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Year 4 - Special Senses > Opthalmology - Acute Visual Disturbances > Flashcards

Opthalmology - Acute Visual Disturbances Flashcards

1
Q

What are the subdivisions of loss of vision?

A
  • painless
  • painful
  • gradual
  • transient
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2
Q

What are the causes of sudden painless loss of vision?

A
  • giant cell arteritis (GCA)
  • retinal artery occlusion
  • retinal vein occlusion
  • retinal detachment
  • vitreous haemorrhage
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3
Q

What is GCA?

A

Ischaemia of the optic nerve resulting in visible optic disc swelling.

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4
Q

Cause of GCA.

A

Inflammation of the temporal arteries and subsequent thrombosis of the short posterior ciliary arteries, leading to ischaemia of the optic disc.

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5
Q

Risk factors for GCA.

A
  • age >50 years
  • female sex
  • PMHx PMR
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6
Q

Symptoms of GCA.

A
  • sudden painless loss of vision
  • new onset temporal headache
  • jaw claudication
  • scalp tenderness
  • diplopia
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7
Q

Signs of GCA.

A
  • reduced visual acuity
  • reduced colour vision
  • pale, swollen optic disc on fundoscopy
  • relative afferent pupillary defect
  • scalp and temporal artery tenderness
  • pulseless temporal artery
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8
Q

Bedside investigations for GCA.

A
  • visual acuity assessment
  • colour vision assessment
  • blood pressure (HTN is risk factor)
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9
Q

Laboratory investigations for GCA.

A
  • FBC (?anaemia, thrombophilia)
  • CRP (raised)
  • ESR (>50)
  • LFT (?raised ALP and ALT)
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10
Q

Specialist investigations for GCA.

A
  • temporal artery biopsy (mononuclear cell infiltration)
  • duplex ultrasound of temporal artery (halo sign)
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11
Q

Management of GCA.

A

High dose systemic steroids.

Urgent referral to opthalmologist / rheumatologist.

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12
Q

Complications of GCA.

A
  • permanent blindness
  • risk of second eye involvement
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13
Q

Retinal infarction occurs after what period of oxygen deprivation?

A

90 minutes

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14
Q

Types of retinal artery occlusion.

A
  • central retinal artery occlusion
  • branch retinal artery occlusion
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15
Q

Cause of retinal artery occlusion.

A
  • emboli to the retinal artery
  • thrombus formation within the retinal artery
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16
Q

Risk factors for retinal artery occlusion.

A
  • hypertension
  • diabetes
  • hyperlipidaemia
  • smoking
  • antiphospholipid syndrome
  • malignancy
  • sickle cell anaemia
  • GCA
  • SLE
  • COCP
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17
Q

Symptoms of retinal artery occlusion.

A

Sudden painless visual loss.

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18
Q

Signs of retinal artery occlusion.

A

Visual assessment:
- reduced visual acuity
- relative afferent pupillary defect

Fundoscopy findings:
- retinal pallor
- Cherry-red spot
- neovascularisation

NB: arrhythmias, heart murmurs or carotid bruit may mean risk of thrombus formation.

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19
Q

Bedside investigations - retinal artery occlusion.

A
  • visual acuity
  • colour vision
  • pupil assessment (RAPD)
  • blood pressure (?HTN)
  • ECG (?AF)
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20
Q

Laboratory investigations - retinal artery occlusion.

A
  • FBC
  • ESR / CRP (exclude GCA)
  • coagulation screen
  • glucose
  • lipid profile
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21
Q

Relevant laboratory investigations for patients below the age of 50 (where atherosclerosis is less likely), and retinal artery occlusion is suspected.

A
  • vasculitis screen (ANA, ANCA, dsDNA, anti-GMB)
  • serum protein electrophoresis
  • infection screen
  • thrombophilia screen
  • treponemal serology
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22
Q

Imaging for retinal artery occlusion.

A
  • carotid artery doppler (?carotid artery stenosis)
  • CXR (?sarcoidosis, tuberculosis)
  • echocardiogram (?valvular heart disease)
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23
Q

Management of retinal artery occlusion.

A

Manage as a stroke and therefore prompt referral to the stroke team:
- 300mg aspirin for 14 days
- secondary stroke prevention

NB: If patient presents within 90 minutes, an effort is made to dislodge the embolus (ocular massage, re-breathing into a bag).

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24
Q

Complications of retinal artery occlusion.

A
  • neovascularisation of the optic disc and fundus
  • neovascularisation of the iris
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25
Q

Cause of retinal vein occlusion.

A

Atherosclerosis of the retinal veins causes endothelial damage, turbulent flow and thrombus formation.

This impedes venous drainage of the retina, causing venous engorgement.

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26
Q

Risk factors for retinal vein occlusion.

A
  • age >65
  • diabetes mellitus
  • hypertension
  • hyperlipidaemia
  • thrombophilia
  • malignancy
  • SLE
  • glaucoma
  • COCP
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27
Q

History of retinal vein occlusion.

