Passmedicine Flashcards
1
Q
What is orbital cellulitis?
A
Infection of fat and muscle posterior to the orbital septum within the orbit but not involving the globe
2
Q
What tends to cause orbital cellulitis?
A
Spreading URTI from sinuses
3
Q
How is orbital cellulitis managed?
A
Medical emergency req. hospital admission + urgent senior RV
Req. IV antibx
4
Q
What is periorbital cellulitis?
A
Aka. preseptal cellulitis
Less serious infection anterior to orbital septum, due to superficial injury (e.g. chalazion, insect bite etc.)
5
Q
What can periorbital cellulitis progress to?
A
Orbital cellulitis
6
Q
What are risk factors for orbital cellulitis?
A
Childhood Prev. sinus infection Lack of Hib vaccination Recent eyelid infection/insect bite on eyelid (periorbital cellulitis) Ear or facial infection
7
Q
How does orbital cellulitis present?
A
Redness/swelling around eye Severe ocular pain Visual disturbance Proptosis Ophthalmoplegia/pain with eye movements Eyelid oedema + ptosis Drowsiness, NV in meningeal involvement
8
Q
How do you differentiate orbital from periorbital cellulitis?
A
Reduced visual acuity, proptosis, ophthalmoplegia/pain w eye movement are NOT consistent with preseptal cellulitis
9
Q
What investigations should you do for orbital cellulitis and what results will they find?
A
FBC - WBC raised, raised inflammatory markers
CT with contrast scan of orbits, sinuses and brain - inflammation of orbital tissues deep to septum, sinusitis
Blood culture + microbiological swab to determine organism
10
Q
What are the most common causes of orbital cellulitis?
A
Streptococcus
Staphylococcus aureus
Hib
11
Q
What things will you see on Ex with orbital cellulitis?
A
Decreased vision Afferent pupillary defect Proptosis Dysmotility Oedema Erythema
12
Q
What are causes of optic neuritis?
A
MS
DM
Syphilis
13
Q
What are the features of optic neuritis?
A
Unilateral decrease in visual acuity over days-hrs
Poor discrimination of colours, red desaturation
Pain worse on eye movement
Relative afferent pupillary defect
Central scotoma
14
Q
How do you manage optic neuritis?
A
High dose steroids
15
Q
How long does recovery from optic neuritis normally take?
A
4-6 weeks
16
Q
If >3 white matter lesions are found on MRI what is the risk of developing MS in the next 5 years?
A
50%
17
Q
What is optic neuritis very commonly the first presentation of?
A
MS
18
Q
What are cataracts?
A
Condition of eye where lens gradually opacifies, i.e. becomes cloudy
19
Q
What does the opacification of the lens in cataracts mean?
A
It’s more difficult for light to reach the retina –> reduced/blurred vision
20
Q
What is the leading cause of curable blindness world wide?
A
Cataracts
21
Q
What % of >65yos have a visually impairing cataract in 1 or both eyes?
A
30%
22
Q
What is the commonest cause of cataracts?
A
Normal ageing
23
Q
What are other causes of cataracts?
A
Smoking Increased alcohol consumption Trauma DM Long term corticosteroids Radiation exposure Myotonic dystrophy Hypocalcaemia
24
Q
What is a typical presentation of cataracts?
A
Gradual onset of reduced vision, faded colour vision (difficulty distinguishing colours), glare and halos around lights
25
What is glare?
Lights appearing brighter than they are
26
What are signs of cataracts?
Red reflex defect (cataracts prevent light getting to retina)
27
What investigations should be done for suspected cataracts?
Ophthalmoscopy after pupil dilatation (should have normal fundus + optic n)
Slit lamp examination will identify visible cataract
28
What are the different types of cataracts?
Nuclear
Polar
Subcapsular
Dot opacities
29
What is a nuclear cataract?
Forms in the nucleus (centre of lens)
Changes lens refractive index
Common in old age
30
What is a polar cataract?
Localised opacity
Commonly inherited
Lie in visual axis
31
What is a subcapsular cataract?
Lie just deep to lens capsule in visual axis
32
What most commonly causes subcapsular cataracts?
Steroid use
33
In which patients are dot opacity cataracts most commonly seen?
Common in normal lenses, diabetics, myotonic dystrophy
34
How are cataracts managed non-surgically?
Early stages - age related cataracts managed with stronger glasses/contact lenses, using brighter lighting (optimises vision but doesn't slow down cataract progression, surgery will be needed eventually)
35
What is the surgical management of cataracts?
Removal of cloudy lens and replacement with artificial lens
36
When should individuals be referred for cataract surgery?
