Ophthalmology Flashcards
(161 cards)
1
Q
What to ask in an ophthalmology hx?
A
Ask about pain, redness, watering, change in appearance of the eye, altered vision, and if the problem is unilateral/ bilateral, distinguish between blurred and double vision Trauma, previous similar episodes, systemic illness, eye disease in the family, if using medication, take a drug history(including eye drops)
2
Q
How to measure visual acuity?
A
Test + record central vision of each eye separately for near and distance vision with glasses on- cover the non-test eye carefully
If can’t read the 6/9 line, use a pinhole to improve refraction
Near vision= checked using a near-vision testing card/ newspaper
3
Q
Examination of the eye?
A
Eyelids should be symmetrical- check skin around the eyelids, position, eyelashes of, and any inflammation, crusting, or swelling of the lid/ lid margin
Bright light for eye surface- bright and shiny?, if indication of corneal damage= use fluorescein stain
Note any redness
4
Q
Examining the ocular media?
A
Darken the room and check you have good batteries in the ophthalmoscope
Check the red reflex
Examine the disc- hand on forehead and support lid with thumb, look for shape, colour and size of the cup
Follow each of 4 main vessels–> periphery
Examine macula by asking patient to look directly at light
Examine peripheral retina by asking patient to look up, down
5
Q
Dilating pupils with a short-acting mydriatic e.g. 0.5-1% tropicamide makes examination easier, but patients may have what?
A
Temporarily blurred vision- should not drive home
6
Q
What other 3 things to examine?
A
Visual fields in each 4 quadrants
If complains of double vision- move an object to the nine positions of gaze- tell you which increases double vision
Pupils- round, central, of equal size, respond equally to light and accomodation, abnormalities: Horner’s syndrome, fixed dilated pupil(trauma, mydriatic drops, acute glaucoma, 3rd nerve palsy,) afferent pupillary defect(optic neuritis, retinal disease,) Argyll Robertson pupil(DM, neurosyphilis,) Holmes- Adie pupil(unilaterally in young adults)
7
Q
Things warranting emergency eye referral(A&E or emergency eye clinic)?
A
Sudden loss of vision, acute glaucoma, perforating injury/ intraocular foreign body, chemical burns, retinal detachment, corneal ulcer, sudden onset diplopia/ squint+ pain, temporal arteritis with visual symptoms
8
Q
Things warranting same-day eye referral(<24 hours)?
A
Hyphema/ vitreous haemorrhage, orbital fracture, sudden onset of ocular inflammation e.g. iritis/ ophthalmic herpes zoster, corneal foreign bodies/ abrasions
9
Q
Things warranting an urgent <2 week referral?
A
Central visual loss, sinister ‘floaters,’ flashing lights without a field defect, chronic glaucoma with pressure>35mmHg
10
Q
Things warranting a routine referral?
A
Gradual loss of vision, chronic glaucoma(unless pressure>35mmHg,) chronic red eye conditions, painless diplopia/ squint, chalazion/ stye/ cyst, ptosis
11
Q
Things to ask/ do for eye trauma?
A
Take a careful history; establish the nature of the trauma, measure acuity and examine both eyes carefully recording your findings, try to instill local anaesthetic drops + then examine, unable–> assess in casualty, encourage accident prevention, e.g. wearing protective goggles
12
Q
Things to ask/ do for corneal abrasion? Important differential dx?
A
Take a careful history to exclude high-speed particles that could cause penetrating injury, if severe pain- apply a few drops of local anaesthetic e.g. proxymetacaine 0.5% before examining, use fluorescein stain, with cobalt blue light illumination to detect abrasion- stains green, evert the upper lid to ensure no foreign body is left in the eye, advise chloramphenicol 0.5% eye drops QDS until healing is complete
Herpes keratitis- needs antiviral eye drops
13
Q
If metal or a penetrating injury is suspected, refer to who? Superficial foreign bodies removed how? After removal, treat how? If left >12 hours, what may form?
A
Eye casualty
With a corner of clean card after instilling local anaesthetic
Topical ABx e.g. chloramphenicol 0.5% drops 2-hourly for 3d, then QDS for 4d
A rust ring may form around a metal foreign body- refer to eye casualty for removal
14
Q
Symptom of arc eye? Seen in who? Due to what? Management?
A
Severe eye pain, watering, blepharospasm a few hours after exposure
Welders, sunbed users, skiers, mountaineers, and sailors who don’t use adequate eye protection
Corneal epithelial damage as result of exposure to UV light
Pad eye, analgesics and cyclopentolate 1% eye drops BD, recovery<24 hours, if not refer, advise protective wear for future exposure
15
Q
Blunt injury from what? Globe rupture presentation? More minor injuries? Refer urgently if what?
A
Fists, squash balls etc
A wound and severely reduced vision
Subconjunctival haemorrhage/ corneal abrasion
Visual acuity affected, double vision, lacerated conjunctiva, hyphaema, unable to see posterior limit of subconjunctival haemorrhage(may indicate orbital fracture,) persistent pupil dilation(may indicated torn iris,) signs of retinal damage(oedema, choroidal rupture,) cannot assess the eye
16
Q
Presentation of ‘blow out’ fracture of the orbit? From what? Refer for what?
A
Blurred/ double vision, pain on moving the eye, enophthalmos, infraorbital nerve loss, inability to look upwards due to trapping of inferior rectus muscle
Blunt trauma e.g. squash ball injury
XR and assessment of eye trauma via A&E
17
Q
Refer to what if penetrating injury is a possibility? What can confirm diagnosis? S+S? Do not do what?
A
Eye casualty i.e. hx of flying object/ working with hammers, drills, lathes, or chisels where a metal fragment may fly off
XR/ CT scan
Wound may be tiny, eye is painful and waters, vision may be normal initially/ be very poor(depending on size of foreign body,) photophobia, hyphaema, and/ or pupil distortion
Remove large foreign bodies(dart/ knife)- support with padding whilst transferring the patient supine to casualty/ A&E, cover the other eye to prevent damage from conjugate movement
18
Q
Use what before examining chemical burns? What causes great damage? Refer where? Tx how?
A
Topical anaesthetic e.g. proxymetacaine 0.5% before examining
Alkali injuries
Eeye casualty
Hold the lids open, brush out any powder, and irrigate with large amounts of clean saline/ water
19
Q
Consider what conditions with pain? Gritty eye discomfort? Pain on moving the eye? Referred pain? Photophobia?
A
Corneal foreign body, keratitis, iritis, scleritis, acute glaucoma, ophthalmic shingles, arc eye
Conjunctivitis, entropion, trichiasis, dry eye, episcleritis
Optic neuritis
Tension headache, migraine, refractive error, trigeminal neuralgia, ophthalmic shingles, GCA, ocular muscle imbalance, increased ICP
Conjunctivitis and migraine
20
Q
Causes of papilloedema? Refer to who?
A
Intracranial SOL, encephalitis, SAH, benign IC HTN, malignant HTN, optic neuritis, disc infiltration, ischaemic optic neuropathy, retinal venous obstruction, metabolic causes e.g. hypocalcaemia
Same-day specialist medical opinion
21
Q
Bilateral causes of exophthalmos? Unilateral? What is microphthalmios? Ass with what?
