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Opthalmology 👁 Flashcards

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1
Q

What is diabetic retinopathy?

A

A microvascular complication of diabetes, caused by hyperglycaemia-induced damage to the retinal blood vessels

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2
Q

What are the 3 stages of diabetic retinopathy?

A

Background retinopathy - microaneurysms develop in the retinal blood vessels

Pre-proliferative retinopathy - widespread changes including flame haemorrhages and cotton wool spots

Proliferative retinopathy - scar tissue and new blood vessels form, risk of retinal detachment

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3
Q

What are the risk factors for diabetic retinopathy?

A

Poor glycaemic control
Length of diabetes diagnosis
Hypertension
Renal dysfunction
Pregnancy
Dyslipidaemia

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4
Q

What is the pathophysiology of diabetic retinopathy?

A

Hyperglycaemia damages the retinal small vessels and endothelial cells

Increased vascular permeability leads to leaking blood vessels, blot haemorrhages and hard exudates

Damage to blood vessel walls leads to microaneurysm and venous bleeding

Damage to nerve fibres in the retina causes fluffy white patches called cotton wool spots

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5
Q

What are the symptoms of diabetic retinopathy?

A

May be asymptomatic
Blurred vision
Loss of colour vision
Floaters
Sudden vision loss

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6
Q

What will be seen on fundoscopy in diabetic retinopathy?

A

Microaneurysms
Dot and blot haemorrhages
Hard exudates
Cotton wool spots
Neovascularisation

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7
Q

What are the investigations used in diagnosis of diabetic retinopathy?

A

Ophthalmoscopy
Optical coherence tomography
Fluorescein angiography

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8
Q

What are the complications of diabetic retinopathy?

A

Vision loss
Retinal detachment
Vitreous haemorrhage
Rubeosis iridis
Optic neuropathy
Cataracts

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9
Q

What is the management of diabetic retinopathy?

A

Diabetic control
Lifestyle modifications

For proliferative disease:
- Pan-retinal photocoagulation - extensive laser treatment across the retina
- Anti-VEGF agents - used to reduce macular oedema and neocascularisation
- Steroid injections
- Vitrectomy

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10
Q

What is glaucoma?

A

Damage to the optic nerve caused by a rise in intraocular pressure

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11
Q

Where is aqueous humour produced by?

A

The ciliary bodies

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12
Q

Where does aqueous humour drain out of the anterior chamber?

A

Through to the trabecular meshwork to the canal of Schlemm, which is located at the angle between the cornea and the iris

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13
Q

What is the pathphysiology of open-angle glaucoma?

A

There is a gradual increase in resistance to flow through the trabecular meshwork

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14
Q

What is the pathophysiology of acute angle closure glaucoma?

A

The iris bulges forwards and seals off the trabecular meshwork from the anterior chamber, preventing aqueous humour from draining

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15
Q

What are the risk factors for open angle glaucoma?

A

Increasing age
Family history
Black ethnic origin
Myopia
Hypertension
Cardiovascular disease
Diabetes
Corticosteroid use

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16
Q

What is the onset of primary open angle glaucoma?

A

Chronic and progressive

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17
Q

What is the presentation of primary open angle glaucoma?

A

May be asymptomatic
Peripheral vision loss
Fluctuating pain
Headaches
Blurred vision
Halos around lights

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18
Q

How is intraocular pressure measured?

A

Non-contact tonometry - involved shooting a puff of air at the cornea and measuring the corneal reponse

Goldmann applanation tonometry - involves a device mounted on a slip lamp that makes contact with the cornea and applies various pressures

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19
Q

What investigations are used in the diagnosis of glaucoma?

A

Goldmann applanation tonometry
Slit lamp assessment
Visual field assessment
Gonioscopy (diagnostic) - assess angle between iris and cornea
Central corneal thickness assessment

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20
Q

What is the first line management of primary open angle glaucoma?

A

Topical prostaglandin analgoue (latanoprost) or prostamide
Topical beta blocker (timolol)

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21
Q

What are the second line management options of primary open angle glaucoma?

