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Y4 Special senses > Opthalmology > Flashcards

Opthalmology Flashcards

1
Q

What is the leading cause of severe, irreversible vision loss in people over 55?

A

Acute macular degeneration

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2
Q

Risk factors for AMD

A

Age
Smoking
Ethnicity (caucasian)
Concomitant diseases
- Cardiovascular disease
- Hypertension

Ocular characteristics
- Light iris
- Hyperopia

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3
Q

What is drusen?- hallmark of AMD

A

Yellow deposits under the retina
Undigested cellular debris from degeneration of RPE (retinal pigment epithelium) cells as part of normal ageing process accumulates as drusen

Hard drusen
- Small hard, solid deposits

Soft drusen
- Larger soft deposits

Drusen may remain unchanged for years without causing sight loss
95% of elderly patients have a small number of drusen

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4
Q

Characteristics of early AMD

A
  • Few medium-sized drusen
  • Pigmentary abnormalities
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5
Q

Characteristics of intermediate AMD

A

> 1 large druse/numerous medium drusen
Geographic atrophy that does not extend to macular centre

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6
Q

Characteristics of dry AMD

A
  • Non-exudative/atrophic
  • Drusen & GA extend to the macular centre
    20% of AMD related severe visual loss

gradual vision loss

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7
Q

Characteristics of advanced wet AMD

A
  • Exudative/neovascular
  • Choroidal neovascularisation
  • 80% of AMD related severe visual loss

Rapid vision loss over days/weeks

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8
Q

What can cause hypo/hyperpigmentation of the RPE?

A
  • Age-dependent phagocytic and metabolic insufficiency of postmitotic RPE cells
  • Progressive accumulation of lipofuscin (age pigment) granules
  • Cytotoxic component which has the potential to damage proteins, lipids and DNA
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9
Q

AMD progression

A

Soft drusen ‘lift’ the RPE away from Bruch’s membrane, which may result in
- Hypoxic state
- Inflammation

Soft drusen are more likely to promote progression to advanced AMD

Later the stage of dry AMD- higher the probability it will progress to advanced AMD in 5 years

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10
Q

How does dry AMD convert into wet AMD?

A

Vascular endothelial growth factor plays a role

Drusen- inflammation- macrophages- VEGF- VEGF signalling cascade

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11
Q

Where does Drusen accumulate in dry AMD?

A

Between the RPE and Bruch’s membrane

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12
Q

What are the characteristics of advanced dry AMD

A
  • Confluent drusen
  • Central and paracentral degeneration of the macula
  • Atrophy of chriocapillaris, RPE and photoreceptors
  • Geographic atrophy is a term used to describe advanced map-like area of atrophy extending to foveal centre
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13
Q

Key symptoms of AMD

A

Key symptoms include subacute loss of and/or distortion of the central visual field, reduced visual acuity, night blindness, and photopsia.

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14
Q

Primary investigations for AMD

A

The primary investigation methods include slit-lamp biomicroscopy, colour fundus photography, fluorescein angiography, and ocular coherence tomography (OCT).

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15
Q

Management of AMD

A

Management generally involves smoking cessation, and depending on the type of ARMD, zinc and antioxidant supplements (dry ARMD) or anti-vascular endothelial growth factor (anti-VEGF) injections (wet ARMD).

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16
Q

What is metamorphosia?

A

Visual distortion – particularly line perception when tested with Amsler grids.

(Google amsler grids)

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17
Q

Signs of AMD

A

Visual distortion – particularly line perception when tested with Amsler grids. This is known as metamorphopsia.
Drusen in dry ARMD – yellow pigmented spots on the retina that are collected around the macula
Subretinal or intraretinal haemorrhages in wet ARMD – seen as red patches on the retina around the macula

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18
Q

Symptoms of AMD

A

Reduced visual acuity, worse for near vision and central vision (patients may say they struggle seeing faces)
Variability in visual disturbance from day to day is characteristic
Poor vision at night
Photopsia – perceived flickering of lights
Glare

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19
Q

How to treat dry AMD

A

Zinc and antioxidant vitamin A, C and E supplements have been shown to reduce progression by up to 30%.

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20
Q

How to treat wet AMD

A

Anti-vascular endothelial growth factor (anti-VEGF) injections limit progression and can even reverse vision loss – typically administered in monthly injections.

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21
Q

What drives the progression of wet AMD?

A

VEGF-A induced neovascularisation drives the progression of wet AMD
VEGF-A is thought to cause abnormal blood vessel growth and leakage

VEGF-stimualted new blood vessels extend through Bruch’s membrane
Fluid and blood leaks beneath and into the retina
Formation of fibrous scar tissue
Central vision loss

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22
Q

What is a Disciform scar?

A
  • Wet AMD eventually gives rise to a disciform (disc-like appearance scar)
  • The scar represents the portion of the macula that has been permanently damaged
    It will cause a blind spot (scotoma) in the field of vision
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23
Q

What are four risk factors that give a greater risk of wet AMD development

A
  • More than five drusen
  • Large (soft or confluent) drusen
  • Pigment clumping in the RPE
  • Systemic hypertension
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24
Q

Fundoscopic examinatino of wet AMD

A
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25
Q

What is AMD?

A

Degeneration of the central retina (macula) is the key feature with changes usually bilateral. ARMD is characterised by degeneration of retinal photoreceptors that results in the formation of drusen which can be seen on fundoscopy and retinal photography.

Blurs central vision

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26
Q

What is the uvea?

A

The pigmented layer of the eyeball

Consists of three parts:
- Iris
- Ciliary body
- Choroid- the most vascular layer in the body

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27
Q

Auto-immune causes of uveitis

A

Autoimmune
- Sarcoid
- SLE
- MS
- Bechet’s

Infections
- CMV, HSV
- Candida
- Toxoplasma
- TB

Drug induced
- Bisphosphonates
- Rifabutin
- Aciclovir

Traumatic

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28
Q

How to divide uveitis on keratic precipitates

A

Granulomatous- button fatty deposits on the cornea

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29
Q

Anterior uveitis

A

Inflammation of the iris

Blurring of vision
Pain
Photophobia- blood vessels dilate, leak WBC into anterior chamber, clear aqueous to turbid fluid
Redness of the eye- conjunctiva

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30
Q

Signs of uveitis

A
  • Keratic precipitates- with inflammation comes heat, they rise but become trapped by the cornea
  • Cells in anterior chamber
  • Fibrin in anterior chamber
  • Flare in anterior chamber (beam of light, can see white blood cells)
  • Posterior synechae
  • Cells in vitreous
  • Choroiditis lesions
  • Macular oedema
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31
Q

