Opthalmology Drugs Flashcards
1
Q
Aqueous humor production is decreased by CAB:
A
- carbonic anhydrase inhibitors (e.g., acetazolamide).
- α2 agonists (e.g., clonidine, brimonidine).
- beta blockers (e.g., timolol)
2
Q
What structures passes through the superior orbital fissure?
A
1.oculomotor nerve
2. Trochlear nerve
3. Branches of ophthalmic nerve (CN V1)
4. Abducens nerve
5. Opthalmic vein
3
Q
What are the branches of the ophthalmic nerve?
A
- Frontal nerve
- Supra-orbital
- Supra- trochlear
- Lacrimal nerve
- Naso- ciliary nerve
- Infra- trochlear nerve
4
Q
Function of the long ciliary nerve?
A
Long pupil diameter (Mydriasis)
5
Q
Function of the short ciliary nerve?
A
Short pupil diameter (mitosis)
6
Q
Function of the short ciliary nerve?
A
Short pupil diameter (mitosis)
7
Q
What innervates the Levator palpebrae superioris?
A
Oculomotor nerve
8
Q
What are the parts of conjunctiva ?
A
- Palpebral (tarsal) conjunctiva: lines the inner surface of the eyelid
- Bulbar conjunctiva: lines the anterior surface of the eyeball
9
Q
What are the three layers of tear film?
A
- Mucous layer (innermost layer): Mucins produced by goblet cells on the inside of the conjunctiva.
- Aqueous layer (middle layer): Isotonic fluid composed mainly of water, electrolytes (Na+, K+, Cl-, HCO3-), proteins (lysozyme, lactoferrin, defensins), EGF, IgA secreted by the lacrimal gland, Hydrates the cornea and lubricates the eye.
- Lipid layer (outermost layer): Oils produced by Meibomian glands: Prevents drying and cooling of the eye
10
Q
Visual field pathway (picture):
A
Insert
11
Q
Whats refractory media?
A
- Cornea
- Lens
- Aqueous humor
- Vitreous body
12
Q
A defect in refractive media leads to:
A
Refractive errors (myopia, hyperopia)
13
Q
What causes refractive errors?
A
- Deviations in eye anatomy: axial eye length of the eyes and cornea curvature.
- Any defect in refractive media
14
Q
A picture of myopia, hyperopia and emmetropia
A
Insert picture
15
Q
What are the three main divisions of loss of vision?
A
Transient (seconds to hours)
Acute (seconds to days): anterior chamber, posterior chamber and cortical
Chronic (weeks to months): anterior chamber, posterior chamber and cortical
16
Q
What are causes of transient loss of vision?
A
TIA
Migraine with aura
17
Q
What causes acute loss of vision?
A
Anterior chamber:
1. Liquid: water (corneal edema, acute angle closure glaucoma) and blood (hyphema)
2. Solid: foreign body and trauma
Posterior chamber:
1. Vitreous hemorrhage
2. Retinal detachment
3. Acute macular lesion
4. Optic neuritis
5. Occlusion of retinal artery or vein
Occipital: infarction or hemorrhage
18
Q
What are the causes of chronic loss of vision?
A
Anterior chamber:
1. Cataract
2. Glaucoma
3. Corneal scar
4. Refractive error
Posterior chamber:
1. Age related macular degeneration
2. Diabetic retinopathy
3. Retinal vascular insufficiency
4. Compressive optic neuropathy: intracranial masses, intra-orbital masses, orbital masses
Occipital:
1. Papilledema (increased intra-ocular pressure)
19
Q
What medications lead to chronic loss of vision?
A
Sil-de-nafil
Amiodarone
20
Q
What are the common presentations of eye?
A
- Loss of vision
- Red eye
- Ocular pain
- Floaters
- Flashes of light
- Photophobia
- Diplopia
21
Q
Based on the anatomical divisions what causes the red eye?
A
- Eyelids and lashes
- Orbit
- Lacrimal system
- Cornea
- Conjunctiva
- Sclera
- Anterior chamber
22
Q
Based on the anatomical divisions what causes the red eye?
A
- Eyelids
- Orbit
- Lacrimal system
- Cornea
- Conjunctiva
- Sclera
- Anterior chamber
23
Q
What are the main causes of eyelid swelling?
A
- Allergies
- Infection
- Systemic disease
24
Q
What are the differential diagnosis for ptosis?
A
- Aponeurotic
- Scar or mass affect
- Myasthenia gravis
- Horner syndrome
- Pseudoptosis (dermato-chalasis, enophthalmus)
- Third cranial nerve palsy
25
Treatment for ptosis?
Surgery to lift or support the eyelid:
1. Blepharoplasty
2. Levator muscle resection
3. Frontal sling (using forehead muscles to help lift the eyelid).
26
Whats trichiasis?
Eyelashes growing inward
27
Whats trichiasis?
Eyelashes growing inward
28
Clinical features of trichiasis?
1. Pain
2. Red eye
3. Sensation of foreign body
4. Corneal abrasion with secondary ulceration and scaring
5. Tearing
29
Clinical features of trichiasis?
1. Pain
2. Red eye
3. Sensation of foreign body
4. Corneal abrasion with secondary ulceration and scaring
5. Tearing
30
Whats the treatment for trichiasis?
1. Topical lubricant
2. Electrolysis
3. Cryotherapy
4. Repeated eyelashes epilation
31
Causes of trichiasis?
1. Entropion
2. Chronic inflammation of the eyelid (blepharitis)
3. Trauma, burn
4. Age change
32
Whats entropion?
Lid margin folds inward towards the globe
33
Causes of entropion?
1. Age
2. Orbicularis oculi muscle spasm
34
Causes of entropion?
1. Age
2. Orbicularis oculi muscle spasm
35
Entropion most commonly affects?
Lower eyelid
36
Treatment for entropion?
1. Topical lubricant + Artificial tears and ointments
2. Evert eyelid with tape (skin tape)
3. Surgery
4. Soft contact lenses: protect the cornea from external injury
5. Botulinum toxin application on the orbicularis muscle: in case of spastic entropion
37
Whats ectropion?
Lid margin folds outward
38
What are the clinical features of ectropion ?
Exposure keratitis
39
What are the clinical features of ectropion ?
Exposure keratitis
40
Treatment of ectropion?
Symptomatic treatment:
1. Artificial tears and ointments: lubricate the conjunctiva
2. Eye patch: prevents eye desiccation
3. Surgery for definitive treatment
41
Complications of abnormality of the eyelid?
1. Keratitis
2. Conjunctivitis
3. Corneal ulcer
42
What innervates: orbicularis oculi, levator palpebrae superioris muscle and superior tarsalis muscle ?
Facial nerve: innervates the orbicularis oculi muscle
Oculomotor nerve: innervates the levator palpebrae superioris muscle
Sympathetic nervous system: innervates the superior tarsalis muscle
43
Definition of ptosis?
Partial or full drooping of the eyelids could be unilateral or bilateral
44
Causes of ptosis?
1. Malformation of the levator palpebrae superioris muscle.
2. Hypothyroid myopathy.
3. Excessive weight on the upper eyelid (e.g., hemangioma, hematoma, infections, tumors of the upper eyelid) prevents full opening of the eye.
4. Oculomotor nerve palsy.
5. Neuromuscular disease (e.g., myasthenia gravis, myotonia, botulism)
6. Sympathetic nerve injury (Horner syndrome
Causes palsy or weakness of the superior tarsal muscle).
45
Treatment of ptosis?
Surgical
46
Treatment of ptosis?
Surgical
47
What are the indications of surgery in ptosis?
1. Congenital ptosis
2. Impaired vision
3. Eye fatigue
4. Difficulty reading
5. Compensatory head alignment
48
What is the most imp complication in case of ptosis?
Amblyopia (lazy eye)
49
What is the most imp complication in case of ptosis?
Amblyopia (lazy eye)
50
Complications of entropion?
1. Trichiasis
2. Corneal lesion (scar)
3. Lazy eye
51
What is hordeolum ?
It’s an acute inflammation of the gland in the eyelid
52
What are types of hordeolum?
1. External hordeolum (anterior lid margin): moll gland
2. Internal hordeolum (posterior lid margin): eibbomian gland
53
What is the cause of hordeolum?
Infection: s. Aeurus
54
Onset and appearance of hordeolum?
Onset: sudden
Appearance: (inflammed): redness/ erythema, painful , pus filled nodule, swelling
May rapture and produce purulent discharge
55
What is chalazion?
It’s a chronic, lipo-granulomatous swelling in the eyelid
56
What are the types of chalazion?
1. Internal/ deep chalazion: meibomian gland.
2. External/ superficial chalazion: moll
57
Hat are the risk factors for hordeolum and chalazion?
1. Poor eye hygiene
2. Chronic blepharitis
3. Eye trauma
58
Clinical features of chalazion? (Onset and appearance)?
1. Slowly growing/ chronic
2. Firm painless, rubbery nodule
3. The nodule usually presents away from the eyelid
4. Heaviness of the eyelid
59
Ow to diagnose chalazion or meibioum?
Clinical diagnosis
60
Whats the treatment For chalazion ?
1. Eyelid hygiene
2. warm compresses
3. Eye massage
4. if no improvement afer 1 mo, consider incision and curettage.
5. chronic/ recurrent lesion must be biopsied to rule out malignancy
61
What if the chalazion or meibioum persists?
