Opthalmology Flashcards
Man complains of eyes feeling gritty and noticing crusting of his eyelids.
Blepharitis
What is Blepharitis?
and what two dermatological conditions is it associated with?
It is a low-grade inflammation of the lid margins caused by blockage of eye-lids oil glands or overgrowth of bacteria.
Assoc: Rosacea, Seborrheic dermatitis
Same man later notices he has a lump on his effected eyelid. The lump is not painful
Chalazion
A chalazion is a _______ gland lipogranuloma
Meibomian gland lipogranuloma.
Cyst caused by blockage of meibomian gland orifices
– Stagnated secretions leadto non-infective lid inflammation
A woman complains of a painful red lump on her eyelid
Stye
What is a Stye?
a.k.a.external hordeolum
It is an infection of the sebaceous glands at Zeis (at the base of the eyelashes) or apocrine glands of Moll, usually due to Staph. Aureus
How to manage a Stye?
Management: hot compressions with flannel 3-4 times daily, may need antibiotics or drainage
8 year old boy is febrile and has had tenderness and oedema over one eyelid. He has no issues with eye movements. This all happened after a sports day at school.
Peri-orbital (preseptal) cellulitis
Most common cause of peri-oribital cellulitis?
Pre-septal cellulitis, usually caused by Staphylococcus aureus or Streptococcus organisms usually due to trauma to the periorbital skin, but can also spread from a paranasal sinus infection or dental abscess
In young, unimmunised children it may also be caused by Haemophilus influenzae type b (accompanied with meningitis, etc.)
How to differentiate Peri-orbital cellulitis to Orbital cellulitis?
Peri-oribital cellulitis: no proptosis or limitations or pain in ocular movements
Orbital Cellulitis: inflammatory proptosis, painful or limited ocular movement and reduced visual acuity
Young child is febrile and has swelling over one eye. There is limited and painful eye movements.
Orbital Cellulitis
What is Post-septal cellulitis most commonly due to?
Staphylococcus aureus or Streptococcus organisms usually due to untreated infection of the paranasal sinuses (sinusitis) or orbital trauma
Possible complications of Orbital Cellulitis?
Abscess formation, meningitis, or cavernous sinus thrombosis
What investigations would be done for Orbital Cellulitis?
Blood work, Blood culture, Septic workup - CT should be performed to assess the posterior spread of infection and a lumber puncture may be required to exclude meningitis
mx of orbital Cellulitis?
Abx + Ix
Cefotaxime OR
Ceftriaxone (IV) + Flucloxacillin (IV)
Urgent surgical drainage of the sinuses or of an orbital, subperiosteal or intracranial abscess may be required to prevent loss of vision
Baby is very teary and there is a lot of mucopurulent discharge in one eye
Nasolacrimal Duct obstruction –> can lead to Dacryocystitis (inflammation)
What is the cause for Nasolacrimal duct obstruction?
Blockage of the nasolacrimal duct, usually congenital due to failure of the membrane at the end of the tear duct (valve of Hasner) to open at birth, but can also be secondary to duct stenosis or infection
–> Can lead to Dacryocystitis which is inflammation
What are the clinical features of a Nasolacrimal duct obstrction?
Increased tear lake, mucous or mucopurulent discharge and epiphora.
- When pressure is applied over the lacrimal sac, there is reflex of mucoid or mucopurulent material from the punctum. The regurg. material can cause recurrent conjunctivits
How to manage Dacryocystitis or Nasolacrimal duct obstruction?
and if complications?
For mild cases- warm compression, massage the lacrimal duct to encourage the drainage of the purulent material. Consider topical Abx: CHLORAMPHENICOL.
if complications (e.g. cellulitis) then oral Abx
What is the difference between Meiobian abscess, Chalazion and Stye?
Chalazion is non-infection granulomatory infection of the meiobian gland leading to a lump caused by obstruction.
Meiobian abscess if infection of the gland usually caused by Staph. It is tender and usually discharges –> treat with wrm compressions and use Flucloxacillin if there is surrounding cellulitis.
