Ophtalmology General Flashcards
Ophthalmology for the Undergraduate Medical Student in South Africa (Bachelors of Medicine and Bachelors of Surgery). (238 cards)
1
Q
Causes of Exposure Keratopathy
A
Anaesthesia Unconsciousness Exophthalmos Bell's Palsy with lagophthalmos Severe ectropion
2
Q
Parts of the Lens
A
Capsule
Cortex
Nucleus
3
Q
Causes of Cataracts
A
Age Metabolic disease (especially DM) Drugs (especially steroids) Trauma Uveitis Infections of the Foetus (CMV, Rubella, Toxoplasmosis) Smoking
4
Q
Symptoms: Cataracts
A
Gradual painless LOV
Monocular diplopia
Vision varies with illumination
New myopia
5
Q
Complications of Cataracts
A
Phagolytic Glaucoma
Phagoanaphylactic Uveitis
6
Q
Indications for Cataract Surgery
A
Functional impairment
Need to see fundus
Complications
7
Q
Contraindications to Cataract Surgery
A
Patient refusal
Supportive management is adequate
Surgery will not improve the vision
8
Q
Causes of Ectopia Lentis
A
Trauma
Collagen disease e.g. Marfan’s Disease
9
Q
Complications of Ectopia Lentis
A
Pupil Block
Acute Angle Closure Glaucoma
10
Q
Functions of Aqueous Humour
A
Nutrition of surrounding structures
Transport of waste from surrounding structures
Thermoregulation of surrounding structures
Optical medium for light conduction
Maintenance of IOP
11
Q
Symptoms: Acute Angle Closure Glaucoma
A
Acute deep-seated unilateral ocular pain radiating to hemicranium Nausea & vomiting Red eye Dramatic reduction in VA Coloured halos around lights Reflex tearing Photophobia
12
Q
Signs: Acute Angle Closure Glaucoma
A
Reduced VA Fixed middilated pupil Ciliary injection Corneal haze Positive eclipse test Fundus not seen Raised IOP, hard on palpation
13
Q
Emergency Treatment: Acute Angle Closure Glaucoma
A
Carbonic Anhydrase Inhibitor (Acetazolamide) Glycerol Topical Beta-Blocker Pilocarpine Systemic analgesia Anti-emetics Urgent ophthalmological referral
14
Q
Causes: Secondary Acute Angle Closure Glaucoma
A
Posterior Synechiae in anterior uveitis
Lens swelling in advanced cataracts
Lens displacement
Drugs: miotics and mydriatics
15
Q
Signs: Primary Open Angle Glaucoma
A
Visual acuity normal until terminal Loss of visual fields Neuroretinal rim pallor Increased cup/disk ratio Nasal displacement of vessels Nerve fibre layer haemorrhage Increased IOP
16
Q
Medical Treatment: Primary Open Angle Glaucoma
A
Topical Beta-blockers
Topical Prostaglandin Analogues
Topical Adrenaline preparations
Topical Pilocarpine
17
Q
Causes: Secondary Open Angle Glaucoma
A
Clogging of trabeculum
Trabeculitis
Trabecular scarring
Drugs: steroids
18
Q
Symptoms: Congenital Glaucoma
A
Tearing
Photophobia
Blepharospasm
19
Q
Signs: Congenital Glaucoma
A
Megalocornea/Enlarged Globe
Corneal haze
Enlarged optic cup
Small/moderate IOP
20
Q
Non-Infective Causes of Uveitis
A
Trauma Sarcoidosis Ankylosing Spondylitis Juvenile Chronic Arthritis Reiter's Syndrome Behcet's Syndrome Sympathetic Ophthalmia Infection elsewhere
21
Q
Infective Causes of Uveitis
A
Toxoplasma Tuberculosis Syphilis HSV HZV CMV Meningococcus Candida
22
Q
Symptoms: Anterior Uveitis
A
Dull vision Redness Tearing Deep seated eye pain Photophobia
23
Q
Signs: Anterior Uveitis
A
Decreased VA Cilliary injection Anterior chamber flare Keratic precipitates Hypopion Miosis Positive iritis test Discomfort not relieved by local anaesthetic Dull view of fundus
24
Q
Symptoms: Posterior Uveitis
A
LOV
25
Signs: Posterior Uveitis
Vitreous haze: flare and cells
| Inflammatory foci: cotton wool appearance, retinal vasculitis
26
Complications: Anterior Uveitis
```
Posterior Synechiae
Irregular fixed pupil
Secondary acute angle closure
Blockage of trabeculum by cells/debris
Trabeculitis --> Trabecualr sclerosis
Cataract
```
27
Complications: Posterior Uveitis
```
Choroidoretinal scar formation
Permanent loss of visual acuity
Exudative retinal detachment
Rhegmatogenous retinal detachment
Papillitis
Optic atrophy
```
28
Characteristics of Uveal Naevus
```
Small size (<3 disk diameters)
Does not grow after puberty
Does not distort surrounding structures
Flat
Asymptomatic
```
29
Characteristics of Uveal Melanoma
```
Large
Expands
Elevated
Distorts surrounding structures
Cause loss of vision
```
30
Difference between superficial and deep retinal haemorrhage
SUPERFICIAL: tracks along fibres of nerve fibre layer, therefore flame-shaped or striated appearance.
