Pathology Flashcards
1
Q
Which tumours can affect the ventricles and choroid plexus
A
Colloid cyst - often at interventricular foramen
Ependymomas - arise from ependymal cells
Choroid plexus tumours
2
Q
What is hydrocephalus
A
Accumulation of CSF in the brain
Usually due to some sort of blockage in the system
Can cause the head to enlarge and increases pressure in brain
Treated with a shunt
3
Q
List the different types of ventricular haemorrhage
A
Epidural hematoma, arterial bleed between skull and dura
Subdural hematoma, venous bleed between dura and arachnoid
Subarachnoid haemorrhage
4
Q
What is idiopathic intracranial hypertension
A
Increase in CSF pressure but no imaging features of hydrocephalus
No known cause
Causes headache and visual disturbance
5
Q
What is papilloedema
A
Optic disc swelling due to raised intracranial pressure - puts pressure on the optic nerve
Causes enlarged blind spot, blurred vision and loss of vision
Graded from 1-5
6
Q
What can cause raised intracranial pressure
A
Head injury
Space occupying lesion, tumour, abscess or haemorrhage
Hydrocephalus
Meningitis - leads to inflammation
7
Q
What occurs if raised ICP is not relieved
A
Brain damage
8
Q
What visual changes can occur with raised ICP
A
Transient blurry vision Double vision - diplopia Loss of vision Papilloedema Pupillary changes
Can affect one or both eyes depending on cause
9
Q
How can raised ICP affect the optic nerve
A
Compresses them
Will also compress the blood supply to the retina
Leading to swelling off the optic disc - papilloedema
10
Q
What visual symptoms occur with papilloedema
A
Transient visual obscurations Transient flickering Blurring Constriction of the visual field Decreased colour perception
11
Q
Describe the appearance of the optic disc in papilloedema grade 1-5
A
Blurry margins in all grades 1 - C shaped halo 2 - circular halo 3 - peripheral vessels disappear from view 4 - central vessels disappear 5- no visible vessels
12
Q
What can damage the oculomotor nerve
A
Compression by raised ICP
Tentorial herniation - pushed through notch by raised ICP
13
Q
Which fibres tend to be affected first when the oculomotor nerve is compressed
A
Parasympathetic
They usually sit on the outside of the nerve
14
Q
List symptoms of oculomotor nerve damage
A
Paralysis of extra-ocular muscles
No/slow pupillary reflex (parasympathetic not working)
Dilated pupil - when it becomes fixed it means there has been severe damaged
Ptosis - damage of nerve to LPS
Eye looking down and out - superior oblique still works
15
Q
Describe symptoms of trochlear nerve damage
A
Paralysis of superior oblique muscle - cannot move inferomedially
Diplopia when looking down
16
Q
What is diplopia
A
Double vision
17
Q
What can damage the trochlear nerve
A
Stretching
Compression - ICP
isolated injury is very unusual
18
Q
What type of damage is the abducent nerve susceptible to
A
Stretch
19
Q
What are the symptoms of abducent nerve damage
A
Eye can’t move laterally in horizontal plane - lateral rectus is paralysed
Medial deviation of eye
20
Q
What are cataracts
A
Opacification within the lens
Leads to reduction in vision which affects daily living
21
Q
What can cause cataracts
A
Degenerative changes in lens fibres - age (most common)
Cumulative UVB damage
May also be caused by hypertension, smoking
Trauma - can be a sudden cataract
Metabolic - diabetes
Congenital
Drug induced - steroids
Intra-uterine infections - rubella, CMV, toxoplasmosis
22
Q
What is glaucoma
A
A group of diseases characterised by progressive optic nerve damage and visual field loss
Abnormal increase in pressure in the eye
Due to the amount of vitreous fluid and aqueous humour
23
Q
What areas of the eye does glaucoma have the biggest consequences
A
Optic disc and nerve
24
Q
What causes 50% of blindness worldwide
A
Cataracts
rarely causes blindness in UK but is the most common cause of gradual visual impairment,
25
What are the two types of glaucoma
Open angled - primary and secondary
| Angle closure - primary or secondary
26
What causes open angled glaucoma
Poor drainage through the trabecular network
Fluid builds up
Primary - nothing to see in eye
Secondary - there is something else is blocking the drains – red cells, white cells in uveitis, protein etc.
