Opthalmology Flashcards
(148 cards)
1
Q
What is a glaucoma ?
A
- Optic neuropathies caused by an increase in intraocular pressure = damages the optic nerve
2
Q
What are the 7 RF for open angle glaucoma ?
A
- Increasing age
- FHx
- Afro-Carbibbean ethnicity
- Myopia (nearsightedness)
- DM
- HTN
- Corticosteroids
3
Q
What are the presenting features of open angle glaucoma ?
A
Gradual onset peripheral vision loss
4
Q
Findings on fundoscopy in open angle glaucoma
A
- Optic disc cupping (Cup-to-disc ratio >0.7)
- Optic disc pallor
- Bayonetting of vessels
5
Q
What is the management of open angle glaucoma ?
A
- First line = Laser : 360 degrees trabeculoplasty If IOP >=24mmHg
- Second = Medical management : prostaglandin analogue eye drops (Latanoprost)
- Third : BB (Timolol).
- Surgery : Trabeculectomy in refractory cases
6
Q
What are the RF for acute angle closure glaucoma ?
A
- Hypermetropia (long-sightedness)
- Pupillary dilatation
- Cataracts
- Increasing age
7
Q
What are the presenting features of acute angle closure glaucoma ?
A
- Sudden onset severe pain : may be ocular or headache
- Painful red eye.
- Blurred vision
- Halos around lights
- N&V.
- Symptoms worse with mydriasis (e.g. watching tv in a dark room).
8
Q
What are the 6 features seen on examination in acute angle closure glaucoma ?
A
- Red eye
- Hazy cornea
- Decreased visual acuity
- Semi-dilated non-reacting pupil
- Fixed size pupil
- Hard eyeball on gentle palpation
9
Q
What is the management of acute angle closure glaucoma ?
A
- Immediate admission and referral to ophthalmologise (keep pt supine without a pillow)
- Combination of eye drops : Pilocarpine 2%, Timolol, and apraclonidine.
- IV Acetazolamide
- Definitive : laser peripheral iridotomy
10
Q
How does latanoprost work and what are its SE?
A
- Prostoglandin analogue
- Increases uveoscleral outflow (aqueous humour)
- Once daily
- SE : brown pigmentation of iris, increased eyelash length
11
Q
How does timolol work and what is a contraindication ?
A
- BB
- Reduces aqueous humour production
- Avoided in asthmatics and pts with heart block
12
Q
How does apraclonidine work, when is it avoided and what is an adverse effect ?
A
- Alpha-2 receptor agonist
- Reduces aqueous humur production & increases uveoscleral outflow.
- Avoided if taking MAOI or tricyclic antidepressant
- Adverse effect : hyperaemia
13
Q
How does Dorzolamide work ?
A
- Carbonic anhydrase inhibitor
- Redices aqueous humur production
14
Q
What is the mechanism of action of pilocarpine and its adverse effects ?
A
- Muscarinic receptor agonist
- Increases uveoscleral outflow
- Adverse effects : constricted pupil, headache and blurred vision
15
Q
What happens to the macula in ARMD ?
A
- Frequent and larger Drusen
- Atrophy of the retinal pigment epithelium
- Degeneration of photoreceptors
16
Q
What happens specifically in wet ARMD?
A
- Neovascularisation
- New blood vessels develop in the choroid and grow into the retina
- When they leak fluid / blood = oedema and faster vision loss
17
Q
RF for ARMD
A
- Older age (>75)
- Smoking
- FHx
- Other cardiovascular RF (HTN, DM, dyslipidaemia).
18
Q
What are the features of ARMD ?
A
- Loss of CENTRAL vision : gradual in dry ARMD, Subacute in wet ARMD
- Crooked or wavy appearance to straight lines (metamorphopsia).
- Deterioration in vision at night
- Flashing lights
- Fluctuations in visual disturbance that varies from day to day
19
Q
What is seen on examination in ARMD ?
A
- Reduced visual acuity on a Snellen chart
- Scotoma
- Distortion of straight lines assessed with Amsler grid test
- Drusen on fundoscopy
20
Q
What investigations are done in ARMD
A
- Initial : Slit lamp -> view of retina and macula.
- Optical coherence tomography : for diagnosing and monitoring
- Fluorescein angiography : shows oedema and neovascularisation in wet AMD
21
Q
How is ARMD managed ?
