Lecture ILO’s

Question 1

What causes the pupil to constrict and dilate?

Answer 1

Constrict - parasympathetic
Dilate - sympathetic

Question 2

What muscles control extra-ocular movements and what nerves innervate them?

Answer 2

Third cranial nerve (oculomotor) moves the superior rectus, inferior rectus, medial rectus

Fourth cranial nerve (trochlear) moves the superior oblique

Sixth cranial nerve (abducens) moves the lateral rectus

Question 3

What muscles causes eye elevation?

Answer 3

Levator palpebrae superioris - innervated by 3rd cranial nerve
Superior tarsal plate - innovated by sympathetic fibres

Question 4

Role of sympathetic system to the eye, where does it run and what happens if this is damaged?

Answer 4

Dilates eye and prevents ptosis
Runs from cervical to lumbar region of spine
Damaged = horners syndrome - constricted eye and ptosis

Question 5

What is ptosis?

Answer 5

Ptosis= >2mm of cornea covered by eyelid

Question 6

Unilateral causes of ptosis

Answer 6

Involutional changes - ageing - muscle degeneration
Congenital
3rd nerve palsy
Horner’s Syndrome - sympathetic problem
Trauma to levator muscle

Question 7

Bilateral causes of ptosis

Answer 7

Involutional changes
Congenital
Myasthenia gravis (one side can be more affected)
Myotonic dystrophy
Mitochondrial myopathies
Dermatochalasis
Trauma to levator muscle

Question 8

Dermatochalasis

Answer 8

Excessive skin on upper / lower eye Lid

Presents with recurrent blepharitis which have now resolved (edges of your eyelids become red and swollen)

Question 9

Involutional Ptosis

Answer 9

Connections to levator palpabrae superioris break down
• Diagnose by excluding other causes (only history and examination usually required)
• Surgical repair required if obscuring vision

Question 10

Myotonic dystrophy clinical features

Answer 10

• Autosomal dominant
• Trinucleotide repeats (DM1); tetranucleotide repeats (DM2)→anticipation through generations
• Cause muscular dystrophy

Clinical features:
• Muscle weakness and wasting (lower motor neurone)
– Bilateral ptosis
– Wasted SCM
– Wasted temporalis
– Little lines on forehead
– Hatchet jaw

• Prolonged contraction/delayed relaxation
– Percussion myotonia (thumb flexes with a tendon hammer)
– Difficulty relaxing muscles-grip (muscle spasms following contraction)

• Male pattern balding
• Cataracts
• Diabetes
• Gynaecomastia
• Low IQ - learning disability
• Heart conduction defects - heart block

Question 11

Horners syndrome causes and common symptoms

Answer 11

• Sympathetic supply to eye interrupted (parasympathetic overrides to affected side):
– Ptosis - drooping of the upper eye lid
– Meiosis - constricted pupils
– Enophthalmos - eye sinks deeper into eye socket
– Anhydrosis - inability to sweat

Question 12

Horners syndrome causes
Central
Pre ganglionic
Post ganglionic

Answer 12

Central
- CVA
- Syringomyelia
- Multiple sclerosis
- Meningitis & Encephalitis
- Brain or spinal cord tumour
- Trauma (central)

Preganglionic
- Cervical rib
- Lymphadenopathy
- Thyroid mass (goitre, tumour, surgery)
- Lung apex pathology (tumour)
- Thoracic aorta, subclavian aneurysm
- Trauma (chest)

Postganglionic
- Carotid artery dissection/aneurysm
- Cavernous sinus thrombosis
- Middle ear infection
- Cluster headaches
- Trauma (neck and head)

Question 13

• Myasthenia gravis is caused by antibodies against which receptors:

A. Acetylcholine
B. Adrenaline
C. Glutamate
D. GABA
E. Dopamine

Answer 13

A

Question 14

Myasthenia gravis is associated with enlargement of which organ
A. Hypothalamus
B. Pituitary gland
C. Spleen
D. Thyroid
E. Thymus

