Ophthalmology Flashcards
(217 cards)
1
Q
Signs of retinal vascular disease
A
Vascular changes: Arteriosclerosis, AV crossing changes, venous tortuosity, cotton wool spots Microaneurysms Haemorrhages Hard exudates Neovascularization
2
Q
What are microaneurysms and what can they suggest
A
Little round dots from vessel outpouchings
Need to think about an OCT scan to check for macular oedema
3
Q
What are the different categories of haemorrhage
A
Dot and blot
Flame
Pre-retinal
Roth spots
4
Q
Describe dot and blot haemorrhages
A
Haemorrhage in the middle retinal layer due to diabetes/HTN
5
Q
Describe flame haemorrhage
A
Haemorrhage in the superficial nerve fibre layers due to CRV occlusion
6
Q
Describe pre retinal haemorrhage
A
Haemorrhage near the vitreous, between the retina and the posterior hyaloid
Caused by trauma, valsalva, neovascularisation
7
Q
Describe roth spots
A
Haemorrhage with central opacity
May be due to seeding of septic emboli (IE), anaemia or haematological diseases
8
Q
What are hard exudates and what can cause them
A
Lipid deposition in the outer layer due to abnormal vascular permeability
Ill defined, discrete
Assoc w diabetes
9
Q
What is a macular star and what causes it?
A
Star of cream on the macula due to swelling and exudate of the optic nerve head
Due to cat scratch disease or ocular syphilis
10
Q
What are cotton wool spots and what cause them
A
Ischaemic infarction in the nerve fiber layer
Assoc with diabetes, HTN, SLE, leukaemia, HIV
11
Q
What is neovascularization and what causes it
A
Hypoxia leading to vasoformative factors and neovascularization
May occur in the retina, optic disc, iris or angle
Caused by diabetes, RVO, retrolental fibroplasia (of prematurity), sickle cell disease and inflammatory diseases
12
Q
What do you do for neovascularization and what risk does it pose?
A
Treated with laser to prevent further development
Neovascularization increases the risk of new bleeds
13
Q
What does venous occlusion look like
A
Dilated venules, haemorrhage, oedema
Increased venous tortuosity
May occur centrally or at a branch
14
Q
What does arterial occlusion look like
A
Retinal pallor and oedema arteriole construction column interruption cherry red spots visible emboli retinal pallor
15
Q
What does retinal degeneration look like and what should you do?
A
Atrophy, pigmentation and scarring of retina
Presence of drusen- collection of material in pigment layer of retina
If present, get an OCT to check for macular oedema
16
Q
What are the types of retinal elevation?
A
By fluid- retinal detachment
By solid mass- tumour, choroidal neovascularization
Vitreous detachment
Retinal tear
17
Q
What is cystoid macular oedema
A
Hard exudates and swelling at the back of the eye
Petalloid appearance on FFA
18
Q
What does viritis look like
A
Stranding and tiny cells at the back of the eye
19
Q
What does multifocal choroiditis look like
A
Similar to cotton wool spots
Differentiate with lack of diabetes hx and lack of haemorrhages
20
Q
What does retinitis look like and what causes it
A
One large cotton wool spot
Likely see vitreous cells in the anterior chamber
Mostly due to toxoplasmosis
21
Q
What do granulomas look like and what causes them
A
Pale white spots at the back of the eye
Caused by sarcoid or TB
22
Q
What is a good exam system for eye trauma
A
From front to back of eye
Start with visual acuity, end with 5 neuro exams- vision, pupils, visual fields, movement and colour vision
23
Q
Describe metal trauma to the eye
A
Often secondary to grinding metal
Presents with red, sore and irritated eye
Fluoroscein shows scratches
Can sometimes see foreign body in eye or inner upper eyelid
Use a small needle to flick out of eye unless over pupil
24
Q
Describe blunt trauma to the eye
A
Eyelid bruising, subconjunctival haemorrhage (blood between conjunctiva and scleara)
Reassure if otherwise visually intact
25
What is hyphaema
Anterior chamber haemorrhage between cornea and iris
Blocks angle, risks increase of pressure and angle crisis