A
- Slow / reduce progression
- Avoid smoking
- Control BP
- Vitamin supplementation
22
Q
What specific medication can be used in wet ARMD ?
A
- Anti-VEGF medications (Ranibizumab)
- Target Vascular endothelial growth factor which stimulates the development of new blood vessels in the retina
23
Q
Causes of an acutely red PAINLESS eye
A
- Conjunctivitis
- Episcleritis
- Subconjunctival haemorrhage
24
Q
7 causes of an acutely PAINFUL red eye
A
- Acute angle-closure glaucoma
- Anterior uveitis
- Scleritis
- Corneal abrasions or ulceration
- Keratitis
- Foreign body
- Traumatic or chemical injury
25
PAINLESS red, bloodshot eye
Purulent discharge
Itchy / gritty sensation
Diagnosis and management
- Bacterial conjunctivitis
- Often staph aureus (or gonococcus if STI)
- If needed : chloramphenicol / fusidic acid eye drops (pregnant women)
26
PAINLESS red, blood shot eye
Clear discharge
Tender preauricular lymph nodes
Coryzal symptoms
Viral conjunctivits
Often adenovirus
27
- Bilateral swelling of conjunctival sac and eyelid
- Prominent itch
- Watery discharge
Diagnosis and management
- Allergic conjunctivits
- Oral or topical antihistamines (cetirizine)
- Topical mast-cell stabilisers (sodium cromoglicate) can be given 2nd line
28
What is anterior uveitis
- Inflammation of the middle layer of the eye
- Choroid, ciliary body and iris
29
What are the presenting features of anterior uveitis
- ACUTELY painful, red eye
- Photophobia
- Blurred vision
- Excessive lacrimation
30
What is seen on examination in anterior uveitis?
- Miosis +/- irregulalry shaped pupil
- Ciliary flush
- Hypopyon
31
What is anterior uveitis associated with ?
- HLA-B27
- Seronegative spondyloarthropathies
- Behcet's disease
- Sarcoidosis
32
How is anterior uveitis managed ?
- Urgent ophthalmologist referral
- Steroids (eye drops, oral or IV)
- Cycloplegics / mydriatic (e.g. cyclopentolate or atropine eye drops = antimuscarinis)
33
How do cycloplegics work in anterior uveitis ?
- Antimuscarinins
- Paralyse the ciliary muscles = dilates the pupil and reduces pain
34
what kind of pupil is seen in neyrosyphilis ?
- Argyll-Robertson pupil
- Small, irregular pupils
- Accommodates but
35
- Asymmetrical slow reduction in visual acuity.
- Fading of colours
- Halos around lights
- Glaring of lights / "starbursts" around lights
Cataracts
36
What is cataracts and what 2 investigations are done to diagnose
- Progressively opacification of the lens
- Slit lamp : shows cataracts
- Opthalmoscope : shows loss of red reflex with normal optic nerve and fundus
37
Conservative and definitive management of cataracts
1. conservative : glasses
2. Definitve : surgery - surgical replacement with artificial lens
38
What are the diffferentials for sudden, painless vision loss ?
- Retinal detachment
- Central retinal artery occlusion
- Central retinal vein occlusion
- Vitreous haemorrhage due to diabetic retinopathy
39
what is seen on fundoscopy in central retinal artery occlusion
- Pale retina
- 'Cherry red spot on retina'
40
What is a key sign of central retinal artery occlusion ?
Relative afferent pupillary defect
41
What are the features of retinal vein occlusion
Sudden, painless reduction or loss of visual acuity
42
what is seen on fundoscopy in retinal vein occlusion
- Widespread hyperaemia
- Severe retinal haemorrhages -> 'Stromy sunset'
43
How is retinal vein occlusion managed ?