Answer 14

E

Question 15

Third nerve palsy

Answer 15

• Ptosis (levator palpebrae superioris)
• Mydriasis (parasympathetic supply via oculomotor nerve→short cilliary nerves)
• Eye= down and out (unopposed effect of lateral rectus and inf. oblique)
• Enophthalmos
Causes- Diabetes, atherosclerosis, posterior communicating artery aneurysm, space occupying lesion, brain infection/inflammation, cavernous sinus thrombosis, multiple sclerosis

Question 16

Blepharitis of the eyelid

Answer 16

Blepharitis of the eyelid
• Blepharitis is a chronic inflammation of the lid margin
• The condition is common and more severe in the elderly

• Two types - Blepharitis staphylococcal and also seborrheic type
• May predispose to blepharoconjunctivis and loss of lashes

• Characteristic symptoms (often intermittent, with exacerbations and remissions occurring over long periods):
• Burning, itching and/ or crusting of the eyelid.
• Symptoms are worse in the mornings.
• Both eyes are affected.
• Recurrent hordeolum (stye)
• Contact lens intolerance.

Question 17

Blepharitis management

Answer 17

• Requires ongoing maintenance treatment,self-care measures such eyelid hygiene and warm compresses continued even when symptoms are well controlled to minimise number and severity of relapses.
• Baby shampoo diluted1:10 with warm water and gently wiping along the lid margins to clear any lid debris.

• If self- care measures are ineffective consider prescribing a topical antibiotic (chloramphenicol) to be rubbed into the lid margin - can get OTC.

Question 18

Chalazion (meibomian cyst)

Answer 18

• Ameibomiancyst/chalazionisasterile,inflammatory granuloma caused by the obstruction of a sebaceous gland.
• Obstruction of the gland duct causes the gland to enlarge and to rupture spontaneously or persist as a chronic nodule.
• Ameibomian cyst may develop acutely with anoedematous, erythematous eyelid or arise insidiously as a firm, painless nodule.
• If there is secondary infection it can spread to preseptal cellulitis requiring oral or sometime IV antibiotics.

• Rarely, a meibomian cyst may become secondarily infected. If the infection spreads to other ocular glands or neighbouring tissues this may lead to periorbital or orbital cellulitis.

Question 19

Management of Meibomian Cyst

Answer 19

•Meibomian cyst is usually self- limiting and rarely causes serious complication
• Warm compress then gently massage (don’t massage in circles, massage towards lid margin)

If the mebomium cyst is persistent (>4/52), recurrent, causing significant astigmatism, cosmetically unacceptable, or there is uncertainty about the diagnosis, refer the person to an ophthalmologist for further management.

• Incision and curettage
No treatment — if the meibomian cyst is small and asymptomatic.

Question 20

Stye or hordeolum

Answer 20

Stye or hordeolum
Acute localized infection or inflammation of the eyelid margin. bacterial infection usually caused by staphylococcal infection

External stye
• Appears on the eyelid margin.
• infection of an eyelash follicle and its associated sebaceous or apocrine gland.

• Internal stye
• Occurs on the conjunctival surface of the eyelid.
• infection of a Meibomian gland (situated within the tarsal plate).

Question 21

Stye management

Answer 21

• Self Care
• Usually self-limiting and rarely causes serious complications.
• Warm compress - 5–10 minutes 2–4 times daily until the stye drains or resolves.

• Patient not to attempt to puncture the stye.
• Advise to avoid using eye makeup or contact lenses until the area has healed.

• For a painful external stye, consider treatment in primary care for symptom relief:
• Plucking the eyelash from the infected follicle, to facilitate drainage.

• Incision and drainage of the stye using a fine sterile needle.

• Consider prescribing a topical antibiotic only if there are clinical features of spreading infection causing conjunctivitis
• Refer the person to an ophthalmologist for possible specialist incision and drainage if:
• Not improving with management in primary care.
• An internal stye is particularly large and painful.

