opthalmology Flashcards
amblyopia
reduced vision in a structually normal eye
anirdia
absence of iris
anterior chamber
aqueous chamber lying between cornea and iris
aphakia
absence of lens
aqueous humour
secretion of the ciliary body which flows through the pupil into the anterior chamber and largely leaves the eye via the drainage angle
arcuate scotoma
-what and feature of?
an arc shaped blind spot running from the blind spot to the peripheral visual field
- position determined by course of damaged retinal nerve fibres
- feature of chronic glaucoma
astigmatism
refractive error that prevents the light rays from coming to a single focus on the retina because of the irregular corneal curvature
- near and far sight are blurry
blepharitis
inflammation of the eyelids, most commonly the lid margins
blepharospasm
spasm which may be tonic or chronic, of the orbicularis oculi muscle (closes the eyelid)
buphthalmos
the large eyeball in infantile glaucoma
blind spot
each eye has a normal blind spot which corresponds to the optic nerve head
blind spot
each eye has a normal blind spot which corresponds to the optic nerve head
canal of schlemm
a circular drainage canal (a venous sinus) into which aqueous humour drains from the trabecular meshwork before discharging into the anterior ciliary veins
canthus
the angle at either end of the eyelid aperture, specified as outer or inner
cataract
opacity of the lens
chemosis
conjunctival oedema and swelling
choroid
thin, highly vascular membrane covering the posterior 5/6 of the eyeball between the retina and sclera
conjunctiva
mucous membrane lining the inner surfaces of the eyelids and the anterior part of the sclera
conjunctival concretion
cluster of small hard yellowish-white calcified matter mostly in the clear membrane on the inside of the eyelid
convergence
movement of the eyes turning inwards towards each other
cornea
the curved transparent anterior portion of the fibrous outer coat of the globe of the eye
cyclodiode laser
trans- scleral diode laser photo-coagulation used to lower intra-ocular pressure in advanced glaucoma
cyclodiode laser
trans- scleral diode laser photo-coagulation used to lower intra-ocular pressure in advanced glaucoma
cycloplegic
a drug that temporarily puts the ciliary muscle at rest, paralyses accomodation and dilates the pupil
dacryocystitis
inflammation of the lacrimal sac
dacrocystorhinostomy
an operation to produce an alternative drainage route between the lacrimal sac and the nose
diabetic retinopathy
microvascular disease of the retina in diabetes
drainage angle
the zone in the anterior chamber through which the aqueous must pass to leave the eye
lies at the point of convergence of the iris with the cornea
diplopia
the condition in which a single object is seen as two rather than one
divergence
movement of the eyes turning outwards away from each other
ectropion
turning out of the eyelid
emmetropia
state of normal vision
endophthalmitits
this is an inflammation of the interior of the eye
- can be a complication of all intraocular surgeries and or procedures
- with the potential of loss of vision or even the eye itself
- eye looks cloudy and inflammed
enopthalmos
recession of the eye (globe) into the orbit
enotropion
a turning inward of the eyelid
enucleation
complete surgical removal of the eyeball
episclera
the free connective tissue between the sclera and the conjunctiva
episclera
the free connective tissue between the sclera and the conjunctiva
evisceration
removal of the eye’s contents leaving the scleral shell and the extraocular muscle intact
-performed to reduce pain or improve aesthetics in a blind eye with endophalmitis
exenteration
removal of the entire contents of the orbit, including eyeball, lids and periostium
exopthalmos
abnormal protrusion of the eyeball -due to endocrine
fornix
the junction of the lid (palpebral) and globe (bulbar) conjunctivas. the pocket into which medication is instilled
fundus, ocular
the interior of the eye visible through the pupil with the use of an opthalmoscope
comprises of the retina, pars planna, retinal blood vessels and sometimes choroidal vessels
glaucoma
complex group of eye disorders having a common feature of optic nerve damage of a characteristic type affecting the optic nerve head
-assoc. with elevated or unstable intra-ocular pressures
goldman’s applanation tonometer
a slit lamp mounted instrument which estimates the intraocular pressure by the force required to flatten a given corneal area
heterochromia
difference in colour of the two irises or of different parts of the same iris
hypermetropia
long sighted
hyphaema
haemorrhage into the anterior chamber
hypopyon
collection of white cells in the anterior chamber of the eye forming a fluid level
iris
the muscular and vascular diaphragm interposed between the cornea and the crystalline lens
keratic precipitates KP
fine cellular deposits at the back of the cornea
keratitis
inflammation of the cornea, which may or may not be assoc. with infection
limbus
junctional zone where the cornea joins the sclera
macula
the cone rich portion of the retina, used for fixation of gaze
meibomian cyst (tarsal cyst, chalazion)
a small localised swelling of the eyelid resulting from obstruction and retention of secretions of meibomian glands
-non malignant condition
miotics
drugs that constrict the pupil
maybe used to treat glaucoma and accomodative strabismus
miosis
constriction of the pupil
mydriatics
drugs that dilate the pupil
may be used to facilitate fundal examination, cataract and retinal surgery and to treat ocular inflammations
myopia
short sighted
term used to describe the optical status of the eye in which the images of distant objects are focused short (in front) of the retina.
The patient suffers from blurred distance vision
phaco
phacoemulsificaiton
a procedure to removal the crystalline lens in cataract surgery that consists of emulsifying and aspirating the contents of the lens with the use of a low frequency ultrasonic needle inserted into the eye at the limbus (cataract surgery)
photophobia
abnormal sensitivity and discomfort to light
phthisical eye
a shrunken blind eye, which is undergoing severe degenerative changes.
Results in poor cosmetic appearance.
