opthamology Flashcards
A patient presents with yellow discharge from the eye. On history taking the patient denies pain, photophobia, or blurring of the vision. What is the most likely diagnosis?
conjunctivitis (bacterial)
What is going to help you distinguish between viral and bacterial types of conjunctivitis?
yellow is mostly bacterial
watery is most likely viral
What features would raise a suspicion that perhaps this patient has a more atypical causative organism for their conjunctivitis?
green frothy purulent discharge
there could be corneal perforation (risk)
need to do STD screen
In a neonate, what would you suspect in a day 5-19 baby who presents with sticky discharge from the eye?
Chlamydia
treatment is tetracycline and oral abx
A patient presents with vesicles around the orbit. What is it most likely to be?
herpes simplex virus the treatment is eye drops with acyclovir 5 times per day.
What supplies the cornea of the eye with sensation?
The ophthalmic branch of trigeminal nerve (5)
What would you be concerned about in a contact wearer that presents with severe pain and a fairly normal looking eye on examination?
acanothameoba
Why do you not give steroids in a patient that presents with a red eye?
It could be a herpes simplex epithelial keratosis and make the dendritic ulcer worse. Also it may make the clinical symptoms leading to delayed diagnosis.
An elderly patient (long sighted) presents to the emergency department with vomiting. You observe she is wearing sunglasses in the february and is moaning in pain.
This could be acute angle closure glaucoma
treament is laser surgery
how can you tell the difference between episcleritis and scleritis?
episcleritis is benign and self-limiting
when asked in the history there is none of the four cardinal signs
scleritis on the other hand there is pain and tenderness on palpation (severe)
it is full thickness inflammation of the sclera
What are the other conditions associated with scleritis?
Rhuematoid arthritis
SLE
Wegeners
polyteritis nodosa
A toddler presents to the GP practice with red itchy eyes. When you look at the conjunctiva there is a cobblestone appearance.
this is most likely vernal conjunctivitis
IgE mediated
can lead to corneal ulceration if untreated
What is the treatment for vernal conjunctivitis?
topical mast cell topical steroids (only to be given by ophthalmologist) with topical steriods: 10% of people have increased eye pressure
In your examination of the eye there is inflammation fo the iris… which has a characteristic hazy appearance in the anterior chamber. what is this called?
acute anterior uveitis
What does acute anterior uveitis present with?
pain photophobia discharge
When you dilate the eye in the acute anterior uveitis what do you expect
relaxation of the ciliary muscles which will decrease the pain (spasm)
prevention of posterior synechiae (Iris adhering to the cornea)
When you are dieting the pupil in a patient with anterior uveitis, you observe that the pupil is irregularly shaped. What is this called and how does it occur?
It is called posterior synechiae and it occurs due to the Iris becoming attached to the cornea.
A patient presents to you with recurrent anterior uveitis. What are you now going to be considering in your differential?
autoimmune juvenile arthritis GI UC or chrons (ask about bowel motions) ankolsing spondylitis (MRI spine and sacroiliac joint) sarcoidosis * chest X ray
An elderly patient presents with vesicles on the distribution of the ophthalmic branch of the trigeminal nerve what are you worried about?
iritis?
There is nasal involvement in shingles what is this sign called?
Huchingsons sign need oral antiviral medication
When would you consider an interaocular foreign body?
if there is a history of hammering a nail (angle grinding)
To confirm suspicion radiological imaging at different angles to confirm a moving opacity in the eye.
When a patient presents with a subconjunctival haemorrhage what other investigations would you order?
BP (hypertension)
FBC (platelets)
Coagulopathy screen (liver function)
What does a corneal melt present with?
pain and blurry vision
active inflammation leading to auto digestion of the cornea
mangement surgical glue
What are the causes of red eye that you must think about when asking the patient a history in the ED
conjunctivitis uveitis keratitis acute angle closure glaucoma scleritis
How do you treat a conjunctival infection:
chloramphenicol drops or ointment: bacterial
viral no abx required
education about spread to their eye and hygiene should be given
What about a girl that comes into the clinic with her mother complaining of red itchy streaming eyes. She has a background history of eczema and asthma. When further questioned these happen seasonly in the spring time. What is your diagnosis and what sit he treatment?
Allergic conjunctivitis this can be treated with a 6 week course of topical sodium cromoglycate drops or with antihistamines (zirtek) for the duration of the hay fever season.
