Ophthalmology Revision Lecture

8/6/2019 Ophthalmology Revision Lecture

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Ophthalmology for Finals

-Revision Lecture

Dania Al-Nuaimi


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Lecture Outline

Anatomy

Approach to the Ophthalmic Patient

The Red Eye Loss of Vision

Sudden

Gradual

Quiz


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Surface Anatomy


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APPROACH TO THE OPHTHALMICPATIENT


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Ophthalmic History

Presenting Complaint

History of Presenting Complaint

Past Ophthalmic History

Previous surgery, trauma, refractive error Past Medical History

Diabetes, hypertension, atopy

Family History genetic/congenital conditions, glaucoma,cataract

Social History Smoking, alcohol, can they put eye drops in themselves?

Drug History and allergies


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History of Presenting Complaint

Onset gradual/sudden

Duration transient/persistent

Is visual acuity affected?

Is there loss of vision?

Total/sectoral/field loss

One or both eyes?

Is the eye red? distribution and intensity of redness

Pain/discomfort/photophobia

Discharge? Floaters/flashing lights

Glare?

Trauma/chemical injury/foreign body


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Examination

Visual Acuity

Pupils

External Eye Examination

Lids

Conjunctiva

Episclera

Sclera

Cornea Anterior Chamber

Lens

Fundoscopy

Visual Fields to

Confrontation

Ocular Motility

Slit lamp examination


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THE RED EYE


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Systematic Approach

Lids

Conjunctiva

Episclera Sclera

Cornea

Anterior Chamber


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Lids

Blepharitis

itching, burning, FB sensation

tearing

crusting

swollen lids

conjunctival injection

Blocked Meibomian glands Chalazion

Rx - lid hygiene, topical antibiotic,oral doxycycline


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Conjunctiva

Subconjunctival Haemorrhage

Conjunctivitis

Bacterial Viral

Allergic

Conjuntivitis in infants Other conjunctival lesions


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Subconjunctival Haemorrhage

No pain/mild discomfort

Vision normal

? trauma exclude foreignbody

Well demarcated area

No discharge

Check

For areas of other bruising

history of anticoagulants

BP

(?Anticoagulant status, FBC)


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Conjunctivits - Bacterial

Acute

Mild gritty discomfort

Mucopurulent discharge

Normal Vision No Staining of cornea

No Systemic symptoms

Commonest pathogens:

Staph epidermidis

Staph aureus

Strep pneumoniae

H. influenzae

Rx antibiotics

Chloramphenicol QDS 1/52


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Conjuncitivis - Viral

Acute (7-10/7)

Mild Gritty discomfort

Slight/moderate photophobia

Watery Secretion or discharge

Visual acuity normal or sl reduced Lids follicles

Corneal opacities subepithelial

Systemic symptoms- eg. sore throator flu like symptoms

Pre-auricular lymph node may beswollen

Rx conservative Cool compress

Artificial tears


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Conjunctivitis - Chlamydial

Subacute onset (2-3/52) Discomfort - gritty Photophobia -Variable Discharge -Watery pus Visual acuity Normal/Slightly Reduced Lid oedema Diffuse conjunctival hyperaemia Cornea

Clear Late: pannus and/or diffuse fibrosis, also

of conjunctiva

Systemic symptoms: None related to STI

Rx Topical Chloramphenicol Systemic Doxycycline (Refer to GUM

clinic)


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Conjunctivitis - Allergic

Bilateral

Discomfort itching

Discharge clear

Seasonal Chemosis

Papillae/cobblestones

Rx avoidance of stimulus,mast cells stabilisers,

antihistamines, steroids


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Conjunctivitis - Neonatal

Ophthalmia neonatorum < 1 month old notifiable disease Causative organisms

Neisseria gonorrhoea

Chlamydia Trachomatis

Commonly acquired from birth canal Immature local immunity Potentially sight threatening May result in serious systemic disease Rx