A

Combine a topical prostaglandin analogue or prostamide with a topical beta blocker

Switch to or add in a second line drug:
- Topical sympathomimetic
- Topical carbonic anhydrase inhibitor
- Topical miotic

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22
Q

What is the management of refractory primary open angle glaucoma?

A

Laser therapy - selective laser trabeculoplasty or argon laser trabeculoplasty
Surgery - trabeculectomy to form a new outflow channel

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23
Q

What are the risk factors for acute angle closure glaucoma?

A

Increasing age
Female
East Asian ethnicity
Hypermetropia
Mydriatic drugs

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24
Q

What types of medications can precipitate acute angle-closure glaucoma?

A

Adrenergic medications e.g noradrenaline
Anticholingeric medications e.g oxybutynin and solifenacin
Tricyclic antidepressants e.g amitriptyline

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25
What is the presentation of acute angle closure glaucoma?
Severely painful red eye Blurred vision Halos around lights Associated headache, nausea and vomiting
26
What are the signs of acute angle closure glaucoma on examination?
Red eye Hazy cornea Decreased visual acuity Mid-dilated pupil Fixed-size pupil Hard eyeball on gentle palpation
27
What are the primary investigations for diagnosis of acute angle closure glaucoma?
Slit-lamp examination - Shallow anterior chamber - Optic disc cupping - Optic disc pallor Gonioscopy Tonometry
28
What is the initial management of acute angle closure glaucoma?
Lie the patient flat Analgesia and anti-emetics Carbonic anhydrase inhibitor - acetazolamide Topical beta blocker - timolol Topical alpha-2-agonist - brimonidine Topical cholinergic - pilocarpine
29
What is the definitive management of acute angle closure glaucoma?
Iridotomy - a hole is made in the iris, allowing aqueous humour to enter the anterior chamber without passing through the pupil This relieves the pressure pushing the iris forward against the cornea, and opens the pathway for aqueous humour to drain
30
What is scleritis?
Scleritis is inflammation of the sclera, the outer layer of connective tissue surrounding the eye - the white part
31
What is episcleritis?
Inflammation of the episclera - the clear layer on top of the white sclera
32
What conditions are associated with scleritis?
Autoimmune diseases - Rheumatoid arthritis - SLE - IBD - Vasculitis
33
What are the risk factors for scleritis?
Female Autoimmune disease Trauma Ocular surgery Ocular infection
34
What is the presentation of scleritis?
Red, inflamed sclera Congested vessels Severe pain Pain with eye movement Photophobia Excessive tear production Reduced visual acuity
35
What are the differences between scleritis and episcleritis?
Scleritis - More severe pain - Deep inflamed vessels rather than superficial - Vessels do not blanch to topical phenylephrine - Vessels are immobile via cotton tipped applicator
36
What investigations are used in the diagnosis of scleritis?
Bloods - FBC, U&E, LFTs, bone profie ESR and CRP Autoimmune screen B scan ultrasonogrpahy of the globe
37
What is the first line management of scleritis?
NSAIDs Corticosteroids - topical, oral or IV
38
What is the management of refractory scleritis?
DMARDs Biological agents e.g infliximab Surgical intervention
39
What is the management of episcleritis?
Usually self-limiting - Analgesia - Lubricating eye drops
40
What is conjunctivitis?
Inflammation of the conjunctiva - the thin layer of tissue that covers the inside of the eyelids and the sclera
41
What are the common bacterial causes of conjunctivitis?
Staphylococcus aureus Haemophilus influenzae Streptococcus pneumoniae Chlamydia and neisseria gonorrhoeae
42
What are the common viral causes of conjunctivitis?
Adenovirus Coxsackie Enterovirus Herpes simplex
43
What are the symptoms of conjunctivitis?
Itchiness in one or both eyes Conjunctival injection Gritty sensation Discharge - Purulent in bacterial infection - Watery in viral and allergic conjunctivitis Tearing Difficulty opening eyes in the morning - bacterial conjunctivitis
44
