Opthalmology Flashcards
Papillodema indicates…
Raised ICP
First line management of suspected meningitis (photophobia, headache, neck stiffness)
Ceftriaxone
Horner’s syndrome features
Miosis
Anhydrosis
Ptosis
Sudden visual loss in diabetics, what test should you do? And what are you thinking of?
Slit lamp to try and visualise any RBC in the vitreous
Worried about vitreos haemorrhage due to the extra vessels (proliferative diabetic retinopathy)
Features of vitreous haemorrhage
Painless visual loss
Red hue
Hx of diabetes
What is the most common cause of blindness in the UK?
Age related macular degeneration
2 forms of macular degneration
Wet
Dry
What is age related macular degeneration
Degeneration of retinal photoreceptors resulting in the formation of DRUSEN (yellow round spots)
What are drusen?
Yellow round spots in the eye
What is the difference between wet and dry ARMD?
Wet is more aggressive and can detatch the retina
Signs of ARMD
Distortion of vision (e.g. blurred)
Examination shows drusen (yellow areas)
Wet may show red patches of intra-retinal leakage
Pt feels like something stuck in eye, pain, photophobia, dendritic ulcer. Cause?
Herpes simplex keratitis
Management of herpes simplex keratitis
Topical aciclovir
Referral to opthalmologist
Diagnosis of ARMD
Slit lamp to identify any pigment (Druser)and or exudate or haemorrhagic changes
Fluorescein angiography can be used if neovascular ARMD is suspected, which can guid antii-VEG-F therapy
Ptosis and DILATED pupil
Third nerve palsy
Ptosis and miosis
Horner’s
Treatment of acute optic neuritis
High dose steroids
Investigation of choice for MS
MRI brain
Then can do lumbar puncture if necessary (oligoclonal bands)
Signs of optic neuritis
Blurred vision
Headache
Causes of tunnel vision (narrow visual field)
Papilloedema
Glaucoma
Retinitis pigmentosa (genetic loss of vision, often trouble seeing at night)
Choroidoretinitis (inflammation of choroid, the coating of the eye). It’s a form of posterior uveitis.
Causes of sudden loss of vision
Vitreous haemorrhage
Retinal detachment
Retinal igrane
Ischaemic/vascular. I.e. occlusion of central retinal vein or artery
Eye stuck together and red Dx?
Conjunctivitis
Treatment of conjunctivitis
Can watch and wait and see if it improves OR topical chloramphenicol
What is blepharitis?
Inflammation of the eyelids (swollen, irritated and red)
Treatment of acute closed angle glaucoma
Pilocarpine drops (constricts the pupil and releases the aqueous humour) Admit them to hospital
Definitive treatment of acute closed angle glaucoma
Laser peripheral iridotomy
Sudden, painless loss of vision.
Severe retinal haemorrhages on fundoscopy
Central retinal vein occlusion
Acute visual loss, pale retina with a cherry red spot
Central retinal artery occlusion
Red eye NOT painful, slight watering and mild photophobia
Episcleritis
Vessels move with gentle pressure as they are very superficial
Scleritis is?
Inflammation of deep vessels in the eye, often painful, with blurred vision.
The vessels DO NOT move when gentle pressure is applied
Management of episcleritis
Conservative, maybe artifial tears
Differentiating between scleritis and episcleritis
Phenylephrine drops
If eye redness improves = episcleritis
Key aspects of ophthalmology history
Onset 1 eye vs 2 eyes Activities they were doing at the time Do they wear glasses Any pain Any associated symptoms
Aspects of ophthalmologic examination
Visualise anterior segment
Slit lamp
Posterior eye examination
Questions to ask in ophthalmology
Redness Discharge Itching Burning Oedema Floaters
Causes of discharge from eye
Corneal trauma Blepharitis Conjunctivitis Stye Chemical = emergency, what chemical was it?
