Pathology Part 1

Question 1

Amaurosis fugax

Answer 1

Transient, painless loss of vision
o “Like a curtain coming down”
o Lasts ~5min with full recovery
o Examination usually normal

Question 2

Anterior uveitis

Answer 2

Describes inflammation of the anterior portion of the uvea - iris and ciliary body. It is associated with HLA-B27 and may be seen in association with other HLA-B27 linked conditions.

Question 3

Features of Anterior uveitis

Answer 3

>   acute onset
>   ocular discomfort & pain
>   pupil may be small +/- irregular 
>   photophobia (often intense)
>   blurred vision
>   red eye
>   lacrimation
>   ciliary flush: a ring of red spreading outwards
>   hypopyon
>   visual acuity initially normal → impaired

Question 4

Hypopyon

Answer 4

describes pus and inflammatory cells in the anterior chamber, often resulting in a visible fluid level

Question 5

Disorders associated with Anterior uveitis

Answer 5

1. ankylosing spondylitis
2. reactive arthritis
3. ulcerative colitis, Crohn’s disease
4. Behcet’s disease
5. sarcoidosis: bilateral disease may be seen

Question 6

Chorioretinitis

Answer 6

Is a form of posterior uveitis and is associated with cytomegalovirus and toxoplasmosis (cats).

Question 7

Management of Anterior uveitis

Answer 7

1. Urgent review by ophthalmology
2. Cycloplegics (mydriatic) eye drops
3. Steroid eye drops

Question 8

Investigations of Anterior uveitis

Answer 8

Slit lamp

Question 9

Conjunctivitis

Answer 9

Inflammation of the conjunctivae. It is very common

Question 10

Bacterial Conjunctivitis

Answer 10

Acute onset red, gritty eyes with purulent discharge that causes the eyes to be stuck together on wakening
▪      Minimal pain & Red eye 
▪	Will spread from one eye to the other
▪	Clear cornea 
▪	Normal pupillary light response

Question 11

Causes of Bacterial Conjunctivitis

Answer 11

▪ Staph aureus, strep. pneumonia, h. influenzae
▪ Pseudomonas
▪ In babies: chlamydia trachomatis, Neisseria gonorrhoea
▪ Chlamydia in sexually active adults

Question 12

Management of Bacterial Conjunctivitis

Answer 12

1. Chloramphenicol
2. If neonate, refer to ophthalmology
3. Fusidic acid
4. Pseudomonas – gentamicin
5. Chlamydia – oxytetracycline, azithromycin

Question 13

Causes of viral Conjunctivitis

Answer 13

1. Adenovirus
2. Herpes simplex
3. Herpes zoster

Question 14

Symptoms of viral conjunctivitis

Answer 14

▪ Swollen and tender pre-auricular lymph nodes
▪ Watery eye (sticky in bacterial conjuncitivits)
▪ Red eye
▪ Extreme eye movements can cause pain
▪ Tends to occur with a URTI

Question 15

Keratitis

Answer 15

Inflammation of the cornea. Often caused by corneal abrasion

Question 16

Causes of Keratitis

Answer 16

> bacterial
fungal
amoebic
parasitic: onchocercal keratitis (‘river blindness’)

Question 17

Types of bacteria in bacterial Keratitis

Answer 17

> Staphylococcus aureus

> Pseudomonas aeruginosa - contact lens wearers

Question 18

What bacteria causes keratitis in contact kens wearers?

