Opthalmology Flashcards
(254 cards)
1
Q
Why do people with diabetic retinopathy go blind?
A
Maculopathy
New vessels
2
Q
Flame haemorrhages occur with with?
A
Hypertension
Occlusion to vessels
3
Q
Why do cotton wool spots form?
A
Ischaemia causes a stagnation of axoplasm (the cytoplasm within axons) leading to build up of debris
4
Q
Pathology of age-related macular degeneration?
A
Retinal pigment epithelium damage leading to death of photoreceptors (dry) or new vessel formation (wet).
RPE acts as a supporting cell to the photoreceptors
5
Q
How do symptoms differ between partial and total retinal detachment?
A
Partial = flashes of light (due to traction) Total = complete loss of light sensitivity
6
Q
What lifestyle choice in particular antagonise thyroid eye disease?
A
Smoking
7
Q
What’s the difference between proptosis and exopthalmus
A
proptosis- protrusion of eye for any reason
exopthalmus- protrusion of eye specifically for thyroid eye disease
8
Q
Anterior uveitis is associated with which rheum condition?
A
Ankylosing spondylitis (HLA-B27) + Behcet’s, Crohns + Reiters
9
Q
How can anterior uveitis be treated?
A
Cyclopentolate- dilates pupil to stop iris becoming adhesive to the sclera.
Prednisolone drops
10
Q
Bilateral anterior uveitis is indicative of?
A
Sarcoid
11
Q
What’s the commonest orbital tumour in the over 50s?
A
Lymphoma
12
Q
Long term steroids causes what eye problem?
A
Cataracts
13
Q
Ethambutol for TB causes what eye problem if suceptible?
A
Optic nerve damage
14
Q
Indomethacin (NSAID) causes what eye problem?
A
Corneal deposits
15
Q
Marfan’s is associated with which eye problems?
Name 3
A
Myopa
Lens dislocation
Retinal detachment
16
Q
Blue sclera is typical of?
A
Osteogenesis imperfecta
brittle bones
17
Q
What are the levels of diabetic retinopathy?
A
Level 0- none
Level 1- background retinopathy
Level 2- pre-proliferative
Level 3- proliferative
18
Q
Term used to describe when the eyelids turn in or out?
A
Entropion turning in- lid curling in causes lashes to irritate the eye
Ectropion turning out- eyes dry out as lids don’t shut properly
19
Q
Orbicularis oculi is supplied by which nerve?
A
Seventh
20
Q
If a patient can’t close the eye and the eye is not rolling backwards when they try to shut their eye, what can you use as a short term measure for a few months until hopefully the seventh nerve palsy has recovered?
A
Botox injections into the antagonist muscles to cause constant closure
21
Q
If can’t open eye, what else should you check for?
A
Pupil dilation- posterior communicating artery aneurysm (parasympathetic knockout)
If not dilated- diabetic? Giant cell arteritis? Etc
Eye looking down and out?
22
Q
If suspect a fracture of orbital floor what can you test for?
A
Sensation In cheek as the infraorbital nerve goes through the infraorbital foramen below the eye
23
Q
If the floor of the orbit is fractured going into the maxillary sinus, what should patients avoid doing?
A
Blowing their nose as air goes into the maxillary sinus and into the orbit via the communication through the orbital floor, will increase pressure leading to ischaemia and blindness. For about two weeks avoid
If persisting double vision, may have caught inferior muscle in the fracture but leave time for bruising to resolve.
24
Q
Why is the limbus of the eye important and what is its function?
A
The limbus is where the sclera meets the conjunctiva on the cornea (in front of the iris edge), it contains epithelial stem cells that are produced to replace the cornea in concentric layers
If damaged, need a corneal transplant or stem cell transplant
25
How can fluoroscene help you to identify where on the eye is a foreign body?
Dye that shows disruption of the epithelium, if there are linear scratch marks means the body is embedded on inner eyelid (may not be able to see the foreign body in eye)
26
Why does the cornea look cloudy and lose its transparency in acute closed-angle glaucoma?
What is the explanation of other glaucoma signs?
The na-k atpase transporter is in the inner most endothelium layer of the corneal conjunctiva and if Ischaemic don't remove water out so cornea gets too hydrated and loses transparency.
Fixed mid dilated pupil as iris sphincter is ischaemic
Severe pain due to increased pressure
27
When does acute closed-angle glaucoma typically occur?
At night when the iris contracts towards the angle as it dilates closing an already narrow angle
28
What is the definition of glaucoma?
Progressive optic neuropathy with corresponding visual field loss
29
How can anterior uveitis affect iris appearance?
May cause irregular shape, if inflammation causes pupil margin to become to stuck down to the conjunctiva in front of it.
They may complain of poor vision at night if Iris can't dilate.
Can see better by dilating the eye to see where it is unable to dilate (because stuck down)
30
What is the pathology of age related macular degeneration (dry)
Atrophy of the retinal pigment epithelium leads to deposits of photoreceptor debris causing drusen spots.
31
What causes cupping- large cup to disc ratio?
Glaucoma
Giant cell arteritis (may get recurrent unilateral amaroux fugax and temporal headache, jaw claudication)
Optic nerve atrophy
32
What might you feel in the temporal artery for someone with giant cell arteritis?
Why treat if temporal artery biopsy comes back normal?
Pulseless temporal artery (if occluded)
Or tender thickened artery
Can get skip lesions
33
70 year old man with low vision in right eye yesterday, short sighted
Whats differential?
Note no pain and unilateral so
Central retinal vein occlusion
Wet age-related macula degeneration (especially if bleed)
Ischaemic optic neuropathy- atherosclerotic
34
What visual problems are associated with advanced diabetic retinopathy?
Vitreous haemorrhage
| Retinal detachment
35
If lost vision in one eye and on testing acuity it improves with the pinhole, what does that narrow down the diagnoses to?
Corneal or lens problems, like cataracts even
36
What pathology does a relative afferent pupillary defect suggest?
