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Y2 Ophthalmology > Vascular and Neuro-Opthalmic Disease > Flashcards

Vascular and Neuro-Opthalmic Disease Flashcards

1
Q

Cause of retinal artery occlusions

A

Thromboembolism - from atherosclerosis
Arteritis (for central retinal artery occlusion)

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2
Q

What is central retinal artery occlusion

A

Occlusion of the central retinal artery causing infarction of inner 2/3 of retina and vision loss

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3
Q

What structure supplies the outer 1/3 of retina

A

Choroid

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4
Q

What arteritis can cause central retinal artery occlusion

A

Giant cell arteritis

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5
Q

Symptoms of central retinal artery occlusion

A

Sudden, painless severe loss of vision
Unilateral

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6
Q

Signs of central retinal artery occlusion

A

Relative afferent pupil defect (RAPD)
Thread like arteries
Retina becomes pale and oedematous
Cherry red spot at fovea

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7
Q

What is relative afferent pupil defect

A

When one of the eyes responds differently to light

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8
Q

What is the normal pupil response to light

A

When light is shone on one eye, the pupil should constrict
The other eye should simultaneously constrict as well due to consensual light reflex
When the light is removed, both should dilate at the same time

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9
Q

How is relative afferent pupil defect tested

A

Swinging light test

  1. Shine the light onto one eye then wait about 3 sec then switch to the other eye
  2. When shone to the affected one - the affected pupil dilates more instead of constrict / the affected one constricts less than the affected one
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10
Q

Management of central retinal artery occlusion

A

Immediate referral to stroke clinic
Identify and treat underlying cause

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11
Q

What is branch retinal artery occlusion

A

When one of the branches of central retinal artery becomes occluded -> ischaemia to the area the branch supplies

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12
Q

Symptoms of branch retinal artery occlusion

A

Acute, painless visual impairment
Unilateral
Severity of visual loss depends on which area is affected

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13
Q

Signs of branch retinal artery occlusion

A

Absence of perfusion (shown as white plaques on fundoscopy)

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14
Q

Management of branch retinal artery occlusion

A

Refer to stroke clinic

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15
Q

What is amaurosis fugax

A

Transient central retinal artery occlusion

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16
Q

Amaurosis fugax is seen in

A

Giant cell arteritis

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17
Q

Symptoms of amaurosis fugax

A

Transient painless visual loss
“like a curtain coming down”
Lasts for 5 minutes then full recovery

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18
Q

Are there any findings on fundoscopy for amaurosis fugax

A

Usually no abnormal signs

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19
Q

management of GCA with visual impairment

A

IV methylprednisolone
Same day ophthalmology review

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20
Q

What does Virchow’s triad describe

A

the 3 factors that contribute to the development of venous thrombosis

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21
Q

What are the 3 factors in Virchow’s triad

A

Endothelial damage
Abnormal blood flow
Hypercoagulable state

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22
Q

Examples of conditions that can cause endothelial damage

A

Diabetes
Trauma / surgery
Atherosclerosiss

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23
Q

Examples of conditions that can cause hyper coagulable state

A

Malignancy
Pregnancy
Sepsis
IBD

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24
Q

Examples of conditions that can cause abnormal blood flow

A

Immobility
Afib
Left ventricular dysfunction
Obesity
Pregnancy

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25
Q

What is central retinal vein occlusion

A

Formation of thrombus in central retinal vein blocking drainage of blood from the retina

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26
Q

Risk factors of retinal vein occlusion

A

Increasing age
Hypertension
CVD
Diabetes
Glaucoma

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27
Q

What happens if venous drainage is blocked by thrombus

A

Blood pools in the retina
Leakage of fluid and blood -> macular oedema and retinal haemorrhages
Damage to tissue in the retina
Neovascularisation

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28
Q

Symptoms of retinal vein occlusion

A

Sudden painless loss of vision
Branch retinal vein occlusion may result in visual loss in the affected area only
Unilateral

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29
Q

What are the findings on fundoscopy for retinal vein occlusion

A

Macular oedema
Dilated tortuous veins
Blot haemorrhages, severe retinal haemorrhages
Widespread hyperaemia (widespread redness due to pooling of blood)

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30
Q

Management of retinal vein occlusion

A

Managed conservatively
IV Anti VEGF for macular oedema
Laser photocoagulation for retinal neovascularization

