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Ophthalmology Flashcards

1
Q

Causes of papilloedema

A
  • Space-occupying lesion: neoplastic, vascular
  • Malignant hypertension
  • Idiopathic intracranial hypertension
  • Hydrocephalus
  • Hypercapnia
  • Hypoparathyroidism and hypocalcaemia
  • Vitamin A toxicity
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2
Q

Eyelid problems

A
  • Blepharitis: inflammation of eyelid margins typically leading to red eye
  • Stye: infection of glands of eyelids
    o Mx: hot compresses and analgesia
  • Chalazion (Meibomian cyst): retention cyst of Meibomian gland
  • Entropion: in-turning of eyelids
  • Ectropion: out-turning of eyelids
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3
Q

Differentials for painless acute red eye

A

o Conjunctivitis
o Episcleritis
o Subconjunctival haemorrhage

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4
Q

Differentials for painful acute red eye

A

o Acute angle closure Glaucoma
o Anterior uveitis
o Scleritis
o Corneal abrasions or ulceration
o Keratitis
o Foreign body
o Traumatic or chemical injury
o Endophythalmitis
o Dry eyes

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5
Q

Causes of acute visual loss

A

Optic nerve
- Anterior ischaemic optic neuropathy
- Optic neuritis

Retina
- Central retinal artery occlusion
- Central retinal vein occlusion

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6
Q

What is age related macular degeneration

A

Degeneration of central retina causing progressive deterioration in vision, often bilateral

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7
Q

Risk factors for macular degeneration

A
  • Advancing age
  • Smoking
  • Family history (white or Chinese ethnic origin)
  • CVD = Hypertension, Dyslipidaemia, Diabetes mellitus
  • Obesity (poor diet low in vits and high in fat)
  • Females
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8
Q

Classification of macular degeneration

A
  • Dry (90%) = drusen (yellow round spots in Bruch’s membrane), slow progression
  • Wet (10%) = choroidal neovascularisation, rapid progression
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9
Q

Presentation of macular degeneration

A
  • Subacute onset of central visual field loss
  • Reduction in visual acuity for near field objects
  • Difficulties in dark adaptation with overall deterioration in vision at night
  • Fluctuations in visual disturbance
  • Photopsia (perception of flickering or flashing lights)
  • Glare around objects
  • Crooked or wavy appearance to straight lines (metamorphopsia)
  • Visual hallucinations  Charles-Bonnet syndrome
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10
Q

Examination of macular degeneration

A
  • Amsler grid testing  distortion of line perception
  • Fundoscopy  presence of drusen, fluid leakage or haemorrhage
  • Atrophy of retinal pigment epithelium
  • Degeneration of photoreceptors
  • Scotoma (central patch of vision loss)
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11
Q

Investigations of macular degeneration

A
  • Slit lamp microscopy + colour fundus photography
  • Fluorescein angiography
  • Ocular coherence tomography
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12
Q

Management of macular degeneration

A
  • Refer to ophthalmology for assessment and management
  • Zinc with vitamins A, C and E
  • Stop smoking
  • Blood pressure control
  • Anti Vascular endothelial growth factors (ranibizumab, aflibercept, bevacizumab) for wet ARMD ± steroids
  • Laser photocoagulation
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13
Q

What is primary open-angle glaucoma

A
  • Optic nerve damage caused by raised intraocular pressure caused by blockage in aqueous humour
  • Gradual increase in resistance to flow through trabecular meshwork
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14
Q

Risk factors for open-angle glaucoma

A
  • Increasing age
  • Family history
  • Black ethnic origin
  • Myopia (near-sightedness)
  • Hypertension
  • Diabetes mellitus
  • Corticosteroids
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15
Q

Presentation of open-angle glaucoma

A
  • May be asymptomatic
  • Gradual onset of peripheral vision loss
  • Fluctuating pain
  • Headaches
  • Blurred vision
  • Halos around lights, particularly at night
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16
Q

Fundoscopy findings in open-angle glaucoma

A

Optic disc cupping
optic disc pallor
bayonetting of vessels
cup notching
disc haemorrhages