27
How does open angled glaucoma present
Very slow onset
Usually asymptomatic - picked up by screening
Will see an open anterior chamber angle, raised intra-ocular pressure, “cupping” of the optic disc and progressive loss of visual fields
28
How do you treat primary open angled glaucoma
Pharmacological treatment - prostaglandin then B-blocker or CAI then truspot/alphagan
Then surgery - trabeculectomy
Make a fistula in the eye to allow drainage
29
What causes angle closure glaucoma
Iris becomes opposed to the lens and stops fluid flowing round to the trabecular network
Drainage is patent but fluid cannot get to it
The iris can close over the angle
Fluid builds up and increases pressure
30
How does angle closure glaucoma present
```
Unilateral
Visual loss
Pain
Red eye
Cloudy / Hazy cornea
Fixed, mid dilated pupil
Severe headache
May have nausea and vomiting
Raised intra-ocular pressure (50-80mmHg)
```
Can be a medical emergency
31
How do you treat angle closure glaucoma
Laser treatment to the iris - iridotomy
Zap a hole to allow fluid to drain - reduces recurrence
Can also give IV Diamox – carbonic anhydrase inhibitor, topical anti-hypertensives, topical steroids, pilocarpine
32
What is 'cupping' of the optic disc
Edges of the optic disc become rolled up and the centre depressed
Caused by pressure damage
33
Which cancers can affect the eye
BCC
SCC
Melanoma
34
Which part of the body is the only one with no reported incidence of malignancy
lens
35
What is conjunctivitis and how does it present
Inflammation of the conjunctiva
Caused swelling, redness, pain and heat
Usually viral
36
What is scleritis and how does it present
Inflammation of the sclera
rarer and more severe
Associated with pain on movement and deep redness
37
Episcleritis is usually self-limiting - true or false
True
| It's a superficial inflammation
38
What is ARMD
Age related macular degeneration
39
What are the 2 types of macular degeneration
Dry - no vascular proliferation
- more common
Wet - vascular proliferation
- eye grows new blood vessels within the macula to ‘repair’ dry ARMD damage but they leak
40
How do you treat wet macular degeneration
Anti-VEGF monoclonal antibodies
Injected into the eye
Stops proliferation of blood vessels
41
What is Drusen
Accumulation of dry product of inflammation (e.g. proteins, lipid etc)
Appear as little yellow plaques on retina
42
What is an Argyll Robertson pupil
Accommodates but doesn’t react
| Doesn’t constrict/dilate but you can see near and far
43
What eye pathologies can be caused by diabetes
```
Blurred vision - increased osmotic pressure
Peripheral neuropathy can affect eyes
Cataracts
Rubeotic glaucoma
Retinopathy
```
44
How does diabetes cause cataracts
Increased sugar in lens, converted to sorbitol which gets stuck in the cells
Alters the osmotic gradients and leads to swelling and fibre disruption
45
What is retinopathy
Poor functioning of vessels in the eye
Leaky and haemorrhages
Leads to vision loss
46
What vascular diseases can affect the eye
Arterial occlusion -thromboembolic disease in carotids
| Venous - giant cell arteritis (temporal)
47
What happens if you have a TIA in the central artery of the eye
Sudden visual loss in one eye - like a curtain coming down
| Not painful
48
What is the cardinal feature of an eye movement defect
Double vision (diplopia)
49
What is the cardinal feature of a visual defect
Loss of visual acuity
| Loss of visual fields
50
List potential causes of eye disease
```
Vascular disease
Tumours - SOL
Trauma
Demyelination - MS
Inflammation/infection
Congenital abnormalities
```
51
What does a VIth nerve palsy lead to
Palsy of the lateral rectus
Will no longer be able to abduct the eye
Causes horizontal double vision
52
What can cause a VIth nerve palsy
Microvascular
Raised Intracranial pressure
Tumour - acoustic neuroma
Congenital
53
Why is the VIth nerve susceptible to damage by raised ICP
The course of the nerve
| It runs over a tip in the bone and is easily compressed
54
What does a IVth nerve palsy lead
Palsy of the superior oblique muscle
Eye will sit higher and outwards
Cannot move the eye down and in
