Ophthalmology for Finals -Revision Lecture

Dania Al-Nuaimi

Lecture Outline
Anatomy Approach to the Ophthalmic Patient The Red Eye Loss of Vision
Sudden Gradual

Quiz

Surface Anatomy

APPROACH TO THE OPHTHALMIC PATIENT

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

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

Examination
Visual Acuity Pupils External Eye Examination
Lids Conjunctiva Episclera Sclera Cornea Anterior Chamber Lens

Visual Fields to Confrontation Ocular Motility Slit lamp examination

Fundoscopy

THE RED EYE

Systematic Approach
Lids Conjunctiva Episclera Sclera Cornea Anterior Chamber

Lids
Blepharitis
itching, burning, FB sensation tearing crusting swollen lids conjunctival injection Blocked Meibomian glands
Chalazion

Rx - lid hygiene, topical antibiotic, oral doxycycline

Conjunctiva
Subconjunctival Haemorrhage Conjunctivitis
Bacterial Viral Allergic

Conjuntivitis in infants Other conjunctival lesions

Subconjunctival Haemorrhage
No pain/mild discomfort Vision normal ? trauma exclude foreign body Well demarcated area No discharge Check
For areas of other bruising history of anticoagulants BP (?Anticoagulant status, FBC)

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

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 throat or flu like symptoms Pre-auricular lymph node may be swollen Rx conservative
Cool compress Artificial tears

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 None related to STI

Systemic symptoms: Rx

Topical Chloramphenicol Systemic Doxycycline (Refer to GUM clinic)

Conjunctivitis - Allergic
Bilateral Discomfort itching Discharge clear Seasonal Chemosis Papillae/cobblestones Rx avoidance of stimulus, mast cells stabilisers, antihistamines, steroids

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

Episclera
Pingueculum Degenerative yellow-white deposit 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

Scleritis
Uncommon Sight-threatening inflammation Bilateral (50% cases) Moderate/severe pain classically wakes the patient at night Purplish hue - involvement of the deep episcleral vessels Systemic diseases are present in 50% of patients
Connective tissue diseases
Eg. RA, Wegener s. SLE etc.

Rx NSAIDs or Steroids

Cornea
Abrasion Ulcers
Bacterial Viral
Herpes Simplex

Acanthamoeba

Corneal Abrasion
FB/Trauma Blurred vision Pain Photophobia Watering Usually heals within 48hrs Rx chloramphenicol QDS 1/52

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

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 geographic ulcer

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

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, connective tissue disorders

Uveitis
Circumcorneal purple + diffuse conjunctival injection Cornea Keratic precipitates Anterior chamber -flare, cells +/- hypopyon Iris - Often hyperaemic Pupil -Contracted +/Synechiae May have activity in posterior chamber and signs in fundus

Anterior chamber - AACG

Acute angle closure Glaucoma

Age Usually 50 + Usually Unilateral Severe pain
radiating to forehead Nausea and vomiting

Visual acuity reduced usually onset 2-3 hours Slight photophobia Watery secretion or discharge Hypermetropia (shallow anterior chamber) Preceded by episodes of blurring pain or haloes for an hour or two in some early evenings for a few weeks

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

Red Eye Questions

1. An 81 year old man is admitted to hospital with nausea and vomiting. On examination the right eye looks red and the pupil is dilated fixed and oval in shape. He complains of severe pain around the eye and sees rings of light around bright objects. A. B. C. D. E. Acute Anterior Uveitis Acute Glaucoma Blepharitis Conjunctivitis Episcleritis

Red Eye Questions

2. A 30 year old man with ankylosing spondylitis complains of a painful eye with reduced vision. On examination the patient dislikes bright light and the eye is red, especially around the cornea. The pupil is small and fixed. A. B. C. D. E. Acute Anterior Uveitis Acute Glaucoma Blepharitis Conjunctivitis Episcleritis

Red Eye Questions

3. An 18 year old man presents with a gritty red eye. On examination the conjunctiva is red and swollen and he has a sticky yellow discharge. A. B. C. D. E. Acute Anterior Uveitis Bacterial Conjunctivitis Blepharitis Viral Conjunctivitis Allergic Conjunctivitis