Damage to the optic nerve (afferent pathway) or damage to the retina (so signal from that eye suggests less light coming in compared to signal from other eye)
37
Look in an eye and see flame haemorrhages (linear shape rather than blobs) and hyperaemic swollen disc. How do you differentiate between diabetic retinopathy and central retinal vein occlusion?
Unilateral or bilateral?
38
Typical glaucoma follows the isnt rule, what does this mean?
Inferior fibres affected first- loose superior vision first
Then superior fibres
Nasal
Temporal fibres- from macula thus central vision lost last
39
What symptoms differentiate conjunctivitis from uveitis?
Conjunctivitis suggests discharge (unless viral)
| Uveitis associated with photophobia
40
How do you distinguish between episcleritis and scleritis?
In Episcleritis when you apply vasoconstrictor drops the vessels blanch as they are more superficial, whereas in scleritis the vessels are deeper so less likely to blanch
41
What infectious condition of the eye gets much worse when steroids are given?
Herpes simplex, from a dendritic ulcer may become extensive
42
If a foreign body penetrates through the cornea what imaging do you need?
you need a CT to see if its in the retina
43
What type of chemical burns are worse in the eye and why?
Alkaline because it causes drying of the conjunctiva and lower lid which enables the proteins in different layers to stick together causing adhesion
44
A whole class of kids have got a red sticky eye, what might be the cause?
Adenovirus
45
In which patients would you avoid dilating their eyes in eye clinic?
Closed-angle glaucoma (?)
46
Bilateral 'panda eyes' after a trauma with subconjunctival haemorrhages and ecchymosis (extending into eyelids), what needs to be excluded and how?
Basal skull fracture
| Ct scan
47
A patient complains of diplopia, how can you determine which eye is malfunctioning?
Getting them to do the movement provoking most diplopia, cover each eye in turn. The eye on which the outer-most image is seen is malfunctioning.
48
What are common causes of a loss of the red reflex in the eye?
Dense cataracts
| Intraocular bleeding
49
What are the different kinds of inflamed lid swellings called?
Marginal cyst- non-infected cyst of Zeis or Moll glands
Hordeolum externum- infected lash follicle ± glands
Hordeolum internum- infected meibomiam gland
Chalazion- residue swelling of old hord. Internum
What do the glands produce
Zeis = sebum, Moll = sweat, Meibomiam = lipid of tear film
50
Causes of blepharitis (lid inflammation)
Staphs
Seborrhoeic dermatitis
Rosacea
51
Rx of blepharitis?
Fusidic acid (local antibiotic) or doxycycline PO
Clean crusts of skin scales off lashes
Steroid drops
52
Patient has photophobia and watering of the eyes, no meningism. What IHx and what Rx should be avoided?
Dendritic ulcer due to herpes simplex.
IHx: 1% fluorescein drops
Steroids without aciclovir cover may cause corneal invasion, scarring and blindness.
Rx: Aciclovir
53
Baby is 8months old, mother reports she has persistently watery eyes and keeps getting conjunctivitis, what could be the cause?
Nasolacrimal duct non-canalization
May not open until 1 year, if fails to canalize can be probed under GA
54
Elderly chap has a swollen lump medial of his eye and pus in his eye. What would you be most worried about?
If a squamous cell cancer was blocking the lacrimal drainage system leading to accumulation and then infection in the lacrimal duct
55
Which nerve innervates the lacrimal gland for tear production?
Parasympathetics of trigeminal nerve
56
Common causes of orbital cellulitis?
Staphs
Strep pneumoniae
Strep pyogenes
Strep milleri
57
Causes of dry eye
Reduced tear production:
Old age
Sjögrens
Infiltration- sarcoid, amyloid, leukaemia, haemachromatosis
Increased evaporation: post-exposure keratitis
Mucin deficiency- Steven Johnson syndrome, pemphigoid
58
Rx to confirm dry eye?
Schirmer's test
| Strip of filter paper on lower lid, tears should soak >15mm in 5 mins otherwise there's reduced production
59
Patient has red eye with engorged vessels and exopthalmous that may be pulsatile. What is the diagnosis and Rx?
Carotico-cavernous fistula
Carotid vessel opens into the venous cavernous sinus, sometimes following aneurysm rupture.
Can try ligating or embolising the artery
60
Which nerve is involved in ophthalmic shingles?
| What is the cause?
Ophthalmic branch of the trigeminal nerve (V1)
Herpes zoster
61
What can you look for in ophthalmic shingles that suggests the eye is involved as well as the skin around it?
Hutchison's sign:
| If nose tip is involved it means the nasociliary branch of trigeminal is involved (which also supplies the globe)
62
Inheritance of hereditary retinoblastoma?
Autosomal dominant
63
All the cranial nerve palsies controlling eye movements can be due to vasculopathy or tumours, what are the specific concerning causes distinct to each one?
Oculomotor- posterior communicating artery aneurysm
Trochlear- congenital trauma
Abducens- raised intracranial pressure (nerve compressed at edge petrous temporal cone)
64
Name the cranial nerve responsible:
Diplopia going down stairs
Diplopia when looking to side
Eye looks down and out
And muscles paralysed
Downward gaze- CN IV (superior oblique)
Sideways gaze- CN VI (lateral rectus)
Medial + Up- CN III (med + inf rectus, inf oblique)
65
Patient has one eye looking down and out, how does pupil changes indicate likely cause of third nerve palsy?
Fixed dilated pupil as parasympathetics of CN III goes to pupillary sphincter
Pupil involvement suggests compression from tumour etc as fibres are carried peripherally in nerve
Pupil spared suggests vascular cause (diabetes, hypertension)
66
What pattern do you see in covering up one eye in convergent and divergent squints?
When won't this test work?
In convergent squint, covering up dominant eye causes iris to move laterally to the middle.
In divergent squint, on covering the lazy eye moves inward towards the middle
Won't work if the fovea can't fixate, so the deviating eye won't move.
67
What nerves control pupil size?
Efferent
Constriction- parasympathetics via CN III + then short ciliary nerve > sphincter pupillae
Dilatation- sympathetics around ophthalmic artery or with the nasociliary nerve
68
What is a Marcus Gunn pupil?
| What causes it?