A stye (external hordeolum) is an abscess of the sebaceous gland associated with an eyelash caused by staphylococci. Mx: warm compresses, repeated until the stye points and spontaneously discharges. Removal of the eyelash often aids resolution. Topical antibiotics are not required.
Woman complains of red eyes. Initially it was just one eye but then it spread to the next. There is a lot of watery discharge. On examination, eye movements are normal, and pre-auricular lymphadenopathy is noted.
Conjunctivitis
What is more common - Viral or bacterial conjunctivitis?
and what agents?
Viral is more common - due to adenovirus
Bacterial is more common in paeds - strep, staph and Gonorrhea
Chlamydia trachomitis eye infection can present as either:
-Inclusion Conjunctivitis (chronic bacterial conjunctivitis and follicular cobblestoning of the inner eyelid
OR
-Trachoma
What is trachoma?
Cause? Demographic?
It is a non-sexual infection caused by Chlamydia trachomitis - it is chronically follicular and can cause scarring of the eyelids - which can close off the lacrimal glands causing dryness, change direction of eyelash growth and possible corneal scarring and blindness.
It occurs in developing countries due to poor sanitation.
Mx of Conjunctivitis?
and if Nesisseria gonorrhea or Chlamydia trachomitis?
Viral: Supportive care, hygeine. Bacterial: Chloramphenicol eye drops
if Neisseria: Ceftriaxone
If Chlamydia: azithromycin
What prophylactic eye drops can new borns be given to prevent ophthalmia neonatorum?
Prophylactic erythromycin eye drops
Woman complains of itchy eyes during the spring. His eyes are found to be red and have a ‘glassy’ appearance.
Conjuncitvitis! (allergic)
Clinical presentation of allergic conjunctivitis?
- Itching is the hallmark symptoms, no discharge, occurs in spring. Eyes have a glassy appearance, “alergic shiners” (dark circles under the eyes)
What is vernal conjunctivits?
IgE mediated - thought to affect young males with a history of atopy. More common in sumer
Conjunctivitis affecting:
– Adults, late teens to 50s
– Bilateral conjunctiva and lid involvement (atopic dermatitis), conjunctival and corneal scarring
Atopic Keratanoconjunctivits
Conjunctivitis affecting:
– History of poor lens hygiene or poor lens fit
– Giant papillae, sterile infiltrates, peripheral vascularisation
Contact lens keratocojunctivitis
Man was poked in the eye after re-enacting his favourite Star Wars scene with an imaginary friend. His eye is brightly red, but there is no pain or changes in vision.
Subconjunctival haemorrhage
Causes of subconjunctival haemorrhage?
Trauma, Coag issue, increased venous pressure (straining in pregnancy or on the toilet), vomiting, choking, sneezing
A man was doing some work in a building site when he suddenly feels something in his eye.
Corneal foreign body or chemical injury
Management of foreign body in eye?
Topical anaestehtic (not to be used if there is an abrasion), cotton bud if not embedded if embedded use the tip of 25g needle
Prophylactic Abx (chloramphenicol) and patient education about future
How to manage Chemical in eye?
Chemical injury: irrigate, check pH (tear pH is ~8 normally), call poisons hotline
A woman has had a red teary eye for a while. However now she has pain and photophobia in that eye. Fluorescein staining is performed - see faint lines on the eye
Corneal abrasion
What are the clinical features of corneal abrasion/
pain, red eye, photophobia
How to Manage corneal abrasion and what not to do?
Chloramphenicol eye drops and oral analgesia.
Do not use topical anaesthetic as they can cause secondary keratitis
Whats an entropion?
It is inward turning of the eyelid margin and appendages such that the pilosebaceous unit and mucocutaneous junction are directed posterior towards the globe
A man has a red and painful eye which has been getting worse over the last week. Fluorescein staining is performed. A dendritic ulcer is seen.
