Ophthalmology Flashcards

Question

WHAT ARE EXAMPLES OF PAINFUL RED EYES?

Answer 1

1. Scleritis 2. Anterior uveitis AKA iritis 3. Corneal abrasion 4. Herpes keratitis 5. Acute angle-closure glaucoma

Answer 2

Scleritis is an inflammatory condition in which the outer shell of the eye, the sclera, becomes oedematous and tender

Answer 3

1. RA 2. SLE 3. IBD 4. Sarcoidosis

Answer 4

1. Red eye 2. Classically painful (in comparison to episcleritis), but sometimes only mild pain/discomfort is present 3. Watering and photophobia are common 4. Gradual decrease in vision

Answer 5

1. NSAIDs E.g. oxyphenobutazome and indomethacin

Answer 6

Inflammation of the anterior portion of the uvea - iris and ciliary body

Answer 7

1. HLA B27 Ankylosing spondylitis 2. Reactive arthritis 3. Sarcoidosis

Answer 8

1. Unilateral 2. Acute onset 3. Ocular discomfort & pain (may increase with use) 4. **Pupil may be small +/- irregular due to sphincter muscle contraction** 5. **Ciliary flush** 6. Photophobia (often intense) 7. Blurred vision 8. Red eye 9. Lacrimation

Answer 9

1. Urgent review by ophthalmology 2. **Cycloplegics** (dilates the pupil which helps to relieve pain and photophobia) e.g. Atropine, cyclopentolate 3. **Steroid** eye drops

Answer 10

Conjunctivitis is the most common eye problem presenting to primary care. It is characterised by sore, red eyes associated with a sticky discharge

Answer 11

1. Normally a self-limiting condition that usually settles without treatment within 1-2 weeks 2. Topical antibiotic therapy is commonly offered to patients, e.g. Chloramphenicol. Chloramphenicol drops are given 2-3 hourly initially where as chloramphenicol ointment is given qds initially 3. Topical fusidic acid is an alternative and should be used for pregnant women. Treatment is twice daily 4. Contact lens should not be worn during an episode of conjunctivitis 5. Advice should be given not to share towels 6. School exclusion is not necessary

Answer 12

1. Bilateral symptoms conjunctival erythema, conjunctival swelling (chemosis) 2. Itch is prominent 3. the eyelids may also be swollen 4. May be a history of atopy 5. May be seasonal (due to pollen) or perennial (due to dust mite, washing powder or other allergens)

Answer 13

1. first-line: topical or systemic antihistamines 2. second-line: topical mast-cell stabilisers, e.g. Sodium cromoglicate and nedocromil

Answer 14

This presents as a bright red patch under the conjunctiva following rupture of a small conjunctival vessel

Answer 15

1. Spontaneously 2. Slight trauma 3. Local congestion due to coughing or sneezing. 4. In head injury, blood from a fracture at the base of the skull may travel through the floor of the orbit and into the subconjunctival space

Answer 16

There is no discharge. Usually, the condition is painless and does not usually impair vision.

Answer 17

The episclera is the thin layer of vascular tissue overlying the sclera

Answer 18

1. Red eye 2. Classically not painful (in comparison to scleritis), but mild pain may be present 3. Watering and mild photophobia may be present 4. In episcleritis, the injected vessels are mobile when gentle pressure is applied on the sclera. In scleritis, vessels are deeper, hence do not move

Answer 19

1. Phenylephrine drops 2. Phenylephrine blanches the conjunctival and episcleral vessels but not the scleral vessels. 3. If the eye redness improves after phenylephrine a diagnosis of episcleritis can be made

Answer 20

1. Conservative 2. Artificial tears may sometimes be used

Answer 21

Herpes zoster ophthalmicus (HZO) describes the reactivation of the varicella-zoster virus in the area supplied by the ophthalmic division of the trigeminal nerve. It accounts for around 10% of case of shingles.

Answer 22

1. Vesicular rash around the eye, which may or may not involve the actual eye itself 2. Hutchinson's sign: rash on the tip or side of the nose. Indicates nasociliary involvement and is a strong risk factor for ocular involvement

Answer 23

1. Oral antiviral treatment for 7-10 days * ideally started within 72 hours * intravenous antivirals may be given for very severe infection or if the patient is immunocompromised * topical antiviral treatment is not given in HZO 2. Topical corticosteroids may be used to treat any secondary inflammation of the eye 3. oOular involvement requires urgent ophthalmology review

Answer 24

1. Ocular: conjunctivitis, keratitis, episcleritis, anterior uveitis 2. Ptosis 3. Post-herpetic neuralgia

Answer 25

Diabetic retinopathy is the most common cause of blindness in adults aged 35-65 years-old.

