Opthalmology Flashcards
1
Q
Definition of glaucoma
A
Group of disorders characterised by optic neuropathy due to (in majority) raised IOP
2
Q
Factors predisposing to acute angle closure glaucoma
A
Hypermetropia (long sightedness)
Pupillary dilatation
Lens growth associated with age
3
Q
Features of acute angle closure glaucoma
A
- Severe pain
- Decreased visual acuity
- Symptoms worse with mydriasis, e.g. watching TV in a dark room
- Hard, red eye
- Haloes around lights
- Semi-dilated non-reacting pupil
- Corneal oedema resulting in dull or hazy cornea
- Systemic upset, e.g. nausea and vomiting, abdominal pain
4
Q
Initial management of acute angle closure glaucoma
A
Combination of eye drops
IV acetazalomide
Topical steroids
5
Q
Eye drops used in acute angle closure glaucoma
A
Direct parasympathomimetic, e.g. pilocarpine
Beta blocker, e.g. timolol
Alpha-2 agonist, e.g. apraclonide
6
Q
Mechanism of action of pilocarpine in acute angle closure glaucoma
A
Contraction of ciliary muscle → opening trabecular meshwork → increased outflow of aqueous humuor
7
Q
Mechanism of action beta blocker in acute angle closure glaucoma
A
Decreases aqueous humour production
8
Q
Mechanism of action apraclonidine in acute angle closure glaucoma
A
- Decreases aqueous humour production
- Increases uveoscleral outflow
9
Q
Mechanism of action IV acetazolamide in acute angle closure glaucoma
A
Reduces aqueous secretions
10
Q
Definitive management acute angle closure glaucoma
A
Laser peripheral iridotomy
11
Q
Most common cause of blindness in UK
A
Age-related macula degeneration
12
Q
Characteristics of dry macular degeneration
A
Drusen - yellow round spots in Bruch’s membrane
13
Q
Characteristics of wet macular degeneration
A
Choroidal neovascularisation - leakage of serous fluid and blood can subsequently result in rapid loss of vision
14
Q
Presentation of macular degeneration
A
- Reduction in visual acuity, particularly near field objects
- Difficulties in dark adapation, overall deterioration of vision at night
- Fluctuations in visual disturbance, may vary significantly day to day
- Photopsia and glare around objects
- Visual hallucinations (Charles-Bonnet syndrome)
15
Q
What is photopsia
A
Perception of flickering or flashing lights
16
Q
Speed of onset of reduction in visual acuity in macular degeneration
A
Gradual in dry
Subacute in wet
17
Q
Signs of macular degeneration
A
- Distortion of line perception on Amsler grid testing
- Drusen on fundoscopy, become confluent in later disease to form macular scar
18
Q
Signs of wet ARMD on fundoscopy
A
Well demarcated red patches (intra-retinal or sub-retinal fluid leakage or haemorrhage)
19
Q
What are drusen
A
Yellow areas of pigment deposition in the macular area
20
Q
Treatment dry ARMD
A
Combo zinc with vitamins A, C and E - reduce progression
21
Q
Treatment wet ARMD
A
Anti-VEGF
Laser photocoagulation
22
Q
What is anterior uveitis
A
Inflammation of anterior portion of uvea - iris and ciliary body
23
Q
Associations anterior uveitis
A
HLA-B27 and linked conditions:
- Ankylosing spondylitis
- Reactive arthritis
- UC, Crohn’s
- Behcet’s
- Sarcoidosis
24
Q
Features anterior uveitis
A
- Acute onset
- Ocular discomfort and pain
- Pupil small +/- irregular
- Photophobia
- Blurred vision
- Red eye
- Lacrimation
- Ciliary flush
- Hypopyon
- Visual acuity initially normal → impaired
25
What is ciliary flush?
