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Saif Abbas Chatoo Chatoosa@cardiff.ac.uk Note : No copyright Is intended for images - sources have been provided where possible Learning Outcomes Intro – Anatomy Glaucoma Cataract Red Eye Macular Degeneration Diabetic Retinopathy Hypertensive retinopathy Neuro-ophthalmology Conjunctivitis Orbital cellulitis SBA Label Structure A A A. Canal of Schlemm B. Ciliary Body C. Ciliary Zonule D. Iris E. Choroid SBA Label Structure A A. Canal of Schlemm B. Ciliary Body C. Ciliary Zonule D. Iris E. ChoroidAnatomy Source : geekymedics.com SBA Lee an 18 year old , comes to the clinic with unilateral Lacrimation (excess tears) and watery discharge. Grittiness , Stinging, Burning . His left eye is red. He hasn’t had anything like this before. He is sexually active but the cultures you order are negative. What is your first line management? A. Cold compress B. Mast cell stabiliser/anti-histamine eyedrops C. topical Broad SepctrumA Abx + Oral Doxy / Azithro D. topical abx + IM ceftriaxone E. topical chloramphenicol SBA Lee an 18 year old , comes to the clinic with unilateral Lacrimation (excess tears) and watery discharge. Grittiness , Stinging, Burning . His left eye is red. He hasn’t had anything like this before. He is sexually active but the cultures you order are negative. What is your first line management? A. Cold compress B. Mast cell stabiliser/anti-histamine eyedrops C. topical Broad SepctrumA Abx + Oral Doxy / Azithro D. topical abx + IM ceftriaxone E. topical chloramphenicol Blepharitis Inflammation of the eyelid margin due to infection . Sometimes due to meibomian grease gland blockage Management Symptoms • Lid hygiene (Warm Compress ) • Burning • Grittiness • Antibiotics (anterior) • Mild photophobia Topical : Sodium fusidic acid , chloramphenicol https://medicalpicturesinfo.com/blepharitis/ • Crusting and redness of Oral: Azithromycin for ulcerative lid margin lid margins • Antibiotics (posterior) Tests Systemic tetracyclines (block staphylococcal lipase production) • Lid biopsy • Weak topical steroids • Lid margin culture • Tear Replacement Conjunctivitis – Infective & Allergic Symptoms Inflammation of the Conjunctiva • Lacrimation (excess tears) Grittiness , Stinging, Burning Source : passmedicine.com • Allergic - Cold compress /lubricant - Mast cell stabiliser/anti-histamine eyedrops - ADD Topical corticosteroid + NSAID • Bacterial Management 1 = topical chloramphenicol Gonorrhoeal = topical abx + IM ceftriaxone Chlamydial = topical Broad SepctrumA Abx + Oral Doxy / Azithro •st Viral 1 line : antihistamines + artificial tears - ADD topical corticosteroids - ADD topical ganciclovir for adenovirus • Reduce transmission risk * hand hygiene , avoid eye rubbing , towel sharing) SBA A 40 year old patient , Zahid , comes into the A&E dept after a car accident. He says that he hit his head during the accident. He has a known pmHx of Hypertension. The globe is protruding at 8mm. There is visual disturbance and reduced motility. What is the definite management for this patient? A. Peripheral iridotomy B. CT scan C. Dorzolamide eye drops D. Wait and watch https://www.wikem.org/w E. Lateral Canthotomy MS-3-152-g008.png49_NJ SBA A 40 year old patient , Zahid , comes into the A&E dept after a car accident. He says that he hit his head during the accident. He has a known pmHx of Hypertension. The globe is protruding at 8mm. There is visual disturbance and reduced motility. What is the definite management for this patient? A. Peripheral iridotomy B. CT scane C. Dorzolamide eye drops D. Wait and watch E. Lateral Canthotomy Source: eyeguru.org SBA Bashir has a painless red eye, with no visual disturbance . You think you know what he has , so you give some Phenylephrine drops , which improves the redness. What condition is it ? A. Episcleritis B. Scleritis C. Subconjunctival Haemorrhage D. Bacterial conjunctivitis E. Dry eye SBA Bashir has a painless red eye, with no visual disturbance . You think you know what he has , so you give some Phenylephrine drops , which improves the redness. What condition is it ? A. Episcleritis B. Scleritis C. Subconjunctival Haemorrhage D. Bacterial conjunctivitis E. Dry eye - Science Photo Library - Stock Image - C014/2766 Subconjunctival Haemorrhage