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Phase 4 Question Knowledge > Opthalmology > Flashcards

Opthalmology Flashcards

1
Q

Glaucoma

A

Optic nerve damage from rise in IOP

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2
Q

Glaucoma patho

A
  • Imbalance in aq humour production / drainage - usually blockage
  • increased pressure on retina / optic nerve - damage to peripheral retina first, then central, cupping of optic disc
  • normal pressure 10-21 mmHg
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3
Q

Open angle glaucoma

A
  • chronic
  • degeneration of trabecular meshwork -> increased resistance -> increased IOP, degeneration of optic nerve

RFs
- older, FHx, black, myopia (near sighted)

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4
Q

Open angle glaucoma Px

A
  • asym - dx on screening
  • tunnel vision (lose peripheries)
  • pain
  • headaches
  • blurred vision
  • halos around lights (worse at night)
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5
Q

Open angle glaucoma Screening

A
  • strong FHx - every 2yrs from 30yo
  • every 5yrs >40yo, every 2yrs >60
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6
Q

Open angle glaucoma Ix

A

Fundoscopy
- optic disc cupping - ratio >0.5
- pale disc - atrophy
- vessel bayonetting
- haemorrhage at risk
- vertical thinning

Visual field assessment
- loss of peripheral vision

Non-contact tonometry
- puff of air, estimate IOP (raised)

Goldmann applanation tonometry
- gold std for IOP - device on slit lamp in contact with cornea

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7
Q

Open angle glaucoma Mx

A
  • start when IOP >24
  • 360-degree selective laser trabeculoplasty
  • Latanoprost eye drops - prostaglandin
  • Timolol - BB
  • Acetazolamide - carbonic anhydrase inhibitor
  • Brimonidine - sympathomimetics
  • Trabeculectomy
  • plastic tube shunt
  • Inform DVLA
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8
Q

Acute angle closure glaucoma (AACG)

A
  • acutely raised IOP from physically obstructed outflow (iridocorneal angle)

Pupillary block
- lens pushes against iris, blocks aq humour flow through pupil, iris / lens pushed anteriorly - closes iridocorneal angle + blocks trabecular meshwork

Closure of outflow angle
- pupil dilates, iris thickens, IC angle reduces, can close spontaneously

  • retina damaged from stretching, decreased blood supply

RFs
- hyperopic (far-sighted) - shallow anterior chambers
- older, F>M, FHx, Chinese
- meds causing pupil dilation - antihistamines

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9
Q

AACG Px

A
  • red, painful eye
  • N+V, headache
  • halo around lights
  • sx worse with pupil dilatation - eg will be watching TV in dark room
  • pupil sluggish + dilated
  • eye hard to palpation
  • reduced visual acuity
  • hazy cornea (oedema)
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10
Q

AACG Ix

A
  • tonometry - IOP >60
  • gonioscopy - look at angle (lens on slit lamp)
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11
Q

AACG Mx

A
  • lie on back w/o pillow, urgent ophthal referral
  • timolol - topical BB
  • prednisolone
  • oral/IV acetazolamide
  • oral glycerol + IV mannitol
  • pilocarpine - miotic eye drops
  • analgesia +/- antiemetics
  • laser iridotomy - both eyes
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12
Q

Age-related macular degeneration (ARMD)

A

Degeneration of macula (central retina) -> blindness

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13
Q

ARMD Patho

A

Degeneration of retinal photoreceptors, formation of drusen, atrophy of retinal pigment epithelium

Dry / atrophic - 90% - early
Drusen, changes in pigmentation of retinal pigment endothelium

Wet / exudative - 10% - late
choroidal neovascularisation, VEGF, oedema, rapid vision loss

RFs
older, F>M, smoker, FHx, IHD, HTN, dyslipidaemia, DM

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14
Q

ARMD Px

A
  • reduction in visual acuity - near field / central
  • worse vision at night
  • day to day change in vision
  • photopsia - flashing lights
  • glare around objects
  • visual hallucinations -> Charles-Bonnet syndrome
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15
Q