DEEP: tracks along deeper fibres, therefore a dot&blot appearance.
31
Define: Retinal Microaneurysms
small, perfectly round, red spots on retina with diameter smaller than that of the large vein at the disk margin
32
Difference: Hard Exudates vs Cotton Wool Spots
HARD EXUDATES:
1. Yellowish-white spots with well-circumscribed margins
2. Represent intraretinal lipid deposition
COTTON WOOL SPOTS
1. White spots, poorly circumscribed, striated/fluffy margins
2. Represent severe nerve fibre layer ischaemia or infarction
33
Hypertensive Retinal Changes
1. Diffuse narrowing in visible arteriolar blood columns (generalised vasoconstriction)
2. Areas of focal narrowing (indicates diastolic >110mmHg)
3. Arteriolar obstruction + vessel wall necrosis = nerve fibre layer haemorrhages, hard exudates, cotton wool spots
4. Optic disk swelling (indicates diastolic 130-140mmHg)
34
Arteriosclerotic Retinal Changes
1. Diffuse narrowing of arteriolar blood columns (hypertrophy and fibrosis)
2. Copper wiring/Silver wiring
3. AV nipping (venule tapers to disappear behind arteriole)
4. Venule direction change at crossing
35
Pathology of Diabetic Retinopathy
1. Capillary outpouching = microenurysms
| 2. Capillary occlusion = leakage, haemorrhage, ischaemia
36
Complications of Neovascularisation
1. Neovascular glaucoma
2. Massive intraretinal exudation
3. Vitreous heamorrhage
4. Tractional retinal detachment
37
Classify Extramacular Retinopathy
A: BACKGROUND
Microaneurysms
Hard exudates
Haemorrhages (mainly deep)
```
B: PRE-PROLIFERATIVE
Venous kinking/beading/looping
Cotton wool spots
Extensive deep haemorrhages
Vascular occlusions
```
C. PROLIFERATIVE
Neovascularisation
38
Classify Maculopathy
A. BACKGROUND
Microaneurysms
Haemorrhages (mainly deep)
B. EXUDATIVE
Oedema
Hard exudates
C. ISCHAEMIC
Angiographic
39
Treatment: Diabetic Retinopathy
1. Glucose control
2. Early ophthalmology referral
3. Argon laser photocoagulation
40
Signs: Central Retinal Arterial Occlusion
```
Reduced VA (to hand movements or no PL)
Visual field loss
RAPD
Mild optic disk swelling
Milky white retina
Cherry red spot (of macula)
Narrowed arterioles and venules
Embolism may be visible in artery
```
41
Management of Central Retinal Arterial Occlusion
1. Digital globe massage
2. Inhalation of 95% Oxygen + 5% CO2
3. Systemic vasodilators (isosorbide dinitrite)
4. Acetazolamide
5. Ophthalmology referral
42
Ophthalmological interventions in central retinal arterial occlusion
Retrobulbar vasodilator injection
| Paracentesis to remove aqueous humour
43
Treatable causes of central retinal arterial occlusion
carotid arteriosclerosis
polycythaemia
systemic hypertension
diabetes mellitus
44
Associations of central retinal venous occlusion
Hypertension
Arteriosclerosis
Diabetes Mellitus
Glaucoma
45
Signs: Central Retinal Venous Occlusion
1. LOV variable
2. Afferent pupil defect
3. Dilated/tortuous venules
4. Optic disk swelling
5. Nerve fibre layer retinal haemorrhages
6. Cotton wool spots
7. Hard exudates
46
Which form of retinal occlusion has neovascularisation as complication?
Central Retinal Vein Occlusion
47
Risk Factors: Retinopathy of Prematurity
1. Birth weight <30 weeks
| 4. High saturation oxygen therapy
48
Classification: Age-Related Macular Degeneration
A. Atrophic type / dry / avascular degeneration
| B. Exudative type / wet / subretinal neovascularisation
49
Symptoms: ARMD
1. Painless LOV
2. Metamorphosia
3. Central/Paracentral scotoma
50
Specific Therapies: Wet Type ARMD
Laser photocoagulation
Photodynamic therapy
Intravitreal injection of anti-VEGF agents
51
Initial Presentation of Retinoblastoma
1. Leukocoria (67%)
2. Strabismus (20%)
3. Proptosis
4. Uveitis
5. Hyphema
6. Glaucoma
52
Treatment of Retinoblastoma
```
Enucleation
Radiotherapy
Photocoagulation
Cryotherapy
Chemotherapy
```
53
Classify: Retinal Detachment
Serous/Exudative
Traction
Rhegmatogenous
54
Principles of Retinal Detachment Surgery
Reapply edges of the break to the RPE
Relieve vitreous traction
Drain subretinal fluid
55
Causes: Optic Disk Swelling
1. Congenital anomalies e.g. Hamartoma
2. Passive swelling e.g. raised ICP, optic nerve compression, systemic hypertension
3. Inflammatory e.g. papillitis
4. Vascular e.g. AION, CRVO)
5. Infiltration e.g. neoplasia
56
Causes: Optic Neuritis
Autoimmune e.g. demyelinating disease
Systemic infections e.g. EBV, CMV, measles, syphilis, TB
Idiopathic systemic inflammations e.g. sarcoidosis
Adjacent inflammation e.g. choroidoretinitis, orbital cellulitis
57
Signs: Optic Neuritis
1. Reduced VA
2. Central scotoma
3. Sluggish pupillary reaction to light
4. RAPD
5. Disc swelling
6.
