optho Flashcards
Features of horners syndrome
Miosis
Ptosis
Enopthalmos - sunken in
Anihidrosis
Causes of optic neuritis
MS
Diabetes
Syphilis
Management of optic neuritis
High dose steroids
(Recovery 4-6 weeks)
Features of optic neuritis
Unilateral decrease in visual acuity - over hours or days
Poor discrimination of colours
Pain worse on eye movement
Relative afferent pupillary defect
Central scotoma
Investigation of optic neuritis
MRI of brain with orbits with contrast
Is diagnostic
A 50-year-old woman presents to the emergency department with severe left eye pain over the last 4 hours. She has no changes in her vision, nausea, or vomiting and has a past medical history of rheumatoid arthritis and takes methotrexate. She does not wear any contact lenses.
Her pulse is 92 bpm, her blood pressure is 123/75 mmHg, and she is afebrile. The left eye is deep red and injected throughout. When palpating the eye, the injected vessels do not move and her eye is tender. The right eye is normal and visual fields and acuity are intact.
What is the most likely diagnosis?
Scleritis
Main features = extremely painful, deep red injected eye, patient has systemic connective tissue disease, reduced visual acuity, blurred vision
Management of scleritis
same day assessment by an ophthalmologist
Oral NSAIDS = 1st
Oral glucocorticoids - more severe
Immunosuppressive drugs for resistant cases
What is orbital cellulitis
result of an infection affecting the fat and muscles posterior to the orbital septum - not involving the globe
Usually caused by URTI spreading from sinuses
Is a medical emergency - risk of cavernous sinus thrombosis and intracranial spread
Risk factors of orbital cellulitis
Childhood 7-12 years
Previous sinus infection
No Hib vaccine
Recent eyelid infection
Ear or facial infection
Presentation of orbital cellulitis
Redness and swelling around the eye
Severe ocular pain
Visual disturbance
Proptosis
Opthalmoplegia
Eyelid oedema and ptosis
Drowsiness +/- nausea and vomiting in meningeal involvement
IVX orbital cellulitis
FBC
Clinical examination
CT with contrast
Blood cultures and microbial swab
MXM orbital cellulitis
Hospital admission for IV abx
Leading mechanisms for ocular trauma
Blunt trauma
Penetrating injury
What type of fracture associated with blunt force
Blow out fracture ie fist to the face/squash ball
Structures involved in blow out fracture
herniation of the fat
Tethering of inferior recuts
Infraorbital nerve
Inferior nerve get trapped in inferior wall of orbit
What is hyphaema
Blood in anterior chamber
What medical condition could show a dislocated lense
Marfans
SEIDELS
fluoroscein drops into the eye - would show any aqueous damage
Sympathetic opthalmia
Exposure to intraocular antigens > due to penetrating injury to one eye > but can get auto-immune reaction in both eyes
Inflammation in both eyes > may lead to penetrating blindness
How to remove small foreign body on cornea
slit lamp
Local anaesthetic
Edge of needle > scrape of scoop
Cover with chloramphenicol ointment after
Investigation for intro-ocular foreign body
imaging - x-ray or CT
Chemical injury management
Quick history
Check toxbase if possible
Check pH
Irrigate +++ (2L saline)
Then assess under slit lamp
Ametropia
refractive error present - light focused in front of or behind retina
There are 3 refractive states:
Myopia - before the retina
Emmetropia
Hyperopia - after retina
Emmetropia
Normal vision
Anisometropia
Significant difference between right and left ametropia
Anisometropia
Significant difference between right and left ametropia
Amblyopia
Lazy eye
Astigmatism
Rugby ball eye shape - blurry vision
Spectacle prescriptions
+3.00 / -2.00 x 90
Recommended imaging for optic neuritis
MRI brain and orbits with contrast
Steadily worsening loss of vision over the previous few months - followed by a sudden deterioration
Examination findings of a central scotoma and red patches
Wet age-related macular degeneration
Dendritic corneal ulcer
Herpes simplex virus
Tx. - topical acyclovir
MoA of timolol
Used in primary open-angle glaucoma by reducing aqueous production
MoA of prostaglandin analogues
Increases uveoscleral outflow
MoA sympathomimetics
Reduces aqueous production and increases outflow
