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Opthamology Flashcards

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1
Q

How is aqueous humour produced and how does it drain

A

Aqueous humour is produced by ciliary bodies behind the iris. It flow through the lens to the anterior chamber and drains through the trabecular network between the iris and cornea via the canal of schlemm.

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2
Q

What is the pathophysiology of acute -closed angle glaucoma

A

Blocked drainage of the aqueous humour from the anterior chamber via the canal of schlemm causing a sudden increase in intra-occular pressure.

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3
Q

What is the pathophysiology of chronic- open angle glaucoma

A

Slow blockage of the drainage of the aqueous fluid - causing a gradual increase in intra-ocular pressure.

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4
Q

Risk factors for acute-closed angle glaucoma

A
  • hypermetropia
  • shallow anterior chamber
  • female
  • FH
  • > 50 y/o
  • Drugs –> anti-cholinergics; sympathomimetics; TCA’s; anti-histamines
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5
Q

Risk factors for chronic-open angle glaucoma

A
  • Myopia
  • DM/HTN/ Migraine
  • FH
  • African/asian
  • increasing age
  • systemic steroids
  • ocular hypertension (increased IOP on 2 occasions - monitor every 6-12m)
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6
Q

Compare the presentation of closed v open angle glaucoma

A

CLOSED

  • sudden onset
  • prodrome (rainbow haloes around lights at night)
  • severe deep, boring pain
  • +- n&v +- headache
  • reduced acuity and blurred vision
  • fixed, dilated, irregular pupil
  • eye feels hard +- red eye

OPEN

  • can be asymptomatic
  • peripheral visual field defect (superior nasal first) - see as parts of page missing
  • central field intact until optic nerve damage is irreversible
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7
Q

Investigations for glaucoma

A
  • Tonometry –> (>21 for open; can be >40 for closed)
    (thick cornea affects reading)
  • slit lamp - OPEN (cup:disc ration increased); CLOSED (corneal oedema; iris atrophy)
  • Gonioscopy - shows whether open/closed angle
  • fundoscopy - CLOSED (cloudy cornea +- circumcorneal injection); OPEN (cupping of optic disc)
  • Visual field assessment/OCT for OPEN
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8
Q

Management of acute - closed angle glaucoma

A
  • refer urgently to ophthalmology
  • pilocarpine 2-4% - drops stat (miosis opens blockage)
  • topical BB (timolol - to reduce aq. formation)
  • acetazolamide IV (500mg STAT)
  • analgesia +- anti-emetics

Once reduced IOP-> bilateral peripheral iridotomy
OR surgical iridectomy/lensectomy

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9
Q

Management of chronic open-angle glaucoma

A
  • life-long mx; INFORM DVLA
  • control of conditions e.g. DM/HTN
    Medical - eyedrops
    1) timolol
    2) Latanoprost
    3) brimonidine
    4) dorzolamide/ acetazolamide (PO)
    5) pilocarpine
    Surgical
  • laser trabeculoplasty
  • trabeculectomy (create new channel to increase drainage)
  • artificial shunt
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10
Q

Eye drops available for use in glaucoma, MOA, S.E & CI

A

1) BB (timolol)
MOA - I. adrenoreceptors in ciliary body to reduce aq. production
S.E - irritation, dry eyes, bronchospasm
CI - asthma, HF, bradycardia
2) PG analogue (Latanoprost)
MOA - increase uveroscleral outflow
S.E - uveitis, photophobia, bradycardia, increased eyelash length, iris and periocualr pigmentation
CI - Pregnancy, acute uveitis
3) a-agonist (brimonidine)
MOA - reduced aq. production and increases uveroscleral outflow
S.E - dizzy, dry mouth, headache, red eye, skin reactions
CI - raynaud’s, CVD
4) Carbonic anhydrase I (Dorzolamide - drops; acetazolamide PO)
MOA - reduces aq. secretion
SE - uveitis, headaches
CI - renal/hepatic impairment
5) Miotics (pilocarpine)
MOA - contract ciliary muscles to open drainage ch.
SE - eye pain, bradycardia
CI - uveitis

