Ophthalmology Flashcards
1
Q
What is a glaucoma? What are the two types?
A
Optic nerve damage caused by significant rise in intraocular pressure caused by blockage in aqueous humour trying to escape eye
Open-angle and closed-angle
2
Q
Label the following:
A
3
Q
Label:
A
4
Q
What fills the vitreous chamber?
A
Vitreous humour
5
Q
What fills the anterior chamber and posterior chamber?
A
Aqueous humour (supplies nutrients to the cornea)
6
Q
What is the aqueous humour produced by? Where does it flow?
A
Ciliary body (flows from ciliary body, around lens, under iris through the anterior chamber through trabecular meshwork and into the canal of Schlemm - then into general circulation)
7
Q
What is the normal intraocular pressure? How is this created?
A
10-21mmHg
Created by resistance to flow through the trabecular meshwork into the canal of Schlemm
8
Q
What happens in open-angle glaucoma?
A
Gradual increase in resistance through the trabecular meshwork (slow and chronic onset)
9
Q
What happens in acute angle-closure glaucoma?
A
Iris buldges forwards and seals off the trabecular meshwork from anterior chamber (emergency)
10
Q
What happens to the optic disc when intraocular pressure is raised?
A
Cupping of the optic disc (greater than 0.5 is abnormal)
11
Q
What are the risk factors for open angle glaucoma?
A
Increased age
FH
Black ethnic origin
Nearsightedness (myopia)
12
Q
How does open-angle glaucoma present?
A
Asymptomatic (often diagnosed by routine screening)
Affects peripheral vision first creating tunnel vision, also:
- Fluctuating pain
- Headaches
- Blurred vision
- Halos appearing around lights
13
Q
What are the two ways of measuring intraocular pressure?
A
Non-contact tonometry - shooting “puff of air” at cornea and measuring corneal response (less accurate, good for screening)
Goldmann applanation tonometry - device mounted on slip lamp which makes contact with cornea and applies different pressures to measure intraocular pressure (gold standard)
14
Q
How is open angle glaucoma diagnosed?
A
Goldman applanation tonometry - check intraocular pressure
Fundoscopy - check optic disc cupping and optic nerve health
Visual field assessment - peripheral vision loss
15
Q
At what intraocular pressure is treatment started?
A
24mmHg or above
16
Q
What is the management of open angle glaucoma?
A
Prostaglandin analogue eye drops (e.g. latanoprost) are first line - increase uveoscleral outflow
Other options:
- Beta-blockers (timolol) reduces production of aqueous humour
- Carbonic anhydrase inhibitors (e.g. dorzolamide) reduces the production of aqueous humour
- Sympathomimetics (e.g. brimonidine) reduces production fo aqueous humour and increase uveoscleral outflow
Surgery
17
Q
What are the side effects of prostaglandin analogue eye drops (e.g. latanoprost)?
A
Eyelash growth
Eyelid pigmentation
Iris pigmentation
18
Q
What is the surgery for open angle glaucoma?
A
Trabeculectomy (if eyedrops ineffective)
Creat new channel from anterior chamber through sclera to a location under conjunctiva (creating “bleb”) where aqueous humour drains
19
Q
Where is the pressure build up greatest in acute angle-closure glaucoma?
A
Posterior chamber causing pressure behind iris and worsening of closure of angle
20
Q
What are the risk factors for acute angle-closure glaucoma?
A
Increasing age
Female (4:1)
FH
Chinese and east asian origin (unlike open-angle glaucome, rare in black ethnicity)
Hypermetropia (long sightedness)
21
Q
Which medications can precipitate acute angle-closure glaucoma?
A
Adrenergic medications e.g. noradrenalin
Anticholinergic medications e.g. oxybutynin and solifenacin
TCA e.g. amitriptyline (have anti-cholinergic effects)
Mydriatic eye drops
22
Q
How does acute angle-closure glaucoma present?
A
Severely painful red eye
Blurred vision
Halos around lights
Associated headache, nausea and vomiting
23
Q
How does acute angle-closure glaucoma appear on examination?
A
Red-eye
Teary
Hazy cornea
Decreased visual acuity
Dilatation of affected pupul
Fixed pupil size
Film eyeball on palpation
24
Q
What is the inital management of acute open-angle glaucoma?
A
Referred for same-day assessment by opthalmologist
- Lie patient on back without pillow
- Give pilocarpine eye drops (2% blue, 4% brown)
- Acetazolamide 500mg orally
- Analgesia and antiemetic if required
25
How does **pilocarpine** work?
On **muscarinic receptors** in **sphincter muscles** of iris causing **constriction of pupil** (**miotic agent**)
Causes **ciliary muscle contraction**
Opening up **pathway** from **flow of aqueous humour** from **ciliary body** around iris and **into trabecular meshwork**
26
How does **acetazolamide** work?
**Carbonic anhydrase inhibitor** (reducing production of aqueous humour)
27
What **medical options** are there in **secondary care** for **acute angle-closure glaucoma**?
**Pilocarpine**
**Acetazolamide** (oral / IV)
**Hyperosmotic agents** e.g. **glycerol** or **mannitol** increases osmotic gradient between blood and fluid in eye
**Timolol** = beta-blocker that reduces production of aqueous humour
**Dorzolamide** = **carbonic anhydrase inhibitor** reducing production of aqueous humour
**Brimonidine** = **sympathomimetic** reducing production of aqueous fluid and increasing uveoscleral outflow
28
What is the **surgical** management of **acute angle-closure glaucoma**?
