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4. Senior Block- Special Senses > Opthalmology > Flashcards

Opthalmology Flashcards

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1
Q

Which bones make up the orbit?

A 
Ethmoid
Zygomatic
Frontal 
Sphenoid
Lacrimal 
Palatine 
Maxilla
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2
Q

Give 3 functions of the eyelids

A

Protect eye from trauma
Protect eye from excessive light
Maintain lubrication of eyeball by distributing tears

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3
Q

Give the 6 orbital muscles

A 
Lateral rectus
Medial rectus
Superior rectus
Inferior rectus
Inferior oblique
Superior oblique
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4
Q

What nerve supplies the orbicularis oculi muscle and what does this muscle do?

A 
Facial nerve (CN VII)
Closes eyelids, helps to drain tears
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5
Q

What nerve supplies the levator palpebrae superioris and what does this muscle do?

A 
Oculomotor nerve (CNIII)
Opens the eyelid
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6
Q

Which ocular muscles does the oculomotor nerve supply?

A 
Medial rectus
Superior rectus
Inferior rectus
Inferior oblique
(Levator palpebrae superioris)
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7
Q

What nerve innervates the lacrimal gland and how does it act under autonomic innervation?

A

Lacrimal nerve, branch of opthalmic nerve, branch of the trigeminal nerve (CN V)
Parasympathetic –> increased secretion
Sympathetic –> decreased secretion

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8
Q

Describe the path of lacrimal fluid

A

Secreted from lacrimal gland via lacrimal ducts
Swept across eye via eyelids
Lacrimal canaliculi drain fluid into lacrimal sac
Enters nasolacrimal duct to enter the inferior meatus in the nose

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9
Q

What layer of the eye is known as the white of the eye?

A

Sclera

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10
Q

Give 3 roles of the cornea

A

Maintains transparency
Protects the eye
Refracts incoming light

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11
Q

What nerve innervates the cornea?

A

Long ciliary nerves from the opthalmic branch of the trigeminal nerve

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12
Q

What separates the anterior chamber from the posterior chamber of the eye?

A

The iris

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13
Q

Where does the aqueous humour drain?

A

The trabecular meshwork

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14
Q

What is mydriasis?

A

Dilation of the pupil via the dilator pupillae muscles. Sympathetic innervation in dull light

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15
Q

What is miosis?

A

Constriction of the pupil via the sphincter pupillae. Parasympathetic innervation in bright light

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16
Q

What is the role of the choroid?

A

Divides sclera and retina
Contains nerves and blood supply to the retina
Removes waste from outer retina
Reduces reflections by absorbing excess light

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17
Q

What are the 2 main layers of the retina?

A

Neural

Pigmented

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18
Q

What is the macula?

A

The center of the retina. Highly pigmented area

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19
Q

What is the fovea?

A

Area of the macula that has a high concentration of light detecting cells so is responsible for high acuity vision.

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20
Q

List the 6 extraocular muscles

A 
Lateral rectus 
Medial rectus 
Inferior rectus
Superior rectus
Superior oblique 
Inferior oblique
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21
Q

Where do the nasal fibres cross in the optic pathway?

A

Optic chiasm

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22
Q

What is the name of the nucleus in the brain that receives the optic tracts?

A

Lateral geniculate nucleus

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23
Q

What is a scotoma?

A

Blind spot

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24
Q

What condition may cause a central scotoma?

