6.1.5. Recognises common ocular abnormalities and refers when appropriate.

Question 1

Allergic Conjunctivitis

 SAC & PAC

Answer 1

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 2

 VKC

Answer 2

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 3

 AKC

Answer 3

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 4

 Acute allergic

Answer 4

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 5

Bacterial conjunctivitis

Answer 5

• 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 6

Viral conjunctivitis

Answer 6

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

Question 7

Sub conjunctival haemorrhage

Answer 7

• 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 8

Episcleritis

Answer 8

• 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 9

Corneal abrasion

Answer 9

• 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 10

Hordeolum

Answer 10

• 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 11

Chalazion

Answer 11

• 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 12

Layers of the retina:

Answer 12

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 13

Normative data charts (ETDRS) (find picture)

Answer 13

• Statistical analysis of tissue thickness compared to normative data; number in each sector represents average total retinal thickness in that sector
• Colours represent a probability score (not like thickness temperature maps), colour scale represents 100% of population in a normative data base
• Central 90% = green
• Bright yellow = 1-5% of population would have retina that thin
• Red = 0-1% of normal population would have retina that thin
• Lemon = 1-5% of normal population would have retina that thick
• Pink = 0-1% of normal population would have retina that thick
  *

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

(find picture) CSR

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

Where is OCT indicated?

Answer 19

• Suspected maculopathy
  
  • Distortion on amsler
  • AMD (standard in hospitals)
  • Diabetes
  • Macula detachments, holes, swelling, etc.
• Glaucoma
  
  • RNFL thickness
  • Optic disc
  • Macula thickness
• Choroidal Melanoma
• Drusen Vs Exudates
• ERMs
• CRVO

Question 20

What principle does OCT work upon?

Answer 20

A scan - represents depth & reflectivity of a point in the scan

B scan - combines multiple A scans to form a cross sectional image (what we normally see!)

C scan - combines multiple B scans to form a 3D image. Looks cool but has little value except to impress the px!

Question 21

Types of Retinal Oedema & Common Associated Conditions

Answer 21

• 3 Types
  1. Diffuse retinal thickening (thick & loss of regularity)
  2. Cystoid oedema (dark black pockets)
  3. Sub retinal fluid (between RPE & neural retina)
• Commonly Associated Conditions
  
  • Wet AMD
  • Diabetic maculopathy
  • CSR
  • Secondary to cataract/ocular surgery

Question 22

Drusen Vs Hard Exudates

Answer 22

• 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 23

Types of PEDs & Common Associated Conditions

Answer 23

• 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 24

Lid lesions (signs of malignancy)

Answer 24

• 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 25

# Recognises using appropriate techniques, these conditions: Cataract

Answer 25

- Retroillumination of the lens - Optic section of the lens

Question 26

# Recognises using appropriate techniques, these conditions: Glaucoma or Glaucoma suspects

Answer 26

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

Question 27

# Recognises using appropriate techniques, these conditions: Anterior eye conditions

Answer 27

Technique - Diffuse direct illumination - In this method the illumination beam and viewing system are sharply focused on the same area using a wide beam with a diffusing filter and low magnification (also useful for general viewing of the eye and adnexa).

Question 28

Chalazion

Answer 28

- Descript - Sterile inflammation of meibomian gland (cyst) causing stagnation of secretion from the gland, leading to a more chronic lesion. Can follow an internal hordeolum - Cause - May occur spontaneously or follow an acute hordeolum (internal), chronic bleph - Sxs - painless lid lump, rarely induced astigmatism - Management - warm compress & massage. Steroid or excision

Question 29

Hordeolum

Answer 29

- Descipt - Either external (stye-acute bacterial infection of eyelash glands) or internal (meibomian gland) - Causes - chronic bleph - Sxs - tenderness, pain if internal sometimes, watering - Management - warm compress & massage, if mucous discharge then antibiotic treatment using chloramphenicol

Question 30

Trichiasis

Answer 30

- Descript - misdirected lashes - Causes - chronic blepharitis, infection like herpes zoster, surgery, trauma - Management - removal, laser ablation

Question 31

Distichiasis

Answer 31

- Descript - growth of abnormal number of lashes - Causes - intense chronic inflammation like steven johnsons, or OCP. Can be congenital! - Management - removal, ablation, cryotherapy

Question 32

Sqamous cell papilloma

Answer 32

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

Question 33

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

Answer 33

- 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 34

Melanocytic naevus

Answer 34

- (low chance for malignancy) - 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 35

Molluscum Contagiosum

Answer 35

- 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 36

Basal cell carcinoma

Answer 36

- 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 37

Squamous cell carcinoma

Answer 37

- 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 38

Other eyelid cysts:

Answer 38

- Cyst of Zeiss - cyst of anterior lid margin - Cyst of Moll - retention cyst near canthus - Sebaceous cyst - Epidermal inclusion cyst - implantation of epidermis into dermis following trauma or surgery, round, firm & whitish-yellowish looking due to keratin - Dermoid cyst - Xanthelasma

Question 39

Keratocanthoma

Answer 39

- 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 40

Conjunctival lesions

Answer 40

- 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 41

AMD & Macular abnormalities

Answer 41

- PED - If drusenoid, then regular AMD management - If serous or fibrous with signs of AMD, then most likely urgent within 1-2 weeks as suspect wet AMD - Macula hole - If Lameller hole & not causing trouble with vision or too much distortion, then worth monitoring over next 6 months whilst giving amsler - ERM - Monitor, 1 yr recall - If VMT, then separate management as may progress to macula hole so might require referral within 3-4 weeks if vision worse than 6/7.5 - CSR - Routinely referred soon 3-4 weeks - Some HES will only want to see CSR if chronic for at least 4 months because normally it will resolve itself in 6 or so weeks. Photodynamic laser - Oedema - Referred urgently within 2 weeks e.g. proliferative DR, CRVO, after cataract surgery

Question 42

Retinitis Pigmentosa

Answer 42

- 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 43

Iris Melanoma

Answer 43

- Descript - pigmented area of iris, normally inferior - Causes - UV, white - Signs & Sxs - pupil distortion, causes cataracts & uveitis, raised, has surface vessels (DD from iris naevus), 3-5mm - Management - take a photo & refer routinely for iridectomy. If angle invaded, iridocylotomy. Radiotherapy