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11
Q

S.E of trabeculectomy and how to prevent it

A
  • reduces IOP - can cause retinal damage (contact lenses reduce leakage)
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12
Q

Complications of glaucoma

A
  • loss of vision
  • retinal A/V occlusion
  • affects other eye
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13
Q

Presentation of conjunctivitis

A 
Often bilateral; purulent discharge
- Bacterial: sticky; crusty lid
- Viral: watery, no itch
- allergic: watery, itcy, lid swelling
 Discomfort
 Conjunctival injection (Vessels moved over sclera)
 Acuity, pupil responses and cornea are unaffected.
 blurring of vision - clears when blink
 if cornea involved - photophobia
 red eye
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14
Q

Risk factors for conjunctivitis

A
  • contact exposure
  • contact lenses
  • trauma
  • chemical/UV exposure
  • AI disease
  • Allergies
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15
Q

Causes of conjunctivitis

A

 Viral: adenovirus; HSV
 Bacterial: s.aureus, step, haemophilus, chlamydia, gonococcus
 Allergic - hayfever (may - aug); dust allergy (worse in AM)

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16
Q

Ix for conjunctivitis

A
  • O/E - papillae (allerguy); follice formation (viral)
  • measure visual acuity)
  • ?swab
  • inflamed LN (viral)
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17
Q

Rx of conjunctivitis

A

ALL –> no contact lenses, lid hygiene 3 x d
 Bacterial: chloramphenicol 0.5% ointment (can return to school 24h after starting)
 Allergic: anti-histamine drops: e.g. emedastine (or PO) allergen avoidance; cold compress; sodium cromoglycate (mast cell stabiliser); severe -steroids
 Viral - self-limiting

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18
Q

What is giant papillary conjunctivitis and its rx

A
  • conjunctivitis caused by iatrogenic FB (contact lenses, prostheses, sutures)
  • shows giant papillae on tarsal conjunctivae
    Rx - remove FB; cromoglycate
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19
Q

Vernal keratoconjunctivitis - presentation and rx

A
  • in male children with a hx of atopy
  • itchy, photophobia, lacrimation, papillary conjunctivitis on upper tarsal plate (giant cobblestones), limbal follicles and white spots, punctate lesions on corneal epithelium.
    SEVERE - opaque oval plaque replacing upper zone of corneal epi
    Rx - olopatadine (Anti-hist + mast cell stab)
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20
Q

What is contact dermatoconjunctivitis

A
  • allergic conjunctivitis caused by eyedrops/ cosmetics

- np response to anti-hist/mast cell stab

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21
Q

What is the pathophysiology of retinal detachment

A

Holes/tears in retina allow fluid to separate sensory retina from retinal pigmented epithelium

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22
Q

Causes of retinal detachment and risk factors

A
  • MAIN - pre-existing posterior vitreous detachment causing traction on retina –> adhesions –> tears
  • secondary to retinal surgery, trauma, DM/HTN,
    Other risks –> myopia, FH, previous PVD< glaucoma, ca/inflamm eye disease
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23
Q

Presentation of retinal detachment

A 
4 F’s
 Floaters: numerous, acute onset, “spiders-web”
 Flashes (photopsia)
 Field loss (curtain)
 Fall in acuity (macular involved)
 Painless
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24
Q