A

Macular degeneration

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25
What factors may cause monocular visual loss?
Damage to the optic nerve Trauma Inflammation Abscess
26
What condition may cause bitemporal hemianopia?
Pituitary adenoma
27
What conditions may cause homonymous hemianopia?
``` Stroke Trauma Cerebral infection Brain tumours Abscess ```
28
Why do refractive errors occur?
Disorder of the size and shape of the eye
29
Describe the accommodation reflex
Far away object= lens is pulled to become thinner. Ciliary muscles relax and the suspensory muscles tighten Close object= lens becomes thicker. Ciliary muscles contract so suspensory muscles loosen
30
What is myopia?
Short-sightedness eye can focus on close by objects but not ones in the distance. Due to a long axial length or the lens being too thick and curved.
31
What is hypermetropia?
Long-sightedness Eye can focus on distant objects but not objects close by Due to a short axial length or a loss of elasticity in the lens. Associated with advancing age (presbyopia)
32
What is astigmatism?
The cornea does not have the same degree of curvature along its whole surface so images are focussed at different points on the retina.
33
What is a squint/strabismus?
Eyes are misaligned
34
``` With regard to a squint, what do these terms mean: Eso- Exo- Hyper- Hypo- ```
``` Eso = turning in Exo = turning out Hyper = looking up Hypo = looking down ```
35
What is a concomitant squint?
Angle of the squint is the same in all directions of gaze
36
What is an non concomitant squint?
Angle of the squint varies with gaze
37
What is a convergent squint?
Esotropia
38
What is a divergent squint?
Exotropia
39
What is the most common type of squint in young children?
Esotropia- one eye turned in
40
What 2 tests can be done to investigate a squint?
Corneal reflection- reflection of bright light will not be symmetrical Cover test- movement of the uncovered eye to fixate as the other eye is covered will suggest a manifest squint
41
Describe the results of a cover test in a left convergent (esotropic) squint
Left eye covered, right eye focuses | Right eye covered, left eye moves out to take up fixation
42
Describe the results of a cover test in a left divergent (exotropic) squint
Left eye covered, right eye focuses | Right eye covered, left eye moves in to take up fixation
43
Give 3 reasons to treat a squint
Leads to amblyopia (lazy eye) Reduced coordination Psychosocial effects May have sinister underlying cause
44
Give the 3Os for treating a squint
Optical --> assess for refractive errors and prescribe glasses Orthoptic --> pathing the good eye forces the squint to focus Operation --> can have resection and recession of the rectus muscles. Helps alignment and gives good cosmetic results
45
Describe the ocular presentation of a 3rd nerve palsy
Ptosis Proptosis Fixed pupil dilation "Down and out" pupil
46
Give 3 causes of a 3rd nerve palsy
Cavernous sinus lesion Diabetes Cranial tumour PCA aneurysm
47
Describe the ocular presentation of a 4th nerve palsy
Diplopia Head tilt Cannot look down and in, SO paralysed
48
Give 3 causes of a 4th nerve palsy
Trauma Diabetes Brain tumour Idiopathic
49
Describe the ocular presentation of a 6th nerve palsy
Horizontal diplopia | Eye cannot move laterally as LR paralysed
50
Describe the pupillary light reflex
As light is shone in one eye, the impulses travel down the optic nerve and optic radiations to the visual cortex in the occipital lobe and synapse on BOTH left and right Edinger-Westphal nuclei. The efferent pathway made up of cranial nerve III, synapses at the ciliary ganglions and then acts on BOTH eyes to either constrict the pupils.
51
What is the meaning of the consensual light reflex?
Both pupils constrict when light is only exposed to one eye
52
What happens to the pupil in bright light?
Constricts- via circular muscles contracting
53
What happens to the pupil in dim light?
Dilates- via radial muscles contracting
54
Give 3 causes of an afferent defect
Optic neuritis Optic atrophy Retinal disease
55
Explain the pathophysiology of an afferent defect
Eg. Light shone in right eye. Right optic nerve damaged so no afferent conduction (via optic nerve) to the cortex. Therefore, no consensual pupil constriction in the left eye. Light shone in the left eye. Signal sent to the optic nuclei and consensual reflex present so right will also constrict as the efferent pathway is still intact.
56
What test can be done to prove a Relevant Afferent Pupillary Defect (RAPD)?
Swinging flashlight test
57
Explain the swinging flashlight test