Features of subconjunctival haemorrhage
Fragile vessels rupture
Often from straining, check if they have high blood pressure
The cornea is NOT INVOLVED
This will resolve spontaneously
Symptoms of iritis
Blurring of vision
Photophobia
Eye pain
Red eye
What is ectropion re eye?
The eyelid is turned away from the eyeball
Causes of ectropion
Muscle weakness Facial paralysis (Bell’s palsy) Scars and damaged skin Previous surgery Growths (pushing the eyelid out of place)
Signs and symptoms of ectropion
Watery eyes (can’t drain properly) Excessive dryness Grittiness Irritation because they aren’t being irrigated properly Sensitivity to light
Mx of ectropion
Eye drops
Surgery is the definitive treatment
Name of oil secreting glands in eyelash’s
Glands of Zeis
What causes a stye?
Infection of a gland of Zeis in the eye
Causes a swelling like a piece of barley
Symptoms of a stye
Swelling above the eye
Redness and oedema around the eye
It’s basically an infection
Treatment of stye
Pluck eyelash to improve drainage
Hot compresses for comfort
Oral antibiotics because get to internal structures better
What is the structural support of the eyelid, that also helps with irrigation of the eye?
Tarsal plates
Gradual onset, swelling of the eyelid
Chalazian
Symptoms of chalazion
Small, almost fatty swelling in the eyelid
Caused by mebomium gland obstruction
Mx of chalazion
Conservative if not too bad
Hot compresses
Oral antibiotics if significant infection
Steroid injection
Surgery for persistent lesions
What is ptosis?
From the Greek “to fall”
Drooping of the upper eyelid
Acquired causes of ptosis
Neurogenic
Myogenic (e.g. myasthenia gravis)
Myopathies
Tumour pulling the eyelid down
Anything affecting nerve -> muscle
Mx of ptosis
Surgery
Brow suspension
Treat the underlying cause.
Myopia is
Short sightedness
What drains aqueous humour from the anterior chamber?
Trabecular meshwork
What secretes aqueous humour?
Ciliary epithelium
What causes glaucoma?
Drainage system blocked for aqueous humour
Increases pressure
What can the increased pressure in glaucoma lead to?
Damage to optic nerve -> vision loss!
Pathophysiology of open angle glaucoma
The angle between the lens is open
The blockage is from a slow clogging of the trabecular meshwork
Causes a gradual pressure increase
Symptoms of open angle glaucoma
Gradual loss of peripheral vision because of outer rim atrophy
Continued damage leads to loss of central vision as well
Pathophysiology of closed angle glaucoma
Angle above lens is too small
Lens is pushed against the iris
Rapid build up of pressure
Symptoms of closed angle glaucoma
Eye pain Redness Blurry vision Headaches and nausea Visual haloes
Diagnosis of glaucoma
Tonometry to assess intraocular pressure
Visual field testing
Imaging looking for optic nerve damage (cupping of optic nerve)
Mx glaucoma
Medications to lower pressure = production or outflow
Production reducers = beta blockers and carbonic anhydrase inhibitors
Increase outflow = prostaglandin analogues
Also alpha adrenergic agonists and surgery (lasers)
Trabeculoplasty to open up trabecular meshwork in open angle
Iridotomy to put a hole in the iris = closed angle glaucoma
What is under the optic disc?
The head of the optic nerve
How do you find the optic disc?
Trace the blood vessels to the point of coalescence
Pathophysiology of diabetic retinopathy
Micro angiopathy causing damage to the small blood vessels of the retina as a result of hyperglycaemia
RF of diabetic retinopathy
Poor diabetic control
Duration of diabetes
What is the spectrum of diabetic retinopathy?
Background
Pre proliferative
Proliferative
Advanced
Components of background diabetic retinopathy
Microaneurysms (appear as little red dots on the retina)
Dot and blot haemorrhages (like bigger dots on the retina)
Components of pre-proliferative diabetic retinopathy
Any signs of retinal ischaemia
Cotton wool spots (white, fluffy areas of necrotic tissue)
Components of proliferative diabetic retinopathy
New vessels at the optic disc
New vessels elsewhere
Signs of advanced diabetic retinopathy
Recurrent vitreous haemorrhage from bleeding areas of neovascularisation (bleeding from new vessels)
Retinal detachment
What is the primary treatment for proliferative diabetic retinopathy?