Compresses, steroid drops, 1/52 off work
Continue to assess for risk of rebleeding
26
What is orbital blowout fracture
Fracture of bones surrounding eye
| May present with poor eye movements due to trapping of muscles in bone shards or inflammation
27
Describe chemical ocular trauma management
Irrigate eye under tap until at hospital, then use bags of saline attached to Morgan lens- several litres will be needed
Assess limbus as this is stem cell site and may influence need for corneal transplant
Complication- anaesthetic cornea with conjunctiva overgrowing
28
Which is worse between acid and alkali burns
Alkali as it causes liquefactive necrosis as opposed to coagulative necrosis
29
Describe management of UV/IR trauma
Can only give lubricating drops
30
Describe penetrating/intraocular trauma
Usually a result of high speed metal such as bullet
Comes complaining of eye pain and blurring
Can see part of iris prolapsing to plug hole (teardrop pupil) or opacification of the lens causing an absent red reflex. There may also be a vitreous bleed
Management is usually surgical
31
Describe lid laceration risks and processes
Risk of tear duct dysfunction causing persistent teariness
Risk of poor lid closure
Risk of scar and infection
Requires skilled surgical repair
32
Describe scleral laceration
May be partial or full thickness of sclera
Pain and blurred vision
Iris may plug hole (like penetrating injury)
33
Definition of conjunctivitis
Inflammation of the conjunctiva
34
Causes of conjunctivitis
```
Viral
Bacterial
Chlamydial
Seasonal/perennial
Vernal
Atopic
```
35
Describe viral conjunctivitis
History of previous URTI, pre-auricular lymphadenopathy
Painless, tight, swollen and uncomfortable eyes
Normal vision unless excess swelling
Watery discharge
Scleral and eyelid reddness, follicles
Normal pupils
36
Treatment of viral conjunctivitis
Meticulous hygeine, compresses, lubricants, swabs
37
Describe bacterial conjunctivitis
```
Soreness, pain, heat, tightness
Normal vision unless excess swelling
Purulent discharge
Red and boggy conjunctiva, follicles and papillae
Normal pupils
```
38
Treatment of bacterial conjunctivitis
Swab for culture, hygeine, chloramphenicol
39
Describe chlamydial conjunctivitis
History of urethritis if assoc with reiter's syndrome
Symptoms: If type ABC it's eyelid inflammation (trachoma)
If type D-K it's long term lower eyelid conjunctivitis
Vision normal if conjunctivitis, eventual blindness if trachoma
Mucopurulent discharge
Hyperaemic vessels and follicles
Normal pupils
40
Treatment of chlamydial conjunctivitis
Tetracycline abx, treat parents and sexual partners
41
Describe allergic conjunctivitis
History of atopy, allergy, contact lens wear
Itching, red eyes, lid swelling, URT symptoms
Normal vision unless excess swelling, mucoid discharge
Redness often sectorial, sometimes diffuse
Papillae
Normal pupils
42
Treatment for allergic conjunctivitis
Systemic antihistamines are firstline
43
Describe vernal conjunctivitis
Occurs in 9-19 year olds, in boys more than girls
Itch, mucus, redness and photophobia
Tarsal or limbal papillae
Lipid deposits from leaky vessels (pseudogerontoxon)
Peripheral fibrovascular pannus
Shield ulcer
44
Treatment for vernal conjunctivitis
Remove fibrovascular pannus
| Most children grow out of vernal, give antihistamines,steroids
45
Define keratitis
Inflammation of the cornea
46
Causes of keratitis
```
Infection
Trauma
Dry eyes
UV
Contact lenses
```
47
Symptoms of keratitis
```
Foreign body feeling
Photophobia
Teariness
Reduced vision
Watery/purulent discharge
Pain
Limbus hyperaemia
Corneal opacification
```
48
Appearance of keratitis
```
Bacterial- white hazy opacifications due to WBC infiltrate
Hypophion- pus level in front of iris
If HSV- dendritic ulcers on fluoroscopy
May also have geographic ulcers
Dilated or N pupils
```
49
Management of keratitis
```
Corneal scrape and gram stain, culture and sensitivitiy
Urgent ABX if bacterial
Antivirals if viral
