EYE

Question 1

What is difference between sclera and cornea?

Answer 1

Sclera - fibrous outer protective coating of eye CONTINUOUS with cornea anteriorly (transparent layer forming the front of the eye). Cornea is avascular - it gets nutrition from fluid in anterior chamber which is secreted by ciliary body. Inner layer of corneal cells - pumps fluid out of corneal tissue - otherwise corneal odema occurs

Question 2

Where is the retina? What is it made up of?

Answer 2

Retina is back of the eye. Cones - mainly in macula - responsible for colour vision.

Rods are more in periphery.

Blood supply - central retinal artery

Venous - central retinal vein and opthalmic vein

Question 3

What are five symptoms of eye disease?

Answer 3

Reduced acuity

Redness

Pain
Photophobia

Discharge

Question 4

Causes of cataracts?

Answer 4

Age

Familial - genetics

Congenital Infections

Associated disease - muscular dystrophy, Downs, diabetes mellitus, cushings syndrome

Drugs - steroids, amiodarone, phenothiazines

Hypercalcaemia

Wilsons disease

Galactosaemia

Question 5

Symptoms and management of cataracts?

Answer 5

Gradual, PAINLESS, visual loss

initially difficult to see in the dark

Glare and poor vision whilst night driving

Haloes around light.

Management: Cataract extraction and lens replacement

Question 6

What is Charles Bonnet Syndrome?

Answer 6

A syndrome usually found in older people with VISUAL IMPAIRMENT

Vivid, elaborate and recurrent visual hallucinations in psychologically normal people.

CBS can be visual equivalent of phantom limb where active brain is filling in gaps post visual loss.

Most commone cause is age related macular degeneration

Question 7

How does a conjunctivitis present? When should you refer?

Answer 7

Red inflamed conjunctiva

Clear Cornea

Gritty feeling in the eye

no pain

Normal vision

IF Severe or worsening pain, photophobia or reduced vision - prompt referral to opthalmologist to exclude a more serious diagnosis like keratitis

Question 8

How would you recognise an allergic conjunctivitis?

Answer 8

Red inflamed conjunctiva

Clear Cornea

Gritty feeling in the eye

no pain

Normal vision

ASSOCIATION WITH HAYFEVER/Seasonal?

Fhx of atopy

Itch

Bilateral

Watery discharge

rarely - preservative in eye drops

Rhino-conjunctivitis

Pappilae in conjunctivae (can be cobblestone in appearance)

Chemosis - oedema

IF Severe or worsening pain, photophobia or reduced vision - prompt referral to opthalmologist to exclude a more serious diagnosis like keratitis

Question 9

How would you manage an allergic conjunctivitis?

Answer 9

1. Topical Naphazoline hydrochloride
2. Oral antihistamines
3. Nasal steroids
4. Ocular Normal saline drops/lubricant - use liberally
5. Advise against rubbing eyes - increases
6. Do not use contact lens during symptomatic period
7. Cold compress
8. Avoid triggers - allergens

• *FOR REFRACTORY CASES**
• ocular antihistamine +/- ocular sodium chromoglycate
• mod-severe symptoms incomplete/poor control on avoidance and drug treatment NEED IN VIVO SKIN TESTING OR IN VITRO SERUM TESTING to consider targeted immunotherapy. Referral to specialist for steroids and immunotherapy after skin patch testing.

Question 10

Most common cause of viral conjunctivitis?

Answer 10

Adenovirus

Question 11

How would you identify a viral conjunctivitis?

Answer 11

Adenovirus - often occurs in epidemics - many contacts in family or community. Starts as an URTI.

1. Can be unilateral - with other eye involved in 2-3 days
2. Red inflamed conjunctivae
3. Gritty feeling in eye
4. Thin watery discharge
5. PRE - auricular LN involved and enlarged
6. Subconjunctival haemorrhage can occur with adenovirus
7. Eyelid can be inflammed.
8. Can last for 2-3 weeks
9. IF photophobia or reduction in visual acuity - then opthalmology referral

o/e Papillae with follicular pattern

CAN Do a slit lamp examination looking for corneal opacity

Question 12

Management of viral conjunctivitis?

