Week 2 - F - Ophthamology 5 - Glaucoma and some eye inflammation Flashcards
What is glaucoma?
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
What are the two main types of glaucoma?
Angle open glaucoma
(acute) angle closure glaucoma
Which type of glaucoma is usally asymptomatic and has a progressive nature?
This is open angle glaucoma
How does open angle glaucoma typically present? What cause the increased intraocular pressure?
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
How does acute angle closure glaucoma present?
- 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
What type of eyesight is more commonly affected in people with acute angle closure glaucoma?
Patients who are far sighted (hyperopes (hypermetropes) )
When feeling the eye in acute angle closure glaucoma, how does it feel?
Usually feels hard rock hard due to the build up of pressure behind the eye
What percentage of patients with glaucoma does primary angle open glaucoma account for?
Accounts for 90% of patients with glaucoma
What type of vision will a patient with glaucoma complain of?
Patient will complain of tunnel vision as peripheral vision is first to go
What will look different on fuundoscopy?
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
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
Ophthalmic prostoglandin analogues - latanoprost
Ophthalmic beta blockers - timolol
Ophthalmic carbonic annhydrase inhibitors - dorzlamide
Ophthalmic alpha 2 adrenoergic agonists - brimonidine
Which of the glaucoma medications opens to uveoscleral outflow?
Prostoglandin analogues - latanoprost increases uveoscleral outflow
If drugs do not work as the treatment of open angle glaucoma, what are the next two stages of treatment?
Next stage after drugs - laser trabeculoplasty
Finally - trabeculotomy via surgery (removes trabecular meshwork therefore clearing outflow of fluid)
What is the treatment for acute angle closure glaucoma?
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
If drug treatment does not work in acute angle closure, what can be carried out?
Anterior chamber paracentesiss to relieve pressure from the eye
Can follow up with a laser iridotomy to both eyes to open up angle
If drug treatment was successful in controlling the intraocular pressure, what treatment is recommended now?
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
In glaucoma, what is the intraocular pressure above?
Pressure greater than 21mmHg
What are the two different types of inflamed eyelid?
Can have anterior and posterior blepharitis
What is the treatment of belphariits before prescribing antibiotics?
Eye hygiene - massage and warm decompression
In anterior blepharitis can get seborrheic belpahritis (dry and dandruff) and can get staphlococcal infections What can the staphlococcal infection cause?
Can causes swellings of the glands in the eyelid causing a condition known as styes
Anterior blephariits can be caused by staphlyococcal infection this infection involves the lash follicles and lashes What can this cause to the lashes?
this can cause inturning of the lashes - trichiasis
What other condition is inturned eyelashes associated with?
Associated with chlamydia trachomatis
What does the inturning of the eyelashes cause to the cornea?
Can cause corneal scratching
An external eyelid stye is also known as a horlodeum externum, what does this look like?
abscess or infectioons Looks like a red painful bump on the surface of the eyelid
What is the treatment of a stye? (try remember treatment of bacterial conjunctival infection)
Management includes hot compresses and analgesia
Then give chloramphenicol if associated conjunctivits or Topical fusidic acid if swab comes back as staph aureus
What causes posterior blephariits?
Meibomain gland dysfunction - associated with acne rosacea
What does posterior blepharitis spare?
Spares the lid margins and lashes
What does meibomian gland secrete and therefore constitutes to the dry eye when there is dysfuntion?
Secretes the outer lipid layer of tear film - meibum
Corneal ulcers have all the same causes as keratitis What can be a soothing treatment of corneal ulcers?
Chloramphenicol
Anterior uveitis is also known as iritis What are some autoimmune causes of anterior uveitis?
Reiter’s syndrome (reactive arthritis, urethreitis and uveitis)
Sarcoidosis
Ankylosing spondylitis
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?
There will be no discharge in anterior uveitis normally
In reiter’s syndrome associated with uveitis, urethreitis and reactive arthritis What is the reactive arthritis commonly caused by?
Commonly caused by post GI infection (campylobacter/salmonella or by genital infections eg chlamydia trachomatis)
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)
Management urgent review by ophthalmology cycloplegics (dilates the pupil which helps to relieve pain and photophobia)
e.g. Atropine, cyclopentolate steroid eye drops
• 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?
Scleritis Scleritis - treat with NSAIDs , steroids if not working, immunosuppresants if not working
How does scleritiis differ from episcleritis?
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
What is episcleritis?
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)
Is vision affected in episcleritis or scleritis?
Vision is unaffected in episcleritis but may be affected in scleritis
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?
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)
Patient presents with mild tenderness of the eye which is red. Vision is unaffected Which between episcleritis and scleritis is this suspected to see?
Think more of episcleritis
Can look the same as scleritis which is why it is important for phenylephrine test
Patient presents with a very painful red eye. The vessels of the eye are injected What is this thought to be?
Think scleritis
In scleritis and glaucoma, what are some different factors?
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
What is the difference in treatment plan of episcleritis and scleritis?
Episclertitis - self limtiing and treat with topical NSAIDs or mild steroids
Scleritis - treat with oral NSAIDs, oral Steorids
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?
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
What condition is episcleritis associated with?
Has an association with gout
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?
Cotton wool spots, hard exudates, blurred vision
Does not have neovascularisation or microaneursyms
What renal condition can be associated with hypertension and cerebral aneursyms causing blurred vision if they leak?
Autosomal dominant polycystic kidney disease
What conditions are associated with photophobia in the eye?
Most eye infections are assoicated wtith photohobia
And so is papilloedema and meningitis
Which drops can be given to dilate the eye?
Tropicamide or cyclopentate
Wich drug is first line for pimary open angle glaucoma?
Lotanoprost - causes brown pigment
