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Year 6 - Surgery > Surgery: Ophthal > Flashcards

Surgery: Ophthal Flashcards

1
Q

What are the features of diabetic retinopathy?

A

Background: venodilation, microaneurysms, hard exudates

Pre-Proliferative: soft exudates

Proliferative: new vessel formation

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2
Q

What are the features of hypertensive retinopathy?

A

I: arteriolar narrowing + silver wiring

II: AV nipping

III: flame shaped haemorrhages + cotton wool spots

IV: papilloedema = raised IOP

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3
Q

What should you listen for if the pt complains of amaurosis fugax?

A

Carotid Bruits

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4
Q

What causes pupil constriction?

A

Acetylcholine - PNS - Circular Muscles

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5
Q

List causes of miosis (4)

A

Constricted pupil: horners, cluster headaches, Argyll-Robertson, drugs

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6
Q

Horner’s Syndrome Triad

A

Ptosis

Miosis

Anhidrosis - pre ganglionic affects face, central affects face arms trunk, post ganglionic not affected

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7
Q

What are the causes of Horner’s syndrome?

A 
Pre-Ganglionic Lesion:
Trauma
Top Rib
Thyroidectomy
pancoast Tumour
Central Lesion:
Stroke
Syringomyelia
multiple Sclerosis
tumour Swelling
Post-Ganglionic Lesion:
Carotid Aneurysm
Carotid Artery Dissection
Cavernous Sinus Thrombosis
Cluster Headache
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8
Q

Argyll-Robertson Pupil

A

Bilateral, accommodates but does not react, neurosyphilis

Damage to the pretectal region in the midbrain

The nickname prostitutes pupil helps remember the O/E and cause

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9
Q

What causes pupil dilation?

A

Adrenaline - SNS - Dilator Muscles

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10
Q

List causes of mydriasis (6)

A

Dilated pupil: third nerve palsy, raised ICP, Holmes-Adie, congenital, trauma, drugs

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11
Q

3rd Nerve Palsy Triad

A

Ptosis

Mydriasis

Divergent strabismus in a down and out position

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12
Q

What are the causes of a 3rd nerve palsy?

A

Idiopathic

Medical - ischaemia - Pupil Sparing: HTN, DM, MS

Surgical - pressure on PNS - Pupil Dilatation: painful PCOM aneurysm, cavernous sinus thrombosis, tumour, trauma, raised ICP

Think PHD: PCOM, HTN, DM

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13
Q

Holmes-Adie Pupil

A

Unilateral, Sluggish, Viral

Damage to post ganglionic parasympathetic fibres

Syndrome = pupil + absent ankle and knee reflexes

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14
Q

Which CN has the longest intracranial route?

A

Abducens

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15
Q

Ddx of Red Eye

A

Painful: orbital cellulitis, herpes, dryness, keratitis, ulcer, uveitis, scleritis, acute glaucoma

Painless: episcleritis, trichiasis, subconjunctival haemorrhage

Both: blepharitis, viral>allergic>bacterial conjunctivitis, foreign body

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16
Q

Which viruses can cause keratitis? (3)

A

Herpes simplex, VZV, adenovirus

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17
Q

What can happen when contact wearers go swimming?

A

Keratitis caused by acanthamoeba

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18
Q

What constitutes the uveal tract? (3)

A

Iris, ciliary body, choroids

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19
Q

How does corneal pathology and uveitis classically present? (3)

A

Usually recurring w photophobia, watering, pain

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20
Q

How does orbital cellulitis px? (3)

A

Unilateral, ophthalmoplegia, proptosis

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21
Q

What can mimic the cobblestone papillae in conjunctivitis?

A

The use of contacts

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22
Q

Painless + sudden loss of vision

A

Retinal artery occ: emboli, GCA + fundoscopy shows retinal pallor and cherry red spot

Retinal vein occ: thrombus, myeloma + fundoscopy shows haemorrhages, cotton wool spots, swollen optic disc

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23
Q

Which muscles other than the extraocular are paralysed following a 3rd nerve palsy?

A

Levator palpebrae superioris + pupillary constrictor

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24
Q

Why is the eye ‘down and out’ in 3rd nerve palsy?

A

Unopposed SO and LR action

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25
Q

Why is the eye ‘up and in’ in 4th nerve palsy?

A

Paralysis of SO

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26
Q

What is the anatomy of the retina?

A

Optic nerve, ganglion cells, bipolar cells, cone/rod, pigment epithelium

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27
Q

Outline the visual pathway

A

Optic nerve, chiasm, tract, lateral geniculate nucleus in thalamus, meyers loop, primary visual cortices in occipital lobes

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28
Q

What are the components of the physical examination?

