Ophthalmology 4 Flashcards by John Darlington

Name some important investigations to do into someone you suspect has cataracts:

Visual acuity test

Red reflex*

Fundoscopy

Intra-ocular pressure
- differential open angle

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What are some differentials for diploia?

Orbital causes:

Grave’s
Trauma
Tumour

Neuromuscular:
- Myasthenia gravis

Palsies:

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What is the function of the muscles of the eye?

Medial and lateral: one function.

The rest can be remember with the pneumonic: SIN RAD, which stands for:

- Superiors - intort 
- Rectus - adduct

Superior Rectus: Elevates, Intorts, Adducts
Inferior Rectus: Depresses, Extorts, Adducts

Superior Oblique: Intorts, Abducts
Inferior Oblique: Extorts, Abducts

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What is the most common causes of 3rd nerve palsies?

Neuropathy

diabetes mellitus
this will spare the pupil

Posterior communicating artery aneurysm

Tumour

Vasculitis

Demylination

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What type of diplopia does 4th nerve palsy get?

Vertical

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What is an improtant aspect of 6th nerve palsy?

False localising sign

- raised ICP

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How is diplopia investigated?

Bloods:

glucose
inflammatory

Imaging:

CT angiogram (fi suspect posterior communicating artery aneurysm)
CT head (tumour)

Referral to neurosurgery
- posterior aneurysms can involve so important to refer

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If there is a medical management for diplopia how should they be managed?

Treat underlying cause

Inform DVLA
- all patients with diplopia must inform

Prisms
Botulism injection

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What are the signs on fundoscopy of retinal vein occlusion?

Vessel tortuosity

Optic disc swelling

Retinal haemorrhages

Cotton wool spots

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What are the major causes of central retinal vein occlusion?

Hypertension
Hypercholesteromia
Diabetes
Smoking

Coagulative conditions

polycythaemia
factor V Leiden

SLE

COCP

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How is a central vein occlusion investigated?

*Blood pressure
*Glucose

Bloods:

FBC
CRP
ESR
Coagulation screen

X-rays:

OCT Scan
Fluorescent angiogram

If there is suggestion of underlying pathology then: 
Autoimmune screen: 
- RF 
- ANCA
- ANA 
- Anti-cardiolipin 
- ACE

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What investigations are done into a central arterial occlusion?

Rule out GCA

Then:
Sent to TIA clinic
- CT head
- carotid doppler

Treatment:

aspirin
Clopidogrel

No driving for 1 month

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What type of optic neuropathy does GCA cause?

Anterior Ischemic Optic Neuropathy

This specifically relates to disruption of the posterior ciliary arteries

reduced visual acuity
RAPD
loss of colour vision
disc swelling

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When checking vision acuity in someone with glasses, what two ways should it be checked?

Normal Snellen chart
+
Pinholes

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How can you differentiate between an ulcer and abrasion of the cornea?

Ulcer penetrates into the stroma which will turn complete green with fluorescein straining

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Outline the differences in different types of corneal ulcers:

Bacteria:

acute onset
Painful with photophobia
round lesion
7 days worth
contact wearers

Viral:

Insidious onset
painful with irritation
dendritic shape
<7 days

Fungal

delayed on set
painful +photophobia
feathery edges

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What are the key symptoms of uveitis?

Red eye

Painful eye
- especially on movement

Photophobia

+/-
Visual acuity changes

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What are the causes of uveitis and what are some of the longer sequalae?

Causes:
Idiopathic

Infection (TB, STIs)

Autoimmune (HLAB27)

Sequalae:

Glaucoma
Clouding of the cornea
Cataracts

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What is the main defect in corneal abrasions?

Epithelium

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What signs may make you think there has been globe rupture?

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Irregular shape to iris - iris may ruptured out
360 subconjunctiva haemorrhage
Flat Anterior chamber

Management:

Visual assessment
CT - if suspect foreign body

Analgesia
Antibiotics
Tetanus

What are the symptoms of a retrobulbar haemorrhage?

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Pain
Sub-Conjunctival Haemorrhage
Reduced vision 
RAPD 
Proptosis Reduced mobility 
Reduced mobility

*reduced vision and movements as the blood compresses on the optic nerves

What is the complication that can occur with a sub-orbital fracture?

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Trap door
- where the inferior intraocular muscles get trapped preventing eye movements

When the patient tries to move their eye they can get a reflex bradycardia

What are the main causes of a traumatic red eye?

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Corneal ulcer/ abrasion

Retrobulbar Haemorrhage

Penetrating injury

Chemical injury

What are the main causes of a non-traumatic red eye?

