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Ophthalmology Flashcards

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1
Q

Name the condition:

  1. small, irregular pupils
  2. Accommodation reflex present (ARP)
  3. Pupillary reflex absent (PRA) (no response to light)

Causes (2)

A

Argyll-Robertson pupil

Causes

  1. Syphillis
  2. Diabetes
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2
Q
  1. Dilated pupil
  2. Unilateral
  3. Slowly reactive to accommodation
  4. Minimal if at all response to light
  5. Once pupil constricted it remains small for an abnormally long time
A

Holmes-Adie pupil

Benign condition common in women

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3
Q

What is Holmes-Adie syndrome?

A

Association of Holmes-Adie pupil with absent ankle/knee reflexes

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4
Q 
Glaucoma types (3) 
Caused by?
A
  1. Closed angle/ angle closure glaucoma
  2. Opened angle glaucoma
  3. Normal-tension
    Caused by raised intraocular pressure secondary to impairment of aqueous flow
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5
Q

Closed angle/ angle closure glaucoma (8)

Insidious vs sudden 
Pain or no pain 
Red or not red
Sight 
Dilated or restricted 
Other features (2) 
Worse with restricted or dilated pupils
A

Raised IOP due to narrow angle between iris and cornea, passage for outflow of aq. humour is too narrow. Due to lens being pushed against iris.

Features

  1. Sudden onset eye/ head pain
  2. Hard, red eye
  3. Haloes
  4. Decreased visual acuity
  5. Semi-dilated non reacting pupil
  6. Worse with mydriaisis
  7. Systemic upset e.g N&V, AP
  8. Corneal oedema, dull/ hazy cornea
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6
Q

What does hypermetropia mean?
What does mydriasis mean?
What does myopia mean?

A

To be long sighted
Dilated pupils
Short/near sighted

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7
Q

Closed angle/ angle closure

Predisposing factors

A
  1. Hypermetropia
  2. Pupillary dilatation
  3. Lens growth associated with age
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8
Q

Closed angle/ angle closure

Mx

A

Emergency - refer to ophthalmologist

  1. Pilocarpine (increased outflow of the aqueous humour))
  2. BB (e.g. timolol, decreases aqueous humour production)
  3. alpha-2 agonist (e.g. apraclonidine, dual mechanism, decreasing aqueous humour production and increasing uveoscleral outflow)
  4. intravenous acetazolamide (reduces aqueous secretions)

Post acute attack
1. Laser peripheral iridotomy
Creates a tiny hole in the peripheral iris → aqueous humour flowing to the angle

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9
Q

Primary open angle glaucoma

RFs (6)

A
  1. HTN
  2. DM
  3. Steroids
  4. FH
  5. Black
  6. Myopia
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10
Q

Primary open angle glaucoma

Features (3)

A
  1. Insidious onset
  2. Peripheral visual field loss/ tunnel vision/ scotomas
  3. Optic disc cupping
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11
Q

Fundoscopy signs of primary open-angle glaucoma (5)

A
  1. Optic disc cupping
  2. Optic disc pallor
  3. Bayonetting of vessels
  4. Cup notching (usually inferior where vessels enter disc)
  5. Disc haemorrhages
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12
Q

Primary open angle glaucoma

Mx

A

First line
1. prostaglandin analogue (PGA) eyedrops
Second line
2. BB, carbonic anhydrase inhibitor, or sympathomimetic eye drops
If more advanced
3. surgery or laser treatment can be tried

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13
Q

What is transient monocular visual loss (TVML)

Name four causes:

A 
Visual loss lasting less than 24 hours
Causes
1. ischaemic/vascular (e.g. thrombosis, embolism, temporal arteritis etc). e.g. occlusion of central retinal vein/artery
2. vitreous haemorrhage
3. retinal detachment
4. retinal migraine
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14
Q

Dense shadow that starts peripherally progresses towards the central vision
A veil or curtain over the field of vision
Straight lines appear curved
Central visual loss
Retinal tear

A

Retinal detachment

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15
Q

features include afferent pupillary defect, ‘cherry red’ spot on a pale retina
Due to thromboembolism

A

Central retinal artery occlusion

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16
Q

severe retinal haemorrhages are usually seen on fundoscopy
causes: glaucoma, polycythaemia, hypertension
=

A

Central retinal vein occlusion

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17
Q

causes: diabetes, bleeding disorders, anticoagulants
features may include sudden visual loss, dark spots
=

A

Vitreous haemorrhage

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18
Q

Flashes of light (photopsia) - in the peripheral field of vision
Floaters, often on the temporal side of the central vision
=

A

Posterior vitreous detachment

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19
Q

Herpes zoster ophthalmicus

Mx

A
  1. PO antivirals for 7-10 to be started within 72 hours of rash - IV if immunocompromised or very severe
  2. Topical steroids in any inflammation of the eye

If eye involvement –> ophth review

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20
Q

Features of herpes zoster opthalmicus

A
  1. vesicular rash around the eye, which may or may not involve the actual eye itself
  2. Hutchinson’s sign
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21
Q

What is Hutchinson’s sign?