Close follow up
NOT STEROIDS
```
50
Complications of keratitis
Persistent inflammation can lead to scarring
| Corneal perforation may require eye removal
51
Describe scleritis
```
Less common
Severe pain
deep vessel injection
Assoc with HZO, RA
Must be treated with steroids
Blindness can occur
```
52
Describe episcleritis
```
More common
Uncomfortable not painful
Superficial vessel injection
No systemic assocs
Symptom management only
```
53
Define acute angle closure crisis
Increased intraocular pressure due to obstruction of aqueous outflow by partial/total closure of peripheral iris angle- usually spontaneous
AKA iris meets lens
54
Risk factors for AACC
Short eye
Narrow angle
Thick lens (age)
55
Symptoms of AACC
```
Intense eye pain and headache
Nausea and vomiting
Photophobia
Premonitory symptoms (fatigue, yawning, cravings)
Hypermetrope (blurred near vision)
Ciliary flush
```
56
Describe pupils and vision with AACC
Vision blurred due to corneal oedema
| Fixed, mid dilated pupil due to iris ischaemia
57
Appearance and signs of AACC
Circumcorneal injection
Hazy cornea
ON swelling and atrophy if prolonged
Increased intraocular pressure- feels rock hard compared to normal eye
58
Management of AACC
IOP reduction- alpha agonists, beta blockers, mitotics (all topical)
- Carbonic anhydrase inhibitors, osmotics (systemic)
Surgical management- Peripheral laser iridotomy for new aqueous channel
clear lens extraction/trabeculotomy
59
Complications of AACC
Loss of vision due to ON death
60
Define anterior uveitis/iritis
Inflammation of uveal tissue- iris
61
Causes of ant. uveitis
Idiopathic
Assoc with HLA B27- IBD, reiter's syndrome, ank spond, psoriatic arthritis
Juvenile chronic arthritis
Bechets syndrome
Sarcoidosis
Collagent vascular issues- SLE, polyarteritis nodosa, wegener's granulomatosis
Infection- HSV, HZV, HIV, CMV, candida, toxoplasmosis
Trauma- in sympathetic ophthalmia, the immune system targets all uveal tissue to contain damage, but ends up harming both eyes
62
Symptoms of ant uveitis
```
Deep aching pain
Redness
Photophobia
Blurred vision
Pain on accommodation
```
63
Signs of ant uveitis
```
Reduced acuity
Circumcorneal injection
Cells and flare on slit lamp
Keratic precipitates
Iris nodules
Severe- see hypopyon
```
64
Management of ant uveitis
Subdue inflammation with corticosteroids NOT IF INFECTIVE
Cycloplegics to prevent post synechiae
If increased IOP give ocular hypotensives like timolol
Antivirals
Injected or systemic corticosteroids if necessary
65
Complication of ant uveitis
Post synechiae (risk of angle closure crisis)
Seclusio/occlusio pupillae
Iris bombe- 360 degrees of synechiae
Glaucome secondary to trabecular inflammation, steroid or pupil block
Sectorial iris atrophy secondary to HZO- iris looks moth eaten
Reduced IOP
Cataracts
Cystoid macular oedema
Neovascularisation
66
Definition of posterior uveitis
Inflammation of uveal tissue- choroid/ciliary body
67
Causes of post uveitis
Idiopathic
Assoc with HLA B27- IBD, reiter's syndrome, ank spond, psoriatic arthritis
Juvenile chronic arthritis
Bechets syndrome
Sarcoidosis
Collagent vascular issues- SLE, polyarteritis nodosa, wegener's granulomatosis
Infection- HSV, HZV, HIV, CMV, candida, toxoplasmosis
Trauma- in sympathetic ophthalmia, the immune system targets all uveal tissue to contain damage, but ends up harming both eyes
68
Symptoms of posterior uveitis
Less painful than anterior
Floaters
Blurred vision
69
Signs of posterior uveitis
Visible inflammatory products (vitritis)
Inflammatory focus on choroid/retina- commonly toxoplasmosis
Inflammatory sequelae
- Cystoid macular oedema
- Vascular sheathing/occlusion- seen with fluroscein
- Optic disc swelling
70
Management of posterior uveitis
```
Orbital floor steroid injection
Post subtenons steroid injection
ABX, Anti-TB therapy (if necessary)
Antivirals if viral
Immunosuppression if choritis, HSV/HZV
```
71
Define subconjunctival haemorrhage
Unilateral bleed under the conjunctiva
