CMG Flashcards

Question

Olapatadine

Answer 1

Due acting agent, AH & MSC. 0.1% eye drop preparation. > 3 years old, x1 drop 2 a day, max tx duration 4 months. X PREGANNCY, X LACTATION, X CL. SAC, but can be used off-licence, atopic keratoconjucntivitis, AAC. Quite a few general & ocular side effects. Ocular side effect: Mydrasis, visual disturbance, eye lid margin crusting. General side effects include: headache taste disturbance nasal dryness asthenia (weakness) dizziness rhinitis fatigue hypersensitivity.

Answer 2

Loratadine & Cetrazine- P & GSL. Both are 10mg, x1 a day both are non sedative AH. For age of 12 years. Differs depending on the px age which will be less.

Answer 3

MCS inhibit influx of calcium preventing degranulation, can take 7-14 days for symptomatic relief. POM, eye drop, 0.1%, MSC, Antiinflammatory, SAC & PAC. but can be used off label, vernal etc. 0.1%, age> 4 years, 1-2 drops x4 daily. X PREGNANCY, X CL, caution BF. Normal ocular side effets &general side effects

Answer 4

MCS inhibit influx of calcium preventing degranulation, can take 7-14 days for symptomatic relief. POM OR P or gsl. 2%, but under age of 6 needs to be checked if more than 14 days use. POM: For the prophylaxis and symptomatic treatment of acute allergic conjunctivitis, chronic allergic conjunctivitis and vernal keratoconjunctivitis P: SAC & PAC. Can use in P & BF. Adults and children (1 month and over): one or two drops to be administered into each eye four times daily.

Answer 5

POM- Antiinflammatory, non steroidal anti-inflammatory. Anti-inflammatory potency without the side effects of corticosteroids. NSAIDS are formed of family compounds called eicosanoids which act as a potent anti-inflammatory mediators. Principle eicosanoids as found in the short delayed respond of ocular allergy. Licences for SAC & PAC & corneal abrasion. 0.1% x1 drop x4 a day as long as required For ocular pain- x1 drop x4 a day for 2 days. NSAIDs can result in Keratitis. due to eptelial breakdown, corneal thinning, ulceration etc... Can cause MO, IOP,vasodilation, misses.

Answer 6

This is a self limiting reaction to an allergen which comes into contact with conjunctiva provoking an immediate (Type 1) IGE mediated response, common in Children, Allergens are grass pollen, animal dander Predisposing factors: Hx of allergic diseases. Reassure, disappears in few hours, usually unilateral if direct contact. Antihistamines as prophylactic Sodium cromoglicate 2% (as POM), or gutt lodoxamide 0.1%, or dual-acting antihistamine/mast cell stabiliser, e.g. gutt. olopatadine 0.1% (off-label use), or gutt ketotifen 0.025% (off-label use)

Answer 7

Aetiology: Type I hypersensitivity (IgE-mediated) reaction to specific airborne allergens. Conjunctival mast cell degranulation liberates histamine and other inflammatory mediators into the tissues and tear film, causing dilatation of conjunctival vessels (→red eye), increased permeability of blood vessels (→oedema), itch Seasonal allergic conjunctivitis (hay fever conjunctivitis) caused by seasonal allergens, especially grass pollen onset of symptoms associated with seasonal production of allergens, e.g. tree pollen: spring; grasses: early summer; weeds and fungal spores: late summer condition not sight-threatening, but reduces quality of life and is associated with a significant economic burden Perennial allergic conjunctivitis (PAC) caused by non-seasonal allergens such as house dust mite or animal dander symptoms throughout the year; may be seasonal exacerbations less common and usually less severe than SAC Often associated with allergic rhinitis (between 30–71% of patients with allergic rhinitis also have allergic conjunctivitis or conjunctival symptoms). Predisposing factors: Atopic disposition Personal history of allergic disease (hay fever, asthma, eczema, food or drug allergy) Family history of allergic disease Exposure to allergens Managent: Identify allergen(s). Requires thorough history and possible use of symptom diary matching to pollen calendars Advise avoidance of allergen(s) Cool compresses for symptomatic relief Advise against eye rubbing (causes mechanical mast cell degranulation) Worse scenarios can use a steroid: Flurometolone, Lotepresdnol POMS No management BUT can refer to immunologist if recurrent & no helps routine- B1. LODOXAMIDE, OLOPATADINE, KERAFINE, SODIUMCROMOGLIGATE.