ARMD Ix

A
  • Snellen - reduced acuity
  • Amsler grid testing - line crooked
  • Fundoscopy - Drusen, red patches in wet ARMD
  • Slit lamp - pigmentary/exudative/haemorrhagic changes
  • colour fundus photography
  • fluorescein angiography
  • indocyanine green angiograph - see choroidal circulation
  • optical coherence tomography (OCT) - 3d retina
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16
Q

ARMD Mx

A
  • stop smoking, control BP
  • zinc, vit A, C, E
  • Anti-VEGF
  • laser photocoagulation (risk of acute visual loss)
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17
Q

Diabetic retinopathy

A

Retinal deterioration from blood vessel damage due to high blood sugar levels

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18
Q

Diabetic retinopathy Px

A
  • painless reduction of central vision
  • dark painless floaters - haemorrhages
  • painless visual loss - severe haemorrhage
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19
Q

Diabetic retinopathy Ix

A
  • visual acuity
  • spots in red reflex - vitreous haemorrhage
  • fundoscopy
  • dilated retinal photography + ophthalmoscopy
  • OCT / fluorescein angiography
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20
Q

Diabetic retinopathy Mx

A
  • optimise BMs, BP, lipids, healthy diet, stop smoking

maculopathy
- anti-VEGF

non-proliferative
- observation / panretinal laser photocoagulation

Proliferative
- panretinal laser photocoagulation
- anti-VEGF

Vitreous haemorrhage
- vitreoretinal surgery

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21
Q

Diabetic retinopathy fundoscopy

A

Blot haemorrhages
Hard exudates
Microaneurysms
Venous beading
Cotton wool spots
Intraretinal microvascular abnormalities
Neovascularisation

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22
Q

Diabetic retinopathy classification

A

Non-proliferative
- Mild - 1+ microaneurysms
- Moderate - microaneurysms, blot haemorrhages, hard exudates, cotton wool spots, venous beading
- Severe - blot haemorrhages + microaneurysms in 4 quadrants, venous beading in 2 quadrants, IMRA in any quadrant

Proliferative
- neovascularisation
- fibrous tissue
- vitreous haemorrhage

Diabetic maculopathy
- macular oedema
- ischaemic maculopathy
- hard exudates

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23
Q

Diabetic retinopathy Cx

A

Retinal detachment
Vitreous haemorrhage
Rebeosis iridis - new blood vessel formation in iris
Optic neuropathy
Cataracts

