Phase 4 Emily > Ophthalmology > Flashcards

Ophthalmology Flashcards

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1
Q

Define: glaucoma

A

refers to the optic nerve damage caused by a rise in intraocular pressure. Raised intraocular pressure is caused by a blockage in aqueous humour trying to escape the eye. There are two types of glaucoma:

Open-angle glaucoma
Acute angle-closure glaucoma

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2
Q

Rf: open angle glaucoma acute

A

Increasing age
Family history
Black ethnic origin
Myopia (nearsightedness)

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3
Q

Px: open angle glaucoma

A

Glaucoma affects the peripheral vision first, resulting in a gradual onset of peripheral vision loss (tunnel vision).

It can also cause:

Fluctuating pain
Headaches
Blurred vision
Halos around lights, particularly at night

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4
Q

Diagnosis: open angle glaucoma

A

Goldmann applanation tonometry for the intraocular pressure
Slit lamp assessment for the cup-disk ratio and optic nerve health
Visual field assessment for peripheral vision loss
Gonioscopy to assess the angle between the iris and cornea
Central corneal thickness assessment

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5
Q

Fundoscopy signs of open angle glaucoma?

A
  1. optic disc cupping
  2. optic disc pallor
  3. bayonetting of vessels - vessels have breaks
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6
Q

Mx: open angle glaucoma

A

normal pressure of 24mmHg or above

1) 360 selective laser trabeculopathy
2) prostaglandin analogue eye drops e.g. latanoprost

3) Beta blocker eye drops,
- carbonic anhydrase inhibitor eye drops,
- sympathomimetic

4) trabeculectomy surgery = create a new channel for fluid to exit

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7
Q

Define: acute angle- closure glaucoma

A

iris bluges forward and seals off the trabecular meshwork from the anterior chamber prevention aqueous humour from draining and leading to a continual increase in intracocular pressure

pressure builds in posterior chamber pushing iris forward and exacerbating angle closure

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8
Q

RF: acute angle closure glaucoma

A

Increasing age
Family history
Female (four times more likely than males)
Chinese and East Asian ethnic origin
Shallow anterior chamber

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9
Q

what medications can precipitate acute angle closure glaucoma?

A

Adrenergic medications (e.g., noradrenaline)
Anticholinergic medications (e.g., oxybutynin and solifenacin)
Tricyclic antidepressants (e.g., amitriptyline), which have anticholinergic effects

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10
Q

Px: acute angle closure glaucoma

A

Severely painful red eye
Blurred vision
Halos around lights
Associated headache, nausea and vomiting

Signs on examination include:

Red eye
Hazy cornea
Decreased visual acuity
Mid-dilated pupil
Fixed-size pupil
Hard eyeball on gentle palpatio

ASSESS VERY QUICKLY OR COULD GO BLIND!!

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11
Q

Ix: acute angle closure

A

tonometry = assess for elevated ICP

gonioscopy = visualise angle

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12
Q

Mx: acute angle closure glaucoma

A

emergency admission

While waiting:
Lying the patient on their back without a pillow
Pilocarpine eye drops (2% for blue and 4% for brown eyes)
Acetazolamide 500 mg orally
Analgesia and an antiemetic, if required

Secondary care
1) pilocarpine eye drops
2) acetazolamide agents e.g IV mannitol
3) timolol = beta blocker reduced production of aqueous humour
4) Dorzolamide = carbonic anhydrase inhibitor, reduce production of aqueous humour
5) Brimonidine = sympathomimetics

definitive tx = bilateral laser iridotomy

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13
Q

What screening is done for people with FH of glaucoma?

A

1st degree relative - annual screening from age of 40

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14
Q
A
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15
Q

Define: age related macular degeneration

A

progressive condition affecting the macula
MC cause of blindness in the UK

2 types:
Wet (also called neovascular), accounting for 10% of cases
Dry (also called non-neovascular), accounting for 90% of cases

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16
Q

What is the role and anatomy go the macula?

