Ophthalmology 18/05/20

Question 1

symptoms of blepharitis

Answer 1

• usually bilateral - due to meibomian body dysfunction or infection
• gritty, burny eyes
• often eyelid margin redness, swelling suggestive of infection (most common = S epidermidis)
• change in eyelashes (ingrowth/loss)
• association with ROSACEA and increased chance of developing styes/chalazia

Question 2

management of blepharitis

Answer 2

Lid hygiene:
- remove any debris
- chloramphenicol ointment to eyelash bases
- lid massage with warm compress
- artificial tears for dry eyes
~ Treat rosacea ~

Question 3

COMMON causes of conjunctivitis

Answer 3

VIRAL - systemic illness/sore throat/lymphadenopathy
ALLERGIC - acute allergy/hay fever/topical medication
BACTERIAL - usually staph, consider neisseria/chlamydia in neonates

Question 4

symptoms of conjunctivitis (ALLERGIC)

Answer 4

• bilateral chemosis and watery
• prominent itch
• may be atopy/seasonal history

Question 5

symptoms of conjunctivitis (VIRAL)

Answer 5

• biateral chemosis and watery
• recent URTI/systemic illness
• lymphadenopathy (pre-auricular LNs)

Question 6

symptoms of conjunctivitis (BACTERIAL)

Answer 6

• purulent discharge

- eyes stuck together in mornings

Question 7

treatment of conjunctivitis

Answer 7

• history (allergic)
• topical/systemic antihistamines (sodium cromoglicate if unresponsive to AHs in allergy)
• viral usually self-limiting (1-2 wks) - don’t share towels, school excl not necessary
• chloramphenicol as an antibiotic topically (fusidic acid in preg)

Question 8

what produces lipid layer of tear film?

Answer 8

meibomian glands

Question 9

what produces aqueous layer of tear film?

Answer 9

lacrimal glands

Question 10

what produces mucin layer of tear film?

Answer 10

goblet cells

Question 11

episcleritis symptoms

Answer 11

• UNILATERAL
• mild irritation
• no pain
• intense localised redness (confused with haemorrhage)
• self-resolving within 2 wks

Question 12

scleritis symptoms

Answer 12

• UNILATERAL
• darker red area (due to deeper layer than EPIscleritis)
• typically painful (can be mild-severe)
  REFERRAL REQUIRED as can lead to loss of vision

Question 13

treatment of stye

Answer 13

• self-limiting but often recurrent
• warm compress
• lash removal/stye drainage
• topical antibiotic if necessary

Question 14

treatment of chalazion

Answer 14

• warm compress
• lid massage
• referral if chronic

Question 15

common causes of GRADUAL vision disturbance

Answer 15

• cataracts
• chronic glaucoma
• optic nerve compression

Question 16

common causes of SUDDEN vision disturbance

Answer 16

• VASCULAR (e.g. thrombosis, embolism, temporal arteritis, including CRA/CRV occlusion)
• vitreous haemorrhage
• papilloedema
• retinal detachment
• acute glaucoma

Question 17

VARIABLE ONSET vision disturbance causes

Answer 17

• optic/retrobulbar neuritis

- diabetic retinopathy

Question 18

optic/retrobulbar neuritis symptoms/signs

Answer 18

progressive over days

• pain worse on eye movement
• RAPD
• colour (red) desaturation
• central scotoma
• other symptoms of demyelination (association with MS)

Question 19

management of optic neuritis

Answer 19

• treat underlying cause, commonly MS so high dose steroids

Question 20

symptoms of vitreous haemorrhage

Answer 20

smaller bleed =
- cobwebs/shadows/floaters/hazy vision
- may be redness to vision
- usually unilateral
moderate bleed = 
- multiple dark spots
big bleed = 
- can cause sudden total visual disturbance

Question 21

symptoms of retinal detachment

Answer 21

• peripheral shadow that progressively moves centrally (sudden onset floaters commonly)
• flashes of light (photopsia)
• straight lines appearing curved

Question 22

symptoms of cataracts

Answer 22

gradual onset of:

• reduced vision (faded colour vision)
• glare and halos around lights
• NO red reflex

Question 23

fundoscopy findings in primary open angle glaucoma (chronic simple)

Answer 23

1. Optic disc cupping - cup-to-disc ratio >0.7 (normal = 0.4-0.7)
2. Optic disc pallor - indicating optic atrophy
3. Bayonetting of vessels - vessels have breaks as they go into the deep cup and re-appear at the base

Question 24

RFs for primary open angle glaucoma

Answer 24

• age
• genetics
• ethnicity (black population at increased risk)
• myopia (near-sightedness)
• diabetes
• hypertension

Question 25

RFs for ACUTE ANGLE CLOSURE glaucoma

Answer 25

- age - hypermetropia (long-sightedness) - pupillary dilation (eg. 3rd nerve palsy)

