Ophthalmology Flashcards
(84 cards)
1
Q
What is a Kayser-Fleischer ring?
A
A dark ring in the eye that appears to encircle the iris
2
Q
Cause of Kayser-Fleischer rings
A
Copper deposition in the iris
Usually secondary to Wilson’s disease
Other causes: cholestasis, primary biliary cirrhosis, cryptogenic cirrhosis
3
Q
What is corneal arcus/arcus senilis?
A
A white, grey, or blue ring in the corneal margin/at the periphery of the iris
4
Q
What causes arcus senilis (AKA corneal arcus)?
A
Cholesterol deposits
i.e. caused by hypercholeseterolaemia
5
Q
Signs in Grave’s ophthalmopathy
A
Chemosis
Conjunctival oedema
Exophthalmos
Proptosis
6
Q
Differentials for a painless acute red eye
A
Blepharitis Ectropion/Entropion Chalazion Trichiasis Subconjunctival haemorrhage Pterygium Foreign body/trauma
7
Q
Differentials for a painful acute red eye
A
Erosion Keratitis Allergic/bactieral/viral conjunctivitis Dry eues Acute angle closure glaucoma Iritis Scleritis
8
Q
Definition of blepharitis
A
Inflammation of the eyelid margin
9
Q
Clinical features of blepharitis
A
Itching Burning Mild foreign body sensation Tearing Crusting around eyes on waking Eythematous, thickened eyelid margins Crusts and debris within lashes Conjunctival injection or mild mucous discharge
10
Q
Management of blepharitis
A
Warm compresses 15 minutes BD (melts oil produced by meibomian glands occluding the orrifice)
Followed by eyelid scrub
May need antibiotic ointment
11
Q
Definition of a stye
A
An acute lesion arising from an infected meibomian gland or other sebaceous cyst under the eyelid
AKA hordeola
12
Q
Definition of a chalazinon
A
A chronic lesion caused by blockage of meibomain gland leading to granulation tissue formation etc.
13
Q
Conditions predisoposing to recurrent chalazia
A
Rosacea
Seborrheic dermatitis
Blepharitis
Diabetes
14
Q
Management of chalazia and styes
A
Warm compresses BD
Massage in direction of lashes
Oral antibiotics if associated cellulitis
(conservative measures resolve 50%)
Second-line: intralesional steroid injections
Incision and curettage
15
Q
Definition of ectropion
A
eversion of the lower eyelid
16
Q
Definition of entropion
A
Inversion of an eyelid
17
Q
Causes of ectropion
A
Age-related tissue relaxation
CN VII palsy
Posttraumatic or postsurgical changes
18
Q
Causes of entropion
A
Age-related tissue relaxation
Postinfectious or post traumatic changes
Blepharospasm
19
Q
Management of entropion/ectorpion
A
Entropion: surgery
Ectropion: tear supplements, occular lubricants at night, surgery for definitive treatment
20
Q
Definition of subconjunctival haemorrhage
A
A collection of blood between the sclera and the conjunctiva
21
Q
Clinical features of subconjunctival haemorrhage
A
History of trauma or contact (often)
Focal flat red region on ocular surface
Red-brown-yellow-clear natural development
Often no symptoms (may have foreign body sensation)
22
Q
Definition of pterygium
A
A triangular wedge of fibrovascular conjunctival tissue that typically starts mediall on the nasal conjunctiva and extends laterally onto the cornea (can cross the iris and pupil)
23
Q
Definition of pinguecula
A
A yellow-white appearing lesion on the nasal portion of the eye that does not cross the cornea due to degeneration of collagen fibres in the eye
24
Q
Definition of keratitis
A
A general term used to describe corneal inflammation
25
How many layers are there of the corena
5
26
Clinical features of keratitis
Pain or sensation of FB
photophobia
Lacrimation
Vision may be reduced if ulcer in visual axis
Herpetic: dendritic ulcer (with terminal bulbs) stained with fluorescein
27
Management of keratitis
Herpetic: acyclovir ointment hourly for 24h then 5x per day for 14 days
Contact lens-associated: referral to ophthal for scraping of ulcer and commencement of antibiotic treatment
28
Definition of acute uveitiis
Inflammation of the uveal tract, including the iris, ciliary body and choroid
29
Conditions predisposing to acute uveitis
```
Wegener granuomatosis
Sarcoidosis
Ankylosing spondylitis
IBD
Behcet's syndrome