What lies behind the iris

A

Lens
The iris would stick onto the lens

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32
Q

Circumcorneal congestion
Posterior synechiae

A

The posterior part of the iris gets stuck to the lens

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33
Q

Intermediate uveitis

A

Inflammation of ciliary body
Blurring of vision
Floaters- cells in vitreous form clumps

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34
Q

Signs of intermediate uveitis (cilairy body)

A
  • Snow balls
  • Cells in vitreous
  • Snowbanking
  • Sheathing of blood vessels
  • Macular oedema
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35
Q

Posterior uveitis

A

Blurring of vision
Floaters
No pain

Common cause is Toxoplasma

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36
Q

Cycloplegics

A

Dilates the pupil
Breaks up the sticking
Causes paralysis of the ciliary muscle

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37
Q

Complications of anterior uveitis

A
  • Posterior synechiae
  • Pupillary membrane
  • Ocular hypertension/glaucoma
  • Hypotony
  • Cataract
  • Cystoid macular oedema

Once you treat the inflammation the pressure should come down

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38
Q

Complications of topical steroids to the eye

A

Cataracts and raised pressure (normally after 4 or 5 days the pressure goes up)

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39
Q

With anterior uveitis and increased pressure what can you manage the patient with?

A

Steroids (however this will also increase pressure) so add a blood pressure lowering medication

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40
Q

How can you tell whether raised pressure is due to steroids or the inflammation

A

See if the inflammation is getting worse or better

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41
Q

What type of cataract do you get with topical steroids to the eye?

A

Posterior sub-capsule cataract
Red crumb appearance

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42
Q

Cystoid macular oedema

A

Petalloid appearance

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43
Q

Intermediate uveitis

A
  • Cystoid macular oedema
  • Glaucoma
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44
Q

How do you manage uveitis in the acute phase

A

Cycloplegic mydriatic drops e.g. cyclopentolate
These cause iris dilation and help to break/prevent posterior synechiae
Corticosteroids (topical, oral, IV, or IM), typically starting on an hourly regimen and then gradually tapered
Analgesia

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45
Q

How do you manage chronic uveitis?

A

Chronic uveitis may necessitate systemic steroid-sparing immunosuppressants, such as methotrexate or mycophenolate. Evidence also supports the use of biologic therapies targeting specific elements of the inflammatory cascade, such as adalimumab.

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46
Q

How do you investigate uveitis?

A

Thorough examination and investigations are crucial to ascertain underlying disease processes causing inflammation. These may include:

Complete ocular examination including slit-lamp testing
Blood tests for autoimmune markers
Infectious disease screening

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47
Q

What is the JH reaction in syphilis?

A

Jarisch-Herxheimer reaction

The JH reaction is a systemic reaction resembling bacterial sepsis that usually begins 6 to 8 hours after the initial treatment of syphilis with effective antibiotics, especially penicillin. It is particularly common when secondary syphilis is treated but can occur at any stage.

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48
Q

What passes through the optic canal?

A

Transmits the optic nerve and ophthalmic artery.

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49
Q

What passes through the superior orbital fissure?

A

Transmits the lacrimal, frontal, trochlear (CN IV), oculomotor (CN III), nasociliary and abducens (CN VI) nerves. It also carries the superior ophthalmic vein.

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50
Q

What passes through the inferior orbital fissure?

A

Transmits the zygomatic branch of the maxillary nerve, the inferior ophthalmic vein, and sympathetic nerves.

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51
Q

What structure is behind the orbit, meaning a brain herniation would be pulsatile?

A

Internal carotid artery

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52
Q

What is seen in a third nerve palsy?

A

Ptosis
Superior, inferior, and medial recti; inferior oblique; and levator palpebrae superioris) and autonomic (pupillary sphincter and ciliary) muscles.

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53
Q

What is opthalmoplegia?

A

Ophthalmoplegia is a condition characterised by the paralysis or weakness of one or more of the extraocular muscles responsible for eye movement. It can affect the muscles controlling eye movements in any direction and may be unilateral (affecting one eye) or bilateral (affecting both eyes).

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54
Q

What is retrobulbar hemorrhage

A

Retrobulbar hemorrhage (RBH) is a rapidly progressive, sight-threatening emergency that results in an accumulation of blood in the retrobulbar space

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55
Q

How to manage retrobulbar haemorrhage due to compartment syndrome?

A

Lateral canthotomy

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56
Q

Most common cause of a blow-out fracture in kids?

A

Knees into face on a trampoline

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57
Q

What is the relationship between the levator palpebrae superioris and the superior tarsal plate?

A

LPS is attached onto STP
Elevates the eyelid

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58
Q

What is the difference between axial proptosis and extra-axial proptosis?

A

Axial
- The globe is displaced directly forward due to swelling within the muscle cone of the orbit. This can be caused by a lesion within the muscle cone or directly behind the globe.

Extra-axial
- The globe is displaced sideways or vertically due to swelling outside the muscle cone

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59
Q

Causes of axial proptosis

A
  • Thyroiditis
  • Orbital cellulitis
  • Neuroblastoma
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60
Q

Causes of extra-axial proptosis

A
  • Osteomas
  • Abscesses
  • Lacrimal gland tumours
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61
Q

Purpose of the choroid plexus

A

The choroid is a dense network of blood vessels and pigmented stroma between the retina and the sclera. The choroid supplies nutrition to the posterior layers of the retina.

It is black to absorb reflections of light

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62
Q

What is the most common benign tumour of the orbit?

A

Pleomorphic adenoma
Has malignant potential so has to be removed using a cryo tweezer still kept within the capsule

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63
Q

What can occur in squint surgery if more than 4 muscles are damaged at once?

A

Ischaemia leading to blindness

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64
Q

Signs of raised ICP

A
  • 6th nerve palsies
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65
Q

Describe production and drainage of aqueous humour

A

Aqueous humour secreted by ciliary processes
within ciliary body

Flows from posterior chamber, through pupil
into anterior chamber

Nourishes lens and cornea

Drains through iridocorneal angle (between iris
and cornea)

Via trabecular meshwork into canal of Schlemm
(circumferential venous channel draining into
venous circulation)

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66
Q

Are your pupils constricted or dilated when you are sleeping?

A

Constricted
Parasympathetic pathways

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67
Q

Investigation in opthalmology to look into the eye

A

Slit lamp
Get to see a cross section of the eye

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68
Q

How do you know where you are on fundoscopy?

A

Branches of the blood vessels will join in an arrow formation together- all points towards the optic canal

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69
Q

Possible complication of a sub-periosteal abscess

A

Can drain into the cavernous sinus

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70
Q

What is the most common cause of proptosis?