- Refer to opthalmologist
- Anti-VEGF (renibizumab) = macular oedema
- Laser photocoagulation = neorevascularisation
44
What is Blepharitis : presentation and management
- Inflammation of the eyelid margins
- Bilateral grittiness/discomfort with swollen and red eyelids
- Hot compress twice daily / cooled boiled water and baby shampoo on cotton wool
45
What are the 2 types of stye, presentation and management
- Hordeolum externum : infection of sebaceous or sweat glands
- Hordeolum internum : infection of meibomian glands
- Tender, red lump on eyelid
- Hot compress and analgesia
46
Chalazion : what, features, management
- Blocked and swollen meibomian gland (cyst)
- Firm, painless lump in eye
- Warm compress and gentle massage
47
Entropion : what and management
- Eyelid turned inwards
- Tape down eyelid with regular lubticating drops
- Definitive = surgery
48
Ectropion. : what and management
- Eyelid turned outwards
- Regular lubricating eyedrops
49
Trichiassis : what and management
- Inward growth of eyelashes
- Remove affected eyelashes
50
Periorbital cellulitis : causes and features
- Eyelid and skin infection IN FRONT of orbital septum
- Most frequently : staph aureus
- Swollen, red, hot skin around the eyelid and eye
51
How is periorbital cellulitis distinguished from orbital cellulitis ?
- Contrast CT
52
How is periorbital cellulitis managed ?
- Urgent opthalmology referral
- Oral co-amoxiclav
53
What is orbital cellulitis ?
Infection around the eyeball involving tissues BEHIND the orbital septum
54
What are the features of orbital cellulitis ?
- Redness and swelling around the eye
- Severe ocular pain
- Visual disturbance
- Proptosis -> eye bulges forwards
- Opthalmoplegia / pain with eye movements
- Eyelid oedema and ptosis
55
How is orbital cellulitis managed ?
IV antibiotics
56
Features of corneal abrasions
Eye pain
Foreign body sensation
Photophobia
Watering eye : epiphora
Red eye
57
How can corneal abrasions be visualised
- Fluorescein stain -> yellow-orange colour that collects in abrasions / ulcers highlighting them, especially when viewed under cobalt blue light
58
What are lubricating eye drops based on ?
- Hypromellose -> least viscous (effects last 10 mins)
- Polyvinyl alcohol drops -> middle viscous
- Carbomer -> most viscoius (last 30-60 mins)
59
What is keratitis
Inflammation of the cornea
60
What can cause keratitis ?
- Viral infection - HSV (most common) = herpes simplex keratitis
- Bacterial infection - pseudomonas (contact lens wearers) or staphylococcus
- Fungal infection - candida or aspergillus
- Contact lens-induced acute red eye (CLARE)
- Exposure keratitis - caused by inadequate eyelid coverage (e.g ectropion)
61
How does keratitis present ?
- Red eye : pain and erythema
- Photophobia
- Foreign body, gritty sensation
- Hypopyon may be seen
62
How is keratitis managed ?
- Same day referral to rule out bacterial keratitis = Slit lamp
- Fluorescein staining shows a dendritic corneal ulcer
- Topical or oral antivirals (aciclovir, ganciclovir if viral)
63
What is seen on fundus examination in background diabetic retinopathy
- Microaneurysms
- Retinal haemorrhages
- Hard exudates
- Cotton wool spots
64
What is seen on fundoscopy in pre-proliferative diabetic retinopathy ?
- Venous bleeding
- Multiple blot haemorrhages - - Intraretinal microvascular abnormality (IRMA).
65
What is seen on fundoscopy in proliferative diabetic retinopathy
- Neovascularization and vitreous haemorrhage.
66
What is seen on fundoscopy in diabetic retinopathy
- Exudates within macula and macular oedema.
67
How is non proliferative diabetic retinopathy managed ?
Close monitoring and careful diabetic control
68
How is proliferative diabetic retinopathy managed ?
- Pan-retinal photocoagulation (SE = decrease in night vision)
- Anti-VEGF
- Surgery (vitrectomy) in severe disease
69
How is hypertensive retinopathy classified ?
Keith-wagener classification
- I = arteriolar narrowing and increased light reflex = sliver wiring
- II = AV nipping
- III = 'Cotton wool exudates, flame and bot haemorrhages
- IV = papilloedema
70
How does episcleritis and scleritis differ in presentation ?
- Episcleritis : PAINLESS red eye, often laterally.
- Scleritis : PAINFUL red eye, watering and photophobia, reduced visual acuity, blue sclera
71
what test can help differentiate between episcleritis and scleritis ?
- Phenylephrine eye drops -> in episcleritis, this will cause the redness to disappear. In scleritis it will have no effect.
