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Flashcards in Ophthalmology Deck (84):
1

What is a Kayser-Fleischer ring?

A dark ring in the eye that appears to encircle the iris

2

Cause of Kayser-Fleischer rings

Copper deposition in the iris
Usually secondary to Wilson's disease

Other causes: cholestasis, primary biliary cirrhosis, cryptogenic cirrhosis

3

What is corneal arcus/arcus senilis?

A white, grey, or blue ring in the corneal margin/at the periphery of the iris

4

What causes arcus senilis (AKA corneal arcus)?

Cholesterol deposits

i.e. caused by hypercholeseterolaemia

5

Signs in Grave's ophthalmopathy

Chemosis
Conjunctival oedema
Exophthalmos
Proptosis

6

Differentials for a painless acute red eye

Blepharitis
Ectropion/Entropion
Chalazion
Trichiasis
Subconjunctival haemorrhage
Pterygium
Foreign body/trauma

7

Differentials for a painful acute red eye

Erosion
Keratitis
Allergic/bactieral/viral conjunctivitis
Dry eues
Acute angle closure glaucoma
Iritis
Scleritis

8

Definition of blepharitis

Inflammation of the eyelid margin

9

Clinical features of blepharitis

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

Management of blepharitis

Warm compresses 15 minutes BD (melts oil produced by meibomian glands occluding the orrifice)
Followed by eyelid scrub
May need antibiotic ointment

11

Definition of a stye

An acute lesion arising from an infected meibomian gland or other sebaceous cyst under the eyelid

AKA hordeola

12

Definition of a chalazinon

A chronic lesion caused by blockage of meibomain gland leading to granulation tissue formation etc.

13

Conditions predisoposing to recurrent chalazia

Rosacea
Seborrheic dermatitis
Blepharitis
Diabetes

14

Management of chalazia and styes

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

Definition of ectropion

eversion of the lower eyelid

16

Definition of entropion

Inversion of an eyelid

17

Causes of ectropion

Age-related tissue relaxation
CN VII palsy
Posttraumatic or postsurgical changes

18

Causes of entropion

Age-related tissue relaxation
Postinfectious or post traumatic changes
Blepharospasm

19

Management of entropion/ectorpion

Entropion: surgery
Ectropion: tear supplements, occular lubricants at night, surgery for definitive treatment

20

Definition of subconjunctival haemorrhage

A collection of blood between the sclera and the conjunctiva

21

Clinical features of subconjunctival haemorrhage

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

Definition of pterygium

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

Definition of pinguecula

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

Definition of keratitis

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)

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

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

44

Normal intraocular pressure

Up to 20mmHg

45

Clinical features of open angle glaucoma

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

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)

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

Acute retinal tears
Past history of contralateral retinal detachment
Lattice degeneration
Previously undergone cataract surgery
Severe myopia
Severe ocular trauma
Diabetes
Stickler syndrome

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

Age
Genetic variants
Family history
Smoking
Cardiovascular disease
Hypertension
Obesity
Diet low in omega 3 fatty acids and dark green leafy vegetables

71

Clinical presentation of dry macular degeneration

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

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

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

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