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17
Q

Investigations of open-angle glaucoma

A
  • Non-contact tonometry (screening)  measure pressure
  • Goldmann applanation tonometry (GS)
  • Slit lamp  ‘cupping’
  • Perimetry  visual fields
  • Gonioscopy  peripheral anterior chamber configuration and depth
  • Central corneal thickness
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18
Q

Management of open-angle glaucoma

A
  • Started at intraocular pressure of 24 mmHg or above
  • 1st line 360 degree selective laser trabeculoplasty
  • 2nd line Prostaglandin analogue eye drops (latanoprost)
  • 3rd line beta-blocker (timolol) eye drops, carbonic anhydrase inhibitor eye drops, sympathomietic eye drops
  • Trabeculectomy considered in refractory cases
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19
Q

Side effects of prostaglandin analogue eye drops

A

eyelash growth, eyelid pigmentation, iris pigmentation (browning)

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20
Q

Prevention of open-angle glaucoma

A

Pts with positive family history should be screened annually from age 40

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21
Q

What is acute angle-closure glaucoma

A
  • Optic neuropathy due to raised intraocular pressure
  • Iris bulges forwards and seals off trabecular meshwork from anterior chamber preventing aqueous humour from draining
  • Pressure builds in posterior chamber, pushing iris forwards and exacerbating angle closure
  • MEDICAL EMERGENCY
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22
Q

Risk factors for angle-closure glaucoma

A
  • Hypermetropia (long-sightedness)
  • Pupillary dilatation
  • Cataracts
  • Lens growth associated with age
  • Family history
  • Female
  • Chinese and East Asian ethnic origin
  • Shallow anterior chamber
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23
Q

Triggers of angle-closure glaucoma

A
  • Adrenergic medications (noradrenaline)
  • Anticholinergic medications (oxybutynin and solifenacin)
  • Tricyclic antidepressants (amitriptyline)
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24
Q

Presentation of angle-closure glaucoma

A
  • Severely painful red eye
  • Hazy cornea
  • Decreased visual acuity  blurred vision
  • Symptoms worse with mydriasis (watching TV in dark room)
  • Headache
  • Haloes around lights
  • Semi-dilated non-reacting oval pupil
  • Corneal oedema results in dull or hazy cornea
  • Hard eyeball on gentle palpation
  • Systemic: N+V, abdo pain
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25
Q

Investigations of angle-closure glaucoma

A
  • Tonometry  elevated IOP (40-60 mmHg)
  • Gonioscopy
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26
Q

Management of angle-closure glaucoma

A
  • Urgent referral to ophthalmologist and immediate admission
  • IV/oral acetazolamide  reduces aqueous production
  • Combination of eye drops  direct parasympathomimetic (pilocarpine), iopidine drops
  • Analgesia and antiemetic if required
  • IV mannitol, timolol, dorzolamide, brimonidine
  • Definitive: laser bilateral peripheral iridotomy
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27
Q

What is retinal detachment

A

Occurs when neurosensory tissue that lines the back of the eye comes away from its underlying pigment epithelium

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28
Q

Risk factors for retinal detachment

A
  • Diabetes mellitus
  • Myopia
  • Age
  • Previous surgery for cataracts
  • Eye trauma (boxing)
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29
Q

Presentation of retinal detachment

A
  • New onset floaters or flashes
  • Sudden onset, painless and progressive visual field loss  curtain or shadow progressing to centre of visual field from periphery
  • Central visual acuity if macula involved
  • Peripheral visual fields may be reduced
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30
Q

Examination of retinal detachment

A
  • Swinging light test  relative afferent pupillary defect if optic nerve involved
  • Fundoscopy  red reflex lost, retinal folds appear pale/opaque/wrinkled forms
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31
Q

Management of retinal detachment

A
  • Urgent referral to ophthalmologist for assessment with slit lamp and indirect ophthalmoscopy for pigment cells and vitreous haemorrhage
  • Surgery  Vitrectomy + gas/oil tamponade/scleral buckle, cryotherapy to secure
  • Laser photocoagulation
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32
Q

Complication of retinal detachment

A

Permanent visual loss

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33
Q

What is blepharitis

A

Inflammation of eyelid margins

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34
Q

Risk factors for blepharitis

A

Rosacea

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35
Q

Causes of blepharitis

A
  • Meibomian gland dysfunction
  • Seborrhoeic dermatitis/staph infection
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36
Q

