Ophthalmology Conditions Flashcards

Question

What medications can precipitate acute angle closure glaucoma?

Answer 1

Adrenergic medications e.g. noradrenalin Anticholinergic medications e.g. oxybutynin and solifenacin TCAs e.g. amitriptyline as have anticholinergic effects (inhibits parasympathetic effect, causing glaucoma in those with narrow anterior chambers by dilating pupil and causing pupillary block)

Answer 2

``` Severely painful red eye Teary Hazy cornea Decreased visual acuity Dilatation of the affected pupil Fixed pupil size Firm eyeball on palpation ``` Halos around lights Associated headache, nausea, vomiting

Answer 3

Same day assessment Lie patient on back, no pillow Give pilocarpine eye drops - 2% for blue, 4% brown eyes Give acetazolamide (carbonic anhydrase inhibitor reduces production of aqueous humour) Give analgesia Anti-emetic if needed

Answer 4

``` Pilocarpine Acetazolamide IV/PO Hyperosmotic agents e.g. glycerol, mannitol to increase osmotic gradient between blood and fluid Timolol - beta-blocker Dorzolamide Brimonidine ``` Definitive treatment - laser iridotomy; hole in iris for humour to flow from posterior chamber to anterior Relieves pressure pushing iris against the cornea

Answer 5

Age related macular degeneration

Answer 6

Wet - 10% cases Dry - 90% Wet carries a worse prognosis

Answer 7

Drusen on fundoscopy Yellow deposits of proteins and lipids that appear between the retinal pigment epithelium and Bruch's membrane Normal drusen - <63 micrometres and hard Large and greater numbers early sign, common to both wet and dry

Answer 8

Atrophy of the retinal pigment epithelium | Degeneration of the photoreceptors

Answer 9

Choroid layer at bottom - contains blood vessels Bruch's membrane Retinal pigment epithelium Photoreceptors

Answer 10

Development of new vessels growing from the choroid layer into the retina These vessels can leak fluid/blood, cause oedema VEGF released

Answer 11

``` Age Smoking White or chinese Family history CVD, HTN Ocular characteristics - light iris ```

Answer 12

Gradual worsening central visual field loss Reduced visual acuity Crooked or wavy appearance to straight lines

Answer 13

Presents more acutely Presents with loss of vision over days Progresses to full loss of vision over 2-3 years Often progresses to bilateral disease

Answer 14

Snellen - reduced acuity Scotoma - central patch of vision loss Amsler grid test - distortion of straight lines Fundoscopy - Drusen Slit lamp biomicroscopic fundus exam Optical coherence tomography - cross section of retina for wet AMD Fluorescein angiography - second line for wet AMD

Answer 15

Focus on lifestyle measures to slow progression Avoid smoking Control BP Vitamin supplements - zinc and antioxidants (not recommended to smokers due to increase in lung ca)

Answer 16

Anti-VEGF e.g. ranibizumab, bevacizumab, pegaptanib slows development of new vessels injected into vitreous chamber once a month Photodynamic therapy with Verteperfin - light activated compound, taken up by dividing cells inc neovascular tissue Injected IV, activated by illumination, is sparing of healthy tissue Need to be started within 3 months to be beneficial If untreated can become functionally blind within 2 years Is a treatable disease

Answer 17

5.5mm in diameter with the fovea at the centre

Answer 18

Outer blood retinal barrier Prevents leak of ECF from choriocapillaries to subretinal space Actively pumps ions and water out of subretinal space Absorbs stray light Storage, metabolism and transport of Vitamin A in visual cycle

Answer 19

Drusen | RPE hyperplasia and atrophy

Answer 20

Soft drusen enlarge, become more numerous and coalesce giving a localised elevation of the RPE Lifts it away from Bruch's membrane Results in hypoxic state and inflammation

Answer 21

Confluent drusen Central and paracentral degeneration of the macula Atrophy of choriocapillaries, RPE and photoreceptors Geography atrophy - map like area of atrophy extending from foveal centre

Answer 22

Based on location of lesion in relation to fovea: subfoveal juxtafoveal extrafoveal

Answer 23

For Wet AMD Characterised by angiographic Classic - CNV clearly visible Occult - obscured, not visible

Answer 24

More than 5 drusen Large - soft and confluent drusen Pigment clumping in the RPE Systemic hypertension

Answer 25

Visual hallucinations due to visual loss | Common in those with wet AMD

Answer 26

Damage to small blood vessels in retina | Chronic hypertension or malignant HTN

Answer 27

Walls of the arterioles become thickened and sclerosed increasing reflection of light

Answer 28

Arterioles cause compression of the veins where they cross | Due to sclerosis and hardening of the arterioles

Answer 29

Due to ischaemia and infarction in the retina, causing damage to nerve fibres Appear as fluffy white patches on the retina Result of accummulation of axoplasmic material within the nerve fibre layer

Answer 30

Cotton wool spots Retinal haemorrhages - rupture and release of blood into the retina Papilloedema - ischaemia to optic nerve, causes optic nerve swelling and blurring of disc margins Silver wiring Hard exudates Arteriovenous nipping

Answer 31

Hyperglycaemia damages retinal small vessels and endothelial cells. Increased vascular permeability leads to leakage from the blood vessels, blot haemorrhages and hard exudates. Damage to blood vessel wall - microaneurysms and venous bleeding. Damage to nerve fibres in retina - cotton wool spots Intraretinal microvascular abnormalities - dilated and tortuous capillaries Shunt between arterial and venous vessels Neovascularisation - growth factors released in the retina, development of new blood vessels

Answer 32

Non-proliferative - background, can develop into proliferative Proliferative - new blood vessels have developed, vitrous haemorrhages Diabetic maculopathy

Answer 33

Mild - microaneurysms Moderate - microaneurysms, blot haemorrhages, hard exudates, cotton wool spots, venous bleeding Severe - blot haemorrhages, microaneurysms in 4 quadrants venous beating in 2 quadrants intraretinal microvascular abnormality

Answer 34

Ischaemic maculopathy | Macular oedema

Answer 35

Retinal detachment Vitreous haemorrhage - bleeding into the vitreous humour Rebeosis iridis - new blood vessel formation in the iris Optic neuropathy Cataracts

Answer 36

Laser photocoagulation Anti VEGF medications - ranibizumab, bevacizumab Vitreoretinal surgery

Answer 37

Microvascular occlusion | Microvascular leakage

Answer 38

