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Phase 3B > Ophthalmology > Flashcards

Ophthalmology Flashcards

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1
Q

What are some common colour changes that may be seen in the eyes due to pathology?

A
  • Red: bleeding or inflammation
  • Blue: indicates thinning of the sclera (RA and osteogenesis imperfecta)
  • Yellow: jaundice
  • Brown/black: pigmentation
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2
Q

What are the main ‘red flag’ features or a red eye?

A
  • Impaired vision
  • Pain/photophobia
  • Lack of ocular discharge (if discharge present, more likely to be infection ie conjunctivitis)
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3
Q

What kind of ocular pathology causes rapid onset visual loss?

A
  • Vascular eg Central retinal vein occlusion

- Inflammatory ie GCA

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4
Q

What kind of ocular pathologies cause slow onset loss of vision?

A

-Degenerative causes ie age related macular degeneration

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5
Q

What is acute angle closure glaucoma?

A
  • Rare but serious cause of red eye
  • Associated with raised intra-ocular pressure
  • Normal: 10-21mmHG
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6
Q

What are the risk factors for acute angle closure glaucoma?

A

-Hypermetropia (long sightedness)
-Increase in age
-Pupillary dilatation
>is sat in a dark room watching a movie when the pain starts

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7
Q

What are the symptoms of acute angle closure glaucoma?

A
  • Severe pain (eye pain or headache)
  • Decrease in visual acuity
  • Worse with dilated pupil
  • Red eye
  • Haloes around lights
  • Systemic upset ie nausea and vomiting
  • Photophobia
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8
Q

What are the signs of acute angle closure glaucoma?

A
  • Red eye
  • Semi-dilated, non reacting pupil
  • Corneal oedema: dull/hazy cornea
  • Poor visual acuity
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9
Q

What type of visual loss dose acute glaucoma cause?

A

-Primarily causes visual loss by peripheral visual field deficit

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10
Q

How is acute angle closure glaucoma investigated?

A 
-Slit lamp examination.
>Shows large cup and nerve fibre loss
-Gonioscopy
-Automated perimetry (allows assessment of visual field)
-Meaure intraocular pressure
-Visual field loss on assessment
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11
Q

How is acute glaucoma managed?

A

-Urgent referral to ophthalmology
1. Lower the pressure
>topical carbonic anhydrase inhibitors (dorzolamide) or topical beta blockers
>+oral/iv acetazolamide
2. Constrict the pupil
>Pilocaprine drops (topical cholinergic agonist)
3. Prevent recurrence
>laser +/- surgery

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12
Q

What is chronic glaucoma/primary open angle glaucoma?

A
  • Optic neuropathy associated with raised intra-ocular pressure
  • Prevalence increases with age
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13
Q

What are the risk factors for chronic open angle glaucoma?

A
  • Increasing age
  • Family history
  • Myopia (short sightedness)
  • Hypertension
  • DM
  • Afro-caribbean origin
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14
Q

What are the features of chronic glaucoma?

A

-Triad of:
>raised IOP
>Abnormal disc
>visual field defect

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15
Q

What are the symptoms of chronic glaucoma?

A

-Insidious onset
-Often asymptomatic
-Routine finding
-Peripheral visual field loss
>nasal scotoma leading to tunnel vision
-Decreased visual acuity

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16
Q

How is chronic glaucoma investigated?

A
  • Fundoscopy
  • Automated perimetry (assess visual fields)
  • Slit lamp examination
  • Applanation tonometry
  • Central corneal thickness measurement
  • Gonioscopy
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17
Q

What are the signs of chronic glaucoma on fundoscopy?

A
  • Optic disc cupping
  • Optic disc pallor: optic atrophy
  • Bayonetting of vessels
  • Cup notching
  • Disc haemorrhage
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18
Q

How is chronic glaucoma treated?

A

-Eye drops
>prostaglandin analogue eyedrops ie lantoprost
-2nd line:
>beta blocker or carbonic anhydrase inhibitor or sympthomimetic eyedrops
-If more advanced: surgery or laser treatment
-Regular reassessment to exclude progression and VF loss

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19
Q

What is age related macular degeneration?

