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Yr4 - Neuro + SS > Opthalmology > Flashcards

Opthalmology Flashcards

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1
Q

Features of mydriatic and cycloplegic drops

A

Dilate pupils for visualisation of the retina
Paralyse accommodation in management of children with amblyopia
Used in refraction of children for the prescription of glasses

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2
Q

Features of Atropine

A

1-2 drops - 0.5-1%
Antimuscarinic - blocks response of iris sphincters muscles and accommodative muscles of ciliary body
Lasts 1-2 weeks
CI - HTN, untreated narrow angle glaucoma

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3
Q

Features of Cyclopentolate

A

1-2 drops - 0.5-1%
Antimuscarinic - blocks response of iris sphincter muscles and accommodative muscles of ciliary body
Effect in 25-75 mins, recovery over 6-24 hours
CI - untreated narrow angle glaucoma, allergy

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4
Q

Features of Tropicamide

A

1-2 drops of 1%
Antimuscarinic - blocks response of iris sphincter muscles and accommodative muscles of ciliary body
Effect in 15-20 mins, recovery over 4-8 hours
CI - allergy, untreated narrow angle glaucoma

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5
Q

Features of Phenylephrine

A

1-2 drops 2.5/10%
Sympathetic agonist - stimulation of iris dilation muscle
Effect 3-6 hours
CI - avoid in children, untreated narrow angle glaucoma

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6
Q

Side effects of mydriatic and cyloplegic drops

A

Whitening of eyelids due to vasoconstriction - resolves as drops wear off
Atropine can cause redness of face and warm sensation to touch
Sting the eyes for few seconds
Patients cannot drive until blurring worn off

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7
Q

Features of Fluorescein drops

A

Orange die - used to highlight defects or foreign bodies in the corneal epithelium
- can be used when measuring IOP
Check for allergy

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8
Q

Side effects of Fluorescein drops

A

Skin discolouration - lasts 6-12 hours
Staining of clothes
Discolour contact lenses

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9
Q

Define Blepharitis

A

Inflammation of the eyelid margins

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10
Q

Symptoms of Blepharitis

A

Gritty, itch, dry sensation in the eyes
Eyes sticking together in morning
Symptoms worse in mornings
Recurrent hordeolum

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11
Q

Mx of Blepharitis

A

Warm compress
Cleaning the margins of the eye with a cotton bud + sterilised water + baby shampoo
Lubricating eye drops can remove symptoms
- hypromellose - least viscous, lasts 10 mins
- polyvinyl alcohol - normal starting choice
- carbomer - most viscouse, lasts 30-60 mins
Avoid eye makeup

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12
Q

DDx for eyelid inflammation

A 
Meibomian cyst or stye
Infection 
Psoriasis
Dermatitis
Tumours
Connective tissue disorders
Trauma
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13
Q

Define Hordeolum

A 
Stye
Acute localised infection or inflammation of eyelid margin
External
- appears on eyelid margin
- causes by eyelash follicle
Internal - Meibomian
- occurs on conjunctival surface of eyelid
- infection of Meibomian gland
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14
Q

Clinical presentation of a stye

A

Acute-onset painful localised swelling near eyelid margin

  • over several days
  • usually unilateral
  • eye may water excessively (epiphora)
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15
Q

Mx of a stye

A

Warm compress
Advise to not attempt to puncture stye
Avoid eye makeup or contact lenses

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16
Q

Define Meibomian cyst

A

Inflammation of Meibomian gland

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17
Q

Mx of Meibomian cyst

A

Hot compress

Analgesia

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18
Q

Define Entropion

A

Eyelid turns inwards with lashes against the eyeball

  • can lead to corneal damage and ulceration
  • painful
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19
Q

Mx of entropion

A

Tape down eyelid to prevent from turning inward
- regular drops prevent the eye from becoming dry
Surgical management

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20
Q

Define ectropion

A

Eyelid turns outwards with inner aspect of eyelid exposed
Usually affects the bottom lid
- can result in exposure keratopathy - eyeball not not adequately lubricated or protected

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21
Q

Mx of ectropion

A

Mild cases don’t require treatment
Regular lubricating eye drops
Surgical intervention