``` Duration of DM Hyperglycaemia HTN. hyperlipidaemia Nephropathy Pregnancy ``` Obesity, smoking, alcohol, physical inactivity

Answer 39

Neovascularisation - new blood vessels found on the surface of the iris often associated with diabetes in advanced proliferative retinopathy

Answer 40

When the lens in the eye becomes cloudy and opaque, describes any opacity or reduction in clarity of the crystalline lens Lens focuses light onto the retina

Answer 41

They occur before birth | Screened for red reflex during neonatal examination

Answer 42

Most develop over years with advanced age in the presence of risk factors ``` Increasing age Smoking Alcohol Diabetes Steroids Hypoglycaemia ```

Answer 43

Cataracts cause generalised reduction in visual acuity, starbursts around light Glaucoma - peripheral loss of vision, halos around lights Macular degeneration - central loss of vision, crooked or wavy appearance to straight lines

Answer 44

Usually asymmetrical, as both eyes affected separately Very slow reduction in vision Progressive blurring of vision Change of colour of vision, colours becoming more brown or yellow Starbursts around lights, particularly at night time Loss of red reflex - can appear white or grey, show up on photographs

Answer 45

Surgery - drill and break lens into pieces, remove and implant artificial lens into the eye or lens extraction by phacoemulsification - ultrasound energy Cataracts can mean other conditions e.g. AMD or diabetic retinopathy can go undetected, until after surgery and still have poor visual acuity

Answer 46

Rare but serious complication Inflammation of inner contents of the eye Usually due to infection Treated with intravitreal antibiotics Otherwise loss of vision and loss of the eye

Answer 47

``` Congenital Age Drugs - systemic steroids or steroid eye drops Systemic disease - diabetes, down's Other ocular disease - uveitis Trauma ```

Answer 48

Per-operatively - posterior capsular rupture, vitreous loss Early-post op - endophthalmitis Late post-op - posterior capsule opacification

Answer 49

Trauma to sphincter muscles in the iris, e.g. cataract surgery Anterior uveitis causing adhesions Acute angle glaucoma causing ischaemic damage - vertical oval pupil Rubeosis iridis - neovascularisation of the iris in diabetic retinopathy Coloboma - congenital malformation, hole in the iris causing irregular pupil shape Tadpole pupil - spasm in a segment of the iris, temporary, associated with migraines

Answer 50

``` Third nerve palsy Holmes-Aide syndrome Raised ICP Congenital Trauma Stimulants such as cocaine Anticholinergics ```

Answer 51

``` Horner's syndrome Cluster headaches Argyll Robertson pupil - neurosyphilis Opiates Nicotine Pilocarpine ```

Answer 52

Ptosis - levator palpebrae superioris Dilated non-reactive pupil Divergent strabismus - down and out eye Oculomotor supplies all muscles except lateral rectus and superior oblique - so down and out from these

Answer 53

Oculomotor nerve travels through cavernous sinus close to posterior communicating artery Therefore cavernous sinus thrombosis or posterior communicating aneurysm can compress ``` Idiopathic Tumour Trauma Cavernous sinus thrombosis Posterior communicating aneurysm Raised ICP ```

Answer 54

Sparing - microvascular because parasympathetic fibres spared - spares the pupil - diabetes, HTN, ischaemia Full - surgical third due to physical compression

Answer 55

Ptosis Miosis Anhidrosis May also have enopthalmos - sunken eye Light and accommodation not affected

Answer 56

Central - 4 Ss Stroke, MS, swelling (tumour), syringomyelia Pre-ganglionic - 4Ts Tumour (pancoast), trauma, thyroidectomy, top rib - cervical rib growing above first rib Post-ganglionic - 4Cs Carotid aneurysm, carotid artery dissection, cavernous sinus thrombosis, cluster headache

Answer 57

Heterochromia - difference in colour of the iris on the affected side

Answer 58

Sympathetic arise from spinal cord These are pre-ganglionic Enter into sympathetic ganglion at the base of the neck Exit as post-ganglionic, travel to the head, run alongside internal carotid artery

Answer 59

Cocaine eye drops Stops noradrenalin re-uptake at the NMJ Causes normal eye to dilate as more noradrenaline available so causes dilation, but in Horner's there is no release initially So no reaction Or - adrenaline eye drops won't dilate a normal pupil, but will dilate a Horner's

Answer 60

Unilateral dilated pupil Sluggish to react to light Slow dilation of the pupil following constriction, over time pupil will get smaller Damage to post-ganglionic parasympathetic fibres Holmes Adie syndrome also has absent ankle and knee reflexes

Answer 61

Specific to neurosyphilis | Constricted pupil, accommodates when focusing on near object but does not react to light

Answer 62

Inflammation of the eyelid margins

Answer 63

Gritty, itchy, dry sensation in the eyes Associated with dysfunction of the Meibomian glands

Answer 64

Hot compress Gentle cleaning of eyelid margins to remove debris Lubricating eye drops: Hypromellose Polyvinyl alcohol Carbomer

Answer 65

Infection of glands of zeis or glands of moll | Sebaceous glands at the base of the eyelashes

Answer 66

Hot compresses and analgesia | Topical antibiotics e.g. chloramphenicol if associated with conjunctivitis or persist

Answer 67

Blockage of Meibomian gland | Swelling in the eyelid, typically not tender

Answer 68

Hot compress, analgesia | Topical antibiotics if actuely inflamed

Answer 69

Tender red lump along eyelid | May contain pus

Answer 70

Eyelid turns inwards with the lashes against the eyeball Results in pain, can cause corneal damage and ulceration

Answer 71

Taping eyelid down Use regular lubricating drops to prevent eye drying out Definitive management with surgical intervention

Answer 72

HLA-B27 associated ``` Apical fibrosis Anterior uveitis Aortic regurgitation Achilles tendonitis AV node block Amyloidosis And cauda equina syndrome ``` Peripheral arthritis

Answer 73

Vision - normal or reduced Painful or painless Check IOP

Answer 74

