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Opthalmology Flashcards

1
Q

what does this image show

A

Cataract on slit lamp examination

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2
Q

What is a cataract?

A

a very common cause of gradual visual loss caused by the opacification of the crystaline lens

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3
Q

what are the causes of cataracts?

A
  • Ageing
  • trauma
  • metabolic disorders eg galacosemia
  • medications
  • congenital problems
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4
Q

what medications cause cataracts?

A

PC SAAD

    • corticosteroids
  • allopurinol
  • aspirin
  • chloroquine
  • diuretics
  • phenothiazines
  • simvastatin
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5
Q

What is the main presentation of cataract?

A

Gradual visual loss

visual acuity depends on the type of cataract

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6
Q

what are the types of cataracts?

A
  1. Cortical
  2. subcapular
  3. Star flower
  4. congenital
  5. nuclear
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7
Q

describes the typical symptoms of a cortical cataract?

A

Good visual acuity

may complain of halos around lights and glare

can cause double vision or fractured vision

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8
Q

describe the symptoms of a subcapsular cataract?

A

Good vision in dim lighting on dilation

worse in bright lights

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9
Q

describe the cause of a star flower cataract?

A

Trauma

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10
Q

describe a nuclear cataract presrentation?

A

the most common type of cataract

associated with increased ageing

causes blurred vision and washed out colours

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11
Q

on examination of the patient who presents with :

  • gradual decreased visual acuity

you find there is:

  • diminished red light reflects
  • normal fundus and optic nerve reduced visual acuity

slit lamp examination shows:

  • a cloudy anterior chamber

what is the diagnosis?

A

cataract

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12
Q

what is the management of a cataract?

A

Surgical

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13
Q

what are some intraoperative complications of cataract surgery?

A

Lens capsule rupture

haemorrhage

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14
Q

what are some post-operative complications of cataract surgery?

A

Lens dislocation

capsule opacification

infection and inflammation / post op endopthalmitis

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15
Q

what does this image show?

A

small white crystalline drusen

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16
Q

what does this image show?

A

Larger confluent soft drusen

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17
Q

what does this image show?

A

Dry macular degeneration

  • pigmented epithelium
  • choroid and retinal clumping
  • geographical atrophy
  • drusen
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18
Q

what does this image show?

A

Wet macular degeneration

  • chorodial neurovascular membranse
  • sub- retinal haemorrhages and exudates
  • localised retinal detachment - which can then cause retinal scarring appearing as a black blob
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19
Q

what is the macula?

A

where visual acuity is at its highest

Has functioning rods and cones

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20
Q

what is the fovea?

A

Located at the centre of the macula

there are only cones

this is where there is the best visual acuity

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21
Q

what is macular degeneration?

A

mainly an age-related condition

causing a gradual visual loss

early stages are associated with normal or near normal vision

later stages have decreased visual acuity and eventual loss of central vision

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22
Q

what are the two types of macular degeneration?

A

Wet/ dry

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23
Q

describe the pathophysiology behind dry macular degeneration?

A

There is atrophy of the retina

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24
Q

describe the pathophysiology behind wet macular degeneration?

A

There is new vessel growth under the retina

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25
Q

what sign do both types of macular degeneration share in the initial stages of the disease process?

A

drusen

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26
Q

In dry macular degeneration what is the most common presenting complaint?

A

Central Scotoma (visual loss) with good peripheral vision but which deteriorates

lead to legal blindness – is the most common cause of legal blindness in the UK

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27
Q

what is the management of dry macular degeneration?

A

Low vision aids

limited evidence for nutritional supplements and antioxidants

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28
Q

what is the most common presenting complaint of wet macular degeneration?

A

Distorted vision

micropsia leading to central’s scotoma’s

has faster visual loss then with dry macular degeneration

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29
Q

what is the management of wet macular degeneration?

A

rapid referral treating with injections of anti-TNF beta- macugen

or

laser after IV photosensitive drugs- verteporfin (if under the fovea)

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30
Q

how can you differentiate between wet and dry macular degeneration?

A

florosine test

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31
Q

What is the angle?

A

The name given to the space between the posterior surface of the cornea and the interior surface of the iris

it is where the aqueous leaves the eye

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32
Q

what is aqueous?

A

Nourishing fluid for the lens made by the ciliary body entering through the eepiscleral veins

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33
Q

what range should put the intraocular pressure be?

A

< 21

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34
Q

What is the pathophysiology of open angle glaucoma?

A

Dysfunction of the outflow of aqueous humour

due to obstruction in the draining

causes an increase of intraocular pressure

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35
Q

what does this image show?

A

Glaucoma characterised by :

an increased cup:disc ratio and notching of the optic nerve

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36
Q

A patient present with:

  • Halos around lights
  • aching brow pain
  • headaches nausea and vomiting
  • reduced visual acuity
  • eye redness

on examination you note:

  • elevated intraocular pressure
  • corneal oedema
  • fixed dilated pupil

what is your diagnosis?

A

acute or subacute angle closure glaucoma

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37
Q

in more advanced disease what is the presentation of open and glaucoma?

A

Peripheral visual loss leading to Scotoma

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38
Q

what is the management of open angle glaucoma?

A

Observation of ocular hypertension with regular checkups

use of :

  • topical beta-blockers - timodolol
  • prostanoids - latanoprist
  • carbonic anhydrases - dorzolamide
  • alpha agonists - bromide

in more severe cases:

carbonic anhydrase inhibitors acetalozalamide –> surgery

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39
Q

what is the pathophysiology of angle closure glaucoma?

A

An urgent but uncommon dramatic symptomatic events

there is closure of the anterior chamber angle

results in elevation of intraocular pressure

usually sudden but can be chronic

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40
Q

what other risk factors associated with angle closure glaucoma?