A 
Acuity
Fields
Inspect external eye
Accommodation
Motility
Corneal reflex
Pupils
Ant segment
Fundus
IOP
Fluorescein
Lid Eversion
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29
Q

Hx

A 
Onset
Worsening
Mono/binocular
Contact lens wearer
Recent eye surgery
Antecedent activities
Past visual acuity
Unusual sx
Other medical conditions - diabetes

Tried any tx
Did someone tell them to come in

Problems w skin, joints, bowels

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30
Q

What requires immediate action?

A

Acute glaucoma esp >35mmHg -> blockage central retinal artery -> irreversible loss of vision

Infection - ant chamber parathentesis and tap, collect ventrous sample, inject abx

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31
Q

Opthal SVR

A 
Pain
Vision
Redness
Discharge
Itching
Burning
Swelling
Photophobia
FB sensation
Am stickiness
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32
Q

What narrows down ddx for acute red eye?

A

Painful - abnormal lids, diffuse conjunctival infection, abnormal cornea

Painless - diffuse + localised

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33
Q

What are your ddx if a painful acute red eye w normal lids/cornea and no diffuse conjunctival infection?

A

Angle closure glaucoma, uveitis, scleritis

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34
Q

What causes discharge?

A

Blepharitis, stye, dryness, conjunctivitis, corneal trauma

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35
Q

What causes foreign body sensation?

A

Trichiasis, dryness, conjunctivitis, abrasion, contact lens intolerance, foreign body

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36
Q

What causes itching/burning?

A

Blepharitis, dryness, conjunctivitis, inflamed pinguecula, keratitis, inflamed pterygium, contact lens intolerance, allergy

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37
Q

What do you need to check w photophobia?

A

Corneal +/or ant chamber involvement

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38
Q

Ddx of sudden vision loss

A

Transient: amaurosis fugax

Persistent: vaso-occlusive disorder, optic nerve disorder, retinal detachment

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39
Q

Ocular emerg: medical vs surgical

A

Med: periorbital cellulitis, conjunctivitis, iritis, glaucoma, central retinal artery occlusion

Surg: orbital fracture, eyelid laceration, extraocular FB, chemical burn, corneal abrasion, hyphema, globe rupture, retinal detachment

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40
Q

Does subconjunctival haemorrhage cause loss of vision?

A

No: usually resolves by itself in ~2wks

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41
Q

Which conditions predispose to iritis? (2)

A

Rheumatic Disease + Syphillis

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42
Q

What are the pathognomonic sx of iritis?

A

Redness, blurred vision, photophobia

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43
Q

Tx for Iritis

A

Stay in darkened environment, warm compresses, analgesia, steroid drops tailored down over 4wks +/- cycloplegics, F/U

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44
Q

Episcleritis vs Scleritis

A

The sclera will go white w phenylephrine in episcleritis

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45
Q

What are the effects of phenylephrine in the eye?

A

Pupil Dilation + Vasoconstriction

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46
Q

How is acute glaucoma classified?

A

1°/2° open angle glaucoma, 1°/2° angle closure +/- glaucoma, acute angle closure crisis

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47
Q

Mx of acute angle closure crisis

A

Drops to red production of aqueous and constrict pupil, oral acetazolamide, oral glycerol, IV mannitol, ant chamber paracentesis

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48
Q

Mx of Retinal Detachment

A

Limit movement by bed rest and eye patches whilst referring to ophthal

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49
Q

What pattern of orbital injury is a/w trauma directly to the globe?

A

Buckling Effect

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50
Q

Mx of Penetrating FB

A

A-E, do NOT remove, assess acuity, consider CT head, urgent transfer via ambulance to eye hosp

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51
Q

What does the lens divide the eye into anatomically?

A

Ant Segment: further split into ant/post chamber relative to the iris

Post Segment: vitreous, retina, uvea, sclera

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52
Q

What is the limbus?

A

The junction b/w cornea and sclera

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53
Q

What devastating infection can you get following recent eye surgery?

A

Endophthalmitis

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54
Q

What is the most common bug in contact lens wearers?

A

Pseudomonas

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55
Q

What abx do you use in contact wearers instead of chloramphenicol?

A

Quinolones

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56
Q

What causes chronic >6wks conjunctivitis? (2)

A

Chlamydia + Molluscum

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57
Q

Which bacteria can penetrate an intact corneal surface?

A

Gonorrhoea

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58
Q

Tx for Blepharitis

A

Protect ocular surface w lubricant

Artifical tears

Warm compresses

PO doxycycline

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59
Q

What is a chalazion? And tx?