If visual impairment present, impact on quality of life and patient wishes to have surgery
37
What information should patients be provided with before cataract surgery?
Information on the refractive implications of various types of intraocular lenses
38
What information should patients be provided with after cataract surgery?
Advise on the use of eye drops and eyewear
| What to do if vision changes + management of other ocular problems
39
How successful is cataract surgery?
85-90%
40
What are post-surgical complications of cataract
| surgery?
Posterior capsule opacification (thickening of lens capsule)
Retinal detachment
Posterior capsule rupture
Endopthalmitis
41
What is endopthalmitis?
Inflammation of aqueous +/- vitreous humour
42
Why is it important to do a contrast CT scan of orbits, sinuses and brain in those presenting with orbital cellulitis?
Support the diagnosis
| Search for possible complications, e.g. abscesses which may req. surgical drainage
43
What is the commonest cause of blindness in the UK?
Age related macular degeneration
44
What occurs in age related macular degeneration?
Degradation of the central retina (macula)
Features usually bilateral
45
What is ARMD characterised by?
Degeneration of the retinal photoreceptors --> formation of drusen
46
What can you use to see drusen?
Fundoscopy, retinal photography
47
What was the traditional classification of ARMD?
Dry + wet
48
What are the features of dry ARMD and how common is it?
90%
| Geographic atrophy, drusen, yellow round spots in Bruch's membrane
49
What are the features of wet ARMD and how common is it?
10%
Exudative
Choroidal neovascularisation, leakage of serous fluid + blood
Can lead to rapid loss in vision
50
Of wet and dry ARMD which has the worse prognosis?
Wet
51
What is the more updated classification of ARMD?
Early ARMD - non-exudative, age related: drusen + alterations to retinal pigment epithelium
Late ARMD - neovascularisation, exudative
52
What is the average age of presentation of ARMD?
70y
53
What are risk factors for ARDM?
```
Advanced age - biggest RF (>75)
Smoking
FH
Hypertension
Dyslipidaemia
DM
```
54
How does ARMD typically present?
Reduction in visual acuity, particularly for near field objects
Difficulties in dark adaption, poor vision at night
Fluctuations in visual disturbance (varies from day to day)
Photopsia (flickering/flashing lights, glare around objects)
55
What sign may be seen in ARMD?
Distortion of line perception on Amsler grid testing
56
What changes may be seen in dry ARMD on fundoscopy?
Drusen, yellow areas of pigment deposition in macular area which later may become confluent and scar
57
What changes may be seen in wet ARMD on fundoscopy?
Well demarcated red patches (may be intra-retinal/sub-retinal fluid leakage or haemorrhage)
58
What is the investigation of choice in ARMD?
Slit lamp microscopy (will identify pigmentary, exudative or haemorrhagic changes)
Usually accompanied w. colour fundus photography so have a baseline to identify future changes against
59
What investigations should be done in neovascular ARDM?
Fluorescein angiography (to guide intervention with anti-VEGF therapy)
60
What other investigation may be done in ARMD?
Ocular coherence tomography (look at retina in 3D and reveal areas of dx not seen by microscopy)
61
What is the management of dry ARMD?
Zinc, vitamin A, C, E (to reduce dx progression)
62
What is the management of wet ARMD?
Anti-VEGF - can stabilise/reverse visual loss
Start within first 2m of diagnosis if possible
Laser photocoagulation slows progression of ARMD where neovascularisation is present but risk of acute visual loss after Rx so anti-VEGF preferred
63
Give e.g.s of anti-VEGF agents
Ranibizumab, bevacizumab, pegaptanib
Given 4wkly by injection
64
What is papilloedema?
Swelling of optic disc caused by increased intracranial pressure
65
What are the features of papilloedema on fundoscopy?
```
Usually bilateral
Venous engorgement first sign
Loss of venous pulsation
Blurring of optic disc margin
Elevation of optic disc
Loss of optic cuo
Paton's lines
```
66
What are Paton's lines?
Concentric/radial retinal lines cascading from optic disc due to papilloedema
67
What causes papilloedema?
```
Space occupying lesion - neoplastic/vascular
Malignant hypertension
Idiopathic intracranial hypertension
Hydrocephalus
Hypercapnia
```
rare: hypoparathroidism, hypocalcaemia, vit A toxicity
68
What is a classic history of raised intracranial pressure?
Headache worse in the morning associated with blurred vision and vomiting
69
What is the pathophysiology of primary open angle glaucoma?