72
Give 4 RF for scleritis
- RA
- SLE
- Sarcoidosis
- Granulomatosis with polyangiitis
73
How is scleritis managed ?
- Same day assessment by ophthalmologist
- First line = oral NSAIDs
- More severe = oral glucocorticoids
74
Give 5 predisposing factors to subconjunctival haemorrhage
- HTN
- Bleeding disorders (e.g thrombocytopenia)
- Whooping cough
- Medications (antiplatelets, DOACS, warfarin)
- Non-accidental injury
75
How does a subconjunctival haemorrhage present ?
- Patch of BRIGHT RED blood underneath the conjunctiva
- PAINLESS
- No effect on vision
76
what is posterior vitreous detachment and how does it present ?
- Separation of the vitreous membrane from the retina
- Sudden appearance of floaters
- Flashing lights
- Blurred vision
- Cobweb across vision
77
What is seen on opthalmoscopy in posterior vitreous detachment and what does it predispose people to ?
- Weiss ring
- Retinal tears and retinal detachment
78
- Sudden onset painless peripheral vision loss (shadow coming across vision)
- Blurred or distorted vision
- New onset floaters and flashes
Retinal detachment
79
what occurs in retinal detachment and what is it often due to ?
- Neurosensory tissue of retina separates from underlying pigment epithelium.
- Often due to retinal tears allowing vitreous fluid to get under the neurosensory retina
80
how is a retinal tear managed ?
- Create adhesions between retina and choroid
- Laser therapy / cryotherapy
81
How is retinal detachment managed ?
- Reattach retina and reduce traction / pressure to prevent recurrence
- Vitrectomy, scleral buckling or pneumatic retinopexy
82
Initial night blindness, followed by peripheral vision loss (tunnel vision)
Retinitis pigmentosa
83
what is retinitis pigmentosa ?
Genetic condition causing the degeneration of the photoreceptors (particularly rods) in the retina.
84
what is seen on fundoscopy in retinitis pigmentosa ?
- Black bone spicule-shaped pigmentation in the peripheral retina
- Mottling of the retinal pigment epithelium
85
Give 3 systemic diseases associated with retinitis pigmentosa
- Usher syndrome
- Bassen-Kornwig syndrome
- Refsum disease
86
Give 8 causes of a dilated pupil
- Congenital
- Stimulants (e.g. cocaine)
- Anticholinergics (e.g oxybutynin)
- Trauma
- Third nerve palsy
- Holmes-Adie syndrome
- Raised ICP
- Acute angle-closure glaucoma
87
Give 6 causes of a constricted pupil
- Horner syndrome
- Cluster headaches
- Argyll-Robertson pupil (neurosyphilis)
- Opiates
- Nicotine
- Pilocarpine
88
What are the 3 features of a third nerve palsy ?
- Ptosis
- Dilated, non reactive pupil
- ‘Down and put’ eye position
89
If the pupil is NOT affected in a third nerve palsy, what does it suggest about the underlying cuase ?
- It is microvascular as the parasympathetic fibres are spared
- Examples : DM, HTN, Ischaemia
90
If a third nerve pasly DOES affect the pupil, what does it suggest about the underlying cause ?
- There is compression of the nerve as the parasympathetic fibres are affected
- Examples : Tumour, Trauma, Cavernous sinus thrombosis , Posterior communicating artery aneurysm, Raised ICP
91
what are the 4 possible features of Horner's syndrome ?
- Ptosis
- Miosis
- Anhidrosis
- Possible enophthalmos = sunken eye
92
What are the 4 central lesions that can cause horner's syndrome and what is the site on anhidrosis ?
- S: Stroke
- S : multiple Sclerosis
- S : Swelling (tumours
- S: Syringomyelia (cyst in spinal cord)
FACE, ARM AND TRUNK
93
what are the 4 preganglionic lesions that can cause horner's syndrome and where does the anhidrosis occur ?
- T : Tumour (pancoast)
- T : Trauma
- T : Thyroidectomy
- T : Top rib
FACE
94
What are the 4 postganglionic lesions that can cause Horner's syndrome and where does the anhidrosis occur ?
C : Carotid aneurysm
C : Carotid artery dissection
C : Cavernous sinus thrombosis
C : Cluster headache
NO ANHIDROSIS
95
what is congenital Horner's syndrome assocatiated with ?