Pupil has relative afferent pupillary defect
Lack of afferent feedback from CN II- optic neuritis, optic atrophy, retinal disease
69
Causes of a fixed dilated pupil
CN III lesion (carried parasymp):
Cavernous sinus lesion, superior orbital fissure syndrome, diabetes, posterior communicating artery aneurysm
Mydriatrics (eye drops)
Trauma- blow to iris
Acute glaucoma
Coning- uncal herniation of temporal lobes
70
```
Name that syndrome:
Tonic pupil
Dilated
Doesn't really respond to light
Slowly constricts for accommodation
```
Absent ankle/knee jerks
Hypotension
Holmes-Adie syndrome
Often in young women who complain of blurred near vision
71
Ptosis, miosis and anhydrosis suggests....
Where is the lesion site?
Horner's syndrome
(Interruption of sympathetic chain)
Anhydrosis = lesion proximal to carotid plexus
Sweat fibres diverge at this point
72
Child is noted to have ptosis, miosis (constricted pupil) and anhydrosis. What sign would further suggest congenital Horner's?
Iris heterochromia- part of the iris as a different colour
73
Patient has horner's syndrome (miosis, ptosis, anhydrosis)
| What causes would you be considering?
In order of it's route:
Stroke- posterior inferior cerebellar a or basilar
Hypothalamic lesion
Pancoast's tumour
Klumpke's palsy
Cervical adenopathy
Cavernous sinus thrombosis
MS
74
What is the only feature you need for mild non-proliferative diabetic retinopathy?
1+ microaneurysms
| Occurs as high sugar= high blood flow =damage to endothelium and pericytes =aneurysm
75
What features characterise moderate non-proliferative diabetic retinopathy, not present in the mild form?
Blot haemorrhages
Cotton wool spots
Venous beading
Intraretinal microvascular abnormalities (dilated small vessels)
76
How does severe non-proliferative diabetic retinopathy differ from moderate?
Both involve blot haemorrhages, in severe = in all 4 quadrants
Both have venous beading, in severe= in 2 quadrants
Intraretinal microvascular abnormalities worse
77
What forms of eye disease are commoner in type 1 and type 2 diabetes?
Proliferative and pre-proliferative = type 1
| Maculopathy = type 2 (other vascular risk factors?)
78
Bilateral constricted pupil
No response to light
Constricts to accommodation
Poor dilation
Argyll Robertson pupil
Neurosyphilis + diabetes
79
Difference in presentation of Holmes-Adie pupil and Argyll Robertson pupil?
Holmes-Adie is dilated and lack of response to light, with slow response to accommodation
Argyll Robertson is constricted and lack of response to light with accommodation intact
(Neurosyphilis, diabetes)
80
How is pathological myopia defined and what are the risks?
More than 6 dioptres out
| Lengthened eye may stretch retina causing retinal detachment and retinal atrophy etc
81
Testing visual fields, the patient has an upper quadrantanopia, where is the likely site of the lesion?
Temporal lobe lesions as the optic radiation heads to the visual cortex.
82
A lesion at the tip of the occipital lobe would cause what kind of visual field defect?
Homonymous hemianopic scotoma with macular sparing
83
Why is acuity preserved in occlusion of the posterior cerebral artery?
The middle cerebra artery also supplies central areas
84
Patient has a very painful red eye and cloudy corneal. Rx?
Pilocarpine- activates parasympathetics muscarinic agonist For constriction
Acetazolamide- Carbonic anhydrase i, reduces aqueous formation
IV mannitol- in emergency to draw fluid out
Topical steroids, b-blockers, a-agonists, prostaglandin analogues
85
What conditions are associated with anterior uveitis
```
Ank spond
Behcet's
Crohns/UC
Dem infectious diseases- herpes, HIV, syphilis, TB
Reiters- arthritis after GU infections
```
86
Rx for anterior uveitis?
Prednisolone drops to reduce inflammation
| Cyclopentolate to keep iris dilated and prevent adhesions
87
Episcleritis is associated with:
```
Rheumatic fever (group b strep)
Polyarteritis nodosa (PAN)
SLE
```
Tends to be commoner than scleritis and segmental often
88
What types of things can cause corneal ulcers?
```
Bacteria- many, pseudomonas progresses fast
Viral- herpes simplez or zoster
Fungal- candida, aspergillus
Protozoal- acanthamoeba
Vasculitis- rheumatoid arthritis
```
89
Management of corneal ulcers until organism is known?
```
Alternate:
Chloramphenicol drops (gram +ve)
Ofloxacin drops (gram -ve fluoroquinolone)
```
Admit if immunosuppressed or diabetic
(Herpes dendritic ulcers, give Aciclovir ointment)
90
How can you differentiate episcleritis and scleritis on examination?
10% phenylephrine or pressure with a cotton bud causes blanching of vessels in episcleritis, but not in scleritis where vessels are deeper
```
Episcleritis = common, benign, dull ache
Scleritis = rare, serious, acuity may be affected
```
91
Difference in Rx between episcleritis and scleritis?
Episcleritis- topical or systemic NSAIDs
| Scleritis- oral steroids, ciprofloxacin or topical vancomycin drops
92
Rx for allergic conjunctivitis?
Antihistamine drops
Sodium cromoglicate
Steroid drops
93
70 year old lady with sudden vision loss and a headache, what test would you do, what are you worried about?
ESR
| Giant cell arteritis
94
Sudden painless loss of vision, what 5 questions help with a differential?
HELLP
Headache? Giant cell arteritis
Eye movements hurt? Optic neuritis
Lights/flashes before visual loss? Detached retina
Like a curtain descending? Amaurosis fugax- emboli or GCA
Poorly controlled diabetes?
95
What is the pathogenesis of Anterior Ischaemic Optic Neuropathy?
Vessel involved?
Arteritic- giant cell arteritis
Atherosclerotic- vasculopath
Posterior ciliary artery blockage leads to ischaemia of the optic disc (pale/swollen)
96
Patient has sudden painless vision in her eye, she has noticed pain in her jaw on eating. ESR is 50
Further tests + Rx?