Question 26

symptoms of chronic simple glaucoma

Answer 26

often insidious, picked up on routine optometry - peripheral visual field loss - nasal scotomas progressing to 'tunnel vision' - decreased visual acuity - optic disc cupping

Question 27

symptoms of acute angle closure glaucoma

Answer 27

- severe pain: may be ocular or headache - hard, red-eye - decreased visual acuity - halos around lights - semi-dilated non-reacting pupil on RAPD - corneal oedema results in dull or hazy cornea - nausea and vomiting - symptoms worse with mydriasis (e.g. watching TV in a dark room)

Question 28

common red flag for 3rd nerve palsy

Answer 28

post. communicating artery aneurysm | tumour

Question 29

features of iritis/anterior uveitis

Answer 29

acute onset - red, watery eye (with ciliary flush) - pain - irregular/small pupil - photophobia - blurred vision (visual acuity initially normal → impaired) - hypopyon; describes pus and inflammatory cells in the anterior chamber, often resulting in a visible fluid level

Question 30

management of iritis/ant. uveitis

Answer 30

urgent review by ophthalmology - dilate pupil to relieve acute symptoms eg. atropine - steroid eye drops

Question 31

corneal ulcer symptoms (similar presentation to HSV keratitis)

Answer 31

``` more common in contact lense users - pain and irritation (watery) - photophobia - focal fluorescein staining of the cornea can lead to vision loss if not treated ```

Question 32

management of corneal ulcer

Answer 32

- antimicrobials - steroid eye drops - cornea transplant if severe scarring/vision loss

Question 33

entropion/ectropion

Answer 33

- entropion: in-turning of the eyelids | - ectropion: out-turning of the eyelids

Question 34

(Holmes-)Adie pupil features

Answer 34

benign condition, mostly affecting women - unilateral in 80% of cases - dilated pupil - efferent pupil defect - once the pupil has constricted it remains small for an abnormally long time - slowly reactive to accommodation but barely to light

Question 35

management of open-angle glaucoma

Answer 35

- prostaglandin analogue drops (eg. latanoprost) - can then offer beta-blocker (eg. timolol), carbonic anhydrase inhibitor (eg. acetazolamide) or sympathomimetic eyedrop (eg. brimonidine) - surgery (trabeculectomy) or laser treatment - follow up!

Question 36

explanation of glaucoma management

Answer 36

prostaglandin analogue (eg. latanoprost) - increased uveoscleral outflow - AEs = brown pigmentation of iris, extra eyelash length beta blocker (eg. timolol) - reduced aqueous production - avoid in asthmatics/heart block carbonic anhydrase inhibitors (eg. acetazolamide) - reduced aqueous production sympathomimetics (eg. brimonidine - alpha2 adrenoceptor agonist) - reduced aqueous production - increased uveoscleral outflow - avoid in those on MAOIs/TCAs - AEs = hyperaemia miotics (eg. pilocarpine - muscarinic recetptor agonist) - increased uveoscleral outflow - AEs = constricted pupil, blurred vision, headache

Question 37

management of acute closed angle glaucoma

Answer 37

urgent referral to ophthalmology management options include: - inducing pupillary constriction with topical pilocarpine - timolol (BB) - apraclonidine - reducing aqueous secretions with IV acetazolamide - laser or surgery

Question 38

anterior ischaemic optic neuropathy features

Answer 38

risk factors of atheroscerosis increase risk - sudden, painless loss or blurring of vision in one eye - usually noticed upon waking from sleep (it is believed that the normal drop in blood pressure during sleep triggers an interruption of blood flow to the optic nerve)

Question 39

anterior ischaemic optic neuropathy FUNDOSCOPY features

Answer 39

- central flame haemorrhages localised around optic disc - cotton wool infarcts localised to disc - peripheral retina clear (if not then consider retinal vein occlusion)

Question 40

age-related macular degeneration (AMD) features

Answer 40

subacute onset of visual loss with: - reduced visual acuity, particularly close objects - may have distortion (eg. bent lines) - night blindness - day to day fluctuations in visual disturbance - photopsia (flashing lights/glare)

Question 41

dry vs wet AMD signs

Answer 41

90% AMD = dry - dry = geographic atrophy, drusen - wet = neovascularisation, haemorrhage

Question 42

retinitis pigmentosa features

Answer 42

associations with various rare diseases, including Alport's - night blindness often first - tunnel vision due to loss of the peripheral retina - fundoscopy: black bone spicule-shaped pigmentation in the peripheral retina

Question 43

what is Hutchinson's sign?

Answer 43

- vesicles extending to the tip of the nose | - this is strongly associated with ocular involvement in shingles (anterior uveitis)