A

rash on the tip or side of the nose. Indicates nasociliary involvement and is a strong risk factor for ocular involvement
Seen in herpes zoster opthalmicus

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22
Q

RA ocular manifestations (5)

Iatrogenic ocular manifestations (2)

A
  1. keratoconjunctivitis sicca (most common)
  2. episcleritis (erythema)
  3. scleritis (erythema and pain)
  4. corneal ulceration
  5. keratitis

Iatrogenic
steroid-induced cataracts
chloroquine retinopathy

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23
Q

Scleritis

Features (4)

A
  1. red, watery eye
  2. classically painful (in comparison to episcleritis)
  3. photophobia
  4. gradual decrease in vision
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24
Q

How to differentiate between scleritis and episcleritis

Mx episcleritis

A

Sclertitis painful, episcleritis isn’t

phenylephrine drops can be used to differentiate between the two. If eye redness improves after phenylephrine –> episcleritis

Mx artificial tears

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25
What is keratitis? Common bacteria (2)
Inflammation of the cornea Microbial keratitis is potentially sight threatening and should therefore be urgently evaluated and treated 1. Staph A 2. Pseudomonas aeruginosa is seen in contact lens wearers
26
Keratitis | Features (4)
1. red eye: pain and erythema 2. photophobia 3. foreign body, gritty sensation 4. hypopyon may be seen
27
Painful red eye in a contact lens wearer Diagnostic test Mx
``` Keratitis Slit lamp Mx 1. Topical quinolone 2. Cycloplegic for pain relief ```
28
Age Related Macular Degeneration (ARMD) Features (5) ``` Speed of visual loss What type of sight is lost first? (2) Other features (2) ```
1. Subacute visual loss 2. Near field loss 3. Deterioration at night 4. Photopsia, (a perception of flickering or flashing lights), 5. Crooked or wavy appearance to straight lines
29
ARMD Ix including fundoscopy findings (5) Fundoscopy findings in wet ARMD
1. Amsler grid testing - distortion of line perception 2. Fundoscopy: drusen + central scotoma 3. slit-lamp microscopy + colour fundus photography 4. fluorescein angiography (wet ARMD) 5. ocular coherence tomography (wet ARMD) Fundoscopy- wet ARMD well demarcated red patches may be seen which represent intra-retinal or sub-retinal fluid leakage or haemorrhage
30
ARMD types
Dry 90% of cases Wet 10% of cases - worse prognosis
31
What is the role of vascular endothelial growth factor (VEGF) in ARMD?
VEGF stimulates new vessel growth in wet ARMD which leads to oedema and more rapid loss of acuity.
32
ARMD Mx Dry Wet
1. Dry ARMD zinc with anti-oxidant vitamins A,C and E | 2. Wet ARMD anti-VEGF agents, e.g ranibizumab, bevacizumab and pegaptanib - 4 weekly injection.
33
``` Define: Blepharitis Stye Chalazion Entropion Ectropion ```
blepharitis: inflammation of the eyelid margins typically leading to a red eye, grittiness and discomfort stye: infection of the glands of the eyelids chalazion = Meibomian cyst entropion: in-turning of the eyelids ectropion: out-turning of the eyelids
34
What is a chalazion? | Mx
Retention cyst of the Meibomian gland. It presents as a firm painless lump in the eyelid. Resolve spontaneously some require surgical drainage
35
What is a stye? How does it differ from a chalazion?
Chalazion are cysts of the meibomian gland/ oil glands deep in the eye lid (internal) Stye's are usually an infected an eyelash caused by Staph Aureus (external) Mx hot compresses and analgesia, only give abx if assoc. conjunctivitis
36
Blepharitis features (4) Rx
1. Usually bilateral 2. grittiness and discomfort, particularly around the eyelid margins 3. eyes may be sticky in the morning 4. eyelid margins may be red and swollen Rx 1. Hot compress BD 2. Lid hygiene 3. Artificial tears
37
``` Anterior uveitis Genetics Features (5) Acute/ insidious Restricted or dilated pupil Other (3) ``` Is visual acuity affected?
1. HLA B27 Features 1. Acute onset, painful red eye 2. Pupil irregular and small 3. Photophobia 4. Blurred vision 5. Lacrimation Visual acuity is initially normal, then becomes impaired