A

Blocked meibomian gland a/w blepharitis, rosacea, seborrhoeic dermatitis

Tx associations + if persistent incise/curettage

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60
Q

What is characteristic of scleritis?

A

Pain that wakes them up at night

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61
Q

What is the most common systemic disorder a/w scleritis?

A

RA

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62
Q

What is the worst thing you can give to a pt with a dendritic ulcer?

A

Steroids

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63
Q

What is the Hutchinson sign?

A

When they have herpes zoster vesicles on the tip of their nose, along nasociliary nerve distribution, makes intraocular involvement more likely

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64
Q

Why is a white eye worrying following a chemical injury?

A

Indicates limbal ischaemia and therefore poor prognosis as the limbal stem cells repopulate the corneal epithelium

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65
Q

Mx of Chemical Injury

A

Stop hx and immediately wash out until neutralised + forniceal sweep for particulate matter

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66
Q

What are the cardinal signs of orbital>preseptal cellulitis?

A

Chemosis, reduced ROM, diplopia, proptosis, RAPD

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67
Q

How does acute angle closure glaucoma px?

A

Painful red eye a/w blurred vision with halos and N+V

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68
Q

What’s the normal range of IOP?

A

10-21mmHg

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69
Q

What should you give to a pt w acute angle closure glaucoma whilst they’re being transferred to ophthal?

A

IV/PO 500mg Diamox + get the pt to lie down

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70
Q

What is the sign of retinal detachment?

A

Single arcuate flash in the corner of vision typically noticed in the dark

71
Q

What do you want to know about acute painless loss of vision?

A

Unilateral vs bilateral if unilateral is it monocular vs hemianopia

72
Q

Ddx: transient loss of vision

A

Amaurosis fugax, papilloedema, GCA, migraine

73
Q

At what levator function will a frontalis suspension be required?

A

<4mm

74
Q

What is the importance of the medial canthal tendon as a landmark?

A

Think about the lacrimal gland below and masses above

75
Q

What is the earliest sign of optic neuritis?

A

Colour Desaturation

76
Q

Why do you get a third nerve palsy following a SAH?

A

Aneurysm of the posterior communicating artery

77
Q

Which CN lies most medially in the cavernous sinus?

A

Abducens

78
Q

What is the mechanism of damage to the 3rd 4th 6th CNs in raised ICP?

A

They get compressed against the tentorium cerebelli

79
Q

What structures pass through the optic canal? (3)

A

Optic nerve, ophthalmic artery, meninges

80
Q

What are the layers of the cornea? (5)

A

A-E: anterior epithelium, bowman’s layer, connective stroma, descemet’s membrane, endothelium

81
Q

Why do you get disciform keratitis?

A

Hypersensitivity to the viral antigen > infection

82
Q

What causes nummular keratitis?

A

Adenovirus

83
Q

What deficiency would result in Bitot’s spots?

A

Vit A

84
Q

List causes of dry eyes

A

Aqueous def: obstruction, Sjogrens, sarcoidosis, lymphoma, SLE, AIDS, reflex sensory block, meds

Inc evaporation: abnormal lids, meibomian gland dysfunction (blepharitis), goblet cell def (chemical burns, trachoma, SJS, cicatricial pemphigoid, vit A def)

85
Q

What condition is reflex sensory block seen in?

A

Diabetes

86
Q

Myopia

A

Light is focussed in front of the retina, the refractive power is too great or AP diameter too long, corrected w concave lens

87
Q

Hypermetropia

A

Light is focussed behind the retina, the refractive power is too weak or AP diameter too short, corrected w convex lens

88
Q

Astigmatism

A

Optical power of eye uneven across different meridians, usually regular ie perpendicular to each other, tx w toric lens / CLs / refractive surg

89
Q

Presbyopia

A

Loss of normal accommodation w failure to focus on near objects

90
Q

What are the types of cataracts?

A

Nuclear sclerotic, cortical, posterior subcapsular

91
Q

Which type of cataracts causes nearsightedness?

A

NS

92
Q

Which type of cataracts is seen in steroid use?

A

Posterior Subcapsular

93
Q

Marfans vs Homocystinuria

A

Both get subluxed lens but upwards in Marfans and downwards in homocystinuria

94
Q

Cataract Surgery

A

Phacoemulsification > ECCE > ICCE

95
Q

At which point do you start worrying if a child can’t see?

A

> 3mnths

96
Q

What is Foster-Kennedy syndrome?

A

Unilateral visual loss w pale atrophic disc and contralateral papilloedema

97
Q

What is the common gene mutation in retinoblastoma?

