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SPM- Opthamology > Loss of Vision and Ophthalmic Emergencies > Flashcards

Loss of Vision and Ophthalmic Emergencies Flashcards

1
Q

If loss of vision is painful what structures are likely to be involved?

A

Anterior of the eye is associated with painful loss of vision- these structures have a rich innervation

Iris, cornea, sclera

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2
Q

If loss of vision is painful what structures should be considered?

A

Posterior components of the eye-
Lens, Vitreous, Retina

Note- optic neuritis can cause pain of movement of the eye due to inflammation of the nerve

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3
Q

If vision loss is sudden what sort of causes should you consider?

A

Vascular causes are acute onset

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4
Q

If someone presents with loss of history what should you ask about?

A

When did this happen?
Painful
Painless
How quickly did this come on? Was it sudden?
How is your vision at the moment?
Has the loss been permanent since onset or has it been transient?
Have you lost central vision or peripheral vision?- Struggling to read or bumping into things
One of both eyes affected?- Processes such as diabetic retinopathy cause bilateral damage
Any other associated symptoms? E.g. Headache, polydipsia, polyuria

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5
Q

When a patient presents with loss of vision what should always be checked?

A

Check Visual Acuity- Could be OSCE so learn this

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6
Q

What is an RAPD?

A

It is a sign of an optic nerve lesion. There is consensual reflex but no direct as there has been loss of sensory input to the affected side. Therefore appears to dilate when the light is shone into the affected eye.

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7
Q

If someone presents with painless loss of vision which part of the eye is likely to be affected?

A

Structures from the lens backwards- back of the eye

Except for optic neuritis which causes pain on eye movement

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8
Q

If loss of vision is sudden what causes should you consider?

A

Vascular causes:
Retinal Vein Occlusion
Retinal Artery Occlusion

May affect central retinal vessels or branches of the vessels

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9
Q

How are vessel arcades spilt in the eye?

A

Superior or inferior

Nasal or Temporal

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10
Q

What do you see on fundoscopy with a branch retinal vein occlusion?

A

Haemorrhages confined to the affected area

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11
Q

What do you see with a central retinal vein occlusion?

A

Fairly severe picture
Wide spread haemorrhages throughout the retina
Swollen disc

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12
Q

What do you see with a branch retinal arteriolar occlusion?

A

Pallor of the retina in the area supplied by the vessel- it looks less pink than the surrounding area
May be able to see embolic area in the vessel- pale

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13
Q

What are the most common causes of branch arteriolar occlusion?

A

Emboli- often either cardiac or carotid source

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14
Q

What do you see on fundoscopy with a central retinal artery occlusion?

A

Pallor of the entire retina
Cherry red spot at the macula

Aim to treat within 8 hours- IV acetazolamide, ocular massage, re-breath into paper bag, anterior chamber paracentesis, refer to stroke/TIA clinic

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15
Q

What are some causes of sudden painless loss of vision?

A

Central Retinal Artery or Vein Occlusion
Anterior Ischaemic Optic Neuropathy (arteritis or non arteritic (embolic))
Retinal detachement
Vitreous Haemorrhage

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16
Q

What is anterior ischaemic optic neuropathy?

A

Ischaemia to the anterior optic nerve and optic disc

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17
Q

What are the two categories of causes for anterior ischaemic optic neuropathy?

A

Arteritic- GCA/Temporal Arteritis

Non Arteritic- Embolic (Cardiac or Carotid source)

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18
Q

What are the features of anterior ischaemic optic neuropathy seen on fundoscopy?

A

Pallor of the optic disc
Blurring of the edges of the optic disc (loss of sharp border)

Often also have altitudinal visual field defect

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19
Q

What must be ruled out in patients with anterior ischaemic optic neuropathy? How might this be done?

A

Giant cell arteritis

History of headaches, scalp tenderness, pain when brushing hair, fatigue, lethargy. Bloods- raised ESR and CRP

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20
Q

What is a leading cause of vitreous haemorrhage?

A

Proliferative diabetic retinopathy causes fragile vessels to form which are prone to bleeding, these can then bleed into the vitreous humour.

Bleeding causes a disruption of clear optical media and so there is vision loss.

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21
Q

Why is an increase in the number of floaters more concerning for a diabetic patient?

A

Could be a sign of bleeding vessels, causing vitreous haemorrhage. These need to be checked out.

Fragile vessels for due to proliferative diabetic retinopathy.

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22
Q

Describe the process that can cause retinal detachment?

A

PVD can pull on the retina and cause retinal tears. Fluid can then track underneath the retina leading to retinal detachment.

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23
Q

What are the symptoms of retinal detachment?

A

Flashes and Floaters (sx of PVD)

Loss of vision, central vision is lost if the macula becomes involved.

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24
Q

What are some causes of retinal detachment?