Ring of red spreading outwardsW
26
What is hypopyon
Pus and inflammatory cells in anterior chamber, often results in visible fluid level
27
Management anterior uveitis
Urgent opthal review
Cycloplegics, e.g. atropine, cyclopentolate
Steroid eye drops
28
What is Argyll-Robertson pupil
Small irregular pupils
No response to light, but response to accommodate
29
Causes of Argyll-Robertson pupil
Diabetes mellitus
Syphilis
30
Presentation of cataracts
- Reduced vision
- Faded colour vision
- Glare
- Halos around lights
31
Complications following cataract surgery
- Posterior capsule opacification
- Retinal detachment
- Posterior capsule rupture
- Endopthalmitis
32
What is endophthalmitis
Inflammation of aqueous and/or vitreous humour
33
Features central retinal artery occlusion
Sudden painless unilateral visual loss
Relative afferent pupillary defect
34
Fundoscopy central retinal artery occlusion
Cherry red spot on pale retina
35
Features central retinal vein occlusion
Sudden, painless reduction or loss of visual acuity, usually unilateral
36
Fundoscopy central retinal vein occlusion
Widespread hyperaemia
Severe retinal haemorrhages
37
Indications for treatment CRVO
Macular oedema - intravitreal anti-VEGF
Retinal neovascularisation - laser photocoagulation
38
Infectious causes chorioretinitis
Toxoplasmosis
CMV (particularly in immunocompromised)
Syphilis
TB
39
Autoimmune causes chorioretinitis
Sarcoidosis
Behcets
SLE
40
Presentation chorioretinitis
Unilateral vision changes, blurred vision
Scotomas (blind spots)
Floaters
41
Opthalmoscopic findings chorioretinitis
Focal or diffuse areas retinal whitening
'Pizza pie' fundus - retinal spots (superficial retinal infarction and flame shaped haemorrhage)
42
Management toxoplasmosis chorioretinitis
Pyrimethamine and sulfadiazine
43
Management CMV chorioretinitis
Ganciclovir or valganciclovir
44
Management autoimmune chorioretinitis
Systemic corticosteroids mainstay
Often in combination with other immunosuppressive agents e.g. methotrexate, azathioprine
45
Features corneal abrasion
Eye pain
Lacrimation
Photophobia
Foreign body sensation and conjunctival injection
Decreased visual acuity in affected eye
46
Management corneal abrasion
Topical antibiotic (to prevent secondary bacterial infection)
47
Causes of corneal ulcer
Bacterial keratitis
Fungal keratitis
Viral keratitis - herpes simplex, herpes zoster
Acanthamoeba keratitis
48
What is Acanthamoeba keratitis associated with?
Contact lens use
49
Features of acanthamoeba keratitis
Eye pain
Photophobia
Watering of eye
50
Classification of diabetic retinopathy
Non-proliferative diabetic retinopathy - mild, moderate, severe
Proliferative diabetic retinopathy
Maculopathy
51
Features mild non-proliferative diabetic retinopathy
1 or more microaneurysm
52
Features moderate non-proliferative diabetic retinopathy
Microaneurysms
Blot haemorrhages
Hard exudates
Cotton wool spots (soft exudates), venous beading/looping, and intraretinal microvascular abnormalities are less severe than in severe NPDR
53
Features severe non-proliferative diabetic retinopathy
Blot haemorrhage and microaneurysms in 4 quadrants
Venous beading in at least 2 quadrants
Iintraretinal microvascular abnormalities in at least 1 quadrant
54
Features proliferative diabetic retinopathy
Retinal neovascularisation (may lead to vitreous haemorrhage)
Fibrous tissue forming anterior to retinal disc
55
Features of diabetic maculopathy
Hard exudates and other 'background' changes on macula
56
Management diabetic maculopathy
If change in visual acuity, intravitreal anti-VEGF
57
Management non-proliferative diabetic retinopathy
Regular observation
If severe/very severe, consider panretinal laser photocoagulation
58
Management proliferative diabetic retinopathy
Panretinal laser photocoagulation
Intravitreal VEGF inhibitors
If severe or vitreous haemorrhage, vitreoretinal surgery
59
Complications of panretinal photocoagulation
Decrease in night vision
Generalised decrease in visual acuity
Macular oedema
60
Cause of episcleritis
Majority idiopathic
Inflammatory bowel disease
Rheumatoid arthritis
61
Features episcleritis
Red eye
Classically not painful, but mild pain/irritation common
Watering and photophobia may be present
62
Episcleritis vs scleritis
Scleritis painful, episcleritis not
Scleritis vessels not mobile, episcleritis mobile on gentle pressure
Scleritis vessels don't blanch with phenylephrine, do with episcleritis
63
% of episcleritis bilateral
50%
64
Management episcleritis
Conservative
Artificial tears sometimes used
65
What is stye
Infection of glands of eyelids
66
What is entropion
In turning of eyelids
67
What is ectropion
Out turning of eyelids
68
What is chalazion
Retention cyst of Meibomian gland
69
Presentation of chalazion
Firm painless lump of eyelid
70
Treatment chalazion
Majority of cases resolve spontaneously, some require surgical drainage
71
Features of herpes simplex keratitis
