commonly due to local trauma eg. fingernails, branches

175
Q

CP of corneal abrasion?

A

eye pain, lacrimation, photophobia, foreign body sensation, conjunctival injection, decreased visual acuity

176
Q

Blunt ocular trauma with associated hyphema

A

High risk for raised IOP -> secondary glaucoma?

177
Q

Herpes zoster opthalmicus is caused by what?

A

Varicella zoster

178
Q

What is a carotid cavernous fistula?

A

Abnormal communication between carotid artery and the cavernous sinus

179
Q

What causes carotid cavernous fistulas?

A

Secondary to trauma e.g. head injuries, surgery

180
Q

How does carotid cavernous fistulas present?

A
  • Pulsatile proptosis
  • Bruit
  • Severe conjunctivitis
  • Cranial nerve involvement
181
Q

What is the gold standard for carotid cavernous fistulas?

A
  • Cerebral Angiography
182
Q

How is carotid cavernous fistulas managed?

A

Coil embolization or balloon occlusion

183
Q

Which cranial nerves are in cavernous sinus?

A

3,4,6,5 - opthalmic and maxillary

184
Q

“pizza pie” appearance on fundoscopy?

A

CMV retinitis -> HIV patient

185
Q

Horners is loss of innervation to what?

A

Sympathetic chain

186
Q

How to tell right vs left 4th nerve palsies?

A

Vision improves when head tilts towards the unaffected side

187
Q

Age-related macular degeneration?

A

Changes in the central area of the retina (macula) in people >50yrs.

188
Q

Changes that occur in age-related macular degeneration?

A
  • 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
Q

How is age-related macular degeneration classified?

A
  • Early AMD: low, medium or high risk of progression
  • Late AMD: intermediate, wet active, dry, or wet inactive
190
Q

Commonest cause of severe visual impairment in older adults?

A

Advanced AMD

191
Q

RFs for age-related macular degeneration?

A

old age, smoking, FHx, genetic factors

192
Q

Complications of age-related macular degeneration?

A

visual impairments and blindness, visual hallucinations, depression, falls and fractures, reduced quality of life

193
Q

Early and intermediate AMD is not associated with what?

A

disturbances of central visual function

194
Q

Advanced AMD can cause…

A

severe visual impairment

195
Q

Geographic atrophy in AMD tends to progress…

A

slowly

196
Q

uncreated neovascular AMD can progress within…

A

weeks or months- severe visual loss

197
Q

CP of age-related macular degeneration?

A
  • 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
Q

Scotoma?

A

black or grey patch affecting central field of vision

199
Q

Photopsia?

A

flickering or flashing lights

200
Q

Metamorphopsia?

A

distorsion of vision (straight lines=wavy)

201
Q

Age-related macular degeneration examination signs?

A
  • visual acuity may be normal or reduced
  • fundoscopy= drusen (early stages); pigmentary, exudate, haemorrhagic or atrophic changes affecting the macula
202
Q

Age-related macular degeneration Ix?

A

Refer urgently to opthalmologist for diagnosis:
slit-lamp biomicroscopy, colour fundus photography, fluorescein angiography

203
Q

If AMD affects both eyes, what should the patient do?

A

Inform DVLA

204
Q

Age-related macular degenration: Mx for geographic atrophy?

A

limited: counselling, smoking cessation, visual rehab

205
Q

Age-related macular degenration: Mx for neovascular AMD?

A
  • anti-VEGF (vascular endothelial growth factor) eg. ranibizumab intravitreal injection monthly for 3ms then variable after.
206
Q

Blepharitis?

A

Inflam of eyelid margins.

207
Q

What is blepharitis due to?

A
  • Posterior blepharitis= common, meibomian gland dysfunction
  • Anterior= seborrhoeic dermatitis/staph infection
208
Q

Blepharitis is more common in pts with what?

A

Rosacea

209
Q

What do the meibomian glands do?