Burst blood vessels between the conjunctiva and the sclera Symptoms • PAINLESS red eye , NO loss of vision , Can be Asymptomatic Causes • Idiopathic , post eye or head injury , cough or vomit , haemophilia , HTN Source: eyecenters.com Tests • Check BP , FBC , LFTs, Clotting Management • NO treatment required . Red eye turns yellow before improving Episcleritis & Scleritis Episcleritis = Idiopathic inflammation of the vascular connective tissue layer that lies between the sclera and conjunctiva Management Symptoms • Red eye • Artificial tears • Eye tenderness and pain • Steroids (oral prednisolone) • Photophobia • Oral NSAIDs phenylephrine drops may be used to differentiate between episcleritis and scleritis. Episcleritis of the eye - Stock Image - C014/2766 - Science Photo Library Phenylephrine blanches the conjunctival and episcleral vessels but not the scleral vessels Chalazion & Stye Acute swelling of/on eyelid Source : Fort Worth Eye Associates Meibomian gland blockage – CHALAZION Infection of eyelash follicle - STYE Symptoms CHALAZION Management Typically initially painless but Internal : can become uncomfortable • Lid hygiene (Warm Compress ) usually Hard bump felt outside and • Chloramphenicol meibomian inside gland • If Chalazion persists may need excision STYE • NICE abx only if associated External: Painful conjunctivitis usually staph Glands of zeis Gland of moll SBA Reza had a Sudden onset Unilateral pain ,Photophobia , Blurred vision , Floaters, Red eye, and irregular pupil, among other presentations as seen in the image. He has a pmhx of Ankylosing Spondylitis. What is your first line management for this patient? A. IV paracetamol B. Azathioprine C. Atropine 1% D. IV dexamethasone E. Cyclopentolate 1% Image from Medscape SBA Reza had a Sudden onset Unilateral pain ,Photophobia , Blurred vision , Floaters, Red eye, and irregular pupil, among other presentations as seen in the image. He has a pmhx of Ankylosing Spondylitis. What is your first line management for this patient? A. IV paracetamol B. Azathioprine C. Atropine 1% D. IV dexamethasone E. Cyclopentolate 1% Image from Medscape Anterior Uveitis Inflammation of the Iris & Ciliary Body Management Symptoms • Sudden onset Unilateral pain 1. Corticosteroid treatment ( IV dexamethasone) • Photophobia 2. DMARDs 3. Antimuscarinic cycloplegic (cyclopentolate) • Blurred vision • Floaters • Red eye • Irregular pupil • hypopyon Spondyloarthropathies Associated HLA-B27 Conditions IBD Sarcoidosis Chemical Injury Management Symptoms • Take a History or Collateral Hx • Painful red eye • Watering • ACID VS ALKALI (worse) • Decrease in VA • Skin Burn • ACCIDENT VS DELIBERATE • Erythema • Blistering • ADMIT & TEST PH Signs • IRRIGATE !!! • Corneal abrasion • Topical steroids , Abx, cycloplegics (paralyse iris and • Blanching of limbus reduce pain). Citric and ascorbic acid , analgesiaYou do a slit lamp examination on Vijay with a fluorescein stain , because he has been complaining of discomfort and rubbing his eyes a lot. How would you describe what you see. SBA A. Dot and blot erosion B. Dendritic pattern defect C. Punctate epithelial erosions D. Pinprick scarring E. Epithelial tear Eyerounds.orgYou do a slit lamp examination on Vijay with a fluorescein stain , because he has been complaining of discomfort and rubbing his eyes a lot. How would you describe what you see. SBA A. Dot and blot erosion B. Dendritic pattern defect C. Punctate epithelial erosions D. Pinprick scarring E. Epithelial tear Eyerounds.org Keratitis Viral infection of cornea Tests Causes • Fluorescein stain – Slit lamp exam Symptoms • Corneal scraping • Cytology MCS+PCR (viral) • Hx contact lenses – pseudomonas • FBC • Painful red eye aeruginosa • HIV test • Photophobia • Acanthamoeba – soil / contam water • Decrease VA • Eye trauma • Small pupil • Conjunctivitis Herpes simplex Keratits • Bacterial (strep/staph/pseudomonas) • Discharge ( watery or • Herpes Simplex webeye.ophth.uiowa.edu Pus) • Dendritic branching • Epithelial defect Management • Corneal clouding • Topical Anti-viral (Acyclovir) or Chloramphenicol Endophthalmitis Viral infection of cornea Tests • Slit Lamp Examination : Hypopyon Causes Symptoms (pus layer) • Full infection screen (FBC , ESR. • Endogenous (endocarditis) Viral