A

The macula is found in the centre of the retina. It generates high-definition colour vision in the central visual field. It has four layers:

Choroid layer (at the base), which contains the blood vessels that supply the macula
Bruch’s membrane
Retinal pigment epithelium
Photoreceptors (towards the surface)

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17
Q

RF: macular degeneration

A

Older age
Smoking
Family history
Cardiovascular disease (e.g., hypertension)
Obesity
Poor diet (low in vitamins and high in fat)

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18
Q

Px: macular degeneration

A

Visual changes associated with AMD tend to be unilateral, with:

Gradual loss of central vision
Reduced visual acuity
Crooked or wavy appearance to straight lines (metamorphopsia)

Wet AMD presents more acutely

(whereas glaucoma is peripheral vision loss)

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19
Q

Examination: macular degeneration

A

Reduced visual acuity using a Snellen chart

Scotoma (an enlarged central area of vision loss)

Amsler grid test can be used to assess for the distortion of straight lines seen in AMD

Drusen may be seen during fundoscopy

Use:
- slit lamp
- optical coherence tomography

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20
Q

Mx: macular degeneration

A

No specific tx fro dry AMD
- avoid smoking
- control BP
- vitamin supplementation

Wet AMD
- anti-VEGF medications (blocks simulates development of new blood vessels in retina)
- injected into vitrsesou chamber once a month

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21
Q

Define: diabetic retinopathy

A

involves damage to the retinal blood vessels due to prolonged high blood sugar levels.

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22
Q

Grading of diabetic retinopathy

A

Background – microaneurysms, retinal haemorrhages, hard exudates and cotton wool spots

Pre-proliferative – venous beading, multiple blot haemorrhages and intraretinal microvascular abnormality (IMRA)

Proliferative – neovascularisation and vitreous haemorrhage

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23
Q

Complications: diabetic retinopathy

A

Vision loss

Retinal detachment

Vitreous haemorrhage (bleeding into the vitreous humour) - red hue with sudden vision loss

Rubeosis iridis (new blood vessel formation in the iris) – this can lead to neovascular glaucoma

Optic neuropathy

Cataracts

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24
Q

Mx: diabetic retinopathy

A

Non-proliferative:
requires close monitoring and careful diabetic control.

proliferative:

  • Pan-retinal - photocoagulation (PRP) – extensive laser treatment across the retina to suppress new vessels
  • Anti-VEGF medications by intravitreal injection
    (given together)

Surgery (e.g., vitrectomy) may be required in severe disease

An intravitreal implant containing dexamethasone is an option for macular oedema.