may also become painful and require enuculeation or appearance improved with fitting of a cosmetic shell
photopsia
flashing lights associated with migraine headaches, posterior vitreous detachment or retinal detachment
presbyopia (old sight)
physiologically blurred near vision, commonly evident soon after the age of 40
punctum
a tiny aperture in the margin of each eyelid, at the inner canthus almost level with the caruncle, that opens into the lacrimal duct
retina
light sensitive, innermost nervous tissue, layer of the eye which lies between the vitreous body and the choroid
- extends from the ora serrata to the optic disc and comprises ten layers
- The retina converts light into nerve impulses for transmission to visual and motor centres in the brain
sclera
tough white opaque portion of the fibrous outer coat of the eye
scotoma
an area of partial or complete blindness surrounded by a normal or relatively normal visual field
sjorgrens syndrome
a chronic connective tissue disease characterised by failure of lacrimal secretion and dryness of all mucous membranes
often assoc. to rheumatoid arthritis
hyperopia
long sighted
slit lamp
microscope for examining the eye under magnification and providing a slit like beam of light
strabismus squint
condition in which the lines of sight of the two eyes are not directed towards the same fixation point
synechia
adhesion of the iris to the cornea (anterior synechia)
adhesion of the irirs to the lens (posterior)
temporal arteritis
sight threatening condition resulting from a systemic vasculitis
-dx based on CPR and ESR
give steroids!! sight threatening
tonometer
an instrument for the objective measurement of intra-ocular pressure
uveal tract
the major vascular comparment of the eye comprising iris, ciliary body and choroid
vitreous
gel of the eye, lying between the crystalline lens and the retina
keratoconus and rx
progressive thinning of the cornea
treated with riboflavin and UVA light to cause new collagen cross linking
RX options for retinal detachment
–cryoptherapy with cold probe or
-photocoagulation with laser
-sceral bulking with silicone oil
pneumatic retinopexy with gas injections
vitrectomy - removed and replaced with gas or oil
cornea replacement
- complete= penetrating keratoplasty
- partial= lamellar keratoplasty
macular hole repair Rx
vitrectomy- remove some of the vitreous gel to stop it pulling on the retina and a mix of gas/ air is inserted into the space
trichiasis
inward growing of eye lashes
red eye causes
- allergic CJ
- infectious conjunctivitis
- iritis
- scleritis
- episcleritis
- CN VII palsy
- stromal keratitis
- epithelial keratitis
- acute angle closure glaucoma
Binocular diplopia causes and type of diplopia
Binocular Diplopia (improves when close one eye) CN 3= vertical diplopia CN IV= vertical diplopia CN VI= horizontal diplopia internuclear opthalmoplegia= horizontal restrictive myopathy= thyroid- tight IR
monocular diplopia causes
cataracts does not improve when one eye closed
binocular visual loss causes
Chiasm lesion= bitemporal hemianopia
post-chiasm lesion= homonymous hemianopia
monocular visual loss causes
refractive error (improves with pinhole) retina detachment (RAPD) optic nerve (RAPD) vitreous haemorrhage cataract macula
epiphoria causes
red eye ectropion (eyelid face outwards) CN VII palsy punctal stenosis nasolacrimal duct stenosis (hard stop) canalicular stenosis (soft stop)
CN VII palsy presentation
red eye
inability to close eye
CNVI palsy
horizontal diplopia
loss of lateral rectus so eyes converge
loss of abduction
CN IV PALSY
superior oblique
vertical diplopia
eye faces upwards
CN IIII
all the rest eye looks down and out due to LR and SO vertical diplopia unable to adduct mydriasis -aniscoria ptosis
Horner’s syndrome
miosis ptosis anihydrosis enopthalmos- sink sympathetic NS
ocular causes of visual field defects
glaucoma- most common cause
macula degeneration- central scotoma
retinal detachment
optic neuritis- enlarged blind spot
neurological causes of visual field defects
space occupying lesion- pituitary, meningioma
aneurysm
stroke
trauma
orbital causes of visual field defects
optic nerve glioma
meningioma
hemangioma
vascular causes of visual field defects
branch retinal and central retinal
left optic nerve field defect
no light perception of left eye
chiasm field defect
bitemporal hemianopia
right optic tract field defect
incongrous left homonymous hemianopia
left lateral geniculate nucelus field defect
right homonymous quadruple sectoranopia
left temporal lobe field defect
right homonymous hemianopia upper quadrant
left parietal lobe field defect
right homonymous hemianopia lower quadrant
PITS
left occipital lobe
right homonymous hemianopia- macula sparing
retinitis pigmentosa presentation
normal visual acuity reduced visual field pigmentation in the retina usually initially loss of night vision tunnel vision
what is retinitis pigmentosa
breakdown retina cells
genetic inhertied disorder
affects photoreceptors
peripheral retina loss
assoc. syndromes to retinitis pigmentosa
alport
refsum
usher
due to RPDR gene- autosomal dominant or x-linked
management of retinitis pigmentosa
no cure
Vit A supplements
complete blindness is rare but visual field loss will continue to be lost
causes of RAPD
optic neuropathy
retinal pathology
how is an RAPD identified
swinging flashlight test
optic neuropathy fundoscopy
normal retinal appearance in optic neuropathy
depends on pathology
if optic papillitis (head of optic nerve) = presents with oedema around the optic disc
retinopathy fundoscopy
whitening of the retina- ischaemic
optic neuritis causes
MS
diabetes
syphilis
presentation of optic neuritis
- unilateral decrease in Visual acuity over hours
- poor discrimination- red desaturation
- pain worse on eye movement (infammation causes traction on inflammed meninges)
- RAPD
- central scotoma
treatment of optic neuritis
high dose steroids
takes 4-6 weeks to recover
visual loss: macula pathology causes
- macular degeneration
- diabetic maculopathy
macula degeneration fundoscopy features
drusden RPE atrophy choroidal neovascularisation subretinal or sub RPE haemorrhage RPE detachment disciform scar at the macula
diabetic maculopathy signs
widespread haemorrhages
wide exudation
cisterna
causes of chiasmic field defect
pituitary adenoma
causes of homonymous hemianopia
stroke, trauma, tumour, infection
acute visual loss definition
rapid onset, <72 hours
usually monocular
may herald binocular disease
acute ocular vascular causes of visual loss
Central retinal vein occlusion
central retinal artery occlusion
branch retinal vein occlusion
branch retinal artery occlusion
acute neurologic vascular causes of visual loss
Arteritic anterior optic neuropathy- GCA
non-arteritic AION
optic neuritis
papillitis
acute systemic vascular cause of visual loss
CVD
Haematological
inflammatory and infection
where are binocular field defects located?
either chiasm or posterior visual pathway
acute non vascular causes of visual loss
traumatic
non-traumatic causes: retinal detachment and vitreous haemorrhage
chronic causes of visual loss
- lifestyle: tobacco, alcohol
- macula degeneration ( painless)
- retinitis pigmentosa
- cataracts (painless)
- refractive error (painless)
- diabetic retinopathy
- chronic open angle glaucoma (painless)
- drugs
- papilloedema (IC HTN)
painful causes
- systemic eg sarcoidosis
- IC HTN- headache
- lesion: glaucoma, optic neuritis
- mechanical= thyroid eye disease
amaurosis fugax
- painless temporary loss of vision
- curtain descending
- vascular/ ischaemic cause
- can represent a TIA so give aspirin
painless causes of visual loss
CRAO CRVO BRVO BRAO proliferative diabetic retinopathy glaucoma retinal detachment amaurosis fugax
painful causes of visual loss
optic neuritis
scleritis
keratitis
endophalmitis
definition of partial sight registration
when either the central vision ie visual acuity in the best eye is around 6/18 to 6/60 or at any level of central vision when a reasonably significant field defect is present
definition of blind sight registration
when either the central vision ie visual acuity in either eye is counting fingers or at any level of central vision when a significant field defect is present
investigations for visual loss 4
- confrontation visual fields
- measurement of visual acuity- snellen and pinhole
- swinging flashlight test- RAPD CHECK
- Fundoscopy
cherry red spot on fundoscopy suggests
central retinal artery occlusion
complete starry night on fundoscopy suggests
- also known as blood and thunder
- multiple flame haemorrhages and dialted veins
- may or may not have cotton wool spots
- chronically may only be small haemorrhages in periphery
central retinal vein occlusion
branch retinal artery occlusion fundoscopy signs
opaque retina on one half/ section and then normal retina on the other
branch retinal vein occlusion fundoscopy sign
areas of starry night sky
hx of abrupt, painless, significant loss of vision and a white eye is…
central retinal artery occlusion
hx of abrupt, painless, visual loss suggests
branch retinal artery occlusion
hx of painless loss of vision, often noted in am after rising from sleep
>50
gradual onset
suggest central retinal vein occlusion
causes of central retinal artery occlusion
linked to arteriosclerotic vascular disease, CVD, thrombus, temporal arteritis, hyperocaguable state
cause of branch retinal artery occlusion
often an emboli from the carotid artery
RF for branch retinal vein occlusion
- talc IV drug abuser
- fat from long bone #
- problems with endocarditis or calcifications
- vasculitis
examination findings for central retinal artery occlusion
vision: light perception or worse
field: massive visual field loss
pupil: large RAPD
Fundus: opaque retina with a cherry red spot, oedematous
examination findings for branch retinal artery occlusion
vision: variable- depends on the size and location
pupil: may have a RAPD depends on defect of the size
field: loss corresponds to occluded artery
Fundus: opaque retina adjacent to occluded artery with an embolus at proximal end of arteriole- often bifurcation
central retinal vein occlusion assoc.