``` Conjunctivitis Scleritis Keratitis Corneal foreign body Episcleritis ```

Answer 75

Subconjunctival haemorrhage

Answer 76

Hypertension On any anticoagulation Check INR - if raised, needs to be addressed ASAP

Answer 77

Eyelid turns outwards Inner aspect of the eyelid exposed, usually affects bottom lid Can lead to exposure keratopathy as eyeball is exposed

Answer 78

Inward growth of the eyelashes, can result in corneal damage and ulceration

Answer 79

Remove the eyelash - epilation Recurrent cases may require electrolysis, cryotherapy or laser treatment to prevent lash regrowing

Answer 80

Eyelid and skin infection in front of the orbital septum In front of the eye Presents with swelling, redness, hot skin around the eyelids and eye

Answer 81

Systemic antibiotics | May require observation if vulnerable to prevent development into orbital

Answer 82

Infection around the eyeball, behind the orbital septum Sight threatening emergency ``` Pain on eye movement Reduced eye movements Changes in vision Abnormal pupil reactions Forward movement of the eyeball - proptosis ```

Answer 83

Medical emergency Requires admission IV antibiotics Surgical drainage if abscess MRI/CT helpful in diagnosis and planning treatment

Answer 84

Ciliary body contract --> pull suspensory ligaments --> flatten lens --> less refraction vice versa if ciliary body relax

Answer 85

Trauma Drugs - steroids, amiodarone, allopurinol Systemic disease - Diabetes, myotonic dystrophy, neurofibromatosis type 2

Answer 86

Inflammation of the conjunctiva | the tissue that covers the inside of eyelids and sclera

Answer 87

Bacterial Viral Allergic

Answer 88

``` Unilateral or bilateral Red eyes Bloodshot Itchy or gritty sensation Discharge from the eye ``` Does not cause pain, photophobia or reduced visual acuity Vision may be blurry due to discharge

Answer 89

Purulent discharge Inflamed conjunctiva Typically worse in the morning, eye stuck together Starts in one eye, spread to the other

Answer 90

Clear discharge Other symptoms of viral infection e.g. dry cough, sore throat, blocked nose Contagious Preauricular lymph nodes

Answer 91

Usually resolves without treatment after 1-2 weeks Good hygiene Avoid contact lenses Abc - chloramphenicol and fusidic acid

Answer 92

Neonatal conjunctivitis Gonococcal infection Can cause loss of sight Complications e.g. pneumonia

Answer 93

Contact with allergens Causes swelling of conjunctival sac and eyelid Significant watery discharge, itchy Antihistamines Topical mast cell stabilisers - preventing mast cells releasing histamines

Answer 94

Inflammation in the anterior uvea - iritis

Answer 95

Iris, ciliary body, choroid

Answer 96

Chronic - more granulomatous - more macrophages, less severe | Lasts more than 3 months

Answer 97

HLA B27 conditions Ankylosing spondylitis Inflammatory bowel disease Reactive arthritis

Answer 98

``` Sarcoidosis Syphilis Lyme's disease TB Herpes virus ```

Answer 99

Unilateral Starts spontaneously Without a hx of trauma or precipitating events May occur with a flare of an associated disease e.g. reactive arthritis Dull aching painful red eye Ciliary flush - ring of red spreading from cornea Reduced visual acuity Floaters, flashes Miosis - constriction due to sphincter contraction Photophobia - ciliary muscle spasm Pain on movement Excessive tears Posterior synechiae - adhesions pulling iris, abnormally shaped Hypopyon - collection of white blood cells in anterior chamber

Answer 100

Referral for same day assessment due to emergency red eye Refer to rapid access clinic for topical steroids Steroids Cycloplegic-mydriatic medications e.g. cyclopentolate or atropine (antimuscarinic, block iris sphincter and ciliary body) Immunosuppressants e.g. DMARDs, TNF inhibitors Laser therapy, cryotherapy, vitrectomy

Answer 101

Inflammation of episclera Outermost layer of sclera Underneath conjunctiva

Answer 102

Young and middle aged adults Not usually due to infection Associated with inflammatory disorders e.g. RA or IBD

Answer 103

``` Acute onset, unilateral Typically not painful Can have mild pain Segmental redness - lateral sclera Foreign body sensation Dilated episcleral vessels Watering of eye No discharge ```

Answer 104

``` Usually self limiting Will recover in 1-4 weeks Lubricating eye drops Simple analgesia Cold compresses Systemic NSAIDs naproxen ```

Answer 105

Conjunctivitis in the first 30 days of life Bacteria - strep, staph Neisseria gonorrhoea Chlamydia

Answer 106

Inflammation of the full thickness of the sclera | Most severe is necrotising scleritis, can lead to perforation of the sclera