Answer 18

Pseudomonas aeruginosa

Question 19

Features of Keratitis

Answer 19

1. red eye: pain and erythema
2. photophobia
3. foreign body, gritty sensation
4. hypopyon may be seen

Question 20

Diagnosis of Keratitis

Answer 20

o Fluorescein

o Corneal scrape

Question 21

Management of suspected keratitis in contact wearers

Answer 21

Same-day referral to an eye specialist is usually required to rule out microbial keratitis

Stop using contact lens until the symptoms have fully resolved

Topical antibiotics - typically quinolones

Question 22

Complications of Keratitis

Answer 22

> corneal scarring
perforation
endophthalmitis
visual loss

Question 23

Endophthalmitis

Answer 23

Inflammation of the intraocular space occupied by the vitreous. If it involves all layers and the peri-ocular tissues, it is known as panopthalmitis. Potentially devastating infection

Question 24

Causes of Endophthalmitis

Answer 24

>

Staph epidermidis
Most cases are after cataract procedures
Injury 
Contact lenses

Question 25

Symptoms of Endophthalmitis

Answer 25

1. Red eye 2. Decreased vision 3. Extreme pain

Question 26

Investigations for Endophthalmitis

Answer 26

o Slit lamp | o Ultrasound

Question 27

Management of Endophthalmitis

Answer 27

> Immediate referral | > Intravitreal vancomycin

Question 28

Blepharitis

Answer 28

Inflammation of the eyelid margins

Question 29

Anterior blepharitis

Answer 29

Inflammation of the eyelid margins | caused by seborrhoeic dermatitis/staphylococcal infection

Question 30

Posterior blepharitis

Answer 30

Inflammation of the eyelid margins. caused by either meibomian gland dysfunction or acne rosacea

Question 31

Symptoms of Blepharitis

Answer 31

``` o Itchy, sore, red eyelids o Burning sensation in the eyes o Photophobia o Swollen eyelid margins o Cysts ```

Question 32

Management of Blepharitis

Answer 32

1. Hot compresses twice a day 2. Mechanical removal of the debris 3. artificial tears 4. Chloramphenicol, Fusidic acid, Doxycycline

Question 33

Episcleritis

Answer 33

Common and usually benign condition characteristed by inflammation of the epislcera . Usually idiopathic

Question 34

Features of Episcleritis

Answer 34

1. red eye 2. classically not painful (in comparison to scleritis), 3. watering and mild photophobia

Question 35

Episcleritis management

Answer 35

Self-limiting | Artificial tears

Question 36

Difference between scleritis and episcleritis

Answer 36

Severe pain in scleritis, mild/none in Episcleritis

Question 37

Scleritis features

Answer 37

1. red eye 2. classically painful (in comparison to episcleritis), 3. watering and photophobia are common 4. gradual decrease in vision

Question 38

Difference between scleritis and episcleritis

Answer 38

Episcleritis is inflammation of the superficial, episcleral layer of the eye. It is relatively common, benign and self-limiting. Scleritis is inflammation involving the sclera. It is a severe ocular inflammation, often with ocular complications.

Question 39

What condition is associated with scleritis?

Answer 39

Associated with rheumatoid arthritis

Question 40

Scleritis

Answer 40

Severe infection throughout the entire thickness of the sclera. It is very rare and more common in women

Question 41

Scleritis management

Answer 41

1. Oral NSAIDs | 2. Oral steroids

Question 42

Ocular manifestations of Rheumatoid arthritis

Answer 42

``` keratoconjunctivitis sicca (most common) episcleritis (erythema) scleritis (erythema and pain) corneal ulceration keratitis ```

Question 43

Orbital cellulitis

Answer 43

The result of an infection affecting the fat and muscles posterior to the orbital septum, within the orbit but not involving the globe. It is usually caused by a spreading upper respiratory tract infection from the sinuses and carries a high mortality rate. Orbital cellulitis is a medical emergency.