72
Causes of subconjunctival haemorrhage
```
Severe cough
HTN
Straining
Valsalva
Anticoagulation
```
73
Symptoms/signs of subconj haemorrhage
Painless, focal blotchy redness
74
Management of subconj haemorrhage
Self resolving
75
Causes of floaters
Posterior vitreous detachment
Bleeding due to neovascularization/torn retina
Inflammatory cells- retinitis
76
History to take from floaters
```
Onset
Flashers
Vision
Any field loss (makes retinal detach more likely than tear)
PMHx POHx
```
77
What do retinal tear and post vitreous detachment floaters look like
Retinal tear- tiny black dots if haemorrhage
Post vit detachment- little gray line
Flashers at the edge of the tear
Treat with laser
78
What does retinal detachment look like to patients
Floaters and flashers plus field loss
| Curtain like effect
79
What does vitreous haemorrhage look like
Blurred vision and floaters
May be with attached or detached vitreous
May be due to neovascularization
If blood clouds the vitreous may need vitrectomy
80
Define blepharitis
Diffuse lash follicle inflammation
81
Causes of blepharitis
Usual staph aureus
82
Symptoms of blepharitis
```
Gritty sensation
Tenderness
Lid debris
Red thick lid margins
Mild conjunctival infection
```
83
Management of blepharitis
Lid scrubs with warm water and baby shampoo
| Topical erythromycin ointment
84
Define orbital cellulitis
Infection of lids and orbital tissue
85
Causes of orbital cellulitis
Spread from blocked or infected sinuses (paeds)
Spread from trauma or bite or stye
Compromised adults- consider fungus
86
Symptoms of orbital cellulitis
```
Diffuse swelling and lid discoloration
Pain
Lid tenderness
Conjunctival engorgement
Proptosis
Reduced eye movements
Diplopia
Reduced vision if cellulitis is post-septal- ON may be compromised
```
87
Management of orbital cellulitis
Orbital imaging- rule out sinusitis, subperiosteal abscess, tumour
If paeds ethmoid sinusitis is the cause, IV ABX
May require drainage if no improvement or abscess
At risk adults may need a sinonasal biopsy to diagnose fungal infection
88
Define glaucoma
Optic neuropathy with axonal loss
| May be associated with increased IOP or visual field loss
89
How does aqueous movement occur
Ciliary body secretes aqueous humour
This is drained by the trabecular meshwork through the angle of the eye into the anterior chamber
It is drained by episcleral vein
90
What causes open angle glaucoma
Resistance in the trabecular meshwork
Primary- the angle is smaller than usual
Secondary- cells or inflammatory mediators cause a clog
91
What causes closed angle glaucoma
Lens touches the iris so there is nowhere for the aqueous to move
Primary- narrow anterior chamber angle
Secondary- tumour, synechiae
92
What are risk factors for glaucoma
```
Age
FHx
Increased IOP
Myopia
Steroids
HTN
African ethnicity
Migraines
```
93
Symptoms of open angle glaucoma
Often asymptomatic
| May have visual loss
94
Signs of open angle glaucoma
Increased IOP
Optic disc cupping
Crookenberg spindle- brown spots on the lens as iris rubs off cells onto it
Visual field loss if advanced
95
Ix for open angle glaucoma
Tonometry- may have elevated IOP
| Gonioscopy- mirrored lens to look at angle of eye
96
Symptoms of closed angle glaucoma
Rapid onset pain, redness and blurriness
| Mid dilated fixed pupil
97
Signs of closed angle glaucoma
```
Increased IOP
Optic disc cupping
Indentation of ON head
Peripheral vision loss
Pathological blind spot spread
Grants haemorrhage- bleeding on or around disc
```
98
Investigations for closed angle glaucoma
IOP will be elevated
99
Sx of infantile glaucoma
Haxy cornea
Watering
Photophobia
Buphthalmos- enlarged eye
100
Management of glaucoma
If mild signs and OK nerve, watch and wait
Otherwise
- Local eyedrops- mitotics, prostaglandins, alpha agonists, CAI inhibitors, osmotic agents
- Surgery- Peripheral iridotomy, shunts/iStent, xen gel stent, cyclocryotherapy to ciliary body, goniotomy/trabeculotomy if paeds
101
Explain how mitotics work for glaucoma
