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Ophthalmology Flashcards

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1
Q

How do you record the results of someones snellen chart reading

A

Testing distance/line they can correctly read

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2
Q

What do you do if a patient can’t read the top line of the snellen chart

A

Try at 3 metres instead of 6
If still can’t then get them to count fingers at 1 metre
If still can’t get them to recognise hand movement at 1 metre
If still can’t then test light perception

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3
Q

How do you examine the macula during fundoscopy

A

Ask the patient to look into the light

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4
Q

Drops used to dilate pupils

A

Tropicamide 1% - antimuscarinic
Cyclopentolate 1% - antimuscarinic
Phenylephrine 2.5% - alpha-1 agonist

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5
Q

On a humphrey visual field test what to the black ring, black dot and triangles represent

A

Black ring = they CAN see it
Black dot = they CAN’T see it
Triangle - normal, physiological blind spots

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6
Q

What are the early changes of age related macular degeneration

A

Drusen
Macular pigmentary changes
Normal/near normal vision

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7
Q

What are the 2 main types of age related macular degeneration

A

Geographic atrophy/atrophic/dry

Neovascular/exudative/wet

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8
Q

What is the most common type of age related macular degeneration - wet or dry

A

Dry

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9
Q

Risk factors for age related macular degeneration

A 
Age >65
Smoker
FH
Female 
HTN
Obesity
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10
Q

Typical findings/symptoms associated with dry ARMD

A 
Gradual loss of central vision (scotoma)
May begin as distortion
Difficulty reading/seeing fine detail
Struggle to see faces clearly
Peripheral vision spared
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11
Q

Fundoscopy findings of dry ARMD

A

Drusen in the macular area

Macular atrophy - pale, mottled macula

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12
Q

Typical findings/symptoms associated with wet ARMD

A

Sudden loss of central vision and distortion

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13
Q

How do you manage wet ARMD

A

Urgent referral for anti-VEGF injections - progresses quickly and has a high chance of 2nd eye involvement
Or photodynamic therapy

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14
Q

Fundoscopy findings of wet ARMD

A

Drusen in the macular area
Macular atrophy - pale, mottled macula
Choroidal neovascularisation - small focal pale pink-yellow or green-grey elevations at the macula. Microhaemorrhage and exudates.

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15
Q

What can be used to assess whether patients vision is being distorted, or whether they have loss of central vision

A

Amsler grid

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16
Q

Names of the anti-VEGF injections used for wet ARMD

A

Ranibizumab (Lucentis)

Aflibercept (Eylea)

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17
Q

How often are anti-VEGF injections for wet ARMD

A

Every 1-2 months for as long as necessary

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18
Q

What are the 2 main types of diabetic retinopathy

A

Non-proliferative

Proliferative

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19
Q

Fundoscopy findings of non-proliferative diabetic retinopathy

A

Microaneurysms
Macular oedema
Hard exudates
Cotton wool spots

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20
Q

What is the key feature of proliferative diabetic retinopathy

A

Neovascularisation

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21
Q

Main management options for proliferative diabetic retinopathy

A

Anti-VEGF injections

Laser treatment

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22
Q

What are macular holes

A

As we age vitreous shrinks + pulls away from retinal surface, if attached too firmly can tear retina as it does this, fluid seeps through hole onto macular –> central vision blurring + distortion.