culture • Painful red eye • Exogenous(cataract surgery / • Sudden decrease in VA • Conjunctival infection Intravitreal injection) Hypopyon • PmHx of ocular surgery • Infection and trauma • Hypopyon • Corneal oedema Management - Intravitreal injection of Abx - Biopsy of vitreous for culture - VitrectomyZee tells you that he is waiting for surgery for his glaucoma that made him feel sick and his eyes red. He is hypermetropic. (he can’t remember which type , but he tells you the name of the drug that he is using in the mean time that also makes his pupils ‘small’– what medication is he using and what type of Glaucoma does he have? SBA A - pilocarpine – open angle glaucoma B - pilocarpine – closed angle glaucoma C- timolol – closed angle Glaucoma D- Timolol – open angle Glaucoma E - tropicamide – closed angle GlaucomaZee tells you that he is waiting for surgery for his glaucoma that made him feel sick and his eyes red he is hypermetropic . IT had come on acutely and his Visual Acuity had been affected. (he can’t remember which type , but he tells you the name of the drug that he is using in the mean time that also makes his pupils ‘small’– what medication is he using and what type of Glaucoma does he have? SBA A - pilocarpine – open angle glaucoma B - pilocarpine – closed angle glaucoma C- timolol – closed angle Glaucoma D- Timolol – open angle Glaucoma E - tropicamide – closed angle Glaucoma Glaucoma African , The optic nerve, which connects the Ethnicity Caribbean , Asian origin eye to the brain, becomes damaged It's usually caused by fluid building up in the front part of the eye, which RISK increases pressure inside the eye. Age FACTORS Family Hx • Risk increases • Short sightedness with age Other eye • Diabetes • 2% of people condits • Hypertension >40 • Corticosteroids Visual field / Slit lamp / Applanation Investigations Tonometry (IOP)Glaucoma Comparison Summary Source: drdigvijaysingh.com Source: Podcast Ep 10: Gout, Glaucoma, Bronchitis, Spider Bites & More - RoshReview.com Primary Open Angle Glaucoma • Peripheral vision field loss – Nasal Scotoma to Tunnel vision • Decreased Visual Acuity Management Source:DrLaltanpuiaChhangte Fundoscopy second 1. Optic disc cupping - cup-to-disc ratio >0.7 (normal = 0.4-0.7), occurs as loss of disc substance makes line: optic cup widen and deepen first line: if more advanced: 2. Optic disc pallor - indicating optic atrophy prostaglandin blocker(timolol), 3. Bayonetting of vessels - vessels have breaks as analogue (PGA) Selective laser they disappear into the deep cup and re-appear at eyedrops (e.g. - carbonic trabeculoplasty the base latanoprost) a(e.g. dorzolamide) (POAG) 4. Additional features - Cup notching (usually inferior - sympathomimetic where vessels enter disc), Disc haemorrhages brimonidine) Glaucoma DRUGS Medication Type Examples MOA Key stuff to remember Prostaglandin analogue Latanoprost Increases Uveoscleral - Give OD outflow - Brown pigmentation of Iris , increased eyelash length Beta Blocker Timolol , betaxolol Reduces aqueous - Avoid in Asthmatics and production heart block Sympathomimetics ( alpha Brimonidine - Reduces aqueous - Hyperaemia 2 adrenoreceptor agonist) production - Avoid if taking MAOI or - Increases Uveoscleral TCA outflow Carbonic anhydrase Dorzolamide Reduces aqueous - sulphonamide reaction inhibitor production Miotics (muscarinic Pilocarpine Increase Uveoscleral outflow - Miotic pupil , headache, receptor antagonist) blurred vision. Primary Acute (closed ) angle Glaucoma Features Management • severe pain: may be ocular or headache • decreased visual acuity urgent referral to an ophthalmologist • symptoms worse with mydriasis (e.g. watching TV in a - Reducing aqueous dark room) secretions with IV • hard, red-eye acetazolamide • haloes around lights - inducing pupillary • semi-dilated non-reacting pupil constriction with topical • corneal oedema results in dull pilocarpine + timolol or hazy cornea • systemic upset may be seen, - Laser eye surgery Peripheral Iridotomy (PACG) such as nausea and vomiting and even abdominal painShama is a 45 year old female with a history of type 2 diabetes, who presents for a SBA routine eye check at her optician. Fundoscopy produces the following image, and the optician refers her to ophthalmology. What