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Neurology and Special Senses > Ophthalmology Conditions > Flashcards

Ophthalmology Conditions Flashcards

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1
Q

What is blepharitis?

A

Range of conditions causing eyelid inflammation

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2
Q

What is the difference between anterior and posterior blepharitis?

A

Anterior - involve the lashes

Posterior - involve meibomian glands

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3
Q

What complications are associated with blepharitis?

A

Dry eye
Conjunctivitis
Keratitis

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4
Q

What is the pathophysiology of blepharitis?

A

Build up of bacteria on lash follicle or gland orifice

Immune response to this causes collateral damage and further inflammation

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5
Q

How does blepharitis present?

A 
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
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6
Q

How is blepharitis managed?

A

Lid hygiene and topical chloramphenicol

+Stop mascara use, remove crusts, warm compress, tear supplements

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7
Q

What makes up the uvea/vascular layer of the eye?

A

Iris
Choroid
Ciliary body

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8
Q

What is the difference between causes of unilateral and bilateral uveitis

A

Unilateral - infectious, acute cause

Bilateral - chronic systemic cause

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9
Q

How can anterior uveitis be further categorised?

A

Iritis - just iris

Iridocyclitis - iris and ciliary body

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10
Q

When do most patients present with anterior uveitis?

A

Between 20-50yo

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11
Q

What can cause anterior uveitis?

A

Idiopathic - 50%
Inflammatory - ank spond. sarcoidosis, Behcet’s, IBD, Kawasaki, SLE
Infectious - Lyme disease, herpes
Trauma

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12
Q

Where does the most severe injections in anterior uveitis occur?

A

At the limbus - opposite to conjunctivitis (further away from limbus)

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13
Q

What is the pathogenesis of uveitis?

A

Antigen thought to provoke inflammatory response that breaks down eye-blood barrier. This enables WBC and proteins to enter anterior chamber

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14
Q

How does uveitis present?

A 
Symptoms occur over hours-days
Painful - worse pain on eye movement
Red
Photophobia
Blurred vision
Watery eye - may overflow
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15
Q

What signs are seen on examination in a patient with uveitis?

A 
Reduced visual acuity
Perilimbal injection
Direct photophobia
Keratic precipitates - WBC visible as little white spots
Small fixed oval pupil
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16
Q

How is uveitis managed?

A

Refer to ophthalmology within 24hrs

Cycloplegic dilating agents
Corticosteroids

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17
Q

Why and what are cycloplegia dilating agents used for uveitis?

A

Relieve pain
Prevent adhesions

Atropine and Cyclopentolate

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18
Q

Why are corticosteroids used for uveitis?

A

Reduce inflammation

Prevent adhesions

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19
Q

What complications are associated with uveitis?

A

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

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20
Q

What are posterior synechiae?

A

Inflammatory adhesions between lens and iris

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21
Q

What must you examine for if a patient has uveitis?

A 
Back pain - ank spond
Rash/bite - lyme
Resp. Symptoms - Sarcoidosis
GI symptoms - IBD
Cold sore - herpes
Oral/genital ulcers - Behcet's
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22
Q

What is affected in intermediate uveitis?

A

Posterior ciliary body
Peripheral retina
Choroid

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23
Q

What features are associated with intermediate uveitis?

A

Painless floaters
Decreased vision
Minimal redness and pain

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24
Q

What is affected in posterior uveitis?