Question 44

Risk factors for Orbital cellulitis

Answer 44

1. Childhood 2. Previous sinus infection 3. Lack of Haemophilus influenzae vaccination 4. Recent eyelid infection/ insect bite on eyelid (Peri-orbital cellulitis) 5. Ear or facial infection

Question 45

Features of Orbital cellulitis

Answer 45

``` o Sudden onset of unilateral swelling of conjunctiva and lids o Proptosis o Pain on movement o Relative afferent pupillary defect o Fever o Severe malaise ```

Question 46

Investigation of Orbital cellulitis

Answer 46

CT which may shows Inflammation of the orbital tissues deep to the septum, sinusitis.

Question 47

Management of Orbital cellulitis

Answer 47

Admission to hospital for IV antibiotics

Question 48

Preseptal cellulitis

Answer 48

It is an infection of the soft tissues anterior to the orbital septum - this includes the eyelids, skin and subcutaneous tissue of the face, but not the contents of the orbit.

Question 49

Preseptal cellulitis causes

Answer 49

Staph. aureus Staph. epidermidis Streptococci and anaerobic bacteria.

Question 50

Investigations of Preseptal cellulitis

Answer 50

> Bloods - raised inflammatory markers > Swab of any discharge present > Contrast CT of the orbit may help to differentiate between preseptal and orbital cellulitis.

Question 51

Management of Preseptal cellulitis

Answer 51

1. All cases should be referred to secondary care for assessment 2. Oral antibiotics are frequently sufficient - usually co-amoxiclav

Question 52

Complications of Preseptal cellulitis

Answer 52

Bacterial infection may spread into the orbit and evolve into orbital cellulitis

Question 53

Features of Argyll-Robertson pupil

Answer 53

1. small, irregular pupils | 2. no response to light but there is a response to accommodate

Question 54

Causes of Argyll-Robertson pupil

Answer 54

> diabetes mellitus | > syphilis

Question 55

A chalazion (Meibomian cyst)

Answer 55

A retention cyst of the Meibomian gland. It presents as a firm painless lump in the eyelid. The majority of cases resolve spontaneously but some require surgical drainage

Question 56

Stye

Answer 56

infection of the glands of the eyelids

Question 57

Entropion

Answer 57

In-turning of the eyelids

Question 58

Ectropion

Answer 58

Out-turning of the eyelids

Question 59

Dendritic ulcer

Answer 59

Herpes simplex keratitis causes this ulcer

Question 60

Herpes zoster ophthalmicus (HZO)

Answer 60

Describes the reactivation of the varicella-zoster virus in the area supplied by the ophthalmic division of the trigeminal nerve. It accounts for around 10% of case of shingles.

Question 61

Herpes zoster ophthalmicus (HZO) features

Answer 61

Vesicular rash around the eye, which may or may not involve the actual eye itself Hutchinson's sign: rash on the tip or side of the nose. Indicates nasociliary involvement and is a strong risk factor for ocular involvement

Question 62

Management of Herpes zoster ophthalmicus (HZO)

Answer 62

1. Oral antiviral treatment for 7-10 days 2. intravenous antivirals may be given for very severe infection or if the patient is immunocompromised 3. ocular involvement requires urgent ophthalmology review

Question 63

Curtain coming down < 5 minutes

Answer 63

amaurosis fugax

Question 64

Holmes-Adie pupil

Answer 64

> unilateral in 80% of cases > dilated pupil > once the pupil has constricted it remains small for an abnormally long time > slowly reactive to accommodation but very poorly (if at all) to light

Question 65

Stage 1 hypertensive retinopathy

Answer 65

Arteriolar narrowing and tortuosity | Increased light reflex - silver wiring

Question 66

Stage 2 hypertensive retinopathy

Answer 66

Arteriovenous nipping

Question 67

Stage 3 hypertensive retinopathy

Answer 67

Cotton-wool exudates | Flame and blot haemorrhages

Question 68

Stage 4 hypertensive retinopathy

Answer 68

Papilloedema

Question 69

Papilloedema

Answer 69

Papilloedema describes optic disc swelling that is caused by increased intracranial pressure. It is almost always bilateral.

Question 70

Features of Papilloedema

Answer 70

blurring of the optic disc margin elevation of optic disc loss of the optic cup Paton's lines: concentric/radial retinal lines cascading from the optic disc

Question 71

Causes of Papilloedema

Answer 71

``` space-occupying lesion: neoplastic, vascular malignant hypertension idiopathic intracranial hypertension hydrocephalus hypercapnia ```

Question 72

Vitreous haemorrhage

Answer 72

Bleeding into the vitreous humour. It is one of the most common causes of sudden painless loss of vision. It causes disruption to vision to a variable degree, ranging from floaters to complete visual loss.