Increase aqueous outflow by constricting pupil
| Eg. pilocarpine
102
Explain how prostaglandin analogues work for glaucoma + se
Increase aqueous outlow through the uveosclera eg. xalatan
| Cause browning of blue irises, eyelash growth and eye sinking
103
Explain how b blockers work for glaucoma + se
Reduce aqueous production eg. timoptol
| Bradycardia, heart block, HF, SOB, infant apnea, confusion, fatigue, nightmares, mask hypoglycaemia
104
Explain how CAIs work for glaucoma + se
Reduce aqueous production eg. azopt
| Stinging, conj. hyperaemia, eyelash crust, bitter taste
105
Explain how a agonists work for glaucoma + se
Reduce aqueous production eg. Iopidine
| Hypokalaemia, renal issues, allergy, fatigue, somnolence, HTN, dry mouth, taste change
106
Explain how osmotic agents work for glaucoma + se
Reduce vitreous volume via osmosis eg. mannitol, glycerol
107
What structures can diabetes affect in the eye (aside from the retina and macula)
Tear film- reduced quantity and stability
Cornea- decreased sensitivity, risking fungal and viral infection, erosions, persistent defects and punctate keratitis
Iris- mitotic pupil, neovascularisation, cataract
108
What are risk factors for diabetic retinopathy
```
Age
DM duration
glycaemic control
Smoking
Obesity
Pregnancy
BP
Lipids
Anaemia
Alcohol
PMHx
Ethnicity
```
109
What are signs of diabetic retinopathy and maculopathy
```
Microaneurysm- unique to diabetes
Dot and blot and flame haemorrhage
Cotton wool spots
Druse
Hard exudate
Pigment
Vascular changes- sausaging, intra-retinal microvascular anomalies (pre-proliferative)
Vascular growth- new disc and retinal vessels (proliferative changes)
Macular oedema
```
110
How do we classify diabetic retinopathy
Pre-proliferative
Neovascular proliferative
Fibrovascular proliferative
May be with or without maculopathy
111
What is pre-proliferative change
Microaneurysms, dot blot haemorrhage, exudate
| Indicate leakage from arterioles
112
What is neovascular proliferative change
New blood vessels, suggests, chronic retinal ischaemia
113
What is fibrovascular proliferative change
Pre-retinal fibrovascular stalk
| Indicates severe retinal ischaemia
114
What are risks to vision in proliferative retinopathy?
1. Neovascualrization
2. Vessel size
3. Vessel location- worse if near macula
4. Haemorrhage
115
How do we classify maculopathy
Focal- leakage from small microaneurysms. Shows yellow ring (circinate exudate)
Ischaemic- capillaries underlying fovea are occluded, increased vessel tortuosity
Diffuse- all leak
116
How do we manage diabetic retinopathy
Laser treatment for blockage
Focal laser for leaks
Avastin to decrease macular oedema and neovascularization
General measures- BP and glycaemic control, lipids, renal monitoring
117
What can cause age related macular degeneration
Uncertain- exacerbated by smoking though!
118
Symptoms of wet ARMD
Vision loss, usually unilateral
Distorted vision
Macular discolouration
Serum and blood leakage
119
Symptoms of dry ARMD
Pigment degeneration in fovea
Drusen
Vision loss
Distorted vision
120
Management of ARMD
Periodic VEGF injection
Smoking cessation
Vitamin tablets
Refer to ophthalm if new vision loss
121
What do you examine with pupils
Size and shape, symmetry
Near and light reflexes
RAPD
122
What is anisocoria
Difference in pupil size- a problem if more tha 1mm difference and different reaction to light
123
Causes of anisocoria
Medicines- mydriatics, mitotics, atropine
Trauma- surgery, post synechiae
Disease- uveitis, glaucoma (compression may stun iris into dilating), syphillis
Systemic meds- narcotics, opioids
Syndromes- horners, CNIII palsy
124
What can cause small anisocoria
Horner syndrome
| Argyll Robertson syndrome
125
Causes of horner's syndrome
Sympathetic pathway disruption so
- Brainstem disease
- Spinal cord tumour
- Carotid dissection (pain)
- Lung apex tumour
- Neck lesion
126
Symptoms of horners syndrome
```
Unilateral
Miosis
Ptosis
Enophthalmos (eye sinking)