A
Graves’ disease
Graves’ disease, orbital disease, vascular disease e.g. cavernous sinus thrombosis, carotid- cavernous fistula; sinus disease
Small eyes- Down’s syndrome + other genetic abnormalities
22
Q
Preseptal/ periorbital cellulitis causes what? Cause? Typically affects who? What can be used to differentiate it from orbital cellulitis? Tx how? Can progress to what?
A
Swelling + redness + hot skin around the eye, children following mild trauma- normally unilateral
H.influenzae/ s.pneumoniae
Infection= localised to the skin and superficial tissues
CT scan
Tx as localised cellulitis- oral/ IV ABx e.g. flucloxacillin, admission for observation may be required
Orbital cellulitis
23
Q
Orbital cellulitis typically from what? Presents? Severe cases can lead to what? If suspected refer to who for what?
A
Infection spread from the paranasal sinuses- involves tissues behind the orbital septum
Usually pain, double/ blurred vision, and general malaise, signs= fever, eyelid swelling, proptosis, and inability to move the eye
Severe= can lead to septicaemia, meningitis and cavernous sinus thromboses- CT + LP to exclude meningitis
Ophthalmology for IV antibiotics/ surgical drainage- cefotaxime
24
Q
Features differentiating orbital cellulitis to periorbital cellulitis?
A
Pain on eye movement, reduced eye movements, changes in vision, abnormal pupil reactions and forward movement of the eyeball
25
S+S of orbital tumours? If suspected, refer for?
Unilateral proptosis, orbital pain- in rapidly growing malignant tumours especially, lid swelling/ distortion, limitation of eye movements +/- diplopia, reduced visual acuity if involvement of optic nerve, retina, or vascular supply
Urgent ophthalmology opinion
26
Orbital tumours may be what 3 things?
Primary(benign/ malignant)- any orbital structure may be involved, due spread from adjacent structures, due to blood-borne metastases
27
What is trichiasis? What is needed?
Ingrowing lashes--> irritable feeling +/- recurrent infection, severe--> corneal damage + ulceration
Eyelash removal (epilation,) electrolysis, cryotherapy/ laser tx
Same day ophthalmology referral if risk to sight
28
What is madarosis? Tx?
Loss of eyelashes- usually due to blepharitis(condition usually bilateral + ass w/ other S+S of blepharitis,) other causes= plucking/ rubbing(unilateral/ bilateral,) alopecia areata and discoid lupus(scarring madarosis)
Tx the cause
29
What is poliosis? Usually a what? Associated with what?
Depigmentation of the eyelases
Family hx, AI disease e.g. thyroid and Vogt- Koyanagi-Harada syndrome
30
What is entropion? Most commonly affects what? Increases with? Temporary relief method? Can cause what if untreated? Refer for what?
In-turning of the eyelids due to degenerative changes/ secondary to scarring, lower eyelid
Age- rare<40 y/o
Eyelashes rub on cornea and irritate the eye
Taping lower lid--> the cheek
Corneal vascularisation, ulceration, and infection
Rapid surgical correction, same-day referral if risk to sight
31
What is ectropion? Can result in? Causes? Most common? Refer for?
Turning out of the lower eyelid, exposure keratopathy
Watering and eye irritation
Elderly/ those with facial nerve palsy
Surgery, mild= no tx, regular lubricating eye drops, risk to sight= same-day referral--> ophthalmology
32
How to assess ptosis(drooping of the upper eyelid)? Lid margin should move how much? In severe ptosis? Tx what? How to determine the cause?
Look downwards as far as possible and then upwards as far as possible
>8mm, <4mm in severe
The cause
Look at the pupil: dilated= 3rd nerve palsy, refer--> neuro/ constricted= Horner's syndrome/ normal= old age, congenital, MG, muscular dystrophy, myopathy, botulism
33
Congenital ptosis causes what? Children may compensate by doing what? 50% have associated what? Refer for what as obstructing vision may cause what?
Unilateral/ bilateral weakness of the levator muscle
Tilting their heads upwards to see better
Superior rectus muscle weakness
Surgical correction- amblyopia
34
Neurological causes of ptosis? Muscular and mechanical causes of ptosis?
3rd nerve palsy- often complete if pupil is dilated(refer urgently to neurology to exclude cerebral haemorrhage/ tumour)
Horner's syndrome
Tabes dorsalis secondary to syphilis
Senile- most common, due to age-related changes in the levator muscle, refer if causing problems
MG, muscular dystrophy e.g. myotonic/ oculopharyngeal dystrophy, myopathy e.g. Graves', mechanical- due to allergy/ mass effect of tumour
35
Causes of localised eyelid swelling? 2 forms of stye(common eyelid infection)?
Stye, chalazion, papilloma, xanthelasma, sebaceous cyst, marginal cyst of Zeis/ Moll, dermoid cyst- usually upper inner and outer angles of the orbit, BBC usually lid margin, lacrimal gland + lacrimal sac disorders
External(hordeolum externum) + internal (" internum)
36
Most common form of stye? Infection of a lash follicle/ associated gland of Moll/ Zeis usually by what organism? Confined to what? Always points where? Tx how?
External stye (hordeolum externum)- s.aureus
The skin- outwards
Hot compresses + oral/ topical Abx e.g. chloramphenicol ointment
37
Internal stye is an abscess of what? Often causes less what than an external stye? May point where? Tx how?
Meibomian gland
Swelling
Inwards onto the conjunctiva(red patch with yellow centre before it bursts) or outwards through the skin
Same as external stye- hot compresses + oral/ topical ABx
38
What is a marginal cyst of Zeis or Moll? Tx?
Non-infected swellings of the glands of Zeis/ Moll
No tx unless troublesome then refer
39
RFs for styes? Symptoms typically resolve within how long once the stye has been what? Possible complications?
Chronic blepharitis + acne rosacea
5-7 days- spontaneously ruptured/ drained
Infective conjunctivitis, Meibomian cyst formation/ periorbital/ orbital cellulitis
40
Assessment + examination for suspected stye? Refer to who if malignant eyelid tumour suspected?
Asking about the timescale of symptoms; previous episodes; associated eye symptoms; any RFs/ triggers
Typical clinical features- eversion of the lower + upper eyelids; signs of a complication; signs of an alternative diagnosis inc atypical features suggesting a malignant eyelid tumour(rare)
Urgently to an ophthalmologist
41
When does a chalazion occur? Tx? If recurrent infection/ chronic cyst, refer to who to ophthalmology for what? Refer early if what and why?
Following an internal stye- the Meibomian gland may become blocked forming a cyst--> swelling typically not tender, can be tender and red
May resolve spontaneously, but often become infected- tx with topical ABx and/ or chronic
Hot compress and analgesia, consider topical ABx i.e. chloramphenicol if acutely inflamed
Surgical drainage= rarely if conservative fails
Incision and curettage, <7 y/o as large cysts can affect refraction and generate amblyopia
42
What is a squamous cell papilloma? Refer for what?
Benign skin tumour, may form a horn-like lesion
Excision/ curettage
43
What is blepharitis? Causes what sensation? Ass with what leading to what? Tx? Lubricating eye drops that can relieve symptoms(over 2-3 months with regular eye car 3x/ week)?
Inflammation of the eyelid margins
Gritty, itchy, dry sensation in the eyes
Dysfunction of the Meibomian glands(secrete oil onto the eye surface,)--> styes and chalazions
Hot compresses + gentle cleaning of the eyelid margins to remove debris using cotton wool dipped in sterilised water + baby shampoo
Hypromellose= least viscous- lasts around 10 minutes
Polyvinyl alcohol= worth starting with
Carbomer= most viscous, lasts 30-60 minutes
44
Tx blepharitis exacerbations with what? What may be useful for patients not responding to lid care and topical ABx? Tx dry eye symptoms with what?