Answer 12

1. Strict hygiene (hand washing, do not share towels)
2. Cold compress application to eye
3. topical lubricant
4. Review if signs of bacterial infection - thick, purulent yellow discharge
5. Review urgently in ED if reduced vision/photophobia or reduced acuity/blurring of vision

NB: HSV and HZV can also cause viral conjunctivits - seek expert opinion

Question 13

How would a bacterial conjunctivitis present?

Answer 13

Red inflamed conjunctivae

Gritty eye

Clear vision

Discharge is THICK, PURULENT - in the morning eyelids stuck together

Crusting of the eyelids

Question 15

What organisms cause bacterial conjunctivitis?

Answer 15

1. Staph Aureus
2. Strep Pneumoniae
3. Heamophilus influenzae B - esp in incompletely vaccinated kids under 5 (otitis-conjunctivitis syndrome)
4. Pseudomonas Aeruginosa
5. STI - chlamdiya trachomatis

Neisseria Gonnhorea

Question 16

Management of bacterial conjunctivitis

Answer 16

Many resolve within 7 days without treatment

ALL NEONATES AND YOUNG INFANTS REQUIRE TREATMENT

Chloramphenicol 0.5% eye drops, One drop into affected eye four times daily for up to one week.

OR Framycetin 0.5% one drop qid for seven days

Both can cause hypersensitivity reactions

Question 17

What are the main presentations of chlamydia conjunctivitis?

Answer 17

1. Adult with prolonged conjunctivitis (acute, subacute, chronic with mucopurulent discharge)
2. Neonate with red eye - 1-2 weeks post delivery. (Scanty purulent discharge)
3. ATSI with trachoma

Neonatal transmission - can reflect Mother to child, accidental transmission or sexual abuse

Question 18

How would you investigate a suspected chlamydia conjunctivitis?

Answer 18

Conjunctival swab for nuclei acid amplification testing (NAAT) eg PCR - are recommended in ALL NEONATES with conjunctivitis and in patients with persistent conjunctivitis when C. trachomatis is suspected.

Question 19

Management approach for suspected chlamydia tracomatis conjunctivitis?

Answer 19

1. Conjunctival swab for Chlamydia PCR (NAAT)
2. Oral azithromycin (1g stat in adults). In neonates 20mg/kg orally daily for 3 days.
3. Notify to Health Dept
4. STI screening for parents ( if in a child)
5. Consider pneumonia risk in infants (50% develop same)

Question 20

What is trachoma?

Answer 20

A form of chronic c.trachomatis conjunctivitis caused by repeated infection by C. trachomatis serotypes A, B, Ba or C.

Leading cause of preventable infectious blindness in the world - common in ATSI communties in remote parts of Aus.

Without treatment - recurrent infection –> scarring of eyelids - which can cause trichiasis, corneal scarring, ulceration and loss of vision

Question 21

What are some non pharmacological management options in trachoma?

Answer 21

1. Liaise with the regional population health units regarding prevalence within the community and chemoprophylaxis guidelines in that setting.
2. Advise families of the importance of facial cleanliness
3. Ask routinely about safe and functioning washing facilities in the home, in childcare and at school.
4. Regular screening and treatment of infection.
5. Refer trichiasis to opthalmologist

Question 22

How does gonococcal conjunctivitis present? Management?

