Opthalomology Finals Flashcards
How does vitreous haemorrhage present?
Painless vision loss
Red Hue in Vision
Floaters/dark spots in vision
Decreased visual acuity
Main cause of vitreous haemorrhage
Proliferative Diabetic Retinopathy
What investigations and findings for Vitreous Haemorrhage (3)
dilated fundoscopy: may show haemorrhage in the vitreous cavity
slit-lamp examination: red blood cells in the anterior vitreous
fluorescein angiography: to identify neovascularization
Retinal Detachment Signs/Symptoms
new onset floaters/flashes
sudden onset, painless vision loss - like a curtain
Mx of retinal detachment
Same day emergency referral - there laser therapy
Risk Factors for retinal detachment
Diabetes
Myopia (nearsightedness)
Age
Previous surgery for cataracts
Eye trauma - boxing
4 main causes of PAINFUL Red Eye
Hint - ASA
A - Anterior Uveitis
S - Scleritis
A - Acute Angle Closure Gluaocoma
BONUS:
Corneal abrasions or ulceration
Keratitis
Foreign body
Features of Anterior Uveitis (Get 5 at least)
Hypopyon
Painful Red Eye - DULL ACHE
Ciliary Flush
Abnormally shaped pupils
Photophobia
Lacrimation
Blurred vision
Reduced visual acuity
Causes of Painless Red eye
subconjunctival haemorrhage
episcleritis
Conjuncitivitis
Associated Conditions with Anterior Uveitis
Ankylosing spondylitis (and other seronegative spondylos)
IBD
Mx of anterior uveitis
Urgent referral to opthalmology
Steroid eye drops
Atropine/cyclopentolate
When should screening for glaucoma be done for those with a FHx
From age 40, annually
Primary Open Angle Glaucoma features
Peripheral vision loss (Think of the ‘O’ as a tunnel)
Optic disc cupping
Decreased visual acuity
Fluctuating pain - headaches sometimes
Halos
Dx of Open Angle Glaucoma (2)
Goldmann applanation tonometry for the intraocular pressure
Slit lamp assessment for the cup-disk ratio and optic nerve health
Management of Open Angle Glaucoma
Also 3 medications that can help - (ABCD)
360° selective laser trabeculoplasty
Meds:
A - Prostaglandin Analogue - Latanoprost - Increases uveoscleral outflow
B - BB - BLOCKS aqueous production
C - Carbonic anhydrase inhibitor eye drops - (e.g. Dorzolamide) - reduces aqueous production
What is Anisocoria
This is uneven pupil size
What is Holme’s Adie Pupil
Benign condition, where usually ONE pupil does not constrict - remains dilated
Homer Simpson Lazy
What is Argyll-Robertson pupil (ARP)
Accomodation Reflex Present (ARP)
Both pupils do not directly respond to light, but respond when light is shone in OTHER eye
Presents as small, irregular pupils
What is Hutchinson’s sign? What is is caused by?
HS - vesicles extending to the tip of the nose.
Caused by Varicella Zoster Virus reactivation (Shingles)
What does Hutchinson’s sign indicate and what are patients at risk of?
It indicates ocular involvement (inflammation can spread ‘ocular-ly’).
These patients are at risk of anterior uveitis
2 side effects of Latanoprost (Prostaglandin analogue)
‘TAN’ - Brown pigmentation of iris
PR - (PRETTY) Increased eyelash length
Features of MILD NPDR
MOD NPDR (4)
MILD - Just micro-aneurysms
MOD - microaneurysms
blot haemorrhages
hard exudates
cotton wool spots (‘soft exudates’ - represent areas of retinal infarction)
venous beading/looping
SEVERE NPDR features (2)
blot haemorrhages and micro-aneurysms in 4 quadrants
venous beading in at least 2 quadrants
Features of PDR
retinal neovascularisation - may lead to vitrous haemorrhage
Management of NPDR
regular observation
if severe/very severe consider PRP
Management of Diabetic Maculopathy
if there is a change in visual acuity then intravitreal vascular endothelial growth factor (VEGF) inhibitors - ranibizumab
CMV retinitis sign
PIZZA PIE APPEARANCE
CRVO features
Stormy sunset appearance - this represents vitreous haemorrhage
Sudden painless loss of vision
Retinal oedema
Cotton wool spots
Hard exudates
Why does a branch retinal vein occlusion (BRVO) occur
thought to occur due to blockage of retinal veins at arteriovenous crossings. It results in a more limited area of the fundus being affected.
