Week 2 - G - Ophthamology 6 - Thyroid eye/Sjorgen's/Optic neuritis, Horners

Question 1

What is the difference between exopthalmos and proptosis?

Answer 1

Proptosis can refer to any organ that is pushed forward

Exopthalmos only refers to the eyes being the bulging of the eyes

Question 2

What are extraocular signs of thyroid eye disease? Thyroid eye disease is relevant to hyperthyroidism

Answer 2

Exopthalmos, lid oedema and retraction and lag

Question 3

What are ocular signs of thyroid eye disease?

Answer 3

Chemosis - oedema of the conjunctiavae - can see the chemosis here redeness of the eye (injection)

Question 4

Why does the eye buldge forward in Grave’s? (exopthalmos is exclusive to grave’s)

Answer 4

The autoimmune anitbodies in Graves (anti-TSH antibodies, TRabs(TSH receptor antibodies)) inflame the muscles and fat in the eye causing them not to function and the eye bulges forward

Question 5

What is the treatment of hyperthyroidism?

Answer 5

Give patient Carbimazole as first line

If contraindicated give propylthiouracil

Question 6

If the patient begins to develop ulcers, fevers and sore throat when on carbimzole What is this? What should they do?

Answer 6

This is agranulocytosis - seen in treatment with carbimazole

It is due to a deficiency of WBC -leukopenia

They should be immediately taken off and switched to propylthiouracil

Question 7

In hypothyroidism, what can happen to the eyebrow?

Answer 7

It is common to have a loss of the outer 1/3rd of the eyebrow

Question 8

Why in hypothyroidism can you get increased lactation? What is the most common cause of hypothyroidism? What is the most common antibody in this common cause?

Answer 8

In hypothyrodism , because of the main cause which is anti-TPO antibodies - seen in Hashimotos thyroiditis, this causes a decrease in T4 and T3 levels

This acts as negative feedback to increase TRH and TSH hormones

TRH causes increased production of thyroid hormones and prolactin

Question 9

What other autoimmune conditions is Hashimoto’s thyroiditis associated with?

Answer 9

Associated with pernicious anaemia - Pernicious anaemia is the most common cause of vitamin B12 deficiency as it attacks the cells in the stomach which produce intrinsic factor required for B12 absorption

Vitamin B12 is needed for normal RBCs

Diabetees mellitus

Addisons disease

Question 10

Keratoconjunctivitis sicca - dry eyes Xerostomia - dry mouth Rheumatoid arthritis usually What syndrome is this?

Answer 10

This is Sjorgen’s syndrome

Question 11

What glands does sjorgen’s syndrome affect and what are the antibodies in sjorgen’s syndrome?

Answer 11

Massive parotid gland swelling and lacrimal gland swelling

Antibpdies are anti Ro and anti La antibodies

Question 12

What are the causes of the dry mouth and eyes in sjorgen’s syndrome? What test is done to check for dry eyes?

Answer 12

The autoimmune destruction of the salviary (dry mouth ) and lacrimal (dry eyes) glands cause the dry eye Schrimer’s test is done to check for the dry eyes

Question 13

What drug can help with both the treatment of the dry eyes and mouth if the artifical tears and salivary substitutes are not affective?

Answer 13

Topical pilocarpine can help stimulate secretion by the exocrine glands This is a cholinergic drug

Question 14

What is the treatment gven for severe dry eyes?

Answer 14

Topical ciclosporin

Question 15

What other rhuematological condition may cause keratoconjunctivits sicca? It is also associated with slceritis/episcleritis

Answer 15

Rheumatoid arthritis

Question 16

common condition caused by blunt injury to the eye. It is characterized by decreased vision in the injured eye a few hours after the injury. It causes what is known as a bruised retina What is the medical name for this?

Answer 16

Commotio retinae

Question 17

If suspecting a corneal abrasion, what dye is give to identify this?

Answer 17

Give the patient fluorescein dye - identifies the area of epithelial loss

Question 18

In trauma always carry out visual acuities, if there is blood in the anterior chamber, what is this called and what should you do?

Answer 18

This is an hyphaema - refer to ophthamology

Question 19

If a patient presents with a chemical burn, is acid or alkali more dangerous and what is the treatment?