A
  • Most common cause of blindness in the UK
  • Degeneration of the central retina (macula)
  • Bilateral changes
  • Females>males
  • Disease of age >70
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20
Q

What are risk factors for ARMD?

A
  • Increasing age
  • Smoking
  • Family history
  • Hypertension
  • Dyslipidaemia
  • DM
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21
Q

What are the symptoms of ARMD?

A
  • Visual loss (subacute onset)
  • Decrease in visual acuity (near field )
  • Decrease in night time/dark vision
  • Fluctuating visual disturbance (varies from day to day)
  • Photopsia (flickering/flashing lights, glare around objects)
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22
Q

What is dry ARMD?

A
  • Earlier disease
  • most cases are dry
  • General atrophy
  • Presence of drusen
  • Alterations to the reintal pigment epitherlium
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23
Q

What are drusen in regards to ARMD?

A
  • Yellow round spons in the Bruch’s membrane

- Sign of dry ARMD

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24
Q

What is wet ARMD?

A
  • Worse prognosis
  • Later disease
  • Exudative with neovascularisation
  • Characterised by choroidal neovascularisation
  • Leakage of serous fluid and blood can result in rapid loss of vision
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25
What are the signs of macular degeneration?
-Distortion of line perception -Drusen on fundoscopy (dry) and may later form a macular scar -Wet: well demarcated red patches (intra/subretinal leakage or haemorrhage)
26
What investigations need to be done for ARMD?
- Slit lamp microscopy with colour fundus photography - Fluorescein angiography (to look for neovascularisation) - Optical coherence tomography
27
How is ARMD treated?
-Vitamins 'ACE to Z' (a,c,e and zinc) -Antivascular endothelial growth factor for wet ARMD >ranibizumab (slows progression of neovascularisation) -Blind registration and visual aids
28
What are cataracts?
- Common condition = lens gradually opacifies and becomes cloudy) - Decreased visual acuity and blurred vision - Leading cause of blindness worldwide
29
What are the causes of cataracts?
- Most common cause: normal ageing - Smoking - Alcohol - DM - Trauma - Steroids - Radiation - Metbolic disorders - Congenital ie TORCH infections
30
How does the type/classification of cataract relate to its cause?
- Nuclear: old age - Polar: inherited - Subscapular: steroid use - Dot opacities: common in normal lenses, seen in diabetics and myotonic dystrophy
31
What are the symptoms of cataracts?
- Gradual onset - Decrease in vision - Faded colour vision - Glare - Haloes around lights
32
What is the hallmark sign of cataracts which can be elicited on examination?
-Defect in/loss of red reflex
33
What investigations need to be done for cataracts?
-Ophthalmoscopy on dilated pupil >need to see normal fundus and normal optic nerve -Slit lamp examination
34
How are cataracts managed?
-Conservative management initially >stronger glasses >encourage use of brighter lights -Surgery >definitive treatment - removes cloudy lens and replaces with artificial one >referral for: visual impairment, impact on QoL, pt choice
35
What are some possible complications of cataract surgery?
- Posterior capsule opacification (thickening of lens capsule) - Retinal detachment - Posterior capsule rutpture - Endophthalmitis (inflammation of the aqueous and or vitreous humour)
36
What is vitreous detachment?
- Precedes retinal detachment. - Vitreous shrinks with age and can sometimes pull away causing bleeds or retinal detachment - Causes flashes and floaters
37
What is retinal detachment?
- Acute sudden painless loss of vision - Holes/tears in the retina allow fluid to separate the sensory retina from the retinal pigmented epithelium - Visual defect location depends on which part of the retina has detached - A retinal tear needs fixing before detachment occurs
38
What are some risk factors/causes of retinal detachment?
- Myopia (short-sightedness) - Cataract surgery - Diabetes - Hypertension - Trauma - Vasculitis