Answer 8

Aetiology: Severe and potentially sight-threatening allergic eye disease characterised by chronic inflammation of the ocular surface Complex immunopathology which is type 1 & type 4, including T-cell mediated (type 4 hypersensitivity) Symptoms of AKC typically begin in the late teens or early twenties and can persist until the fourth or fifth decade of life. The peak incidence of AKC occurs between the ages of 30 and 50 years VKC as a child more prone to AKC as adults. Predisposing factors: There is a strong association with staphylococcal lid margin disease Atopic dermatitis. SIGNS & SYMPTOMS: Bilateral, all year round w exacerbations SIGNS: Crusting of eye lids, chronic staphylococcal blepharitis, Limbal inflammation conjunctival hyperima Tarsal giant papillae. These px increased risk of developing HSK, Atopic Cataract, RD, Keraotocnous, Corneal involvement- may start as Punctate epitheliopathy, can progress to macro erosion (widespread loss of the corneal epithelium ) and a plaque, sub epithelial scarring, neovas/pannus, thinning and rarely perforation. Corneal mucous plaques are a collection of mucus, epithelial cells, lipid, and proteinaceous debris, which are firmly adhered to the underlying corneal epithelium LODOXAMIDE, OLOPATADINE, KERAFINE, SODIUMCROMOGLIGATE. Management: A3, URGENT referral within 1 week to Ophthalmologist for corneal involvement, including plaque or macro erosion. B1- Milder cases, Routine referral. Multidisciplinary management: with dermatology & immunology.

Answer 9

Aetiology: Type 1 & Type 4 complex hypersensitivity reaction, very uncommon allergic disorder of children- Vernal keratoconjunctivis characterised by chronic inflammation of the ocular surface More common in some other parts of the world, e.g. Mediterranean region, parts of Africa, Indian sub-continent Complex immune reaction Onset usually before 10 years of age; M:F = 2-4:1 and typically resolves during puberty Symptoms typically bilateral & symmetrical in both eyes Palpebral hyperaemia and chemosis of conjunctiva when active macro or giant tarsal papillae (1mm or greater in diameter; ‘cobblestone’ appearance) Limbal hyperaemic, oedematous, thickened limbus Trantas’s Dots (discrete white superficial accumulations of eosinophils and degenerating epithelial cells) limbal phenotype may be unilateral Corneal (usually in upper third) punctate epithelial keratopathy macro-erosion (coalescent epithelial loss) plaque (deposited on Bowman’s layer, preventing re-epithelialisation); ‘shield ulcer’ in US terminology subepithelial scarring (often ring-shaped) Management Generally needs referral for multidisiplinary management. No referral if no sight threading concerns, w antihistamines, Sodum Cromo or lodoxamide, or Olopatadine (off label)

Answer 10

Mixed hypersensitivity reaction, type 1 & type 4. CL released or due to ocular prosthetics, exposure sutures, scleral bucklers, filtration blebs, floppy eye lid syndrome. Mixed hypersensitivity reaction, type 1 & type 4. Type 1 - immediate hypersensitivity reaction mediated by iGE- Possible allergens include 1)protein on lens surface 2) bacterial cell wall constitutes 3) other lens contaminants reaction cause of deregulation of mast cells Type v- delated hypersensitivity medicated by T cells - amplifies the inflammatory response. Pharmacological management: Type 1 sensitivity reation- MCS, AH. Lodoxamide & Sodium Cromoglicate Off label, Olapatadine & Ketoifen for 6 weeks for GPC only. In cases where MSC & AH do not work can use non penetrating topical steroid such as Flurometheolone & Loteprednol - this can manage the type 4 sensitivity reaction too for 6 weeks.

Answer 11

Follicles: hyperplasia of lymphoid tissue generally seen in viral or chlamydial conditions smooth, pale, pink-to-yellow, elevated lesions surrounded by displaced vessels, dome shaped, small, GREY, WHITE DOME SHAPED W SURROUNDING BV, base of bump & periphery is red. Papillae: thickened irregular epithelium usually more discrete and more red than follicles side walls of papillae appear perpendicular to tarsal plate contain vascular core visible at apex as vascular tuft Full of inflammatory cells. Block, flat topped shapes, vascular centre,

Answer 12

POM, eye drop, 0.5%, Anti-inflammatory, corticosteroid, Use following ocular surgery but off-licence, in keratoconjunctvitis sicca, ptregiyum, pingeculi, gpc. Cautions: Loteprednol, as with other corticosteroids, can cause ocular hypertension and should be used with caution in patients with glaucoma. Risk of CSR Prolonged use of corticosteroids may suppress host–immune responses and increase the possibility of secondary ocular infection. In diseases causing thinning of the cornea or sclera, corticosteroids have been associated with perforations. XCL Use in caution w Pregnancy & BF. Licenced for adults only. Can cause increase IOP, need to take pressure readings @ beginning of tx, 2 weeks end of tx.

