Acute Ophthalmology 2 Flashcards by Minhee Kim

Ophthalmic trauma: causes

Chemical injury - EMERGENCY
Blunt trauma
Sharp and penetrating trauma

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Ophthalmic trauma: causes of loss of vision due to trauma

Corneal scarring and anterior segment damage - alkali burn
Disrupted globe - penetrating trauma
Siderosis bulbi (iron deposition) - intraocular metallic foreign body
Compressive optic neuropathy - retrobulbar haemorrhage
Traumatic optic neuropathy - bony or shearing injury

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Ophthalmic trauma - types

Eyelid, periocular, orbital haematoma
Orbital bony wall fracture
Subtarsal foreign body
Lid laceration
Lacrimal drainage system - oculoplastic repair + stent
Conjunctival laceration - suturing
Corneal abrasion - abx + cycloplegia
Corneal foreign body
Penetrating injury of cornea, sclera, iris, lens, retina
Hypahaema - blood in anterior chamber ; glaucoma
Lens dislocation
Traumatic cataract
Glaucoma - damage to trabecular meshwork
Vitreous haemorrhage + retinal commotio - retinal degeneration due to blunt trauma
Retinal tear
Choroid rupture - vision loss if underlying macula
Scleral perforation
Retrobulbar haemorrhage - canthotomy
Traumatic optic neuropathy

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Ophthalmic trauma - chemical injury: substances, why is alkali most destructive?

Alkali
Acid
Detergents 
Irritants (mace, pepper)
Superglue

Alkalis cause liquefactive necrosis
Continue to penetrate eye to deep layers, causing ischaemia, scarring of cornea and blindness
(Vs acid cause coagulative necrosis thus impede own progress)

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Ophthalmic trauma - chemical injuries: management

Wash out eye IMMEDIATELY
Measure pH of tear w litmus paper
Topical anaesthetic drops
Copious irrigation (saline, Ringers solution)
Check remaining foreign body: evert eyelid, swipe fornices
Examine eye: visual acuity, IOP, dilate pupils for fundal examination

Further Mx
Topical: abx, vitamin C, cycloplegia (pain)
Oral Vitamin C
Surgery: limbs cell transplant, corneal graft

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Ophthalmic trauma - blunt injuries: aetiology

Sport (balls), leisure activities, road traffic accidents, fist

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Ophthalmic trauma - blunt injuries: features

Lid ecchymosis 
Orbital haemorrhage 
Subconjunctival haemorrhage 
Hyphaemia 
Lens dislocation 
Orbital wall fracture 
Vitreous haemorrhage 
Commotio retinae
Retrobulbar haemorrhage

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Ophthalmic trauma - blunt injuries: examination

From lids to retina, front to back
Eye movements - exclude orbital wall fracture
Infra-orbital numbness
Cornea + conjunctiva - FBs
Fluorescein drops - exclude corneal abrasion
Fundus examination

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Ophthalmic trauma - blunt injury: hyphaema definition and management

Blood in anterior chamber
Blackball hyphaema: blood fills entire AC

Exclude vitreous, supra, subretinal haemorrhage - fundus Exam, USS if not visible
Topical steroids and dilating drops - minimise inflammation and reboeeding

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Ophthalmic trauma - blunt trauma: traumatic iritis definition and management

Inflammation of anterior chamber occurring commonly after blunt trauma

Topical steroids and mydriatic drops

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Ophthalmic trauma - blunt trauma: retrobulbar haemorrhage significance, features, management

EMERGENCY: Cause rapid blindness from compartment syndrome; raised IOP, compressive optic neuropathy

Pain, proptosis, reduced vision, poor pupil reaction (test consensual reflex in bruised eye)

Emergency lateral conthotomy and cantholysis

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Ophthalmic trauma - blunt trauma: commotio retinae definition, features, management

Retinal opaqueness due to fragmentation of photoreceptor layer and oedema following blunt trauma

Blurred vision if macula affected
Retina appears opaque

Completely resolves

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Ophthalmic trauma - blunt trauma: orbital floor fracture features and management

Diplopia - orbital tissue/eom entrapment
Enophthalmos

Orbital floor repair

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Ophthalmic trauma - penetrating trauma: features

high velocity injuries - intraocular FB

Misshapen pupils

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Ophthalmic trauma - penetrating injuries: superficial corneal injury causes, features

Corneal FB, Subtarsal FB

Pain, photophobia, watering, red eye, FB sensation
Corneal FB: visible on pen torch, slit lamp
Subtarsal FB: visible on everting lid, vertical abrasions

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Ophthalmic trauma - penetrating trauma: corneal abrasion features, management, RES

