Opthalmology Flashcards
what are the differentials for an acute red eye?
acute angle closure glaucoma
anterior uveitis
scleritis
conjunctivitis
subconjunctival haemorrhage
endopthalmitis
what is acute angle closure glaucoma?
rapid increase in intraocular pressure due to obstruction of aqueous humour outflow.
what is glaucoma?
a group of optic neuropathies characterized by progressive damage to the optic nerve, often due to raised IOP.
what are the different types of glaucoma?
Primary open angle glaucoma (most common)
Primary angle closure glaucoma (opthalmic emergency)
secondary glaucoma
normal tension glaucoma
which is the most common type of gluacoma?
primary open angle glaucoma
what is the pathophysiology of primary open angle glaucoma?
dysfunction of the trabecular meshwork leading to gradual chronic increase in IOP which over time causes optic nerve damage, resulting in visual field loss.
what are the risk factors of primary open angle glaucoma?
age > 40 years
black ethnicity
FHx
myopia (short sightedness)
DM
corticosteroid use
what are the symptoms of primary open angle glaucoma?
usually asymptomatic and detected on routine eye screening
can present with vision field loss as progresses
what are the investigations for primary open angle glaucoma?
tonometry - pressure measurement at opticians, raised > 21 mmHg
refer to opthalmology
what is the management of primary open angle glaucoma?
first line treatment - prostaglandin analogues (e.g. latanoprost)
second line - betablockers (timolol) , carbonic anhydrase inibitors (dorzolamide, acetazolamide) + alpha 2 agonist (brimonidine)
can also have laser and surgical trabeculectomy)
What is primary open angle glaucoma?
A common type of glaucoma characterized by increased intraocular pressure and progressive optic nerve damage.
True or False: Primary open angle glaucoma is typically asymptomatic in its early stages.
True
What is the primary goal of treating primary open angle glaucoma?
To lower intraocular pressure.
Name one class of medication commonly used to treat primary open angle glaucoma.
Prostaglandin analogs.
Fill in the blank: The first-line treatment for primary open angle glaucoma often includes _______.
Topical medications.
What is the role of beta-blockers in glaucoma treatment?
To reduce aqueous humor production and lower intraocular pressure.
Multiple choice: Which of the following is NOT a common treatment for primary open angle glaucoma? A) Laser therapy B) Oral steroids C) Topical medications
B) Oral steroids
What is laser trabeculoplasty?
A procedure that uses laser energy to improve the drainage of fluid from the eye, lowering intraocular pressure.
True or False: Surgery is considered only after medication and laser treatments fail in primary open angle glaucoma.
True
What is the significance of adherence to glaucoma medication?
Adherence is crucial for maintaining effective intraocular pressure control and preventing vision loss.
Name one side effect of prostaglandin analogs.
Increased eyelash growth.
Fill in the blank: The intraocular pressure target for most patients with primary open angle glaucoma is ______ mmHg.
Less than 21 mmHg.
What is the purpose of regular eye examinations in glaucoma management?
To monitor intraocular pressure and assess optic nerve health.
Multiple choice: Which of the following is a potential risk factor for developing primary open angle glaucoma? A) Age B) High blood pressure C) Family history D) All of the above
D) All of the above
What is a common surgical option for treating advanced glaucoma?
Trabeculectomy.
what is seen on fundoscopy for acute angle closure glaucoma?
dull hazy cornea
What is the role of alpha agonists in glaucoma treatment?
To reduce aqueous humor production and increase uveoscleral outflow.
what are symptoms of acute angle closure glaucoma?
sudden onset deep eye pain
blurred vision with halo around lights
headache, nausea, vomiting
acute red eye
fixed dilated nonreactive pupil
What lifestyle modification can help manage intraocular pressure?
Regular aerobic exercise.
Multiple choice: Which of the following treatments is considered the last resort for glaucoma management? A) Medications B) Laser therapy C) Surgery
C) Surgery
What is the importance of tonometry in glaucoma management?
Tonometry measures intraocular pressure, which is essential for glaucoma diagnosis and monitoring.
True or False: All patients with primary open angle glaucoma will experience vision loss.