A

Retina and choroid

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25
What features are associated with posterior uveitis?
Bilateral Painless floaters Gradual visual loss Absence of redness, pain and photophobia
26
What is infectious keratitis and what is it also known as?
Infection of the cornea Corneal ulcer
27
What causes infectious keratitis?
Microorganisms getting in via defect in corneal epithelium
28
What must be done if a patient has a corneal ulcer?
Take swab under topical anaesthesia
29
What risk factors are associated with corneal ulcers?
Wearing contact lenses Dry eyes and blepharitis Diabetes and immunosuppression Topical corticosteroid use
30
How do corneal ulcers present?
Severe pain Photophobia FB sensation Reduced vision
31
How are corneal ulcers managed?
Topical broad spectrum quinolone
32
What can be seen on examination of a corneal ulcer?
Hypopyon - white fluid in anterior chamber | White lesions on cornea - infiltrate
33
What is the prognosis of corneal ulcers?
Good prognosis Increased risk of long term visual disability in: Elderly, Contact lens wearers, Fungal disease
34
What causes herpetic keratitis?
HSV1
35
What happens in herpetic keratitis? | What is the hallmark feature on examination?
Virus travel along trigeminal nerve to ophthalmic division to corneal nerve Dendritic ulcer pattern seen
36
How is herpetic keratitis treated?
Topical aciclovir
37
What is an acanthamoeba? Who does it most often affect?
Rare sight threatening protozoal infection Seen in contact lens wearers
38
How does acathamoeba present?
Pain out of proportion to clinical signs
39
How is acanthamoeba treated?
Propamidine Chlorhexadine Several months
40
What risk factors are associated with corneal abrasion?
Inability to close eyes | Wearing contact lenses
41
How does corneal abrasion present?
``` Watery red eye Unable to keep open/repeated blinking Photophobia Decreased visual acuity FB sensation ```
42
What investigations would you request for someone with a corneal abrasion?
None normally needed CT = 1st choice X-ray if metallic FB MRI contraindicated for metallic FB Fluorescein examination
43
What would you see on fluorescein examination of a corneal abrasion?
Yellow stained abrasion | Usually visible to naked eye
44
How is corneal abrasion managed?
Topical NSAID's Topical Chloramphenicol - prevent bacterial infection Tetanus prophylaxis Follow up and review
45
How are corneal foreign bodies managed?
Remove (IF EXPERIENCED) Topical anaesthetic Irrigate eye or remove with cotton wool bud Then treat as abrasion (NSAIDs, chloramphenicol, tetanus prophylaxis)
46
How are contact lens wearers who have a corneal abrasion managed?
Topical anti-pseudomonas antibiotics | No contact lens for 2 weeks
47
What is the prognosis for a corneal abrasion on the visual axis?
Potential for loss of visual acuity - scarring
48
What must you exclude with penetrating corneal injury?
Full thickness injury - this means ruptured globe
49
What mustn't you do if a patient has a penetrating corneal injury?
Apply pressure to the globe
50
What is Seidel's test (ophthalmology)?
Used to assess leakage from cornea, sclera or conjunctiva If see paler fluid within pool or dye leaks then injury has penetrated anterior chamber
51
What are the red flags associated with penetrating corneal injury?
Obvious deep laceration Subconjunctival haemorrhage Pupil or iris deformity
52
How would you manage a patient with penetrating corneal injury?
Urgent referral to ophthalmologist Eye shield Advise not to cough, blow nose or strain
53
What is glaucoma?
Damage to the optic nerve head with progressive loss of retinal ganglion cells and their axons Associated with raised IOP
54
How does aqueous humour normally drain in the eye?
Ciliary epithelium secrete aqueous humour Pass through trabecular meshwork at the iridocorneal angle Pass through canal of scheme Into aqueous veins and episcleral venous system
55
Where is flow reduced in open angle primary glaucoma?
Trabecular meshwork
56
What IOP is seen in open angle primary glaucoma?
>21mmHg
57
What risk factors are associated with open angle primary glaucoma?
``` Age Afro-caribbean Myopia Retinal disease Family history ```
58
How can primary open angle glaucoma be managed?
Topical drops Laser trabeculoplasty Surgical trabeculectomy
59
What is the pathophysiology of primary open angle glaucoma?
``` Poorly understood Could be: Raised IOP reduce blood flow to nerve head leading to vascular perfusion problem or Autoimmune damage of the nerve head ```
60
What examinations would you carry out if you suspect primary open angle glaucoma?
