Week 2 - F - Ophthamology 5 - Glaucoma and some eye inflammation

Question 1

What is glaucoma?

Answer 1

This is a condition where the optic nerve of the eye becomes damaged due to a raised intra-ocular pressure when the fluid in the eye cannot drain properly

Question 2

What are the two main types of glaucoma?

Answer 2

Angle open glaucoma

(acute) angle closure glaucoma

Question 3

Which type of glaucoma is usally asymptomatic and has a progressive nature?

Answer 3

This is open angle glaucoma

Question 4

How does open angle glaucoma typically present? What cause the increased intraocular pressure?

Answer 4

Gradual loss of vision sometimes asymptomatic due to an increased pressure in the eye, usually due to a decreased in drainage at the trabecular meshwork The peripheral vision is lost first

Question 5

How does acute angle closure glaucoma present?

Answer 5

• C-orneea appears hazy due to oedema
• L-ight appears to have halos and blurred vision
• O-ccurs due to blocked drainage of aquaoeus humour
• S- shallow anterior chamber
• E-yeballs feel hard due to increased IOP
• D-ilated pupils which is worse at night (or in the dark)

Patinet may also be vomiting

Question 6

What type of eyesight is more commonly affected in people with acute angle closure glaucoma?

Answer 6

Patients who are far sighted (hyperopes (hypermetropes) )

Question 7

When feeling the eye in acute angle closure glaucoma, how does it feel?

Answer 7

Usually feels hard rock hard due to the build up of pressure behind the eye

Question 8

What percentage of patients with glaucoma does primary angle open glaucoma account for?

Answer 8

Accounts for 90% of patients with glaucoma

Question 9

What type of vision will a patient with glaucoma complain of?

Answer 9

Patient will complain of tunnel vision as peripheral vision is first to go

Question 10

What will look different on fuundoscopy?

Answer 10

Increased cup to disc ratio in glaucoma - the cup represents the non optic nerve part so this increased ratio signifies dying nerve fibres due to pressure - cup-to-disc ratio >0.7 (normal = 0.4-0.7), occurs as loss of disc substance makes optic cup widen and deepen

Question 11

The treatment for glaucoma is to reduce intra-ocular pressure What are the drug options for primary open angle glaucoma? (give one example of each drug) all the drugs are topical

Answer 11

Ophthalmic prostoglandin analogues - latanoprost

Ophthalmic beta blockers - timolol

Ophthalmic carbonic annhydrase inhibitors - dorzlamide

Ophthalmic alpha 2 adrenoergic agonists - brimonidine

Question 12

Which of the glaucoma medications opens to uveoscleral outflow?

Answer 12

Prostoglandin analogues - latanoprost increases uveoscleral outflow

Question 13

If drugs do not work as the treatment of open angle glaucoma, what are the next two stages of treatment?

Answer 13

Next stage after drugs - laser trabeculoplasty

Finally - trabeculotomy via surgery (removes trabecular meshwork therefore clearing outflow of fluid)

Question 14

What is the treatment for acute angle closure glaucoma?

Answer 14

Give patient a Carbonic annyhdrase inhibitor - dorzalomide and Beta blocker - timolol/betoxalol and Miotic - pilocarpine -

miotics open the closed corneoslceral angle where the trabecular meshwork is located

Question 15

If drug treatment does not work in acute angle closure, what can be carried out?

Answer 15

Anterior chamber paracentesiss to relieve pressure from the eye

Can follow up with a laser iridotomy to both eyes to open up angle

Question 16

If drug treatment was successful in controlling the intraocular pressure, what treatment is recommended now?

Answer 16

Once any symptoms have been controlled, the first line (and often definitive) treatment is laser iridotomy - Peripheral irodotomy (laser or surgery) is now carried out in BOTH eyes to open up the aqueous drainage outflow

Question 17

In glaucoma, what is the intraocular pressure above?

Answer 17

Pressure greater than 21mmHg

Question 18

What are the two different types of inflamed eyelid?

Answer 18

Can have anterior and posterior blepharitis

Question 19

What is the treatment of belphariits before prescribing antibiotics?

Answer 19

Eye hygiene - massage and warm decompression

Question 20

In anterior blepharitis can get seborrheic belpahritis (dry and dandruff) and can get staphlococcal infections What can the staphlococcal infection cause?

Answer 20

Can causes swellings of the glands in the eyelid causing a condition known as styes

Question 21

Anterior blephariits can be caused by staphlyococcal infection this infection involves the lash follicles and lashes What can this cause to the lashes?

Answer 21

this can cause inturning of the lashes - trichiasis

Question 22

What other condition is inturned eyelashes associated with?

Answer 22

Associated with chlamydia trachomatis

Question 23

What does the inturning of the eyelashes cause to the cornea?

Answer 23

Can cause corneal scratching

Question 24

An external eyelid stye is also known as a horlodeum externum, what does this look like?

Answer 24

abscess or infectioons Looks like a red painful bump on the surface of the eyelid

Question 25

What is the treatment of a stye? (try remember treatment of bacterial conjunctival infection)

Answer 25

Management includes hot compresses and analgesia

Then give chloramphenicol if associated conjunctivits or Topical fusidic acid if swab comes back as staph aureus

Question 26

What causes posterior blephariits?