**Laser iridotomy** (definitive treatment) - **laser** makes **hole in iris** to allow aqueous humour to **flow from posterior chamber** into **anterior chamber** relieving pressure
29
What is the **most common cause** of **blindness** in the **UK**?
**Age-related** degeneration of the **macular** causing **progressive deterioration** in vision
30
What is a **key fundoscopy finding** in **macular degeneration**?
**Drusen**
31
What are the **two types** of **age related macular** degeneration?
**Wet** (worse prognosis)
## Footnote
**Dry**
32
What are the **four layers** of the **macular**?
**Choroid layer** (bottom = blood vessels to macula)
**Bruch's membrane**
**Retinal pigment epithelium**
**Photoreceptors**
33
What are **drusen**?
Yellow deposits of **protein** and **lipids** that appear **between** **retinal pigment epithelium** and **Bruch's membrane**
Some is normal (\<63 micrometres) and hard
Larger and more = **early sign of macular degeneration**
34
What **features** are common to both **wet and dry AMD**?
**Atrophy** of the **retinal pigment epithelium**
**Degeneration** of the **photoreceptors**
35
What **feature** is **unique to wet AMD**?
Development of **new vessels** growing from **choroid layer** into **retina** - can **leak fluid** or blood and cause **oedema** and more rapid loss of vision
36
What is **targeted** in the treatment of **wet AMD**?
**Vascular endothelial growth factor** (VEGF)
37
What are the **risk factors** for **AMD**?
Age
Smoking
White / chinese ethnic origin
FH
CVD
38
How does **AMD** present?
Gradual worsening **central visual field loss**
Reduced **visual acuity**
**Crooked or wavy appearance to straight lines**
39
How does **wet age-related macular degeneration** present?
More **acutely** - loss of vision over **days** and progresses to full loss over **2-3 years** (often progresses to **bilateral**)
40
What are the **examination findings** for **AMD**?
**Reduced acuity** using a **Snellen chart**
**Scotoma** (central patch of vision loss)
**Amsler grid test** - look for distortion of straight lines
**Fundoscopy** - drusen are key findings
41
What **specialist** investigations are there for **AMD**?
**Slit-lamp biomicroscopic fundus examination** by a specialist to **diagnose AMD**
**Optical coherence tomography** to gain cross-sectional view of layers of retina to **diagnose wet AMD**
**Flurescein angiography -** gives fluroscein contrast and photograph retina to look in detail at the **blood supply to retina** (useful to **show up and oedema** and **neovascularisation**) - used second line to diagnose wet AMD if **optical coherence tomography** doesn't exclude wet AMD
42
What is the **management** of **dry AMD**?
No specific treatment for **dry age-related macular degeneration**, focus on slowing disease progression:
* **Avoid smoking**
* **Control blood pressure**
* **Vitamin supplementation** (has evidence in slowing progression)
43
What is the **treatment** of **wet AMD**?
**Anti-VEGF medication****s**e.g.**ranibizumab**,**bevacizumab**and**pegaptanib**
Injected directly into **vitreous chamber** of eye once a month (**slow** and **reverse** progression of disease)
Need to be started within **3 months** to be **beneficial**
44
What is **diabetic retinopathy**?
**Blood vessels** in **retina** are damaged by **prolonged exposure** to **high blood sugar levels**
45
What happens in **diabetic retinopathy**?
**Hyperglycaemia** caused damage to **retinal small vessels** and **endothelial cells** = **vascular permeability** and **blot haemorrhages** and formation of **hard exudates** (yellow / white deposits of **lipids** in the retina)
46
What is the result of **damage** to **blood vessels** in **diabetic retinopathy**?
**Microaneurysms** and **venous beading**
47
What is the **result** of **damage to nerve fibres** in **diabetic retinopathy**?
**Cotton wool spots = fluffy white patches** on retina
48
What are the **intraretinal microvascular abnormalities** in **diabetic retinopathy**?
**Dilated** and **tortous** **capillaries** in retina, acting as **shunt** between **arterial** and **venous vessels**
49
What is **neovascularisation**?
**Growth factors** are **released** in the **retina** cauing **development of new blood vessels**
50
Label the following:
51
Label the following:
52
What are the **two classification****s**of**diabetic retinopathy**?
**Non-proliferative** and **proliferative** (depending on if new blood vessels have developed)
Proliferative = background or **pre-proliferative**
Classified based on fundus examination
53
What are the **categories** of **non-proliferative diabetic retinopathy**?
**Mild** = microaneurysms
**Moderate** = microaneurysms, blot haemorrhages, hard exudates, cotton wool spots and venous bleeding
**Severe** = blot haemorrhages plus microaneurysms in 4 quadrants, venous beading in 2 quadrants, intraretinal microvascular abnormality (IMRA) in any quadrant
54
What categorises **proliferative diabetic retinopathy**?
**Neovascularisation**
**Vitrous haemorrhage**
55
What **categorises** diabetic maculopathy?
**Macular oedema**
**Ischaemic maculopathy**
56
What are some **complications** of **diabetic retinopathy**?
**Retinal detachment**
**Vitreous haemorrhage** (bleeding in to the vitreous humour)
**Rebeosis iridis** (new blood vessel formation in the iris)
**Optic neuropathy**
**Cataracts**
57
What is the **management** of **diabetic retinopathy**?