What are the differentials for an acute painful red eye?
Acute angle-closure glaucoma Anterior uveitis Scleritis Corneal abrasions Keratitis Foreign body Traumatic or chemical injury
45
What are the differentials of an acute painless red eye?
Conjunctivitis Episcleritis Subconjunctival haemorrhage
46
What is the first line management of conjunctivitis?
Watch and wait Practice good hygeine No exclusion period from school, nursery or childminder Artificial tears - over the counter eye drops
47
What is the second line management of conjunctivitis?
Topical antibiotics - Chloramphenicol 0.5% eye drops - Chloramphenicol 1% ointment
48
What is central retinal artery occlusion?
The sudden blockage of the central retinal artery, obstructing blood flow to the eye
49
What are the causes of central retinal artery occlusion?
Most commonly caused by an embolism, but can be caused by arteritis
50
Where does the central retinal artery supply?
It supplies blood to the optic nerve, and the inner two thirds of the retina
51
What are the risk factors for central retinal artery occlusion?
Cardiovascular disease Diabetes Hypertension Older age Female Polymyalgia rheumatica Carotid artery stenosis
52
What is the presentation of central retinal artery occlusion?
Sudden painless loss of vision Reduced visual acuity Afferent pupillary defect Pale retina Cherry red spot on fundoscopy
53
What investigations may be useful alongside a clinical diagnosis of central retinal artery occlusion?
ESR/CRP - investigate for underlying temporal arteritis Vasculitis screening Coagulation screen HbA1c/lipid profile
54
What is the initial management of central retinal artery occlusion?
Reperfusion therapy - Pentoxifylline or hyperbaric oxygen Reduction in intraocular pressure - Acetazolomide or mannitol IV steroids Thrombolytic therapy
55
What is the long term management of central retinal artery occlusion?
Reduction in cardiovascular risk DVLA notification if there is complete loss of vision in one eye
56
What is blepharitis?
Inflammation of the eyelid margins
57
What are the causes of blepharitis?
Meibomian gland dysfunction Seborrhoeic dermatitis Staphylococcal infection
58
What is the presentation of blepharitis?
Bilateral symptoms Grittiness and discomfort Sticky eyes in the morning Eyelid margins may be red Styes and chalazions Secondary conjunctivitis
59
What is the management of blepharitis?
Hot compresses twice a day Mechanical removal of debris from lid margins Artificial tears
60
What is periorbital cellulitis?
An eyelid and skin infection in front of the orbital septum
61
What is the investigation of periorbital cellulitis?
Urgent ophthalmology referral for assessment to distinguish from orbital cellulitis CT scan is performed
62
What is the treatment of periorbital cellulitis?
Oral antibiotics - usually co-amoxiclav
63
What is orbital cellulitis?
Infection of the tissues contained within the orbital cavity (behind the orbital septum)
64
What is orbital cellulitis most commonly caused by?
Streptococcal and staphylococcal species
65
How does orbital cellulitis develop?
Infection can be spread from: - Peri-orbit - URT - Sinuses - Lacrimal sac
66
What are the risk factors for orbital cellulitis?
Young age URTI Sinusitis Trauma Immunosuppression Lack of HiB vaccine Periorbital cellulitis Ear infection
67
What is the presentation of orbital cellulitis?
Swelling and redness of eyelids Pain on ocular movement Diplopia Fever Proptosis Reduced visual acuity Ptosis Chemosis
68
What are the differentials of orbital cellulitis?
Periorbital cellulitis Cavernous sinus thrombosis Acute blepharitis
69
How is orbital cellulitis differentiated from periorbital cellulitis?
The following features are not seen in periorbital cellulitis: - Reduced visual acuity - Proptosis - Ophthalmoplegia with eye movements
70
What investigations are used in the diagnosis of orbital cellulitis?
CT with contrast Blood cultures Microbiological swab VBG - assess for sepsis FBC CRP
71
What is the management of orbital cellulitis?
Admit to hospital IV antibiotics - Co-amoxiclav or ceftriaxone - Clindamycin + metronidazole if penicillin allergic Analgesia
72
What is the surgical management of orbital cellulitis?