Pain, red eye, photophobia, watering, FB sensation

Red eye, fluorescein staining of epithelial defect, every lid for STFB

Wipe off CFB, STFB w cotton bud
Topical Chloramphenicol
Topical cyclopentolate - if photophobia

RES: with v sharp injuries, new epithelium do not adhere to stroma and repeatedly slough off
Tx = lubricating drops, bandage contact lens

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Acute loss of vision in inflamed eye - Uveitis: anatomical types

Anterior uveitis - iris, ciliary body (AC inflammation)
Intermediate uveitis - vitreous, ciliary body (vitreous inflammation)
Posterior uveitis - choroid, retina (retina/choroid inflammation)
Pan-uveitis - iris, ciliary body, vitreous, choroid, retina

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Acute LOV in inflamed eye - uveitis: anterior uveitis features

Pain - due to inflammation of ciliary body, pain on contraction
photophobia
watering

Red eye w circumciliary injection (around cornea) 
Hazy cornea (Keratoprecipitates/WBC on corneal endothelium)
Irregular pupil (Posterior synechiae - adhesion of lens to iris due to inflammatory cells) 
Cells and flares in AC (inflammatory breakdown of iris-blood barrier)

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Acute LOV in inflamed eye - uveitis: intermediate uveitis features

Floaters, blurred vision, no pain

Vitreous cells
Snowballs (pre-retinal inflammatory aggregates)
Snow-banking (pars plana exudation)
Macular oedema

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Acute LOV in inflamed eye - uveitis: posterior uveitis features

Painless blurring of vision, floaters, photopsia (flashing lights)

Cells in AC, vitreous
Choroiditis - raised lesions wo pigment 
Retinitis - cotton wool spots, haemorrhages
Macular oedema 
Vitreal detachment 
Retinal detachment

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Acute LOV in inflamed eye - uveitis: investigations

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Slit lamp
B scan ocular ultrasonography (in AAU to exclude posterior involvement when fundus cannot be seen)

First uveitis not investigated - majority idiopathic 
In recurrent uveitis - distinguish bw infective, inflammatory 
FBC, U+E 
ACE (sarcoidosis) 
CXR (TB, sarcoidosis) 
Syphilis 
HLA B27, A29
ANA
ANCA

Acute LOV in inflamed eye - uveitis: infective management

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Idiopathic - treat as infective

Infective:
topical abx
Topical steroids (reduces Jarisch-Herxheimer reaction - inflammatory reaction against bacterial lysis once antimicrobials commence, in TB, syphillis)

Acute LOV in inflamed eye - uveitis: inflammatory uveitis management

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Corticosteroids - topical, peri-ocular, oral, IV

Sustained release implants in vitreous - minimise SE due to blood-retinal barrier

Acute LOV in inflamed eye - posterior scleritis: features

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Visual loss (thickened posterior sclera)
Severe pain, not relieved by analgesia
Ocular tenderness
Diplopia
Painful eye movements (due to EOM insertion on inflamed sclera + myosotis)

Dilated fundoscopy: exudative retinal detachment
B scan US: thickened posterior sclera

Acute LOV in inflamed eye - posterior scleritis: investigations

``` Inflammatory cause: Rh factor ANA P-ANCA C-ANCA ```

Acute LOV in inflamed eye - posterior scleritis: management

NSAIDs - non-necrotising disease Corticosteroids - topical, peri-ocular, oral, IV Rheumatology referral

Acute LOV in inflamed eye - advanced keratitis: features

Opaque cornea | Severe reduction in visual acuity

Acute LOV in inflamed eye - advanced keratitis: predisposing factors

Contact lens wear - bacterial, Acanthamoebal keratitis Previous HSV, HZV infection - viral keratitis Travel to tropical country - fungal keratitis Loss of corneal sensation - neurotrophic keratitis Inability to close eye (lagophthalmos) - exposure keratitis

Acute LOV in inflamed eye - peripheral ulcerative keratitis: definition, cause, treatment

Immune complex deposition in peripheral cornea, which causes damage to stroma via release of matrix metalloproteinase RA, Wagner’s granulomatosis Systemic immunomodulator

Acute painful LOV in non-inflamed eye - causes

Giant cell arteritis Optic neuritis Migraines Idiopathic Intracranial Hypertension

Acute Painful LOV in non-inflamed eye - GCA: ophthalmic features

Suspect in >50yo w headache + visual disturbance Unilateral altitudinal field defect: anterior ischaemic optic neuritis (disc swollen) posterior ischaemic optic neuritis (disc normal) Unilateral field defect: central retinal artery occlusion

Acute painful LOV in non-inflamed eye - optic neuritis: definition

Visual disturbance with eye pain, commonly in young women, due to inflammation of optic nerve

Acute painful LOV in non-inflamed eye - optic neuritis: types

Papillitis: inflammation of optic nerve head - swollen optic disc Retrobulbar neuritis: inflammation of optic nerve behind globe - normal optic disc

Acute painful LOV in non-inflamed eye - optic neuritis: aetiology