Cutaneous anhydrosis
Scleral redness
```
127
Investigation for Horners syndrome
Topical cocaine- normal pupil dilates, abnormal won't due to loss of noradrenaline at junction
Apraclonidine- see reverse effect
Imaging to determine cause
128
Cause of argyll robertson pupil
Neurosyphillis
129
Sx of argyll robertson pupil
Small irregular pupils
| Normal near reflex, absent light reflex
130
What can cause large pupils
Adie's pupil
| CNIII palsy
131
What can cause Adies pupil
Postganglionic parasympathetic denervation
| - Idiopathic, diabetes, viral, traumatic
132
Symptoms of adie's pupil
Light and near reflexes sluggish
Eventual pupil tonicity
Can see vermiform movements as parts of pupillary sphincter are re-innervated
If coupled with reduced reflexes- Holmes Adie syndrome
133
Investigations for adie's pupil
Hypersensitivity to pilocarpine- abnormal pupil will construct due to upregulated neurotransmitter receptors
134
Causes of CNIII palsy
Compressive: aneurysm, tumour, tentorial herniation
| Non-compressive: Diabetes, HTN, atherosclerosis
135
Sx of CNIII palsy
```
Unilateral
Pupil dilation IF compressive lesion
Eyes down and out
Limited down, up and adduction movements
Normal abduction
Ptosis
```
136
Management of CNIII palsy
Removal of compressive lesion
| Scan to exclude compressive lesions
137
What is RAPD
Pupil response to consensual light but not direct
138
Causes of RAPD
```
ON compression or inflammation
Chiasma compression
Retinal detachment
Large unilateral macular lesion
Unilateral glaucoma
```
139
Investigation for RAPD
Swinging light test
140
Associations of atopic keratoconjunctivitis
Eczema and opportunistic infection
141
Where can atopic keratoconjunctivitis manifest
Papillary
Periorbital
Deep cornea
142
Symptoms of atopic keratoconjunctivitis
Itch
Photophobia
Watering
Redness
143
Management of mild atopic keratoconjunctivitis
```
Avoid allergens and rubbing
Cold compresses
Topical and systemic antihistamines
Mast cell stabilisers for prevention
NSAIDs, patanol
```
144
Management of severe atopic keratoconjunctivitis
Topical corticosteroids- high then tail off quickly
Cyclosporine
Immunosuppressants
Surgery- papilla excision/keratectomy
145
Complications of atopic keratoconjunctivitis
Marginal keratitis- pale inside of iris due to staph toxins
Rosacea/blepharitis- assoc with contact lens wear
If adenovirus- pseudomembranes and scarring which need to be peeled.
Corneal subepithelial infiltrates- degrade vision but settle on their own
146
Symptoms of HSO
Blepharo-conjunctivitis
Keratititis in 50%
Dendritic ulcer on fluroscopy
147
Management of HSO
50% self resolve
Acyclovir
Risk of recurrence is 25% in 5 years
148
Complications of HSO
Amoeboid ulcer if given steroids without acyclovir coverage
Disciform keratitis- keratitis leads to endothelitis leads to oedema leads to pot belly cornea on slit lamp
Anaesthetic, scarred and vascularised cornea
149
Symptoms of giant cell arteritis
Unilateral headache
Weight loss
Amaurosis fugax
150
Investigations for GCA
CRP and ESR
| Temporal artery biopsy
151
Ophthalmoscopy findings for GCA
Unilateral pale, swollen disc with flame haemorrhages
152
Management of GCA
Immediate steroids
153
Definition of cataracts
Clouding of the lens
154
Causes of cataracts
```
Age related- most common
Gongenital
Diabetes
Toxic- corticosteroids
Traumatic- radiation
Secondary such as to anterior uveitis
```
155
Symptoms of cataract
Progressive blurring is affected eye
| Can improve with pinholes
156
Investigations for cataracts
Slit lamp- can determine location and grade
Ophthalmoscopy- lose the red reflex
Visual acuity
157
Management of cataracts
Intracapsular lens extraction- lens and capsule, zonules dissolved
Extracapsular extraction- lens removed, leaving capsule- requires large incision
Phacoemulsification- high frequency US to emulsify cataract using tiny incision- preferred!
Intraocular lenses- placed into capsule or clipped to iris- allows tiny incisions- adjunct to others!
