Clinical managementy Flashcards
(114 cards)
1
Q
Myopia presentation:
A
Blur, close working distance, headaches
>-6D: RRD, glaucoma, cataract, tilted disc
2
Q
Other types of myopia:
A
Nocturnal myopia: low visual cue in dark > tonic accomodation
Pseudomyopia: large near work > ciliary spasam > increased accomodation
3
Q
Other types of myopia:
A
Nocturnal myopia: low visual cue in dark > tonic accomodation
Pseudomyopia: large near work > ciliary spasam > increased accomodation
4
Q
Myopia treatment:
A
Glasses/CL
OrthoK (peripheral myopic blur)
0.125 atropine
Hoya miosmart glasses
LASIK (corneal stroma removal)
5
Q
Atropine:
A
Muscarinic receptor blocker, paralyses ciliary muscle
Thought to induce peripheral blur
Cheap, must be taken until adulthood
6
Q
Myopia risk reductions:
A
Decreased near work / increased working dist.
Gaze breaks
Increased light exposure
Balance diet
7
Q
Hyperopia presentation:
A
Blur, headaches
AAGC, crowded ONH
May appear >35yo (latent)
8
Q
Astigmatism presentation:
A
Blur, light halo, night glare, fatigue, headaches
9
Q
Refractive error tests:
A
Visual acuity
Fundoscopy
Refraction/cyclo
Cover test (refractive amblyopia)
10
Q
Cycloplegic drops
A
Cyclopentolate/Tropicamide
Muscarinic receptor blockers, paralyse ciliary muscle
Also cause mydriasis
11
Q
Presbyopia (accomadative amplitude) with age:
A
10 AA~12D
40 AA<3D (presbyope)
50 AA~0D
12
Q
Presbyopia treatment
A
Glasses
MF CL’s/glasses
LASIK > 60yo (stabilised)
Improved lighting/Font size
13
Q
Cataract presentation:
A
Nuclear: myopic shift, blur, contrast desensitivity, tritan defect
Cortical: Astigmatism, poor night vision, large contrast desensitivity
PSC: blur, contrast loss, poor near work/day vision (pupil constrition)
COMORBID WITH GLAUCOMA
14
Q
Cataract clinical testing:
A
VA + Pelli Robson (± glare)
Dilated Slit lamp + retro illumination (severity/comorbidity)
Ishihara (tritan with losci 3)
Pupil test (monocular cat RAPD)
15
Q
Clinical question for cataracts:
A
Onset
Progression
Effect on life
Systemic diseases (HT, DM)
Medications (Cort.)
Risk factors: Work/surgery/smoker
Allergies (to medications)
16
Q
Cataract treatment:
A
Phacoemulsification: replace lens with IOL
20 minutes under local anaestetic
17
Q
Post cataract surgery risks:
A
50% posterior capsule opacity ~2y
<1% IOL rupture/dislocation / endopthalmitis / RD
18
Q
Cataract counselling:
A
Cataract symptoms > Progression
Surgery > better QoL
Post surgery risks
19
Q
Cataract progression without surgery:
A
AAGC (most common co-morbidity) from lens pressure on iris
morgagnian cataract (lens breaks)
20
Q
Tests for DED
A
Schirmer (±Anaesthetic): 5 minutes. <5mm severe, 5-10 moderate >10mm mild
TBUT: NaFL + Cobalt filter. <10s indicates DED
Meibomian expression: Clear/fluid indicates healthy
21
Q
Px education of DED:
A
Usually underlying cause of DED cannot be cured
Intend to treat symptoms
22
Q
Benzalkonium chloride negative effects
A
Epithelial cell apoptosis, corneal nerve damage / poor wound healing, decrease tear film stability and decrease goblet cell density
23
Q
DED treatment severity level 1
A
Education of DED/diet, local environment change, systemic drug elimination, eye drops (lipid for MGD), lid hygiene/compress
24
Q
DED treatment severity level 2:
A
Preservative free drops, tea tree oil for demodex, punctual occlusion / moisture chamber, ointments, short term topical antibiotic/steroid/secretagogue.
