What are risk factors for age-related macular degeneration?
- Advancing age
- Smoking
- Family history
- CVD - hypertension, dyslipidaemia, diabetes mellitus
What are the two forms of age-related macular degeneration
Dry:
* 90% of cases
* also known as atrophic
* characterised by drusen - yellow round spots in Bruch’s membrane
* Treat with zinc + vitamin A,C,E
Wet:
* 10% of cases + worst prognosis
* also known as exudative or neovascular macular degeneration
* characterised by choroidal neovascularisation
* leakage of serous fluid and blood can subsequently result in a rapid loss of vision (red patches on fundoscopy)
* carries the worst prognosis
* Stabilise with anti-VEGF
What is the mangement of primary open angle glaucoma?
- Offer 360° selective laser trabeculoplasty (SLT) first-line to people with an IOP of ≥ 24 mmHg
- Prostaglandin analogue (PGA) eyedrops should be used next-line
What are the features of central retinal artery occlusion?
- Sudden, painless unilateral visual loss
- Relative afferent pupillary defect
- ‘cherry red’ spot on a pale retina - rest of retina is pale due to restricted blood flow
It is caused by thromboembolism (from atherosclerosis) or arteritis (e.g. temporal arteritis)
What are the differences seen on fundosocpy of central retinal artery vs vein occlusion?
CRAO: cherry red’ spot on a pale retina
CRVO: widespread hyperaemia + severe retinal haemorrhages - ‘stormy sunset’
What are the features of scleritis?
- red eye
- classically painful (in comparison to episcleritis), but sometimes only mild pain/discomfort is present
- watering and photophobia are common
- gradual decrease in vision
What are risk factors for scleritis?
- rheumatoid arthritis: the most commonly associated condition
- systemic lupus erythematosus
- sarcoidosis
- granulomatosis with polyangiitis
What is the management of scleritis?
- Same-day opthalmologist assessment
- oral NSAIDs are typically used first-line
- oral glucocorticoids may be used for more severe presentations
- immunosuppressive drugs for resistant cases (and also to treat any underlying associated diseases)
How does episcleritis differ from scleritis?
- Classically not painful, but can be irritating
- In episcleritis, the injected vessels are mobile when gentle pressure is applied on the sclera. In scleritis, vessels are deeper, hence do not move
- Phenylephrine drops may be used to differentiate between episcleritis and scleritis. Phenylephrine blanches the conjunctival and episcleral vessels but not the scleral vessels
- Management: convervative + artificial tears
What are features of acute angle-closure glaucoma?
- severe pain: may be ocular or headache
- decreased visual acuity
- symptoms worse with mydriasis (e.g. watching TV in a dark room)
- hard, red-eye
- haloes around lights
- semi-dilated non-reacting pupil
- corneal oedema results in dull or hazy cornea
- systemic upset may be seen, such as nausea and vomiting and even abdominal pain
What is the management of acute angle-closure glaucoma?
- Emergency ophthalmologist review
- Eye drops to include: a direct parasympathomimetic, beta-blocker and alpha-2 agonist
- Intravenous acetazolamide (reduce aqueous secretions)
- Definitive: laser peripheral iridotomy
What is the presentation of herpes simplex keratitis?
- red, painful eye
- photophobia
- epiphora
- visual acuity may be decreased
- fluorescein staining may show an epithelial ulcer
Treat with topical aciclovir
What is the mechanism of action of pilocarpine?
Pilocarpine is a direct parasympathomimetic
Contraction of the ciliary muscle → opening the trabecular meshwork → increased outflow of the aqueous humour
What is the mechanism of action of timolol?
Timolol is a beta blocker
It decreases aqueous humour production
What is the mechanism of action of apraclonidine?
Apraclonidine is an alpha-2 agonist
It has a dual mechanism: decreasing aqueous humour production and increasing uveoscleral outflow
What is anterior uveitis and what are its features?
Anterior uveitis describes inflammation of the anterior portion of the uvea - iris and ciliary body.
Features:
* Acute onset
* Ocular discomfort & pain (may increase with use)
* Pupil may be small ± irregular due to sphincter muscle contraction
* Photophobia (often intense)
* Blurred vision
* Red eye
* Lacrimation
* Ciliary flush: a ring of red spreading outwards
* Hypopyon; describes pus and inflammatory cells in the anterior chamber, often resulting in a visible fluid level
* Visual acuity initially normal → impaired
What conditions are associated with anterior uveitis?
HLA B27 conditions:
* ankylosing spondylitis
* reactive arthritis
* ulcerative colitis, Crohn’s disease
* Behcet’s disease
* sarcoidosis: bilateral disease may be seen
What is the management of anterior uveitis?
- Urgent review by ophthalmology
- Cycloplegics (dilates the pupil which helps to relieve pain and photophobia) e.g. Atropine, cyclopentolate
- Steroid eye drops
What are the causes and features of optic neuritis?
Causes:
* Multiple sclerosis (most common)
* Diabetes
* Syphilis
Features:
* Unilateral decrease in visual acuity over hours or days
* Poor discrimination of colours, ‘red desaturation’
* Pain worse on eye movement
* Relative afferent pupillary defect
* Central scotoma (blind zone)
What is the investigation of choice and management of optic neuritis?
Investigation: MRI of the brain and orbits with gadolinium contrast is diagnostic in most cases
Management:
* High-dose steroids
* Recovery usually takes 4-6 weeks
What investigations should you do when you suspect acute angle-closure glaucoma?
Tonometry - to measure IOP
Gonioscopy - a special lens for the slit lamp that allows visualisation of the angle
What are the presentations of the following conjunctivitis?
- Bacterial
- Viral
- Allergic
- Chemical
- Bacterial - mucopurulent
- Viral - scant, watery
- Allergic - stringy, whitlish
- Chemical - usually tearing
A 65 year old man has loss of vision of sudden onset in his left eye. He has a 10 year history of type 2 diabetes mellitus. On the swinging torch test, both pupils constrict when light is shone into the right eye, but neither pupil constricts when light is shone into the left eye. His red reflex is present and there are a few microaneurysms visible in the periphery of both fundi. His left optic disc looks swollen with blurred margins.
Which is the most likely cause of his loss of vision?
A. Anterior ischaemic optic neuropathy
B. Asymmetrical cataracts
C. Diabetic maculopathy
D. Left retinal detachment
E. Right occipital cortex stroke
A. Anterior ischaemic optic neuropathy
What is the classification of diabetic retinopathy?
Non-proliferative diabetic retinopathy (NPDR)
Proliferative retinopathy (PDR)
Maculopathy
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