Topical ABx
Oral ABx e.g. doxycycline 50mg OD for 3 months
Preservative- free tear supplements e.g. Liquifilm Tears
45
What does anterior blepharitis refer to? Can be caused by what? Posterior blepharitis? What can occur? Sx commonly worse when? Commonly ass with what conditions? DDx? Referral indicated when?
Inflammation of the base of the eyelashes- bacteria(staphylococcal,) or seborrheic
Inflammation of the Meibomian glands
Mixed anterior + posterior blepharitis
In the mornings- dry eye syndrome, seborrheic dermatitis + rosacea(tx with metronidazole)
Malignant tumours of the eyelid, eczema, infection, infestation + AI disease
Sx of corneal disease/ becomes painful and/ or red, loss of vision, orbital/ pre-septal cellulitis suspected, persistent localised disease/ eyelid asymmetry, underlying conditions needing secondary tx, ongoing sx despite tx in primary care, uncertain diagnosis
46
What is dry eye syndrome(keratoconjunctivitis sicca)? Commonly ass with what? Causes? Tx? Refer to ophthalmology when? Longer acting drops do what and short-acting drops only give relief for how long?
Tear secretion reduces with age--> eye irritation + redness which is often worse in centrally heated buildings + as the day goes on, the eye feels gritty, vision is occasionally blurred, reflex watering in severe cases
Blepharitis
Reduced tear production(Sjogren's,) increased evaporation (e.g. exposure keratitis)
Artificial tears- preservative- free drops, if one doesn't work- use another, treat associated lid disease e.g. blepharitis, if simple med fails try combined short- and long-acting drops
Continuing symptoms despite tx, serious/ underlying condition suspected, abnormal lid anatomy/ function, diagnostic uncertainty
Blur vision for a time, 30 minutes- may need frequent application
47
How is dry eye syndrome categorised? Ddx? Who is it more common in? Complications? Ix?
Aqueous tear deficiency- reduced secretion from lacrimal glands, evaporative tear deficiency- increased tear film evaporation often due to a deficient lipid layer in the tear film
Meibomian gland dysfunction, blepharitis, lacrimal gland deficiency, low blink rate, malposition of eyelids, contact lens wear, corneal refractive surgery, medication, Sjogren's, diabetes mellitus
Aged>50 y/o, females had refractive surgery
Keratinisation of the ocular surface, corneal scarring, thinning, ulceration/ neovascularisation; visual loss
Slit lamp exam of cornea + tear film + Schirmer's test to rule out Sjogren's- optometry/ ophthalmology referral may be needed
48
What is epiphoria? Acute dacryocystitis? Tx? Chronic dacryocystitis seen in who? Presents? Refer for what?
Watering eyes- due to overproduction/ outflow obstruction, caused by corneal irritation, iritis, acute glaucoma, ectropion, blocked tear duct
Acute infection of the tear sac- can spread to surrounding tissues, Abx- flucloxacillin, abscess--> refer for surgical drainage
Middle-aged + elderly, watery eye discharges mucus regularly--> syringing of the lacrimal system/ surgery
49
What is infantile dacryocystitis(blocked tear duct)? Swab to exclude chlamydia when? Tx? % fail to clear by 1 year, refer to who and tx?
Delay in canalisation/ obstruction of the lacrimal duct causing persistent watering/ sticky eyes in 20% babies
Vision= normal + is no conjunctival inflammation, if lower lid conjunctiva= reddened
Bathe with cooled boiled water
Avoid ABx eye drops unless clear infection
Spontaneous resolution= the norm
4%, paediatric ophthalmologist- probing the duct to clear it
50
'Red flags' for potentially dangerous red eye? Refer to specialist to be seen how soon?
Reduced visual acuity, pain deep in the eye- not surface irritation as with conjunctivitis, absent/ sluggish pupil response, corneal damage on fluorescein staining, hx of trauma
On the same day
51
Ddx if inflammation of the orbit? Lid disease? Scleral inflammation? Conjunctival disease? Corneal disease? Uveal/ iris inflammation? Other causes?
Thyroid eye disease/ exomphalos, tumour, orbital cellulitis
Stye, chalazion, blepharitis, allergic eye disease
Scleritis/ episcleritis, post-op inflammation
Viral/ bacterial infection, chlamydial infection, allergy, subconjunctival haemorrhage
Foreign body/ trauma, corneal ulceration, corneal abrasion, dry eye, arc eye, ophthalmic shingles
Anterior uveitis, posterior uveitis/ toxoplasma
Acute glaucoma, post-op endophthalmitis
52
Types of conjunctivitis? General sx? Red flags?
1) Viral= most common, likely adenovirus, tx= reassurance(likely to get sore throat, dry cough, blocked nose and clear eye discharge, possible tender pre-auricular lymph nodes)
2) Allergic- acute allergy, meds, hayfever, clear mucus eye discharge, tx= antihistamine eye drops/ oral antihistamines, chronic seasonal symptoms= mast-cell stabilisers
3) Bacterial- normally s.aureus/ s.pneumoniae + h.influenzae, can be STD- related, tx= ABx drops. contact lens wearers + immunocompromised= greatest risk of comps e.g. keratitis
(Typically worse in the morning, usually starts in one eye + can then spread to the other)
Conjunctival blood vessel dilation, vision can be affected but resolves after a blink, unilateral/ bilateral, itchy/ gritty sensation, eye discharge- NO PAIN/ PHOTOPHOBIA/ REDUCED VISUAL ACUITY
53
Tx of conjunctivitis? What is hyperacute conjunctivitis? Ophthalmia neonatorum?
Good hygiene + avoid contact lenses, cleaning eyes with cooled boiled water + cotton wool, bacterial= topical chloramphenicol qds for 5d + fusidic acid eye drops if sx not improving in 3-5 days
Rapidly developing severe conjunctivitis typically caused by infection with n.gonorrhoeae
Conjunctivitis within the 1st 4 weeks of life- can be infectious/ non-infectious
54
Painless vs painful red eye?
Conjunctivitis, episcleritis, subconjunctival haemorrhage
Glaucoma, anterior uveitis, scleritis, corneal abrasions/ ulceration, keratitis, foreign body, traumatic/ chemical injury
55
Urgent ophthalmology referral for infective conjunctivitis if?
Red flag indicating serious cause of red eye, ophthalmia neonatorum, suspected gonococcal/ chlamydial conjunctivitis, possible herpes infection, suspected periorbital/ orbital cellulitis, corneal ulceration/ significant keratitis/ pseudomembrane presence, hx of recent intraocular surgery, conjunctivitis ass w/ severe RA/ immunocompromise, corneal involvement ass w/ soft contact lens use
56
Discussion with/ referral to ophthalmology if what for infective conjunctivitis?
Diagnostic uncertainty, lack of appropriate equipment to make definitive diagnosis/ recurrent conjunctivitis, persistent, or due to molluscum contagiosum
57
When does seasonal allergic conjunctivitis occur? Ass with what? Perennial? Vernal keratoconjunctivitis? Atopic keratoconjunctivitis? Giant papillary conjunctivitis?