A

Sudden painless visual loss.

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28
Q

Signs of retinal vein occlusion.

A
  • retinal haemorrhage
  • dilated veins
  • relative afferent pupillary defect
  • macular oedema
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29
Q

Signs suggestive of ischaemic retinal vein occlusion.

A
  • relative afferent pupillary defect
  • cotton wool spots
  • neovascularisation
  • raised intraocular pressure
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30
Q

Bedside investigations for retinal vein occlusion.

A
  • visual acuity
  • colour vision
  • pupil examination (RAPD)
  • intraocular pressure
  • blood pressure
  • ECG
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31
Q

Laboratory investigations for retinal vein occlusion.

A
  • FBC
  • ESR / CRP (exclude GCA)
  • lipid profile
  • coagulation screen
  • plasma protein electrophoresis
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32
Q

Management of retinal vein occlusion.

A

Identifying and treating underlying medical conditions.

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33
Q

Complications of retinal vein occlusion.

A
  • cystoid macular oedema
  • neovascular glaucoma
  • retinal detachment
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34
Q

Treatment of macular oedema.

A

anti-VEGF injections

35
Q

Treatment of neovascular glaucoma.

A

Laser therapy

36
Q

What is retinal detachment?

A

The retina pulls away from the underlying retinal pigment epithelium, resulting in the accumulation of fluid in the potential space between the layers.

If fluid accumulates, this causes the retina to detach and results in blindness.

37
Q

Causes of retinal detachment.

A
  • proliferative diabetic retinopathy
  • retinal vein occlusion
  • retinopathy of prematurity
  • blunt trauma
  • inflammation
38
Q

Symptoms of retinal detachment.

A
  • sudden painless loss of vision (dark curtain or shadow)
  • new onset of floaters
  • new onset of flashes in periphery
39
Q

Signs of retinal detachment.

A
  • impaired visual acuity

Fundoscopy: opaque translucent layer; retinal tears; vitreous haemorrhage.

40
Q

Bedside investigations of retinal detachment.

A
  • visual acuity
  • intraocular pressure (low)
  • fundoscopy
41
Q

If fundal view is hazy and you suspect retinal detachment, which specialist investigation can you request?

A

B-scan (ultrasound of the eye).

Reveals retinal tears and detachment.

42
Q

Management of retinal detachment.

A

Urgent referral to opthalmology for retinal detachment surgery:
- pars plana vitrectomy (removal of vitreous humour)
- scleral buckle (bands placed around exterior globe to support retinal tears)

43
Q

What is vitreous haemorrhage?

A

A bleed into the vitreous humour the eye, secondary to damage to retinal blood vessels.

44
Q

Which blood vessels usually bleed to cause vitreous haemorrhage?

A

Blood vessels formed due to neovascularisation - they are brittle vessels prone to leaking or breaking in the event of a retinal tear, or retinal detachment.

45
Q

Causes of vitreous haemorrhage.

A
  • proliferative diabetic retinopathy
  • posterior vitreous detachment
  • retinal tears
  • retinal detachment
  • trauma
46
Q

Symptoms of vitreous haemorrhage.

A
  • blurred vision
  • floaters
47
Q

Signs of vitreous haemorrhage.

A
  • hazy fundal view
  • loss of red refelx
  • retinal tear
  • retinal detachment
  • tobacco dust in vitreous
48
Q

Goals of treatment in vitreous haemorrhage.

A
  • stop the bleeding
  • preserve vision
  • repair damage to the retina
49
Q

Management options for vitreous haemorrhage.

A
  • observation (suitable if no retinal tear or detachment)
  • laser therapy (suitable in proliferative diabetic retinopathy, and retinal tears)
  • surgical intervention (suitable in posterior vitreous detachment)
50
Q

What are the causes of sudden painful visual loss?

A
  • GCA
  • eye trauma
  • keratitis
  • herpes zoster ophthalmicus
  • AACG
  • optic neuritis
  • orbital cellulitis
51
Q

Which nerve is affected in herpes zoster ophthalmicus (HZO)?

A

Shingles affecting the ophthalmic branch (V1) of the trigeminal nerve.

52
Q

Risk factors for herpes zoster ophthalmicus.

A
  • advancing age
  • immunosuppression
  • pregnancy
  • neonates
53
Q

Symptoms of herpes zoster ophthalmicus.

A

Viral prodromal phase of fever, malaise, headache.

Pre-herpetic neuralgia along dermatome of V1.

Rash following dermatomal distribution of V1.

Additional symptoms:
- conjunctivitis
- reduced visual acuity
- red eye
- pain

54
Q

What is Hutchinson’s sign?

A

Cutaneous lesions on the tip, side or root of the nose.

Indicates involvement of the V1 nasal branch by VZV; strong predictor of ocular involvement.

55
Q

Investigations of herpes zoster opthalmicus.