Answer 26

Lazer eye surgery

Answer 27

1. Microaneurysms 2. Blot haemorrhages 3. Hard exudates 4. Cotton wool spots ('soft exudates' - represent areas of retinal infarction), venous beading/looping and intraretinal microvascular abnormalities (IRMA) less severe than in severe NPDR

Answer 28

1. Retinal neovascularisation - may lead to vitrous haemorrhage 2. Fibrous tissue forming anterior to retinal disc 3. More common in Type I DM, 50% blind in 5 years

Answer 29

1. **All patients** * optimise glycaemic control, blood pressure and hyperlipidemia * regular review by ophthalmology 2. **Maculopathy** * if there is a change in visual acuity then intravitreal vascular endothelial growth factor (VEGF) inhibitors 3. **Non-proliferative retinopathy** * regular observation * if severe/very severe consider panretinal laser photocoagulation 4. **Proliferative retinopathy** * panretinal laser photocoagulation * intravitreal VEGF inhibitors * if severe or vitreous haemorrhage: vitreoretinal surgery

Answer 30

Vitreous haemorrhage

Answer 31

1. multiple sclerosis: the commonest associated disease 2. diabetes 3. syphilis

Answer 32

1. unilateral decrease in visual acuity over hours or days 2. **poor discrimination of colours, 'red desaturation'** 3. pain worse on eye movement 4. relative afferent pupillary defect 5. central scotoma

Answer 33

1. high-dose steroids 2. recovery usually takes 4-6 weeks

Answer 34

Keratitis describes inflammation of the cornea. Microbial keratitis is not like conjunctivitis - it is potentially sight threatening and should therefore be urgently evaluated and treated.

Answer 35

1. Bacterial * typically Staphylococcus aureus * Pseudomonas aeruginosa is seen in contact lens wearers 2. Fungal 3. amoebic * acanthamoebic keratitis * accounts for around 5% of cases * increased incidence if eye exposure to soil or contaminated water * pain is classically out of proportion to the findings 4. Parasitic: onchocercal keratitis ('river blindness') Remember, other factors may causes keratitis: 1. Viral: herpes simplex keratitis * Dendritic corneal ulcer 2. Environmental * photokeratitis: e.g. welder's arc eye * exposure keratitis * contact lens acute red eye (CLARE)

Answer 36

1. Red eye: pain and erythema 2. Photophobia 3. Foreign body, gritty sensation 4. Hypopyon may be seen

Answer 37

1. Contact lens wearers 2. Assessing contact lens wearers who present with a painful red eye is difficult 3. An accurate diagnosis can only usually be made with a slit-lamp, meaning same-day referral to an eye specialist is usually required to rule out microbial keratitis

Answer 38

1. Stop using contact lens until the symptoms have fully resolved 2. Topical antibiotics 3. Typically quinolones are used first-line 4. Cycloplegic for pain relief 5. e.g. cyclopentolate

Answer 39

1. Orbital cellulitis is the result of an infection affecting the fat and muscles posterior to the orbital septum, within the orbit but not involving the globe. 2. It is usually caused by a spreading upper respiratory tract infection from the sinuses and carries a high mortality rate. 3. Orbital cellulitis is a medical emergency requiring hospital admission and urgent senior review.

Answer 40

1. Periorbital (preseptal) cellulitis is a less serious superficial infection anterior to the orbital septum, resulting from a superficial tissue injury (chalazion, insect bite etc...). 2. Periorbital cellulitis can progress to orbital cellulitis.

Answer 41

1. Redness and swelling around the eye 2. Severe ocular pain 3. Visual disturbance 4. Proptosis 5. Ophthalmoplegia/pain with eye movements 6. Eyelid oedema and ptosis 7. Drowsiness +/- Nausea/vomiting in meningeal involvement (Rare)

Answer 42

1. Reduced visual acuity, proptosis, ophthalmoplegia/pain with eye movements are NOT consistent with preseptal cellulitis

Answer 43

1. Full blood count – WBC elevated, raised inflammatory markers. 2. Clinical examination involving complete ophthalmological assessment – Decreased vision, afferent pupillary defect, proptosis, dysmotility, oedema, erythema. 3. CT with contrast – Inflammation of the orbital tissues deep to the septum, sinusitis. 4. Blood culture and microbiological swab to determine the organism. Most common bacterial causes – Streptococcus, Staphylococcus aureus, Haemophilus influenzae B.

Answer 44

1. Admission to hospital for IV antibiotics * Prevent the occurance of cavernous sinus thrombus

Answer 45

Central retinal vein occlusion (CRVO) is a differential for sudden painless loss of vision.