A

PVD- Causing retinal tear and fluid tracks underneath the tear
Myopia- Longer eye ball means there is a thinner retina more prone to breaking
Trauma- stretching and compressing of the globe occurs with blunt trauma that can cause tears and detachment

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25
Q

What are some signs of retinal detachment?

A

Fundoscopy- blurring of vessels and retina appears to be coming towards you
Visual field defect depending upon the area affected
Loss of central vision if the macula is involved

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26
Q

What is the management for retinal detachment?

A

Urgent referral to ophthalmology

Surgical management- Vitrectomy and re-attaching the retinal (maybe with laser)

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27
Q

What is a PVD?

A

Posterior vitreal detachment- normal process of ageing is that the vitreous shrinks. can cause retinal tear. Sx of flashes and floaters.

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28
Q

What should you do for sudden onset flashes and floaters?

A

Refer to ophthalmologist as could be retinal detachment

Once macula is involved unlikely to regain central vision

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29
Q

What are some causes of gradual loss of vision?

A 
Cataract (accelerated- tends to be more slow)
Age related macular degeneration
Diabetic retinopathy
Primary Open Angle Glaucoma
Papilloedema (bilateral raised ICP)
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30
Q

What can cause a cataract to develop rapidly?

A

Trauma to the eye- blunt trauma or any foreign object coming into contact with the eye

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31
Q

Why form of macular degeneration can cause fairly rapid loss of vision?

A

Wet Macular Degeneration- new vessels that form are unstable and can result in bleeding into the macula.

Treated with VEGF inhibitors

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32
Q

what kind of visual loss does macular pathology cause?

A

Central vision loss
Central scotoma

(Macula is responsible for central vision not peripheral)

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33
Q

What is the cup? What is a normal ratio?

A

Axons of the nerve entering the disc- this is effectively dead space. Normal is cup to disc ratio is less than 0.3

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34
Q

What conditions cause cupping of the optic disc?

A

Glaucoma- raised pressure within the eye leads to damage to the optic nerve which limits peripheral vision

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35
Q

What is papilloedema?

A

Bilateral optic disc swelling due to raised ICP.

Loss of clear margins, loss of pink healthy appearance, difficult to see blood vessels overlying the disc

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36
Q

What are two causes of papilloedema?

A 
Raised ICP (Always do MRI Head)
Idiopathic Intra-cranial Hypertension
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37
Q

What kind of visual loss does papilloedema cause?

A

Loss of peripheral vision

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38
Q

If a patient describes misty, foggy or glare in the vision what should be considered?

A

Cataract-

Disturbance in clear optical media such as cornea and aqeous/vitreous too

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39
Q

If a patient describes distortion of central vision or central scotoma what should be considered?

A

Macular pathology

For any issue with central vision think macula

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40
Q

If a patient describes flashes and floaters what should be considered?

A

PVD

Retinal Detachement

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41
Q

What condition needs to be ruled out if someone has anterior ischaemic optic neuropathy?

A

GCA- ESR, CRP, Temporal Headaches, Scalp Tenderness

Treat first with high dose steroids and then investigate

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42
Q

What features in a history might you find in a patient with GCA?

A 
Temporal headaches
Scalp tenderness
Pain on brushing hair
Fever
Lethargy
Weight loss
Jaw claudication
PMR- Association causing shoulder and hip pain
Sudden loss of vision- Anterior ischaemic optic neuropathy
43
Q

What blood tests should be requested for patients with suspected GCA?

A

ESR (Goes up)
CRP (Goes up)
Platelets (Goes up)

44
Q

How might the temporal artery appear in patients with GCA?

A

Large
Boggy
Non-pulsatile
Tender

45
Q

What are some causes of central retinal artery occlusion?

A

Embolic- Carotids or cardiac source
Atherosclerotic disease
Raised IOP
Arteritis- GCA

46
Q

What are the symptoms of central retinal artery occlusion?

A

Painless loss of vision or a visual field defect (if branch)
Preceded amaurosis fugax

Note- Painless as it is the back of the eye that is affected

47
Q

What are some signs of central retinal artery occlusion?

A 
RAPD
Pale retina
Cherry red spot (macula)
Visual field defect
No perception of light
48
Q

What is the management for central retinal artery occlusion?

A

IV Acetazolomide
Re-breath into paper bag
Occular massage
Anterior chamber paracentesis

Start aspirin and refer to TIA/stroke clinic

49
Q

Why should you check inflammatory markers for central retinal artery exclusion?

A

To rule out GCA as this is very serious is not treated urgently with high dose steroids

50
Q

What is keratitis?

A

Inflammation of the cornea

51
Q

What are some causes if keratitis?

