Opthalmology Flashcards
How are diabetic retinopathy and retinal vascular occlusive disease imaged?
Fluorescein dye
How is macular oedema best detected?
Fluorescein angiography
A 52 year old female presents with two month history of giddiness. Examination reveals a nystagmus to both extremes of gaze and a tendency to fall to the right. She has a deafness of the right ear. What reflex is also likely to be affected and what is the diagnosis?
Corneal reflex may be lost
Acoustic neuroma
A 73 year old female presents acutely with nausea vomiting and giddiness. She has recently been treated for heart failure with atrial fibrillation and receives digoxin, furosemide and ramipril. What test should be done to do with her vision? What does she have?
Colour vision
Digoxin toxicity
What is conjunctivitis medicamentosa?
People use cheap over the counter preparations to treat their dry eyes
Excessive use of topical medications and preservative toxicity causes conjunctivitis
A 40 year old model who enjoys sunbathing is referred to an opthalmologist with 6 month history of vascularisation extending into nasal aspect of the cornea in her right eye. What is it?
Pterygium
What is a pterygium?
Benign growth of the conjunctiva
Grows from nasal side of conjunctiva
Caused by UV light exposure
A 50 year old man presents to his GP complaining of a foreign body sensation in left eye. GP notices that the lower eye lid is inverted. What is it?
Entropion
What is an entropion? How is it treated?
Eyelid folds inward
Eyelashes constantly rub on cornea so very uncomfortable
Surgery is indicated
A 40 year old man is referred to opthalmologist with soft yellowish patches over sclera at 3 and 9 o’clock positions. The patient is asymptomatic. What does he have? What should be done about it?
Pinguecula
Benign condition can be left alone
How does anterior uveitis present?
Pain of acute onset
Lacrimation
Circumcorneal redness
Small pupil/irregular
What will be seen on slit lamp exam in anterior uveitis?
White precipitates on back of cornea and cells in anterior chamber
How do you treat anterior uveitis?
Steroids
A patient is diagnosed with a dendritic ulcer after fluorescein staining. How should it be managed?
Antiviral ointment - aciclovir 3% 5x daily until complete healing
How should acute angle closure glaucoma be managed?
Miotic agent - pilocarpine
Carbonic anhydrase inhibitors
Topical beta blockers
How is acute angle closure glaucoma confirmed?
Elevated intraocular pressure more than 60mmHg
How might a 3rd nerve palsy due to posterior communicating artery aneurysm differ from one caused by vascular disease such as diabetes?
External compression due to aneurysm - external fibres only, fixed dilated pupil followed by partial ten complete palsy
Vascular disease - innermost fibers affected most, pupil function preserved but palsy and ptosis more prevalent
What are some causes of a swollen optic disc?
Malignant HTN Raised intracranial pressure due to space occupying lesion or infection Renal failure Chronic carbon dioxide retention Idiopathic intracranial HTN Hypocalcaemia
What is central serous chorioretinopathy?
Serous detachment of neurosensory retina occurs over area of leakage from choriocapillaris through retinal pigment epithelium at pole of fundus resulting in diminished visual acuity and distortions of visual perception
What are some causes of central serous chorioretinopathy?
Idiopathic
Hypercortisolaemia - pituitary/adrenal disease, corticosteroids, adrenocorticotrophic hormone
What are signs and symptoms of retinal detachment?
Flashes
Floaters
Blurring or distortion of vision
Shadow/curtain spreading across vision
Which is the most common area affected in retinal detachment?
Superior temporal
How does a dendritic ulcer usually present?
Pain Photophobia Blurred vision Conjunctivitis Chemosis (oedema of the conjunctiva)
Why are steroid drops contraindicated in dendritic ulcer?
Induce massive amoeboid ulceration and blindness
A patient has an acute painless loss of vision with flame shaped haemorrhages radiating out from the disc and oedema. What is the problem?
Central retinal vein occlusion
What are risk factors for central retinal vein occlusion?
Age over 55 HTN Hyperlipidaemia Diabetes Mellitus Oral contraceptive pill Raised intraoccular pressure Smoking Polycythemia Myeloma SLE Hypercoagulable states
A 38 year old man has been complaining of headaches, dizziness and poor concentration for some time. He is brought to hospital with weakness on the left side. His haemoglobin is 200. What is going on?
Polycythemia Vera causing focal neurological signs as a result of cerebral thrombosis due to increased viscosity
A 70 year old man presents with constant severe pain in his right eye and forehead of one day duration. He has been long sighted for years but the vision in his right eye has rapidly deteriorated over the past 2 days. On examination the eye is red and congested with a dilated non responsive pupil. What is the immediate management?