Left eye damaged Light in Left eye= eye constricts poorly to light and consensual response in the right hand side (half constricts) Light in right eye= eye constricts fully to light and consensual response in the left means it also constricts fully Light in left eye again = left eye dilates instead of constricts as perception of the light is poor
58
What is the cause of an efferent pupillary defect?
3rd Nerve Palsy
59
Give 3 causes of a fixed dilated pupil
Mydriatics Trauma Acute glaucoma Coning
60
What is a Tonic (Adie) pupil?
Lack of parasympathetic innervation results in poor constriction to light. Presents with sudden blurring of vision, often in young women
61
How does Horner's Syndrome present ocularly?
Miotic pupil | No dilation in the dark
62
Give 2 causes of Horner's Syndrome
Pancoast tumour MS Aortic aneurysm
63
What is an Argyll Robertson pupil?
Bilateral miosis Poor pupillary dilation Pupil irregularity Accommodates but does not react Associated with diabetes and syphilis
64
Give 4 predisposing factors for cataract formation
``` Increasing age Diabetes Smoking Trauma to lens High myopia Excess alcohol FHx of cataracts Long term steroid use Genetics HIV Positive ```
65
What is a cataract?
A cataract is the loss of transparency/opacity of the lens. Can result from disruption to the lens fibres configuration, capsule or epithelium
66
Describe the 3 types of cataracts
Subcapsular= located directly under the lens capsule. Has a granular or plaque appearance. Quick progression and cause glare from bright light. Nuclear= Involves lens nucleus. Patient becomes myopic due to increase in refractive index. Colours appear more yellow/brown Cortical= in the cortex of the lens. Radial wedge shaped opacities which cause astigmatic changes
67
Give 4 clinical features of cataracts
Blurred vision Loss of stereopsis- judging distance Gradual painless loss of vision Difficulty driving at night due to glare of lights Colour vision dampened- see more yellows/browns
68
Give 3 indications for cataract surgery
Troubling symptoms Lifestyle is restricted Can no longer drive
69
What is the name of cataract surgery?
Phacoemulsification +/- lens transplant
70
Describe the process of cataract surgery
Day case procedure under LA. Small incision made and lens removed by phacoemulsion. (lens broken down using ultrasound pulsed and then sucked out via a cannula). A new lens is folded and then inserted into the eye
71
What investigation is done prior to cataract surgery?
Ocular biometry- measures curvature of cornea and length of eye to predict best lens implant
72
What is the post-op care for post cataract surgery?
Can return home straight away afterwards Need antibiotic and anti-inflammatory drops for 3-6 weeks Need to change glasses prescription
73
Give 4 potential complications of cataract surgery
``` Posterior capsule thickening Astigmatism Eye irritation Anterior uveitis Vitreous haemorrhage ```
74
Give 4 predisposing factors for open angle glaucoma
``` Fhx of glaucoma African-American/Latino Diabetic CV disease Increasing age Hypertension ```
75
What is the pathophysiology of chronic glaucoma?
Obstruction in drainage of the aqueous humour via the trabecular meshwork leads to increase in intraocular pressure. There is a wide gap between the iris and the cornea. The increased intraocular pressure (>21 mmHG) causes optic neuropathy with death of retinal ganglion cells and their optic nerve axons.
76
Give 3 clinical features of open angle glaucoma
Asymptomatic for many years- picked up incidentally Symptoms bilateral: Blurred vision Visual field loss - irreversible Difficulty crossing busy roads
77
Who is invited to open angle glaucoma screening?
``` >35 years old Afro-Caribbean Myopia Diabetic eye disease Thyroid eye disease ```
78
Why is screening important in chronic glaucoma?
Asymptomatic disease until visual field loss but by this point the symptoms are irreversible
79
Give 4 investigations that can be done to assess open angle glaucoma and what they look for
- Tonometry= measures the intraocular pressure - Perimetry= measures visual fields - Gonioscopy= visualises anterior chamber drainage to see if angle is open or closed - Fundoscopy with slit lamp= assesses if there is optic disc cupping- optic disc atrophy + wider and deeper so the vessels look like they have breaks. (- OCT= looks for damage to the retina)
80
How is open angle glaucoma managed medically?
- Prostaglandin analogues= increase uveoscleral outflow - Beta blockers (Timolol)= decrease production of aqueous - Alpha-adrenergic agonists= decrease production of aqueous - Carbonic anhydrase inhibitors= decrease production of aqueous - Miotics (Pilocarpine)= decrease resistance to aqueous outflow
81
What is trabeculoplasty?
Laser therapy to increase aqueous outflow to reduce intraocular pressure.
82
What surgery can be done to treat open angle glaucoma?