Iris is clear of the meshwork, trabecular network functionally offers an increased resistance to aqueous flow --> raised intraocular pressure
(basically slow clogging of trabecular meshwork)
70
What are the causes of primary open angle glaucoma?
Increased age
| Genetics
71
What are the symptoms of primary open angle glaucoma?
Slow rise in intraocular pressure (asymptomatic for long time)
Typically present following an ocular pressure measurement during routine ex by optometrist
72
What are the signs of a primary open angle glaucoma?
Increased intraocular pressure
Visual field defect
Pathological cupping of optic disc
73
What are glaucomas?
Group of eye diseases characterised by increased intraocular pressure which if left untreated can lead to pressure on the optic nerve and blindness
74
Describe the path which aqueous humour usually takes in the eye
AH secreted by ciliary epithelium, travels in space between lens and iris and into the trabecular network (like a spongey drain), this funnels the AH into the canal of schlemm and then into aqueous veins then into episcleral veins
75
What is the pathophysiology of glaucoma?
AH drainage pathway becomes blocked --> increased pressure in ant. chamber eye --> optic nerve damage --> vision loss
76
Define intraocular pressure
Pressure >21mmHg
77
What is the most common type of glaucoma?
Open angle
78
What kind of vision loss do you get with primary open angle glaucoma?
Initially peripheral vision loss, as pressure increases which can lead to loss in central vision as well
79
What is the pathophysiology of closed angle glaucoma?
Angle between iris and cornea too small, so passage for AH outflow is too narrow
Due to lens being pushed against iris --> rapid build up on intraocular pressure and symptoms
80
What investigations should be done for suspected primary open angle glaucoma?
Automated perimetry to assess visual field
Slit lamp ex with pupil dilatation to assess optic n. + fundus for baseline
Applanation tonometry to measure IOP
Central corneal thickness measurement
Gonioscopy to assess peripheral anterior chamber configuration + depth
Assess risk of future visual impairment
81
How do you assess risk of future visual impairment?
Assess risk factors e.g. IOP, central corneal thickness, FH, life expectancy
82
How are the majority of patients with primary open angle glaucoma managed?
Eye drops that lower IOP
83
What is the 1st line Rx for primary open angle glaucoma?
Prostaglandin analogue eye drop
84
What is the 2nd line Rx for primary open angle glaucoma?
Beta-blocker, carbonic anhydrase inhibitor or sympathomimetic eyedrop
85
What are treatment options for more advanced primary open angle glaucoma?
Surgery/laser Rx
86
Why is reassessment essential in primary open angle glaucoma?
Exclude progression + visual fiel loss
87
Which patients who have had primary open angle glaucoma need more frequent reassessment?
If IOP uncontrolled, patient high risk or there is progression
88
Give an example of a prostaglandin analogue
Latanoprost
89
How do prostaglandin analogues work in the treatment of primary open angle glaucoma?
Increase uveoscleral outflow
90
What are SEs of latanoprost?
Brown pigmentation of iris, increased eyelash length
91
How do beta blockers work in the treatment of primary open angle glaucoma?
Reduce aqueous production
92
What beta blockers are used to treat primary open angle glaucoma?
Timolol, betaxolol
93
What patients should you not use timolol in for treatment of primary open angle glaucoma?
Asthmatics, those with heart block
94
How do sympathomimetics work in treating primary open angle glaucoma?
Reduces aqueous production + increases outflow
95
Give an e.g. of a symphathomimetic used to treat primary open angle glaucoma
Brimonidine (alpha2-adrenoceptor agonist)
96
What are SEs of brimonidine?
Hyperaemia
Cannot be used with MAOI/TCAs
97
How do carbonic anhydrase inhibitors work in treating primary open angle glaucoma?
Reduce aqueous production
98
How do miotics work in treating primary open angle glaucoma?
Increases uveoscleral outflow
99
Give an e.g. of a carbonic anhydrase inhibitor
Dorzolamide
100
Give an e.g. of a miotic
Pilocarpine (muscarinic receptor agonist)
101
What are SEs of carbonic anhydrase inhibitors?
Systemic absorption may --> sulphonamide-like reactions
102
What are SEs of miotic agents?
Constricted pupil, headache, blurred vision
103
What kind of surgery may be offered for refractory primary open angle glaucoma?
Trabeculectomy
104
What features are associated with episcleritis?
Red eye
Classically not painful (maybe mildly painful)
watering
Mild photophobia
105
How can you differentiate between episcleritis and scleritis?
Phenylephrine drops - blanches episceral vessels but not scleral, so if redness improves after phenylephrine --> episcleritis
Clinically - scleritis usually painful, episcleritis usually not
106
How is episcleritis managed?