Answer 22

1. Abrupt onset of copious and purulent eye discharge, eye lid oedema and fever.
2. Neonate within 2-5 days of birth with thick purulent discharge
3. Conjunctival Swab for Microscopy, culture and sensitivity AND Nucleic acid amplification testing (Eg PCR) for Neisseria Gonorrhea.
4. Contact Opthalmologist (Esp if corneal opacity)
5. Commence IM ceftriaxone 1g (50mg/kg in children over one month (otherwise cefotaxime 50mg/kg) stat and azithromycin 1g stat (20mg/kg) (as co-infection with chlamyda common)
6. Irrigate eyes several times a day with normal saline till purulence subsides

Question 23

How does a corneal abrasion present

Answer 23

Usually history of foreign body or trauma

Patient has:

+/- pain

Blepharospasm (twitching/blinking)

photophobia

lacrimation

sensation of foreign body

visual acuity may be reduced

Question 24

Management of corneal abrasion?

Answer 24

1. Topical tetracaine eye drop 1% one drop to affected eye.
2. Instill Fluroscein 1% eye drops and examine under a cobalt blue light looking for corneal abrasion.
3. Examine under the eye lids for foreign body
4. Consider 0.5% chloramphenicol eye drops, 1 drop four times a day for one week (prophylaxis)
5. Eye patch (if no infection and no f/b)
6. Review in 24 hrs
7. If not recovering in 24hrs refer to ophthalmologist

Question 26

Settings where keratitis can occur?

Answer 26

1. Contact lenses 2. Spreading infection from blepharitis - causes marginal keratitis 3. Autoimmune - peripheral ulcerative keratitis 4. Compromised ocular surface after trauma 5. Herpes Virus - HSV, HZV 6. Bacteria - eg gonococcal 7. Contaminated water - bacterial, fungal, parasitic

Question 27

What is keratitis?

Answer 27

Acute corneal inflammation

Question 28

Patient presents with blepharitis and then develops photophobia +/- blurred vision

Answer 28

Exclude keratitis

Question 29

Treatment of acute bacterial keratitis?

Answer 29

1. Commence empirical ciprofloxacin 0.3% eye drops - one drop to affected eye EVERY HOUR 2. URGENT REFERRAL TO Opthalmologist - sight threatening emergency (they will perform corneal scraping and may consider steroids and other treatment options) 3. Treat the primary cause - eg blepharitis, or advise safe use of contact lenses

Question 31

Causes of infectious keratitis?

Answer 31

Bacterial - staph. aureus, staph epidermidis,strep pneumo, pseudomonas, aeruginosa, Viral - HZV HSV Fungi,mycobacteria or acanthomeba

Question 32

How does an infectious keratitis present?

Answer 32

red eye PAINFUL with PHOTOPHOBIA +/- reduced visual acuity Swelling Corneal epithelial defect highlighted by fluorescein stain CAN ALSO HAVE stromal infiltrates, corneal oedema and ulcer, Hypopyon (layering of white blood cells in anterior chamber) Fibrin - proteinaceous exudate Wessley ring infiltrate

Question 33

What is hypopyon?

Answer 33

White cells layering in the anterior chamber (like pus hyphaema)

Question 34

What is the most common infection in contact lens wearers?

Answer 34

BACTERIAL KERATITIS (95%)

Question 35

What is the key distinguishing feature of herpes keratitis? Treatment?

Answer 35

Dendritic ulcer (Geographic ulcer) on fluorescein staining and view under cobalt blue light. Swab for HSV NAAT/PCR Commence empirical TOPICAL ACYCLOVIR 3% eye ointment into the affected eye five times a day for two weeks. OR if not available oral acyclovir 400mg 5 times a day for seven days Refer for urgent opthalmological review

Question 36

How would you manage herpes zoster opthalmicus?

Answer 36

**Oral** Acyclovir EIGHT HUNDRED milligrams 5 times a day for seven days (20mg/kg in a child) URgent Opthalmological referral (oral for HZV - topical for HSV)

Question 37

Most common cause of congenital NLD (nasolacrimal duct) obstruction?

Answer 37

Incomplete canalisation at the distal end (Closest to the nose) - leaves an IMPERFORATE membrane at the valve of HASNER

Question 38

What is a congenital dacryocystocele? How does it present? What are the complications?