Surgical drainage and sinus washout Lateral canthotomy - cutting the corner of the eye to relieve pressure
73
What is retinal detachment?
Where the inner neurosensory retina separates from the underlying retinal pigment epithelium
74
What is the pathophysiology of retinal detachment?
A retinal tear allows vitreous fluid to get under the neurosensory retina and fill the space between them
75
Why is sight threatened in retinal detachment?
The neurosensory retina relies on the blood vessels of the choroid for its blood supply - the choroid is attached to the retinal pigment epithelium
76
What are the risk factors for retinal detachment?
Lattice degeneration Posterior vitreous detachment Trauma Diabetic retinopathy Retinal malignancy Family history
77
What is the presentation of retinal detachment?
Dots, lines or haze Flashes Painless, progressive visual field loss Blurred vision Decreased visual acuity Relative afferent pupillary defect
78
What is a relative afferent pupillary defect?
Dilation of the pupil when light is rapidly moved from the unaffected to the affected eye
79
What is seen on fundoscopy in retinal detachment?
Asymmetric red reflex Vitreous opacities Detached retinal folds - appear pale, opaque and wrinkled
80
What investigations are used in the diagnosis of retinal detachment?
Slip lamp examination Fundoscopy B-scan ultrasonography
81
What is B-scan ultrasonography?
An ophthalmic ultrasound which allows visualisation of the posterior segment of the eye
82
How is the retina reattached?
Vitrectomy - Fixing the tear, removing the vitreous fluid and inserting gas/oil to hold the retina in place Scleral buckling - A 'buckle' is attached to the sclera, putting pressure on the sclera, and holding it in place Pneumatic retinoplexy - Injecting a gas bubble into the vitreous body and positioning the patient so the gas bubble pressues the separated layer back into place
83
What is macular degeneration?
Degeneration of the central retina (macula)
84
What are the risk factors for macular degeneration?
Advancing age Smoking Family history Female Cardiovascular disease Obesity
85
What is the presentation of macular degeneration?
Gradual loss of central vision Reduced visual acuity Crooked or wavy appearance to straight lines Difficulties in dark adaptation Photopsia - perception of flickering or flashing lights
86
What are the types of macular degeneration?
Dry macular degeneration - most common, characteristed by drusen Wet macular degeneration - characterised by neovascularisation of the choroid
87
What are drusen?
Drusen are yellow deposits of proteins and lipids between the retinal pigment epithelium and Bruch's membrane
88
What are the layers of the macula?
Choroid layer (at base) Bruch's membrane Retinal pigment epithelium Photoreceptors (towards surface)
89
What is the macula?
The macula is the central area of the retina, which generates high definition colour vision
90
What is the pathophysiology of wet macular degeneration?
New vessels develop from the choroid layer and grow into the retina. If the vessels leak fluid or blood, this can cause oedema and vision loss
91
What examination findings are associated with macular degeneration?
Reduced visual acuity Scotoma (enlarged central area of vision loss) Amsler grid test (to test for distortion of straight lines) Drusen seen on fundoscopy
92
What is the initial investigation of choice in macular degeneration?
Slit lamp testing
93
What is the management of dry macular degeneration?
No specific treatment - Avoiding smoking - Controlling blood pressure - Vitamin supplementationW
94
What is the treatment of wet macular degeneration?
Anti-VEGF medication (vascular endothelial growth factor), to prevent development of new blood vessels in the retina
95
What is keratitis?
Inflammation of the cornea
96
What are the pathogenic causes of keratitis?
Bacterial - Staphylococcus aureus most common - Pseudomonas aeruginosa seen in contact lens wearers Fungal Amoebic Parasitic Viral - Herpes simplex keratitis
97
What are the clinical features of keratitis?
Red eye Painful eye Photophobia Gritty sensation Hypopyon
98
What is hypopyon?