Conservative, e.g. NSAIDs/steroids (resistant cases)
| Artificial tears
107
Define mydriasis
Dilated pupil
108
What can cause mydriasis?
```
Third nerve palsy
Holmes-Aldie pupil
Traumatic iridoplegia
Pheochromocytoma
Congenital
```
109
What drugs can cause mydriasis?
Topical mydriatics: tropicamide, atropine
Sympathomimetic drugs: amphetamines, cocaine
Anticholingeric drugs: TCAs
110
What tend to be the causes of Argyll-Roberston pupil?
DM
| Syphillis
111
What are the features of Argyll-Robertson pupil?
Small irregular pupils, no response to light but response to accommodate
ARP - accommodation reflex present, PRA - pupillary reflex absent
112
What is the first line treatment of primary open angle glaucoma in those with asthma?
Latanoprost
113
Define blepharitis
Inflammation of eyelid margins typically leading to red eye
114
Define stye
Infection of glands of eyelid
115
Define chalazion
Retention cyst of the Meibomian gland
116
Define entropion
In-turning of the eyelids
117
Define ectropion
Out-turning of the eyelids
118
What are the different types of styes?
External (hordeolum externum)
| Internal (hordeolum intenum)
119
What causes a hordeolum externum?
Infection (usually staph) of gland of Zeis (sebum producing) or glands of Moll (sweat glands)
120
What causes a hordeolum internum?
Infection of Meibomian glands
| May leave residual chalazion
121
What is involved in the management of s tye?
Hot compresses
Analgesia
Topical antibx ONLY if assoc. conjunctivitis
122
How does a chalazion present?
Firm, painless lump in eyelid
123
How do you manage a chalazion?
Usually resolve spontaneously
| Sometimes req. surgical drainage
124
How can an ectropion/entropion present?
Watering and pain in affected eye
125
What is the other name for anterior uveitis?
Iritis
126
What is anterior uveitis?
Inflammation of the anterior portion of the uvea (iris + ciliary body)
127
What HLA allele is anterior uveitis associated with?
HLA-B27
128
What are the features of anterior uveitis?
```
Acute onset
Ocular discomfort + pain (may increase with use)
Pupil may be small + irregular
Intense photophobia
Blurred eye
Red eye
Lacrimation
Ciliary flush
Hypopyon
Visual acuity initially normal -->. impaired
```
129
What is hypopyon?
Pus and inflammatory cells in the anterior chamber often resulting in a visible fluid level
130
What conditions are associated with anterior uveitis?
```
Ankylosing spondylitis
Reactive arthritis
Ulcerative colitis, Crohn's disease
Behcet's disease
Sarcoidosis: bilateral disease may be seen
```
131
How do you manage anterior uveitis?
Urgent ophthalmology RV
Cyloplegics
Steroid eye drops
132
What are cytoplegics?
Substances that dilate the pupil and help to relieve pain + photophobia
133
Give e.g.s of cytoplegics
Atropine, cyclopentolate
134
What are slit lamp findings for anterior uveitis?
Keratic precipitates, flares, hypopyon, posterior synechiae
135
What is the name of the classification system used for hypertensive retinopathy?
Keith-Wagener
136
What is the classification of hypertensive retinopathy?
Stage 1 - arteriolar narrowing + tortuosity, increased light reflex, silver wiring
Stage 2 - AV nipping
Stage 3 - cotton wool exudates, flame + blot haemorrhages
Stage 4 - papilloedema
137
What causes diabetic retinopathy?
Hyperglycaemia --> increased retinal blood flow + abnormal metabolism in retinal vessel walls --> damage to endothelial cells + pericytes --> endothelial dysfunction --> increased vascular permeability
Pericyte dysfunction --> microaneurysm formation
Neovasculisation is due to production of growth factors in response to retinal ischaemia
138
What was the traditional classification of diabetic retinopathy?
Background retinopathy - microaneurysms, blot haemorrhages (=< 3), hard exudates
Pre-proliferative retinopathy - cotton wool spots, >3 blot haemorrhages, venous beading/looping, deep/dark cluster haemorrhages, commoner in T1DM
139
What is the new classification of diabetic retinopathy?