Answer 46

1. increasing age 2. hypertension 3. cardiovascular disease 4. glaucoma 5. polycythaemia

Answer 47

1. sudden, painless reduction or loss of visual acuity, usually unilaterally 2. fundoscopy * widespread hyperaemia * severe retinal haemorrhages - 'stormy sunset'

Answer 48

1. Fundoscopy * Flame haemorrhages * Cotton woll spots

Answer 49

1. the majority of patients are managed conservatively 2. indications for treatment in patients with CRVO include: 3. macular oedema - intravitreal anti-vascular endothelial growth factor (VEGF) agents 4. retinal neovascularization - laser photocoagulation

Answer 50

Retinitis pigmentosa primarily affects the peripheral retina resulting in tunnel vision

Answer 51

1. night blindness is often the initial sign 2. tunnel vision due to loss of the peripheral retina (occasionally referred to as funnel vision) 3. fundoscopy: black bone spicule-shaped pigmentation in the peripheral retina, mottling of the retinal pigment epithelium

Answer 52

Blepharitis is inflammation of the eyelid margins. It may due to either meibomian gland dysfunction (common, posterior blepharitis) or seborrhoeic dermatitis/staphylococcal infection (less common, anterior blepharitis). Blepharitis is also more common in patients with rosacea

Answer 53

1. symptoms are usually bilateral 2. grittiness and discomfort, particularly around the eyelid margins 3. eyes may be sticky in the morning 4. eyelid margins may be red. Swollen eyelids may be seen in staphylococcal blepharitis 5. styes and chalazions are more common in patients with blepharitis 6. secondary conjunctivitis may occur

Answer 54

1. softening of the lid margin using hot compresses twice a day 2. 'lid hygiene' - mechanical removal of the debris from lid margins * cotton wool buds dipped in a mixture of cooled boiled water and baby shampoo is often used * an alternative is sodium bicarbonate, a teaspoonful in a cup of cooled water that has recently been boiled 3. artificial tears may be given for symptom relief in people with dry eyes or an abnormal tear film

Answer 55

Vitreous haemorrhage is bleeding into the vitreous humour. It is one of the most common causes of sudden painless loss of vision. It causes disruption to vision to a variable degree, ranging from floaters to complete visual loss. The source of bleeding can be from disruption of any vessel in the retina as well as the extension through the retina from other areas. Once the bleeding stops, the blood is typically cleared from the retina at an approximate rate of 1% per day1.

Answer 56

1. Diabetes 2. Trauma 3. Anticoagulants 4. Coagulation disorders 5. Severe short sightedness

Answer 57

1. proliferative diabetic retinopathy (over 50%) 2. posterior vitreous detachment 3. ocular trauma: the most common cause in children and young adults

Answer 58

1. painless visual loss or haze (commonest) 2. red hue in the vision 3. floaters or shadows/dark spots in the vision

Answer 59

1. decreased visual acuity: variable depending on the location, size and degree of vitreous haemorrhage 2. visual field defect if severe haemorrhage

Answer 60

1. dilated fundoscopy: may show haemorrhage in the vitreous cavity 2. slit-lamp examination: red blood cells in the anterior vitreous 3. ultrasound: useful to rule out retinal tear/detachment and if haemorrhage obscures the retina 4. fluorescein angiography: to identify neovascularization 5. orbital CT: used if open globe injury

Answer 61

1. miosis (small pupil) 2. ptosis 3. enophthalmos\* (sunken eye) 4. anhidrosis (loss of sweating one side)

Answer 62

1. Heterochromia (difference in iris colour) is seen in congenital Horner's 2. Anhidrosis: see below 3. Pharmacologic tests * can be useful to confirm the diagnosis of Horner syndrome and localise the lesion * apraclonidine drops (an alpha-adrenergic agonist) can be used: causes pupillary dilation in Horner's syndrome due to denervation supersensitivity but produces mild pupillary constriction in the normal pupil by down-regulating the norepinephrine release at the synaptic cleft

Answer 63

1. Retinal detachment occurs when the neurosensory tissue that lines the back of the eye comes away from its underlying pigment epithelium. 2. It is a reversible cause of visual loss, provided it is recognised and treated before the macula is affected

Answer 64

1. Age 2. Previous surgery for cataracts (accelerates posterior vitreous detachment) 3. Myopia 4. Eye trauma (consider boxing) 5. Family history 6. Previous history of retinal break/detachment in either eye

Answer 65

1. Detachment should be suspected if patients complain of new onset floaters or flashes, as these indicate pigment cells entering the vitreous space or traction on the retina respectively. 2. Sudden onset, painless and progressive visual field loss, described as a curtain or shadow progressing to the centre of the visual field from the periphery should also raise suspicion of detachment. 3. If the macula is involved, central visual acuity and visual outcomes become much worse.