False
What is the mechanism of action of carbonic anhydrase inhibitors in glaucoma treatment?
They decrease aqueous humor production.
Fill in the blank: Regular follow-up visits for glaucoma patients are typically scheduled every _______ months.
3 to 6 months.
What is acute angle closure glaucoma?
A type of glaucoma characterized by a sudden increase in intraocular pressure due to the blockage of the drainage angle of the eye.
True or False: Acute angle closure glaucoma is a medical emergency.
True
What are common symptoms of acute angle closure glaucoma?
Severe eye pain, headache, nausea, vomiting, blurred vision, and seeing halos around lights.
Fill in the blank: The sudden increase in intraocular pressure in acute angle closure glaucoma can lead to ______ if not treated promptly.
permanent vision loss
Which demographic is at higher risk for acute angle closure glaucoma?
Older adults, particularly women.
What is the first-line treatment for acute angle closure glaucoma?
Medications to lower intraocular pressure, such as carbonic anhydrase inhibitors and topical beta-blockers.
Multiple Choice: Which of the following is NOT a treatment for acute angle closure glaucoma? A) Pilocarpine B) Mannitol C) Aspirin
C) Aspirin
What is the role of laser peripheral iridotomy in the management of acute angle closure glaucoma?
It creates a new drainage pathway for aqueous humor to relieve intraocular pressure.
True or False: Acute angle closure glaucoma can occur in both eyes simultaneously.
True
What is the typical intraocular pressure range in acute angle closure glaucoma?
Usually above 30 mmHg.
Fill in the blank: Acute angle closure glaucoma is often precipitated by ______ of the pupil.
dilation
What is a common finding on examination of a patient with acute angle closure glaucoma?
Mid-dilated, nonreactive pupil and corneal edema.
Multiple Choice: Which of the following medications is used to treat acute angle closure glaucoma? A) Timolol B) Ibuprofen C) Acetaminophen
A) Timolol
What is the purpose of using mannitol in acute angle closure glaucoma?
To rapidly decrease intraocular pressure by osmotically drawing fluid out of the eye.
Short Answer: How can acute angle closure glaucoma be prevented in at-risk individuals?
By performing prophylactic laser peripheral iridotomy.
True or False: Acute angle closure glaucoma can be managed solely with eye drops.
False
What is the significance of a ‘shallow anterior chamber’ in the diagnosis of acute angle closure glaucoma?
It indicates a narrow angle, which can predispose to angle closure.
Fill in the blank: The condition often occurs in patients with _______ eyes.
hyperopic (farsighted)
What is the typical age range for the onset of acute angle closure glaucoma?
Typically occurs in individuals over 60 years old.
Multiple Choice: Which symptom is least likely to be associated with acute angle closure glaucoma? A) Severe headache B) Sudden vision loss C) Itchy eyes
C) Itchy eyes
management of superficial corneal abrasion?
topical lubricants OTC / eye drops
5/7 at least course of topical abx if risk of infection
arrange review in 24 hours
refer to opthalmology if any penetrating injury or red flag features present (i.e. severe pain, changes to vision etc)
what is pterygium?
creamy coloured raised triangle of skin on the conjunctiva - more common on nasal side
who is pterygium common in?
people who work outdoors in dusty warm climates
management of pterygium?
no need to treat unless enroaching over the pupil and causing vision loss - then needs referall for excision
what is an important differential of pterygium?
carcinoma in situ - if any atypical features, refer for biopsy
what is corneal vascularization?
excessive growth of blood vessels onto the cornea
what can cause corneal vascularization?
severe eyelid disease, rosacea or excessive contact lense wearer
management of corneal vascularization?
refer to opthalmology
advise to stop contact lenses for > 2 months
what are the causes of a corneal ulcer?
bacterial (most common)
viral
fungal
acanthamoeba
what is the most common bacterial cause of corneal ulcer?
pseudomonas aeruginosa - esp in contact lense wearers
most common viral causes of corneal ulcer?
