Opthalmology Flashcards
(140 cards)
1
Q
What are some common colour changes that may be seen in the eyes due to pathology?
A
Red (bleeding, inflammation)
Blue (thinning of sclera - RA, osteogenesis imperfecta)
Yellow (jaundice)
Brown/black (pigmentation)
2
Q
What are the main ‘red flag’ features of a red eye?
A
Impaired vision
Pain/photophobia
Lack of ocular discharge (if discharge present, more likely to be infection like conjunctivitis)
3
Q
What kind of ocular pathology causes rapid onset of visual loss?
A
Central retinal artery occlusion (cherry red spot in macula) - e.g. amaurosis fugax Central retinal vein occlusion Giant cell arteritis Retinal detachment Vitreous haemorrhage
4
Q
What kind of ocular pathologies cause slow onset loss of vision?
A
Degenerative causes, e.g. Age-related macular degeneration
5
Q
What is acute angle closure glaucoma?
A
Rare but serious cause of red eye
Associated with raised IOP (>21 mmHg)
6
Q
Give 3 RFs for acute angle closure glaucoma
A
1) Hypermetropia (long-sightedness)
2) Increase in age
3) Pupillary dilatation (i.e. pain comes on sitting in the cinema watching a movie)
7
Q
What are the symptoms of acute angle closure glaucoma?
A
Severe pain (eye pain or headache) Decrease in visual acuity Worse with dilated pupil (TV in dark room) Red eye Haloes around lights Systemic upset (N+V, abdo pain) Photophobia
8
Q
What are the signs of acute angle closure glaucoma?
A
Red eye
Semi-dilated, non-reacting pupil
Corneal oedema
Poor visual acuity
9
Q
What type of visual loss does acute angle closure glaucoma cause?
A
Peripheral visual field deficits
10
Q
How is acute angle closure glaucoma investigated?
A
Slit lamp examination Gonioscopy Automated perimetry (to assess visual field) Measure IOP Visual field loss on assessment
11
Q
How is acute glaucoma managed?
A
Urgent referral to ophthalmology
1) Lower the pressure (topical beta blockers [timolol] + carbonic anhydrase inhibitor [PO/IV acetazolamide])
2) Constrict the pupil (pilocarpine drops - topical cholinergic agonist)
3) Prevent recurrence (laser iridotomy - hole in iris)
12
Q
Give 2 drugs that can be used to reduce IOP in acute angle closure glaucoma
A
Timolol (topical beta blocker)
Acetazolamide (PO/IV carbonic anhydrase inhibitor)
13
Q
What is the definitive treatment for acute angle closure glaucoma?
A
Laser iridotomy
14
Q
What is chronic glaucoma/primary open angle glaucoma?
A
Progressive optic neuropathy associated with visual field loss and raised IOP
15
Q
What are the RFs for chronic glaucoma?
A
Increasing age Fix Myopia (short-sightedness) Hypertension Diabetes mellitus Afro-Caribbean origin
16
Q
What are the clinical features of chronic glaucoma?
A
Triad of:
1) Raised IOP (>21 mmHg)
2) Abnormal disc
3) Visual field defect (tunnel vision)
17
Q
What are the symptoms of chronic glaucoma?
A
Decreased peripheral vision (nasal scotoma leading to tunnel vision)
Insidious onset
Often asymptomatic
Routine finding during opticians appointment
Decreased visual acuity
18
Q
How is chronic glaucoma investigated?
A
Fundoscopy Automated perimetry (assess visual fields) Slit lamp examination Automated tonometry (measure IOP) Gonioscopy (checks drainage angle)
19
Q
What are the signs of chronic glaucoma on fundoscopy?
A
Optic disc cupping (Cup:Disc ratio >0.66) Optic disc pallor (optic atrophy) Bayonetting of vessels Cup notching Disc haemorrhage
20
Q
How is chronic glaucoma treated? Give a side effects each.
A
Eye drops!
1) Latanoprost (prostaglandin analogues)
2) Timolol (BB)
S/E:
latanoprost - increased eyelash length
timolol - watch out in asthmatics and heart failure (drains to nose - very vascularised)
21
Q
What is age-related macular degeneration (ARMD)?