Get vertical double vision
55
How might people compensate for a IVth nerve palsy
Tilting their head
56
What can cause a IVth nerve palsy
Congenital defect
Microvascular complication
Tumour
If bilateral it is usually trauma
57
How does the eye appear in a IIIrd nerve palsy
Eye will sit down and out
Dilated pupil
Drooping eyelid
Affects MR, SR, IR, IO, sphincter papillae and LPS
58
What can cause a IIIrd nerve palsy
```
Microvascular problems
Tumour
Aneurysm (will be painful!) - 3rd nerve passes very close the PCA so aneurysm in this can compress the nerve
MS
Congenital
```
59
What causes inter-nuclear ophthalmoplegia
MS
Vascular issues
etc etc
60
What is the inter-nuclear pathway involves in
Allows the eyes to work together
| SO they look the same way, at the same time, at the same speed
61
What pathologies commonly cause defects in the optic nerve
Ischaemic optic neuropathy
Optic neuritis - common in MS
Tumours - rare
62
How does an optic nerve defect affect the visual fields
Either complete loss of vision unilaterally or loss of horizontal field in one eye
63
How does optic neuritis present
```
Progressive, unilateral vision loss
Pain behind the eye, especially on movement
Colour desaturation
Central scotoma
Enlarging blind spot
RAPD
Optic disc swelling
```
64
Which pathologies can affect the optic chiasm
Pituitary tumour
Craniopharyngioma
Meningioma
65
Defect in the optic chiasm leads to what visual defect
Bitemporal hemianopia
66
What pathologies can cause defects in the optic tracts and their radiations
Tumours
Demyelination
Vascular anomalies
67
How does a defect in the optic tracts and their radiations present
Homonymous defect - affects the same side of each eye
Macula is not spared
Affects in quadrants or as hemianopia (halves)
68
What pathologies can cause defects in the occipital cortex
Vascular disease
| Demyelination - MS
69
How do defects in the occipital cortex present
Homonymous defect - affects same side of both eyes
| Macular sparing
70
List causes of sudden visual loss
```
Vascular occlusion - central retinal artery or vein
Ischaemic optic neuropathy
Vitreous haemorrhage
Amaurosis Fugax
Retinal detachment
Retrobulbar neuritis
ARMD - wet type
Closed angle glaucoma
Optic neuritis
Giant Cell Arteritis
Cerebral infarct involving the optic tract or occipital cortex
```
71
Haemorrhage from abnormal blood vessles occurs in which eye pathologies
Diabetic retinopathy
| Wet ARMD
72
What are the signs and symptoms of a central retinal artery occlusion
```
Sudden visual loss - total or subtotal
No pain
RAPD
Pale retina
Pink spot at fovea as still has some blood supply from choroid - cherry red spot
```
73
What can cause a central retinal artery occlusion
Carotid artery disease
Emboli from the heart
- may see common CV risk factors
GCA
74
What can cause a central retinal vein occlusion
Endothelial damage - diabetes
Abnormal blood flow - hypertension
Hypercoagulable states - cancer
75
What are the signs and symptoms of a central retinal vein occlusion
```
Sudden vision loss - mod to severe
Painless
RAPD
Retinal haemorrhages - flame shaped, stormy sunset
Cotton wool spots
Dilated, tortuous veins
Disc swelling
```
76
What is ischaemic optic neuropathy
Occlusion of the circulation to the optic nerve head
Can be caused by giant cell arteritis (inflammation occludes the vessels) or atherosclerosis (usual risk factors)
Leads to sudden, severe visual loss - irreversible
RAPD
Swollen optic disc with hyperaemia. Pale disc later
77
List symptoms of giant cell arteritis
```
Headache - temporal
Jaw/tongue claudication
Scalp tenderness
Tender and enlarged scalp arteries
Malaise
Shoulder girdle weakness
Recent weight loss
Sudden visual loss - if progresses to ION
May also have blurred vision, amaurosis fugax and diplopia
```
78
What are the symptoms of a vitreous haemorrhage
Sudden loss of vision
Floaters in vision
Loss of the red relflex
May see the haemorrhage on fundoscopy
79
What are the signs and symptoms of retinal detachment
```
Painless vision loss
Sudden onset of flashes/floaters
Dark shadow in peripheral vision, increasing in size
May have RAPD
