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Flashcards in Ophthalmology Deck (35):
1

Ophthalmoscopy | Pathology

Increased cup:disc ratio; glaucoma
Pale optic disc; optic atrophy
Blurry contour; papilloedema in raised ICP

2

AMD | Clinical features

Gradual loss of vision
Painless
Central vision only, peripheral vision spared

Wet AMD; sudden central vision loss, distortion

3

AMD | Types

Dry AMD, 90%; drusen, RPE atrophy

Wet AMD, 10%; haemorrhage, exudate, neovascularisation, pigment epithelial detachment

4

AMD | Management

Dry AMD; observation, RF modification

Wet AMD; urgent ophthalmology referral, intravitreal antiVEGF injections, RF modification

5

Primary open angle glaucoma | Clinical features

History
Triad

Gradual loss of vision
Painless
Peripheral vision
Haloes, eye ache
Scotoma

1. Visual field defect
2. Abnormal disc
3. Raised IOP

6

Glaucoma | Investigations

Goldmann tonometry; for IOP

Normal range 10-20mmHg
Ocular hypertension (OHT) >21mmHg
AACG >40mmHg

7

Primary open angle glaucoma (POAG) | Management

Medical

Implications for driving
SEs

Patient counselling

[Medical]
Topical prostaglandin analogues; travoprost
Topical beta-blockers; timolol
Topical carbonic anhydrase inhibitors; acetazolamide
Topical alpha2-adrenergic agonists

[Implications for driving]
Inform of driving standards
If glaucoma affects both eyes, must inform DVLA

[Patient counselling]
Effect of drops
SEs
Importance of compliance
Probability of lifetime treatment
That they will not notice any day-to-day benefit

8

AMD | RFs

Age >50yrs
Smoking
FH +ve

9

Acute angle closure glaucoma (AACG) | Clinical features

History
Signs

Sudden onset loss of vision
Painful
Eye redness
Fixed semi-dilated pupil
Corneal oedema; cloudy appearance due to waterlogged cornea

Deep, dull, periorbital headache
Nausea/vomiting
Haloes around lights

10

Acute angle closure glaucoma (AACG) | RFs

Female
Hypermetropia; long-sighted, smaller eye, shallower anterior chamber, more likely to occlude
Previous AACG in fellow eye
Asian ethnicity

11

Acute angle closure glaucoma (AACG) | Management

PLAN

Medical
Surgical

[PLAN]
Admit patient to hospital
Check IOP hourly until under adequate control

[Medical]
SYSTEMIC carbonic anhydrase inhibitors
1. IV acetazolamide stat
2. PO acetazolamide QDS

TOPICAL beta-blockers
1. Timolol 0.5% 1 drop BD

[Surgical]
Laser peripheral iridotomy (LPI)
Prophylaxis of contralateral eye with LPI
Cataract surgery, artificial 'pseudophakic' lens thinner allowing deepening of anterior chamber

12

Occular emergencies

Acute angle closure glaucoma (AACG)
Central retinal artery occlusion (CRAO)
Retinal detachment

Orbital cellulitis
Postoperative infective endophthalmitis

13

Central retinal artery occlusion (CRAO) | Clinical features

History
Signs

Sudden onset loss of vision
Painless
Unilateral
RAPD

Cherry red spot in the macula
Pale swollen retina
Emboli

14

Central retinal artery occlusion (CRAO) | RFs

Atherosclerotic
Embolic
Inflammatory

[Atherosclerotic]
HTN, DM
Hypercholesterolaemia
Smoking

[Embolic]
Carotid artery disease; TIA/stroke
Arrhythmias; AF
Valve vegetations; infective endocarditis

[Inflammatory]
Vasculitis; GPA, giant cell arteritis (GCA)

15

Central retinal artery occlusion (CRAO) | Investigations

BP, FBC, BM, blood cultures
Lipid profile
Coagulation profile

MUST r/o GCA in >50yrs; FBC, CRP, ESR, temporal artery biopsy

Carotid Doppler USS; carotid artery plaques/stenosis

Vasculitis autoantibodies; ANA, ANCA, DNA, RF

To r/o infective endocarditis; ECG, echocardiogram, blood cultures

16

Central retinal artery occlusion (CRAO) | Management

PLAN

Medical

Urgent ophthalmology referral within hours; retinal ischaemia similar to 'stroke', may restore vision

[Medical]
IV acetazolamide

17

Retinal detachment | Clinical features

History
Signs

Sudden onset loss of vision
Painless
Preceded by flashes of light, floaters, or 'curtain' visual field defect

If macula is involved central vision is affected, otherwise peripheral loss

Demarcation lines 'high tide marks' / tear
Retinal thinning
Pale detached retina
Loss of RPE peripheral markings

