Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

FinalYearSeries:Ophthalmology101:eye historyandredflagsforUKMLA Sze Jing Chuah OphthalmologyST2 NHS TaysideLearningObjectives 1. Recall basic eye anatomy 2. Take a basic ophthalmological history 3. Identify redflags 4. Consider differentials for a red eyePart1: EyeAnatomy Engravingofthe eye in A Complete Physico-Medicaland Churugicalonthe HumanEyeand the Demonstration ofNatural Vision(Degraver,1780)Whatmakesupaneyeanditsfunctions? 1. Form –ciliarybodypumps aqueous,vitreousis ascaffold, sclera formsits casing 2. Position–extraocularmuscles,ligaments,orbit 3. Sustenance –ophthalmicartery, choroid, tearfilm 4. Hydration–lids,lacrimalgland, conj 5. Light –tear film,cornea,lensrefract;iris gatekeepsamount;retina receives 6. Sight –retina,opticnerve,occipitallobe 7. Movement–extraocularmuscles,nervesupplyKeywords: Limbus Nasal Inner andouter Anteriorand posteriorLids • Tear film • Closure oLa▪ Neurogenice.g.bells ▪ Mechanicale.g.TEDConj • Mucus membrane • Bulbar • Palpebra • FornixCornea • Most innervated tissue per sqm – very painful! • Collagen • Arrangedin parallel – makesit transparent • Curvature is important o Givesitsrefraction o 2/3 of refractionSclera 1. Continuous with cornea 2. Same collagen,but arranged out of order – makesit opaqueUvea • Muscular layer made of: 1. Iris ▪ Dilationand constriction ▪ Spasm -photophobia 2. Ciliary body ▪ Produces aq ▪ Holdsthe lensin placewith zonules 3. Choroid ▪ Bloodsupplyof theouter 2/3 of the retinaLens • Does the remaining1/3 of refraction • Can accommodate up to the age of 40 • Cataract • SatsumaVitreous • Embryological and developmentalscaffolding • PVD – flashes and floatersRetina • Rods – peripheral and dark vision • Cones – colour and HD • Inverted Projection map • Wallpaper o thereispotential spaceOpticDiscandnerve • Papilloedema – a swollen nerve • Cupanddisc o Cup – white–pit withno GCs o Disc – pinkrim– hasGCs o GlaucomaisthedeathofGCs – not always duetopressure!VasculatureEssentially: • Central and branch retinalartery • Central and branch retinalveins • Both can become blocked – CRAO/BRAO and CRVO/BRAOTheendofpart1 • Questions?Part2: RedFlags,RedEye, andHistoryTakingWhatmakesupaneyeanditsfunctions? 1. Form – ciliarybody pumps aqueous,vitreous is a scaffold, scleraforms its casing 2. Position – extraocular muscles,ligaments, orbit 3. Sustenance – ophthalmic artery, choroid,tear film 4. Hydration – lids,lacrimalgland, conj 5. Light – tear film,cornea,lens refract; iris gatekeeps amount; retinareceives 6. Sight – retina,optic nerve, occipitallobe 7. Movement – extraocular muscles,nerve supplyWhatcancauseittogowrong? • Surgicalsieve o Infective – conjunctivitis, keratitis o Autoimmune – allergy,uveitis, scleritis o Vascular– CRAO, CRVO o Trauma– retrobulbar haemorrhage, blowout fracture, globe rupture o Neoplastic – SOLs causing papilloedema, nerve palsies, horner's NICERedFlags–SamedayreferraltoOph 1. Reducedvisionorvisual acuity 2. Deeppainintheeyeortendernessonpalpationoftheglobe 3. Photophobia 4. Unequal pupilorabnormalpupil reactions 5. Highvelocity orchemical injury 6. Contactlensuse 7. Fluoresceinstaining 8. Neonatal conjunctivitis – conjunctivitisinthe infantinthe first28daysoflife Theredeye https://www.eyenews.uk.com/features/ophthalmology/post/decoding-the-red-eyePainfulredeye SBAs A) Anterior uveitis B) Scleritis A 36Fcontact lenswearerhascomeintodaywithavery C) Conjunctivitis painful,photophobicandredleft eye.Visionisdownto6/12. Onslitlampexamyounotice conjunctivalinjection,anda D) Microbialkeratitis circularepithelialdefectstainingwithfluoresceinmeasuring 2mm . Whatisthemostlikelydiagnosis? • DA 25Mwhohas achronichistoryof backpainhas presentedwith averypainful, injected, andphotobicrighteye. Hedescribes