**Laser photocoagulation**
**Anti-VEGF** medications e.g. **ranibizumab** and **bevacizumab**
**Vitreoretinal surgery** (keyhole surgery on the eye) in severe disease
58
What is **hypertensive retinopathy**?
Damage to **small blood vessels** in retina related to **systemic hypertension** (result of **chronic hypertension** / quick in **malignant hypertension**)
59
What **signs** occur in the **retina** in response to **hypertension**?
**Silver wiring** / **copper wiring** = walls of arterioles become thickened and sclerosed causing **increased reflection of light**
**Arteriovenous nipping** = arterioles cause **compression** of **veins** where they cross (again due to sclerosing and hardening of arterioles)
**Cotton wool spots** = caused by **ischaemia** and **infarction** in retrina causing damage to nerve fibres
**Hard exudates** = caused by damaged vessels leaking **lipids** into the retina
**Retinal haemorrhages** = damaged vessels rupturing and releasing blood into retina
**Papilloedema** caused by **ischaemia** to the **optic nerve** resulting in optic nerve swelling (**oedema**) and blurring of margins
60
Label the following:
61
Label the following:
62
What are the **stages** to the **Keith-Wagener Classification**?
**Stage 1:** Mild narrowing of the arterioles
**Stage 2:** Focal constriction of blood vessels and AV nicking
**Stage 3:** Cotton-wool patches, exudates and haemorrhages
**Stage 4:** Papilloedema
63
What is the **management** of **hypertensive retinopathy**?
**Controlling blood pressure** and risk factors e.g. smoking, blood lipid levels
64
What is **cataracts**?
**Lens** in eye becomes **cloudy and opaque** reducing **visual acuity** and light that enters eye
65
What is the **role of the lens**?
**Focus** light coming into the eye onto the **retina**
66
What is the **lens** held in place by?
**Suspensory ligaments** attached to the **ciliary body** (this contracts and relaxes to focus the lens - contracts = releases tension and lens thickens)
67
What is the **lens** nourished by?
**Surrounding fluid** (no blood supply) - grows and develops through life
68
When does **congenital cataracts** form? How is it screened for?
**Before birth** - screened for using **red reflex** during neonatal examination
69
What are the **risk factors** for **cataracts**?
Increasing age
Smoking
Alcohol
Diabetes
Steroids
Hypocalcaemia
70
How does **cataracts** present?
**Asymmetrical** as both eyes are affected separately
* **Slow reduction** in **vision**
* **Progressive blurring**
* Change in colour of vision = more brown / yellow
* **Starbursts** can appear around lights (particularly at night)
71
What is a **key sign** of **cataracts**?
**Loss** of **red reflex** (might show up on photographs)
72
How to **differentiate** **cataracts**, **glaucoma**, **macular degenration**?
**Cataracts** = generalised **reduction in visual acuity** with **starbursts** around lights
**Glaucoma** = peripheral vision loss with **halos around lights**
**Macular degeneration** = **central** loss of vision with **crooked** or **wavy appearance** to **straight lines**
73
What is the **management** of **cataracts**?
At what level vision is this done?
If **manageable** then **no intervention**
**Surgery** = phaecoemulsification (dissolving lens with US) and implanting **artifical lens** into the eye (usually under **local anaesthetic**)
Vision = less than 6/12
74
Why may surgery not be successful for cataracts?
May **prevent detection** of other pathology e.g. **macular degenration** / **diabetic retinopathy**
75
What is **endopthalmitis**?
**Rare** but **serious complication** of **cataracts surgery** = **inflammation** of the **inner contents** of the eye usually caused by **infection** can be treated with **intravitreal abx**
Can cause **loss of vision** / **eye itself**
76
What **stimulates** the **circular muscles** in the **iris**?
**Parasympathetic nervous system** using **acetylcholine** as a **neurotransmitter** (nerve fibres travel along the **oculomotor** cranial nerve)
77
What **stimulates** the **dilator muscles**?
**Parasympathetic nervous system** using **adrenaline** as a **neurotransmitter**
78
What can cause an **abnormal pupil shape**?
**Trauma** to the **sphincter muscles** in the iris (**cataracts surgery** or other eye operations)
**Anterior uveitis** causing **adhesions** (scar tissue)
**Acute angle closure glaucoma** (ischaemic damage to the muscles = **vertical oval** pupil shape)
**Rubeosis iridis** (neovascularisation in the iris) distorts shape of iris and pupil - associated w **diabetic retinopathy**
**Coloboma** is a **congenital malformation** in eye - hole in iris
**Tadpole pupil** - spasm in a segment of iris causing misshapen pupil (**temporary** and **associated** with **migraines**)
79
What are some **causes of mydriasis** (dilated pupil) ?
**Third nerve palsy**
**Holmes-Adie syndrome**
**Raised intracranial pressure**
**Congenital**
**Trauma**
Stimulants, such as **cocaine**
**Anticholinergics**
80
What are some **causes** of **miosis** (**constricted pupil**)?
**Horners** syndrome
**Cluster** headaches
**Argyll-Robertson pupil** (in neurosyphilis)
**Opiates**
**Nicotine**
**Pilocarpine**
81
How does a **third nerve palsy** **appear**?