Carbonic anhydrase inhibitors
Reduces aqueous production
MoA miotics
Increases uveoscleral outflow
Ptosis + dilated pupil
3rd nerve palsy
Ptosis + constricted pupil
Horners
What usually causes blow out fractures
Direct blow to the central orbit from a fist or a ball
Most common blowout fracture
Inferior blowout - orbital fat prolapses into the maxillary sinus and may be joined by prolapse of the inferior recuts muscle resulting in Diplopia
Organs with autonomic innervation
Sympathetic innervation of arterioles, sweat glands and arrector muscles
Smooth muscles of iris and ciliary body associated with the lens
Lacrimal glands
Salivary glands
Sympathetic innervation route -
originates from autonomic centres
Passes down spinal cord
Exits spinal cord with T1 - L2 spinal nerves
Travel to sympathetic chains running the length of vertebral column
Pass into all spinal nerves
Pass into splanchnic nerves > organs
What is the commonest cause of a red eye
conjunctivitis 30% of all primary care cases
Red painful eye and photophobia , fluorescein and slit lamp exam - dendritic ulcer
What is the causative organism
HSV
20 year old female presents with red, severely painful eyes - phenylephrine drops > redness does not blanch
What is the mxm for this
Oral NSAIDs
For scleritis
What is used to test between episcleritis and scleritis
phenylephrine drops - non-blanching is scleritis
Which conditions can cause anterior uveitis
UC
Syphilis
Leukaemia
HLA B27
Child has a 1 day history of redness and swelling around the eyes with pain on eye movement and history of a URTI - what is the initial investigation
CT scan
65yr old woman complains of sudden, painless loss of vision since this morning - L fundus shows flame haemorrhage and RAPD
What is the diagnosis
Central Vein occlusion
67 year old man with T2D, present with visual disturbances for 3 hours - reports black spots obscuring left eye with a red hue
Vitreous haemorrhage
What is a risk factor for retinal detachment
Myopia
What is seen on fundoscopy of someone with a retinal artery occlusion
Pale retina with a cherry red spot
Retinitis pigmentosa
bony spicule
What is the main cause of a retinal artery occlusion
Giant cell arteritis
3 year old is brought to GP as his mother is concerned about cross-eyes - corneal light reflection tests confirms strabismus .
What is the management ?
Opthalmology clinic where they are given an eye patch
Eye changes classically seen in thyroid eye disease / Graves’ disease
inability to close the eyelids
Eye is down and out
3rd nerve palsy
What in thyroid eye disease would warrant an urgent review by opthalmology
Optic disc swelling
A 60 year old diabetic patient has microaneurysms and new blood vessel formation - no changes on the macula
Definitive management ?
Pan-retinal laser coagulopathy
What is a risk factor for developing glaucoma
Steroids
Most common cause for retinal artery occlusion
Arteroi-sclerosis related thrombosis
Most common cause for retinal artery occlusion
Arteroi-sclerosis related thrombosis
What describes the change in the optic disc seen in glaucoma
Increased cup to disc ration - cupping
What isn’t a feature of angle-closure glaucoma
Symptoms worse on bright light - patients actually find it worse in dark room due to dilation > putting pressuring on trabecular mesh work or something
Which type of visual field loss is associated with open angle glaucoma
nasal stepping - peripheral vision is lost first in open angle glaucoma
Central scotoma
macular degeneration
What are the side effects of 1st line for open angle glaucoma
Change in eye colour / pigment
Longer eyelashes
Latintaprost
What do you see with a right sided trochlear nerve palsy
up and outwards
Trochlear nerve > SO > attaches behind to move it forwards and down so if not working it will start to drift up
Oculomotor nerve palsy
CN III - down and out
Ptosis, diplopia and eye that is fixed down and laterally - an aneurysm of which vessel is most commonly implicated
Left posterior communicating artery
Which foramen does CN III IV and VI pass through
Superior orbital fissure
On visualising the retina of an 88-year old man with increasingly blurred vision and reduced central vision, choroidal neovascularisation
Diagnosis ?