Use of oral bisphosphonates
```
30
Symptoms of iritis (acute anterior uveitis)
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Deep pain
Redness
Photophobia
Blurred vision
Tearing
```
```
Red. visual acuity
Constricted, nonresponsibe pupil
Leukocytes or flare in anterior chamber
KERATIC PRECIPITATES (WBC stuck to posterior surface in cornea)
Synechiae (iris adhesions to lens/anterior chamber angle AKA scar)
Hypopyon
Raised intraocular pressure
Band keratopathy
```
31
Definition of hypopyon
Pus in anterior chamber
32
Posterior uveitis presentation
Blurred vision
Floaters
Raised IOP
Disc or macular oedema
33
Management of iritis
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REFER TO OPHTHAL within 24h
Mydriatics (red. formation of posteirior synechiae + red. pain from ciliary spasm)
Topical steroids
Systemic analgesia
Work up to rule out secondary causes
```
34
Complications of iritis
Inflammatory glaucoma
Posterior synechiae
Peripheral anterior synechiae (adhesion of iris to cornea)
Cataracts
Band keratopathy and macular oedema if chronic
35
Definition of scleritis
A severe destructive, vision-threatening inflammation involving the deep episclera and sclera
36
Definition of episcleritis
Inflammation between the sclera and conjunctiva (ring around iris without inflammation)
37
Clinical presentation of scleritis
Pain (deep, boring ache, severe enough to interfere with sleep and appetite)
Photophobia
Lacrimation
Red eye
Hyperaemic patches beneath bulbar conjunctiva
Normal palpebral conjunctiva
Nocdular: hyperaemic, oedematous, raised nodule
Necrotising: avascular area (white in middle of red)
38
Management of scleritis
Oral NSAIDs first-line in mild-moderate
Corticosteroids
Immunomodulatory agents (MTX for RA, cyclophosphamide or mycophenolate for Wegener's)
Surgical indications: perforation, excessive thinning with high risk of rupture, high-grade astigmatism
39
Management of penetrating eye injury
Immediately protect with non-pressure shield and transfer to ophthal
40
Management of chemical injury
Copious irrigation for at least 15 minutes
Chlorsig ointment QID, review in 2 days
+/- bandage contact lens
topical antipiotic drops/ointment (pseudomonas coverage if contact lens wearer)
Topical NSAIDs for pain relief
Minor abrasions heal in 24h with symptomatic treatment only
If increase in pain, immediately return!
41
Definition of open-angle glaucoma
A chronic condition in which the angle between the iris and cornea is not obstructed, but aqeous humour does not adequately drain from the anterior chamber
42
Definition of acute closed-angle glaucoma
Occurs when the iris bows forward and completely blocks fluid access to the trabecular meshwork - positive feedback loop - rapid increased in IOP, excruciating eye pain and rapid loss of vision
43
Risk factors for chronic open angle glaucoma
```
Old age
Family history
Black race
Thinner central corneal thickness
Systemic HTN
Diabetes
Myopia
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44
Normal intraocular pressure
Up to 20mmHg
45
Clinical features of open angle glaucoma
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Symptomatic visual field loss (missing stairs - inf. field, notice portions of words missing when reading, difficulty driving)
Abnormal visual field examination
Fundoscopy:
- Inc. cup:disc ratio
- Pitting or notching of rim
- vertical elongation of the cup
Raised IOP on tonometry
```
46
Management of open angle glaucoma
Aim to reduce IOP by 20-40%
Medical agents: topicall preferred - should be applied with passive lid closure and punctal occlusion
Surgical management (if failed medical)
- laser trabeculoplasty
47
Medications which reduce IOP
```
Prostaglandin analogues - latanoprost
Beta-blockers - timolol
Alpha2 selective adrenergic agonistis
Cholinergic agonists - pilocarpine
Carbonic anhydrase
```
48
Presentation of acute angle-closure glaucoma
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Severe ocular pain and redness
Reduced vision
Coloured halos around lights
Headache
Nausea and vomiting