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24
Q

Hypertensive retinopathy

A

damage to small blood vessels in retina from systemic HTN

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25
Hypertensive retinopathy Px
- can be asym - double vision / blurred vision / reduced acuity / visual field defects - headaches - eye pain - N+V - end organ damage - HF, AKI, chest pain
26
Hypertensive retinopathy Ix
- BP - fundoscopy - OCT / fluorescein angiography
27
Hypertensive retinopathy fundoscopy
- silver / copper wiring - AV nipping - cotton wool spots - hard exudates - retinal haemorrhages - papilloedema
28
Hypertensive retinopathy Keith-Wagener classification
Stage 1 - mild narrowing of arterioles, increased light reflex (silver wiring) Stage 2 - focal constriction of blood vessels + AV nipping Stage 3 - cotton wool exudates, flame + blot haemorrhages (may collect around fovea - macular star) Stage 4 - papilloedema
29
Hypertensive retinopathy Mx
- control BP - stop smoking - control lipids
30
Cataracts
- lens opacifies - lens fibres aggregate, deposit, cause clouding Causes smoking, alcohol, age, trauma, DM, long-term steroids, radiation, myotonic dystrophy, hypocalcaemia
31
Cataracts Px
- gradual onset, asymmetrical - reduced visual acuity - faded colour vision - starbursts around lights - at night - loss of red reflex - white/brown lens when light shone on eye
32
Cataracts Ix
- ophthalmoscopy - normal fundus / optic nerve - slit lamp
33
Cataracts Mx
- surgery - stronger glasses, brighter lights in meantime
34
Cataracts surgery cx
- posterior capsule opacification - retinal detachment - posterior capsule rupture - endophthalmitis - inflammation of aq/vit humour - intravitreal abx to tx
35
Blepharitis
- inflammation of eyelid margins Causes - meibomian gland dysfunction - lack of oil, drying of eyes - seborrhoeic dermatitis / staph infection Px - bilateral - gritty, sticky eyes - red eyelid margins - swollen - staph Mx - hot compress - lid hygiene - cotton wool buds, warm water, baby shampoo - artificial tears - dry eyes
36
Stye
- painful red lump on eyelid edge - like acne Types External - infection of glands of zeis / moll Internal - infection of meibomian glands Px external - tender red lump along eyelid +/- pus internal - deeper, more painful, may point inwards Mx - hot compress - analgesia - topical abx if conjunctivitis
37
Chalazion
- meibomian gland blocked - meibomian cyst Px - swelling in eyelid - may be painless / tender - red Mx - hot compress - analgesia - topical abx if inflamed - surgical drainage if the above fails
38
Entropion
- eyelid turns in Mx - tape eyelid down, eye drops to prevent eye drying - surgery - definitive - same day ophthal referral if risk to sight
39
Ectropion
- eyelid turns out, usually bottom Mx - mild - no tx - eye drops - surgery - same day ophthal referral if risk to sight
40
Trichiasis
- inward growth of eyelash Px - painful - red, watery eye - feels like FB in eye Mx - remove eyelash - electrolysis, cryotherapy, laser tx if recurrent growth - same day referral if risk to sight
41
Abnormal pupil shape causes
- trauma, eg cataracts surgery - anterior uveitis - adhesions - AACG - vertical oval shape - rubeosis iridis - neovascularisation of iris - coloboma - congenital malformation - tadpole pupil - spasm in iris - migraines
42
Mydriasis causes
- 3rd nerve palsy - Homes-Adie syndrome - raised ICP - congenital - trauma - phaeochromocytoma - drugs - atropine, cocaine, amphetamines, TCAs
43
Miosis causes
- Horner syndrome - cluster headaches - Argyll-Robertson pupil - opiates - nicotine - pilocarpine
44
3rd nerve palsy
- ptosis - dilated pupil - divergent strabismus - down + out eye Causes - idiopathic With sparing of pupil (microvascular - psym fibres spared): - DM, HTN, ischaemia Full palsy - compression - tumour, trauma, cavernous sinus thrombosis, PCA aneurysm, raised ICP
45
Horner syndrome
- damage to sympathetic nerves system supplying face - ptosis, miosis, anhidrosis Central lesions - anhidrosis of arm, trunk, face (4 Ss) - Stroke - MS - Swelling (tumours) - Syringomyelia - also encephalitis Pre-ganglionic lesions - anhidrosis of face (4 Ts) - Tumour - eg Pancoast - Trauma - Thyroidectomy - Top rib - cervical rib Post-ganglionic lesions - no anhidrosis (4 Cs) - Carotid aneurysm - Carotid artery dissection - Cavernous sinus thrombosis - Cluster headache Congenital Horner syndrome - associated with heterochromia Ix - Cocaine eye drops? - cause dilatation in normal eye, not in Horner's - adrenaline eye drops - as above