Wet macular degeneration
Tx for dry macular degeneration
Vit C, E, beta carotene and zinc
Senior woman diagnosed with dry macular degeneration - what is seen on fundoscopy
drusen
What is not associated with cataract development
Hypertension
What is the most associated risk factors for cataracts
Old age
Steroids
DM
Smoking
What is a sign of cataract
A defect in the red reflex
75 year old present with left homonymous hemianopia - where is the lesion
Right optic tract
55 year old male present with bitemporal hemianopia - has a PMH of pituitary adenoma - where is the lesion
Optic chiasm - tunica celiac
Patient presents to A&E after a RTA - left homonymous hemianopia with macular sparing - where is the lesion
Occipital cortex - due to macular sparing (further back in the brain)
III nerve palsy
Least common in optho
Innervates everything else
IV nerve palsy
Superior oblique - to look left and down (R)
And so eye is looking up - patient has vertical double vision
Depression in adduction
VI Nerve Palsy
Most common
Most serious
Lateral recuts is not working and so cannot abduct and also turns inward
Causes:
Micro vascular
Raised intracranial pressure
Tumours + congenital
How does raised intracranial pressure cause VI palsy
Pressure increases inside cranium - brain gets pushed down - comes over Petrous bone and into the orbit > eyes goes into squint
VI nerve palsy symptoms
Squint
Diplopsia
VI nerve palsy investigation
Fundoscopy - papiiloedema
IV nerve palsy symptoms
Patients can present with a tilt (incyclo-torsion weak)
Vertical double vision
IV nerve palsy bilateral symptom
Torsion
Chin depressed
Blurry vision - asthenopia
Causes of IV palsy
Congenital decompensated
Microvascular
Tumours
Bilateral - trauma
III nerve palsy symptoms
If only IV and VI nerve are working > abducted and looking down = ocular position , down and out (w/ ptosis)
Blown pupil (dilated - sphincter papillae not innervated)
Painful III nerve palsy***
Aneurysm !
Posterior communicating artery of circle of Willis is compromised = LIFE THREATENING
Causes of visual field defects
Vascular disease
Space occupying lesions
Demyelination
Trauma
How many bones make up the orbit
7
What is a dendritic ulcer
Caused by HSV
Causative organism of dendritic ulcer
Herpes simplex
What treatment should you avoid in dendritic ulcer
Do not give a steroid
Investigation for III nerve palsy caused by Pcomm artery aneurysm
MR angiogram
What causes cupping
Glaucoma
What is Oculo- coherence tomography
Non-invasive way to monitor to see in greater detail of the eye
What investigation is useful for ARMD
OCT scan
When would you see a hypopyon
Anterior uveitis
What is a hyphaema
Haemorrhage - blood in the anterior chamber
What is the main risk factor for acanthamoeba keratitis
Contact lens use
What symptom are you most likely to experience with increased intraocular pressure
Reduced peripheral vision
Clinical features of wet age related macular degeneration
A reduction in visual acuity - particularly for near field objects = subacute
Difficulties seeing in the dark
Fluctuation in visual disturbances
Photopsia /glare around objects
Positive AMSLER grid testing
New blood vessels > choroidal neovascularisation
What are the investigation for ARMD
Slit - lamp microscopy
Fluorescein angiography
Ocular coherence tomography
Treatment of ARMD
Vascular endothelial growth factor (anti-VEGF)
+ laser photocoagulation
What is optic neuritis associated with
MS, diabetes and syphillis
*red desaturation
Optic neuritis
*horners syndrome + neck pain
Carotid artery dissection
*teardrop sign on x-ray
Due to a blowout fracture
What innervates orbicularis oculi
Facial nerve - palpebral part gently closes the eye, orbital part tightly closes the eye
What is the action of superior tarsal muscle ? (Muellers)
Elevating the upper eyelid - affected in Horner’s
(Sympathetic innervation)
What type of glands produce meibum ?
Tarsal glands / meibomian glands
Innervation of the extra-ocular muscles
LR6 (lateral rectus - CN VI)
SO4 (superior oblique - CN IV)
AO3 (all else - CN III)
Name these
What produces lacrimal fluid
Lacrimal gland - innervated by CN VII (parasympathetic)
Fluid - washes over eye > medial angle > drains through lacrimal punctuation > lacrimal sac > nasal meatus
What make up the 3 layers of the eye
Fibrous = sclera + cornea
Uvea - vascular layer = ciliary body + iris + choroid
Retina = macula + optic disc + retina
Where is the vitreous body found
Posterior segment of eye
What produces aqueous humour
The ciliary body
Route of aqueous humour
It is produced by the ciliary body
It then circular within the posterior chamber
It then passes through the pupil into the anterior chamber
And is then reabsorbed into scleral venous sinus (Canal of Schlemm) at iridocorneal
What makes up the retina
Optic disc - only point of entry/exit for blood vessels
Macula - greatest density of cones
Fovea - area of most acute vision
CN II affected
Why is the optic disc the ‘blind spot’
There are no photoreceptors there
Features of rods
Contain rhodopsin - activated by light (requires vit. A)
High convergence —> increased sensitivity, reduced acuity
Features of cones
3 types
Low convergence —-> increased acuity, reduced sensitivity
What type of palsy is this ?