39
How does retinal detachment present? Think about the 4Fs..
1. Flashes 2. Floaters 3. Fall in acuity 4. Field loss - Painless loss of acuity - like a curtain falling down - Complain of seeing 'spider webs'
40
What investigations are done for retinal detachment?
- B-scan USS - Ophthalmoscopy - Slit lamp examination
41
What would the investigations for retinal detachment show?
- Grey, opalescent retina which balloons forwards | - 'Peeling away' of retina, tears may be visible
42
How is retinal detachment managed?
-Urgent ophthalmology referral -Rest -Positioned according to location of detachment >superior detachment: lie flat >inferior detachment: sit at 30* with head up -Laser therapy -Urgent surgery
43
What is a vitreous haemorrhage?
- Bleeding into areas around the vitreous humour | - Causes sudden painless loss of vision
44
What are the risk factors/causes of vitreous haemorrhage?
-Anything which can cause neovascularisation or bleeding risk >Diabetes >Bleeding disorders >Retinal tear/detachment >Trauma >Central retinal vein occlusion which has neovascularised >Wet ARMD
45
What are the symptoms of vitreous haemorrhages?
- Small bleed: floaters, dark spots | - Large bleed: obscured, complete loss of vision
46
What are the signs of vitreous haemorrhage on examination?
- Absent red reflex | - Retina not visible
47
What investigations should be done for vitreous haemorrhage?
- Fundoscopy - B scan USS - Eye examination > decreased visual acuity
48
How is a vitreous haemorrhage managed?
- Usually spontaneously resorbs | - If dense/severe: vitrectomy to remove the blood
49
What is a central retinal artery occlusion?
- Considered a form of stroke - Dramatic visual loss within seconds of occlusion - acuity limited to finger counting or worse - Less common than CRVO
50
What are the causes/risk factors of CRAO?
- Thromboembolic/vascular disease - Arteritis - AF - Heart valve disease - Diabetes - Smoking - Hyperlipidaemia
51
What are the features of CRAO?
-Sudden painless loss of vision
52
What are the signs of CRAO?
- Relative afferent pupillary defect: MARCUS-GUNN pupil | - Fundoscopic signs: white retina, cheery red spot at macular
53
How is CRAO managed?
- Treat as stroke - Immediate CT head - Exclude GCA (using ESR) - Intraocular hypotensives (acetazolamide) - Decrease IOP by ocular massage - Address cv risk factors to reduce recurrence
54
What is central retinal vein occlusion?
-Sudden painless LOV
55
What are the risk factors/causes of CRVO?
- Glaucoma - Polycythaemia - Hypertension - DM - Increasing age - Vascular disease
56
What are the symptoms of CRVO?
- Sudden painless loss of vision | - Severe drop in acuity
57
What are the signs of CRVO on fundoscopy?
- Cotton wool spots - Swollen optic nerve - Macular oedema - Severe retinal haemorrhage * cheese and tomato pizza appearance
58
How is CRVO managed?
- Ophthalmology - Intra-vitreal anti-vgef therapy - Dexamethasone implants
59
What are some complications of CRVO?
- Neovascularisation | - Chronic macular oedema
60
What is optic neuritis?
-Inflammation of the optic nerve
61
What are the causes of optic neuritis?
- MS - Syphillis - Diabetes - Leber's optic atrophy (hereditary form of visual loss) - Vitamin deficiency
62
What are the symptoms of optic neuritis?
- Unilateral subacute loss of vision - Pain on eye movement - Dyschromatopsia (poor colour vision discrimination)
63
What are the signs of optic neuritis?
- Marcuss-Gunn pupil (RAPD - seen on swinging light test) - Central scotoma (areas of depressed vision) - Decrease in visual acuity on eye examination
64
How is optic neuritis managed?
-High dose steroids >Iv methylprednisiolone for 72 hours -MRI if ?MS
65
What is retinitis pigmentosa?
- Inherited degeneration of the retina - Usually affects males - Inherited AD, AR, X linked
66
Which gene is mutated in retinitis pigmentosa?
-Retinitis pigmentosa GTPase regulator gene (RPGR)
67
What are the feautres of retinitis pigmentosa?
- Night blindness (usually one of the first symptoms) - Tunnel vision (due to loss of peripheral retina) - Central daytime visual loss follows - Eventual blindness - Family hx