Answer 107

``` Rheumatoid arthritis SLE Inflammatory bowel disease Sarcoidosis Granulomatosis with polyangiitis ```

Answer 108

``` Acute onset 50% cases bilateral Severe pain Pain with eye movement Photophobia Eye watering Reduced visual acuity Abnormal pupil reaction to light Tenderness to palpation ``` Severe 8-9/10 boring pain May have diffuse or nodular swelling

Answer 109

Consider underlying systemic condition NSAIDs - topical/systemic Steroids Immunosuppression - appropriate to the underlying condition e.g. methotrexate for RA Refer to eye emergency dept

Answer 110

``` Scleromalacia perforans - diffuse scleral thickening seen in rheumatoid Keratitis - persistent ulceration Uveitis Cataract formation Glaucoma ```

Answer 111

Immune complex dependent microangiopathy

Answer 112

Scratches or damage to the cornea, cause of red, painful eye ``` Contact lenses - assoc. infection with pseudomonas Foreign bodies Fingernails Eyelashes Entropion - inward turning eyelid ```

Answer 113

Herpes keratitis | Requires antiviral drops

Answer 114

``` History of contact lenses or foreign body Painful red eye Foreign body sensation Watering eye Blurring vision Photophobia ```

Answer 115

Fluorescein stain Collects in abrasions - yellow-orange colour Slit-lamp examination

Answer 116

Same day assessment Mild in primary care ``` Removal of foreign bodies Simple analgesia Lubricating eye drops Antibiotic drops - chloramphenicol FU after 24 hours ``` Chemical abrasions - immediate irrigation for 20-30 minutes, urgent referral Mild uncomplicated usually heal over 2-3 days

Answer 117

``` Viral infection - herpes Bacterial - pseudomonas, staph Fungal - candida, aspergillus CLARE - contact lens acute red eye Exposure keratitis - inadequate eye lid covering, e.g. ectropion ```

Answer 118

The epithelial layer of the cornea If inflammation of the stroma - stromal keratitis

Answer 119

Stromal necrosis Vascularisation and scarring Can lead to corneal blindness

Answer 120

``` Painful red eye Photophobia Vesicles around the eye Foreign body sensation Watering eye Reduced visual acuity ``` Fever, vesicular lid lesions Follicular conjunctivitis Preauricular lymphadenopathy

Answer 121

Staining with fluorescein Shows dendritic corneal ulcer (branching and spreading of the ulcer) Slit-lamp examination Corneal swabs, scrapings

Answer 122

Same day assessment Aciclovir - topical or oral Ganciclovir eye gel Topical steroids for stromal keratitis Corneal transplant may be required after infection to treat corneal scarring caused by stromal keratitis

Answer 123

Type 1 HSV common important cause of ocular disease Usually acquired in early life from close contact e.g kissing Primary infection may cause a conjunctivitis, then resolution and latency in trigeminal ganglion Risk of reactivation if immunosuppression, systemic illness

Answer 124

Ophthalmic shingles Affects ophthalmic division of the trigeminal nerve Prodromal period, unwell Pain and vesicles in nerve distribution Lid swelling, may be bilateral Keratitis Iritis Secondary glaucoma

Answer 125

Staph epidermidis Staph aureus Strep pneumonia Pseudomonas

Answer 126

Keratoconjunctivitis sicca - dry eye Breach in corneal epithelium e.g. trauma or surgery Contact lens wear Prolonged use of topical steroids

Answer 127

Pain - severe Purulent discharge Visual loss Hypopyon - mass of white cells collected in anterior chamber White corneal opacity - site of polymorphonuclear infiltration of the stroma

Answer 128

Fungal | Interstitial - any vascular keratitis that affects the corneal stroma without epithelial involvement

Answer 129

``` Angle closure glaucoma Corneal ulcer/keratitis Uveitis Endophthalmitis Retrobulbar optic neuritis Orbital cellulitis Giant cell arteritis ```

Answer 130

Embolic retinal artery occlusion Migraine and aurea Raised intracranial pressure Prodromal in GCA

Answer 131

``` Vitreous haemorrhage Retinal artery occlusion Retinal detachment AMD Other macular disease Optic neuritis Ischaemic optic neuropathy Orbital disease affecting the optic nerve Intracranial disease affecting the visual pathway ```

Answer 132

Discomfort - blepharitis, dry eye, conjunctivitis, allergy Pain on movement - optic neuritis Pain around the eye - GCA, migraine, cellulitis, headache Severe pain - keratitis, abrasion, foreign body, uveitis, angle closure glaucoma, endophthalmitis, scleritis, myositis of extraocular muscles

Answer 133

Neurogenic - nerve palsies, failure to control squint, visual field defects Myogenic - thyroid eye disease, myasthenia, myositis, myopathy Orbital - trauma, SOLs Monocular - corneal disease, cataracts

Answer 134

(Short sightedness) Parallel rays of light brought to a point of focus before they reach the retina Eye too long/large - axial Optical focusing apparatus of the eye is too powerful

Answer 135

Long sightedness Eye is too short Focusing apparatus too weak (lens and cornea) Treated with a convex lens

Answer 136

After a cataract extraction, the eye is rendered highly hypermetrophic Because the lens provides one third of the refractive power of the eye

Answer 137

Insertion of an intraocular lens at the time of surgery Contact lenses Aphakic spectacles

Answer 138

Can spread to cause a brain abscess

Answer 139

Lacrimal gland tumours Optic nerve gliomas - in neurofibromatosis type 1 Meningiomas Lymphomas Rhabdomyosarcomas Mets e.g. neuroblastomas in kids, breast, lung, prostate

