6.1.5. Recognises common ocular abnormalities and refers when appropriate.

Question 1

Blepharitis treatment

Answer 1

• Posterior - dry warm compress 10 minutes twice daily, eyelid bag >40 degrees to melt meibum
• Anterior - wet warm compress to loosen collarettes and crusts for anterior bleph
• Lid massage (mixed/posterior) – melt the meibum and encourage blockage out
• Lid cleansing to remove deposits and bacteria from lid margin - gel e.g. TTO/blephasol or wipes e.g. Blephademodex/blephaclean
• Avoid cosmetics directly on lid margin
• Once symptoms resolve can reduce measures to minimum of twice weekly
  Other options
• Chloramphenicol ointment bds, rubbing onto lid margin with finger
• Demodex if over 70 and/or CD
• Weekly in office treatments with 50% TTO to kill mites
• Nightly treatment with 5% TTO/products with terpinene-4-ol to prevent mating/migration
• Initial management followed by referral if three months of treatment does not produce sufficient response
  *

Question 2

Allergic Conjunctivitis

SAC & PAC

Answer 2

o Avoid allergen, cold compress, avoid eye rubbing to prevent degranulation of mast cells
o Ocular lubricants to be used 3-4x daily for symptomatic relief i.e. viscotears
o Topical AH to relieve itching i.e. antazoline sulphate 0.5% tds
o Topical MCS i.e. sodium cromoglicate 2% qds
o Oral antihistamine i.e. loratadine od

Question 3

Allergic Conjunctivitis

 VKC

Answer 3

o Cold compress when acute
o Ocular lubricants symptomatic relief ^
o Topical MCS e.g. sodium cromo 2% qds
o Refer to HES urgently if active limbal or corneal involvement

Question 4

Allergic Conjunctivitis

 AKC

Answer 4

o Cold compress
o Lid hygiene for associated blepharitis
o Avoid known allergens
o Local pharmacy for loratadine od
o Topical MCS i.e. sodium cromo 2% qds
o Urgent referral if active limbal or corneal involvement

Question 5

Allergic Conjunctivitis

 Acute allergic

Answer 5

o Most resolve spontaneously within a few hours
o Avoid eye rubbing
o Cool compress for symptomatic relief
o Identify allergen and avoid future contact
o Ocular lubrication for symptomatic relief
o If recurrent, prophylactic topical MCS e.g. sodium cromo 2% as POM

Question 6

Bacterial conjunctivitis

Answer 6

• Self-limiting 5-7 days without treatment
• Bathe eyelids with cooled boiled water
• Advice on contagious nature of condition
• Topical antibiotic may improve short term outcome:
  Drops 0.5%, dose:
• 1 drop every 2 hours for 48 hours
• Then, every 4 hours during waking hours
• Eye drops may be supplemented with ointment at night
• Treatment course should last 5 days
  Ointment 1% dose
• qds for 2 days
• bds for 5 days
• CL wearer – quinolone i.e. levofloxacin (PoM)

Question 7

Viral conjunctivitis

Answer 7

 Self-limiting 1-2 weeks
 Cold compress
 Generally caused by adenovirus
 Anti-viral agents are generally ineffective
 Artificial tears may relieve symptoms

Question 8

Sub conjunctival haemorrhage

Answer 8

 Refer for BP check if necessary
 Reassurance, condition usually clears within 5-10 days
 Cold compress may reduce discomfort
 Ocular lubrication if irritation is present

Question 9

Episcleritis

Answer 9

 Self-limiting in 7-10days
 Cold compress
 If severe discomfort, ocular lubricants for 1-2wks
 PoM if IP if px is particularly symptomatic e.g. FML

Question 10

Corneal abrasion

Answer 10

• Rule out multiple parts, incl. double lid eversion
• Loose FBs irrigated with saline
• FB on conjunctiva removed with sterile cotton bud
• Assess depth & carry out seidel test
• Remove FB under topical anaesthetic
• Topical antibiotic, chloramphenicol 0.5% 4x daily for 5 days if likelihood of infection
• CL wearer – quinolone

Question 11

Hordeolum

Answer 11

• External (stye) – associated gland of zeiss/moll - tender inflamed swelling of lid margin, may point anteriorly through skin
• Internal – acute bacterial infection of MG - tender inflamed swelling within tarsal plate – more painful than a stye, may point anteriorly through skin or posteriorly through conj
• Most resolve spontaneously or discharge, following by resolution in case of external
• Hot compress
• AB ointment in case of copious mucopurulent discharge – chloramphenicol 1% tds for 1 week (fusidic acid if allergic/bf/pregnant)
• Rare – refer routinely for incision in cases than do not discharge (more common in internal)

Question 12

Chalazion

Answer 12

• Most result on conservative management – hot compress, lid massage (B2 – no referral)
• Regular lid hygiene for bleph – most likely posterior
• Routine refer if: persistent, recurrent, causing significant astigmatism, cosmetically unacceptable

