Opthalmology Flashcards
(318 cards)
1
Q
what does this image show
A
Cataract on slit lamp examination
2
Q
What is a cataract?
A
a very common cause of gradual visual loss caused by the opacification of the crystaline lens
3
Q
what are the causes of cataracts?
A
- Ageing
- trauma
- metabolic disorders eg galacosemia
- medications
- congenital problems
4
Q
what medications cause cataracts?
A
PC SAAD
- corticosteroids
- allopurinol
- aspirin
- chloroquine
- diuretics
- phenothiazines
- simvastatin
5
Q
What is the main presentation of cataract?
A
Gradual visual loss
visual acuity depends on the type of cataract
6
Q
what are the types of cataracts?
A
- Cortical
- subcapular
- Star flower
- congenital
- nuclear
7
Q
describes the typical symptoms of a cortical cataract?
A
Good visual acuity
may complain of halos around lights and glare
can cause double vision or fractured vision
8
Q
describe the symptoms of a subcapsular cataract?
A
Good vision in dim lighting on dilation
worse in bright lights
9
Q
describe the cause of a star flower cataract?
A
Trauma
10
Q
describe a nuclear cataract presrentation?
A
the most common type of cataract
associated with increased ageing
causes blurred vision and washed out colours
11
Q
on examination of the patient who presents with :
- gradual decreased visual acuity
you find there is:
- diminished red light reflects
- normal fundus and optic nerve reduced visual acuity
slit lamp examination shows:
- a cloudy anterior chamber
what is the diagnosis?
A
cataract
12
Q
what is the management of a cataract?
A
Surgical
13
Q
what are some intraoperative complications of cataract surgery?
A
Lens capsule rupture
haemorrhage
14
Q
what are some post-operative complications of cataract surgery?
A
Lens dislocation
capsule opacification
infection and inflammation / post op endopthalmitis
15
Q
what does this image show?
A
small white crystalline drusen
16
Q
what does this image show?
A
Larger confluent soft drusen
17
Q
what does this image show?
A
Dry macular degeneration
- pigmented epithelium
- choroid and retinal clumping
- geographical atrophy
- drusen
18
Q
what does this image show?
A
Wet macular degeneration
- chorodial neurovascular membranse
- sub- retinal haemorrhages and exudates
- localised retinal detachment - which can then cause retinal scarring appearing as a black blob
19
Q
what is the macula?
A
where visual acuity is at its highest
Has functioning rods and cones
20
Q
what is the fovea?
A
Located at the centre of the macula
there are only cones
this is where there is the best visual acuity
21
Q
what is macular degeneration?
A
mainly an age-related condition
causing a gradual visual loss
early stages are associated with normal or near normal vision
later stages have decreased visual acuity and eventual loss of central vision
22
Q
what are the two types of macular degeneration?
A
Wet/ dry
23
Q
describe the pathophysiology behind dry macular degeneration?
A
There is atrophy of the retina
24
Q
describe the pathophysiology behind wet macular degeneration?
A
There is new vessel growth under the retina
25
what sign do both types of macular degeneration share in the initial stages of the disease process?
drusen
26
In dry macular degeneration what is the most common presenting complaint?
Central Scotoma (visual loss) with good peripheral vision but which deteriorates
lead to legal blindness – is the most common cause of legal blindness in the UK
27
what is the management of dry macular degeneration?
Low vision aids
limited evidence for nutritional supplements and antioxidants
28
what is the most common presenting complaint of wet macular degeneration?
Distorted vision
micropsia leading to central's scotoma's
has faster visual loss then with dry macular degeneration
29
what is the management of wet macular degeneration?
rapid referral treating with injections of anti-TNF beta- macugen
or
laser after IV photosensitive drugs- verteporfin (if under the fovea)
30
how can you differentiate between wet and dry macular degeneration?
florosine test
31
What is the angle?
The name given to the space between the posterior surface of the cornea and the interior surface of the iris
it is where the aqueous leaves the eye
32
what is aqueous?
Nourishing fluid for the lens made by the ciliary body entering through the eepiscleral veins
33
what range should put the intraocular pressure be?
\< 21
34
What is the pathophysiology of open angle glaucoma?
Dysfunction of the outflow of aqueous humour
due to obstruction in the draining
causes an increase of intraocular pressure
35
what does this image show?
Glaucoma characterised by :
an increased cup:disc ratio and notching of the optic nerve
36
A patient present with:
* Halos around lights
* aching brow pain
* headaches nausea and vomiting
* reduced visual acuity
* eye redness
on examination you note:
* elevated intraocular pressure
* corneal oedema
* fixed dilated pupil
**what is your diagnosis?**
acute or subacute angle closure glaucoma
37
in more advanced disease what is the presentation of open and glaucoma?
Peripheral visual loss leading to Scotoma
38
what is the management of open angle glaucoma?
Observation of ocular hypertension with regular checkups
use of :
* topical beta-blockers - timodolol
* prostanoids - latanoprist
* carbonic anhydrases - dorzolamide
* alpha agonists - bromide
in more severe cases:
**carbonic anhydrase inhibitors** acetalozalamide --\> **surgery**
39
what is the pathophysiology of angle closure glaucoma?