Split into non-proliferative diabetic retinopathy and proliferative diabetic retinopathy
Mild NPDR
1 or more microaneurysm
```
Moderate NPDR
microaneurysms
blot haemorrhages
hard exudates
cotton wool spots, venous beading/looping and intraretinal microvascular abnormalities (IRMA) less severe than in severe NPDR
```
Severe NPDR
blot haemorrhages and microaneurysms in 4 quadrants
venous beading in at least 2 quadrants
IRMA in at least 1 quadrant
```
Proliferative retinopathy
Retinal neovascularisation (may lead to vitreous haemorrhage), fibrous tissue forming anterior to retinal disc, more common in T1
```
140
What is maculopathy based on?
Location as opposed to severity, anything is potentially serious
141
What does maculopathy look like?
Hard exudates + other background changes on macula
142
In which type of diabetes is maculopathy more common?
T2
143
What is herpes zoster ophthalmicus?
Reactivation of varicella zoster virus in area supplied by ophthalmic division of trigeminal nerve
144
What are the features of HZO?
Vesicular rash around eye, may or may not involve eye
145
What is Hutchinson's sign?
Rash on tip/side of nose
| Indicates nasociliary involvement and strong risk factor for ocular involvement (anterior uveitis)
146
How do you manage HZO?
Oral antivirals 7-10d
Started wi 72h
IV antivirals if severe infection/pt immunocompromised
Topical corticosteroids for inflammation of eye
Ocular involvement req. urgent ophthalmology RV
147
What are the complications of HZO?
Oocular: conjunctivitis, keratitis, episcleritis, anterior uveitis
Ptosis
Post-herpetic neuralgia
148
What are the features of allergic conjunctivitis?
Bilateral symptoms conjunctival erythema and swelling (chemosis)
Itch
Eyelids may be swollen
Hx of atopy/may be seasonal or perennial
149
What allergens may cause seasonal allergic conjunctivitis?
Pollen
150
What allergens may cause perennial conjunctivitis?
Dust mites, washing powder
151
What is 1st line treatment for allergic conjunctivitis?
Topical antihistamines
| Systemic antihistamines if other symptoms, e.g. rhinosinusitis
152
What is 2nd line treatment for allergic conjunctivitis?
Topical mast cell stabilisers, e.g. sodium cromoglicate/nedocromil
153
Define transient monocular visual loss
Sudden, transient loss of vision lasting less than 24h
154
What are the most common causes of sudden painless loss of vision?
Ischaemic/vascular (e.g. thrombosis, embolism, temporal arteritis, this includes central retinal artery and vein occlusions)
Vitreous haemorrhage
Retinal detachment
Retinal migraine
155
What is amaurosis fugax?
Temporary painless sudden loss in vision that is due to a vascular cause
156
What can cause amaurosis fugax?
Large artery dx e.g. atherothrombosis, embolism, dissection
Small artery disease, e.g. anterior ischaemic optic neuropathy or vascularitis, e.g. TA
May be due to a TIA (should be treated with 300mg aspirin)
157
How does amaurosis fugax commonly present?
Curtain coming down
158
What causes ischaemic optic neuropathy?
Occlusion of the short posterior ciliary arteries causing damage to the optic nerve
159
What can cause central retinal vein occlusion?
Glaucoma
Polycythaemia
HTN
160
What is seen on fundoscopy in central retinal vein occlusion?
Severe retinal haemorrhages
161
What can cause central retinal artery occlusion?
TE, arteritis (e.g. TA)
162
What does central retinal artery occlusion appear like on fundoscopy?
Pale retina, cherry red spot
163
What feature is common on examination in central retinal artery occlusion?
Afferent pupillary defect
164
What can cause vitreous haemorrhage?
DM, bleeding disorders, anticoagulants
165
What are typical features of vitreous haemorrhage?
Sudden visual loss, dark spots
166
What are features of retinal detachment?
Features of vitreous detachment, which may precede retinal detachment including flashing light/floaters
167
What are features of posterior vitreous detachment?
Flashes of light (photopsia) in peripheral field of vision
| Floaters often on temporal side of vision
168
What are features of retinal detachment?
Dense shadow that starts peripherally and progresses towards central vision
A veil/curtain over field of vision
Straight lines appear curved
Spider web like flashing flights around vision
Central visual loss
169
What are the features of vitreous haemorrhage?
Large bleeds cause sudden vision loss
Moderate bleeds may be described as numerous dark spots
Small bleeds may cause floaters
170
What is strabismus?
Squint - misalignment of visual axes
171
How are squints categorised?
Concomitant
| Paralytic
172
What causes a concomitant squint?
Imbalance of extraocular muscles
173
What causes a paralytic squint?
Due to paralysis of extraocular muscles (rare)
174
Which of convergent and divergent squints are most common?
Convergent more common
175
How can you diagnose a squint?