Take temporal artery biopsy
| Prednisolone 80mg OD
97
If a vitreous haemorrhage is large enough to cause loss of vision what other signs will be present?
Loss of the red reflex
| Retina may not be seen
98
25 year old female has noticed a change in her colour vision, red's appear less red and her eye movements hurt
EHx is normal. What is the diagnosis?
+ cause?
Optic neuritis
MS
syphilis, devic's demyelination (anti-aquaporin 4 Abs), leber's optic atrophy, diabetes, vitamin deficiency
99
Different fundus appearance of retinal artery occlusion and retinal vein occlusion?
Retinal artery occlusion- pale fundus with cherry red spot at the macula
Retinal vein occlusion- stormy sunset with hyperaemia and haemorrhages
100
Causes of gradual loss of vision?
The Cat chose a Mac, with her Clau gave the DOSH
```
Cataracts
Macular Degeneration
Glaucoma
Diabetic retinopathy
Optic atrophy
Slow retinal detachment
Hypertension
```
101
What does choroiditis look like on fundoscopy?
Acute phase: grey white raised patch on the retina, vitreous opacities, cells in the anterior chamber
Later: Choroidoretinal scar- white patch with pigment around
(Layers out to in go sclera, choroid, retina)
102
Commonest malignancy of the eye?
Appearance?
Choroid melanomas
Black/grey mottling on the fundus
103
Difference between wet and dry macular degeneration?
Dry- due to death of retinal pigment epithelium, gradual
Drusen
Wet- new vessels grow into the retina and leak, sudden
Exudate, blood on the retina
104
15 year old comes in with gradual visual loss and on the slit-lamp has prominent yellow flecks in the retina. Diagnosis?
Stargardt's macular degeneration
105
Patient has noticed a loss of red/green discrimination and on examination has pale disc. What lifestyle changes would you recommend?
Optic atrophy + loss of colour discrimination may be due to cyanide free radical damage from smoking and alcohol excess
Vitamins may help
106
What are drusen?
Without RPE support
Abnormal axonal metabolism = calcified mitochondria
Axons rupture, mitochondria released and further calcified
Optic disc gets lumpy and irregular
Optic cup is absent and vessels branch abnormally
107
Rx of wet age-related macular degeneration?
Intravitreal VEGF inhibitors:
monthly bevacizumab or yearly ranibizumab
Laser photocoagulation- not if on the fovea
Intravitreal steroids- Triamcinolone
108
A patient is found to have raised intraocular pressure, how long should you follow up the patient for?
Yearly for life, it increases risk of glaucoma leading to blindness
109
Definition of glaucoma?
3 or more locations on visual field testing are outside the normal range
AND optic cup-to-disc ratio is greater than 97.5% of normal population range
(NOT raised intraocular pressure)
110
In glaucoma, what patterns in the vessels crossing the disc can you see?
Atrophy: The vessels may disappear from view and reappear further across the cup, as the neurons disappear the cup deepens so vessels can plunge in and be lost from view.
111
What kind of defects requiring glasses affect the risk of open or closed angle glaucoma?
Myopia- short sighted has risk of open angle glaucoma (related to structural susceptibility of the optic nerve head?)
Hypermetropia- long sighted increases risk of closed angle glaucoma
(Smaller eye, more compressed?)
112
Risk factors for open angle glaucoma?
Age
Afro-caribbean, FHx
Diabetes, thyroid eye disease
113
Rx for open angle glaucoma to lower intraocular pressure?
PB-CAMS
Prostaglandin analogues- (end in PROST) increase outflow from uveosclera
b-blockers (timolol, betaxolol) reduce aqueous production
Carbonic anhydrase inhibitors (dorzolamide, acetazolamide)
a-agonists (brimonidine) reduces production + outflow
Mitotics (pilocarpine) mAChR agonist, reduces resistance to outflow
Surgery if drugs fail (trabeculectomy)
114
Patient has 0.8 cup to disc ratio and raised intraocular pressure, has diabetes and asthma. Rx?
PB-CAMBS
Wouldn't give b-blockers as no first pass metabolism of crossing liver before can get to sensitive organs. Also wouldn't give in heart failure
Prostaglandin analogues, carbonic anhydrase inhibitors, a-agonists, mitotics etc
115
Whenever a cataract is found what easy other test should you do?
Fasting blood glucose to exclude diabetes
116
In cataracts caused by steroid use, where does the opacity form?
Subcapsular, deep to the lens capsule
117
How do cataracts present In adults?
Blurring
Gradual worsening vision
Difficulty seeing in bright light (glare/dazzle)
Diplopia
118
Patient has cataracts and drives, at what point should you offer surgery?
When they can't read number plate at 67 feet
Cash-strapped NHS PCTs might say when acuity goes below 6/12 in both eyes
119
Post-op complications of cataract surgery?
Posterior part of capsule thickens- use Yag laser to remove
Astigmatism becomes more noticable
Eye irritation
Anterior uveitis
Rarely: vitreous haemorrhage, retinal detachment, glaucoma, endophthalmitis
120
Baby is born with cataracts, what do you need to do?
A TORCH screen!
TOxoplasmosis, Rubella, CMV, Herpes simplex + HIV
Urgent referral- before 4 weeks!!
121
When might the optic disc appear to have blurred margins?
Papilloedema from:
Raised intracranial pressure
Malignant hypertension
Cavernous sinus thrombosis
Optic neuritis
122
What can precipitate retinal detachment?
Vitreous detachment- if it is firmly fixed to the retina in some places, as the jelly collapses it can pull strongly on the retina
Intraocular melanoma
Fibrous bands in vitreous from diabetes- that may pull on retina
Post-cataract surgery
Trauma
123
Differing stages of macular hole according to thickness?
1a: impending hole, yellow spot seen at fovea
2b: 200-300um wide hole in foveola (Rx needed)
3: full thickness hole (400um hole with vitreous separated from macula
124
What test can you use to differentiate macular hole from cystoid macular oedema and choroidal neovascularisations?