158
Complications of cataract surgery
Iris prolapse or trauma
Anterior capsule tear
Dropped nucleus
159
Why is corneal transplant more straightforward and how long does it take to work
It is avascular so few rejections and no immunosuppression needed
12-18mos for optimal vision
160
Indications for corneal transplants
Keratoconus following failure of hard lens correction- cornea protruding, thin and distorted
Keratopathy or oedema- painful blisters and scars secondary to surgery or glaucoma
Dystrophy- genetic disorders and ageing
Infection causing ulcers
Trauma- chemical or physical
Pterygium
Melanoma
161
Types of corneal transplant
Penetrating- whole cornea
Anterior laminal- host endothelium remains
Endothelial- only endothelium transplanted
162
Definition of dry eye
Multifactorial evaporative or aqueous defect of the tears and ocular surface, exacerbated by contact lenses and environmental conditions
163
Symptoms of dry eye
Dryness
Grittiness
Irritation
Burning
164
Definition of sjogren syndrome
A chronic, systemic, inflammatory autoimmune disorder characterised by lymphocytic infiltration of the exocrine organs (Aqueous deficient in nature)
165
Symptoms of sjogren syndrome
```
Xerophthalmia (dry eye)
Xerostomia (dry mouth)
Parotid enlargement
Arthralgia
Reynauds
RA
Lymphoma
Eating or speaking difficulties
```
166
Causes of sjogren syndrome
Genetic
Environmental
Sex hormones
Viral trigger sometimes
167
Classification of sjogren syndrome
Primary- dry eye and mouth with no rheumatoid issues
| Secondary- dry eye, mouth and rheumatoid
168
Pathophysiology of sjogren syndrome
Gland changes lead to reduced aqueous, hyperosmolar tears, inflammation, cytokine invasion, epithelial damage and then more gland changes
169
Signs of eye sjogren syndrome
```
Ocular redness
Corneal dullness
Blepharitis
Meibomian dysfunction
Mucous trands on cornea
Poor tear film stability
```
170
Investigations for eyes with sjogren syndrome
Schrimmer test- wets less than 5mm of card touching sclera in 5m
fluroscein- stains epithelial loss
Rose bengal- stains dead or uncovered cells
171
Oral signs of sjogren syndrome
```
Tongue sticks to depressor
Dental caries
Periodontal disease
Predisposition to candida
Parotid enlargement
```
172
Signs of rheum sjogren
Arthritis- symmetrical and polyarticular
173
Ix for rheum sjogren and oral sjogren
```
RF positive
ANA positive
Anti Ro positive in primary
Anti La positive in almost half of primary
Salivary gland biopsy
```
174
Treatment of eye sjogren level 1
Symptoms mild and with no signs- tear supplements and environmental changes
175
Treatment of eye sjogren level 2
Moderate symptoms, mild signs- as for 1 plus tear gel nocte, short course of topical steroids, cyclosporine A, nutritional supplements
176
Treatment of eye sjogren level 3
Severe symptoms with marked signs: 2 plus tetracyclines, serum tears, punctal occlusion, acetylcystine (which breaks mucus strands)
177
Treatment of eye sjogren level 4
Extreme symptoms, severe signs: Systemic anti inflammatories, topical vitamin A, moisture chamber glasses
178
Other treatments for sjogren syndrome
Cholinergic parasympathetic mimetics
DMARDs (hydroxychloroquine)
Immunosuppression
Multidisciplinary care
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Define strabismus
Misaligned eyes
180
Causes of strabismus
Brain, cranial nerves, NMJ or extraocular muscle dysfunction
181
Symptoms of strabismus
Diplopia if reported
| Often based on parental report- not fixing/following/full eye movement
182
Types of strabismus
Phoria- present when eyes dissociated
| Tropia- present with binocular vision
183
Positional categories of strabismus
Eso/exotropia- adduction/abduction
| Hyper/hypotropia- superior/inferior deviation
184
Examination of strabismus
Corneal light reflex test- should be just nasal of pupil but is displaced in misaligned eye
Cover test- deviated eye will move to fix once good eye is covered
Uncover test- look for deviation as cover is removed
Alternate cover test- as eyes switch cover they both move- can measure degree of strabismus
Prism cover testing- prism over deviated eye to neutralize alternate cover movement- allows determination of surgery
185
Management of strabismus