Trabeculectomy- puts pressure valve in the border of the sclera and the cornea
83
What is the function of rod cells?
Sense contrast and motion. Assist in seeing in darker environments
84
What is the function of cone cells?
Sense fine detail and colour vision
85
Describe the blood supply to the retina
Inner 2/3rds= central retinal artery | Outer 1/3rd= choroidal blood supply
86
What are the 3 mechanisms of retinal detachment?
Rhegmatogenous= retinal tears result in retinal fluid passing from the vitreous space to the subretinal space which peals the retina away Exudative= subretinal fluid accumulation without a tear. Occurs due to diabetes, hypertension, vasculitis, macular degeneration or tumours Tractional= formation of vitreoretinal bands which pull on the retina as the eye moves.
87
What is retinal detachment?
Detachment of the neurosensory retina from the retinal pigment epithelium. Loss of retinal function due to disturbed metabolic processes. If detached for >12 hours there is retinal ischaemia and degeneration
88
Give 3 predisposing factors for rhegmatogenous retinal detachment
``` Severe myopia Previous intraocular surgery Posterior vitreous detachment Trauma Retinal detachment of contralateral eye Family history ```
89
Give 3 predisposing factors for exudative retinal detachment
``` Pre-eclampsia Diabetes Hypertension Penetrating eye trauma Retinoblastoma ```
90
Give 3 predisposing factors for tractional retinal detachment
Proliferative diabetic retinopathy Retinopathy of prematurity Sickle cell retinopathy
91
Give 4 clinical features of retinal detachment
``` 4 Fs: Floaters Flash of light (photopsia) Field loss (scotoma) Fall in acuity ``` Sudden painless loss of vision RAPD
92
What is seen on fundoscopy in retinal detachment?
Grey, opalescent retina Balloons forward May be able to see retinal tear- retina floats freely in vitreous
93
How is a retinal detachment managed conservatively?
Rest | Posture- if superior detachment, lie flat. If inferior detachment, lie 30 degrees head up
94
How is a minor retinal detachment managed?
Laser photocoagulation
95
How is a major retinal detachment managed?
Prompt surgery: Vitrectomy External/internal tamponade= close tear
96
What is retinitis pigmentosa?
Progressive hereditary dystrophy of the retina which starts between ages 5-30 years
97
Give 4 clinical features of retinitis pigmentosa?
``` Night blindness Narrowing field of vision Glare sensitivity Defects in colour and contrast perception Late stage= blindness ```
98
How is retinitis pigmentosa investigated?
Fundoscopy= pattern of dark spots Perimetry= test field of vision Electroretinography
99
How is retinitis pigmentosa managed?
No known cure Inform DVLA Psychological support
100
What is posterior vitreous detachment?
Detachment of the posterior vitreous cortex from the internal limiting membrane of the retina. Due to age related degeneration of the vitreous body, myopia or eye injury
101
Give 2 symptoms of posterior vitreous detachment
Asymptomatic Floaters Photopsia with eye movements
102
What is seen on slit lamp examination in posterior vitreous detachment?
Irregular ring= visible posterior vitreous
103
How is posterior vitreous detachment managed?
No treatment if no symptoms If symptoms present treat the cause eg. retinal detachment, retinal hole
104
What is a vitreous haemorrhage?
Extravasation of blood in the vitreous body
105
Give 3 potential mechanisms for vitreous haemorrhage
- Rupture of neovascular vessels in ischaemic changes of the retina eg. proliferative diabetic retinopathy, retinal vein occlusion - Rupture of physiological vessels eg. symptomatic posterior vitreous haemorrhage, retinal tear - Haemorrhage from adjacent site eg. tumour macroaneurysm
106
Give 3 clinical features of vitreous haemorrhage
``` Floaters Visual loss Unilateral, painless Worse after sleep No red reflex in severe cases ```
107
What can be seen on slit lamp examination of vitreous haemorrhage?
Blood between vitreous base and limiting membrane
108
How is vitreous haemorrhage managed?
Watch and wait Treat underlying cause +/- Vitrectomy
109
Give 3 predisposing factors for retinal vein occlusion
``` >80 years old Atherosclerosis Hypertension Diabetes Glaucoma Vasculitis ```
110
How does ischaemic retinal vein occlusion present?
Sudden, severe loss of vision in affected eye | RAPD
111
How does non-ischaemic retinal vein occlusion present?
Subacute, mild to moderate loss of vision, no RAPD
112
How does retinal vein occlusion look on fundoscopy?
Dot and blot and/or flame haemorrhages in all 4 quadrants Ischaemic= cotton wool spots, macular oedema, papilloedema
113
How is retinal vein occlusion managed?
Laser therapy Intravitreal injection of VEGF-inhibitors Panretinal photocoagulation
114
How is retinal vein occlusion investigated?