Question 22

Ectropion of the eyelid

Answer 22

Ectropion of the eyelid
• Ectropion is an outward rotation of the eye lid margins(lower lid)
• Occursin 4% of the population over 50 years of age (bilateral in 70% of cases)
• Most common as a result of horizontal lid laxity (lossof elasticity and muscle tone)
• Other causes include contracture of skin due to trauma, burns, skin tumours and actinic changes to skin due to prolonged sun exposure
• Paralytic causes of ectropion include facial palsies

• Ectropion is a physical sign rather than a disease entity
• Presents as a sore red and watery eye
• Mild cases require no treatment but advise that
rubbing of the eyelids my increase lid laxity

Question 23

Entropion of the eyelid

Answer 23

Entropion of the eyelid
• Entropion is an inward rotation of the tarsus and lid margin (usually lower eyelid)
• This as a result of loss of elasticity and muscle tone of the eyelids, usually with age
• As a result the lid lashes come into contact with the ocular surface
• Presents as foreign body sensation and irritation with red watery eye with blurring of vision

Question 24

Entropion of the eyelid treatment

Answer 24

• Taping the eyelid to the cheek;

• Injecting the muscles of the eyelid with
botulinum toxin.

• Lubricating eye ointment is often
prescribed in the meantime to protect
the front of the eye

• Severe and ongoing entropion is
referred for surgery to local ophthalmologist. A small operation is performed to turn the eyelid back to its normal position.

Question 25

Peri-orbital cellulitis

Answer 25

Peri-orbital cellulitis • Infection occurring in the eyelid tissues superficial to (anterior to or above) the orbital septum. • In young children, high risk of extension into the orbit

Question 26

Orbital cellulitis

Answer 26

Orbital cellulitis • Infection affecting the muscles and fat within the orbit, posterior or deep to the orbital septum, not involving the globe. • Severe sight and life-threatening emergency

Question 27

Pre disposing factors to peri orbital cellulitis

Answer 27

Preseptal cellulitis • Upper respiratory tract infection • Dacryocystitis • Hordeolum (stye) • Impetigo (skin infection) • Trauma, sharp or blunt, around eye • Recent surgery around eye

Question 28

Predisposing factors to orbital cellulitis

Answer 28

Orbital cellulitis • Acute sinusitis (especially ethmoid sinusitis) • Trauma including orbital fracture • Dacryocystitis • Preseptal cellulitis • Dental abscess

Question 29

Signs and Symptoms of pre septal cellulitis

Answer 29

Preseptal cellulitis - symptoms • Acute onset of swelling, redness and tenderness of lids • Fever • Malaise • Irritability in children Signs • erythema of skin (can extend beyond orbital rim) • lid oedema, warmth, tenderness • ptosis • pyrexia (fever greater than 38°C, normal temperature ranges from 36-37.5°C)

Question 30

Signs and Symptoms of orbital cellulitis

Answer 30

Orbital cellulitis - more widespread infection • Sudden onset of unilateral swelling of conjunctiva and lids that may be painful • Pain on ocular movement • Blurred vision and reduced visual acuity • Diplopia • Fever • Severe malaise Signs • proptosis • restriction of extraocular motility • pain with eye movement • visual acuity may be reduced • pupil reactions may be abnormal (RAPD) • pyrexia

Question 31

Management of pre orbital cellulitis

Answer 31

Preseptal cellulitis • Diagnosis made clinically • CT scan • Children may require admission to hospital for observation • Systemic antibiotics (oral and/or parenteral) according to local guidelines

Question 32

Orbital cellulitis management

Answer 32

Orbital cellulitis • confirmation of diagnosis • CT scan • blood tests, possibly including microbial culture • admission to hospital • systemic antibiotics (intravenous) • drainage of orbital abscess and microbiological culture of fluid • co-management with ENT and paediatric specialist colleagues

Question 33

Diseases of the conjunctiva

Answer 33

Subconjuctival haemorrhage Infective conjunctivitis Allergic conjunctivitis Pterygium Pinguecula

Question 34

Diseases of the eyelids

Answer 34

• Blepharitis of the eyelid (Infective & Seborrheic Blepharitis) • Chalazion (blocked meibomian gland duct) • Stye (small abscess on the eye lid) • Ectropionoftheeyelids. • Entropion of the eyelids. • Periorbital (preseptal) cellulitis of the eyelid.