58
Complications: Optic Neuritis
Secondary optic atrophy
| Permanent LOV
59
Causes: Optic Neuritis with Normal VA
Idiopathic
Congenital abnormalities
Increased ICP
Systemic hypertension
60
Causes: Optic Neuritis with Reduced VA
Vascular events
Inflammation
Infiltration
Compression
61
Commonest causes of optic neuritis in adults and children
ADULTS: Multiple Sclerosis
CHILDREN: Viral
62
Define Anterior Ischaemic Optic Neurophathy (AION)
Partial or complete infarction of the optic disk due to posterior ciliary arterial occlusion
63
Signs: AION
```
Severe LOV
Reduced VF
Sluggish pupillary reaction to light
RAPD
Pale swollen disk
```
64
Causes: AION
Giant cell arteritis
| Artesclerosis
65
Causes: Optic Atrophy
```
Congenital
Traumatic
Inflammatory
Compression
Vascular
Metabolic
```
66
Inflammatory causes of optic atrophy
Optic neuritis
| Widespread retinitis
67
Compression causes of optic atrophy
Tumours
Aneurysm
Chronic disc swelling
68
Vascular causes of optic atrophy
```
CRAO
AION
Glaucoma
Diabetes Mellitus
Arteriosclerosis
```
69
Metabolic causes of optic atrophy
Methanol poisoning
| Nutritional amblyopia
70
DDX: Rapid painful onset of proptosis in child
orbital cellulitis
| rhabdomyosarcoma
71
DDX: Rapid painful onset of proptosis in adult
orbital cellulities
| pseudotumour
72
Important history in new onset proptosis
Malignancies
Thyroid dysfunction
Orbital trauma
Sinusitis
73
Causes: Pseudoproptosis
Eye enlargement (buphthalmos)
Contralateral enophthalmos
Eyelid retraction
Shallow orbit
74
DDX: Proptosis + Increased resistance to ocular retropropulsion
Solid tumour
| Thyroid eye disease
75
DDX: Restricted Eye Movements
Restrictive myopathy e.g. ocular ophthalmopathy
Splinting of optic nerve e.g. meningioma
Neurological lesion
Blow out fracture with muscle entrapment
76
DDX: Proptosis worsened by vascular engorgement
1. Orbital varices
| 2. Capillary haemangioma
77
Characteristics: Preseptal Cellulitis
```
Secondary to trauma/local skin infection
Periorbital swelling and tenderness
Infection does not penetrate orbital septum
No proptosis
No impairment of eye movement
Tx: Oral antibiotics
```
78
Characteristics: Orbital Cellulitis
```
Dangerous: arises in paranasal sinuses
Orbital pain
Diplopia
Eyelid oedema
Generalised redness of eye
Conjunctival chemosis
Proptosis
Limited eye movements
```
79
Complications: Orbital Cellulitis
Blindness
Meningitis
Brain Abscess
Cavernous Sinus Thrombosis
80
Define orbital varices
Vascular hamartoma consisting of plexus of thin walled veins with connections to normal orbital circulation
81
Characteristics: Orbital varices
```
Intermittent non-pulsatile proptosis
Pain
Orbital haemorrhage
No bruit
Precipitated by vascular engorgement
```
82
Characteristics: Caroticocavernous Fistula
```
Reduced VA
Generalised redness (severe)
Conjunctival chemosis
Pulsatile proptosis
Audible bruit
Ophthalmoplegia
```
83
Vascular Tumours of the Orbit
Capillary Haemangioma
Cavernous Haemangioma
Lymphangioma
84
Orbital Tumour Classification
1. Lymphoproliferative tumours (e.g. Inflammatory Pseudotumour)
2. Vascular tumours
3. Lacrimal gland tumours
4. Rhabdomyosarcoma
5. Cystic tumours
6. Neural tumours
7. Metastatic tumours
85
Lacrimal Tumours
Pleomorphic Adenoma
| Adenocarcinoma
86
Cystic Tumours of the Orbit
Dermoid cyst
Mucocele
Hydatid cyst
87
Neural Tumours of the Orbit
Optic Nerve Glioma
| Optic Nerve Sheath Meningioma
88
Decisions in suspected strabismus
1. Is strabismus present?
2. Is strabismus concommitant or incomitant?
3. Is there a danger of amblyopia?
4. What should be done?
89
Definition: Strabismus
Misalignment of visual axes
90
```
Define:
Esotropia
Exotropia
Hypertropia
Hypotropia
```
1. Deviant eye inwards
2. Deviant eye outwards
3. Deviant eye upwards
4. Deviant eye downwards
91
Consequences: Strabismus
Amplyopia
Suppression
Diplopia
92
Define Amblyopia
Subnormal vision due to abnormal visual experience;
| sensory adaptation mechanism to prevent diplopia
93
Types of Amblyopia
1. Strabismic Amblyopia
2. Deprivation Amblyopia
3. Refractive Amblyopia
94
Concomitant vs Incomitant Strabismus
Concomitant strabismus has no impairment of eye movement;
| Angle of deviation is the same in all test positions.