May see the tear with ophthalmoscope
```
80
Sudden visual loss occurs with dry ARMD - true or false
False
It occurs with wet ARMD
Dry leads to progressive loss
81
What are the signs and symptoms of wet ARMD
```
Rapid central visual loss
Distortion - straight lines bend (metamorphopsia)
Haemorrhage and exudate on imaging
Oedema over macula - slightly paler
Fluid build up on OCT
```
82
What are the signs and symptoms of closed angle glaucoma
```
Painful, red eye
Sudden visual loss
Headache
Nausea and vomiting
Cloudy cornea
Circumcorneal injection
Dilated pupil
```
83
List causes of gradual visual loss
```
Cataract
Dry ARMD
Refractive error
Glaucoma - open angle
Diabetic retinopathy
Age related changes
```
84
What are the symptoms of cataracts
Gradual visual decline - haziness/blurriness
| May get a glare
85
How do you treat cataracts
Surgical removal of the lens - phacoemulsification
| Replace with an intra-ocular lens implant
86
What are the signs and symptoms of dry ARMD
Gradual visual decline - blurriness
Central vision missing - central scotoma
Drusen - build up of exudate seen as yellow deposits around macula
May also see abnormal pigmentation in this area
Atrophic parts of retina on imaging
87
What is a refractive error
Eye cannot clearly focus images
| Includes being short or long sighted and stigmatism
88
What are the signs and symptoms of open angled glaucoma
Often asymptomatic - picked up by optician
Cupped disc
Visual field defects
High IOP
89
How does raised ICP lead to papilloedema
Optic nerve is also surrounded by meninges and therefore CSF
So an increase in pressure in the SAS around the optic nerve affects it
90
What is the major complication of raised ICP
Brain ischaemia and swelling
| Brain gets pushed through the foramen magnum which compresses the brain stem and the patient will stop breathing
91
Malignant hypertension can lead to papilloedema - true or false
True
92
What leads to accumulation of CSF
Obstruction to it's circulation
Overproduction
Inadequate absorption
93
What is idiopathic intercranial hypertension
Cause of papilloedema
May be a result of stenosis of cerebral sinuses, increased abdominal pressure (obesity), microemboli
Poorly understood
94
What can happen if disc swelling becomes chronic
They become atrophic and pale
| There may be a loss of visual function and even blindness
95
What signs might you see in retinopathy
Microaneurysms - dot and blot haemorrhages
Hard exudate
Cotton wool patches
Abnormal blood vessels
Venous beading – segmentation of the veins
IRMA – shunt vessels between the arterioles and venules formed by the ischaemic drive, normal vessels, not very leaky
96
What drives new vessel formation
VEGF
97
What is the difference between NVD and NVE
NVD - new vessels on disc
- worse prognosis
- suggests severe ischaemia
NVE - new vessels in periphery
- occurs locally to the ischaemia
98
What is rubeosis iridis
Vessel formation on the iris
Due to extreme VEGF production due to severe ischaemia
Irreversible
Very poor prognostic sign – suggests severe ischaemia
99
Why can diabetic patients lose vision
Retinal oedema
Vitreous haemorrhage
Scarring and tractional retinal detachment
100
How do you manage diabetic eye disease
```
Optimise control
Laser treatment - photocoagulation to stop bleeds
Vitrectomy - surgical
Rehabilitation
Anti-VEGF injections
```
101
List features of hypertensive retinopathy
```
Attenuated blood vessels
Cotton wool spots
Hard exudate
Retinal haemorrhage
Optic disc oedema
```
102
How does an infarcted retina appear
Very Pale
103
What are keratic precipitates
Deposits of white cells in the eye
| Appear as little white dots in the eye
104
List some infective causes of uveitis
TB
Herpes zoster
Syphilis
105
List some non-infective causes of uveitis
Idiopathic
Sarcoidosis
Ankylosing spondylitis
Juvenile arthritis
106
List features of thyroid eye disease
```
Proptosis
Lid retraction and lag
Lid oedema
Restrictive myopathy
Glaucoma
Injection
```
107
How can SLE affect the eyes
Leads to red, inflamed eyes
| Deep tissue involved - scleritis
108
How can RA affect the eyes
Dry eyes
Scleritis
Corneal melt
109