A
  • Female
  • hyperopia
  • another eye having it
  • shallow peripheral anterior chamber
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41
Q

when is chronic angle glaucoma usually diagnosed?

A

When still asymptomatic on regular eye checks

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42
Q

When is open angle glaucoma usually detected?

A

On regular eye checkups as open angle glaucoma is usually asymptomatic until more advanced disease

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43
Q

what investigating is diagnostic for angle closure glaucoma?

A

gorioscopy

plus checking IOP and visual fields

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44
Q

What is the acute management of angle closure glaucoma?

A

This is a medical emergency and requires immediate referral

treatment is through decreasing intraocular pressure using:

  • PO acetazalamide and iv mannitol
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45
Q

what can be done to prevent angle closure glaucoma from occurring again?

A

iridotomy

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46
Q

what is optic neuritis?

A

Inflammation of the optic nerve

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47
Q

what causes optic neuritis?

A
  • idiopathic usually
  • MS
  • sinus infections
  • vericella zoster virus
  • syphilis
  • sarcoidosis
  • lupus
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48
Q

what does this image show?

A

optic neuritis:

Pale optic disc

inflammation / swelling of the optic disc

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49
Q

what is the presentation of optic neuritis

A

acute or subacute onset of pain (peri orbital or reticulo bulbar)

  • getting worse with movements

loss of vision

visual acuity gets worse after one to 2 weeks

usually there is almost full recovery

colour desaturation

relative afferent pupillary defect

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50
Q

what investigations should you perform in optics neuritis?

A

MRI of the optic nerves – MS

if the history is suggestive of other causes then investigate those:

  • serum ACE- increased in sarcoidosis
  • ana - positive in SLE
  • VDRL - positive in syphilis
  • PCR for varicella
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51
Q

how do you treat optic neuritis?

A

Steroids speed recovery - PO prednisolone

but it does not improve outcomes

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52
Q

if optic neuritis occurs repeatedly or for a prolonged period of time what can happen to the optic nerve?

A

atrophy and become pale

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53
Q

how can toxoplasmosis causes secondary optic neuritis?

A

there is an area of neuro retinitis close to the optic nerve

causing it to become swollen

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54
Q

how do you treat secondary optic neuritis to toxoplasmosis?

A

Steroid and antibiotics

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55
Q

what does this image show?

A
  • Micro aneurysms and cotton wool spots
  • intra retinal haemorrhages
  • lipid exudates and macular haemorrhages
  • macular oedema can occur

Diabetic retinopathy

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56
Q

what are the two types of diabetic retinopathy?

A

non-proliferative

proliferative

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57
Q

described non-proliferative diabetic retinopathy

A

It is the early stages of the disease and is less severe

blood vessels become leaky and fluid leaks into the retina

causing blurred vision

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58
Q

describe proliferative diabetic retinopathy

A

New blood vessels grow which are fragile

these can haemorrhage really quickly

this can cause vision loss and scarring

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59
Q

what is the pathophysiology of diabetic retinopathy?

A

There is progressive diabetic microvascular leakage and occlusions

With then progressive proliferation of vessels

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60
Q

what is the presentation of diabetic retinopathy?

A

Floaters

blurred vision

vision loss

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61
Q

when is diabetic retinopathy usually diagnosed?

A

In the early stages of disease through diabetic eye screening

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62
Q

what should you do if you suspect macular oedema in diabetic retinopathy or otherwise?

A

order optical coherence tomography

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63
Q

what is diabetic maculopathy?

A

Diabetic maculopathy is a condition that can result from retinopathy

Maculopathy is damage to the macula - the part of the eye which provides us with our central vision

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64
Q

what should you do if you suspect diabetic maculopathy?

A

Order fluorescein angiography

laser treatment

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65
Q

what does a fluorescent angiography show?

A

shows blood vessels and capillary non-perfusion

plus shows the formation of new vessels and haemorrhages

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66
Q

what investigation is required if you suspect retinal detachment?

A

Beta scan occular ultrasound

a non invasive tool for diagnosing lesions of the posterior segment of the eyebal

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67
Q

what is the management of diabetic retinopathy?

A

diabetic control

injections of anti-vascular endothelial growth factor

laser

surgery

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68
Q

What does this image show?

A

retinal artery occlusion of the central artery

  • thin retinal arteries
  • retinal oedema and pallor
  • optic disc becomes pale after months
  • you see a cherry red spot
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69
Q

what does this image show?

A

Retinal artery occlusion of a branch artery

  • retinal pallor following the branch of the artery thats occluded
  • narrowing of the artery after the embolus
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70
Q

what causes retinal artery occlusion?

A

Embolus or atherosclerosis from the carotid artery

  • reaching the ophthalmic artery or a branch of it in the eye
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71
Q

what is the presentation of retinal artery occlusion?

A

Sudden almost total loss of vision- central occlusion

if visual field loss – branch occlusion

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72
Q

what is the relevant afferent pupillary defect like in retinal artery occlusion?

A

relevant afferents pupillary defect is usually still present

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73
Q

What investigations should you perform in retinal artery occlusion?

A

Usually diagnosis is just through the fundoscopy

a carotid Doppler can be used to aid diagnosis

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74
Q

what is the management of retinal artery occlusion?

A

Urgent referral with therapeutic intervention in 4-6 6 hours

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75
Q

what is transient monocular visual loss a symptom of?

A

It is a symptom of TIA

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76
Q

what is a presentation of transient monocular visual loss?

A

Describe as a curtain coming over vision

lasting around 30 minutes

full recovery after

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77
Q

what does this image show?

A

Flame haemorrhages due to the inability to drain blood

  • if it is localised it indicates a branch occlusion
  • widespread indicating that central occlusion
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78
Q

what is retinal vein occlusion?