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22
Q

Define peri-orbital cellulitis

A

Infection of eyelid and area around the eye

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23
Q

Define orbital cellulitis

A

Infection of orbital soft tissues

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24
Q

Presentation of orbital cellulitis

A 
Lid oedema
Fever
Painful swelling of eyelids
- impairs vision and prevents eye from opening
Shiny and red eyelids
Systemically unwell
Bulging eyes
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25
Mx of orbital cellulitis
Iv abx
26
Presentation of pre-orbital cellulitis
Lid oedema No visual loss, conjunctival oedema or protrusion of eyeball Afebrile and systemically well Tender, erythematous swollen eyelids
27
Mx of pre-orbital cellulitis
Oral abx
28
Causes of ptosis
Mechanical - lid pulled down due to gravity of large mass/scar Aponeurotic - defect in levator aponeurosis - senile - post-op Myogenic - myopathy of levator muscle or NMJ - myasthenia gravis - myotonic dystrophy - congenital Neurogenic - innervational defect - CN III nerve palsy - Horner syndrome - partial
29
Define presbyopia
Lens hardening and flattening due to increasing age - impaired ability to accommodate - reduction in close up vision/accommodation - noticeable around age 40
30
How is intraocular pressure maintained
``` Aqueous humour - balance between rate of production and drainage - secreted from ciliary epithelium - drainage through posterior chamber, into anterior chamber, through trabecular meshwork into Schlemm's cells Alpha-2 receptors - reduce IOP - reduce aqueous production - increase uveoscleral drainage Beta-2 receptors - increase IOP - increase aqueous production ```
31
Measurement of IOP
Non-contact tonometry - shoots puff of air at cornea and measures corneal response Goldmann applanation tonometry - gold standard - device mounted on slit lamp which makes contact with cornea and applies different pressure to front of cornea - more accurate
32
Normal IOP
11-21 mmHg | - high IOP does not equate to glaucoma
33
Drug mx of high IOP
``` Beta blockers - Timolol - decrease aqueous production Alpha agonists - Apraclonidine - Dipivefrin - decrease production and increase drainage Prostaglandin analogues - Latanoprost - increase uveoscleral outflow Carbonic-anhydrase inhibitors - Dorzolamine - decrease production Parasympathomimetic - Pilocarpine - increase outflow by constricting iris ```
34
Define keratitis
Inflammation of cornea
35
Causes of keratitis
``` Viral - herpes simplex Bacterial - pseudomonas - staphylococcus Fungal - candida - aspergillus Contact lens acute red eye Exposure - inadequate eyelid cover - ectropion ```
36
Presentation of keratitis
``` Painful red eye Photophobia Vesicles around eye - herpes Foreign body sensation Watering eye Reduced visual acuity ```
37
Complications of keratitis
``` Stromal keratitis - inflammation of upper layer of iris - stromal necrosis - vascularisation - scarring Corneal scarring Blindness ```
38
Ix for keratitis
Staining with fluorescein show dendritic corneal ulcer Slit lamp Corneal swabs or scrapings - isolate virus
39
Mx of keratitis
``` Same day referral to ophthalmologist Topical/oral acyclovir Ganciclovir eye gel Topical steroids - stromal keratitis Corneal transplant - corneal scarring ```
40
Define conjuctivitis
Inflammation of cornea
41
Types of conjunctivitis
``` Bacterial - purulent discharge - worse in mornings - highly contagious - easily spreads to other ye Viral - clear, watery discharge - coryzal symptom may be present - tender periauricular lymph nodes Allergic - allergen exposure and hx - swelling of conjunctival sac and eyelid - significant watery discharge and itchiness ```
42
Presentation of conjunctivitis
Red eyes Bloodshot Itchy/gritty sensation Discharge
43
Mx of conjunctivitis
``` Usually resolves spontaneously in 1-2 weeks Good hygiene to avoid spreading - avoid towel sharing - wash hands Avoid contact lenses Bacterial - abx eye drops - chloramphenicol - fusidic acid Allergic - antihistamines Under 1 month old - urgent ophthalmology review as maybe gonococcal infection ```
44
Define corneal abrasion
Scratches or damage to cornea
45
Causes of corneal abrasion
Contact lenses Fingernails Eyelashes/foreign bodies Entropion
46
Presentation of corneal abrasion
``` Hx of foreign body Painful red eye Foreign body sensation Watering eye Blurred vision Photophobia ```
47
Ix for corneal abrasion
Fluorescein stain - collects in abrasions/ulcers highlighting them Slit lamp exam
48
Mx of corneal abrasion
Simple analgesia Lubricating eye drops Abx eye drops Follow up in 1 week to check healing
