Ophthal Review #3 – Anterior Segment + Glaucoma

Cataracts

  1. Presentation
    1. Slow, progressive visual loss
  2.  Type
    1. Nuclear
      1. Myopic shift
      2. Yellow/brown discolouration of central elns
    2. Posterior subcapsular
      1. Plaque-like opacity
      2. Glare and difficulty reading
      3. Type seen in steroid usem diabetes, trauma
    3. Cortical
      1. Radial/spiculated opacity in the peripheries
      2. Often symptomatic until central changes develop
  3. Refer for surgery

Uveitis

  1. History
    1. Pain
    2. Photophobia, direct and consensua;
    3. Decreased VA
  2. Exam
    1. Cells and flare
    2. Ciliary flush (no perilimbal sparing)
    3. Keratic percipitates
    4. Hypopion
    5. Synechiae may develop
  3. Workup (choose based on clinical history of other symptoms)
    1. TB workup
    2. VDRL/RPR
    3. HIV
    4. Toxoplasmosis
    5. HLA B27
    6. Colonoscopy (IBD)
    7. CXR (sarcoidosis)
  4. Complications
    1. Catarcts
    2. Secondary glaucoma
  5. Manage
    1. Cycloplegic
    2. Topical steroid
    3. Treat substrate

Acute angle closure glaucoma

  1. History
    1. Pain
    2. Onset in conditions where eyes dilate
    3. Whoever writes our exams seems to have an obsession with little old Vietnamese ladies who read by fireplaces at three in the morning
  2. Examination
    1. SL: narrow angle on gonioscopy
    2. Raised IOP (normal: 12-22 mmHg)
  3. Treatment
    1. alpha-2 agonist
    2. beta-blockade
    3. carbonic anhydrase inhibitors systemically
    4. prostaglandin analogs

Open angle glaucoma

  1. Definition
    1. Optic neuropathy with characteristic findings of optic nerve head and specific pattern of visual field defects that is often but not always associated with increased IOP
  2. Exam
    1. Raised IOP
    2. Loss of colour vision
    3. Arcuate scotomata
    4. Nasal step
    5. Fundoscopy
      1. Cup-disc ratio  >0.5
      2. Notching (most prominent inferiorly as where rim is most thick in normal eyes)
      3. Bayonetting
  3. Treatment
    1. alpha-2 antagonists
    2. beta blockade
    3. carbonic anhydrase inhibition topically
    4. prostaglandin agonists
    5. miotics
    6. sympathomimetics

 

 

 

 

 

Ophtal Review #2 Conjunctiva,Cornea and Glasses

Conjunctivits

  • Bacterial
    • Purulent discharge
    • Commonly bilateral
    • Conjunctival papillae
    • Chemosis
    • Contact lens use: risk factor for Pseudomonas
    • Topical chloramphenicol, consder systemic antibiotics
  • Viral
    • Starts in one eye then moves to the other
    • Watery discharge
    • Inferior palpebral conjunctival follicles
    • Tender palpable preauricular lymph nodes
    • Artifical tears, antihistamine drops, topical steroids
  • Allergic
    • Conjunctival chemosis
    • Artifical tears, antihistamine drops, topical steroids
  • Vernal conjunctivitis
    • Itch
    • Thick, ropey discharge
    • Spring/ summer recurrences
    • Artifical tears, antihistamine drops, mast cell stabiliser
    • Shield ulcer: topical steroids, topical erythromycine, cycloplegic
    • Consider tacrolimus

Chemical injury

  • Emergency management
    • Copious irrigation for at least 30 min
    • Normalise pH to neutral
    • Cycloplegic
    • Chloramphenicol
    • Analgesia
    • Acetazolamide if IOP
  • Trivia
    • Alkalis (colliquative necrosis) are wose than acids (coagulative necrosis)

Corneal foreign body / abrasion

  • Presentation
    • Linear ulcerations: suspect cojunctival foreign body under the eyelid
    • Fluoroscein staining
    • Seidel’s sign is the anterior chamber fluid waterfalling out when fluroscein stained; indicates perforation
    • Contact lens use: risk factor for Pseudomonas
  • Treatment
    • Removal of foreign body with cotton bud, needle, or dental burr
    • Noncontact lens use: chloramphenicol topical
    • Contact lens: ciprofloxacin topical
    • Followup in 1 week for corneal foreign bodies