Fluorescein angiography- can see if it is ischaemic or not
115
Give 4 predisposing factors for retinal artery occlusion
``` Carotid artery atherosclerosis Atrial fibrillation Vasculitis >60 years old Male ```
116
Give 3 features of retinal artery occlusion
Sudden painless loss of vision in one eye Descending curtain visual loss RAPD
117
How does retinal artery occlusion present on ophthalmoscopy?
Grey discolouration of the entire retina | Cherry red spot at the fovea centralis
118
How is retinal artery occlusion investigated (non-eyes)?
Carotid doppler Echocardiogram Rule out temporal arteritis- ESR, temporal artery biopsy
119
How is retinal artery occlusion managed?
Medical emergency Eyeball massage Carbogen therapy Decrease intraocular pressure Vasodilators
120
Describe the 2 mechanisms of developing retinoblastoma
- Heritable= autosomal dominant mutation on 1 of the retinoblastoma (Rb) alleles plus a spontaneous mutation of the other Rb allele resulting in a non-functioning Rb gene --> Retinoblastoma (bilaterally) - Sporadic= two spontaneous mutations in the same cell affecting both Rb alleles. Tends to be unilateral
121
At what age does retinoblastoma present?
<3 years old- most common childhood intraocular malignancy
122
Give 4 clinical features of retinoblastoma
``` Leukocoria (white pupillary reflex) Strabismus (squint) Painful red eye Loss of vision Advanced= retinal detachment ```
123
What is seen on fundoscopy in retinoblastoma?
Greyish-white vascularised retinal tumour
124
How is retinoblastoma investigated?
Ocular US Contrast MRI of head Genetic testing for Rb1 gene- can screen siblings
125
How is retinoblastoma managed if the eye is salvageable?
Cryotherapy Photocoagulation Brachytherapy Chemotherapy
126
How is retinoblastoma managed if the eye is not salvageable?
Enucleation= removal of eye | Adjuvant high dose chemotherapy
127
Give 3 signs of poor prognosis in retinoblastoma
Late diagnosis Tumour grown into choroidal layer of optic nerve Bilateral involvement
128
What is a macular hole?
Vitreous loses some water content which causes it to shrink causing traction on the retinal tissue. This causes a small tear in the macular region of the retina. No associated with retinal detachment
129
How does a macular hole present?
Distorted vision and blurring | Visual loss
130
What can be seen on fundoscopy and slit lamp examination of a macular hole?
Fundoscopy= small punched out area on the macula with yellow-white deposits Slit lamp= round excavation with well defined edges and grey halo
131
How is a macular hole managed?
Watch and wait (early cases) Vitrectomy Tamponade= air bubble put in vitreous to put macular back in position
132
Give 5 risk factors for Age-related macular degeneration (ARMD)
``` >55 years old Female White CV disease Hx of cataract surgery Increasing age FHx and genetics Smoking Obesity ```
133
What is the pathophysiology of Wet Age-related macular degeneration (ARMD)?
10% of Age-related macular degeneration (ARMD) Pathological choroidal neovascular membranes develop under the retina. Fluid and blood leaks out of the vessels to result in sudden localised elevation of the macula and detachment of the retinal pigment epithelium
134
Describe the onset of Wet Age-related macular degeneration (ARMD)
Acute or insidious onset over weeks to months | Presents unilaterally first
135
What is seen on fundoscopy in Wet Age-related macular degeneration (ARMD)?
Fluid exudation Detachment of the retina Fibrous disciform scars Grey retinal discolouration
136
What is the pathophysiology of Dry Age-related macular degeneration (ARMD)?
90% of Age-related macular degeneration (ARMD) Deposition of yellow-white material in and under the retinal pigment epithelium (drusen). Results in slow progressive atrophy of the retinal pigment epithelium
137
Describe the onset of Dry Age-related macular degeneration (ARMD)
Slow progressive visual impairment over decades. Can be unilateral or bilateral
138
What is seen on fundoscopy in Dry Age-related macular degeneration (ARMD)?
Drusen Mottling Retinal pigment epithelium atrophy
139
Give 4 clinical features of Age-related macular degeneration (ARMD)
``` Contrast perception difficulty Hard to read and make out faces Poor night vision Visual fluctuations Scotoma Metamorphopsia= distortion of visual images ```
140
How is Age-related macular degeneration (ARMD) investigated and what extra tests can be done for Wet ARMD?
Fundoscopy Amsler grid Wet= OCT of macula, colour fundus photography, fluorescence angiography
141
How is Dry Age-related macular degeneration (ARMD) managed?
``` Supportive treatment Decrease risk factors- stop smoking, lose weight Antioxidants Increase vegetables in the diet Patient education ```