Presentation of Posterior vitreous detachment

A
  • monochromatic photpsia in peripheral temporal field

- no change in vision yet

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25
Ix for retinal detachment
- visual acuity (reduced when macula involed - +- vitreous haemmorrhage) - visual fields (defect correlates to detached area) - pupil reflexes (RAPD if involved macula) - slit-lamp (visualise detachment +- tears) - OCT - access extent - fundoscopy - grey, opalescent retina, ballooning forward
26
Rx for retinal detachment
``` If macula still intact can save vision - if exudate - ix cause > Urgent surgery - Vitrectomy + gas tamponade +- laser coagulation to secure the retina - early tears can seal with laser/cryo - restrict head movements POST -OP - abx and steroids ```
27
Differentials of transient visual loss
```  Vascular: TIA, migraine  MS  Subacute glaucoma  Papilloedema  optic neuritis ```
28
Pathophysiology of vitreous haemorrhage
- small extravasations of blood which produce vitreous floaters can be from new vessels (DM) or retinal detachment/ tears/trauma
29
Presentation of vitreous haemorrhage
 Small bleeds → small black dots / ring floaters |  Large bleed can obscure vision → no red reflex, retina can't be visualised
30
Ix and Mx of vitreous haemorrhage
Ix - B scan US to identify cause Mx -VH undergoes spontaneous absorption  Vitrectomy may be performed in dense VH
31
Risk factors for age-related macular degeneration
```  Smoking  ↑age  Genetic factors/FH  hx cataract surgery  CVD/HTN  ethnicity ```
32
Dry v WET ARMD
Dry (Geographic Atrophy)  Drusen: fluffy white spots around macula  Degeneration of macula (changed to retinal pigmented epi)  Slow visual decline over 1-2yrs - difficulty reading Wet ( Subretinal Neovascularisation)  Aberrant vessels grow into retina from choroid and → haemorrhage (via VEGF)  Rapid visual decline (sudden / days / wks) - distortion  Fundoscopy shows macular haemorrhage → scarring --> central vision loss  Amsler grid detects distortion
33
Presentation of ARMD
```  Elderly pts.  Central visual loss  reduced contract sensitivity (abnormal dark adaptation)  reduced acuity  ?photopsia ```
34
Ix of ARMD
OCT (optical coherence tomography) - Gives high resolution images of the retina - Wet --> (subretinal and intra-retinal oedema) - dry --> (drusen, geographic atrophy)  Visual acuity  fundoscopy - drusen, scars, bleeds  Amsler grid - distortion in wet  fluroscein angiography (inject to visualise vasculature) - wet allows to assess for neovascularisation and haemorrhages
35
Mx of ARMD
smoking cessation, inform DVLA, visual rehab, regular check-ups, correct other optic illness and risk factors - Antioxidant vitamins (C,E) + zinc may help early ARMD ``` Wet --> anti-VEGF injections (avastatin/lucentis) - monthly for 3m intravitreally (reduces neovascularisation SE - endophthalmitis OR photodynamic therapy (destroys neovac membrane) ```
36
Eye conditions associated with DM
- cataracts (lens absorbs glucose and converts to sorbitol via aldose reductase) - glaucoma - occular motos nerve palsy (CN 3&6) - diabetic retinopathy
37
Pathogenesis of diabetic retinopathy
 Microangiopathy (narrowing A) → occlusion  Occlusion → ischaemia → new vessel formation in retina  Bleed → vitreous haemorrhage  Carry fibrous tissue ̄c them → retinal detachment  Occlusion also → cotton wool spots (ischaemia)  Vascular leakage → oedema and lipid exudates  Rupture of microaneurysms → blot haemorrhage
38
Screening for eye disease in DM
 All diabetics should be screened annually (in T1DM for 12 y/o)  Fundus photography  Refer those with maculopathy, NPDR and PDR to ophthalmologist  30% NPDR develop PDR in 1yr
39
Ix for diabetic retinopathy
 Fluorescein angiograph  Visual acuity  slit lamp/ fundoscopy  OCT (macula oedema?_