- Heterochromia (difference in iris colour on affected eye)
96
How can Horner's syndrome be tested for?
- Cocaine eye drops
- Stops noradrenaline reuptake at NMJ.
- This causes a normal eye to dilate.
- In Horner’s, the nerves do not release noradrenaline and so there is no pupil reaction.
97
what are the features of Holmes-Adie pupil ?
- Dilated : damage to postganglionic parasympathetic nerve fibres
- Sluggish to react to light
- Responsive to accommodation (the pupil constricts when focusing on a near object)
- Slow to dilate following constriction (“tonic” pupil)
98
what is seen in Holmes-Adie syndrome ?
- Holmes Adie pupil
- Absent ankle and knee reflexes
99
what is herpes zoster opthalmicus ?
- Reactivation of the varicella-zoster virus in the area supplied by the opthalmic division of the trigeminal nerve
100
How does herpes zoster opthalmicus present ?
- Vesicular rash around the eye
- Hutchinson's sign = rash on the trip or side of the nose. Indicates nasociliary involvement
101
How is herpes zoster opthalmicus managed ?
- Oral antiviral Tx for 7-10 days started within 72 hrs.
102
what is the most common cause of a persitent watery eye in an infant and how is it managed ?
- Nasolacrimal duct obstruction
- Teach parents to massage the lacrimal duct
103
what is hyphema, management of complication (in the context of trauma)
- Definition : Blood in the anterior chamber of the eye.
- Management : Strict bed rest and urgent lateral canthotomy
- Complication : glaucoma
104
what are the 4 features of orbital compartment syndrome and how is it managed ?
- Eye pain/swelling
- Proptosis
- 'Rock hard' eyelids
- Relevant afferent pupillary defect
- Urgent lateral canthotomy
105
what are the causes of a relative afferent pupillary defect ?
- Retina: detachment
- Optic nerve: optic neuritis e.g. multiple sclerosis
106
Common presentation of vitreous haemorrhage
- Painless visual loss or haze (commonest)
- Red hue in the vision
- Floaters or shadows/dark spots/cobwebs in the vision
107
who is often affected by vitreous haemorrhage ?
Diabetics
108
- Post renal transplant
- Blurred vision
- Fundoscopy : cotton-wool spots, infiltreates and haemorrhages
Cytomegalocirus retinitis
109
Investigations done in open angle glaucoma
- Automated perimetry : asses visual field
- Slit lamp examination with pupil dilatation to assess optic nerve and fundus for a baseline
- Applanation tonometry to measure IOP
- Gonioscopy to assess peripheral anterior chamber configuration and depth
110
Does the iris cover the trabecular meshwork in open-angle glaucoma
NO
Iris is clear on the meshwork
111
Investigations done in acute angle closure glaucoma
1. Tonometry -> look for elevateed IOP
2. Gonioscopy
112
Is the peripheral iris covering the trabecular meshwork in acute closed angle glaucome ?
- YES
- This leads to a narrowing of the anterior chamber, impairing aqueous outflow and causing a sudden rise in IOP = sight threatening
113
An elderly female smoker presents with reduced visual acuity, complaining of 'blurred' vision. On examination there is a central scotoma and fundoscopy reveals multiple drusen. Likely diagnosis ?
Macular degeneration
114
An elderly patient with a history of atrial fibrillation presents with a sudden painless loss of vision in one eye. Fundoscopy reveals a 'cherry red' spot on a pale retina.