38
Anterior uveitis | Mx
1. urgent review by ophthalmology 2. cycloplegics (dilates the pupil which helps to relieve pain and photophobia) e.g. Atropine, cyclopentolate 3. steroid eye drops
39
What is papilloedema?
Optic disc swelling that is caused by increased intracranial pressure. Bilateral
40
Papilloedema | Features (6)
1. venous engorgement: usually the first sign 2. loss of venous pulsation 3. blurring of the optic disc margin 4. elevation of optic disc 5. loss of the optic cup 6. Paton's lines: concentric/radial retinal lines cascading from the optic disc
41
``` Name the condition: severe pain (may be ocular or headache) decreased visual acuity, patient sees haloes semi-dilated pupil hazy cornea ```
Acute angle closure glaucoma
42
``` Name the condition: acute onset pain blurred vision and photophobia small, fixed oval pupil, ciliary flush ```
Anterior uveitis
43
``` Name the condition: severe pain (may be worse on movement) and tenderness may be underlying autoimmune disease e.g. rheumatoid arthritis ```
Scleritis
44
Name the condition: | purulent discharge if bacterial, clear discharge if viral
Conjunctivitis
45
Name the condition: | history of trauma or coughing bouts, painless, red eye
Subconjunctival haemorrhage
46
Name the condition | typically red eye, pain and visual loss following intraocular surgery
Endophthalmitis
47
Retinitis pigmentosa Features (2) Fundoscopy findings
1. night blindness 2. tunnel vision due to loss of the peripheral retina Fundoscopy: 1. black bone spicule-shaped pigmentation in the peripheral retina 2. mottling of the retinal pigment epithelium
48
1. Cherry red spot 2. Sudden loss of vision 3. Due to thromboembolism
Central retinal artery occlusion
49
1. sudden, painless reduction or loss of visual acuity 2. unilaterally 3. Fundoscopy: severe retinal haemorrhages
Central retinal vein occlusion
50
1. Reduced vision 2. Faded colour vision: making it more difficult to distinguish different colours 3. Glare: lights appear brighter than usual 4. Halos around lights Defect in red reflex
Cataracts
51
Cataracts | Ix (2)
1. Fundoscopy: normal fundus and optic nerve | 2. Slit-lamp examination. Findings: visible cataract
52
Complications post cataract op (4)
1. Posterior capsule opacification: thickening of the lens capsule 2. Retinal detachment 3. Posterior capsule rupture 4. Endophthalmitis: inflammation of aqueous and/or vitreous humour
53
Chorioretinitis | Causes (5)
``` syphilis cytomegalovirus toxoplasmosis sarcoidosis tuberculosis ```
54
Fluorescein examination: yellow stained abrasion which is usually visible to the naked eye. Mx
Corneal abrasion Topical antibiotic
55
Corneal ulcers Common in which type of pt? Features (4)
Contact lens wearers 1. eye pain 2. photophobia 3. watering of eye 4. focal fluorescein staining of the cornea
56
Diabetic retinopathy | Types
Non proliferative | Proliferative
57
Non proliferative diabetic retinopathy features Mild Moderate Severe
Mild =>1 microaneurysm Moderate 1. microaneurysms 2. blot haemorrhages 3. hard exudates 4. cotton wool spots 5. venous beading/looping 6. intraretinal microvascular abnormalities (IRMA) Severe 1. blot haemorrhages and microaneurysms in 4 quadrants 2. venous beading in at least 2 quadrants 3. IRMA in at least 1 quadrant
58
Proliferative diabetic retinopathy | Features
1. retinal neovascularisation - may lead to vitrous haemorrhage 2. fibrous tissue forming anterior to retinal disc (more common in T1DM, 50% blind in 5 years)
59
Diabetic maculopathy
1. hard exudates and other 'background' changes on macula | More common in T2DM
60
A patient presents with an acute, painful red eye associated with photophobia and epiphora. Fluorescein staining reveals a ragged area on the cornea Mx
Herpes simplex keratitis 1. Ophth review 2. Topical aciclovir
61
Horner's syndrome | Features
1. miosis (small pupil) 2. ptosis 3. enophthalmos* (sunken eye) 4. anhidrosis (loss of sweating one side)
62
Congenital Horner's
heterochromia (difference in iris colour)
63
Keith-Wagener classification of hypertensive retinopathy