IV acetazolamide
What is dacrocystitis?
Inflammation of the lacrimal sac
Usually caused by staph aureus
A 40 year old lady presents acutely to the GP with marked photophobia and decreased vision. The GP notes the presence of corneal injection and a small pupil. Slit lamp examination reveals hazy fluid. What is the likely diagnosis?
Uveitis
What are characteristic features of acute uveitis?
Photophobia
Circumlimbal injection
Abnormally shaped pupil/different size to unaffected eye
Which drugs can be used for the management of primary open angle glaucoma? How do they work?
Prostaglandin analogues: latanoprost, increase uveoscleral outflow
Beta blocker: timolol, reduce aqueous production
Sympathomimetics: brimonidine, reduce aqueous production and increase outflow
Carbonic anhydrase inhibitor: dorzolamide, reduce aqueous production
Miotics: pilocarpine, increase uveoscleral outflow
What is the most common cause of blindness in the U.K.?
Age related macular degeneration
What is the management for age related macular degeneration?
Refer for opthalmological assessment within 1 week
Stop smoking
High dose beta carotene, vitamin c and e, zinc
Wet AMD: photocoagulation, photodynamic therapy, anti VEGF
What is normal range for intraocular pressure?
10-21 mmHg
What are risk factors for primary open angle glaucoma?
Age Family history Black Myopia HTN Diabetes
What are the Keith Wagener grades of hypertensive retinopathy?
Grade 1: tortuosity and silver wiring of arteries
Grade 2: AV nipping
Grade 3: flame haemorrhages and cotton wool spots
Grade 4: papilloedema
What are hallmarks of pre proliferative retinopathy?
Venous abnormalities - beading, reduplication
Cotton wool spots
What are signs of papilloedema on fundoscopy?
Venous engorgement Blurring of optic disc margin Elevation of optic disc Loss of optic cup Patons lines: concentric/ radial retinal lines cascading from optic disc
What are causes of papilloedema?
Space occupying lesion: neoplastic, vascular Malignant HTN Idiopathic intracranial HTN Hydrocephalus Hypercapnia Hypoparathyroidism and hypocalcaemia Vitamin A toxicity
What is the most common cause of contact lens acquired infection?
Pseudomonas aeruginosa
What is dacryocystitis? How does it present?
Infection of lacrimal sac
Watering eye (epiphora)
Swelling and erythema at inner canthus of eye
What is a Marcus gunn pupil?
Relative afferent pupillary defect
Damage to afferent pathway - retina or optic nerve
Pupil will abnormally dilate when light shone onto it due to consensual relaxation response from healthy eye dominates
What is a danger of hyphaema?
Secondary glaucoma
What is the definition of blindness?
Visual acuity less than 3/60 or inability to count fingers in daylight at distance of 3m
What is a pinguecula?
Conjunctival degeneration
Yellow/white deposit on conjunctiva adjacent to limbus
What is entropion of the eye? What is the management?
Out turning of the eyelids
Eye lubricants and tape to pull eyelid outwards whilst awaiting surgery
What are the most common causes of a sudden painless loss of vision?
Ischaemic optic neuropathy: temporal arteritis, atherosclerosis Occlusion of central retinal vein Occlusion of central retinal artery Vitreous haemorrhage Retinal detachment
What are some causes of central retinal vein occlusion?
Glaucoma
Polycythemia
Hypertension
What factors predispose to acute angle closure glaucoma?
Hypermetropia (long sightedness)
Pupillary dilatation
Lens growth associated with age
What are features of acute angle closure glaucoma?
Severe pain: ocular or headache Decreased visual acuity Symptoms worse with mydriasis (dark room) Hard red eye Haloes around lights Semi dilated non reacting pupil Corneal oedema - dull or hazy Nausea and vomiting
What is the appearance on fundoscopy of an eye with central retinal vein occlusion?
Severe haemorrhages
Cheese and tomato pizza appearance
What are risk factors for primary open angle glaucoma?
Age over 40 Family history Black Myopia Hypertension Diabetes Mellitus
How does primary open angle glaucoma present?
Peripheral visual field loss
Nasal scotomas progressing to tunnel vision
Decreased visual acuity
Optic disc cupping
What is endophthalmitis?
Inflammation of interior of eye
Complication of intraocular surgeries, particularly cataracts
Presents with severe pain, loss of vision, red eye, hypopyon
What is the most common cause of blindness in adults age 35-65?
Diabetic retinopathy
What is hutchinsons sign?