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31
Q

What is vitreous haemorrhage

A

Bleeding into the vitreous cavity

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32
Q

Where is the vitreous cavity

A

posterior chamber

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33
Q

What are the causes of vitreous haemorrhage

A

Proliferative diabetic retinopathy
Trauma
Retinal vein occlusion
Retinal tear

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34
Q

Symptoms of vitreous haemorrhage

A

If mild - floaters
If severe - acute painless visual loss or haze

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35
Q

Clinical signs of vitreous haemorrhage

A

Loss of red reflex
Haemorrhage on fundoscopy

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36
Q

Investigations for vitreous haemorrhage

A

fundoscopy
Ultrasound B scan of the eye
Fluorescein angiography
orbital CT

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37
Q

Management of vitreous haemorrhage

A

Treat underlying cause - e.g. laser photocoagulation / anti-VEGF / optimise blood glucose control

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38
Q

What is the muscle that control superior eyelid movement

A

levator palpebrae superioris

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39
Q

What are the muscles that control ocularmovement

A

Superior rectus
Inferior rectus
Medial rectus
Lateral rectus
Inferior oblique
Superior oblique

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40
Q

Describe the structure of levator palpebrae superioris

A

A small portion of LPS contains smooth muscle called superior tarsal muscle

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41
Q

Describe the innervation of levator palpebrae superioris

A

LPS - Oculomotor nerve CN III
Superior tarsal muscle (smooth muscle) - sympathetic nervous system

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42
Q

Describe the attachment of levator palpebrae superioris

A

Origin: from the lesser wing of sphenoid bone, right above optic foramen
Attachment: superior tarsal plate

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43
Q

Describe the action of levator palpebrae superioris

A

Elevate the upper eyelid

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44
Q

Where is the common origin of the 4 recti muscles

A

All originate from the common tendinous ring

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45
Q

What is the common tendinous ring

A

Ring of fibrous tissue surrounding the optic canal

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46
Q

Describe how do the rects muscles attach to the eye

A

Straight attachment to the eye = direct path from origin to attachment

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47
Q

Do the oblique muscles originate from common tendinous ring

A

No

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48
Q

Describe how do the oblique muscles attach to the eye

A

Angular attachment to the posterior surface of sclera

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49
Q

Describe the innervation of the recti muscles

A

All oculomotor CN III EXCEPT lateral rectus - abducens nerve CN VI

50
Q

Describe the innervation of the oblique muscles

A

Superior oblique - trochlear nerve CN IV
Inferior oblique - oculomotor nerve CN III

51
Q

Function of superior rectus muscle

A

Elevate when in abduction

52
Q

Function of inferior rectus muscle

A

Depress when in abduction

53
Q

Function of medial rectus

A

Adduct the eyeball

54
Q

Function of lateral rectus

A

Abduct the eyeball

55
Q

What is special about the attachment of superior oblique muscle

A

It originates from the sphenoid bone then passes through a trochlea so it attaches to the posterior sclera in an angular way

56
Q

Superior oblique muscle is posterior to

A

Superior rectus

57
Q

Inferior oblique muscle is posterior to

A

Lateral rectus

58
Q

Function of superior oblique muscle

A

Depress when in adduction

59
Q

Function of inferior oblique muscle

A

Elevate when in adduction

60
Q

Causes of CN III palsy

A

Aneurysm
Uncal herniation through tentorium
Diabetes
Cavernous sinus thrombosis
Vasculitis

61
Q

What is uncal herniation through tentorium

A

A type of brain herniation caused by increase in intracranial pressure

62
Q

What causes uncal herniation through tentorium

A

Expanding mass lesions within the skull
Haemorrhage in brain
= increase intracranial pressure causing herniation

63
Q

Most common cause of third nerve palsy

A

Aneurysm

64
Q

Where is the aneurysm causing CN III palsy usually located at

A

Posterior communicating artery

65
Q

Presentation of third nerve palsy CN III

A

Down and out eye
Ptosis
Pupils may be dilated

66
Q

What causes the down and out eye in third nerve palsy

A

Due to unopposed superior oblique and lateral rectus muscles
- superior oblique function - depress when eye is adducted
- lateral rectus function - abduct the eye