Red painful eye
Photophobia
Epiphora
Visual acuity may be decreased
Flourescein staining may show epithelial ulcer
72
Treatment herpes simplex keratitis
Immediate referral to an opthalmologist
Topical aciclovir
73
Features of Holmes-Adie pupil
Dilated pupil
Once pupil has constricted, remains small for an abnormally long time
Slowly reactive to accommodation, but very poorly (if at all) to light
Unilateral in 80%
More common in women
74
What is Holmes-Adie syndrome
Holmes-Adie pupil in association with absent ankle/knee reflexes
75
Features of Horner's syndrome
Miosis (small pupil)
Ptosis
Enophthalmos (sunken eye)
Anhidrosis (loss of sweating one side)
76
Unique feature of congenital Horner's sydnrome
Heterochromia
77
Features of Horner's syndrome caused by central lesions
Anhidrosis of face, arm, and trunk
78
Central lesions causing Horner's syndrome
Stroke
Syringomyelia
Multiple sclerosis
Tumour
Encephalitis
79
Features of Horner's syndrome caused by pre-ganglionic lesions
Anhidrosis of face
80
Pre-ganglionic lesions causing Horner's syndrome
Pancoast's tumour
Thyroidectomy
Trauma
Cervical rib
81
Features of Horner's syndrome caused by post-ganglionic lesions
No anhidrosis
82
Post-ganglionic lesions causing Horner's syndrome
Carotid artery dissection
Carotid aneurysm
Cavernous sinus thrombosis
Cluster headache
83
Stage I hypertensive retinopathy
Arteriolar narrowing and tortuosity
Increased light reflex - silver wiring
84
Stage II hypertensive retinopathy
Arteriovenous nipping
85
Stage III hypertensive retinopathy
Cotton wool exudates
Flame and blot haemorrhages
86
Stage IV hypertensive retinopathy
Papilloedema
87
What is keratitis
Inflammation of cornea
88
Causes of keratitis
- Bacterial
- Viral
- Fungal
- Amoebic
- Parasitic
- Environmental
89
Most common bacterial cause keratitis
Staphylococcus aureus
90
Pathogen causing bacterial keratitis in contactg lens wearers
Pseudomonas aeruginosa
91
Features amoebic keratitis
Increased incidence of eye exposed to soil or contamined water
Pain out of proportion to findings
92
Environmental causes keratitis
Photokeratitis, e.g. welders arc eye
Exposure keratitis
Contact lens acute red eye
93
Viral cause keratitis
Herpes simplex
94
Clinical features keratitis
Red eye, pain and erythema
Photophobia
Foreign body, gritty sensation
Hypopyon
95
Management keratitis
Stop using contact lens until fully resolved
Topical antibiotics, typically quinolones
Cycloplegic for analgesia, e.g. cyclopentolate
96
Complications keratitis
Corneal scarring
Perforation
Endophalmitis
Visual loss
97
Cause of lens dislocation
Marfans syndrome
Homocystinuria
Ehlers-Danlos syndrome
Trauma
Uveal tumours
Autosomal ressive ectopia lentis
98
Direction of lens dislocation in Marfans syndrome
Upwards
99
Direction of lens dislocation in homocystinuria
Downwards
100
What is mydriasis
Large pupil
101
Causes of mydriasis
Third nerve palsy
Holmes-Adie pupil
Traumatic iridoplegia
Phaeochromocytoma
Congenital
Drug
102
Drug causes of mydriasis
Topical mydiatrics, e.g. topicamide, atropine
Sympathomimetic drugs, e.g. amphetamines, cocaine
Anticholinergic drugs, e.g. TCAs
103
Management nasolacrimal duct obstruction
Teach parents to massage lacrimal duct
Symptoms resolve in 95% by 1yo, unresolved refer opthal for consideration of probingF
104
Features of orbital compartment syndrome
Eye pain/swelling
Proptosis
Rock hard eyelids
RAPD
105
Management orbital compartment syndrome
Urgent lateral canthotomy
106
Causes optic neuritis
Multiple sclerosis
Diabetes
Syphilis
107
Features optic neuritis
Unilateral decrease in visual acuity over hours/days
Poor discrimination of colours, red desaturation
Pain worse on movement
RAPD
Central scotoma
108
Treatment optic neuritis
High dose steriods
Recovery takes 4-6 weeks
109
Fundoscopy findings papilloedema
Venous engorgement
Loss of venous pulsation
Blurring of optic disc margin
Elevation of optic disc
Loss of optic cup
Paton's lines - concentric/radial retinal lines cascading from the optic disc
110
Causes of papilloedema
Space occupying lesion - neoplastic, vascular
Malignant hypertension
Idiopathic intracranial hypertension
Hydrocephalus
Hypercapnia
Rare:
Hypoparathyroidism and hypocalcaemia
Vitamin A toxicity
111
First line treatment open angle glaucoma
360 selective laser trabeculoplasty
112
When should laser trabeculoplasty be offered in open angle glaucoma
If IOP ≥24mmHg
113
Limitations of 360 selective laser trabeculoplasty in open angle glaucoma
Can delay need for eye drops but does not remove chance they'll be needed at all
Second procedure may be needed at later date
114
Second line treatment open angle glaucoma
Prostaglabin analogue eyedrops
115
Third line treatment open angle glaucoma
Beta blocker eye drops
Carbonic anhydrase inhibitor eye drops
Sympathomimetic eye drops
116
Treatment refractory open angle glaucoma
Trabeculectomy
117
Prostaglandin analogue eye drop e.g.