A

An interruption of normal venous drainage from the retinal tissue

causing symptoms of acute visual loss

it can be central or one of its branches

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79
Q

what is the presentation of retinal vein occlusion?

A

Painless sudden vision loss - central

blurring of vision and field defects- branch

almost always unilateral

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80
Q

what risk factors are associated with retinal vein occlusion?

A
  • Hypertension
  • diabetes
  • atherosclerosis
  • glaucoma
  • increased age
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81
Q

how do you confirm the diagnosis of retinal vein occlusion?

A

Fluorescein angiography

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82
Q

how do you manage retinal vein occlusion?

A

injections of anti tVEGF

  • such as rabibizumab or bevacizumab
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83
Q

what proportion of patients with retinal vein occlusion will develop ischaemia?

A

1/3

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84
Q

how does central retinal vein occlusion with ischaemia differ from vein occlusion without ischaemia on funduscopy?

A

There isn’t much haemorrhage in CRVO with ischaemia

and you would see:

  • swelling of the optic disc
  • with cotton wool spots
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85
Q

what is a complication of central retinal vein occlusion with ischaemia?

A

Neovascularisation requiring laser treatment

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86
Q

What does this image show?

A

anterior ischaemic optic neuropathy

Looks very similar to vein occlusion but just occurring much closer to the optic disc and nowhere else

near the optic disc you would find:

  • flame haemorrhages
  • some cotton wool spots
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87
Q

what is anterior ischaemic optic neuropathy?

A

Interruption of the blood flow to the front of the optic nerve

causing loss of vision as visual information is not passed on to the brain

can be arteric or non arteric

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88
Q

what is the most common cause of arteric anterior ischaemic optic neuropathy?

A

giant cell arteritis

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89
Q

what are the most common causes of non arteric anterior ischaemic optic neuropathy?

A
  1. drop in blood pressure
  2. increased intraocular pressure
  3. narrowed arteries/ viscous blood
  4. vasculitis
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90
Q

which is most common arteric or non arteric (ischemic optic neuropathy)?

A

non arteric

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91
Q

if you suspect that anterior ischaemic optic neuropathy has been caused by giant cell arteritis what should you do?

A
  1. then give immediate high-dose corticosteroids (pred) and reffer for same day assessment by rheumatologist/opthalmologist for eye involvement
  2. Perform urgent blood tests of ESR CRP and FBC
  3. temporal artery biopsy is then required to confirm (usually)
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92
Q

what is the presentation of anterior ischaemic optic neuropathy?

A

sudden painless loss or blurring of vision usually most noticeable after waking from sleep

wost after about two weeks

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93
Q

what is the afferent pupillary reflexes like in anterior ischaemic optic neuropathy?

A

always present

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94
Q

what is the management of anterior ischemic optic neuropathy?

A

corticosteroids or anti VEGF (but not much evidence)

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95
Q

a patient presents with:

  • floaters
  • the patient notes that symptoms have been present for a few weeks

examination you note that there is:

  • a slight visual fields defecits

- What is the most likely diagnosis?

A

Retinal detachment

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96
Q

What does the image below show?

A

retinal detachment

pale area is fluid accumulation

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97
Q

what is retinal detachment?

A

An acute or progressive condition in which the neuro retina separates from the retinal pigment epithelium

there is an accumulation of sub- retinal fluid and loss of retinal function

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98
Q

what type of retinal detachment is most common?

A

Secondary Due to traction - usually retinal tear

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99
Q

what are the three types of retinal detachment

A
  1. primary(rhegmatogenesis)
  2. secondary
  3. exudative
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100
Q

what causes floaters?

A

Either traction or vitreous haemorrhage

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101
Q

do floaters and flashes always mean pathological retinal detachment?

A

No they can be benign detachments which do not lead to retinal detachment

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102
Q

how do you manage retinal detachment is?

A

laser for tears

surgery

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103
Q

what is a complication which can occur due to retinal detachment?

A

Proliferative vitreoretinopathy

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104
Q

what is hysterical blindness?

A

Functional neurological symptom disorder

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105
Q

what is the difference between conversion disorder and hysterical blindness?

A

conversion disorder Is when blindness is precipitated by a stressor

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106
Q

what’s is the DSM five criteria of hysterical blindness?

A
  1. one symptom of altered vocabulary motor or sensory function
  2. clinical findings showing incompatibility between symptoms and recognised medical disorders
  3. symptoms are not better explained by other medical or mental conditions
  4. symptoms cause clinically significant distress or functional/social impairment
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107
Q

what is the difference between acute and chronic hysterical blindness/ what the other two ways of classifying it?

A

Acute lasting under six months

chronic lasting over six months

persistent

episodic

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108
Q

what is the characteristic feature of hysterical blindness?

A

there is tunnelling of vision

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109
Q

How would you manage hysterical blindness?

A

Reassurance and explanation

psychotherapy

occupational therapy

medications such as SSRIs

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110
Q

what is squint?

A

a.k.a. strabismus.

  • Misalignment of the eyes where one eye fixates on the chosen object
  • the other is deviated
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111
Q

what is the presentation of strabismus in adults?

A

Diplopia and visual confusion – seeing the different objects in one place

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112
Q

what is the presentation of strabismus in children?

A

usually asymptomatic

is found on screening but causes ambylioplopia

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113
Q

what is acquired strabismus?

A

the malfunction of one or more cranial nerves namely:

  • oculomotor (three)
  • trochlear (four)
  • abducens (six)

plus abnormal eye movements

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114
Q

what is reactive strabismus?

A

Mechanical restriction of eye movements due to conditions like graves or orbital fractures

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115
Q

what is the sensory strabismus?

A

Reduction in visual acuity of one eye

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116
Q

what is acute onset strabismus?