Periodically and with seasonal allergens e.g. tree/ grass pollen
Non-seasonal environmental allergens often found in the home e.g. house dust mites, mould spores/ animal dander
Most common + severe in hot arid environments
Severe and usually associated with atopic dermatitis of the eyelids
Has a mechanical component and can occur due to chronic micro-trauma e.g. contact lens
58
Sight-threatening causes of a red eye? Hx and examination?
Acute glaucoma, anterior uveitis, corneal ulcer, contact lens- related red eye + corneal foreign body, neonatal conjunctivitis, trauma, chemical injuries, scleritis, endophthalmitis
Onset + duration of sx, unilateral/ bilateral, associated sx, use of lenses, trauma/ chemical exposure, previous episodes, relevant medical hx + medication
Inspection, visual acuity assessment, fluorescein examination, pupil reactions
59
Features in red eye hx indicating same-day ophthalmology assessment?
Reduced visual acuity, moderate-severe pain, headache, photophobia, ciliary injection, fluorescein staining of the cornea, unequal/ misshapen pupils/ abnormal pupillary reactions/ painful pupillary constriction, loss of red reflex, corneal defect/ haze, hyphaema/ hypopyon(pus in the anterior chamber), high-velocity injury, foreign body/ penetrating lesion, chemical eye injury, contact lens use, conjunctivitis in infant in first 28 days of life
60
What is subconjunctival haemorrhage? Common in who? Clears when? Associations? Check what? If severe/ recurrent check what x2? Avoid what? If foreign body sensation, what can help?
Spontaneous painless localised haemorrhage under the conjunctiva- generally unilateral + asymptomatic
The elderly
Spontaneously in 1-2 weeks, but may recur
HTN, clotting disorders, leukaemia, increased venous pressure, whooping cough, medications- warfarin, NOACs, antiplatelets, NAI
BP/ FBC + clotting screen- NSAIDs + aspirin
Lubricating eye drops
61
What is corneal vascularisation? What if they're a contact lens wearer? Refer for what?
Growth of blood vessels onto the cornea- in patients with severe lid disease, rosacea/ due to excessive contact lens wear
Advise to remove contact lenses for at least 2 months
To ophthalmology for specialist management to prevent long-term damage
62
Episcleritis is unilateral in what fraction of cases? Presents how? Tx? Ineffective/ if in doubt, do what? Ass w/?
2/3
Diffuse inflammation of the eye with minimal tenderness and NO discharge, typically NOT painful, segmental redness, watering of the eye
NSAID e.g. ibuprofen 400mg tds/ ketorolac 0.5% eye drops QDS, lubricating eye drops can help, cold compresses, safety netting
Refer to ophthalmology for consideration of steroid tx
Inflammatory disorders e.g. RA + IBD
63
Is scleritis uni/ bilateral? Peak age? Affects what and can be what? Presents how? May be accompanying what? Ass w/? Tx? Comps?
Either, 40-60 y/o, anterior or posterior segment- diffuse/ nodular/ necrotising(most severe)
Severe pain, pain with eye movement, photophobia, eye watering, reduced visual acuity, abnormal pupil reaction to light, tenderness to palpation of the eye
Uveitis + keratitis
50%= systemic illness(herpes zoster, RA, SLE, polyarteritis nodosa, Wegener's granulomatosis, trauma, infection/ surgery)
Refer urgently--> ophthalmology, NSAIDs, steroids, immunosuppression appropriate to underlying systemic condition
Cataracts, glaucoma, retinal detachment
64
What condition likely follows a carotid aneurysm rupture? Aetiology? Presentation? Ix? Tx?
Cortical cavernous fistula--> reflux of blood into the cavernous sinus
Surgery, trauma/ spontaneous
Engorged eye vessels, lid and conjunctival oedema, bilateral proptosis + diplopia
Pulsatile loud bruit over the eye/ sensation of tinnitus
MRI arteriography
Surgery
65
What is keratitis? Causes? Most common cause? Common causes of bacterial keratitis? RFs? Presentation?
Corneal inflammation
Viral i.e. HSV, bacterial, fungal i.e. candida/ aspergillus, contact lens acute red eye(CLARE,) exposure keratitis (inadequate eyelid coverage) e.g. eyelid ectropion
Herpes simplex
Pseudomonas + staph
Contact lens wearers, smokers, poor hygiene, immunocompromised/ trauma
Normally unilateral, moderate--> severe pain, rapid onset, red eye, photophobia + poor vision, eye discharge
66
Signs in bacterial keratitis? Tx? Marginal keratitis presentation? Mx?
Epiphora, lid oedema, hypopyon
Corneal scrap for culture + sensitivities, start ABx immediately
Sore red eye- NO visual sx, steroids + ABx
67
Herpes simplex keratitis can be what? Usually affects only what? What is stromal keratitis? Associated with what complications? Presentation? Ix? Tx?
Primary/ recurrent, epithelial layer of the cornea
Inflammation of the stroma between the endothelium + epithelium
Stromal necrosis, vascularisation + scarring, can lead to corneal blindness
Painful red eye(usually unilateral,) photophobia, vesicles around the eye, foreign body sensation, watering eye, reduced visual acuity(common in children)
Fluorescein staining--> dendritic corneal ulcer, slit-lamp examination, corneal swabs/ scrapings can isolate the virus using a viral culture/ PCR
Same-day assessment--> aciclovir, NOT steroids(only stromal,) corneal transplant for corneal scarring caused by stromal keratitis
68
Iritis/ anterior uveitis most common in who? Presentation? May be secondary to what? 30% ass w/ what? Tx?
Young/ middle-aged adults
Acute onset of pain, photophobia, blurred vision + reduced acuity, watering, circumcorneal redness, small/ irregular pupil +/- keratitic precipitates on posterior cornea +/- hypopyon, pain increases as eyes converge and pupils constrict
Corneal graft rejection/ eye infections
Seronegative arthropathies, chronic= sarcoidosis, syphilis, Lyme disease, TB, herpes virus- most= idiopathic
69
3 things making up the uvea? Ix? Tx for anterior uveitis/ iritis? Comps?
Iris, ciliary bodies + the choroid
Slit lamp--> fibrin clot in anterior chamber(WCC deposits)
Bloods, antibodies, CXR
Eye dilatation(cyclopentolate/ atropine eye drops= antimuscarinics) and pred drops, DMARDs + TNF-inhibitors, severe= laser therapy, cryotherapy/ vitrectomy
Posterior synechiae(irregular pupil shape,) glaucoma, cataracts, relapses= common
70
What is anterior uveitis? Intermediate uveitis? Posterior uveitis? Panuevitis?
Inflammation in the anterior segment of the eye
Inflammation of the vitreous
Inflammation of the retina/ choroid
Inflammation in the anterior chamber, vitreous and retina or choroid
71
Epidem of acute angle closure glaucoma? Meds precipitating? Presentation? Signs? Ix? Tx?
Elderly, long-sighted women with early cataract, family hx, Chinese + East Asian ethnicity, shallow anterior chamber
Adrenergic meds= noradrenaline, anticholinergic meds, tricyclics e.g. amitriptyline
Unilateral eye pain, red eye, headache, N+V, poor vision
Corneal oedema, mild dilated pupil
Tonometer
Reduce IOP with oral acetazolamide + IV mannitol, pilocarpine drops to constrict the eye + BB drops (timilol,) surgery can be done to prevent second occurrence (iridotomy)
72
How may closed-angle glaucoma present (3 ways)?