How does Marfan's present in the eyes
Displacement of the lens
| Will go up the way
110
\what can cause a subconjunctival haemorrhage
Can be spontaneous - particularly if on anti-coagulants
Trauma
Hypertension
111
What can lead to orbital cellulitis
Insect bite
Eye lid trauma
In kids it's often caused by sinus infection that travels up to eye
112
What is the major consequence of orbital cellulitis
Brain abscesses - this can be life threatening
113
Who is vulnerable to acanthamoeba infections
Contact lens wearers
114
Describe how different types of pain suggest pathology in different parts of the eye
Grittiness - surface problem
| Achy pain - intraocular
115
What is the difference between anterior and posterior blepharitis
Anterior - lid margin and lashes affected
- lid margin is redder than deep eye
Posterior - due to Meibomian gland dysfunction
- redness is in deep part of the lid
116
What are the Meibomian glands
oil secreting glands in the posterior part of the lid
| if they don't work properly it can lead to blepharitis
117
What are the symptoms of blepharitis
Similar to conjunctivitis
Gritty eyes - foreign body sensation
Mild discharge
118
What are the signs of seborrheic anterior blepharitis
Red lid margin
Lots of scales
No ulcers
Lashes stuck together
119
What are the signs of staphylococcal anterior blepharitis
Red lid margin
Lashes distorted - loss or ingrown
Styes
Marginal ulcers
120
What are the signs of posterior blepharitis
lid margin and lashes unaffected
Gland opening swollen
Dry secretions at gland openings
Meibomian cysts
121
What other condition is posterior blepharitis associated with
Acne rosacea
122
How do you treat blepharitis
Lid hygiene - daily bathing
Supplementary tear drops
Oral doxycycline for 2-3 months
123
List causes of conjunctivitis
```
Viral - watery, after URTI
Bacterial - purulent, sticky
Chlamydia - low grade and chronic
Allergic
Chemical/drugs
Associated with skin disease
```
124
List symptoms of conjunctivitis
```
Red eye
Foreign body sensation - gritty eyes
Discharge - watery or purulent
Pre-auricular lymph nodes - viral causes
Chemosis
Itch (in allergic)
Papillae or follicles
Vision unaffected
```
125
In herpes zoster infections, why would you be concerned if the nose was affected
If the tip of the nose is affected it means the nasocilliary nerve has been affected and so it is likely the eye will be involved
This is when shingles affects the V1 nerve
126
List signs and symptoms of corneal ulcers
```
Pain - needle like and severe
Photophobia
Profuse lacrimation - watery
Red eye - around the cornea
Corneal opacity
Staining with fluorescein
Hypopyon
```
127
How do autoimmune corneal ulcers occur
Common in RA
| Indicates that the systemic autoimmune condition is poorly controlled
128
Aside from bacteria and viruses, what can cause corneal ulcers
Exposure keratitis - seen in those who cannot fully close their eyes (thyroid or nerve palsy)
Dry eyes - Sjorgen's
Neurotrophic - herpes zoster
Vit A deficiency
129
How do you treat a corneal ulcer
Corneal scrape to identify cause
Antimicrobials if bacterial
Antiviral if herpetic - aciclovir for 7-`10 days
Anti-inflammatory if autoimmune
130
List causes of anterior uveitis
Idiopathic - 50-60%
Autoimmune - UC, sarcoid, ank spond (associated with HLA-B27)
Infective - TB, syphilis, herpes (uncommon)
Malignancy
Trauma
131
List signs and symptoms of anterior uveitis
```
Pain - dull ache
May have reduced vision - blurry
Photophobia
Red eye - around cornea
Ciliary injection
Cells and flare in anterior chamber
Precipitates
Hypopyon
Irregular pupil
Posterior synechiae – pupil gets stuck down, may not dilate well
```
132
How do you manage anterior uveitis
Topical steroids - 4-8 weeks
Hourly with gradual taper
Mydriatics - paralyses the muscle and reduces photosensitivity and pain from spasm
Investigate systemic causes
133
Which other pathology is episcleritis associated with
Gout
134
How do you differentiate between episcleritis and scleritis
Adding a vasoconstrictor like topical phenylephrine – in episcleritis the redness would blanche, if deeper inflammation like scleritis it would not