A

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
Q

CP of blepharitis?

A

burning, itching,erythema and crusting of eyelids, worse in morning. Chronic, relapses and exacerbations common.

211
Q

Mx of blepharitis?

A
  • 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
Q

When to refer a pt with blepharitis?

A
  • 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
Q

Pathophysiology of diabetic retinopathy?

A

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
Q

Classification of diabetic retinopathy?

A

1) non-proliferative diabetic retinopathy (NPDR)
2) proliferative retinopathy (PDR)
3) maculopathy

215
Q

Non-proliferative diabetic retinopathy?

A

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
Q

NPDR: cotton wool spots?

A

Soft exudates that represent areas of retinal infarction

217
Q

Proliferative diabetic retinopathy?

A

Retinal neovascularisation- may lead to vitrous haemorrhage; fibrous tissue forming anterior retinal disc; common in DMT1, 50% blind in 5yrs

218
Q

Diabetic retinopathy: maculopathy?

A

based on location rather than severity; hard exudates and other ‘background’ changes on macula; check visual acuity; common in DMT2

219
Q

Mx of all diabetic retinopathy?

A

optimise glycaemia control, BP and hyperlipidaemia; regular review by opthal.

220
Q

Mx of non-proliferative retinopathy?

A

Regular observation; if severe then consider panretinal laser photocoagulation.

221
Q

Keratitis?

A

inflam of cornea

222
Q

Why should microbial keratitis be urgently evaluated and Mx?

A

not like conjunctivitis, it’s potentially sight threatening

223
Q

Causes of keratitis?

A
  • bacterial
  • fungal
  • amoebic
  • parasitic
  • viral
  • environmental: photokeratitis (welder’s arc eye) , exposure keratitis, contact lens acute red eye (CLARE)
224
Q

Bacterial causes of keratitis?

A

staph aureus
pseudomonas aeruginosa in contact lens wearers

225
Q

Amoebic causes of keratitis?

A

acanthamoebic keratitis
increased incidence in eye exposure to soil or contam water, pain out of proportion to findings

226
Q

Parasitic causes of keratitis?

A

Onchocercal keratitis (river blindness)

227
Q

Viral causes of keratitis?

A

Herpes simplex keratitis

228
Q

Features of keratitis?

A

red eye (pain and erythema), photophobia, foreign body (gritty sensation), hypopyon

229
Q

Referral for keratitis?

A

Contact lens wearers= accurate diagnosis only from a slit-lamp so need same day referral to eye specialist to rule out microbial keratitis

230
Q

Keratitis Mx

A

stop contact lens until full resolved; topical quinolones; cyclopentolate for pain relief

231
Q

Cx of keratitis?

A

corneal scaring, perforation, endophthalmitis, visual loss

232
Q

Causes of optic neuritis?

A

MS, diabetes, syphilis

233
Q

Features of optic neuritis?

A

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
Q

What is relative afferent pupillary defect?

A

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
Q

Ix for optic neuritis?

A

MRI of brain and orbits with gadolinium contrast

236
Q

Mx of optic neuritis?

A

high-dose steroids; recovery usually 4-6w

237
Q

Prognosis of optic neuritis

A

MRI: if > 3 white-matter lesions, 5-year risk of developing multiple sclerosis is c. 50%

238
Q

Characteristics of glaucoma?

A

visual field defects
changes to optic nerve head eg. pathological cupping or pallor of optic disc

239
Q

Ocular HTN?

A

consitent/recurrently raised IOP but no signs of glaucoma- may progress to glaucoma so needs monitoring

240
Q

how is glaucoma classified?

A
  • 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
Q

Most common type of glaucoma?

A

primary open angle glaucoma (POAG)

242
Q

Mx of all types of glaucoma with IOP of 24mmHg or more, PACG and risk of visual impairment?

A

360° selective laser trabeculoplasty.