Presentation of blepharitis

A
  • Symptoms usually bilateral
  • Grittiness and discomfort, particularly around eyelid margins
  • Eyes may be sticky in the morning
  • Crusts and scales on eyelashes
  • Eyelid margins may be red
  • Swollen eyelids may be seen in staph blepharitis
  • Styes and chalazions mor common
  • Secondary conjunctivitis may occur
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37
Q

Management of blepharitis

A
  • Softening lid margin using hot compresses twice a day
  • Lid hygiene
    o Mechanical removal of debris from lid margins
    o Cotton wool buds dipped in cooled boiled water and baby shampoo
    o Sodium bicarbonate in cooled boiled water
  • Artificial tears for symptoms relief
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38
Q

Causes of optic neuritis

A
  • Multiple sclerosis
  • Other: sarcoidosis, Syphilis, diabetes
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39
Q

Presentation of optic neuritis

A
  • Unilateral decrease in visual acuity over hrs or days
  • Poor discrimination of colours  red desaturation
  • Pain worse on eye movement
  • Relative afferent pupillary defect
  • Central scotoma
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40
Q

Investigation of optic neuritis

A

MRI brain and orbits with gadolinium contrast

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41
Q

Management of optic neuritis

A

High dose steroids

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42
Q

What is keratitis

A

Inflammation of cornea

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43
Q

Causes of keratitis

A
  • Bacterial: staph aureus, pseudomonas aeruginosa (contact lens wearers)
  • Fungal
  • Amoebic: acanthamoebic keratitis (soil or contaminated water)
  • Parasitic: onchocercal keratitis (river blindness)
  • Viral: herpes simplex
  • Environmental: photokeratitis, exposure keratitis, contact lens acute red eye (CLARE)
  • Mechanical or trauma
  • Chemical
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44
Q

Presentation of keratitis

A
  • Red eye: pain and erythema
  • Photophobia
  • Foreign body, gritty sensation
  • Hypopyon
  • Blurred vision
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45
Q

Management of keratitis

A
  • Same-day Referral of contact lens wearers for slit lamp assessment
  • Stop using contact lens until symptoms fully resolved
  • Topical antibiotics: quinolones
  • Cycloplegic for pain relief: cyclopentolate
46
Q

Complications of keratitis

A
  • Corneal scarring
  • Perforation
  • Endophthalmitis
  • Visual loss
47
Q

Causes of conjunctivitis

A
  • Bacterial  staph, gonoccocus
  • Viral  adenovirus
  • Allergic
48
Q

Presentation of conjunctivitis

A
  • Unilateral/bilateral red, bloodshot eyes
  • Itchy or gritty sensation
  • Purulent discharge  bacterial
    o Typically worse in morning when eyes may be stuck together
  • Clear/serous discharge  viral
    o Associated with dry cough, sore throat, blocked nose, tender preauricular lymph nodes
49
Q

Management of conjunctivitis

A
  • Usually resolves without Tx after 1-2 wks
  • Good hygiene to avoid spreading
    o Avoid sharing towels or rubbing eyes
    o Regularly washing hands
  • Avoid using contact lenses
  • Cleaning eyes with cooled boiled water and cotton wool can help clear discharge
  • Antibiotic eye drops: Chloramphenicol or fusidic acid
  • <1m old need urgent ophthalmology review
  • Antihistamines if allergic conjunctivitis
50
Q

What is anterior uveitis

A

Idiopathic inflammation of iris and ciliary body

51
Q

Risk factors for anterior uveitis

A
  • Young, white males
  • HLA-B27  ankylosing spondylitis
  • IBD
  • Sarcoidosis
  • Behcet’s disease
  • Infection  shingles, toxoplasmosis, TB, syphilis, HIV
52
Q

Presentation of anterior uveitis

A
  • Acute onset
  • Red, painful and watery eye
  • Photophobia
  • Blurred vision
  • Lacrimation
  • Ciliary flush (ring of red spreading outwards)
  • Mild reduction in visual acuity
53
Q

Investigation for anterior uveitis

A

Slit lamp examination
o Keratic precipitates
o Hypopyon (white cells, pus and debris)
o Irregular pupil
o Flare = inflammatory protein
o Posterior synechiae