assoc. too glaucoma and open angle glaucoma
central retinal vein examination findings
vision: variable
pupil: afferent defect
field: general depression
fundus: starry night sky - haemorrhages in all 4 quadrants
branch retinal vein examination findings
pupil: variable
afferent defect variable
field variable
haemorrhages in one-two quadrants depending on vein
management of central retinal artery occlusion
if seen within 100 mins of onset
- massage the eyeball to lower the intra-ocular pressure (apply firm pressure with the eyelid closed for 5 seconds to acutely raise the intraocular pressure and then let go) sudden release of pressure can break the occluding material
- refer to opthalmology
- consider the source
why does CRAO produce a cherry red spot
opaque retina- due to ischaemia to the retina which produces oedema of ganglion cells and axons
cherry red spot since ganglion cells are absent in the macula so there is the normal macular red reflex from the underlying choroidal blood flow is accentuated as a cherry red spot
management of branch retinal artery occlusion
determine the source
no specific ocular treatment
management central retinal vein occlusion
- refer the patient to an opthalmologist
- 40-70% will have open angle glaucoma
- 60% will develop neovascular glaucoma
- assess for systemic illness
branch retinal vein occlusion fundoscopy signs
- flame haemorrhages adjacent to the dilated engorged occluded vein
- occlusion site where retinal artery crosses the vein
- superior branch veins are occluded more often
management branch retinal vein occlusion
opthalmic referral to treat possible
- macular oedema
- neovascular proliferation
acute vascular systemic defect causing visual loss presentation
again painless and acute visual loss
which is due to vascular occlusion, or leaking vessels
other assoc. symptoms of systemic disease eg arthralgia, fever and malaise
fundoscopy presentation for systemic visual loss 6
- cotton wool spots (ischaemic micro-infarction of ganglion cells)
- flame shaped haemorrhages
- lipid exudates (due to serum extravasation through damaged vesels)
- embolic plaques- platelet aggregation from damaged endothelium
- calcific emboli from damaged cardiac valves
- dot and blot haemorrhages- internal retinal elements confine these capillary haemorrhages to their characteristic round shape
cardiovascular causes of visual loss 6
- hypertensive retinopathy
- retinall arteriosclerosis
- cardiac vascular disease
- carotid atheromatous disease
- hypotension leading to anterior ischaemic optic neuropathy
- vasculitis
hypetensive retinopathy grading
1=arteriolar narrowing
2=focal narrowing and greater arteriole constriction
3=addition of flame haemorrhages, cotton wool spots and lipid exudates
4= grade 3 plus papilloedema, retinal oedema often assoc, with renal, CNS and cardiac involvement
retinal arteriosclerosis pathophysiology
- sclerosis causes widening of the arteriole’s light reflex and causes arterial crossing changes including
- -> nicking or compressing of the AV
- -> distortion of the crossing angle from acute towards a right angle called banking
cardiac vascular disease pathophysiology for causing visual loss
-heart valve problems that may underlie acute visual loss are
–> endocarditis
–> rheumatic fever
–>mitral valve prolapse
–> calcific valvular disease
opthalmoscopy may show multiple emboli or embolic haemorrhages
cardiac atheromatous disease - pathophysiology visual loss 2
- occlusive disease: caused by thrombosis which produces ocular ischaemia- retinal haemorrhages and cotton wool spots
- eroding atheromatous plaque producing cholesterol and platelet emboli that can lead to retinal artery occlusions
endocrine causes of visual loss
- diabetes mellitus
haematological causes of visual loss 5
- leukaemia
- anaemia
- thrombocytopaenia
- hyperviscosity states
- hypercoaguable states
haematological pathophysiology
visual loss
due to retinal haemorrhages or retinal oedema involving the macular area
inflammatory pathophysiology
visual loss
- collagen vascular and infectious diseases
- produce retinopathy of ischaemic infarcts (cotton wool spots), haemorrhages and exudates
inflammatory causes of visual loss 7
inflammatory -lupus -polyarteritis nodosa -dermatomyositis infectious -AIDS -disseminated HSV -disseminated varciella -cytomegalic viral retinitis
4 acute vascular neurologic causes of visual loss
- AION arteritic ischaemic optic neuropathy
- non-arteritic ischaemic optic neuropathy
- papillitis and optic neuritis= inflammatory optic nerve
- vascular occlusion in the CNS
GCA pathophysiology
hypo-perfusion or sometimes occlusion of the short posterior ciliary arteries causing ischaemia to the optic disc and the anterior optic nerve producing visual loss
GCA cause
- arteritis- (inflammation of artery walls) occlusive
- arteriosclerosis -hypoperfusion and hypoxia
complications GCA
risk of binocular and permanent blindness
presentation of GCA
- Long prodrome of systemic symptoms before visual symptoms
- female over 50
- sudden monocular loss of vision
- visual loss may stutter- fluctuates for a day or two before permanent
- jaw claudication
- headache
- scalp tenderness
- malaise, arthralgia, weight loss, fever
- polymyalgia rheumatica
INX for GCA
- ESR!!!- >60- should treat high dose steroids
- DO NOT WAIT FOR TEMPORAL ARTERY BIOPSY
temporal artery biopsy signs for GCA 3
- giant cells
- elastic fragments
- occlusion
examination findings for GCA
- vision: variable to no light perception
- pupil: afferent pupillary defect
- field: altitudinal field defect is common (usually loss of upper or lower half of field of vision)
fundus: pale, swollen optic disc, small splinter haemorrhages
non arteritic AION exam findings
normal ESR
no arteritis on temporal artery biopsy
assoc, to non-AION
high BP
high lipids
smoking
ambylopia
lazy eye
caused by strabismus
exotropia
In exotropia, when the fixating eye is covered, the outwardly deviated eye will move inward to fixate the viewed object..