Answer 13

Chemical irritation of ocular and/or adnexal tissues by a topically applied drug contact lens care product or cosmetic, or by environmental or occupational substances or Delayed hypersensitivity (cell-mediated) response to a topically applied drug, preservative or other excipient, or cosmetic Preservatives in contact lens care products e.g. polyquaternium compounds (e.g. PQ-1) and biguanides (e.g. PHMB) - can cause reaction Can give steroids for relief, prednisolone preservative free

Answer 14

Chronic follicular conjunctivitis caused by the sexually transmitted microorganism Chlamydia trachomatis (serotypes D-K), an obligate intracellular parasite (i.e. it cannot replicate outside a host cell). Spread by direct contact or fomites. Predisposing factos: Adult hood, genital infection w C Trachoma's Symptoms: More than 2 weeks, gritty, sticky, dropping upper lid Lid and other features oedema +/- ptosis (‘mechanical’) non-tender pre-auricular lymph node swelling (may or may not be present) Conjunctival features hyperaemia and chemosis mucopurulent conjunctivitis large follicles in upper and lower fornices (double eversion of lid needed to view upper fornix) limbal and/or bulbar follicles may also be present Corneal features epithelial keratitis, usually superior subepithelial infiltrates, similar to those seen in adenovirus KC marginal infiltrates superior pannus Management: X CL wear, ocular lubricants Referral to GP for Genito urinary clinic

Answer 15

Adenoviral conjunctivitis is the most common form of acute infective conjunctivitis, accounting for up to 75% of cases 2 syndrome of adenoviral infection: 1) EKC- epidemic keratoconjunctivitis 2) pharyngoconjunctival fever Common in in 20's-40's Follicles on palpebral conjunctiva, especially upper and lower fornix (if abundant, follicles can produce folds) Symptoms of EKC usually appear within 14 days of exposure and typically last 7 to 21 days Usually passes, ocular lubricants for sub epithelial infiltrates can give low potency flurometholone, with a higher frequency initially and then tapered e.g. four times per day (QDS) for 1-month, three times per day (TDS) for 1-month and twice per day (BD) for 4-months).

Answer 16

Ophthalmia Neonatorum (ON) (conjunctivitis of the newborn) occurs within the first month of life. It is a bacterial, chlamydial or viral infection acquired during passage through an infected birth canal. Mucopurlent discharge redness oedema Emergency refer for cultures.

Answer 17

Gentamycin, Aminoglycosides are for gram - bacteria, 0.3% x1-2 drops in the affected eye every 4 hours, >12 years. ? P, Y BF

Answer 18

Self-limiting bacterial infection of the conjunctiva, typically by: Staphylococcus species (Gram +ve) Streptococcus pneumoniae (Gram +ve) Haemophilus influenzae (especially in children) (Gram –ve) Moraxella catarrhalis (Gram-ve) Can occur secondary to viral conjunctivitis. Pharmacological: CLPH Fucidic acid Azithroymicin Contact lens- should be treated with a topical antibiotic effective against Gram –ve organisms, such as an aminoglycoside which is a broad spectrum against gram - bacteria, (e.g. gentamycin) or a quinolone which is for gram + & negative (e.g. levofloxacin or moxifloxacin) Contact lenses should not be worn until the condition has resolved.

Answer 19

Gentamycin Quinolones- Levoflaxcin & Moxiflaxcin which are both broad spectrum antibiotics, gram + & gram - .

Answer 20

A baseline measurement of IOP should always be taken prior to commencement of steroid therapy. Patients newly begun on ocular steroid therapy should have their IOPs measured again after 2 weeks, then every 4 weeks for 2-3 months, then 6-monthly if therapy is to continue It has been recommended in patients receiving intravitreal steroids (injections or implants) to measure IOP at 30 minutes, at 1 week, 2 weeks and then monthly for up to 6 months If a steroid response is detected, discuss with the prescribing clinician the possibility of discontinuing steroid therapy (the chronic steroid response usually resolves in 1-4 weeks, whilst the acute response may resolve within a few days of cessation of steroid therapy). The IOP usually returns to normal within 2-4 weeks after discontinuation, but if the steroid therapy has continued for 18 months or more, the raised IOP may persist for longer

Answer 21

Antiinfective, antibacterial, a semisynthetic macrolide antibiotic with a broad range of activity against Gram-positive bacteria and some community-acquired Gram-negative pathogens 1.5%, licences for bacterial conjunctivitis, After3 days no improvement, reconsider diagnosis X CL, 1 year++++: one drop applied to the conjunctival fornix twice a day, morning and evening, for 3 days.