25
NaFL:
Sodium fluorescein: Xenobiotic (foreign)
Passive entry, is removed via active pump
Accumulates in stressed cells
26
Lissamine Green:
Binds to epithelium of damaged cells
Normally glycolax prevents binding
27
Hordeolum:
Infectious but self limiting (7d)
Warm compress/lubricants
Can use vancomycin antibiotic
28
Chalazion
Self limiting (fast)
Warm compress (promote drainage)
29
BC/SC papilloma
Excision/cryotherapy if desired
30
Skin BCC/SCC
Biopsy > excision/cryo
31
Pingueculum:
Benign, slow growth
UV protection / lubricant
FML drops for flare-ups
Excise if desired
32
Pterygium:
UV protection / lubricant
FML drops for flare-ups
Excise + Conj.-graft If astigmatism/discomfort
33
OSSN:
Biopsy to confirm
Small lesion excised/cryo
Large lesion Chemo + mytomycin c
34
Clinical tests for conjuntival lesions:
Slit lamp
Phenlephrine to blanch vessels
35
Choroidal naevus:
Inform, reassure common condition
Document
36
Choroidal melanoma
Brachytherapy, radiotherapy, chemotherapy
Ophthal
37
Choroidal melanoma symptoms
Serous retinal detachment
Photopsia
Floaters
Asymptomatic
Lipofuscin/drusen
VF defect
Metamorphopsia
38
Presentation of horners
Partial ptosis, miosis, anhydrosis
Blur, hyperaemia
39
Presentation of CN3 palsy
Full ptosis, down/out turn (unopposed LR/SO), mydriasis
Headache
40
Presentation of Myasthenia gravis:
Limb weakness, ptosis, diplopia, worsens during day and with upgaze
41
Presentation of mitochondrial myopathy:
EOM fatigue, bilateral ptosis, decrease in motility
42
Presentation of AAGC:
Iris fixed to lens
Pain, hyperaemia, synechiae
43
Clinical testing for greater in light anisicoria:
Slit lamp for injury/worm constriction
0.1 pilocarpine > early adie's > Ach upregulation > greater constriction in affected pupil
1 pilocarpine > constriction of CN3 palsy
Otherwise pharmacological
44
Clinical testing for greater in dark anisicoria:
Apraclonidine 0.5% > horners desensitization (7d) > A1 upregulation > mydryasis
Hydroxyamphetamine > dilation if 1/2 order neuron, none if 3rd
45
History taking for ptosis:
Age of onset (aquired/congenital)
Symptoms of systemic disease (fatigue/diplopia)
46
Clinical testing for ptosis:
Motility (CN3, myasthenia, mitochondrial)
Pupil assessment (anisicoria)
Slit lamp (mechanical ptosis)
Jaw winking (marcu gunn syndrome)
Ice pack (myasthenia)
47
Clinical testing for anisicoria:
IOP (AAGC high / Horners low)
Motility (CN3 palsy)
Ptosis assessment (partial/full)
Slit lamp (adies, injury, AAGC)
Pupil assesment (greater in dark/light)
48
Apraclonidine:
Strong alpha 2 adrenergic agonist, weak a1 agonist
Increases aqueous outflow and decreases production (vasoconstriction) > lowers IOP in glauc
49
Hydroxyamphetamine:
Mimics norepinephrine, taken up by reuptake pump like NA.
Once taken into presynapse, causes release of NA from presynaptic terminal into synapse.
This requires stored norepinephrine in presynaptic terminal (third neuron), requiring functional neuron.
50
Pilocarpine:
Muscarinic agonist for neuromuscular junction of sphincter, upregulates receptor number > hypersensitivity > constriction.