54
Q

Management of anterior uveitis

A
  • Urgent review by ophthalmology
  • Cycloplegics (Atropine, cyclopentolate)
  • Steroids eye drops
55
Q

What is Periorbital cellulitis

A

Infection of soft tissues anterior to orbital septum but not orbit

56
Q

Presentation of periorbital cellulitis

A
  • Acute onset red, swollen, painful eye
  • Fever
  • Partial or complete ptosis of eye due to swelling
  • Orbital signs absent
  • No pain on eye movements
57
Q

Investigations for periorbital cellulitis

A
  • Bloods  CRP, FBC, blood cultures
  • Swab discharge
  • Contrast CT of orbit
58
Q

Management of periorbital cellulitis

A
  • Referral to ophthalmology for assessment
  • Oral Abx (co-amoxiclav)
  • Surgical drainage
  • May require admission for observation
59
Q

What is orbital cellulitis

A
  • Infection affecting fat and muscles posterior to orbital septum, within the orbit but not involving the globe
  • MEDICAL EMERGENCY
60
Q

Risk factors for orbital cellulitis

A
  • Childhood (mean age of hospitalisation 7-12 yrs)
  • Previous sinus infection
  • Lack of Haemophilus influenzae type b vaccination
  • Recent eyelid infection/insect bite on eyelid (periorbital cellulitis)
  • Ear or facial infection
  • Trauma
61
Q

Causes of orbital cellulitis

A
  • Streptococcus pneumoniae
  • Streptococcus pyogenes
  • Staph aureus
  • Haemophilus influenzae B
62
Q

Presentation of orbital cellulitis

A
  • Unilateral rapid onset erythema and swelling around eye
  • Severe ocular pain
  • Visual disturbance (blurred vision, diplopia, reduction in colour vision)
  • Ophthalmoplegia/ pain with eye movements
  • Eyelid oedema and ptosis
  • Chemosis, proptosis
  • Systemic: fever, headache, malaise
  • Drowsiness +/- N+V in meningeal involvement (rare)
63
Q

Examination of orbital cellulitis

A
  • Reduced visual acuity
  • Afferent pupillary defect
  • Proptosis (foreword movement of eyeball)
  • Dysmotility
  • Reduce periorbital sensation
64
Q

Investigations of orbital cellulitis

A
  • FBC  WBC elevated, raised inflammatory markers
  • CT with contrast  inflammation or orbital tissues deep to septum, sinusitis
  • Blood culture and microbiological swab to determine organism
65
Q

Management of orbital cellulitis

A
  • Admit for IV antibiotics (ceftriaxone with flucloxacillin and metronidazole)
  • May require surgical drainage if abscess forms
66
Q

Complications of orbital cellulitis

A
  • Blindness
  • Intracranial abscesses
67
Q

What is episcleritis

A

Acute onset of inflammation in the episcleral of one or both eyes, idiopathic collagen vascular disorder

68
Q

Associations of episcleritis

A
  • IBD
  • Rheumatoid arthritis
69
Q

Presentation of episcleritis

A
  • Painless red eye
  • Watering and mild photophobia
  • Injected vessels are mobile when gentle pressure applied to sclera
70
Q

Investigation for episcleritis

A

Phenylephrine drops  blanches conjunctival and episcleral vessels but not scleral

71
Q

Management of episcleritis

A
  • Conservative – self-limiting
  • Artificial tears
72
Q

Risk factors for scleritis

A
  • Rheumatoid arthritis
  • SLE
  • Sarcoidosis
  • Granulomatosis with polyangiitis
  • Zoster
  • Post-operative
73
Q

Presentation for scleritis

A
  • Red painful eye  severe dull deep ache
  • Watering
  • Photophobia
  • Gradual decrease in vision
  • Blue sclera
74
Q

Investigation for scleritis

A

Phenylephrine application

75
Q

Management of scleritis

A
  • Same day assessment by ophthalmologist
  • Oral NSAIDs
  • Oral prednisolone
  • Immunosuppressive drugs for resistant cases
76
Q