Fluorescein angiography
125
Why are flame haemorrhages and blot haemorrhages different shape?
Flame haemorrhages occur at the superficial nerve layer, where they can spread out
Blot haemorrhages are deeper in the retina so pressure compacts spread
126
Rx for diabetic retinopathy?
Laser photocoagulation- maculopathy + proliferative
Also for maculopathy:
Intravitreal steroids- triamcinolone
Anti-VEGF drugs (bevacizumab, ranibizumab)
127
What signs do you get in hypertensive retinopathy?
```
MASHH C
Macular oedema (leakage)
AV nipping (arteriolar vasoconstriction)
Silver wiring (thickening)
Hard exudates (leakages)
```
Cotton wool spots (vasoconstriction)
128
Kayser-Fleischer rings are a sign of
Wilson's disease- excessive copper disposition
Get hepatitis + cirrhosis + tremor/ataxia
Also chronic cholestatic disease
129
How can parathyroid levels affect the eyes?
Low- lens opacities
| High- conjunctival and corneal calcification
130
Which granulomatous disorders can cause uveitis Or choroidoretinitis?
And if there's a cranial nerve palsy, what might be the disorder?
```
Sarcoid
TB
Leprosy
Brucellosis (gram -ve rods)
Toxoplasmosis
```
CN involvement- sarcoid
131
Name the associated connective tissue diseases associated with:
Conjunctivitis, episcleritis, scleritis and uveitis
Conjunctivitis- SLE + Reiter's syndrome
Episcleritis- SLE + polyarteritis nodosa
Scleritis- rheumatoid arthritis
Uveitis- ank spond + Reiter's syndrome + Behcet's
Reiters= reactive arthritis, Behcet's = ulcers
132
Rx for Sjogren's syndrome?
Pilocarpine (mACh agonist) -?stimulates glands?
| Topical ciclosporin- moderate/severe dry eye
133
Who gets a 'pizza pie' fundus? What causes the 'pizza pie' look?
Rx?
CMV retinitis, generally HIV +ve patients
Cheese- superficial retinal infarction
Tomato- flame haemorrhages
IV ganciclovir
134
What can cause pseudopapilloedema?
How can it be distinguished from papilloedema?
Looks like blurred disc margics + elevated disc
Associated with Hypermetropia ± astigmatism/tilted disc
Fluorescence angiography shows no leakage of contrast, unlike papilloedema
135
5 year old who is a fussy eater is found to have tunnel vision on testing and dry conjunctiva, what is the diagnosis and Rx?
Xerophthalmia- due to a lack of vitamin E needed to make tears
Corneal dries and loses transparency
May see Bitôt's spots- foamy plaques on the eye surface
Rx: vitamin E
136
A bangladeshi woman comes to you whose eyes have been watering, where would you look to see signs of chlamydia trachomatis infection?
And what would you look for?
Under the upper lid
granular follicles + erythema
As the lids become scarred by infection they change shape and this can result in entropion and ulceration from lash abrasion
137
Rx for active trachoma disease?
In adults?
In children?
Trachoma = eye infection from Chlamydia trachomatis
Rx: adults Tetracycline QDS for 2 weeks, then TDS for 6 weeks
child Azithromycin once/twice a year
138
Cause of river blindness?
Microfilariae of nematode- onchocerca volvulus
Invading conjunctiva, cornea, ciliary body and iris
Transmitted by black flies
139
An african migrant went to the optician and noticed some opacities on his cornea, what tests should you do to look for onchocerciasis?
And Rx?
Skin snip tests- biopsy
Triple-antigen serology
PCR
Rx: Ivermectin (may need to be given for 15 years until adult worms die as it only is effective on progenitors)
140
Patient has had something splinter the globe of their eye and you are thinking about imaging. Why would you avoid mri?
It could be magnetic
141
When should you refer a corneal abrasion on?
After 24 hours at home if still have sensation of something in their eye, stain it with fluorescein- if it stains repeat in 24 hours
Still it stains- refer
142
A regular sunbed user has suddenly found they can't open their eyes and they are watering profusely, what's the diagnosis and Rx?
Arc eye from corneal damage
| Rx: local anaesthetic every 2 minutes
143
What is it called if in the anterior chamber there is:
Pus
Blood
Oedema of conjunctiva?
Pus- hypopion
Blood- hyphaema
Oedema of conjunctiva- chemosis
144
Young man got kicked in the eye with a football very hard, eye is bruised and has subconjunctival haemorrhage, what would you examine for and use to Ix?
Blowout fracture of orbit floor
EHx: loss of sensation in lower lid skin: intra-orbital nerve injury as nerve travels through foramina in floor of orbit
IHx: CT
Orbit contents may herniate into maxillary sinus, inferior rectus and inferior oblique muscles may get caught in the fracture and require release
145
Rx to prevent synechiae (iris adhering to corneal) in anterior uveitis?
What is the risk of these?
Cycloplegics- dilate the pupil
Cyclopentolate
Tropicamide
Risk of glaucoma in those with a +ve FHX
146
Which of the following drugs may be causing a patient to have dry eyes?
Amitriptyline, Propranolol, Paracetamol, Amoxicillin?
Propranolol (reduce aqueous production)
147
What is it called if in the anterior chamber there is:
Pus
Blood
Oedema of conjunctiva?
Pus- hypopion
Blood- hyphaema
Oedema of conjunctiva- chemosis
148
Young man got kicked in the eye with a football very hard, eye is bruised and has subconjunctival haemorrhage, what would you examine for and use to Ix?
Blowout fracture of orbit floor
EHx: loss of sensation in lower lid skin: intra-orbital nerve injury as nerve travels through foramina in floor of orbit
IHx: CT
Orbit contents may herniate into maxillary sinus, inferior rectus and inferior oblique muscles may get caught in the fracture and require release
149
What visual impairment enables someone to register as blind in the UK?
Acuity worse than 3/60 or acuity >3/60 if there is substantial visual field loss (as in glaucoma)
150
Rx to prevent synechiae (iris adhering to corneal) in anterior uveitis?