95
Causes: Incomitant Strabismus
1. Neurological - CN III, IV, VI
2. Myoneural junction - MG
3. Muscular - thyroid
4. Mechanical - blow-out, orbital mass
96
Characteristics: Incomitant Strabismus
Angle of deviation varies with direction of gaze
Angle of deviation maximal in test position of affected muscle
Strabismus not present in all gaze directions
Ocular torticollis
97
Muscles innervated by CNIII/Oculomotor Nerve
```
Medial Rectus
Inferior Rectus
Superior rectus
Inferior Oblique
Levator Palpebrae Superioris
Sphincter Pupillae
Cilliary muscle
```
98
Tests for Strabismus
Corneal light reflex
| Cover test
99
Neurons of Light Reflex Pathway
1. Afferent neurons from retinal ganglion cells
2. Intercalated neurons from pretectal nucleus synapse
3. Edinger-Westphal parasympathetic outflow in CNIII
4. Cilliary ganglion efferent fibres to iris/cilliary muscles
100
Triad of the Near Reflex
1. Accommodation
2. Convergence
3. Miosis
101
Causes: Light-Near Dissociation
Prechiasmal visual pathway lesion (RAPD, Marcus Gunn Pupil)
Dorsal midbrain syndrome (region of pretectal nucleus)
Adie's pupil (lesion of cilliary ganglion)
Argyl-Robertson pupil (bilateral small pupils, NB in neurosyphilis)
102
Characteristics: Horner's Syndrome
1. Partial ptosis of upper lid
2. Miosis
3. Anhydrosis
4. Anisochromia
All on one side of the face
103
Occulomotor Nerve (CNIII) supplies...
```
Medial Rectus
Superior Rectus
Inferior Rectus
Inferior Oblique
Parasympathetic fibres to intraocular muscles
```
104
CNIII paralysis causes:
1. Horizontal and vertical diplopia
2. Inability to elevate, depress and adduct
3. Ptosis
4. Dilate, non-reactive pupil
105
Lesions causing CNIII paralysis
Intracranial aneurysms
Head injuries
Brain tumours
106
Characteristics: CNIV (Trochlear Nerve) paralysis
Vertical and/or oblique diplopia
Diplopia worse on adduction
Head tilted to opposite shoulder
107
Causes: CNIV Paralysis
1. Congenital
2. Closed head injury
3. Vascular disease
4. Space occupying lesion
5. Aneurysm
108
CNVI (Abducens Nerve) Palsy Characteristics
Horizontal diplopia
| Diplopia worse on looking in affected eye's direction
109
Causes: CNVI Palsy
```
Intracranial tumours
Head injuries
Vascular disease
Raised ICP
Aneurysm
```
110
Myasthenia Gravis test:
Edrophonium Chloride (Tensilon) test
111
Define Nystagmus
Rhythmic involuntary to and fro movements of eyes
112
Nystagmus Classifications
1. Type
2. Speed
3. Direction
113
Nystagmus Types
A. Jerk Nystagmus
| B. Pendular Nystagmus
114
Nystagmus Directions
Horizontal
Vertical
Rotary
115
Phsyiological Nystagmus Types
Endpoint
| Caloric
116
Visual System Manifestation of Grave's Disease
1. Eyelid swelling
2. Eyelid retraction
3. Lid lag
4. Conjunctival chemosis/erythema
5. Proptosis = Exophthalmos
6. Limited eye movements (may cause diplopia)
7. Exposure keratopathy
8. Optic neuropathy
117
Ocular Manifestations of Diabetes Mellitus
1. Increased ocular infections
2. Sudden refractive changes
3. Cataracts
4. Increased incidence of anterior uveitis
5. Diabetic Retinopathy
6. Neovascular glaucoma
7. Extraocular muscle paralysis
118
Define Amaurosis Fugax
sudden LOV in one eye which recovers spontaneously within a few minutes
119
Ocular Manifestations of Rheumatoid Arthritis
1. Keratoconjunctivitis Sicca
2. Increased incidence of corneal infections
3. Peripheral corneal thinning
4. Scleritis
120
Ocular Manifestations of Juvenile Chronic Arthritis
1. Chronic Anterior Uveitis
2. Posterior Synechiae
3. Dense cataracts
4. Glaucoma
121
Visual Manifestations of SLE
```
OCULAR
Dry eyes
Peripheral corneal thinning
Anterior uveitis
Retinopathy
```
CNS
Homonymous hemianopia
Optic atrophy
CN III and VI paresis
122
Reiter's Syndrome Triad
1. Conjunctivitis
2. Urethritis
3. Arthritis
+/- Uveitis, Keratitis
123
Behcet's Syndrome Triad
1. Oral/Genital ulcers
2. Arthritis
3. Anterior uveitis
124
AIDS retinal vascular involvement
Cotton wool spots
Microaneurysms
Retinal haemorrhages
125
AIDS opportunistic infections in the eye
HZV Ophthalmicus
CMV
Toxoplasma retinochoroiditis
Cryptococcus Neoformans retinochoroiditis
126
AIDS tumours in the eye
Kaposi's Sarcoma
SCC of the eyelids
Burkitt's lymphoma of the orbit
127
Define: Phacomatoses
Disease in which neurological abnormalities are associated with congenital defects of the skin, eyes, etc.