A
Most common cause of blindness in the UK
Degeneration of the central retina (macula)
22
Q
What is the epidemiology of ARMD?
A
Females > males
Avg age of presentation >70 yrs
23
Q
What are the RFs for ARMD?
A
Increasing age Smoking FHx HTN Dyslipidaemia DM
24
Q
What are the symptoms of ARMD?
A
Central visual loss Wavy lines (distortion of line perception) Poor night vision Flickering/flashing objects Glare around objects
25
Wet vs Dry ARMD.
Which is more common?
What is a key feature of each?
Which carries the worse prognosis?
Dry:
90% cases
Asociated with DRUSEN in Bruch's membrane
Wet
10% cases
Choroidal neurovascularisation
Worse prognosis
26
Give 3 investigations done in ARMD?
1) Gold standard = Slit lamp microscopy with colour fundus photography
```
Ocular coherence tomography (OCT)
Fluorescein angiography (looking for neovascularisation - wet ARMD)
```
27
What will be seen on fundoscopy in someone with:
a) Dry ARMD?
b) Wet ARMD?
a) Dry: Drusen in Bruch's membrane
| b) Well-demarcated red patches (haemorrhages)
28
How is dry ARMD managed?
Vitamins ACE to Z
(vitamin A, C, E and zinc)
Maybe blind registration and visual aids
29
How is wet ARMD managed?
Anti-VEGF infections (e.g. ranibizumab)
| Slows/prevents progression of neovascularisation
30
What is the leading cause of blindness worldwide?
Cataracts
31
What are cataracts?
Lens gradually opacifies
More difficult for light to reach retina
Leads to decreased visual acuity and blurred vision
32
Give some causes of cataracts
```
Normal ageing (most common)
Smoking, Alcohol, DM
Trauma
STEROIDS
Radiation, metabolic disorders
Congenital (e.g. due to TORCH infections)
```
33
How does the type/classification of cataract relate to its cause?
Nuclear - old age
Polar - inherited
Subcapsular - Steroid use
Dot opacities - common in normal lenses, also seen in diabetes and myotonic dystrophy
34
What are the symptoms of cataracts?
```
Gradual onset
Decrease in vision
Faded colour vision
Flare (lights brighter than normal)
Haloes around lights
```
35
What hallmark sign of cataracts can be elicited on examination?
Defect in/loss of red reflex
36
What investigations need to be done for cataracts?
1) Opthalmoscopy on DILATED PUPIL (normal fundus, normal optic nerve)
2) Slit lamp examination (shows visible cataracts)
37
How are cataracts managed?
Conservative (stronger glasses, encourage use of brighter lighting)
SURGERY = definitive Rx. Phacoemulsification - remove cloudy lens and replace with an artificial one.
38
What are some possible complications of cataract surgery?
Posterior capsule opacification (thickening of lens capsule)
Retinal detachment
Posterior capsule rupture
Endophthalmitis (inflammation of aqueous +/or vitreous humour)
39
What is vitreous detachment?
Precursor to retinal detachment
| Also causes flashes and floaters
40
What is retinal detachment?
Sudden, painless loss of vision
Holes/tears in retina allow fluid to separate the sensory retina from the visual pigmented epithelium
41
Where will the visual loss be in a superior retinal detachment?
Inferior field loss
42
Give 6 RFs for retinal detachment
```
Myopia
Cataract surgery
Diabetes
Hypertension
Trauma
Vasculitis
```
43
How does retinal detachment present?
Straight lines appear curved
Flashes + Floaters
Fall in acuity (painless)
Field loss (veil/curtain loss)
Complain of seeing 'spider webs'
44
What investigations are done for retinal detachment?
B-scan USS = best test - flying-angel sign
Ophthalmoscopy
Fundoscopy - Schaffer's sign
Slit lamp examination - billowing
Showing: grey, opalescent retina which balloons forwards
45
How is retinal detachment managed?
```
Urgent referral to ophthalmology
Rest
Positioned according to location of detachment
Laser therapy
Urgent surgery
```
46
What is vitreous haemorrhage?