A patient comes in complaining of a red eye. On further questioning they reveal that they are in pain, they are sensitive to the light and have blurry vision. There is no discharge. What is your differential?
uvetitis, keratitis, and herpes simplex corneal ulceration.
What is your treatment for a herpes complex corneal ulcer?
need to be commenced on zovirax ointment 5 times per day and cyclopentolate 1% drops and immediate referral to the eye clinic.
A little old granny comes into the emergency deparemtn with severe headache and nausea and vomiting. On further questioning the patient has pain localized to the eyes. She also says her vision is a bit blurry. Looking at her glasses she is long sighted (hypermetropic). On eye exam, her pupils are mid ovale dilatated and cornea is hazy.
This is acute angle glaucoma until proven otherwise.
The treatment is the yag laser iridotomy
This allows fluid outflow. This is a vision preserving not curative.
A little child comes in and is rubbing his eyes. You notice as he comes in he has a erthymatous rash on his face. His mom is worried that he has red yes. On further questioning he has hay fever and a history of asthma as well. On examination of his conjunctivae he has cobblestoning.
vernal conjunctivitis this is treated with mast cell stabilizers and topical steroids
If it is not treated it can lead to punctuate epitheiopathy or epithelial macroerosions
You have a 16 year old girl walk in to your practice with her mother. Her mother explains that 5 weeks ago she had just received contacts for the first time. Now she is complaining of blurry vision, feeling like something is in her eye, and light bothering her. On eye examination you see expanding oval, yellow white dense stromatolites infiltrate and stromatolites suppurations and hypopyon.
This patient most likely has bacterial keratitis.
A 23 year old walks into your GP practice. He is a contact lens wearer and complains of severe pain. He doesn’t have any redness on eye exam and it appears normal looking. What should you do?
suspect acanthamoeba. Wa he wearing his contacts while swimming.
1. inflitrates the anterior stroma and then ulcerates and satellite lesions. can have stromal opacification.
treatment is chlorhexidine
A patient comes in with painful vesicles in a dermatomyositis distrubution over the opthamolic bracnh of the right trigéminal nerve.Also the lateral portion of the mose is involved.
This is herpes zoster can lead to dendritic ulceration and it stains with fluorescein.
Sudden loss of vision ins a young patient is most likely to be?
optic neuritis
central serous retinopathy
retinal detachment
Sudden loss of vision in a older patient is most likely causes by?
vascular- giant cell arthritis, central rental vein occlusion and central retinal artery occlusion. DO AN ESR retinal detachment vitreous heamorrhage wet macular degeneration cerebral infarction (CVA)
gradual loss of vision differential
cataract glaucoma presbyopia retinopathy/ DM. macular degeration progressive optic nerve neuropathy
What is the differential for transient loss of vision?
child- raised ICP young patient= ophthalmic migraine elderly- embolic (reversible ischemic attack’s) amaurosis fugax subacute angle closure glaucoma
What is the sign associated with amaurosis fugax?
cherry red macula
treatment is surgical decompression of the retinal anterior chamber.
What are the signs of subacute angle closure glaucoma?
colored halos around white light in decreased light.
What are the signs and symptoms of a cataract?
a cataract is a congenital or aquired opacity in the lens.
symptoms: gradual reduction in visual acuity
glare in the sunlight
signs:
dullness of the red light reflex
loss of the red reflex (hyper mature cataract)
complications of a cataract surgery?
Safe procedure: 98% of the time surgery is without any serious complications. serious complications: supra choroidal heamorrhage retinal detachment bacterial endophthalmitis
What are the other operative complications of cateract surgery?
corneal odema
iris prolapse
stitch problems- loosening or abscess
malpostion of the lens- glare halos or double vision
rupture of the posterior capsule with or without vitreous loss
retinal detachmentin high miopes
cystiod macular oedema.
wet Macular degeneration signs
present as sudden central vision distortion (metamorphosia)
what are the side effects of intraviteral injections
infection
retinal detachment
cataracts
intractable glaucoma
What are the signs of wet macular degeration?
macular edema or heamorrhage on OCT interestingly and subretinal fluid
on FFA leakage of flurescein
What is the management of macular degeneration?
macushield for patients greater than 50 years old with drusen dry
stop smoking
anti- veg 94% hold vision
30% show improvement but need lifelong repeat treatment
PDT- 50% hold vision none improve
What are the signs of dry macular degeneration?
vision impairment
What are the types of diabetic maculopathy?
focal exudative
diffuse edema
ischemic type
What is the management of focal exudative
responds well to focal laser
What is the treatment for diffuse oedema?
responds poorly to focal laser unless 40 years to less newer treatment anti-VEGF injections
What is a name of an anti VEGF drug?
lucentísima
What is the treatment for the ischemic type of diabetic maculopathy?