46
Holmes Adie Pupil
- benign, part of Holmes-Adie syndrome - neuro disorder with absent ankle / knee reflexes Px - unilateral in 80% - dilated pupil - once pupil constricts, small for a while - slow reaction to accommodation, barely any to light
47
Argyll-Robertson pupil
- Syphilis, also DM Px - small, irregular pupils - no response to light, response to accommodation
48
Conjunctivitis
inflammation of conjunctiva - layer of tissue on inside of eyelids / sclera bacterial / viral / allergic
49
Conjunctivitis Px
- uni/bilateral - red eye - bloodshot - itchy / gritty - discharge - NO pain, photophobia, reduced acuity Bacterial - purulent discharge, worse in morning (eyes stuck together) - can start unilateral, then spread - highly contagious Viral - clear discharge, other viral sx, lymph nodes, - highly contagious
50
Red eye ddx
Painless - conjunctivitis - episcleritis - subconjunctival haemorrhage Painful - glaucoma - anterior uveitis - scleritis - corneal abrasions / ulceration - keratitis - FB - trauma / chemical injury
51
Conjunctivitis Mx
- usually resolves alone 1-2 wks - wash hands, don't share towels, clean eyes - bacterial - abx eye drops - chloramphenicol / fusidic acid topical (pregnancy) - no contact lenses, topical fluorescein to identify corneal staining - neonate <1mo - urgent ophthal review - ?gonococcal infection -> loss of sight, pneumonia
52
Allergic conjunctivitis
- contact with allergens Px - bilateral - swelling - watery discharge - itch - Hx of atopy - seasonal / perennial Mx - antihistamines - topical / oral - topical mast-cell stabilisers - for chronic sx
53
Anterior uveitis
Inflammation of anterior part of uvea - iris, ciliary body, choroid
54
Anterior uveitis causes
Acute - HLA B27 - Ankylosing spondylitis - IBD - Reactive arthritis Chronic - >3mo - granulomatous (macrophages) - sarcoidosis (?bilateral) - syphilis - lyme disease - TB - herpes virus
55
Anterior uveitis Px
- unilateral - spontaneous acute sx - dull, aching, painful eye - red eye - ciliary flush - ring of red from cornea outwards - reduced acuity - flashes, floaters - miosis - photophobia - pain on movt - lacrimation - abnormal shaped pupil - adhesions - hypopyon - WBCs in ant chamber - yellow fluid
56
Anterior uveitis Ix
- slit lamp
57
Episcleritis
- benign self-limiting inflammation of episclera (just beneath conjunctiva) - RA / IBD association, not usually infection
58
Anterior uveitis Mx
- same day ophthal assessment - steroids - oral / topical / IV - cyclopentolate / atropine eye drops - cycloplegic (paralyse ciliary muscles) + mydriatic (dilate pupil) - immunosuppressants - DMARDs, TNF inhibitor - laser therapy, cryotherapy, surgery (vitrectomy)
59
Episcleritis Px
- acute, unilateral - painless / mild pain - red eye - red patch - FB sensation - dilated episcleral vessels - move with gentle pressure - eye watering, no discharge
60
Episcleritis Ix
- phenylephrine drops - blanch conjunctival / episcleral vessels (not scleral)
61
Episcleritis Mx
- if doubt, ophthal referral - self-limiting - 1-4wks - lubricating eye drops for sx - analgesia, cold compress - severe - NSAIDs, steroid eye drops
62
Scleritis
- full thickness inflammation of sclera - generally non-infective - if necrotising - can perforate RFs - RA, SLE, IBD, sarcoidosis, granulomatosis with polyangiitis
63
Scleritis Px
- red eye - painful - watering - photophobia - gradual reduction in vision - abnormal pupil reaction to light - eye tender to palpation
64
Scleritis Mx
- same day ophthal referral - NSAIDs - oral / topical - 1st line - Steroids - oral / topical - more severe - immunosuppressants - resistant cases
65
Corneal abrasions
- scratches / damage to cornea Causes - Contact lenses (beware pseudomonas) - FB - fingernails, eyelashes, entropion - chemical - acid
66
Corneal abrasion Px
- hx of FB / contact lens - painful red eye - FB sensation - watery eye - blurred vision - photophobia
67
Corneal abrasion Ix
- fluorescein stain - yellow / orange in abrasion/ulcer - slit lamp
68
Corneal abrasion mx