Pan retinal coagulation
What is the method behind pan retinal photocoagulation?
Burn the retina with a laser
Reduce VEGF by reducing oxygen demand of the retina
Stops proliferation of new vessels (which are going to cause you to go blind)
Steps of hypertensive retinopathy
Grade 1 = very subtle, narrowing of arterioles
Grade 2 = AV nipping
Grade 3 = similar features to diabetic retinopathy, cotton wool spots, hard exudates, retinal haemorrhages
Optic disc of malignant hypertension
All the features of grade 3 hypertensive retinopathy + optic disc swelling
Symptoms of malignant hypertension
Headaches
Eye pain
Reduced visual acuity
Focal neurological deficits
Mx of malignant hypertension
Antihypertensives
Admission to hospital
What might you see on fundoscopy for glaucoma?
Increased ratio of cup to disc
Is optic disc swelling the same as papilloedema?
No, papilloedema is specifically due to raised ICP
Optic disc swelling is after any pathology causing it, e.g. malignant hypertension
When might you see a pale disc on fundoscopy?
Optic nerve atrophy
Caused by optic neuritis, glaucoma or general retinal ischaemia
What causes secondary optic nerve atrophy
Long-standing papilloedema
What should you do if you detect papilloedema?
Imaging
When might you see a cherry red spot on fundoscopy?
Central retinal artery occlusion
How might central retinal artery occlusion present?
Sudden, profound loss of vision
What actually is the cherry red spot seen in central retinal artery occlusion?
The fovea against a backdrop of a very pale retina
What causes central retinal vein occlusion?
Atherosclerotic thickening, compressing and blocking the vein
What are you seeing on central retinal vein occlusion?
Retinal hypoxia leads to endothelial cell damage which leads to extravasation of blood
What does vein occlusion look like on fundoscopy?
Like someone has brushed with a purple paint brush
Most common cause of irreversible blindness in the uk?
Age related macular degeneration
1st line treatment of open angle glaucoma
Latanoprost (prostoglandin analogue)
Eye changes colour when on glaucoma treatment, which drug has this side effect?
Latanoprost
Treatment of central retinal artery occlusion
IV acetazolamide
Cupping and high pressure on fundoscopy, with some visual field defects indicates…
Glaucoma
What does the fourth cranial nerve do in terms of eye movement?
Down and in (look towards nose)
Damage e.g. trauma -> can’t do that movement with one side/both
Double vision and when asked to look down and in, can’t do it with right eye, which nerve has been affected?
4th nerve palsy
How does Leber’s optic atrophy usually present?
Young patient
Loss of vision in one eye, followed by the other
Optic disc pallor indicates…
Optic atrophy
Causes of optic atrophy
Glaucoma due to raised intraocular pressure
Retinitis pigmentosa
Choroiditis
Central retinal artery occlusion
Multiple sclerosis
Leber’s optic atrophy (or Leber’s hereditary optic neuropathy)
Syphilis
What does 6/9 (-2) indicate in opthalmogy notation?
From 6m, can get to the 9th line, where they made 2 mistakes reading it
Most common cause of elderly ‘clouding’ of vision
Cataracts
Features distinguishing Ramsey-Hunt syndrome from Bell’s palsy
Prominent otalgia
Vesicular rash in the external auditory meatus, palate or tongue.
A 51 year old female patient attends A&E complaining of a red right eye. She reports that her red eye started suddenly, and she can her a ‘whooshing noise’. She also reports diplopia, a headache and loss of vision.
On examination her visual acuity is 1/60 in her right eye. Her conjunctiva is injected, and she has a restriction in her right eye movements in all direction. The eye is severely proptosed and pulsatile.
What is the most likely diagnosis?
Carotid-cavernous fistula