Corneal light reflection test - hold light source 30cm from face to see if light reflects symmetrically on pupils
176
What is the cover test used to determine?
The nature of the squint
177
Describe how to carry out the cover test
Ask child to focus on object
Cover one eye
Observe movement of uncovered eye
Cover other eye and repeat test
On covering the eye without the squint, the other eye should move to take up fixation
178
How do you manage squint?
Eye patch to prevent amblyopia
| Refer to secondary care
179
What is esotropia?
Squint in which eye deviates towards the nose
180
What is exotropia?
Squint in which eye deviates towards the temples
181
What is hypertropia?
Squint in which eye deviates superiorly
182
What is hypotropia?
Squint in which eye deviates inferiorly
183
What causes blepharitis?
Meibomian gland dysfunction (posterior blepharitis, common) or seborrheic dermatitis/staph infection (less common, anterior blepharitis)
184
What is the function of the Meibomian glands?
Secrete oil on to surface of eye to prevent rapid evaporation of tear film
Dysfunction --> drying of eyes and irritation
185
What are the features of blepharitis?
Usually bilateral
Grittiness, discomfort around eyelid margin
Eyes may be sticky in morning
Eyelids margins may be red/swollen (swollen in staphylococcal blehapritis)
styes/chalazions more common
Secondary conjunctivitis may occur
186
How is blepharitis managed?
Hot compresses x2/day (to soften lid margin)
Lid hygiene
Artificial tears for those with dry eyes/abnormal tear film
187
What is involved in lid hygiene?
Mechanical removal of debris from lid margin
| Cotton wool buds dipped in cooled boiled water and baby shampoo or sodium bicarb
188
What are the features of dry eye syndrome?
Commonly effects elderly
Bilateral gritty feeling, symptoms worse at end of day
Assoc with pain
189
What are the features of an acute angle closure glaucoma?
Severe pain - may be ocular/headache
Decreased visual acuity, haloes
Semi-dilated pupil
Hazy cornea
190
What are the features of anterior uveitis?
Acute onset
Pain
Blurred vision, photophobia
Small, fixed, oval pupil, ciliary flush
191
How can the discharge from conjunctivitis help distinguish between a bacterial/viral causses?
Purulent discharge = bacterial
Clear discharge = viral
192
What clues in the hx may point toward subconjunctival haemorrhage being the cause of red eye?
Hx trauma or coughing bouts
193
What is endophthalmitis?
Inflammation of the anterior + posterior chambers of the eye
194
What is the typical presentation of endophthalmitis?
Red eye, pain, visual loss following intraocular surgery
195
What is preseptal cellulitis?
Inflammation of the soft tissue anterior to the orbital septum - includes eyelids, skin, sc tissue of face
196
What tends to cause preseptal cellulitis?
Tends to be spread of infection from breaks in skin/local infections (e.g. sinusitis/URTI)
197
What are the most frequent causative organisms for preseptal cellulitis?
Staph aureus
Staph epidermis
Strep
Anaerobic bacteria
198
How does preseptal cellulitis tend to present?
Red, swollen, painful eye of acute onset
| May have fever
199
What are the signs of preseptal cellulitis?
Erythema/oedema of eyelids, can spread to surrounding skin
Partial/complete ptosis due to eyelid swelling
Orbital signs must be ABSENT
200
What investigations should be done in preseptal cellulitis?
Bloods - raised inflammatory markers
Swabs of discharge
Contrast CT of orbit may help distinguish preseptal and orbital cellulitis
201
How should preseptal cellulitis be managed?
Always refer to secondary care
Oral antibx (co-amoxiclav)
Admission for observation if child
202
What are complications of preseptal cellulitis?
Bacterial infection can spread into orbit --> orbital cellulitis
203
What is posterior vitreous detachment?
Separation of vitreous membrane from retina
204
Why does posterior vitreous detachment occur?
Due to natural changes to vitreous fluid of eye with ageing
205
What are the features of posterior vitreous detachment?
Doe not causes pain/loss of vision but can lead to tears/detachment of retina
206
Why is it important to rule out retinal tears/detachment in those presenting with posterior vitreous detachment?
Retinal tear/detachment can lead to permanent loss of vision
207
Why can posterior vitreous detachment happen with age?
Vitreous fluid becomes less viscous and doesn't hold its shape as well so pulls vitreous membrane away from retina towards the centre of the eye
208
What eye condition predisposes to posterior vitreous detachment and why?
Myopia
| myopic eye has longer axial length
209
What are the symptoms of posterior vitreous detachment?