A

Bacterial- Gram positive or negative
Viral- Herpes Simplex Virus (Causes a dendritic ulcer)
Acanthamoeba- associated with use of tap water to clean contact lenses

52
Q

What signs may be seen with bacterial keratitis?

A 
Redness
Hypopyon- pus in the anterior chamber
Photophobia
Painful eye
Watering of the eye
Reduced visual acuity due to haze
53
Q

What is leading cause for bacterial keratitis?

A

Contact lens misuse- e.g. poor hand hygiene, wearing them at night

54
Q

What are the findings of keratitis due to HSV?

A

Dendritic ulcer on fluorescein staining

Presentation tends to be less severe than a bacterial infection. If patient also wears soft contact lenses consider acanthamoeba which causes more severe symptoms with similar signs.

55
Q

What is uveitis?

A

Inflammation of the uvea (iris, ciliary body and choroid)- non-specific

56
Q

What is a key associated of acute anterior uveitis?

A

Associated with sero-negative arthropathies which are associated with HLA-B27 +Ve status e.g. Ankylosing Spondylitis

57
Q

What are some signs/symptoms of uveitis?

A

Photophobia- inflamed iris painful when causing pupil constriction
Posterior Synechiae- inflammatory exudate makes aqueous humour sticks and adhesions for between iris and anterior surface of the lens
Hypopyon- Pus/Inflammatory material in the anterior chamber
Red eye

58
Q

What is a posterior synechiae and what causes it?

A

Iris is adhered to the anterior surface of the lens. This occurs in uveitis because the inflammatory exudate makes the iris stick to the lens.

59
Q

What is a hypopyon?

A

Inflammatory exudate in the anterior chamber of the eye which collects under gravity

60
Q

What is acute angle closure glaucoma?

A

The drainage angle of the aqueous humour becomes acutely obstructed causing large increases in IOP

61
Q

What are some risk factors for developing acute angle closure glaucoma?

A

Hypermetropic/Long sighted as the shorter eyeball means there is less space and structures are closer together
Night time- more likely to obstruct the angle when the iris is dilated

62
Q

What are the signs/symptoms of acute angle closure glaucoma?

A

Extremely painful
Red eye
Unilateral headache
Fixed mid-dilated pupil
Associated nausea and vomiting due to the pain
Haloes around bright lights due to corneal oedema with increased IOP

63
Q

What are some signs of acute angle closure glaucoma?

A

Corneal oedema- speckled appearance
Red eye
Fixed mid-dilated pupil
Decreased visual acuity

64
Q

What is the management of acute angle closure glaucoma?

A

Urgent referral to ophthalmology
Medical Therapy- IV Acetazolomide, Beta Blockers, Mannitol, Topical Pilocarpine to constrict pupil
Surgical- Iridectomy

65
Q

What are some of the symptoms of optic neuritis?

A 
Often unilateral
Loss of vision
Pain on eye movement
Reduced colour vision
Central scotoma
Red desaturation
66
Q

What is optic neuritis associated with?

A

Multiple sclerosis- do work-up for this

67
Q

How does the colour red change with optic neuritis?

A

Red desaturation

68
Q

What signs may be present for optic neuritis?

A 
Decreased colour vision
Red de-saturation
Central scotoma
Optic disc may look normal
RAPD- Optic nerve lesion, pupil on affected side appears to dilate
69
Q

What are some causative organisms of microbial keratitis?

A

Staph
E.coli
Pseudomonas

70
Q

What is the management for microbial keratitis?

A 
Refer to ophthalmology
Scrapings for MC and S
Topical Intensive Abx- e.g. Ofloxacin 
Dilator Eye drops to reduce pain
Avoid wearing contact lenses
71
Q

If someone presents with a lid laceration what is the main priority?

A

To check the integrity of the globe- are there any scleral or corneal lacerations. If so refer to ophthalmology?

72
Q

When should a lid laceration be referred to opthamology?

A 
If it involves the lacrimal apparatus
If it involves the medial canthus
If it involves the levator complex
If it involves the lid margin
If there has been any globe perforation
73
Q

What should be done for simple lid lacerations?

A

Tetanus prophylaxis

Repair with 6/0 monofilament

74
Q

What is a peri-orbital haematoma?

A

Occurs following blunt trauma to the eye

Bruising that surrounds the eye

75
Q

What should be done for any blunt trauma to the eye?

A

Check the globe for any damage- sclera or corneal lacerations
Perform fundoscopy- trauma can cause retinal detachment, vitreous haemorrhage
Check visual acuity
If suspecting any bony-fractures X-ray or CT

76
Q

What is a hyphaema?

A

Blood in the anterior chamber- can occur following trauma

77
Q

What is the treatment for peri-orbital haematoma?

A

Analgesia and cold compress

78
Q

What is a blow-out fracture?

A

Fracture of the orbital wall, floor or roof

79
Q

What are some symptoms of a blow-out fracture?