1) Latent= when screening the opposite eye after an episode of acute/ subacute glaucoma, asymptomatic, normal IOP, anterior chamber= shallow with a narrow angle
2) Subacute= episodic haloes around bright lights, impaired vision +/- frontal headache/ eye pain, attacks precipitated by the pupil dilating, exam between attacks= normal, during- pupil= semi-dilated and cornea slightly clouded, at risk of acute attack
3) Acute= blockage of aqueous drainage from anterior chamber--> increase in IOP from 15-20 to 60-70mmHg, may be hx of subacute attacks, eye pain with acute loss of vision in one eye +/- abdominal pain/ nausea/ vomiting
73
Examination + tx of acute angle closure glaucoma?
Reduced vision; cornea looks hazy due to oedema; pupil= fixed and dilated; circumcorneal redness; eyeball feels hard due to increased pressure; poor fundal view +/- cataract
Refer acute/ subacute glaucoma as an emergency to ophthalmology, specialist= miosis to open drainge channels and acetazolamide +/- apraclonidine and/ or latanoprost drops to reduce aqueous production, peripheral iridotomy to allow free aqueous production once IO pressure reduced, prophylactic surgery on contralateral eye
74
Always do what with sudden loss of vision in one eye? Causes?
Refer as an emergency to ophthalmology- unless certain it's a migraine/ stroke
Acute glaucoma, migraine, stroke/ amaurosis fugax, wet AMD, migraine, temporal arteritis
75
2nd most common cause of blindness? Aetiology? Sx in branch vein occlusion? Central vein occlusion?
Retinal vein occlusion
HTN/ atherosclerosis, polycythaemia, diabetes, glaucoma, high cholesterol, smoking, SLE
Blurring of vision and a field defect, fundoscopy= flame haemorrhages in region that the occlusion is at
Blurring of vision, may get more vision loss, may also have a relative afferent pupillary defect, widespread flame haemorrhages + optic disc swelling
76
Ix and tx for retinal vein occlusion?
Fundoscopy, full medical hx, FBC, ESR, BP, serum glucose, fundus fluorescein angiogram
Refer immediately to an ophthalmologist, tx macular oedema and prevent comps such as neovascularisation of retina + iris and glaucoma: laser photocoagulation, intravitreal steroids e.g. dexamethasone, anti-VEGF therapies
77
Aetiology for retinal artery occlusion? Sx? Exclude what?
AF, smoking, hyperlipidaemia, HTN and diabetes- due to an atherosclerotic plaque, emboli/ GCA
Sudden visual loss in one eye + afferent pupil defect, retina= appears white +/- cherry red spot at the macula, retinal embolus may be visible
Temporal arteritis
78
Ix and tx for retinal artery occlusion?
Fundoscopy= pale retina with cherry red spot(macula which has a thinner surface shows red coloured choroid below)
Reduce chance of CVS events- prescribe aspirin + start on BP medication + a statin
<1 hour= ocular massage to preserve some vision, refer as emergency to ophthalmology- optic atrophy + blindness= usual outcome
79
Vitreous haemorrhage secondary to what? Leads to what? Produces what? May require what? Presents? Do what?
Central/ branch RVO
Neovascularisation, retinal detachment and tears--> floaters/ full vision obscured
Generally get better on their own- vitrectomy
Sudden reduction in vision, loss of red reflex, difficulty visualising the retina
Refer to ophthalmology
80
Anterior ischaemic optic neuropathy occurs when? 2 forms? Ask about what? Presentation? Ix? Tx?
The short ciliary arteries are damaged
Arteritic- inflammation + non-arteritic- arterial emboli
GCA Sx
Central vision drops suddenly + irreversibly, underlying condition sx, relative afferent pupillary defect, disc= swollen, pale +/- haemorrhages
CRP, ESR, FBC
Refer as emergency
Give steroids
81
What is the angle? Issues here leads to what? Most common type of glaucoma? What is optic disc cupping? A normal eye will have what? Level for raised IOP?
The space between the posterior surface cornea and anterior surface of the iris- where the aqueous leaves the eye
Glaucoma- chronic open- angle glaucoma
Cup= area without nerves or blood in it, telltale of glaucoma
21 mmHg
82
Major RF for chronic simple glaucoma(open-angle)? Other RFs? What med can cause raised IOP? Presentation? Signs?
Raised IOP, family hx, abnormal BP, myopia, increased age, Black race, increased plasma viscosity
May be detected during routine optometrist examination/ through routine screening for diabetics/ patients with family hx, present late as visual acuity is preserved until visual fields are severely impaired
Optic nerve damage, visual field loss + high IOP
83
Variants of chronic simple glaucoma?
Ocular HTN- high IOP, no field loss
Normal tension glaucoma- field loss, disc cupping, normal IOP
84
Tx for chronic open-angle glaucoma? Medical tx?
Advise>40 y/o to have regular optometry check-ups, family hx= biannual checks of their IOP(tonometry) + annual visual filed checks at optician from 40 y/o
Refer those with high pressures/ notice disc cupping--> ophthalmology, follow-up life-long, reduce IOP to slow disease progression
Topical prostaglandin analogue- increase outflow of aqueous, topical B-blocker- decrease aqueous secretion, topical carbonic anhydrase inhibitor- decrease secretion, topical alpha-agonist- decrease secretion + increase outflow
Trabeculectomy- target not met with medical tx
85
Glaucoma may occur in those with diabetic retinopathy, central/ branch retinal vein obstruction or ocular ocular ischaemia? Pathology? Pressures? Suffer from what? Tx?
Neovascular/ secondary glaucoma
Blood vessels grow across the iris + iridiocorneal angle, preventing fluid drainage
40-70mmHg, pain from corneal oedema
Surgical- severe--> if blind= eye is removed
86
Congenital glaucoma is usually what? Presents how? Do what? Tx?
Bilateral
Irritation of the eye, photophobia, large eyes w/ large fixed pupils +/- cloudy cornea
Refer to paediatric ophthalmologist, surgery
87
Pathophysiology of macular degeneration? Uni/ bilateral? RFs?
Older--> development of drusen(water from photoreceptors) in the retina, accumulates in the RPE--> poorly functioning, dry AMD= retinal atrophy, wet AMD= new vessel growth under the retina
Always bilateral- one eye= more severely affected
Increased age, +ve family hx, smoking, high BP
88
Presentation of macular degeneration?
Deterioration/ distortion of central vision- affects reading/ face recognition first- worse with changes in lighting
Dark patch rapidly fades may be noticed on waking- interpreted as 'seeing a shadowy figure'
Severe visual loss= visual hallucinations- usually faces/ stars
89
All patients start with what type of AMD? Caused by what? What accounts for 50% of blindness due to AMD?
Dry AMD- atrophy of the neuroretina, macular cells break down--> drusen formation, drusen increase + central vision decreases
Wet AMD- drusen lifts the retinal pigment epithelium away from it's blood supply, new blood vessels grow from the choroid and may bleed--> scars--> irreversible loss of central vision
90
Presentation of dry vs wet AMD? Examination? Tx?
Dry= central scotoma with OK peripheral vision
More rapid change in vision with objects becoming smaller + lines not appearing straight
Slit lamps, colour fundus photography, ocular coherence tomography--> cross-section of the retina, visual acuity may be reduced/ normal
Urgent referral--> ophthalmology within a week
Dry= vitamin A, E and zinc, wet= photodynamic lasers, IV photosensitive drugs + intravitreal injections of anti-TNF beta
91
What does diabetes cause? Leads to what? Signs commonly seen?