68
Which diseases are assocated with retinitis pigmentosa?
- Usher syndrome (affects hearing and vision) | - Alport syndrome (kidney disease, hearing loss, eye abnormalities)
69
What are the signs of retinitis pigmentosa on fundoscopy?
- Black bone spicule shaped pigmentation in peripheral retina - Mottling of retinal pigment epitherlium - Decrease acuity on examination
70
How can retinitis pigmentosa be treated?
- Visual aids and blind registration - Electrical stimulation of retinal ganglion cells - Neural prosthetics
71
What is diabetic retinopathy?
- Painless, gradual decrease in central vision | - Associated with vitreous haemorrhage
72
Why does diabetes cause retinopathy?
- Hyperglycaemia causes increase in retinal blood flow which damages the endothelial cells - Endothelial dysfunction = increased vascular permeability (visual exudates on fundoscopy) - Microaneurysms and neovascularisation occurs later
73
How can diabetic retinopathy be classified?
- Background (non-sight threatening) - Pre-proliferative - Proliferative
74
What are the features of 'background' diabetic retinopathy?
- Dots, blots and spots 1. Microaneurysms (dots) 2. Blot haemorrhages (<3) 3. Hard exudates
75
Features of pre-proliferative Diabetic retinopathy?
- Cotton wool spots - >3 blot haemorrhages - Venous beading/looping - Deep/dark cluster haemorrhages - More common in T1DM
76
What are the features of proliferative diabetic retinopathy?
- Retinal neovascularisation - Fibrous tissue forming anterior to the retinal disc - More common in T1DM - 50% blind in 5 years
77
What are the risk factors for diabetic retinopathy?
- Early/long term diagnosis - Hypertension - Renal disease with proteinuria - Pregnancy - Minority ethnic groups
78
How is diabetic retinopathy diagnosed?
-Dilated retinal photography with accompanying ophthalmoscopy
79
How is diabetic retinopathy treated?
- Good glycaemic control - Laser treatment - Intravitreal steroids - Anti-VEGF (vascular endothelial growth factor)
80
What are the complications of diabetic retinopathy?
``` -Visual loss due to: >macular oedema >macular ischaemia >vitreous haemorrhage >retinal detachment ```
81
What is diabetic maculopathy?
- Hard exudates and other background changes on the macula | - More common in T2Dm
82
What is the management for diabetic maculopathy?
- Check visual acuity | - Treat with laser therapy
83
What is hypertensive retinopathy?
-Eye disease/damage from hypertension | >occurs from chronic, poorly controlled hypertension or malignant hypertension
84
What may cause accelerated hypertensive retinopathy?
- Exacerbation of essential HTN - Intrinsic renal disease - Renal artery stenosis - Pheochromocytoma - Cushing's and Conn's
85
What are the features of hypertensive retinopathy?
- Microinfarcts - Heightened light reflex on the artery (silver wiring) - arteriovenous nipping - Flame haemorrhages - Exudates - Papilloedema - Neovascularisation
86
What are the Keith-Wagener classification stages of hypertensive retinopathy?
- Stage 1: arteriolar narrowing + tortuosity and increased light reflex - Stage 2: arteriovenous nipping - Stage 3: spots, dots, blots (cotton wool spots, exudates, flame and blot haemorrhages) - Stage 4: papilloedema
87
What are some other causes of poor vision in hypertension?
- Acute optic nerve damage - Macular oedema - Retinal artery closure/occlusion - Choroidal ischaemia
88
How is hypertensive retinopathy managed?
- Control hypertension - Manage stroke risk - Regular eye checks for hypertensive pts
89
What are the features of subconjunctival haemorrhage?
- Sudden onset - Bright red blood (stays bright red as Hb gets oxygenated from the atmosphere) - Distinct border - Blood spreads freely around the whole globe
90
What are the causes of subconjunctival haemorrhage?
- Trauma to the eye - Heavy bouts of coughing - Contact lenses - Hypertension - Bleeding disorders - DM - CHD/vascular disease - medications: warfarin, aspiring, NSAIDs, steroids - Spontaneously in the elderly
91
How is subconjunctival haemorrhage managed?
