Pathology Part 1 Flashcards
Amaurosis fugax
Transient, painless loss of vision
o “Like a curtain coming down”
o Lasts ~5min with full recovery
o Examination usually normal
Anterior uveitis
Describes inflammation of the anterior portion of the uvea - iris and ciliary body. It is associated with HLA-B27 and may be seen in association with other HLA-B27 linked conditions.
Features of Anterior uveitis
> acute onset > ocular discomfort & pain > pupil may be small +/- irregular > photophobia (often intense) > blurred vision > red eye > lacrimation > ciliary flush: a ring of red spreading outwards > hypopyon > visual acuity initially normal → impaired
Hypopyon
describes pus and inflammatory cells in the anterior chamber, often resulting in a visible fluid level
Disorders associated with Anterior uveitis
- ankylosing spondylitis
- reactive arthritis
- ulcerative colitis, Crohn’s disease
- Behcet’s disease
- sarcoidosis: bilateral disease may be seen
Chorioretinitis
Is a form of posterior uveitis and is associated with cytomegalovirus and toxoplasmosis (cats).
Management of Anterior uveitis
- Urgent review by ophthalmology
- Cycloplegics (mydriatic) eye drops
- Steroid eye drops
Investigations of Anterior uveitis
Slit lamp
Conjunctivitis
Inflammation of the conjunctivae. It is very common
Bacterial Conjunctivitis
Acute onset red, gritty eyes with purulent discharge that causes the eyes to be stuck together on wakening ▪ Minimal pain & Red eye ▪ Will spread from one eye to the other ▪ Clear cornea ▪ Normal pupillary light response
Causes of Bacterial Conjunctivitis
▪ Staph aureus, strep. pneumonia, h. influenzae
▪ Pseudomonas
▪ In babies: chlamydia trachomatis, Neisseria gonorrhoea
▪ Chlamydia in sexually active adults
Management of Bacterial Conjunctivitis
- Chloramphenicol
- If neonate, refer to ophthalmology
- Fusidic acid
- Pseudomonas – gentamicin
- Chlamydia – oxytetracycline, azithromycin
Causes of viral Conjunctivitis
- Adenovirus
- Herpes simplex
- Herpes zoster
Symptoms of viral conjunctivitis
▪ Swollen and tender pre-auricular lymph nodes
▪ Watery eye (sticky in bacterial conjuncitivits)
▪ Red eye
▪ Extreme eye movements can cause pain
▪ Tends to occur with a URTI
Keratitis
Inflammation of the cornea. Often caused by corneal abrasion
Causes of Keratitis
> bacterial
fungal
amoebic
parasitic: onchocercal keratitis (‘river blindness’)
Types of bacteria in bacterial Keratitis
> Staphylococcus aureus
> Pseudomonas aeruginosa - contact lens wearers
What bacteria causes keratitis in contact kens wearers?
Pseudomonas aeruginosa
Features of Keratitis
- red eye: pain and erythema
- photophobia
- foreign body, gritty sensation
- hypopyon may be seen
Diagnosis of Keratitis
o Fluorescein
o Corneal scrape
Management of suspected keratitis in contact wearers
Same-day referral to an eye specialist is usually required to rule out microbial keratitis
Stop using contact lens until the symptoms have fully resolved
Topical antibiotics - typically quinolones
Complications of Keratitis
> corneal scarring
perforation
endophthalmitis
visual loss
Endophthalmitis
Inflammation of the intraocular space occupied by the vitreous. If it involves all layers and the peri-ocular tissues, it is known as panopthalmitis. Potentially devastating infection
Causes of Endophthalmitis
>
Staph epidermidis Most cases are after cataract procedures Injury Contact lenses
Symptoms of Endophthalmitis
- Red eye
- Decreased vision
- Extreme pain
Investigations for Endophthalmitis
o Slit lamp
o Ultrasound
Management of Endophthalmitis
>
Immediate referral
> Intravitreal vancomycin
Blepharitis
Inflammation of the eyelid margins
Anterior blepharitis
Inflammation of the eyelid margins
caused by seborrhoeic dermatitis/staphylococcal infection
Posterior blepharitis
Inflammation of the eyelid margins. caused by either meibomian gland dysfunction or acne rosacea
Symptoms of Blepharitis
o Itchy, sore, red eyelids o Burning sensation in the eyes o Photophobia o Swollen eyelid margins o Cysts
Management of Blepharitis
- Hot compresses twice a day
- Mechanical removal of the debris
- artificial tears
- Chloramphenicol, Fusidic acid, Doxycycline
Episcleritis
Common and usually benign condition characteristed by inflammation of the epislcera . Usually idiopathic
Features of Episcleritis
- red eye
- classically not painful (in comparison to scleritis),
- watering and mild photophobia
Episcleritis management
Self-limiting
Artificial tears
Difference between scleritis and episcleritis
Severe pain in scleritis, mild/none in Episcleritis
Scleritis features
- red eye
- classically painful (in comparison to episcleritis),
- watering and photophobia are common
- gradual decrease in vision
Difference between scleritis and episcleritis
Episcleritis is inflammation of the superficial, episcleral layer of the eye. It is relatively common, benign and self-limiting. Scleritis is inflammation involving the sclera. It is a severe ocular inflammation, often with ocular complications.