18

Retinal detachment | RFs

Myopia
Trauma
Previous ophthalmic surgery

19

Retinal detachment | Management

Surgery

[Surgery]
Vitrectomy within 24hrs

20

Orbital cellulitis | Clinical features

Paediatric ocular pain
Loss of vision
Painful limited EOM
Proptosis
Periorbital erythema, swelling/oedema, warmth, tenderness
Unilateral

Fever, malaise

21

Orbital cellulitis | RFs

Children, male
Recent sinusitis; H. influenzae
Lack of HiB vaccination
Recent eyelid surgery

22

Orbital cellulitis | Management

PLAN

Medical

[PLAN]
Admit to hospital
Urgent referral to oculoplastics/ENT

[Medical]
Abx; IV cefuroxime/ceftriaxone

23

Post-operative infective endophthalmitis | Clinical features

History
Triad

Sudden onset loss of vision
Painful
Inflamed red eye; injected conjunctiva
Hypopyon; pus in anterior chamber

Fixed unreactive pupil
Abnormal red reflex

1. Recent ocular surgery within 1/52 ago
2. Poorly controlled DM; immunocompromised
3. Painful sudden vision loss

24

Post-operative infective endophthalmitis | Investigations & Management

PLAN

Medical

Vitreous tap; intraocular fluid sample

PLAN
Immediate referral to ophthalmology
Intravitreal abx injection

25

Conjunctivitis | Clinical features

Bacterial
Viral
Allergic
Chlamydial

HSV-1
Fungal

Bacterial; red, sticky, gritty

Viral; red, watery, gritty
Adenovirus

Allergic; red, itchy, swelling, watery/mucoid, bilateral

Chlamydial; red, persistent mucopurulent discharge, unilateral

HSV-1; dendritic ulcer
Fungal; immunocompromised

26

Conjunctivitis | Investigations

Conjunctival swabs; Gram-stain, culture, PCR
PCR; unresponsive chlamydial/viral infection

Corneal scrape

Fluorescein staining; dendritic ulcers, corneal abrasion, bacterial keratitis (severe may increase risk of corneal perforation)

27

Conjunctivitis | Management

Non-pharmacological
Pharmacological

[Non-pharmacological]
Avoid contact lens wear with topical treatment
Contact lens wear should be discontinued until at least 48hrs after complete resolution of sx
Reduce risk of transmission; good hand hygiene, avoid sharing towels

[Pharmacological]
Bacterial; topical chloramphenicol
Viral; topical acyclovir
Chlamydial/gonococcal; immediate referral to ophthalmology as risk of corneal scarring
Allergic; topical/PO antihistamine

28

Anterior uveitis | Clinical features & RFs

Sudden onset loss of vision
Painful
Red eye
Photophobia
Without discharge (watery)

RFs; HLA-B27 gene association, IBD, psoriasis, spondyloarthritides (PsA, AS, JIA)

29

Anterior uveitis | Management

Referral to ophthalmology

Topical corticosteroid; topical prednisolone 1%
Pupillary dilation if synechiae; topical cyclopentolate

30

Abducens palsy, CN6 | Clinical features, Investigations & Management

Horizontal diplopia
Worse on ipsilateral gaze and in the distance
Limited abduction of ipsilateral eye

Inv; CT/MRI head to r/o head injury, raised ICP, or compressive lesions (SOL)

Tx; referral to orthoptics, fresnel prism

31

Occulomotor palsy, CN 3 | Clinical features, Investigations & Management

Horizontal and vertical diplopia
Unilateral ptosis
Fixed dilated pupils
'Down and out' gaze
Limited EOM up and inwards

Inv; CT/MRI to r/o trauma/aneurysm/SOL/stroke

Tx; ?neurosurgery depending on underlying cause

32

Trochlear palsy, CN4 | Clinical features & Management

Vertical diplopia
Worse with near vision
Torsion of images

Tx; referral to orthoptics, prisms, surgical correction

33

'Blowout' fracture | Clinical features & Management

Periorbital bruising, oedema, haemorrhage, pain
Upward gaze diplopia
Limited upward gaze
Enopthalmos

[Management]
Advise not to blow their nose, communication with sinuses may cause orbital infection

PO abx

Maxillofacial surgery

34

Myasthenia gravis | Clinical features, Investigations & Management

Variable and fatiguable sx
Diplopia
Ptosis

Inv; antiACh antibodies, edrephonium test, CT/MRI
CXR; thymoma, thyroid disease

Tx; referral to neurology to assess extent of systemic involvement
Anticholinesterases

35

Paediatric ophthalmology | Conditions

RB
Congenital cataract
ROP

[Retinoblastoma]
Leukocoria
Abnormal red reflex
Raised mass involving macula
Tx; urgent ophthalmology referral

[Congenital cataract]
Leukocoria
Abnormal red reflex
Amblyopia
Tx; urgent paediatric cataract surgery

[Retinopathy of prematurity]
Vitreous haemorrhage
Retinal detachment

Inv; ROP postnatal screening at 4-7wks of age
Laser photocoagulation