A

Usually caused by intracranial processes such as:

  • mass lesions
  • infarcts
  • increased intracranial pressure

Acute onset history

can be:

  • recurrent
  • consecutive(occurs more thanonce but w different causes each time)
  • residual (treatment not fully successful)
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117
Q

what what pathologies can strabismus be associated with?

A
  • MG
  • super nuclear palsys
  • global developmental delay such as cerebral palsy
  • any causes of acute onset strabismus:
    • mass lesions

infarcts

increased intracranial pressure

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118
Q

what is the management of strabismus?

A

If there is an underlying cause treat that

refractory errors treated with glasses

ambyloplopia or diplopia corrected by covering the functional eye

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119
Q

what is ambyloplopia?

A

visual impairment resulting from abnormal visual stimulation during childhood

due to eye misalignment

but not attributable to structural abnormalities of the eye or of visual pathways

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120
Q

what is the difference between strabismus and ambyloplopia?

A

Strabismus, the medical term for “crossed-eye”, is a problem with eye alignment, in which both eyes do not look at the same place at the same time.

Amblyopia, the medical term for “lazy-eye”, is a problem with visual acuity, or eyesight.

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121
Q

what the causes ambyloplopia?

A

caused by misalignment of the eyes

  • for accurate binocular vision each eye must have a clear focus aligned vision
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122
Q

what muscles does the oculomotor nerve Innervate?

A
  • superior, inferior and medial rectus
  • inferior oblique
  • as well as ciliary muscles
  • pupillary reflex muscles
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123
Q

what is the function of the oculomotor nerve?

A

elevation and intorsion (medially and down out)

rotation of the eye up and in

eye lid opening

pupilary consitriction

accommodation

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124
Q

what are causes of oculomotor nerve palsy?

A

diabetic neuropathy + hypertension ( causing micro-angiopathy)

compression or trauma from PCA aneurysms or base of skull fractures

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125
Q

What muscles does the trochlear nerve innervate?

A

innervate the superior oblique

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126
Q

what is the movement that the trochlear nerve causes?

A

rotating the eye clockwise ( so down and in)

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127
Q

what other common causes of trochlear nerve palsy?

A

microangiopathy

  • by diabetic neuropathy
  • hypertension

trauma

fourth nerve palsy (congenital)

atherosclerosis

cavernous sinus thrombosis

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128
Q

what muscle does the abducens nerve innervate?

A

lateral rectus

129
Q

what movement is the abducens nerve responsible for?

A

abduction of the eye - looking laterally

130
Q

what can cause abducens nerve palsy?

A

Trauma especially at the superior orbital fissure

cavernous sinus thrombosis

diabetic neuropathy

131
Q

what movement is the superior rectus responsible for?

A

elevation and intorsion (clockwise) (CNIII)

132
Q

what movements is the lateral rectus responsible for?

A

Looking laterally (ie L eye looking L) (CNIII)

133
Q

what movement is the inferior rectus responsible for?

A

depression and in torsion (anticlockwise) (CNIII)

134
Q

what movement is the inferior obleque responsible for?

A

External rotation of the eye and some aspect of elevation (CNIII)

135
Q

what is the movement of the superior oblique?

A

internal rotation and some aspects of depression (CN IV)

136
Q

what is the function of the lateral rectus?

A

abduction of the eye – looking laterally (CN VI)

137
Q

what is the function of the medial rectus?

A

Adduction- looking medially (CNIII)

138
Q

what does the following images show?

A

papilloedema

  • Venous engorgement
  • haemorrhages
  • blurring of optic margins
  • elevation of optic disc
139
Q

what is usually the first sign of papilloedema on fundoscopy?

A

Venous engorgement

140
Q

What is papilloedema?

A

Swelling of the optic nerve occurring due to an increase in ICP or CSF

141
Q

what are symptoms of papilloedema?

A

Double vision (especially in CN IV palsy)

blindspot, blurring of vision

visual obstruction

eventually total visual loss

142
Q

what are some causes of papilloedema?

A
  1. MS
  2. Head trauma
  3. anything causing inflammation of the brain or surrounding tissue (tumours sarcoidosis)
  4. CSF obstructions
  5. increased ICP
  6. hypertension
  7. uveitis
  8. central retinal vein occlusion
  9. anterior ischaemic optic neuropathy
  10. sometimes anaemia
143
Q

what is the management of papilloedema?

A

Managing underlying cause

steroids to reduce inflammation (especially in MS)

the use of diuretics to decrease CSF

144
Q

what is the difference between papilloedema and disc swelling?

A

if there issnt an increased ICP then it is considered disc swelling/disc oedema

145
Q

what other finding on funduscopy can be mistaken for papilloedema?

A

Optic drusen and which are benign and harmless CT is used to exclude this

146
Q

what image is shown below?

A

retinitis pigmentosa

  • Atrophy of the retina and retinal pigmented epithelium
  • washy pallor of the optic nerve
  • retinal vascular attenuation
147
Q

what is retinitis pigmentosa?

A

A hereditary condition of retinal degeneration caused by the loss of rods and cones

148
Q

what symptoms are present in retinitis pigmentosa?

A

Initially there is loss of night-time vision

then progressive loss of peripheral vision

eventually leading to decreased visual acuity

149
Q

What is the management of retinitis pigmentosa?

A

Vitamin a – retinol

fish oils

gene therapy

  • these have some benefit but not curative
150
Q

what to do enlarged blind spots on visual fields indicate?

A

Papilloedema

151
Q

what field defect is shown below?

A

Left eye anospia

152
Q

which lesion would cause left eye anospia?

A

lesion of the left optic nerve (1)

153
Q

in the lesion of the left optic nerve what would the pupillary light reflex be in both eyes?

A

when light is shone into L eye = absent

when light is shone into R eye = present

154
Q

what conditions can cause optic nerve lesions which leads to eye anospia?