```
Sudden appearance of floaters
Flashes of light
Blurred vision
cobweb across vision
Dark curtain coming down over vision = retinal detachment
```
210
What is a sign of posterior vitreous detachment?
Weiss ring on ophthalmoscopy = detachment of vitreous membrane around optic nerve forms ring shaped floater
211
How should suspected vitreous detachment be investigated?
Examination by ophthalmologist within 24h to rule out retinal tears/detachment
212
How do you manage vitreous detachment?
As it does not cause permanent loss of vision, symptoms generally resolve over 6m - so no Rx necessary
213
How do you manage a retinal tear/detachment?
Surgery
214
What factors predispose to acute angle closure glaucoma?
Hypermetropia
Pupillary dilatation
Lens growth associated with age
215
What are the features of acute angle closure glaucoma?
```
Severe pain (ocular/headache)
Decreased visual acuity
Symptoms worse with mydriasis (e.g. watching TV in dark room)
Hard, red eye
Haloes around lights
Semi-dilated non-reacting pupil
Corneal oedema results in dull/hazy corneal
Systemic upset (e.g. NV)
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216
How is closed angle glaucoma managed?
Urgent referral to ophthalmology
| Reduce aqueous secretions - acetazolamide + inducing pupillary constriction with topical pilocarpine
217
What thing may contraindicate giving supplements to prevent the progression of ARMD?
Being a smoker - beta-carotene has been found to increase lung cancer risk
218
What drugs can precipitate angle closure glaucoma?
Mydriatic eye drops
219
What are the features of Horner's syndrome?
Miosis (small pupil)
Ptosis
Enophthalmos (sunken eye)
Anhidrosis (loss of sweating on 1 side)
220
What central lesions may cause anhidrosis?
```
Stroke
Syringomyelia
Tumour
MS
Encephalitis
```
221
Where do central lesions cause anhidrosis?
The face, arms, trunk
222
Where do pre-ganglionic lesions cause anhidrosis?
The face
223
What pre-ganglionic lesions can cause anhidrosis?
Pancoast tumour
Thyroidectomy
Trauma
Cervical rib
224
Do post-ganglionic lesions cause anhidrosis?
No
| E.g.s of these lesions: carotid artery dissection, carotid aneurysm, cavernous sinus thrombosis, cluster headache
225
What are risk factors for vitreous haemorrhage?
```
DM
Trauma
Anticoagulants
Coagulation disorders
Severe short sightedness
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226
What conditions are associated with blepharitis?
Acne rosacea
Dry eye syndrome
Seborrheic dermatitis
227
What kind of visual defect do glaucomas primarily cause?
Impairs peripheral visual fields
228
What is the epidemiology of primary open angle glaucoma?
2% of population over 40y are affected
229
What are risk factors for primary open angle glaucoma?
```
Genetics
Black
Myopia
HTN
DM
Corticosteroid
```
230
How does POAG tend to present?
Often insidious presentation and detected during routine optometry appointments
231
What are potential features of POAG?
Peripheral visual loss
Decreased visual acuity
Optic disc cupping
232
What are the fundoscopy signs of POAG?
1. Optic disc cupping - cup-to-disc ratio >0.7 (normal = 0.4-0.7), occurs as loss of disc substance makes optic cup widen and deepen
2. Optic disc pallor - indicating optic atrophy
3. Bayonetting of vessels - vessels have breaks as they disappear into the deep cup and re-appear at the base
4. Additional features - Cup notching (usually inferior where vessels enter disc), Disc haemorrhages
233
Why is proliferative diabetic retinopathy a risk factor for vitreous haemorrhage?
New vessels that grow into the vitreous are fragile + bleed easily
234
What is vitreous haemorrhage?
Bleeding into the vitreous humour
235
What is the biggest cause of vitreous haemorrhage?
Proliferative diabetic retinopathy
Other two major causes are posterior vitreous detachment and ocular trauma
236
What investigations should be done in suspected vitreous haemorrhage?
Dilated fundoscopy: may show haemorrhage in the vitreous cavity
Slit-lamp examination: RBCs in anterior vitreous
USS: rule out retinal tear/detachment + if haemorrhage obscures the retina
Fluorescein angiography: identify neovascularization
Orbital CT: used if open globe injury
237
Which investigation is papilloedema a contraindication for?
LP - due to risk of coning
238
Where does drusen tend to collect around in ARMD?
Macula
239
What is retinitis pigmentosa?
Genetic disorder of the eye that affects primarily the peripheral retina resulting in tunnel vision
240
What are the features of retinitis pigmentosa?
