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Ophthalmology Flashcards

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1
Q

What is glaucoma?

A

Optic nerve damage caused by rise in intraocular pressure caused by blockage in aqueous humour

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2
Q

Where would you find vitreous humour?

A

In vitreous chamber of eye

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3
Q

Where would you find aqueous humour?

A

In the anterior chamber (between cornea and iris) and posterior chamber (between lens and iris) of eye

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4
Q

What is the role of the aqueous humour, where is it produced, and where does it drain?

A

Supplies nutrients to cornea
Produced by ciliary body
Drains through trabecular mesh work to canal of Schlemm at angle between cornea and iris

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5
Q

What is normal intraocular pressure?

A

10-21mmHg
Created by resistance to flow through trabecular meshwork

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6
Q

What is the pathophysiology of open angle glaucoma?

A

Gradual increased in resistance to flow through trabecular moshwork

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7
Q

What is the pathophysiology of acute angle closure glaucoma?

A

Iris bulges forwards and seals off trabecular mesh work from anterior chamber preventing aqueous humour from draining
Continual build up of pressure and acute onset of symptoms
EMERGENCY

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8
Q

What happens to the optic disc with raised intraocular pressure?

A

Cupping of optic disc

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9
Q

What are the risk factors for open angle glaucoma?

A

Increasing age
Family history
Black ethnic origin
Myopia (nearsightedness)

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10
Q

Outline presentation of open angle glaucoma

A

Affects peripheral vision first, resulting in gradual onset tunnel vision
Fluctuating pain
Headaches
Blurred vision
Halos around lights (particularly at night)

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11
Q

How do you measure intraocular pressure?

A

Non-contact tonometry- Puff of air at cornea and measures response
Goldmann applanation tonometry (gold standard)- Lamp applies pressure to cornea

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12
Q

How is open angle glaucoma diagnosed?

A

Goldmann applanation tonometry
Slit lamp to assess cup-disc ratio and optic nerve health
Visual field assessment
Gonioscopy (assess angle between iris and cornea)
Central corneal thickness

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13
Q

Outline management of open angle glaucoma

A

Started at IO pressure >24mmHg
360 degree selective trabeculoplasty
Prostaglandin analogue eye drops (latanoprost)- Increase uveoscleral outflow
BB eye drops (timolol)- Reduce production of aqueous humour
Carbonic anhydride inhibitors (dorzolamide)- Reduce production of aqueous humour
Sympathomimetics (brimonidine)- Reduce production of aqueous fluid and increase uveoscleral outflow
Trabeculectomy- If other treatment ineffective- Creates bleb

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14
Q

What are the side effects of prostaglandin analogue eye drops (latanoprost)?

A

Eyelash growth
Eyelid pigmentation
Iris pigmentation (browning)

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15
Q

What is acute angle closure glaucoma?

A

Iris bulges forward and seals off trabecular mesh work from anterior chamber, preventing aqueous humour draining, leading to continual increase in IO pressure
Pressure builds in posterior chamber, pushing iris forward and exacerbating angle closure
EMERGENCY

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16
Q

What are the risk factors for acute angle closure glaucoma?

A

Increasing age
Family history
Female (4x more likely)
Chinese and East Asian ethnic origin
Shallow anterior chamber

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17
Q

Which medications can precipitate acute angle closure glaucoma?

A

Adrenergic meds (noradrenaline)
Anticholinergic meds (oxybutynin and solifenacin)
TCAs (amitriptyline)

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18
Q

How does acute angle closure glaucoma present?

A

Severely painful red eye
Blurred vision
Halos around lights
Associated headache, nausea and vomiting

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19
Q

List signs on examination of acute angle closure glaucoma

A

Red eye
Hazy cornea
Decreased visual acuity
Mid dilated pupil
Fixed size pupil
Hard eyeball on gentle palpation

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20
Q

What is the initial management of acute angle closure glaucoma?