HSV keratitis
What are common causes of Keratitis and corneal ulcers -
Prolonged contact lens use, Trauma, neurotrophic Cornea, Photokeratitis (due to intense UV exposure (snow blindedness or welder’s arc eye)
progressive redness, pain (like ‘sand poured into eye’), photophobia, lacrimation, reduced vision
Keratitis
What are some complications of keratitis?
Corneal scar, corneal ulceration (when infection gets tot he corneal stroma), corneal perforation
Mx of Keratitis?
Treat cause:
Bacterial: topical ciprofloxacin
Viral: Aciclovir
What is a pterygium? and what are the RF?
Fibrovascular overgrowth over conjunctiva and cornea, usually medial/nasal.
RF: UV exposure, dusty environment
Mx of Pterygium?
Sunglasses, lubricants, surgiery (if affecting visual axis, if constantly irritated or if cosmetic reason)
An elderly diabetic man has been noticing a gradual change in his vision. Lately, he’s been noticing a lot of glare and halos around lights at night.
Cataracts
What is Cataracts?
Opacity of the natural lens, most common cause of reversible blindness
Cortical cataracts - radial or spoke like opafication in the cortex of the lens is associated with ______ and ____
Ageing and DM.
Associations of cataracts?
Ageing, DM, UV-B light, Blunt trauma, genetics, Atopic, dermatitis, Cigarette smoking, corticosteroid use
What congenital conditions can cataracts be associated with?
Rubella Syndrome, Patau’s syndrome, DS, Edqard;s, Congenital syphillis
Gradual decrease in visual acuity (also cuts out blue light), glare, dazzles, halos around lights at night, change in red eye reflex (leukocoria)
Cataracts!
A man has been hit by a squash ball in the eye. He presents to the ED with a red eye.
Hyphaema - accumulation of red blood cells within the anterior chamber of the eye.
A young man presents with eye pain after having worsening lower back pain over the last few months.
Anterior uveitis - Anterior uveitis is specifically that of the iris (iritis) and anterior chamber
What is anterior Uveitis associated with?
Associated with HLA-B27 conditions (in 50%) such as ankylosing spondylitis, but also associated with other autoimmune disorders (JIA, GPA, sarcoidosis, Kawasaki disease, IBD, MS) and many infections
Clinical features: redness with circumciliary infection (limbal flush), blurred vision and reduced visual acuity, photophobia, pain, floaters (dark spots in visual field), irregular pupil due to posterior synechiae, keratic precipitates, hypopyon (yellowish exudate in the lower part of the anterior chamber of the eye)
Anterior uveitis
Management of anterior uveitis?
treat cause: Topical corticosteroids, mydriatic agents (breaks down recently formed posterior synchiae e.g. cyclopentolate)
A young woman sees her GP with redness and aching on one eye. On examination, the redness is localised to one sector.
Episcleritis
What is Episcleritis and how does it present?
Inflammation of the episclera (thin layer of connective tissue between the conjunctiva and the sclera)
– Typically affects young adults and is usually idiopathic
■ Clinical features: moderate aching, conjunctival inflammation is
usually localised to one sector (but can be diffuse)
– Mildersymptomsthanuveitisandscleritis
How to differentiate Episcleritis and Scleritis?
By use of phenylephrine 2.5% eye drops
whereby episcleritic hyperaemia blanches
What are the clinical features of Scleritis?
Redness of the sclera and conjunctiva (sometimes changing to a purple hue), severe ocular pain, photophobia, tearing, decrease in visual acuity
What is the common cause for Scleritis?
Usually not due to infection, but caused by connective tissue disease (eg. chronic granulomatous conditions such as GPA)
Blue Sclera of _________
Osteogenesis Imperfecta
An elderly man notices he’s having trouble seeing things, especially in the center of his vision.
Age-related macular degeneration
What is age related macular degeneration?
Progressive age related damage to the macula resulting in loss of central vision and metamorphosia
Risk factors for Age-related macular degeneration?
Age-ing, family history, genetics (certain genes for complement system proteins, also Stargardt’s syndrome which is an autosomally recessive juvenile macular degneration), hypertension, obesity, smoking etc.