Question 13

OCT - layers of retina ( and where abnormalities would be)

Answer 13

1. Inner limiting membrane
2. RNFL
3. Ganglion cell layer
4. Inner plexiform layer
5. Inner nuclear layer
6. Outer plexiform layer
7. Outer nuclear layer
8. Outer limiting membrane
9. Photoreceptor layer
   ^^neurosensory retina

–< SUBRETINAL; above RPE but below neurosensory retina, where subretinal fluid would be i.e., WET AMD

10. RPE; maintains the photoreceptors; cells absorb stray light, form the outer blood retinal barrier and regenerate’s visual pigment; highly pigmented layer between neurosensory retina and Bruchs membrane

–< SUB RPE; where drusen would be i.e. DRY AMD

• Bruch’s membrane; involved in the controlled passage of nutrients and waste products to and from retina
• Choroid; provides 2/3 of nutrients to retina and RPE; made up of vessels which supply the outer retina; important at macula where retinal circulation is absent
• Sclera

Question 14

Macula scan: raster cube scan

Answer 14

• 50% total RGCs at macula
• GCC (ganglion cell complex i.e. innermost 5 layers, ILM, RNFL, GCL, IPL, INL)
• GChart only measures thickness of GCC i.e. NRR, not things like disc swelling
• Peripheral macular thickness asymmetry can occur in healthy eyes, but central macular thickness is highly symmetrical

Question 15

Retinal nerve fibre layer: circumpapillary scan

Answer 15

• Provides thickness measurements of RNFL
• Produces a RNFL thickness map beginning and ending nasally, with superior, temporal and nasal quadrants in between
• Thickness compared to normative data base, plotted on a probability graph depicting 95%, 5% and 1% confidence limits
• The greater amount of nerve fibre layers coming from superior and inferior sections of the disc is highlighted by the double hump of RNFL thickening at those poles (absence of double hint = indicates nerve fibre loss in these areas

Question 16

Common macula problems

Answer 16

• Central serous retinopathy / central serous chorio-retinopathy
• Sudden onset of visual symptoms i.e., distortion, micropsia, partial scotoma
• Raised area at macula
• OCT visible dark area of sub-retinal fluid i.e., above RPE but below sensory retina
• This is a serous detachment (serous = fluid)
• CSR occurs most commonly in younger male patients / type A
• Generally, resolves in 4-6 weeks without treatment

Question 17

Macular hole

Answer 17

• Routine referral to ophthalmology if full thickness / VA drop
• Vitrectomy which can help to close hole with some slow recovery to normal VA

Question 18

ERM & wrinkling of retinal surface

Answer 18

• Routine referral if symptomatic / px wants surgery
• Vitrectomy & membrane peel

Question 19

Drusen Vs Hard Exudates

Answer 19

• Drusen are formed between Bruch’s membrane and the retinal pigmented epithelium
• Hard exudates form within the retina predominantly at the level of the outer plexiform layer
• Exudates normally by area of oedema - therefore if you see exudates, suspect oedema!

Question 20

Types of PEDs & Common Associated Conditions

Answer 20

• 3 Types:
  1. Drusenoid (AMD)
  2. Serous (dome shape due to fluid) - CSR, idiopathic
  3. Fibrovascular (membrane & oedema) - wet AMD
• Commonly Associated Conditions
  
  • Wet AMD
  • Diabetic Maculopathy
  • Central Serous Retinopathy
  • Secondary to Cataract / Ocular surgery

Question 21

Lid lesions (signs of malignancy)

Answer 21

• Bleeding
• Asymmetrical shape
• Change in colour
• Ulceration, irregularity, telangiectasia, pearly appearance, and loss of eyelid margin architecture (notching)
• Diplopia or Proptosis indicating orbital invasion!

Question 22

Glaucoma or Glaucoma suspects

Answer 22

• Vertical elongation of cup
• Thinking of ISNT - may do OCT to double check
• Disc haems

Question 23

Sqamous cell papilloma

Answer 23

• Descript - benign epithelial tumour, skin-tag & wart like
• Causes - human papilloma virus
• Management - normally goes by itself, excision, cryotherapy & laser or chemical ablation

Question 24

Serborrhoeic Keratosis (basal cell papilloma) (look in kanski!)

