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PACES 2.0 > Ophthalmology > Flashcards

Ophthalmology Flashcards

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1
Q

Initial questions in history

A

Duration
Rate of profession
Monocular/binocular
Associated pain/systemic symptoms
Constant/intermittent
Effect on ADLs

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2
Q

Order of examination

A

Visual acuity
Colour vision
Fields
Eye movements
Pupillary light reflexes
Accommodation
Fundoscopy

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3
Q

Organisation for support of blind or partially sighted people

A

Royal National Institute of Blind People

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4
Q

Vision improving with pinhole

A

Could be refractive error or cataract

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5
Q

Vision does not improve with pinhole

A

Retinal
Optic nerve
Cortical

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6
Q

3 C’s of the optic disc

A

Colour
Cup
Contour

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7
Q

Visual field defect location: bitemporal hemianopia

A

Optic chiasm

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8
Q

Visual field defect location: left homonymous hemianopia

A

Right cerebral hemisphere

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9
Q

Visual field defect location: right homonymous hemianopia with macular sparing

A

Left occipital lobe

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10
Q

Visual field defect location: left homonymous inferior quadrantinopia

A

Right parietal lobe

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11
Q

Visual field defect location: right homonymous superior quadrantinopia

A

Left temporal lobe

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12
Q

Visual field defect location: right inferior altitudinal defect

A

Right retina/optic nerve

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13
Q

Visual field defect location: right complete field defect

A

Right optic nerve/retina

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14
Q

Visual field defect location: bilateral central scotoma

A

Optic nerve/retina

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15
Q

Visual field defect location: bilateral enlarged blind spot

A

Optic nerve

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16
Q

How to look for affected eye in diplopia

A

Ask patient to look in direction where diplopia is worst
Cover one eye
Outermost image disappears in eye with limited movement

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17
Q

Signs associated with Horner’s syndrome

A

Wasting of the small muscles of the hands
Scars suggesting neck surgery/trauma
Cervical lymphadenopathy

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18
Q

Dilated pupil suggests

A

III nerve palsy
Adie’s pupil

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19
Q

Constricted pupil suggests

A

Horner’s syndrome

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20
Q

Argyll Robertson pupils are

A

Small
Irregular
Do not react to light
Constrict with accommodation

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21
Q

Asymmetry of pupil size suggests

A

Motor defect

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22
Q

Relative afferent pupillary defect looks for

A

Failure to halt dilatation
Nerve fatigue

Sensitive for partial afferent defects

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23
Q

Causes of sudden visual loss

A

Vitreous haemorrhage
Retinal artery occlusion
Retinal vein occlusion
Haemorrhagic/wet age-related macular degeneration
Ischaemic optic neuropathy
Pituitary apoplexy
Stroke
Trauma