ARMD can either be dry or wet - What is the difference?
Dry (most common, 90%): yellow deposits (drusen) in the macula between the retinal pigment and the choriod (Brush’s membrane) worsens as Drusen enlarge
Wet: a break in Bruch’s membrane leads to choroidal neovascularisation that causes bleeding and leakage of proteins that can damage the over-lying retina and cause acute vision loss
What are the clinical features of macular degeneration?
Drastically decreasing visual acuity, slow recovery of visual function after exposure to bright lights,
central scotoma, difficulty reading (can be helped using a magnifying glass),
straight lines appear wavy (metamorphopsia) and some patched appear blank when viewing an Amsler grid
How do you manage Age related macular degeneration?
Dry and wet?
Lifestyle changes
Dry: No treatment, high dose of anti-oxidants could be helpful
Wet: Anti-vascular endothelial grwoth factor (anti-VGEF) agents (Ranibizumba), photodynamic therapy
Does Diabetic Nephropathy come before or after nephropathy?
It precedes!
Signs seen in Non-proliferative retinopathy:
Hard exudates, microanneurysms, cotton woolspots, venous abnormalities, dot and blot haemorrhages
What is seen in proliferative retinopathy?
It is a sequelae to non-proliferative so you see cotton woolspots + Dot and blot haemorrhages
And you see Neovascularisation (they can grow into the vitreous humour and may bleed as vitreous haemorrhages) and may also see retinal detachment
Symptoms of Diabetic retinopathy?
Usually asymptomatic until late stages
Management of Diabetic retinopathy?
- Better diabetic control, annual screening
- Laser panretinal photocoagulation (stops neovascularisation by stopping ischaemic symptoms
- Anti-VEGF (ranibizumab)
- Vitrectomy (replacement of the vitreous with saline)
A man presents to his ophthalmologist for a follow- up regarding his open angle glaucoma. A recent referral letter from his GP reveals hypertension and no history of diabetes
Hypertensive retinopathy
Grade 1/2/3/4 hypertensive changes of the retina?
Grade 1: Silver wiring
Grade 2: Previous changes and arteriovenous nicking (AV nicking)
Grade 3: Previous changes and flame-shaped haemorrhages and exudates (cotton wool spots, hard exudates)
Grade 4: previous changes and papilloedema (CAN CAUSE VISUAL LOSS (especially in malignant hypertension)
(Management: better control of hypertension (retinal changes can regress)
In HTn retinopathy - you see silver wiring in which grade?
Grade 1
In HTn retinopathy - you see papillodema in which grade?
Grade 4
An elderly woman suddenly loses vision of one eye. This is associated with no pain or redness. Her medical history is unremarkable other than a TIA last week.
Central artery occlusion
Cause of central retinal artery (stroke of the eye)?
usually due to embolism but can be due tot temporal arteritis
Sudden monocular loss of vision with no pain or redness?
Central retinal artery occlusion
Cherry red spot macula and diffuse pallor of the retina?
Central retinal artery occlusion
Why is there a cherry red spot macula?
(due to visualisation of underlying choroid under the fovea)
How do you confirm the diagnosis of central retinal artery occlusion
By doing a fluorescein angiogram
How do you manage Central retinal artery occlusion?
Aim is to drop the IOP to dislodge the emboli:
Ocular massage, anterior chamber paracentesis, mannitol, hyperbaric oxygen therapy
An elderly man reports sudden unilateral blurring of vision. He has a history of hypertension and diabetes mellitus. His eye is not painful or red.
Central Retinal Vein Occlusion
Painless acute mononuclear blurred vision
Central Retinal Vein Occlusion
Retinal haemorrhages in all four quadrants, “blood and thunder” fundus or “fundus splashed with blood” dilated and tortuous veins
Central Retinal Vein Occlusion
Management of Central Retinal Vein Occlusion?
Ranibizumab (VEGF inhibitor), laser photocoagulation.
Complication of Central Retinal Vein Occlusion?