A

MS

central retinal artery occlusion

155
Q

what field defect is shown below?

A

Left nasal heamienopia

156
Q

what can cause left nasal hemienopia?

A

Internal carotid artery aneurysm expanding medially

157
Q

where is the site of the lesion of left nasal hemienopia?

A

left temporal fibres from optic nerve

158
Q

what visual field defect is shown below?

A

bi temporal heteronymous hemienopia?

159
Q

where is the site of the lesion in bi temporal heteronymous hemienopia?

A

optic chiasm (3)

160
Q

what other common causes of lesions in optic chiasms?

A

Pituitary adenoma most commonly

or craniopharangioma

161
Q

what visual field defect is shown below?

A

binasal hemienopia

162
Q

what are the causes of bilateral optic chiasm compression?

A

Calcification of both interior carotid arteries

or congenital hydrocephalus

163
Q

what visual field defect is shown below?

A

right hononymous hemienopia

164
Q

what site of lesion would cause right hononymous hemienopia?

A

left optic tract

or lateral geniculate body (if pupilary light reflex is slightly suppressed)

or optic radiation (pupillary light reflex present)

165
Q

what would normally cause lesions of the left optic tract/ lateral geniculate body?

A

MCA occlusion (left)

166
Q

what are some causes of Central scotoma

A

diabetic retinopathy

retinitis pigmentosa

macular degeneration

167
Q

what is a pituitary adenoma?

A

the 3rd most common adult brain tumour:

can be clinically functional (ie secreting)

or non functioning

168
Q

what are the types of functional pituitary adenoma ?

A
  1. prolactin secreting - prolactinoma
  2. growth hormon secreting - acromegaly
  3. adenocorticotrophic hormone secreting - cushings
169
Q

how would a pituitary tmour present

A

headaches + features of increased ICP

visual field defects - bilateral temporal hemienopia

plus if functional sx of XS hormones such as acromegaly or cushings

170
Q

why no non functional pituitary hormonnes sometimes still cause a mild raise in prolactin?

A

compression of the pituitary stalk and interruption of the dopaminergic pathway

171
Q

what is the diagnostic fisrt line test for pituitary tumours?

172
Q

what is the management for pituitary tumours?

A

surgery

with then HRT of any missing hormones depending on blood results

173
Q

what hormones does the pituitary make which you would want to replace?

A
  • levothyroxine
  • corticosteroids
  • androgens
  • oestrogens
  • GH
174
Q

why do hormone deficiencies occur after treatment for pituitary tumour?

A

either pituitary not there

or theres increased demand on the leftover functioning pituitary which it cannot cope with causing hypopituitarism

175
Q

A patient presents with:

  • a burning/itching sensation across the eyelid
  • the feeling of dry eyes or grittiness
  • in the morning they notice that there are crusts on the eyelid
  • and they notice that their eyelashes have been falling out

what is the diagnosis?

A

blepharitis

176
Q

what does the following image show?

A

blepharitis

  • Telangiectasia scaly hard skin a.k.a.coralettes around lashes
  • capped meobian glands
  • eye redness
177
Q

what is the management of Blepharitis?

A

patient education – it is a chronic disease with intermittent flareups

plus eyelid hygiene

omega three fatty acids

artificial tears

during flareups topical corticosteroids/antibiotics if suggestive of infection

178
Q

what is a stye?

A

An infection causing the formation of an abscess at the base of an eyelid

179
Q

what is a chalazon?

A

If inflammation of the moebian glands deep within the eyelid

180
Q

what and pathogens usually cause styes or chalazons?

A

Staphylococcus aureus

staphylococcus epidermis

181
Q

what is the difference between a Stye and a chalazon?

A

stye is more superficial than a chalazon but can still occur at a moebian gland and it was also includes ciliary glands

182
Q

what condition are styes and chalazon s associated with?

A

blepharitis

183
Q

what is a distinguishing diagnostic feature between a stye and chalazon?

A

styes are painful whereas chalazon are not

184
Q

how do you manage chalazon?

A

heat compress and lid massage

185
Q

how do you manage Stye?

A

heat compress

if bad :

  • topical antibiotics and possible drainage
186
Q

what does the image below show?

A

episcleritis

  • intense localised redness
187
Q

what is episcleritis?

A

inflammation of the episclera ( the clear film on top of the whites of your eyes)

188
Q

what is the presentation of episcleritis?

A

intense localised redness mild irritation no pain!

plus

  • tearing
  • with photosensitivity
  • and possibly a gritty sensation
  • almost always unilateral
189
Q

what conditions is episcleritis associated with?

A

inflammatory diseases

190
Q

what is the management of episcleritis?

A

self-limiting and resolves within one – two weeks

191
Q

What does the image below show?

A

scleritis

Redness of the sclera which can develop a blue/purple hue

192
Q

what is the presentation of scleritis?

A

Redness of the sclera which sometimes develops a blue/purple hue

severe ocular pain which radiate to jaw

decreased visual acuity which can lead to blindness

193
Q

what are the types of scleritis?

A
  1. Diffuse-most common
  2. nodular
  3. necrotising
194
Q

what is the management of scleritis?

A

requires urgent referral and oral steroids are prescribed

In necrotising scleritis surgery is required

195
Q

what does the image below show?

A

Iritis

Intense redness of the globe of the eye regular pupils that are stuck to the lens

196
Q

what occurs to the cornea in iritis?

A

large groups of cells clump on the back of the surface of the cornea

Cells and fibrin in the anterior Chamber

197
Q

a patient presents with:

  • unilateral acutely painful eye
  • and they note photophobia
  • have reduced vision
  • they also suffer from inflammatory bowel disease

looking at the eye it looks intensely red and has irregular pupils

what is most likely diagnosis?

A

Iritis a.k.a. anterior uveitis

198
Q

what marker is iritis is associated with?