``` Goldman tonometry - IOP measurement Corneal thickness Gonloscopy - measure iris-corneal angle Visual field assessment Optic disk examination ```
61
What signs could be seen on optic disk examination in a patient with primary open angle glaucoma?
``` Cupping Pallor Bayoneting of vessels Cup notching Disc haemorrhage ```
62
How common is primary open angle glaucoma?
10% of >75yo
63
How does primary open angle glaucoma present?
Initial visual field loss peripheral - asymptomatic for long time Usually picked up on routine optician appointment By checking Visual Fields and Intra Ocular pressure of relatives
64
What conditions does the open angle glaucoma spectrum include?
Ocular hypertension - IOP>21 but nerve and VF normal Normal tension glaucoma - IOP<21 but cupping optic disc and visual field defect
65
What is the prognosis for open angle glaucoma?
Treatment stall progression but doesn't stop or reverse it Good compliance normally means vision retained for lifetime
66
What is secondary open angle glaucoma?
A primary disease causes raised IOP and optic neuropathy
67
What are the causes of secondary open angle glaucoma?
Neurovascular Corticosteroid induced Pseudoexfoliative - deposits in drainage angle Pigment dispersion - pigment deposit block drainage angle
68
What is the pathophysiology of neurovascular caused open angle glaucoma?
Ischaemia of the eye leads to new vessels growing and fibrosing in the drainage angle
69
How is secondary open angle glaucoma treated?
Neurovascular cause - laser treatment and anti-VEGF injections Others - stop corticosteroids and drops
70
What happens in acute closed angle glaucoma?
Acutely raised IOP Obstructed irido-corneal angle Lens pushed against iris
71
What risk factors are associated with closed angle glaucoma?
Age Chinese Women Hypermetropes
72
What are the possible complications of closed angle glaucoma?
Loss of vision | Central retinal artery/vein occlusion
73
What are the causes of closed angle glaucoma?
Severe hypermetropes - narrow angle so vulnerable to blocking off Lens grow as we age - narrow angle Short axial length Thick lens Thin iris Pupil dilation - push iris into angle Alpha-adrenergic agonists and other systemic drugs Lens dislocation Diabetes and Uveitis - meshwork blocked by vasculature and proteins
74
How does closed angle glaucoma present?
Severe acute pain Blurred vision --> vision loss Coloured haloes around lights N&V
75
What can be seen on examination of a patient with closed angle glaucoma?
``` Red eye Hazy cornea Mid-dilated and non-reactive pupil Globe feels hard Shallow anterior chamber Closed irido-corneal angle RIOP (40-70) ```
76
What is the immediate management for acute closed angle glaucoma?
``` Immediate referral Topical drops IV acetazolamide - carbonic anhydrase inhibitor IV mannitol Analgesia and anti-emetics ```
77
What is the definitive closed angle glaucoma management?
Laser iridotomy
78
What is age related macular degeneration?
Central retina changes without obvious precipitating cause occurring in >55yo
79
What are the types of macular degeneration? How common are they?
Dry - geographic atrophy - 90% | Wet - neovascularisation - 10%
80
What is the most common cause of UK blindness?
Age related macular degeneration 25% develop in other eye within 4 years
81
What are the risk factors for age related macular degeneration?
``` Age Smoking Family Hx Diet and Obesity Caucasian CVS risk factors ```
82
How does age related macular degeneration present?
``` Painless loss of central vision Near vision affected most Can't discern between different shades of colour Difficulty adapting from light to dim Photopsia Visual hallucinations ```
83
What is the main differential for age related macular degeneration?
Diabetic maculopathy
84
How is age related macular degeneration diagnosed?
Slit lamp OCT Fundus fuorescein angiography
85
How does dry macular degeneration appear?
Soft druse Changes in pigmentation of retinal epithelium Atrophy
86
How does wet macular degeneration appear?
New vessel growth seen Leakage from vessels - esp in periphery Red patches - haemorrhages
87
How do symptoms of wet and dry macular degeneration vary?
Dry - gradual vision loss, partial vision loss Wet - sudden symptom, straight lines appear wavy
88
How is age related macular degeneration managed?
Dry - no treatment - Vision rehab, smoking cessation help, vitamin supplements Wet - Intravitreal anti-VEGF injections (ranibizumab)
89
What are the ADR's associated with anti-VEGF injections?
Retinal detachment Endophthalmitis Allergic reaction
90
What is retinitis pigmentosa?
Inherited eye disease that is characterised by black pigmentation and gradual degeneration of the retina