Where an accumulation of white blood cells form a whitish layer of fluid in the lower portion of the eye's anterior chamber
99
What is the most common cause of keratitis?
Herpes simplex keratitis
100
How is keratitis diagnosed?
Slit lamp examination Corneal scrapings for viral testing
101
What is seen on slit lamp examination in herpes simplex keratitis?
Fluorescein staining shows a dendritic corneal ulcer - there is a branching appearance of the ulcer
102
What is the management of bacterial keratitis?
Topical antibiotics - First line - quinolones e.g ciprofloxacin Stop using contact lens until symptoms are fully resolved
103
What is the management of herpes simplex keratitis?
Topical or oral antivirals - aciclovir or ganciclovir
104
What is anterior uveitis?
Inflammation of the anterior uvea (iris, ciliary body and choroid)
105
What are the causes of anterior uveitis?
Autoimmune processes - most common Infection Trauma Ischaemia Malignancy
106
What autoimmune diseases is anterior uveitis associated with?
Seronegative spondyloarthropathies - Ankylosing spondylitis - Psoriatic arthritis - Reactive arthritis IBD Sarcoidosis Behcet's disease
107
What is the presentation of anterior uvetitis?
Painful red eye Photophobia Lacrimation Blurred vision Reduced visual acuity
108
What findings on examination are indicative of anterior uveitis?
Ciliary flush - ring of red spreading from the cornea Miosis - constricted pupil Abnormally shaped pupil Hypopyon
109
What is the first line management of anterior uveitis?
Steroids - eye drops, oral or IV Cycloplegics - cyclopentolate or atropine eye drops
110
What are cycloplegics?
Cycloplegics dilate the pupil and reduce pain associated with ciliary spasm
111
What is the management of recurrent anterior uveitis?
Immunosuppressants - DMARDs or anti-TNF medications
112
What are the complications of anterior uveitis?
Visual loss Secondary cataracts Secondary glaucoma Retinal detachment Vitreous haemorrhage
113
What are cataracts?
A cataract is an opacity in the lens, caused by denaturation of the lens proteins, which reduces light entering the eye, and reduces visual acuity
114
What are the causes of cataracts?
Normal ageing process Smoking Alcohol Trauma Diabetes Corticosteroids UV exposure Previous eye surgery Radiation exposure
115
What is the presentation of cataracts?
Slow reduction in visual acuity Progressive blurring of vision Painless Haloes around lights Faded colour vision
116
What is the key examination finding in cataracts?
Loss of the red light reflex
117
What investigations are performed in suspected cataracts?
Ophthalmoscopy - normal fundus and optic nerve Slit-lamp examination - visible cataract
118
What is the definitive management of cataracts?
Surgery (pseudophakia) - involves removing the lens, and implanting an artificial lens
119
What are the complications of cataract surgery?
Posterior capsule opacification - thickening of the lens capsule Retinal detachment Posterior capsule rupture Endophthalmitis
120
What is endophthalmitis?
Inflammation of the inner contents of the eye (aqueous and/or vitreous humour)
121
What is the presentation of endophthalmitis?
Severe pain Loss of vision Redness Happens a few days following surgery
122
What is the treatment of endophthalmitis?
Intravitreal antibiotics
123
What are the risk factors for central retinal vein occlusion?
Hypertension Cardiovascular disease Glaucoma Polycythemia Smoking Obesity Diabetes
124
What is the clinical presentation of central retinal vein occlusion?
Sudden, painless loss of vision
125
What is seen on fundoscopy in central retinal vein occlusion?
Flame haemorrhages Dot and blot haemorrhages Retinal oedema Cotton wool spots Dilated or tortuous retinal veins
126
What are the differentials of central retinal vein occlusion?
Diabetic retinopathy Hypertensive retinopathy Central retinal artery occlusion Retinal detachment
127
What is the management of central retinal vein occlusion?
Laser photocoagulation of retinal neovascularisation anti-VEF injections for macular oedema
128
What are the complications of central retinal vein occlusion?
Neovascularisation Vitreous haemorrhage Hyphaema (bleeding in the anterior chamber)