40
Mx of diabetic retinopathy
 Good BP and glycaemic control  Rx concurrent disease: HTN, dyslipidaemia, renal disease, smoking, anaemia  Laser photocoagulation - Maculopathy: focal or grid - Proliferative disease: pan-retinal (macula spared) +- IV triamcinolone and anti-VEGF if macular oedema  vitrectomy if vitreous haemorrhage - if proliferative left untreated would lose vision in 2 years
41
Grading of diabetic retinopathy
Background Retinopathy: Leakage  Dots: microaneurysms  Blot haemorrhages  Hard exudates: yellow lipid patches ``` Pre-proliferative Retinopathy: Ischaemia  Cotton-wool spots (infarcts)  Venous beading  Dark Haemorrhages  Intra-retinal microvascular abnormalities ``` Proliferative Retinopathy  New vessels  Pre-retinal or vitreous haemorrhage  Retinal detachment Maculopathy  Caused by macular oedema  ↓ acuity may be only sign  Hard exudates w/i one disc width of macula
42
feature of horner's syndrome
Ptosis (partial) Miosis Anhidrosis +- Enophthalmos
43
Causes of horners syndrome
Central  MS; stroke; syringomyelia Pre-ganglionic (neck)  Tumour: (pancoast)T1 nerve root lesion  Trauma: CVA insertion or CEA  Thyroidectomy ``` Post-ganglionic  Cavernous sinus thrombosis (2O to spreading facial infection via the ophthalmic vein)  CN 3, 4, 5, 6 palsies  Carotid A dissection ```
44
What is an argyll robertson pupil
Small, irregular pupils  Accommodate but doesn’t react to light  Atrophied and depigmented iris Causes --> DM/ syphilis
45
What is a holmes-Adie pupil
 Young woman ̄c sudden blurring of near vision  Initially unilateral and then bilateral pupil dilatation  Dilated pupil has no response to light and sluggish (may have slight on slit lamp) response to accommodation.  A “tonic” pupil Syndrome --> + absent knee/ankle jerks + ↓ BP Cause --> damage to postganglionic Parsym fibres (infection?)
46
Causes of a fixed dilated pupil
 Mydriatics: e.g. tropicamide  Iris trauma  Acute glaucoma  CN3 compression: tumour, coning
47
Features and causes of a relative afferent pupillary defect
Features  Minor constriction to direct light  Dilatation on moving light from normal to abnormal eye.  RAPD = Marcus Gunn Pupil Causes  Optic neuritis  Optic atrophy  Retinal disease
48
features of optic atrophy/neuropathy
```  ↓ acuity  ↓colour vision (esp. red)  Central scotoma  Pale optic disc  RAPD ```
49
Causes of optic atrophy/neuropathy
``` CAC VISION Congenital  Leber’s hereditary  Charcot Marie tooth  Friedrich’s ataxia  DIDMOAD (Wolfram's)  Retinitis pigmentosa ``` Alcohol and Other Toxins  Ethambutol  Lead  B12 deficiency Compression  Neoplasia: optic glioma, pituitary adenoma  Glaucoma  Paget’s ``` Vascular: DM, GCA or thromboembolic Inflammatory: MS; DM Sarcoid Infection: HSV;', TB, syphilis Oedema: papilloedema Neoplastic infiltration: lymphoma, leukaemia ```
50
Pathophysiology of uveitis
 Uvea is pigmented part of eye and included: iris, ciliary body and choroid.  Anterior uveitis = Iris + ciliary body  posterior uveitis = choroid
51
Symptoms of anterior uveitis
 Acute pain and photophobia (+- red eye) |  Blurred vision (aqueous precipitates)
52
Features on examination of anterior uveitis
```  Small pupil initially, irregular later  Circumcorneal injection  Hypopyon: pus in anterior chamber  White (keratic) precipitates on back of cornea  Talbots test: ↑pain on convergence ```
53
Associations with anterior uveitis
 Seronegative arthritis: AS, psoriatic, Reiter’s  Still’s / JIA  IBD  Sarcoidosis  Behcet’s  Infections: TB, leprosy, syphilis, HSV, CMV, toxo
54
Mx of anterior uveitis
 Refer to ophthalmologist  treat secondary causes  Prednisolone drops  Cyclopentolate drops: dilates pupil and prevents adhesions between iris and lens (synechiae)
55
Presentation, causes and mx of episcleritis