Question 73

Causes of Vitreous haemorrhage

Answer 73

1. proliferative diabetic retinopathy (over 50%) 2. posterior vitreous detachment 3. ocular trauma

Question 74

Most common cause of vitreous haemorrhage in young adults and children

Answer 74

Ocular trauma

Question 75

Features of Vitreous haemorrhage

Answer 75

1. painless visual loss or haze (commonest) 2. red hue in the vision 3. floaters or shadows/dark spots in the vision

Question 76

Causes of tunnel vision

Answer 76

``` papilloedema glaucoma retinitis pigmentosa choroidoretinitis optic atrophy secondary to tabes dorsalis hysteria ```

Question 77

Tunnel vision

Answer 77

Tunnel vision gives the appearance of looking through a narrow tube. Peripheral vision is obscured, causing a constricted field of view.

Question 78

Retinitis pigmentosa

Answer 78

Retinitis pigmentosa primarily affects the peripheral retina resulting in tunnel vision. Retinitis pigmentosa (RP) is a group of rare, genetic disorders that involve a breakdown and loss of cells in the retina

Question 79

Features of Posterior vitreous detachment

Answer 79

> The sudden appearance of floaters > Flashes of light in vision > Blurred vision > Cobweb across vision The appearance of a dark curtain descending down vision (means that there is also retinal detachment)

Question 80

Investigations for Posterior vitreous detachment

Answer 80

All patients with suspected vitreous detachment should be examined by an ophthalmologist within 24hours to rule out retinal tears or detachment.

Question 81

Pain on eye movement

Answer 81

Optic neuritis

Question 82

Curtain coming down >5 minutes

Answer 82

Retinal detachment

Question 83

Dacrocystitis

Answer 83

Inflammation of lacrimal sac which occurs secondary to blockage of the lacrimal system and is treated with broad spectrum antibiotics.

Question 84

What is worse; alkali or acid burns in the eyes?

Answer 84

Alkali burns to the eye are worse than acid burns, because alkali penetrates the eye, whereas acid is relatively self-limiting by caused the proteins to coagulate and prevent further damage.

Question 85

Hyphaema

Answer 85

Blood in the anterior chamber that may occur following blunt trauma

Question 86

Sympathetic ophthalmia

Answer 86

A dangerous complication of penetrating injury. Injury causes intra-ocular antigens to be released into the immune system. This causes an autoimmune response by the body to be launched against both eyes. Requires immediate treatment with immunosuppression or vision in both eyes will be lost.

Question 87

Most common cancer of the eyelid

Answer 87

Basal cell carcinoma

Question 88

Schirmer’s test

Answer 88

Measures ocular dryness - tear production

Question 89

Damage to the optic chiasm

Answer 89

Bitemporal hemianopia

Question 90

Damage to the optic tracts/radiations

Answer 90

May cause homonymous defects

Question 91

Damage to the occipital cortex

Answer 91

Homonymous defects with macular sparing

Question 92

Eye changes in Wilson's disease

Answer 92

kayser Fleischer rings

Question 93

Eye changes in Down Syndrome

Answer 93

brushfield’s spots

Question 94

Eye changes in Ehlers-Danlos syndrome

Answer 94

Blue sclera

Question 95

Meibomian glands

Answer 95

Are oil glands along the edge of the eyelids where the eyelashes are found. These glands make oil that is an important part of the eye's tears. The oily layer is the outside of the tear film that keeps tears from drying up too quickly.