Rash on tip or side of nose indicates nasociliary involvement with herpes zoster opthalmicus and is a strong risk factor for ocular involvement
What is management of herpes zoster opthalmicus?
Oral antiviral treatment for 7-10 days ideally started in 72 hours
Ocular involvement requires urgent ophthalmology review
What are complications of herpes zoster opthalmicus?
Conjunctivitis Keratitis Episcleritis Anterior uveitis Ptosis Post herpetic neuralgia
What are causes of tunnel vision?
Papilloedema Glaucoma Retinitis pigmentosa Choroidoretinitis Optic atrophy secondary to tabes dorsalis Hysteria
What is the mechanism of action of prostaglandin analogues in primary open angle glaucoma?
Increases uveoscleral outflow
What is the mechanism of action of beta blockers in primary open angle glaucoma?
Reduce aqueous production
What is the mechanism of action of carbonic anhydrase inhibitors in primary open angle glaucoma?
Reduce aqueous production
What is the mechanism of action of miotics (pilocarpine) in primary open angle glaucoma?
Muscarinic agonist
Increases uveoscleral outflow
What are risk factors for primary open angle glaucoma?
FH Black patients Myopia HTN Diabetes
What features on examination might suggest primary open angle glaucoma?
Peripheral visual field loss, nasal scotomas progressing to tunnel vision
Decreased visual acuity
Optic disc cupping. Cup to disc ratio >0.7
Optic disc pallor
Bayoneting of vessels - have breaks as they disappear into cup and reappear at base
Cup notching
Disc haemorrhages
What is the Keith wagener classification of HTN retinopathy?
1: arteriolar narrowing and tortuosity. Increased light reflex - silver wiring
2: arteriovenous nipping
3: cotton wool exudates, flame and blot haemorrhages
4: papilloedema
What are side effects of prostaglandin analogues used in glaucoma?
Increased eyelash length
Iris pigmentation
Periocular pigmentation
Which antibiotics should be used for corneal abrasions?
Contact lens wearer: topical ciprofloxacin to cover for pseudomonas
Non contact wearer: topical erythromycin
What is the name of cataract surgery?
Phacoemulsification
What are complications of cataract surgery?
Early: posterior capsule rupture
Late: posterior capsule opacification
Endopthalmitis
What is used to measure intraocular pressure?
Tonometer
What value is normal for intra ocular pressure?
21
What is gonioscopy?
Measurement of iridocorneal angle used to distinguish between open and closed angle glaucoma
What is important to note about the optic disc in open angle glaucoma?
Cupping - death of nerve fibres and so enlargement of the optic cup
What are risk factors for open angle glaucoma?
Age Family history Race - Afro Caribbean Myopia Intraocular HTN
What is used to test for wet AMD?
Amsler chart
Slit lamp fundoscopy
Optical coherence tomography
Fluorescein angiography
What changes will be seen on a retina with wet AMD?
Drusen
Atrophic change
Choroidal neovascularisation
Leaking blood vessels
What can be used to treat wet AMD?
Photodynamic therapy
Laser photocoagulation
Intravitreal vascular endothelial growth inhibitor
What is a serious viral cause of conjunctivitis?
Adenovirus - causes supethelial deposits, can cause visual loss
What type of conjunctivitis is associated with pre auricular lymphadenopathy?
Viral
Why does chloramphenicol not work for contact lens wearers with bacterial conjunctivitis?
Pseudomonas infection
Chloramphenicol doesn’t cover Gram negative bacteria
Need levofloxacin/gentamicin
What are the 3 components of tear film?
Oil (outside)
Water
Mucin
What are the 2 types of blepharitis?
Anterior: skin at base of eyelashes
Posterior: affects meibomian glands along eyelid margins behind base of eyelashes
What type of cells produce mucin for tear film?
Goblet cells
Which cells produce oil for the tear film?
Meibomian cells
What is a feature of chlamydia conjunctivitis?
Unilateral
Sticky/watery discharge
Pseudomembrane - bleeds when flip eyelid
How many layers are there in the cornea? What are they?
5 Epithelium (only bit that can regenerate) Bowmans layer Corneal stroma Descemets membrane Corneal endothelium
What could be causes of sub conjunctival haemorrhage?
Trauma Coughing/sneezing Diabetes HTN Warfarin Bleeding disorders
What is a synechiae?
Iris adheres to cornea or lens
Why do you get vision loss in orbital cellulitis?
Proptosis, leads to stretching of optic nerve
What is the most common surgery done in the U.K?
Cataract surgery
What is presbyopia?
Stiffening of lens with age
Need reading glasses as can’t focus on near object
What makes up the uvea?
Iris
Ciliary body
Choroid