49
Define hyphema
Blood in anterior chamber
50
Causes of hyphema
Trauma Intraocular surgery Neovascularisation - due to posterior segment ischaemia Spontaneous - bleeding disorders, antiplatelets, iris melanoma
51
Presentation of hyphema
Blurred vision Ocular distortion - kaleidoscope vision Pain, headache and photophobia is IOP raise
52
Ix for hyphema
``` Slit-lamp examination Full ophthalmic examination o Visual acuity o Pupillary examination o Intraocular pressure o Gonioscopy – condition of the angle and the trabecular meshwork o Measure the height of the hyphema from the inferior limbus o Measure IOP ```
53
Mx of hyphema
``` Uncomplicated - eye shield - limited activity - head elevation Monitor eye closely in first few days - high risk of further bleeding Avoid NSAIDs ```
54
Complications of hyphema
Obstruction of trabecular meshwork -> increased IOP Peripheral anterior synechiae - iris adheres to lens Posterior synechia - iris adheres to cornea Corneal bloodstaining Rebleeding
55
Define endophthalmitis
Inflammation of one or more coats of the eye with contagious cavity inflammation
56
Causes of endophthalmitis
Intraocular surgery Penetrating trauma Draining a glaucoma bleb
57
Types of endophthalmitis
``` Acute - staph epidermis - staph aureus - strep - pseudomonas Chronic - propionibacterium acnes - staph epidermis - fungi Trauma - staph epidermis - strep - fungi - gram-neg bacteria Bled-related - strep ```
58
Prestation of endophthalmitis
Very painful red eye | Hypopyon present - leukocytic exudate in anterior chamber of eye
59
Mx of endophthalmitis
Aqueous and vitreous tap Intravitreal abx - vancomycin Topical/oral ciprofloxacin
60
Define cataracts
Opacification of the crystalline lens
61
Causes of cataracts
``` Normal aging Smoking Increased alcohol Trauma DM Long term corticosteroids Radiation exposure Myotonic dystrophy Hypocalcaemia ```
62
Presentation of cataracts
``` Reduced vision Faded colour vision Glare - lights appear brighter than usual Halos around lights Altered red light reflex ```
63
Ix for cataracts
Ophthalmoscopy - normal fundus and optic nerve Slit lam examination - visible cataract
64
Classification of cataracts
``` Nuclear - change lens refractive index - common in old age Polar - localised, lie in visual axis - commonly inherited Subcapsular - due to steroid use - deep to lens capsule, in visual axis Dot opacities - common in normal lenses - seen in diabetes and myotonic dystrophy ```
65
Mx of cataracts
``` Non-surgical - prescribe stronger glasses - use brighter lights Surgical - remove cloudy lens and replace with artificial lens ```
66
Stages of cataract removal
Eyedrops to dilate pupil + local anaesthetic Remove cataract - phacoemulsification - probe inserted via incision and USS used to break up cataract - laser to make incisions and soften cataract for removal - extracapsular cataract extraction - larger incision made and cataract removed whole
67
Complications of cataract surgery
Posterior capsule opacification - thickening of lens capsule Retinal detachment Posterior capsule rupture Endophthalmitis - inflammation of aqueous /vitreous humour
68
Define glaucoma
Optic nerve damage caused by significant rise in IOP | - secondary to blockage of aqueous humour leaving anterior chamber
69
Define primary open angle glaucoma
Gradual increase in resistance through the trabecular meshwork - decreasing drainage of aqueous humour Increased pressure causes cupping of optic disc
70
Glaucoma screening
Annual screening for those over 40 with 1st degree relative that had glaucoma .
71
Risk factors for primary open angle glaucoma
Increasing age FHx Black ethnic origin Nearsightedness (myopia)
72
Presentation for primary open angle glaucoma
Often rise in IOP asymptomatic Affects peripheral vision first then turns to tunnel vision Fluctuating pain, headaches, blurred vision and halos around light
73
Mx of primary open angle glaucoma
``` Prostaglandin analogue eyedrops - latanoprost - increase uveoscleral outflow Betablockers - timolol - reduce production of aqueous humour Carbonic anhydrase inhibitors - dorzolamide - reduced production of aqueous humour Alpha-2-agonist - brimonidine - reduce production of aqueous humour - increase uveoscleral outflow Trabeculectomy surgery when drops ineffective - new channel underneath conjunctiva - forms a bled ```
74
Side effects of prostaglandin analgogues
Eyelash growth Eyelid pigmentation Iris pigmentation
75
Define acute angle closure glaucoma
Ophthalmological emergency Occurs when iris bulges forward and seals off trabecular network - prevents aqueous humor form draining away Pressure build up in posterior chamber