A

Lie patient on back without pillow
Pilocarpine eye drops (2% for blue, 4% for brown)
Acetazolamide 500mg orally
Analgesia and antiemetic if required

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21
Q

How does pilocarpine work?

A

Acts on Muscarinic receptors in sphincter muscles in iris and causes pupil constriction (miosis) and ciliary muscle contraction
Opens pathway for flow of aqueous humour from ciliary body around iris and into trabecular meshwork

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22
Q

How does Acetazolamide work?

A

Carbonic anhydride inhibitor
Reduces production of aqueous humour

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23
Q

What is the definitive treatment of acute angle closure glaucoma?

A

Laser iridotomy
Hole in iris with laser

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24
Q

What is age-related macular degeneration?

A

Progressive condition affecting macula
Most common cause of blindness
2 types- Wet and dry

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25
What is the most common type of age related macular degeneration?
Dry
26
What is the difference between wet and dry AMD?
Dry- No Neovascularisation (90%) Wet- Neovascularisation (10%)
27
What is the function of the macula?
Found in centre of retina Generates high definition colour vision in central visual field
28
What are the 4 layers of the macula?
Choroid- Base layer, contains blood vessels that supply the macula Bruch’s membrane Retinal pigment epithelium Photoreceptors
29
Which condition are Drusen associated with?
AMD Deposits of proteins and lipids between retinal pigment epithelium and Bruchs membrane
30
What are frequent and large Drusen a sign of?
Early sign of AMD
31
What features are common on ophthalmoscope of AMD?
Atrophy of retinal pigment epithelium Degeneration of photoreceptors Drusen
32
What is the chemical that stimulates development of new vessels?
Vascular endothelial growth factor (VEGF)
33
What are the risk factors for AMD?
Old age Smoking FHx CVD (eg: HTN) Obesity Poor diet (low in vitamins, high in fat)
34
Outline presentation of AMD
Unilateral Gradual loss of central vision Reduced visual acuity Crooked or wavy appearance to straight lines (metamorphosia) Gradually worsening ability to read small text
35
What is the difference in presentation of wet and dry AMD?
Wet- More acute presentation- Vision loss can develop within days and progress to complete vision loss in 2-3y- Often progresses to bilateral disease
36
What are the examination findings in AMD?
Reduced visual acuity on snellen chart Scotoma (enlarged central area of vision loss) Amsler grid test (assesses distortion on straight lines) Drusen on fundoscopy
37
What is used to diagnose AMD?
Slit lamp- Detailed view of retina and macula Optical coherence tomography- Cross section of layers of retina- Used for diagnosis and monitoring Fluorescein angiography- Photographs retina to assess blood supply- Shows oedema and Neovascularisation in wet AMD
38
Outline management of dry AMD
Avoid smoking Control BP Vit supplements
39
Outline management of wet AMD
Anti-VEGF meds- Ranibizumab, aflibercept, bevacizumab- Block VEGF and slow development of new vessels Inject directly into vitreous chamber once a month
40
What is diabetic retinopathy?
Damage to retinal blood vessels due to prolonged high blood sugar levels
41
Outline the management of non-proliferative diabetic retinopathy
Close monitoring Diabetic control
42
Outline management of proliferative diabetic retinopathy
Pan-retinal photocoagulation- Extensive laser treatment to suppress new vessels Anti-VEGF Virectomy
43
What is a treatment option for macular oedema?
Intravitreal implant containing dexamethasone
44
List complications of diabetic retinopathy
Vision loss Retinal detachment Vitreous haemorrhage Rubeosis iridis (new blood vessel formation in iris)- Can lead to Neovascular glaucoma Optic neuropathy Cataracts