128
Sturge Weber Syndrome: Optical and Other Manifestations
OPTICAL
Conjunctival haemangioma
Choroidal haemangioma
Open angle glaucoma
OTHER
Facial haemangioma (port wine stain)
Meningeal haemangioma
129
Neurofibrimatosis: Optical and Other Manifestations
```
OPTICAL:
Eyelid neuroma
Iris nodules (Lisch nodules)
Open Angle Glaucoma
Choroidal naevus
Optic nerve glioma
```
OTHER:
Skin neurofibromas
CNS tumours
Endocrine tumours
130
Appearance of Blunt Lid Trauma
Abrasions
| Periorbital Haematoma
131
Treatment of Blunt Lid Trauma
Clean abrasions
Remove foreign bodies
Topical broad spectrum antiseptic - do not get in eye!
Systemic analgesics/anti-inflammatories
132
Different Classes of Lid Lacerations
A. not involving eyelid margin
B. involving lacrimal canaliculi and medial canthal ligament
C. involving eyelid margin
133
Treatment: Ocular Foreign Body
1. Local anaesthetic drops
2. Remove with wet cotton bud or blunt metal spatula
3. Remove rust ring with corneal millar if present
4. Prophylactic topical antibiotic drops
5. Eye covered
6. Examine wound/abrasion daily until disappearance
7. Do not give local anaesthetic TTO
8. Systemic analgesics
134
Management: Penetrating Eye Injury
1. X-rays or CT of orbit and sinuses
2. Refer to ophthalmological unit
3. Protect eye with rigid eye shield during transfer
4. Avoid ointments
5. Antibiotic drops
6. Remove iron/copper containing intraocular foreign bodies ASAP
7. Remove blinded eye within 14 days to prevent sympathetic ophthalmia
135
Complications of Blunt Eye Trauma
Subconjunctival haemorrhage
| Corneal oedema
136
Classify: Ocular Burns
1. Chemical: Acid
2. Chemical: Alkali
3. Thermal
4. Ultraviolet
137
Management: Chemical Ocular Burns
1. Immediate irrigation, sterile n. saline if possible, start at scene of accident!
2. Do not neutralise acid with weak alkali or vice versa
3. Eyelid speculum and topical anaesthetic to stop blepharospasm
4. Wipe foreign material from eye/fornices
5. Test pH periodically (aim for 7)
6. Systemic analgesics
7. Topical cycloplegics
8. Refer to ophthalmologist
138
Complications: Chemical Ocular Burns
```
Glaucoma
Corneal Scarring
Symblepharon
Entropion
Dry eyes
```
139
Management: Thermal Ocular Burns
1. Do not irrigate!
2. Topical antibiotics
3. Cycloplegic drops
4. Systemic analgesics
5. Ophthalmology referral
140
Management: UV Ocular Burns
1. Pad eye
2. Topical cycloplegics
3. Prophylactic antibiotics
4. Systemic analgesics
141
Early Complications: Hyphaema
Raised IOP
Haematocornia
Secondary haemorrhage
142
Treatment: Hyphaema
1. If >5%, admit to hospital for 5 days bed rest
2. Measure IOP, size of hyphaema and corneal condition daily
3. 1% Atropine
4. Topical steroids
5. Oral Cyclokapron
6. Treat raised IOP if presents
7. Assess anterior chamber angle and retina once stable
8. Patient education
143
Intraocular Complications: Blunt Trauma
```
Hyphaema
Motility abnormalities
Traumatic uveitis
Traumatic glaucoma
Traumatic mydriasis
Lens dislocation/subluxation
Cataract formation
Vitreous haemorrhage
Intraretinal/subretinal haemorrhage
Retinal oedema
Retinal holes
Retinal detachment
Choroidal rupture
Contustion of optic nerve
```
144
Signs: Orbital Fracture
```
Diplopia
Limited eye movement
Proptosis/enophthalmos
Periorbital crepitus
Decreased sensation in cheek and tip of nose
```
145
Clinical presentation: Caroticocavernous fistula
```
Loud bruit in head
Visible pulsating exophthalmos
Conjunctival vessels congested
Conjunctiva chemotic/haemorrhagic
Changes in ocular motility
```
146
Categories of eye-related complaints
1. Visual disturbance
2. Ocular or peri-ocular discomfort
3. Discharge
4. Abnormal appearance
147
Questions to ask every eye-patient
1. Is there any visual disturbance
2. Is there any ocular or peri-ocular discomfort
3. Is there any photophobia
4. Is there any discharge from the eye
5. Do the eyelids stick together when waking up in the mornings
148
DDX: Painful Red Eye
1. Conjunctivitis
2. Keratitis
3. Anterior Uveitis
4. Acute Angle Closure Glaucoma
149
Three NB Questions in a Painful Red Eye
1. Is there visual loss?
2. What is the pattern of redness?
3. Could it be acute angle closure glaucoma?
150
DDX: Visual Loss in a Comfortable White Eye
```
MEDIA:
Contact lens loss
Lens dislocation
Lens swelling
Vitreous heamorrhage
RETINA/CHOROID:
Retinal detachment
Wet ARMD
Acute choroidoretinitis
Retinal vascular occlusion
VISUAL PATHWAYS:
AION
Acute optic neuritis
TIA/RIND/CVA
```
151
DDX: Gradual Visual Loss
```
MEDIA:
Change in refractory error
Presbyopia
Cataract
Chronic Choroidoretinitis
RETINA/CHOROID:
Dry ARMD
RP
Choroidal melanoma
VISUAL PATHWAYS:
Space occupying lesion
```
152