``` Presentation  Localised reddening: can be moved over sclera  Painless / mild discomfort  Acuity preserved - after phenylephrine vessels blanch ``` Causes  Usually idiopathic  May complicate RA or SLE Rx: Topical or systemic NSAIDs
56
Presentation, causes and mx of scleritis
Presentation  Severe pain: worse on eye movement  Generalised scleral inflammation  Vessels won’t move over sclera  Conjunctival oedema (chemosis) - after phenylephrine vessels will not blanchj Causes --> Wegener’s; RA; SLE; Vasculitis Mx --> Refer to specialist most need or corticosteroids or immunosuppressants
57
complications of scleritis
Scleromalacia (thinning) → globe perforation
58
Corneal abrasian - causes, symtpoms, ix and rx
Epithelial breech w/o keratitis --> Caused by trauma Symptoms  Pain  Photophobia  Blurred vision Ix --> Slit lamp: fluorescein stains defect green Rx --> Chloramphenicol ointment for infection prophylaxis
59
Corneal ulcer + keratitis (corneal inflam) causes
bacterial, herpetic, fungal, protozoa, vasculitic (RA)  - - - Dendritic ulcer = HSV - Acanthamoeba: protazoal infection affecting contact lens wearers swimming in pools
60
Presentation and ix for Corneal ulcer + keratitis
```  Pain, photophobia  Conjunctival hyperaemia  ↓ acuity  White corneal opacity - severe --> scarring and visual loss ``` Ix --> seen ̄c fluorescein on slit lamp
61
Mx for Corneal ulcer + keratitis
Refer immediately to specialist who will:  Take smears and cultures; no contact lenses  Abx drops, oral/topical aciclovir; pain relief  Cycloplegics/mydriatics ease photophobia  Steroids may worsen symptoms: professionals only
62
Opthalmic shingles presentation
 Pain in CNV1 dermatome precedes blistering rash  40% → keratitis, iritis Hutchinson’s sign  Nose-tip zoster due to involvement of nasociliary branch.  ↑ chance of globe involvement as nasociliarry nerve also supplies globe  Ophthalmic involvement - Keratitis + corneal ulceration (fluorescein stains) - ± iritis
63
key questions to ask if have sudden vision loss
HELLP:  Headache associated: GCA  Eye movements hurt: optic neuritis  Lights / flashes preceding visual loss: detached retina  Like curtain descending: TIA, GCA  Poorly controlled DM: vitreous bleed from new vessels
64
Pathophysiology and causes of anterior ischaemic optic neuropathy
Optic nerve damaged if posterior ciliary arteries blocked by inflammation or atheroma. - Pale / swollen optic disc Causes  Arteritic AION: Giant Cell Arteritis  Non-arteritic AION: HTN, DM, ↑ lipids, smoking
65
Symptoms and signs of optic neuritis
Symptoms  Unilateral loss of acuity over hrs – days  ↓ colour discrimination (dyschromatopsia)  Eye movements may hurt ``` Signs  ↓ acuity  ↓ colour vision  Enlarged blind-spot  Optic disc may be: normal, swollen, blurred  Afferent defect ```
66
Causes of optic neuritis
```  Multiple sclerosis (45-80% over 15yrs)  DM  Drugs: ethambutol, chloamphenicol  Vitamin deficiency  Infection: zoster, Lyme disease ```
67
Rx of optic neuritis
 High-dose methyl-pred IV for 72h |  Then oral pred for 11/7
68
Presentation, causes and mx of central retinal artery occlusion
Presentation  Dramatic unilateral visual loss in seconds  Afferent pupil defect (may precede retinal changes)  Pale retina --> cherry-red macula Causes  GCA  Thromboembolism: clot, infective, tumour Rx If seen w/i 6h aim is to ↑ retinal blood flow by↓IOP  Ocular massage  Surgical removal of aqueous  Anti-hypertensives (local and systemic)
69
Caues, presentation and complitations of central retinal vein occlusion
Commoner than arterial occlusion Causes: arteriosclerosis, ↑BP , DM, polycythaemia ``` Pres: sudden unilat visual loss ̄c RAPD - Fundus: Stormy Sunset Appearance Tortuous dilated vessels  Haemorrhages  Cotton wool spots ``` Complications  Glaucoma  Neovascularisation Prognosis: possible improvement for 6mo-1yr