esotropia
When the fixating eye is covered, the other eye will move outward from its inwardly deviated position to fixate the viewed object.
hypertopia
In hypertropia, when the fixating eye is covered, the upwardly deviated eye will move downward to fixate the viewed object.
presentation of non AION
painless
often noticed upon awakening
>50 years
examination findings for non AION
no difference to arteritic except the swollen nerve is usually NOT pale in non arteritis cases
visual field defect for vascular occlusion in the CNS
homonymous hemianopia or quadrantanopia as ischaemic or haemorrhage infarcts of the visual pathways and cortex
presentation of vascular occlusion in the CNS visual loss
- normal visual acuity
- homonymous hemianopia or quadrant
optic neuritis main causes- inflammatory optic nerve disease
multiple sclerosis diabetes syphilis vitamin deficiency leber's ischaemic due to thrombosis
presentation of optic neuritis
monocular visual loss acute onset over hours or days unilateral loss affects colour vision poor descrimination especially red RAPD central scotoma dull retrobulbar eye ache which is aggravated with eye movement
examination findings for optic neuritis
vision: decreased in most cases- no light perception
pupil: RAPD, unless previous episode in other eye to balance it
Field: central scotoma and altitudinal field loss are common- ie often top half
Fundus: normal disc in many cases- can be some swelling or pale
raised ESR
management optic neuritis
high dose steroids
takes 4-6 weeks to recover
location of optic neuritis
- retrobulbar neuritis= means in the posterior part of the optic nerve so wont see disc changes
- papillitis= means anterior so get papilloedema
what should not be given in optic neuritis
oral steroids as may lead to more reccurrences
use IV??
papillitis vs papilledema
- vision
- pupil response
- optic disc
- haemorrhages
- cells in vitreous
- cause
papillitis
- reduced vision
- afferent defect
- swollen disc
- haemorrhages
- cells in vitreous
- inflammation
papilloedema
- normal vision
- normal pupil response
- swollen disc
- haemorrhages
- no cells in the vitreous
- caused by raised ICP
assoc. conditions to papillitis
- lupus
- sarcoidosis
- syphilis
retinal detachment presentation
4f’s
- floating spots (floaters)
- flashing lights
- may detect a curtain or shade obscuring any part of field of vision
- fall in acuity
- central vision loss
- straight lines appear curved
- painless
- gradual over days
- fhx of myopia
- can be gradual over days
types of retinal detachment
- rhegmatogenous retinal detachment
2. tractional retinal detachments
rhegmatogenous retinal detachment
- tear in the retina causes fluid to pass from the vitreous space into the subretinal space
- trauma
tractional retinal detachments
- pulling on the retina
- more common in myopic eyes
- cataracts for myopic eyes increases the risk
RF/ causes of retinal detachments 6
- age
- previous surgery for cataracts
- myopia
- eye trauma
- fhx
- phx of retinal break
examination findings for retinal detachment
- vision: normal to hand motions, if macular detached
-pupil: RAPD
loss of red reflex
decreased visual acuity
-field: any areas of visual field may be obscured, depending on which area of the retina is detached
-fundus: dilated exam show elevated waxy, gray appeararing retina, ballooning forward
management of patient presenting with flashing lights and floaters
refer to opthalmology immediately
retinal detachment management
- refer to opthalmology
- rest
- if detachment is superior then nurse flat
- if detachment is inferior then lie 30 degrees head up
- laser photocoagulation therapy
- surgery
surgery options for retinal detachment
- vitrectomy and gas tamponade scleral silicone implants
- cryotherapy to secure retina
vitreous haemorrhage cause
vitreous haemorrhage is a separation of the posterior vitreous from the retina
- normal ageing degeneration
- retinal blood vessels may also tear in separation
- sudden visual loss
- dark spots
- painless
is. ..
vitreous haemorrhage
- acute visual loss
- painless
- flashing lights and floaters
- straight lines appeared curve
- central vision loss
- curtain over field of vision
retinal detachment
flashing light and floaters painless blurred vision cobweb across vision is..
posterior vitreous detachment
vitreous haemorrhage causes 6
- diabetic retinopathy
- retinal break
- retinal detachment
- posterior vitreous detachment
- neovascularisation from retinal vein occlusions
- anticoagulants
management vitreous haemorrhage
urgent referral to opthalmology
rf for vitreous detachment
- ageing
- myopic eye
sign for vitreous detachment
weiss ring= floater on opthalmoscopy
management for vitreous detachment
wait 6 months
management for vitreous and retinal detachment
need surgery
red flags for visual loss 6
sudden onset headache--? GCA pain- glaucoma, keratitis, scleritis pain on eye movement, optic neuritis, scleritis distorition- macular worse in morning- RVO, macular oedema
optic neuropathy meaning
damage to optic nerve of any cause
causes of optic neuropathy
- Ischaemic optic neuropathy= AION, PION, radiation
- optic neuritis
- compression from lesions thyroid
- infiltrative eg infection
- toxic
- trauma
- hereditary
drugs that cause Bull’s eye maculopathy 2
- chloroquine
- hydroxychloroquine
drugs that damage the RPE 3
- mellaril
- chloroquine
- plaquenil
drugs that damage optic nerve 3
ethambutol
chloramphenicol
quinine
what dose of chloroquine- aralen is toxic
> 300 daily dose
monitoring on chloroquine for
<250
>250 daily
<250= annually >250= 2-4 times yearly
hydroxychloroquine- plaquenil dose that is toxic and monitoring
> 400 can be tolerated but check eye every 4 month
<400check annually
ethambutol what damage does it cause 5
optic nerve optic disc oedema visual loss colour defect central field visual loss
toxic dose of ethambutol
> 25
thyroid
-2 eye signs specific to grave’s
lid lag and lid retraction
eye disease in thyroid
- lid lag and retraction
- proptosis or exopthalmos
- secondary corneal exposure
- ocular motility restriction
- optic nerve compression
what is the big complication from thyroid eye disease
optic nerve compression
inx for thyroid eye disease
- examine thyroid, visual field, pupil, acuity, exopthalmometry
- thyroid levels
- CT and USS- check eye muscles
management during active phase for thyroid eye
- dry= artifical tears
- dark glasses
- corneal exposure-treat with tarsorrhaphy-suture lid close
- optic nerve compression: steroids, irradiation, surgical orbital decompression
management during inactive phase for thyroid eye disease
- eyelid lengthening to reduce lid retraction
- ocular muscle surgery to relieve diplopia
- orbital decompression to reduce proptosis
mechanisms of diabetes and poor vision 4
- macrovascular- facial palsy and cornea exposure, occipital stroke - homonymous hemianopia
2.microvascular-temporary squint, retinopathy
maculopathy - premature lens opacities- cataracts
4.osmotic lens changes–> refractive errors with hypoglycaemic episodes
pathology of diabetic retinopathy 5 stages
- no diabetic eye changes
- background diabetic retinopathy
- pre-proliferative dr
- proliferative dr
- vitrous haemorrhage or fraction retinal detachment
pathogenesis of retinopathy
- leaky vessels- hard exudates, oedema
2. occlusion- ischaemia- cotton wool spots and neovascularisation
earliest detectable sign of DM retinopathy