Red Eye Questions

4. A 28 year old contact lens wearer presents with a painful red eye. On examination she has a corneal defect that stains with fluorescein and there is a hypopyon. A. B. C. D. E. Acute Anterior Uveitis Bacterial Conjunctivitis Bacterial Corneal ulcer Viral Conjunctivitis Allergic Conjunctivitis

Red Eye Questions

5. A 25 year old lady presents with a gritty red eye. She has had a cough for the past week. On examination she has a watery discharge and on everting the lid there are follicles present. A. B. C. D. E. Acute Anterior Uveitis Bacterial Conjunctivitis Blepharitis Viral Conjunctivitis Allergic Conjunctivitis

Sudden Painless Loss of Vision

Amaurosis Fugax Giant Cell Arteritis Papilloedema Vitreous haemorrhage (DR) Central Retinal Artery Occlusion Central Retinal Vein Occlusion Retinal Detachment Optic neuropathy

Central Retinal Artery Occlusion

White swollen retina with cherry red spot at macula Afferent pupillary defect Causes: GCA, atherosclerosis/carotid artery disease Associations:

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

Retinal Detachment

Floaters Flashing lights Field loss Falling Acuity

Gradual Loss of Vision

Cataract Chronic Glaucoma Diabetic Retinopathy Hypertensive Retinopathy Age Related Macular Degeneration Optic Atrophy

Cataract

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

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

Nuclear Sclerotic Cataract

Cortical Cataract

Clinical Evaluation
What is the cause of the cataract? Does the amount of lens opacity correspond to the degree of visual impairment? Is the patients ability to function sufficiently educed to warrant surgery? What is the prognosis for improvement of vision? Are there any ocular/systemic considerations? Does the patient want surgery

Functional Considerations
Legal or corporate requirements for vision Driving
car bus HGV

Flying Other mechanical equipment Personal

Glaucoma

Glaucoma
Group of diseases Primary open angle is the commonest in the UK POAG asymptomatic Often picked up by routine optometric examination May or may not have raised IOP Characterised by optic nerve and visual field changes

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

Diabetic Eye Disease

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

Diabetic Retinopathy
Background Non or preproliferative Proliferative Maculopathy

Background Diabetic Retinopathy

Microaneurysms, dot and blot haemorrhages, hard exudates, occasional cotton wool spots

Non-Proliferative Diabetic Retinopathy

Intra-retinal microvascular abnormalities, venous beading/loops, clusters of large blot haemorrhages, multiple cotton wool spots

Proliferative Diabetic Retinopathy

New vessels at disc or elsewhere on retina

Diabetic Maculopathy

Macular oedema, exudates, microaneurysms

Macular Degeneration

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.

Visual symptoms
Blurred central vision difficulty reading colour and contrast disturbances metamorphopsia Central scotoma

Dry AMD
Hard Drusen Soft Drusen

Wet AMD

Loss of Vision Questions

1. A 78 year old man complains of increasing difficulty in reading and recognising people s faces. Fundus examination reveals a speckled appaerance of both maculae A. B. C. D. E. Amaurosis fugax Cataract Macular Degeneration Acute Glaucoma Central Retinal Vein Occlusion

Loss of Vision Questions

2. A 70 year old woman complains of gradual blurring of vision and increasing difficulty driving at night due to the glare of oncoming headlights. Ophthalmoscopy reveals opacities when checking the red reflex. A. B. C. D. E. Amaurosis fugax Cataract Macular Degeneration Acute Glaucoma Central Retinal Vein Occlusion

Loss of Vision Questions

3. A 57 year old man with atrial fibrillation presents with sudden loss of vision in his right eye. He said that the vision went totally blank for 15 minutes but now everything was back to normal. Fundus examination was normal. A. B. C. D. E. Amaurosis fugax Cataract Macular Degeneration Acute Glaucoma Central Retinal Vein Occlusion