51
Horners testing with cocaine: q
Cocaine hydrochloride (10%), blocks norepinephrine reuptake in presynaptic terminal
Horners will fail to dilate after 60 minutes from lack of norepinephrine release
52
History taking for red eye:
Location (unilateral>FB/trauma)
Type of pain
Visual changes
Associated signs (itchy/dry/photophobia/discharge)
Health conditions
53
DDX for red eye:
CLs (peripheral ulcer, CLARE, GPC)
Corneal defect (keratitis)
Intraocular inflammation (AAGC, uveitis)
Outer Inflammation:
Phenylephrine blanches conjunctivitis, not scleritis
54
Bacterial conjunctivitis presentation:
With fever, earache, burning, hyperaemia in fornix
Acute: Mucopurulent discharge, Papillae, diffuse hyperaemia, gritty/burning
Hyperacute: Excessive purulent discharge, hyperaemia, chemosis, pain
Chronic: Mucoid discharge, papillae, diffuse hyperaemia, crusty lids
55
Bacterial conjunctivitis treatment:
Self limiting, lid hygiene / lubricants / optional chloramphenicol 0.5% drops qid
Hyperacute > GP referal
56
Cloramphenicol:
Bs antibiotic; Bacteriostatic
Causes blur, stinging, bitter taste (systemic absorbtion)
57
Chlamydial conjunctivitis presentation:
Adult inclusion (genital): unilateral hyperaemia, watery/purulent, follicles, preauricular lymph swelling
Trachoma (direct): mucopurulent, irritation, dry eye, blur, follicles, corneal involvement
Infantile: lid oedema, watery, pseudomembrane
58
Chlamydial conjunctivitis treatment
Topical Fluoroquinolone reduces follicular conjunctivitis
Oral doxycycline 100mg bid, as bs antibiotic
59
Adenovirus conjunctivitis symptoms
Follicular (mild): watery, hyperaemia, discomfort, follicles
Pharyngeal fever (common): pharyngitis, fever, hyperaemia, chemosis, watery, follicles
Epidemic (severe): hyperaemia, chemosis, watery, follicles, preauricular lymph swelling, membrane formation, sub. Conj. Haemorrhage
60
Adenovirus treatment:
Educate on contagious (no swimming/sharing towels)
Self limiting, steroid Prednisolone 1% if needed somewhere
Pred Forte inhibits transcription of inflammatory genes
61
Herpes simplex conjuntivitis presentation and treatment:
Watery, irritiation, follicules, HSV vessicles on lids
Self limiting, corneal involvement treated with oral aciclovir
62
HSK presentation
Epithelial: ulcer (dendritis, geographic, metaherpetic, neurotrophic)
Stromal: Dense infiltrate, melting
Endothelial: disciform/diffuse infiltrate with stromal infiltration
Anterior chamber: uveitis (trabeculitis, high IOP, synechiae)
63
HSK recurrent treatment:
Dendritic/geographic ulcer: 3% aciclovir ointment 5/d for 2 week
Metaherpetic/neurotrophic: lubricants (no live virus)
Stromal/endothelial: corticosteroid (Pred Forte 1%) + aciclovir
64
HSK primary infection treatment:
Will resolve spontaenously, warn Px not to share towel
With oral acyclovir 400mg 5/d (10d)
Px to know it will recur under stress
65
HZO presentation
Lid vesicles, oedema, Hutchinson's sign > nose vesicles (nasociliary branch of CNV1)
Conjunctivitis/ keratitis/ uveitis/ neuritis
66
HZO treatment:
Epithelial: acyclovir 800mg 5/d for week
Stromal: corticosteroid (pred forte 1%) + aciclovir 400mg 3/d
67
Acanthamoeba keratitis presentation:
Great pain (radial keratoneuritis), patchy infiltrate, unresponsive to antiviral/bacterial treatment
FBS, blur, photophobia
Punctuate keratopathy > ring infiltrates
68
Acanthamoeba treatment:
Topical drug cocktail against cysts
Biguanides (polyhexamethylese: PHMB) + diamidines (Hexamidine)
Hourly 0.2% of each then tapered
69
SAC/PAC presentation
Bilateral hyperaemia, watery, chemosis, itching
Associated nasal/respiratory symptoms
70
SAC/PAC treatment
Cool compress, avoid allergens, avoid rubbing (mechanical mast cell degranulation), hygiene
Lubricants with:
Topical antihistamine ketotifen 0.025% as needed
or Levocabastine 0.05% qid
71
Vernal keratoconjunctivitis presentation and treatment
Bilateral burning, itching, rope mucous discharge, papillae
Topical antihistamine ketotifen 0.025% as needed.