199
Q

What diseases is iritis associated with?

A

seronegative arthropathy :

  • ankylosing spondylitis
  • psoriatic arthropathy

granulomatous disease :

  • sarcoidosis
  • syphilis

and IBD

200
Q

what is important to find out about in someone who you think may have iritis?

A

ask about any associated symptoms such as joint problems, skin problems, mouth ulcers, chest or skin disease and GU symptoms

201
Q

what happens to the intraocular pressure in iritis?

202
Q

what is the treatment of iritis?

A

Topical steroids and managing underlying conditions

203
Q

what does the image below show?

A

Viral conjunctivitis

  • showing watery/sticky discharge and read eye
204
Q

what are the features of viral conjunctivitis?

A
  • Watery/sticky discharge
  • red eye
  • you may see raised white follicles
  • sudden onset of symptoms
  • there may be pre auricular lymphadenopathy
205
Q

what pathogen most commonly causes viral conjunctivitis?

A

adenovirus

206
Q

what is the management of viral conjunctivitis?

A

Self-limiting and doesn’t respond to antivirals

207
Q

what other features of allergic conjunctivitis?

A
  • Looks similar to viral
  • has a watery/mucus discharge
  • red eye due to capillary dilattaion
  • increased permeability usually an allergic trigger
  • swollen itchy eye which is fairly short lived
208
Q

what type of hypersensitivity reaction causes allergic conjunctivitis?

209
Q

what is chronic allergic conjunctivitis?

A

A severe pathology requiring specialist care as it can cause corneal ulceration

210
Q

what are the features of chronic allergic conjunctivitis?

A

Large pupils

corneal ulceration

sticky mucus

211
Q

wise management of chronic allergic conjunctivitis?

A

Topical steroids

212
Q

atropine can cause an allergic reaction in the eyes what is its presentation?

A
  • Occurring shortly after atropine is applied
  • causes inflamed skin with ulceration
  • discharge and red eyes
  • pupils are dilated because of the atropine drops
213
Q

what does the image below show?

A

Purulent discharge

sticky discharge and crusting

very red eyes

214
Q

what pathogens usually cause bacterial conjunctivitis?

A
  1. Staphylococcus
  2. Streptococcus
  3. Haemophilus
  4. Neisseria
  5. chlamydia
  6. gonorrhoea
215
Q

what does the history of conjunctivitis starting in one eye and then spreading to the other eye suggest?

A

Bacterial infection

216
Q

what is the management of bacterial conjunctivitis?

A

Chloramphenicol drops + fucidic acid

217
Q

what can cause recurrent conjunctivitis? And what is the treatment?

A

blockage of the Naso lacrimal ducts

Surgical to pass obstruction

218
Q

what is inclusion conjunctivitis?

A

When an STI is a cause of conjunctivitis such as chlamydia or gonorrhoea

219
Q

what is the most common STI to cause conjunctivitis in adults?

220
Q

What is an indicative feature of inclusion conjunctivitis?

A

Associated corneal inflammation

221
Q

what is ophthalmia neonatorium?

A

conjunctivitis within the first three weeks of life

contracted when passing through the birth canal

222
Q

what pathogen usually causes ophthalmia neonatorium?

A

gonorrhoea and chlamydia

herpes simplex

Staphylococcus aureus

223
Q

why is ophthalmia neonatorium very dangerous?

A

pathogens such as:

  • herpes simplex
  • gonorrhoea

…can cause vision loss

224
Q

what does the image below show?

A

herpes simplex​

  • These are vesicobulbar eruptions around the eye
  • erythema
  • lid oedema
225
Q

what is the presentation of herpes simplex virus around the eyes?

A

Pain and erythema

lid oedema

may see possible oral lesions

severely inflamed eyes

226
Q

what symptoms will occur if herpes simplex got to the cornea?

A

pain

photophobia

watery discharge

227
Q

what investigation is needed if you suspect corneal herpes simplex?

And what would you see?

A

Fluorescent staining so you can see the characteristic dendritic shape

228
Q

how would you manage herpes simplex of the eye?

A

Topical acyclovir

per oral can be used if it’s not reached the cornea

229
Q

why is it really important not to give steroids to read eye without specialist advice?

A

Can cause corneal ulcers and scarring

230
Q

what investigation can show a corneal ulcer?

A

Rose bengal stain

231
Q

Patient presents with:

  • vesico bulbar eruptions on the nose, upper lip and forehead

what is a potential diagnosis?

A

Herpes zoster virus affecting the cutaneous distribution of the ophthalmic branch of the trigeminal nerve

232
Q

who does herpes zoster virus usually affect?

A

Adults and older children

233
Q

what is the management of herpes zoster virus of the face?

A

PO acyclovir

early treatment is important

234
Q

what happens if herpes zoster virus of the face is untreated?

A

Severe corneal inflammation can occur causing neovascularisation

which has lipid exudates leading to corneal clouding and thinning

235
Q

what should you do if the eye is involved in a herpes zoster infection?

A

Refer immediately

236
Q

what is keratitis?

A

A bacterial infection of the cornea which is very rare but very serious

237
Q

what does the image below show?

A

Hazy cornea with central abscess - bacterial keratitis

238
Q

what does an immune ring on funduscopy in bacterial keratitis suggest?

A

Infection with serriata

239
Q

what is the management of bacterial keratitis?

A

Intense antibiotic therapy – ofloxacin

until more specific abx can be used

immediate referral for diagnosis and treatment

240
Q

what is a symptom that the patient would complain of in bacterial keratitis?

A

painful red eye with loss of vision

241
Q

what does the image below show?

A

Lid mild position

242
Q

what is the presentation of lid malposition ?

A

Pain and watery eyes

  • due to lashes curving inwards
  • abrading the cornea
243
Q

what are causes of lid malposition ?