loss of pericytes from retinal capillaries and breakdown of blood retinal barrier
diabetic maculopathy presenation
macular oedema
mild NDPR or background diabetic retinopathy
- micro-aneurysms- dot haemorrhages- greater than or equal to 1
- +/-blot haemorrhages- deeper haemorrhages
- +/-hard exudates = protein leaks
moderate NDPR 4
- cotton wool spots
- venous beading
- IRMA= dilated tortuous capillaries in retina
- +mild changes
severe NDPR
- blot haemorrhage and/or microaneurysms in all 4 quadrants
- venous beading in greater than or equal to two quadrants
IRMA in greater than or equal to 1 quadrants
what are cotton wool spots
nerve fibre layer infarct
what are venous beading
congested veins
proliferative diabetic retinopathy
-neovascularisation
-fibrous tissue = NVD neovascularisation of the disc, neovascularisation elsewhere NVE
proliferation of extra retinal fibrovascular tissue occurs
management of proliferative DR
-urgent referral to opthamology
when would an emergency referral for diabetic retinopathy be needed 4
and what is the risk of this
1. rubeosis iridis= new vessels on iris risk of glaucoma secondary 2. retinal traction and detachment 3.vitreous haemorrhage 4. pre-retinal haemorrhage
signs of diabetic maculopathy 3
- macular oedema
- hard exudates
- microaneurysms or dot haemorrhages
presentation of diabetic maculopathy
- loss of visual acuity
- unlike PDR can be asymptomatic initially
- affects central more than peripheral vision
INX for diabetic maculopathy
ocular coherence tomography OCT
- OCT helps to identify cystoid macular oedema
- funudus fluorescein angiography for ischaemia
treatment for diabetic maculopathy
-intravitreal anti VEGF injections
what is ranibiziumab, aflibercept, bevacizumab
Anti VEGF injections
what is clinically significant macular oedema CSMO
presence of retinal thickening with or without hard exudates within a radius of <1 disc diameter of the centre of the foeva
- sight threatening
eye screening for diabetic eye by age
0-30 years onset= first exam 5 years after onset, minimum follow up is annually
31+ years onset= first exam at time of dx, review annually
pregnancy onset= first exam during first trimester, and then every 3 months
eye screening for diabetic eye by severity and treatment
mild and mod= review every 4 months
severe= fundus fluorscein check - treat with pan retinal laser coagulation
management for diabetic eye
- eye follow up
- laser photocoagulation for
- macular oedema
- proliferative DR- remove new vessels - diabetic control
- vitrectomy
- maculopathy give VEGF injections
- focal for hard exudates
- grid for CSMO
vitrectomy indications for diabetes
- if pan retinal laser is not possible (vitreous haemorrhage blocks retinal view)
- traction retinal detachment
- no space left for laser
- repeated PRLP fails to control neovascularisation
- persistent vitreous haemorrhage after 3 months
macular degeneration vs glaucoma
macular degeneration= loss of central vision
glaucoma= loss of peripheral vision
what is the leading cause of blindness in the >65 in the UK
age related macular degeneration
pathogenesis of ARMD
there is degeneration of retinal photoreceptors causing pigment, drusen in the macula
over time it progresses to retinal atrophy and central retinal degeneration causing central loss of vision
most common type of ARMD
dry atrophic type 80-90%
features of dry ARMD
slower progressive loss cause is unknown drusen and changes at macula prevention best treatment vitamins no other treatment
features of wet/ exudative/ proliferative ARMD
10-20%
-pathological choroidal neovascular membranes CNVM develop under the retina
-choroidal neovascularisation
-the CNVM can leak fluid and blood causing a central disciform scar
-vision deteriorates rapidly and distortion is a key feature
-opthalmoscopy
fluid exudation, localised detachment of pigment
which of these are a feature of ARMD - loss of night vision -reduction in visual acuity -peripheral vision loss -central vision loss -acute loss -gradual loss -blurry small words -reduction of visual acuity- long sight -fluctuating vision loss -photopsia -glare straight lines appear curvy
- older age
- central vision loss
- loss of night vision
- gradual loss
- blurry small words
- reduction of visual acuity- especially short sight-fine detail
- fluctuating
- photopsia
- glare
- straight lines appear curvy -metamorphosia
elderly female presents with reduced visual acuity complaining of blurred vision, glare
on examination there is a central scotoma
macular degeneration
risk factors for macular degeneration 5
- increasing age
- smoking
- CVD
- FHX
- cataract surgery
what is used to monitor macular degeneration
Amsler grid
fundus presentation of atrophic macular degeneration
- drusen: small round deposits under the retina- in the macula bilaterally
- atrophy of the RPE
fundus presentation of wet macular degeneration
- all features of atrophic degeneration plus
- neovascular membrane under the retina which causes- neovascular proliferations leak
- subretinal haemorrhages
- serous detachments of macula and eventual
investigations for macular degeneration
- Fundoscopy
- slit lamp
- fluoroscein angiography for wet type if signs of neovascular- as can guide anti VEGF
- occular CT coherence tomography for monitoring
where are drusen found
in macular degeneration around the macula small yellow deposits
-lipoporteinaceous deposits
what can laser proliferation be used for in ARMD
if wet ARMD is detected early and caused by neovascular membrane outside the centre of the macula then new blood vessels can be destroyed by laser photocoagulation
wet ARMD management options 9
- needs prompt treatment to avoid visual loss
- arrange a fluoroscein angiogram at the outset and then 4-6 weekly reviews with a photograph and OCT
- anti-VEGF- intravitreal vascular endothelial growth factor inhibitors- monthly Bevacizumab, and ranibizumab
- laser photocoagulation
- photodynamic therapy PDT IV verteporfin
- intravitreal steroids triamcinolone
- visual aids
- diet rich in fruit and green veg
- vitamins and antioxidants
Dry ARMD management
- stop smoking
- antioxidant supplements
- no other treatment options
what do cones do
colour vision
central vision
what do rods do
night vision
peripheral vision
fhx cause of macular degeneraiton
complement factor H mutation
what is the most common cause of damage to the optic nerve
glaucoma
what is normal eye pressure
11 to 21
what is glaucoma
- increased eye pressure as meshwork is narrowed and get damage to optic nerve
- glaucoma is optic neuropathy with death of retinal ganglion cells and their optic nerve axons
two types of glaucoma
chronic open angle glaucoma
acute angle closure glaucoma
risk factors for chronic open glaucoma
- increased IOP
- black
- FHX
- increased age
- HTN
- DM
- myopia
- steroids
diagnosis of COAG
-intraocular pressure measure using tonometry
>21 but not needed
-central corneal thickness measurements
-gonioscopy- peripheral anterior chamber depths
-visual field: central field is intact as forms an arcuate defect with central intact so presentation often delayed
-slit lamp and fundoscopy
symptoms of chronic open angle glaucoma
often asymptomatic until visual fields are impaired
peripheral visual field loss- nasal scotomas
-tunnel vision
-decreased visual acuity
fundoscopy presentation for COAG
- optic disc cupping >0.7
- optic disc pallor- atrophy
- bayonetting of vessels
- cup notching
- disc haemorrhages
screen for COAG IF
> 35 yrs and ?