I - Arteriolar narrowing and tortuosity - Increased light reflex - silver wiring II - Arteriovenous nipping III - Cotton-wool exudates - Flame and blot haemorrhages IV - Papilloedema
64
Serous discharge Recent URTI Preauricular lymph nodes =
Viral conjunctivitis
65
Purulent discharge | Eyes may be 'stuck together' in the morning)
Bacterial conjunctivitis
66
Mx conjunctivitis
Usually settles without treatment within 1-2 weeks 1. Topical chloramphenicol - drops every 2-3 hours or ointment QDS 2. Topical fusidic acid for pregnant women
67
What is the most common cause of a persistent watery eye in an infant? Common age Mx
Nasolacrimal duct obstruction 1 month Mx Massage the lacrimal duct Sx resolve in 95% by the age of one year. If unresolved refer to ophthalmologist for consideration of probing
68
Optic neuritis causes:
multiple sclerosis diabetes syphilis
69
Optic neuritis Features (5) Mx
1. unilateral decrease in visual acuity over hours or days 2. poor discrimination of colours, 'red desaturation' 3. pain worse on eye movement 4. relative afferent pupillary defect 5. central scotoma Mx high-dose steroids recovery usually takes 4-6 weeks
70
``` Explained the Relative afferent pupillary defect What is it also known as? What is it caused by? How do you test for it? Seen in which conditions? ```
Marcus-Gunn pupil 'swinging light test'. Caused by a lesion anterior to the optic chiasm i.e. optic nerve or retina Dilatation of the eye when light is shone on the affected eye MS (optic neuritis) Retinal detachment
71
What is the pathway of the pupillary light reflex Afferent Efferent
afferent: retina → optic nerve → lateral geniculate body → midbrain efferent: Edinger-Westphal nucleus (midbrain) → oculomotor nerve
72
``` Spreading upper respiratory tract infection from the sinuses 1. reduced visual acuity 2. proptosis 3. ophthalmoplegia/pain with eye movements 4. Redness, swelling 5. Eyelid oedema + ptosis 6. Drowsiness/ nausea/ vomiting Medical emergency --> ADMIT IV abx ```
Orbital cellulitis Caused by commonly Mx
73
Orbital cellulitis Ix Most common organisms (3)
1. Bloods - raised infection markers 2. Ophthalmological assessment- decreased vision, afferent pupillary defect, proptosis, dysmotility, oedema, erythema. 3. CT with contrast – Inflammation of the orbital tissues deep to the septum, sinusitis. 4. Blood culture and microbiological swab to determine the organism. Most common bacterial causes – Streptococcus, Staphylococcus aureus, Haemophilus influenzae B.
74
Squint | Types
1. Concomitant - Due to imbalance in extraocular muscles - convergent 2. Paralytic - Due to paralysis of extraocular muscles - divergent
75
Ix (2) | Mx (2)
1. corneal light reflection test - holding a light source 30cm from the child's face to see if the light reflects symmetrically on the pupils ``` 2. Cover test ask the child to focus on an object cover one eye observe movement of uncovered eye cover other eye and repeat test ``` Mx referral to secondary care eye patches may help prevent amblyopia
76
Cataracts causes
1. Ageing 2. Smoking 3. Increased alcohol consumption 4. Trauma 5. Diabetes mellitus 6. Long-term corticosteroids 7. Radiation exposure 8. Myotonic dystrophy 9. Metabolic disorders: hypocalcaemia
77
Severe dry eyes management:
Punctal plugs if there is frequent use of eye drops without features of inflammation
78
white focal retinitis with overlying vitreous inflammation.
= toxoplasmosis
79
'pizza pie', with retinal spots and flame haemorrhages-
cytomegalovirus | central retinal vein occlusion
80
Mydriatic drops are a known precipitant of ?
acute angle closure glaucoma
81
Intermittent squint in newborns less than 3 months | Mx
normal and does not need to be investigated
82
night blindness + tunnel vision =
Retinitis pigmentosa
83
Preauricular lymph nodes | bacterial or viral conjunctivitis?
viral
84
Punctate fluorescein staining of the cornea is common in patients with
dry eyes
85
Dots + blots + haemorrhages and lipid exudates =
background retinopathy
86
vision improving with a pin hole =
refractive error

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