91
How does retinitis pigmentosa present?
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
92
What is the pathogenesis of retinitis pigmentosa?
Photoreceptor death - rods first | Cell death lead to inflammation of vitreous humour
93
What is the epidemiology of retinitis pigmentosa?
Some cases X linked - more men | Peak ages - 7.5, 17 and >50yo
94
Why do you not get a relative afferent pupillary defect in Retinitis Pigmentosa?
It is bilateral and symmetrical
95
What is the prognosis for Retinitis pigmentosa?
Most legally blind by 40yo
96
How is Retinitis pigmentosa managed?
Visual rehab Counselling No way to stop disease progression
97
What is retinoblastoma?
Most common childhood ocular cancer originating from primitive retinal cells
98
Describe the epidemiology of retinoblastomas
Autosomal dominant Average age of diagnosis - 18 months 10% of cases hereditary
99
What is the pathophysiology of retinoblastoma?
Mutation in retinoblastoma tumour suppressor gene on chromosome 13 Follow 2 hit model: Sporadic - both mutations at fertilisation Inherited - one mutation inherited, other occur after birth
100
How does retinoblastoma present?
Absence of red-reflex - Leukocoria (white pupil) Strabismus - squint Varied ocular symptoms as disease progress - red eye, nystagmus, vision loss
101
How are retinoblastoma managed?
``` Range of options: Enucleation External beam radiation therapy Chemo Photocoagulation ```
102
How is retinoblastoma diagnosed?
Examination under general anaesthesia with fully dilated pupil MRI
103
What is the prognosis of retinoblastoma?
Excellent - >90% survive Increased risk of other malignancy - Ewing's sarcoma, osteosarcoma, neuroblastoma Metastasis to bone and brain rare Long term decrease in visual acuity and visual fields
104
What do the central retinal and posterior ciliary arteries supply?
Central - optic disc and central retina Posterior - Outer retina Both must function to maintain retinal function
105
What causes retinal artery occlusion?
Equivalent to cerebral stroke with end organ ischaemia: ``` Atheroma related thrombus Emboli Inflammatory cause - giant cell, SLE, wegener's Thrombophilic disorder COCP and cocaine Vasospasm ```
106
What is the peak age of retinal artery occlusion?
60-80yo
107
Describe the vessels that supply the retina
Internal carotid -- ophthalmic --> Central retinal and Posterior ciliary arteries Circle of zinn formed from posterior ciliary arteries
108
How is retinal artery occlusion diagnosed?
Clinical diagnosis ESR, CRP and vasculitis screen req. if suspect giant cell arteritis Full CVS exam
109
How does retinal artery occlusion present?
Sudden unilateral painless loss of vision | Amaurosis fugax history
110
What can be seen on examination of a patient with retinal artery occlusion?
Relative afferent pupillary defect Pale retina with cherry red spot Centre of macula thin, can see underlying vascular choroid Oedematous retina
111
How is retinal artery occlusion managed?
NEEDS TO BE STARTED WITHIN 100 MINS - still make attempts upto 24hrs after event ``` Giant cell arteritis suspected - IV steroids Treatments have very little evidence: Ocular massage Inhale high CO2 content Topical glaucoma drops Anterior chamber paracentesis ```
112
What is the long term management of retinal artery occlusion?
Reduce CVS and atherosclerotic risk factors
113
What is the prognosis for retinal artery occlusion?
Only 1/3 get improved vision even with rapid treatment
114
What causes retinal vein occlusion?
Disruption to virchow's triad: - Thrombus - Increased viscosity of blood - Disease of the vein wall - Compression from outside - arterial hypertension
115
What are the key risk factors for retinal vein occlusion?
``` Advancing age Hyperlipidaemia Hypertension Diabetes Raised IOP Inflammatory disease Hyperviscosity syndromes Renal disease ```
116
What are the types of retinal vein occlusion?
Branch retinal vein - more common | Central retinal vein - less common
117
How do branch and central retinal vein occlusion vary?
Branch - Image distortion, visual field defect 50% get 6/12 vision back Central - Start on walking Cotton wool spots, flame haemorrhages and RAPD (if ischaemia) on fundoscopy
118
What signs and symptoms are seen with both branch and central retinal vein occlusion?
Unilateral painless loss of vision | Vascular dilatation and Tortuous vessels on fundoscopy
119
How is retinal vein occlusion investigated?
``` BP Lipid profile ESR Blood glucose (Thrombophilia screen) ```
120
How can retinal vein occlusion be managed?
Manage CVS risk factors Laser treatment - if associated macula oedema or neovascularisation Intravitreal anti-VEGF - neovascularisation