Bleeding into areas around the vitreous humour
Causes SUDDEN PAINLESS LOSS OF VISION
47
Give 6 RFs for vitreous haemorrhage
```
Diabetes
Bleeding disorders
Retinal tear/detachment
Trauma
CRVO which has neovascularised
Wet ARMD
```
48
What are the symptoms of vitreous haemorrhage?
Small bleed = floaters, dark spots
| Large bleed = obscured/ complete loss of vision
49
What are the signs of vitreous haemorrhage on examination?
Absent red reflex
| Retina not visible
50
What investigations should be done for vitreous haemorrhage?
Fundoscopy
B-scan (specialised eye USS)
Eye examination showing decreased visual acuity
51
How is vitreous haemorrhage managed?
Usually spontaneously resorbs
| If dense/severe = vitrectomy to remove the blood
52
What is a central retinal artery occlusion (CRAO)?
Form a stroke
Dramatic visual loss within seconds of occlusion
Acuity limited to finger counting or worse
Less common than CRVO
53
Give 6 RFs for central retinal artery occlusion
```
Thromboembolic/vascular disease
Arteritis (e.g. GCA)
AF
Heart valve disease
Diabetes
Smoking
Hyperlipidaemia
```
54
What are the features of CRAO?
Sudden painless loss of vision
55
What are the signs of CRAO?
Marcus-Gunn pupil (relative afferent pupil defect - RAPD)
Signs on fundoscopy:
1) White retina
2) Cherry red spot on macula
56
How is CRAO managed?
```
Treat as stroke - local stroke protocol
Immediate CT head
Exclude GCA (ESR)
Intraocular hypotensives (acetazolamide)
Decrease IOP by ocular massage
```
Long term = address CV RFs to reduce risk of recurrence
57
What is central retinal vein occlusion?
Sudden, painless LOV
| More common than CRAO
58
What are 6 RFs/ causes of CRVO?
```
Glaucoma
Polycythaemia
Hypertension
Diabetes mellitus
Increasing age
Vascular disease
```
59
What are the symptoms of CRVO?
Sudden painless loss of vision
| Severe drop in acuity
60
What are the signs of CRVO on fundoscopy?
```
Cotton wool spots
Swollen optic nerve
Macular oedema
Severe retinal haemorrhage
Tortuous and engorged retinal veins
```
'cheese and tomato pizza appearance'
61
How is CRVO managed?
Call ophthalmology urgently
Intra-vitreal anti-VEGF therapy
Dexamethasone implants
62
What are some complications of CRVO?
Neovascularisation
| Chronic macular oedema
63
What is optic neuritis?
Inflammation of the optic nerve
64
What are the causes of optic neuritis?
```
MS = most common
Syphilis
Diabetes
Leber's optic atrophy (hereditary visual loss)
Vitamin deficiency
```
65
What are the symptoms of optic neuritis?
Unilateral, subacute LOV
Pain on eye movement
Dyschromatopsia (poor colour vision discrimination)
66
What are the signs of optic neuritis?
Marcus-Gunn pupil (RAPD - seen on swinging light test)
Central scotoma (areas of depressed vision)
Decrease in visual acuity on eye examination
67
How is optic neuritis managed?
HIGH DOSE STEROIDS
- IV methylprednisolone for 72 hours
- then oral pred for 11 days
MRI if ?MS
Most make a full recovery within 2-6 weeks
68
What is retinitis pigmentosa?
Inherited degeneration of the retina
More common in males
Can be inherited AD, AR, or X-linked
69
What are the features of retinitis pigmentosa?
```
NIGHT BLINDNESS = first sign
Tunnel vision
Central daytime visual loss follows
Eventual blindness
FHx
```
70
Which diseases are associated with retinitis pigmentosa?
Usher syndrome - most common, affects hearing and vision
Alport syndrome - kidney disease, hearing loss, eye abnormalities
etc
71
What are the signs of retinitis pigmentosa on fundoscopy?
Mottling
| Black bone spicule shaped pigmentation in peripheral retina
72
How can retinitis pigmentosa be managed?