stage is her condition: What stage is her condition? A. Proliferative diabetic retinopathy B. severe Pre proliferative diabetic retinopathy C. Pre proliferative maculopathy D. mild pre proliferative retinopathy E. Moderate pre proliferative retinopathyShama is a 45 year old female with a history of type 2 diabetes, who presents for a SBA routine eye check at her optician. Fundoscopy produces the following image, and the optician refers her to ophthalmology. What stage is her condition: What stage is her condition? A. Proliferative diabetic retinopathy B. severe Pre proliferative diabetic retinopathy C. Pre proliferative maculopathy D. mild pre proliferative retinopathy E. Moderate pre proliferative retinopathy Diabetic Retinopathy Clinical picture Management Changes noted on retina often during routine screening prior to symptoms. High–risk proliferative retinopathy should be Visual Loss (maculopathy) treated with photocoagulation to reduce risk of severe visual loss Vitreous Haemorrhage (severe visual loss) No interventions for mild-moderate diabetic retinopathy, monitor annually and maintain good control CAUSE : Pre-proliferative to be monitored at 4-6 Small vessel occlusion monthly with peripheral scatter laser treatment as proliferative stage approaches! Ischaemic retina VEGF – Proliferation of new vessels Micro Aneurysm Intra retinal Hard Exudate Haemorrhage Localised capillary dilation – small red Within nerve fibre layer – follows divergence of axons Yellow white intra retinal deposits dots in clusters or alone Dot or Blot shaped or flame shaped Sources : glycosmedia.com Cotton Wool Spots Venous Abnormality Neovascularisation Greyish white patches in nerve fibre Venous dilation , beading , Proliferation of New Vessels as retina layer – Local ischaemia duplication (IRMA) becomes more iscahemic Diabetic Retinopathy Mild >1 Microaneurysms : Non Proliferative Microaneurysms + blot haemorrhage + Moderate Hard exudate + cotton wool spots + : Non Proliferative sometimes IRMA Blot Haemorrhages and Severe : Non microaneurysms in 4 Quadrants Proliferative Venous bleeding in at least 2 Quads IRMA in at least 1 Quad Source : passmedicine.com Proliferative NeovascularisationMahdi is a 65 year old male who rarely visits the hospital. He notes that his vision is ‘not normal’ and had been deteriorating over time. He has a BP of 150/95. on fundoscopy you see the following. What grade is his condition? A. I B. II C. III D. IV E. V pathguy.comMahdi is a 65 year old male who rarely visits the hospital. He notes that his vision is ‘not normal’ and had been deteriorating over time. He has a BP of 150/95. on fundoscopy you see the following. What grade is his condition? A. I B. II C. III D. IV E. V pathguy.comHypertensive Retinopathy – Keith Wagner staging Arteriolar narrowing and tortuosity – I increased light reflex – silver wiring Arteriovenous nipping II III Cotton wool exudates Flame and blot Haemorrhages IV Papilledema Papilledema Optic Disk swelling due to raised intracranial pressure Causes Features •venous engorgement •loss of venous pulsation: •space-occupying lesion: •blurring of the optic disc neoplastic, vascular margin •malignant hypertension •elevation of optic disc •loss of the optic cup •idiopathic intracranial •Paton's lines: concentric/radial hypertension retinal lines cascading from the Jonathan Trobe, M.D. - University of •hydrocephalus optic disc Michigan Kellogg Eye Center •hypercapnia MANAGE 2. Acetazolamide OR Topiramate short term (weight loss) 3. Repeated Lumbar PunctureA 70 year old man , Jeremy , is investigated for blurred vision. Fundoscopy reveals 70-year-old man is investigated for blurred vision. Fundoscopy reveals drusen, retinal epithelial and macular neovascularisation. An Amsler Grid test is +ve What is the most appropriate next investigation? SBA A. Vitreous fluid sampling B. MRI orbits C. Ocular tonometry D. Fluorescein angiography E. Slit-lamp examinationA 70 year old man , Jeremy , is investigated for blurred vision. Fundoscopy reveals 70-year-old man is investigated for blurred vision. Fundoscopy reveals drusen, retinal epithelial and macular neovascularisation. An Amsler Grid test is +ve What is the most appropriate next investigation? SBA A. Vitreous fluid sampling B. MRI orbits