70
Presentation and complications of branch retinal vein occlusion
 Presentation: unilateral visual loss  Fundus: segmental fundal changes  Comps: retinal ischaemia → VEGF release and neovascularisation (Rx: laser photocoagulation)
71
Causes of gradual visual loss
``` Common  Diabetic retinopathy  ARMD  Cataracts  Open-angle Glaucoma Rarer  Genetic retinal disease: retinitis pigmentosa  Hypertension  Optic atrophy ```
72
Commonest causes of blindness worldwide
```  Trachoma  Cataracts  Glaucoma  Keratomalacia: vitamin A deficiency  Onchocerciasis  Diabetic Retinopathy ```
73
Presentation and causes of cataracts
``` Presentation  Increasing myopia  Blurred vision → gradual visual loss  Dazzling in sunshine / bright lights  Monocular diplopia ``` ``` Causes  ↑Age: 75% of >65s  DM  Steroids  Congenital -Idiopathic; Infection: rubella; Metabolic: Wilson’s, galactosaemia; Myotonic dystrophy ```
74
Ix and mx of cataracts
``` Ix  Visual acuity  Dilated Fundoscopy - opacity  Tonometry  Blood glucose to exclude DM ``` Mx Conservative - stop smoking, eat healthily , inform DVLA  Glasses  Mydriatic drops and sunglasses may give some relief ``` Surgery  Consider if symptoms affect lifestyle or driving (<6/10)  Day-case surgery under LA  Phacoemulsion + lens implant  1% risk of serious complications - Anterior uveitis / iritis - VH - Retinal detachment - Secondary glaucoma -Endophthalmitis (→ blindness in 0.1%)  Post-op capsule thickening is common --> Easily Rx ̄c laser capsulotomy.  Post-op eye irritation is common and requires drops ```
75
pathophysiology and presentaion and retinitis pigmentosa
Collection of progressive dystrophies of the photoreceptors and pigment epithelium  Mostly AR inherited  AD has best prognosis  X-linked has worst prognosis  Affects ~ 1/2000 Can be associated with friedrich's ataxia and ushers syndrome Presentation  Night blindness  ↓↓ visual fields → tunnel vision  Myopia  worsening photpsia  LATE --> reduced colour and central vision  Most are registrable blind (<3/60) by mid 30s
76
Ix and mx for retinitis pigmentosa
``` Fundoscopy  Pale optic disc: optic atrophy  Peripheral retina pigmentation: spares the macula Assess visual field, IOP and OCT Mx --> no treatment - inform DVLA - Counselling ```
77
Features of retinoblastoma
- 1:15,000 Live births (often present <5 y/o) Can be inherited/ non-inherited - Inherited -->AD mutation of RB gene (a TSG) 80% penetrance - 1 mutant allele in every retinal cell; if the other allele mutates → retinoblastoma. Associations of inherited - 5% occur with pineal or other tumour - ↑ risk of osteosarcoma and rhabdomyosarcoma Signs  Stabismus  Leukocoria (white pupil) → no red reflex
78
Ix and Rx of retinoblastoma
Ix --> examine under GA; MRI orbit (extension); RB1 gene mutation assessment Rx --> Chemo (in bilateral); enucleation(large/ retinal detachment); photo-coagulation (small) - screen parents and siblings - follow up MRI every 6m for 5 years Untreated --> invades and metastasis - death in <2 years
79
Causes of lid swelling
Mechanical - ectropion - endotropium - FB/ Trichasis Inflammatory - Blepharitis - Stye (hordeolum externum) - Chalazion (hordeolum internum) Infection - Preseptal cellulitis - Orbital cellulitis
80
Ectropion v endotropium
- endotropium (Lid inversion → corneal irritation; Degeneration of lower lid fascia) - ectropion (Low lid eversion → watering and exposure keratitis; Assoc. with ageing and facial N. palsy)
81
Stye v chalazion
Stye or hordeolum externum - An abscess / infection in a lash follicle which points outwards. - Rx: local Abx – e.g. fusidic acid Chalazion or hordeolum internum - Abscess of the Meibomian glands which points inwards onto conjunctiva. - Sebaceous glands of eyelid
82