1. If symptoms persist or recur, refer to ophthalmology for additional management.
This may include:
2. Topical antibiotics (e.g., bacitracin, erythromycin) +/- topical corticosteroids
3. Oral antibiotics (e.g., doxycycline)
4. Procedural intervention, e.g.: Incision and drainage or curettage
6. Intralesional steroid injection for a chalazion
7. Biopsy
62
Why is it a red flag for persistent chalazion or recurrent?
meibomian gland carcinoma (biopsy)
63
What are the complications for chalazion and meibioum?
1. Preseptal cellulitis
2. Orbital cellulitis
64
What are the complications for chalazion and meibioum?
1. Preseptal cellulitis
2. Orbital cellulitis
65
Whats the treatment for meibioum?
1. Eyelid hygiene
2. Warm compreser
3. Eye massage
4. If persistent more than two weeks => Topical antibiotic and topical steroids + incision and drainage
66
What is blephritis?
It’s a chronic/ recurrent inflammation of the eyelid margins.
67
What are the clinical features of blephritis?
1. Redness
2. Swelling
3. Pain
4. Itchiness
5. Foreign body sensation (crusty scaling or oily deposits on the eyelid margin)
68
Blephritis
69
What are the types of blephritis?
1. Anterior blepharitis: inflammation of the anterior margin of the eyelids, involving the skin, eyelashes, and follicles
2. Posterior blepharitis: inflammation of the posterior margin of the eyelids; associated with meibomian gland dysfunction
70
What are the causes of blephritis ?
Anterior: infection: s. Aerus
Posterior: meibomian gland dysfunction => promote growth of bacteria
71
How to mange blephritis?
Warm eyelid compress
Eyelid cleansing with massage
Artificial tears as needed for dry eyes
topical or systemic antibiotics (doxycycline) as needed.
if severe, ophthalmologist may prescribe a short course of topical corticosteroids, omega-3 fatty acids
Explain to patient that the condition is chronic and long-term supportive therapy is necessary.
72
Complications of blephritis?
Hordeolum and chalazion
Conjunctivitis
Keratitis
Ectropion
Entropion
Trichiasis
Preseptal cellulitis or orbital cellulitis
73
What do you advise a patient who has glaucoma ?
Never apply a pressure on the eyes so you don’t increase the IOP
74
Whats Xanthelasm?
Lipid deposits in the upper medial eyelid
75
Whats Xanthelasm?
Lipid deposits in the upper medial eyelid
76
Xanthelasm is associated with what condition?
Hyperlipidemia
77
Explain the drainage of the tears?
tears drain from the eyes through the upper and lower lacrimal puncta → superior and inferior
canaliculi → lacrimal sac → nasolacrimal duct → nasal cavity (inferior meatus)
78
What are the causes of dry eye syndrome (kerato-conjunctivitis sicca)?
1. aqueous-defcient
2. Evaporative
3. Mixed
79
What leads to aqueous deficient in dry eyes?
1. Sjögren syndrome (autoimmune etiology; e.g. RA, SLE) (autoimmune disorder where the immune system attacks moisture producing glands).
2. non-Sjögren syndrome (not related to autoimmune disorder: (idiopathic age-related disease; lacrimal gland scarring e.g. trachoma.
3. decreased secretion e.g. contact lenses, CN VII palsy, anticholinergics, antihistamines, diuretics, β -blocker s).
80
What medications induce dry eyes?
1. Anti cholinergic
2. Anti - histamine
3. Beta blocker
81
What are the causes of evaporative dry eyes?
evaporative (normal lacrimal function, excessive evaporation of aqueous layer)
■ meibomian gland dysfunction (posterior blepharitis)
■ vitamin A defciency
■ eyelid abnormalities e.g. ectropion, CN VII palsy (decreased blinking)
■ contact lenses
82
Whats the pathophysiology of the dry eyes?
1. Underproduction of lacrimal gland
2. Increased evaporation
83
What are the risk factors for dry eyes?
1. Environmental factors: e.g., dry room air, smoke, prolonged screen time
2. Abnormal lid positioning (e.g., entropion or ectropion)
3.↓ Blink rate (e.g., cranial nerve lesions V or VII)
4. Medication
5. Vitamin A deficiency
6. Contact lens intolerance
7. Local injury: e.g., trauma or resulting from surgery or radiation,
8. Systemic autoimmune diseases (e.g., primary and secondary Sjogren syndrome)
Infections (e.g., herpes simplex keratitis, HIV)
84
Clinical features of dry eyes?
1. dry eyes
2. red eyes
3. blurred vision, tearing
4. eye pain
85
How do you examine dry eyes and what are the signs?
1. Slit lamp exam
2. decreased tear meniscus, decreased tear break-up time (normally should be >10 s),
punctate staining of cornea with fluorescein.
86
Punctuate epithelial erosion due to secondary cause of dry eyes
87
Punctuate epithelial erosion due to secondary cause of dry eyes
88
Mention two tests for dry eyes?
1. Slit lamp
2. Schirmer test
89
Complication of dry eyes ?
Corneal abrasions or scar
90
treatment of dry eyes ?
1. Treat the underlying cause (autoimmune diseases).
2. Avoid triggers (contact lens, dry air, smoke, prolonged screen time).
3. Supportive therapy: artificial tears (day) / lubricants (night).
4. punctal plug insertion
5. tarsorrhaphy (sew lids together) if severe.
91
Whats the pathophysiology of epiphoria ?
1. Excessive production of tears
2. Impaired drainage
92
What are the causes of epiphoria?
1. emotion, pain
2. environmental stressor (cold, wind, pollen, sleep deprivation).
3. lid/lash malposition: ectropion, entropion, trichiasis.
4. inflammatory: conjunctivitis, dacryoadenitis, uveitis, keratitis, corneal foreign body.
5. dry eyes (refex tearing).
6. lacrimal drainage obstruction (congenital failure of canalization, aging, rhinitis, dacryocystitis)
7. paradoxical gustatory lacrimation refex (“crocodile tears”)
93
What investigation would you do for epiphoria?
1. using fluorescein dye, examine for punctal refux by pressing on canaliculi => positive test is when you press and the tear comes out that means there’s an obstruction and no drainage.
2. Jones dye test: fluorescein placed in conjunctival and cotton applicator placed in nose to
detect fow (i.e. rule out lacrimal drainage obstruction).
94
How to treat epiphoria?
1. lid repair for ectropion or entropion.
2. eyelash removal for trichiasis.
3. punctal irrigation (dilation and irrigation).
4. nasolacrimal duct probing (infants)
5. tube placement: temporary (Crawford) or permanent (Jones)
6. surgical: dacryocystorhinostomy – forming a new connection between the lacrimal sac and the nasal
cavity
95
Whats the purpose for irrigation?
1. Diagnosing Blockage: if saline flows freely into the nose or if it gets blocked or refluxes back.
2. Clearing Minor Obstructions:
3. Preparation for Further Treatment:
- If the irrigation confirms a complete obstruction, the patient may need further interventions like:
- Punctal dilation (widening the puncta).
- Nasolacrimal duct probing (especially in infants).
- Dacryocystorhinostomy (DCR) surgery to bypass the blocked duct.
96
Whats dacrocystitis?
acute or chronic infection of the lacrimal sac
97
What are the causes of acute/ chronic dacrocystitis?
- Congenital/acquired (dacryostenosis) → stasis of tears → secondary bacterial infection.
- Acute dacryocystitis is often caused by streptococci or staphylococci.
- Chronic dacryocystitis can be caused by pneumococci, H. influenzae, and Pseudomonas.) → lacrimal sac inflammation
98
Hat are the clinical features of acute dacryocystitis?
1. Erythema
2. edema
3. warmth
4. significant pain below the medial canthus of the eye
5. Pressure on the swelling causes pain and purulent discharge from the punctum.
6. Epiphora
7. Fever (may be present)
99
What are the clinical features of chronic dacrocystitis?
Epiphoria
Mucopurulent discharge from the punctum
100
What is naso-lacrimal duct probing?
- A procedure in which the lacrimal punctum is dilated and a flexible metallic probe is inserted into the
nasolacrimal duct (NLD).
- Used to diagnose NLD obstruction (dacryostenosis).
- Also used to treat refractory (congenital dacryostenosis) that does not respond to lacrimal sac massage. Ocular infection is a contraindication
101
Whats the contraindication for nasolacrimal probe ?
1. Ocular infection
2. Acute dacrocystitis
102
How to diagnose acute dacryocystitis ?
1. Clinical
2. If there is discharge => Pus culture (AB)
3. Blood culture: in patients with systemic symptoms (fever)
4. Dacryocystography (DCG)
103
Whats dacryocystography?
A contrast imaging of the lacrimal sac and NLD
Performed in patients with dacryostenosis secondary to trauma (altered anatomy) or suspected tumors (to locate the tumor).
104
When does dactrocystography contraindicated?
Suspected infection - dacrocystitis (infection must be treated)
105
How to diagnose chronic dacrocystitis?
1. Clinical
2. Culture of the discharge
3. Investigations to confirm/locate NLD obstruction: NLD probing/syringing dacryostenosis); DCG
106
Whats treatment for acute dacryocystitis ?
1. warm compresses
2. NSAIDs
3. Systemic antibiotics
4. Incision and drainage if lacrimal sac (abscess) occurs
5. DCR (treatment of the NLD obstruction): after treating the infection
107
Whats the treatment for chronic dacryocystitis?
Antibiotics (culture-specific)
DCR (to prevent recurrence)
108
Whats congenital dacryostenosis?
nasolacrimal duct (NLD) atresia/obstruction in an infant caused by a developmental anomaly and characterized by epiphora (excessive tearing).
