Opthalmology Flashcards
What are some common colour changes that may be seen in the eyes due to pathology?
Red (bleeding, inflammation)
Blue (thinning of sclera - RA, osteogenesis imperfecta)
Yellow (jaundice)
Brown/black (pigmentation)
What are the main ‘red flag’ features of a red eye?
Impaired vision
Pain/photophobia
Lack of ocular discharge (if discharge present, more likely to be infection like conjunctivitis)
What kind of ocular pathology causes rapid onset of visual loss?
Central retinal artery occlusion (cherry red spot in macula) - e.g. amaurosis fugax Central retinal vein occlusion Giant cell arteritis Retinal detachment Vitreous haemorrhage
What kind of ocular pathologies cause slow onset loss of vision?
Degenerative causes, e.g. Age-related macular degeneration
What is acute angle closure glaucoma?
Rare but serious cause of red eye
Associated with raised IOP (>21 mmHg)
Give 3 RFs for acute angle closure glaucoma
1) Hypermetropia (long-sightedness)
2) Increase in age
3) Pupillary dilatation (i.e. pain comes on sitting in the cinema watching a movie)
What are the symptoms of acute angle closure glaucoma?
Severe pain (eye pain or headache) Decrease in visual acuity Worse with dilated pupil (TV in dark room) Red eye Haloes around lights Systemic upset (N+V, abdo pain) Photophobia
What are the signs of acute angle closure glaucoma?
Red eye
Semi-dilated, non-reacting pupil
Corneal oedema
Poor visual acuity
What type of visual loss does acute angle closure glaucoma cause?
Peripheral visual field deficits
How is acute angle closure glaucoma investigated?
Slit lamp examination Gonioscopy Automated perimetry (to assess visual field) Measure IOP Visual field loss on assessment
How is acute glaucoma managed?
Urgent referral to ophthalmology
1) Lower the pressure (topical beta blockers [timolol] + carbonic anhydrase inhibitor [PO/IV acetazolamide])
2) Constrict the pupil (pilocarpine drops - topical cholinergic agonist)
3) Prevent recurrence (laser iridotomy - hole in iris)
Give 2 drugs that can be used to reduce IOP in acute angle closure glaucoma
Timolol (topical beta blocker)
Acetazolamide (PO/IV carbonic anhydrase inhibitor)
What is the definitive treatment for acute angle closure glaucoma?
Laser iridotomy
What is chronic glaucoma/primary open angle glaucoma?
Progressive optic neuropathy associated with visual field loss and raised IOP
What are the RFs for chronic glaucoma?
Increasing age Fix Myopia (short-sightedness) Hypertension Diabetes mellitus Afro-Caribbean origin
What are the clinical features of chronic glaucoma?
Triad of:
1) Raised IOP (>21 mmHg)
2) Abnormal disc
3) Visual field defect (tunnel vision)
What are the symptoms of chronic glaucoma?
Decreased peripheral vision (nasal scotoma leading to tunnel vision)
Insidious onset
Often asymptomatic
Routine finding during opticians appointment
Decreased visual acuity
How is chronic glaucoma investigated?
Fundoscopy Automated perimetry (assess visual fields) Slit lamp examination Automated tonometry (measure IOP) Gonioscopy (checks drainage angle)
What are the signs of chronic glaucoma on fundoscopy?
Optic disc cupping (Cup:Disc ratio >0.66) Optic disc pallor (optic atrophy) Bayonetting of vessels Cup notching Disc haemorrhage
How is chronic glaucoma treated? Give a side effects each.
Eye drops!
1) Latanoprost (prostaglandin analogues)
2) Timolol (BB)
S/E:
latanoprost - increased eyelash length
timolol - watch out in asthmatics and heart failure (drains to nose - very vascularised)
What is age-related macular degeneration (ARMD)?
Most common cause of blindness in the UK
Degeneration of the central retina (macula)
What is the epidemiology of ARMD?
Females > males
Avg age of presentation >70 yrs
What are the RFs for ARMD?
Increasing age Smoking FHx HTN Dyslipidaemia DM
What are the symptoms of ARMD?
Central visual loss Wavy lines (distortion of line perception) Poor night vision Flickering/flashing objects Glare around objects
Wet vs Dry ARMD.
Which is more common?
What is a key feature of each?
Which carries the worse prognosis?
Dry:
90% cases
Asociated with DRUSEN in Bruch’s membrane
Wet
10% cases
Choroidal neurovascularisation
Worse prognosis
Give 3 investigations done in ARMD?