An urgent but uncommon dramatic symptomatic events
there is closure of the anterior chamber angle
results in elevation of intraocular pressure
usually sudden but can be chronic
40
what other risk factors associated with angle closure glaucoma?
* Female
* hyperopia
* another eye having it
* shallow peripheral anterior chamber
41
when is chronic angle glaucoma usually diagnosed?
When still asymptomatic on regular eye checks
42
When is open angle glaucoma usually detected?
On regular eye checkups as open angle glaucoma is usually asymptomatic until more advanced disease
43
what investigating is diagnostic for angle closure glaucoma?
gorioscopy
plus checking IOP and visual fields
44
What is the acute management of angle closure glaucoma?
This is a medical emergency and requires immediate referral
treatment is through decreasing intraocular pressure using:
* PO acetazalamide and iv mannitol
45
what can be done to prevent angle closure glaucoma from occurring again?
iridotomy
46
what is optic neuritis?
Inflammation of the optic nerve
47
what causes optic neuritis?
* idiopathic usually
* MS
* sinus infections
* vericella zoster virus
* syphilis
* sarcoidosis
* lupus
48
what does this image show?
**optic neuritis:**
Pale optic disc
inflammation / swelling of the optic disc
49
what is the presentation of optic neuritis
acute or subacute onset of pain (peri orbital or reticulo bulbar)
* getting worse with movements
loss of vision
visual acuity gets worse after one to 2 weeks
usually there is almost full recovery
colour desaturation
**relative afferent pupillary defect**
50
what investigations should you perform in optics neuritis?
MRI of the optic nerves – MS
if the history is suggestive of other causes then investigate those:
* serum ACE- increased in sarcoidosis
* ana - positive in SLE
* VDRL - positive in syphilis
* PCR for varicella
51
how do you treat optic neuritis?
Steroids speed recovery - PO prednisolone
but it does not improve outcomes
52
if optic neuritis occurs repeatedly or for a prolonged period of time what can happen to the optic nerve?
atrophy and become pale
53
how can toxoplasmosis causes secondary optic neuritis?
there is an area of neuro retinitis close to the optic nerve
causing it to become swollen
54
how do you treat secondary optic neuritis to toxoplasmosis?
Steroid and antibiotics
55
what does this image show?
* Micro aneurysms and cotton wool spots
* intra retinal haemorrhages
* lipid exudates and macular haemorrhages
* macular oedema can occur
**Diabetic retinopathy**
56
what are the two types of diabetic retinopathy?
non-proliferative
proliferative
57
described non-proliferative diabetic retinopathy
It is the early stages of the disease and is less severe
blood vessels become leaky and fluid leaks into the retina
causing blurred vision
58
describe proliferative diabetic retinopathy
New blood vessels grow which are fragile
these can haemorrhage really quickly
this can cause vision loss and scarring
59
what is the pathophysiology of diabetic retinopathy?
There is progressive diabetic microvascular leakage and occlusions
With then progressive proliferation of vessels
60
what is the presentation of diabetic retinopathy?
Floaters
blurred vision
vision loss
61
when is diabetic retinopathy usually diagnosed?
In the early stages of disease through diabetic eye screening
62
what should you do if you suspect macular oedema in diabetic retinopathy or otherwise?
order optical coherence tomography
63
what is diabetic maculopathy?
Diabetic maculopathy is a condition that can result from retinopathy
Maculopathy is damage to the macula - the part of the eye which provides us with our central vision
64
what should you do if you suspect diabetic maculopathy?
Order fluorescein angiography
laser treatment
65
what does a fluorescent angiography show?
shows blood vessels and capillary non-perfusion
plus shows the formation of new vessels and haemorrhages
66
what investigation is required if you suspect retinal detachment?
Beta scan occular ultrasound
a non invasive tool for diagnosing lesions of the posterior segment of the eyebal
67
what is the management of diabetic retinopathy?
diabetic control
injections of anti-vascular endothelial growth factor
laser
surgery
68
What does this image show?
**retinal artery occlusion of the central artery**
* thin retinal arteries
* retinal oedema and pallor
* optic disc becomes pale after months
* you see a cherry red spot
69
what does this image show?
**Retinal artery occlusion of a branch artery**
* retinal pallor following the branch of the artery thats occluded
* narrowing of the artery after the embolus
70
what causes retinal artery occlusion?
Embolus or atherosclerosis from the carotid artery
* reaching the ophthalmic artery or a branch of it in the eye
71
what is the presentation of retinal artery occlusion?
Sudden almost total loss of vision- central occlusion
if visual field loss – branch occlusion
72
what is the relevant afferent pupillary defect like in retinal artery occlusion?
relevant afferents pupillary defect is usually still present
73
What investigations should you perform in retinal artery occlusion?
Usually diagnosis is just through the fundoscopy
a carotid Doppler can be used to aid diagnosis
74
what is the management of retinal artery occlusion?
Urgent referral with therapeutic intervention in 4-6 6 hours
75
what is transient monocular visual loss a symptom of?
It is a symptom of TIA
76
what is a presentation of transient monocular visual loss?
Describe as a curtain coming over vision
lasting around 30 minutes
full recovery after
77
what does this image show?
Flame haemorrhages due to the inability to drain blood
* if it is localised it indicates a branch occlusion
* widespread indicating that central occlusion
78
what is retinal vein occlusion?