What condition is associated with scleritis?
Associated with rheumatoid arthritis
Scleritis
Severe infection throughout the entire thickness of the sclera. It is very rare and more common in women
Scleritis management
- Oral NSAIDs
2. Oral steroids
Ocular manifestations of Rheumatoid arthritis
keratoconjunctivitis sicca (most common) episcleritis (erythema) scleritis (erythema and pain) corneal ulceration keratitis
Orbital cellulitis
The result of an infection affecting the fat and muscles posterior to the orbital septum, within the orbit but not involving the globe. It is usually caused by a spreading upper respiratory tract infection from the sinuses and carries a high mortality rate. Orbital cellulitis is a medical emergency.
Risk factors for Orbital cellulitis
- Childhood
- Previous sinus infection
- Lack of Haemophilus influenzae vaccination
- Recent eyelid infection/ insect bite on eyelid (Peri-orbital cellulitis)
- Ear or facial infection
Features of Orbital cellulitis
o Sudden onset of unilateral swelling of conjunctiva and lids o Proptosis o Pain on movement o Relative afferent pupillary defect o Fever o Severe malaise
Investigation of Orbital cellulitis
CT which may shows Inflammation of the orbital tissues deep to the septum, sinusitis.
Management of Orbital cellulitis
Admission to hospital for IV antibiotics
Preseptal cellulitis
It is an infection of the soft tissues anterior to the orbital septum - this includes the eyelids, skin and subcutaneous tissue of the face, but not the contents of the orbit.
Preseptal cellulitis causes
Staph. aureus
Staph. epidermidis
Streptococci and anaerobic bacteria.
Investigations of Preseptal cellulitis
> Bloods - raised inflammatory markers
Swab of any discharge present
Contrast CT of the orbit may help to differentiate between preseptal and orbital cellulitis.
Management of Preseptal cellulitis
- All cases should be referred to secondary care for assessment
- Oral antibiotics are frequently sufficient - usually co-amoxiclav
Complications of Preseptal cellulitis
Bacterial infection may spread into the orbit and evolve into orbital cellulitis
Features of Argyll-Robertson pupil
- small, irregular pupils
2. no response to light but there is a response to accommodate
Causes of Argyll-Robertson pupil
> diabetes mellitus
> syphilis
A chalazion (Meibomian cyst)
A retention cyst of the Meibomian gland. It presents as a firm painless lump in the eyelid. The majority of cases resolve spontaneously but some require surgical drainage
Stye
infection of the glands of the eyelids
Entropion
In-turning of the eyelids
Ectropion
Out-turning of the eyelids
Dendritic ulcer
Herpes simplex keratitis causes this ulcer
Herpes zoster ophthalmicus (HZO)
Describes the reactivation of the varicella-zoster virus in the area supplied by the ophthalmic division of the trigeminal nerve. It accounts for around 10% of case of shingles.