109
what are the clinical features of congenital dacryostenosis?
Epiphora within 2–4 weeks of birth
Palpation of the lacrimal sac may cause tears to leak from the lacrimal punctum.
110
How to diagnose congenital dacryostenosis?
Clinical diagnosis
Lacrimal duct prob
111
Whats the treatment of congenital dacryo-stenosis?
1. Lacrimal sac massage
2. Dilation or stenting of the duct (lacrimal duct prob)
3. Dacryocystorhinostomy (DCR): if other measures fail
A surgical procedure in which a direct connection is created between the lacrimal sac and the nose to allow for unimpeded drainage of tears.
Can be performed either through a skin incision or endoscopically through the nose.
112
Whats the complication of dacryostenosis?
acute/chronic dacryocystitis
113
Dacryoadenitis
114
Whats dacryoadenitis?
infammation of the lacrimal gland (outer third of upper eyelid)
115
What are the causes of acute dacryoadenitis?
1. Infection (most common)
Viral: mumps, EBV, CMV, herpes zoster
Bacterial: S. aureus, Streptococcus, Gonococcus, Mycobacterium tuberculosis
Fungal: histoplasmosis, blastomycosis
2. Inflammatory
116
What are the clinical features of dacryoadenitis?
1. Rapid onset
2. Unilateral pain/discomfort over the lacrimal gland (lateral upper eyelid)
3. Characteristic S-shaped ptosis
4. possibly proptosis
5. mucopurulent discharge
6. Palpebral conjunctival hyperemia and chemosis
7. Limitation of eye movement
8. diplopia (indicates orbital cellulitis)
9. Ipsilateral preauricular lymph node enlargement and fever may be present.
117
How to diagnose acute dacryoadenitis?
Eye swabs: in patients with ocular discharge
Complete blood count, blood culture, viral serologies: in patients with fever
CT scan: to look for evidence of orbital cellulitis
118
Whats the serious complication of dacryoadenitis?
Orbital cellulitis
119
How to confirm orbital cellulitis ?
CT features of orbital cellulitis include inflamed and edematous extraocular muscles with fat stranding.
120
How to treat acute dacryoadenitis (viral)?
1. Good eye hygiene
2. Warm compressor
3. NSAIDS
(Self limiting)
121
What are the causes of chronic dacryoadenitis?
1. Inflammatory/granulomatous conditions (most common): sarcoidosis
2. Autoimmune conditions: Graves' disease, Sjögren syndrome
3. Neoplastic: lacrimal gland tumor, lymphoma, leukemia
4. Chronic infections (less common): tuberculosis
122
What are the clinical feature of chronic dacryoadenitis?
Painless swelling
S shaped ptosis
123
What are the diagnostic tests would you do to diagnose chronic dacryoadenitis?
1. Eye swabs: in patients with ocular discharge
2. Screening for chronic infections (e.g., tuberculosis, Chlamydia trachomatis, gonorrhea) (less common)
3. CT scan: to rule out a malignant etiology
4. Fine needle/incisional biopsy of the lacrimal gland: indicated only if imaging/blood tests are inconclusive
Investigations based on the suspected etiology
124
Define this clinical presentation ?
Exophthalmos: Anterior displacement (protrusion) of the globe.
125
Whats the difference between exophthalmos’s and proptosis?
1. Exophthalmos generally refers to an endocrine etiology or protrusion of >18 mm (as measured by a Hertel exophthalmometer).
2. Proptosis generally refers to other etiologies (e.g. cellulitis) or protrusion of <18 mm
126
Mention three causes for this clinal features?
1. Congenital abnormality
2. Blow out fracture
3. Orbital fat atrophy
127
What investigation would you do for exophthalmus?
1. CT/MRI head/orbits
2. ultrasound orbits
3. thyroid function test
128
What do you need to rule out before diagnosing exophthalmus?
Lid retraction
129
What are the causes of exophthalmus?
1. Graves’ disease (unilateral or bilateral, most common cause in adults)
2. Orbital cellulitis (unilateral, most common cause in children)
3. 1° or 2° orbital tumour
4. retrobulbar hemorrhage
5. Cavernous sinus thrombosis or fistula
130
Whats pre-septal cellulitis?
=> Infection of the soft tissues anterior to the orbital septum (a membrane that extends from the orbital rims to the eyelids and lies anterior to the orbital contents).
131
Whats orbital cellulitis ?
Soft tissue infection posterior to the orbital septum
132
Whats the most common cause of orbital cellulitis?
Bacterial sinusitis
133
How to differentiate between orbital cellulitis and preseptal cellulitis ?
By the red flags of orbital cellulitis
134
What are red flags of orbital cellulitis ?
1. Proptosis
2. Chemosis
3. Decreased visual acuity
4. Ophthalmoplegia
5. Signs of optic neuropathy (e.g., dyschromatopsia, RAPD)
135
How do you diagnose orbital cellulitis and pre-septal cellulitis ?
1. Clinical diagnosis
2. CT with contrast (orbit and sinuses)
136
Whats the treatment for pre-septal cellulitis and orbital cellulitis ?
1. Pre-septal cellulitis: empiric oral antibiotics
2. Orbital cellulitis: empiric IV antibiotics
137
What are the complications of this ?
1. Vision loss
2. Orbital compartment syndrome
3. Brain abscess
4. Cavernous sinus thrombosis
138
What does the pre-septal cellulitis involve?
1. The surrounding skin
2. Eyelid
3. Orbicularis oculi muscle
139
In which age group is the pre-septal cellulitis common in ?
Children less than 5
140
What are the findings in preseptal cellulitis?
Soft tissue thickening anterior to the orbital septum.
141
What are the complications of preseptal cellulitis?
1. Orbital cellulitis
2. Meningitis
3. Encephalitis
142
What does the orbital cellulitis involve?
1. Orbital fat
2. Extra ocular muscles
3. Neurovascular tissue
143
Causes of orbital cellulitis?
1. Bacterial rhinosinusitis (most common)
2. Odontogenic infection
3. Preseptal cellulitis
4. Dacryocystitis
5. Direct inoculation, e.g., orbital trauma, surgery
144
Whats the treatment of orbital cellulitis?
1. admit
2. blood cultures x2
3. orbital CT
4. IV antibiotics (cefriaxone + vancomycin) for 1 wk
5. surgical drainage of abscess w/close follow-up, especially in children
145
Clinical features of pre-septal cellulitis or orbital cellulitis?
146
Whats epi-scleritis ?
inflammation of the episclera
147
Epi- scleritis is more common in ?
Female, unilateral
148
What are the clinical features of epi-scleritis?
Acute onset of symptoms
Mild eye pain/irritation and watering
Eye redness
Vision is not affected
149
How to differentiate between the scleritis and episcleritis?
Vasoconstricting eye drops (phenylephrine) may allow episcleritis to be differentiated from scleritis, the superficial veins will blanch.
150
How to differentiate between the scleritis and episcleritis?
Vasoconstricting eye drops (phenylephrine) may allow episcleritis to be differentiated from scleritis, the superficial veins will blanch.
151
Treatment of episcleritis?
1. Symptomatic treatment (e.g., cold compresses, eye lubrication)
2. In persistent or severe cases: NSAIDs and/or topical steroids
3. Treatment of any underlying conditions
152
What are the causes of episcleritis?
1. Idiopathic
2. Associated with systemic disease (RA)
153
What do you need to rule out before confirming that its episcleritis?
1. Scleritis
2. Keratitis
3. Conjunctivitis
154
Whats scleritis?
Transmural inflammation of the sclera
155
What are the causes of scleritis ?
1. collagen vascular disease, e.g. SLE, RA, GPA, ankylosing spondylitis.
2. granulomatous, e.g. tuberculosis, sarcoidosis, syphilis
3. metabolic, e.g. gout, thyrotoxicosis
4. infectious, e.g. S. aureus, S. pneumoniae, P. aeruginosa, herpes zoster
5. chemical or physical agents, e.g. thermal, alkali, or acid burns • idiopathic
156
Clinical features of scleritis ?
1. Subacute onset of symptoms
2. Severe deep, aching, and boring eye pain that is exacerbated by eye movement and palpation; may radiate to the rest of the face
3. Eye redness
4. Photophobia and/or loss of vision
5. Fixed scleral nodules (esp. in anterior nodular scleritis)
6. Scleral thinning (esp. in scleromalacia perforans): may appear as violet or blue discoloration of the eye
Diagnostics
157
sclera may have a purple or “violaceous” hue (best seen in natural light), due to thinning of scleral
fbres exposing the bluish-coloured uvea, a sign in which condition?
Scleritis
158
Whats this sign
violaceous hue can been seen in scleritis
159
failure to blanch with topical phenylephrine
Scleritis
160
What are the classification of scleritis ?
1. anterior scleritis can be further classifed as:
A. difuse
B. nodular
C. necrotizing with infammation, or necrotizing without inflammation (scleromalacia perforans)
2. posterior scleritis can be further classifed as:
A. difuse
B. nodular
161
What type of scleritis?
Anterior diffuse scleritis
162
Anterior nodular scleritis
163
Anterior scleritis with inflammation and necrotising
164
Anterior scleritis without inflammation with necrosis (scleromalacia perforans)
165
What are the clinical features of anterior scleritis ?
1. pain radiating to face.
2. may cause scleral thinning.
3. some cases necrotizing.