1) Gold standard = Slit lamp microscopy with colour fundus photography
Ocular coherence tomography (OCT) Fluorescein angiography (looking for neovascularisation - wet ARMD)
What will be seen on fundoscopy in someone with:
a) Dry ARMD?
b) Wet ARMD?
a) Dry: Drusen in Bruch’s membrane
b) Well-demarcated red patches (haemorrhages)
How is dry ARMD managed?
Vitamins ACE to Z
(vitamin A, C, E and zinc)
Maybe blind registration and visual aids
How is wet ARMD managed?
Anti-VEGF infections (e.g. ranibizumab)
Slows/prevents progression of neovascularisation
What is the leading cause of blindness worldwide?
Cataracts
What are cataracts?
Lens gradually opacifies
More difficult for light to reach retina
Leads to decreased visual acuity and blurred vision
Give some causes of cataracts
Normal ageing (most common) Smoking, Alcohol, DM Trauma STEROIDS Radiation, metabolic disorders Congenital (e.g. due to TORCH infections)
How does the type/classification of cataract relate to its cause?
Nuclear - old age
Polar - inherited
Subcapsular - Steroid use
Dot opacities - common in normal lenses, also seen in diabetes and myotonic dystrophy
What are the symptoms of cataracts?
Gradual onset Decrease in vision Faded colour vision Flare (lights brighter than normal) Haloes around lights
What hallmark sign of cataracts can be elicited on examination?
Defect in/loss of red reflex
What investigations need to be done for cataracts?
1) Opthalmoscopy on DILATED PUPIL (normal fundus, normal optic nerve)
2) Slit lamp examination (shows visible cataracts)
How are cataracts managed?
Conservative (stronger glasses, encourage use of brighter lighting)
SURGERY = definitive Rx. Phacoemulsification - remove cloudy lens and replace with an artificial one.
What are some possible complications of cataract surgery?
Posterior capsule opacification (thickening of lens capsule)
Retinal detachment
Posterior capsule rupture
Endophthalmitis (inflammation of aqueous +/or vitreous humour)
What is vitreous detachment?
Precursor to retinal detachment
Also causes flashes and floaters
What is retinal detachment?
Sudden, painless loss of vision
Holes/tears in retina allow fluid to separate the sensory retina from the visual pigmented epithelium
Where will the visual loss be in a superior retinal detachment?
Inferior field loss
Give 6 RFs for retinal detachment
Myopia Cataract surgery Diabetes Hypertension Trauma Vasculitis
How does retinal detachment present?
Straight lines appear curved
Flashes + Floaters
Fall in acuity (painless)
Field loss (veil/curtain loss)
Complain of seeing ‘spider webs’
What investigations are done for retinal detachment?
B-scan USS = best test - flying-angel sign
Ophthalmoscopy
Fundoscopy - Schaffer’s sign
Slit lamp examination - billowing
Showing: grey, opalescent retina which balloons forwards
How is retinal detachment managed?
Urgent referral to ophthalmology Rest Positioned according to location of detachment Laser therapy Urgent surgery
What is vitreous haemorrhage?
Bleeding into areas around the vitreous humour
Causes SUDDEN PAINLESS LOSS OF VISION
Give 6 RFs for vitreous haemorrhage
Diabetes Bleeding disorders Retinal tear/detachment Trauma CRVO which has neovascularised Wet ARMD
What are the symptoms of vitreous haemorrhage?
Small bleed = floaters, dark spots
Large bleed = obscured/ complete loss of vision
What are the signs of vitreous haemorrhage on examination?
Absent red reflex
Retina not visible
What investigations should be done for vitreous haemorrhage?
Fundoscopy
B-scan (specialised eye USS)
Eye examination showing decreased visual acuity
How is vitreous haemorrhage managed?
Usually spontaneously resorbs
If dense/severe = vitrectomy to remove the blood
What is a central retinal artery occlusion (CRAO)?
Form a stroke
Dramatic visual loss within seconds of occlusion
Acuity limited to finger counting or worse
Less common than CRVO
Give 6 RFs for central retinal artery occlusion
Thromboembolic/vascular disease Arteritis (e.g. GCA) AF Heart valve disease Diabetes Smoking Hyperlipidaemia
What are the features of CRAO?
Sudden painless loss of vision
What are the signs of CRAO?
Marcus-Gunn pupil (relative afferent pupil defect - RAPD)
Signs on fundoscopy:
1) White retina
2) Cherry red spot on macula
How is CRAO managed?
Treat as stroke - local stroke protocol Immediate CT head Exclude GCA (ESR) Intraocular hypotensives (acetazolamide) Decrease IOP by ocular massage
Long term = address CV RFs to reduce risk of recurrence
What is central retinal vein occlusion?