A

Bony pain and tenderness
Pain on eye movements- due to trapping of ocular fat outside the fracture
Enopathalmus- eye regressed into orbital cavity
Dipolpia- if ROM is reduced
Parasthesia over maxillary area- due to damage to infra-orbital nerve

80
Q

What is a cause of blow-out fracture?

A

Typically blunt trauma

81
Q

What is the management is a blow-out fracture is suspected?

A

X-Ray/CT

Refer to ophthalmology or max-fax

82
Q

What is the name of a the sign that can indicate an orbital fracture/blow out fracture on imaging?

A

Tear drop sign

There is bulging of peri-orbital fat into the normally air-filled sinuses that looks like a tear drop

83
Q

What is a hyphaema?

A

Blood in the anterior chamber

84
Q

What can cause a hyphaema?

A

Trauma to the eye which causes shearing/damage to blood vessels of the iris resulting in bleeding into the anterior chamber

85
Q

What are some symptoms fo hyphaema?

A

Blurring of vision- reduces clarity of aqueous humour
Staining of corneal epithelium also cause blurring of vision
Theres blood in the front of their eye- people will probably complain about that
Photophobia- damage to the iris cause inflammation which makes pupillary constriction painful

86
Q

What is the management for hyphaema?

A

As with any trauma to the eye:
Check the integrity of the globe for any other damage
Fundoscopy- vitreous haemorrhage, retinal detachment
Check visual acuity
Refer to opthamology

Topical steroids- reduces inflammation and stabilises the blood aqueous barrier to reduce the risk of re-bleed
Rest- Want to avoid increases in blood pressure that could cause a re-bleed
Reduce Intra-occular pressure if required- blood can clog up trabecular meshwork

87
Q

What is the management of secondary bleeds causing secondary hyphaema?

A

As for primary

May require surgical evacuation as red cells adhere to and stain the corneal epithelium

88
Q

If suspecting an intra-occular foreign body what is important to ask about in the history?

A 
Velocity
Eye protection
Tetanus vaccination
What was the material?
How did it happen?
Associated symptoms?
89
Q

What investigations should be done if IOFB suspected?

A

Fundoscopy to see if any objects can be seen
X-Ray/CT (NOT MRI- unless you want to remove it very fast)
Refer to ophthalmology
Intensive ABx- Ciprofloxacin 750mg BD

90
Q

What might cause a globe rupture?

A

Blunt trauma- compressive force
Sharp objects/Lacerations
High velocity objects

91
Q

What is the management for a globe rupture?

A

Urgent referral to ophthalmology for surgical repair
Plastic shield- protect and avoid pressure on eye
Tetanus Prophylaxis
Imaging to check for IOFB- X-Ray/CT
Anti-biotics

92
Q

What are some symptoms of a ruptured globe?

A

Severe pain
Loss of vision- loss of optical media
Photophobia
May develop infection

93
Q

What does a scleral laceration look like?

A

Very dark wedge due to laceration exposing underlying coroid

94
Q

What may an acutely forming cataract in a young patient be a sign of?

A

If there has been any perforation of the cornea a foreign object coming into contact with the lens can cause it to opacify

Also blunt trauma

Therefore any acutely forming cataract be aware of IOFB and trauma

95
Q

What should be done for all chemical burns?

A

Irrigate
Irrigate
Irrigate

Till neutral pH/pH of normal eye achieved or for at least 30 minutes

Use 0.9% Saline (NaCl).

Refer to opthamology

96
Q

What are some symptoms of chemical injury to the eye?

A

Red eye
Pain
Reduced vision (check acuity)
Photophobia

97
Q

Why is an alkali more concerning than an acid burn to the eye?

A

Alkalis will progress and erode to cause perforation

Acids cause scarring at site of contact so will not cause perforation

98
Q

What are some signs of chemical injury to the eye?

A 
Corneal injection
Redness
Clouding of the cornea
Limbal ischaemia (concerning as site of stem cells for cornea)
Chemosis
99
Q

What else can be given for chemical injury except for irrigation?

A

Dilator eye drops (cycloplegics) and topical steroids to reduce pain
Antibiotics if risk of infection or globe perforation
Vitamin C drops help with healing

100
Q

Why is plaster dust very worrying if it gets into the eye?

A

It is an alkali and the dust is difficult to remove from the eye

101
Q

What is the triad of non-accidental injury?

A

Sub-dural haematoma
Brain damage
Retinal haemorrhages

102
Q

What feature should raise concerns regarding non-accidental injury?

A

Triad- subdural haematoma, retinal haemorrhages, brain damage

Multiple injuries in various stages of heeling.

103
Q

What is orbital cellulitis?

A

Cellulitis (infection) within the orbit

SPM- Opthamology (11 decks)

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