166
What are the signs of posterior scleritis ?
posterior scleritis: rapidly progressive blindness, may cause exudative RD
167
How to diagnose scleritis ?
1. Diagnosis based on history and physical examination
2. Ultrasound: to detect signs of posterior scleritis
3. Orbital CT/MRI: to differentiate between orbital lesions, e.g., tumors, and posterior scleritis [9]
4. Workup for potential systemic disease (e.g., RF, ANA, ANCA, and HLA typing)
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How to treat scleritis ?
1. NSAIDs: first-line therapy in mild to moderate cases
2. Systemic glucocorticoids: in posterior or necrotizing scleritis; patients unresponsive to NSAIDs
3. Systemic immunosuppressive therapy (e.g., azathioprine, methotrexate): in patients unresponsive to steroids
4. Scleral transplantation: in patients with impending perforation
5. Treatment of any underlying systemic conditions
169
Layers of the cornea ? (ABCDE)
Anterior epithelium
Bowman’s Membrane
Corneal Stroma
Descemet’s Membrane
Endothelium
170
What corneal abrasion?
A defect in the epithelial surface of the cornea caused by trauma
171
Whats the function of cornea?
■ transmission of light
■ refraction of light (2/3 of total refractive power of eye)
■ barrier against infection, foreign bodies
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Why is the cornea transparent?
transparency due to avascularity, uniform collagen structure.
173
Causes of corneal abrasion?
1. Direct injury (e.g., scratch from fingernail or makeup brush)
2. Foreign body under the eyelid
3. Prolonged contact lens wear or improperly fitted lenses
4. Entropion
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What are the clinical features of corneal abrasion?
1. Foreign body sensation in the eye
2. Eye pain
3. Epiphora
4. Photophobia
5. Blurred vision
6. Conjunctival injection
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What are the complications of corneal abrasion?
1. infection
2. ulceration
3. recurrent erosion
4. secondary iritis
176
How to diagnose corneal abrasion?
1. Corneal abrasion is a clinical diagnosis.
2. Perform a thorough eye examination, including slit lamp examination with fluorescein staining.
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Corneal abrasion highlighted in fluorescence
178
Whats the treatment of corneal abrasion?
1. topical antibiotic (drops or ointment), abrasion from organic material should be covered against
Pseudomonas.
2. consider topical NSAIDs (caution due to risk of corneal melt with prolonged use).
3. cycloplegic (relieves pain and photophobia by paralyzing ciliary muscle)
4. patch (do not patch contact lens wearers as it can precipitate infection)
5. most abrasions clear spontaneously within 24-48 h
179
Whats corneal ulcer?
traumatic corneal defect caused by a sharp object
180
How to diagnose corneal laceration ?
slit lamp examination to exclude full-thickness defects and foreign bodies
181
What are the signs of corneal laceration?
Signs of full-thickness lacerations include an:
1. Irregularly shaped pupil.
2. presence of blood in the anterior chamber.
3. reduced depth of the anterior chamber
4. prolapse of the iris through the defect
182
Whats corneal ulcer?
a defect of the corneal epithelium and underlying stroma that occurs secondary to infection or inflammation
183
Whats Infectious keratitis?
an infection of the cornea
184
What are the types of keratitis ?
1. Infectious keratitis (bacterial, viral, fungal, acanthamoeba)
2. Non infectious keratitis
185
Whats the most common form of keratitis?
Bacterial keratitis
186
What pathogens involved in bacterial keratitis?
1. staphylococci (Staphylococcus aureus).
2. streptococci (Streptococcus pneumoniae).
3. Pseudomonas aeruginosa
4. Enterobacteriaceae (including Klebsiella)
187
What are the clinical features of bacterial keratitis?
1. Progressive pain
2. Eye redness
3. Foreign body sensation
4. Purulent discharge
5. Photophobia
6. Excessive tearing
7. Blurry vision
8. Conjunctival injection
188
What are the risk factors of bacterial keratitis?
1. Contact lens use
2. Recent eye surgery or injury
3. Immunodeficiency
4. Lacrimal duct stenosis
189
Whats the most common cause of bacterial keratitis in contact lens users ?
Pseudomonas keratitis: Caused by Pseudomonas aeruginosa
(Corneal destruction/perforation within 2–5 days )
190
Whats this clinical feature?
Slit lamp examination
Hypopyon: collection of leukocytes at the bottom of the anterior chamber; occurs in severe cases of keratitis
191
Whats this finding?
Corneal ring ulcer
192
Fluorescein staining in slit lamp in bacterial keratitis can show?
Fluorescein staining:
1. round corneal infiltrate or ulcer
2. Creeping ulcer or serpiginous corneal ulcer in pneumococcus infection
3. (Ring‑) ulcer: (ring-shaped) spread of the pathogen in the cornea
4. Thygeson superficial punctate keratitis: point-shaped lesions in the corneal epithelium
193
Whats the treatment of acute bacterial keratitis ?
1. Topical broad-spectrum antibiotics
2. Consider corticosteroids following identification of pathogen and ∼2 days of antibiotic therapy
3. Therapeutic mydriasis may be considered
4. Corneal transplantation
194
What are the indications for corneal transplantation?
1. threatened or existing large perforations.
2. small corneal perforations with consistent bacterial growth, or suppuration despite antibiotics.
195
What are the complications of bacterial keratitis?
1. Irreversible vision loss.
2. Corneal destruction (potentially leading up to perforation)
3. Leukoma
4. Increase intraocular pressure
196
Leukoma
197
Leukoma
198
Whats leukoma ?
a dense, white opacity of the cornea caused by scarring , inflammation, injuries, or congenital corneal conditions.
199
Adherent leukoma: part of the iris is attached to the cornea
200
Adherent leukoma: part of the iris is attached to the cornea
201
Adherent leukoma: part of the iris is attached to the cornea
202
Mentions findings of this picture ?
1. Hypopyon
2. Leukoma
Keratitis
203
Whats the cause of herpes simplex keratitis ?
infection due to reactivated herpes simplex virus (HSV) type 1 from the trigeminal ganglion
204
Whats the cause of herpes simplex keratitis ?
infection due to reactivated herpes simplex virus (HSV) type 1 from the trigeminal ganglion
205
What are the clinical features of herpes simplex keratitis ?
1. usually unilateral
2. Eye redness
3. ± Eye pain
Foreign body sensation
4. Corneal hypoesthesia
5. Photophobia
6. Blurry vision; can lead to vision loss if untreated
206
Whats the classic form of herpes keratitis ?
classic form of HSV infectious epithelial keratitis is a dendritic (thin and branching) lesion with
terminal end bulbs in epithelium that stains with fuorescein
207
Herpes simplex keratitis
208
Describe what you see?
classic form of HSV infectious epithelial keratitis is a dendritic (thin and branching) lesion with
terminal end bulbs in epithelium that stains with fuorescein
209
Ow to diagnose herpes simplex keratitis?
1. Fluorescein staining: superficial corneal erosions (dendritic ulcers) that resemble the branches of a tree
2. Direct fluorescein antibody test (HSV antigen detection)
3. polymerase chain reaction (PCR) test
210
Lamp photography with fluorescein application under cobalt blue light filter
Fluorescein staining of the cornea under blue light shows green fluorescence of (geographic epithelial defects).
211
What are the herpes simplex keratitis complications?
1. corneal scarring (can lead to loss of vision) and hypoesthesia.
2. chronic interstitial keratitis due to penetration of virus into stroma
3. secondary iritis, secondary glaucoma
212
Treatment of herpes simplex keratitis?
1. Topical trifluridine solution or ganciclovir 0.15% gel
2. Oral antiviral (e.g., acyclovir) when topical treatment cannot be administered by the patient, prophylactic treatment after surgery, or refractory cases despite topical treatment.
3. Corneal transplantation for patients with severe corneal scarring
213
H what shouldn’t be used as a first line treatment in herpes simplex keratitis?
Glucocorticoids should not be used in initial treatment of dendritic epithelial keratitis!
214
What is herpes zoster ophthalmicus?
1.dermatitis in the dermatomal distribution of CN V1 that is typically unilateral and respects the
midline.
2. reactivation of VZV in the ophthalmic division of the trigeminal nerve
215
What is the most common cause of infectious conjunctivitis?
Viral conjunctivitis
216
What viral pathogen lead to conjunctivitis?
Adenovirus
217
Whats conjunctivitis?
Inflammation of conjunctiva
218
What are the causes of conjunctivitis?
1. Infectious
2. Non infectious:
A. allergic
B. toxic: irritants, dust, smoke
C. secondary to another disorder: dacryocystitis, dacryoadenitis, cellulitis, and systemic
infammatory disease
219
Whats the most common cause of red eyes?
Conjunctivitis
220
Whats the most common cause of red eyes?
Conjunctivitis
221
What are the clinical features of conjunctivitis?
1. Conjunctival injection => hyperemia (blood vessels dilation) and red eye.
2. Chemosis: edema of conjunctiva (due to veins dialation and increased blood flow)
222
What are the clinical features of conjunctivitis?
1. Conjunctival injection => hyperemia (blood vessels dilation) and red eye.
2. Chemosis: edema of conjunctiva (due to veins dialation and increased blood flow)
223
A patient complaining of conjunctival injection + chemosis + purulent discharge
Bacterial conjunctivitis (antibiotics)
224
Mention the clinical feature and what’s the cause?
Follicular conjunctivitis
Viral/ chlamydial conjunctivitis
225
Define this abnormality and mention the possible locations?