A

Thyroiditis

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71
Q

What would you see on CT of retinoblastoma

A

White depostis of calcium
Improving with smart phones! Flash on the camera will show white reflexes (alarming) instead of the red reflex

Common in Asian population- improved detection with smart phones

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72
Q

What is glaucoma caused by?

A

Glaucoma is a group of conditions with characteristic optic nerve head changes associated with corresponding visual field defects, with or without raised intra ocular pressure.”

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73
Q

What can glaucoma cause if it’s optic nerve damage?

A

Affects peripheral vision (commonly asymptomatic because of this)
Gradually causes total sight loss

One of the main cause of irreversible blindness in the world

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74
Q

What is the most common type of glaucoma?

A

Chronic: open-angle glaucoma [most common]
Trabecular meshwork deteriorates as age
Many asymptomatic [picked up on routine eye tests]
Increased IOP ↑ optic disc cupping
Gradual loss of peripheral vision

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75
Q

What is seen on fundoscopy with glaucoma

A

Increased optic cup: disc ratio on fundoscopy
(increased optic disc cupping)

Cup is the yellower central circle- nerve fibres scaffold the blood vessels so thy come through the middle. As nerve fibres die, cup becomes bigger

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76
Q

DVLA rules with glaucoma

A

Diagnosed should inform the DVLA
Binocular visual field tests to see if they are still safe

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77
Q

Does glaucoma commonly affect horizontal or vertical visual fields?

A

Horizontal

Vertical are more likely to be visual field tract palsies

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78
Q

Why do you get optic nerve damage with glaucoma?

A
  1. Pressure in anterior chamber- presses on posterior- presses on nerve
  2. Oxygen supply to optic nerve deteriorates over time
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79
Q

What is the main difference between open-angle glaucoma and acute angle closure glaucoma?

A

Chronic open angle= trabecular meshwork deteriorates as you age

Acute closed angle= narrowing of iridiocorneal angle (ophthalmological emergency)

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80
Q

Risk factors for glaucoma

A
  • Increasing age
  • American, South asian descent
  • Family history
  • Those who are really short sighted (more likely to get open angle)
  • Those who are long sighted (more likely to get angle closure)
  • Trauma to the eyes
  • Steroids that increase eye pressures
  • Higher than normal intra ocular pressures
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81
Q

What is a normal IOP?

A

Normal range is quoted as 10 to 21 mmHg with a mean of 16mmHg

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82
Q

What IOP is a major risk factor for the development?

A

IOP >21 mm Hg

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83
Q

Medical therapy to treat glaucoma

A

Beta blockers e.g. Timolol

Muscarinic agonist/ Miotics: e.g. Pilocarpine

Prostaglandin agonist e.g. latanoprost

Alpha Adrenergics: e.g. brimonidine

Carbonic Anhydrase Inhibitors (CAI) e.g.
Dorzolomide eye drops or acetozolomide

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84
Q

Ways of reducing IOP

A
  • Medical therapy
  • Laser therapy (good as medical therapies can have lots of side effects), can destroy parts of the ciliary body so you are not producing as much aqueous humour.
  • Surgery (trabeculectomy)
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85
Q

How do you measure IOP

A

Tonometry measures the pressure inside of your eye by flattening your cornea (the clear part at the front of your eye). The more force that’s needed to flatten your cornea, the higher your eye pressure is. The most common type of tonometry is non-contact or air puff tonometry.

Use goldmann mires- diameter of the two rings will equate to the IOP

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86
Q

What is a filtering bleb in surgery for glaucoma?

A

Trabeculectomy is a filtering surgery where an ostium is created into the anterior chamber from underneath a partial thickness scleral flap to allow for aqueous flow out of the eye.

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87
Q

What is treatment for acute angle closure glaucoma?

A
  • Lie them down- iris flops down
  • IV Acetazolamide
  • IOP lowering drugs- Aprachlonodine, Timolol
  • Laser peripheral irdotomy- do in the other eye!!
  • Steroids
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88
Q

What is it called if you are long sighted?

A

Hypermetropic

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89
Q

Explain the accommodation reflex

A

Light from near-objects more divergent
Greater refraction required to focus onto retina, beyond
capabilities of cornea (which is fixed in shape)
Eye accommodates
1. Pupil constricts (limits amount of light coming through)
2. Eyes converge (to ensure image remains focused on same
point of retina in both eyes)
3. Lens becomes more biconvex (fatter) by contraction
of ciliary muscle
Lens becomes stiffer with age and less able to change
shape

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90
Q

What is a refractive error?

A

Any sight problem that means you have blurry vision

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91
Q

What can be the aetiology of refractive errors?

A
  • Normal corneal power but different axial length
  • Normal axial length but different corneal power (flattened)
  • Physiological or pathological
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92
Q

What are the two different causes of myopia?

A

Either the eyeball is too long (most people)

Or the cornea is too steeply curved

Concave lens- diverges the light again

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93
Q

Two causes of hypermetropia (difficulty seeing near objects clearly)

A

Short axial lenth and normal cornea
or

Low power cornea and average axial length

The convex lens converges the light rays (instead of diverges the light rays which is the treatment for myopia)

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94
Q

Astigmatism

A
  • Anatomical variation, cornea has two axes of curvature

Rugby ball vs football

Results in two foci

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95
Q

In essence what is laser therapy of the eyes?

A

Re-shaping the cornea

Short sighted= try and flatten the cornea

Long sighted= try and curve the cornea

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96
Q

What is the gold standard of measuring visual acuity now?

A

Logarithmic charts instead of snellen chart

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97
Q

What does 6/60 mean with a snellen chart?

A

You can only read the top line (at 6m) Someone else with perfect vision would be able to read this at 60m.

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98
Q

What visual acuity tool can you use on the wards or at home to assess vision?

A

A 3m chart instead of the 6m one

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99
Q

Difference between orthoptist and optometrist?

A

Orthoptist- focus on how the eyes work together. Ambylopia (lazy eye) and strabismus (squint)

Optometrist- Focus on examining the eye itself, and diagnose and treat eye conditions, prescribe glasses and contact lenses, and treat common eye problems. Optometrists may work in hospitals, optical practices, research, academics, or specialty clinics.

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100
Q

What is the pinhole test?

A

If they can see better through the pinhole= it is measurable

Uncorrected refractive error

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101
Q

How do eye patches improve ambylopia?

A
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102
Q

What is a simple test for myopia?

A

Pinhole test
People with myopia, or nearsightedness, can see better with a pinhole test because the pinhole effect blocks out unfocused light rays, allowing only focused light to hit the retina

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103
Q

Why do you need cycloplegic refraction in kids?