A

lid laxity in the elderly

facial palsy e.g. Bell’s phenomenon

244
Q

how would you check for Bell’s phenomenon?

A

eyes roll up when the eyes are closed

245
Q

what is important to check in a patient with lid malposition?

A

appropriate eye closure

corneal sensation

if any of these are absent in the eyes at high risk of exposure and should be referred urgently

246
Q

what is the treatment of lid malposition?

247
Q

a patient presents with:

  • miosis
  • ptosis
  • anhydrosis on one side
  • theyre eye appears sunken on one side

what is the most likely diagnosis?

A

Horner’s syndrome

248
Q

what are the causes of Horner’s syndrome?

A
  1. Congenital (rare)
  2. acquired from:
  • damage to the sympathetic nerves serving the eyes
  • blunt trauma to the neck
  • carotid artery dissection
  • tumours in the neck or chest (neuroblastoma or upper lung tumour)
  • lesions of the midbrain or brainstem or upper spinal-cord
  • lesions of the neck or eye
249
Q

how do you diagnose Horner’s syndrome?

A

Clinically

then try and find the cause:

  • using an MRI
  • ultrasound (carotid artery dissection)
250
Q

what is the treatment of Horner’s syndrome?

A

treating the underlying cause and eye drops

251
Q

what is lens induced glaucoma?

A

occurs secondary to angle closure or open angle glaucoma

or due to trauma to the lens from obstruction of the trabecular meshwork

or cataract extractions etc..

anything which damages the lens!!

252
Q

what is a presentation of lens induced glaucoma?

A

Pain and decreased vision

253
Q

how does angle closure glaucoma cause lens induced glaucoma?

A

Lens swelling or dislocation

254
Q

card is open and glaucoma cause lans induced glaucoma?

A

leakage of lens proteins

255
Q

what does the image below show?

A

Lower lid folding away from the iron turning outwards – eyelid ectropion

256
Q

How do eyelid ectropions differ to lid malpositions?

A

in ectropions the lid turns outwards

in malposition it turns inwards

257
Q

a patient presents with:

  • a drooping eyelid
  • they say theyre eye is red, sore, and irritated
  • noticed theyre eye is watering excessively BUT at the same time they feel dry and gritty
  • Pt has a history of many conjunctival infections

what is most likely diagnosis?

A

eyelid ectropions

258
Q

What are complications of eyelid ectropions?

A

conjunctivitis

rarely corneal ulcer

259
Q

what are causes of eyelid ectropions?

A

nerve palsy (e.g. Bell’s palsy)

lamp ???

exist ???

tumour

burn or trauma

260
Q

how do you manage eyelid ectropions?

A

mild cases are treated symptomatically:

  • eyedrops to keep eyes lubricated
  • good lid hygiene

severe cases: surgery

261
Q

When testing a patient light reflexes:

  • theyre left pupil is smaller in dim light than the right pupil
  • the right pupil does not constrict to light however
  • accommodation is present

what is most likely diagnosis?

A

adies pupil (common in young children)

262
Q

describe the pathophysiology and the results of light tests in adies pupil?

A

parasympathetic denervation of the affected pupil

causes there to be an abnormally dilated pupil at rest

there is poor/sluggish pupil constriction in bright light

causing a reduced sluggish effluent response

this sluggish response occurs if light is shone in both affected and unaffected eye

263
Q

what are causes of aidies pupil?

A
  • idiopathic (adie tonic pupil)
  • viral
  • infections
  • trauma
  • vasospasm from a migraine
  • ocular surgery
  • tumours
264
Q

what is the presentation of aidies pupil?

A

abnormally dilated pupil

sluggish constructive response which patients may notice

as well as photophobia

blurring of vision in one eye when exposed to bright light

265
Q

what other signs may patients with aidies pupil show?

A

sluggish deep tendon reflexes

  • such as the knee-jerk reflex
266
Q

what is the management of adies pupil?

A

usually is not needed as the individual grows and they become accustomed to that eye

chronic cases where it does not resolve the pupil does tend to get smaller with time

267
Q

what is infectious retinitis?

A

An inflammation of the retina

resulting from infection by viruses or bacteria fungi or parasite

268
Q

what are some symptoms which can occur in infectious retinitis?

A

Floaters or decreased vision from bleeding or clusters of inflammatory cells

symptoms can appear suddenly or slowly

may have:

  • photo sensitivity
  • red eyes
  • painful eyes
  • be systemically unwell
269
Q

how would the presentation of vectis retinitis differ in congenital forms than normally?

A

eyes may be misaligned

with in voluntary movements

or abnormal white eye reflex

270
Q

what can HSV and HZV caused infectious retinitis lead to?

A

Acute retinal necrosis

271
Q

can CMV cause infectious retinitis?

A

yes

But only in those who are immunodeficient

272
Q

how do you diagnose infectious retinitis?

A

Intraocular fluid analysis

273
Q

how do you manage infectious retinitis?

A
  • IV
  • oral
  • intraocular drugs

directed at the pathogen

274
Q

what does the image below show?

A

Thyroid eye disease

275
Q

what is the pathophysiology of thyroid eyed disease?

A

eye muscles, eyelids, tear glands, and fatty tissues behind the eyes become inflamed

causing the eye to become red, swollen and uncomfortable

eventually it can cause the eye to push forwards

276
Q

in which type of thyroid disorder does thyroid eye disease occur?

A

Autoimmune– Graves’ disease

277
Q

how does thyroid eye disease caused diplopia?

A

Stiffness of the muscles means that the eyes no longer move in sync with each other

resulting in double vision

278
Q

how does thyroid disease cause a reduction in vision?

A

It can cause pressure on the optic nerve

or form ulcers on the cornea

279
Q

what are the symptoms of thyroid eye disease?