``` Idiopathic MS: most common cause of retrobulbar neuritis; 50% MS patients develop ON, 30% ON patients have underlying MS Infection (viral) Granulomatous inflammation Autoimmune ```

Acute painful LOV in non-inflamed eye - optic neuritis: features

``` Acute LOV: complete; reduced colour vision (red desaturation) Eye pain (on movement) Features of undiagnosed MS: paraesthesia, bladder/bowel dysfunction, limb weakness ```

Acute painful LOV in non-inflamed eye - optic neuritis: management

IV corticosteroids: helps w speeding recovery but not outcome; if vision loss in both eyes or severe pain MRI brain: assess risk of MS

Acute painful LOV in non-inflamed eye - migraine: features

Visual disturbance + headache Fortification spectra (zigzag lines) Scintillating scotoma Transient LOV

Acute painful LOV in non-inflamed eye - IIH: features

Young obese women Headache Transient Visual Obscurations: Uni/bilateral, Triggered by movement / postural changes; due to papilloedema Papilloedema Visual field loss

Acute painful LOV in non-inflamed eye - IIH: management

MRI: rule out SOL MR-angiography: rule out venous sinus thrombosis Urgent treatment - risk of permanent visual field loss Weight loss, stop medications (NSAIDs) Acetazolamide (carbonic anhydrase inhibitor) Shunts: lumbo-/ventriculo-peritoneal

Acute painless LOV - Vitreous haemorrhage: features

Sudden painless loss of vision Large haemorrhage: Total loss of vision, loss of red reflex Small haemorrhage: Floaters Subretinal haemorrhage: central dark scotoma

Acute painless LOV - Vitreous haemorrhage: causes

Trauma Proliferative retinopathy: rupture of fragile new vessels, due to neovascularisation caused by ischaemia Age-related macular degeneration: neovascularisation in wet ARMD Retinal Detachment Posterior Vitreous Detachment

Acute painless LOV - vitreous haemorrhage: management

Emergency - referral to ophthalmologist | Treat complications - glaucoma due to RBCs clogging up trabecular meshwork

Acute painless LOV - retinal detachment: types

Rhegmatogenous: secondary to retinal tear Exudative: secondary to inflammation or vascular abnormalities Tractional: secondary to fibrovascular tissue (from inflammation or neovascularisation)

Acute painless LOV - retinal detachment: features

Sudden painless loss of vision Pre-ceeding: Photopsia, floaters, Visual field defects Macula-on: peripheral vision lost, visual acuity normal Macula-off: central vision lost

Acute painless LOV - retinal detachment: management

Macula-on = emergency (surgery before macular detachment preserves vision) Investigations: New flurry of floaters/photopsia = emergency; need to exclude retinal tears Tobacco dust: retinal pigmented cells in vitreous Peripheral tear: retinopexy (laser to retinal hole) + vitrectomy Macula hole: vitrectomy + epiretinal peel

Acute painless LOV - vascular occlusion: CRVO/BRVO causes

Systemic HTN Raised intraocular pressure Hyperviscosity syndrome Vessel wall disease (DM, Sarcoidosis)

Acute painless LOV - vascular occlusion: CRVO features

Tortuous vessels | flame-shaped haemorrhages

Acute painless LOV - vascular occlusion: CRAO/BRAO causes

Raised intraocular pressure Emoboli: Carotid, AF, valve disease Occlusion by atheroma or inflammation (GCA)

Acute painless LOV - vascular occlusion: CRAO feautres

Cherry red spot | Visible emboli

Acute painless LOV - vascular occlusion: AION, PION definition

Anterior ischaemic optic neuropathy Posterior ischaemic optic neuropathy Hypoperfusion of small vessels supplying optic nerve head (AION) or posterior optic nerve (PION)

Acute painless LOV - vascular occlusion: AION, PION features

AION - optic disc swollen, splinter haemorrhages at disc | PION - optic disc normal

Acute painless LOV - vascular occlusion: AION, PION risk factors

Arteriosclerosis HTN Hypotensive episode Smoking and 'disc at risk' (small optic head)

Acute Ophthalmology 2 Flashcards

(52 cards)