HSV, VzV
what are most common causes of fungal corneal ulcer?
aspergillus
candida - common in trauma with organic material
what are the RF for corneal ulcer?
contact lens wear
corneal trauma
chronic eye disease
immunosuppression
contaminated water exposure
what are the symptoms of corneal ulcer?
severe eye pain
red eye
blurry vision
photophobia
discharge - purulent
what investigations are needed to diagnose corneal ulcer?
slit lamp testing with fluorescein staining
management of corneal ulcer?
same day ref to opthalmology
needs topical abx - levofloxain hourly
stop contact lense wear immediately
how do you treat a viral corneal ulcer?
5x per day topical aciclovir - NO STEROIDS as can worsen
what are some complications of corneal ulcer?
corneal perforation- can lead to intraocular infection
scarring - permanent vision loss
glaucoma
cataracts
what are the symptoms of episcleritis?
mild eye redness
discomfort
but no severe symptoms or pain
what is episcleritis?
localised inflammation of the episclera (thin layer between conjunctiva and sclera)
how long does it take for episcleritis usually to get better?
self limiting in 1-2 weeks
what are the causes of episcleritis?
idiopathic - in 70%
can be due to other disease - autoimmune (RA, SLE, IBD), infections (HSV, lyme disease, syphilis), allergic reactions, environmental triggers (UV exposure, dry air)
how do you diagnose episcleritis?
clinical diagnosis - usually not tests needed
how to manage episcleritis?
Reassure the person that episcleritis is usually self-limiting and is not harmful.
Advise that oral nonsteroidal anti-inflammatories (such as ibuprofen) and artificial tears may help relieve discomfort.
what is scleritis?
painful destructive inflammation of the sclera - often associated with systemic disease. Can lead to acute vision loss if untreated - unlike episcleritis.
what are the two different types of scleritis?
Anterior scleritis - most common (90%) - affects the front of the sclera
Posterior scleritis - the back of the eye - can cause proptosis, retinal detachment and optic disc swelling
what are some systemic causes of scleritis?
RA - most commonly associated with scleritis
wegners granulomatosis
SLE
IBD
HSV, syphillis, tuberculosis
surgery/trauma
what are the symptoms of scleritis?
severe deep boring eye pain
worse with movement
red eye
photophobia
tearing of eyes
reduced vision (unlike episcleritis)
severe tenderness on palpation (unlike episcleritis)
management of scleritis?
same-day assessment by an ophthalmologist
oral NSAIDs are typically used first-line
oral glucocorticoids may be used for more severe presentations
immunosuppressive drugs for resistant cases (and also to treat any underlying associated diseases)
what is anterior uveitis?
inflammation of the iris and is the most common form of uveitis - also known as iritis
what are the causes of anterior uveitis?
idiopathic - most common
autoimmune - HLA b27 (ank spond, RA, psoriatic arthritis)
SLE
IBD
Infections - HSV, VZV, TB, syphillis
trauma to eye
steroid use
sarcoidosis
MS
what are some autoimmune conditions associated with anterior uveitis?
IBD
HLAB27 conditions - andk spond, reactive arthritis, psoariatic arthritis
SLE
RA
bechets disease
what are the symptoms of anterior uveitis?
pain - moderate to severe deep eye pain
red eye
photophobia
blurred vision
tearing
devreased vision
can also have irregular constricted pupil due to sphincter muscle contraction
management of anterior uveitis?
referral for opthalmogy assessment within 24 hours
DO NOT initiate care unless advised by opthalmologist
how does chlamydia conjunctivitis present?
chronic (longer than 2 weeks) low grade irritations and mucous discharge in sexually active person
pre-auricular lymphadenopathy may be present
most cases unilateral but can be bilateral
how does gonorrhoea conjuncitivitis present?
symptoms present rapidly over 24-48 hours
copious amounts of purulent discharge
eye lid swelling
tender preauricular lymphadenopathy
management of subconjunctival haemorrhage?
reassure
improves in 1-2 weeks, self limiting
if recurrent - check FBC/clotting
what should be checked when someone presents with subconjunctival haemorrhage?