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23
Q

Management of macular holes

A

Vitrectomy + fill with gas to hold edges of macular hole in place as it heals

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24
Q

What is the most common hereditary retinal degeneration/dystrophy

A

Stargardt disease

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25
Risk factors for open angle glaucoma
``` Age >40 Raised intraocular pressure African DM FH Myopia Steroid use ```
26
Patho of open angle glaucoma
Clogging of trabecular meshwork/reduced drainage --> gradual increase in IOP --> vascular compression --> ischaemia of optic nerve --> progressive visual impairment
27
Clinical features/history of open angle glaucoma
Initially often asymptomatic Slowly progresses into non-specific symptoms such as mild headaches, impaired adaptation to darkness Generally bilateral progressive visual field loss from peripheral to central vision Halos around lights may occur
28
Fundoscopy findings of open angle glaucoma
Cupping and pallor of the optic disc
29
How do we measure intraocular pressure
Tonometry
30
How do we visualise/assess the iridocorneal angle (e.g. in cases of suspected closed angle glaucoma)
Gonioscopy
31
Management of open angle glaucoma
Topical prostaglandins - Latanoprost AND Topical beta blocker - Timolol OR alpha2 agonists - Apraclonidine 2nd line = laser trabeculoplasty Refractory cases = surgical trabeculoplasty
32
Presentation/history of angle closure glaucoma
``` Sudden onset painful, red and hard eye Frontal headache Blurred vision Halos around lights Nausea and vomiting Dilated and non-reactive pupil Cloudy cornea ```
33
Risk factors for angle closure glaucoma
``` Hyperopia (short eye) Age Female Previous eye trauma Mydriasis (meds - Atropine, decongestants, sympathomimetics) Darkness ```
34
Management of angle closure glaucoma
``` Avoid mydriatic drugs Avoid darkness/covering the eye Analgesics and antiemetics Timolol (beta blocker drop) Apraclonidine (a2 agonist) PO/IV Acetazolamide (carbonic anhydrase inhibitor) IV Mannitol in refractory cases Iridotomy or iridectomy once acute attack has been managed ```
35
Risk factors for/things associated with acquried cataracts
``` Age DM, renal insufficiency/dialysis Smoking, alcohol HTN Hypocalcaemia Wilson's disease, Trisomy 21, Alport syndrome, NF2 Steroids Trauma Radiation Excessive sunlight/UVB FH High myopia ```
36
Symptoms/presentation of cataracts
Reduced visual acuity - blurred, clouded, dim, washed out colour vision (nuclear cataracts) Painless Bilateral Glare - in daylight, low sunlight, headlights, haloes Opacities within red reflex Grey/white/yellow/brownish clouding of the lens Monocular diplopia
37
Which type of cataract is more common in patient with DM or on high dose steroids
Subcapsular cataract
38
Which type of cataract decreases the colour blue
Nuclear cataract
39
Which type of cataracts look like white, wedge like opacities that start in the periphery and work their way to the centre
Cortical cataracts
40
Risk factors for corneal abrasion
Mechanical trauma from external objects Contact lens - dehydration or improper fit Occupation and lack of protective eyewear - e.g. cutting/sawing Prior corneal abrasions
41
Typical features of the history in corneal abrasion
Sudden onset Sensation of foreign body Photophobia Excessive tearing Blepharospasm (involuntarily squeeze eye shut) An initiating event Patients with recurrent/spontaneous erosions have history of trauma/injury from a while back that will have left epithelial structural defect that increases risk of further episodes – report Sx on opening eyes/waking up, daily/weekly/monthly
42
Features of corneal abrasion on examination
Eye is injected Ciliary flush (red/violet ring around cornea) Tearing but no pus May be an obvious foreign body
43
What do we use to stain the eye when looking for corneal abrasions
Fluorescein staining
44
Management of corneal abrasion
Most heal within 1-2 days Don't wear contact lenses whilst it's healing Topical NSAIDs for analgesia Topical abx - contact lens wearers at risk of pseudomonas
45
What are 2 possible complications of corneal abrasions
Corneal ulceration | Keratitis
46
What is infectious keratitis
Microbial invasion of the cornea causing inflammation and damage to corneal epithelium/stroma/endothelium
47
Non-infectious causes of keratitis
Exposure keratitis - dryness due to inadequate eyelid closure Photokeratitis - intense UV exposure Allergic keratitis