121
What complications are associated with retinal vein occlusion?
Macula oedema Retinal neovascularisation - due to hypoxia Secondary glaucoma - due to neovascularisation
122
What is the normal sequence of events in retinal detachment?
1 Vitreous liquefies and shrinks with age 2 Posterior vitreous detachment 3 Traction on retina lead to tear 4 Vitreous seep underneath causing detachment
123
What are the symptoms of posterior vitreous detachment?
Flashing lights | Floaters - often temporal side of central vision
124
How may retinal detachment present?
Shadow start peripherally and progress centrally Begin slowly and progress over hours to weeks Black curtain come down and obstruct view Central vision loss - macula involved Straight lines appear curved
125
What signs would be seen on examination of a patient with retinal detachment?
``` RAPD if severe Loss of red reflex Reduced visual acuity Shafer's sign - vitreous lined with brown pigmented material Tears visible White appearance of detached retina ```
126
What risk factors are associated with retinal detachment?
``` Age Myopes - long eye Family Hx Previous tears Marfan's ```
127
How is retinal detachment diagnosed?
Slit lamp examination | Ultrasound or OCT
128
How is retinal detachment managed?
Same day urgent Ophthalmology review Tear - laser or cryotherapy to make adhesions between neural and pigmented layer Detachment: - Vitrectomy - air/oil injected to push retina back - Scleral buckling - silicone placed on sclera to push eye closer to detached retina - Pneumatic retinopexy - Gas bubble injected - expand
129
What are the complications associated with retinal detachment?
``` Vision loss Scar tissue can fibrose - further detachment Macula oedema Infection Haemorrhage ```
130
What is the prognosis for retinal detachment?
85% successful reattachment Can take months for vision to improve again Managing tears stop 95% from detaching
131
What is a squint (strabismus)?
Eyes don't point in the same direction
132
What are the types of squint?
Congenital/acquired - onset before/after 6 months Concomitant/incomitant Manifest/latent
133
What is a concomitant squint?
Angle between eyes remain same through all positions of gaze
134
What is a manifest squint?
Present when both eyes are open and being used
135
What is a latent squint?
Present only when other eye is shut
136
How can the angle between the eyes in a squint be described?
Exo - divergent angle Eso - convergent angle Hypo - downward deviation Hyper - upward deviation
137
What are concomitant squints associated with?
Poor fine motor skills Hypermetropes or Anisometropia (different refraction in each eye) Opacities
138
What is accommodative esotropia?
Excessive inward turning of eye during accommodation Need drops or patch to correct
139
What tests can be done to examine concomitant squints?
Hirschberg's - hold pen torch at arms length - see where light reflection lies Cover/uncover - cover one eye and observe open eye while the other one is uncovered Alternate cover test - focus on object with occluder rapidly switching between eyes
140
When should concomitant squints be examined?
2 months of age if constant or progressive
141
How are concomitant squints managed?
Correct refractive errors <8 - correct any amblyopia If all fails and squint large - surgery
142
What usually causes incomitant strabismus?
Extra-ocular muscle or nerve damage
143
How are incomitant squints managed?
If due to small vessel disease - conservative with CVS risk factor reduction for 6 months Prisms can be fitted to glasses Surgical correction may be needed
144
How would a cranial nerve 3 palsy appear?
Eye down and out Ptosis Dilated pupil
145
How would a cranial nerve 4 palsy appear?
Vertical diplopia
146
How would a cranial nerve 6 palsy appear?
Eye in
147
What is a hyphema?
Blood in the anterior chamber
148
What can cause a hyphema?
Usually trauma Sickle cell Haemophilia
149
How would hyphema's present?
Painful | Can cause vision loss
150
How would you manage a hyphema?
Steroid drops Cyclopentolate - dilate pupil Limited eye movement Bed rest
151
What is the main complication associated with a hyphema?
Raised IOP
152
What is a hypopyon?
Pus in the anterior chamber
153
What can cause a hypopyon?
Anterior uveitis Behcet's Drug reaction - rifampicin
154
what organism would you expect to be the cause of infectious keratitis in a) contact lens wearer b) general population c) following exposure to dirty water
a) pseudomonas b) staph aureus c) amoebic

Neurology and Special Senses (28 decks)

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