Answer 22

Quinolone, broad spectrum antibiotic, licences for MK, Corneal abrasion, BC, >> 1 years old, 0.5% Systemic fluoroquinolones have been associated with hypersensitivity reactions , even following a single dose. If an allergic reaction to levofloxacin occurs, discontinue the medication. Y BF & P Adults and children: one drop in the affected eye(s) three times a day. The infection normally improves within 5 days and treatment should then be continued for a further 2–3 days. If no improvement is observed within 5 days of initiating therapy, the diagnosis and/or treatment should be reconsidered. The duration of treatment depends on the severity of the disorder and on the clinical and bacteriological course of the infection. For microbial keratitis (bacterial) Empirical treatment for lesions (<1mm) is based fluoroquinolone monotherapy day and night for 48 hours, then every 2 hours daily for 72 hours, then every 4 hours for 7 days. Monitor closely during this period and refer same day if not healing or if symptoms worse

Answer 23

colarettes thick lid margin hyperima

Answer 24

POM- 0.1%, Antiflammatory, corticosteroids, Fluorometholone is contraindicated in viral diseases of the cornea and conjunctiva, fungal diseases of the eye and other infectious diseases where it may mask infection or enhance an existing infection. Prolonged use of corticosteroids may suppress host–immune responses and increase the possibility of secondary ocular infection. In diseases causing thinning of the cornea or sclera, corticosteroids have been associated with perforations. X PREGNANCY, X BF, X CL S Adults and children (2 years and over): shake before use; one or two drops two to four times daily. During the initial 24–48 hours, the dose can be increased to two drops every hour. Generally eye drops containing corticosteroids should not be used for longer than 1 week.

Answer 25

Distraction test if lower lid can be pulled >8mm 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

Answer 26

NAFL- Looks at damaged corneal cells LG- can see damaged conj cells can also show cell death in later stages unlike NAFL which will just highlight.

Answer 27

crusting lid margin swelling & hyperima misdirection of lashes/ lash loss

Answer 28

Quinolone, broad spectrum antibiotic, licences for MK, Corneal abrasion, BC, >> 1 years old, 0.5% Systemic fluoroquinolones have been associated with hypersensitivity reactions & tendon inflammation, , even following a single dose. If an allergic reaction to levofloxacin occurs, discontinue the medication. X CL P & BF>?? For bacterial conjunctivitis 1 year: one or two drops in the affected eye(s) every 2 hours up to eight times daily (while awake) for the first 2 days and then four times daily on days 3–5. The duration of treatment depends on the severity of the disorder and on the clinical and bacteriological course of the infection. The usual treatment duration is 5 days. MK (Bacterial) Empirical treatment for lesions (<1mm) in the absence of the above clinical characteristics is based fluoroquinolone monotherapy day and night for 48 hours, then every 2 hours daily for 72 hours, then every 4 hours for 7 days. Monitor closely during this period and refer same day if not healing or if symptoms worsen.

Answer 29

lid margin hyperima, oily or greasy deposits on lashes/ lid margins This is caused from disorder of cililiary sebaceous glands Zeiss

Answer 30

Anterior bleh: usually staphylococcal can be seborrhoea or demodex posterior (MGD) OR MIXED. Management: Dry warm compresses melt meibomum in posterior blepharitis (compress applied to lid skin twice daily for not less than 5 minutes at 40°C. CLPH, AZYTHROYCIN, SYSTEMIC PX- DOXYCLYCLIN OR MINOCYCLIN OR EETHRYOMYCIN OR AZITHYMYCIN WHERE TERATRACYCLINS ARE CONTRAINDICATED.

Answer 31

Distraction test if lower lid can be pulled >8mm 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 normal position: indicates poor orbicularis tone

Answer 32

Internal& external Acute localised infection or inflammation of the sebaceous or apocrine glands of the eyelid. There are two types: external hordeolum (stye) – acute bacterial infection of the lash follicle and its associated gland of Zeis or Moll internal hordeolum – acute bacterial infection of Meibomian gland These infections are usually staphylococcal Can use CLPH eye ointment in severe cases Amoxicillin

Answer 33

Poxyvirus happens at a young age, or immunicompromised adults w HIV, highly contagious Lesions on lid margin may shed viral toxins into conjunctival sac 1) causing follucliar conjunvtcitis Corneal involvement Skin nodule(s) (typically 2-3 mm diameter), often with a central depression (‘umbilicated’) No visible inflammation Central core has cheese-like or waxy material which may discharge spontaneously