An interruption of normal venous drainage from the retinal tissue
causing symptoms of acute visual loss
it can be central or one of its branches
79
what is the presentation of retinal vein occlusion?
Painless sudden vision loss - central
blurring of vision and field defects- branch
almost always unilateral
80
what risk factors are associated with retinal vein occlusion?
* Hypertension
* diabetes
* atherosclerosis
* glaucoma
* increased age
81
how do you confirm the diagnosis of retinal vein occlusion?
Fluorescein angiography
82
how do you manage retinal vein occlusion?
injections of anti tVEGF
* such as rabibizumab or bevacizumab
83
what proportion of patients with retinal vein occlusion will develop ischaemia?
1/3
84
how does central retinal vein occlusion with ischaemia differ from vein occlusion without ischaemia on funduscopy?
There isn't much haemorrhage in CRVO with ischaemia
and you would see:
* swelling of the optic disc
* with cotton wool spots
85
what is a complication of central retinal vein occlusion with ischaemia?
Neovascularisation requiring laser treatment
86
What does this image show?
**anterior ischaemic optic neuropathy**
Looks very similar to vein occlusion but just occurring much closer to the optic disc and nowhere else
near the optic disc you would find:
* flame haemorrhages
* some cotton wool spots
87
what is anterior ischaemic optic neuropathy?
Interruption of the blood flow to the front of the optic nerve
causing loss of vision as visual information is not passed on to the brain
can be arteric or non arteric
88
what is the most common cause of arteric anterior ischaemic optic neuropathy?
giant cell arteritis
89
what are the most common causes of non arteric anterior ischaemic optic neuropathy?
1. drop in blood pressure
2. increased intraocular pressure
3. narrowed arteries/ viscous blood
4. vasculitis
90
which is most common arteric or non arteric (ischemic optic neuropathy)?
non arteric
91
if you suspect that anterior ischaemic optic neuropathy has been caused by giant cell arteritis what should you do?
1. then give immediate high-dose corticosteroids (pred) and reffer for same day assessment by rheumatologist/opthalmologist for eye involvement
2. Perform urgent blood tests of ESR CRP and FBC
3. temporal artery biopsy is then required to confirm (usually)
92
what is the presentation of anterior ischaemic optic neuropathy?
sudden painless loss or blurring of vision usually most noticeable after waking from sleep
wost after about two weeks
93
what is the afferent pupillary reflexes like in anterior ischaemic optic neuropathy?
always present
94
what is the management of anterior ischemic optic neuropathy?
corticosteroids or anti VEGF (but not much evidence)
95
a patient presents with:
* floaters
* the patient notes that symptoms have been present for a few weeks
examination you note that there is:
* a slight visual fields defecits
**- What is the most likely diagnosis?**
Retinal detachment
96
What does the image below show?
retinal detachment
pale area is fluid accumulation
97
what is retinal detachment?
An acute or progressive condition in which the neuro retina separates from the retinal pigment epithelium
there is an accumulation of sub- retinal fluid and loss of retinal function
98
what type of retinal detachment is most common?
Secondary Due to traction - usually retinal tear
99
what are the three types of retinal detachment
1. primary(rhegmatogenesis)
2. secondary
3. exudative
100
what causes floaters?
Either traction or vitreous haemorrhage
101
do floaters and flashes always mean pathological retinal detachment?
No they can be benign detachments which do not lead to retinal detachment
102
how do you manage retinal detachment is?
laser for tears
surgery
103
what is a complication which can occur due to retinal detachment?
Proliferative vitreoretinopathy
104
what is hysterical blindness?
Functional neurological symptom disorder
105
what is the difference between conversion disorder and hysterical blindness?
conversion disorder Is when blindness is precipitated by a stressor
106
what's is the DSM five criteria of hysterical blindness?
1. one symptom of altered vocabulary motor or sensory function
2. clinical findings showing incompatibility between symptoms and recognised medical disorders
3. symptoms are not better explained by other medical or mental conditions
4. symptoms cause clinically significant distress or functional/social impairment
107
what is the difference between acute and chronic hysterical blindness/ what the other two ways of classifying it?
Acute lasting under six months
chronic lasting over six months
persistent
episodic
108
what is the characteristic feature of hysterical blindness?
there is tunnelling of vision
109
How would you manage hysterical blindness?
Reassurance and explanation
psychotherapy
occupational therapy
medications such as SSRIs
110
what is squint?
a.k.a. strabismus.
* Misalignment of the eyes where one eye fixates on the chosen object
* the other is deviated
111
what is the presentation of strabismus in adults?
Diplopia and visual confusion – seeing the different objects in one place
112
what is the presentation of strabismus in children?
usually asymptomatic
is found on screening but causes ambylioplopia
113
what is acquired strabismus?
the malfunction of one or more cranial nerves namely:
* oculomotor (three)
* trochlear (four)
* abducens (six)
plus abnormal eye movements
114
what is reactive strabismus?
Mechanical restriction of eye movements due to conditions like graves or orbital fractures
115
what is the sensory strabismus?
Reduction in visual acuity of one eye
116
what is acute onset strabismus?