Dry eye syndrome

  • History
    • Burning
    • Dryness
    • Foreign body sensation
    • Usually bilateral and chronic
  • Examination
    • Scanty or irregular tear meniscus
    • Decreased tear break up time under fluoroscein
    • Schirmer test: filter paper in lower eyelid for 5 minute
  • Aetiology
    • Evaporative – blepharitis, meibomian gland dystrophy
    • Hyposecretory – middle aqueous layer tear deficiency; decreased production wtih age
    • Connective tissue disease: SS, RA, Wegener granulomatosis
    • Drugs
  • Treatment
    • Mild – artificial tears
    • Cyclsporin, punctal occlusion

Refractive error

Got lazy. Read this instead.

http://www.ophthobook.com/chapters/optics

Ophthal Review #1 – Posterior Segment Pathology

Age-related macular degeneration

  • History
    • Gradual loss of central vision
  • Examination findings
    • Dry
      • Drusen
      • Retinal pigment epithelium atrophy
      • Geographic atrophy
    • Wet
      • Choroidal neovascularisation
      • Subretinal fluid
  • Further assesement
    • Amsler grid
    • OCT
    • IVFA
  • Treatment
    • Dry: vitamin C + vitamin E + beta-carotene + zinc + cupric oxide
    • Wet
      • Anti-VEGF antibodies
      • Thermal laser photocoagulation

Diabetic retinopathy

  • Examination findings
    • Microaneurysms
    • Intraretinal haemorrhages
    • Venous beading
    • Intraretinal microvascular abnormalities
    • Macular oedema
      • Retinal thickness
      • Hard exudates
    • Neovascularisation in proliferative DR
  • Classification
    • Mild: microaneurysms only
    • Moderate: more than mild, less than severe
    • Severe: >20 intraretinal haemorrhages in all quadrants OR 2 quadrants of venous beading OR 1 quadrant of prominent IRMA
    • PDR: neovascularisation
    • Macular oedema as aspecifier to any of the stages listed above
  •  Treatment
    • Focal or grid laser
    • Panretinal laser photocoagulation
    • Anti-VEGF antibodies

Hypertensive retinopathy

  • Examination findings
    • Chronic
      • Arteriolar narrowing
      • AV nicking
      • Silver-wiring (retinal arteriolar sclerosis)
      • Cotton-wool spots
      • Flame haemorrhages
    • Acute (malignant)
      • Hard exudates in macular star configuration
      • Retinal oedma
      • Optic nerve head oedema
  • Management
    • Refer medics, please do the needful

CRAO

  • Presentation
    • Unilateral painless acute loss of vision occuring over seconds
    • Cherry-red macula on whitened retina
  • Workup
    • CRP + ESR
    • Fasting lipids, glucose
    • ANA + RF + VDRL
    • Carotid dopplers
    • ECG + echo
  • Treatment
    • Ocular massage
    • AC paracentesis
    • Acetazolamide
    • Hyperventilation

CRVO

  • Presentation
    • Unilateral painless acute loss of vision occuring over seconds
    • Blood and thunder retina
    • Dilated tortuous veins
  • Workup
    • VTE workup
  • Treatment
    • Pan-retinal photocoagulation i neovascularisation
    • Aspirin may be used but evidence is poor

Retinal detachment

  • Presentation
    • Painless sudden loss of vision
    • Flashes + floaters
    • A curtain descends
    • Hazy, ill-focused retina or undulating retinal epithelium
    • A break point may be present in rhegmatogenous
  • Workup
    • Ocular USS
  • Classification
    • Macula-on – surgery stat
    • Macula -off – surgery can wait a few days
  • Treatment
    • Laser photocoagulation
    • Cryotherapy
    • Pneumatic retinopexy
    • Vitrectomy
    • Scleal buckle