A
  • Reduced vision
  • photophobia
  • protruding red eyes
280
Q

how do you treat thyroid eye disease?

A

Manage hyperthyroidism

usually settles after 6 to 12 months of thyroid treatment

Symptomatic control with:

  • fake tears
  • if inflammation is severe it can need steroids
  • in very severe surgery for decompression
281
Q

what are complications of thyroid eye disease?

A

Permanent double vision

permanent changes in vision

282
Q

how can toxoplasma damage the eyes?

A

It can cause posterior uveitis

eventually leading to necrotising chorioretinitis

283
Q

what can you get Toxoplasma from

A

uncooked meat or substances contaminated with cat faeces

284
Q

what is the danger of toxoplasma in pregnant women?

A

In the first trimester can cause spontaneous abortion

later in the pregnancy it can lead to:

  • hydrocephalus
  • seizures
  • lymphadenopathy
  • hepatosplenomegaly
  • fever
285
Q

what are symptoms of toxoplasma chorioretinitis?

A

unilateral decrease in visual acuity

floaters

can also cause iritis - causing redness and pain

286
Q

on funduscopy what can chorioretinitis show?

A

white focal retinitis

with overlying vitreous inflammation

can also cause retinal vasculitis

287
Q

how do you diagnose toxoplasma?

A

Serological testing - if negative completely excludes toxoplasma

if positive does not mean it is a current infection or the cause of the chorioretinitis

  • so do PCR of eye fluid
288
Q

when is treatment indicated in infections of toxoplasma?

A

if there are:

  • optic nerve lesions
  • macular threatening
  • larger optic lesions
  • pregnancy
  • mono ocular status
  • immunocompromised
289
Q

what is the treatment of toxoplasma?

A

systemic triple terapy:

  1. pyrimethamine
  2. sulfpthiazide
  3. corticosteriods
290
Q

What does the image below show?

A

Orbital cellulitis

291
Q

a patient presents with:

  • protruding eye
  • nasal pain
  • tenderness of the eye redness
  • inability to open the eyes
  • inability to move eyes
  • double vision
  • loss of vision
  • discharge
  • (fever and headache may also be present )

- what is the diagnosis?

A

orbital cellulitis

292
Q

what is the common pathogens that cause orbital cellulitis?

A

Streptococcus and staphylococcus

293
Q

what usually causes orbital cellulitis?

A

untreated bacterial sinus infection which then spreads behind the orbital septum

can also spread from the tooth infections

or other bacterial infections occurring anywhere in the body entering via the bloodstream

294
Q

what investigations are required in orbital cellulitis?

A

CT/MRI head, nose eyes

cultures of the blood

cultures of eye discharge and nasal discharge

295
Q

what are differentials for orbital cellulitis?

A

pre septal cellulitis

periorbital cellulitis

insect bite

296
Q

how do you treat orbitals Cellulitis?

A

IV antibiotics initially broad-spectrum until the cultures come back

297
Q

what is the difference between orbital and periorbital cellulitis

A

Peri Orbital cellulitis is more superficial to the orbital septum

ocular function remains intact

  • oftentimes PO antibiotics are sufficient in periorbital
298
Q

what does the image below show?

A

Corneal foreign body

299
Q

how do you treat a corneal foreign body?

A

surgical removal

300
Q

What does the image below show?

A

sub conjunctival haemorrage

301
Q

a patient presents with:

  • a sudden onset of a bright red eye

on examination there are :

  • distinct boarders to the bleed

what is the most likely diagnosis?

A

sub conjunctival haemorrage

302
Q

What is important to check in a patient with sub conjunctival haemorrhage

A

occular or orbital injury.

303
Q

In the elderly what is the most common cause of the sub conjunctival haemorrhage?

A

spontaneous

304
Q

What is the treatment of sub conjunctival haemorrhages?

305
Q

a patient presents with:

  • eye pain after work incident - from drilling
  • feld somethinggoing into their eye

which type of injury is most common here?

A

intraocular foreign body

306
Q

what signs would you find on intraocular foreign bodies?

A

Sub conjunctival haemorrhage

corneal laceration

Iris wound

localised cataract

307
Q

what investigations are required in suspected intraocular foreign body?

A

x-ray or ultrasound or CT

308
Q

What is the management of an intraocular foreign body?

A

lensectomy or virectomy

309
Q

what consequences can occur after blunt trauma to the eye?

A

lens dislocation

glaucoma

retinal oedema

retinal detachment

blowout fracture

diplopia

310
Q

why may there be loss of vision after blunt trauma to the eye?

A

compression of the optic nerve or bleeding inside the eye

causing an increase in intraocular pressure

as well as corneal oedema

311
Q

what do restricted eye movements and proptosis indicate in a scenario of blunt trauma to the eye?

A

Raised intraocular pressure

312
Q

what is post operative endopthalmitis?

A

a rare but sight threatening complication of ocular injury

most commonly occurring as a complication of cataract surgery

313
Q

what is the presentation of post op endopthalmitis?

A

acute: within week of surgery

chronic within the first month/2 months of surgery.

Presenting with:

  • visual loss
  • pain, redness and photophobia
  • lid oedema
  • corneal haze
  • absent/sluggish pupillary light reflex
  • intraocular pressure can be raised
  • and endopthalmus
314
Q

what usually causes endopthalmitis?

A

infection with staphylococcus or streptococcus

or retention of foreign materials such as cotton fibres

315
Q

what is the management of post op endopthalmitis?

A

emergency referral to ophthalmologist

for same day treatment with steroids antibiotics

316
Q

what investigations are required to assess the severity of post op endopthalmitis?

A

fresh what????? see notes

317
Q

what are drusen?

A

lipid accumulations under the retina

  • not in themselves pathological but often a sign of macular degeneration

FINALS (24 decks)

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