Usually caused by intracranial processes such as:
* mass lesions
* infarcts
* increased intracranial pressure
Acute onset history
can be:
* recurrent
* consecutive(occurs more thanonce but w different causes each time)
* residual (treatment not fully successful)
117
what what pathologies can strabismus be associated with?
* MG
* super nuclear palsys
* global developmental delay such as cerebral palsy
* any causes of acute onset strabismus:
* mass lesions
infarcts
increased intracranial pressure
118
what is the management of strabismus?
If there is an underlying cause treat that
**refractory errors** treated with glasses
**ambyloplopia or diplopia** corrected by covering the functional eye
119
what is ambyloplopia?
visual impairment resulting from abnormal visual stimulation during childhood
due to eye misalignment
but not attributable to structural abnormalities of the eye or of visual pathways
120
what is the difference between strabismus and ambyloplopia?
Strabismus, the medical term for "crossed-eye", is a problem with eye alignment, in which both eyes do not look at the same place at the same time.
Amblyopia, the medical term for "lazy-eye", is a problem with visual acuity, or eyesight.
121
what the causes ambyloplopia?
caused by misalignment of the eyes
* for accurate binocular vision each eye must have a clear focus aligned vision
122
what muscles does the oculomotor nerve Innervate?
* superior, inferior and medial rectus
* inferior oblique
* as well as ciliary muscles
* pupillary reflex muscles
123
what is the function of the oculomotor nerve?
elevation and intorsion (medially and down out)
rotation of the eye up and in
eye lid opening
pupilary consitriction
accommodation
124
what are causes of oculomotor nerve palsy?
diabetic neuropathy + hypertension ( causing micro-angiopathy)
compression or trauma from PCA aneurysms or base of skull fractures
125
What muscles does the trochlear nerve innervate?
innervate the superior oblique
126
what is the movement that the trochlear nerve causes?
rotating the eye clockwise ( so down and in)
127
what other common causes of trochlear nerve palsy?
microangiopathy
* by diabetic neuropathy
* hypertension
trauma
fourth nerve palsy (congenital)
atherosclerosis
cavernous sinus thrombosis
128
what muscle does the abducens nerve innervate?
lateral rectus
129
what movement is the abducens nerve responsible for?
abduction of the eye - looking laterally
130
what can cause abducens nerve palsy?
Trauma especially at the superior orbital fissure
cavernous sinus thrombosis
diabetic neuropathy
131
what movement is the superior rectus responsible for?
elevation and intorsion (clockwise) (CNIII)
132
what movements is the lateral rectus responsible for?
Looking laterally (ie L eye looking L) (CNIII)
133
what movement is the inferior rectus responsible for?
depression and in torsion (anticlockwise) (CNIII)
134
what movement is the inferior obleque responsible for?
External rotation of the eye and some aspect of elevation (CNIII)
135
what is the movement of the superior oblique?
internal rotation and some aspects of depression (CN IV)
136
what is the function of the lateral rectus?
abduction of the eye – looking laterally (CN VI)
137
what is the function of the medial rectus?
Adduction- looking medially (CNIII)
138
what does the following images show?
**papilloedema**
* Venous engorgement
* haemorrhages
* blurring of optic margins
* elevation of optic disc
139
what is usually the first sign of papilloedema on fundoscopy?
Venous engorgement
140
What is papilloedema?
Swelling of the optic nerve occurring due to an increase in ICP or CSF
141
what are symptoms of papilloedema?
Double vision (especially in CN IV palsy)
blindspot, blurring of vision
visual obstruction
eventually total visual loss
142
what are some causes of papilloedema?
1. MS
2. Head trauma
3. anything causing inflammation of the brain or surrounding tissue (tumours sarcoidosis)
4. CSF obstructions
5. increased ICP
6. hypertension
7. uveitis
8. central retinal vein occlusion
9. anterior ischaemic optic neuropathy
10. sometimes anaemia
143
what is the management of papilloedema?
Managing underlying cause
steroids to reduce inflammation (especially in MS)
the use of diuretics to decrease CSF
144
what is the difference between papilloedema and disc swelling?
if there issnt an increased ICP then it is considered disc swelling/disc oedema
145
what other finding on funduscopy can be mistaken for papilloedema?
Optic drusen and which are benign and harmless CT is used to exclude this
146
what image is shown below?
**retinitis pigmentosa**
* Atrophy of the retina and retinal pigmented epithelium
* washy pallor of the optic nerve
* retinal vascular attenuation
147
what is retinitis pigmentosa?
A hereditary condition of retinal degeneration caused by the loss of rods and cones
148
what symptoms are present in retinitis pigmentosa?
Initially there is loss of night-time vision
then progressive loss of peripheral vision
eventually leading to decreased visual acuity
149
What is the management of retinitis pigmentosa?
Vitamin a – retinol
fish oils
gene therapy
* these have some benefit but not curative
150
what to do enlarged blind spots on visual fields indicate?
Papilloedema
151
what field defect is shown below?
Left eye anospia
152
which lesion would cause left eye anospia?
lesion of the left optic nerve (1)
153
in the lesion of the left optic nerve what would the pupillary light reflex be in both eyes?
when light is shone into L eye = absent
when light is shone into R eye = present
154
what conditions can cause optic nerve lesions which leads to eye anospia?