1. A small domed shape, raised lymphoid follicle with a yellowish-white appearance due to hyperplastic tissue.
2. Usually in the lower eyelid with milky white center surrounded by lymphocytes
2. Located in the palpebral or bulbar conjunctiva
226
Preauricular lymphadenopathy seen in which type of conjunctivitis?
viral or gonococcal conjunctivitis
227
Crusty eyelashes
1. Blephritis
2. Conjunctivitis
228
Crusty eyelashes
1. Blephritis
2. Conjunctivitis
229
Describe what you see?
1. Papillae
2. raised red flat topped bumps
3. central vascular core
4. cobblestone appearance usually in the upper eyelid.
230
What are the types of discharge in conjunctivitis ?
1. Allergic: mucoid
2. Viral: watery
3. Bacterial: purulent
4. Chlamydial: mucopurulent
231
Compare follicular and papillary conjunctivitis?
232
Compare follicular and papillary conjunctivitis?
233
What does ALLERGIC CONJUNCTIVITIS associate with?
• associated with rhinitis, asthma, dermatitis
234
What are the symptoms of allergic conjunctivitis ?
1. ocular pruritus
2. small papillae
3. chemosis and redness
4. thickened and erythematous lids
235
What are the causes of allergic conjunctivitis?
seasonal (pollen, grasses, plant allergens)
236
Whats the treatment of allergic conjunctivitis?
1. allergen avoidance
2. cool compresses,
3. topical antihistamine,
4. topical mast cell stabilizer (e.g. cromolyn, ketotifen, olopatadine)
5. Topical corticosteroids
237
GIANT PAPILLARY CONJUNCTIVITIS (GPC)
238
GIANT PAPILLARY CONJUNCTIVITIS (GPC)
Treatment:
clean, change, or discontinue use of contact lens, and topical corticosteroids
239
Whats GPC?
immune reaction to mucus debris on lenses in contact lens wearers
240
Whats the treatment of GPC?
clean, change, or discontinue use of contact lens, and topical corticosteroids
241
Whats the treatment of GPC?
clean, change, or discontinue use of contact lens, and topical corticosteroids
242
What advises would you give patients with conjunctivitis?
1. Eyelid hygiene
2. Saline irrigation
3. Remove eyelid discharge frequently
4. Avoiding touching the affected eye
5. Wash hands before and after cleaning the eye/applying eye drops
6. Compresses (can be warm or cold)
7. Advise patients to stop using contact lenses for ≥ 2 weeks.
243
What are the types of red eye?
1. Conjunctival
2. Ciliary
3. Mixed
244
What are the types of red eye?
1. Conjunctival
2. Ciliary
3. Mixed
245
What are the three most common cause of viral conjunctivitis ?
1. Adenovirus (associated with a history of URTI) (most common)
2. Herpes Simple’s virus (vesicular lesions)
3. Varicella zoster virus (vesicular lesions)
246
What are the three most common cause of viral conjunctivitis ?
1. Adenovirus (associated with a history of URTI) (most common)
2. Herpes Simple’s virus (vesicular lesions)
3. Varicella zoster virus (vesicular lesions)
247
Whats the treatment of viral conjunctivitis in general ?
Supportive therapy, unless if its HSV or VZV because they lead to keratitis and blindness
248
What are the clinical features of viral conjunctivitis ?
1. Conjunctiva injection
2. Chemosis
3. Watery discharge
4. Periauricular lymphadenopathy (palpable and tender)
5. Lid swelling
6. Follicular conjunctivitis
7.Usually unilateral
249
What if you’re confused if its viral or bacterial conjunctivitis, what type of investigations would you do?
1. Conjunctival swab + culture
2. PCR
250
Subconjunctival and petechial hemorrhage seen in which type of viral conjunctivitis?
Adenovirus
251
Subconjunctival and petechial hemorrhage seen in which type of viral conjunctivitis?
Adenovirus
252
What’s the treatment of adenovirus conjunctivitis?
Supportive therapy
1. Good eye hygiene
2. artificial tears
3. cold compresses
4. Oral analgesics (e.g., NSAIDs)
5. Topical antihistamines for severe pruritus
6. Topical steroids to relieve symptoms and reduce long-term complications
Educate patients on preventive measures against infectious conjunctivitis; adenovirus conjunctivitis is highly infectious.
253
What’s the treatment of adenovirus conjunctivitis?
Supportive therapy
1. Good eye hygiene
2. artificial tears
3. cold compresses
4. Oral analgesics (e.g., NSAIDs)
5. Topical antihistamines for severe pruritus
6. Topical steroids to relieve symptoms and reduce long-term complications
Educate patients on preventive measures against infectious conjunctivitis; adenovirus conjunctivitis is highly infectious.
254
What are the clinical features of HSV 1 conjunctivitis?
1. Typically unilateral
2. Thin, watery discharge
3. Pain
4. (Vesicular) blepharitis
5. (Dendritic epithelial keratitis) of cornea or conjunctiva
6. Preauricular lymphadenopathy
8. Ulcer(s) or vesicular rash on the eyelid
255
Whats the treatment of HSV1 conjunctivitis ?
Provide supportive treatment + topical antivirals (Ganciclovir)
256
Whats the treatment of HSV1 conjunctivitis ?
Provide supportive treatment + topical antivirals (Ganciclovir)
257
A patient with HSV1 conjunctivitis has developed HSV keratitis what would you change in the treatment ?
1. Supportive therapy
2. Topical anti-viral (ganciclovir)
3. ADD ORAL antiviral (acyclovir)
258
What must be avoided in HSV infection as treatment because it will make it worse?
Topical steroids
259
Herpes simplix keratitis (dendritic epithelial lesion)
260
Whats primary VZV infection and reactivation of VZV (shingles)?
1. Primary infection of VZV => chickenpox + mild conjunctivitis
2. Reactivation of VZV (shingles) => herpes zoster ophthalmicus
261
Herpes zoster ophthalmicus: vesicular rash on the eyelids, forehead, nose following ophthalmic branch of triage nail nerve.
Hutchinson’s sign: when vesicles on the nose top which increases the risk of eye involvement.
262
How to diagnose herpes zoster ophthalmicus ?
1. PCR +
2. Vesicles around the eye, forehead and nose (Hutchinson’s sign)
3. History: recent chickenpox infection
263
Herpes zoster keratitis (geographic pattern)
264
Whats the treatment of Patients with isolated (VZV) conjunctivitis?
- Provide supportive therapy for conjunctivitis.
- Start topical antibiotic therapy for acute bacterial conjunctivitis to prevent secondary bacterial infection.
265
Whats the treatment of isolated VZV conjunctivitis + keratitis
Start oral antiviral therapy.
Refer to an ophthalmologist for evaluation.
266
How to differentiate the bacterial conjunctivitis from allergic and viral ?
1. Purulent discharge
2. Not itchy
267
Rapid onset and severe symptoms conjunctivitis ?
suggest neisserial conjunctivitis
268
in neonates (perinatal) or if sexually active must consider (what type of bacterial conjunctivitis)?
N. gonorrhoeae (can cause hyperpurulent conjunctivitis, a serious infection that may rapidly perforate cornea)
269
most common cause (pathogen) of bacterial conjunctivitis in neonates ?
C. trachomatis
270
genitourinary discharge + conjunctivitis
gonococcal conjunctivitis or inclusion conjunctivitis
271
Whats gonococcal conjunctivitis?
1. Conjunctivitis caused by nesseria gonorrhoea.
2. severe type of infectious conjunctivitis most commonly caused by Neisseria gonorrhoeae and characterized by a sudden onset of purulent discharge, rapidly worsening eye pain, and changes in vision. May involve the cornea (e.g., ulcer, perforation).
272
Whats inclusion conjunctivitis?
1. A form of bacterial conjunctivitis caused by Chlamydia trachomatis.
2. characterized by mucopurulent discharge and papillary hypertrophy.
3. Can be spread to the eyes from a preexisting genital infection (from the genitals to the hands to the eyes) or transmitted perinatally or via contaminated swimming pools.
273
What is the most common causative pathogen in bacterial conjunctivitis in adults ?
S.aerus
274
Whats the most common causative pathogen in acute bacterial conjunctivitis in children?
Most common in children: S. pneumoniae and H. influenzae
275
Contact lens wearers are at increased risk of serious infections with gram-negative bacteria such as?
Pseudomonas aeruginosa
276
H what investigations would you order to diagnose bacterial conjunctivitis
Obtain conjunctival culture with Gram stain and Giemsa stain
277
What are the indications of culture of conjunctival swab of purulent discharge?
1. Severe conjunctivitis
2. Contact lens use
3. Recurrent or refractory symptoms
4. Immunodeficiency
5. Possible gonorrheal or chlamydial conjunctivitis
278
Whats the treatment of bacterial conjunctivitis ?
1. Advise patients to immediately remove their contact lenses.
Avoid wearing for ≥ 2 weeks.
Discard disposable contact lenses and contact lens storage cases.
2. Provide supportive therapy for conjunctivitis.
3. Consider a 5–7 day course of topical broad-spectrum antibiotics. (With treatment; 2/3 days its gone, without it takes two weeks)
279
Whats the supportive therapy for bacterial conjunctivitis ?
1. Refrigerated artificial tears.
2. cleaning discharge from the eye
3. compresses (warm or cold)
4. discontinuation of contact lens use.
280
When do you refer the patient to ophthalmologist in case you suspected bacterial conjunctivitis ?