243
Q

Main Cx of glaucoma?

A

irreversible loss of vision (partial or complete)

244
Q

Primary open-angle glaucoma (POAG)?

A

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
Q

RFs for POAG?

A

age, FHx, afro-caribbean, myopia, HTN, DM, corticosteroids

246
Q

POAG CP?

A

insidious onset, chronic, affects both eyes, peripheral visual field loss (tunnel vision), decreased visual acuity, optic disc cupping. Often detected at routine appointment.

247
Q

Fundoscopy signs of POAG?

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
248
Q

Ix of POAG?

A
  • 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
Q

Aim of POAG treatment?

A

Lower IOP to prevent progressive loss of visual field

250
Q

Mx for POAG?

A

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
Q

Most of action and adverse effects of prostaglandin analogues eg. latanoprost for POAG?

A

Increases uveoscleral outflow; once daily.
Brown pigmentation of iris, increased eyelash length.

252
Q

Retinal attachment?

A

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
Q

What does the retinal pigment epithelium allow?

A

Vitreous fluid to accumulate in subretinal space

254
Q

3 types of retinal detachment?

A
  • rhegmatogenous detachment (most common)
  • exudative detachment
  • tractional detachment
255
Q

What is Rhegmatogenous detachment?

A

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
Q

What is exudative detachment caused by?

A

leakage of fluid into the subretinal space, often due to inflammation or malignancy

257
Q

What is tractional detachment caused by?

A

common in proliferative diabetic retinopathy, where abnormal vasculature causes contraction of the vitreous, which then pulls on the underlying retina.

258
Q

RFs for retinal detachment?

A

men, eye trauma, myopia, FHx, DM, cataract surgery

259
Q

Cx of retinal detachment?

A

permanent loss of vision- prompt referral to allow prompt surgical repair before macula is detached

260
Q

When to suspect retinal detachment?

A
  • new onset floaters
  • new onset flashes
  • sudden onset painless and progressive visual field loss
  • reduced acuity, blurred or distorted vision
261
Q

Mx of retinal detachment?

A

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
Q

Advise for pt with retinal detachment?

A

wear eye protection when doing at-risk sports to reduce risk of future eye injury

263
Q

Left homonymous hemianopia?

A

Visual defect to the left ie. lesion of right optic tract

264
Q

Homonymous quadrantanopias?

A

PITS (Parietal-Inferior, Temporal- Superior)

265
Q

Incongruous defect causes?

A

Optic tract lesion; congruous defects= optic radiation lesion or occipital cortex

266
Q

Congruous defect?

A

Complete or symmetrical visual field loss

267
Q

Incongruous defect?

A

Incomplete or asymmetric visual field loss

268
Q

Homonymous hemianopia: incongruous defect is due to a lesion of what?

A

Optic tract

269
Q

Homoymous hemianopia: congruous defect is due to lesion of what?

A

Optic radiation or occipital cortex

270
Q

Homonymous hemianopia with macula sparing: lesion of..

A

Occipital cortex

271
Q

Homonymous quadrantanopias: superior?

A

lesion of the inferior optic radiations in the temporal lobe (Meyer’s loop) (PITS)

272
Q

Homonymous quadrantanopias: inferior?

A

lesion of the superior optic radiations in the parietal lobe (PITS)

273
Q

Bitemporal hemianopia is caused by a lesion where?

A

Optic chiasm

274
Q

Bitemporal hemianopia: upper quadrant defect > lower quadrant defect?

A

inferior chiasmal compression, commonly pituitary tumour

275
Q

Bitemporal hemianopia: lower quadrant defect > upper quadrant defect?

A

superior chiasmal compression, commonly a craniopharyngioma

276
Q

Causes of absent red reflex?

A

cataracts; retinoblastoma; corneal scarring; vitreous haemorrhage.

277
Q

Ocular trauma: hyphema?

A

Blood in anterior chamber of eye

278
Q

What to do in ocular trauma with hyphema?