76
Risk factors for acute angle closure glaucoma
``` Increasing age Female FHx Chinese and east Asian ethnicity Shallow anterior chamber Medications - noradrenaline - oxybutynin - amitriptyline - steroids ```
77
Presentation of acute angle closure glaucoma
``` Severely painful eye Blurred vision Halos around light Associated headache, N+V Epiphora - excessive eye watering Hazy cornea Decreased visual acuity Fixed and dilated affected pupil Firm eyeball on palpation ```
78
Mx of acute angle closure glaucoma
``` Initial steps - lay patient on back without pillow - Pilocarpine eye drops - Acetazolamide 500mg orally - analgesia and antiemetic Secondary - laser iridotomy - creates hole in iris to allow aqueous humour to flow from posterior chamber to anterior ```
79
Pathophysiology of diabetic retinopathy
Hyperglycaemia leads to damage of retinal small vessels and endothelial cells Increased vascular permeability leads to leakage from blood vessels, blot haemorrhages and formation of hard exudates Damage to vessel walls leads to microaneurysms and venous bleeding Damage to nerve fibres causes cotton wall spots Intraretinal microvascular abnormalities (dilated and torturous capillaries in retina) shunt between arterial and venous vessels
80
Classification of diabetic retinopathy
Non-proliferative - no neovascularisation Proliferative - presence of neovascularisation
81
Fundus findings of diabetic eye disease
``` Non-proliferative diabetic retinopathy - mild = microaneurysms - moderate = microaneurysms, blot haemorrhages, hard exudates, cotton wool spots, venous bleeding - severe = blot haemorrhages, microaneurysms in 4 quadrants, venous bleeding in 2 quadrants, IMRA in any quadrant Proliferative diabetic retinopathy - neovascularisation - vitreous haemorrhage Diabetic maculopathy - macular oedema - ischaemic maculopathy ```
82
Complications of diabetic eye disease
``` Retinal detachment Vitreous haemorrhage Rubeosis iridis - new blood vessel formation in iris Optic neuropathy Cataracts ```
83
Mx of diabetic eye disease
``` Laser photocoagulation Anti-VEGR mutations - ranibizumab - bevacizumab Vitreoretinal surgery ```
84
Pathophysiology of central retinal vein occlusion
Thrombus in retinal vein blocks the drainage of blood from retina Pooling of blood in retina - leakage of fluid and blood causing macular oedema and retinal haemorrhages Leads to loss of vision Neovascularisation stimulated by VEGF release
85
Risk factors for central retinal vein occlusion
``` Hypertension High cholesterol DM Smoking Glaucoma SLE ```
86
Presentation of central retinal vein occlusion
Sudden painless loss of vision
87
Ix for central retinal vein occlusion
``` Fundoscopy - flame and blot haemorrhages - optic disc oedema - macular oedema FBC - leukaemia ESR - inflammatory disorders BP BM ```
88
Mx of central retinal vein occlusion
``` Referred immediately Treat macular oedema and prevent neovascularisation Laser photocoagulation Intravitreal steroids - dexamethasone Anti-VEGF therapies ```
89
Define hypertensive retinopathy
Damage to retinal blood vessels relating to systemic hypertension
90
Presentation of hypertensive retinopathy
Silver/copper wiring - walls of arterioles become thickened and sclerosed causing increased light reflection Arteriovenous nipping - arterioles cause compression of veins Cotton wool spots - nerve ischaemia Hard exudates - leaking lipids Retinal haemorrhages Papilloedema
91
Classification of hypertensive retinoapthy
Keith-Wagener classification - stage 1 = anterior narrowing and tortuosity, increased light reflex - stage 2 = arteriovenous nipping - stage 3 = cotton-wool exudates, flame and blot haemorrhages - stage 4 = papilloedema
92
Mx of hypertensive retinopathy
Controlling BP and other risk factors
93
Define central retinal artery occlusion
Branch of ophthalmic artery which arises from internal carotid artery
94
Causes of central retinal artery occlusion
Atherosclerosis | Giant cell arteritis -> vasculitis
95
Risk factors for central retinal artery occlusion
``` Older age Fhx Smoking Alcohol consumption Hypertension Diabetes Poor diet Inactivity Obesity ```
96
Presentation of central retinal artery occlusion
Sudden painless loss of vision RAPD Pale retina with cherry red spot (macula)
97
Mx of central retinal artery occlusion
Refer immediately to ophthalmology Treat underlying cause Mx of risk factors
98
Features of age-related macular degeneration
``` Most common cause of blindness in UK Two types - wet 10% - dry 90% Wet carries worse prognosis ```
99
Pathophysiology of age-related macular degeneration