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24
Q

Reduced red reflex in eye with visual loss

A

Sudden - vitreous haemorrhage

Gradual - cataract

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25
Fundoscopy: background retinopathy
Microaneurysms Blot haemorrhages
26
Fundoscopy: pre-proliferative retinopathy
Cotton wool spots Venous dilation, beading, loops etc
27
Fundoscopy: proliferative retinopathy
Neovascularisation - typically at optic disc Prone to haemorrhage
28
Fundoscopy: high risk and proliferative disease
New vessels on or adjacent to the optic disc >1/4 of its size OR Any new vessels associated with haemorrhage
29
Management of high-risk proliferative retinopathy
Panretinal photocoagulation treatment (laser) - reduces production of angiogenic factors (I.e. VEGF)
30
Panretinal photocoagulation treatment side effects
Reduced night vision Visual field loss May be rendered ineligible to drive
31
Management of background diabetic retinopathy
Annual photographic screening - Diabetic Retinopathy Screening Service
32
Management of pre-proliferative diabetic retinopathy or maculopathy
Refer to hospital eye service within 13 weeks
33
Management of proliferative diabetic retinopathy
Refer to the eye hospital for PRP within 2 weeks
34
Diabetic maculopathy definition
Macular oedema from leaking capillaries/ischaemia due to capillary loss If fovea is threatened -> laser treatment
35
Causes of gradual loss of vision
Cataract Age-related macular degeneration Diabetic maculopathy Glaucoma Retinitis pigmentosa Optic atrophy - compressive, nutritional, toxic
36
Loss of peripheral vision causes
Constrictive - retinitis pigmentosa - glaucoma - laser PRP Unilateral - branch retinal artery/vein occlusion - ischaemic optic neuropathy Bitemporal - chiasmal lesion Homonymous - cerebrovascular disease
37
Loss of central vision causes
Diabetic maculopathy Age-related macular degeneration Optic neuropathy Cataract Branch retinal artery/vein occlusion affecting macula
38
Retinitis pigmentosa inheritance
Autosomal dominant Autosomal recessive X-linked Mitochondrial Sporadic
39
DVLA standards for driving - eyesight
6/10 Snellen acuity - read a number plate at 20m Visual field 120 degrees on the horizon and 20 degrees on vertical
40
Fundoscopy: retinitis pigmentosa
Bone-spicule pattern of retinal pigmentation Attenuation of retinal vessels Pallor of the optic disc
41
Syndromes associated with retinitis pigmentosa
Usher syndrome - neurosensory deafness Refsum disease - look for cerebellar signs Lawrence-Moon-Bardet-Biedl syndrome Kearns-Sayre syndrome - reduced eye movements
42
Investigations in retinitis pigmentosa
Automated/Goldman perimetry - visual fields Electrophysiology - current severity and prognosis Audiology Phytanic acid levels - Refsum disease Molecular genetics analysis
43
Treatment for retinitis pigmentosa
No treatment at present - trials for halting treatments in early stages Registering for partial sight/blindness through ophthalmologist - benefits -> social service support, reduced public transport costs Magnifying glasses - refer to optometrist
44
Optic nerve anatomy
Cells originate in retina Project to lateral geniculate body Midbrain
45
Optic neuropathy and pain
Headache and sudden visual loss - ischaemic optic neuropathy - look for other features of GCA Pain on eye movement - optic neuritis Constant periocular pain - sarcoidosis - Wegener’s granulomatosis
46
Optic atrophy: speed of onset
Acute - ischaemic Subacute - demyelination Gradual - compressive lesion (pituitary tumour) - nutritional - toxic
47
Optic atrophy: bilateral vs unilateral causes
Unilateral - ischaemic - compressive - demyelinating Bilateral - demyelinating - toxic - nutritional - inherited
48
Optic atrophy: signs
Reduced visual acuity RAPD Fundoscopy - pale disc Reduced colour vision VF loss in some lesions (e.g. pituitary tumour) Internuclear ophthalmoplegia (MS) Reduced eye movements (compression/inflammation)
49
Fundoscopy: optic atrophy
Pale optic disc Cupping - glaucomatous optic atrophy
50
Causes of optic atrophy
Hereditary - Leber’s, Freidriech’s ataxia Compression lesions Ischaemic - GCA must be excluded Demyelination Nutritional/toxic - B12 deficiency - smoking, methanol, drugs Trauma Glaucoma
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Visually evoked potentials assess
Optic nerve function - can confirm if loss of vision due to nerve or retina
53
Steroids in optic neuritis
Speeds up recovery Do not affect overall outcome
54
Management of arteritic ischaemic optic neuropathy
High dose steroids - IV methylprednisolone - PO 60mg prednisolone
55
Investigations in optic atrophy
Demyelination - MRI with gadolinium - VEPs Ischaemic - ESR - temporal artery biopsy - BP, carotid Doppler, CBG, HbA1c
56
Sore, prominent eye with visual disturbance, think …
Thyroid eye disease
57
Sore, gritty eyes (tear film disturbance) causes
Thyroid eye disease Sarcoidosis Primary Sjögren’s syndrome Secondary Sjögren’s syndrome
58
Pathophysiology of thyroid eye disease