‘Down and out’
Oculomotor CN III (only superior oblique and lateral rectus are therefor working - SO pushes eye down, LR pulls eye out to the side hence down and out appearance)
What nerve palsy is this ?
Palsy to CN VI (LR is paralysed > hence eye deviates medially)
*double vision looking down
Nerve palsy to CN IV
Management for conjunctivitis
Mild viral = hypromellose + if still angry topic antiviral + Cold compressses
Bacterial = topical chloramphenicol
Allergic = avoidance of triggers
What is keratitis
Inflammation of the cornea
Contact lens related
Herpes Simplex is the commonest causative organism
Presents as a dendritic lesion with fluorescein stain, severe ocular pain associated with foreign body sensation, watery eye, photophobia and reduced visual acuity
Investigations of keratitis
Examination with fluorescein
Corneal swab
Slit lamp
If hypopyon seen > immediate specialist referral + culture
Management of keratitis
Viral = topical antiviral
Bacterial = ofloxacin + chloramphenicol
Fungal = topical anti fungals
Main causes for anterior uveitis
Autoimmune - reiters, UC, ankylosing spondylitis, sarcoidosis
Management of anterior uveitis
Topical steroids
Mydriatics
*gritty eyes, foreign body sensation, mild discharge
Blepharitis
Management = warm compress, tear drops, oral doxycycline
Which eye is shown in the image of a normal retina
RIGHT EYE - the optic disc is present on the nasal side of the retina
How to perform the relative afferent pupillary defect ?
Move the pen torch swiftly between the pupils
Name missing
Bones of the orbit
What conditions results in acute vision loss
Amaurosis fugax
Close angle glaucoma
Vitreous haemorrhage
Pathological changes seen on retina with diabetes
Cotton wool spots
What do you see as hypertensive retinopathy
Copper wiring
Retinopathy seen with retinal artery occlusion
Cherry red spots
Shadow that being in lower, inner part of patient’s vision what retinal detachment is this ?
Superior temporal retinal detachment
Superior - lower
Temporal - inner
‘Phacoemulsification and insertion of an intra-ocular lens into the eye’ describes what procedure
Procedure to fix cataracts
*absent red reflex + dense opacfication of the lens
= cataracts
Lesion at the parietal lobe would result in what ?
Contralateral homonymous inferior quadrantinopia
Lesion at the visual cortex (macula sparing) would result in what ?
Contralateral homonymous hemoanopia
Lesion in the temporal lobe would result in what visual field change?
Contralateral homonymous superior quadrantinopia
Optic tract lesion would result in what visual field change
Contralateral homonymous hemianopia
Management of viral conjunctivitis
Conservative management
management of bacterial conjunctivitis
Chloramphenicol
Management of herpetic keratitis / dendritic ulcer
Topical acyclovir
What investigation is used to differentiate between dry and wet ARMD
Optical coherence tomography (OCT)
What investigation would be useful in differentiating what level of wet ARMD has occurred ie how much new neovascularisation
Fluorescein angiogram
*extended contact lens use
Infectious keratitis
What disease does this retina look like its associated with
Hypertension
> this is hypertensive retinopathy
What is rhodopsin converted into when it is exposed to light ?
> opsin and trans-retinal
What does the conversion of rhodopsin lead to ?
Conversion into opsin and trans-retinal causes the sodium channels to CLOSE and the membrane is hyper-polarised which results in NO neurotransmitter being released into the synapse
A greater potential is then produced in the bipolar cell, and if it is great enough an action potential is generated in the ganglion cells which is propagated to the brain
What is seen on this retina
Optic nerve swelling
What is seen
Dendritic ulcer identified with fluorescein drops
What is this ?
Keratic precipitates
What does a hypopyon look like ?
What are synechiae?
Adhesions between the pupil and iris and can lead to small/irregular pupil
*corneal reflections are not symmetrical = what type of squint ?
Manifest squint
Convergent vs divergent squint
When the uncovered eye moves OUT to take up fixation = convergent
Mechanical closure of aqueous drainage angle’ describes what disease pathway ?