A

urgent referral to opthal speicalist

279
Q

What causes the risk to sight if a pt presents with hyphema following ocular trauma?

A

Raised IOP due to blockage of angle and trabecular meshwork with erythrocytes

280
Q

Ocular trauma: hyphema Mx?

A

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
Q

If a pt presents with hyphema following ocular trauma, an assessment for what should be made?

A

orbital compartment syndrome as may require immediate decompression prior to imaging

282
Q

Features of orbital compartment syndrome?

A

EMERGENCY.
Eye pain/swelling, proptosis, ‘rock hard’ eyeballs; relevent afferent pupillary defect

283
Q

Mx of orbital compartment syndrome?

A

Urgent lateral canthotomy (before imaging) to decompress orbit

284
Q

Orbital compartment syndrome?

A

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
Q

What do subconjunctival haemorrhages result from?

A

Bleeding of blood vessels into subconjunctival space. Vessels usually responsible for supplying the conjunctiva or episclera.

286
Q

Are subconjunctival haemorrhages serious?

A

Rarely indicator of anything sinister

287
Q

RFs of subconjunctival haemorrhage?

A
  • trauma
  • contact lens usage
  • idiopathy
  • newborn, elderly
  • valsalva manoeuvre eg. coughing, straining
  • aspirin, NSAIDs, anticoag
  • HTN
  • DM
  • bleeding disorders
288
Q

Symptoms of subconjunctival haemorrhage?

A
  • red eye
  • unilateral usually
  • most asymptomatic
  • mild irritation
289
Q

Signs of sunconjunctival haemorrhage?

A
  • flad red patch on conjunctiva, well-defined edges and normal conjunctiva surrounding, can be whole conjunctiva
  • vision normal
  • fundus normal
290
Q

Most common area of conjunctiva affected in subconjunctival haemorrhage?

A

inferior

291
Q

Subconjunctival haemorrhage Ix?

A
  • 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
Q

Mx for subconjunctival haemorrhage?

A
  • 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
Q

Posterior vitreous detachment?

A

Separation of vitreous membrane from retina due to natural changes to vitreous fluid of eye with ageing.

294
Q

Cx of posterior vitreous detachment?

A

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
Q

RFs of posterior vitreous detachment?

A
  • 75% people >75yrs
  • female
  • highly myopic (myopic eye has longer axial length than emmetropic eye)
296
Q

Why can posterior vitreous detachment happen as people age?

A

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
Q

CP of posterior vitreous detachment?

A
  • 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
Q

Signs of posterior vitreous detachment on opthalmoscopy?

A

Weiss ring: detachment of vitreous membrane around optic nerve to form a ring-shaped floater

299
Q

Posterior vitreous detachment Ix?

A

all should be examined by othal within 24hrs to rule out retinal tears/detachment

300
Q

Posterior vitreous detachment Mx?

A

doesn’t cause permanent loss of vision and symptoms gradully improve over 6m so no Mx needed.

301
Q

Corneal foreign body features?

A

eye pain, foreign body sensation, photophobia, watering eye, red eye

302
Q

Indications for referral if corneal foreign body?

A
  • ?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
Q

Corneal foreign body red flags?

A

Severe pain, irregular, dilated or non-reactive pupils, signif reduction in visual acuity, hyphema, hypopyon, corneal opacities

304
Q

What to do before referal if the corneal foreign body is chemical injury?

A

Irrigate for 20-30mins with water or normal saline

305
Q

Mx for corneal foreign body?

A
  • 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
Q

Blurred vision?

A

Loss of clarity or sharpness of vision. Important to assess for visual loss, double vision and floaters.

307
Q

Vast majority of pts with blurred vision have what?

A

Long-term refractive errors

308
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

309
Q

Ix for blurred vision?