Answer 26

Meibomain gland dysfunction - associated with acne rosacea

Question 27

What does posterior blepharitis spare?

Answer 27

Spares the lid margins and lashes

Question 28

What does meibomian gland secrete and therefore constitutes to the dry eye when there is dysfuntion?

Answer 28

Secretes the outer lipid layer of tear film - meibum

Question 29

Corneal ulcers have all the same causes as keratitis What can be a soothing treatment of corneal ulcers?

Answer 29

Chloramphenicol

Question 30

Anterior uveitis is also known as iritis What are some autoimmune causes of anterior uveitis?

Answer 30

Reiter’s syndrome (reactive arthritis, urethreitis and uveitis)

Sarcoidosis

Ankylosing spondylitis

Question 31

In anterior uveitis there are symptoms such as • Pain (+ referred pain) • Vision may be reduced • Photophobia • Red eye (circum-corneal) What will there be none of?

Answer 31

There will be no discharge in anterior uveitis normally

Question 32

In reiter’s syndrome associated with uveitis, urethreitis and reactive arthritis What is the reactive arthritis commonly caused by?

Answer 32

Commonly caused by post GI infection (campylobacter/salmonella or by genital infections eg chlamydia trachomatis)

Question 33

Anterior uveitis is one of the important differentials of a red eye. It is also referred to as iritis. 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 * What is the treatment of anterior uveitis? (of course have to treat the disease linked to is as well)

Answer 33

Management urgent review by ophthalmology cycloplegics (dilates the pupil which helps to relieve pain and photophobia)

e.g. Atropine, cyclopentolate steroid eye drops

Question 34

• VERY SERIOUS • Association with serious systemic vasculitides e.g. Rh arthritis, Wegener’s • PAINFUL + • Injection of deep vascular plexus – ‘violaceous hue’ – reddening around eye socket What is this?

Answer 34

Scleritis Scleritis - treat with NSAIDs , steroids if not working, immunosuppresants if not working

Question 35

How does scleritiis differ from episcleritis?

Answer 35

Episcleritis is associated with inflammation on the outer layer of sclera and nodules can occur

Scleritiis is very painful with injection of deep vascular plexus of vessels

Question 36

What is episcleritis?

Answer 36

It is the inflammation of the thin layer of tissue that lies between the conjunctiva and the connective tissue layer that forms the white of the eye (sclera)

Question 37

Is vision affected in episcleritis or scleritis?

Answer 37

Vision is unaffected in episcleritis but may be affected in scleritis

Question 38

Because episcleritis is inflammation of the superficial vessels, what can be used to move the vessels? What test can be used to diagnose between episcleritis scleritis?

Answer 38

Use a cotton bud to move the vessels

• Apply topical phenylephrine 10% will result in blanching of the superficial episcleral vascular network but not the deep plexus, thus distinguishing between episcleritis and scleritis
• In episcleritis the eye will blanche and therefore become more white
• In scleritis the eye will not blacnh and will remain red

Blanching - means when it goes from red to disappear or white (ie blanching rash - when pressure applied, rash disappears or goes white)

Question 39

Patient presents with mild tenderness of the eye which is red. Vision is unaffected Which between episcleritis and scleritis is this suspected to see?

Answer 39

Think more of episcleritis

Can look the same as scleritis which is why it is important for phenylephrine test

Question 40

Patient presents with a very painful red eye. The vessels of the eye are injected What is this thought to be?

Answer 40

Think scleritis

Question 41

In scleritis and glaucoma, what are some different factors?

Answer 41

In scleritis, there is a more vision in the eye but same painfulness

Usually associated with rheumatic disease

Glaucoma can cause vomiting and is not associated with rheumatic diseases but can be associated long sightedness

Question 42

What is the difference in treatment plan of episcleritis and scleritis?

Answer 42

Episclertitis - self limtiing and treat with topical NSAIDs or mild steroids

Scleritis - treat with oral NSAIDs, oral Steorids

Question 43

If the patient has rheumatic disease would you be thinking more along the lines of scleritis or episcleritis? What test is done to diagnose between the two?

Answer 43

Would be thinking more along the lines of scleritis in rheumatoid arthritis

Topical phenylephrine drops (10%) differentiate between the two and there will be blanching in episcleritis and non-blanching in scleritis

Question 44

What condition is episcleritis associated with?

Answer 44

Has an association with gout

Question 45

Accelerated (malignant) hypertension can cause optic disc swelling What are other assoicated features? What does it not have that a type of diabetic retinopathy does have?

Answer 45

Cotton wool spots, hard exudates, blurred vision

Does not have neovascularisation or microaneursyms

Question 46

What renal condition can be associated with hypertension and cerebral aneursyms causing blurred vision if they leak?

Answer 46

Autosomal dominant polycystic kidney disease

Question 47

What conditions are associated with photophobia in the eye?

Answer 47

Most eye infections are assoicated wtith photohobia

And so is papilloedema and meningitis

Question 48

Which drops can be given to dilate the eye?

Answer 48

Tropicamide or cyclopentate

Question 49

Wich drug is first line for pimary open angle glaucoma?

Answer 49

Lotanoprost - causes brown pigment