Question 35

What is the conjunctiva?

Answer 35

The thin, transparent tissue that covers the outer surface of the eye . It begins at the outer edge of the cornea , covering the visible part of the sclera. It is nourished by tiny blood vessels. The conjunctiva also secretes oils and mucous that lubricates the eye.

Question 36

Subconjunctival haemorrhage

Answer 36

• Bleeding into the potential space between conjunctiva and sclera (USUALLY UNILATERAL) • an area of localised, well-demarcated haemorrhage in one eye, in the absence of pain, no reduction of visual acuity, normal pupil reactions, and no corneal staining. • Can be caused violent coughing & sneezing and also vomiting which causes rise in central venous pressure • Usually the condition resolves over few days without any sequelae • Can also be the result of trauma and if so patient should be referred to ophthalmology • If reoccur check for any clotting disorders (Clotting screen & INR for example)

Question 37

Conjunctivitis

Answer 37

• Inflammation of the conjunctiva due to allergic, infection (viral, bacterial or parasitic), mechanical/chemical irritation or neoplasia.

Question 38

Allergic conjunctivitis

Answer 38

• ocular itching (usually bilateral) — if itching is not present an alternative cause should be considered. • Itching may also be described as ‘burning or stinging’. • Other clinical features include: • Watery or mucoid discharge — sometimes referred to as 'tearing'. Discharge may be stringy or ropey due to the presence of a small amount of mucous. • Conjunctival redness . • Conjunctival swelling (chemosis) — bulbar and tarsal conjunctiva may bulge over lid margin or limbus. • Conjunctival papillary reaction. • Eyelid oedema • Allergic conjunctivitis may coexist with other atopic conditions including: • Rhinitis • Asthma • Urticaria • Eczema

Question 39

Allergic conjunctivitis management

Answer 39

• Advise patient: • Avoidance of allergens - washing the hair before going to bed may help reduce allergen exposure. • Avoidance of eye rubbing. • Application of cold compresses to the eyes (for 5–10 minutes once or twice daily) • Application of ocular surface lubricants such as saline solution or artificial tears – caution with contact lenses • Advise the person that after using eye drops or eye ointments, they should not drive or perform other skilled tasks until vision is clear. • If non-pharmacological measures do not provide adequate relief: • Consider prescribing a • Topical antihistamine e.g Emadine • Dual action mast cell stabilizer and topical antihistamine –e.g. Azelastine dual antihistamine and mast cell stabilizing properties

Question 40

Viral conjunctivitis

Answer 40

• The most common cause of viral conjunctivitis is adenovirus (65–90% of cases). • Other viral causes include Herpes simplex, Varicella zoster, Molluscum contagiosum, Epstein-Barr, coxsackie and enteroviruses. • Mild to moderate erythema of conjunctiva, follicles on eyelid eversion and lid oedema. • Petechial subconjunctival haemorrhages. • Less discharge (usually watery) than bacterial conjunctivitis. • Mild to moderate pruritus. • Upper respiratory tract infection and pre-auricular lymphadenopathy.

Question 41

Viral conjunctivitis management

Answer 41

• Most cases are self-limiting— viral (non-herpetic) conjunctivitis usually resolves within one to two weeks without treatment. • Advise the person that symptoms may be eased with self-care measures such as: • Bathing/cleaning the eyelids with cotton wool soaked in sterile saline or boiled and cooled water to remove any discharge. • Cool compresses applied gently around the eye area. • Use of lubricating drops or artificial tears. • Washing hands frequently with soap and water. • Using separate towels and flannels • they may be infectious for up to 14 days from onset. • If the person re-attends with symptoms of conjunctivitis, consider sending swabs for viral PCR (for adenovirus and Herpes simplex virus [HSV]) and bacterial culture and empirical topical antibiotics

Question 42

Bacterial conjunctivitis

Answer 42

• The most common bacterial causes of conjunctivitis are Streptococcus pneumoniae, Staphylococcus aureus and Haemophilus influenzae. • Other bacterial causes include Moraxella catarrhalis, Chlamydia trachomatis, and Neisseria gonorrhoea. •In children, bacterial conjunctivitis is most often caused by Haemophilus influenzae,Streptococcus pneumoniae, and Moraxella catarrhalis. •Purulent or mucopurulent discharge with crusting of the lids which may be stuck together on waking. • If discharge is mucopurulent and copious, infection with Neisseria gonorrhoeae should be considered. • Mild or no pruritus. • Pre-auricular lymphadenopathy — often seen with hyperacute bacterial conjunctivitis (such as Neisseria gonorrhoea).