Gonococcal systemic ceftriaxone Chlamydial systemic erythromycin After counselling refer mother (and partner) to GUM clinic


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Episclera

Pingueculum

Degenerative yellow-whitedeposit

adjacent to the limbus Reassurance/lubricants

May become inflamed

Pterygium

Triangular sheet of

fibrovascular tissue

Dry climate/UV light exposure

Invades the cornea

May become inflamed


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Scleritis

Uncommon

Sight-threatening inflammation

Bilateral (50% cases)

Moderate/severe pain

classically wakes the patient atnight

Purplish hue - involvement ofthe deep episcleral vessels

Systemic diseases are present in

50% of patients Connective tissue diseases

Eg. RA, Wegeners. SLE etc.

Rx NSAIDs or Steroids


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Cornea

Abrasion

Ulcers

Bacterial Viral

Herpes Simplex

Acanthamoeba


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Corneal Abrasion

FB/Trauma

Blurred vision

Pain

Photophobia

Watering

Usually heals within

48hrs

Rx chloramphenicol

QDS 1/52


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Corneal Ulcers - Bacterial

May be associated with Contact Lenses (CL) Pain+++

Reduced Vision

Photophobia

Watery or mucopurulent discharge

Corneal opacification

Staining with Fluourescein

Anterior chamber inflammation +/- hypopyon

Common Causes:

Staph aureus Staph epidermidis

Strep pneumonia

Pseudomonas aeruginosa (CL)

H. Influenzae (children)

Rx antibiotics following scrape


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Cornea Ulcer Viral

Herpes simplex

Primary episode associated with vesicular rash

Recurrent

Blurred vision

Pain++ Photophobia

Watery discharge

Reduced corneal sensation

Dendritic ulcer highlighted by fluourescein

Rx Topical antiviral zovirax 5x/day then taper

If recurrent consider systemic antiviral

Do not prescribe topical steroid as can cause geographiculcer


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Cornea - Acanthamoeba

Acanthamoeba = free-living protozoa

Soil, dust, sea, fresh and chlorinated water

History of CL wear

Foreign body sensation Blurred vision

Photophobia

Discharge watery++

Ring infiltrates

Symptoms worse and disproportionate to signs

Rx topical anti-amoebic agents


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Anterior Chamber - Uveitis

Onset over 1-2 days

Previous history

Visual acuity - Poor

Pain- moderate Photophobia - Moderate /

Severe

Watering

Unilateral or bilateral

Systemic associations:

Eg. HLA B27, connectivetissue disorders


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Anterior chamber - AACG


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Acute angle closure Glaucoma

Age Usually 50 + Usually Unilateral

Severe pain radiating to forehead

Nausea and vomiting

Visual acuity reduced usually onset2-3 hours

Slight photophobia

Watery secretion or discharge

Hypermetropia (shallow anterior

chamber) Preceded by episodes of blurring

pain or haloes for an hour or two insome early evenings for a few weeks


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Acute Angle Closure Glaucoma

Circumcorneal purple + diffuse, conjunctival injection

Hazy Cornea (oedema)

Anterior chamber shallow (N.B. see fellow eye)

Iris - Oedematous and hyperaemic

Pupil - Dilated, oval

Pupil light reflex - Absent or reduced

IOP- Very high

Tenderness - Marked Rx urgent referral to ophthalmologist for acute treatment of

pressure


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Red Eye Questions

1. An 81 year old man isadmitted to hospitalwith nausea andvomiting. On

examination the righteye looks red and thepupil is dilated fixed andoval in shape. Hecomplains of severe painaround the eye and seesrings of light aroundbright objects.

A. Acute Anterior Uveitis

B. Acute Glaucoma

C. Blepharitis

D. ConjunctivitisE. Episcleritis


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Red Eye Questions

2. A 30 year old man withankylosing spondylitiscomplains of a painfuleye with reducedvision. On examinationthe patient dislikesbright light and theeye is red, especially

around the cornea.The pupil is small andfixed.