Answer 140

Mechanical - large lid lump, lid oedema, downward tethering due to scarring, structural abnormalities Neurological - third nerve palsy, Horner's, Marcus Gunn jaw winking syndrome Myogenic - myasthenia gravis, muscular dystrophy, ophthalmoplegia

Answer 141

Autoimmune disease of the voluntary muscles Weakness triggered by periods of muscle activity Relieved by rest Circulating antibodies block the action of acetylcholine at post synaptic nicotinic neuromuscular kunctions

Answer 142

Repeated upgaze, downgaze movements results in fatigue and increased ptosis Look fown for 15s then look at elevated target, lid overshoots then falls Ice applied reduces ptosis Weakness of eyelid closure

Answer 143

Inadequate meibomian oil delivery Ectropion - not adequately apposed Incomplete lid closure e.g. seventh nerve palsy Infrequent blinking - parkinson's

Answer 144

Weakness of zonule - subluxation After ocular trauma Homocystineuria - lens displaced downwards Marfan's

Answer 145

Visual acuity reduced | Eye inflamed - mostly around the limbus - ciliary flush

Answer 146

Blurred central vision Distorted vision - metamorphopsia Reduction or enlargement of an object Loss of the central visual field

Answer 147

Intraocular surgery Uveitis Retinal vascular disease - diabetic retinopathy and retinal vein occlusion Retinitis pigmentosa

Answer 148

Commonest malignant tumour of the eye in childhood Due to germinal mutations or somatic mutations If the eye can be salvaged - systemic chemo and local treatment e.g. cryo Removal of the eye

Answer 149

White pupillary reflex Squint due to reduced vision Occasionally if advanced; painful red eye

Answer 150

At margins of ischaemic retinal infarct | Due to obstruction of axoplasmic flow, build up of axonal debris in the nerve fibre layer of the retina

Answer 151

None - no signs, vision normal Background - signs of leakage, microaneurysms, haemorrhage, exudates away from the macula Maculopathy - exudates, haemorrhage in macula region, central oedema, vision reduced, sight threatening Preproliferative retinopathy - evidence of arteriolar occlusions, RMA, cotton wool spots, veins irregular, vision normal Proliferative retinopathy - release of vasoproliferative substance, new vessel growth on disc or retina, vision normal, sight threatening Advanced retinopathy - bleeding into vitreous, pulling of overlying pigment epithelium

Answer 152

One of the small blood vessels in the conjunctiva ruptures | Releases blood into space between sclera and conjunctiva

Answer 153

Idiopathic - otherwise healthy After a period of strenuous activity e.g. heavy coughing, weight lifting, straining when constipated Trauma to the eye

Answer 154

``` Hypertension Bleeding disorders e.g. thrombocytopenia Whooping cough Medications e.g. warfarin, NOACs, antiplatelets Non accidental injury ```

Answer 155

``` Patch of bright red blood underneath the conjunctiva In front of the sclera Painless Does not affect vision May be history of strenuous event ```

Answer 156

Harmless, resolve spontaneously Within 2 weeks Investigate precipitating factors If there is foreign body sensation, lubricating eye drops can help

Answer 157

Gel inside the eye that maintains the structure of the eyeball, keeps the retina pressed on the choroid Made up of collagen and water

Answer 158

Vitreous gel comes away from the retina, very common, particularly in older patients

Answer 159

``` Painless condition Can be completely asymptomatic Spots of vision loss Floaters Flashing lights ```

Answer 160

No treatment necessary Symptoms improve over time as brain adjusts Can predispose a patient to developing retinal tears or detachment Exclude and assess risk of this, thorough assessment of the retina

Answer 161

Sight-threatening emergency Outer retina relies on blood vessels of the choroid for its blood supply Retina separates from choroid underneath Usually due to retinal tear Allows vitreous fluid to get under the retina, fills space

Answer 162

``` Posterior vitreous detachment Diabetic retinopathy Trauma to the eye Retinal malignancy Older age Family history ```

Answer 163

``` Painless Peripheral vision loss Sudden, shadow like curtain coming across vision Blurred or distorted vision Flashes and floaters ```

Answer 164

Reattach retina, reduce traction or pressure which may cause it to recur Vitrectomy - removing relevant parts of vitreous body and replacing with oil or gas Scleral buckling - silicone buckle to put pressure on outside of eye/sclera so outer eye indents and brings choroid inwards to make contact with retina Pneumatic retinopexy - inject gas bubble into vitreous body and position patient so gas bubble creates pressure and flattens retina

Answer 165

Create adhesions between the retina and choroid Laser therapy Cryotherapy

Answer 166

When a blood clot forms in the retinal veins Central retinal vein runs through optic nerve, drains blood from retina One of four branched veins blocked causes problems in area, whereas central vein causes problems for whole retina Blood in retina = leakage of fluid and blood Causes macular oedema and retinal haemorrhages Damages retinal tissue Loss of vision Release of VEGF to stimulate neovascularisation

Answer 167

Sudden painless loss of vision

Answer 168

``` Hypertension High cholesterol Diabetes Smoking Glaucoma Systemic inflammatory conditions such as SLE ```

Answer 169

Flame and blot haemorrhages Optic disc oedema Macula oedema

Answer 170

``` Full medical history FBC for leukaemia ESR for inflammatory disorders BP for hypertension Serum glucose for diabetes ```

Answer 171

Referral immediately Treatment of macular oedema and prevent complications e.g. neovascularisation, galucoma Laser photocoagulation Intravitreal steroids e.g. dexamethasone intravitreal implant Anti-VEGF therapies e.g. rituximab, bevacizumab

Answer 172

``` Risk factors for atherosclerosis Older age Family history Smoking Alcohol consumption Hypertension Diabetes Poor diet Inactivity Obesity ```