What is diabetic retinopathy

A

Blood vessels in retina are damaged by prolonged exposure to hyperglycaemia

77
Q

Presentation of diabetic retinopathy

A

Asymptomatic vision loss

78
Q

Classification of diabetic retinopathy

A
  • Non-proliferative diabetic retinopathy
    o Mild  microaneurysms
    o Moderate  microaneurysms, blot haemorrhages, hard exudates, cotton wool spots and venous beading
    o Severe  blot haemorrhages plus microaneurysms in 4 quadrants, venous beading in 2 quadrates, intraretinal microvascular abnormality
  • Proliferative diabetic retinopathy
    o Retinal neovascularisation
    o Fibrous tissue forming anterior to retinal disc
    o Vitreous haemorrhage
  • Diabetic Maculopathy
    o Macular oedema
    o Ischaemic maculopathy
79
Q

Management of diabetic retinopathy

A
  • Maculopathy  VEGF inhibitors (ranibixumab, bevacizumab)
  • Non-proliferative  observe, close monitoring, careful diabetic control
  • Proliferative  panretinal laser photocoagulation, intravitreal VEGF inhibitors
  • Vitreoretinal surgery in severe disease
  • Macular oedema  intravitreal implant containing dexamethasone
  • Control BP/diabetes
80
Q

Complications of diabetic retinopathy

A
  • Retinal detachment
  • Vitreous haemorrhage
  • Rubeosis iridis  neovascular glaucoma
  • Optic neuropathy
  • Cataracts
  • Vision loss
81
Q

Risk factors for hypertensive retinopathy

A
  • Smoking
  • Hyperlipidaemia

Chronic/malignant hypertension

82
Q

Presentation of hypertensive retinopathy

A
  • Silver wiring/copper wiring  walls of arterioles become thickened and sclerosed causing increased reflection of light
  • Arteriovenous nipping  arterioles cause compression of veins where they cross
  • Cotton wool spots  ischaemic and infarction causing damage to nerve fibres
  • Hard exudates  damaged vessels leaking lipids into retina
  • Retinal haemorrhages
  • Papilloedema/disc swelling
83
Q

Classification of hypertensive retinopathy

A

Keither-Wagener
- Stage 1 – mild narrowing of arterioles
- Stage 2 – focal constriction of blood vessels ad AV nicking
- Stage 3 – cotton-wool patches, exudates and haemorrhages
- Stage 4 – papilloedema

84
Q

Risk factors for corneal ulcer

A
  • Contact lens use
  • Vitamin A deficiency
85
Q

Causes of corneal ulcer

A
  • Bacterial keratitis
  • Fungal keratitis
  • Viral keratitis  herpes simplex, herpes zoster
  • Acanthamoeba keratitis (associated with contact lens use
86
Q

Presentation of corneal ulcer

A
  • Eye pain
  • Photophobia
  • Watering of eye
  • Focal fluorescein staining of cornea
87
Q

Risk factors for central retinal artery occlusion

A
  • Older age
  • Family history
  • Smoking
  • Alcohol consumption
  • Hypertension
  • Diabetes
  • Poor diet
  • Inactivity
  • Obesity
88
Q

Causes of central retinal artery occlusion

A
  • Thromboembolism = atherosclerosis
  • Arteritis = temporal arteritis
89
Q

Presentation of central retinal artery occlusion

A
  • Sudden, painless unilateral visual loss
  • Relative afferent pupillary defect
  • Fundoscopy = ‘Cherry red’ spot on pale retina
90
Q

Management of central retinal artery occlusion

A
  • Refer immediately to ophthalmology
  • Immediate management
    o Ocular massage
    o Removing fluid from anterior chamber to reduce intraocular pressure
    o Inhaling carbogen to dilate artery
    o Sublingual isosorbide dinitrate
  • Treat underlying condition
    o Temporal arteritis  high dose prednisolone
  • Can try intraarterial thrombolysis
91
Q

Risk factors for central retinal vein occlusion

A
  • Hypertension
  • High cholesterol
  • Diabetes
  • Smoking
  • Glaucoma
  • Systemic inflammatory conditions  SLE
  • Increasing age
  • Polycythaemia
92
Q

Presentation of central retinal vein occlusion

A
  • Sudden painless loss of vision
  • Fundoscopy  flame and blot haemorrhages ‘stormy sunset’, optic disc oedema, macula oedema
93
Q