B. Acute Glaucoma

C. Blepharitis

D. Conjunctivitis

E. Episcleritis


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Red Eye Questions

4. A 28 year old contact

lens wearer presents

with a painful red eye.

On examination shehas a corneal defect

that stains with

fluorescein and there

is a hypopyon.


B. Bacterial Conjunctivitis

C. Bacterial Corneal ulcer

D. Viral Conjunctivitis

E. Allergic Conjunctivitis


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Red Eye Questions

5. A 25 year old lady

presents with a gritty

red eye. She has had a

cough for the pastweek. On examination

she has a watery

discharge and on

everting the lid thereare follicles present.



C. Blepharitis




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Central Retinal Artery Occlusion

White swollen retina with cherry red spot at macula

Afferent pupillary defect

Causes: GCA, atherosclerosis/carotid artery disease

Associations:


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Central Retinal Vein Occlusion

Commoner than arterial occlusion

Most occur in age >65

Dilated, tortuous veins, retinal haemorrhages all 4 quadrants, mild optic disc oedema

Associations: Diabetes, hypertension, smoking, inflammatory disorders


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Retinal Detachment

Floaters

Flashing lights

Field loss

Falling Acuity


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Gradual Loss of Vision

Cataract

Chronic Glaucoma

Diabetic Retinopathy Hypertensive Retinopathy

Age Related Macular Degeneration

Optic Atrophy


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Cataract


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Cataract

Cataract = lens opacity

Account for 40% global

blindness

Can be congenital or

acquired

Main risk factor = AGE

Cataracts are present in : 16% age 65-69

71% age >85

Other Risk factors:

Sunlight

Smoking

Alcohol

Dehydration

Radiation

Corticosteroids

Diabetes Mellitus

Trauma


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Signs and Symptoms

Reduced vision

near / distance / both (what daily activities?)

Glare

oncoming headlights

Myopic shift

second sight

monocular diplopia

when lens changes occur differentially within lens


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Nuclear Sclerotic Cataract


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Functional Considerations

Legal or corporate requirements for vision

Driving

car bus

HGV

Flying

Other mechanical equipment

Personal


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Glaucoma


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Glaucoma

Group of diseases

Primary open angle is the commonest in theUK

POAG asymptomatic Often picked up by routine optometric

examination

May or may not have raised IOP

Characterised by optic nerve and visual fieldchanges


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Glaucomatous disc

Enlarged cup:disc ratio

asymmetry in cup size

loss of neuroretinal rim

loss of ISNT rule

laminar dots

bayonetting of vessels

Disc margin Haems

Peripapillary atrophy


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Diabetic Eye Disease


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Diabetic Eye Disease

Presents through community screening of all

diabetics

Causes gradual loss of vision

Not common in puberty or before 5 years of

duration in type 1 diabetes

May be present in as much a 38% of type 2

diabetics at presentation

Preventable through good glycaemic control


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Diabetic Retinopathy

Background

Non or pre-proliferative

Proliferative

Maculopathy


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Proliferative Diabetic Retinopathy

New vessels at disc or elsewhere on retina


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Diabetic Maculopathy

Macular oedema, exudates, microaneurysms


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Macular Degeneration


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Macular Degeneration (AMD)

Presents as gradual or sudden loss of vision

Affects approximately

1% of those < 65 years

20% of those over 75 years

Commonest cause of registrable blindeness in UK

Can slow progression with:

dietary supplementation intra-vitreal injections

laser.


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Visual symptoms

Blurred central vision

difficulty reading

colour and contrast disturbances

metamorphopsia

Central scotoma


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Dry AMD

Hard Drusen Soft Drusen


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Wet AMD


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Loss of Vision Questions

1. A 78 year old man

complains of

increasing difficulty in

reading andrecognising peoples

faces. Fundus

examination reveals a

speckled appaeranceof both maculae

A. Amaurosis fugax

B. Cataract

C. Macular Degeneration

D. Acute Glaucoma

E. Central Retinal Vein

Occlusion


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2. A 70 year old womancomplains of gradualblurring of vision andincreasing difficultydriving at night due tothe glare of oncomingheadlights.Ophthalmoscopy

reveals opacities whenchecking the redreflex.