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25
Define: cataracts
progressively opaque eye lens, which reduces the light entering the eye and visual acuity.
26
RD: cataracts
Increasing age Smoking Alcohol Diabetes Steroids Hypocalcaemia
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Px: cataracts
usually asymmetrical, as both eyes are affected separately. It presents with: Slow reduction in visual acuity Progressive blurring of the vision Colours becoming more faded, brown or yellow Starbursts can appear around lights, particularly at night loss of red reflex
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Mx: cataracts
No intervention at first Cataract surgery - breaking lens, remove and implant artificial lens
29
What is Blepharitis? Cause and management?
- inflammation of the eyelid margins - cause gritty, itchy, dry sensation in the eyes - dysfunction of meibomian glands = secrete meibum Management = warm compress and gentle cleaning
30
What is a Stye?
Hordeolum external = infection of the glands of Zeis or glands of Moll. Hordeoulum internum = infection of meibomian glands Cause tender red lump along eyelid that may contain pus
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What is the treatment for Stye's?
Hot compress Analgesia Antibiotics if conjunctivitis or symptoms remain
32
What is an chalazion and treatment?
Meibomian gland becomes blocker and swells - swelling in eyelid non tender Treat: warm compress and gentle massage towards eyelashes to drain
33
What is entropion vs ectropion?
Entropion = Eyelid turn inward with the lashes pressed against the eye - cause corneal damage and ulceration Ectropion = eyelid turns outwards exposing inner aspect - exposure keratopathy as eyeball exposed
34
What is the treatment for entropion and ectropion?
Entropion - tape eyelid down + lubricate - surgical Ectropion - lubricate drops - significant cases = surgical
35
What is trichiasis?
Inward growth of eyelashes - results in pain and can cause corneal damage and ulceration Treat: - remove affected eyelashes - electrolysis or cryotherapy - refer to ophthalmology if risk to sight
36
What is periorbital cellulitis?
AN eyelid and skin infection in front of the orbital septum - hot, woollen, red skin around the eyelid and eye
37
Management: Periorbital cellulitis
1. contrast CT head scan = Must differentiate from orbital cellulitis 2. systemic antibiotics
38
What is orbital cellulitis?
An infection around the eyeball involving the tissues behind the orbital septum - eye pain - reduced eye movements - vision changes - abnormal pupil reactions - proptosis
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Management: orbital cellulitis
1. Emergency admission 2. IV antibiotics 3. surgical drainage if abscess forms
40
Define: conjunctivitis
Inflammation of the conjunctiva - the thin layer fo tissue that covers the inside of the eyelids and sclera Bacterial, viral or allergic Unilateral or bilateral
41
How does conjunctivitis present?
Red, bloodshot eye Itchy or gritty sensation Discharge Bacterial - purulent discharge - worse in morning - highly contagious viral - clear discharge - comes with dry cough, sore throat and blocked nose - tender pr-auricular lymph nodes - contagious (no pain, photophobia ore reduced visual acuity)
42
Management: conjunctivitis
resolves within 1-2 weeks - clean eyes with cooled boiled water and cotton water to clear discharge - chloramphenicol or fusidic acid eye drops (bacterial if necessary)
43
What is optic neuritis?
Demyelination of the optic nerve which present with: - Unilateral reduced vision - Central scotoma (enlarged blind spot) - Pain on eye movement - Impaired colour vision (red)
44
Define: central retinal artery occlusion
Obstruction to blood flow through the central retinal artery (branch of ophthalmic artery)
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RF: central retinal artery occlusion
RF fro cardiovascular disease - smoking BP - diabetes - raised cholesterol RF for giant cell arteritis - white ethnicity older age - female - polymyalgia rheumatica
46
Px: central rental artery occlusion
- sudden painless loss of vision - relative afferent pupillary defect - pupil in affected eye contract more when light is shone than other eye than when it is shone in the affected eye Fundoscopy = pale retina, cherry red spot
47
Mx: central retinal artery occlusion
vision threatening emergency - GCA is a reversibel case = Ear, temporal artery biopsy immediate mx attempt to resolve blockage - ocular massage - anterior chamber paracentesis - inhaled carbogen sublingual isosorbide denigrate Iv mannitol
48
Define: retinal vein occlusion
blood clot forms in the retinal veins, blocking the drainage of blood from the retina
49
Px: retinal vein occlusion
PAINLESS blurred vision or loss Fundoscopy: Dilated tortuous retinal veins Flame and blot haemorrhages Retinal oedema Cotton wool spots Hard exudates 'blood and thunder'
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Mx: retinal vein occlusion
Immediate ophathmology referral - anti - VEGF therapies (e.g., ranibizumab and aflibercept) - Dexamethasone intravitreal implant (to treat macular oedema) - Laser photocoagulation (to treat new vessels)
51
Define and causes: infective keratitis
refers to inflammation of the cornea. There are many causes of keratitis: Viral infection (e.g., herpes simplex) MC Bacterial infection (e.g., Pseudomonas or Staphylococcus) Fungal infection (e.g., Candida or Aspergillus) Contact lens-induced acute red eye (CLARE) Exposure keratitis, caused by inadequate eyelid coverage (e.g., ectropion)
52
Px: infective keratitis
Primary infection often involves mild symptoms of blepharoconjunctivitis (inflammation of the eyelid margins and conjunctiva). Recurrent infection may present with: Painful red eye Photophobia Vesicles (fluid-filled blisters) Foreign body sensation Watery discharge Reduced visual acuity
53
Mx: infective keratitis
Topical or oral antivirals corneal transplant - to treat permanent scarring and vision loss
54
Define: retinal detachment
neurosensory layer of the retina (containing photoreceptors and nerves) separating from the retinal pigment epithelium (the base layer attached to the choroid). This is usually due to a retinal tear, allowing vitreous fluid to get under the neurosensory retina and fill the space between the layers.
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RF: retinal detachment
Lattice degeneration (thinning of the retina) Posterior vitreous detachment Trauma Diabetic retinopathy Retinal malignancy Family history
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Px: retinal detachment
painless condition that can present with: Peripheral vision loss (often sudden and described as a shadow coming across the vision) Blurred or distorted vision Flashes and floaters
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Mx: retinal detachment