Can result in neovascularisation and growth of new vessels in the iris which can lead to an acute neovascular glaucoma.
Fundoscopy shows scattered superficial haemorrhages, cotton wool spots, and tortuous veins in area of affected vein
Branch retinal vein occlusion
Occlusion of one of the branches of the central retinal vein, usually due to compression by retinal arterioles at the arteriovenous crossing points
Branch retinal vein occlusion
An elderly woman is known to see ‘floaters’ in her vision for the last few years. Suddenly, she notices an increase in the amount of floaters. As she’s taken to the ED, she then notices a dark shadow moving over her vision
Retinal Detachment
In retinal detachment, the retina peels away from it’s underlying _______ and _______
Retinal pigment epithelium and choroid.
There are two types of retinal detachment - Rhegmatogenous and Non-Rhegmatogenous. Which is more common
Rhegmatogenous (most common): full-thickness retinal holes or tears, usually due to posterior vitreous detachment but can also be due to trauma
Young person who has been progressively losing peripheral vision finally decides to see an ophthalmologist. She notes that her mother had tunnel vision before she was tragically killed by a hippopotamus.
Retinitis Pigmentosa
What is retinitis pigmentosa?
A group of inherited dystrophies (multiple modes of inheritance) characterised by progressive degeneration and dysfunction of the retina, primarily affecting photoreceptor and pigment epithelial function
Clinical features: night and peripheral vision are lost progressively, leading to a constricted visual field (tunnel vision) and markedly diminished vision
Retinitis Pigmentosa
Infant is found to have leukocoria by her GP.
Retinoblastoma
Fundoscopy shows typical ‘bone-spicule’ deposits or attenuated retinal vessels
Retinitis Pigmentosa
What age group does Retinoblastoma affect?
Children less than 5years
Malignant tumour of the eye that is either heritable (autosomal dominant, mutation of RM1 tumour suppressor gene on chromosome 13) or not heritable
Retinoblastoma
Presentation of Retinoblastoma?
Leukocoria, Strabismus, Persistent eye pain, redness, deteriorating vision
‘Cottage cheese and tomato ketchup’ or ‘pizza’ appearance
CMV
Pale-centred haemorrhage, IVDU with some spots
Roth spots of infective endocarditis
‘Leopard skin’ pattern on fluorescein angiogram
Intraocular lymphoma
usually diffuse large B cell
An elderly woman was watching TV in her dark lounge room when her eye suddenly became painful. Her husband rushed to the ED where the eye was red and had a mid-dilated fixed pupil.
Glaucoma
What is glaucoma? and how is it classfied?
Progressive optic neuropathy characterised by progressive loss of retinal ganglion cells and their axons leading to a visual function deficit, classified as primary, congenital, and secondary
Normally aqueous is actively secreted into the _______by the ciliary processes. it then passes through the pupil into the _______ and leaves the eye, predominantly via the trabecular meshworl, Schlemm’s canal and the episcleral veins to reach the blood stream (the conventional pathway)
Normally, aqueous is actively secreted into the posterior chamber by the ciliary processes, it then passes through the pupil into the anterior chamber and leaves the eye, predominantly, via the trabecular meshwork, Schlemm’s canal and the episcleral veins to reach the bloodstream (the conventional pathway)
Primary Classification of glaucoma is dependent on whether or not the __________ is clear of the trabecular meshwork (____ angle) or covering the meshwork (_____ angle)
Primary classification of glaucoma is dependent on whether or not the peripheral iris is clear of the trabecular meshwork (‘open angle’) OR covering the meshwork (‘closed angle’)
What is the uveoscleral pathway for the aqueous?