Herpes zoster ophthalmicus (HZO) features
Vesicular rash around the eye, which may or may not involve the actual eye itself
Hutchinson’s sign: rash on the tip or side of the nose. Indicates nasociliary involvement and is a strong risk factor for ocular involvement
Management of Herpes zoster ophthalmicus (HZO)
- Oral antiviral treatment for 7-10 days
- intravenous antivirals may be given for very severe infection or if the patient is immunocompromised
- ocular involvement requires urgent ophthalmology review
Curtain coming down < 5 minutes
amaurosis fugax
Holmes-Adie pupil
> unilateral in 80% of cases
dilated pupil
once the pupil has constricted it remains small for an abnormally long time
slowly reactive to accommodation but very poorly (if at all) to light
Stage 1 hypertensive retinopathy
Arteriolar narrowing and tortuosity
Increased light reflex - silver wiring
Stage 2 hypertensive retinopathy
Arteriovenous nipping
Stage 3 hypertensive retinopathy
Cotton-wool exudates
Flame and blot haemorrhages
Stage 4 hypertensive retinopathy
Papilloedema
Papilloedema
Papilloedema describes optic disc swelling that is caused by increased intracranial pressure. It is almost always bilateral.
Features of Papilloedema
blurring of the optic disc margin
elevation of optic disc
loss of the optic cup
Paton’s lines: concentric/radial retinal lines cascading from the optic disc
Causes of Papilloedema
space-occupying lesion: neoplastic, vascular malignant hypertension idiopathic intracranial hypertension hydrocephalus hypercapnia
Vitreous haemorrhage
Bleeding into the vitreous humour. It is one of the most common causes of sudden painless loss of vision. It causes disruption to vision to a variable degree, ranging from floaters to complete visual loss.
Causes of Vitreous haemorrhage
- proliferative diabetic retinopathy (over 50%)
- posterior vitreous detachment
- ocular trauma
Most common cause of vitreous haemorrhage in young adults and children
Ocular trauma
Features of Vitreous haemorrhage
- painless visual loss or haze (commonest)
- red hue in the vision
- floaters or shadows/dark spots in the vision
Causes of tunnel vision
papilloedema glaucoma retinitis pigmentosa choroidoretinitis optic atrophy secondary to tabes dorsalis hysteria
Tunnel vision
Tunnel vision gives the appearance of looking through a narrow tube. Peripheral vision is obscured, causing a constricted field of view.
Retinitis pigmentosa
Retinitis pigmentosa primarily affects the peripheral retina resulting in tunnel vision. Retinitis pigmentosa (RP) is a group of rare, genetic disorders that involve a breakdown and loss of cells in the retina
Features of Posterior vitreous detachment
> The sudden appearance of floaters
Flashes of light in vision
Blurred vision
Cobweb across vision
The appearance of a dark curtain descending down vision (means that there is also retinal detachment)
Investigations for Posterior vitreous detachment
All patients with suspected vitreous detachment should be examined by an ophthalmologist within 24hours to rule out retinal tears or detachment.
Pain on eye movement
Optic neuritis
Curtain coming down >5 minutes
Retinal detachment
Dacrocystitis
Inflammation of lacrimal sac which occurs secondary to blockage of the lacrimal system and is treated with broad spectrum antibiotics.
What is worse; alkali or acid burns in the eyes?
Alkali burns to the eye are worse than acid burns, because alkali penetrates the eye, whereas acid is relatively self-limiting by caused the proteins to coagulate and prevent further damage.
Hyphaema
Blood in the anterior chamber that may occur following blunt trauma
Sympathetic ophthalmia
A dangerous complication of penetrating injury. Injury causes intra-ocular antigens to be released into the immune system. This causes an autoimmune response by the body to be launched against both eyes. Requires immediate treatment with immunosuppression or vision in both eyes will be lost.
Most common cancer of the eyelid
Basal cell carcinoma
Schirmer’s test
Measures ocular dryness - tear production
Damage to the optic chiasm
Bitemporal hemianopia
Damage to the optic tracts/radiations
May cause homonymous defects
Damage to the occipital cortex
Homonymous defects with macular sparing
Eye changes in Wilson’s disease
kayser Fleischer rings
Eye changes in Down Syndrome
brushfield’s spots
Eye changes in Ehlers-Danlos syndrome
Blue sclera
Meibomian glands
Are oil glands along the edge of the eyelids where the eyelashes are found. These glands make oil that is an important part of the eye’s tears. The oily layer is the outside of the tear film that keeps tears from drying up too quickly.