- positive fhx
- african carribean
- myopic
- diabetic
- thyroid eye disease
follow up for COAG is
4-6 monthly
management for COAG
- Prostaglandin analogues- lantoprost or travoprost- increase uveoscleral outflow
- beta blockers eg timolol- decrease production of aqueous
- alpha adrenergic agonists - brimonidine, apraclonidine
- carbonic anhydrase inhibitors- acetazolamide, dorzolamide
- miotics- pilocarpine
- sympathomimetic- dipivefrine
- fixed dose combination treatment
- laser therapy trabeculoplasty
- trabeculectomy
pathogenesis COAG
- cause unknown- but increased IOP- retinal ganglion cell death
In open-angle glaucoma, the angle in your eye where the iris meets the cornea is as wide and open as it should be, but the eye’s drainage canals become clogged over time, causing an increase in internal eye pressure and subsequent damage to the optic nerve. It is the most common type of glaucoma
optic disc cupping means
and glaucoma changes
loss of disc substances making the disc look larger
- asymmetric cupping suggests glaucoma
- as damage progresses disc pales and cup widens and deepens so vessels appear to have breaks as disappear into cup -bayonetting
- disc vessels are also displaced nasally
- nasal and superior fields are lost first and temporal fields last
optic cup ratio definition for glaucoma
glaucoma is present when on field testing, 3 or more locations are outside normal limits and the cup to disc ratio is >0.7 (optic disc cupping)
pathogenesis acute angle closure glaucoma
blockage of the trabeculae meshwork duct occurs at the anterior chamber angle- therefore aqueous fluid cant drain so the pressure increases
-displacement of the lens and the iris obstructs the fluid outflow across the trabecular meshwork
Mechanisms that push the iris from behind including, most commonly, relative pupillary block (where accumulation of aqueous in the posterior chamber forces the peripheral iris anteriorly, causing anterior iris bowing, narrowing of the angle
Mechanisms that pull the iris into contact with the TM (e.g., contraction of inflammatory membrane as in uveitis, fibrovascular tissue as in iris neovascularisation
also with time friction can cause scar tissue between TM and iris
factors predisposing to AACG are
hypermetropia= long sightedness
pupillary dilatation
lens growth assoc. to age
A 64-year-old woman presents to the emergency department with severe pain around her right eye of 4-hour duration, accompanied by blurred vision in that eye. She is also nauseated. Examination shows a red right eye with oedematous cornea and a wide pupil that is unresponsive to light. Intra-ocular pressure is extremely elevated (60 mmHg), only in the right eye.
acute angle closure glaucoma
A 50-year-old man presents for a routine eye examination with no symptoms. He has elevated intra-ocular pressure of 25 mmHg in the right eye and 30 mmHg in the left eye. On dilated examination, the cup-to-disc ratio is 0.5 in the right eye and 0.8 in the left eye. Corneal thickness and gonioscopy are normal. Subsequent automated testing of visual fields demonstrates peripheral visual field loss greater in the left eye than in the right. Repeated automated visual field testing shows that the visual field defects are reproducible.
open angle glaucoma
A 75-year-old woman presents with new-onset distortion in one eye. Vision is 20/80 in the involved eye. has smoked 20 cigarettes a day for most of her life. blurred vision and difficult reading small print
AMD
A 65-year-old man presents with generally decreased vision and difficulty driving at night due to glare from oncoming headlights. He describes having trouble reading the small print on his television screen. He is healthy and has no history of any other eye problems. His best corrected visual acuity is noted to be 20/50 in the right eye and 20/40 in the left eye. On examination, a yellowish opacification of the lens in the left eye is noted.
cataracts
A 67-year-old man presents with a 2-day history of sudden visual loss in his right eye. He is slightly myopic and had successful cataract extraction with intraocular lens implantation 3 years earlier. He does not remember this eye ever having been injured. No pain was associated with the vision loss, and his blood pressure is normal with medication. The patient describes the loss of vision as a veil covering the visual field.
retinal detachment
A 65-year-old man with a history of hypertension and hypercholesterolaemia notices sudden, painless vision loss in his right eye. The vision loss is limited to the superonasal quadrant of his visual field. He first noticed the visual field loss approximately 6 weeks ago. For the past 2 weeks, however, he has started to have blurred vision centrally, making reading difficult.
CRVO
A 40-year-old man presents to the emergency department complaining of red eye without purulent discharge. He also has pain, photophobia, blurred vision, and tearing. On slit-lamp examination, the attending ophthalmologist notices a small irregular pupil, conjunctival injection around the corneal limbus, and WBCs in the anterior chamber.
uveitis
primary vs secondary glaucoma
primary= in a patient with anatomical predisposition- ie no known cause secondary= due to a cause eg haemorrhage
presentaation of acute angle closure glaucoma
- mid dilated pupil
- n and v
- ciliary injection
- corneal oedema- rise in IOP
- steamy vision
- see halos and rainbows around light
- pain severe and achy
- cloudy eyes
- headache
- blurred vision
signs of acute angle closure glaucoma
- whole cornea is cloudy
-fixed mid dilated pupil
-not reacting to light
-red eye
-sore
IOP
visual field defect
optic disc cupping
when is AAC glaucoma worse
- dim light so in winter as the pupil dilates so pushes iris up
- anatomical= in small eyes -hypermetropia- increase risk as lens capsule keeps growing in life so lens gets bigger
management of AACG
refer to opathalmoloy emergency give -beta blockers eg timolol -carbonic anhydrase eg acetazolamide -mitotic eye drops- pilocarpine -prostaglandin analogues eg latanoprost -sympathomimetics eg brimonidine- alpha 2 receptor agonist
- laser iridotomy-creation of opening in iris to allow aqueous humor to flow from posterior to anterior
- iridectomy surgical
complications of AACG
visual loss
CRVO CRAO
repeat episodes
lantoprost SE
-increased eyelash length
iris pigmentation
periocular pigmentation
pathology cataracts
- any opacity of the crystalline lens may be considered cataracts
- light scattering opacity in the lens
commonest cause of blindness in the world
cataracts
risk factors for cataracts
- usually ageing assoc.