142
How is Wet Age-related macular degeneration (ARMD) managed?
4-6 weekly reviews Stop smoking Increase green leafy vegetable intake 1st line= VEGF inhibitor injection into vitreous body 2nd line= Laser coagulation, photodynamic therapy
143
What is papilloedema?
Optic disc swelling caused by raised intracranial pressure. Almost always bilateral
144
Give 3 causes of papilloedema
Space occupying lesion Malignant hypertension Hydrocephalus Hypercapnia
145
Give 4 signs on fundoscopy of papilloedema
``` Venous engorgement Loss of venous pulsation Blurring optic disc margin Elevation of optic disc Loss of optic cup ```
146
What symptoms may be present alongside papilloedema?
``` Headaches Nausea Vomiting Diplopia Pulse like ringing in the ears ```
147
Give 3 risk factors for optic atrophy
Glaucoma Ischaemia Compression of optic nerve Hydrocephalus
148
What is optic atrophy?
Death of the retinal ganglion cell axons that comprise the optic nerve. Occurs secondary to optic nerve damage. Loss of axons + shinkage of myelin leading to gliosis and optic cup widening
149
Give 2 clinical features of optic atrophy
Visual loss Scotoma Colour blindness
150
What is seen on fundoscopy in optic atrophy?
Pale optic disc | Sharp edges
151
What is an optic nerve head drusen and what does it look like on fundoscopy?
Globular calcified hyaline bodies located in the optic nerve head. Often an incidental finding Fundoscopy= blurred optic disc, irregular margins, pseudopapilledema, yellow-white nodules
152
What is optic neuritis?
Inflammation of the optic nerve commonly due to MS
153
Give 4 clinical features of optic neuritis
Unilateral decrease in visual acuity over days Poor discrimination of colours- red desaturation Pain on eye movements RAPD Central scotoma
154
How is optic neuritis managed?
High dose steroids | Will recover in 6 weeks
155
What is the pathophysiology of giant cell arteritis?
Cell-mediated immune response to endothelial injury. Results in inflammation and local vascular damage.
156
Give 3 risk factors for giant cell arteritis
``` Polymyalgia rheumatica Women >50 years old Genetic predisposition White ```
157
Give 5 clinical features of giant cell arteritis
``` Fever Weight loss New onset onset Loss of vision Night sweats Fatigue/malaise Jaw claudication Diplopia ```
158
How is giant cell arteritis diagnosed?
Need 3/5 of: - >50 years - Headaches - Temporal artery abnormality - Raised ESR (>50mm/h) - Histopathological abnormalities (from temporal artery biopsy)
159
How is giant cell arteritis managed?
High dose IV glucocorticoids --> prevents vision loss Low dose aspirin Low dose oral glucocorticoids for 1-2 years
160
Give 3 complications of giant cell arteritis
Permanent vision loss Cerebral ischaemia Aortic aneurysm
161
Give 3 causes of orbital cellulitis
Tooth infection Otitis media Orbital trauma Ophthalmic surgery
162
What is orbital cellulitis?
Infection of orbital contents such as the fat and extraocular muscles. Globe is not affected. It is a complication of URTIs especially bacterial rhinosinusitis
163
Give 4 clinical features of orbital cellulitis
``` Proptosis Ophthalmoplegia Fever Malaise Reduced vision Diplopia RAPD Ocular pain Eyelid swelling ```
164
How is orbital cellulitis managed?
Empirical IV antibiotics | Vancomycin + Ceftriaxone/Ciprofloxacin for 1-2 weeks
165
Give 3 predisposing factors of acute angle glaucoma
``` Female Advanced age Mydriasis Asian Eye injury ```
166
What is the pathophysiology of acute angle glaucoma and what is the difference between primary and secondary
Blocked trabecular network causes raised intraocular pressure Primary= due to anatomical features Secondary= due to scaring, lens luxation etc
167
Give 5 clinical features of acute glaucoma
``` Unilateral, inflammed, reddened and severely painful eye Frontal headache Nausea and vomiting Blurred vision + halo around light Cloudy cornea Unresponsive pupil- mid-dilated ``` Sudden onset- rapid, permanent vision loss
168
How is acute angle glaucoma investigated?
Hard globe on palpation Slit lamp Gonioscopy (Gold standard) Tonometry
169
How is acute angle glaucoma managed?
Eye drops- Timolol (beta-blockers), Apraclonidine Carbonic anhydrase inhibitor oral/IV- Acetazolamide Topical cholinergics- Pilocarpine Analgesia Antiemetics Surgery= Iridotomy
170
How is chemical conjunctivitis managed?
Irrigate with water until the pH returns to normal
171
Give 3 predisposing factors for retrobulbar haemorrhage
Vomiting after eye surgery Hypertension Orbital trauma Anticoagulation
172
What is the pathophysiology of retrobulbar haemorrhage
Rare, rapidly progressing sight-threatening emergency due to accumulation of blood in the retrobulbar space. Can lead to increased IOP, stretching of the optic nerve and blockage of vascular structures supplying the eye.