BP
how does ophthalmic herpes zoster present?
pain tingling or numbness around the eye precedes a blistering rash
in 50% the eye is also affected with signs of scleritis, episcleritis, keratitis, iritis, visual loss or occulomotor palsy
which nerve does ophthalmic herpes zoster affect?
ophthalmic branch of the trigeminal nerve
what is a classical sign of ophthalmic HSV?
hutchinson sign - rash on tip of nose due to involvement of nasociliary branch of the trigeminal nerve
management of ophthalmic HSV?
Referral of all cases to eye casualty or an emergency eye service for same-day assessment and specialist management.
If same-day assessment is not possible or practical, specialist ophthalmological advice should be sought regarding initiating drug treatment in primary care.
what are complications of ophthalmic HSV?
Corneal scarring and visual impairment.
Corneal perforation.
Secondary infection with bacteria or fungi.
Systemic infection, such as aseptic meningitis, encephalitis, or hepatitis.
What are differentials for sudden painless vision loss?
amaurosis fugax
central retinal vein occlusion
central retinal artery occlusion
vitreous haemorrhage
retinal detachment
what is amaurosis fugax
transient loss of vision in one eye often described as a “curtain” or “shade” descending over the visual field
what is amaurosis fugax a sign of?
typically due to retinal ischaemia - often occurs as a sign of stroke about to happen
can be a sign of underlying vascular disease
management of amaurosis fugax?
immediate opthalmology ref
what is central retinal vein occlusion and how can it present?
occlusion of the central retinal vein
presents as sudden unilateral painless vision loss
what can be seen on fundoscopy of central retinal vein occlusion?
cotton wool spots and retinal haemorrhages seen
what increases the risk of central retinal vein occlusion?
age, HTN, CVDm hyperlipidaemia, DM, glaucoma, polycythemia
what is central retinal artery occlusion and how does this present?
occlusion of the central retinal artery causing ischaemia of the retina
presents as sudden painless vision loss
can also present with afferent pupillary defect
what is seen on fundoscopy of retinal artery occlusion?
pale retina + cherry spot
what is vitreous haemorrhage and how does it present?
sudden or gradual haemorrhage into the vitreous space
presents with range of either sudden vision loss if severe or sudden onset floaters/flashes and shadows
what can cause vitreous haemorrhage?
retinal detatchment
retinal tear
diabetic retinopathy
trauma
central retinal vein occlusion
what is seen on fundoscopy for vitreous haemorrhage?
dark area of haemorrhage
what is retinal detachment?
sudden seperation of the retina from the underlying epithelium
what are the risk factors for retinal detachment?
FHx of retinal detachment
Previous retinal detachment
age
near sighted
previous occular trauma
how does retinal detachment present?
often as shadows in peripheral vision that close inwards to the centre
straight lines appear wavy
flashes of light
sudden or complete vision loss
how should retinal detachment be managed?
referred urgently to opthal - risk of complete permanent vision loss
what is a retinal migraine?
sudden loss of vision in one eye or scinitllating scotoma - refers to the vision changes that preceed a migraine i.e. aura
what is the most common cause of blindness in the UK?
age related macular degeneration
what is age related macular degeneration?
degeneration of the central macula / central retina
this leads to degeneration of the retinal photoreceptors - leading to production of drusen deposits
what are the RF for age related macular degeneration?
age
fhx
smoking
CVD risk factors
what are the two different types of age related macular degeneration?
dry - 90%, most common - referred to as “early”
wet - 10% - referred to as “late”
what is early age related macular degenration characterised by on fundoscopy?
presence of drusin deposits - yellow deposits in the macula
what is late age related macular degeneration characterised by on fundoscopy?
choroidal neovasculairsation
has worse prognosis - leads to more rapid loss of vision
what are the symptoms of AMD?
loss of central vision
scotoma
straight lines appear wavy
difficulty seeing in the dark/low light
flashing lights / glare around objects
management of AMD?
needs ref to opthalmology within 1 week if suspected
anti-VGEF drops
stop smoking
supplements can be recommended by opthalmology i.e. antioxidants
DVLA
certificate of visual impairement
what are the rules re the DVLA for AMD?
if affects one eye- no need to inform DVLA
if affects both eyes - need to inform DVLA
if you suspect acute angle closure glaucoma, how should the patient lie until assessment?