135
How do you manage episcleritis
Usually self-limiting
Lubrication
Rarely a topical NSAID
136
Which other pathologies is scleritis associated with
RA
Wegener's granulomatosis
Many connective tissue diseases
137
List symptoms of scleritis
VERY painful
Will wake you up from sleep and cannot touch the eye
Injections of the deep vascular plexus - diffuse and deep redness
138
How do you treat scleritis
Oral NSAIDs
Oral steroids
Steroid sparing agents
139
A droopy eyelid may be a sign of what extra-ocular pathology
Lung cancer
| This is a sign of Horner's syndrome (constricted pupil and reduced ipsilateral sweating)
140
What is RAPD and how would you diagnose it
Relevant afferent pupil defect
Do the swinging light test
You would see paradoxical dilation of one pupil when you shine the light in it
141
New vessels form in dry ARMD - true or false
False
| This occurs in wet ARMD and can lead to visual loss
142
What are the signs of a macular pathology
Disturbance of central vision
| Straight shapes and faces become distorted
143
How can you treat diabetic retinopathy
get diabetes under control
laser treatment - target the new vessels
anti-VEGF injections
144
In the UK, what vision level is considered partially sighted
6/60
145
In the UK, what vision level is considered severely visually impaired
3/60
146
What is emmetropia
normal vision
147
What is presbyopia
Loss of accommodation seen in old age
148
What is myopia
being short sighted
| Eye is too large so focuses light before the retina
149
what is hypertropia
being long sighted
| eye is small so focuses light behind the retina
150
List causes of a red eye
```
Infective Conjunctivitis
Foreign Body
Allergic Conjunctivitis
Corneal Abrasion
Blepharitis/ Chalazion
Dry Eyes
Subconjunctival Haemorrhage
Glaucoma
Anterior Uveitis
```
151
Pain and photophobia is characteristic of which condition
Anterior uveitis
152
Superficial dendritic ulcers are characteristic of what
Herpes simplex infection/ulcer
153
Sudden and painful loss of vision is suggestive of what
Acute angle closure glaucoma
154
What is amaurosis fugax
A transient loss of vision in one eye lasting usually
| only a few minutes and at most a few hours - essentially a TIA involving the eye
155
What can cause amaurosis fugax
Usually secondary to embolic event from carotid or heart
| Must be investigated as a TIA – risk of stroke is high
156
How do you treat wet ARMD
Anti-VEGF injections - injected straight into the vitreal body of the eye
This inhibits the growth factors stimulating new vessel growth
157
What are the risk factors for diabetic retinopathy
Increased duration of diabetes - 90% of type ones will have it after 20 years
Poor diabetic control
158
Active treatment is available for dry ARMD - true or false
False
| Only available for wet ARMD in the form of anti-VEGF injections
159
Halo's forming around lights is a sign of which eye condition
Associated with corneal oedema which is seen in acute angle closure glaucoma
160
Giant cell arteritis can lead to irreversible blindness - true or false
True
One of the true ophthalmic emergencies
Blindness can be bilateral and irreversible
161
How do you treat giant cell arteritis
High dose oral steroids which are tapered down over months
162
What type of discharge is seen in bacterial eye infections
Sticky and purulent
163
What type of discharge is seen in viral eye infections
Watery
| Also seen in surface eye irritation such as foreign bodies
164
What type of eye pain indicates a surface issue
Scratchy / gritty / discomfort
| E.g. conjunctivitis, foreign body
165
What type of eye pain indicates an intraocular issue
Severe / deep / aching pain
| E.g. iritis, scleritis, angle closure glaucoma
166
What type of redness indicates an intraocular issue
Diffuse injection
| If it is greatest around the cornea - circumcorneal
167
What is chemosis
Oedema of the conjunctiva Makes the eye look like jelly
| Seen in conjunctivitis
168
How do you treat bacterial conjunctivitis
Treat with topical antibiotics ie chloramphenicol
169
How do you treat viral conjunctivitis
Supportive treatment
| Cool compresses, lubricants etc.