67
Q

What causes ptosis in third nerve palsy

A

Because levator palpaebrae superioris is innervated by CN III = cannot elevate eyelid

68
Q

What causes a painful CN III palsy

A

Aneurysm

69
Q

Causes of trochlear nerve palsy

A

Congenital
Blunt head trauma
Tumour
Microvascular

70
Q

most common cause of trochlear nerve palsy CN IV in children

A

Congenital - present at birth

71
Q

Most common cause of trochlear nerve palsy CN IV in adults

A

Trauma

72
Q

Presentation of trochlear nerve palsy CN IV

A

Vertical diplopia when looking inferiorly - due to limitation of depression in adduction, the affected eye on adduction will be elevated
Contralateral Head tilt
Chin-down head posture

73
Q

Why do patients with fourth nerve palsy CN IV present with variable head positioning

A

To compensate for the vertical diplopia

74
Q

When is vertical diplopia usually noticed in patients with fourth nerve palsy

A

When reading a book / going downstairs

75
Q

Cause of sixth nerve palsy (abducens nerve)

A

Raised intracranial pressure
Tumour
Congenital
Microvascular

76
Q

Most common cause of sixth nerve palsy

A

Raised intracranial pressure

77
Q

Symptoms of sixth nerve palsy

A

horizontal diplopia worse when attempt to look to the affected side
Esotropia - when the eye turns inwards due to unopposed adduction

78
Q

What is internuclear ophthalmoplegia

A

Injury/dysfunction in the medial longitudinal fasciculus causing horizontal disconjugate eye movement

79
Q

What is the medial longitudinal fascicules

A

Tract which acts as the central connection for CN III, CN IV and CN VI

80
Q

Causes of internuclear ophthalmoplegia

A

Multiple sclerosis
Stroke

81
Q

How does multiple sclerosis cause internuclear ophthalmoplegia

A

Multiple sclerosis causes demyelination of the medial longitudinal fasciculus

82
Q

Presentation of internuclear ophthalmoplegia

A

Impairment of adduction
Horizontal nystagmus of the abducting eye on the CONTRALATERAL side

83
Q

Describe the transmission of special sensory information from the retina to the lateral geniculate nucleus

A
  1. Axons of the retinal ganglion receive impulses from the photoreceptors of the eyes
  2. The axons then join together to form optic nerve
  3. Optic nerve enters the cranial cavity via optic canal
  4. Optic nerves from each eye unite to form optic chasm
    - Fibres from the nasal (medial) half of each retina cross over each other
    - Fibres from the temporal (lateral) half do not cross over
  5. The nerves then enter a optic tract and each optic tract travels to Lateral geniculate nucleus
  6. Synapses at the lateral geniculate nucleus
84
Q

Describe the transmission of special sensory information from the lateral geniculate nucleus to the visual cortex of occipital lobe

A
  1. Synapse at lateral geniculate nucleus -> optic radiations
  2. The radiations loop through parietal / temporal lobe
  3. The radiations that travel through the parietal lobe corresponds to the upper half of the retina hence lower visual field
  4. The radiations that travel through the temporal lobe corresponds to the lower half of the retina hence upper visual field
  5. the optic radiations terminate in the visual cortex which is at the occipital lobe, forming a final image
85
Q

Where is the visual cortex located at

A

Occipital lobe

86
Q

Describe the visual fields and each part of the eye responsible for it

A

The temporal part of left eye -> right visual field
The nasal part of left eye -> left visual field

The temporal part of right eye -> left visual field
The nasal part of right eye -> right visual field

87
Q

Where is the defect at that causes total unilateral visual loss in one eye

A

Optic nerves of the affected eye before crossing over optic chasm

88
Q

Causes of unilateral visual loss

A

Ischaemic optic neuropathy
Optic neuritis

89
Q

What is optic neuritis

A

Inflammation of the optic nerve

90
Q

What causes optic neuritis

A

Multiple sclerosis
Diabetes
Syphilis

91
Q

Symptoms of optic neuritis

A

Progressive unilateral vision loss
Pain behind eye
Pain worse on eye movement
Poor discrimination of colours
Central scotoma - black/blurry/blind spot in the middle of one’s vision