48
What are the main risk factors for keratitis
Contact lens wear Corneal trauma Corneal abrasion Immunocompromisation
49
Signs and symptoms of keratitis
``` Painful, red eye Increased lacrimation Discharge Lid oedema Decreased visual acuity Photophobia ```
50
Management of keratitis
Screen for immunosuppression Broad spectrum topical antibiotic Oral analgesia Don't wear contact lenses whilst eye is inflamed
51
What is herpes simplex keratitis
Caused by type 1 herpes simplex virus Primary infection in early life may be asymptomatic or have fever/conjunctivitis/swelling Resolution + latency of virus in trigeminal ganglion Reactivated and causes epithelial keratitis, risk of reactivation higher if immunocompromised Typically appears as a dendric ulcer May heal without scar or progress to stromal keratitis + scar
52
Management of herpes simplex keratitis
Topical antivirals (should heal in around 2 weeks)
53
What is herpes zoster ophthalmicus
Varicella zoster virus Affects ophthalmis division of trigeminal nerve Usually has prodromal period
54
What is the technical term for being near-sighted
Myopia
55
What is the technical term for being long-sighted
Hyperopia
56
Do patients with myopia struggle to see distance or near
Distance
57
Do patients with hyperopia struggle to see distance or near
Near (and often distance as well)
58
What is the shape of the eye like in myopia
Too curved, too long or both
59
What is the shape of the eye like in hyperopia
Too flat, too short or both
60
What shape lens is used to correct myopia and is this given a '+' or '-'
Spherical Concave (-)
61
What shape lens is used to correct hyperopia and is this given a '+' or '-'
Spherical Convex (+)
62
Are the lenses used to for myopia divergent or convergent
Divergent
63
Are the lenses used for hyperopia divergent or convergent
Convergent
64
What is astigmatism
Lens/cornea isn't spherical, it's irregular, so there are multiple focal points on the retina
65
What is the shape of the lens used to correct astigmatism
Cylindrical
66
What is presbyopia
Loss of lens ability to change shape to focus on near objects - due to ageing
67
A central scotoma indicates a lesion/damage to where
Macula/retina
68
Monocular loss of vision indicates a lesion where
Optic nerve
69
Bitemporal hemianopia indicates a lesion where
Optic chiasm
70
Homonymous hemianopia indicates a lesion where
Contralateral optic tract or optic radiation
71
Mnemonic for remembering lesion locations in homonymous quadrantinopias
PITS (Parietal-Inferior, Temporal-Superior)
72
Homonymous hemianopia with macula sparing indicates a lesion where
Contralateral occipital cortex
73
Presentation of central retinal artery occlusion
Sudden, painless, severe loss of vision/visual field defect Usually unilateral Affected pupil responds poorly to light
74
Causes of central retinal artery occlusion
Thrombus - GCA, SLE | Embolus - carotid plaques, endocarditis
75
Fundoscopy appearance of central retinal artery occlusion
Pale, opaque fundus with a red fovea (cherry red spot)
76
Management of central retinal artery occlusion
If suspected embolus then carotid doppler and echo If suspected GCA then high dose steroids Reduce IOP - topical Timolol, oral/IV Acetazolamide Can try to dislodge an embolus by intermittent digital massage over the closed eyelid or anterior chamber paracentesis
77
Risk factors for central retinal vein occlusion
``` HTN Age Glaucoma DM Anything that causes neovascularisation ```
78
Presentation of central retinal vein occlusion
Painless loss of vision - usually sudden but can occur over days/weeks
79
Fundoscopy findings of central retinal vein occlusion
Haemorrhages thoughout the retina Dilated and tortuous retinal veins Retinal oedema These changes are typically diffuse if obstruction involves the central retinal vein and are limited to one quadrant if obstruction involves only a branch of the central retinal vein.
80
What are the three main mechanisms for retinal detachment
Rhegmatogenous (most common type) Tractional Exudative (serous)
81
Describe what causes rhegmatogenous retinal detachment
Occurs due to a retinal break/tear/hole that allows fluid from the vitreous cavity between the retina and RPE
82
Describe what causes tractional retinal detachment
Occurs when fibrous/fibrovascular tissue (usually formed secondary to injury/inflammation/neovascularisation) attaches to the vitreous and pulls the retina from the RPE. Most commonly due to diabetic retinopathy.
83