- DM
- genetics in children
- smoking
- alcohol
- sunlight
- trauma
- radiotherapy
- HIV
- drugs eg steroids
- intraocular tumors
- trauma
- long term UV exposure
inx cataracts
- blood glucose
- hx and exam
- opthalmoscopy
- slit lamp exam
four types of cataracts
- mature
- nuclear sclerotic NS
- posterior subcapsular
- cortical spokes
most common type of cataracts
nuclear sclerotic
nuclear sclerotic cataracts
- usually characterised by darkening and hardening of the lens
- nucleus- central part of lens
- slow and insidious dimming of distance vision while good reading vision preserved
- hardening of nucleus increases refractive index - myopic refractive error shift
- common in old age
mature cataracts
when the entire lens is opacified nucleus and cortex
- most dont reach this stage due to surgery
posterior subcapsular cataracts
- this type of cataract shows with aggregations of degenerated epithelial fibers beneath the posterior lens capsule commonly in the visual axis
- symptoms are glare especially in the sunlight and from ongoing headlights
- also reduced reading vision
- can be caused by high dose steroids
- recently created lens fibres break down eg after x-ray ,trauma, steroids
cortical spokes cataracts
- looks like bike spoke
- peripheral spokes against the red fundus reflex are commonly seen in this type of cataracts
- opacified cortical lens fibers
- otherwise few visual problems until spokes involve visual axis
ocular causes of cataracts
- trauma
- uveitis
- high myopia
- steroid eye drops
- intraocular trauma
systemic causes of cataracts
- diabetes and other metabolic
- systemic steroids, chlorpromazine
- x-radiation
- congenital rubella
- atopic dermatitis
- myotonic dystrophy
- down syndrome
symptoms and signs of cataracts
-painless loss of vision
-glare and halos-dazzle in sunlight
-can get monocular diplopia
-change in refraction
-altered colour perception
-decreased visual acuity- especially in bright lights
-difficulty driving at night
-dark silhouette against red reflex
loss of stereopsis affects distance judgements
management cataracts
- mydriatic drops
- shades
- stronger glasses/ light improvement
- if symptoms are restricting or unable to read number plate at 20m then offer surgery
- phacoemulsion and intraocular lens implant
- patient choice not based on visual acuity
complications of phacoemulsion
- posterior capsule opacification
- retinal detachment
- endophalmitis
- posterior capsule rupture
- iris prolapse
- cystoid macular oedema
- vitreous loss
prevention of cataracts
- use sunglasses
- oxidative stress decrease with antioxidants and caffeine
- stop smoking
inx for cataracts
- examination- red reflex
- look for systemic cause in <60or if unilateral cataract
- biometry to enable accurate intraocular lens power calculation
red eye causes
bilateral
- allergic conjunctivitis- mostly itchy
- infective conjunctivitis- discharge
- keratoconjunctivitis sicca
unilateral
- CN VII palsy
- entropion
- trichiasis
- stromal keratitis
- epithelial keratitis
- episcleritis
- scleritis
- iritis
- acute angle closure glaucoma
5p’s of red eye
pain pus pink pupil pressure
red eye bilateral
bilateral watery discharge
follicles
viral conjunctivitis
red eye bilateral
purulent discharge
gritty or burning
bacterial conjunctivitis
red eye bilateral
predominantly itchy
allergic conjunctivitis
causes of a red eye
conjunctivitis dry eyes CN VII palsy entropion or trichiasis stromal keratitis epithelial keratitis acute angle closure glaucoma iritis scleritis episcleritis
watery eye infant
cause treatment
nasolacrimal duct obstruction
rx: lacrimal duct massage
ciliary injection meaning
inflammation within the anterior segment of the eye
injection most intense adjacent to the edge of the cornea-limbal area
diffuse injection meaning
denotes an inflammed surface conjunctiva- conjunctivitis - more around the outside of the eye
scletoral injection
episcleritis
ciliary injection with purulent discharge
indicates a corneal ulcer
> 30
diffuse injection
mucoid crusting
reduced schrimer tear test
dry eyes
management of allergic conjunctivitis
avoid allergen shower and was hair sodium p. opatanol-mast celll stabiliser anti-histamine eg antazoline -antihistamine drops eg emedastine NSAID eg Ketorolac avoid steroids
management of viral conjunctivitis
symptomatic relief
artificial tears, decongestants
bacterial conjunctivitis rx
most settle no treatment
topical chloromycetin drops or chloramphenicol
ointment at night
-if fails take swabs for STI
topical fusidic acid for pregnant women
newborn baby purulent eye discharge
need to to consider chlamydia/ gonorrhoea
chlamydia eye presentation
bleeding
bacterial that doesnt go away
treat systemically
gonorrhoea eye presentation
purulent discharge
vision threatening
treat systemically IV
SE of topical steroids
secondary infections
delayed corneal epithelial wound healing
cataract formation
permanent rise in intraocular pressure- glaucoma
dry eyes
-diffuse inflammation
severe RA
crusting on eyelids
superficial punctate keratopathy SPK
inx dry eyes
schrimer tear test
<10mm after 5 minutes
treatment dry eyes
artifical tears
long term ocular lubricants
viscotears and lacrilube
punctal occlusion
sub-conjunctival haemorrhage cause
spontaneous
secondary to trauma
epithelial keratitis presentation
ciliary injection no pus aching pain foreign body sensation gritty sensation smaller pupil red eye photophobia
risk factors keratitis
dry eyes
corneal graft
contact lens wearers
corneal ectasian
causes of keratitis
chronic HSV infection -HSV actahamoeba gram positive gram negative rods pseudomonas most common contact wearers
contact wearers keratitis pathology
-pseudomonas
-acathamoeba
inflammatory keratitis
-white dot in ulcer
pain
trauma contact lens wearer abuse severe dry eyes complication from topical steroidal exposure keratitis
inx keratitis
fluoroscein
management of keratitis by pathology
refer to opthalmology
-bacterial= antibiotics -topical quinolones
viral= topical oral antivirals
fungal= antimyoctics
also can give cyclopentolate to relieve
complications of ulcers
-hypophyon= pus in the ant chamber
visual loss
scarring
perforation
stromal keratitis
abscess
infection in stroma
urgen attention
uveitis presentation
-throbbing pain ciliary injection photophobia smaller pupil red eye distorted pupil no pus severe and aching pain
anterior uveitis
irits
anterior cyclitis
intermediate uveitis
vitreous
posterior uveitis
retina/ choroid
panuveitis
all of the uvea
anterior uveitis presentation
red eye pain kerato precipitates photophobia assoc. seronegative
intermediate/ posterior uveitis
painless
floaters
blurred vision
less common
management uveitis
refer to opthalmology
steroid eye drops
cyclopentolate to dilate
complications of uveitis
cataract
macular oedema
secondary glaucoma
scleritis presentation
often assoc. with ocular tenderness deep boring pain can be segmental or whole scleral swelling produces more injection can be sight threatening smaller pupil
risk factors scleritis
RA
inx scleritis
fluoroscein
epinephrine- wont blanch vessels
management scleritis
urgent referral
topical or oral steroids
scleromalacia perforans necrotising
severe form of sscleritis
blue black patches where sclera has thinned out
