Opthalmology - Vision Loss, Disorders of ocular media and posterior eye Flashcards

1
Q

Ddx transient vision loss

Differentiating features

A

Retinal TIA

**Retinal Migraine **

**Papilledema **

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2
Q

Ddx ocular media disorders that cause acute vision loss

A
  • Keratitis
  • Acute glaucoma/ corneal edema
  • Anterior uveitis
  • Hyphema or trauma
  • Acute lens changes/ lens dislocation/ lens opacity
  • Vitreous hemorrhage
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3
Q

Hyphaema

Features

A
  • Hyphaema refers to blood in anterior chamber
  • May result from blunt trauma or spontaneously in ds characterized by neovascularization (eg. DM)
  • Slit lamp examination shows blood in anterior chamber ± ↑IOP
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4
Q

Acute lens changes

Causes

A
  • Due to changes in size, clarity or positioning of lens resulting in alteration of focus of light onto the retina
  • Lens dislocation can occur in trauma or ectopia lentis
  • Acute lens opacity can occur in rapid changes in glucose or electrolyte levels
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5
Q

Vitreous hemorrhage

Causes

A
  • Causes include trauma, spontaneous retina tear, spontaneous vitreous detachment or retinal neovascularization (eg. PDMR, wet ARMD)
  • Sudden, painless loss of vision
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6
Q

Ddx Retinal Disorders that cause acute vision loss

A

C/BRAO
C/BRVO
Retinal detachment
Acute maculopathy
Posterior uveitis or retinitis

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7
Q

Ddx Optic nerve disorders that cause acute vision loss

A
  • Optic neuritis
  • Compressive optic neuropathy
  • Ischemic optic neuropathy
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8
Q

Retinal vein occlusion/ retinal artery occlusion

Features

A

RAO:
- Can result from thrombosis, embolism or CRA arteritis
- Usually a/w severe sudden painless partial or complete visual loss - RAPD +ve
- Fundus: embolus (early) or milky white infarct + cherry spot (late)

RVO:
- Typically subacute painless partial/complete visual loss
- ± RAPD+ if severe venous stasis leads to venous infarct
- ‘Blood and thunder’ appearance on fundus (disc swelling, diffuse nerve fibre/pre-retinal haemorrhage, CWSs)

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9
Q

Retinal detachment

Features

A
  • May be preceded by floaters (small vitreous bleeds or vitreous detachment) and photopsia (vitreoretinal traction)
  • Typically results in a painless curtain-like loss of visual field on the opposite side of the actual detachment
  • Vision will be severely impaired if macula is involved
  • RAPD ± (only if severe) and fundoscopy shows elevated retina with folds
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10
Q

Acute maculopathy

Features

A
  • Causes include ARMD, central serous retinopathy, macular hole
  • Maculopathies classically a/w central scotoma, blurred vision or visual distortion
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11
Q

Optic neuritis

features

A
  • Characterized by focal demyelination of optic nerve
  • ↓VA and washed out colour vision with RAPD+ of onset over a few days
  • Pain on eye movement if optic sheath is involved
  • May be a/w antecedent flu-like viral syndrome
  • Fundus: papillitis (nerve head swelling), may be ABSENT in retrobulbar ON, optic atrophy after oedema resolved
  • A/w multiple sclerosis esp in young female
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12
Q

Acute vision loss

Key questions for ddx

A

History:
- Trauma or surgery
- Transient/ acute (vascular/ infective) vs chronic/ progresive (structural causes)
- Pattern of vision loss: Monocular prechiasmal lesion; Binocular chiasmal/ post-chiasmal lesion
- Visual disturbance: Visual distortion/ metamorphopsia in maculopathy, Glare in cataracts, Rainbow haloes around lights in glaucoma
- Pain or red eye: keratitis, uveitis, acute glaucoma, optic neuritis?
- A/w neurological defects? Severe nausea and vomiting, rhinorrhea (glaucoma)?