NOT LASER!!!!!! tight control of glucose and BP
What are the signs of diabetic pre-proliferation?
venopathy
cotton wool spots
deep dark flame shaped major hates
intra retinal micro vascular abnormalities
tight control of diabetes and laser treatment
What are the signs of proliferative diabetic retinopathy?
new blood vessels at the disc
new blood vessels elsewhere
vitreous heamorrhage
What is the management of proliferative diabetic retinopathy?
panretinal photocoagulation immediately
Why do diabetics go blind?
In type 2 diabetes Maculopathy
traditional detachment of the macula (type 1 diabetics)
non-resolving vitreous haemorrhage
Why do we screen diabetics?
to pick up retinopathy at a stage where vision has not been affected and to treat effectively with laser.
Can laser prevent blindness in all cases of diabetes?
no but in 90% it can
There is a patient that comes in and on the H test you see that the eye is turned down and out and not able to turn medically. There is also is also ptosis of the eyelid.
surgical third nerve palsy
parasympathetic fibers travel superficial isn’t he nerve and therefore compressed by aneurysms, trauma, and tumors. LOOK for DILATED PUPIL!!!! NEURO EMERGENCY
medical third nerve palsy- HTN or diabetes NORMAL PUPIL REFLEX
There is a patient that has a pupil that has a head tilt and is diplopia when reading.
fourth nerve limited depression of the eye
normal caused by congenital lesions
trauma can cause and vascular lesions
The patient is not able to abduct the eye
6 th CN palsy convergent squint causes are DM and HTN mimicked are myasthenia travis thyroid myopathy orbital myositis
What are the names of two glaucoma medications?
prostaglandin analogues (latanoprost) beta blockers timolol
What is the management of the 4th CN palsy
prism in reading glasses
What are the symptoms of a blowout fracture?
periocular echymosis and oedma
infraoribital nerve anaesthesia
ophthalmoplegia (up and down gaze)
enophthalmos- if severe
What are the investigations of a blow out fracture?
coronal CT scan- tear drop sign and the HESS test 0 restriction of up and down gaze
What is the treatment of a blowout fracture?
subciliary incision
periosteum elevation and entrapped orbital contents freed
defect repaired with synthetic material
periosteum sutured
What are the the signs of the of a medial wall blow out fracture?
periorbital subcutaneous emphysema and ophthalmoplegia- addiction and abduction if medial rectus muscle is entrapped
What is the treatment of a medial wall blow out fracture?
release of entrapped tissue
repair of bony defect
Vision loss in glaucoma?
temporal or nasal pattern
Orbital roof fracture is also associated with?
subconjunctival heamorrhage without visiable posterior limit
raccoon eyes
base of skull fracture
What is the medical treatment of chemical burns?
irrigation 30 minutes topical steroids (7-10 days) topical and systemic ascorbic acid to enhance collagen production topical citric acid topical and systemic tetracycline
What do you check in a third nerve palsy?
pupils
the eye appears down and out
In a fourth nerve palsy what will patients complain of?
double vision when reading
what is retinal occlusion?
What are you going to see on OCT and Fluoroscopy?
Fundoscopy= scattered flame shaped
cotton wool localised ischemia
Fluoroscopy= ischemia neovascular hyperplasia
OCT macular oedema and going to see fluid
what is the treatment for retinal occlusion
At first it is loss of vision without pain… anti-VEGF for life injections
but as the disease progresses there is rubosis which blocks into the angle of the eye to increase pressure to pressure
at this point they need PCP laser.
Type 1 most likely gets
retinopathy and proliferation
type 2 diabetes gets what
focal exudate maculopathy
What are you going to do to treat focal exudative maculopathy?
cauterization by laser
3 months later go back and check if the oedema is gone if not re laser
How do you treat diffuse diffuse oedema maculopathy?
good glycemic control and BP control
no role of laser or injection (IV)
What are the causes of a dull red light reflex?
cataract
vitreal heamorrhage
retinal detachment