Answer 34

Ocular manifestation of rosacea, a chronic relapsing inflammatory condition of the skin predominantly affecting the centrofacial region (cheeks, nose, and forehead). Multifactorial pathophysiology, including genetic susceptibility, environmental factors (e.g. UV radiation, spicy foods, alcohol), Multifactorial pathophysiology, including genetic susceptibility, environmental factors (e.g. UV radiation, spicy foods, alcohol), and presence of immunogenic stimuli due to microorganisms on the skin, Bacteria is staphylococcal. Signs: Lids, tear film Cornea Conjunctiva IPL Omega 3 Ocular lubricants Azythrymycin antibiotic drops OR if steroid drops- check IOPS. ONLY PRESCRIBE IF CONFIRMED ROSACEA DIAGNOSIS: Orał tetracycline antibiotics, Doxycycline- 40mg, x1 a day for 6 weeks. Ethyromycin & Azitrymycin

Answer 35

Lice in the eyelashes from pubes, management to STD clinic & safe guarding if child TX: Ointment, Permethrin 1% lotion applied to lashes for 10 minutes with eyes closed and then rinsed to remove NB: insecticides can be toxic to the cornea should only be undertaken by experienced practitioners as such preparations are toxic to the ocular surface. Lice removed w forceps Symptoms: Black eggs & main lice. bites.

Answer 36

Can Advised CLPH Congenital: NAFL disappearance test Massage downwards, x10 strokes a day, x2 daily & regular lid cleaning. Acquired: Lacrimal syringing- Irrigation test, dilate puncta & synringe saline, Jone NAFL test: Check if significant amount of NAFL in tear meniscus after 2 minutes, indicated restricted damage Ask px to blow nose: if nail there, lacrimal system patent Place anaesthetic bud in nose, if staines lacrimal system patent Probing Canalicular currerage x ray - DCG DCR- Dacryocysthinostomy

Answer 37

Chronic or Acute Bacterial infection of lacrimal sac, in young kids can also be dacryoceole which is a accumulation of mucoid fluid. Most common in neonates & adults > 30 years F>>M, if prone to sinus issues, infection due to gram + & gram -. Management: CLPH Oral antibiotics, Co Amoxiclav, x3 a day - 5-7 days OR Ethyromycin if penicillin allergy,

Answer 38

Caused due to Staph & Strep species, FEVER!!! PRE-CELLULITIS Adults can start Co- Amoxiclav but no improvement in 24-48 hours, emergency referral. Amoxicclin- 500mg x3 a day for 5-7 days flucloxacillin- CELLULITIS- x4 a day for 5-7 days dosage depends on adult or child.

Answer 39

Can given oral NSAIDS or topicalFlurbiprofen , > 12 years, 150-200mg, a day. usually can be given in internvals. Milder steroids, Lotepredenol & Flurometholone. Artificial tears in dried for 1-2 weeks.

Answer 40

Start on high dose of oral NSAIDs if non necrotising IF contraindicated then analgesia + urgent referral to HES If necrotising- Emergency referral. Sunglasses Px usually 40-60, M>RF Can be due to infections, HZO, Posterior Sclertiits- RD, MO, ONH oedema - eye maybe white. Exstasia, bulging, choirdshowing through in anterior vectorising Scleral VESSELS DO NOT blanch WITH VASOCONSTRITORS, if it is superficial redness will disappear. Phenylephrine 2.5% & deep vessels do not move w cotton bud.

Answer 41

Anterior- IRIS & Pars plicta Int- Pars plana, anterior choroid Posterior- Choroid, retina, ON, retinal vasculature Pan Uveitis. Anterior is split into Irits: Iris inflammation only Iridocyclitis: more common, which affects iris & Pars pliciata (anterior part of CB) Use SUN scale to establish grading Predisposing factors, can be endogenous or exogenous. Age over 20 years, around 40. Complex HLA B27 antigen Manage: Sunglasses, Check IOP Dilated exam Rue our snow ball/ snow banking Specsfor near if cycloplegia. First episode, can manage, imitate therapy & review in 3 days Pedisolone 1% (not in children) or dexamethasone 0.1%, hourly until inflammation controlled if improvement in 3 days, reduce to every 2 hours for 5 days. Topical steroids should be taped over no LESS THAN 6 WEEKS. Cyclopentolate x3 a day for 7 days. No improvement refer: second or subsequent episode refer for systemic review, after therapy for rheumatologist referral .

Answer 42

more prone to uveitis

Answer 43

Non- typically acute onset Granulmatous- mutton fat, KP, due to chronic Uveitis

Answer 44

Inflammatory response of the peripheral cornea to bacterial (e.g. Staphylococcal) exotoxins rather than direct inoculation. Stromal infiltrate, which may be round or arcuate, single or multiple, unilateral or bilateral. Infiltrates are typically adjacent to the limbus and separated by an interval of clear cornea. Ocular lubricants Sunglasses CLPH Low dose steroid if needed, however the immunosuppressive effect of the steroid enhances the risk of infection. Can be prednisolone 0.5% or Loteprdelone 0.5%.