A

Kids have a very good accommodation reflex. This can potentially hide refractive errors.

104
Q

What are some causes of the loss of red reflex in kids?

A
  • Cataracts
  • Coats disease (abnormal blood vessels)
  • Retinoblastoma
  • Retinopathy of prematurity and retinal detachment
105
Q

What are some causes of cataracts in kids?

A
  • TORCH infections (Toxoplasmosis, Other- syphyllis, varicella, Rubella, Cytomegalovirus, Herpes Simplex
  • Enzyme deficiency-Galactokinase
  • Diabetes
106
Q

What is pseudo-squint due to epicanthal folds?

A

Epicanthal folds= Vertical skin folds that cover the inner corners of the eye (common in down syndrome and asian population)

The eyes are actually aligned correctly.

107
Q

How do you differentiate between pseudo-squint and a true squint?

A

Light reflex
In pseudo the light reflexion will be the same in both eyes

108
Q

What actually happens in a squint to lead to ambylopia

A

Squint occurs when both the eyes don’t point in the same direction
The two eyes see different things
The brain can’t combine the two different images from the two eyes together
The brain then ignores one eye and the vision in that eye can deteriorate

Very important before the age of 7 as the eyes have not developed

109
Q

What is the difference between Esotropia and Esophoria?

A

Esotropia is when one or both of the eyes turn inwards when looking at an object

Esophoria where one or both of the eyes turn inward when relaxed- do not do that when both eyes are focused on an object

110
Q

How do you test for ‘tropias’

A

Cover test
When one eye is covered during the cover test, the affected eye will typically move to fixate on the target.

111
Q

Causes of ptosis in kids

A
  • Traumatic
  • Congenital dysgenesis of levator
  • Neurogenic & myogenic horner’s syndrome
  • Myasthenia
  • Hemangioma
112
Q

What is a coloboma?

A

Failure of the optic fissure to close (Iris/choroidal and retina/macula)

Nystagmus and squints can occur- brain’s attempt to compensate for the eye’s abnormalities

113
Q

What is watery eye/epiphora?

A

Excessive tearing
Nasolacrimal duct non canalisation; most settle in first year of life, reassurance and massage if no improvement

114
Q

What is retinopathy or prematurity

A

Low birth weight and born before 31 week of gestation
Abnormal blood vessels grow in the retina

115
Q

How to test vision in kids

A

8 weeks to 12 months- Keeler preferential looking cards (barcodes)

3-18 months- Cardiff acuity cards (simple picture)

2-4 years- Kay pictures

4+ years- LogMAR keeler book (can be used in patients with stroke who can’t speak)

116
Q

Other things to look at (orthoptics) for kids

A
  • Compensatory head posture
  • Ptosis
  • Nystagmus
  • Unequal pupils
  • Facial asymmetry
  • Signs of trauma
117
Q

How can you tell a real squint from a fake squint?

A

See where the corneal reflection is (white spot)
If not central- real squint

118
Q

4th nerve palsy presentation

A

Face turned
Head tilted
Chin depression

All to accommodate for an eye turned up

119
Q

Look at ocular motility documentation

A
120
Q

What is the vision like of a newborn?

A

Blurry and black and white

121
Q

What can ambylopia be caused by

A

Strabismus
Anisometropia (difference in refractive error)
High bilateral refractive
Stimulus deprivation- ptosis, cataract
High astigmatism- makes vision difficult to adapt to

122
Q

How to treat ambylopia

A
  • Patching
  • Atropine
123
Q

What is squint surgery and why is it neeed?

A

The surgeon uses a lid speculum to hold the eye open, detaches part of the eye muscle, and moves it to a new position. The muscle is then fixed with dissolvable stitches that are hidden behind the eye

The surgeon uses a lid speculum to hold the eye open, detaches part of the eye muscle, and moves it to a new position. The muscle is then fixed with dissolvable stitches that are hidden behind the eye

However…not a permanent fix- can come back

124
Q

What further tests would you do to ensure strabismus is not a result of fundus of media pathology

A

Cataract or retinoblastoma
OCT
MRI
Blood tests

125
Q

How prisms are used with squints

A

Prisms bend light
Measures the strabismus

126
Q

Why do people with childhood squints not have diplopia?

A
  • The brain suppresses part of the retina to avoid diplopia
  • Essentially making patients operate monocularly
  • Depending on whether the patient is esotropic or exotropic, either the nasal half or temporal half of the retina will be suppressed
127
Q

What are the two branches of the oculomotor nerve

A

Superior- LPS, superior rectus

Inferior- medial rectus, inferior rectus, inferior oblique

128
Q

Classic features of 3rd nerve palsy

A
  • Ptosis
  • Eye depressed and abducted
  • Pupil may be dilated and unreactive
  • Diplopia
129
Q

Why is a pupil involvement worrying?

A

Dilated/unreactive/blown
Indicative of compressive aetiology

Need a scan ASAP!

130
Q

Aetiologies of 3rd nerve palsies

A
  • Microvascular (diabetes, hypertension)
  • PCA aneurysm
  • SOL
  • Trauma
  • Demyelinating disease
  • Infection
  • GCA
  • Congenital
131
Q

Back of head trauma leads to..

A

4th nerve palsy
Trochlear nerve
Only nerve to leave brainstem backwards, before curling around anteriorly

132
Q

Classic features of 4th nerve palsies

A

Eye is facing up and inwards
CHP head tilt to unaffected side, chin depression
Diplopia vertical
Torsion

133
Q

Aetiologies for trochlear nerve palsies

A
  • Trauma to the back of the head
  • Microvascular (DM, hypertension)
  • Demyelinating disease (MS)
  • Tumour
  • Aneurysm
  • Congenitla
134
Q

How do you treat trochlear nerve palsies

A
  • Prism
  • Surgery
135
Q

Where does the 6th nerve exit

A

The change in intraocular pressure can cause downward herniation of the brainstem, resulting in stretching or compression of the sixth nerve.

Exits the pons and runs over the petrous temporal ridge

136
Q

How do prisms fix double vision?

A

How Do Prism Glasses Fix Double Vision? A prism added to eyeglasses bends light before it travels through the eye. The light is redirected to the right place on the retina in each eye. The brain then fuses the two images together to produce one, clear picture.

137
Q

Eye signs/symptoms of myasthenia gravis

A
  • Ptosis
  • Strabismus
  • Diplopia
  • Accommodation fatigue (blurred vision)
138
Q

What is the treatment in a myasthenia gravis crisis?