170
What features are suggestive of chlamydia conjunctivitis
Young patient - sticky + red in first 10 days after birth
Unilateral
Follicular conjunctivitis
Diagnose by PCR swab
171
List risk factors for corneal ulcers
Corneal abrasion
Contact lens wearer
Dry eye
Iatrogenic -loose suture or surgery
172
If you apply topical steroids to a herpetic ulcer what can happen
It can lead to a geographic ulcer - the infection spreads across the eye
173
How do you treat chlamydial conjunctivitis in an infant
Swabs
Erythromycin
contact traces
174
How does a blocked nasolacrimal duct present in infancy
Sticky + white uninflamed eye from 2 months
| Congenital block in the duct
175
How do you treat a blocked nasolacrimal duct
Bathe and massage sac
Most resolve spontaneously by 1 year
Syringe and probing if not resolving
176
What is the leading cause of blindness in people of working age in industrialized countries
diabetic retinopathy
177
List risk factors for developing diabetic retinopathy
```
Increasing duration of diabetes
Poor blood sugar control
Hypertension
Dramatically* improved diabetic control - sudden increase in control leads to short term worsening of the retinopathy
Hypercholesterolaemia
Pregnancy
```
178
Describe the pathogenesis of diabetic retinopathy
Chronic hyperglycaemia
Glucose molecules attaches to the basement membrane of the vasculature of the retina
Causes a loss of pericytes
This leads to vascular dysfunction and increases permeability
Reduced O2 transport leads to tissue hypoxia
Vaso-formative factors produced - VEGF
New vessel formataion occurs to overcome the hypoxia
New vessels do more harm than good – they leak a lot
Get haemorrhage and scarring
179
What is the function of the pericytes in the eye
Pericytes help with the tight junctions in the eye vasculature – maintain eye/blood barrier
They are lost in diabetic retinopathy
180
How can diabetic retinopathy lead to retinal detachment
DR can cause scarring
| Contraction of scarring in the vitreous can lead to retinal detachment
181
What causes visual loss in diabetic retinopathy
Retinal oedema affecting the fovea - macular oedema
Vitreous haemorrhage - due to leaking of the new vessels
Scarring/ tractional retinal detachment
182
How is diabetic retinopathy classified
By the grade of the retinopahty and the maculopathy
183
List the grades of retinopathy seen in diabetic retinopathy
```
None
Mild - micro-aneurysms
Moderate - microaneurysm, hard exudates, flame shaped haemorrhage
Severe
Proliferative - new vessles
```
184
How do you manage each grade of retinopathy
None-severe - observe and re-screen
| If proliferative you give laser treatment
185
List the grades of maculopathy seen in diabetic retinopathy
No maculopathy
Observable maculopathy - exudates between 1 & 2 disc diameters of the centre of the fovea
Referable maculopathy - any blot haemorrhages or hard exudates – within 1 disc diameter
186
How can you treat the maculopathy seen in diabetic retinopathy
You treat if they have reduced vision
Intravitreal anti-VEGF injections are the gold standard now – better outcomes for preserving vision
Focal laser at macula – if they don’t respond to injection
187
Describe the pathogenesis of glaucoma
Usually blockage to aqueous outflow - obstruction to drainage
Causes raised intra-ocular pressure
Damage and loss of retinal nerve fibres at optic disc
Visual field loss
188
What is considered normal IOP
11.5-21.5 mmHG is considered normal
189
Why is peripheral vision lost first in glaucoma
In periphery lots of photoreceptor's feed into the same ganglion cell, in the macula less photoreceptors per ganglion
Therefore, loss of ganglion cells in periphery is noticed first as it wipes out more photoreceptors
190
List risk factors for primary open angle glaucoma
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Age
raised intraocular pressure
Afro-Carribean origin
Family history
Myopia – short sighted is a risk
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191
Being highly myopic (very short sighted) increased the risk of which other condition