129
What is hypertensive retinopathy?
Hypertension causes damage to the retina through arteriolar vasoconstriction and leakage
130
What is the presentation of hypertensive retinopathy?
Blurred vision Sudden vision loss Floaters in the visual field
131
What is seen on fundoscopy in severe hypertensive retinopathy?
Cotton-wool spots Retinal haemorrhages A 'macular star' Papilloedema
132
What are the stages of hypertensive retinopathy?
1 - arteriolar narrowing and tortuosity 2 - arteriovenous nipping 3 - cotton wool exudates and blot haemorrhages 4 - papilloedema
133
What is a 'macular star'?
Where flame and blot haemorrhages collect around the fovea
134
What are the differentials of hypertensive retinopathy?
Diabetic retinopathy Retinal vein occlusion Age-related macular degeneration
135
What investigations can be used in the diagnosis of hypertensive retinopathy?
Fundoscopy Fluorescein angiography OCT
136
What is the management of hypertensive retinopathy?
For neovascularisation: Laser photocoagulation vEGF inhibitors
137
What is retinitis pigmentosa?
An inherited disorder that causes progressive visual loss and night blindness due to degeneration of the rod cells
138
What are the inheritance patterns of retinitis pigmentosa?
Autosomal dominant Autosomal recessive X-linked
139
What is the presentation of retinitis pigmentosa?
Tunnel vision - damage to peripheral retina Reduced visual acuity in dim light Difficulty adapting to low light conditions Loss of central vision comes later
140
What is seen on fundoscopy in retinitis pigmentosa?
Peripheral bone-spicule pigmentation Optic disc pallor Retinal vessel attenuation
141
What is the management of retinitis pigmentosa?
Visual aids Vitamin A supplementation Genetic counselling
142
What is vitreous haemorrhage?
The presence of blood within the vitreous humour
143
What is the vitreous humour?
The transparent gel-like substance that fills the posterior segment of the eye
144
What is the main cause of vitreous haemorrhage?
Proliferative diabetic retinopathy
145
What are the other causes of vitreous haemorrhage?
Retinal tears Retinal detachment Ocular trauma Age related macular degeneration Retinal vein occlusion
146
What is the presentation of vitreous haemorrhage?
Painless loss of vision Blurred vision Floaters Loss of visual acuity
147
What are the differentials of vitreous haemorrhage?
Retinal detachment Retinal tear Retinal vein occlusion Macular degeneration
148
What investigations are used in the diagnosis of vitreous haemorrhage?
Fundoscopy Slit-lamp examination OCT Fluorescein angiography B-scan ultrasonography
149
What is the management of vitreous haemorrhage?
Conservative management Treatment of underlying cause Vitrectomy
150
What is posterior vitreous detachment?
When the vitreous body comes away from the retina
151
What is the presentation of posterior vitreous detachment?
Floaters Flashing lights Blurred vision
152
What is the management of posterior vitreous detachment?
No treatment required - over time, symptoms will improve on their own
153
What are the two most important differentials to exclude?
Retinal tear Retinal detachment
154
What is optic neuritis?
Inflammatory condition of the optic nerve, causing acute painful visual loss
155
What condition is optic neuritis associated with?
Multiple sclerosis
156
What is the presentation of optic neuritis?
Acute painful visual loss Poor discrimination of colours Pain worse on eye movement Relative afferent pupillary defect Central scotoma
157
What investigation is diagnostic of optic neuritis?
MRI brain and orbits with contrast
158
What is the first line management of optic neuritis?
IV methylprednisolone
159
What is a corneal abrasion?
A defect in the corneal epithelium, typically due to trauma
160
What are the features of corneal abrasion?
Eye pain Lacrimation Photophobia Foreign body sensation Conjunctival injection
161
What investigations are used in the diagnosis of corneal abrasion?
Fluorescein staining
162
What is the management of corneal abrasion?
Topical antibiotic - prevention of secondary bacterial infection

Finals 🩺 (28 decks)

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