Answer 173

White patients over 50 Particularly females And those already affected by GCA or polymyalgia rheumatica

Answer 174

Sudden painless loss of vision Relative afferent pupillary defect Fundoscopy - pale retina, cherry-red spot, due to lack of perfusion

Answer 175

Pupil in the affected eye constricts more when light is shone in the other eye, compared to when it is shone in the affected eye. Because the input is not being sensed by the ischaemic retina, but is being sensed by the normal retina causing consensual reflex

Answer 176

Referral immediately Check for GCA - ESR and temporal artery biopsy, give steroids - prednisolone 60mg If presents shortly after symptoms, try to dislodge thrombus: Occular massage remove fluid from anterior chamber to reduce IOP Inhaling carbogen (5% carbon dioxide, 95% oxygen) to dilate artery sublingual isosorbide Dinitrate to dilate the artery Long term management reduce reversible risk factors

Answer 177

Inflammation of the optic nerves

Answer 178

Acute demyelinating - most common, due to MS Ischaemic - GCA, diabetic papillopathy Corticosteroid-responsive - autoimmune diseases, SLE Infections - TB, mycoplasma, Lyme's Nutritional - B12 deficiency Drugs - Amiodarone, ethambutol, isoniazid, methanol intoxication

Answer 179

Posterior scleritis Maculopathy Retinopathy Big blind spot syndrome

Answer 180

Visual impairment Pain around the eye Dyschromatopsia - impairment of colour vision Light flashes Increased symptoms with raised body temperature Decreased pupillary light reaction in the affected eye

Answer 181

Full ophthalmological examination Testing visual acuity, contrast and colour vision, visual field testing MRI - developing MS Bloods - FBC, ESR, TFTs, autoantibodies, syphilis Serological testing CXR - infection LP

Answer 182

Consider corticosteroids in acute phase - methylprednisolone

Answer 183

Lesion to the tip of the nose Increased chance of ocular involvement Treatment is with aciclovir

Answer 184

Inflammatory phase Followed by 'inactive' fibrotic phase Sight loss can occur when delay in start of treatment Onset of hyperthyroidism and TED usually within 18 months of each other

Answer 185

``` Bilateral Burning watery eyes (with foreign body sensation if cornea involved) Worse in morning - eyes may stick Red inflamed eyelid Crusts/scales along eyelashes Tear film deficiency ```

Answer 186

Reduce inflammation | Prevent adhesions

Answer 187

Relapse Posterior synechiae (adhesions from lens to iris) Cataract Glaucoma (due to steroids)

Answer 188

``` Back pain - ank spond Rash/bite - lyme Resp. Symptoms - Sarcoidosis GI symptoms - IBD Cold sore - herpes Oral/genital ulcers - Behcet's ```

Answer 189

Painless floaters Decreased vision Minimal redness and pain

Answer 190

Retina and choroid

Answer 191

Virus travel along trigeminal nerve to ophthalmic division to corneal nerve Dendritic ulcer pattern seen

Answer 192

None normally needed CT = 1st choice X-ray if metallic FB MRI contraindicated for metallic FB Fluorescein examination

Answer 193

Retinal detachment Endophthalmitis Allergic reaction

Answer 194

Inherited eye disease that is characterised by black pigmentation and gradual degeneration of the retina

Answer 195

Night blindness Ring scotoma - loss of all peripheral vision --> tunnel vision --> blindness Black bone spicule pigmentation of the peripheral retina Mottling of retinal pigmented epithelium Waxy looking disc

Answer 196

Photoreceptor death - rods first | Cell death lead to inflammation of vitreous humour

Answer 197

Some cases X linked - more men | Peak ages - 7.5, 17 and >50yo

Answer 198

Visual rehab Counselling No way to stop disease progression

Answer 199

Autoimmune reaction to thyroid stimulating hormone receptors Infiltration of lymphocytes into orbital tissue, release of cytokines Hyperosmotic shift causing oedema

Answer 200

``` Current smoking Female sex Middle age Autoimmune thyroid disease Uncontrolled thyroid function Radio-iodine therapy ```

Answer 201

``` Occular irritation Ache - worse in mornings Red eyes Diplopia - restricted ocular mobility Change in appearance of eyes, bulging eyes Dry or watery Mild photophobia Dyschromatopsia - colour deficiency ``` Proptosis - lid retraction, lid lag, orbital fat prolapse Exposure keratopathy - photophobia, tearing, grittiness, pain, due to incomplete lid closure

Answer 202

TSH Free thyroxine - T4 Anti-TSH receptor autoantibodies, TPO Thyroid uptake scan

Answer 203

Superior limbic keratoconjunctivitis Conjunctival injection - over rectus muscles - enlargement of conjunctival vessels Glaucoma may result from decreased episcleral venous outflow Strabismus - presents as hypotropia or esotropia due to involvement of inferior and medial rectus Optic nerve compression

Answer 204

``` Visual acuity Ishihara colour assessment Exophthalmometry Assess lid lag, lid retraction Corneal exposure Intraocular pressure Orthoptic assessment ```

Answer 205

Pain - feeling on globe, or with movement Redness - eyelids, conjunctiva Swelling - lids, chemosis (swelling of conjunctiva) Impaired function - decrease in eye movements, acuity

Answer 206

Type I - minimal inflammation and restrictive myopathy – mainly fat expansion Type II - significant orbital inflammation and restrictive myopathy

Answer 207

``` Optimise endocrine control Stop smoking Avoid radioiodine Lubricants (Ocular Hypotensives) NSAIDS Selenium, rituximab Steroids Steroid sparing agents Radiotherapy Surgery - orbital decompression, strabismus surgery, blepharoplasty Botulinum toxin to reduce upper lid swelling Prisms to control diplopia ```