45
What is diabetic maculopathy?
Exudates within macula Macular oedema
46
Outline grading of diabetic retinopathy
Background- Microaneurysms, retinal haemorrhages, hard exudates, cotton wool spots Pre-proliferative- Venous bleeding, multiple blot haemorrhages, intraretinal micro vascular abnormality (IMRA) Proliferative- Neovascularisation and vitrous haemorrhage
47
Outline pathophysiology of diabetic retinopathy
Hyperglycaemia damages retina, small vessels and endothelial cells Increased vascular permeability = Leaky blood vessels, blot haemorrhages and hard exudates (yellow/white deposits of lipids and proteins in retina) Damage to blood vessels leads to Microaneurysms and venous beading Damage to nerve fibres in retina= Cotton wool spots IMRA- Dilated and tortuous capillaries in retina- Act as shunt between arterial and venous vessels in retina Neovascularisation- Release of growth factors into retina, new blood vessel development
48
What is management of hypertensive retinopathy?
Control BP and manage risk factors
49
Outline classification of hypertensive retinopathy
1- Mild narrowing of arterioles 2- Focal constriction of blood vessels and AV nicking 3- Cotton wool spots, exudates, haemorrhages 4- Papilloedema
50
List features of hypertensive retinopathy
Silver/copper wiring- Arterioles thickened and scleroses AV nipping- Arterioles cause compression of veins due to sclerosis and hardening Cotton wool spots- Damaged nerve fibres caused by ischaemia and infarction in retina Hard exudates- Damaged vessels leak lipids onto retina Retinal haemorrhages Papilloedema- Ischaemia of optic nerve results in optic nerve swelling
51
What is hypertensive retinopathy?
Damage to small blood vessels in retina relating to HTN Change happens slow (chronic) or quickly (malignant HTN)
52
What is a cataract?
Progressively opaque lens-- Reduces light entering eye and visual acuity
53
What is the role of the lens?
Focus light on the retina Held in place by suspensory ligaments attached to ciliary body Ciliary body contracts and relaxes to change shape of lens
54
How does the ciliary body work?
Contracts and relaxes to change shape of lens Contracts-- Releases tension on suspensory ligaments = Lens thickens Relaxes-- Suspensory ligaments tension = Lens narrows
55
What is special about the blood supply to the lens?
No blood supply Nourished by aqueous humour
56
How do you test for congenital cataracts?
Red reflex
57
What are the risk factors for cataracts?
Increasing age Smoking Alcohol Diabetes Steroids Hypocalcaemia
58
Outline presentation of cataracts
Asymmetrical Slow reduction in visual acuity Progressive blurring of vision Colours more faded-- Brown/yellow Starbursts at night Loss of red reflex
59
Outline management of cataracts
Cataract surgery-- Artificial lens Cataract can hide presence of macular degeneration and diabetic retinopathy-- May still have reduced visual acuity
60
What is a key complication of cataracts?
Endophthalmitis-- Inflammation of inner contents of eye-- Rare but serious complication of cataract surgery-- Can lead to vision loss
61
How is endophthalmitis treated?
Intravitreal antibiotics
62
What is an Argyll-Robertson Pupil?
Neurosyphilis Constricted pupil Accommodates but does not react to light Often irregularly shaped
63
What is a Holmes-Adie Pupil?
Damage to post-ganglionic parasympathetic fibres Dilated Sluggish to react to light Accommodates Slow to dilate following constriction
64
What is Holmes-Adie syndrome?
Holmes-Adie pupil Absent ankle and knee reflexes
65
Which muscles are responsible for pupil constriction?
Circular muscles in iris Stimulated by PNS using acetylcholine as a neurotransmitter Travels along CN III
66
Which muscles are responsible for pupil dilation?
Dilator muscles Stimulated by SNS using adrenaline as a neurotransmitter
67
List possible causes of a tadpole pupil
Migraines Horner syndrome
68