MS
central retinal artery occlusion
155
what field defect is shown below?
Left nasal heamienopia
156
what can cause left nasal hemienopia?
Internal carotid artery aneurysm expanding medially
157
where is the site of the lesion of left nasal hemienopia?
left temporal fibres from optic nerve
158
what visual field defect is shown below?
bi temporal heteronymous hemienopia?
159
where is the site of the lesion in bi temporal heteronymous hemienopia?
optic chiasm (3)
160
what other common causes of lesions in optic chiasms?
Pituitary adenoma most commonly
or craniopharangioma
161
what visual field defect is shown below?
binasal hemienopia
162
what are the causes of bilateral optic chiasm compression?
Calcification of both interior carotid arteries
or congenital hydrocephalus
163
what visual field defect is shown below?
right hononymous hemienopia
164
what site of lesion would cause right hononymous hemienopia?
left optic tract
or lateral geniculate body (if pupilary light reflex is slightly suppressed)
or optic radiation (pupillary light reflex present)
165
what would normally cause lesions of the left optic tract/ lateral geniculate body?
MCA occlusion (left)
166
what are some causes of Central scotoma
diabetic retinopathy
retinitis pigmentosa
macular degeneration
167
what is a pituitary adenoma?
the 3rd most common adult brain tumour:
can be clinically functional (ie secreting)
or non functioning
168
what are the types of functional pituitary adenoma ?
1. prolactin secreting - prolactinoma
2. growth hormon secreting - acromegaly
3. adenocorticotrophic hormone secreting - cushings
169
how would a pituitary tmour present
headaches + features of increased ICP
visual field defects - bilateral temporal hemienopia
plus if functional sx of XS hormones such as acromegaly or cushings
170
why no non functional pituitary hormonnes sometimes still cause a mild raise in prolactin?
compression of the pituitary stalk and interruption of the dopaminergic pathway
171
what is the diagnostic fisrt line test for pituitary tumours?
MRI
172
what is the management for pituitary tumours?
surgery
with then HRT of any missing hormones depending on blood results
173
what hormones does the pituitary make which you would want to replace?
* levothyroxine
* corticosteroids
* androgens
* oestrogens
* GH
174
why do hormone deficiencies occur after treatment for pituitary tumour?
either pituitary not there
or theres increased demand on the leftover functioning pituitary which it cannot cope with causing hypopituitarism
175
A patient presents with:
* a burning/itching sensation across the eyelid
* the feeling of dry eyes or grittiness
* in the morning they notice that there are crusts on the eyelid
* and they notice that their eyelashes have been falling out
**what is the diagnosis?**
blepharitis
176
what does the following image show?
**blepharitis**
* Telangiectasia scaly hard skin a.k.a.coralettes around lashes
* capped meobian glands
* eye redness
177
what is the management of Blepharitis?
patient education – it is a chronic disease with intermittent flareups
plus eyelid hygiene
omega three fatty acids
artificial tears
during flareups topical corticosteroids/antibiotics if suggestive of infection
178
what is a stye?
An infection causing the formation of an abscess at the base of an eyelid
179
what is a chalazon?
If inflammation of the moebian glands deep within the eyelid
180
what and pathogens usually cause styes or chalazons?
Staphylococcus aureus
staphylococcus epidermis
181
what is the difference between a Stye and a chalazon?
stye is more superficial than a chalazon but can still occur at a moebian gland and it was also includes ciliary glands
182
what condition are styes and chalazon s associated with?
blepharitis
183
what is a distinguishing diagnostic feature between a stye and chalazon?
styes are painful whereas chalazon are not
184
how do you manage chalazon?
heat compress and lid massage
185
how do you manage Stye?
heat compress
if bad :
* topical antibiotics and possible drainage
186
what does the image below show?
episcleritis
* intense localised redness
187
what is episcleritis?
inflammation of the episclera ( the clear film on top of the whites of your eyes)
188
what is the presentation of episcleritis?
intense localised redness mild irritation no pain!
plus
* tearing
* with photosensitivity
* and possibly a gritty sensation
* almost always unilateral
189
what conditions is episcleritis associated with?
inflammatory diseases
190
what is the management of episcleritis?
self-limiting and resolves within one – two weeks
191
What does the image below show?
**scleritis**
Redness of the sclera which can develop a blue/purple hue
192
what is the presentation of scleritis?
Redness of the sclera which sometimes develops a blue/purple hue
severe ocular pain which radiate to jaw
decreased visual acuity which can lead to blindness
193
what are the types of scleritis?
1. Diffuse-most common
2. nodular
3. necrotising
194
what is the management of scleritis?
requires urgent referral and oral steroids are prescribed
In necrotising scleritis surgery is required
195
what does the image below show?
**Iritis**
Intense redness of the globe of the eye regular pupils that are stuck to the lens
196
what occurs to the cornea in iritis?
large groups of cells clump on the back of the surface of the cornea
Cells and fibrin in the anterior Chamber
197
a patient presents with:
* unilateral acutely painful eye
* and they note photophobia
* have reduced vision
* they also suffer from inflammatory bowel disease
looking at the eye it looks intensely red and has irregular pupils
**what is most likely diagnosis?**
Iritis a.k.a. anterior uveitis
198
what marker is iritis is associated with?