Ocular Emergencies: Painful red eyes
Acute angle closure glaucoma
Open eye injuries
Chemical burns
Corneal abscess
153
Ocular Emergencies: Comfortable White Eyes
CRAO
AION
Acute retinal tear with vitreous haemorrhage
Retinal detachment which threatens to involve the macula
154
In order to produce a clear image the eye must have...
1. Constant dimensions
2. Clear optical pathway
3. Ability to focus light on the retina
155
3 Layers of the Eye
1. Outer fibrous layer (sclera, cornea)
2. Middle vasculo-muscular layer (uveal tract)
3. Inner neural layer (retina)
156
3 Internal Zones of the Eye
1. Aqueous
2. Lens
3. Vitreous
157
Six structures of the visual system
1. Eye
2. Ocular adnexa
3. Orbit
4. Visual pathways
5. Cranial nerves
6. Sympathetic and parasympathetic supply
158
7 Features of the Visual System
1. High resolution (photoreceptor density, macula)
2. Wide field (binocularity)
3. Ocular movement (binocular single vision)
4. Stereopsis (depth perception from binocular single vision and higher centres)
5. Colour representations
6. Integration
7. Interpretation
159
Components: Anterior Segment
```
Cornea
Anterior chamber
Posterior chamber
Iris
Ciliary body
Lens
Zonules
```
160
Components: Posterior segment
```
Sclera
Choroid
Retina
Optic disk
Vitreous humour
```
161
Layers of the Cornea
1. Epithelium
2. Bowman's Membrane
3. Stroma
4. Descemet's Membrane
5. Endothelium
* note: new research indicates Dua's Layer between 3&4
162
Nerve supply to the cornea
Ophthalmic division of the Trigeminal Nerve (CN V)
163
Function of Cornea
1. Transparency for vision
| 2. Optical refraction
164
Two refractive components of the eye
Cornea
| Lense
165
Refractive power of cornea
45 dioptres
166
Factors causing corneal transparency
1. Avascularity
2. Relative acellularity and uniform structure
3. Relative dehydration
167
Conjunctiva is continuous with:
Skin at lid margin
| Corneal epithelium at the limbus
168
Sclera is continuous with:
Cornea at the limbus anteriorly
| Dural sheath of optic nerve posteriorly
169
Intra-ocular pressure is maintained at steady level through which mechanisms?
A. Constant secretion of aqueous humour into posterior chamber by ciliary body
B. Constant drainage of aqueous humour by trabecular meshwork in anterior chamber angle
170
Accommodation is mediated by which pathway?
Parasympathetic
171
Parts of the Ciliary Body
1. Pars Plicata - secretes aqueous, anterior part)
2. Pars Plana - posterior part, provides safe access to interior of eye
3. Ora Serrata - juntion between retina and ciliary body)
172
Retinal Structures visible with direct ophthalmoscope
Optic nerve head and cup
Central retinal artery and nasal/temporal branches
Central retinal vein and nasal/temporal branches
Neural retina
Macula lutea with foveolar light reflex
173
Explain: Arterial Supply to the Eye
A. Ophthalmic artery is the first branch of the intracranial portion of the internal carotid artery
B. Opthalmic artery branches into the central retinal artery, long posterior ciliary artery and short posterior ciliary artery
174
Explain: Venous Drainage of the Eye
A. Vortex veins, anterior ciliary veins and central retinal vein
B. Drain into superior and inferior ophthalmic veins
C. Communicate with cavernous sinus
175
Differentiate External Hordeolum, Internal Hordeolum, Chalazion
External: staph abscess of eyelash follicle
Internal: staph abscess of meibomian gland
Chalazion: obstruction of meibomian gland duct
176
Treatment: Internal Hordeolum
1. remove affected eyelash
2. local antibiotic cream
3. warm compress
177
Treatment: External Hordeolum
1. local antibiotic cream
2. systemic antibiotic if cellulitis severe
3. drainage when head forms
178
Treatment: Chalazion in absence of spontaneous resolution
1. incision and curettage
2. antibiotic cream
3. cover eye for day
4. systemic pain relief
179
Aetiology: Chronic Blepharitis
1. staph infection of eyelid follicles
| 2. abnormal secretions of eyelashes/meibomian glands
180
Associations: Chronic blepharitis
seborrhoeic dermatitis
acne rosacea
atopic eczema
dry eyes
181
Complications: Chronic Blepharitis
recurrent conjunctivitis
internal hordeolum
external hordeolum
chalazion
182
Treatment: Chronic Blepharitis
1. eyelid hygiene
2. antibiotics
3. warm compresses
4. manual expression of thickened secretions
5. treat seborrhoeic dermatitis of scalp
183
Medication options in chronic blepharitis
1. fucidic acid cream
2. antibiotic ointments
3. steroid drops
4. tetracyclines
184
Reasons to treat molluscum contagiosum
1. speedy recovery
2. reduce transmission
3. prevent corneal complications
185
Complication of molluscum contagiosum
toxic secondary keratoconjunctivitis
186
