eyes3 Flashcards
(36 cards)
Causes of a white pupil and differential questions on history?
RETINOBLASTOMA is most important to exclude
60% unilateral (if bilateral usally hereditary - ask FHx) ask about inward or outward turning of eye
congenital cataract
persistent hyperplastic primary vitreous (PHPV)
May also have a small eye (micropthalmia)
Coats’ disease (a severe exudative form of retinal telangiectasia)
may have pink or grey reflex instead of true white
retinal detachment
usually history of trauma/usually unilateral
retinopathy of prematurity (RoP)
a history of prematurity (<27 weeks gestation) and low birthweight (<1200 g).
coloboma toxocariasis (a retinal infection caused by roundworms routinely found in dogs and cats). (ask about exposure to small animals and farm animals)
Visual testing in infants and kids?
In babies, 1) preferential looking and observation may represent testing options, as may 2)objection to occlusion. In cases of significant unilateral vision loss, covering the good eye may cause the patient distress, compared with little or no effect of covering the eye with suspected loss, thereby providing basic feedback.
3. Monitoring the patient’s ability to scan and pick up objects of different sizes may provide an additional clue. Recording should be simple (eg ‘identifies 100s and 1000s with right eye’; Figure 3). Preschool children can usually match symbols or letters adequately. The distance at which the test is performed should be noted (Figure 4). For children, a distance of 3 m is usually adequate. When using symbols, an attempt should be made to determine at what distance the child can identify a shape; as the shapes becomwwe smaller in size, the child may repeatedly answer ‘circle’ – this is an indication that they are unable to identify key differences.
- OPTHALMOSCOPY
Treatment options for retinoblastoma?
selective intra-arterial chemotherapy (SIAC) and intravitreal chemotherapy and radiotherapy.
ENUCLEATION in advanced disease
SIAC delivers a targeted approach to drug delivery to the eye via the ophthalmic artery, thereby minimising systemic effects of treatment, compared with a systemic chemotherapeutic approach.
If vitreous seeding has occured - then intravitreal injections can help
What are the risks of hereditary retinoblastoma even after treatment
Hereditary retinoblastoma represents a lifetime risk of developing secondary and new primary malignancies, including osteosarcoma, primitive neuroectodermal tumours and melanomas
Surveillance post treatment for retinoblastoma
Lifelong follow-up remains essential for all patients previously treated for retinoblastoma, with increased vigilance required for patients with hereditary involvement.
This will need to be done in concert with the treating ophthalmologist. Surveillance can be every one to three months following treatment, then every four to six months and then annually. This will be titrated to the individual patient.
Five year survival post SIAC for retinoblastoma in developed countries?
over 95%
Visual acuity changes in retinoblastoma longterm? Effect on driving?
In mild-to-moderate retinoblastoma, up to 53% of patients may retain visual acuities of 6/12 or better, which may be compatible with the legal driving limit in Australia.
In more significant disease or those cases with macular involvement, obtaining vision better than 6/60 remains unlikely and >50% of eyes remain below this mark.
Patient presents with red, photophobic eye - what examinations are important
Stain with Fluoroscein 1% and view under cobalt blue light
CHECK visual acuity (no change in conjunc)
Opthalmoscopy - checking for pupil size and reactions
Slit lamp examinaton
Treatment of Uveitis? HLA- B27 pos uveitis?
- Urgent referral to ophthalmology for topical steroids and cycloplegics.
- If HLA bB27 pos - then screening of family members and screening questions for other conditions such as ankylosing spondylitis.
What does this post traumatic image represent?
Iris prolapse after corneal laceration
note the teardrop pupil
Patient presents with suspected traumatic/penetrating eye injury what will you look for on history and exam
- conjunctival chemosis (inflammation)
- Subconjunctival haemorrhage
- Hyphaema
- Corneal laceration
- Prolapse of iris
- May be difficult to open eye
- Enquire about tetanus vaccination history
- ASK patient to fast in case surgery is required
- Protect the eye with an eye shield
- Send to emergencty department urgently via ambulance
What does a seidel test show?
Aqueous outflow through the cornea in peneterating injury - positive seidel test
fluroscein staining and cobalt blue light
What should be avoided when examining a patient with penetrating eye injury?
Avoid intraocular pressure testing
Leave foreign body insitu
long term complicaitons of penetrating eye injury
proliferative vitreoretinopathy
endopthalmitis
traumatic catarct
corneal scarring (may need corneal transplant)
Retinal detachment
Visual symptoms/photophobia/light senstiivity/glare
Unilateral blurred vision and floaters and decreased acuity over 10 days - DDx?
retinal tear or detachment
vitreous haemorrhage
posterior vitreous detachment
diabetic vitreous haemorrhage
migraine.
What are the mechanisms of retinal detachment
a break or tear in the retina (rhegmatogenous detachment)
uncontrolled diabetes causing a tractional retinal detachment.
Tractional can also be caused by trauma
RF’s for retinal detachment
Myopia – more than 40% of all patients with a retinal detachment are myopic.1 Treating the myopia through cataract or laser refractive surgery does not remove the risk of retinal detachment. Patients most at risk are those with longer axial lengths who have a spectacle correction of –6.00 DS or greater.
Age – the incidence of retinal detachment increases with age because of the increased incidence of PVD.
Surgery – can lead to increased vitreoretinal traction either during or after the operation, particularly in the elderly. Post-surgery rates of retinal detachment of up to 3% have been described, albeit in complicated surgical cases.
Trauma – both direct and indirect trauma to the eye may lead to detachment. Contact sport is a risk factor, although falls in elderly patients remain responsible for a significant proportion of retinal detachment cases.2 Penetrating eye injuries may lead to scarring and tractional complications.2
Systemic disease – several conditions, including Marfan syndrome, Stickler syndrome, connective tissue disease and uncontrolled diabetes mellitus, confer a higher risk of retinal detachment. Patients with these conditions should undergo regular ocular examinations.
Treatment of retinal detachment
Surgery
laser
cryo
may need vitreectomy
Prognosis is worse if macula is involved
afterwards avoid heavy lifting/bending/coughing/nose blowing in immediate term
75% go back to 6/12 which is driivng limit
Aboriginal patient with sticky eyes - history questions
Where are you from?
How many houses are there in your community?
Who else lives in your house?
Then ask specific questions about his eyes:
How much discharge is there?
Does the discharge glue his eyes together?
Have any drops been used to treat the discharge?
Has anyone else who usually lives with Danny had sore or sticky eyes?
Has anyone in Dora’s household had sore or sticky eyes?
Aboriginal patient with sticky eyes - examination
examine the eyelids, looking for inturned eyelashes
examine the cornea and note if there is any opacity
evert the upper eyelid and examine the conjunctiva
According to grading of trachoma - what is follicular
5 or more follicles visible on everted eye lid
Treatment of trachoma
Oral Azithromycin 20mg/kg stat dose
Screen family members
Encourage daily hand and face washing
PHone call to local public health unit to see if there is regular screening scheduled