Ocular ischaemia--> new blood vessel formation on the iris, less aqueous liquid to leave the eye, RF for glaucoma, lens= increased glucose uptake, RF for cataracts, vessels then bleed + increase risk of retinal detachments
Cotton wool spots, oedema/ flare haemorrhage due to vascular leakage
92
Types of diabetic eyes? Tx?
Non-proliferative: micro-aneurysms, haemorrhages, hard exudate + cotton wool spots
Proliferative: fine new vessels appear--> vitreous haemorrhages--> maculopathy--> oedema--> vision threatened
BP tx + good BM control, maculopathy/ proliferative retinopathy= laser photocoagulation + anti-vEGF
93
Number one cause of trauma? Sx of trauma? Investigate how? Tx? Another common cause? Need to rule out what?
Foreign bodies
Subconjunctival haemorrhages + corneal lacerations
US + X-ray, remove item + ABx
Blunt trauma--> hyphaema, raised IOP and vision loss
Lens dislocation, macular oedema/ ON compression
94
How does retinal detachment occur? RFs? Types?
Fluid enters space between photoreceptors and RPE--> retina is lifted or detached from the RPE--> field defect
High myopia, eye surgery + diabetes
Rhegmatogenous- due to retinal tear/ break, tractional= due to tissue attachments to vitreous + pulls retina from the RPE, exudative- fluid build-up
95
How does retinal detachment occur? RFs? Types?
Fluid enters space between photoreceptors and RPE--> retina is lifted or detached from the RPE--> field defect
High myopia, eye surgery + diabetes
Rhegmatogenous- due to retinal tear/ break, tractional= due to tissue attachments to vitreous + pulls retina from the RPE, exudative- fluid build-upR
96
How does retinal detachment occur? RFs? Types?
Fluid enters space between photoreceptors and RPE--> retina is lifted or detached from the RPE--> field defect
High myopia, eye surgery + diabetic retinopathy, eye trauma, retinal malignancy, older age, family hx
Rhegmatogenous- due to retinal tear/ break, tractional= due to tissue attachments to vitreous + pulls retina from the RPE, exudative- fluid build-up
97
Retinal detachment symptoms? Signs? Ix? Tx?
3 Fs: flashes, floaters + field defects, may have RAPD
Fundoscopy
Superior retinal detachment--> inferior field defect, seal with lasers, gas/ laser therapy/ surgery
Vitrectomy, scleral buckling, pneumatic retinopexy
98
What do if long-standing floaters/ flashes? If sx are of recent onset and no other sx? If sx of recent onset and associated visual field loss, reduced acuity, pain/ inflammation of the eye?
No need for referral
Refer urgently to ophthalmology outpatients
Refer as ophthalmology emergency
99
What is optic neuritis? Presentation? Causes? Tx? Week 2 and 6 weeks
Disc swelling due to inflammation/ demyelination--> rapid visual loss and reduced colour vision; discomfort on eye movements, temporary worsening of symptoms when hot; optic disc swelling
MS; DM; viral infections
Refer urgently to ophthalmology to confirm, steroids in severe cases
Visual loss usually stabilises after what week and recovers after what week?
100
Causes of cataracts? RFs? Untreated congenital cataracts in babies causes what?
Trauma, eye disease, systemic disease
Family hx of age-related cataracts, corticosteroid tx, smoking, prolonged exposure to UV B light
Deprivation amblyopia
101
Main sx of cataracts in adults? In babies and children?
Gradual + painless reduction in visual acuity- gradual difficulty in reading, recognising faces/ watching TV, glare may become most dominant sx at first--> difficulty seeing in bright sunshine/ driving at night
Poor vision, white/ grey pupil (leukocoria,) involuntary eye movements, squint, sensitivity to light/ glare issues
102
Cataracts O/E? Adult with this should be encouraged to have what? Referral based on? For babies and children? Tx?
Visual acuity usually reduced, ophthalmoscope= opacity in the lens, reduced/ obliterated red reflex
Eye exam by an optometrist to assess visual acuity, exclude other causes
How vision is affected, what surgery involves including risks and benefits, QOL affected if no surgery, whether they want surgery
Urgent referral to an ophthalmologist--> removal of natural lens +/- posterior chamber lens implantation as day case under LA, healing= 2-6 weeks
75-95% without other pathology--> 6/12 vision or better 3 months post-op, need testing for new spectacles 6 weeks post-op to allow refractive changes to settle
103
Types of cataracts? Comps of cataracts surgery?
Posterior subcapsular cataract- good vision when the pupil is dilated i.e. in dim light, bright light--> constricts--> profound vision loss
Cortical= good visual acuity as central lens is clear, may complain of a halo of light and glare, trauma-related--> sunflower shape, congenital (zonular cataract)
Intraocular infection(endophthalmitis); pain + blurred vision +/- red eye +/- tenderness--> surgeon for ABx within 2-3 hours(>12h--> blindness,) posterior capsule rupture, broken/ protruding sutures, vitreous haemorrhage, glaucoma, posterior capsular opacification- sx similar to the original cataract, tx= laser therapy
104
Pathophysiology of diabetic retinopathy?
Hyperglycaemia--> damage to the retinal small vessels + endothelial cells, increased vascular permeability--> leakage from the blood vessels, blot haemorrhages and formation of hard exudates, microaneurysms + venous beading
Damage to nerve fibres in the retina--> fluffy white patches to form called cotton wool spots
Intraretinal microvascular abnormalities(IMRA)= dilated and tortuous capillaries- act as a shunt between the arterial and venous vessels in the retina
Neovascularisation= growth factors released in the retina--> new blood vessels
105
Classification of diabetic retinopathy? Based on what?
Non-proliferative and proliferative(non can develop into proliferative)
Fundus examination
106
Types of non-proliferative diabetic retinopathy? Proliferative?
Mild: microaneurysms, moderate= microaneurysms, blot haemorrhages, hard exudates, cotton wool spots and venous bleeding, severe= blot haemorrhages + microaneurysms in 4 quadrants, venous bleeding in 2, intraretinal microvascular abnormality (IMRA) in any quadrant
Neovascularisation, vitreous haemorrhage
107
Comps of diabetic retinopathy? Tx?
Retinal detachment, vitreous haemorrhage, rebeosis iridis, optic neuropathy, cataracts
Laser photocoagulation, anti-VEGF e.g. ranibizumab and bevacizumab, vitreoretinal surgery
108
Cause of bilateral homonymous hemianopia? Homonymous hemianopia? Homonymous quadrantanopia?
Bilateral damage to the visual cortex- usually CVA
Strokes involving the MCA- macular fibres may be preserved if posterior cerebral artery is functional
Temporal lobe disease with superior defect + parietal lobe disease with inferior loss, causes= vascular events, tumours, trauma
109
Causes of bitemporal hemianopia?
Compressive chiasmal lesions, e.g. pituitary tumour, craniopharyngioma/ meningioma
110
What is an altitudinal defect? Causes? When is a blind spot enlarged? Causes?
Field defect respecting the horizontal= optic nerve disease e.g. optic neuropathy, optic neuritis
If the optic disc is enlarged- papilloedema, disc inflammation, infiltration with lymphoma
111
Bilateral causes of central scotoma? Unilateral?