-Conservative management | >unless episode of trauma: look for oribital/ocular injury
92
What is anterior uveitis?
- AKA Irisitis - Important differential of red eye - Painful red eye with decreased visual acuity
93
Which conditions is anterior uveitis associated wtih?
-Seronegative arthropathies (HLA B27) >ank spond. psoriatic arthirits, enteropathic arthritis, IBD -Granulomatous disease >Sarcoidosis, syphillis -Bechet's disease >mouth and genital ulcers, skin rashes etc
94
What are the symptoms of anterior uveitis?
- Acute painful red eye - Unilateral - Photophobia - Blurred vision (acuity can be impaired) - Lacrimation
95
What are the signs of anterior uveitis?
- Intense redness of the globe - Normal/decreased acuity - Irregular smal pupil - Hypopyon - Ciliary flush
96
What is a hypopyon?
-Pus and inflammatory cells in the outer chamber of the eye (looks like white dots) and a visible fluid level
97
What is ciliary flush?
-A ring of red and pruple spreading outwards from the cornea
98
How is anterior uveitis managed?
-Dilate the eye to relieve the pain and photophobia with atropine -Urgent ophthalmology >steroid drops
99
What is episcleritis?
-Common benign unilateral or bilateral inflammation of the episclera (layer between the conjunctiva and the connective tissue layer that forms the white of the eye)
100
What are the features of episcleritis?
- Mild irritation of the eye - Localised redness - watery, mild photophobia - No loss of vision or discharge
101
How is episcleritis managed?
-Conservative >NSAIDs if painful -Eyedrops/artificial tears ease irritation
102
How do you clinically differentiate between scleritis and episcleritis as a cause of red eye
-Scleritis is PAINFUL -Use of phenylephrine drops >blanches the conjunctival and episcleral vessels but not the scleral vessel >episcleritis eye redness improves with phenylephrine
103
What is scleritis?
- Rare and serious condition | - Associated with systemic vasculitis and connective tissue disease
104
Which conditions is sceritis associated with?
-RA >may have blue sclera -Vasculitis
105
What are the features of scleritis?
- Very painful red eye - Loss of vision - watering - Photophobia
106
How is scleritis managed?
- Oral NSAIDs - Oral prednisolone - Cyclophosphamide or other immune suppressants to tackle the cause
107
Complications of scleritis?
- Scleral thinning - Ischaemia of the anterior segment of the globe - Raised intraocular pressure - Retinal detachment - Uveitis - Cataract - Phthisis (globe atrophy)
108
What is keratitis?
-Infection/inflammation of the conrea
109
What is the most common cause of viral keratitis?
-Herpes simplex virus
110
How does HSV keratitis tend to present?
- 'Dendritic shape' corneal ulcer | * buzzword
111
What are the symptoms of HSV keratitis?
- Red, painful eye - Photophobia - Epiphora (excessive watering of the eye) - Decreased visual acuity - Foreign body sensation
112
Investigations for HSV keratitis?
-Flourescin staining to look for a dendritic ulcer
113
How is HSV keratitis managed?
-Urgent referral to ophthalmology -Topical acyclovir -AVOID steroids >causes enlargement of the dendritic ulcer
114
What is bacterial keratitis?
- Bacterial infection of the cornea | - Rare and serious
115
What are the features of bacterial keratitis?
``` -Symptoms: >Painful red eye >loss of vision -Signs: >hazy cornea with central abscess ```
116
How is bacterial keratitis managed?
- Urgent referral | - intense abx
117
What is a corneal abrasion?
-Any defect of the corneal epithelium -Commonly caused by trauma >finger nail >branches >dust
118
What are the features of conreal abrasion?
- Pain - Photophobia - Foreign body sensation - Decreased acuity - Conjunctival injection
119
How is corneal abrasion investigated for?
- Flourescin staining and slit lamp examination | - Yellow stained abrasion will show up
120
How is corneal abrasion managed?
-Topical antibiotics to prevent bacterial superinfection | eg chloramphenicol
121
What is a corneal ulcer?
-Epithelial defect in the cornea with underlying inflammation/infection
122
What are the causes/risk factors of corneal ulcers?