lie flat on their back with NO pillow - to open the angle and drain fluid
what are the two types of squint?
concomitant (most common)
paralytic
what causes a concomitant squint?
imbalance in extra-occular muscles leading to the visual pathways not developing from one eye
what causes a paralytic squint?
due to complete paralysis of the extraocular muscles
what is ambylopia?
also known as “lazy eye”
management of squint?
early referral to opthalmology
can use an eye patch to relearn the occular pathways
what type of corneal ulcer is caused by HSV?
dendritic corneal ulcer
what is the management of a dendritic ulcer?
immediate ref to opthalmology
what is optic neuritis?
inflammation of the optic nerve
what causes optic neuritis?
can be idiopathic with no cause identified
can be due to other conditions - MS, diabetes, syphilis most common
what are the symptoms of optic neuritis?
sudden onset visual impairement
central scotoma
decreased colour vision
photophobia and pain on eye movement
relative afferent pupillary defect
what is the management of optic neuritis?
ref to opthalomology same day
high dose steroids
takes 4-6 weeks to recover
what is the triad of horners syndrome?
PTOSIS
ANHYDROSIS (not sweating on one side)
ENOPHTHALMOS - sinking of eye into socket
MIOSIS - constriction of pupil
soo… constricted pupil, with eyelid drooping and no sweating = horners
what can cause horners syndrome?
pancoast tumour
stroke
MS
carotid artery dissection
what can applying mydriatic (dilating) drops predispose patients to if they have other comorbidities such as diabetic retinopthay?
acute angle closure glaucoma
what are cataracts?
A cataract is a common eye condition where the lens of the eye gradually opacifies i.e. becomes cloudy. This cloudiness makes it more difficult for light to reach the back of the eye (retina), thus causing reduced/blurred vision.
what are the symptoms of cataracts?
Reduced vision
Faded colour vision: making it more difficult to distinguish different colours
Glare: lights appear brighter than usual
Halos around lights
what is a sign of cataract on examination?
loss of red eye reflex
what investigation is used to diagnose cataracts?
slit lamp - cataract is visible
what is the management of cataracts?
initially conservative in early stages - can use glasses/contact lenses, however does not slow progression
surgery is ultimately needed - removes the cloudy lens and replaces with artificiant one
what are some complications post cataract surgery?
posterior capsule opacification
retinal detachment
posterior capsule rupture
endophthalmitis
who should be routinely screened for open angle glaucoma and when?
those over 40 years who have a positive family history of glaucoma should be screened annually from aged 40 years
what eye changes does syphilis cause?
bilateral small and irregular shape pupil
known as argyll robertson pupil
what is argyll robertson pupil?
associated with syphilis
bilateral small and irregular shape of pupils, that accomodate (constrict when looking at near objects) but do not react to light
likely diagnosis in young patient with progressive night time blindness and tunnel vision?
retinitis pigmentosa
what fundoscopy changes are seen in retinitis pigmentosa?
black bone spicule shaped pigmentation in the peripheral retina
what medication should be avoided in patients who are high risk of glaucoma?
amitriptyline - can cause exacerbation of glaucoma
what antibiotic should be prescribed for preseptal cellulitis?
flucloxacillin
or co-amoxiclav
what is the most common complication post cataract surgery?
posterior capsular thickening - occurs in 20% of people, presents as gradual blurred central vision
what is the minima corrected visual acuity at which the DVLA will permit patients to drive safely?
6/12
what is the visual acuity at which you are declared legally blind?
best corrected vision worse than 3/60
what causes retinoblastoma?
RB1 tumour suppressor gene
how does retinoblastoma present?
white pupillary reflex - red reflex test, if unable to see red reflex needs urgent ref
strabismus
reduced visual acuity
management of suspected retinoblastoma?
urgent 2ww ref to opthalmology
what is an eye side effect of amiodarone?
the development of corneal microdeposits - which can cause night glare when driving
what eye drops are given for allergic conjunctivits?
Sodium cromoglicate
what medication causing orange staining of contact lenses?
sulfasalazine