A
  • Visual acuity with Snellen chart
  • Visual fields
  • Fundoscopy
310
Q

What is a good way to check if blurred vision is due to a refractive error or not?

A

Pinhole occluders when checking visual acuity; if blurring improves with pinhole occluder then likely to be refractive error

311
Q

Mx for blurred vision?

A
  • gradual, corrected by pinhole and no other symptoms= optician review
  • other eg. visual loss or pain= urgent opthal review
312
Q

Optic atrophy?

A

pale, well demarcated disc on fundoscopy; usually bilateral and causes gradual loss of vision (due to optic neuropathy)

313
Q

Acquired causes of optic atrophy?

A
  • 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
Q

Congenital causes of optic atrophy?

A
  • 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
Q

Squint (strabismus)?

A

Misalignment of visual axes

316
Q

Squint can be divided into what types?

A

Concomitant (common) and paralytic (rare)

317
Q

Why is it important to detect a squint?

A

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

318
Q

What causes a concomitant squint?

A

Due to imbalance in extraocular muscles. Convergent is more common than divergent

319
Q

What causes a parlytic squint?

A

Paralysis of extraocular muscles

320
Q

Ix for squint?

A
  • 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
Q

Mx for squint?

A

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
Q

What may help prevent amblyopia if pt has a squint?

A

Eye patches

323
Q

Why does a squint develop?

A

Lack of coordination that prevents the gaze of both eyes being directed at the same point in space

324
Q

Causes of squint?

A
  • refractive errors, poor visual acuity, neurodevelopmental conditions, brain lesions, cranial nerve palsies, low birth weight, prematurity, FHx, hypermetropia
325
Q

Parents often present their children with what if they have a squint?

A

‘turning eye’

326
Q

Causes of red eye?

A
  • AACG
  • anterior uveitis
  • scleritis
  • conjunctivitis
  • subconjunctival haemorrhae
  • endophthalmitis
327
Q

Cause of conjunctivitis if discharge is purulent?

A

Bacterial

328
Q

Cause of conjunctivitis if discharge is clear?

A

Viral

329
Q

In subconjunctival haemorrgae, the patient may have a history of what?

A

Trauma or coughing bouts

330
Q

Endophthalmitis?

A

typically red eye, pain and visual loss following intraocular surgery

331
Q

Transient monocular visual loss (TMVL)?

A

Sudden transient loss of vision that lasts <24hrs

332
Q

Causes of sudden painless loss of vision?

A
  • ischaemic/vascular icl. thrombosis, embolism, arteritis, occlusion of central retinal vein and occlusion of central retinal artery.
  • vitreous haemorrhage
  • retinal detachment
  • retinal migraine
333
Q

Differentials for amaurosis fugax?

A

large artery disease (artherothrombosis, embolus, dissection); small artery occlusive disease (vasculitis eg. temporal arteritis, anterior ischaemic optic neuropathy); venous disease; hypoperfusion; TIA

334
Q

Immediate Mx for amaurosis fugax?

A

Aspirin 300mg as may be TIA

335
Q

Amaurosis fugax

A

Sudden loss of vision; often see curtain coming down (altitudinal field defects)

336
Q

What is ischaemia optic neuropathy due to?

A

Occlusion of short posterior ciliary arteries, causing damge to optic nerve

337
Q

Central retinal vein occlusion?

A

Cause of sudden vision loss. Causes: glaucoma, polycythaemia, HTN. Common with age, more common than arterial occlusion. See severe retinal haemorrhages on fundoscopy.

338
Q

Central retinal artery occlusion is due to what?

A

Thromboembolism (from atherosclerosis) or arteritis

339
Q

Differentiate between posterior vitreous detachment, retinal detachment and vitreous haemorrhage?

A

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
Q

Ptosis + dilated pupil =?

ptosis + constricted pupil = ?

A

Ptosis + dilated pupil = third nerve palsy; ptosis + constricted pupil = Horner’s

FINALS (34 decks)

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