Retinal detachment - have larger eye so retina is thinner and vitreous is more watery so can move about more and separate more easily
Open angled-glaucoma
192
Being highly hypermetropic (very long sighted) increased the risk of which other condition
Acute angle closure glaucoma
193
What are the main subtypes of cataract
Nuclear Sclerotic – most common type, brown/green appearance
Cortical – spoke like pattern
Posterior Subcapsular - cataract develops at the back of the lens between the lens and the back of the capsule
Mature - appears white
194
A mature cataract has an increased operative risk - true or false
True
195
What is the most common cause of blindness in the elderly in the western world
ARMD
196
How do you manage dry ARMD
No active treatment, just prevent progression to wet ARMD
Low Visual Aids
Dietary / smoking advice
- Vitamin rich diet can reduce further visual loss and prevent progression to Wet ARMD
- Macula is very sensitive to smoking damage so promote cessation
Amsler Grid - allows patients to monitor visual distortion – one of the first signs of progression to wet is increased distortion of straight lines
Blind registration
197
What is OCT
Ocular Coherance Tomography
Cross sectional map of the retina
Can be used to diagnose and monitor wet ARMD
198
How do you treat a central retinal artery occlusion
Only effective if presentation within 12-24 hrs
Treatment aims at dislodging blockage and restoring circulation
Ocular massage - can change the pressure in the eye and force may dislodge the blockage
Paper bag breathing – increases PCO2 which causes reflex vasodilation and may allow the blockage to move
IV Diamox - CAI which drops the intraocular pressure so pressure behind blockage is greater than in front and may push it on
Anterior Chamber Paracentesis – remove some aqueous fluid to reduce IOP and again move blockage down vascular tree
199
What causes a cotton wool spot to appear in the retina
It is ischamia of the nerve fibre layer of retina
200
How do you treat a central retinal vein occlusion
If no signs of ischaemia - observe (every 3 months initially then less frequently)
If ischaemic but no neovascularition - observe closely (every 4-6 weeks )
If ischaemic with neovascularisation – requires urgent argon laser pan-retinal photocoagulation
also try and find underlying risk factors and modify them
201
How do you treat ischaemic optic anterior neuropathy
No active treatment
| Assess and treat the risk factors - e.g. smoking
202
How do you treat a retinal detachment
If picked up as early retinal tear can be lasered to prevent progression to proper detachment
Vitrectomy – similar to keyhole in the eye, clear away the vitreous gel, laser the initial tear and put a bubble of gas in to hold retina in place while things heal
203
What is retrobulbar neuritis
Similar to optic neuritis except the inflammation is behind the optic nerve head so cannot be seen
204
Which eye symptoms and signs can suggest a neurological issue
Optic nerve function – acuity, visual field, colour vision, pupil response
Ocular motility – 3rd, 4th, 6th nerve palsies
205
What investigations should be done for bilateral papilloedema
Suggests raised ICP
Needs urgent imaging to rule out SOL
If no SOL you may be looking at IIH which can be diagnosed by LP
206
How do you trea optic/retrobulbar neuritis
IV steroids may hasten recovery but not affect final VA. Oral steroids may worsen outcome
May be role for B Interferon
207
What can cause Horner's syndrome
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Pancoast tumour
Carotid/Aortic aneurysms
Lesions of neck
Congenital
Idiopathic
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Anything affecting the sympathetic chain
208
Horizontal field defects are seen when which part of the tract is affected
Anything in front of the chiasm
209
Vertical field defects are seen when which part of the tract is affected
Structures behind the chiasm
210
What is a hyphaema
Fluid level of blood in the eye
211
What is a hypopyon
Fluid level of white blood cells in the eye
| Sign of severe intra-ocular infection