Wet and Dry - large number of Drusen - yellow deposits of protein and lips between retinal pigment epithelium and Bruch's membrane Atrophy of retinal pigment epithlium Degeneration of photoreceptors Wet - development of new vessels growing from choroid layer in retina - can leak fluid causing oedema
100
Risk factors for ARMD
``` Increasing age Smoker White or Chinese ethnic origin FHx CVS disease ```
101
Presentation of ARMD
Gradual worsening central visual field loss Reduced visual acuity Crooked or wavy appearance of straight lines Wet presents more acutely
102
Examination features of ARMD
Reduced acuity using Snellen chart Scotoma - blind spot Amsler grid test - assess distortion of straight lines Fundoscopy/slip lamp - drusen Optical Coherence Tomography - diagnose wet ARMD Fluorescein angiography - shows oedema and neovascularisation
103
Mx of ARMD
Dry - no specific treatment - focus on lifestyle measures - avoid smoking, control BP - vitamin supplementation to slow measures Wet - anti-VEGF medications injected into vitreous chamber
104
Define posterior vitreous detachment
Vitreous humour maintains surface structure of the eye and keeps retina pressed onto choroid Detachment occurs when vitreous humour comes away from retina
105
Presentation of PVD
Painless Spots of vision Floaters Flashing lights
106
Mx of PVD
Improves over time as brain adjusts | Predisposes patient to retinal tears and detachment - important to assess retina
107
Define retinal detachment
Retina separates from choroid Usually due to retinal tear allowing vitreous fluid to get under retina Outer retina relies on blood vessels from choroid for blood supply - sight threatening emergency
108
Risk factors for retinal detachement
``` Posterior vitreous detachment Diabetic retinopathy Trauma to eye Retinal malignancy Older age Fhx ```
109
Presentation of retinal detachement
Sudden peripheral vision loss Blurred or distorted vision Flashes and floaters
110
Mx of retinal detachment
Vitrectomy - remove relevant parts of vitreous body and replacing with oil or gas Scleral buckling - forces pressure from outside of eye so choroid indents and makes contact with retina Pneumatic retinopexy - injecting gas bubble into vitreous body to create pressure that forces retina onto choroid
111
Mx of retinal tear
Laser or cryotherapy to create adhesions between retina and choroid
112
Define uveitis
Inflammation of one or all parts of uvea - iris - ciliary body - choroid - retina
113
Types of uveitis
Anterior - iris and ciliary body - common in ankylosing spondylitis, Reiters syndrome, RA, IBD, SLE - often HLA-B27 + Posterior - choroid, retina and retinal vasculature - often seen in sarcoidosis, MS, TB, herpetic eye disease - classified by duration, age of onset or presence of granulomas
114
Presentation of anterior uveitis
``` Pain - burning Red eye Blurred vision Photophobia Dilated ciliary vessels Cells in anterior chamber Headaches Keratic precipitates ```
115
Presentation of posterior uveitis
``` Floaters Blurred vision Photopsia Vasculitis Optic disc swelling ```
116
Ix for uveitis
``` Ocular - fluorescein angiogram - OCT - intravitreal tap - endophthalmitis culture and sensitivity - cytology - toxoplasmosis and CMV PCR Blood tests - routine - immunologial - auto-antibody screen - HLA testing - syphilis - HIV test - toxoplasmosis X-rays - CXR - sarcoidosis, TB - Lumbosacral spine - ankylosing spondylitis - MRI brain and optic nerve - MS Mantoux test ```
117
Mx of uveitis
Cycloplegic drops - atropine - pain relief - prevent posterior synechiae Steroid drops
118
Define herpes zoster ophthalmicus
Reactivation of varicella zoster virus in the area supplied by the ophthalmic division of CN V
119
Presentation of herpes zoster ophthalmicus
Vesicular rash around eye Hutchinson's sign - rash on tip or side of nose indicated nasociliary involvement - strong risk factor for ocular involvement
120
Mx herpes zoster ophthalmicus
Oral antiviral treatment for 7-10 days IV antiviral in immunocompromised or severe infection Topical corticosteroids to treat secondary inflammation of eye Ocular involvement requires urgent ophthalmology review
121
Define giant cell artertis
Systemic vasculitis of medium and large arteries | - typically temporal
122
Risk factors for temporal arteritis
Female White Over 50 Polymyalgia rheumatia
123
Presentation of giant cell arteritis
``` Severe unilateral headache - temporal and forehead Scalp tenderness - notice when brushing hair Jaw claudication - can lead to weight loss Blurred or double vision Irreversible painless sight loss ```
124
Ix for temporal arteritis