Small proportion of the aqueous drains across the _______ into he supra-choroidal space and is absorbed into the ________
Small proportion of the aqueous drains across the ciliary body into he supra-choroidal space and is absorbed into the venous circulation
Retinal detachment is cleavage between the _______ and the __________
Retinal detachment is cleavage between the neurosensory retina and the retinal pigment epithelium (RPE)
Retinal detachment can be ______, _______ or _______
Rhegmatogenous, tractional or exudative
In Rhegmatogenous retinal Detachment there is a ______ which allows ______ to pass into the subretinal space
In Rhegmatogenous RD there is a tear which allows vitreous to pass into the subretinal space. Tears may be caused by vitreous detachment, degenerative retinal changes, trauma or iatrogenically.
Tractional RD is found in conditions such as __________ (5)
Diabetic retinopathy, Central retinal vein occlusion, posterior uveitis, central serous retinopathy
Exudative Retinal detachment is caused by damage to the ______ resulting in ______ in the . Main causes are __________ (3)
Exudative Retinal detachment is caused by damage to the RPE resulting in fluid accumulation in the subretinal space. Main causes are intraocular tumour, posterior uveitis, central serous retinopathy
What are the basic clinical features of retinal detachment
Sudden onset, flashes of light, floaters, curtain of blackness (peripheral field loss), loss of central vision, decreased IOP
What would you see on opthalmoscopy in retinal detachment?
Detached retina is grey-white with surface blood vessels, loss of red reflex
What is the reason behind floaters in retinal detachment?
What is the reason behind flashes of light in retinal detachment?
What is the reason for curtain of blackness/peripheral field loss in RD?
Floaters: hazy spot in the line of vision which move with eye due to drops of blood from torn vessels bleeding into the vitreous.
Flashes of light: due to mechanical stimulation of the retinal photoceptors
Curtain of blackness: darkness in one field of vision when the retina detaches in that area
Mx of Retinal detachment?
Prophylactic: symptomatic tear (flashes or floaters)- can be sealed off with laser with the goal of preventing progression to detachment
Rhegmatogenous: Scleral buckle procedure or Pneumatic retinopexy - both treatments used with localisation of retinal tears/holes and subsequent treatment with laser to create adhesions between the RPE and neurosensory retina
Complications of retinal detachment?
Loss of vision, vitreous haemorrhage, recurrent detachment
–> a retinal detachment is an emergency, especially if the macula is still attached
Blood and thunder appearance on fundoscopy?
CRVO
___________ retina is the most common site for horseshoe tears
Supratemporal retina
What is the triad of retinitis pigmentosa on fundoscopy?
APO:
Arteriolar narrowing
Perivascular bony-spicule pigmentation
Optic disc pallor
Night blindedness, decreased peripheral vision, decreased central vision
Retinitis pigmentosa.
Aqueous is produced by the ciliary body and flows from the _______ to the anterior chamber through the pupil and drain into the episcleral veins via the trabecular meshwork and the __________
Aqueous is produced by the ciliary body and flows from the posterior chamber to the anterior chamber through the pupil and drain into the episcleral veins via the trabecular meshwork and the canal of schlemm
What is the sequelae for Vitreous detachment, retinal tear and retinal detachment?
Posterior Vitreous detachment can lead to a retinal tear which can then progress to retinal detachment
What is posterior vitreous detachment?
When the central vitreous commonly shrinkes and liquifies with age. During syneresis, molecules that hold water condense causing vitreous floaters. The liquid vitresou moves between posterior vitreous gel and retina - the vitreous is peeled away and separated from the internal limiting membrane of the neurosensory retina posterior to the vitreous base
How do PVD present?
Floaters, flashes of light
What can be complications of PVD? And when are they more common?
Traction areas can cause tears or detachment. This can in turn lead to vitreous haemorrhage if bridging retinal vessels are torn. Complications are more common in myopes and following occular trauma
New of markedly increased floaters or flashes require _________
Require a dilated fundus exam to rule out retinal tears/detachment
What is a vitreous haemorrhage?
Bleeding into the vitreous cavity
What are the clinical features of a Vitreous haemorrhage?