Central retinal artery occlusion
115
An elderly short-sighted man presents with flashing lights which are worse on eye movement and are located in the temporal visual field. He also describes some upper visual field loss 'like a curtain coming down' is a stereotypical history of:
Retinal detachment
116
An elderly man presents an acute, painful red eye associated with decreased visual acuity. His symptoms are worse in the dark. On examination he has a semi-dilated non-reacting pupil
Acute angle closure glaucoma
117
A man who is on treatment for HIV presents with a painful, vesicular rash on the right side of his face around the eye. Fluorescein staining reveals multiple small defects on the right cornea
Herpes zoster opthalmicus
118
An elderly man with a long history of diabetes presents with sudden visual loss in one eye. For the past few days he had been experiencing floaters and 'cobwebs'. Visual acuity is reduced to sensing light is a stereotypical history of
Vitreous haemorrhage
119
what is the mechanism of action of pilocarpine
Muscarinic receptor antagonist
Direct parasympathomimetic
120
A young man presents with an acute, painful red eye associated with photophobia and blurred vision. On examination the pupil is small and irregular is a stereotypical history of
Anterior uveitis
121
An elderly patient with a history of chronic glaucoma and hypertension presents with a sudden painless loss of vision in one eye. Fundoscopy reveals multiple flame-shaped haemorrhages and optic disc oedema is a stereotypical history of
Central retinal vein occlusion
122
An elderly patient with a history of hypertension presents with decreasing visual acuity and peripheral visual field loss. Fundoscopy reveals optic disc cupping is a stereotypical history of:
Primary open angle glaucoma
123
A woman with a history of rheumatoid arthritis presents with severe, constant pain in her right eye. On examination the right eye is red and there is a degree of photophobia. Visual acuity is normal is a stereotypical history of :
Scleritis
124
A patient presents with a 'droopy eyelid'. On examination they have unilateral miosis, ptosis and narrow palpebral aperture giving the appearance of enophthalmos is a stereotypical history of:
Horner's syndrome
125
A woman with a history of rheumatoid arthritis presents after developing a red right eye. There is no pain, discharge or photophobia although the eye is tearing. Visual acuity is normal
Episcleritis
126
A patient presents with an acute, painful red eye associated with photophobia and epiphora. Fluorescein staining reveals a ragged area on the cornea (epithelial ulcer)
Herpes simplex keratitis
127
A 30-year-old man presents with visual problems. His vision is much worse in the dark and he has now started to lose peripheral vision. He has a family history of similar problems
retinitis prigmentosa = YOUNG
128
A woman is noted to have a unilateral mydriatic pupil which is minimally reactive to light
Holmes-Adie pupil
129
An elderly short-sighted man presents with a floater on the temporal field of vision. Visual acuity is normal for the patient is a stereotypical history of
Posterior vitreous detachment
130
2 features of an Argyll-Robertson pupil
- Small, irregular ppupils
- Accommodates but does not react to light
131
Mnemonic for Argyll-Robertson pupol
ARP = Accommodation Reflex Present (ARP) but Pupillary Reflex Absent (PRA)
132
2 causes of ARP
DM
Syphilis
133
5 RF for orbital cellulitis
- Childhood
- Previous sinus infection
- Lack of Hib vaccination
- Recent eyelid infection / insect bite of eyelid (preorbital cellulitis)
- Ear or facial infection
134
Presentation of herpes simplex keratitis
- Red, painful eye
- Photophobia
- Epiphora
- Decreased visual acuity
- Fluorescein staining may show epithelial ulcer
135
Management of herpes simplex
Immediate opthalmology referral
Topical aciclovir
136
What is seen on fundoscopy in retinitis pigmentosa
Black bone spicule-shaped pigmentation in the peripheral retina
137
what is a complication of blunt ocular trayma with associated hyphema ?
- Glaucoma due to raised IOP
138
A young patient presents with visual symptoms. Acute unilateral worsening of vision. Associated pain with eye movements. RAPD seen and reduced visual acuity in affected eye. Likely diagnosis and two other common symptoms seen in this condition
Optic neuritis
Reduced colour vision
Central scotoma
139
How should any contact lens wearing patient present with a painful red eye be managed and why ?
Urgent referal to eye casualty to exclude microbial keratitis
140
Serious complication of surgery to replace lens in cataracts
Endophthalmitis
141
Cause of nuclear cataracts
Change in lens refractive index - old age
142
Cause of polar cataracts
INherited
143
Cause of subcapsular cataracts
S = steroids
144
Cause of dot opacities cataracts
D = DM = mytonic Dystrophy
145
explain which way the eye with deviate in different types of suint
the nose: esotropia
temporally: exotropia
superiorly: hypertropia
inferiorly: hypotropia
146
presention of stye in SBA and management
- Painful swelling of eye, yellow head pointing to the lid margin
- Analgesia and warm compress
147
how can drusen be described in SBA
Accumulations of extracellular material between Bruch's membrane and the retinal pigment epithelium of the eye
148