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Conjunctivitis

Uveitis

Acute angle closure glaucoma

Scleritis / episcleritis

Cellulitis

What is astigmatism?

Refractive error where there light focuses on different areas due to irregular shape of the eye - usually described as a rugby ball shape

What is the distortion seen in ARMD?

Metamorphopsia | - blurring of straight lines

What are the major risk factors for retinal detachment?

Previous retinal detachment Recent surgery Myopia - long spaced eye Trauma Family history

What is the first branch to come off the internal carotid?

Central retinal branch

What drug is given for GCA which is causing vision loss? and what is the underlying cause to GCA?

Methylprednisolone *mainstay to reduce vision loss in the other eye Underlying disease: - Anterior Ischemic Optic Neuropathy due to disruption of the posterior ciliary arteries

What are structures which hold the lens in place - and what conditions are associated with them breaking causing dislocation?

Zonules Marfan's syndrome Ehrler's Danlos syndrome

What are the risk factors for cataracts?

Traumatic - blunt force - think boxer Diabetes Steroid use Advancing age Congenital

What are the stages of checking vision?

Snellen Counting fingers Hand motions Light and dark

What are some red flags in the history of eye examination?

Flashers/ floaters Headache - N&V - Jaw/ temporal Transient vision loss Halos

What is the different type of chart that can be used for assessing visual acuity?

DRSET | - type of logmar

What is Fluorescein angiography?

A dye which is injected to the arm. Passes up through the system into the eye which will give details on the vasculature of the eye. Helps for macular degeneration, neovascularisation (as you can see where the dye does not go, where it leaks etc)

What are the risk factors for ARMD and what is the pathophysiology?

Age Smoking Hypertension Family history Patho: build up of debris (drusen) between the choroid and retina leading to atrophy of pigmented epithelium and rods and cones *remember only affects macula as it receives its blood supply from the choroid exclusively

What are the main investigations conducted into ARMD?

OCT Fluorescein Angiography Amsler's grid

In primary open angle glaucoma what can be seen on fundoscopy? and what are your diagnostic investigations?

>0.7 cup to disc ratio Optic disc pallor (atrophy occurring) Investigations: - Automated perimetry - Tonometry - Gonioscopy - to assess angle - Slit lamp examination *over 40 should be screened annually if family history

What are the most common pathogens to cause keratitis?

Staph Aureus Pseudomonas

What are the major complications that can occur with the eye when in ICU?

Corneal abrasion Exposure keratopathy Chemosis - due to ventilation pressures - too tight endotrachael tubing * causes keratitis but exposing the eye Conjunctivitis Ischaemic optic neuropathy - same position - poor blood pressure Acute Angle Glaucoma - due lying prone

What is the diagnostic investigation into retrobulbar haemorrhage? Management?

CT Scan of orbits Canthotomy/ canthyolysis

What is the normal pressure in the anterior chamber?

10-21mmHg

What are the diagnostic investigations into primary open angle glaucoma?

Goldmann Application tonometry Visual field testing - perimetry Fundoscopy - optic disc to cup size >0.5 is abnormal

What is the management of open angle glaucoma?

Latanoprost - side effects include eye lash elongation - eyelid pigmentation and iris pigmentation * increases outflow Timolol - reduce production Dorzolamide - carbonic anhydrase inhibitor Surgical: - trabeculectomy * creates a small plebe

Outline the pathophysiology of diabetic retinopathy, how likely is to to cause blindness? and how is it treated?

Basement membrane dysfunction which initially causes leaks and aneurysms (Dots) These can the leak (blots) The fluid leaked is reabsorbed and leaves behind debris (hard exudates) Eventually the basement membrane pericytes close up causing ischemia and micro-infarcts (cotton wool spots) - this then triggers VEGF release The mixture of fluid from new vessels and aneurysms accumulates in the macula causing macula oedema Treatment: - control of BP and glucose - pan-retinal photocoagulation - Anti- VEGF

What are some of the factors which can make diabetic retinopathy worse?

``` Smoking Poor glycaemic control Smoking Pregnancy Failing to comply with annual check up ```

What are in the investigations done into diabetic retinopathy?

Photographs of fundus OCT (source macular oedema) Fluorescein angiography (source leakage)

Outline tests done into open angle glaucoma:

Applanation tonometry Slit lamp examination - check cup to disc ratio Automated perimetry visual assessment Measurement of corneal thickness Gonioscopy measurement

What are the complications of diabetic retinopathy?

Retinal detachment Vitreous haemorrhage Optic neuropathy Cataracts

Ophthalmology 4 Flashcards

(49 cards)