immediate referral retinal tears - laser therapy - cryotherapy retinal detachment - vitrectomy = remove vitreous gel from behind retina - scleral buckle - pneumatic retinopexy
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Define: scleritis
Inflammation of the sclera - most idiopathic - systemic inflammatory condition = rheumatoid arthritis, vasculitis - infection - mc in women
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Px: scleritis
more gradual onset. It can be unilateral or bilateral. Features include: Red, inflamed sclera (localised or diffuse) Congested vessels Severe pain (typically a boring pain) Pain with eye movement Photophobia Epiphora (excessive tear production) Reduced visual acuity Tenderness to palpation of the eye
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Mx: scleritis
NSAIDs (oral) Steroids (topical or systemic) Immunosuppression appropriate to the underlying systemic condition (e.g., methotrexate in rheumatoid arthritis)
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Define: episcleritis
involves benign and self-limiting inflammation of the episclera, the outermost layer of the sclera, just below the conjunctiva. Episcleritis is relatively common in young and middle-aged adults. It is often associated with inflammatory disorders, such as rheumatoid arthritis and inflammatory bowel disease. It is not usually caused by infection.
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Px: episcleritis
Episcleritis usually presents with acute-onset unilateral features: Localised or diffuse redness (often a patch of redness in the lateral sclera) No pain (or mild pain) Dilated episcleral vessels ((no photophobia or discharge and normal visual acuity (these symptoms suggest scleritis).)
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How to differentiate between episcleritis and scleritis?
Applying phenylephrine eye drops It will cause blanching of the episcleral vessels, causing the redness to disappear. It will not affect scleral vessels and will not impact the redness in scleritis.
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Mx: episcleritis
self limiting in 1-2 weeks - analgesia - lubricating eye drops
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Define: anterior uveitis
aka iritis inflammation of anterior uvea - consists of iris, ciliary body, choroid involves inflammation in the anterior chamber of the eye - becomes infiltrated by neutrophils, lymphocytes, macrophages (hypopyon refers to a fluid collection of inflammatory cells)
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RF/assocaitions: anterior uveitis
associated with underlying an autoimmune condition, particularly: Seronegative spondyloarthropathies (e.g., ankylosing spondylitis, psoriatic arthritis and reactive arthritis) Inflammatory bowel disease Sarcoidosis Behçet’s disease
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Px: anterior uveitis
Painful red eye (typically a dull, aching pain) Reduced visual acuity Photophobia (due to ciliary muscle spasm) Excessive lacrimation (tear production) Examination findings include: Ciliary flush (a ring of red spreading from the cornea outwards) Miosis (a constricted pupil due to sphincter muscle contraction) Abnormally shaped pupil due to posterior synechiae (adhesions) pulling the iris into abnormal shapes Hypopyon (inflammatory cells collected as a white fluid in the anterior chamber)
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Mx: anterior uveitis
referred for urgent assessment ophthalmologist. Mx: 1. Steroids (eye drops, oral or intravenous) 1. Cycloplegics (e.g., cyclopentolate or atropine eye drops) Cycloplegics dilate the pupil and reduce pain associated with ciliary spasm
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When is uveitis silent
Juvenile idiopathic arthritis - screening in these children - no red eye, no pain, no photophobia
70
Define: subconjunctival haemorrhage
small blood vessels within the conjunctiva rupture, releasing blood into the space between the sclera an d the conjunctiva appear after strenuous exercise idiopathic in healthy people
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Who is predisposed to subconjuctival haemorrhage?
several factors may predispose sto the condition and are worth assessing: Hypertension Bleeding disorders (e.g., thrombocytopenia) Whooping cough Medications (e.g., antiplatelets, DOACs or warfarin) Non-accidental injury
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Px: subconjuctival haemorrhage
patch of bright red blood underneath the conjunctiva - painless - does not affect vision
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Mx: subconjunctival haemorrhages
Subconjunctival haemorrhages can be confidently diagnosed based on a simple history and examination. Underlying causes should be considered, for example: Checking the blood pressure Checking the INR in patients taking warfarin They are harmless and will resolve spontaneously without treatment, usually in around two weeks. Lubricating eye drops may be helpful if there is mild irritation.
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Endophthalmitis
Post ocular surgery red reduced vision lid swelling conj swelling
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Thyroid eye disease
Exophthalmos/proptosis = bulging eye inflammation, swelling, hypertrophy of the tissue behinds the eyeballs force them forward MX: stop smoking = massively changes outcomes
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Presentation: painless, sudden vision loss in one eye
central retinal artery occlusion - artery becomes blocked with an embolus - cherry spot on pale retina
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Mx: retinal artery occlusion
poor prognosis - if acutely presents = intrarterial thrombolysis - underlying condition treated e.g. IV steroids for temporal arteritis
78
Define and Px: Corneal abrasion
defect of corneal epithelium form recent trauma e.g. nail, branch Px: eye pain lacrimation photophobia foreign body sensation and conjunctival injection decreased visual acuity in the affected eye
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Ix: corneal abrasion
fluorescein staining - shows scratch
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Mx: corneal abrasion
topical abx - prevent secondary bacterial infection
81
What is Hutchinson's sign?
vesicles extending to the tip of the nose - associated with ocular involvement in shingles
82
What is an Argyll Robertson pupil?
- react poorly to light - accomodate well - tertiary syphillis - small pupils bilateral
83
What is Holmes-Adie pupil?
Holmes ADIe = DIlated pupil - females - absent leg reflexes
84
What are the grades of hypertensive retinopathy?
I = Arteriolar narrowing and tortuosity Increased light reflex - silver wiring II Arteriovenous nipping III Cotton-wool exudates Flame and blot haemorrhages These may collect around the fovea resulting in a 'macular star' IV Papilloedema
85
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