Describe what causes exudative retinal detachment
Detachment due to a build up of fluid underneath the retina without tear/hole/break. Usually due to an inflammatory condition, but can also be secondary to hypertension, central retinal vein occlusion (haemorrhage), papilloedema or a retinal tumour.
84
Presentation of retinal detachment
Usually sudden and significant loss/deterioration in central vision Preceding flashes of lights in temporal visual field Loss of peripheral field as dark veil/cloud before loss of central vision
85
What is orbital/periorbital cellulitis
Infection of the muscles/fat posterior to the orbital septum, not involving the globe
86
What features would make you think orbital cellulitis rather than periorbital cellulitis
Ophthalmoplegia, proptosis, visual disturbances | More significant pain, tenderness, swelling and fever
87
What investigation do you order if you suspect orbital cellulitis
CT sinuses and orbits with contrast
88
What is infective endophthalmitis
Inflammation of the aqueous and/or vitreous humor.
89
Presentation of conjunctivitis
Red and discharge without significant pain/photophobia/visual loss
90
What types of conjunctivitis are there
``` Allergic Bacterial Viral Gonorrheal Chlamydial ```
91
Topical antibiotic of choice for superficial eye infections such as conjunctivitis
Chloramphenicol
92
Ophthalmic emergencies
``` Central retinal artery occlusion Central retinal vein occlusion Retinal detachment Orbital/peri-orbital cellulitis Infective endophthalmitis ```
93
Presentation of infective endophthalmitis
``` Photophobia Ocular discharge Ocular/periocular inflammation Injected eye Hypopyon Reduced/absent red reflex Fever ```
94
Anterior uveitis/iritis is inflammation of which structures
Iris and ciliary body
95
Causes of anterior uveitis/iritis
Idiopathic HLA-B27 related - seronegative arthropathy/inflammatory disease Viral eye disease - herpes, CMV, HIV
96
Presentation of anterior uveitis/iritis
``` Painful, red eye Photophobia Tearing Dull pain radiating around the orbit Constricted/non-reactive pupil Ciliary flush Idiopathic or infectious are usually unilateral Inflammatory usually bilateral ```
97
What is bacterial/microbial keratitis
Corneal ulcer - bacterial infection of the cornea
98
Risk factors for bacterial keratitis
``` Contact lens wear Foreign bodies Trauma Chemical injuries Dry eyes Immunosuppression ```
99
Presentation of bacterial keratitis
Rapid onset of pain, redness, photophobia, discharge, decreased vision Conjunctival injection Hypopyon Mucopurulent discharge
100
What in the history would make you consider fungal keratitis
Trauma involving organic material | Immunocompromised
101
Which cranial nerve VI and what is its function
Abducens Lateral rectus muscle Eye abduction
102
What abnormality will you see at rest in a patient with a CN VI palsy
Estropia (eye turned in)
103
Cranial nerve IV and its function
Trochlear Superior oblique Intorts, depresses and abducts the eye
104
Causes of abducens, occulomotor or trochlear nerve palsy
``` Trauma (head/eye injury) Microvascular ischaemia - DM, HTN MS Vasculitis Meningitis Raised IOP Intracranial lesion ```
105
In abducens nerve palsy, is the diplopia horizontal or vertical/oblique
Horizontal
106
In trochlear nerve palsy is the diplopia horizontal or vertical/oblique
Vertical/oblique
107
Which cranial nerve palsy can cause you to tilt your head to the opposite side to compensate for diplopia
Trochlear (IV) nerve palsy
108
What is the most common type of orbital fracture
Blow out fracture - usually a result of trauma. A direct blow to the orbit causes a sudden increase in intra-orbital pressure which decompresses by fracturing one of the walls of the orbit (most commonly inferior)
109
Clinical findings of an occulomotor nerve palsy
``` Eye is down and out (infraducted and abducted) Ptosis Pupil dilation (mydriasis) ```
110
CN III
Occulomotor
111
What clinical feature can help to differentiate an occulomotor nerve palsy caused by compression Vs microvascular disease
Pupil involvement usually indicates a compressive cause
112
Which condition can cause a painless 3rd nerve palsy with pupil sparing in somebody without vascular risk factors/DM
Myasthenia gravis
113
What causes myasthenia gravis
Autoimmune response which damages ACh receptors
114
Features/symptoms of myasthenia gravis
Muscle weakness Diplopia + ptosis with pupil sparing Oropharyngeal weakness - dysphagia, dysarthria Fluctuating symptoms Failure of respiratory muscles Symptoms exacerbated by heat and improved by cold Symptoms worse during physical stress - e.g. infection, surgery