Causes, features and rx of blepharitis
Chronic inflammation of eyelid Causes: seborrhoeic dermatitis, staphs ``` Features  Red eyes  Gritty / itchy sensation  Scales on lashes.  Often assoc. ̄c rosacea ``` Rx  Clean crusts of lashes ̄c warm soaks May need fusidic acid drops
83
Causes of ptosis
- due to intrinsic LPS weakness ``` Bilateral  Congenital  Senile  MG  Myotonic dystrophy ``` Unilateral  3rd Nerve palsy  Horner’s syndrome (partial)  Mechanical: xanthelasma, trauma
84
Features, causes and Rx of Lagophthalmos
Difficulty in lid closure over the globe which may → exposure keratitis Causes: exophthalmos, facial palsy, injury Rx  Lubricate eyes ̄c liquid paraffin ointment  Temporary tarsorrhaphy may be needed if corneal ulcers develop.
85
Pathophysiology and presentation of pre-septal and orbital cellulitis
Pre-septal - infection anterior to orbital septum - s.aureus; s.epidermis; strep - caused by laceration/ insect bite - sx --> red; tender ?fever/malaise Orbital - life threatening infection of soft tissue behind orbital septum - s.pneumoniae; s.aureus; s.epidermis - secondary to ethmoidal sinusitis/ pre-septal cellulitis - sx --> red; tender; proptosis; chemosis; opthalmoplegia; reduced acuity; pain; ↓ ROM of eye; fever
86
Rx and complications of pre-septal and orbital cellulitis
- Admit - analgesia; warm compress (pre-septal) - Abx (PO - pre-septal and IV orbital) e.g. cefuroxamine - monitor optic N function every 4h +- imaging - ?surgery if orbital collection Blindness due to optic N. pressure. complications - central rentinal A/V occlusion; optic neuropathy; meningitis; brain abscess; increased IOP; endopthalmitis
87
Causes and presentation of Carotico-cavernous fistula
May follow carotid aneurysm rupture -->reflux of blood into cavernous sinus. Causes: spontaneous, trauma ``` Presentation  Engorgement of eye vessels  Lid and conjunctival oedema,  Pulsatile exophthalmos  Eye bruit ``` Rx  Oral antivirals: famciclovir, aciclovir
88
Causes of proptosis
Force pushing intraconally (axial) - optic N tumour - post. inflam disease (scleritis/choroiditis), graves, glaucoma Force pushing extraconally (non-axial) - lacrimal gland tumour, orbital cellulitis/ tumour, trauma - Carotico-cavernous fistula
89
Causes of a paralytic squint
CNIII  Ptosis (LPS)  Fixed dilated pupil (no parasympathetic)  Eye looking down and out  Causes - Medical: DM, MS, infarction - Surgical: ↑ ICP, cavernous sinus thrombosis, posterior communicating artery aneurysm CNIV  Diplopia especially on going down stairs  Head tilt  Test: can’t depress in adduction  Causes - Peripheral: DM (30%), trauma (30%), compression - Central: MS, vascular, SOL CNVI  Eye is medially deviated and cannot abduct  Diplopia in the horizontal plane.  Causes - Peripheral: DM, compression, trauma - Central: MS, vascular, SOL  Rx: botulinum toxin can eliminate need for surgery
90
Mangement of FB in eye
 Chloramphenicol drops 0.5% prevent infection  Eye patch  Cycloplegic drops may ↓ pain( Tropicamide, cyclopentolate)
91
What is an intra-ocular haemorrhage
 Blood in anterior chamber = hyphaema  Small amounts clear spontaneously, but some may need evacuation.  Complicated by corneal staining and glaucoma (pain)  Keep IOP↓ and monitor
92
Presentation and mx of an orbital blowout fracture
Blunt injury → sudden ↑ in orbital pressure - herniation of orbital contents into maxillary sinus (by orbital flow #) Presentation  Ophthalmoplegia + Diplopia (Tethering IR + IO muscles)  Loss of sensation to lower lid skin (Infraorbital nerve injury)  Ipsilateral epistaxis (Damage to anterior ethmoidal A)  ↓ acuity  Irregular pupil that reacts slowly to light Mx Fracture reduction and muscle release necessary.
93
Causes of floaters in vision