Question 43

Bacterial conjunctivitis management

Answer 43

Bacterial conjunctivitis is usually self limiting and resolves in 5-7 days. Treat with topical antibiotics if severe or circumstances require rapid resolution. Chloramphenicol drops/ointment

Question 44

Conjunctivitis associated with contact lens wear

Answer 44

Conjunctivitis associated with contact lens wear • If topical fluorescein does not identify any corneal staining and the person does not require referral to ophthalmology: • Advise them to immediately stop contact lens use. • Advise regular bathing/cleaning of the eyelids with cotton wool soaked in sterile saline or boiled and cooled water to remove any discharge. • Advise that contact lenses should be kept out until all symptoms of the infection have gone. If certain there is no corneal damage. • Treat and arrange follow up. • Have a low threshold for referral to ophthalmology if there is any suspicion of corneal involvement as this is a potentially sight-threatening condition.

Question 45

Pterygium

Answer 45

• Pterygium is a fibrovascular triangular growth of the conjunctiva progressing from the bulbar conjunctiva to the cornea (often bilateral) • Mostly seen in elderly male patients (possibly due to occupational exposure) • Prevalence varies between 1.2 % in Caucasians to 23% in afrocarribean patients. • Usually attributed to prolonged exposure to UV light, dust and wind. • HPV has also been recently implicated in the pathogenesis of Pterygium

Question 46

Pterygium symptoms

Answer 46

• Often mild irritation associated with some redness, dryness and foreign body sensation • Starts with scarring and thickening and distortion of the bulbar conjunctiva • Subsequently slow insidious growth onto the cornea surface. • More common from the nasal side of the eye • Overtime may be exacerbated by incidents of acute inflammation.

Question 47

ptergium management

Answer 47

• Advise on UV protection such as using brimmed hat, tinted lenses, (wrap around style for side protection) - can reduce risk of progression and of becoming inflamed and irritated • Use ocular lubricants for symptomatic relief (drops during the day & lubricant ointments at night) • Acute inflammation of ptergium–refer to ophthalmology for use of either non penetrating topical steroid or nsaid eye drops.

Question 48

ptergium complications

Answer 48

• A pterygium can grow over the corneal surface • Because of tissue shrinkage it can put tension on the cornea causing astigmatism (deviation from the normal spherical curvature • This causes a reduction in the sharpness of vision • Patients may also be concerned about the cosmetic appearance of the Pterygium. • Surgery remains the ultimate treatment in more resistant cases (ophthalmology referral)

Question 49

Pinguecula

Answer 49

• A degenerative conjunctival lesion usually situated nasally at the limbus • Presents as a small raised spot , white to yellowish in colour • Usually asymptomatic but may have small foreign body sensation • Seen with increasing age with most patients over 70 years male> female • Usually due to long term exposure to UV radiation

Question 50

Pinguecula vs Pterygium

Answer 50

Pinguecula is easily distinguished from a Pterygium because it does not cross limbus to involve the cornea • Pinguecula doesn’t progress to become Pterygium, they are two distinctive conditions. Pinguecula stays localised and doesn’t affect vision

Question 51

Pinguecula - Management

Answer 51

• Reassure the patient about the benign nature of the lesion • Advise UV protection to minimise inflammation risk • This includes wearing a brimmed hat,sunglasses in wrap- around style for side protection. • Ocularlubricants usually used for symptomatic relief–eye drops daytime and ointments at night • When inflamed responds to brief course of topical steroid or NSAID eye drops • Ophthalmology referral for excision is rarely required