Sudden, painless LOV
More common than CRAO
What are 6 RFs/ causes of CRVO?
Glaucoma Polycythaemia Hypertension Diabetes mellitus Increasing age Vascular disease
What are the symptoms of CRVO?
Sudden painless loss of vision
Severe drop in acuity
What are the signs of CRVO on fundoscopy?
Cotton wool spots Swollen optic nerve Macular oedema Severe retinal haemorrhage Tortuous and engorged retinal veins
‘cheese and tomato pizza appearance’
How is CRVO managed?
Call ophthalmology urgently
Intra-vitreal anti-VEGF therapy
Dexamethasone implants
What are some complications of CRVO?
Neovascularisation
Chronic macular oedema
What is optic neuritis?
Inflammation of the optic nerve
What are the causes of optic neuritis?
MS = most common Syphilis Diabetes Leber's optic atrophy (hereditary visual loss) Vitamin deficiency
What are the symptoms of optic neuritis?
Unilateral, subacute LOV
Pain on eye movement
Dyschromatopsia (poor colour vision discrimination)
What are the signs of optic neuritis?
Marcus-Gunn pupil (RAPD - seen on swinging light test)
Central scotoma (areas of depressed vision)
Decrease in visual acuity on eye examination
How is optic neuritis managed?
HIGH DOSE STEROIDS
- IV methylprednisolone for 72 hours
- then oral pred for 11 days
MRI if ?MS
Most make a full recovery within 2-6 weeks
What is retinitis pigmentosa?
Inherited degeneration of the retina
More common in males
Can be inherited AD, AR, or X-linked
What are the features of retinitis pigmentosa?
NIGHT BLINDNESS = first sign Tunnel vision Central daytime visual loss follows Eventual blindness FHx
Which diseases are associated with retinitis pigmentosa?
Usher syndrome - most common, affects hearing and vision
Alport syndrome - kidney disease, hearing loss, eye abnormalities
etc
What are the signs of retinitis pigmentosa on fundoscopy?
Mottling
Black bone spicule shaped pigmentation in peripheral retina
How can retinitis pigmentosa be managed?
Visual aids and blind registration
Electrical stimulation of retinal ganglion cells
Novel therapies (neural prosthetics)
What is diabetic retinopathy?
Microangiopathy causing damage to small blood vessels of retina (result of hyperglycaemia)
Causes gradual decrease in CENTRAL vision
How can diabetic retinopathy be classified?
1) Background
2) Pre-proliferative
3) Proliferative
4) Advanced
What are the features of ‘background’ diabetic retinopathy?
Dots, blots and spots:
1) Microaneurysms (dots)
2) Blot haemorrhages (= 3)
3) Hard exudates
Features of pre-proliferative diabetic retinopathy?
1) Cotton wool spots - dead nerve cells
2) >3 blot haemorrhages
3) Venous beading/looping
4) Dark cluster haemorrhages
More common in T1DM
What are ‘cotton wool spots’? What condition are they seen in?
Dead nerve cells
Seen in pre-proliferative diabetic retinopathy and hypertensive retinopathy
What is the key feature of proliferative diabetic retinopathy?
Why does this occur?
Retinal neovascularisation - due to insufficient retinal perfusion and subsequent ^production of VEGF
Give 4 complications of advanced diabetic retinopathy
1) Recurrent vitreous haemorrhage (from bleeding areas of neovascularisation)
2) Retinal detachments
3) Rubeosis (neovascularisation occurs at iris)
4) Progressive glaucoma
How is diabetic retinopathy treated?
Good glycaemic control
Laser treatment
Intravitreal steroids
Anti-VEGF
What is diabetic maculopathy?
Hard exudates + other ‘background changes’ on the macula
Check visual acuity
More common in T2DM
Rx: laser therapy
What is hypertensive retinopathy?
Symptoms?
Cause?
Eye disease/damage from hypertension
Usually asymptomatic. May cause reduced visual acuity and headaches.
Can occur from chronic, poorly controlled hypertension or malignant hypertension
What may cause accelerated hypertensive retinopathy?
Exacerbation of essential HTN Intrinsic renal disease Renal artery stenosis Phaeochromocytoma Cushing's and Conn's
Give 4 features of hypertensive retinopathy seen on fundoscopy?
Arteriovenous nipping (Grade II)
Flame haemorrhages
Cotton wool spots
Papilloedema (Grade IV)
What are the Keith-Wagener classification stages of hypertensive retinopathy?