Autoimmune inflammation of extra-ocular muscles and retro-orbital fat
59
Thyroid eye disease: presenting complaints and signs
Eyes appear prominent - lid retraction, proptosis Double vision - extraocular muscle restriction Unilateral progressive vision loss - optic atrophy
60
Focused examination in thyroid eye disease
Exclude optic atrophy Visual acuity Pupils - RAPD Fundoscopy Exclude corneal exposure Examine for signs of Grave’s disease - goitre - thyroid status
61
Classification of thyroid eye disease
NOSPECS - goes from asymptomatic -> signs -> symptoms -> muscle -> cornea -> vision loss
62
Investigations for thyroid eye disease
Orbital imaging - CT/MRI Orthoptic review TFTs Thyroid autoantibodies - anti-TSH/TPO/thyroglobulin
63
Differential diagnosis for thyroid eye disease
Orbital mass Orbital cellulitis Orbital fracture Myaesthenia gravis
64
Management of thyroid eye disease acutely
Tear film lubrication Steroids +/- steroid sparing agents Cessation of smoking Optimise thyroid control
65
Management of thyroid eye disease if optic nerve compression
Steroids +/- steroid sparing agents Surgical decompression Orbital RT
66
Management of thyroid eye disease if corneal exposure
Tear film lubrication Steroids +/- steroid sparing agents Surgical decompression OR Lid lengthening surgery
67
Stable/burnt-out thyroid eye disease management
Burns out after 1-5 years Cosmetic surgery Squint surgery for diplopia Lid lengthening surgery
68
Bitemporal hemianopia starting superiorly
Pituitary tumours
69
Bitemporal hemianopia starting inferiorily
Craniopharyngiomas
70
Focused examination for bitemporal hemianopia
Eye movements Facial sensation Signs of acromegaly, thyroid dysfunction etc
71
Investigations for bitemporal hemianopia
MRI pituitary Hormones - IGF-1, ACTH, cortisol, TFTs, FSH, LH, testosterone
72
Differential diagnosis for bitemporal hemianopia
Compression - pituitary adenoma/apoplexy - craniopharyngioma - meningioma - ICA aneurysm Tilted optic discs Nasal retinitis pigmentosa
73
Management of bitemporal hemianopia
Depends on aetiology Hormone replacement Surgery RT If prolactinoma, dopamine agonist - bromocriptine/cabergoline
74
Homonymous hemianopia differential diagnosis
Infarct - embolic versus arteritic Haemorrhage Tumour MS Migraine Trauma
75
Weber’s syndrome clinical features
III nerve palsy Contralateral hemiparesis
76
III nerve palsy clinical features
Down and out eye Ptosis
77
Differential diagnosis of ocular deviation and ptosis
III nerve palsy Myaesthenia gravis Orbital mass Inflammation Cellulitis Fracture
78
Causes of III nerve palsy
Pupil sparing, no other clinical features - microvascular infarction Compressive lesion - aneurysm, meningioma Brainstem infarction - Weber’s syndrome Brainstem demyelination - MS GCA Trauma Congenital
79
Investigation and management of III nerve palsy caused by compressive lesion
MRI Angiogram Neurosurgical referral
80
Investigation and management of III nerve palsy caused by microvascular infarction
BP CBG Lipids ESR/CRP If no evidence of cardiovascular risk factors - MRI to exclude compression Optimise cardiovascular risk factors
81
Anatomy of Horner’s lesion
1st order neuron - hypothalamus to T1/2 2nd order neuron - spinal cord to superior cervical ganglion 3rd order neuron - travels via internal carotid artery to orbit - innervates dilator muscle of iris
82
Clinical features of Horner’s based on location: 1st order neuron
Hemiparesis Cranial nerve palsies Wasting of small muscles of the hand
83
Clinical features of Horner’s based on location: 2nd order neuron
Wasting of the small muscles of the hands Cervical scars Carotid bruits
84
Clinical features of Horner’s based on location: 3rd order neuron
Carotid bruit - internal carotid dissection Cavernous sinus pathology - III, IV, V1, V2, VI
85
No dilation of eye with hydroxamphetamine
3rd order neuron lesion
86
Effect of cocaine on pupil in Horner’s syndrome
No dilation of pupil at 60mins
87
Investigations in Horner’s syndrome
Cocaine - confirm diagnosis Hydroxyamphetamine - confirm location MRI - brain, spine, neck, cavernous sinus CXR CT Thoracic Carotid Doppler Lymph node biopsy
88
Causes of Horner’s syndrome: 1st order neuron
Stroke Tumour Demyelination Syringomyelia Trauma
89
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Causes of Horner’s syndrome: 2nd order neuron
Pamcoast’s tumour Surgery Trauma Common carotid dissection
91
Causes of Horner’s syndrome: 3rd order neuron
Internal carotid artery dissection Cavernous sinus thrombosis/tumour Orbital tumour
92
Management of wet AMD
Ophthalmology referral Intra-vitreal anti-VEGF
93
Prognosis of wet AMD
Progress to blindness in 2 years without treatment
94
Ocular manifestations of sarcoidosis
Anterior uveitis Posterior uveitis Panuveitis Conjunctival granulomas Optic nerve involvement Lacrimal gland enlargement Eyelid abnormalities
95
Management of ocular sarcoidosis
Steroid eye drops Oral steroids DMARDs - MTX

PACES 2.0 (11 decks)

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