1. Suspected MRSA infection
2. Red flags in conjunctivitis (including contact lens use)
3. Symptoms that persist after > 1 week of treatment (because usually 3 days the injection has to resolve)
281
Red flags in conjunctivitis?
1. pain
2. vision changes
3. corneal involvement
4. symptoms suggestive of neisserial conjunctivitis or herpes simplex conjunctivitis
5. risk factors that predispose patients to serious infections, e.g., contact lens use,
immunodeficiency, or a history of recurrent conjunctivitis.
282
Topical antibiotic for eyes Indicated for patients who:
1. Wear contact lenses
2. Have mucopurulent discharge and eye pain
3. Have known ocular surface disease
283
What are the complications of this condition?
Keratitis
Anterior uveitis
Preseptal cellulitis
Chronic bacterial conjunctivitis (symptoms lasting > 4 weeks)
284
What are the clinical features of nesseria gonorrhea ?
1. Hyperacute conjunctivitis
2. Marked eye swelling
3. Profuse purulent discharge
4. Possibly symptoms of genitourinary gonorrhea or disseminated gonococcal infection
285
What expected to see in gram stain ?
Gram stain: intracellular gram-negative diplococci
286
What do you need to Rule out in patients with suspected N. gonorrhoeae infection?
Rule out N. meningitidis in patients with suspected N. gonorrhoeae infection
287
Why is N. gonorrhoeae infection an ocular emergency?
can lead to keratitis, perforation, and blindness without prompt treatment
288
Whats the treatment of N. Gonorrhea bacterial conjunctivitis ?
1. Start immediate systemic antibiotic treatment (IV or IM ceftriaxone)
2. Consider adding topical antibiotic therapy (e.g., if keratitis is suspected).
3. Consult ophthalmology and infectious diseases early.
4. Irrigate the affected eye(s) with saline.
5. Provide supportive therapy for conjunctivitis
289
What causes CHLAMYDIAL CONJUNCTIVITIS ?
C. trachomatis
290
Chlamydia conjunctivitis presents in two forms:
1. Neonatal chlamydial conjunctivitis (perinatal delivery)
2. Adult inclusion conjunctivitis (STD or contaminated hands after touching genital secretions).
3. trachoma: a severe form of chlamydial conjunctivitis.
291
What causes trachoma?
A repeated infections with chlamydia trachomatosis serotypes A,B,Ba and C.
292
What are the symptoms of trachoma?
1. Recurrent conjunctivitis With scarring of inner eyelid.
2. Trichiasis
3. Blindness
4. Severe form of Keratoconjuctivits => corneal damage, ulceration and scarring
293
What are the symptoms of trachoma?
1. Recurrent conjunctivitis With scarring of inner eyelid.
2. Trichiasis
3. Blindness
294
Mention SAFE strategy for trachoma ?
S: surgery => trichiasis
A: antibiotics azithromycin
F: facial cleanliness
E: environmental improvement
295
When does the neonate get the chlamydia/ gonorrhea usually?
Gonorrhea: first 5 days
Chlamydia: 3- 14 days (longer incubation period)
296
What prophylaxis given for neonates in case of chlamydia/ gonorrhea conjunctivitis?
Erythromycin 0.5% ointment
297
Explain the progression of trachoma?
Active phase:
1. active trachoma inflammation
2. Mucopurulent discharge
3. Papillary reaction
4. Conjunctival follicles (with involution leading to Herbert pits if untreated)
Cicatricial phase: develops if the active phase is severe and prolonged
1. Chronic/recurrent inflammation in both eyes → conjunctival scarring and progressive conjunctival shrinkage
2. Can lead to corneal ulcers and opacities, superficial neovascularization with cellular infiltration (corneal pannus), entropion, and/or trichiasis
Also Begins with follicles in the upper eyelid (superior palpebrae conjunctiva)
Then scar to the inner eyelid (Arlt’s line).
298
Arlt’s line
299
Arlt’s line
300
Whats treatment of trachoma?
1. oral (azithromycin)
2. topical tetracycline
3. IV cefriaxone ofen given in the emergency department
301
What are the sings of inclusion conjunctivitis ?
chronic conjunctivitis with follicles and subepithelial infltrates
302
Inclusion conjunctivitis
303
Inclusion conjunctivitis
304
Chlamydia trachoma this (McCoy cells culture)
305
Chlamydia trachomatis (McCoy cells culture)
306
The most common infectious cause of blindness worldwide
Trachoma (c. Trochomatis serotypes A-C)
307
Herbert pits
308
Whats eitiology of allergic conjunctivitis ?
IgE-mediated hypersensitivity reaction (type I) against specific allergens
309
Clinical features of allergic conjunctivitis ?
(Bilateral)
(Itching)
Conjunctival injection
Discharge and crust formation mucoid discharge
Chemosis
Burning or foreign-body sensation
310
Pinguecula
311
Pingoucele is associated with what?
Whats the treatment?
1. Sun exposure and wind exposure
2. Cosmetics only
312
Pterygium
313
Clinical features of pterygium
Clinical Features: may induce astigmatism (blurry vision) and decrease vision.
314
What are the indications of excision of pterygium?
1. chronic inflammation.
2. threat to visual axis
3. cosmetics
(irritative symptoms may be treated with lubricating drops)
315
Sub-conjuctival hemorrhage
316
Keratoconus
317
This associated with what conditions?
1. Down syndrome
2. atopy/ Allergic asthma
3. contact lens use
4. Neurodermatitis
5. Hay fever
6. Marfan syndrome
7. Ehlers-Danlos syndrome
8. Down syndrome
318
Munson’s sign
319
Arcus senalis
320
Whats arcus senalis ?
1. hazy white ring in peripheral cornea, <2 mm wide, clearly separated from limbus.
2. common, bilateral, benign corneal degeneration due to lipid deposition, part of the aging process
3. may be associated with hypercholesterolemia if age <40 yr check lipid profle
4. no associated visual symptoms, complications, or treatment necessary
321
What investigations would you do?
Lipid profile
322
Define this condition?
Keratoconus: a noninflammatory corneal condition in which the cornea becomes thinner than normal and develops a conic shape, bulging outward at the center.
323
H what are the clinical findings of Keratoconus ?
Progressive decrease in visual acuity
Myopia
Astigmatism
Photophobia
324
What diagnostics tests would you do for Keratoconus?
1. Slit lamp examination showing protrusion and thinning of the cornea.
2. Ultrasound pachymetry (measurement of corneal thickness via ultrasound)
3. Computerized corneal topography
325
Whats the treatment of Keratoconus ?
1. Correcting astigmatism and myopia: glasses or rigid gas permeable contact lenses
2. If conservative treatment options fail: keratoplasty
326
What are the complications of Keratoconus ?
Corneal hydrops (corneal rupture): tearing of the Descemet membrane and endothelium → penetration of intraocular fluid into the stromal tissue of the cornea → acute pain and deterioration in vision caused by corneal opacification
327
Arcus senalis is common in ?
Elderly 50-60 years old
328
Kayser-Fleischer ring
329
Whats Kayser-Fleischer ring?
green-brown, copper deposits are a diagnostic sign of Wilson disease.
330
Associated with what condition?
Wilson disease
331
Whats the treatment of Kayser-Fleischer Ring?
Treat the underlying cause
332
Whats the function of cornea?
- transmission of light
■ refraction of light (2/3 of total refractive power of eye)
■ barrier against infection, foreign bodies
333
What is the cornea transparent ?
transparency due to avascularity and uniform collagen structure.
334
Whats this? And what are the clinical features?
1. Foreign body.
2. pain, tearing, photophobia, foreign body sensation, and red eye
335
What are the signs?
1. foreign body
2. conjunctival injection
3. epithelial defect that stains with fuorescein.
336
What do you do to examine a patient with a sudden onset acute pain which followed by a trauma/ windy weather and his eyes are red, swelled and sensitive to light?
slit lamp examination, evaluation for open globe injury, and eversion of the upper eyelid.
337
Whats this?
Corneal Rust rings
338
How to manage foreign body in the cornea?
Removal of the corneal foreign body
339
When are you afraid of the foreign body ?
Foreign body behind lid may cause multiple vertical corneal epithelial abrasions due to blinking
340
What are the complications of foreign body ?
1. abrasion
2. infection
3. ulcer
4. scarring
5. secondary iritis
341
Whats corneal abrasion?
A defect in the epithelial surface of the cornea caused by trauma
342
What are the causes of corneal abrasion?
1. Direct injury (e.g., scratch from fingernail or makeup brush)
2. Foreign body under the eyelid
3. Prolonged contact lens wear or improperly fitted lenses
4. Entropion
5. Trachoma
343
What are the clinical features of corneal abrasion?
1. Foreign body sensation in the eye
2. Eye pain
3. Epiphora
4. Photophobia
5. Blurred vision
6. Conjunctival injection
344
How to diagnose corneal abrasion?
Corneal abrasion is a clinical diagnosis.
Perform a thorough eye examination, including slit lamp examination with fluorescein staining.
345
Corneal abrasion due to foreign body
346
Whats the treatment of corneal abrasion?
1. topical antibiotic (drops or ointment), abrasion from organic material should be covered against
Pseudomonas.
2. consider topical NSAIDs (caution due to risk of corneal melt with prolonged use), cycloplegic (relieves
pain and photophobia by paralyzing ciliary muscle).
3. patch (do not patch contact lens wearers as it can precipitate infection).
4. most abrasions clear spontaneously within 24-48 h
347
Whats recurrent corneal erosions?