```  Retinal detachment  VH  Diabetic retinopathy / Hypertension  Old retinal branch vein occlusion  Syneresis (degenerative opacities in the vitreous) ```
94
Causes of photopsia in vision
Headache, n/v: migraine; retinal detachment
95
Causes of haloes in vision
hazy ocular media – cataract, corneal oedema, acute glaucoma Haloes + eye pain = acute glaucoma Jagged haloes which change shape are usually migrainous.
96
Name some tropical eye diseases and there managment
- Traucoma (c.trachomatis) Rx - tetracycline ointment - onchocerciais (nematode) Rx - ivermectin - xerophthalmia and keratomalacia (vit A def) Get night blindness and dry conjunctivea - corneal ulceration and perforation RX - Vit A supplement
97
Grades of hypertensive retinopathy
Keith-Wagener Classification 1. Tortuosity and silver wiring 2. AV nipping 3. Flame haemorrhages and soft / cotton wool spots 4. Papilloedema Grades 3 and 4 = malignant hypertension
98
Eye signs in vascular occlusion
 Emboli → amaurosis fugax: GCA, carotid atheroemboli  Microemboli → Roth spots: infective endocarditis  Boat-shaped haemorrhage ̄c pale centre
99
Signs of metabolic disease in the eyes
 Kayser-Fleischer Rings: Wilson’s  Exophthalmos: Graves’  Corneal calcification: HPT
100
Eye signs in HIV
CMV retinitis: pizza-pie fundus + flames HIV retinopathy: cotton wool spot
101
Mydriatic eye drops
Anti-musc - tropicamide (duration 3h) - cyclopentolate (duration 24h - paeds) Causes pupil dilation and loss of light reflex + blurred vision due to cilicary paralysis Sympathomimetics - Para-hydroxyamphetamine, phenylephrine  Don’t affect the light reflex or accommodation Indications  Eye examination  Prevention of synechiae in ant. uveitis / iritis
102
Causes of diplopia
Monocular Cornea/lens - refractive erros; keratoconus; corneal scarring; cataracts Extra-ocular muscles - myasthenia gravis; grave's disease; orbital # Biocular Nerves - CN 3,4,6 palsy; MSl DMl GCA Brain - stroke; aneurysm; SOL; migraine; raised IOP (abducens affected first)
103
Diplopia red flags
Posterior comm A anuerysm - + largely poorly reactive pupil Horners (carotid dissection) - + affected eye movemtns/pupils Multiple CN palsies- intracranial/meningeal tumour + fatigue - myasthenia gravis + scalp tenderness - GCA
104
What compensatory mechanisms can there be for proptosis
Bell's protective reflex where eye rolls to back of head to prevent dry eyes
105
Pathogenesis of thyroid eye disease
orbital fat expansion due to lymphocyte infiltrating orbital tissue and releasing cytokines - promote release of mucopolysaccharides from fibroblasts - resulting osmotic shift causes oedema of orbital fat
106
Causes of dry eyes
- BB - Anti-depressants - reduced blinking - PD/nerve palsy/ shingles (reduced corneal reflex), exopthalamus - HRT and menopause - air con - blepharitis
107
Mx of dry eyes
artificial tears tape eye shut no air con
108
Classification of orbital fractures
Le-fort 1) horizonal maxillary (can include orbit) - seperates teeth from upper face 2) pyramidal # - # passes through inf orbital rim + maxillry sinus lateral wall 3) craniofacial disjunction - # passes through orbital wall + zygomatic arch
109
Symptoms, causes and management of posterior uveitis (choroiditis)
Sx - bilateral; floaters; ?photophobia; gradual vision loss/ reduced acuity; ?red eye; dilated pupils Fundoscopy - pale lesions +- atrophic paleness Causes - EBV; VZV; TB; LYME; SYHPHILIS; IBD/RA; CA Mx - antimicrobials and steroids
110
Differentials of orbital cellulitis
- angioedema - thyroid eye disease - orbital tumour - chalazion cyst - necrotising fasciitis - severe conjunctivitis
111
Causes of papilloedema
``` space-occupying lesion: neoplastic, vascular malignant hypertension idiopathic intracranial hypertension hydrocephalus hypercapnia ```

Finals (6 decks)

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