Answer 66

1. On examination, peripheral visual fields may be reduced, and central acuity may be reduced to hand movements if the macula is detached. 2. The swinging light test may highlight a relative afferent pupillary defect if the optic nerve is involved. 3. On fundoscopy, the **red reflex is lost** and retinal folds may appear as pale, opaque or wrinkled forms. If the break is small, however, it may appear normal.

Answer 67

1. Any patients with new onset flashes and floaters should be referred urgently (\<24 hours) to an ophthalmologist for assessment with a slit lamp and indirect ophthalmoscopy for pigment cells and vitreous haemorrhage.

Answer 68

1. **Central retinal vein occlusion** * incidence increases with age, more common than arterial occlusion * causes: glaucoma, polycythaemia, hypertension * severe retinal haemorrhages are usually seen on fundoscopy 2. **Central retinal artery occlusion** * due to thromboembolism (from atherosclerosis) or arteritis (e.g. temporal arteritis) * features include afferent pupillary defect, 'cherry red' spot on a pale retina

Answer 69

1. AV nipping 2. Cotton wool spots 3. Hard exudates 4. Flame-shaped haemorrhages 5. Papillioedema

Answer 70

Papilloedema describes optic disc swelling that is caused by increased intracranial pressure. It is almost always bilateral.

Answer 71

1. venous engorgement: usually the first sign 2. loss of venous pulsation: although many normal patients do not have normal pulsation 3. **blurring of the optic disc margin** 4. elevation of optic disc 5. loss of the optic cup 6. Paton's lines: concentric/radial retinal lines cascading from the optic disc

Answer 72

1. space-occupying lesion: neoplastic, vascular 2. malignant hypertension 3. idiopathic intracranial hypertension 4. hydrocephalus 5. hypercapnia

Answer 73

Typically red eye, pain and visual loss following intraocular surgery

Answer 74

Bilaterally small pupils that accommodate but don't react to bright light. Causes include neurosyphilis and diabetes mellitus

Answer 75

1. Blepharitis: inflammation of the eyelid margins typically leading to a red eye 2. Stye: infection of the glands of the eyelids 3. Chalazion (Meibomian cyst) 4. Entropion: in-turning of the eyelids 5. Ectropion: out-turning of the eyelids

Answer 76

Age-related macular degeneration

Answer 77

1. Marcus Gunn pupil (relative afferent pupillary defect) is diagnosed during the swinging light test. If there is damage to the afferent pathway (retina or optic nerve) of one eye, the pupil of that affected eye will abnormally dilate when a light is shone into it. 2. This is because the consensual pupillary relaxation response from the healthy eye will dominate. 3. Marcus Gunn pupil can be found in patients with multiple sclerosis. 4. Therefore, given the history, this should be ruled out in this patient.

Answer 78

1. papilloedema 2. glaucoma 3. retinitis pigmentosa 4. choroidoretinitis 5. optic atrophy secondary to tabes dorsalis 6. hysteria

Answer 79

Prostaglandin analogues

Answer 80

1. eye pain 2. foreign body sensation 3. photophobia 4. watering eye 5. red eye

Answer 81

1. Suspected penetrating eye injury due to high-velocity injuries (e.g. drilling, lawn moving or hammering) or sharp objects (e.g. as glass, knives, pencils or thorns) 2. Significant orbital or peri-ocular trauma has occurred. 3. A chemical injury has occurred (irrigate for 20-30 mins before referring) 4. Foreign bodies composed of organic material (such as seeds, soil) should be referred to ophthalmology as these are associated with a higher risk of infection and complications 5. Foreign bodies in or near the centre of the cornea 6. Any red flags e.g. severe pain; irregular, dilated or non-reactive pupils; significant reduction in visual acuity.

Answer 82

1. external (hordeolum externum): infection (usually staphylococcal) of the glands of Zeis (sebum producing) or glands of Moll (sweat glands). 2. internal (hordeolum internum): infection of the Meibomian glands. May leave a residual chalazion (Meibomian cyst)

Answer 83

A chalazion (Meibomian cyst) is a retention cyst of the Meibomian gland. It presents as a firm painless lump in the eyelid. The majority of cases resolve spontaneously but some require surgical drainage

Answer 84

management includes hot compresses and analgesia. CKS only recommend topical antibiotics if there is an associated conjunctivitis

Answer 85

Squint (strabismus) is characterised by misalignment of the visual axes. Squints may be divided into concomitant (common) and paralytic (rare). It is important to detect as uncorrected may lead to amblyopia (the brain fails to fully process inputs from one eye and over time favours the other eye).

Answer 86

1. referral to secondary care 2. eye patches may help prevent amblyopia

Ophthalmology Flashcards

(114 cards)