A

IV IG
Plasmapheresis

139
Q

Medication used in myasthenia gravis

A

Anticholinesterase agents
Pyridostigmine

Steroids

140
Q

What is chemosis?

A

Chemosis is a swelling of the conjunctiva, the clear membrane that covers the whites of the eyes

141
Q

What does exenterate mean?

A

Remove the contents of a bodily cavity (common of the orbit)

142
Q

What would a Short Tau Inversion Recovery MRI sequence be useful for?

A

Looking at swelling
STIR sequence suppresses the signal from fat

143
Q

Commonest cause of proptosis unilateral/bilateral

A

Thyroiditis

144
Q

Symptoms of thyroiditis

A
  • Double vision
  • Watery eyes
  • Lateral flare
  • Photophobia
  • Redness
  • Upper lid retraction
  • Swelling
  • Dry gritty eyes
145
Q

What causes proptosis with thyroiditis?

A

Antibodies attack the tissue around the eye

Stimulate the thyroid to produce T3/T4 which suppresses TSH

146
Q

What is the score to determine active thyroid eye disease- management

A

Most need artificial tears

Mourits score - would treat with a score of 3 with steroids

  • Spontaneous retrobulbar pain
  • Pain on eye movement
  • Redness of eyelids
  • Redness of conjunctiva
  • Swelling of the eyelids
  • Swelling of the caruncle or plica
  • Increase in proptosis
147
Q

What is a serious complication with thyroid eye disease?

A

Dysthyroid optic neuropathy
- Optic nerve is compressed
- Potential vision loss
- Inflammation and swelling of the orbital tissues

148
Q

What is a white-eye blowout fracture?

A
  • Lack of visible signs of trauma on inspection (hence white eye)
  • More elastic bones in children- muscle is trapped in the fracture leading to pain, double vision and sometimes nausea or slow heart rate
149
Q

Signs/symptoms of blow-out fractures

A
  • Double vision
  • Enopthalmus
  • Loss of vision
  • Surgical emphysema- blowing nose, air travels through broken ethmoid sinus
  • Other facial injuries/head/neck
150
Q

Treatment for blow-out fractures

A
  • Meshwork placed inferiorly
  • Max-fax surgeons
151
Q

Orbital cellulitis

A
  • Usually relatively mild
  • Can be blinding
  • Can be fatal
152
Q

How can orbital celluiits be fatal?

A

Necrotising fascitis
Posteriorly venous thrombosis in the cavernous sinus
Cerebral abscess
Meningitis

153
Q

What is orbital cellulitis?

A

Infection of the tissues around the eye, fat and muscles within the eye socket

(posterior septal cellulitis)- deeper infection and you lose vision

154
Q

What is pott’s puffy tumour?

A

Swelling of the forehead, infection in the frontal sinus. Pus in the cranium

155
Q

What is Ophthlalmia neonatorum

A

Infant could have picked up an infection in vaginal birth
Can result in serious corneal disease and blindness
Urgent samples sent
Topical antiboitic drops
Admit under paeds
Will need systemic treatment

156
Q

Symptoms and treatment of allergic conjunctivitis

A
  • Itching, redness, history of atopy
  • Chemosis and papillae in conjunctiva
  • Topical antihistamine
  • Oral antihistamine
  • Topical steroids
157
Q

What are the differences between episcleritis/scleritis

A

Episcleritis has minimal dismofort, self-limiting, possibly topical NSAIDs/Mild steroids

Scleritis is extremely painful, can affect vision, treated with oral NSAIDs, oral prednisolone

158
Q

Main symptoms to ask about when someone presents with a red eye

A
  • Pain
  • Visual loss (corneal ulceration, glcuaoma, iritis)
  • Gritty sensation (conjunctivitis, dry eye, foreign body)
  • Itching (allergic eye disease, blepharitis)
159
Q

What is the management of bacterial conjunctivitis

A

OC Cloramphenicol 1% QDS for 1 week

160
Q

How do you manage chlamydial conjunctivits

A

Swab chlamydia
Refer to GUM
Topical antibiotics and systemic Azithromycin or Tetracycline

161
Q

Viral or fungal causes of corneal ulcers

A

Viral- HSK, HZO, Adenovirus

Fungal- Acanthamoeba

162
Q

What from the history would make you think about corneal ulcers?

A
  • Very painful
  • Photophobia
  • Contact lens wearers
  • Facial cold sores
  • Rash or vesicles
  • Recent injury/abrasions
163
Q

What is fluorescein?

A

Medical dye

Checks for corneal abrasions, ulcers or foreign bodies

Can also examine blood vessels in the retina and choroid

164
Q

What is Herpes Simplex Keratitis?

A

Infection of the cornea by the HSV virus

Common cause of corneal ulcers

165
Q

Pterygia and Pingueuculum ?

A

Both non-cancerous growths that appear on the conjunctiva

Pinguecula- a yellowish, benign bymp which does not grow into the cornea

Pterygium- A growth that can extend onto the cornea (associated with UV exposure, dryness and irritants)

166
Q

What is Blepharitis?

A

Inflammation of meibomian glands

Results in dry eye
- Grittiness and redness

Treatment- eyelid hygiene and lubricant eye drops

166
Q

Which conditions are the most sight threatening

A

Angle closure glaucoma
Vision reduces within minutes to hours
Scleritis and corneal ulcer

167
Q

What would you use to help examine the eye?

A
  • Snellen chart (visual acuity)
  • Opthalmoscope (blue light) corneal abrasions, ulcers
  • Magnifying aid- foreign bodies, minute abrasions
  • Fluroscein- steans the tear film to highlight any corneal damage
  • Slit lamp- detailed view of the eye
167
Q

How can you tell the difference between episcleritis and sclerotis

A

Episcleritis- looks like a little red triangle (outer blood vessels) more likely to be a foreign body

Scleritis- tends to be a deeper red, more diffuse and a lot more painful!

Phenelffrin- would blanch with episcleritis (superficial)

168
Q

How would you treat a Hypopyon?

A

Intensive drops of Fluroquinolones

169
Q

Associated conditions of Iritis (inflammation of iris)

A
  • Sarcoidosis
  • HZO
  • Syphyllis
  • TB
170
Q

What would you see on examination of the eye with Iritis?

A

Keratic precipitates
Posterior psynaechiae

171
Q

What do diopters mean?

A

A measure of refractive power

172
Q

How many diopters does the cornea have?

A

40
Responsible for 2/3 of refraction of light
Cornea protects from UV rays, protects the eye

173
Q

What is the main role of the lens?

A

Accommodation reflex

174
Q

What is the uvea?