Past opthalmic history:
- Severe myopia > retinal detachment
- Severe hyperopia > AACG
- Contact lens > Bacterial keratitis
- Previous ocular surgeries: keratitis, uveitis, corneal edema…etc

Past history:
- Vascular diseases: RAO/ RVO/ ION/ Visual pathway stroke
- DM: Vitreous hemorrhage, acute maculopathy
- MS/ Autoimmune disease: Optic neuritis
- Medications

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13
Q

Acute vision loss

All ddx

A

Transient vision loss/ Amaurosis fugax
- Retinal TIA
- Retinal migraine
- Papilledema

Ocular media:
- Keratitis
- Corneal edema/ acute glaucoma
- Anterior uveitis
- Hyphema
- Acute lens dislocation
- Vitreous hemorrhage

Retinal:
- C/BRAO, C/BRVO
- Retinal detachment
- Acute maculopathy
- Posterior uveitis/ retinitis

Optic nerve:
- Optic neuritis
- Compressive optic neuropathy
- Ischemic optic neuropathy

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14
Q

Ddx monocular and binocular vision loss

A

Monocular: prechiasmal lesion
- Peripheral loss → subtotal retinal detachment, ION, BRAO/BRVO, (chiasmal ds)
- Central loss → maculopathy (+ve scotoma) or optic nerve (-ve scotoma)
- Altitudinal → corresponding retinal vascular or optic disc disease

Binocular suggestive of chiasmal/post-chiasmal lesions
- Bitemporal → chiasmal lesions, eg. pituitary tumour, craniopharyngioma, suprasellar meningioma
- Homonymous → post-chiasmal, eg. parietal/temporal lesions, occipital infacts

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15
Q

Acute vision loss

  • Clinical exams
A

□ Inspection: erythema, tearing, light sensitivity, proptosis, ptosis

□ VA/VF: not corrected by pinhole

□ Pupils: symmetry, reactivity to light, pupillary reflex, RAPD → RAPD: fairly specific for unilateral optic nerve pathologies

□ EOM testing

□ Fluorescein testing for corneal pathologies

□ IOP testing for glaucoma

□ Slit lamp examination for anterior pathologies

□ Ophthalmoscopic examination for posterior pathologies → Red reflex: loss indicates media opacity

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16
Q

Chronic vision loss

All ddx

A

Cloudy media
- Corneal opacity: corneal edema from anterior uveitis, trauma, cataract surgery, interstitial keratitis, band keratopathy, corneal scarring…etc
- Cataract
- Vitreous hemorrhage

Retinal diseases:
- DM retinopathy
- Age-related macular degeneration
- Retinitis pigmentosa
- Epiretinal membrane
- Cystoid macular edema
- Macular hole
- Choroid malignancies

Optic nerve disorders:
- Chronic glaucoma
- Optic neuropathy

Refractive error

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16
Q

Cataract

  • Causes
  • Types
  • S/S
  • Dx
  • Mx
A

Cause: light-scattering opacity in the lens
- Congential cataracts
- Senile cataract (nuclear sclerotic, cortical, posterior subcapsular)
- Secondary cataract:
→ Ocular ds: trauma, uveitis, scleritis (esp if necrotizing), ↑↑myopia, ocular RT in intraocular tumours
→ Systemic ds: myotonic dystrophy, systemic steroids or chlorpromazine, DM/metabolic ds, congenital rubella, atopic dermatitis, Down’s syndrome

Symptoms:
- Gradual painless vision loss over years
- Glare
- Myopic shift
- Amblyopia
- Secondary glaucoma
Signs:
- Decrease VA in bright light (glare and pupil constriction)
- Loss of red reflex
- Lens opacity on slit lamp exam
- Refractive error

Dx: clinical exam showing lens opacity and exlusion

Mx:
- Phacoemulsification or Extracapsular Cataract Extraction (ECCE) with Intraocular Lens Implantation (IOL)
- Short course steroids and abx
- Visual rehabilitation and new glasses perscription

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16
Q

Chronic vision loss

Key questions
Clinical exams

A

History:
Pattern of visual loss?
- Gradual blurring or dimming of vision
- Distortion → usually maculopathy
- Central scotoma → maculopathy (+ve) or optic neuropathy (-ve)
- Constricting VF → chronic glaucoma (or retinitis pigmentosa)

Other visual disturbances?
- Glares → cataract
- Rainbow haloes → glaucoma

Pain? chronic dull eye pain may occur in glaucoma

Systemic diseases? DM, HTN

P/E:
→ VA, VF
→ pattern of visual loss
→ Pupil exams and RAPD
→ RAPD = optic n. pathology (usually)
→ Red reflex lost in ↑ocular media opacity
→ Fundoscopy for posterior eye pathologies

17
Q

Cataract surgery complications

A
  • Suture-related: corneal astigmatism, irritation
  • Endophalmitis
  • Vitreous loss (risk glaucoma, retinal traction)
  • Iris prolapse
  • Cystoid macular edema
  • Retinal detachment
  • Phacolytic uveitis
  • Posterior capsule opacification
18
Q