causes of entropion/ectropion
1. involutional changes of ageing
| 2. scarring
187
treatment of entropion/ectropion
surgery
188
Causes: Ptosis
1. NEUROGENIC
- CNIII paralysis
- Horner's
2. INVOLUTIONAL
3. MECHANICAL
- oedema
- tumours
4. MYOGENIC
- congenital dystrophy
- myasthenia gravis
189
Malignancies of eyelids in order of incidence
1. Basal cell carcinoma
2. Squamous cell carcinoma
3. Tarsal gland carcinoma
4. Kaposi's sarcoma
190
Name the layers of tear film and what secretes them
OUTER LIPID LAYER - tarsal/meibomian glands
MIDDLE AQUEOUS LAYER - lacrimal gland
INNER MUCIN LAYER - goblet cells of conjunctiva
191
REQUIREMENTS FOR STABLE TEAR FILM
1. constant renewal/blinking
2. intact separate layers
3. smooth surface
4. good eyelid apposition
192
CAUSES: KERATOCONJUNCTIVITIS SICCA (a.k.a. aqueous layer deficiency)
1. IDIOPATHIC - e.g. postmenopausal women
2. INJURIES TO LACRIMAL GLAND
- infection
- surgery
- autoimmune
3. OCCLUSION OF GLAND DUCT BY SCARRING
- chemical burns
- trachoma
- Stevens-Johnson Syndrome
193
CAUSES: LIPID/MUCIN LAYER DEFICIENCIES
1. Blepharitis (lipids)
2. Cicatrial conjunctival disease
- chemical burns
- trachoma
- SJS
3. Xerophthalmia
194
SIGNS SEEN ONLY IN LATE STAGES OF TEAR ABNORMALITIES:
1. corneal vascularisation
2. corneal opacification
3. corneal keratinisation
195
EYELID ABNORMALITIES CAUSING EXPOSURE KERATITIS
1. Abnormal eyelid contour
- trauma
- tumour
- trachoma
2. Abnormal eyelid movement
- lagophthalmos
- symblepharon
196
DEFINE SYMBLEPHARON
adhesion of palpebral and bulbar conjuntiva caused by trachoma, chemical burns or SJS.
197
TREATMENT: TEAR ABNORMALITIES
1. avoid triggers
2. artificial tears
3. gels
4. ointments
198
Treatment: Acute Dacryocystitis
1. local + systemic antibiotics
2. drainage if abscess points
3. dacryocystorhinostomy after resolution
199
QUESTIONS TO ASK IN CONJUNCTIVITIS
1. type of discharge
2. appearance of conjunctiva
3. lymphadenopathy
200
TYPES OF DISCHARGE AND WHAT CONJUNCTIVITES CAUSE THEM
```
WATERY
- viral
- allergic
MUCOID
- vernal
- keratoconjuncitivitis sicca
PURULENT
-bacterial
```
201
CAUSES: FOLLICULAR CONJUNCTIVITIS
1. viral
| 2. chlamydia
202
CAUSES: SUBCONJUNCTIVAL HAEMORRHAGE
```
spontaneous
valsalva
trauma
conjunctivitis
systemic vasculitis
coaggulation defects
```
203
TYPES OF BACTERIAL CONJUNCTIVITIS
acute bacterial conjunctivitis
gonococcal conjunctivitis
chlamydial conjunctivitis
secondary blepharoconjuncitivitis
204
ORGANISMS: ACUTE BACTERIAL CONJUNCITIVITIS
staph aureus
staph epidermidis
haemophilus
streptococcus
205
SYMPTOMS: ACUTE BACTERIAL CONJUNCTIVITIS
redness
scratching
purulent discharge
eyelids stick together in the mornings
206
SIGNS: ACUTE BACTERIAL CONJUNCTIVITIS
generalised conjunctival injection
| purulent discharge
207
SIGNS: GONOCOCCAL CONJUNTIVITIS
```
conjunctival hyperaemia + chemosis
eyelid oedema
copious purulent discharge
membranes/pseudomembranes
preauricular lymphadenopathy
corneal ulceration/perforation
```
208
TREATMENT: GONOCOCCAL CONJUNCTIVITIS
3rd gen cephalosporin e.g. ceftriaxone
| local and systemic
209
CHLAMYDIAL CONJUNCTIVITIS TYPES
A. inclusion conjuntivitis (venereal)
| B. trachoma (poor hygiene)
210
TREATMENT: CHLAMYDIAL CONJUNCTIVITIS
```
A. TOPICAL
- tetracycline
- erythromycin
B. SYSTEMIC
- tetracycline
- erythromycin
- doxycycline
- azithromycin (stat dose, preferred by many)
```
211
FEATURES OF TRACHOMA
```
ACUTE
- folicular conjunctivitis
- keratitis on superior cornea
CHRONIC
- white lines on palpebral conjunctiva
- pannus on superior cornea
LONG TERM
- conjuntival scarring
- entropion
- trichiasis
```
212
VIRAL CONJUNCTIVITIS TYPES
1. Adenoviral
2. Acute haemorrhagic
3. Herpes simplex keratoconjunctivitis
4. Molluscum contagiosum keratoconjunctivitis
213
CLINICAL FEATURES: ADENOVIRAL CONJUNCTIVITIS
```
redness
tearing
scratching
follicles
preauricular lymphadenopathy
photophobia
chemosis
subconjuntival haemorrhage
pseudomembranes
punctate superficial corneal stromal infiltrates
```
214
TREATMENT: ADENOVIRAL CONJUNCTIVITIS
NON-SPECIFIC
1. prophylactic antibiotic drops
2. vasoconstrictor drops
3. steroid drops if infiltrates
215
CLINICAL FEATURES: HAEMORRHAGIC CONJUNCTIVITIS
as with acute viral (scratching, tearing, etc)
bilateral
severe redness, severe subconj haemorrhages
marked tearing
eyelid oedema
palpebral follicles
216
ALLERGIC CONJUNCTIVITIS CLASSIFICATION
1. hayfever conjunctivitis
2. acute allergic blepharoconjuntivitis
3. vernal conjunctivitis
4. GPC
5. SJS
217
TYPES OF VERNAL CONJUNCTIVITIS
a. palpebral
| b. limbal
218
TREATMENT: VERNAL CONJUNCTIVITIS
1. antihistamine drop with vasoconstrictor
2. sodium chromoglycate
3. avoid steroids despite efficacy!