92
Q

Management of optic neuritis

A

High dose steroids- IV methylprednisolone

93
Q

What drug is not indicated in optic neuritis. Why

A

Oral prednisolone. Due to increased risk of recurrent optic neuritis

94
Q

Where is the defect at that causes bitemporal hemianopia

A

Optic chiasm

95
Q

how does lesion at optic chiasm cause bitemporal hemianopia

A

Bitemporal hemianopia = loss of vision at outer half of each eye

The lesion affects the crossover at optic chiasm and the cross over is by the nasal half of optic fibres from each side
The nasal half of optic fibres of left eye is for left visual field and for the right eye it is for the right visual field which are both outer half of each eye

96
Q

Causes of bitemporal hemianopia (optic chiasm defects)

A

Pituitary tumour - prolactinoma / acromegaly
Craniopharyngioma
Meningioma

97
Q

What is homonymous hemianopia

A

Field defect in the same halves of both eyes i.e. right homonymous hemianopia = visual loss of right visual field of each eye

98
Q

Where is the defect at that causes homonymous hemianopia

A

At the optic tract (after optic. chiasm before lateral geniculate nucleus)
if right homonymous hemianopia - lesion is at the left optic tract

99
Q

What is superior homonymous quadrantanopia

A

Field defect in the superior field of both eyes for the same side

100
Q

Where is the defect at that causes superior homonymous quadrantanopia

A

Optic radiation in temporal lobe on the contralateral side - i.e. if visual loss at superior left quadrant - the lesion is on the right

101
Q

Causes of homonymous quadrantanopia/hemoanopia

A

Tumours
Demyelination
Vascular

102
Q

Most common cause of homonymous hemianopenia with macular sparing

A

Occlusive cerebrovascular disease

103
Q

Where is the defect at that causes homonymous hemianopenia with macular sparing

A

Occipital cortex

104
Q

What is the main blood supply to optic nerve head

A

posterior ciliary arteries

105
Q

What is ischaemic optic neuropathy

A

Occlusion of the posterior ciliary arteries causing infarction of optic nerve head

106
Q

What is the most common cause of arteritic anterior ischaemic optic neuropathy

A

Giant cell arteritis GCA

107
Q

Symptoms of arteritis anterior ischaemic optic neuropathy

A

Sudden, painless visual loss
If caused by GCA:
- headache
- scalp tenderness
- enlarged temporal arteries

108
Q

Fundoscope findings for ischaemic optic neuropathy

A

Pale, swollen disc
Pale disc may suggest chronic atrophy of the disc
Larger Optic nerve cupping may be seen

109
Q

What does optic nerve cupping mean

A

When the normal optic nerve cup increases in size due to loss of optic nerve fibres
Commonly caused by glaucoma but may also be seen in severe ischaemic optic neuropathy

110
Q

Management of arteritic ischaemic optic neuropathy

A

IV methylprednisolone

111
Q

What are the causes of non-arteritic anterior ischaemic optic neuropathy

A

Diabetes
Age
High cholesterol
Hypertension

112
Q

What is papilloedema

A

Swelling of the optic disc due to increased intracranial pressure

113
Q

How does increase in intracranial pressure cause papilloedema

A

Because the optic nerve sheath is continuous with the subarachnoid space

114
Q

What factors contribute to the ICP

A

Brain
Blood
CSF
These need to remain constant because the skull is rigid and cannot expand

115
Q

Causes of papilloedema

A

Lesions
Malignant hypertension
Idiopathic intracranial hypertension
Inadequate absorption of CSF / overproduction of CSF / obstruction to CSF circulation
Hydrocephalus (build up of CSF)

116
Q

Idiopathic intracranial hypertension is a common cause of

A

Bilateral disc swelling in young females

117
Q

If there is a lesion in the skull, does it cause an increase in intracranial pressure initially

A

When a mass expands, compensatory mechanisms will initially maintain a normal intracranial pressure
But eventually small increases in volume will produce larger and larger increases in intracranial pressure
-> compromise blood flow -> brain ischaemia and swelling -> brain herniation

118
Q

Symptoms of papilloedema

A

Headache
Enlarged blind spot
Blurring of vision

119
Q

What are the findings on fundoscope for papilloedema

A

Venous engorgement
Loss of venous pulsation
Blurring of optic disc margin

120
Q

Complications of papilloedema

A

Chronic can cause optic atrophy

Y2 Ophthalmology (8 decks)

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