the pain as adull throb.On examinationVA is 6/36andtheviewon slitlampis hazybutyoucan seegrade2cells intheanterior chamber,keraticprecipitates, andposteriorsynechiae.Whatis themostlikelydiagnosis? A)Anterioruveitis B) Scleritis C)Conjunctivitis D) Microbialkeratitis • A A)Migraines A 72FhaspresentedtoAnEwithblurringofvision,asevere B) Acute angleclosureglaucoma throbbingheadache,and3episodesofvomitingsince5pm.Sheis C)Clusterheadache knowntohave migraineswithvisualsymptomsbutsaysthisfeels different.Onexaminationvisioniscountingfingers,there isa mid- D)Subarachnoidhaemorrhage dilatedandfixedpupil,andtheeye isred. • BA 42Fcontactlens wearerhas comein todaywith averypainful, photophobic, andredlefteye.Vision isdown to6/60. On slitlampexamyou notice conjunctivalinjection,anda largecentral epithelial defectstaining with fluorescein measuring4mmby5mm. You notethat thereis ahypopyon. Whatshouldbe the nextstepinmanagement? A) StartPO antibiotics B) Directto opticians C)Startchloramphenicol ointment D) Samedayreferral to ophthalmology • DLesspainfulredeye SBAs A 13M witha historyofasthmaand eczemaattends withseveralmonth history ofbilateral itchyand red eyes. VA is at6/9botheyes.On examinationyounotethat bothlids are slightlypuffyand eyes are red withchemosis. Whatis the mostappropriate next step? A) chloramphenicolointment B) lubricating and antihistamineeyedrops C) same dayreferralto ophthalmology D) hydrocortisone ointment • BA 20Mpresentswitha right red eye withcopious amountsof mucopurulent discharge.The eyelidsarealsoveryswollen.Hereports that the eyeis slightlyuncomfortableandhismaincomplaint is the amount ofdischarge.VA isinitially6/60but aftercleaning theeyeand blinkingitimproves to6/12.Whatis themostimportant differentialto ruleout? A) Viralconjunctivitis B)Staphylococcalconjunctivitis C) Gonnococcalconjunctivitis D)Vernalconjunctivitis • CA32Fhaspresentedwithafocal injectioninthe lefteyestartinginthelast 24hours.Theeye feelsslightlygritty. There is nodischarge.VAis6/6andthe rest ofocularexaminationisnormal. Whichoptionwouldhelpaiddiagnosis? A)instil1% cyclopentolate B) instil10% phenylephrine C)instil4% pilocarpine D) instil1% tropicamide • BHistory TakingRealWorldOphhistory • We focuson the PCand HPC o Only askaboutthe rest ifwe suspect it'srelevant ▪ e.g.vitreous haemorrhage–pmhdiabetes • Key questions: oWhy havethey comein ▪ And they will tell you:Visionblurry/Pain/Painless/Itchy oWhat where they doing oHow long hasitbeengoing onfor • By and large confirm your differentials independently – exam,OCT ForthePurposesoftheCPSA... • Takeyour historyas you would for anormalhistory taking station o Belogicalinyour questions anddifferentials o Mainpresentingfeatureand duration ▪ Systemic symptoms – Pyrexia? Vomiting? Headache? o Oneeye or both? • Interms ofclinicalskillsbecomfortablewith o Direct ophthalmoscope ▪ Beawareofhow anomalfunduslookslike ▪ Papilloedema ▪ Glaucomatousdisc –pale, C:D ▪ CRVOstormysunset ▪ CRAOcherry redspot ▪ Diabeticlasers o Cranialnerve exams ▪ 2 –acuity, fields,ishihara, reflexes, directophthalmoscope ▪ 3, 4, 6 –ocular motilityForthePurposesofBeing aGoodColleague • Visualacuity – PEEK acuity appon Android,MDcalc otherwise • Pupils • +/- pressureTrue EyeEmergencies*thatneedOphthalmology input 1. Acute angle closure 2. Ocular GCA 3. Orbital cellulitis 4. Retrobulbar Haemorrhage 5. Globe Rupture i.e.time = sight,and earliertreatment = better outcomes NICERedFlags–SamedayreferraltoOph 1. Reducedvisionorvisual acuity 2. Deeppainintheeyeortendernessonpalpationoftheglobe 3. Photophobia 4. Unequal pupilorabnormalpupil reactions 5. Highvelocity orchemical injury 6. Contactlensuse 7. Fluoresceinstaining 8. Neonatal conjunctivitis – conjunctivitisinthe infantinthe first28daysoflife