**Ptosis** (drooping upper eyelid)
Dilated non-reacrive pupil
**Divergent strabismus** (squint) in affected eye (**down and out** position)
82
Why does the **eye move outward** and **downwards** in a 3rd nerve palsy?
**Oculomotor nerve** supplies all **extraocular muscles** except **lateral rectus** and **superior oblique**
83
Why does **third nerve palsy** also cause **ptosis**?
(what supplies the obicularis oculi)?
It supplies **levator palpebrae superioris** responsible for **lifting upper eyelid**
Facial nerve = obuicularis oculi (unopposed so cant open eyelid)
84
Why does a **third nerve palsy** also cause a **dilated fixed pupil?**
**Supplies** the **parasympathetic** **fibres** that innervates the **sphincter muscle** of the **iris**
85
How does the **oculomotor** nerve travel from the **brainstem**?
What can cause **compression** of the nerve?
**Straight line** through **cavernous sinus** and close to **posterior communicating artery**
**Cavernous sinus thromobis** and **posterior communicating artery aneurysm**
86
What can **a third nerve palsy** with **sparing of the pupil** suggest? What can cause it?
Suggests **microvascular** cause as **parasympathetic fibres** are spared:
* **Diabetes**
* **Hypertension**
* **Ischaemia**
87
What can cause a **full third nerve palsy**?
**Idiopathic**
**Tumour**
**Trauma**
**Cavernous sinus thrombosis**
**Posterior communicating artery aneurysm**
**Raised intracranial pressure**
(also called a **surgical third**)
88
What is the **triad** in **horner syndrome**?
**Ptosis**
**Miosis**
**Anhidrosis** (loss of sweating)
(may also have **enopthalmos**)
89
What causes horner's syndrome? What journey do the fibres take?
**Damage** to the **sympathetic nervous system**
**Arise** from **spinal cord** (pre-ganglionic nerves) then enter into **sympathetic ganglion** at the base of the neck and exit as **post-ganglionic nerves** (travel to the head along **internal carotid artery**)
90
How can the **location** of the **Horner syndrome** be determined?
By **anhidrosis**:
* Central lesion = arm and trunk and face
* Pre-ganglionic = face
* Post-ganglionic = no anhidosis
91
What are the **causes** of **Horner syndrome**?
4 S's (sentral), 4 T's (torso - pre-ganglionic) 4 C's (cervical - post ganglionic)
* **S**troke
* M**S**
* **S**welling (tumour)
* **S**yringomyelia (cyst in the spinal cord)
* **T**umour (pancoast)
* **T**rauma
* **T**hyroidectomy
* **T**op rib (cervical rib growing above the first rib above clavicle)
* **C**arotid aneurysm
* **C**arotid artery dissection
* **C**avernous sinus thrombosis
* **C**luster headache
92
What is **congenital Horner syndrom****e** associated with?
**Heterochromia** (difference in colour of iris on affected side)
93
What can be **used to test** for **Horner syndrome**?
**Cocaine eye drops** (stops **noradrenaline** **re-uptake** at **neuromuscular junction**)
Normal eye = **dilation**
Horner eye = nerves are not releaseing noradrenaline in the first place so **no difference**
ALTERNATIVELY **low concentration adrenaline eye drop** (0.1%) won't dilate a normal pupil but will dilate a Horner syndrome pupil
94
What is a **Holmes Adie pupil**?
**Unilateral dilated pupil** that is **sluggish** to react to light with **slow dilation** of the pupil following constriction (over time the **pupil gets smaller**)
Caused by **damage** to the **post-ganglionic parasympathetic fibres** (cause is unknown but may be viral)
95
What is **Holmes Adie syndrome**?
**Holmes Adie pupil** with absent **ankle** and **knee reflexes**
96
What is **Argyll-Robertson Pupil**?
Finding in **neurosyphilis** - constricted pupil that **accommodates** when focusing on near objects but **no reaction** to **light**
**Prostitutes pupil** = accommodates but does not react
97
What is **blepharitis**?
**Inflammation** of the **eyelid margins**
98
What are the **features** of **blepharitis**?
**Gritty**, **itchy**, **dry sensation** in the eyes - associated with **dysfunction** of **Meibomian glands** (these secrete oil onto surface of eye)
99
What can **blepharitis** lead to?
**Styes**
## Footnote
**Chalazions**
100
What is the **management** of **blepharitis**?
**Hot compress** and gentle cleaning of eyelid to remove debris using **cotton wool** dipped in sterilised water and **baby shampoo**
101
What **eyedrops** can be used to **relieve symptoms** of **blepharitis**?
**Hypromellose** is least viscous (effect lasts around 10 mins)
**Polyvinyl alcohol** is middle viscous choice
**Carbomer** is most viscous (lasts 30-60 mins)
102
What are the **two types of styes** (may contain pus)?
**Hordeolum externum** = infection of **glands of Zeis** (sebaceous glands at base of eyelashes) or **glands of Moll** (sweat glands at base of eyelids)
**Hordeolum internum** = infection of **Meibomian glands** (deeper and more painful, may be underneath eyelid)
103
What are the **treatment of styes**?
**Hot compresses** and **analgesia** (consider topical antibiotics e.g. **chloramphenicol**) if its associated with **conjunctivits** or persistent
104
What is a **Chalazion**?
Blocked **Meibomian gland** (often called Meibomian cyst) = swelling in eyelid that is non-tender
105
What is the **treatment** of a **chalazion**?