What is a coloboma?
Congenital malformation Causes hole in iris and irregular pupil shape
69
What is rubeosis iridis?
Neovascularisation in iris Associated with poorly controlled diabetes and diabetic retinopathy
70
Which condition can cause a vertical oval pupil shape?
Acute angle closure glaucoma
71
List causes of mydriasis (dilated pupil)
Congenital Stimulants (cocaine) Anticholinergic (oxybutynin) Trauma Third nerve palsy Holmes-Adie syndrome Raised ICP Acute angle-closure glaucoma
72
List causes of mitosis (Constricted pupil)
Horner syndrome Cluster headaches Argyll-Robertson pupil Opiates Nicotine Pilocarpine
73
What are the features of occulomotor nerve palsy?
Ptosis Dilated non-reactive pupil Divergent strabismus (squint) in affected eye-- With down and out position
74
What is the function of the occulomotor nerve?
Supplies all extraocular muscles except lateral rectus and superior oblique Supplies elevator palpebral superioris (lifts upper eyelid) Carries parasympathetic fibres that innervate circular muscle of iris
75
What does a 3rd nerve palsy with sparing of the pupil suggest?
Micro vascular cause-- Parasympathetic fibres are spared = Diabetes, HTN, ischaemia
76
What are the causes of a full 3rd nerve palsy?
Tumour Trauma Cavernous sinus thrombosis Posterior communicating artery aneurysm Raised ICP Idiopathic
77
What is the triad of Horner syndrome?
Ptosis Miosis Anhidrosis (lack of sweating)
78
Outline the journey of the occulomotor nerve
Brainstem through cavernous sinus, close to posterior communicating artery
79
List other features of Horner Syndrome
Enophthalmos
80
What is the mechanism of Horner Syndrome?
Damage to sympathetic nervous system supplying face Sympathetic nerves arise from spinal cord in chest-- Preganglionic nerves-- Enter sympathetic ganglion at Base of neck and exit as post-ganglionic nerves-- Travel to head alongside internal carotid artery
81
How is the location of Horner syndrome identified?
Central lesion (before nerves exit spinal cord) - - Anhidrosis of arm, trunk, and face Preganglionic lesion-- Anhidrosis of face Post-ganglionic lesion-- Don't cause Anhidrosis
82
What are the causes of central Horner Syndrome?
Stroke Multiple Sclerosis Swelling (tumour) Syringomyelia (cyst in spinal cord)
83
What are the causes of Preganglionic lesions?
Tumour (pancoast) Trauma Thyroidectomy Top rib
84
What are the causes of post-ganglionic Horner Syndrome?
Carotid aneurysm Carotid artery dissection Cavernous sinus thrombosis Cluster headache
85
What is associated with congenital Horner Syndrome?
Heterochromia (different iris colour on affected side)
86
What is the effect of cocaine eye drops on Horner syndrome?
Stop noradrenaline re-uptake at NMJ Causes normal eye to dilate as noradrenalin stimulates dilator muscles of iris In Horner eye- Nerves not releasing noradrenalin = No pupil reaction
87
What is the effect of adrenaline eye drops in Horner Syndrome?
Dilate Horner pupil Not dilate normal pupil
88
What is the cause of a Holmes-Adie Pupil?
Caused by damage to post-ganglionic parasympathetic fibres
89
How does a Holmes-Adie Pupil present?
Dilated Sluggish to react to light Responsive to accommodation (pupils constrict well when focusing on near object) Slow to dilate following constriction (tonic pupil)
90
What is Holmes-Adie Syndrome?
Holmes-Adie pupil Absent ankle and knee reflexes
91
What is an Argyll-Robertson Pupil?
Specific finding in neurosyphilis Constricted pupil that accommodates but doesn't react to light
92
What is blepharitis?
Inflammation of eyelid margins Causes gritty, itchy, dry sensation in eyes Associated with dysfunction of Meibomian glands (responsible for secreting meibum (oil) onto surface of eye) Can lead to styes and chalazions
93
What is the management of blepharitis?
Warm compress Gentle cleaning of eyelid margin to remove debris (cotton bud and baby shampoo)
94
What is a stye?