Visual aids and blind registration
Electrical stimulation of retinal ganglion cells
Novel therapies (neural prosthetics)
73
What is diabetic retinopathy?
Microangiopathy causing damage to small blood vessels of retina (result of hyperglycaemia)
Causes gradual decrease in CENTRAL vision
74
How can diabetic retinopathy be classified?
1) Background
2) Pre-proliferative
3) Proliferative
4) Advanced
75
What are the features of 'background' diabetic retinopathy?
Dots, blots and spots:
1) Microaneurysms (dots)
2) Blot haemorrhages (= 3)
3) Hard exudates
76
Features of pre-proliferative diabetic retinopathy?
1) Cotton wool spots - dead nerve cells
2) >3 blot haemorrhages
3) Venous beading/looping
4) Dark cluster haemorrhages
More common in T1DM
77
What are 'cotton wool spots'? What condition are they seen in?
Dead nerve cells
| Seen in pre-proliferative diabetic retinopathy and hypertensive retinopathy
78
What is the key feature of proliferative diabetic retinopathy?
Why does this occur?
Retinal neovascularisation - due to insufficient retinal perfusion and subsequent ^production of VEGF
79
Give 4 complications of advanced diabetic retinopathy
1) Recurrent vitreous haemorrhage (from bleeding areas of neovascularisation)
2) Retinal detachments
3) Rubeosis (neovascularisation occurs at iris)
4) Progressive glaucoma
80
How is diabetic retinopathy treated?
Good glycaemic control
Laser treatment
Intravitreal steroids
Anti-VEGF
81
What is diabetic maculopathy?
Hard exudates + other 'background changes' on the macula
Check visual acuity
More common in T2DM
Rx: laser therapy
82
What is hypertensive retinopathy?
Symptoms?
Cause?
Eye disease/damage from hypertension
Usually asymptomatic. May cause reduced visual acuity and headaches.
Can occur from chronic, poorly controlled hypertension or malignant hypertension
83
What may cause accelerated hypertensive retinopathy?
```
Exacerbation of essential HTN
Intrinsic renal disease
Renal artery stenosis
Phaeochromocytoma
Cushing's and Conn's
```
84
Give 4 features of hypertensive retinopathy seen on fundoscopy?
Arteriovenous nipping (Grade II)
Flame haemorrhages
Cotton wool spots
Papilloedema (Grade IV)
85
What are the Keith-Wagener classification stages of hypertensive retinopathy?
Stage I - arteriolar narrowing + tortuosity, increased silver light reflex (silver wiring)
Stage II - arteriovenous nipping
Stage III - spots, dots and blots (cotton wool spots, exudates, flame haemorrhages)
Stage IV - papilloedema
86
What are some other causes of poor vision in hypertension?
Acute optic nerve damage
Macular oedema
Retinal artery closure/occlusion
Choroidal ischaemia
87
How is hypertensive retinopathy managed?
Control hypertension
Manage stroke risk
Regular eye checks for hypertensive patients - at least yearly
88
Red eye. What is subconjunctival haemorrhage?
Bleeding beneath the conjunctiva - several small fragile vessels that are easily ruptured/broken
89
Red eye. Give 4 features of subconjunctival haemorrhage?
Sudden onset
Bright red blood (stays bright red as Hb easily oxygenated from the atmosphere)
Distinct border
Blood spreads freely so small haemorrhage can easily cover the whole globe
90
Red eye. What are the causes of subconjunctival haemorrhage?
```
Trauma to the eye
Heavy bouts of coughing
Contact lenses
Hypertension
Bleeding disorders
Diabetes mellitus
CHD/vascular disease
Medications - warfarin, aspirin, NSAIDs, steroids
Febrile systemic infections
May occur spontaneously in the elderly
```
91
How is subconjunctival haemorrhage managed?
Conservative (no official Rx required)
| May want to look for orbital/ocular injury if caused by trauma
92
What is anterior uveitis?
aka Iritis
Important differential of a red eye
Painful red eye with decreased visual acuity
93
Give 3 conditions associated with anterior uveitis
1) Seronegative arthropathies (HLA B27) e.g. ank spond, psoriatic arthritis, enteropathic arthritis, IBD
2) Granulomatous disease, e.g. sarcoidosis, syphilis
3) Behcet's disease: mouth + genital ulcers, skin rashes, etc
94
Give 5 symptoms of anterior uveitis?