needs IV steroids
episcleritis presentation
inflammation more superficial episceleral tissue self-limiting segment in the red eye no usually assoc. to pain mild foreign body sensation sector of engorged episcleral and assoc. conjunctival vessels- diffuse injection no pus itchy and burning sometimes small pupil high pressure
inx episcleritis
fluoroscein
will blanch under epinephrine
management episcleritis
self limiting
symptomatic treatment
blepharitis
inflammation of eyelid margins
bilateral grittiness
cause
-sebhorreic dermatitis
meibomian gland dysfunction
features
- bilatera
- gritty
- sticky
- red
- swollen- staph. bleph
- styes are more common
rx
hygiene
hot compress
herpes zoster opthalmicus is
describes the reactivation of the varicella zoster virus in the opthalmic division of the trigeminal nerve
features hzo
vesicular rash around the eye which may or may not involve the actual eye itself
photophobia
red eye
watery eye
Hutchinson’s sign is rash on the tip or side of the nose- inidcates nasocilirary involvement and strong Rf
management hzo
refer to opthalmology
oral anti-viral aciclovir for 7 to 10 days
IV antivirials if severe
topical steroids may be used
complications of HZO
ocular- conjunctivitis, keratitis, ant uveitis
ptosis
post herpatic neuralgia
herpes simplex keratitis
most common cause of corneal blindness also get conjunctivitis, keratitis red eye vesicles on kips pain epiphoira ulceration
papilloedema causes
increased ICP hydrocephalus malignant HTN hypercapnia idiopathic intracranial hypertention tumour trauma
signs of papilloedema
swollen optic disc decreased blurring optic disc margin cork screw blood vessels blood vessel obscuration- blurry disc haemorrhage venous engorgment elevated loss optic cup paton's line
myopic eye
short sighted
eye is bigger
so things from a distance dont meet behind the retina
causes myopia
simple myopia degenerative myopia -malignant or pathological -gets worse over time often with peri disc atrophy and RPE
hypermetropia
long sighted
eye is smaller
rays of light from a close object focus behind
presbyopia
impaired power of accomodation
astigmatism
where cornea is irregularly curved prevent light rays from being brought into common focus on the retina
eye trauma
foreign body UV burns hyphemia perforating injury blow out fractures
chemosis
swollen conjunctiva
can be due to foreign material or ruptured globe
limitation on upper gaze suggests a
blow out fracture
subconjunctival haemorrhage
usually benign can be due to HTN normal va, clear cornea round pupil normal fundus and eye movements
corneal foreign body
normal visual acuity
stain with fluoroscein
normal fundus, eye movements
hyphema
reduced visual acuity clear cornea no stain round pupil abnormal RR-loss of red reflex cant visualise fundus full eye movements blood in anterior chamber
penetrating injuries
reduced visual acuity clear cornea stains peaked pupil cant visualise fundus full eye movements
orbital fracture
normal va clear cornea no stain round pupil abnormal eye movements diplopia
corneal laceration
peaked pupil
penetrating corneal laceration into pupil
entire thickness
traumatic iridodialysis
sign of blunt trauma
separation or tearing of the iris
canaliculus lid laceration
chronic tearing
orbital floor fracture
blunt trauma
orbital contents can herniate down
inferior rectus becomes trapped so trapped in upgaze
diplopia
acute alkali chemical keratoconjunctivitis
irrigate eye immediately
uv eye burn treatment
cyclopentolate
topical antibiotics
patching
complications hyphaema
lens dislocates
glaucoma
retinal detachment
peaked distorted pupil suggests
corneal laceration
refer
styes are
swelling on the lids
infection in the oil gland in the eyelid
often staph aureus
horodeolum externum
outward
lash follicles or sweat gland of moll and seis
horodeolum internum
abscess of meibomian glands and point inwards opening into the conjunctiva
less local reaction
leave a residual swelling called a chalazion
pinguecula
degenerative yellow vascular grey nodules on the conjuctiva either side of corneum
if inflammed can use ttopical steroids
entropion
lid inturning irritates cornea taping lower eyelids to cheek or botox injections surgery
ectropion
assoc.
old age
facial palsy
out turning eyelids
horner
miosis
ptosis
annihydrosis
third nerve
down and out
mydriasis
ptosis
causes of third nerve palsy
cavernous sinus lesions
superior orbital fissures
diabetes and HTN
PCA aneurusm
but vascular lesions spare the pupil eg diabetes and HTN in the nerve
other causes of a fixed dilated pupil
mydriatics
trauma
acute glaucoma
holmes adie pupil
tonically dilated pupil
accompanied by absent knee and ankle jerks
slow response to accomodation and light
idiopathic
loss of parasympathetic to the eye
benign-often women
slowly refractive to light with more definite accomodation
Horner causes
central lesions (anihydrosis face arms and trunk)
stroke
MS
tumour
pre-ganglionic anihydrosis only face
tumour- pancoast
thyroidectomy
trauma
post-ganglionic no anihydrosis
carotid artery aneurysm
cavervous sius thrombosis
carotid artery dissection
hutchinson’s
unilateral dilated pupil unresponsive to light
compression to occulomor nerve on same side by intracranial mass
argyll robertson
bilateral small pupils that accomodate but dont react to bright lights
neurosyphilis and DM
tropia and phoria
tropia- always present- cover test
phoria- only seen on alternate cover test
conmitant strabismus
due to imbalance of extraocular muscles
inherited CNS problem
constant upon direction of gaze
non comitant strabismus
due to paralysis of nerve
depends upon direction of gaze
acquired nerve palsy
therefore may only be evident when patient attempts to use the weak muscle
ambylopia
lazy eye
failure to achieve normal visual acuity
reduction of corrected central visual acuity even though the eye appears structually normal
can be unilateral or bilateral
pathology ambylopia
50%
due to if one eye sees significantly worse (diplopia) - due to a refractive error= then the brain suppresses the image from the poorer seeing eye so a squint develops
the brain also begins to rely on the good eye
so vision of the bad eye is suppressed and neural connections diminish and fail to develop
ambloypia need to treat by
age 8
causes ambylopia
poor alignement irregular shape eye hypermetropia and myopia opacifications of ocular media in one eye signifcant asymmetric refractive index retinoblastoma
management of strabismus and ambloypia
-refer children with squints to opthalmology
corneal light reflection test and other testsing
E game
eye patch the good eye so suppressed eye has to be used
binocular diplopia means
diplopia will go when each eye is covered separately
monocular diplopia means
diplopia will be present when each eye is covered separately
- cataracts
- cortical abnormality
horizontal diplopia
lateral rectus palsy
vertical diplopia causes
3rd nerve palsy - aniscoria, dilated pupil, down and out, ptosis
thyroid orbiopathy
cranial nerve 4
3rd nerve palsy causes
space occupying lesion- dilated pupil
ischaemic cause- normal pupil as no effect on parasympathetic supply
signs of thyroid orbitopathy present
tightness of eye muscles
lid and conjunctiva
causes 4th nerve palsy
trauma- blow out
diabetes
tumour
idiopathic