- if ?sight-threatening - ophthal referral - remove FB - analgesia - lubricating eye drops - abx - chloramphenicol eye drops - cyclopentolate eye drops - dilate pupil - may help sx - 24hr follow up, heal in 2-3d - chemical - 20-30min irrigation, urgent ophthal referral
69
Indications for ophthal referral with corneal FB
- penetrating eye injury - significant orbital trauma - chemical - organic FB - eg seeds, soil - FB near centre of cornea - red flags - severe pain, irregular / non-reactive pupils, reduced visual acuity
70
Keratitis
Inflammation of cornea - potentially sight-threatening
71
Keratitis causes
- Viral - herpes simplex - Bacteria - pseudomonas / staph - Fungal - candida / aspergillus - Amoebic - acanthamoebic keratitis - eg contaminated water - pain out of proportion to findings - Parasitic - onchocercal keratitis - river blindness - Contact lens acute red eye (CLARE) - Exposure keratitis - from inadequate eyelid coverage (eg ectropion)
72
Corneal ulcer
- defect in cornea, 2ndary to infection (eg abrasion from trauma) RFs - contact lenses - vit A deficiency Px - eye pain, photophobia, watering of eye Ix - fluorescein stain - focal stain Mx - if contact lenses - same day ophthal referral - slit lamp to r/o microbial keratitis - topical abx - quinolones - cyclopentolate - pain relief
73
Herpes simplex keratitis
- most common cause of keratitis - usually only epithelial layer, stromal keratitis if deeper Px - painful red eye - photophobia - vesicles around eye - FB sensation, watering eye - reduced acuity Ix - fluorescein - dendritic corneal ulcer - slit lamp - corneal swabs / scrapings - PCR / viral culture Mx - acyclovir topical / oral - ganciclovir eye gel - topical steroids - stromal keratitis - if corneal scarring - corneal transplant
74
Subconjunctival haemorrhage
- rupture + bleeding of small vessels in conjunctiva - bleed in between sclera + conjunctiva
75
Subconjunctival haemorrhage causes
- trauma - heavy lifting / coughing - straining, eg constipated - HTN, bleeding disorders, whooping cough, blood thinners, NAI
76
Subconjunctival haemorrhage Px
- patch of bright red blood - painless - no vision loss
77
Subconjunctival haemorrhage Mx
- resolve spontaneously in 2wks - Ix for ?underlying condition - lubricating eye drops - if FB sensation
78
Posterior vitreous detachment
detachment of vitreous gel from retina RFs - older - myopic (near sighted - longer axial length)
79
Posterior vitreous detachment Px
- ?asym - painless - spots of vision loss - floaters - flashing lights
80
Posterior vitreous detachment Ix
- same day ophthal assessment - r/o retinal detachment - ophthalmoscopy - Weiss ring - ring-shaped floater around optic nerve
81
Posterior vitreous detachment Mx
- no tx - brain adjusts
82
Retinal detachment
- retina separates from underlying pigment epithelium / choroid - choroid supplies blood to retina -> detachment is sight-threatening - usually due to retinal tear - then vitreous fluid gets under retina RFs - posterior vit detachment, diabetic retinopathy, trauma, retinal malignancy, older, FHx, myopia, previous cataracts surgery
83
Retinal detachment Px
- painless - peripheral vision loss - sudden, like shadow - blurred / distorted vision - flashes / floaters - macula involvement -> central vision loss - optic nerve involvement - RAPD
84
Retinal detachment Ix
- same day ophthal assessment - fundoscopy - loss of red reflex, pale/opaque/wrinkled retinal folds - slit lamp, indirect ophthalmoscopy
85
Retinal detachment Mx
Retinal tears - create adhesions between retina / choroid - laser therapy - cryotherapy Retinal detachment - reattach retina - vitrectomy - scleral buckling - pneumatic retinoplexy
86
Retinitis pigmentosa
- congenital, inherited degeneration of rods / cones in retina
87
Retinitis pigmentosa Px
- most cases, sx start in childhood - night blindness - tunnel vision / loss of peripheral vision
88
Retinitis pigmentosa Ix
- fundoscopy - bone-spicule pigmentation, arteriole narrowing, waxy/pale optic disc
89
Retinitis pigmentosa Mx
- genetic counselling - vision aids - sunglasses - DVLA - potential tx - vitamins, antioxidants, oral acetazolamide, steroid injections, anti-VEGF, gene therapy
90
Central retinal vein occlusion (CRVO)
thrombus forms in retinal vein, blocks blood drainage from retina
91
CRVO patho