Answer 24

• Descript - light- to dark-brown plaque with a friable, greasy, verrucous surface and a ‘stuck-on’ appearance
• Causes - elderly, common, numerous
• Management - shave biopsy, excision, laser, cryotherapy

Question 25

Melanocytic naevus (low chance for malignancy)

Answer 25

- Descript - can be congenital (kissing naevus possible), compound naevus (rasied & scaly), junctional naevus (uniform & brown), intradermal naevus (most common, no malignancy potential) - Management - complete excision if suspect melanoma

Question 26

Molluscum Contagiosum

Answer 26

- Descript - viral infection; caused by poxvirus, very young or adults immuno compromised - Causes - linked with AIDs, eczema, swimming pools - Sxs - Skin nodule(s) (typically 2-3 mm diam), often with a central depression (‘umbilicated’), Can cause conjunctivitis - follicles, redness, watering, photophobia, epitheliopathy etc - White cheesy material can be discharged **- Management - self-limiting (goes after few weeks or months), referral if no resolve for excision**

Question 27

Basal cell carcinoma

Answer 27

- Risk Factors - Old, White, UV exposure - Types: - Nodular - pearl like, few dilated vessels - Nodulo-ulcerative - centre ulcerated, pearly rolled edges, telangiectasia - Sclerosing - looks clear, margins hard to define. Don’t mistake for blepharitis! - Management - needs referral (soon) for biopsy

Question 28

Squamous cell carcinoma

Answer 28

- Risk Factors - Old, White, UV exposure, Immunocompromised - Types: - Nodular - hyperkeratotic with crusting, erosions, fissures - Ulcerating - red base, defined “hard looking” borders with a slight crusty look - Cutaneous horn - Management - needs referral (urgent within a week) for biopsy

Question 29

Ectropian

Answer 29

- Outward rotation of lid margin - **TESTS:** - Distraction test - if lower lid can be pulled >6mm from globe, it is lax, positive test indicates canthal tendon laxity - Snap-back test - with finger, pull lower lid down towards inferior orbital margin release: lid should snap back lid slow to return to its normal position: indicates poor orbicularis tone - Types - Involutional (age related causing laxity), Cicatricial (scarring of skin), Paralytic (facial palsy i.e. Bell’s), Mechanical (tumour, lid swelling etc), Congenital (rare bilateral condition) - Management - less lid rubbing (induces laxity), drops, routine referral if severe

Question 30

Entropian

Answer 30

- Inward rotation of lid margin - **TESTS:** - Distraction test - if lower lid can be pulled >6mm from globe, it is lax, positive test indicates canthal tendon laxity - Snap-back test - with finger, pull lower lid down towards inferior orbital margin release: lid should snap back lid slow to return to its normal position: indicates poor orbicularis tone - Test of Induced Entropion (TIE-2 test) - ask patient to look down hold upper lid up as high as possible ask patient to close the eyes as tightly as possible The TIE-2 test is positive if this provokes an intermittent lower lid entropion - Types - Involutional, Cicatricial (scarring & contraction of palp conj e.g. in chronic bleph), Spastic (random orbicularis contraction e.g. after surgery or blepharospasm), Congenital (rare) - Management - Lash epilation, Lubrication, routine referral if severe

Question 31

Keratocanthoma

Answer 31

- Descript - Rare, rapidly growing, keratin filled crater, pink dome - Causes - white, UV, immunosuppresive therapy - Management - spotaneous involution after growing for 2-3 months, taking up to a year!! leaving a scar! Excision also works

Question 32

Conjunctival lesions

Answer 32

- Pinguecula - UV protection. Lubricants. If inflammed, steroids. Referral if vision affected or cosmetically unacceptable - Pterygium - UV protection. Lubricants. If inflammed, steroids. Referral if vision affected or cosmetically unacceptable or astigmatism induced - Retention cyst - Goes by itself, or punctured with a needle using a topical anaesthetic - Conjunctivochalasis - Lubrication & treat chronic bleph. Conjunctival resection (cutting out tissue) if severe. - Concretions - Lubrication. Removed using needle under topical anaesthesia.

Question 33

Retinitis Pigmentosa

Answer 33

- Descript - inherited diffuse retinal degenerative disease affecting rods then cones - Cause - genes - Signs - Dark adaptation trouble, VF loss, Bone-spicules, Narrower A/V, Disc pallor, Possible maculopathy - Management - Genetic counselling, LVAs & adaptations like expanding FOV

Question 34

Fuch’s Dystrophy

Answer 34

- Descript - bilateral endothelial loss, >women - Causes - inherited, middle age onset - Signs - blurring more in morning due to oedema, corneal guttata, beaten bronze appearance

Question 35

Choroidal Naevus Vs Melanoma

Answer 35

- C - Close to ON - O - Orange pigment lipofuscin - N - No drusen - S - Symptoms (F+F, visual disturbance if raised) - T - Thickness (>2mm) - A - Absence of halo (ring of pallor) - N - New - T - Too big (>5mm)

Question 36

CHRPE

Answer 36

common benign lesion, usually congenital. Can be single or grouped (bear tracks) Linked to FAP (familial adenomatous polyposis) (liver condition) if 4 or more CHRPEs that are separated more than bear tracks are detected. - Low malignancy risk so just monitor