(systemic complaints may be so severe that patients are misdiagnosed as having neurological or GI infections - EXAMINE EYES)
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```
Conjunctival hyperaemia
Hazy cornea
Fixed mid-dilated pupil
Red. visual acuity
Raised IOP (usually higher than 40)
```
49
Investigation for determinining if open or closed angle glaucoma
Gonioscopy
50
Management of acute glaucoma
TREAT IMMEDIATELY - OPHTHAL EMERGENCY
- IV Diamox (acetazolamide - osmotic drug)
- Topical eye drops to reduce IOP (timolol, pilocarpine, latanoprost)
- Prompt laser peripheral iridotomy (to open angle) as soon as cornea is clear of inflammation
51
Risk of bilateral acute glaucoma
Risk of occurring in second eye after presentation in 1 eye is 80%, therefore perform laser iridotomy on both eyes
52
Definition of retinal detachment
Separation of the neurosensory retina from the retinal pigment epithelium leading to accumulation of subretinal fluid in the potential space between the 2
53
Risk factors for retinal detachment
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Acute retinal tears
Past history of contralateral retinal detachment
Lattice degeneration
Previously undergone cataract surgery
Severe myopia
Severe ocular trauma
Diabetes
Stickler syndrome
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54
3 types of retinal detachment
Rhegmatogenous (most common)
Tracitonal
Exudative
55
Clinical features of retinal detachment
Sudden onset
Flashes of light
Floaters (hazy spots in line of vision which move with eye position)
Peripheral field loss
Loss of central vision (if macula "off" - also separated)
Low IOP
Loss of red reflex - detached retina is grey-white with surface vessels
56
Management of retinal detachment
(rhegmatogenous)
| Ophthal referral - surgery
57
Causes of retinal artery occlusion
```
Emboli:
- atherosclerotic plaques
- Endocarditis
- Fat
- Atrial myxoma
Thrombosis:
- Systemic vasculitis (e.g. SLE)
- Giant cell arteritis
```
58
What is rubeosis iridis
Neovascularisation of the retina or iris
59
Clinical presentation of retinal artery occlusion
Sudden, painless severe vision loss or visual field defect
Usually unilateral
(if related to GCA, age over 55, headache, tender palpable temporal artery, jaw claudication etc)
Pupil may respond poorly to light
Pale, opaque fundus with cherry red spot fovea on white-yellow background
"Box-carring" of vessels
Retinal oedema (pale retina)
Embolus sometimes visible
60
Perfusion of central macula following retinal artery occlusion
By presence of cilioretinal artery present in 15% of people
61
Management of retinal artery occlusion
Treat immediately if occlusion occurred within 24h
Reduce IOP:
- topical timolol
- IV or oral acetazolamide (Diamox)
- intermittent digital massage over closed eyelid
(may lead to dislodge embolus and enter smaller branch of artery - reduce area of retinal ischaemia)
Surgical or laser-mediated embolectomy uncommonly performed
IF GCA: HIGH DOSE SYSTEMIC CORTICOSTEROIDS
62
Time after occlude vessel before retinal infarction occurs
90 minutes
63
Risk factors for retinal VEIN occlusion
```
Age over 65
HTN
DM
Obesity
Hypercoagulable state (Factor V Leiden)
Glaucoma
REtinal arteriolar abnormalities
Arteriosclerotic vascular disease
```
64
Clinical features of branch retinal vein occlusion
Some are asymptomatic
Scotoma or visual field defect with blurred or grey vision in ONE area
retinal haemorrhage - focal or wedge-shaped (flame-shaped, dot and blot haemorrhages)
+/- Venous dilation
Visual acuity relatively normal
65
Clinical features of central retinal vein occlusion
Painless acute onset unilateral BLURRED vision
Ipsilateral relative afferent pupillary defect
Retinal haemorrhage (scattered and diffuse)
Dilated and tortuous veins
Cotton wool spots (50%)
66
Invesitgation for retinal vein or artery occlusion
Fluorescein angiography
67
Management of retinal VEIN occlusion
No treatment to restore vision
Treat underlying cause/contributing factors
Retinal laser photocoagulation OR intra-vitreal anti-VEGF to reduce neovascularisation and reduce risk of neovascular glaucoma