HLA B 27
199
What diseases is iritis associated with?
seronegative arthropathy :
* ankylosing spondylitis
* psoriatic arthropathy
granulomatous disease :
* sarcoidosis
* syphilis
and IBD
200
what is important to find out about in someone who you think may have iritis?
ask about any associated symptoms such as joint problems, skin problems, mouth ulcers, chest or skin disease and GU symptoms
201
what happens to the intraocular pressure in iritis?
Decreases
202
what is the treatment of iritis?
Topical steroids and managing underlying conditions
203
what does the image below show?
Viral conjunctivitis
* showing watery/sticky discharge and read eye
204
what are the features of viral conjunctivitis?
* Watery/sticky discharge
* red eye
* you may see raised white follicles
* sudden onset of symptoms
* there may be pre auricular lymphadenopathy
205
what pathogen most commonly causes viral conjunctivitis?
adenovirus
206
what is the management of viral conjunctivitis?
Self-limiting and doesn't respond to antivirals
207
what other features of allergic conjunctivitis?
* Looks similar to viral
* has a watery/mucus discharge
* red eye due to capillary dilattaion
* increased permeability usually an allergic trigger
* swollen itchy eye which is fairly short lived
208
what type of hypersensitivity reaction causes allergic conjunctivitis?
Type I
209
what is chronic allergic conjunctivitis?
A severe pathology requiring specialist care as it can cause corneal ulceration
210
what are the features of chronic allergic conjunctivitis?
Large pupils
corneal ulceration
sticky mucus
211
wise management of chronic allergic conjunctivitis?
Topical steroids
212
atropine can cause an allergic reaction in the eyes what is its presentation?
* Occurring shortly after atropine is applied
* causes inflamed skin with ulceration
* discharge and red eyes
* pupils are dilated because of the atropine drops
213
what does the image below show?
Purulent discharge
sticky discharge and crusting
very red eyes
214
what pathogens usually cause bacterial conjunctivitis?
1. Staphylococcus
2. Streptococcus
3. Haemophilus
4. Neisseria
5. chlamydia
6. gonorrhoea
215
what does the history of conjunctivitis starting in one eye and then spreading to the other eye suggest?
Bacterial infection
216
what is the management of bacterial conjunctivitis?
Chloramphenicol drops + fucidic acid
217
what can cause recurrent conjunctivitis? And what is the treatment?
blockage of the Naso lacrimal ducts
Surgical to pass obstruction
218
what is inclusion conjunctivitis?
When an STI is a cause of conjunctivitis such as chlamydia or gonorrhoea
219
what is the most common STI to cause conjunctivitis in adults?
Chlamydia
220
What is an indicative feature of inclusion conjunctivitis?
Associated corneal inflammation
221
what is ophthalmia neonatorium?
conjunctivitis within the first three weeks of life
contracted when passing through the birth canal
222
what pathogen usually causes ophthalmia neonatorium?
gonorrhoea and chlamydia
herpes simplex
Staphylococcus aureus
223
why is ophthalmia neonatorium very dangerous?
pathogens such as:
* herpes simplex
* gonorrhoea
...can cause vision loss
224
what does the image below show?
**herpes simplex**
* These are vesicobulbar eruptions around the eye
* erythema
* lid oedema
225
what is the presentation of herpes simplex virus around the eyes?
Pain and erythema
lid oedema
may see possible oral lesions
severely inflamed eyes
226
what symptoms will occur if herpes simplex got to the cornea?
pain
photophobia
watery discharge
227
what investigation is needed if you suspect corneal herpes simplex?
And what would you see?
Fluorescent staining so you can see the characteristic dendritic shape
228
how would you manage herpes simplex of the eye?
Topical acyclovir
per oral can be used if it's not reached the cornea
229
why is it really important not to give steroids to read eye without specialist advice?
Can cause corneal ulcers and scarring
230
what investigation can show a corneal ulcer?
Rose bengal stain
231
Patient presents with:
* vesico bulbar eruptions on the nose, upper lip and forehead
**what is a potential diagnosis?**
Herpes zoster virus affecting the cutaneous distribution of the ophthalmic branch of the trigeminal nerve
232
who does herpes zoster virus usually affect?
Adults and older children
233
what is the management of herpes zoster virus of the face?
PO acyclovir
early treatment is important
234
what happens if herpes zoster virus of the face is untreated?
Severe corneal inflammation can occur causing neovascularisation
which has lipid exudates leading to corneal clouding and thinning
235
what should you do if the eye is involved in a herpes zoster infection?
Refer immediately
236
what is keratitis?
A bacterial infection of the cornea which is very rare but very serious
237
what does the image below show?
Hazy cornea with central abscess - **bacterial keratitis**
238
what does an immune ring on funduscopy in bacterial keratitis suggest?
Infection with serriata
239
what is the management of bacterial keratitis?
Intense antibiotic therapy – ofloxacin
until more specific abx can be used
immediate referral for diagnosis and treatment
240
what is a symptom that the patient would complain of in bacterial keratitis?
painful red eye with loss of vision
241
what does the image below show?
Lid mild position
242
what is the presentation of lid malposition ?