Stage I - arteriolar narrowing + tortuosity, increased silver light reflex (silver wiring)
Stage II - arteriovenous nipping
Stage III - spots, dots and blots (cotton wool spots, exudates, flame haemorrhages)
Stage IV - papilloedema
What are some other causes of poor vision in hypertension?
Acute optic nerve damage
Macular oedema
Retinal artery closure/occlusion
Choroidal ischaemia
How is hypertensive retinopathy managed?
Control hypertension
Manage stroke risk
Regular eye checks for hypertensive patients - at least yearly
Red eye. What is subconjunctival haemorrhage?
Bleeding beneath the conjunctiva - several small fragile vessels that are easily ruptured/broken
Red eye. Give 4 features of subconjunctival haemorrhage?
Sudden onset
Bright red blood (stays bright red as Hb easily oxygenated from the atmosphere)
Distinct border
Blood spreads freely so small haemorrhage can easily cover the whole globe
Red eye. What are the causes of subconjunctival haemorrhage?
Trauma to the eye Heavy bouts of coughing Contact lenses Hypertension Bleeding disorders Diabetes mellitus CHD/vascular disease Medications - warfarin, aspirin, NSAIDs, steroids Febrile systemic infections May occur spontaneously in the elderly
How is subconjunctival haemorrhage managed?
Conservative (no official Rx required)
May want to look for orbital/ocular injury if caused by trauma
What is anterior uveitis?
aka Iritis
Important differential of a red eye
Painful red eye with decreased visual acuity
Give 3 conditions associated with anterior uveitis
1) Seronegative arthropathies (HLA B27) e.g. ank spond, psoriatic arthritis, enteropathic arthritis, IBD
2) Granulomatous disease, e.g. sarcoidosis, syphilis
3) Behcet’s disease: mouth + genital ulcers, skin rashes, etc
Give 5 symptoms of anterior uveitis?
1) acute, painful red eye
2) unilateral
3) photophobia
4) blurred vision
5) lacrimation
Give 5 signs of anterior uveitis
Intense redness of the globe
Normal/decreased acuity
Irregular small pupil
Hypopyon (pus in outer chamber - looks like white dots, visible fluid level)
Ciliary flush (ring of red and purple spreading out from cornea)
What is the name for the collection of white cells seen in the outer chamber of the eye in anterior uveitis? What is it?
Hypopyon
Collection of pus and inflammatory cells
How is anterior uveitis managed?
1) Dilate eye to relieve pain and photophobia (Atropine or cyclopentolate)
2) Urgent r/v by ophthalmology
3) Steroid eye drops
What is episcleritis? Key features? Rx?
Common, benign, mild irritation of the eye.
Localised redness
Watery, mild photophobia
No discharge or loss of vision
Rx: NSAIDS if pain, if needed - eyedrops to ease irritation
How do you differentiate between episcleritis and scleritis?
Scleritis is PAINFUL (episcleritis is not)
Phenylephrine drops - will not blanch the scleral vessels, so if eye redness improves after phenylephrine then diagnosis of episcleritis can be made
What is scleritis?
Rare, serious condition. Associated with SLE, RA, any form of vasculitis
People with RA may also have blue sclera
What are the key features of scleritis?
Rx?
V painful red eye
Loss of vision, watering, photophobia
Rx: Oral NSAIDs, oral prednisolone, cyclophosphamide (to tackle causative vasculitis)
What are the complications of scleritis?
Scleral thinning Ischaemia of the anterior segment of the globe Raised IOP Retinal detachment Uveitis Cataract Phthisis (globe atrophy)
What is keratitis?
Most common cause?
Infection/inflammation of the cornea
Herpes simplex virus
How does HSV (herpes) keratitis tend to present?
DENDRITIC SHAPE corneal ulcer
Red, painful eye Photophobia Epiphora (excessive eye watering) Decreased visual acuity (sometimes) Foreign body sensation
Investigations for HSV keratitis?
Fluorescein staining to look for dendritic ulcer
How is HSV keratitis managed?
Urgent referral to ophthalmology
Topical acyclovir
AVOID STEROIDS
Why is it important to avoid steroids in HSV keratitis?
Can cause enlargement of the dendritic ulcer
What is a corneal abrasion? How does it present?
Any defect of corneal epithelium.
Most commonly occurs following trauma
Features: pain, photophobia, foreign body sensation, decreased acuity, conjunctival injection
How is corneal abrasion investigated?
Fluorescein staining + slit lamp examination
Yellow-stained abrasion will show up
How is corneal abrasion managed?
Topical antibiotics to prevent bacterial superinfection (e.g. Chloramphenicol)
What is a corneal ulcer?