What is the risk of these?
Cycloplegics- dilate the pupil
Cyclopentolate
Tropicamide
Risk of glaucoma in those with a +ve FHX
151
Which of the following drugs may be causing a patient to have dry eyes?
Amitriptyline, Propranolol, Paracetamol, Amoxicillin?
Propranolol (reduce aqueous production)
152
What is keratoconus and the Rx for it?
The corneal is conical rather than round, distorting vision
May be sensitive to light and have diplopia
Rx: rigid gas-permeable lenses or eventually corneal transplant
153
13 year old boy who has moved here from spain has itchy eyes, blepharospasm, tearing and the sensation of a foreign body in his eye.
EHx: No foreign body can be seen and lid skin looks normal
Under lid, there is thick mucoid discharge from large conjunctival papillae that look like cobblestones
What is the danger and differential?
Vernal keratoconjunctivitis or atopic keratoconjunctivitis
As young and mucoid discharge (rather than watery) it is more likely to be VKC- more common in males
AKC occurs equally in both sexes and in 20/30s
Risk of corneal scarring and shield ulcers- permanent damage to sight
154
Rx for vernal keratoconjunctivitis?
And if corneal disease develops- shield ulcers, scarring...
Olopatadine- antihistamine drops
Lodoxamide- mast cell stabilizer drops
Corneal = steroid drops, or ciclosporin drops (T cell activity)
155
Name some antihistamine drops you can use for seasonal or perennial allergic conjunctivitis
Seasonal- end in INE
Olopatadine
Azelastine, epinastine, emedastine
Perennial- all year round + some seasonal changes
Olopatadine
Lodoxamide
156
What is the difference between giant papillary conjunctivitis and atopic keratoconjunctivitis?
The cause
Atopy (AKC) Vs lid reaction to a foreign body (GPC)
Both have conjunctival papillae on the underside of the lid
157
Patient noticed a shower of black floaters in his left eye, what is the management?
Refer immediately for specialist assessment, may be due to retinal detachment
158
How does panretinal photocoagulation work?
Side effects?
Reduces the number of hypoxic cells in the periphery producing VEGF because of the hypoxia.
SEs: poor peripheral vision and night vision due to rod destruction
159
Where is the typical location for ductal carcinoma of the breast Vs Paget's disease of the breast?
Malignant breast lumps- upper outer quadrant
Paget's- under the nipple + bloody discharge, itching, eczematous change at the nipple (still a type of cancer)
160
Cold and red eye is likely to be?
Adenovirus
161
Which is the only infection that can get through a corneal abrasion that is not inflamed?
Gonorrhoea
162
What visual impairment enables someone to register as blind in the UK?
Acuity worse than 3/60 or acuity between 6/60 and 3/60 if there is substantial visual field loss (as in glaucoma tunnel vision)
163
Hypopion and an ulcer in the eye, what's the cause and Rx?
```
Bacterial ulcer (hence pus)
Rx: gentamycin + ceftriaxone
```
164
Patient has shingles, what is Hutchinson's sign?
Involvement on the tip of the nose suggests the eye is involved, as ciliary body nerve supplies both
165
Difference between pterygyum and pingecula?
Pterygyum is terrible and overlies the cornea, pingcula stops before the limbus (the iris border)
166
Main risk factor for pterygyum? (Overgrowth of the conjunctiva)
Sun exposure
167
What is the main difference between anterior uveitis and glaucoma?
Both red and painful eye
Uveitis (ciliary body and iris inflammation)- may have an irregular pupil or pus in the anterior chamber, bilateral, worse around the limbus (ciliary flush)
Glaucoma- cloudy cornea, headache, vomiting (sounds like migrane)
168
Suspect closed-angle glaucoma, what can you give before going to A+E for an peripheral iridotomy?
PAT:
Pilocarpine
Acetazolamide
Timolol (b-blocker)
169
Difference between open angle glaucoma and closed angle glaucoma?
Open angle = drainage (big eyes- Black + myopic + chronic)
Closed angle = mechanical blockage from iris (small eyes- Asian + hypermetropia + acute)
(Chinese people are short sighted)
170
Difference between open angle glaucoma and closed angle glaucoma?
Open angle = drainage (big eyes- Black + myopic + chronic)
Closed angle = mechanical blockage from iris (small eyes- Asian + hypermetropia + acute)
(Chinese people are have small eyes, long sighted)
171
What visual field defect do you get in an chronic open angle glaucoma?
Arcuate scotoma
172
First line Rx for open angle glaucoma (chronic asymptomatic)?
Prostaglandins
2nd: trabeculectomy as there is an issue in drainage
173
Complications in diabetes causing proliferation?
Macula oedema
```
Vitreous haemorrhage (more blood vessels)
Secondary closed angle glaucoma (as vessels go around the iris)
Retinal traction (± detachment)
```
174
Complications in proliferative diabetic retinopathy?
Macula oedema
```
Vitreous haemorrhage (more blood vessels)
Secondary closed angle glaucoma (as vessels go around the iris)
Retinal traction (± detachment)
```
175
Two main types of retinal detachment?
Rhegmatogenous- break in a retina often trauma related
| Traction + exudative- fluid builds up behind a non-broken retina, diabetes + retinopathy of prematurity + sickle cell
176
Difference in presentation of retinal vein occlusion and retinal artery occlusion?
No vision in artery, slight vision retained in vein
177
What is the difference in visual field defect given by a lesion in the optic tract compared to the optic radiation?
Optic tract- homonymous hemianopia
| Optic radiation- quadrantic hemianopia
178
Contact lens wearer develops a white area on upper cornea and blepherospasm (can't open eye). Possible cause?
Acanthamoeba keratitis
179
Name for when the iris is swollen and yellowish green 'muddy iris'?
Iridocyclitis
| =anterior uveitis as uvea is the ciliary body and iris and chorioid
180
Most important difference between varicella ophthalmicus and a herpes simplex ulcer?