Answer 38

Obstruction at BOTH proximal and distal ends of NLD (nasolacrimal duct) Distends **Appears as bluish bulge below the medial canthus - appears shortly after birth - URGENT opthalmology referral to avoid complications (they will usually PROBE the duct)** CX are: 1. Acute Dacryocystitis (infection) 2. Nasal congestion

Question 39

How is a dacryocystocele managed?

Answer 39

Digital massage and NLD probing Needs to be done by the opthalmologist

Question 40

Symptoms of dacryostenosis? NLD obstruction?

Answer 40

Congenital NLD obstruction - 6% newborns - Most common cause of chronic tearing/eye discharge in infants and young kids Spontaenous resolution by 6 months in 90% NLD persisting beyond 12 months are unlikely to resolve spontanouesly SYMPTOMS: Chronic or intermittent tearing and debris on the eyelashes (NO redness of eye) though irritation from rubbing can cause redness of lower eyelid

Question 41

Examination findings of dacryostenosis (Cong NLD obstruction)

Answer 41

INSPECT - Increaese in SIZE OF TEAR MENISCUS debris on lashes/increased tears PALPATE lacrimal sac - Tears/discharge can reflux into eye with pressure on duct Dye Disappearance test - one drop of flourescein 1% eye drop - if most of the dye disappears after 5 mins - no obstruction

Question 42

Indications for specialist referral in congenital nasolacrimal duct obstruction?

Answer 42

Unclear diagnosis - or patient also has photophobia/blepharospasm, and/or asymettrical corneal diameters (suggests infantile glaucoma). Persisting symptoms beyond 6 months Acute dacryocystitis (Erythema, swelling, warmth, tender, purulent discharge from lacrimal sac) Dacryocystocele Signs of anisometropia (unequal refractive power of both eyes) or amblyiopia (squint)

Question 43

What is the treatment of Nasolacrimal duct obstruction?

Answer 43

Age under 6 months - nasolacrimal massage and observation If not improving by 6 months may need probing by opthalmologist

Question 44

What is a hyphaema?

Answer 44

Bleed into the anterior chamber of the eye 4 grades (grade IV is eightball, grade 3 more than 1/2, grade 2 More than 1/3, Grade 1 - less than 1/3). Complications: 1. Secondary haemorrhage (from exertion usually) 2. Traumatic glaucoma 3. Visual loss secondary to acute glaucoma.

Question 45

How do you treat a hyphaema?

Answer 45

1. Avoid unecessary movement and vibration 2. Avoid smoking and Alcohol. 3. Eye shield over the affected eye 4. Acutely raise the patients head to 30 degrees. 5. Managment is bed rest for 5 days and daily review of patient. 6. Analgesia, tetracaine 1% eye drop, oxycodone 7. IOP needs to be checked one week after resolution of hypaema (exclude ghost cell glaucoma) 8. Then check IOP yearly (increased risk of glaucoma after hyphaema)

Question 47

Clinical features of Episcleritis?

Answer 47

Sectoral REDNESS (less than 2 weeks) Not painful minor discomfort/dryness 30% of cases associated with IBD or conn. tissue (Eg RA) Treat - topical lubricants and oral NSAIDs if dx unclear - send to Opthalmology

Question 48

Clinical features of scleritis?

Answer 48

Diffuse scleral injection moderate to severe pain Worse on eye movement tender to touch Increased tears, Photophobia No systemic symptoms Can be associated with RA Tx - URGENT REFERAL TO OPTHALMOLOGY - usually steroid/NSAID may use systemic therapies if underlying connective tisssue eg methotrexate

Question 49

Clinical features of subconjunctival haemorrhage?

Answer 49

Visible blood in the eye - can move and change colour (yellow/green) NO pain can be irritated RF's - DM, HTN, Anticoags, clotting disorders Look for associated trauma/ICH NO ix Topical lubricant is mx