Surgical- weaken strong muscle, strengthen weak muscle, reposition muscles
186
Pseudoesotropia
Medial sclera is buried with lateral gaze so eyes look crossed
Normal on exam- child will grow out of it
187
Infantile esotropia
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Onset up to 2 months of age secondary to poor fusion
Other motility issues such as nystagmus
Need to manage amblyopia
Surgery at 6-12 months
50% need another surgery too
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188
Refractive esotropia
Onset 18mo-5y
Shows hyperopia, accommodation stimulates convergence
Often corrects with hyperopic glasses but may require surgery
189
Intermittent exotropia
Onset at 2-5y of age worse with distance vision
May close eye in bright light
Surgery for depth perception and cosmesis
May improve, progress to constant or stay stable without intervention
190
SO palsy
Congenital or acquired
Ipsilateral hypertrope worse with contralateral gaze and ipsilateral tilt
Surgery- IO weakening or SO tuck
191
Define amblyopia
Poor visual cortex development secondary to blurred visual input- ie. problem is in BRAIN not EYE
192
Causes of amblyopia
Refractive- anisometropia goes to astigmatism goes to hyperopia goes to myopia
Strabismus
Stimulus deprivation
193
Management of amblyopia
Patching- good eye is occluded for 2-6h per day
| Good eye blurring with atropine- but beware toxicity (red, mad, hot)
194
Causes of abnormal red reflex in children
Retinoblastoma
Congenital cataract
Congenital glaucoma
195
Describe retinoblastoma
RB1 gene mutation with high survival with treatment
Risk of other malignancies if inherited
Presents as red reflex loss, poor vision, eye misalignment
Can treat with cryo, laser, radiation and chemo
196
Describe congenital cataract
20% aare inherited showing a loss of the red reflex
| Surgery needs to take place at 4-6 weeks of age with an IOL at 6 months
197
Describe congenital glaucoma
Abnormal drainage angle requiring surgery
| Photophobia, teariness, hazy cornea and buphthalmos
198
Describe retinopathy of prematurity
Fibrovascular retinal proliferation in pre term infants- worry about potential retinal detachment
Watch and wait- if there are issues, do laser photocoagulation
199
Describe neurofibromatosis
Autosomal dominant disorder
| Lisch nodules show up as tan lumps on the iris, increase with age
200
Describe abusive head trauma
Multiple retinal haemorrhages often extending to the periphery
Check for other injuries including external ocular and brain
201
Describe lens subluxation
Assoc with marfan syndrome, haemocystinuria
202
Describe blue sclera
Assoc with osteogenesis imperfecta secondary to type I collagen deficiencey
203
Describe findings of congenital ptosis
Fair or poor LPS action with lack of lid crease
| There may also be lag on down gaze with or without upgaze problems
204
What are types of acquired ptosis
Involutional
Neurogenic
Myogenic
Mechanical
205
Causes and presentation of involutional ptosis
due to aponeurotic dehisence- CL wearers often
Shows good LPS action, high lid crease and no lid lag on down gaze
Frontalis may be overactive as it tries to raise the eyebrows to compensate
206
Causes of neurogenic ptosis
CNIII palsy, horners
207
Causes of myogenic ptosis
Chronic progressive external ophthalmoplegia, myaesthenia gravis
208
Causes of mechanical ptosis
Upper lid tumours, trauma, surgery
209
Causes of lid retraction
Congenital
| Acquired- midbrain lesion, thyroid eye disease
210
Pathophysiology of thyroid eye disease
Lymphocytic infiltration leading to msucle and fat becoming oedematous and expanding
Doposition of hyaluronic acid and GAGs
211
Signs of thyroid eye disease
Thick extraocular muscles
Max eye diameter outside orbital rim
Tenting of optic neuritis
212
Management of thyroid eye disease
Watch for signs of corneal exposure
| Optic nerve if compressed may need surgical decompression
213
Define ectropion
Eyelid margin is away from the globe
214
Involutional ectropion
Laxity of canthal tendon of eye
215
Cicatricial ectropion
Scar at cheek pulling lid down
216
Paralytic ectropion
CNVII palsy due to orbicularis oculi as in bells palsy, parotid excision, accoustic neuroma
217
Mechanical ectropion
Lower eyelid oedema