219
TREATMENT: GIANT PAPILLARY CONJUNCTIVITIS
1. no contact lens wear for 3/12
2. topical mast cell stabilisers
3. topical steroids
4. discard solution with preservatives
220
OCULAR COMPLICATIONS: STEVENS-JOHNSON SYNDROME
1. conjunctival destruction with symblepharon formation
2. destruction of goblet cells
3. destruction of duct of lacrimal gland
4. conjunctival scarring
5. entropion
6. trichiasis
7. corneal ulceration/vascularisation/perforation
221
TREATMENT: OCULAR SJS
topical steroids
cyclosporin
ophthalmology referral
222
NEONATAL PROPHYLACTIC OCULAR AGENTS
1. silver nitrate (for gonococcus, not for chlamydia)
2. povidone iodine
3. antibiotic drops
223
TREATMENT: NEONATAL GONOCOCCAL CONJUNCTIVITIS
a. topical penicillin G with irrigation for 5 days
| b. systemic benzylpenicillin or cefotaxime
224
TREATMENT: NEONATAL CHLAMYDIAL CONJUNCTIVITIS
oral erythromycin syrup
225
TREATMENT: PTERYGIUM
1. artificial tears
2. antihistamine drops
3. vasoconstrictor drops
4. antibiotic drops (secondary infection)
5. steroid drops (noninfective inflammation)
6. surgical excision
226
INDICATIONS FOR PTERYGIUM SURGERY
1. discomfort not relieved by medical treatment
2. increasing astigmatism
3. growth over visual axis
4. enabling contact lens wear
5. cosmesis
6. suspect malignancy
227
CONJUNCTIVAL TUMOURS
1. naevi
2. melanoma
3. squamous cell carcinoma
4. kaposi's sarcoma
228
CLINICAL FEATURES: CORNEAL INFILTRATION/ULCERATION
```
redness
pain
photophobia
blepharospasm
tearing
reduced vision
halos around lights
```
229
CORNEAL LESIONS THAT SHOULD BE REFERRED
1. reducing visual acuity
2. staining with fluorescein, except peripheral HSV
3. any hypopion
230
ORGANISMS THAT INVADE CORNEA WITHOUT NEEDING AN ENTRY PORTAL
1. N. Gonorrhoea
2. N. Meningitides
3. Corynebacterium Diphtheria
231
MOST COMMON ORGANISMS CAUSING CORNEAL ULCERATION
1. Pneumococcus
2. Pseudomonas
3. Staph aureus/epidermidis
232
MANAGEMENT: CORNEAL ULCERATION
1. irrigate eye with normal saline
2. cycloplegic drops
3. antibiotic drops (gatifloxacin, moxifloxacin, ciprofloxacin, ofloxacin)
4. ophthalmology consultation/referral
233
COMPLICATIONS: CORNEAL ULCERATION
1. permanent corneal thinning
2. permanent corneal opacification
3. corneal perforation
4. anterior uveitis with hypopion
5. endophthalmitis
6. permanent LOV
234
CLINICAL FEATURES: FUNGAL CORNEAL ULCERATION
1. red inflamed eye
2. satellite lesions
3. hypopion with fungus
4. slowly enlarging ulcer
235
TREATMENT OF FUNGAL CORNEAL ULCERATION
A. Topical Natamycin/Amphotheracin B
| B. Systemic Fluconazole
236
TREATMENT: HSV CORNEAL ULCERATION
A. Topical acyclovir
| B. Cycloplegia
237
COMPLICATIONS: HSV CORNEAL ULCERATION
```
Disciform keratitis
Stromal keratitis (when erronously treated with steroids)
```
238
MANAGEMENT: HZV OPHTHALMICA
1. early referral
2. systemic acyclovir
3. topical acyclovir with fluorescein
4. careful use of steroids
5. systemic analgesia