A

Bedside:
- visual acuity
- conjunctival / skin swab for PCR

56
Q

Management of herpes zoster ophthalmicus.

A

Promp referral to ophthalmologist.

Antiviral therapy and concurrent use of oral steroids.

Supportive treatment with cold compresses, oral analgesics and topical lubricants.

57
Q

Complications of herpes zoster ophthalmicus.

A
  • postherpetic neuralgia (pain in V1 distribution lasting >1 month after heal of rash)
  • repeat corneal ulcers
  • visual loss
  • cranial nerve palsy (CN III, IV and VI)
58
Q

What is optic neuritis?

A

Inflammatory neuropathy of the optic nerve affecting one eye at a time.

59
Q

Association of optic neuritis.

A

Multiple sclerosis (MS)

60
Q

Pathophysiology of optic neuritis.

A

Autoimmune T cells destroy the myelin sheath of the optic nerve, resulting in an inflammatory neuropathy of the nerve.

Same pathophysiology of MS.

61
Q

Risk factors for optic neuritis.

A
  • known MS
  • female sex
  • young age
62
Q

Symptoms of demyelinating optic neuritis.

A
  • acute / subacute unilateral loss of vision
  • retrobulbar / peri-ocular pain
  • flashes
  • visual field loss
  • reduced contrast sensitivity

Vision worsens over hours to days.

63
Q

Signs of optic neuritis.

A
  • reduced visual acuity
  • reduced colour vision
  • relative afferent pupillary defect
  • internuclear opthalmoplegia (MS)
  • optic nerve pallor
64
Q

Imaging for optic neuritis.

A

MRI of the brain and orbits with gadolinium contrast, revealing enhancement of the optic nerve.

May identify white matter lesions suggestive of MS.

65
Q

Medical management of optic neuritis.

A

IV methylprednisolone, followed by oral prednisolone taper.

66
Q

Findings of Optic neuritis treatment trial (ONTT).

A

Demonstrated an increased rate of visual recovery in patients treated with high dose IV steroids AND reduced risk of developing MS within 2 years.

Final visual outcome is similar to the placebo group at 6 months.

67
Q

Complications of optic neuritis.

A
  • contrast sensitivity reduced
  • relative afferent pupil defect
  • abnormalities of colour perception
  • recurrence
68
Q

Anatomical difference between

a) peri-orbital cellulitis

b) orbital cellulitis

A

a) anterior to the orbital septum (pre-septal)

b) posterior to the orbital septum (post-septal)

69
Q

Causes of orbital cellulitis.

A

Local spreading infection from acute bacterial sinusitis, typically from the paranasal sinuses.

70
Q

Symptoms of orbital cellulitis.

A
  • erythema and swelling around the eye
  • blurred vision
  • painful eye movements
  • change in colour vision
  • fever
71
Q

Signs of orbital cellulitis.

A
  • reduced visual acuity
  • relavent afferent pupillary defect
  • conjunctival injections
  • fever
  • proptosis
  • altered colour vision
72
Q

Laboratory investigations for orbital cellulitis.

A
  • FBC (?neutrophilia)
  • CRP (elevated)
  • lactate (?septic)
  • blood cultures
  • microscopy, culture and sensitivity swabs (conjunctiva and nasopharynx)
73
Q

Imaging of orbital cellulitis.

A

CT orbit, sinuses and brain.

74
Q

Management of orbital cellulitis.

A

Medical management:
- IV antibiotics
- MDT input

Surgical management:
- evacuation of orbital pus
- drainage of paranasal sinus pus

75
Q

Complications of orbital cellulitis.

A
  • cavernous sinus thrombosis
  • loss of vision
  • intracerebral abscess
  • meningitis
  • death
76
Q

What is peri-orbital cellulitis?

A

Infection in the eyelid tissue anterior to the orbital spetum, usually caused by superficial injury (e.g. insect bite, conjunctivitis).

77
Q

Symptoms of peri-orbital cellulitis.

A
  • eyelid pain
  • redness of eyelid
  • eyelid swelling
78
Q

Signs of peri-orbital cellulitis.

A
  • eyelid redness
  • fever
  • no significant pain
  • no pain on eye movement
  • normal visual acuity
  • systemically well
79
Q

Differentiating between peri-orbital cellulitis and orbital cellulitis.

A
80
Q

Investigations for peri-orbital cellulitis.

A

No specific investigations for peri-orbital cellulitis.

If there is any suspicion of orbital cellulitis, referral to secondary care for further investigation is required.

81
Q

Management of peri-orbital cellulitis.

A

Oral co-amoxiclav first line, with follow up in 48 hours.

Safety netting (e.g. if eye pain, disturbance to vision) need to seek further help.

82
Q

Complications of peri-orbital cellulitis.

A

Can spread to cause orbital cellulitis - safety net for this.

83
Q

Management of presbyopia.

A

Reading glasses.

If the patient also has an additional ametropia, bifocals or trifocals can be used.

Year 4 - Special Senses (17 decks)

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