173
What are the clinical features of retrobulbar haemorrhage
``` Eye pain Periorbital bruising Eyelid haematoma Proptosis Visual loss Nausea and vomiting ```
174
How is retrobulbar haemorrhage managed?
Rapid intervention to prevent visual loss | Decompress orbit surgically
175
What is Keratoconjunctivitis sicca?
Unable to produce enough tears resulting in dry eyes
176
What conditions is Keratoconjunctivitis sicca associated with?
``` Diabetes Sjogren's Thyroid disorders RA Lupus ```
177
Give 3 predisposing factors for Keratoconjunctivitis sicca
>50 years Female Low vitamin A Contact lens use
178
Give 4 clinical features of Keratoconjunctivitis sicca
``` Stinging Scratching Red eye Photophobia Watery eyes Blurred vision FB sensation ```
179
How is Keratoconjunctivitis sicca prevented?
``` Sunglasses Take eye breaks from screens Dehumidifier Stop smoking Artificial tears ```
180
What is blepharitis?
Inflammation of the rims of the eyelids associated with seborrhoeic dermatitis, rosacea and acne
181
Give 3 symptoms of blepharitis
Burning Sore eyes Itching Lid cysts
182
How is blepharitis managed?
Eye hygiene Lid cleaning Topical antibiotics No cure- will have repeated episodes
183
What is herpes zoster ophthalmicus (HZO)?
HSV infection of ophthalmic branch of cranial nerve V
184
Give 4 symptoms of herpes zoster ophthalmicus (HZO)§
``` Pain Altered sensation on forehead unilaterally Malaise Headaches Fever ``` Eyes= vesicles on lid margins, episcleritis, keratitis, anterior uveitis, secondary glaucoma
185
How is herpes zoster ophthalmicus (HZO) managed?
``` Rest and fluids Avoid contact with elderly or pregnant Pain relief Topical lubricants Systemic antivirals ```
186
What is a hyphema?
A hyphema is an anterior chamber haemorrhage. The blood pools and can block the iris resulting in vision being blocked. It is painful and can cause permanent vision problems
187
Give 3 causes of hyphema
Trauma Sickle cell Haemophilia
188
Give 3 clinical features of hyphema
Visible blood in the front of the eye Photophobia Pain Cloudy vision
189
How is a hyphema managed?
Patch over the eye Bed rest Limit eye movements Daily eye pressure checks
190
What is a corneal abrasion?
Scratch of corneal epithelium
191
Give 4 causes of a corneal abrasion
``` Foreign body Entropion Prolonged contact lens use UV light Thermal burn Dry eyes Trauma ```
192
How is a corneal abrasion diagnosed?
Fluorescein staining
193
How is a corneal abrasion managed?
Removal of foreign bodies Analgesia Infection prophylaxis Eye patching
194
What is the prognosis of corneal abrasion
Usually heals within 48 hours with no follow up needed.
195
What is a corneal erosion?
Detachment of the corneal epithelium from the tissue layers below including the basement membrane and Bowman's membrane
196
Give 3 causes of corneal erosion
``` Corneal dystrophy Corneal ulcer Contact lens use Diabetes Dry eye ```
197
What is keratitis?
Inflammation of the cornea which can lead to irreversible vision loss
198
Give 3 risk factors for bacterial keratitis
Contact lens use Recent eye surgery Immunodeficiency
199
Give 2 potential bacterial causes of bacterial keratitis
Staph aureus Strep pneumoniae P. aeruginosa Syphilis
200
What are the clinical features of bacterial keratitis
``` Eye pain FB sensation Purulent discharge Photophobia Tearing Blurry vision Red eye ```
201
How is bacterial keratitis diagnosed?
Slit lamp and fluorescein staining +/- cultures
202
How is bacterial keratitis managed?
Topical broad spectrum antibiotics | Corticosteroids
203
What is herpes simplex keratitis?
Inflammation of the cornea due to reactivated HSV1 in the trigeminal ganglion
204
How is herpes simplex keratitis managed?
Topical ganciclovir Oral aciclovir Corneal transplant
205
What is herpes zoster keratitis?
Inflammation of the cornea due to reactivated HZV when ophthalmic nerve involved (shingles)
206
How is herpes zoster keratitis managed?
Oral aciclovir
207
What is posterior uveitis?
Inflammation of vitreous body, choroid and retina
208
Give 4 potential causes of posterior uveitis
``` CMV EBV Syphilis TB Toxoplasmosis Rubella HSV VZV Bechets SLE IBD Wegener's ```
209
How does posterior uveitis present?
Floaters Scotoma Blurred vision
210
What is seen on ophthalmoscopy in posterior uveitis?
Leukocytes in vitreous humour
211
What is anterior uveitis?
Inflammation of iris and ciliary body
212
Give 3 causes of anterior uveitis
``` Idiopathic RA Sarcoidosis IBD SLE ```
213
How does anterior uveitis present?
``` Dull progressive periocular pain Ocular hyperaemia Photophobia Blurry vision Increased lacrimation Hypopyon ```
214
How is anterior uveitis investigated?
Slit lamp Tonometry Conjunctival smear
215