Risk factors of CRVO
increasing age
hypertension
cardiovascular disease
glaucoma
polycythaemia
Side effects of PRP
Decreased visual fields
Decreased night vision
Management of CRVO
mainly conservative
macular oedema - intravitreal anti-vascular endothelial growth factor (VEGF) agents
retinal neovascularization - laser photocoagulation
Features of Wet Macular Degeneration
Characterised by choroidal neovascularisation - red patches
Gradual loss of central vision - scotoma
Crooked or wavy appearance to straight lines (metamorphopsia)
Features of Dry Macular Degeneration
characterised by drusen - yellow/amber round spots in Bruch’s membrane
Gradual loss of central vision - scotoma
Crooked or wavy appearance to straight lines (metamorphopsia)
Investigations of macular degeneration
Slit lamp examination gives a detailed view of the retina and macula
fluorescein angiography is utilised if neovascular ARMD is suspected
Mx of DRY Macular degeneration
Mx of WET Macular degeneration
combination of zinc with anti-oxidant vitamins A,C and E
Anti-vascular endothelial growth factor (VEGF) - ranibizumab, bevacizumab and pegaptanib,. The agents are usually administered by 4 weekly injection.
Causes of Central Scotoma
Age related macular degeneration - painless
Optic neuritis - Painful
Causes of “colour changes” in vision (2)
Optic Neuritis - poor colour discrimination (red desaturation)
Cataracts - Faded Colour vision - HARDER to distinguish
Causes of “RAPD”
Ocular trauma
CRAO
Optic Neuritis
Ocular Trauma signs
eye pain/swelling
proptosis
‘rock hard’ eyelids
relevant afferent pupillary defect
hx of trauma
Ocular trauma management
opthlamic emergency - urgent lateral canthotomy
Associated conditions w/scleritis (3)
rheumatoid arthritis: the most commonly associated condition
systemic lupus erythematosus
sarcoidosis
Scleritis mx
Painful red eye - so same day emergency referral
Oral NSAIDS first line
Oral glucocorticoids if more severe
Episcleritis asx conditions
Rheumatoid Arthritis
Inflammatory bowel disease
how to differentiate between scleritis and episcleritis?
phenylephrine drops may be used to differentiate - conjunctival and episcleral vessels but not the scleral vessels
if the eye redness improves after phenylephrine a diagnosis of episcleritis can be made
What group is PDR more common in
T1DM
Horner’s syndrome
miosis (small pupil)
ptosis
enophthalmos* (sunken eye) (may have)
anhidrosis (loss of sweating one side)
Causes of Horner’s
(4S, 4T, 4C)
4S - Central (cause anhidrosis of face AND body)
S – Stroke
S – Multiple Sclerosis
S – Swelling (tumours)
S – Syringomyelia (cyst in the spinal cord)
4T - Pre-ganglionic (cause anhidrosis of face)
T – Tumour (Pancoast tumour)
T – Trauma
T – Thyroidectomy
T – Top rib (a cervical rib growing above the first rib and clavicle)
4C’s - Post-Ganglionic - no anhidrosis
Carotid artery dissection
Carotid aneurysm
Cavernous sinus thrombosis
Cluster headache
Signs of congenital Horner’s syndrome
heterochromia
How to dx Horner’s
Cocaine eye drops
Squint mx
referal to secondary care
Also eye patches to help bad eye develop
Investigation for Acute Angle closure glaucoma
tonometry to assess for elevated IOP
gonioscopy (literally looking, oscopy, at the angle, gonio): a special lens for the slit lamp that allows visualisation of the angle
mx of Acute Angle Closure Glaucoma
Same day emergency referral
In community -
Lying the patient on their back without a pillow
Pilocarpine eye drops (2% for blue and 4% for brown eyes) - miotic agent, opens pathway for aqeuous humour to leave
Acetazolamide 500 mg orally - reduces aqueous humour
Laser iridotomy is usually required as a definitive treatment.