Investigations for central retinal vein occlusion

A
  • FBC  anaemia
  • ESR  inflammatory disorders
  • Blood pressure  hypertension
  • Serum glucose  diabetes
94
Q

Management of central retinal vein occlusion

A
  • Immediate referral to ophthalmology
  • Laser photocoagulation for retinal neovascularisation
  • Intravitreal steroids  dexamethasone intravitreal implant
  • Anti-VEGF therapies for macular oedema  ranibizumab, aflibercept or bevacizumab
95
Q

Complications of central retinal vein occlusion

A

Neovascularisation

96
Q

Causes of corneal abrasions

A
  • Trauma
  • Contact lenses
  • Foreign bodies
  • Fingernails
  • Eyelashes
  • Entropion
97
Q

Presentation of corneal abrasions

A
  • Painful red eye
  • Foreign body sensation
  • Watery eye
  • Blurring vision
  • Photophobia
98
Q

Investigations of corneal abrasions

A
  • Fluorescein stain
  • Slit lamp examination
  • XR/CT
99
Q

Management of corneal abrasions

A
  • Same-day assessment by ophthalmologist if potentially sight-threatening
  • Remove foreign bodies
  • Simple analgesia
  • Lubricating eye drops
  • Abx eye drops  chloramphenicol
  • Follow up after 24 hrs
  • Chemical abrasions  immediate irrigation for 20-30 mins and urgent referral to ophthalmology
  • Uncomplicated corneal abrasions heal over 2-3 days
100
Q

Complications of corneal abrasions

A
  • Pseudomonas infection from contact lens
  • Chemical abrasions  severe damage and loss of vision
101
Q

Types of cataracts

A
  • Nuclear (old age)
  • Cortical (wedge shaped spokes
  • Posterior subcapsular (steroid use)
102
Q

Risk factors for cataracts

A
  • Increasing age
  • Smoking
  • Alcohol
  • Diabetes
  • Steroids
  • Hypercalcaemia
  • Myotonic dystophy
103
Q

Presentation of cataracts

A
  • Asymmetrical
  • Very slow reduction in visual acuity
  • Progressive blurring of vision
  • Change of colour of vision with colours becoming more brown/yellow
  • ‘Starbursts’ can appear around lights, especially at night
  • Loss of red reflex
104
Q

Management of cataracts

A

Cataract surgery (phacoemulsification) – replace with artificial lens

105
Q

Complications of cataracts surgery

A
  • Endophthalmitis – inflammation of inner contents of eye
    o Tx: intravitreal Abx injected into eye
  • Posterior capsule opacification
    o Tx: YAG laser
  • Posterior capsule rupture
  • Retinal detachment
106
Q

What is a subconjunctival haemorrhage

A

Common condition where one of the small blood vessels within conjunctiva ruptures and release blood into space between sclera and conjunctiva

107
Q

Risk factors for subconjunctival haemorrhage

A
  • Hypertension
  • Bleeding disorders = thrombocytopenia
  • Whooping cough
  • Medications  warfarin, NOACs, antiplatelets
  • Non-accidental injury
108
Q

Causes of subconjunctival haemorrhage

A
  • Heavy coughing, sneezing
  • Weight lifting
  • Straining when constipated
  • Trauma to eye
109
Q

Presentation of subconjunctival haemorrhage

A
  • Patch of bright red blood underneath conjunctiva
  • Painless
  • Not affect vision
110
Q

Management of subconjunctival haemorrhage

A
  • Resolves spontaneously without Tx in around 2 weeks
  • Treat any underlying risk factors
  • Foreign body sensation  lubricating eye drops
111
Q

Causes of a dilated pupil (mydriasis)

A
  • Congenital
  • Stimulants (cocaine)
  • Anticholinergics (oxybutynin)
  • Trauma
  • Third nerve palsy
  • Holmes-Adle syndrome
  • Raised intracranial pressure
  • Acute angle-closure glaucoma
112
Q

Causes of a constricted pupil (miosis)

A
  • Horner syndrome
  • Cluster headaches
  • Argyll-Robertson pupil (neurosyphilis)
  • Opiates
  • Nicotine
  • Pilocarpine

Finals (23 decks)

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