A

RB1 on Chr13

98
Q

How do you screen for retinoblastoma? (3)

A

Red reflex, Hirschberg test, structural abnormalities

99
Q

What raises concerns about a child’s vision?

A

Clumsy, photophobic, squint, nystagmus, cloudy cornea

100
Q

What are causes of a cloudy cornea in a child?

A

STUMPED

Sclerocornea
Tears in Descemet’s
Ulcer
Metabolic
Peter’s Anomaly
Endothelial Dystrophy
Dermoid
101
Q

What are the signs of congenital glaucoma?

A

Corneal clouding, globe enlargement, megalocornea, scleral ring enlargement, tears in descemet’s, rapid cupping

102
Q

Why must you never miss herpes simplex in a neonate?

A

Encephalitis

103
Q

Congenital Glaucoma vs Endothelial Dystrophy

A

ED: reasonable vision, normal IOP, no inc in corneal diameter

104
Q

What is the histological definition of the macula?

A

The region where the ganglion cell layer is more than one cell thick

105
Q

Which drug causes bulls eye maculopathy?

A

Hydroxychloroquine: annual retinal screening after five yrs

106
Q

Ddx for Uveitis

A

Infection, Sarcoidosis, Lymphoma

Plus IBD if anterior + MS if intermediate

107
Q

Miller Fisher Syndrome

A

Variant of GBS: ophthalmoplegia, ataxia, areflexia

108
Q

What does red desaturation and pain on eye movements suggest?

A

Optic Neuritis

109
Q

Does the pupil dilate early/late in a surgical 3rd nerve lesion?

A

Early as the parasympathetic fibres lie on the outside

110
Q

What else would you like to measure in a pt w a 3rd nerve palsy?

A

The BP (HTN) and BM (DM)

111
Q

What are the causes of a 6th nerve palsy?

A

The same as 3rd: HTN, DM, MS plus raised ICP

112
Q

What are the clinical signs of cataracts?

A

Dec red reflex + lens opacification

113
Q

Ddx of Cataracts

A

OAG + Macular Degeneration

114
Q

Which CN lesion results in a dilated and fixed pupil?

A

III

115
Q

Which CN are involved in the corneal reflex?

A

Afferent V + Efferent VII

116
Q

Px of Horner’s syndrome

A

Ptosis, miosis, ipsilateral anhidrosis

117
Q

Px of third nerve palsy

A

Ptosis, globe deviation down and out, abnormally dilated pupil (not always present)

118
Q

Px of sixth nerve palsy

A

Dec aBduction resulting in binocular horizontal diplopia

119
Q

Px of Holmes Adie’s pupil

A

Larger pupil on the affected side which reacts slowly to bright light

NB: no ptosis & normal accommodation reflex

120
Q

List two causes of Horner’s syndrome

A

Pancoast tumour & carotid artery dissection

121
Q

List two causes of carotid artery dissection

A

Severe whiplash injuries & prolonged neck extension

122
Q

Gold standard test to exclude carotid artery dissection

A

Angiography either MRA or CTA

123
Q

The pupil size in Horner’s syndrome

A

Smaller

124
Q

Ddx for poor fundal view

A

Cataracts, vitreous haemorrhage, corneal scar

125
Q

RFs for age-related macular degeneration (AMD)

A

Age, smoking, FHx

126
Q

Px of AMD

A

Central visual loss but peripheral and night vision not affected

127
Q

What is amblyopia?

A

Poor vision in an eye due to something preventing a clear retinal image being formed in childhood

128
Q

Most common causes of amblyopia

A

Uncorrected hypermetropia & constant squint

129
Q

Myopia

A

Shortsighted

130
Q

Hypermetropia

A

Longsighted

131
Q

Most common cause of cataract

A

Senile i.e. age-related

132
Q

The clinical triad of retinitis pigmentosa

A

Arteriolar attenuation, bone–spicule peripheral retinal pigmentation, waxy optic disc pallor

133
Q

Eye changes in diabetes

A

Retinopathy & maculopathy

134
Q

Diabetic retinopathy

A

Dot and blot haemorrhages -> cotton wool spots -> proliferative i.e. neovascularisation

135
Q

Diabetic maculopathy

A

Dot and blot haemorrhages & sometimes exudates

136
Q

What does the presence of exudates in the macular suggest?

A

Oedema

137
Q

Other features of retinitis pigmentosa

A

FHx, night blindness, loss of peripheral vision

138
Q

How would you formally assess tunnel vision?