Varicella you can treat with steroids, not in HSV
181
A patient has had blurring and yellow-tinged vision. What heart failure tablet is he at risk of toxicity from with those symptoms?
Digoxin
182
Which drug causes a bull's eye maculopathy?
Hydroxychloroquine- SLE + rheumatoid arthritis
Macula is hyperpigmented, with a zone of depigmentation and another ring of pigmentation.
183
What intraocular pressure is found in acute closed angle glaucoma?
>30mmHg
184
What medication do you give to someone with acute closed angle glaucoma until surgery is ready?
Pilocarpine
Acetazolamide (reduce aqueous formation)
Sometimes the same medications as for chronic open angle glaucoma are used
185
What is the difference between an iridotomy and an iridectomy as glaucoma Rx?
```
Iridotomy = hole with laser
Iridectomy = surgical hole
```
186
What makes up the uvea?
Iris
Ciliary body
Choroid
(All inflamed in anterior uveitis)
187
What is Talbot's test and when is it used?
+ve in acute closed angle glaucoma:
| On convergence and constriction of pupils as they focus on a finger approaching their nose their pain increases
188
What causes of panuveitis don't cause anterior uveitis?
Both caused by:
Sarcoid + Behcet's, Herpes + TB + HIV
Panuveitis: also toxoplasmosis, lymphoma
Ant uveitis: ank spond, Crohn's/UC, syphilis
189
What's the difference in pathology between anterior, intermediate and posterior uveitis?
Anterior: iris, ciliary body + choroid
Posterior: choroid + retina (white spots on retina)
Intermediate: vitreous cell inflammation
190
How is anterior and posterior uveitis differentiated on slit lamp?
Anterior- cells + hypopyon in anterior chamber
| Posterior- white patches on the retina
191
What do children with juvenile arthritis need to be screened for every 4 months until they are old enough to report symptoms?
Anterior uveitis
192
What is the sign of corneal inflammation (keratitis)?
White area on the cornea
193
What investigations can be done on a corneal ulcer to identify the cause?
Fluoroscein- dendritic HSV
Smear
Gram stain
Scrape
194
Which causes of a red eye are associated with reduced vision?
```
From out to in:
Corneal abrasions or conjunctivitis
Acute glaucoma (cloudy cornea)
Scleritis
Anterior uveitis
```
195
In a chronic ulcer what stains in the IHx should be requested?
```
Giemsa stain (malaria + protozoa)
Periodic acid Schiff (fungi)
Ziehl-Neelsen (TB)
Ulcer scrape
Cultures
```
196
Which microorganisms require chocolate agar?
Neisseria + haemophilis
197
What does the retinal histology show in someone with atheroscerotic anterior ischaemic optic neuropathy?
Necrosis + apoptosis of photoreceptors
| Leads to sudden painless visual loss
198
In a suspected retinal artery occlusion what needs to be excluded and how?
Giant cell arteritis
| Check ESR and CRP + symptoms
199
Commonest gram +ve and gram -ve causes of corneal ulcers?
G+ve: Staphs (coagulase -ve)
Corynebacteria
G-ve: Moraxella, Pseudomonas aeruginosa
200
In retinal vein occlusion, what is the aim of Rx?
Occlusion and back up of blood leads to ischaemia
Neovascularisation threatens vision, so:
Anti-VEGF
Laser photo-coagulation
201
To prevent a retinal break turning into a retinal detachment, what options are there?
Crytherapy or laser retinopexy to put it back down
202
Four F's of retinal detachment?
Flashes
Floaters (in a rain of them)
Field defects
Fall in acuity
203
Surgical options for retinal detachment?
Vitrectomy
Gas tamponade to hold retina in place whilst cryoretinopexy fixes it in place
Post-op detachment in 5-10%
204
What is strabismus?
An official term for a squint (eyes looking in different directions)
205
What is the difference between papillitis and papilloedema?
Papillitis- optic nerve head inflammation
| Papilloedema- raised intracranial pressure
206
Which muscle mediates accommodation?
Ciliary body muscle
207
What does amblyopia mean?
Reduced acuity, not correctable with lenses
| No anatomical defect
208
What do the following mean?
A. Anisometropia
B. Aphakia
C. Epiphora
A. Different refractive errors in each eye
B. No lens (ie because removed for cataracts)
C. Overflow of tears onto cheek
209
What is
A. Tonometer
B. Tarsorrhaphy
A. Device for measuring intraocular pressure
| B. Uniting upper and lower eyelids in a surgical procedure
210
In recording acuity, which number goes on top and bottom?
On top = distance from Snellen chart
On bottom = line they could read (60/36/24...6)
6/60
211
Which glands are the source of the abscess in hordeolum externum compared to hordeolum internum?
Hordeolum externum- face outwards
Glands of Moll (sweat)
Glands of Zeis (sebum)
```
Hordeolum internum- face inwards
Meibomiam glands (tear lipids)
```
212
Hordeolum internum is rarer than externum but if someone gets one, what might they be left with?
A Meibomian cyst or chalazion
213
Name for infection of the tear sac?
Dacrocystitis- can lead to cellulitis.
214
What is the difference between dacrocystitis and dacroadenitis?
Dacrocystitis is inflammation of the tear sac that drains tears
Darcoadenitis is inflammation of the lacrimal gland that makes tears
215
A woman has noticed a swelling on the upper outer aspect of her eyelid. She thought it would go away but it's been there fore months. Causes of chronic dacroadenitis?
Dacroadenitis (lacrimal gland inflammation)
Sarcoid
TB
Lymphatic leukaemia, lymphosarcoma
216
What's the name of the test you do in someone with suspected dry eyes?
Schirmer's test: filter paper on lower lid, >15mm of tears in 5 minutes?
217
A patient has a swollen lacrimal sac, what symptom makes a mucocele blockage less likely than a lacrimal sac tumour?
Pain (makes tumour more likely)
218
Rx for orbital cellulitis
Cefotaxime + methotrexate
| ± vancomycin
219
In a child presenting with orbital cellulitis (acute onset proptosis + inflammation) what needs to be ruled out and how?