**Hot compress** and **analgesia** (consider **topical antibiotics** e.g. **chloramphemicol** if acutely inflammed)
**Sugical drainage** may be required
106
What is **entropion**?
**Eyelid turns inwards** with lashes against eyeball
107
What can result from **entropion**?
**Pain**
**Corneal damage**
**Ulceration**
108
What is the **management** of **entropion**?
**Taping eyelid down** to prevent turning inwards (use lubricating eye drops to prevent eye drying out)
**Definitive** = surgical intervention
109
What is **ectropion**?
**Eyelid** turns **outwards** with **inner aspect** of **eyelid exposed**
110
What can **result** from **ectropion**?
What is the **treatment**?
**Exposure keratopathy** (eyeball is exposed and **not adequately lubricated**)
Mild = no treatment (regular lubricating eyedrops)
Severe = surgery
111
What is **trichiasis**?
**Inward** growth of the eyelashes (causes **pain**, **corneal damage**, **ulceration**)
112
What is the **management** of **trichiasis**?
Removal of eyelash (epilation)
If **recurrent** = **electrolysis**, **cryotherapy** or **laser treatment** (prevents lash regrowing)
113
What is **periorbital cellulitis** (aka **preorbital cellulitis**)?
**Eyelid** and **skin infection** in front of the **orbital septum** (in front of eye) presenting with **swelling**, **redness** and **hot skin** around **eyelids** and **eye**
114
How to **distinguish** **preorbital cellulitis** from **orbital cellulitis** (sight and life threatening emergency)?
**CT** scan
115
What is the **treatment** of **preorbital cellulitis**?
**Systemic antibiotics** (oral / IV)
Can develop into orbital cellulitis so vulnerable patients **may require admission**
116
What is **orbital cellulitis**?
**Infection** around the **eyeball** involving tissue **behind** **orbital septum**
117
What are the **distinguishing features** of **orbital cellulitis**?
**Pain** on **eye movement**
**Reduced** eye **movements**
**Changes** in **vision**
**Abnormal pupil reactions**
Forward movement of eye (**proptosis**)
118
What is the **management** of **orbital cellulitis**?
**Admission**
IV abx
**Surgical drainage** if **abscess forms**
119
What is **conjunctivitis**?
**Inflammation** of the **conjunctiva** (thin layer of tissue covering inside of eyelids and **sclera** of eye)
* Bacterial
* Viral
* Allergic
120
How does **conjunctivitis** present?
**Unilateral** or **bilateral**
**Red eyes**
**Bloodshot**
**Itchy** or **gritty sensation**
**Discharge** from the eye
121
What **eye symptoms** does **conjunctivitis** **not cause**?
**Pain**, **photophobia** or **reduced visual acuity** (may be blurry when eye is covered with discharge, when this is cleared the acuity should be normal)
122
How does **bacterial conjunctivitis** present?
**Purulent discharge** and **inflammed conjunctiva** (worse in morning, eyes stuck together)
Highly contagious
123
How does **viral conjunctivitis** present?
**Clear discharge**
Dry cough sore throat, blocked nose
Tender **preauricular** lymph nodes (in front of ear)
**Contagious**
124
What are the **differential diagnoses** of **acute red eye**?
**_Painless red eye_**
* Conjunctivitis
* Episcleritis
* Subconjunctival haemorrhage
**_Painful red eye_**
* Glaucoma
* Anterior uveitis
* Scleritis
* Corneal abrasions or ulceration
* Keratitis
* Foreign body
* Traumatic or chemical injury
125
What is the **management** of **conjunctivitis**?
Usually **resolves** without treatment **after 1-2 weeks**
**Good hygiene** (avoid sharing towels / rubbing eyes / contact lenses)
**Clear eyes** with cooled boiled water / cotton wool
**Abx** **eye drops** if bacterial cause (**chloramphenicol** and **fuscidic acid** eye drops are both options)
If **under 1 month** then **urgent opthalmology review** as **neonatal conjunctivitis** can be associated with **gonococcal infection** and can cause **loss of sight** and **pneumonia**
126
What is **allergic conjunctivitis** cause by?
**Contact with allergens** causing **swelling** of the **conjunctival sac** and **eye lid** with significant watery discharge and itch
127
What can be used to **reduce symptoms** of **allergic conjunctivitis**?
**Antihistamines**
Topical **mast-cell stabilisers** in patients with **chronic seasonal symptoms** (prevent mast cells releasing histamine - use for several weeks before benefit)
128
What is **anterior uveitis** aka **iritis**?
Inflammation in **anterior part** of **uvea** (iris, ciliary body and choroid)
**Choroid** = layer between retina and sclera
129
What **cells** infiltrate the **anterior chamber** of the eye?
What do they cause?
**Neutrophils**
**Lymphocytes**
**Macrophages**
Due to either **autoimmune process**, **infection**, **trauma**, **ischaemia** or **malignancy**
Causing **floaters** in patients vision
130
How to **differentiate chronic anterior uveitis** from **acute**?
**Chronic** = **granulomatous** (more **macrophages**) and **less severe** and longer duration (lasts **more than 3 months**)
131
What is **acute anterior uveitis** associated with?
**HLA B27** conditions
* Ankylosing spondylitis
* IBD
* Reactive arthritis
132
What can **chronic anterior uveitis** associated with?
* **Sarcoidosis**
* **Syphilis**
* **Lyme** disease
* **Tuberculosis**
* **Herpes virus**
133
How does **anterior uveitis** present?