Lanatoprost
118
Mechanism of action prostaglandin analogue eyedrops
Increases uveoscleral outflow
119
Adverse effects prostaglandin analogue eye drops
Pigmentation of iris
Increased eyelash length
120
Beta blocker eye drops e.g.
Timolol
Betaxolol
121
Mechanism of action beta blocker eye drops
Reduces aqueous production
122
When to avoid beta blocker eye drops
Asthmatics
Heart block
123
Sympathomimetic eye drops e.g.
Brimonidine
124
Mechanism of action sympathomimetic eye drops
Reduces aqueous production and increases outflow
125
When to avoid sympathomimetic eye drops
If taking MAOI or TCAs
126
Adverse effects sympathomimetic eye drops
Hyperaemia
127
Carbonic anhydrase eye drops e.g.
Dorzolamide
128
Mechanism of action carbonic anhydrase eye drops
Reduces aqueous production
129
Adverse effects carbonic anhydrase eye drops
Systemic absorption may cause sulphonamide-like reactions
130
Miotic eye drops e.g.
Pilocarpine
131
Mechanism of action miotic eye drops
Increases uveoscleral outflow
132
Adverse effects pilocarpine
Constricted pupil
Headache
Blurred vision
133
Clinical features primary open angle glaucoma
May present insidiously, often detected during routine appointments
Peripheral visual field loss
Decreased visual acuity
Optic disc cupping
134
Fundoscopy signs primary open angle glaucoma
Optic disc cupping - cup to disc ratio >0.7
Opic disc pallor
Bayonetting of vessels (vessels have breaks as they disappear into deep cup and re-appear at base)
Cup notching
Disc haemorrhages
135
Retinitis pigmentosa features
Night blindness often initial sign
Tunnel vision
136
Fundoscopy findings retinitis pigmentosa
Black bone spicule shaped pigmentation in peripheral retina
Mottling of retinal pigment epithelium
137
Disease associated with retinitis pigmentosa
Refsum disease
Usher syndrome
Abetalipoproteinaemia
Lawrence-Moon-Biedl syndrome
Kearns-Sayre syndrome
Alport's syndrome
138
Features of Refsum disea
Cerebellar ataxia
Peripheral neuropathy
Deafness
Ichthyosis
139
Ocular manifestations rheumatoid arthritis
Keratoconjunctivitis sicca
Episcleritis and scleritis
Corneal ulceration
Keratitis
140
Conditions associated with scleritis
Rheumatoid arthritis
SLE
Sarcoidosis
Granulomatosis with polyangiitis
141
Treatment scleritis
Same day opthal assessment
Oral NSAIDs first line
Oral glucocorticoids for more severe presentations
Immunosuppressive drugs for resistant cases
142
Most common causes of sudden loss of vision
Ischaemic/vascular - thrombosis, embolism, temporal arteritis
Vitreous haemorrhage
Retinal detachment
Retinal migraine
143
Ischaemic/vascular causes of sudden loss of vision
Large artery disease - atherothrombosis, embolus, dissection
Small artery occlusive disease - anterior ischaemic optic neuropathy, vasculitis
Venous disease
Hypoperfusion
144
Features ischaemic/vascular sudden loss of vision
Altitudinal field defects - 'curtain coming down'
145
Features of posterior vitreous detachment
- Photopsia in peripheral vision
- Floaters, often temporal side of central vision
146
Features of retinal detachment
- Dense shadow that starts peripherally and progresses towards the central vision
- Veil or curtain over field of vision
- Straight lines appear curved
- Central visual loss
147
Features of vitreous haemorrhage
- Large bleeds cause sudden visual loss
- Moderate bleeds may be described as numerous dark spots
- Small bleeds may cause floaters
148
Causes of tunnel vision
Papilloedema
Glaucoma
Retinitis pigmentosa
Choroidoretinitis
Optic atrophy secondary to tabes dorsalis
Hysteria