A

Middle section of the eye
Made up of
- Choroid
- Ciliary body
- Iris

175
Q

Why is pilocarpine useful in acute angle-closure glaucoma

A

A direct parasympathomimetic (e.g. pilocarpine, causes contraction of the ciliary muscle → opening the trabecular meshwork → increased outflow of the aqueous humour)

176
Q

Causes of horner’s syndrome

A
  • Carotid artery dissection
  • Pancoast tumour
  • Midbrain, brain stem, upper spinal cord lesions
177
Q

What muscles of the eye does oculomotor nerve innervate?

A
  • Superior rectus
  • Medial rectus
  • Inferior rectus
  • Inferior oblique
  • Levator palpebrae superioris
  • Sphincter pupillae
178
Q

What is more worrying, a unilateral constricted or blown pupil?

A

Constricted
- Sympathetic nerve is in the centre of the oculomotor nerve
- Sign of microvascular damage
- Like diabetes

Blown
- Sign of rasied ICP
- Parasympathetic fibres are on the outside of the oculomotor nerve

179
Q

What is the test called to assess colour blindness?

A

Ishihara
If they say they can’t see the first one (12) they are lying- nothing to do with colour blindness, everyone should be able to see that

180
Q

What should you remember with the log-mar scale?

A

Higher the number, worse the vision

181
Q

Explain RAPD (Relative Afferent Pupillary Defect)

A
  • Problem with the way one eye sends light signals to the brain.
  • When light is shone into the healthy eye, both pupils constrict normally
  • When light is shone into the affected eye, both pupils may dilate or show less constriction than expected. This happens because the damaged eye sends weaker signals to the brain, so the brain thinks there is less light coming in.
182
Q

Causes of a loss of red reflex

A
  • Cornea
  • Retinoblastoma
  • Bleed (vitreous humour)
183
Q

Most common cause of dendritic ulcer

A

HSV

184
Q

Normal pressure of the eye

A

10-20mmHg

185
Q

How long can it take to recover from cataract surgery?

A

2-6 weeks

186
Q

How long does cataract surgery normally take?

A

30-45 minutes

187
Q

What type of anaesthetic is done for cataract surgery?

A

Topical anaesthesia- Lidocaine directly onto the cornea, combined with intracameral anaesthesia (injection into the anterior chamber of the eye)

Sub-tenon’s block- local anaesthetic into the sub-tenon’s space, potential space between the sclera and tenon’s capsule

188
Q

What does FACO IOL refer to with cataract surgery?

A

FACO (phacoemulsification)
- Ultrasond waves that break up the lens
- Then vacuumed up

IOL
- Intraocular lens

189
Q

What lens options are there for cataract surgery?

A

Monfocal in the NHS

Choose whether you want to be short or long sighted, will need glasses for either reading or driving

190
Q

What is the after-care from cataract surgery?

A
  • Numbing ointment
  • Wear an eye guard at night for a week
  • Should NOT rub the eye
191
Q

Points for doing both or just one eye for cataract surgery?

A

One eye- in case there is an infection during surgery, likely to be both eyes and you could go blind! Better to do them a few weeks apart to avoid this.

Both eyes- if your patient has to go under general anaesthesia (learning disability, dementia) makes sense to do them both at the same time.

192
Q

Indication of multi-focal lens but the disadvantage

A

Indication- allows you to see at multiple distances
Disadvantage- reduced contrast sensitivity in low-lighting, glare and halos.

193
Q

What drugs are commonly used after cataract surgery?

A

Levofloxacin (broad spectrum floroquinolone)
Dexamethasone

194
Q

Can the new lens adjust it’s thickness?

A

No
That’s why you have monofocal lens- choose your eyesight essentially

The new lens sits inside the capsular bag which is left in place. Corners anchor it down.

195
Q

What systemic conditions can lead to ocular discomfort?

A
  • Sjogren’s
  • Rheumatoid arthritis
  • Thyroid eye disease
  • Rosacea
196
Q

What are neurological causes of ocular discomfort?

A
  • Trigeminal neuralgia
  • Migraine- associated ocular symptoms (photophobia)
  • Ocular neuropathic pain (due to nerve damage)
197
Q

What eyelid conditions can lead to ocular discomfort?

A
  • Blepharitis (inflammation of the eyelid margins)
  • Chalazion (blocked meibomian gland)
  • Entropion
  • Ectropion
198
Q

What infections can cause ocular discomfort?

A
  • Bacterial conjunctivitis
  • Viral conjunctivitis (adenovirus)
  • Herpes simplex keratitis
  • Fungal keratitis
199
Q

What are the causes of blurred vision?

A
  • Refractive errors (myopia, hyperopia, astigmatism, presbyopia)
  • Cataracts (clouding of the lens)
  • Macular degeneration
  • Diabetic retinopathy
  • Optic neuritis
200
Q

What conditions can cause double vision?

A
  • Cranial nerve palsies (3,4,6)
  • Myasthenia gravis
  • Thyroid eye disease
  • Brainstem lesions
  • Orbital trauma or fractures
201
Q

What are the causes of central vision loss?

A
  • Age-related macular degeneration
  • Diabetic macular oedema (swelling in the macular area)
  • Macular hole
  • Stargardt disease (hereditary form of macular degeneration)
202
Q

What can lead to colour vision changes?

A
  • Optic neuritis
  • Medications (ethambutol, digoxin toxicity)
  • Diabetic retinopathy
203
Q

What are the causes of transient visual loss?

A
  • TIA
  • Ocular migraine
  • Papilloedema
  • GCA
204
Q

What can cause distortion of vision?

A
  • Macular degeneration
  • Macular hole
  • Diabetic macular oedema
205
Q

What conditions can lead to night blindness?

A
  • Retinitis pigmentosa
  • Vitamin A deficiency
  • Cataracts
  • Glaucoma
206
Q

What can cause flashes of light?

A
  • Posterior vitreous detachment
  • Retinal tear
  • Migraine with aura
  • Optic neuritis
207
Q

What are common causes of floaters?

A
  • Posterior vitreous detachment
  • Retinal tear or detachment
  • Vitreous haemorrhage
  • Inflammatory conditions
208
Q

What are the causes of purulent ocular discharge?

A
  • Bacterial (staph aureus)
  • Hyperacute bacterial conjunctivitis (neisseria gonorrhoeae)
209
Q

What conditions cause stringy ocular discharge?

A
  • Viral conjunctivitis (most commonly adenovirus)
  • Allergic conjunctivitis
  • Dry eye syndrome
210
Q

What are the causes of discharge associated with contact lens wear?

A
  • bacterial keratitis
  • Fungal keratitis
  • Giant papillary conjunctivitis
211
Q

What are some key symptoms of retinitis pigmentosa?