Answer 208

Eyes don't point in the same direction | Misalignment of the visual axis of the eyes

Answer 209

Protrusion of the eye Displaced directly forwards in a SOL within the extraocular muscle cone - intra-conal lesion e.g. optic nerve sheath meningioma Displaced to one side - extra-conal lesion e.g. tumour of lacrimal glands displaces to nasal side Transient proptosis - valsalva manoeuvre increases cephalic venous pressure Presence of pain with proptosis suggests infection

Answer 210

Anterior uveitis - posterior synechiae - appearance Sequelae of intraocular surgery Blunt trauma to the eye - may rupture sphincter muscle - trauma mydriasis Acute and severe rise in intraocular pressure e.g. glaucoma

Answer 211

Syringomyelia - expanding cavity in the spinal cord, sometimes extends into medulla Small cell carcinoma of the lung apex - cervical chain Neck injury Cavernous sinus disease - catching sympathetic carotid plexus in the sinus

Answer 212

Small pupil on affected side Loss of dilator function Recession of the globe into the orbit - enophthalmos Lack of sweating if the pathway is affected proximal to the base of the skull

Answer 213

Headache worse on waking and coughing Nausea, retching Diplopia - sixth nerve palsy If due to e.g. SOL - visual field loss, cranial nerve palsy Hx of head trauma suggesting subdural haemorrhage, history of medications e.g. oral contraceptives, tetracyclines

Answer 214

Optic disc swollen, edges blurred, superficial capillaries are dilated Large blind spot Abnormal neurological signs may indicate space occupying lesion

Answer 215

Usually presents in overweight women Headache, obscurations of vision and sixth nerve palsies Raised intracranial pressure and disc swelling present Treatment with medications e.g. oral acetazolamide Ventriculoperitoneal shunting Optic nerve decompression

Answer 216

Autoimmune vasculitis ``` Sudden loss of vision Scalp tenderness e.g. on combing Pain on chewing, jaw claudication Shoulder pain Malaise ```

Answer 217

ESR and CRP usually grossly elevated Temporal artery biopsy BP check, blood glucose check

Answer 218

High dose steroids immediately, oral and IV | Dose tapered over ensuing weeks

Answer 219

``` Compression of optic nerve Retinal artery occlusion Glaucoma RICP Optic neuritis Inherited optic nerve/retinal disease Toxic optic neuropathy Tobacco/alcohol ```

Answer 220

Pituitary tumour Meningioma Craniopharyngioma

Answer 221

Homonymous hemianopia | Loss confined to the right or left hand side of the field in both eyes

Answer 222

Congenital/acquired - onset before/after 6 months Concomitant/incomitant Manifest/latent

Answer 223

Superior rectus - abduction and elevation Lateral rectus - abduction Inferior rectus - abduction and depression Inferior oblique - adduction and elevation Medial rectus - adduction Superior oblique - adduction and depression

Answer 224

When blood enters anterior chamber between cornea and iris

Answer 225

Decrease/ Loss of vision (may improve as gravity pulls the blood down) Red tinge to eye

Answer 226

``` Intraocular Surgery Blunt trauma Lacerating Trauma Leukaemia Retinoblastoma ```

Answer 227

Small - Outpatient basis, antifibrinolytics, corticosteroids, mitotics, asparin Non resolving - surgical clean out Pain relief - avoid aspirin and NSAIDs due to platelet interaction

Answer 228

Eyes converging Pupil size reducing Lens changing shape and pattern

Answer 229

``` CRAO Anterior Ischaemic Optic Neuropathy Vitreous Haemorrhage Retinal Vein Occlusion Retinal Detachment Optic Neuritis ```

Answer 230

``` Trauma, Eye Surgery, VEGF injections, Endogenous seeding, Extension of Corneal infection ```

Answer 231

Surgery - Coag neg Staph (epidermis), Trauma - bacillus cereus, Endogenous - S.Aureus,Klebsiella

Answer 232

FBC - leukocytosis Blood cultures - negative LP (if focal signs) Swabs CT sinus and orbit - extension

Answer 233

1) Co Amoxiclav If pen allergic - Clindamycin and Metronidazole MRSA - Vancomycin

Answer 234

1) Check pH with universal indicator 2) Administer topical anaesthetic and remove contact lenses 3) 1L saline irrigation continued until pH is 7 4) Rechecked every 15 minutes

Answer 235

Dexamethasone 1-2 hourly Vitamin C (topically and orally) Citrate and Tetracyclines

Answer 236

Anklyosing Spondylitis, IBD, Reactive Arthritis Sarcoidosis, Syphilis, TB

Answer 237

Oedema White cell infiltration Epithelial defect

Answer 238

Gradual loss of accommodation response due to decline in elasticity, becoming apparent when amplitude is insufficient to carry out near tasks

Answer 239

Difficulty carrying out near tasks Accommodative lag (from distance to near vice versa) Tiring with continuous close work

Answer 240

OTC glasses are normally sufficient If pre-existing refractive error - prescription glasses

Answer 241

Accommodative Insufficiency (Associated with encephalitis and enclosed head trauma) Inability to maintain binocular enlargment as object becomes closer (aka eye strain)

Answer 242

Loss of vision as a result of damage to optic nerve from ischaemia Involves the 1mm head of optic nerve (AKA disc)

Answer 243

Rapid onset unilateral visual loss and decreased acuity Chalky white pallor of optic disc Amaurosis fugax? GCA signs?