Glaucoma

Cause
Types/ Classification

A

Glaucoma:
□ Progressive optic neuropathy with characteristic VF loss
□ Usually a/w raised intraocular pressure (↑IOP) but NOT always (eg. in normotension glaucoma)

Cause:
- Increase production of aqueous humour
- Blockage of humour drainage via Schlemm’s canal or uveoscleral pathway
- Increase IOP causes compressive optic neuropathy, progressive VA loss and pathological cupping of disc

Types:
□ Chronicity: acute vs chronic
□ Aetiology: primary vs secondary
□ IOP: high vs normal
□ Angle status: open angle vs closed angle

Examples:
→ Primary open angle glaucoma (POAG)
→ Acute angle closure glaucoma (AACG)
→ Chronic angle closure glaucoma (CACG)
→ Normal tension glaucoma (NTG)22

19
Q

Primary Open Angle Glaucoma

  • Cause
  • S/S
  • Clinical tests
  • Dx
  • Mx
A
20
Q

Primary angle closure glaucoma
- Cause
- S/S
- Clinical tests
- Dx
- Mx

A
21
Q

Secondary glaucoma
Causes
S/S
Mx

A
22
Q

Vitreous hemorrhage

Causes
S/S
Clinical tests
Mx

A
23
Q

Floaters/ PVD
- Cause
- S/S
- Cx
- Tx

A
24
Q

Retinal detachment

Types
Causes

A
25
Q

Rhegmatogenous retinal detachment

Causes
S/S
Clinical tests
Tx

A
26
Q

Tractional retinal detachment

Causes
S/S
Mx

A
27
Q

Exudative retinal detachment
Causes
S/S
Mx

A
28
Q

Retinitis pigmentosa
Causes
S/S
Dx
Mx

A
29
Q

Choroidal neoplasms
Types
S/S
Dx
Mx

A
30
Q

Maculopathies

Key features

A

Features of macular diseases:
□ Blurred central vision
□ Metamorphopsia (distorted vision) due to disturbance in arrangement of photoreceptors → Micropsia (↓size) or macropsia (↑size)
□ Central scotoma due to part of photoreceptor being covered

31
Q

Age-related macular degeneration
Cause
Types
Classical symptoms

A

Cause: degenerative ds of macula leading to loss of central vision

Types:
- Dry (non-exudative) AMD with geographic atrophy and drusen
- Wet (exudative) AMD with choroidal neovascularization, neovessels grow into subretinal space to form Subretinal Neovascular Membrane and Subretinal Hemorrhage

Symptoms:
□ Asymptomatic in early stages
□ Visual disturbance: usually gradual but may be acute in wet AMD (due to acute subretinal haemorrhage)
→ Visual blurring
→ Metamorphopsia: more common in wet AMD - Amsler grid: used to assess progression of AMD
→ Central scotoma

32
Q

Signs specific to dry ARMD

A
  • Loss of normal foveal reflex
  • Drusens: discrete, subretinal yellow lesions
    → Hard: small, well-defined, of limited significance
    → Soft: larger, poorly-defined, ↑risk of vision loss
    → Cf exudate: duller yellow, less well-defined, not a/w other features of ↑vascular permeability
  • Geographic atrophy: atrophic hypopigmented regions with visualization of choroidal vessels
  • RPE focal hyperpigmentation: plaques of hyperpigmentation
33
Q

Signs specific to wet ARMD

A

□ Subretinal fluid: stereoscopic elevation of retina
□ Subretinal neovascular membrane: grey-green membrane
□ Subretinal haemorrhage
□ Disciform scar in advanced cases (sub-RPE neovascularization leading to subretinal fibrosis)

34
Q

ARMD
- Clinical tests
- Mx

A

Clinical tests:
□ Usually clinical dx for dry AMD
□ Fluorescein retinal angiogram for suspected wet AMD: identify location of membrane (rel. to RPE)
□ Optical coherence tomography: identify retinal oedema and subretinal fluid + monitor for Tx response

Dry ARMD Mx:
- AREDS2 forumlation oral supplement
- Risk factor mx: stop smoking
- Self-monitor with Amsler grid

Wet ARMV Mx:
- Intravitreal VEGF inhibitor
- Photodynamic therapy
- Direct focal laser
- AREDS2 oral supplement

35
Q

Retinal vascular diseases

Signs of retinal vascular leakage

A
36
Q

Signs of retinal vascular occlusion

A
37
Q

Retinal artery occlusion

Causes
Types
S/S

A
38
Q

Retinal vein occlusion

A
39
Q

Diabetic retionpathy

A
40
Q

Hypertensive retinopathy

A
41
Q
A