Signs like fever might suggest one diagnosis
Underlying rhabdomyosarcoma- 1. CT
2. biopsy if still unclear
220
Child has been feeling tired, has lost appetite and has a swollen abdomen. They have got unilateral proptosis. What malignancy could be the cause?
Neuroblastoma (neural crest cells, starts in adrenals or paraspinal nerves).
221
Which dermatome is affected in ophthalmic shingles?
V1
222
What's the difference between keratitis, episcleritis/scleritis and anterior uveitis in their presentation?
Keratitis- might get a white spot on cornea, foreign body sensation
Ant uveitis- get ciliary flush around the limbus, hypopyon
Scleritis/episcleritis- typically focal redness, whereas the other two are more diffuse. (Scleritis- tender globe, episcleritis- nontender)
223
Which connective tissue and vasculitic diseases are associated with scleritis?
Rheumatoid arthritis
SLE
Granulomatosis with polyangiitis (Wegners)
Polyarteritis nodosa
224
Crescent shaped destruction of margin of cornea is known as? Autoimmune causes?
Peripheral ulcerative keratitis
Rheumatoid arthritis, SLE, PAN...
Mooren's ulcer has no systemic association (found in southern hemisphere)
225
What are the advantages and disadvantages of fanciclovir vs aciclovir for ophthalmic shingles?
Fanciclovir is once a day whereas aciclovir is 5x day, but fanciclovir is much more expensive and has more serious side effects like hepatitis and renal failure
226
Rx for a patient who has terrible pain in the V1 dermatome following a shingles outbreak in this area?
Post-herpetic neuralgia
| Amitriptyline or gabapentin (thought to be due to nerve damage)
227
Which chromosome is the retinoblastoma gene mutation found on in the heritable form of the disease?
Chromosome 13
228
Retinoblastoma chemo?
Don't VEC my eye!
Vincristine
Etoposide
Carboplatin
229
What type of squint do children most commonly get?
Convergent (esotropic) squints
230
A patient has diplopia from ocular muscle paralysis, how do you know which muscle it is?
The direction with the greatest diplopia indicates the direction of the pull of the muscle that is paralysed
231
Patient has been holding his head at an angle and says he's been having diplopia. What nerve is likely to be affected?
Ocular torticollis- trochlear CN 4
| Superior oblique muscle is involved in torsion of the eyeball
232
What alternative to surgery can be offered to those with CN 6 paralysis?
Botox
233
In a child with a squint, above what age is an amblyopia likely to be permenant?
Amblyopia = reduced acuity not correctable with glasses
7 years
234
A young woman has blurred near vision, on slit lamp exam the iris is making slow wormy movements And pupil is dilated. What is the likely diagnosis?
Holmes-adie pupil
235
What sign in someone with Horner's syndrome suggests it may be congenital?
Heterochromia (multiple coloured iris)
236
What causes astigmatism?
If the cornea or lens have different curvatures in a horizontal or vertical plane
237
In regards to homonymous quadrantanopia, what lobes are affected if it superior or inferior?
PITS
Superior = temporal lobe
Inferior = parietal lobe
238
Management of age related macular degeneration?
1. Fluorescein angiogram
2. Monthly reviews of photograph + Optical Coherence Tomography
3. VEGFi + photocoagulation
4. Intravitreal steroids
5. Vit C, E, zinc, b-carotene
239
Causes of choroiditis? (Mimics retinoblastoma)
Granulomatous conditions- toxoplasmosis, sarcoid
| ```
Occasionally TB
EHx- raised white patch on retina
```
240
In a disc where there is cupping which way do vessels get displaced as they run over the disc?
Nasally
| Vessels appear over the side of the disc rather than running through the middle
241
How are macular holes staged and diagnosed?
Optical coherence tomography- staging
(This is like a cross section of the retina)
Fluorescein angiography can differentiate macular oedema and choroidal neovascularisation
242
What are the different eye signs in vascular retinopathy caused by hypertension or atherosclerosis compared to diabetes?
All may cause:
vasoconstriction- cotton wool spots
Leaky vessels- hard exudates + macular oedema
Hypertension: Silver wiring + flame haemorrhages
Diabetes: venous beading, dot + blot haemorrhages
243
Eye changes typical of sickle cell anaemia?
Comma shaped conjunctival haemorrhages
| Neovascularisation
244
Causes of tunnel vision:
```
Glaucoma
Stroke
Retinal detachment
Retinitis pigmentosa
Vit A deficiency
```
245
What are the different eye side effects of TB treatment?
Ethambutol- retinopathy (optic neuropathy)
| Isoniazid- reduced red-green perception (prevented by pyridoxine co-prescribing)
246
Management of posterior vitreous detachment?
Check for retinal tear.
| Normal part of ageing, if flashes with no change in acuity then can be left alone
247
How do you exclude an endophthalmitis?
Take a sample of the intravitreous fluid (replacing the 0.2mL fluid removed with substitute).
248
What risk factor may lead to a sterile corneal ulcer?
Contact lens wearing
249
Why might someone have 6/12 vision (good) with central retinal artery occlusion?
Cilioretinal artery providing macular blood supply
| Derived from short ciliary nerves- like choroid arteries
250
How do you determine if someone has an ischaemic or non-ischaemic retinal vein occlusion?
Relative afferent pupillary defect in affected eye
251
How can you tell the difference between vitreous haemorrhage and wet macular degeneration if you can see blood haemorrhage on the retina?
On wet MD you can see the blood vessels of the retina on top of the pool of blood (as the haemorrhage is within the retina underneath the choroid layer)
In vitreous haemorrhage it is completely wiped out with red
252
Someone with bilateral optical nerve swelling, what do you call it?
Bilateral optical nerve swelling
| Can't call it papilloedema unless you KNOW there is raised intracranial pressure
253
When would you treat optic neuritis?
If they only have one working eye (which is affected with optic neuritis) then can give intravitreal steroids.
It won't cure it but will cause faster resolution.
254
What treatment is given for dry macular degeneration?
None available, vitamin supplements