CRP raised Temporal artery biopsy - multinucleated giant cells FBC - normocytic anaemia and thrombocytosis LFTs - raised ALP Duplex USS of temporal artery - hypoechoic halo sign
125
Mx of temporal arteritis
``` Prednisolone 40-60 mg - continue till symptoms stop then slowly wean Don't STOP advice - don't stop abruptly - adrenal crisis - sick day rules - double dose - treatment card - osteoporosis prevention - bisphosphonates and supplemental calcium and vit D - PPI Aspirin 75mg daily Referrals - vascular surgeons - biopsy - rheumatology - diagnosis + mx - ophthalmology - review same day if symptoms get worse ```
126
Compilations of temporal arteritis
``` Early - visual loss - stroke Late - replases - steroid side effects - stroke - aortitis - leading to aortic aneurysm and aortic dissection ```
127
Define scleritis
Full thickness inflammation of sclera
128
Causes of sclertitis
``` Not usually infection Associated with - RA - SLE - IBD - sarcoidosis - granulomatosis with polyangiitis ```
129
Presentation of sclertitis
``` Acute onset to symptoms - 50% bilateral Severe pain Pain on eye movement Photophobia Eye watering Reduced visual acuity Abnormal pupil reaction to light Tenderness to palpation of eye ```
130
Mx of scleritits
Consider underlying systemic conditions NSAIDs Steroids Immunosuppression
131
Features of RA
Scleritis Peripheral corneal thinning - perforation Episcleritis Keratoconjunctivitis sicca - dry eyes
132
Features of SLE
``` Scleritis Peripheral corneal thinning Eyelid erythema Keratoconjunctivitis sicca Retinopathy - primary or secondary due to hypertension ```
133
Pathophysiology of thyroid eye disease
Orbital tissues including extra-ocular muscles infiltrated by inflammatory cells - increased pressure in orbit IgG mediated Associated with thyrotoxicosis Aqueous humour outflow obstruction from eye may lead to secondary glaucoma
134
Stages of thyroid eye disease
``` Acute inflammatory - risk of sight loss - lasts 12-18 months - causes proptosis - can cause obstructive optic neuropathy Chronic fibrotic - leads to restrictive myopathy and diplopia ```
135
Risk factors for thyroid eye disease
Female | Smoking
136
Symptoms of thyroid eye disease
``` Asymptomatic Grittiness - superior limbic keratoconjunctivits Redness Eyelid swelling Diplopia Bulging eyes Visual loss ```
137
Examination findings of thyroid eye disease
Lid retraction - due to fibrotic contracture of levator | Lid lag on down gaze
138
Ix for thyroid eye disease
CT orbit - proptosis - 2/3 of globe should lie within orbit - extraocular muscle infiltration and enlargement TFTs - Graves disease = suppressed TSH, elevated T3 and T4
139
Mx of thyroid eye disease
Manage thyroid dysfunction Ocular lubricants - for corneal exposure Glaucoma topical meds - secondary glaucoma Systemic corticosteroids Orbital radiotherapy Diplopia - squint surgery, prisms, botox Cosmetic - orbital decompression, lid surgery
140
Define retionblastoma
Malignant tumour Develops from immature cells of retina 45% inherited - mutations of RB1 on chromosome 13
141
Presentation of retinoblastoma
Leukocoria - abnormal white reflection from retina May lack red reflex Bilateral in 1/3 cases May develop squint
142
Mx of retinoblastoma
Enucleation of eye Radiotherapy Chemotherapy
143
Define amblyopia
Reduction of corrected visual acuity
144
Define strabismus
Misalignment of eyes | Causes amblyopia due to competitive interaction between cortical inputs from both eyes
145
Types of amblyopia
Primary - develops in child with otherwise normal ocular exam - due to central developmental anomaly Secondary - occurs following ocular disease - refractive error - difference between two eyes gives one blurred image - media opacity
146
Classification of strabismus
Esotropia - convergent squint Exotropia - divergent squint Accommodative - focussing on near object results in excessive convergence - completely corrected by glasses Mixed
147
Mx of stabismus
Nerve conductions to LGN cease to be plastic after 8 years old Correction of any significant refractive error with glasses Removal of any visual obstruction Amblyopia treatment with patching
148
Causes of congenital cataracts
Down's syndrome Hypoparathyroidism TORCH - intrauterine infectsions
149
Mx of congenital cataracts
If severe surgery required in early life to allow for normal development - risk of open angle glaucoma
150
Define retinopathy of premature infants
Proliferative vitreoretinopathy affecting pre-term infants with low birth weight Retinal vessels develop at 4 months gestation, reach nasal periphery at 8 months and temporal periphery 1 month after birth In preterm infants incompletely vascularized retina susceptible to damage from low or high O2 concentrations