Toxic e.g. tobacco, B12 deficiency, MS, age-related macular degeneration, inherited
Glioma of optic nerve, vascular lesion
112
Causes of tunnel vision(loss of peripheral vision)? Loss of vision in one eye?
Glaucoma, retinitis pigmentosa, retinal detachment, functional visual loss
Due to lesions of the retina/ optic nerve anterior to the optic chiasm= retinal detachment, retinal vein occlusion, optic neuropathy, infiltration of the nerve, demyelination, nerve compression
113
Circular muscles in the iris stimulated by what nervous system? What neurotransmitter? Fibres innervating the eye travel along what nerve? Dilator muscles of the pupil? Neurotransmitter?
Parasympathetic- acetylcholine, oculomotor
Sympathetic using adrenalin
114
Rubeosis iridis is associated with what? What is coloboma? Tadpole pupil?
Diabetes and diabetic retinopathy
A congenital malformation in the eye--> a hole in the iris causing an irregular pupil shape
Where there is spasm in a segment of the iris causing a misshapen pupil= usually temporary and associated with migraines
115
Causes of mydriasis(dilated pupil)? Miosis(constricted pupil)?
3rd nerve palsy, Holmes- Adie syndrome, raised ICP, congenital, trauma, stimulants such as cocaine, anticholinergics
Horner's syndrome, cluster headaches, Argyll-Robertson pupil, opiates, nicotine, pilocarpine
116
3rd nerve palsy with sparing of the pupil suggested a what cause as the what are spared? May be due to what? 'Full 3rd nerve palsy' caused by what?
Microvascular cause- parasympathetic fibres
Diabetes, HTN, ischaemia
Compression of the nerve due to physical compression= idiopathic, tumour, trauma, cavernous sinus thrombosis, posterior communicating artery aneurysm, raised ICP
117
Central lesions cause anhidrosis where? Pre-ganglionic lesions? Post-ganglionic lesions? 4 Ss, 4Ts and 4 Cs?
The arm and trunk as well as the face
The face
Don't cause anhidrosis
Stroke, MS, swelling, syringomyelia/ Pancoast's tumour, trauma, thyroidectomy, top rib/ carotid aneurysm, carotid artery dissection, cluster headache
118
Congenital Horner syndrome associated with what? What can test for Horner's syndrome?
Heterochromia(difference in colour of the iris on the affected side)
Cocaine eye drops- act on eye to stop noradrenalin re-uptake at the NM junction
119
What is a Holmes Adie pupil? Syndrome?
A unilateral dilated pupil that is sluggish to react to light with slow dilation following constriction- over time the pupil will get smaller- caused by damage to the post-ganglionic parasympathetic fibres(exact cause is unknown)
Pupil with absent ankle and knee reflexes
120
3 layers to the eye? Fibrous layer consists of what 2 things? Functions? Sclera is attachment for what? Light entering is refracted by what?
Fibrous, vascular and inner
Sclera and cornea
Provide shape to the eye and the deeper structures
Extraocular muscles
The cornea
121
Layer underneath the fibrous layer? Consists of what 3 things? What is and function of the choroid? 2 parts to ciliary body? Ciliary muscle attached to lens of the eye by what? Ciliary body controls what and contributes to what? Smooth muscles fibres in the iris innervated by what?
Vascular= choroid, ciliary body, iris
Layer of connective tissue + blood vessels= nourishment to the outer layers of the retina
Ciliary muscle and ciliary processes
Ciliary processes
The shape of the lens, aqueous humour
Autonomic nervous system= between lens + cornea
122
Inner layer of the eye is formed by what? 2 layers? Pigmented layer attached to what? Supports the choroid in doing what? Neural layer consists of what?
Retina: pigmented(outer) layer + neural (inner) layer
Choroid- in absorbing light(continues whole way around inner surface)
Photoreceptors- located posteriorly + laterally in the eye
123
Anteriorly which layer continues and which one doesn't- what is this part known as? Posteriorly and laterally, which layers are present? Which part is this?
The pigmented layer- the non-visual retina
Both layers of the retina= the optic part of the retina
124
How can the optic part of the retina be viewed? Centre is marked by what? Contains a depression called what? This is responsible for what? Area that the optic nerve enters the retina?
During ophthalmoscopy
The macula, the fovea centralis- high acuity vision
The optic disc(no light detecting cells)
125
Area posterior to the lens? Marked by a narrow canal running from the optic disc to the lens called what? 3 main functions?
Vitreous body- hyaloid canal(fetal remnant)
Contributes to the magnifying power of the eye, supports the lens, holds the layers of the retina in place
126
Anterior chamber is located between what 2 things? Posterior chamber? These are filled with what? Drains where? Blocked drainage leads to what?
Cornea and the iris
Iris and ciliary processes
Aqueous humour
Via the trabecular meshwork(area of tissue at base of the cornea, near the anterior chamber)--> glaucoma
127
Eyeball receives arterial blood primarily via what? Branch of what artery? Arising immediately distal to what? Most important branch of this, supplying what? Occlusion leads to what? Venous drainage of the eye? Drain into what?
Ophthalmic artery- internal carotid artery
The cavernous sinus
Central artery of the retina- internal surface of the retina
Blindness
Superior and inferior ophthalmic veins--> the cavernous sinus
128
Eyelids meet at what? Opening between the 2 eyelids called what? 5 main layers of the eyelid?
Medial and lateral/ inner + outer canthi of the eye, palpebral aperture/ opening
Skin + SC tissue, orbicularis oculi, tarsal plates, levator apparatus, conjunctiva
129
What's in the caruncle? Point at which the cornea and the sclera meet?
Oil and sweat glands- swell with allergen/ topical irritation
Limbus
130
Eyelashes are attached at eyelids with what modified sweat glands? Sebaceous glands located in this layer? 3 parts to the orbicularis oculi?
Ciliary glands of Moll, glands of Zeis
Palpebral, lacrimal and orbital
131
Attachments of the orbicularis oculi muscle? Actions of palpebral, lacrimal and orbital parts of the eyelid? Innervation?
From medial orbital margin, medial palpebral ligament, and the lacrimal bone, inserts--> skin around margin of the orbit, superior and inferior tarsal plates
Palpebral= gently closes the eyelids, lacrimal= involved in tear drainage, orbital= tightly closes eyelids
Facial nerve
132
Two tarsal plates deep to the palpebral region of the orbicularis oculi? Composed of? Superior tarsus acts as an attachment site for what? What lies in the tarsal plates? These secrete what?
Superior tarsus and inferior tarsus- form scaffolding of the eyelid
Dense connective tissue
Levator palpebrae superioris
Meibomian glands- oily substance preventing eyelids from sticking together when closed
133
Levator palpebrae superioris and superior tarsal muscles are only present where? Attachments? Action? Innervation?
Upper eyelid
From lesser wing of the sphenoid--> upper eyelid + superior tarsal plate/ from underside of levator palpebrae superioris--> superior tarsal plate
Opens the eyelid/ assists levator palpebrae superioris in opening the eyelid
Superior branch of the oculomotor nerve/ sympathetic fibres from the superior cervical ganglion
134
Deepest layer of the eyelid? What is it and it's reflected onto what?
The palpebrae conjunctiva= thin mucous membrane, reflected onto the sclera of the eyeball(bulbar conjunctiva)
135
Arterial supply to eyelids from what 3 arteries? Venous drainage medially and laterally?