- can be blockage in 1/4 branches, or blockage in central vein (whole retina affected) - blood pools, fluid leaks, macula oedema, retinal haemorrhages, damage, VEGF, neovascularisation RFs - HTN, high cholesterol, DM, smoking, glaucoma, SLE
92
CRVO Px
- sudden painless loss of vision, unilateral usually
93
CRVO Ix
- fundoscopy - flame + blot haemorrhages, optic disc oedema, macula oedema - FBC, ESR, BP, BMs
94
CRVO Mx
- majority conservative - to prevent neovascularisation - laser photocoagulation, intravitreal steroids, anti-VEGF
95
Central retinal artery occlusion (CRAO)
blockage of central retinal artery
96
CRAO Patho
- central retinal artery, branch of ophthalmic artery, branch of internal carotid Causes - atherosclerosis - older, FHx, smoking, alcohol, HTN, DM... - GCA - >50yo, F>M, PMR
97
CRAO Px
- sudden painless loss of vision - RAPD
98
CRAO Ix
- fundoscopy - pale retina, cherry-red spot macula - ESR, temporal artery biopsy
99
CRAO Mx
- GCA - prednisolone 60mg - ?ocular massage, inhale carbogen, sublingual GTN - ?thrombolysis - tx RFs
100
Vitreous haemorrhage
- bleeding into vitreous humour causes - proliferative diabetic retinopathy - posterior vit detachment - ocular trauma
101
Vitreous haemorrhage Px
- acute, painless visual loss / haze - red hue in vision - floaters, shadows, dark spots - decreased acuity - may have complete visual loss
102
Vitreous haemorrhage Ix
- fundoscopy - haemorrhage - slit lamp - USS - r/o retinal tear, detachment - fluorescein angiography - neovascularisation - orbital CT - if injury
103
Vitreous haemorrhage Mx
- tx cause - blood clears 1%/d
104
Sudden loss of vision DDx
- ischaemic / vascular (amaurosis fugax) - atherosclerosis, embolus, dissection, anterior ischaemic optic neuropathy, vasculitis, TIA, CRVO, CRAO - vitreous haemorrhage - posterior vit detachment - retinal detachment
105
Blurred vision
- loss of clarity of vision Causes - refractive error - cataracts - retinal detachment - ARMD, AACG, optic neuritis, amaurosis fugax Ix - snellen chart - visual fields - fundoscopy Mx - opticians if refractive - ophthal referral if other sx
106
Herpes zoster ophthalmicus (HZO)
- reactivation of VZV in ophthalmic division of trigeminal nerve Px - vesicular rash around eye +/- eye - hutchinson's sign - rash on tip / side of nose Mx - oral antivirals - topical corticosteroids - ophthal review if eye involvement Cx - conjunctivitis, keratitis, episcleritis, anterior uveitis, ptosis, post-herpetic neuralgia
107
Nasolacrimal duct obstruction
- imperforate membrane at lower end of duct -> persist watery eye in infant Mx - parents massage lacrimal duct - in 95% sx resolve by 1yo - ophthal referral for ?probing
108
Hyphema
- blood in anterior chamber of eye - raised IOP - sight-threatening, block IC angle, trabecular meshwork - urgent ophthal referral - admit, bed rest
109
Orbital compartment syndrome
- eg after retrobulbar haemorrhage Px - eye pain, swelling - proptosis - rock hard eyelids - RAPD Mx - lateral canthotomy
110
Optic neuritis
inflammation of optic nerve (often demyelination) -> loss of vision Causes MS, diabetes, syphilis, ischaemic optic neuropathy
111
Optic neuritis Px
- unilateral decrease in visual acuity - blurred / foggy - poor colour discrimination - red desaturation - pain worse on eye movt - RAPD - central scotoma (blind spot) - red eye
112
Optic neuritis Ix
- ophthalmoscopy / slit lamp - often negative - MRI brain + orbits with gadolinium contrast
113
Optic neuritis Mx
- high dose steroids
114
Papilloedema
- optic disc swelling caused by raised ICP - almost always bilateral Causes - SOL, malignant HTN, IIH, hydrocephalus, hypercapnia, hypoparathyroidism, hypocalcaemia, vit A toxicity
115
Papilloedema fundoscopy findings
- venous engorgement - loss of venous pulsation - blurring of optic disc margin - elevation of optic disc - loss of optic cup - Paton's lines
116
RAPD
- relative afferent pupillary defect / Marcus-Gunn pupil - lesion is anterior to optic chiasm - optic nerve / retina Causes - retina - detachment - optic nerve - neuritis, eg MS O/E - swinging light test - affected eye dilates when light shone on it, constricts when light shone on normal eye
117
Tunnel vision causes
- papilloedema - glaucoma - retinitis pigmentosa - choroidoretinitis - optic atrophy after tabes dorsalis - hysteria

Phase 4 Question Knowledge (35 decks)

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