1. recurrent episodes of pain
2. photophobia
3. foreign body sensation with a spontaneous corneal epithelial defect
usually occurs upon awakening associated with improper adherence of epithelial cells to the underlying basement membrane.
348
Whats the treatment of recurrent corneal abrasion?
1. Eye patch, antibiotics ointment until re-epithelialization occurs.
2. topical hypertonic saline ointment at bedtime for 6-12 mo.
3. bandage contact lens superfcial keratectomy with diamond burr polishing, or phototherapeutic
4. keratectomy for chronic recurrences
349
Whats corneal ulcer?
A defect of the corneal epithelium and underlying stroma that occurs secondary to infection or inflammation.
350
What are the causes of corneal ulcer?
Corneal ulcers most frequently occur as a complication of keratitis:
1. Bacterial keratitis (Common organisms: Staphylococcus, Streptococcus, Mycobacterium, and Pseudomonas).
Risk factors:
Contact lens wearing
Corticosteroid use
Eye trauma
2. Viral keratitis
Herpes simplex keratitis
Herpes zoster keratitis
3. Fungal keratitis
4. Noninfectious keratitis [13][15]
Autoimmune disease
Keratoconjunctivitis sicca
Mycotic keratitisCorneal necrosis in bacterial keratitis
351
What are the clinical features of corneal ulcer?
Eye pain and/or foreign body sensation
Epiphora
Conjunctival injection
Photophobia
Blurry/decreased vision
Discharge from eye:
A. Purulent: bacterial
B. Watery: viral
352
How to diagnose corneal ulcer?
Corneal ulcer is a clinical diagnosis based on (slit lamp examination) with fluorescein staining.
353
What are findings indicating viral corneal ulcer in Herpes simplex keratitis?
Herpetic lesions on conjunctiva or lids
Slit lamp examination: dendritic lesions or amoeba-shaped ulcer
354
What are the clinical findings of Herpes zoster keratitis?
Dermatomal vesicular rash
Possible signs of uveitis, iritis, or choroiditis
Slit lamp examination: similar to HSV keratitis
355
What are the complications of corneal ulcer?
Vision loss
Corneal scarring and/or perforation
Endophthalmitis
Iritis
356
Whats treatment for corneal ulcer?
1. urgent referral to ophthalmology
2. culture prior to treatment - opical antibiotics every hour // viral => antiviral therapy
3. must treat vigorously to avoid complications
357
Compare corneal abrasion to ulcer ?
358
Whats uveal tract ? And what are the characteristics ?
1. uveal tract (from anterior to posterior) = iris, ciliary body, choroid
2. vascularized, pigmented middle layer of the eye, between the sclera and the retina
359
Whats uveitis?
uveal inflammation which may involve one, two, or all three parts of the tract.
360
What are the main categories causes of uveitis?
1. Infectious uveitis:
A. Bacterial
B. Viral Viral infections: e.g., herpes simplex conjunctivitis, herpes zoster ophthalmicus, cytomegalovirus infection, rubella
C. Parasitic: (causes posterior uveitis): ocular toxoplasmosis
2. Non- infectious
A. Systemic disease, especially HLA-B27 syndromes (e.g., seronegative spondyloarthropathies, inflammatory bowel disease) => VERY IMPORTANT
B. Trauma (including ocular surgery) can cause traumatic iritis or traumatic iridocyclitis
C. Drug-induced uveitis is uncommon; causative agents include cidofovir, rifabutin, prostaglandin analogues
361
Uveitis is anatomically classifed as:
1. anterior uveitis
2. intermediate uveitis
3. posterior uveitis
4. panuveitis based on primary site of infammation
362
Describe each type of uveitis (location)?
1. Anterior uveitis (most common type): inflammation of the iris and/or the anterior part of the ciliary body (pars plicata).
2. Posterior uveitis: inflammation of the retina and/or choroid
3. Intermediate uveitis: inflammation of the vitreous (vitritis) and the posterior part of the ciliary body (pars plana)
4. Panuveitis: inflammation involving all structures of the uvea
363
Mention (location, aetiology and clinical features) of anterior uveitis?
364
What are the complications of anterior uveitis and its treatment ?
365
Mention the location, aetiology and and clinical features for intermediate and posterior uveitis ?
366
Mention the location, aetiology and and clinical features for intermediate and posterior uveitis ?
367
What are the complications and treatment for both intermediate and posterior uveitis?
368
Which type of uveitis is life threading for vision?
Posterior uveitis and panuveitis
369
Whats the diagnosis ? And what are the signs?
Classic presentation of anterior uveitis
1. Mixed injection: ciliary and conjunctival injection.
2. The dilated pupil is not round suggesting posterior synechia
3. Several whit deposits (keratic precipitates)
370
Anterior uveitis. Mention this sign
Keratic precipitates
371
Dialated pupil but not round; this is due to iris adhering to the lens = posterior synechiae (anterior uveitis)
372
Chorioretinitis
373
Whats treatment of uveitis ?
Supportive measures
Topical corticosteroids (e.g., 1% prednisolone acetate, 0.1% dexamethasone)
Topical cycloplegics (e.g., 1% cyclopentolate, 1% atropine)
Treatment of the underlying etiology [3]
Infectious uveitis: Start specific treatment; see respective articles for details.
Noninfectious uveitis: address the underlying condition
374
Whats ectopia Lents ?and what are the types?
1. displacement of the lens of the eye.
2. partially displaced lens (subluxation): involves little to no loss of visual acuity.
complete displacement of the lens (luxation) results in severe visual impairment.
375
Causes of ectopic Lents?
1. Trauma (most common)
2. Systemic diseases: Marfan syndrome and Homocystinuria
376
Causes of ectopic Lents?
1. Trauma (most common)
2. Systemic diseases: Marfan syndrome and Homocystinuria
377
Explain th Ellen’s displacement in Marfan syndrome and Homocystinuria?
1. Marfan syndrome: superior, temporal subluxation of the lens (upward and outwards)
2. Homocystinuria: inferior, medial subluxation of the lens (downward and inwards)
378
What are the clinical features of lens displacement and what do you find on clinical examination ?
1. decreased VA
2. may get monocular diplopia
3. iridodonesis: tremors of the iris during eye movement
4. Lentodonesis: tremors of the lens during eye movement
5. direct ophthalmoscopy may elicit abnormal red refex
6. The equator of the lens may be visible in the pupil
7. The lens may dislocate into the vitreous or the anterior chamber
8. Features of glaucoma (e.g., raised intraocular pressure) due to pupillary block
9. Evaluation for underlying Marfan syndrome or homocystinuria
379
What test would you preform for lens dislocation ?
visual acuity, slit lamp examination, retinoscopy, and ultrasound of the eye
380
What are the complications of lens displacement ?
1. cataract
2. glaucoma (Acute secondary angle closure glaucoma )
3. uveitis
4.Amblyopia
381
Treatment of lens dislocation?
surgical lens replacement
382
Traumatic lens dislocation
383
Traumatic lens dislocation
384
385
Whats cataract ?
clouding of the ocular lens.
386
What are the causes of cataract ?
1. Acquired (common)
A. Age related
B. Cataract associated systemic disease (DM, Wilson disease, galactosemia, homocystinuria)
C. Hypocalcemia
D. Trauma
E. Uveitis
F. Steroid intake
G. Radiation
H. After vitrectomy (especially after silicone oil is inserted)
2. Congenital:
- Hereditary congenital cataracts
- Caused by TORCH infections (toxoplasmosis, syphilis, VZV, rubella, CMV, HSV)
- Associated with the following comorbidities/syndromes:
- Galactosemia
- Myotonic dystrophy
- Trisomy 21 (in early childhood)
- Trisomy 13
- Trisomy 18
- Alport syndrome
- Neurofibromatosis type 2
- Galactokinase deficiency
- Marfan syndrome
387
What are the clinical features of acquired cataract ?
1. Reduced visual acuity: blurred, clouded, or dim vision, especially at night.
2. Impaired vision: painless, often bilateral
3. Glare: in daylight, in low sunlight, and from car headlights; associated with halos around lights
4. Second sight: a temporary improvement in near vision; especially in patients with nuclear cataracts
5. Monocular diplopia: double vision that disappears when the affected eye is covered or shut
6. Change in color perception
388
What are the clinical features of congenital cataract ?
**Leukocoria**
Strabismus
Nystagmus
**Delay in motor skill development**
Deprivation amblyopia
389
Whats second sight phenomenon in cataract ?
patient is more myopic than previously noted, due to increased refractive power of the lens (in nuclear sclerosis only) patient may read without previously needed reading glasses
390
Snowflake cataract in DM
391
Rosseste shaped cataract (trauma)
392
What are types of cataract:
393
What type of cataract happens in DM?
Cortical (snow flake)
394
Define each type of cataract (morphological) ?
1. Cortical cataract (anterior/posterior): the most common type of cataract; characteristically originates at the outer layer of the lens and grows towards the center, forming a wedge-shaped opacity.
2. Nuclear cataract: a type of cataract that affects the center of the lens, appearing as a yellow-brown discoloration of this area.
3. Subcapsular cataract (anterior/posterior): a type of cataract that manifests directly under the lens capsule; usually in the posterior lens (rapidly progressive) but can also occur in the anterior lens
395
What are the stages of cataract ?
1. Immature cataract
Early stage of cataract progression
Red reflex is still present, allowing for visualization of the retina.
2. Mature cataract
Advanced stage in cataract progression
Red reflex is absent.
There is a white-yellow discoloration of the lens due to complete clouding.