Papilloedema

  • Presentation
    • Swollen, hyperemic discs
  • Aetiology
    • SOL
    • VTE
    • Stroke
    • CNS infection
  • Workup
    • CT head
    • MRI + MRV
    • LP with opening pressure measurement

 

 

 

Diabetic Retinopathy

Findings on fundoscopy

Classification

  • Non-proliferative
    • Mild: microaneurysms only
    • Moderate: worse than mild, less bad than sevre
    • Severe: any of the following
      • >20 intraretinal hemorrhages in all 4 quadrants
      • Two quadrants of venous beading
      • One quadrant of prominent intraretinal microvascular abnormalities (IRMA)
  •  Proliferative
    • Macula-on
    • Macula-off

Management options

  1. Panretinal laser photocoagulation – reducing metabolic demand at the expense of some vision
  2. Less commonly and for spcific indications, vitrectomy and anti-VEGF therapy

Opthalmology (Almost) Pathognomonic Things

Work in progress

Visual fields

  • Arcuate scotomata – Open angle glaucoma
  • Enlarged central scotoma – ARMD
  • Loss of red vision – optic neuritis – MS
  • Nasal step – Open angle gluacoma

Fundoscopy

  • Boat haemorrhage – preretinal – wet ARMD
  • Blood and thunder – CRVO
  • Cherry red macula –  Central retinal artery occlusion
  • Geographic atrophy – dry ARMD
  • Wildfire retina – CMV retinitis

Slit lamp

  • Dendritic ulcer – Herpes simplex
  • Parallel corneal brasiaon – Foreign body udner the eyelid / inverted eyelash
  • Superior corneal shield ulcer – vernal/atopoc conjunctivitis
  • Schaeffer’s sign – pigment cells on corneal endothelium – retinal detachment
  • Siedel’s sign – Full thickness corneal perforation

Constellations

  • Scalp tenderness, jaw claudication, headache, painless red eye – Giant cell arteritis
  • Preauricular node + conjunctivits – viral or gonococcal conjunctivits
  • Hyperacute (12-24/24) onset conjuctivitis, prominent eyelid swelling, marked chemosis, preauricular adenopathy – gonococcal conjunctivitis

Uveitis

Definition

  • Inflammation of the iris, ciliary body and.or choroid (the coloured bodies of the eye)
  • Diagnosis of exclusion

Causes

  • All anatomy
    • Probability diagnosis: Idiopathic (1/3)
    • 10% seronegative spondyloarthropathies
    • 10% sarcoidosis
    • Other autoimmune disease
    • Infections
    • AIDS
    • Reiter’s
  • Anterior probability diagnosis: idiopathic, autoimmune arthropathies
  • Posterior probability diagnosis: Toxoplasma, CMV, idiopathic

History

  • Painful red eye
  • Systemic history particularly useful here

Examination

  • VA: Same or mildly decreased
  • EM: Normal
  • Pupils: Consensual photophobia may be present
  • SL
    • 360-degree perilimbal injection, more intense around the limbus
    • SPK
    • Cell and flare
    • Sterile hypopion

Workup

  • Erythrocyte sedimentation rate (ESR)
  • Antinuclear antibody (ANA)
  • Rapid plasma reagin (RPR)
  • Venereal disease research laboratory (VDRL)
  • Purified protein derivative (PPD)
  • HLA-B27

Treatment

  • Homatropine
  • Pred 1%; opthal initiated only

 

Diabetic Retinopathy

Classification

  • Non-proliferative diabetic retinopathy
    • Mild: Hemorrhages or microaneurysms only
    • Moderate: In between the twain
    • Severe: >20 vascular malformations in each quadrant
  • Proliferative diabetic retinopathy
    • Neovascularisation OR vitreous haemorrhage
    • Classified as macula-on or macula-off

Fundoscopy

  • Microaneurysms
  • Macular oedema
  • Cotton wool spots
  • Intraretinal hemorrhage
  • Lipid exudates
  • Neovascularisation

Treatment

  • Panphotocoagulation – reduces metabolic demand
  • Intravitreal anti-VEGF
  • Vitrectomy for haemorrhage