Answer 244

GCA - ESR/CRP, Temporal Artery Biopsy MRI/USS - between Arteritic and non OCT

Answer 245

IV Methylpred for 3 days (switch to oral and taper) MAB against IL6 (Tocilizumab) Methotrexate

Answer 246

Proliferative diabetic retinopathy (fragile vessels) Posterior vitreous detachment Ocular Trauma

Answer 247

- Sudden painless visual loss - Red Hue (may turn green after breakdown) - New onset floaters/cobwebs - May be worse in the morning if blood settles during sleep

Answer 248

IOP Slit Lamp - Red Cells in anterior vitreous Rule out retinal detachment USS

Answer 249

Exclude retinal detachment Rest with head elevated and re- evaluate in 3-7 days for source

Answer 250

Laser Photocoagulation (for proliferative vasculopathies) Anterior Retinal Cryotherapy Vitrectomy VEGF

Answer 251

Monocular - doesn’t disappear with one eye closed, likely opthalmological aetiology Binocular - with one eye closed it disappears, likely neurological aetiology

Answer 252

``` Emerges from midbrain Travels close to PCA Pierces dura near tentorium cerebelli Lateral cavernous sinus Superior orbital fissure ```

Answer 253

Diabetes GCA Raised ICP PCA Aneurysm

Answer 254

Fixed dilated pupil that doesn’t accommodate Ptosis Unopposed lateral deviation Intortion on looking down Microvascular - pupil sparing

Answer 255

Pupil will be fixed but not dilated

Answer 256

Orbital trauma Diabetes Infarction secondary to hypertension

Answer 257

``` CNIII lesion CNIV lesion CNVI lesion Orbital Blow Out # Thyroid Eye Disease MG ```

Answer 258

Vertical Diplopia Weakness of downward and intortion Compensatory head tilt away from affected side

Answer 259

Inability to look laterally

Answer 260

MS Pontine Cerebrovascular incident Raised ICP (due to long course)

Answer 261

Usually from an object <5cm Force transmits along rim and into orbital floor Force is transmitted into three buttresses (infraorbital, displacement of zygomaticofrontal suture, fracture of zygomatic arch)

Answer 262

``` Periorbital bruising Surgical Emphysema Vertical Diplopia (worse on looking up) Endopthalmos Infraorbital Paraesthesia ```

Answer 263

Plain XRay - Facial, Occipitomental, Submentovertical (droplet sign in maxillary sinus) CT

Answer 264

Don’t blow nose for 10 days Some can be managed with just broad spec abx Surgery

Answer 265

Initial inflammatory phase lasting 6-24 months (expansion of extraocular muscles and orbital fat resulting in proptosis and optic neuropathy) Followed by inactive fibrotic phase Infiltration of lymphocytes stimulate cytokine release and polysaccharide release from fibroblasts - leads to oedema

Answer 266

TSH | IGF1

Answer 267

Current smoker Female Middle Aged Radioiodine therapy

Answer 268

- Receptor sites at NMJ are destroyed - Not enough stimulation to trigger action potential - Increased fatiguability with use (reduced ACh) and improvement with rest

Answer 269

Ptosis Cogan Lid Twitch (down gaze followed by up gaze, eye saccades and lid overshoots) Incomitant strabismus Raised eyebrows Pupils never involved

Answer 270

Tensilon Test (inhibits AChesterase, only useful when they have measurable findings) Repetitive Nerve Stimulation Test (decline in compound muscle action potentials within the first 4-5 stimuli) Single Fibre EMG

Answer 271

Serum Anti ACh Receptor Titre | Serum Anti Muscle Specific Kinase AB titre

Answer 272

Lambert Eaton Syndrome Improvement of symptoms with repeated stimulation

Answer 273

Med - Steroids, Pyridostigmine, Immunomodulators (if refractory) Surgery - Removal of thymus

Answer 274

Hypoperfusion of optic nerve, normally secondary to carotid artery atherosclerosis and secondary thromboemboli Precedes stroke so urgent investigations required Curtain descending down over vision If provoked by gaze - optical lesion

Answer 275

GCA Retinal Migraine Papilledema

Answer 276

Inflammatory markers Carotid imaging and cardiac evaluation MRI/MRA

Answer 277

TIA - stroke work up GCA - Emperic steroids and temporal artery biopsy Antiplatelets/Anticoag

Answer 278

Optic disc swelling secondary to raised ICP Oedema, continued pressure and optic nerve atrophy

Answer 279

BP CT/MRI LP with opening pressure

Answer 280

Asymptomatic Signs of raised ICP Abducens Palsy

Answer 281

Weight reduction Acetazolamide ?CSF Shunt, Duran Venous Stenting

Answer 282

Severe eye pain Significant visual loss Photophobia

Answer 283

Supplementation with Vitamin C, Vitamin E, Zinc, Copper, Lutein and Zeaxanthin

Answer 284

Proliferative diabetic retinopathy Sacrificing the peripheral retina to reduce the production of VEGF by the ischaemic retina and preventing neovascularisation

Answer 285

Serious complication of severe proliferative diabetic retinopathy - new vessels grow on the iris and in the anterior chamber. These vessels have the potential to cause a raised intraocular pressure and a secondary glaucoma and therefore measuring this patient's intraocular pressure is very important.

Answer 286

``` Lid retraction (Dalrymple's sign) Lid lag on down gaze (Von Graefe's sign) ```

Answer 287

The treatment is intravitreal vancomycin as the most common causative organisms after surgery are gram positive. Cultures are taken from the vitreous, either by a tap, or by doing a vitrectomy and antibiotic therapy should be tailored according to culture and sensitivities.

Answer 288

mast cell stabilisers such as Sodium Cromoglycate

Answer 289

Myotonic dystrophy

Answer 290

Ceftriaxone IV, bacitracin ointment and hourly saline lavage

Ophthalmology Conditions Flashcards

(315 cards)