**Unilateral** symptoms starting spontaeously without history of trauma / precipitating event
With **flare** of associated disease e.g. **reactive arthritis**
134
What are the **symptoms** of **anterior uveitis**?
* Dull, aching, painful red eye
* **Ciliary flush** (ring of red spreading from cornea outwards)
* Reduced visual acuity
* Floaters / flashes
* Sphincter muscle contraction causing **miosis** (constricted pupil)
* **Photophobia** due to ciliary muscle spasm
* **Pain** on movement
* Excessive tear formation (**lacrimation**)
* **Abnormally shaped pupil** due to **posterior synechiae**(adhesions) pulling the iris into abnormal shapes
* **Hypopyon** - collection of WBC in anterior chamber, seen as **yellowish** fluid collection settled **in front** of the **lower iris** with a fluid level
135
Which **investigations** can help **establish** diagnosis of **red eye**?
**Same day assessment** by **opthalmologist**
* Full **slit lamp assessment** of different structures
* **Intraocular pressures**
136
What are the **treatment options** for **anterior uveitis**?
**Steroids** (oral, topical or IV)
**Cycloplegic** (paralysing ciliary muscles)-**mydriatic** (dilating pupil) medications e.g. **cyclopentolate** or **atropine** eye drops (**anti-muscarinic** medications, blocking action of **iris sphincter muscles** and **ciliary body**) - dilate pupil and reduce pain associated with ciliary spasm
**Immunosuppressants** e.g. **DMARDS** and **TNF inhibitors**
**Laser therapy**, **cryotherapy** or **surgery** (vitrectomy)
137
What is **episcleritis**?
Self-limiting **inflammation** of the **episclera,** outermost layer of the **sclera** (just underneath the **conjunctiva**)
Not usually caused by infection
138
What is **episcleritis** associated with?
**Inflammatory disorders** e.g. **RA** and **IBD**
139
How does **episcleritis** **present**?
**Acute onset unilateral symptoms**:
* **Typically not painful** but there can be mild pain
* **Segmental redness** (rather than diffuse). There is usually a patch of redness in the lateral sclera.
* **Foreign body** sensation
* **Dilated episcleral vessels**
* **Watering** of eye
* **No discharge**
140
What is the **management** of **episcleritis**?
If in doubt, **refer to ophthalmology**
Usually **self limiting** and recovery in 1-4 weeks
**Lubricating eye drops** can help symptoms
Simple **analgesia**, **cold compress** and **safetynet advice**
**Severe** = systemic **NSAIDs** (e.g. **naproxen**) or **topical steroid eye drops**
141
What is **scleritis**?
**Inflammation** of full thickness of **sclera** (more serious than **episcleritis**) usually not caused by infection
142
What is the **most severe type** of **scleritis**?
**Necrotising scleritis** - normally have **visual impairment** but no pain (can lead to **perforation of sclera**)
143
Which **systemic conditions** may be **associated with scleritis**?
**Rheumatoid arthritis**
**SLE**
**IBD**
**Sarcoidosis**
**Granulomatosis with polyangiitis**
144
How does **scleritis** present?
**Acute** onset (50% = bilateral)
* **Severe** pain
* **Pain** with eye movement
* **Photophobia**
* Eye **watering**
* **Reduced visual acuity**
* **Abnomal pupil** reaction to **light**
* **Tenderness** to **palpation** of eye
145
What is the **management** of **scleritis**?
Potentially life threatening = referred for **same day assessment** by ophthalmologist
* Consider underlying condition
* **NSAIDs** (topical / systemic)
* **Steroids** (topical / systemic)
* **Immunosuppression** appropriate to underlying systemic condition (e.g. **methotrexate** in RA)
146
What are **corneal abrasions**?
What supplies sensory supply to cornea?
**Scratches** or **damage** to the **cornea** (cause of **red**, **painful eye**)
Sensation = **ophthalmic division** of trigeminal nerve
147
What are the **causes** of **corneal abrasions**?
**Contact lenses**
**Foreign bodies**
**Finger nails**
**Eyelashes**
**Entropion** (inward turning eyelid)
148
What **infection** may be present in **abrasion** with **contact lenses**?
**Pseudomonas**
149
What is an **important** differential to rule out in **corneal abrasions**?
**Herpes keratitis**
150
How do **corneal abrasions** present?
History of **contact lenses** or **foreign body**
**Painful red eye**
**Foreign body sensation**
**Watering** eye
**Blurring** vision
**Photophobia**
151
How are **corneal abraisons** diagnosed?
**Fluorescein stain** applied to eye - **yellow - orange colour** collects in **abrasions** or **ulcers** highlighting them
**Slit lamp examination** for more **significant abrasions**
152
What is the **managament** of **corneal abrasions** in **secondary care**?
**Simple analgesia** (e.g. paracetamol)
**Lubricating eye drops** to improve symptoms
**Antibiotic eye drops** (i.e. **chloramphenicol**)
**Bring patient back after 1 week** to check healed
**Cyclopentolate eye drops** dilate the pupil and improve significant symptoms, particularly **photophobia** (usually not necessary)
Uncomplicated corneal abraisons = **heal over 2-3 days**
153
What is **keratitis**? What are the **causes**?