A. Amaurosis fugax

B. Cataract


D. Acute GlaucomaE. Central Retinal Vein

Occlusion


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3. A 57 year old man withatrial fibrillationpresents with suddenloss of vision in hisright eye. He said thatthe vision went totallyblank for 15 minutesbut now everything

was back to normal.Fundus examinationwas normal.

A. Amaurosis fugax

B. Cataract



Occlusion


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4. A 46 year old male

with a below the knee

amputation complains

of worsening visualacuity. Fundoscopy

reveals exudates at the

macula, retinal

haemoorhages andneovascularisation at

the disc.

A. Hypertensive

retinopathy

B. Diabetic retinopathy


D. Central Retinal Artery

Occlusion

E. Central Retinal VeinOcclusion


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5. A 65 year old smoker

with known diabetes

and hypertension

presents with suddenpainless loss of vision.

Examination reveals

scattered

haemorrhagesthroughout the fundus

and a swollen disc.

A. Hypertensive

retinopathy




Occlusion



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Red Eye Questions

1. An 81 year old man isadmitted to hospitalwith nausea andvomiting. On

examination the righteye looks red and thepupil is dilated fixed andoval in shape. Hecomplains of severe pain

around the eye and seesrings of light aroundbright objects.


B. Acute Glaucoma

C. Blepharitis



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Red Eye Questions

2. A 30 year old man withankylosing spondylitiscomplains of a painfuleye with reduced

vision. On examinationthe patient dislikesbright light and theeye is red, especially

around the cornea.The pupil is small andfixed.


B. Acute Glaucoma

C. Blepharitis



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Red Eye Questions

3. An 18 year old man


red eye. On

examination theconjunctiva is red and

swollen and he has a

sticky yellow

discharge.



C. Blepharitis




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Red Eye Questions

4. A 28 year old contact

lens wearer presents

with a painful red eye.

On examination shehas a corneal defect

that stains with

fluorescein and there

is a hypopyon.



C. Bacterial Corneal ulcer




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Red Eye Questions

5. A 25 year old lady


red eye. She has had a

cough for the pastweek. On examination

she has a watery

discharge and on

everting the lid thereare follicles present.



C. Blepharitis




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1. A 78 year old man

complains of

increasing difficulty in

reading andrecognising peoples

faces. Fundus

examination reveals a

speckled appaeranceof both maculae.

A. Amaurosis fugax

B. Cataract


D. Acute Glaucoma

E. Central Retinal Vein

Occlusion


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2. A 70 year old womancomplains of gradualblurring of vision andincreasing difficulty

driving at night due tothe glare of oncomingheadlights.Ophthalmoscopy

reveals opacities whenchecking the redreflex.

A. Amaurosis fugax

B. Cataract



Occlusion


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3. A 57 year old man withatrial fibrillationpresents with suddenloss of vision in his

right eye. He said thatthe vision went totallyblank for 15 minutesbut now everything

was back to normal.Fundus examinationwas normal.

A. Amaurosis fugax

B. Cataract



Occlusion


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4. A 46 year old male

with a below the knee

amputation complains

of worsening visualacuity. Fundoscopy

reveals exudates at the

macula, retinal

haemorrhages andneovascularisation at

the disc.

A. Hypertensive

retinopathy




Occlusion



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5. A 65 year old smoker

with known diabetes

and hypertension

presents with suddenpainless loss of vision.

Examination reveals

scattered

haemorrhagesthroughout the fundus

and a swollen disc.

A. Hypertensive

retinopathy




Occlusion



80/80

Thank you

Ophthalmology Revision Lecture

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