How is anterior uveitis managed?
Glucocorticoids Cycloplegics Analgesia Antibiotics/antiviral
216
What is conjunctivitis?
Inflammation of the conjunctiva
217
How does viral conjunctivitis present?
``` Bilateral Clear, watery discharge Normal vision Conjunctival follicles FB Sensation Photophobia Discharge and crust Red eye ```
218
How does bacterial conjunctivitis present?
``` Unilateral Thick yellow purulent discharge Decrease in vision FB Sensation Photophobia Discharge and crust Red eye ```
219
How does allergic conjunctivitis present?
``` Itching Tearing Sneezing Ptosis FB Sensation Photophobia Discharge and crust Red eye ```
220
Give 3 causes of viral conjunctivitis
Adenovirus HSV VZV
221
Give 3 causes of bacterial conjunctivitis
Staph aureus Strep pneumoniae H influenzae Pseudomonas
222
What type of hypersensitivity reaction is allergic conjunctivitis?
Ig-E mediated | Type 1
223
How is bacterial conjunctivitis managed?
Topical broad spectrum antibiotic
224
How is viral conjunctivitis managed?
Topical antiviral | Cold compress
225
How is allergic conjunctivitis managed?
Avoid triggers Cold compress Antihistamines Corticosteroids
226
What is episcleritis?
Inflammation of the superficial, episcleral layer of the eye
227
Give 3 clinical features of episcleritis
``` Acute onset red eye Discomfort Aching FB sensation Watering Photophobia Recurring episodes Normal vision ```
228
Give 3 associated conditions with episcleritis
``` UC Crohns RA Polyarteritis nodosa SLE Wegener's Thyroid eye disease ```
229
How is episcleritis managed?
Artificial tears NSAIDs Review in 1 week (Self-limiting in 1-2 weeks)
230
What is scleritis?
Inflammation of the full thickness of the sclera
231
Give 3 associated conditions with scleritis
``` RA Granulomatosis SLE Ankylosing spondylitis Gout ```
232
Give 3 clinical features of scleritis
``` Gradual onset Severe boring eye pain Radiates to neck and jaw Worse at night and on eye movements Watering Photophobia Decrease in vision Diplopia Tender globe ```
233
How is scleritis managed?
Oral NSAIDs Immunotherapy= Methotrexate, Azathioprine Biological therapy= Infliximab
234
Explain the pathophysiology of pre-proliferative diabetic retinopathy
Hyperglycemia causes the capillary walls in the eye to become weak and so microaneurysms form. The microaneurysms burst and form haemorrhages deep in the retina called Dot and Blot haemorrhages. The weak vessels are also leaky which can collect under the macula and cause macular oedema. This results in visual loss. As the fluid dries it leaves behind hard exudates. Over time the vessels become obstructed which causes infarction in the nerve fibre layer which presents as cotton wool spots.
235
Describe early, moderate and late fundoscopy findings in pre-proliferative diabetic retinopathy
Early= microaneurysms Moderate= multiple microaneurysms, dot and blot haemorrhages, venous bleeding, cotton wool spots Late= 4-2-1 rule 4- diffuse intraretinal haemorrhages and microaneurysms in all 4 quadrants 2- venous bleeding in 2 quadrants 1- intraretinal microvascular abnormalities in >1 quadrant
236
What percentage of patients with severe pre-proliferative diabetic retinopathy will progress to proliferative diabetic retinopathy within a year?
75% within a year
237
Describe the pathophysiology of proliferative diabetic retinopathy
Prolonged ischaemia of the retina results in VEGF release which stimulates new growth of blood vessels (Neovascularization) The fibrovascular proliferation extends beyond the internal limiting membrane and into the retina and vitreous. Vessels are leaky, fragile and misdirected. As the vitreous shrinks with age the vessels tear causing vitreous haemorrhage and vision loss. Vessels can put tension on the retina and cause a retinal detachment which results in vision loss especially if the macula is involved. The new vessels can leak and cause macular oedema The new vessels can also grow into the anterior chamber which obstructs the trabecular meshwork causing acute glaucoma
238
How often are diabetics screened for retinopathy?
Annually | Every 3 months when pregnant
239
How is diabetic retinopathy investigated?
``` HbA1c Visual acuity Slit lamp IOP measurement- tonometry Gonioscopy Fundoscopy OCT ```
240
How is pre-proliferative diabetic retinopathy managed?
Tight glucose control (HbA1c <7%) Stop smoking Manage BP Laser therapy of microaneurysms
241
How is proliferative diabetic retinopathy managed?
``` Tight glucose control (HbA1c <7%) Stop smoking Manage BP Laser therapy of microaneurysms Photocoagulation Vitrectomy (if retinal detachment) ``` Macular oedema= anti-VEGF injections, corticosteroids

4. Senior Block- Special Senses (4 decks)

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