68
Diabetic retinopathy changes
Non-proliferative:
- retinal microaneurysms
- dot and blot haemorrhages
- flame-shaped haemorrhages
- hard exudates
- cotton wool spots
Pre-proliferative
- large blotchy haemorrhages
- cotton wool spots
- beading of retinal veins
- intra-retinal microvascular abnormality
Proliferative (only 5% DM patients will reach this stage)
- Neovascularisation of iris, disc, retina to vitreous
- retinal detachment
69
Definition of age related macular degeneration
A degenerative disease of the central portion of the retina (the macula) that results primarily in loss of central vision
DRY AKA atrophic
WET AKA neovascular or exudative
70
Risk factors for age-related macular degeneration
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Age
Genetic variants
Family history
Smoking
Cardiovascular disease
Hypertension
Obesity
Diet low in omega 3 fatty acids and dark green leafy vegetables
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71
Clinical presentation of dry macular degeneration
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Loss of central vision over several years
Usually bilateral
Central blind spots late in disease
Painless
Fundoscopy:
- Druse
Changes in retinal pigment epithelium
Areas of chorioretinal (geographic) atrophy
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72
What are drusen
Yellow spots in retina from accumulation of waste products from rods and cones
73
Clinical presentation of wet age related macular degeneration
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RAPID vision loss (days-weeks)
Visual distortion is first symptom
- central blind spot
- curving of straight lines (metamorphosia)
Peripheral and colour vision normal
USUALLY UNILATERAL
Fundoscopic:
- localised retinal elevation
- retinal oedema
- grey-green discoloration under macula
- exudates in or around the macula
- detachment of retinal pigment epithelium
- subretinal haemorrhage in or around the macula
```
74
Definition of metamorphosia
Curving of straight lines as in acute (wet) macular degeneration
75
Early recognition of acute deterioration in macular degeneration
Amsler's grid (focus on centre dot from a distance of 12 inches)
76
Management of dry age related macular degeneration
No way to reverse damage
Can reduce risk of developing advanced AMD if have extensive drusen etc. with daily supplements
- zinc oxide
- copper
- vitamin C
- vitamin E
- Lutein - or beta-carotene/vitamin A in people who haven't smoked (in smokers, beta carotene increases risk of lung cancer)
77
Management of wet macular degeneration
Daily supplements recommended for dry (zinc, copper, vit C/E/A)
Intravitreal anti-VEGF injection +/- intraocular steroids
Laser photocoagulation
Photodynamic therapy
78
Supportive measures for those who have vision loss in macular degeneration
Low-vision devices
- magnifiers
- high-power reading glasses
- large computer monitors
- telescopic lenses
79
Keratoconus
Thinning of the cornea - bulging, causes refractive error treat initially use hard contacts to stop coning
Often from Finnish background
Family history
80
Differential diagnoses for Flashes
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Ophthalmic:
- posterior vitreous detachment
- retinal tear/hole
- retinal detachment
- optic neuritis
Non-ophthalmic
- migraine
- postural hypotension
- occipital traumas
- vertebrobasilar TIAs
```
81
Differential diagnoses for floaters
- Vitreous syneresis
- Vitreous haemorrhage
- Posterior vitreous detachment
- Retinal detachment
- Vitritis
- Tear film debris
82
Drusen v exudates
Drusen are sub retinal deposits of debris from retinal pigment epithelial later
Exudates are intraretinal
83
Soft v hard drusen
Soft: larger, indistinct margins may slowly enlarge and coalesce
Hard: small, round, discrete spots associated with focal dysfunction of RpE usually innocuous
84
Pharmacological classes, mechanisms and examples of topical drops for reduction in intraocular pressure
Alpha adrrnergic inhibitors