115
2 tests used in the diagnosis of myasthenia gravis
Serum ACh receptor antibodies | EMG
116
What medication is used for symptom relief in myasthenia gravis
Acetylcholinesterase inhibitors (neostigmine, pyridostigmine)
117
Which gland is thought to be pathogenic in myasthenia gravis
Thymus
118
How can you tell the difference between monocular diplopia and binocular diplopia
Binocular – one of the two images disappears when either eye is covered Monocular – resolves when the affected eye is covered but remains when the opposite eye is covered
119
Intermittent diplopia that is worse at the end of the day is suggestive of which disease
Myasthenia gravis
120
A painful 3rd nerve palsy with ipsilateral pupil dilatation can be a result of an aneurysm in which vessel
Posterior communicating artery
121
Differentials for diplopia
``` 3rd nerve (occulomotor) palsy 4th nerve (trochlear) palsy 6th nerve (abducens) palsy Previous strabismus or eye surgery Thyroid eye disease (Graves) Myasthenia gravis GCA ```
122
Which special test can be used to help diagnose myasthenia gravis
Tensilon test Injection of Edrophonium chloride (an anticholinesterase) is given and the patient is observed for symptom improvement as their ACh levels build up
123
What is leukocoria
Abnormal white reflection from the pupil (instead of the normal red reflex)
124
Differentials for leukocoria
``` Retinoblastoma Congenital cataract Retinopathy of prematurity Retinal dysplasia Endophthalmitis Persistent hyperplastic primary vitreous ```
125
Strabismus may be normal until what age
3 months
126
What kind of gene is the retinoblastoma gene
Tumour supressor gene - mutations can be sporadic (unilateral) or hereditary (bilateral)
127
Causes of congenital cataracts
Bilateral - genetic, galactosemia, Wilson disease, diabetes, trisomy 21 Unilateral - usually a result of local dysgenesis/congenital structural abnormality
128
What is retinopathy of prematurity
A disease of the retina that affects pre-term infants Elevated/fluctuating partial pressures of oxygen cause pathological extraretinal neovascularisation that can cause haemorrhages, exudation, tractional retinal detachment
129
What is internuclear ophthalmoplegia
Internuclear ophthalmoplegia (INO) is a disorder of conjugate lateral gaze in which the affected eye shows impairment of adduction. When an attempt is made to gaze contralaterally (relative to the affected eye), the affected eye adducts minimally, if at all. The contralateral eye abducts, however with nystagmus
130
'Stormy sunset' is the typical fundoscopy appearance of which condition
Retinal vein occlusion
131
Cherry red spot is the typical fundoscopy appearance of which condition
Central retinal artery occlusion
132
Fundoscopy findings of diabetic retinopathy
``` Microaneurysms Hamorrhages Venous bleeding Hard exudates Cotton wool spots Neovascularisation Photocoagulation scares ```
133
Fundoscopy findings of hypertensive retinopathy
``` Arteriorlar narrowing AV nicking Silver wiring Retinopathy - flame haemorrhages, hard exudates, cotton wool spots Papilloedema ```
134
Symptoms of retinal detachment
``` The 4 'F's Flashes Floaters Field loss Fall in acuite "curtain coming down vision) ```
135
Management of retinal detachment
Surgical vitrectomy and gas tamponade | Then cryo/laser coagulation to secure retina
136
Symptoms of retinitis pigmentosa
Deteriorating night vision | Tunnel bision
137
Fundoscopy findings of dry ARMD
Drusen in the macula
138
Fundoscopy findings of wet ARMD
Subretinal haemorrhages in/around macula | Localised retinal elevation and retinal oedema
139
Symptoms of optic neuritis and optic atrophy
Reduced visual acuity Loss of red colour vision Central scotoma RAPD
140
Fundoscopy appearance of optic neuritis
Swollen optic disc (blurred margin)
141
Fundoscopy appearance of optic atrophy
Pale, featureless optic disc | High cup:disc ratio
142
Fundoscopy findings of chronic open angle glaucoma
High cup:disc ratio | Optic disc atrophy
143
Management of chronic open angle glaucoma
Beta-blocker eye drops Prostaglandin eye drops Alpha-agonist eye drops Carbonic anhydrase inhibitors
144
Symptoms of vitreous haemorrhage
Sudden PAINFUL loss of vision/haze
145
Fundoscopy findings of vitreous haemorrhage
No red reflex | Difficult/unable to visualise the retina

Finals (32 decks)

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