Night blindness is usually the initial sign
| Tunnel vision due to loss of peripheral retina
241
What things do you see on fundoscopy in retinitis pigmentosa?
Black bone spicule-shaped pigmentation in the peripheral retina, mottling of retinal pigment epithelium
242
What diseases are associated with retinitis pigmentosa?
```
Refsum disease: cerebellar ataxia, peripheral neuropathy, deafness, ichthyosis
Usher syndrome
abetalipoproteinemia
Lawrence-Moon-Biedl syndrome
Kearns-Sayre syndrome
Alport's syndrome
```
243
What is central retinal vein occlusion said to look like on fundoscopy?
Cheese and tomato pizza
244
Who gets glaucoma screening and what does it involve?
Those with a positive FH should be screened annual from age 40
This usually takes place at the opticians
245
Why is screening of high risk groups essential for glaucoma?
It has a strong hereditary component and because initial stages of the disease are asymptomatic
246
What is a typical presentation of infective conjunctivitis?
Sore, red eyes associated with a sticky discharge
247
What are the types of infective conjunctivitis and how do you distinguish between them clinically?
Bacterial: purulent discharge, eyes may be stuck together in morning
Viral: serous discharge, recent URTI, preauricular lymph nodes
248
Does infective conjunctivitis settle without treatment?
Usually settles within 1-2w without treatment
249
What treatment can you offer patients with infective conjunctivitis?
Topical antibiotics, e.g. chloramphenicol drops 2-3hrly
250
What should you offer pregnant women with infective conjunctivitis?
Topical fusidic acid
251
What advice should you give to those with infective conjunctivitis?
Do not share towels
Do not wear contact lenses for duration of illness
School exclusion is not necessary
252
If a neonate presents with conjunctivitis with purulent discharge how should they be managed?
Urgent swabs of discharge for microbiological investigation and start systemic antibx
Want to check for gonococcus/chlamydia
253
What is involved in the treatment of an entropion?
Definitive: surgery
| Can use tape (to pull eyelid down) and lubricants in meantime
254
What are the features of Holmes-Adie pupil?
Unilateral (80%)
Dilated pupil
Once pupil constricts stays small for abnormally long time + is slowly reactive to accommodation but very poorly to light (if at all)
255
What is Holmes-Adie pupil associated with?
Absent ankle/knee reflex
256
What is the typical presentation of a chalazion?
Firm, painless lump on eyelid - these resolve spontaneously
257
In which group of people are corneal ulcers most common in ?
Contact lens users
258
What are the features of corneal ulcers?
Eye pain
Photophobia
Watering of eye
Focal fluorescein staining of cornea
259
What is a corneal ulcer?
Infection of cornea by a bacteria, fungus or protist
260
How do you treat corneal ulcers?
Eyedrop tailored to the cause
261
What drug can predispose to corneal ulcer formation?
Steroid eye drops as they supress the immune system to an infection
262
What is the most common presentation of herpes simplex keratitis?
Dendritic corneal ulcer
263
What are the features of herpes simplex keratitis?
```
Red, painful eye
Photophobia
Epiphora
Visual acuity may be decreased
Fluorescein staining may show epithelial dendritic ulcer
```
264
What is the management of herpes simplex keratitis?
Immediate referral to ophthalmology
| Topical aciclovir
265
What is the commonest cause of persistent watery eye in infants?
Nasolacrimal duct obstruction
266
What causes nasolacrimal duct obstruction?
Imperforate membrane, usually at the lower end of the lacrimal duct
267
How is nasolacrimal duct obstruction managed?
Teach patients lacrimal duct massage
Most resolve within 1y, if doesn't refer to ophthalmology for consideration of probing (done under LA)
268
What is Hutchinson's pupil?
Unilaterally dilated pupil which is unresponsive to light
Due to compression of oculomotor nerve on same side by an intracranial mass
269
What causes Horner's syndrome?
Damage to the sympathetic trunk on the same side as the symptoms, e.g. due to trauma, compression, infection, ischaemia
270
What is Marcus-Gunn pupil?
Relative afferent pupillary defect, seen during swinging light ex of pupil response (pupil appears to dilate when light is shone on it)
Mostly caused by damage to optic n (e.g. optic neuritis) or severe retinal dx
271
What causes Adie pupil?
Damage to parasympathetic innervation of eye due to viral/bacterial infection
272
Describe the pathway of pupillary light reflex
Afferent: retina → optic nerve → lateral geniculate body → midbrain
Efferent: Edinger-Westphal nucleus (midbrain) → oculomotor nerve
273
What is the most effective intervention to slow the progression of dry ARMD?
Stopping smoking