Answer 45

Type1- exposure to allergen, allergen taken by allergen presenting cell & goes to TH2- T helper cells, then then activates B cells and forms lymphocytes producing antibodies, B cells produce IgE, which binds to mast cells and sensitises mast cells. FIRST CONTACT Asymptomatic but upon subsequent exposure to allergen, mast cells IGE bind to antigen & release inflammatory molecules causing allergic symptoms- MAST CELL DEGRANULATION. DELAYED Type 4 hypersensitivt reaction Can take unto 24 hours, Th1 cells release cytokines this recruits macrophages & Cytotoxic T cells that mediate tissue injury (effector phase)

Answer 46

Herpes zoster ophthalmicus (HZO), also known as ophthalmic shingles, is caused by a localized reactivation of the varicella zoster virus (VZV) in the ophthalmic division of the trigeminal nerve. VZV is also known as human herpesvirus-3 (HHV-3). It usually lies dormant in the nerve roots and affects older and immune suppressants px in the 5-7th decade. Previous systemic infection of chickenpox, as a child, vaccination has been shown to reduce rate of shignles Skin features: involvement of the skin supplied by the ophthalmic division of the trigeminal nerve (V1 dermatome). Does not cross the midline skin lesions on the side of the tip of the nose (Hutchinson’s sign, indicating nasociliary nerve involvement) indicates three to four times the usual risk of ocular complications. Swollen regional lymph nodes Ocular lesions: Ocular lesions may occur early or develop within one month after the onset of the skin rash and therefore patients may need to be monitored even after the rash starts to improv. mucopurulent conjunctivitis (common), a keratitis (more than half of all cases) punctate epithelial – early sign, within 2 days (50% of cases) pseudodendrites – fine, multiple stellate lesions (around 4-6 days) (DOES NOT STAIN EASILY) nummular – fine granular deposits under Bowman’s layer, COINLIKE, COLEASSE AND FORMS. RING disciform – 3 weeks after the rash (occurs in 5% of cases) endothelial changes and KP episcleritis, scleritis, anterior uveitis secondary glaucoma (check IOP) rarely, posterior segment involvement: retinitis, acute retinal necrosis, choroiditis, optic neuritis, optic atrophy Complications can occur months or years after the acute phase MANAGMENT: Advise rest and general supportive measures (reassurance, support at home, good diet, plenty of fluids) Advise avoidance of contact with elderly or pregnant individuals, also babies and children not previously exposed to VZV (who are non-immune) or immunodeficient patients Anealgesia Ocular lubricants Cycloplegia if uveitis Systemic antiviral- Oral Acyclovir- Early treatment with oral aciclovir 800mg, every 4 hours for 7 days/ 5 days. (within 72 hours after rash onset) reduces the percentage of eye disorders in ophthalmic zoster patients from 50% to 20-30%. This early treatment also lessens acute pain. emergency referral GP, Urgent if no ocular improvement.

Answer 47

The Herpes simplex virus (HSV) is a common cause of viral infections of the eye. The roots of the virus cannot be eradicated and can be reactivated when px feeling unwell, sunlight, medications. This is the most common cause of ocular manifestation of HSV ocular infections. HSV1- Primarily affects mucus membrane of body, above waist, lips, eyes, face HSV2- Below the wait, usually sexually acquired but rarely can cause keratitis. Signs: HSK IS classified depending on the layer of the cornea affected, - Most common form Epithelial keratitis 1) Epiehtlial 2) STromal 3) Endothelial 4) Metaherpectic ulcer Epithelial Initially punctate lesions, coalescing into dendriform pattern dendritic ulcer, single or multiple opaque cells arranged in a stellate pattern progressing to a linear branching ulcer; terminal bulbs may be visible dendritic lesions stain with fluorescein, edges of lesion, containing dead cells, stain with lissamine green continued enlargement may result in an ‘amoebic’ or ‘geographic’ ulcer Stromal Stromal infiltrates, vascularisation, oedema and opacification, leading to scarring and vision impairment. Stromal HSK can be either necrotising or non-necrotising. In non-necrotising stromal HSK, the oedema is localised, and mostly self-limiting. In necrotising keratitis, the stromal inflammation is widespread and the infection progresses to ulceration, necrosis and possible perforation Endothelial (Disciform) keratitis Central or eccentric zone of epithelial oedema overlying an area of stromal thickening, folds in Descemet’s membrane, raised IOP, uveitis and keratic precipitates Metaherpetic ulcer (trophic keratitis) Metaherpetic keratitis is the most severe form of HSV corneal infection. Recurrent attacks of HSV, bullous keratopathy, stromal involvement, endotheliitis, neovascularisation and anterior uveitis characterise the metaherpetic phase of the disease Management: Gancicolvor 0.15% gel x5 a day until complete reepithelisation then x2 a day 7/7- post healing monitor within 72 hours. Refer if not healed in 7 days. Aciclovir- 3% is also an option. Viral retinitis- emergency referral.