Corneal epithelium defect (abrasion) with underlying inflammation/infection
Causes/RFs for corneal ulcer?
Contact lenses
Infection with bacteria, fungi, viruses, etc
Can be initiated by mechanical trauma or nutritional deficiencies
Give 3 features of corneal ulcer
Eye pain
Photophobia
Watery eye
Investigations for corneal ulcer?
Focal fluorescein staining
How do you manage a corneal ulcer?
Stop contact lenses for 1 week
Cool compress
Good hygiene (no sharing towels, wash hands, avoid eye make up)
Topical Abs - Chloramphenicol
What is conjunctivitis, and what are the 3 main types?
Inflammation of conjunctiva. 3 main causes: 1) Viral 2) Bacterial 3) Allergic
Also think about reactive arthritis (can’t see, can’t spee, can’t climb a tree)
What are the general features of conjunctivitis?
Sore, red eyes
Sticky discharge
Features of bacterial conjunctivitis?
Common causative organisms?
Rx?
Purulent discharge, starts unilateral and spreads to bilateral
Staph/strep/haemopilus/neisseria/chlamydia
Self-limiting. General advice (no contact lenses, don’t share towels, no need for school exclusion).
May give chloramphenicol (or fusidic acid if pregnant)
Features of viral conjunctivitis?
Common cause?
Management?
Serous discharge, recurrent URTI, pre-auricular lymphadenopathy
Adenovirus
Self-limiting. Oral analgesia + eye drops (symptomatic relief). General advice (lenses, towels, no school exclusion)
Features of allergic conjunctivitis?
Management?
Often seen with hayfever. Hx atopy etc. Swollen eyelids. Large papillae.
1st line: topical/systemic antihistamines
2nd line: topical mast-cell stabilisers (sodium cromoglicate)
What is non-arteritic ischaemic neuropathy?
Important differential
Ageing process assoc w/ poor blood supply to optic nerve. See swollen optic disc but NOT associated with inflammation.
Key Ddx: GCA
Complications of non-arteritic ischaemic neuropathy?
Diplopia
Emboli can cause central retinal artery occlusion (CRAO)
How is non-arteritic ischaemic neuropathy managed?
High dose steroids
IV methypred 3 days, then oral pred
Features of Horner’s?
Miosis (constricted pupil)
Ptosis
Anhidrosis (lack of sweat)
Enophthalmos (eye retracts into head)
What are 4 causes of Horner’s?
Central: Stroke, MS
Pre-ganglionic: Pancoast tumour
Post-ganglionic: Carotid artery dissection
Management of Horner’s?
Treat underlying disease
Give 3 eye diseases associated with rheumatoid arthritis
Scleritis
Episcleritis
Secondary Sjogren’s with sicca complex (dry eyes)
What are the causes of papilloedema?
SOL Malignant hypertension Idiopathic intracranial hypertension Hydrocephalus Hypercapnia
Rarer (hypoparathyroidism, hypocalcaemia, vitamin A toxicity)
Give 6 features of papilloedema on fundoscopy
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)
Give 6 causes of tunnel vision
Papilloedema Glaucoma Retinitis pigmentosa Choridoretinitis Optic atrophy Hysteria
What is optic atrophy?
PALE optic disc on fundoscopy
Well demarcated
Usually bilateral
Causes gradual visual loss
What are some acquired causes of optic atrophy?
MS Papilloedema (chronic) Raised IOP (glaucoma, tumour) Retinal damage (retinitis pigmentosa) Ischaemia Vitamin deficiencies (B1, B2, B6, B12)
What are some congenital causes of optic atrophy?
Freidrich’s ataxia (AR)
Leber’s optic atrophy (mitochondrial inheritance)
3 differentials for lump in eyelid?
Stye
Chalazion
BCC
2 different types of lid positioning problems?
Entropion (needs surgical correction - eyelashes can cause scarring)
Ectropion
What are the 7 key causes of red eye?
Acute angle closure glaucoma Scleritis Anterior uveitis (iritis) Keratitis Periorbital cellulitis
Give 2 causes of floaters
Posterior vitreous detachment
Retinal detachment
Diabetic retinopathy
What 3 investigations would you do in retinal detachment, and what would you see?
1) Fundus photography - Schaffer’s sign (pigment in anterior vitreous)
2) Ophthalmoscopy
3) B-mode USS - flying angel sign
2 causes of retinal detachment?
Retinal tears
Trauma
Recent cataract surgery
What are the DVLA requirements for vision?
Need combined visual acuity of at least 0.5 (6/12)