Vision can be reduced to mere light perception.
3. Hypermature cataract
End stage of cataract progression
There is a complete white clouding of the lens due to liquification of the cortex.
The nucleus often sinks in the cortex and appears brown.
396
Posterior Subcapsular cataract
397
Cortical cataract
398
Nuclear cataract (mature)
399
:)
400
:)
401
:)
402
How do you diagnose a congenital cataract ?
May be identified on routine newborn red reflex evaluation
403
If congenital cataract is suspected Whats your next step?
refer to an ophthalmologist for further work-up
404
Describe the visual acuity in patients with cataract:
May be normal in patients with early cataracts
Typically decreases with cataract progression
Cortical cataracts may manifest as hyperopia.
405
Describe the findings in patient with cataract in case of using fundoscopy ?
Opacities (including leukocoria)
Darkening
Absent or decreased red reflex
406
What findings you can detect in slit lamp examination for cataract ?
Common: grey, white, yellow, or brownish clouding of the lens
407
Traumatic cataract
408
Traumatic cataract
409
What are the indications for surgery for cataract ?
1. to improve visual function in patients whose vision loss leads to functional impairment.
2. to aid management of other ocular disease (e.g. cataract that prevents adequate retinal exam
or laser treatment of DR).
3. congenital or traumatic cataracts
To improve vision in individuals with significant cataract-related visual disturbances (most common indication)
Cataract causing significant difference in refractive power between the two eyes
Preventing proper evaluation or treatment of the areas of the eye that are posterior to it (e.g., the fundus)
Cataract causing glaucoma (e.g., angle closure glaucoma)
410
What are the contraindications for cataract ?
1. Visual disturbances manageable with corrective lenses
2. Vision is not expected to improve after surgery (e.g., concurrent ocular conditions also causing vision impairment)
3. High surgical risk
411
Whats the name of surgery done for cataract ?
Phacoemulsification (phaco = lens)
412
Where does the new lens implanted ?
The intraocular lens implant (IOL) is placed in the posterior chamber.
413
What are the complication of cataract ?
Blindness
Glaucoma
414
How to prevent cataract?
1. Smoking cessation
2. Management of medical conditions associated with increased cataract risk (e.g., diabetes, hypertension, obesity)
3. Avoidance of UVB radiation (e.g., wearing sunglasses, hats)
4. Wearing eye protection during activities that carry risk of penetrating eye trauma (e.g., while cutting metal or wood)
415
Whats posterior vitreous detachment?
detachment of the posterior vitreous cortex from the internal limiting membrane of the retina
416
Whats the most common cause of vitreous detachment ?
Age-related degenerative liquefaction and collapse of the vitreous body (most common cause)
417
What are the clinical features of vitreous detachment ?
foaters, flashes of light
418
Eye floaters and flashes
419
Patient reported seeing floaters
Posterior vitreous detachment
420
Patient reported seeing floaters
Weiss ring - posterior vitreous detachment
421
Mention the steps of treatment for posterior vitreous detachment:
1. Acute onset of PVD requires a dilated fundus exam to rule out retinal tears/detachment
2. Treatment is not necessary in patients without retinal injury and/or patients in whom symptoms resolve
3. Symptomatic patients with retinal injury require prompt treatment (see complication below)
no specifc treatment available for foaters/fashes of light
422
What are the complications of posterior vitreous detachment ?
Retinal tears/holes
Rhegmatogenous retinal detachment
Vitreous hemorrhage (normally adherent to optic disc, vitreous base (pars plana/ora serrata), and along major retinal blood vessels).
Although most foaters are benign, new or markedly increased foaters or fashes of light require a dilated fundus exam to rule out retinal tears/detachment
423
What are the causes of vitreous hemorrhage?
1. Rupture of neovascular vessels in ischemic changes of the retina
(Proliferative diabetic retinopathy (most common cause))
2. Lesions of the retina (retinal detachment) in symptomatic posterior vitreous detachment.
3. Trauma
424
Clinical features of vitreous hemorrhage ?
Floaters and/or visual loss: typically worse after sleep
425
Whats the treatment for vitreous hemorrhage ?
1. Usually resolves spontaneously 3-6 months
2. If severe enough: vitrectomy: Surgical removal of the vitreous humor and temporary filling of the eye with liquid silicone, saline, or gas to replace the vitreous .
3. Photocoagulation for retinal breaks or proliferative retinal vascular disease.
426
What important investigations must be done in case of vitreous hemorrhage ?
Ultrasound to rule out retinal detachment
427
Central retinal vein occlusion
428
What are the differential diagnosis for floaters?
1. Retinal detachment
2. Posterior vitreous detachment
3. Posterior uveitis
429
Showers of floaters indicate the presence of free cells in the vitreous and are usually associated with
vitreous hemorrhage.
430
Define retinal vessel obstruction?
Retinal vessel occlusion is the complete or partial obstruction of retinal arteries or veins resulting in ischemia , most commonly due to thromboembolism
431
What are the symptoms of retinal vessels obstruction?
1. asymptomatic.
2. manifest as sudden painless loss of vision in the affected eye.
432
What is the classification of central retinal artery occlusion?
Classification of RAO is based on the site of the occlusion.
1. Central retinal artery occlusion (CRAO): obstruction of the central retinal artery after it branches from the ophthalmic artery
2. Branch retinal artery occlusion (BRAO): obstruction of one of the four branches (superior, inferior, nasal, or temporal) of the central retinal artery
433
RAO is a form of:
RAO is a form of acute ischemic stroke.
434
Which is more common central or branchial retinal artery occlusion?
BRAO is more common than CRAO. However, symptomatic CRAO is more common than symptomatic BRAO.
435
Hats the causes of retinal artery occlusion ?
1. Thromboembolism
2. Carotid artery atherosclerosis (most common)
3. Cardiogenic embolism (e.g., due to atrial fibrillation, valvular heart disease, infective endocarditis)
4. Retinal artery thrombosis due to atherosclerosis
5. Vasculitis (5% of cases): e.g., giant cell arteritis (GCA)
436
A patient with carotid bruit, with carotid atherosclerosis, irregular pulse in atrial fibrillation, jaw claudication in patients with GCA both experiment sudden unilateral painless loss of vission
Retinal artery occlusion
437
How do you manage patient with sudden painless unilateral loss of vision and has AF
1. Confirm the diagnosis with comprehensive eye examination; consider retinal imaging.
2. Perform concurrent assessment for underlying serious underlying etiologies (ischemic stroke, GCA).
3. Acute, symptomatic RAO is an ophthalmologic and medical emergency. Do not delay management as permanent retinal damage occurs quickly and there is a high risk of serious comorbid illness (e.g., cerebral stroke, cardiovascular disease).
438
1. Narrow retinal arteries (constricted and segmented) due to decreased blood flow.
2. Pale retina because of edema in the nerve fiber layer due to reduced blood flow which causes ischemia.
3. Cherry red spot at fovea (fovea is avascular naturally): it looks red because it lacks nerve fiber allowing the underlying vascularised choroid to show through ( a classic sign of CRAO)
4. Presence of embolus
439
Compare CRAO and BRAO
440
441
How would you asses for each of the following in case of retinal vessel occlusion?
1. GCA
2. Thromboembolism
3. Hypercoagulable state
1. Inflammatory markers and Temporal artery imaging and/or biopsy
2. Carotid duplex ultrasound, Echocardiogram , ECG
3. Coagulation studies
442
How to treat CRAO?
Treatment:
OCULAR EMERGENCY: attempt to restore blood fow within 2 h (irreversible retinal damage if >90
min of complete CRAO).
massage the globe (compress eye with heel of hand for 10 s, release for 10 s, repeat for 5 min) to
dislodge embolus
decrease IOP
1. topical β-blocker
2. IV acetazolamide
3. IV mannitol (draws fuid from eye)
4. drain aqueous fuid – anterior chamber paracentesis (carries risk of infection, lens puncture)
5. YAG laser embolectomy (that’s why you need to treat cataract)
6. intra-arterial or intravenous thrombolysis
7. hyperbaric oxygen therapy
Symptoms of giant cell arteritis; if present, initiate treatment of GCA with high-dose steroids before obtaining diagnostic studies.
443
Whats the cause of retinal vein occlusion ?
1. thrombosis
2. Diabetes
3. HTN
Common > 40 years old
444
Compare between central retinal vein occlusion and branchal retinal vein occlusion?
445
446
447
Describe what you see on fundoscopy for patients with retinal veins occlusion?
fundoscopy:
“blood and thunder” appearance
difuse retinal hemorrhages
cotton wool spots
venous engorgement
swollen optic disc
macular edema (cystic macular edema)
448
Complications of retinal vein occlusion ?
1. neovascularization of retina and iris (secondary rubeosis), may lead to secondary glaucoma •
2. vitreous hemorrhage
3. macular edema
449
Hats the treatment of retinal vein occlusion?
retinal laser photocoagulation
anti-VEGF, and/or corticosteroid injection
450
Whats retinal detachment ?
Retinal detachment refers to the detachment of the inner layer of the retina (neurosensory retina) from the retinal pigment epithelium.
451
Whats the most common type of retinal detachment ?
The most frequent causes of retinal detachment are tears or holes in the retina (rhegmatogenous retinal detachment),
452
Separation of the retina from the choroid for more than 12 hours leads:
leads to retinal ischemia and retinal degeneration
453
What are the risk factors for retinal detachment?
1. previous intraocular surgery
2. trauma
3. posterior vitreous detachment