1) acute, painful red eye
2) unilateral
3) photophobia
4) blurred vision
5) lacrimation
95
Give 5 signs of anterior uveitis
Intense redness of the globe
Normal/decreased acuity
Irregular small pupil
Hypopyon (pus in outer chamber - looks like white dots, visible fluid level)
Ciliary flush (ring of red and purple spreading out from cornea)
96
What is the name for the collection of white cells seen in the outer chamber of the eye in anterior uveitis? What is it?
Hypopyon
| Collection of pus and inflammatory cells
97
How is anterior uveitis managed?
1) Dilate eye to relieve pain and photophobia (Atropine or cyclopentolate)
2) Urgent r/v by ophthalmology
3) Steroid eye drops
98
What is episcleritis? Key features? Rx?
Common, benign, mild irritation of the eye.
Localised redness
Watery, mild photophobia
No discharge or loss of vision
Rx: NSAIDS if pain, if needed - eyedrops to ease irritation
99
How do you differentiate between episcleritis and scleritis?
Scleritis is PAINFUL (episcleritis is not)
Phenylephrine drops - will not blanch the scleral vessels, so if eye redness improves after phenylephrine then diagnosis of episcleritis can be made
100
What is scleritis?
Rare, serious condition. Associated with SLE, RA, any form of vasculitis
People with RA may also have blue sclera
101
What are the key features of scleritis?
| Rx?
V painful red eye
Loss of vision, watering, photophobia
Rx: Oral NSAIDs, oral prednisolone, cyclophosphamide (to tackle causative vasculitis)
102
What are the complications of scleritis?
```
Scleral thinning
Ischaemia of the anterior segment of the globe
Raised IOP
Retinal detachment
Uveitis
Cataract
Phthisis (globe atrophy)
```
103
What is keratitis?
| Most common cause?
Infection/inflammation of the cornea
| Herpes simplex virus
104
How does HSV (herpes) keratitis tend to present?
DENDRITIC SHAPE corneal ulcer
```
Red, painful eye
Photophobia
Epiphora (excessive eye watering)
Decreased visual acuity (sometimes)
Foreign body sensation
```
105
Investigations for HSV keratitis?
Fluorescein staining to look for dendritic ulcer
106
How is HSV keratitis managed?
Urgent referral to ophthalmology
Topical acyclovir
AVOID STEROIDS
107
Why is it important to avoid steroids in HSV keratitis?
Can cause enlargement of the dendritic ulcer
108
What is a corneal abrasion? How does it present?
Any defect of corneal epithelium.
Most commonly occurs following trauma
Features: pain, photophobia, foreign body sensation, decreased acuity, conjunctival injection
109
How is corneal abrasion investigated?
Fluorescein staining + slit lamp examination
| Yellow-stained abrasion will show up
110
How is corneal abrasion managed?
Topical antibiotics to prevent bacterial superinfection (e.g. Chloramphenicol)
111
What is a corneal ulcer?
Corneal epithelium defect (abrasion) with underlying inflammation/infection
112
Causes/RFs for corneal ulcer?
Contact lenses
Infection with bacteria, fungi, viruses, etc
Can be initiated by mechanical trauma or nutritional deficiencies
113
Give 3 features of corneal ulcer
Eye pain
Photophobia
Watery eye
114
Investigations for corneal ulcer?
Focal fluorescein staining
115
How do you manage a corneal ulcer?
Stop contact lenses for 1 week
Cool compress
Good hygiene (no sharing towels, wash hands, avoid eye make up)
Topical Abs - Chloramphenicol
116
What is conjunctivitis, and what are the 3 main types?
```
Inflammation of conjunctiva.
3 main causes:
1) Viral
2) Bacterial
3) Allergic
```
Also think about reactive arthritis (can't see, can't spee, can't climb a tree)
117
What are the general features of conjunctivitis?