Ophthalmic, facial and superficial temporal arteries
Via the medial palpebral vein--> the angular + ophthalmic veins/ into the superficial temporal vein from the lateral palpebral vein
136
Sensory innervation to the eyelids supplied by what branches of the trigeminal nerve? Muscle innervation?
Ophthalmic nerve(V1)--> upper eyelid, maxillary(V2)--> lower eyelid
Facial nerve, oculomotor nerve + sympathetic fibres
137
The lacrimal are what type of glands and secrete lacrimal fluid onto what? Where is it located? It's anatomical relations?
Serous type exocrine glands--> conjunctiva surfaces and cornea of the eye= cleans, nourishes and lubricates the eyes--> tears when in excess
Anteriorly in the superolateral aspect of the orbit within the lacrimal fossa(depression in the orbital plate of the frontal bone)
Superior= zygomatic process of frontal bone, anterior= orbital septum, posterior= orbital fat, inferolateral= lateral rectus muscle
138
2 main parts to the lacrimal gland? What type of gland comprised of what? Contain what cell type producing what? Lacrimal fluid produced secreted into excretory ducts empty into where? Spread over the cornea how?
Orbital- sits on lateral margin of the levator palpebrae superioris muscle/ palpebral- smaller on inner surface of the eyelid
A compound tubuloacinar gland comprised of lobules--> multiple acini
Serous cells
The superior conjunctival fornix
Blinking
139
System responsible for the drainage of lacrimal fluid from the orbit? Circulates across the eye and accumulates in what? Located where? Drains into what?
Lacrimal apparatus, the lacrimal lake- in the medial canthus of the eye
The lacrimal sac via a series of canals
140
The lacrimal sac is the dilated end of what? Located where? Drains down where and empties into where?
The nasolacrimal duct- in a groove formed by the lacrimal bone + frontal process of the maxilla
The nasolacrimal duct and into the inferior meatus of the nasal cavity
141
Main arterial supply to the lacrimal gland? Venous drainage? Empties into where? Lymphatic drainage is to what into where?
Lacrimal artery from ophthalmic(branch of the internal carotid)
The superior ophthalmic vein--> cavernous sinus
To the superficial parotid lymph nodes--> the superior deep cervical nodes
142
Sensory innervation to the lacrimal gland? Also receives what?
The lacrimal nerve(branch of the ophthalmic nerve from trigeminal nerve
Autonomic nerve fibres: parasympathetic= pre-ganglionic carried in greater petrosal nerve, post-ganglionic with maxillary nerve + finally zygomatic nerve(stimulates fluid secretion from lacrimal gland)
Sympathetic= from superior cervical ganglion carried by internal carotid plexus + deep petrosal nerve, join with parasympathetic in nerve of pterygoid canal(inhibits secretion from lacrimal gland)
143
Boundaries of the orbit formed by how many bones? Thought of as a what shaped structure? Roof formed by what? Frontal bone separates orbit from what? Floor formed by what? Maxilla separates the orbit from what? Medial wall formed by what? Ethmoid bone separates orbit from what?
7 bones
Pyramidal, with apex pointing posteriorly + base situated anteriorly
Frontal bone + lesser wing of the sphenoid- from the anterior cranial fossa
Maxilla, palatine + zygomatic bones- from the underlying maxillary sinus
Ethmoid, maxilla, lacrimal and sphenoid bones- from the ethmoid sinus
144
Lateral wall of the orbit formed by what? Apex located at the opening to what? Base bounded by what- also known as what?
Zygomatic bone + greater wing of the sphenoid
At the opening to the optic canal, the optic foramen
The eyelids- the orbital rim
145
The bony orbit contains what? Any space that isn't occupied is filled with what? This does what?
Eyeballs + extra-ocular muscles, eyelids, CNs 1, 3, 4, 5 + 6, ophthalmic artery, superior + inferior ophthalmic veins
Orbital fat- cushions the eye + stabilises the EO muscles
146
3 main pathways by which structures can enter and leave the orbit?
Optic canal= transmits optic nerve + ophthalmic artery
Superior orbital fissure= lacrimal, frontal, trochlear, oculomotor, nasociliary and abducens nerves
Inferior orbital fissure= zygomatic branch of the maxillary nerve, inferior ophthalmic vein, and sympathetic nerves
147
How many and what are the extraocular muscles?
7: levator palpebrae superioris(superior eyelid movement,) superior, inferior, medial and lateral recti, inferior + superior oblique (eye movement)
148
Recti muscles originate from what? Pass anteriorly to attach to what?
The common tendinous ring--> the sclera of the eyeball
149
Attachments of the superior rectus? Actions? Innervation?
Superior part of the common tendinous ring--> superior + anterior aspect of the sclera
Elevation- also adduction + medial rotation of the eyeball
Oculomotor nerve(CN III)
150
Attachments of the inferior rectus? Actions? Innervation?
From inferior part of the common tendinous ring--> inferior + anterior aspect of the sclera
Depression- also adduction + lateral rotation
Oculomotor nerve(CN III)
151
Attachments of the medial rectus? Actions? Innervation?
From medial part of the common tendinous ring--> anteromedial aspect of the sclera
Adducts the eyeball
Oculomotor nerve(CN III)
152
Attachments of the lateral rectus? Actions? Innervation?
From lateral part of common tendinous ring--> anterolateral aspect of the sclera
Abducts
Abducens nerve(CN VI)
153
Attachments of the superior oblique? Actions? Innervation?
From body of the sphenoid bone, tendon through a trochlea--> sclera, posterior to superior rectus
Depresses, abducts and medially rotates the eyeball
Trochlear nerve(CN IV)
154
Attachments of the inferior oblique? Actions? Innervation?
From anterior aspect of the orbital floor--> sclera, posterior to lateral rectus
Elevates, abducts + laterally rotates the eyeball
CN III
155
How may a CN IV lesion present? CN VI?
Diplopia + head tilt away from the site of the lesion
Affected eye will be adducted
156
Fibres from the nasal portion of the retina cross where which is located where? The optic tracts carry the fibres posterolaterally around what to terminate where? Fibres from what other portion, carrying the nasal fields, do the same as above?
At the optic chiasm- just anterior to the pituitary infundibulum(carrying temporal visual fields)
The cerebral peduncles- at the lateral geniculate bodies of the thalamus
The temporal portion
157
After the lateral geniculate body, the optic radiations do what? Fibres carrying information from the inferior portions of the retina travel by looping laterally through what to where? What visual fields? Known as what?
Split into two, the temporal lobe--> the visual cortex, SUPERIOR visual fields= MEYER'S loop
158
Fibres carrying information from the superior portions of the retina travel by looping superiorly through what to where? What visual fields? Known as what?
The parietal lobe--> the visual cortex, INFERIOR visual fields= BAUM'S loop
159
Way to remember the pathway?
I'MAUDITORY
Inferior colliculus & medial geniculate body= AUDITORY
Superior colliculus & lateral geniculate body= VISUAL
160
Damage to the left optic tract would lead to what? Left Meyer's loop? Left Baum's loop?
Loss of temporal field of left eye + nasal field of right eye
Superior nasal field of left eye + superior temporal field of right eye
Inferior temporal field of right eye + inferior nasal field of left eye
161
Way to remember innervation of extraocular muscles?
LR6S04(lateral rectus= CN6, superior oblique= CN4,) all rest= CN3