Loss of Vision Questions

4. A 46 year old male with a below the knee amputation complains of worsening visual acuity. Fundoscopy reveals exudates at the macula, retinal haemoorhages and neovascularisation at the disc. A. Hypertensive retinopathy B. Diabetic retinopathy C. Macular Degeneration D. Central Retinal Artery Occlusion E. Central Retinal Vein Occlusion

Loss of Vision Questions

5. A 65 year old smoker with known diabetes and hypertension presents with sudden painless loss of vision. Examination reveals scattered haemorrhages throughout the fundus and a swollen disc. A. Hypertensive retinopathy B. Diabetic retinopathy C. Macular Degeneration D. Central Retinal Artery Occlusion E. Central Retinal Vein Occlusion

Answers to Quiz

Red Eye Questions

1. An 81 year old man is admitted to hospital with nausea and vomiting. On examination the right eye looks red and the pupil is dilated fixed and oval in shape. He complains of severe pain around the eye and sees rings of light around bright objects. A. B. C. D. E. Acute Anterior Uveitis Acute Glaucoma Blepharitis Conjunctivitis Episcleritis

Red Eye Questions

2. A 30 year old man with ankylosing spondylitis complains of a painful eye with reduced vision. On examination the patient dislikes bright light and the eye is red, especially around the cornea. The pupil is small and fixed. A. B. C. D. E. Acute Anterior Uveitis Acute Glaucoma Blepharitis Conjunctivitis Episcleritis

Red Eye Questions

3. An 18 year old man presents with a gritty red eye. On examination the conjunctiva is red and swollen and he has a sticky yellow discharge. A. B. C. D. E. Acute Anterior Uveitis Bacterial Conjunctivitis Blepharitis Viral Conjunctivitis Allergic Conjunctivitis

Red Eye Questions

4. A 28 year old contact lens wearer presents with a painful red eye. On examination she has a corneal defect that stains with fluorescein and there is a hypopyon. A. B. C. D. E. Acute Anterior Uveitis Bacterial Conjunctivitis Bacterial Corneal ulcer Viral Conjunctivitis Allergic Conjunctivitis

Red Eye Questions

5. A 25 year old lady presents with a gritty red eye. She has had a cough for the past week. On examination she has a watery discharge and on everting the lid there are follicles present. A. B. C. D. E. Acute Anterior Uveitis Bacterial Conjunctivitis Blepharitis Viral Conjunctivitis Allergic Conjunctivitis

Loss of Vision Questions

1. A 78 year old man complains of increasing difficulty in reading and recognising people s faces. Fundus examination reveals a speckled appaerance of both maculae. A. B. C. D. E. Amaurosis fugax Cataract Macular Degeneration Acute Glaucoma Central Retinal Vein Occlusion

Loss of Vision Questions

2. A 70 year old woman complains of gradual blurring of vision and increasing difficulty driving at night due to the glare of oncoming headlights. Ophthalmoscopy reveals opacities when checking the red reflex. A. B. C. D. E. Amaurosis fugax Cataract Macular Degeneration Acute Glaucoma Central Retinal Vein Occlusion

Loss of Vision Questions

3. A 57 year old man with atrial fibrillation presents with sudden loss of vision in his right eye. He said that the vision went totally blank for 15 minutes but now everything was back to normal. Fundus examination was normal. A. B. C. D. E. Amaurosis fugax Cataract Macular Degeneration Acute Glaucoma Central Retinal Vein Occlusion

Loss of Vision Questions

4. A 46 year old male with a below the knee amputation complains of worsening visual acuity. Fundoscopy reveals exudates at the macula, retinal haemorrhages and neovascularisation at the disc. A. Hypertensive retinopathy B. Diabetic retinopathy C. Macular Degeneration D. Central Retinal Artery Occlusion E. Central Retinal Vein Occlusion

Loss of Vision Questions

5. A 65 year old smoker with known diabetes and hypertension presents with sudden painless loss of vision. Examination reveals scattered haemorrhages throughout the fundus and a swollen disc. A. Hypertensive retinopathy B. Diabetic retinopathy C. Macular Degeneration D. Central Retinal Artery Occlusion E. Central Retinal Vein Occlusion

Thank you