Answer 48

Acanthamoeba keratitis (AK) is a severe sight-threatening corneal infection, particularly if not diagnosed early Acanthamoebae are ubiquitous free-living unicellular protozoans parasites, can exist in 2 forms 1)motile, feeding and replicating form: trophozoite (most common form found in water and easily destroyed) 2) dormant form: cyst (highly resistant to disinfection, can survive for long periods in hostile environments) Veyr rare Management- Emergency referral Analgesia Biguanides & Diamidines- (Antimicrobials) Confirm diagnosis with PCR or corneal scare culture. Surgery topical steroids topical antibiotics

Answer 49

Keratitis can be classified as infectious Keratitis and Non-infectious keratitis. Keratitis is inflammation of the cornea. Infectious - Viral o Adenoviral o Herpetic - Microbial o Bacterial- Trachoma, Gonococcal o Protozoal- Acamthomeba. o Fungal Non-infectious keratitis - Inflammatory- Marginal - Exposure- ectropion - Iatrogenic - Toxicity- Glaucoma meds etc

Answer 50

Most common, Gram + & gram - Psuedonomas is gram- Empirical treatment for lesions (<1mm) in the absence of the above clinical characteristics is based fluoroquinolone monotherapy e.g. gutt levofloxacin/moxifloxacin hourly day and night for 48 hours, then every 2 hours daily for 72 hours, then every 4 hours for 7 days. Monitor closely during this period and refer same day if not healing or if symptoms worsen Gonococcal keratitis- which is sexually transmitted due to Gonorrhoea, affects neonates within 1 week- if not sight threatening can mange with Fluoroqiolone, Trachoma- no1 cause of visual impairment, LONG INCUBATION PERIOD, caused by bacterium Chlamydia trachomatis, Can cause ankloblpeharon- partial or complete fusion of eye lid due to web of skin Symblepharon- tarsal and bulbar conjunctiva adhere to each other Bulbar hyoerima, upper tarsal follicles, lid ptosis, entropion, Herbert's pit- dip at limbus

Answer 51

caused by, Candida sp. (yeast-like) Fusarium sp. (filamentous) Aspergillus sp (filamentous) Fungal keratitis (filamentous) is usually secondary to trauma involving organic material; it can also be contact lens or solution related Fungal keratitis (yeast-like) most usually complicates ocular surface disease or in immunocompromised patient Fungal keratitis produces similar signs to bacterial keratitis; however, it has been claimed that deep lesions, those having a feathery edge, raised profile, presence of satellite lesions and the presence of endothelial plaque are all features suggestive of a fungal as opposed to a bacterial infection. Fungal keratitis may develop more slowly (however Fusarium infection can progress rapidly and invasively) Amphotericin B (as 0.15% eye drops) is the drug of choice in fungal keratitis caused by yeasts (e.g. Candida) Fungal infections usually require combined topical (e.g. natamycin 5%, econazole 1% or voriconazole 1%) and oral (e.g. voriconazole) therapy. Clinical strategies continue to evolve

Answer 52

Adenoviral HZO HZK Cytomegaloviral keratitis

Answer 53

topical AB & Topical steroids. Self limiting Cool compress.

Answer 54

time course associated symptoms severity tx exacerbating factors reliving factors

Answer 55

Infection point, entry through corneal surface, goes to epithelial which introduced microflora to storm, This Microflora infects Stromal keratin triggering inflammation Inflammation attracts enzyme releasing Neutrophils. Progressive inflammation can lead to corneal perforation Wound healing often leaves scarring.

Answer 56

Impressions- applying cellulose acetate to superficial epithelial to obtain sample Swabs Scrapes Biopsy

Answer 57

Cultures - Specific put to medium. to investigate - Blood, chocolate, subouraud. Stain - Gram, giesma, Sensitivity - LOOKS AT TX WE CAN ACHIEVE PCR- takes DNA pathogen to break down Impression cytology - Mass spectromy - breaks down components of specimen to determine pathogen * how to manage

Answer 58

Gram & Giesma Help identify actieral & technique is used to enhance & contrast biological specimen at the microscopic level

Answer 59

Blood, chocolate, Subouraud This is a gel/ liquid used to grow bacterial or micro-organisms Swab specimen across media, multiple, stains For acanthomba you would use non nutrient w coli culture.