151
Mx of retinopathy of prematurity
Laser treatment to ablate ischaemic retina
152
Screening for retinopathy of prematurity
Babies born - less than 32 weeks - less than 1500g
153
Key points of neonatal conjunctivitis
``` Under 1 month is a notifiable disease Gonococcal - 2-4 day post birth - corneal ulceration and perforation Chlamydial - 5-14 days post birth - most common - treat with topical tetracycline or oral erythromycin ```
154
Features of atopic eye disease
Peak age onset 20 years | IgE mediated
155
Features of seasonal allergic conjuctivitis
Symptoms seasonal and mild Examination shows small papillae on tarsal conjuctiva Self-limiting - antihistamine drops helpful - ketotifen
156
Features of perennial allergic conjuctivitis
Mild and may persist all year with seasonal exacerbations Examination shows small papillae on tarsal conjuctiva Mx = olopatadine - antihistamine and mast cell stabiliser
157
Features of atopic keratoconjunctivis
Severe pain, redness and reduced vision Examination shows papillae on conjunctiva - can causing scaring leading to corneal opacification and neovascularisation Mx = cidofovir
158
Define Horner Syndrome
Triad of ptosis, miosis and anhidrosis | Occurs with damage to sympathetic chain
159
Causes of Horners syndrome
``` Central lesions - stroke - MS - tumours - syringomyelia Pre-ganglionic lesions - Pancoast tumour - trauma - thyroidectomy - top rib Post-ganglionic - carotid aneurysm - carotid artery dissection - cavernous sinus thrombosis - cluster headache ```
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Define Argyll Robertson Pupil
Specific finding in neurosyphilis but can also be due diabetes Constricted pupil that accommodates when focussing on near object but doesn't react to light Often irregularly shaped
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Define Holmes Adies Pupil
Unilateral dilated pupil that is sluggish to react to light - slow dilatation followed by constriction Over time pupil gets smaller Due to damage to post-ganglionic parasympathetic fibres
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Presentation of 3rd nerve palsy
``` Ptosis Dilated non-reactive pupil - carries parasympathetic nerve fibres Divergent strabismus - down and out Sparing of pupil suggest microvascular cause ```
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Causes of 3rd nerve palsy
``` Idiopathic Pupillary sparing - diabetes, hypertension, ischaemia Tumour Trauma Cavernous sinus thrombus Posterior communicating artery aneurysm Raised ICP ```
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Ix for 3rd nerve palsy
BP BM CRP Brain imaging
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Mx of 3rd nerve palsy
Correct BP and glucose Usually resolves over 4-6 months May require surgery
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Features of 4th nerve palsy
Leads to paralysis of superior oblique Diplopia on depression Abnormal head posture - head tilt and face turn to unaffected eye
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Causes of 4th nerve palsy
``` Congenital Vascular - diabetes, hypertension Demyelination Tumour Giant cell arteritis Aneurysm ```
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Ix for 4th nerve palsy
``` Head tilt test - tilting head to ipsilateral side induces upward movement of globe to to unopposed superior rectus action BP BM CRP Brain imaging ```
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Mx of 4th nerve plasy
Correct BP and glucose Usually resolves in 4-6 months May require surgery
170
Presentation of 6th nerve palsy
Ipsilateral convergent squint - due to unopposed medial rectus Horizontal diplopia Abnormal head posture
171
Define Nystagmus
Involuntary repetitive back and forth oscillations of the eye May be horizonal (most common), vetical or torsional - description based on fast phase - if no fast phase = pendular
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Features of physiological nystagmus
Caloric testing - warm/cold water put in patient's ear to induce Gaze evoked - normal to mild nystagmus on extreme left/right gaze
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Features of congenital nystagmus
Seen in children up to 1 Initially horizontal pendular nystagmus - later developing jerk stage May be inherited - X-linked or autosomal recessive Indicator of poor vision Should be monitored for refractive error, amblyopia and strabismus
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Causes of acquired nystagmus