Acute angle closure glaucoma
‘T-cell driven inflammation with recruitment of other inflammatory cells such as macrophages’ describes what disease pathway
Development of scleritis
‘Higher intra-ocular pressure resulting in reduced blood flow to the optic head and subsequent nerve loss’ describes the disease pathway for what ?
Proposed mechanism for chronic open angle glaucoma
‘Entry of bacteria, fungi, Protozoa via a defect in the corneal epithelium causing an inflammatory response’ describes what disease pathway
Infectious keratitis
What is the most concerning type of trauma to the eye ?
Alkali burn
(Acid burn = coagulative necrosis that is contained before cornea
, alkali - liquefactive necrosis with breakdown of normal cellular barrier > penetrates past the cornea)
Describe EXOtropia
Uncovered eye moves in to take up fixation
It was in a divergent position = manifest divergent squint
What type of squint moves down to take up fixation
Hypertropia
What type of squint moves up to take fixation
Hypotropia
What type of squint moves out to take up fixation - having been in a convergent position
ESOtropia
The clinical sign ‘chemosis’ is seen with what disease
Viral conjunctivitis
(It is oedema of the conjunctiva)
Episcleritis vs scleritis
Episcleritis = self-limiting (can be fixed with some lubricant)
Scleritis = usually comes about due to associated conditions
*purple appearance of sclera + headache , treated with topical steroids/topical anti-inflammatories can if not managed needs to be treated with IV immunosuppression (scleral melt)
Tx of viral conjunctivitis
Cold compresses / not sharing towels
This is self limiting
Main disease that causes a corneal ulcer
Rheumatoid arthritis
What is the sensation of a corneal ulcer describes as
Needle like !
Tx of dendritic ulcer (HSV)
Gamciclovir
More than acyclovir
Tx for bacterial corneal ulcer
Ciprofloxacin / ofloxacin
(Chloramphenicol is not very useful)
Commonest sign of acute anterior uveitis
Keratic precipitates
Treatment of acute anterior uveitis
Steroids
Mydriatics (dilating drops)
Why are mydriatics useful in acute anterior uveitis
They dilate your pupils and relive pain by relaxing the muscles in your eye - helps with photophobia
Where are elderly people (and also people with hypermetropia) at a higher risk of acute closed angle glaucoma
Because of increased development of cataracts - they push on the trabecular mesh work
*eye is solid, pupil mid dilated , increased IOP
= acute closed angle glaucoma
How to treat ACAG
Pilocarpine
Acetozolamide (Carbonic anhydrase inhibitors)
What is the final management of ACAG
Iridectomy
Most common cause of eye trauma
Corneal foreign body
How to manage a corneal foreign body
Removal with a needle with referral to opthalmology + chloramphenicol for a few days
What are the associated conditions of optic neuritis
MS
Syphilis
What is amaurosis fugax
*curtain coming down on vision
Is transient - lasts a few minutes
Need to assess CVD risk
Are occlusions of blood vessels in the eye painful or painless
Painless loss of vision best describes main sign of vein/artery occlusion
What is the cherry red spot on fundoscopy
Seen in retinal artery occlusion
Describes the coroidal vasculature coming through
*tortuous blood vessels
Central retinal vein occlusion
Why can you get a vitreous haemorrhage
For whatever reason - perhaps due to diabetic retinopathy - there is proliferation of poor quality blood vessels and they burst
Treatment of vitreous haemorrhage
Laser cauterisation
Treatment of retinal detachment
Surgery to reattach
Tx for dry armd ?
None available
Although some suggestions that vitamin supplementation can help prevent further wear and tear
Most appropriate step is to stop smoking
Tx for wet armd
Anti-vegf injections (can be done by specialist nurse) - to stop and decrease size of new blood vessels that leak
VEGF responsible for proliferation of new blood vessels in response to wear and tear
*disc swelling and loss of vision
Ischaemic optic neuropathy
Who deals with squints / ocular muscle problems / palsies
Orthoptist
Who deals with prescription glasses
Optometrist
Lesion affecting the parietal lobe can lead to what visual field defect
Contralateral homonymous inferior quadrantinopia
Lesion affecting visual cortex can result in what visual field defect
Contralateral homonymous hemianopia (macula sparing)
Lesion of optic tract can result in what visual field defect ?
Contralateral homonymous hemianopia
Investigation to confirm dry armd after fundscopy
OCT
What is a chalazion
A meibomian cyst presenting as a firm painless lump in the eyelid