Answer 60

ask & acquire Appraise Apply Audit

Answer 61

use of best available evidence together w the px preferences & practitioners expertise.

Answer 62

Antiinfective, Antibactieral- Licenced for OCular Rosacea & Blepharitis 50mg & 100mg dosage capsules. Broad spectrum tetracycline against gram - & + bacteria. 12 years +, x PREGNANCY, X LACTATION, X renal or hepatic impairment. Adults: 100mg twice daily for 2 weeks, then 100mg daily for 2–3 months; or 40mg modified-release formulation daily for at least 5 months.

Answer 63

Broad spectrum antibiotic, 50mg & 100mg, Licensed fir ocular roseate & blepharitis. > 12 years, X BF, X PREGNANCY Adults: 50mg daily for 2 weeks followed by 100mg daily for the next 10 weeks.

Answer 64

205mg or 500mg Borad spectrucym, antiinfective, antibiotic for Ocular Rosease, Bellhop, Dacryocystitis, 2 month old++ , Adults and children aged over 8 years: 250mg to 500mg every 6 hours. The duration of therapy will depend on the type and severity of the infection, but should generally be as short as possible. Can be used in pregnancy & caution w BF.

Answer 65

Narrow spectrum- Antiinfective, antibactieral, Caution w Pregnancy, X Lactating Suggested doses for pre-septal cellulitis or internal hodeolum: Can also be used for Dacyocystitis Amoxicillin: 500mg, one capsule three times per day for 5-7 days Co-amoxiclav: 500mg:125mg, one capsule three times per day for 5-7 days.

Answer 66

Antiinflammtory, Corticosteroid. 0.5% or 1% For Keratitis or uveitis. No steroid should be used in viral or fungal diseases of the eye. X pregnancy ,caution w BF. Adults only- 18+++ Adults: one or two drops every 1–2 hours until inflammation is controlled, then reduce frequency.

Answer 67

Antiinflammtory, Steroid. 0.1% eg Maxidex Anterior uveitis, tx for non infections inflammatory conditions, > age of 2 years old only X pregnancy, caution BF Adults and children: one or two drops four to six times daily in the affected eye. In severe cases, treatment may be started with one drop every hour but dosage should be reduced to one drop every 4 hours when a favourable response is observed. Gradual tapering off is recommended in order to avoid a relapse.

Answer 68

Antivirals, antiinfectives A- 3% YP, X BF - > 2 months old, 1cm ribbon of ointment should be place in the lower conjunctival sac five times a day at approximately four-hourly intervals (excluding overnight application). Treatment should be continued for at least three days after healing is complete. G- 0.15% - x p, x bf, > 18 years old, Adults: one drop of gel in the inferior conjunctival sac of the eye five times a day until corneal re-epithelialisation is complete, then three instillations a day for 7 days after healing. Treatment does not usually exceed 21 days.

Answer 69

ILube for dry eye 5% Artificial tears/ ocular lubricants X CL, X BF, NO P > 1 month, 1-2 drops x3-4 daily.

Answer 70

2 types AD- Srojens & non sjrorgens ED: MGD, Local or systemic disease Lod aperture disorders Aetiology: Dry eye is a multifactorial disease of the ocular surface characterised by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play aetiological roles. Dry eye affects lacrimal glands, ocular surface, lids these components are known as Lacrimal functional unit, LFU preserves integrity of tear film, transparent of Cornea & quality of image projected onto Retina. Disease/damage to the LFU including nerves can destabilise tearful leading to dry eye. Pharmacological management: Topica steroids Ciclosporin 0.1%- Ikervis, licneced for DED. x1 drop, review every 6 months Liposomal sprays in DED- 3-4 x aday

Answer 71

Dry eye affects lacrimal glands, ocular surface, lids these components are known as Lacrimal functional unit, LFU preserves integrity of tear film, transparent of Cornea & quality of image projected onto Retina. Disease/damage to the LFU including nerves can destabilise tearful leading to dry eye.

Answer 72

Schirmer test (without anaesthesia) ≤ 5mm in 5 min; may be helpful in the diagnosis of Sjögren’s Syndrome, but of limited value in non-Sjögren’s DED >10mm is normal

Answer 73

This is salt content in tears raised tear osmolarity (308 mOsm/l is the most sensitive threshold to distinguish normal from mild/moderate DED, while 315 mOsm/l is the most specific cut off 315= DRY EYE!!! 308- normal to mod dry eye!

CMG Flashcards

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