A

Reduced peripheral vision or “tunnel vision”
Nyctalopia (night blindness)
Impaired dark adaptation
Photopsia (flashing lights)
Glare
Reduced central vision

212
Q

What are the investigations for retinitis pigmentosa?

A

Fundoscopy: revealing peripheral bone-spicule pigmentation, optic disc pallor, and retinal vessel attenuation

Electroretinography (ERG): showing reduced or absent rod responses

Genetic testing: to identify specific genetic mutations

213
Q

Types of local anaesthetic used for eye surgery

A

Sub-tenon
Peri-bulbar
Retro-bulbar

214
Q

Why is hypermetropia (can’t see up close) associated with acute angle closure glaucoma?

A

The eyes are shorter and the structures are crowded together
Smaller space for fluid drainage

215
Q

Why is myopia (can’t see in the distance) associated with open angle glaucoma?

A
  • Longer in shape
  • Structural weakness as everything is stretched)
216
Q

Tests done in glaucoma clinic

A
  • Pachiometry (measure corneal thickness) as this will affect readings
  • ARPD (can get this with glaucoma if one eye is worse than the other) and light reflexes
  • Pressure of the eyes
  • Measure the iridio-corneal angle
217
Q

What pressure should the eye be kept at ideally with glaucoma?

A

7/10 mmHg
You want to keep the pressure particularly low especially as there is already optic nerve damage

218
Q

Why does acute angle-closure glaucoma cause vomiting?

A
  • Raised IOP
  • Stimulating the trigeminal nerve and autonomic pathways
219
Q

What are the indications for trabeculectomy and laser iridotomy in glaucoma management?

A

Trabeculectomy= indicated when medication and laser therapies are insufficient.

Laser iridotomy= angle-closure glaucoma to create a passage between anterior and posterior chambers.

220
Q

Describe the function of a scleral flap in trabeculectomy?

A
  • The scleral flap facilitates controlled aqueous humour drainage to the subconjunctival space, forming a filtering bleb.
221
Q

What is apraclonidine’s mechanism of action in glaucoma, and when is it indicated?

A

Alpha-agonist, reduces aqueous production and increases uveoscleral outflow. It is often used for short-term IOP reduction, post-laser procedures to prevent pressure spikes

222
Q

List the typical clinical features of open-angle glaucoma and explain why cup to disc ratio >0.5 is significant

A

Features= progressive peripheral vision loss, blurred vision, halos and nocturnal headaches

Cup-disc ratio >0.5 glaucomatous optic neuropathy with increased risk of visual field loss

223
Q

What is mitomycin-C used for in trabeculectomy, and how does it act?

A

Mitomycin C is an anti-fibrotic agent used intra-operatively to prevent scarring at the surgical site, enhancing bleb longevity and lowering post-operative IOP

223
Q

Compare sub-tenon, peri-bulbar, and retro-bulbar blocks in opthalmic surgery

A

Sub-tenon= minimal needle penetration; suited for superficial procedures.

Peri-bulbar: greater diffusion of anaesthetic; suitable for longer procedures.

Retro-bulbar: deep injection; ideal for extensive intraocular surgeries requiring globe akinesia.

224
Q

What role does selenium play in thyroid eye disease, and when are intravenous steroids indicated?

A

Selenium has antioxidant properties, potentially slowing disease progression.

IV steroids are reserved for severe cases to rapidly reduce inflammation and prevent optic neuropathy.

225
Q

Why is Timolol preferred in glaucoma surgery instead of bisoprolol?

A

Timolol is selective to both beta 1 and beta 2 receptors which are both present in the eye (maximises chances of lowering IOP)

Bisoprolol is cardio-selctive and only targets beta 1 receptors.

226
Q

What bones form part of the floor of the orbit?

A
  • Zygomatic (lateral walls)
  • Maxilla (floor of the wall)
227
Q

What are the three key features of Horner’s syndrome?

A

Ptosis, miosis, anhidrosis (and sometimes enophthalmos).

228
Q

Name two conditions that cause a relative afferent pupillary defect (RAPD)

A

Optic neuritis, retinal detachment

229
Q

What is the classic pupil abnormality seen in neurosyphilis

A

Argyll Robertson pupils (small, irregular pupils that react to accommodation but not light)

230
Q

What is the most common cause of a tonic (Adie’s) pupil?

A

Idiopathic; often caused by damage to the ciliary ganglion or postganglionic parasympathetic fibers.

231
Q

List two life-threatening causes of a unilateral dilated pupil

A

Compressive third nerve palsy (e.g., from an aneurysm or tumor), raised intracranial pressure (uncal herniation)

232
Q

What is the typical pupillary response in acute angle-closure glaucoma

A

Mid-dilated, fixed pupil that does not react to light

233
Q

List two causes of bilateral pinpoint pupils

A

Opioid overdose, pontine hemorrhage

234
Q

Name three conditions that can cause a relative afferent pupillary defect (RAPD)

A

Optic neuritis, retinal vein occlusion, ischemic optic neuropathy

235
Q

Describe the pupil findings in Parinaud syndrome and the associated anatomical lesion

A

Pupil findings include light-near dissociation (poor reaction to light but intact near response). It is associated with a lesion in the dorsal midbrain, particularly affecting the pretectal area.

236
Q

What is the pharmacological test used to confirm Horner’s syndrome, and how does it work?

A

Apraclonidine test: A weak alpha-adrenergic agonist that dilates the pupil in Horner’s syndrome due to denervation hypersensitivity of the alpha-1 receptors.

237
Q

What is the significance of finding a “Marcus Gunn pupil” in a patient with visual symptoms?

A

It indicates an afferent pathway defect, often due to optic nerve disease or severe retinal damage.

238
Q

A 40-year-old female with a history of chronic ethanol use presents with bilateral small pupils that react poorly to light but constrict during accommodation. What is the most likely diagnosis, and what is a normal eye response to light in an unaffected individual?

A

Holmes-Adie syndrome (tonic pupil). Normal response: In a healthy individual, pupils should constrict normally to both light and accommodation, without the slow constriction seen in Adie’s pupils.

239
Q

What is the significance of the term “6/60” visual acuity, and how would this impact a patient’s ability to function?

A

A visual acuity of 6/60 means the patient can see at 6 meters what a person with normal vision can see at 60 meters. This level of acuity is considered legally blind in many regions, and the patient may have significant difficulty with tasks like reading, driving, and recognizing faces.

240
Q

When testing visual acuity in a 4-year-old child, what is the most appropriate method to use, and how should you record the result?