A

Confrontational visual field techniques

139
Q

Nyctalopia

A

Night Blindness

140
Q

Night Blindness

A

Nyctalopia

141
Q

Shortsighted

A

Myopia

142
Q

Longsighted

A

Hypermetropia

143
Q

Causes of pre senile cataract

A

Steroids, uveitis, diabetes mellitus, high myopia, significant trauma

144
Q

What is cataracts a/w

A

Down’s syndrome & retinitis pigmentosa

145
Q

Which value is important wrt cup to disc ratio

A

If 0.6 or less probably normal & over 0.6 probably glaucoma

146
Q

Causes of swollen optic disc

A

Optic neuritis, anterior ischaemic optic neuropathy inc GCA, papilloedema, severely raised BP

147
Q

What underlying condition presents w optic neuritis?

A

Young pt w multiple sclerosis

148
Q

How to px fundoscopy findings

A

Think of colour, contour, cupping for disc and then work round the retinal periphery

149
Q

Most common cause of retinal detachment

A

Posterior vitreous detachment (PVD) if the vitreous traction is enough to cause a tear

150
Q

Layers of the eye

A

Sclera, choroid, retina, vitreous body

151
Q

Three types of retinal detachment

A

Rhegmatogenous (tear allowing fluid through), tractional (scar tissue), exudative

152
Q

Causes of exudative retinal detachment

A

Inflammation, cancer, Coats disease

153
Q

Tx of minor retinal detachment

A

Photocoagulation, cryopexy, retinopexy

154
Q

Tx of major retinal detachmenty

A

Scleral buckling & vitrectomy

+/- cryopexy or retinopexy

155
Q

What is PVD

A

The vitreous collapses in on itself causing flashes (stops when the vitreous finally separates from the retina) & floaters (which remain for life)

156
Q

How does retinal detachment px

A

A shadow in one eye that gradually progresses from edge of vision across the whole field

157
Q

How does vitreous haemorrhage px

A

Sudden painless onset of floaters often obscuring vision completely within 10-20mins that usually clears over wks-mnths

158
Q

How does acute angle closure glaucoma typically px?

A

Painful red eye w fixed mid-dilated pupil

159
Q

What is the most common cause of blindness in the UK?

A

Age Related Macular Degeneration

160
Q

ARMD: Dry vs Wet

A

Dry: 90% - characterised by drusen-yellow round spots in Bruch’s membrane

Wet: 10% - characterised by choroidal neovascularisation + worst prognosis

161
Q

Tx of wet ARMD

A

Zinc w vits ACE, anti-VEGF agents, laser photocoagulation

162
Q

What does a dendritic corneal ulcer on slit lamp examination w fluorescein stain?

A

Herpes Simplex Keratitis

163
Q

Ix of ARMD

A
  1. Slit lamp microscopy: to identify any pigmentary, exudative or haemorrhagic changes
  2. Fluorescein angiography: if neovascular suspected to guide anti-VEGF therapy
  3. Ocular coherence tomography: to visualise the retina in 3D
164
Q

What is the risk of developing MS if >3 white matter lesions on MRI following optic neuritis?

A

5yrs

165
Q

List five causes of tunnel vision

A 
Glaucoma
Papilloedema
Retinitis Pigmentosa
Chorioretinitis
Tabes Dorsalis
166
Q

Infective Conjunctivitis: Bacterial vs Viral

A

Bacterial: purulent discharge + eyes ‘stuck together’ in the am

Viral: serous discharge, recent URTI, preauricular lymph nodes

167
Q

What drops can be offered for infective conjunctivitis?

A

Chloramphenicol

168
Q

What alternative tx can be given to preg women w infective conjunctivitis?

A

Topical Fusidic Acid

169
Q

What factors predispose to acute angle closure glaucoma? (3)

A

Hypermetropia, mydriasis, lens growth a/w age

NB: myopia is a/w primary open angle glaucoma

170
Q

Mx for AACG

A

Initial: eye drops (pilocarpine, timolol, apraclonidine) + IV acetazolamide

Definitive: laser peripheral iridotomy

171
Q

What are the features of episcleritis?

A

Red eye +/- watering, mild photophobia, mild pain

172
Q

What drops can be used to differentiate b/w episcleritis vs scleritis?

A

If the eye redness improves w phenylephrine a dx of episcleritis can be made

173
Q

Mx of Episcleritis

A

Consrv +/- artificial tears

174
Q

What determines the site of lesion in Horner’s syndrome?

A

Anhydrosis

Face - preganglionic: pancoasts + cervical rib

Plus Arm+Trunk - central: stroke + syringomyelia

Absent - postganglionic: carotid artery dissection

Year 6 - Surgery (6 decks)

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