Pain and watery eyes
* due to lashes curving inwards
* abrading the cornea
243
what are causes of lid malposition ?
lid laxity in the elderly
facial palsy e.g. Bell's phenomenon
244
how would you check for Bell's phenomenon?
eyes roll up when the eyes are closed
245
what is important to check in a patient with lid malposition?
appropriate eye closure
corneal sensation
if any of these are absent in the eyes at high risk of exposure and should be referred urgently
246
what is the treatment of lid malposition?
surgery
247
a patient presents with:
* miosis
* ptosis
* anhydrosis on one side
* theyre eye appears sunken on one side
**what is the most likely diagnosis?**
Horner's syndrome
248
what are the causes of Horner's syndrome?
1. Congenital (rare)
2. acquired from:
* damage to the sympathetic nerves serving the eyes
* blunt trauma to the neck
* carotid artery dissection
* tumours in the neck or chest (neuroblastoma or upper lung tumour)
* lesions of the midbrain or brainstem or upper spinal-cord
* lesions of the neck or eye
249
how do you diagnose Horner's syndrome?
Clinically
then try and find the cause:
* using an MRI
* ultrasound (carotid artery dissection)
250
what is the treatment of Horner's syndrome?
treating the underlying cause and eye drops
251
what is lens induced glaucoma?
occurs secondary to angle closure or open angle glaucoma
or due to trauma to the lens from obstruction of the trabecular meshwork
or cataract extractions etc..
anything which damages the lens!!
252
what is a presentation of lens induced glaucoma?
Pain and decreased vision
253
how does angle closure glaucoma cause lens induced glaucoma?
Lens swelling or dislocation
254
card is open and glaucoma cause lans induced glaucoma?
leakage of lens proteins
255
what does the image below show?
Lower lid folding away from the iron turning outwards **– eyelid ectropion**
256
How do eyelid ectropions differ to lid malpositions?
in ectropions the lid turns outwards
in malposition it turns inwards
257
a patient presents with:
* a drooping eyelid
* they say theyre eye is red, sore, and irritated
* noticed theyre eye is watering excessively BUT at the same time they feel dry and gritty
* Pt has a history of many conjunctival infections
**what is most likely diagnosis?**
eyelid ectropions
258
What are complications of eyelid ectropions?
conjunctivitis
rarely corneal ulcer
259
what are causes of eyelid ectropions?
nerve palsy (e.g. Bell's palsy)
lamp ???
exist ???
tumour
burn or trauma
260
how do you manage eyelid ectropions?
mild cases are treated symptomatically:
* eyedrops to keep eyes lubricated
* good lid hygiene
severe cases: surgery
261
When testing a patient light reflexes:
* theyre left pupil is smaller in dim light than the right pupil
* the right pupil does not constrict to light however
* accommodation is present
**what is most likely diagnosis?**
adies pupil (common in young children)
262
describe the pathophysiology and the results of light tests in adies pupil?
parasympathetic denervation of the affected pupil
causes there to be an abnormally dilated pupil at rest
there is poor/sluggish pupil constriction in bright light
causing a reduced sluggish effluent response
this sluggish response occurs if light is shone in both affected and unaffected eye
263
what are causes of aidies pupil?
* idiopathic (adie tonic pupil)
* viral
* infections
* trauma
* vasospasm from a migraine
* ocular surgery
* tumours
264
what is the presentation of aidies pupil?
abnormally dilated pupil
sluggish constructive response which patients may notice
as well as photophobia
blurring of vision in one eye when exposed to bright light
265
what other signs may patients with aidies pupil show?
sluggish deep tendon reflexes
* such as the knee-jerk reflex
266
what is the management of adies pupil?
usually is not needed as the individual grows and they become accustomed to that eye
chronic cases where it does not resolve the pupil does tend to get smaller with time
267
what is infectious retinitis?
An inflammation of the retina
resulting from infection by viruses or bacteria fungi or parasite
268
what are some symptoms which can occur in infectious retinitis?
Floaters or decreased vision from bleeding or clusters of inflammatory cells
symptoms can appear suddenly or slowly
may have:
* photo sensitivity
* red eyes
* painful eyes
* be systemically unwell
269
how would the presentation of vectis retinitis differ in congenital forms than normally?
eyes may be misaligned
with in voluntary movements
or abnormal white eye reflex
270
what can HSV and HZV caused infectious retinitis lead to?
Acute retinal necrosis
271
can CMV cause infectious retinitis?
yes
But only in those who are immunodeficient
272
how do you diagnose infectious retinitis?
Intraocular fluid analysis
273
how do you manage infectious retinitis?
* IV
* oral
* intraocular drugs
directed at the pathogen
274
what does the image below show?
Thyroid eye disease
275
what is the pathophysiology of thyroid eyed disease?
eye muscles, eyelids, tear glands, and fatty tissues behind the eyes become inflamed
causing the eye to become red, swollen and uncomfortable
eventually it can cause the eye to push forwards
276
in which type of thyroid disorder does thyroid eye disease occur?
Autoimmune– Graves' disease
277
how does thyroid eye disease caused diplopia?
Stiffness of the muscles means that the eyes no longer move in sync with each other
resulting in double vision
278
how does thyroid disease cause a reduction in vision?
It can cause pressure on the optic nerve
or form ulcers on the cornea
279
what are the symptoms of thyroid eye disease?