Topical steroids if severe/corneal (Fluormetholone 0.25% qid)
72
Atopic kerato treatment:
Cool compress, avoid allergen, hygiene
Lubricant during day, ointment during night with:
Systemic antihistamine Cetirizine 10mg/day
73
Mycotic keratitis Treatment
Education, fungal treatment takes time
Natamycin 5% topical, every 2 hours for 3 days. Taper to 6 hourly over 6 weeks
74
Bacterial keratitis presentation:
Painful, wet infiltrate, mucopurulent discharge, hyperaemia
75
Bacterial keratitis treatment:
Ciprofolaxin 3% hourly or
Dual therapy of cephalosporin (+ve) and gentamycin (-ve)
Analgesics (pain), cycloplegics (ciliary spasm), therapeutic CL for ulceration
76
Clinical tests for keratitis:
VA
Slit lamp (discharge, ulcer, corneal involvement)
Corneal scrape (decrease bac load)
IOP inaccurate
Q-tip (HSK)
77
History for keratitis:
Onset (indicates severity)
Pain from 1-10 (Fungal>Bacterial>Protist)
Feel (itchy, burn, FBS)
Type of discharge
Previous of keratitis
CL use (type, cleaning regime)
Risk factors? (holiday to tropics/swimming)
78
CL related issues:
Corneal hypoxia
Corneal neovascularisaion
CL associated DED
3/9'clock stain
Superior epithelial arcute lesions
Tight lens syndrome
Toxic keratitis/conjuntivitis
GPC
CLARE
Peripheral ulcer
Microbial keratitis
79
Central serous retinopathy (CSR):
Serous fluid buildup under the macula, related to stress in working men.
80
PVD symptoms:
Asymptomatic
Flashers
Floaters
Central metamorphopsia
Decreased VA
Ghosting
81
PVD testing
VA
Pinhole
OCT
Amsler
Fundoscopy
Pinhole should increase VA in normal eyes as chromatic abberations decrease. Pinhole will have worse vision in PVD Px
82
Presenting complaints of AMD Px
Poor dark and light adaptation (due to macula loss)
Metamorphopsia / Facial recognition
Blur
Loss of central vision (grey/cloudy/black)
Dark spots
"Red hue (bleed) / cobblestones (drusen)"
83
History for AMD:
Family history
LEE
Risk factors (Smoker, HT, DM)
Describe vision
Family history
84
Clinical tests for AMD
*VA
*VA pinhole (should be worse)
Fundoscopy (Volk)
OCT
Amsler
Macula stress test: 60s bright light, VA should return to baseline in <30s, otherwise poor macula function (from AMD/CSR)
85
Dry AMD treatment:
No real treatment
Smoking cessation
Improve diet
AREDS supplements
Monitor (recheck/amsler)
86
Risk of wet AMD:
Score for pigment change and drusen size
- Drusen >125um = 1 point for each eye
- Pigment change = 1 point for each eye
Score out of 4. 4 = 50% wet progression in 5 years
87
DDX metamorphopsia:
AMD
Macula hole
ERM (macula pucker)
CSR (serous RD)
BRVO
Diabetic retinopathy
Migrane
88
TED management:
Self limiting 1-3 years, rarely is chronic
Lubricants/nocturnal lid taping for symptoms
Grave's is treatev via Carbimazole, or thyroidectomy
89
Sjorens syndrome clinical testing:
Unaesthetized schirmer test <= 5mm in 5 minutes
Rose bengal score >= 4 (van bijsterveld)
Poor salivary function
Auto-antibody testing (anti-ro/anti-La)
90
CRAO presentation:
unilateral
Sudden painless loss of global vision (bar cilioretinal artery)
RAPD
Cherry red spot (thin retina)
91
CRAO treatment:
Px adopt supine posture (ocular perfusion)
Ocular massage (disodge emboli)
CO2 hyperventilation (vasodilation)
Vision will be lost, requires systemic examination/management
92
BRAO presentation:
Sudden painless loss of sectoral VF
Often with RAPD
Cloudy white retinal area
93
BRAO treatment:
Will only lose sector of vision
Requires systemic examination/management
94
Systemic management for retinal vascular occlusion:
Control risk factors (HT/HC/DT)
Smoking discontinued
Contraceptive pill discontinued
Anti-coagulants is nessicary
95
CRVO presentation:
Ischemic: >10DD seen in FFA (severe/uncommon)
Disc/macula oedema, retinal haemorrhaging, CW spots, tortuosity, RAPD, VA<6/60
Non Ischemic:
Mild symptoms of above, no RAPD, VA>6/60
Both cause painless loss of global vision, can be sudden
96
BRVO presentation:
Asymptomatic (if no macula involvement)
Painless loss of VF quadrant
Tortuosity, CWS, haemorrhage in given sector
97
CRVO management:
Anti-VEGF for macula oedema
Monitor for developments
Refer for systemic examination
98
BRVO management:
Anti-VEGF if macula oedema present
Monitor for developments
Refer for systemic examination
99
Presentation of ERM:
Translucent sheen at macula
Thickening > striae of retina
VA decrease
Can occur secondary to inflammation/surgery
100
ERM treatment:
Poor VA > vitrectomy
Monitor otherwise, may resolve via detachment
101
DDX unilateral sudden painless loss of central vision
CRVO/CRAO (RAPD, Cherry RS)
BRAO/BRVO (haemorrhages)
RD (fla/flo, post trauma)
Vit. Haemorrhage (Diabetic ret.)
Macula haemorrhage (AMD>blood on macula)
Ischemic optic neuropathy (ON swelling)
102
Presentation of AMD:
Atrophic: gradual loss of central vision, metamorphopasia, drusen accumulation
Exudative: sudden blurring of central vision, scarring, CNV, RPE detachment/atrophy, haemorrhages
103
Dry AMD treatment:
No cure
Nutritional supp via AREDS study
Cease smoking, maintain HT/DM
104
Wet AMD treatment:
Px education, Amsler/OCT monitor
Anti VEGF injections
105
Drusen composition:
Esterified cholesterol
Phosphatidylcholine
Proteins
Immune / complement components
106
Lipofuscin pathophysiology:
Hypertension/carotid plaque/oxidative damage > Atherosclerosis (accumulation of cholesterol plaque) > altered choroidal circulation > incomplete digestion of outer photoreceptor shedding > accumulation in RPE
107
RP symptoms:
Night blindness
Peripheral VF loss
Photophobia (poor adaptability)
Central vision loss (cone atrophy)
Colour vision loss
108
RP clinical presentation:
Bony spicules
ON pallor
Attenuated vessels
Macula oedema
ERM
109
RP management:
ERG scan
Monitor for seperate diseases
Councelling services
Experimental therapy (exp/international)
110
Hypertension stages:
Vasoconstriction: Arteriolar narrowing
Sclerotic: BV hyperplasia, attenuation, tortuisity, wiring/nipping
Exudative: Oedema, heamorrhage, cotton wool, hard exudates
111
Hypertensive retinopathy:
Arteriosclerosis > hardening of vessels/plaque > AV nipping > Increased permeability > BRB disruption > flame haemorhages/oedema
112
Clinical testing for keratitis/conjuntivitis:
Slit lamp w/NaFL (ulcer analysis)
Pain (scale/Q-tip)
Pressure lacrimal duct/maibomian (lacrimal infection, meibum)
Corneal scrape (lab assessment)
113
VKC and AKC similarities
Both are type I/IV hypersensitivity reactions (mast cell and th2 mediated)
Conj. inflammation, epithelial defects, sheild ulcer, corneal scarring
114
VKC and AKC differences
VKC > childhood > weakens
Giant papillae
AKC > adulthood > Chronic
micro papillae