Sudden loss of vision. May be preceded by many floaters and flashes
Fundoscopy: No red reflex, retina not visible
Vitreous haemorrhage
retina not visible due to blood in vitreous
Clinical features: insidious and asymptomatic, earliest signs are optic disc changes due to increased intraocular pressure (as measured by tonometer, risk if >21mmHg) which causing a gradual increased cup:disc ratio leading to gradual visual field loss
Primary open angle glaucoma
Typically happens in response to dilated pupils, which causes the lens to push against the back of the iris which produces a pressure gradient across the iris and lens causing them to move anteriorly, closing the irido-corneal angle
Closed angle glaucoma - covering the meshwork
Clinical features: acute painful red eye (although usually chronic) that can radiate to the forehead, coloured haloes around bright lights, decreased visual acuity, mid-dilated fixed pupil, increased intraocular pressure may be noticeable on palpation (‘rock hard’ orbit)
Closed angle glaucoma
How to manage Open angle glaucoma?
Aim is to reduce the IOP:
- Needs to be screened from the age of 50yrs
- Agents that suppress aqueous inflow: Beta blockers, alpha2-adrenergic agonists, carbonic anhydrase inhibitors
- Agents that increase aqueous outflow: prostaglandin analogues, alpha2 -adrenergic agonists, cholinergic agonists
- Laser trabeculoplasty
Complete transection of one optic nerve.
Resting pupil size?
Both the same?
Complete transection of both optic nerves.
Resting pupil size?
Both dilated
A young woman presents with loss of vision from one eye some ocular pain. Fundoscopy is normal.
Optic Neuritis (MS)
Inflammation of the _______ nerve is associated with MS
Optic nerve (optic neuritis)
Clinical features: unilateral ocular or periocular pain worse with eye movement, loss or blurring of central vision, loss of colour vision, loss of visual field, enlarged blind spot
Fundoscopy normal
optic neuritis
How do you manage optic neuritis
IV methylprednisolone for 3 days followed by tapering oral course, consider starting management for MS
A middle aged obese woman has been suffering from worsening morning headaches for the past 2 months.
Papilloedema
What do you see on fundoscopy in papilloedema?
- Swelling of the optic disc
- Venous engorgement
- Loss of normal venous pulsations
- Haemorrhages over and/or adjacent to the optic disc
- blurring of optic margins
What is Horner’s syndrome?
Miosis, Ptosis, and anhydrosis
Common causes of Horner’s syndrome?
Lateral medullary syndrome (Wallenberg syndrome) due to PICA infarct, other causes include stroke
2nd order causes: Pancoast tumour on the pulmonary apex
Left central scotoma
Optic nerve lesion
bitemporal hemianopia
Chiasmal lesion (pituitary tumour)
Right upper quadrantanopia
left temporal lobe tumour
Right homonomous hemianopia - Macula-sparing hemianopia
(left calcarine cortex lesion) - lesion of left occipital cortex
What is arteritic anterior ischaemic optic neuropathy associated with?
temporal arteritis
An elderly man has a unilateral headache. As he’s making his way to his GP, he notices what he later describes as a “curtain closing” on his vision in one eye. As he is describing this, his vision has already reverted back to normal.
Amaurosis fugax
What is strabismus?
Eye misalignment typically due to incoordination of the extraocular muscles which prevents bringing the gaze of each eye to the same point
Slowing or limitation of adduction (on the same side as the MLF lesion) during horizontal eye movements
Internuclear Opthalmoplegia (think multiple sclerosis)
Painless eye without redness. Moderately increased IOP - Normal cornea and pupil. Common
Primary open Angle glaucoma
Acute onset, painful red eye, extremely increased IOP wth hazy cornea. Mid dilated, pupil reactive. halo’s around lights
Primary closed angle glaucoma
Risk factors for open angle glaucoma?
A FIAT
Age, Fam Hx, IOP, Afrocan dexcent, Thin Cornea
Mx of Angle closure glaucoma?
BACH Beta blcokers +Mitotic Adrenergics Cholinergics Hyperosmotic agents
5 causes of sudden painless loss of vision?