* Reduced vision
* photophobia
* protruding red eyes
280
how do you treat thyroid eye disease?
Manage hyperthyroidism
usually settles after 6 to 12 months of thyroid treatment
Symptomatic control with:
* fake tears
* if inflammation is severe it can need steroids
* in very severe surgery for decompression
281
what are complications of thyroid eye disease?
Permanent double vision
permanent changes in vision
282
how can toxoplasma damage the eyes?
It can cause posterior uveitis
eventually leading to necrotising chorioretinitis
283
what can you get Toxoplasma from
uncooked meat or substances contaminated with cat faeces
284
what is the danger of toxoplasma in pregnant women?
In the first trimester can cause spontaneous abortion
later in the pregnancy it can lead to:
* hydrocephalus
* seizures
* lymphadenopathy
* hepatosplenomegaly
* fever
285
what are symptoms of toxoplasma chorioretinitis?
unilateral decrease in visual acuity
floaters
can also cause iritis - causing redness and pain
286
on funduscopy what can chorioretinitis show?
white focal retinitis
with overlying vitreous inflammation
can also cause retinal vasculitis
287
how do you diagnose toxoplasma?
Serological testing - if negative completely excludes toxoplasma
if positive does not mean it is a current infection or the cause of the chorioretinitis
* so do PCR of eye fluid
288
when is treatment indicated in infections of toxoplasma?
if there are:
* optic nerve lesions
* macular threatening
* larger optic lesions
* pregnancy
* mono ocular status
* immunocompromised
289
what is the treatment of toxoplasma?
systemic triple terapy:
1. pyrimethamine
2. sulfpthiazide
3. corticosteriods
290
What does the image below show?
Orbital cellulitis
291
a patient presents with:
* protruding eye
* nasal pain
* tenderness of the eye redness
* inability to open the eyes
* inability to move eyes
* double vision
* loss of vision
* discharge
* (fever and headache may also be present )
**- what is the diagnosis?**
orbital cellulitis
292
what is the common pathogens that cause orbital cellulitis?
Streptococcus and staphylococcus
293
what usually causes orbital cellulitis?
untreated bacterial sinus infection which then spreads behind the orbital septum
can also spread from the tooth infections
or other bacterial infections occurring anywhere in the body entering via the bloodstream
294
what investigations are required in orbital cellulitis?
CT/MRI head, nose eyes
cultures of the blood
cultures of eye discharge and nasal discharge
295
what are differentials for orbital cellulitis?
pre septal cellulitis
periorbital cellulitis
insect bite
296
how do you treat orbitals Cellulitis?
IV antibiotics initially broad-spectrum until the cultures come back
297
what is the difference between orbital and periorbital cellulitis
Peri Orbital cellulitis is more superficial to the orbital septum
ocular function remains intact
- oftentimes PO antibiotics are sufficient in periorbital
298
what does the image below show?
Corneal foreign body
299
how do you treat a corneal foreign body?
surgical removal
300
What does the image below show?
sub conjunctival haemorrage
301
a patient presents with:
* a sudden onset of a bright red eye
on examination there are :
* distinct boarders to the bleed
**what is the most likely diagnosis?**
sub conjunctival haemorrage
302
What is important to check in a patient with sub conjunctival haemorrhage
occular or orbital injury.
303
In the elderly what is the most common cause of the sub conjunctival haemorrhage?
spontaneous
304
What is the treatment of sub conjunctival haemorrhages?
nothing
305
a patient presents with:
* eye pain after work incident - from drilling
* feld somethinggoing into their eye
which type of injury is most common here?
intraocular foreign body
306
what signs would you find on intraocular foreign bodies?
Sub conjunctival haemorrhage
corneal laceration
Iris wound
localised cataract
307
what investigations are required in suspected intraocular foreign body?
x-ray or ultrasound or CT
308
What is the management of an intraocular foreign body?
lensectomy or virectomy
309
what consequences can occur after blunt trauma to the eye?
lens dislocation
glaucoma
retinal oedema
retinal detachment
blowout fracture
diplopia
310
why may there be loss of vision after blunt trauma to the eye?
compression of the optic nerve or bleeding inside the eye
causing an increase in intraocular pressure
as well as corneal oedema
311
what do restricted eye movements and proptosis indicate in a scenario of blunt trauma to the eye?
Raised intraocular pressure
312
what is post operative endopthalmitis?
a rare but sight threatening complication of ocular injury
most commonly occurring as a complication of cataract surgery
313
what is the presentation of post op endopthalmitis?
acute: within week of surgery
chronic within the first month/2 months of surgery.
Presenting with:
* visual loss
* pain, redness and photophobia
* lid oedema
* corneal haze
* absent/sluggish pupillary light reflex
* intraocular pressure can be raised
* and endopthalmus
314
what usually causes endopthalmitis?
infection with staphylococcus or streptococcus
or retention of foreign materials such as cotton fibres
315
what is the management of post op endopthalmitis?
emergency referral to ophthalmologist
for same day treatment with steroids antibiotics
316
what investigations are required to assess the severity of post op endopthalmitis?
fresh **what????? see notes**
317
what are drusen?
lipid accumulations under the retina
- not in themselves pathological but often a sign of macular degeneration
318