``` Recent trauma Toxicity - alcohol - phenothiazines - Wernicke's encephalopathy Cerebral disease - stroke - MS - tumour ```
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Ix for acquired nystagmus
Full physical exam - including neuro Toxicity screening Neurological imaging
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Mx of acquired nystagmus
Treatment of any cerebral disease Botox Surgery
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Nystagmus associated with neuro disease
``` Convergence retraction - eyes converge and drawn into orbit on upgaze - dorsal midbrain disease Downbeat nystagmus - foramen magnus lesions Upbeat nystgamus - cerebellar lesions See-saw - chiasmal lesion ```
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Define optic neuritis
Inflammation of optic nerve
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Presentation of optic neuritis
``` Reduced visual acuity Abnormal visual fields Peri-orbital pain RAPD Poor colour vision Optic disc swelling ```
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Causes of optic neuritis
``` Retrobulbar neuritis - disc appears normal in acute phase due to demyelination - early sign of MS Papillitis - disc inflammation - viral infection in young children Ischaemic - GCA, embolic, SLE Compressive Traumatic Toxic - alcohol - B12 deficiency Retinal disease - retinitis pigmentosa ```
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Ix for optic neuritis
``` ESR - exclude GCA FBC Visual field test Vit B12 and folate levels Autoantibody screen Orbital and brain imaging if compressive suspected Temporal artery biopsy ```
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Define papilloedema
Bilateral disc swelling due to raised ICP
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Clinical features of papilloedema
``` Bilateral swollen hyperaemic discs Disc haemorrhages Absent venous pulsations at disc Optic atrophy Champagne cord appearance if chronic ```
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Causes of papilloedema
Intracranial tumour Benign idiopathic hypertension Meningitis Brain abscess
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Ix for papilloedema
Urgent CT head LP BP
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Unilateral causes of swollen optic disc
``` Central retinal vein occlusion Uveitis Ocular hypotony Anterior ischaemic optic neuropathy Optic disc infiltration ```
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Define chiasmal disease
Affects junction of optic nerve and optic chiasm
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Presentation of chiasmal disease
Blurred vision Constricted visual fields - bitemporal hemianopia Headache See-saw nystagmus
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Causes of chiasmal disease
``` Pituitary tumour - compress from below - supero-temporal vision affected first Meningioma Craniopharyngioma ```
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Red eye DDx
``` Subjunctival haemorrhage Blepharitis Conjunctivitis Trauma Keratitis Iritis Episcleritis Scleritis Primary angle closure ```
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Causes of gradual changes in vision
``` Refractive error Cataract Posterior capsule opacification Age-related macular degeneration Retinitis pigmentosa ```
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Causes of monocular diplopia
``` Corneal opacity/scarring/oedema Iris defects Subluxated natural lens Decentred artificial intraocular lens Uncorrected astigmatism ```
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Causes of binocular diplopia
``` Horizontal - decompensated pre-existing eso/exo phoria - CN VI palsy - internuclear ophthalmoplegia - medial orbital wall fracture Vertical - decompensated pre-existing hypo/hyper phoria - CN IV palsy - CN III palsy Variable - thyroid eye disease - MG ```
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Causes of sudden changes in vision
Painful - anterior segment – iritis, scleritis, keratitis, primary angle closure - optic nerve – optic neuritis, arteritic ischaemic optic neuropathy - intracranial – migraine, benign intracranial hypertension Painless - vitreous – vitritis, vitreous haemorrhage - retinal (vascular) – retinal vein occlusion, retinal artery occlusion - retinal (macula) – wet ARMD, diabetic maculopathy - retinal – retinal detachment, retinitis, retinochoroiditis - optic nerve – non-arteritic ischaemic optic neuropathy, compressive optic neuropathy - intracerebral – stroke

Yr4 - Neuro + SS (9 decks)

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