- Ishcaemic optic neuropathy (Temporal arteritis)
- occlusion of central retinal vein
- Occlusion of central retinal artery
- Vitreous haemorrhage
- Retinal Detachment
Flashes of light (photopsia) - in the peripheral field of vision
Floaters, often on the temporal side of the central vision
Posterior Vitreous detachment
Dense shadow that starts peripherally progresses towards the central vision
A veil or curtain over the field of vision
Straight lines appear curved
Central visual loss
retinal Detachment
Large bleeds cause sudden visual loss
Moderate bleeds may be described as numerous dark spots
Small bleeds may cause floaters
Vitreous haemorrhage
Causes of Papillodoema?
Space occupying lesion Malignant Htn Idiopathic intracrnial hypertension Hydrocephalus Hypercapnia
Paton’s lines: concentric/radial retinal lines cascading from the optic disc
Papilloedema
Features of papillodoema on fundoscopy
- venous engorgement: usually the first sign
- loss of venous pulsation: although many normal patients do not have normal pulsation
- blurring of the optic disc margin
- elevation of optic disc
- loss of the optic cup
- Paton’s lines: concentric/radial retinal lines cascading from the optic disc
Visual loss, eye pain and red desaturation are all classical symptoms of
Optic neuritis
3 common causes of optic neuritis?
MS, DM, Syphillis
left homonymous hemianopia means visual field defect to the________ tract
Right optic tract
Primary open angle glaucoma in the right eye present with visual loss of ________
Unilateral peripheral visual field loss
Right sided brain stroke results in visual field loss on the ________
Left side visual field loss
Macula Sparing homonymous hemianopia are lesions of the _______
occipital cortex
Pituitary tumours cause bitemporal hemianopia’s - with upper or lower quadrant defect?
Upper quadrant defect
Craniopharyngioma cause bitemporal hemianopia’s - with upper or lower quadrant defect?
Lower quadrant defect.
Pituitary causes upper quadrant defect
Night blindness + funnel vision =
Retinitis Pigmentosa
How do you manage Acute Glaucoma?
Management options include reducing aqueous secretions with acetazolamide and inducing pupillary constriction with topical pilocarpine
which age related macular degeneration is associated with?
i) characterised by choroidal neovascularisation
ii) characterised by drusen - yellow round spots in Bruch’s membrane
i) Wet
ii) Dry
Firstline management of Blepharitis?
Hot compressions and removal of eyelid debris
How do you differentiate (bloodwork) Type I DM to Type II?
C-peptide will be low in individuals with type 1 diabetes mellitus (as the pancreas is not making enough insulin precursor, which breaks down to form C-peptide and insulin) , and normal or high in individuals with type 2 mellitus.
__________ describes the reactivation of the varicella zoster virus in the area supplied by the ophthalmic division of the trigeminal nerve. It accounts for around 10% of case of shingles
Herpes zoster ophthalmicus (HZO)
_______ sign n Herpes zoster opthalmicus: rash on the tip or side of the nose. Indicates nasociliary involvement and is a strong risk factor for ocular involvement
Hutchinson
A 45-year-old woman presents complaining of visual disturbance. Examination reveals a left homonymous hemianopia. Where is the lesion most likely to be?
Right Optic tract = right optic radiation or occipital cortex
How to differentiate Glacouma to uveitis in a red painful eye?
glaucoma: severe pain, haloes, ‘semi-dilated’ pupil
uveitis: small, fixed oval pupil, ciliary flush
_________ are a known precipitant of acute angle closure glaucoma. This scenario is more common in exams than clinical practice.
Mydriatic eye drops
Visual distrubances in temporal arteritis are secondary to ______________
Anterior ischaemic optic neuropathy
Watery eyes with swelling/erythema at the inner canthus of the eye
Dacrocystitis
Red painful eye + photophobia + man wears contacts + Gritty sensation + hypopyon may be seen
Keratitis
How do you manage a Stye?
management includes hot compresses and analgesia. CKS only recommend topical antibiotics if there is an associated conjunctivitis
Is entropion in turning or out turning of the eyelids?
In turning