Answer 19

Alkali is more addangerous as it can penetrate into intracular structures Treatment is (solution to pulliton is dilution) by irrigation with 2L saline fluid (0.9% NaCl)

Question 20

• Penetrating injury to one eye exposure of intra-ocular antigens auto-immune reaction in both eyes What is this and what can it cause?

Answer 20

This is sympathetic opthalmia and can cause bilateral blindness

Question 21

What is the injured eye and what is the contralateral eye known as in sympathetic ophthalmia?

Answer 21

Injured eye - exciting eye Contralateral eye - sympathising eye

Question 22

What type of uveitis is described in sympathetic ophthalmia?

Answer 22

Granulomatous uveitis due to the inflammation in the eye

Question 23

What is the immediate management of a patient presenting with sympathetic ophthalmia?

Answer 23

Give patient topical and systemic steroids

Question 24

• Progressive visual loss (unilateral) • Pain behind eye, especially on movement What is this?

Answer 24

This is optic neurtis

Question 25

What is the vision loss in optic neuritis described as? Which vision is lost?

Answer 25

Described as a central scotoma and loss of colour vision

Question 26

Which drug used in the treatment of tuberculosis causes optic neuritis?

Answer 26

* Rifampicin - Hepatotoxic and GI * Isoniazid - hepatotoxic and peripheral neuritis * Pyrazinimde - hepatotoxic and gout * Ethambutol - Optic neuritis

Question 27

Which disease is associated with optic neuritis leading to demyelination of the optic nerve?

Answer 27

MS - multiple sclerosis

Question 28

Why is there painful eye movement in optic neuritis? (relates to where the extraocular muscles insert)

Answer 28

Due to the extraocular muscles inserting into the common tendinous ring, when they contract to move the eye this will cause movement of the optic nerve and therefore pain

Question 29

Which extraocular muscles insert at the common tendinous ring and which do not?

Answer 29

Lateral, medial, superior and inferior rectus All the rectus muscles attach to the common tendinous ring The superior and inferior oblique do not Also the levator palpabrae superioris does not

Question 30

What is the nerve supply to all the extraocular muscles?

Answer 30

Superior, medial and inferior rectus - oculomotr nerve Inferior oblique - oculomotor nerve Levator palpebrae superioris - oculomotor nerve Superior oblique - trochlear nerve Lateral rectus - Abducent nerve

Question 31

What is the treatment for otpic neuritis?

Answer 31

It is self limiting so will gradually recover Can use oral steroids (prednisolone)

Question 32

What are the four signs of horner's sydnrome?

Answer 32

Miosis - constricted pupil Annydrosis - lack of sweating face Ptosis - drooping eyelid Enopthalmos - sunken eyeball

Question 33

Horners is caused by disruption to the cervical sympathetic ganglion Give three example causes of horner's syndrome?

Answer 33

Klumpke's palsy- lower brachial nerve palsy (C8 and T1) Pancoast tumour of the lung Cervical rib - can impede stellate ganglion

Question 34

What two ganglia join to make the stellate ganglion of the sympathetic chain?

Answer 34

Inferior cervical ganglion and T1

Question 35

In Horner's what is the muscle in the eyelid that is supplied by sympathetics and cause elevation of the eyelid? (it adjoins the levator palpabrae superioris)

Answer 35

This is the superior tarsal muscle (Muller's muclse) - it is a smooth muscle supplied by sympathetics

Question 36

What does the sympathetic supply to cause miosis if damaged?

Answer 36

They supply the dilator pupillae of the eye whcih cause dilation of the pupil These dilator pupillae are also known as radial pupillae When injured they cannot contract to dilate the eye

Question 37

What are the 3 parts of the uvea?

Answer 37

Choriod , iris and ciliary muscles

Question 38

Chorioretinitis is an inflammatory condition affecting the choroid and the retina Usually asymptomatic unless affecting the macula What can the infection cause on the macula? What causes chorioretinitis?

Answer 38

Causes a granulomatous reaction on the macula Caused by either congenital toxoplasmosis (spread in cat faces) or CMV Symptoms - floating black spots, blurred vision, pain or redness in the eye