Hordeolum externum- Infection of glands of Zeis or glands of Moll (sweat glands at base of eyelashes)- Tender red lump along eyelid, may contain pus Hordeolum internum- Infection of Meibomian glands- Deeper, more painful, may pont in towards eyeball under eyelid
95
How are styes managed?
Hot compress and analgesia Topical antibiotics (chloramphenicol) if associated with conjunctivitis/symptoms persistent
96
What is a chalazion?
Meibomian gland becomes blocked and swells Swelling in eyelid, typically not tender
97
How is a chalazion treated?
Warm compresses and gentle massage towards eyelashes Rarely surgical drainage required
98
What is an entropion?
Eyelid turns inwards with lashes pressed against the eye Pain and can result in corneal damage and ulceration
99
How are entropions managed?
Taping eyelid down to prevent it from turning inwards Definitive management- Surgical Lubricating eye drops
100
What is an ectropion?
Eyelid turns outwards Usually affects bottom lid
101
What is a complication of an ectropion?
Exposure keratopathy
102
Outline the management of an ectropion?
Regular lubricating eye drops More significant cases may require surgery
103
What is trichiasis?
Inward growth of eyelashes Results in pain
104
What is a complication of trichiasis?
Corneal damage Ulceration
105
What is the management of trichiasis?
Remove affected eyelashes Recurrent cases- Electrolysis/cryotherapy/laser treatment
106
What is periorbital cellulitis?
Eyelid and skin infection in front of orbital septum
107
Outline presentation of periorbital cellulitis
Swollen, red, hot skin around eyelid and eye
108
How is periorbital cellulitis distinguished from orbital cellulitis?
CT scan
109
How is periorbital cellulitis treated?
Systemic antibiotics Can develop into orbital cellulitis- If vulnerable patient- Admit for monitoring
110
What is orbital cellulitis?
Infection around eyeball- Involves tissues behind orbital septum
111
What are the symptoms of orbital cellulitis?
Pain with eye movement Reduced eye movements Vision changes Abnormal pupil reactions Proptosis
112
What is the management of orbital cellulitis?
Emergency admission IV antibiotics Surgical drainage if abscess forms
113
What is conjunctivitis?
Inflammation of conjunctiva (thin layer of tissue that covers the eyelids and sclera Can be bacterial/viral/allergic
114
Outline presentation of bacterial conjunctivitis
Purulent discharge Worse in morning, eyes may be struck together Starts in one eye, spreads to other- Highly contagious Red, bloodshot eye Itchy/gritty sensation No pain/photophobia/reduced visual acuity
115
Outline presentation of viral conjunctivitis
Clear discharge Dry cough/sore throat/blocked nose Tender pre-auricular lymph nodes Very contagious Red, bloodshot eye Itchy/gritty sensation No photophobia/pain/reduced visual acuity
116
List causes of acute painful red eye
Acute angle-closure glaucoma Anterior uveitis Scleritis Corneal abrasions/ulceration Keratitis Foreign body Traumatic/chemical injury
117
List causes of acute painless red eye
Conjunctivitis Episcleritis Subconjunctival haemorrhage
118
Outline management of conjunctivitis
Usually resolves in 1-2wks w/o treatment Hygiene measures to reduce spread Cooled boiled water and cotton wool to clear discharge Bacterial- Chloramphenicol/fusidic acid eye drops Neonates- Urgent assessment (may be caused by gonococcal infection)
119
What is the management of neonatal conjunctivitis?
Urgent ophthalmology assessment May be caused by gonococcal infection- Can cause permanent vision loss
120
Outline presentation of allergic conjunctivitis
Contact with allergens Swelling of conjunctival sac and eyelid Itching and watery discharge
121
Outline management of allergic conjunctivitis
Antihistamines Topical mast-cell stabilisers- If chronic seasonal symptoms- Prevent mast cells releasing histamine
122

Final Year (14 decks)

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