- Most common in contact lens wearers - Infection with bacteria, fungi, viruses, acanthamoeba - Can be initiated by mechanical trauma or nutritional deficiencies
123
What are the features of a corneal ulcer?
- Eye pain - Photophobia - Watery eye
124
Investigations for corneal ulcer?
-Focal fluorescin staining
125
How do you manage a corneal ulcer?
- Stop contact lenses for 1 week - Cool compress - good hygiene - Topical abx: chloramphenicol
126
What is conjunctivitis?
-Inflammation of the conjunctiva
127
What are the 3 main causes of conjunctivitis?
1. viral 2. bacterial 3. allergic -reactive arthritis and history of chlamydia or campylobacter also need to be discussed
128
What are the general features of conjunctivitis?
- Sore red eyes | - Sticky discharge
129
What are the features of bacterial conjunctivitis?
- Purulent discharge - Eyes can be stuck together in the morning - Starts in one eye and then spreads to the other
130
What are the common causative organisms for bacterial conjunctivitis?
- Staph - Strep - Haemophillus - Neisseria - Chlamydia
131
How is bacterial conjunctivitis treated?
- Self limiting in 1-2 weeks - Hygiene advice about lenses, towel sharing etc - Topical abx: chloramphenicol
132
What abx should be used for conjunctivitis if pt is pregnant?
-Topical fusidic acid
133
What are the features of viral conjunctivitis?
- Serous discharge - Recent URTI - Re-auricular lymphadenopathy
134
What is the most common cause of viral conjunctiviits?
-Adenovirus
135
How is viral conjunctivitis managed?
- Conservative management | - Oral analgesia and artificial eye drops for symptomatic relief
136
What ar ethe features of allergic conjunctivitis?
- Often seen in the context of hayfever - Bilateral symptoms - Conjunctival erythema and swelling (chemosis) - History of atopy - Swollen eye lids - may be seasonal - Sticky mucous discharge - large papillae
137
How is allergic conjunctivitis treated?
- Topical/systmic antihistamines | - 2nd line: topical mast cell stabilisers (sodium cromoglicate, nedocromil)
138
What is non-arteritis ischaemic neuropathy?
- Ageing process associated with poor blood supply to the optic nerve - Swollen optic disc - Painless loss of vision - Needs to be excluded from GCA - No raised inflammatory markers
139
What are the complications of non-arteritis ischaemic neuropathy?
- Diplopia | - Emboli can lodge in the retinal artery and cause CRAO
140
How is non-arteritic ischaemic neuropathy managed?
-High dose steroids to protect the eye | >IV methylpred for 3/7 then oral
141
What are the features of Horner's syndrome?
1. Miosis (constricted pupil) 2. Ptosis 3. Anhidrosis 4. Enophthalmos (eye retracts backwards into the head)
142
What are the causes of Horner's syndrome?
- Pancoast lung tumour - Carotid artery dissection - Stroke - MS - Brain tumour - Encephalitis
143
How is horner's syndrome managed?
-Treat underlying cause
144
What are they types of eye disease associated with RA?
- Scleritis - Episcleritis - Secondary Sjogren's with sicca complex (dry eyes)
145
What is papilloedema?
-Optic disc swelling
146
What are the causes of papilloedema?
- SOL (Neoplastic, vascular, abscess) - Malignant hypertension - IIH - Hydrocephalus - Hydrocephalus - Hypercapnia
147
What are the features of papilloedema on fundoscopy?
- Venous enlargement - Loss of venous pulsation - Blurring of optic disc margin - Elevation of optic disc - Loss of optic cup - Paton's lines (concentric/radial retinal lines cascading from the optic disc)
148
What are the causes of tunnel vision?
- Papilloedema - Glaucoma - Retinitis pigmentosa - Choridoretinitis - Optic atrophy
149
What is optic atrophy?
- Pale optic disc on fundoscopy - Well demarcated - Usually bilateral - Causes gradual vision loss
150
What are some acquired causes of optic atrophy?
-MS -Papilloedema -Raised ICP -Retinal damage ie retinitis pigmentosa -Ischaemia -Vit deficiencies: B1, B2, B6, B12
151
What are some congenital causes of optic atrophy?
- Fredrich's ataxia | - Leber's optic atrophy

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