Features of Bacterial Conjunctivitis
Purulent discharge
Eyes “stuck” together
Highly Contagious
Management of bacterial conjunctivitis
Self-limiting usually
Hygiene measures - stay away from peeps and do not share THINGS. School exclusion not necessary tho
Chloramphenicol or fusidic acid (for pregnant women) eye drops
Features of Viral Conjunctivitis
Watery discharge
Recent URTI
Preauricular lymph nodes
Allergic Conjunctivitis Features
Bilateral symptoms conjunctival erythema, conjunctival swelling (chemosis)
Itchy
swollen eyelids
May be a history of atopy
May be seasonal (due to pollen) or perennial (due to dust mite, washing powder or other allergens)
Keratitis vs conjunctivitis
Conjuncitivits - whites of eyes (conjunctiva) - painless red eye
Keratitis - Cornea (colour) - painful red eye
Keratitis features
red eye: pain and erythema
photophobia
foreign body, gritty sensation
hypopyon may be seen
Causes of bacterial Keratitis and mx
typically Staphylococcus aureus
Pseudomonas aeruginosa is seen in contact lens wearers
stop using contact lens until the symptoms have fully resolved
topical antibiotics
typically quinolones are used first-line
cycloplegic for pain relief
e.g. cyclopentolate
Causes of Loss of Red Reflex (2)
Cataracts
CRAO
Features of acanthamoebic keratitis
increased incidence if eye exposure to soil or contaminated water
associated with contact lenses
pain is classically out of proportion to the findings
Dx of Keratitis
slit-lamp
mx of keratitis
Management
stop using contact lens until the symptoms have fully resolved
topical antibiotics
typically quinolones are used first-line
cycloplegic for pain relief
e.g. cyclopentolate
Corneal Abrasion Features
RED eye pain
lacrimation
photophobia
foreign body sensation
decreased visual acuity in the affected eye
KEY: fluorescein staining
examination typically reveals a yellow-stained abrasion
Herpes Simplex Keratitis (due to HSV mostly) Features
KEY: DENDRITIC ULCER ON SLIT LAMP
red, painful eye
photophobia
visual acuity decreased
Keith Wagener Staging (SAFE)
S - Slim (mild narrowing of aterioles) - STAGE 1
A - AV nicking - STAGE 2
F - Flame - haemorrhages - STAGE 3 (+COTTON WOOL SPOTS)
E - Oedema - Papilloedema
Mx of Hypertensive retinopathy
managing BP, risk factors
Dx of Optic neuritis
MRI of the brain and orbits with gadolinium contrast
How to tell Pre-orbital and orbital cellulitis apart
mx for orbital
Using a CT
mx for orbital - Oral/IV abx
Features of a 3rd nerve palsy?
“down and out appearance of eye”
dilated and fixed pupil
ptosis
Causes of a 3rd nerve palsy
diabetes mellitus
vasculitis e.g. temporal arteritis, SLE
Aneurysm
Features of 6th nerve palsy
This will result in a cross eyed look
Features of a fourth nerve palsy
vertical diplopia (think of 4 and the number 2)
classically noticed when reading a book or going downstairs
subjective tilting of objects (torsional diplopia)
the patient may develop a head tilt, which they may or may not be aware of - they do this to avoid the vertical diplopia