A

In a 4-year-old child, visual acuity is often tested using a tumbling E chart or picture chart where the child is asked to identify the orientation of the letter E or various pictures. The result is recorded similarly to adults, using a fraction (e.g., 6/12), where the first number represents the testing distance (6 meters) and the second number indicates the line the child can correctly identify.

241
Q

You perform a visual acuity test in a child with suspected amblyopia. The child can read the 6/12 line with both eyes, but struggles to identify letters with one eye closed. How would you proceed with further testing and what is the significance of this finding?

A

The child’s inability to read the letters with one eye closed suggests monocular vision loss, consistent with amblyopia. To confirm, perform a cover-uncover test to assess for any latent strabismus. If amblyopia is suspected, additional tests such as cycloplegic refraction and a retinal examination should be performed to rule out refractive errors or ocular pathology. The result of 6/12 acuity with both eyes open but worse with one eye closed is a hallmark of amblyopia, and early treatment (like corrective lenses or patching) is crucial for preventing permanent visual impairment.

242
Q

In a 40-year-old patient with suspected optic neuritis, how would you distinguish the visual acuity loss from that caused by diabetic retinopathy using standard clinical tests?

A

In optic neuritis, the visual acuity loss is typically monocular, with a possible relative afferent pupillary defect (RAPD) on the affected side. Visual acuity is usually reduced to 6/12 or worse, and the patient may experience pain on eye movement. In contrast, diabetic retinopathy usually presents with bilateral visual changes, often due to macular edema or hemorrhages, and there is no RAPD. Additionally, fundoscopic findings in optic neuritis would show optic disc swelling, whereas diabetic retinopathy would show microaneurysms, cotton wool spots, and exudates.

243
Q

What is the pathophysiology behind diabetic retinopathy, and how would you differentiate it from hypertensive retinopathy on fundoscopic examination?

A

Diabetic Retinopathy: Microvascular changes, microaneurysms, neovascularization.

Hypertensive Retinopathy: Arteriolar narrowing, cotton wool spots, retinal hemorrhages.

244
Q

What ophthalmic complaints require immediate referral to specialist care or emergency services?

A
  • Sudden, painless loss of vision (e.g., retinal artery occlusion, retinal detachment).
  • Severe eye pain with nausea/vomiting (e.g., acute angle-closure glaucoma).
  • Eye trauma with suspected globe rupture or intraocular foreign body.
  • Chemical burns to the eye (acid or alkali exposure).
  • Red eye with reduced vision and photophobia (e.g., keratitis, scleritis, uveitis).
  • New onset of flashes and floaters with a shadow or curtain effect in the visual field (retinal tear).
  • Sudden diplopia associated with neurological symptoms (e.g., stroke, aneurysm).
245
Q

Identify eye conditions that require referral but are not urgent. What symptoms or signs would prompt these referrals?

A
  • Gradual vision loss (e.g., cataracts, early glaucoma, or diabetic retinopathy).
  • Persistent conjunctivitis that does not improve with initial treatment.
  • Eyelid abnormalities such as ptosis, ectropion, or recurrent chalazion.
  • Recurrent or persistent dry eye unresponsive to over-the-counter treatments.
  • Early signs of glaucoma detected on routine testing.
246
Q

Which eye conditions can be safely managed by a newly qualified practitioner in primary care?

A
  • Subconjunctival hemorrhage without trauma or associated systemic symptoms.
  • Allergic conjunctivitis (treated with antihistamines and lubricants).
  • Blepharitis (eyelid hygiene with warm compresses).
  • Mild bacterial conjunctivitis (topical antibiotics).
  • Dry eyes (artificial tears, lifestyle modifications).
  • Styes (reassurance and warm compresses).
  • Corneal abrasions without infection signs (topical antibiotics for prevention and lubricants).
247
Q

A patient presents with red eye. What features help you decide whether the condition requires urgent referral, non-urgent referral, or primary care management?

A

Urgent referral:

Red eye with vision loss, severe pain, or photophobia.
Corneal opacity, hypopyon, or irregular pupil.
Associated systemic symptoms (e.g., fever, malaise).
Non-urgent referral:

Chronic redness or discomfort without vision loss.
Symptoms persisting despite initial treatment.
Abnormalities of the eyelid or mild visual field defects.
Primary care management:

Mild discomfort, no vision changes, or systemic symptoms.
Self-limiting conditions like conjunctivitis or episcleritis.

248
Q

A 57-year-old patient with a 15-year history of type 2 diabetes complains of gradual blurring of vision. Fundoscopy reveals microaneurysms and hard exudates. How would you approach the diagnosis and management of this patient’s condition?

A

Diagnosis: Likely diabetic retinopathy (non-proliferative stage) with macular edema.
Perform a dilated eye exam and optical coherence tomography (OCT) to confirm macular edema.
Management:
Optimize glycemic control (HbA1c ≤ 7%).
Control hypertension and hyperlipidemia.
Refer to ophthalmology for possible anti-VEGF injections or laser therapy if macular edema is confirmed.
Ensure regular (at least annual) retinal screening.

249
Q

4 things that need to be assessed when a patient presents with orbital cellulitis

A
  • Signs of sepsis EWS or 3 or more, unwell looking patient, concern regarding acute change in mental state
  • Visual acuity
  • Eye movements
  • Proptosis
  • Pupils for RAPD
  • Fundoscopy looking for optic disc swelling
  • Nasal signs and symptoms (congestion, discharge, history of sinusitis)
250
Q

What medical treatments should be instigated for orbital cellulitis

A

Intravenous antibiotics covering aerobes and anaerobes

Anaerobes
- Metronidazole
- Clindamycin
- Vancomycin

Aerobes
- Co-amoxiclav
- Ceftriaxone
- Penicillins

251
Q

What urgent investigations are required for orbital cellulitis?

A

CT orbits and sinuses- preferred over MRI in adults because of delineation of bony anatomy of orbits and sinuses.
MRI may be used in children to reduce radiation exposure

  • FBC
  • CRP
  • Blood cultures
  • U&E to assess renal function
  • Microbiology swab of any discharge
252
Q

You see a medial orbital sub-periosteal abscess on imaging on the patient with orbital cellulitis.

What should be the next step?

A

Emergency drainage of orbital abscess and ethmoid and maxillary sinuses

Functional endoscopic sinus surgery with drainage of orbital abscess

253
Q

What are the potential complications of untreated orbital cellulitis

A
  • Loss of vision/blindness
  • Meningitis
  • Cerebral abscess
  • Cavernous sinus thrombosis
254
Q

Give 4 differential diagnoses of eyelid swelling in adults

A
  • Pre-septal cellulitis
  • Angioedema
  • Trauma
  • Infected chalazion

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