**Keratitis** = inflammation of cornea
* **Viral infection** with **herpes simplex**
* **Bacterial** infection with **pseudomonas** or **staphylococcus**
* **Fungal** infection with **candida** or **aspergillus**
* **Contact lens acute red eye** (CLARE)
* **Exposure keratitis** (caused by inadequate eyelid coverage e.g. eyelid ectropion)
154
What is the **most common cause of keratitis**? What kind of inflammation can it cause?
**Herpes simplex keratitis**
Affects **epithelial layer** of **cornea** (can be **primary** or **recurrent**)
155
What is **inflammation** in **stroma** called?
What can it lead to?
**Stromal keratitis** (stroma = layer between epithelium and endothelium)
Associated with **stromal necrosis**, **vascularisation** and **scarring** can lead to **corneal blindness**
156
How does **herpes keratitis** present?
**Painful** **red eye**
**Photophobia**
**Vesicles** around the eye
**Foreign body sensation**
**Watering eye**
**Reduced visual acuity** (subtle to significant)
157
What **investigations** are there for **herpes keratitis**?
**_Slit lamp examination_** to find and diagnose keratitis
Staining with **fluorescein** will show **dendritic corneal ulcer** (branching and spreading of ulcer)
Corneal **swabs** or **scrapings** can be used to **isolate** the virus using a **viral culture** or **PCR**
158
What are the **management** options for **Herpes Keratitis** in **secondary care**?
**Aciclovir** (topical or oral)
**Glanciclovir** eye gel
**Topical steroids** (used alongside antivirals for stromal keratitis)
**Corneal transplant** (maybe after infection resolves to treat corneal scarring by stromal keratitis)
159
What is a **subconjunctival haemorrhage**?
Small blood vessel in the **conjunctiva** ruptures between **sclera** and **conjunctiva** (often appearing after **coughing**, **weight lifting**, or **straining** when **constipated**)
160
Which **conditions** may predisposed to **subconjunctival haemorrhage**?
**HTN**
**Bleeding disorders** e.g. **thrombocytopaenia**
**Whooping cough**
**Medications** (warfarin, NOAC, antiplatelet)
**Non-accidental injury**
161
How does a **subconjunctival haemorrhage** present?
**Bright red blood** underneath conjunctiva
**Painless**
Doesn't affect vision
162
How is a **subconjunctival haemorrhage** diagnosed?
**History** and **examination**
163
What is the **managament** of **subconjunctival** haemorrhage?
Resolves without treatment (2 weeks)
**Investigate** for possible causes?
**Foreign body sensation** = lubricating eye drops
164
What is the **vitreous humou****r?**
Gel inside eye maintaining structure and **keeping retina** pressed on the **choroid** (made from **collagen** and **water**)
Aging = **less firm** and able to keep shape
165
Who is **posterior vitreous** **detachment** most common in?
**Older** patients
166
How may **posterior vitreous detachment** present?
**Painless**
**Spots of vision loss**
**Floaters**
**Flashing lights**
167
What is the **management** of **posterior vitreous detachement**?
No treatment - **brain adjusts** over time
Can **predispose** to **retinal tears** or **retinal detachment** (assess retina to rule out)
168
What is **retinal detachment**?
**Retina** separates from **choroid underneath** (due to **retinal tear** allowing **vitreous fluid** to get underneath retina)
169
Why is **retinal detachment** a **sight-threatening** injury?
**Outer retina** relies on the **blood vessels** of the **choroid** for its blood supply
170
What are the **risk factors** for **retinal detachment**?
**Posterior vitreous detachment**
**Diabetic retinopathy**
**Trauma to the eye**
**Retinal malignancy**
**Older age**
**FH**
171
How does **retinal detachment** present?
**Peripheral vision loss** (sudden - like a curtain coming down vision)
**Blurred** and **distored vision**
**Flashes** and **floaters**
**RAPD**
172
How should **patients presenting with flashes / floaters** be managed?
Assess **retina** for **tears** or **detachment**
173
How are **retinal tears** managed?
Create **adhesions** between **retina** and **choroid** to prevent detachment:
* **Laser therapy**
* **Cryotherapy**
174
How can **retinal detachment** be treated?
**Vitrectomy** - removing relevant parts of vitreous body and replace with **oil / gas**
**Scleral buckling** - using **silicone**"buckle" to put pressure on the outside of the eye (**sclera**) to outer eye **indents** to bring the **choroid** inwards and into **contact** with the **detached retina**
**Pneumatic retinopexy** - injecting gas bubble into vitreous body and positioning patient so bubble creates pressure that flattens retina against choroid
THEN TREAT RETINAL TEARS
175
What is a **central retinal vein occlusion**?
Blood clot (**thrombus**) forms in the **retinal veins** and **blocks drainage** of blood from retina (central retinal vein runs through optic nerve)
176
How many veins come together to form **central retinal vein**?
**4**
177
What happens in **blocking of retinal vein**?
**Pooling** of blood
**Leakage** of fluid / blood = **macular oedema** and **retinal haemorrhages**
Release of **VEGF** causing **neovascularisation**
178
How does **retinal vein occulsion** present?
**Sudden painless loss of vision**
179
What are the **risk factors** for **retinal vein occulsion**?
**Hypertension**
**High cholesterol**
**Diabetes**
**Smoking**
**Glaucoma**
Systemic inflammatory conditions **e.g.** **systemic lupus erythematosus**
180
What are the **characteristic** findings on fundoscopy for **retinal vein occlusion**?