Sore, red eyes
| Sticky discharge
118
Features of bacterial conjunctivitis?
Common causative organisms?
Rx?
Purulent discharge, starts unilateral and spreads to bilateral
Staph/strep/haemopilus/neisseria/chlamydia
Self-limiting. General advice (no contact lenses, don't share towels, no need for school exclusion).
May give chloramphenicol (or fusidic acid if pregnant)
119
Features of viral conjunctivitis?
Common cause?
Management?
Serous discharge, recurrent URTI, pre-auricular lymphadenopathy
Adenovirus
Self-limiting. Oral analgesia + eye drops (symptomatic relief). General advice (lenses, towels, no school exclusion)
120
Features of allergic conjunctivitis?
| Management?
Often seen with hayfever. Hx atopy etc. Swollen eyelids. Large papillae.
1st line: topical/systemic antihistamines
2nd line: topical mast-cell stabilisers (sodium cromoglicate)
121
What is non-arteritic ischaemic neuropathy?
| Important differential
Ageing process assoc w/ poor blood supply to optic nerve. See swollen optic disc but NOT associated with inflammation.
Key Ddx: GCA
122
Complications of non-arteritic ischaemic neuropathy?
Diplopia
| Emboli can cause central retinal artery occlusion (CRAO)
123
How is non-arteritic ischaemic neuropathy managed?
High dose steroids
| IV methypred 3 days, then oral pred
124
Features of Horner's?
Miosis (constricted pupil)
Ptosis
Anhidrosis (lack of sweat)
Enophthalmos (eye retracts into head)
125
What are 4 causes of Horner's?
Central: Stroke, MS
Pre-ganglionic: Pancoast tumour
Post-ganglionic: Carotid artery dissection
126
Management of Horner's?
Treat underlying disease
127
Give 3 eye diseases associated with rheumatoid arthritis
Scleritis
Episcleritis
Secondary Sjogren's with sicca complex (dry eyes)
128
What are the causes of papilloedema?
```
SOL
Malignant hypertension
Idiopathic intracranial hypertension
Hydrocephalus
Hypercapnia
```
Rarer (hypoparathyroidism, hypocalcaemia, vitamin A toxicity)
129
Give 6 features of papilloedema on fundoscopy
```
Venous engorgement
Loss of venous pulsation
Blurring of optic disc margin
Elevation of optic disc
Loss of optic cup
Paton's lines (concentric/radial retinal lines cascading from the optic disc)
```
130
Give 6 causes of tunnel vision
```
Papilloedema
Glaucoma
Retinitis pigmentosa
Choridoretinitis
Optic atrophy
Hysteria
```
131
What is optic atrophy?
PALE optic disc on fundoscopy
Well demarcated
Usually bilateral
Causes gradual visual loss
132
What are some acquired causes of optic atrophy?
```
MS
Papilloedema (chronic)
Raised IOP (glaucoma, tumour)
Retinal damage (retinitis pigmentosa)
Ischaemia
Vitamin deficiencies (B1, B2, B6, B12)
```
133
What are some congenital causes of optic atrophy?
Freidrich's ataxia (AR)
| Leber's optic atrophy (mitochondrial inheritance)
134
3 differentials for lump in eyelid?
Stye
Chalazion
BCC
135
2 different types of lid positioning problems?
Entropion (needs surgical correction - eyelashes can cause scarring)
Ectropion
136
What are the 7 key causes of red eye?
```
Acute angle closure glaucoma
Scleritis
Anterior uveitis (iritis)
Keratitis
Periorbital cellulitis
```
137
Give 2 causes of floaters
Posterior vitreous detachment
Retinal detachment
Diabetic retinopathy
138
What 3 investigations would you do in retinal detachment, and what would you see?
1) Fundus photography - Schaffer's sign (pigment in anterior vitreous)
2) Ophthalmoscopy
3) B-mode USS - flying angel sign
139
2 causes of retinal detachment?
Retinal tears
Trauma
Recent cataract surgery
140
What are the DVLA requirements for vision?
Need combined visual acuity of at least 0.5 (6/12)