**Flame and blot haemorrhages** (cheese and tomato pizza)
## Footnote
**Optic disc oedema**
**Macula oedema**
181
Which **associated** conditions to test for in **retinal vein occlusion**?
**Full medical history**
**FBC** for leukaemia
**ESR** for inflammatory disorders
**Blood pressure** for hypertension
**Serum glucose** for diabetes
182
What is the **management** of **retinal vein occlusion**?
**Referred** to **ophthalmologist** for **assessment** and **management**
To **treat macular oedema** and prevent complications **e.g. neovascularisation** of retina and iris and glaucoma:
* **Laser photocoagulation**
* **Intravitreal steroids** (e.g. dexamethasone intravitral implant)
* **Anti-VEGF** therapies (e.g. **ranibizumab**, **aflibercept** or **bevacizumab**)
183
What is the **central retinal artery** a branch of?
**Opthalmic artery** (branch of **internal carotid**)
184
What can cause **occlusion of the retinal artery**?
**Atherosclerosis**
**Giant cell arthritis** (vasculitis affecting the **ophthalmic** or **central retinal artery**)
185
What are the **risk factors** for **retinal artery occlusion** by **atherosclerosis**?
**Older** age
**FH**
**Smoking**
**Alcohol** consumption
**HTN**
**Diabetes**
**Poor diet**
**Inactivity**
**Obesity**
186
Who is at risk of **retinal artery occlusion** secondary to **giant cell arteritis**?
**White** patients
**\> 50**
**Female**
Those affected by **giant cell arteritis** / **polymyalgia rheumatica**
187
How does **central retinal artery** occlusion present?
**Sudden painless loss of vision**
**Relative afferent pupillary defect** (pupil in affected eye constricts more when light shone in other eye, input is not being sensed by the ischaemic retina when testing direct light reflex)
188
What will **fundoscopy** show for **central retina occlusion**?
**Pale retina** with a **cherry-red spot** (macula = thinner surface showing red choroid and **contrasting with pale retina**)
189
What is the **management** of suspected **central retinal occlusion**?
**Referred** immediately to ophthalmologist
Older patient = **tested** (ESR and temporal artery biopsy) and treated with **high dose steroids** (i.e. **prednisolone** **60****mg**)
190
What is the **immediate** and **long term** **management** of **central retinal artery occlusion**?
**_Immediate_** (if presenting shortly after symptoms)
* **Ocular massage** (to dislodge)
* **Remove fluid** from **anterior chamber** to **reduce intraocular pressure**
* Inhaling **carbogen** (mix 5% CO2 and 95% O2 to dilate artery)
* Sublingual **isosorbide dinitrate** to dilate the artery
**_Long term_**
* Treat **reversible risk factors** and **secondary prevention**
191
What is **retinitis pigmentosa?**
**Congenital inherited condition** where there is **degenration** of the **rods** and **cones** in the retina (can occur with **systemic disease** or isolated)
Mostly **rods** degenerate more causing **night blindness** (decreased central and peripheral vision)
192
How does **retinitis pigmentosa** present?
**Night blindness** (first symptom)
**Peripheral vision** is lost before **central vision**
FH is important
193
What will **fundoscopy** show for **retinitis pigmentosa**?
**Pigmentation** - "**bone-spicule**" pigmentation (similar to bone matrix)
Concentrated around **mid-peripheral** area of the retina
Associated **narrowing** of the **arterioles** and waxy / pale appearance to optic disc
194
Which **conditions** are associated with **retinitis pigmentosa**?
**Usher’s Syndrome** = hearing loss plus retinitis pigmentosa
**Bassen-Kornzweig Syndrome** = disorder of **fat absorption** and **metabolism** causing progressive neurological symptoms and retinitis pigmentosa
**Refsum’s Disease** = metabolic disorder of **phytanic acid** causing **neurological, hearing and skin** symptoms and **retinitis pigmentosa**
195
What is the **general management** of **retinitis pigmentosa**?
**Referral** to ophthalmologist for **assessment and diagnosis**
Genetic counselling
**Vision aids**
**Sunglasses** to protect retina from accelerated damage
**Driving limitations** and **informing DVLA**
Regular follow up
196
What options to **slow disease progress** in **retinitis pigmentosa**? (not lots of evidence)
**Vitamin** and **antioxidant supplements**
**Oral acetazolamide**
**Topical dorzolamide**
**Steroid injections**
**Anti-VEGF injections**
**Gene therapy** is a **potential future treatment**
197
What are some causes of **sudden painless loss of vision**?
**Retinal detachment**
**Temporal Arteritis**
**Vitreous haemorrhage**
**Retinal vein occlusion**
**Retinal artery occlusion**
**Wet age related macular degeneration**
**Anterior ischemic optic neuropathy**
**Optic neuritis**
**Posterior Vitreous Detachment**
**Cerebrovascular accident**
**Migraine**
198
What is a squint also known as?
**Strabismus** (misalignment of the visual axis)
199
What are the **two different types of squints**?
**Concomitant** (imbalance in extraocular muscles - convergent more common than divergent)
**Paralytic** (paralysis of extraocular muscles)
200
How is a squint detected?
**Corneal light reflexion test** (light source 30cm away to see if equal reflection)
Cover test elicits nature of squint: ask pt to focus on an object and cover one eye then look for movement of eye
201
What is age related stiffening of the lens called?
Presbyopia