C. Ocular tonometry D. Fluorescein angiography E. Slit-lamp examination Age Related Macular Degeneration AGE risk > 65 Features Investigations x3 >75 ▪ Slit lamp ▪ Subacute onset of PmHx. visual Loss microscopy Hypertension, RISK Smoking ▪ Colour fundus d, DiabetesiaFACTORS ▪ Reduction in Visual photography Acuity ▪ Fluorescein ▪ Reduced night vision angiography FHxily ▪ fluctuation x4 = 1 ▪ Photopsia (flickering/ ▪ Ocular coherence degree tomography (OCT) relatives flashing lights & glare ▪ Amsler Grid Wet Vs Dry Macular Degeneration WET (neovascular) 10% DRY (atrophic) 90% ▪ Choroidal neovascularisation ▪ Drusen-Yellow spot around Burch’s ▪ Rapid loss of vision caused by blood & membrane serous fluid /oedema . RPE detachment Wet Vs Dry Macular Degeneration WET (neovascular) 10% DRY (atrophic) 90% Management Anti- VEGF (vascular endothelial growth factor) Smoking cessation / education/ reading e.g. ranibizumab aids /diet 4 weekly injection Laser Photocoagulation can be used but has Zinc + Vitamins A, C , E reduced a risk of acute visual loss progression of disease by 1/3 Photodynamic therapy - IV dye thromboses subretinal neovascA 70 year old woman , Zara has come in with Reduced vision , faded colour vision and halos, as well as glaring lights. Since you find it easy to use an ophthalmoscope you confidently look for the red reflex , which is defective. What condition do you suspect A Macular degeneration B Glaucoma C Cataract D diabetic retinopathy E Herpes zoster ophthalmicusA 70 year old woman , Zara has come in with Reduced vision , faded colour vision and halos, as well as glaring lights. Since you find it easy to use an ophthalmoscope you confidently look for the red reflex , which is defective. What condition do you suspect A Macular degeneration B Glaucoma C Cataract D diabetic retinopathy E Herpes zoster ophthalmicusA 30 year old female , Rie, from Japan recently gave birth to a boy in the whilst on holiday in the UK. She recalls having a vaccination 15 days before her pregnancy was confirmed but she is unable to remember the name of the condition. The baby was born with skin lesions and a low birth weight. Further tests suggest sensorineural deafness, bilateral cataracts, patent ductus arteriosus, salt and pepper retinopathy. What condition does the child potentially have? A cytomegalovirus B congenital rubella syndrome C Cri du chat syndrome D Trisomy 21 https://doi.org/10.1016/S1473- 3099(09)70141-0 E Hallermann–Streiff syndrome Michigan Kellogg Eye Centref Cataract Age Related opacification of the lens – Trauma Wilson’s disease Diabetes most common cause of visual mellitus impairment Build up of opacity on the crystalline Drug induced AGE (but Hypocalcaemia lens congenital) dystrophy Radiation Smalcohol Cataract Features Management •Conservative management ▪ Reduced Vision ▪ Faded colour vision • prescribing stronger ▪ Glare ( lights appear glasses/contact lens •encouraging the use of brighter ) brighter lighting ▪ Halos around lights Surgery eventually needed - Investigations only effective treatment ▪ Red reflex defect - light small-incision extracapsular orphacoemulsification doesn’t reach retina cataract extraction with ▪ Slit lamp exam insertion of an intraocular lens Cataract • Nuclear: change lens refractive index, common in old age • Polar: localized, commonly inherited, lie in the visual axis • Subcapsular : due to the lens capsule, inep the visual axis • Din normal lenses, also seen in diabetes and myotonic dystrophy • Cortical : forms in shell layer of lens aka cortex Source : passmedicine.comAn 84-year-old man, Phillip, presents with loss of vision in his left eye since the morning. He is otherwise asymptomatic and has had no associated eye pain or headaches. His past medical history includes ischaemic heart disease but he is otherwise well. On examination he reaction is normal. Fundoscopy reveals a red spot over a pale and opaque retina. What is theght most likely diagnosis? A Vitreous Hamorrhage B Retinal detachment C Ischaemic optic neuropathy D CRVA E CRAOAn 84-year-old man, Phillip, presents with loss of vision in his left eye since the morning. He is otherwise asymptomatic and has had no associated eye pain or headaches. His past medical history includes ischaemic heart disease but he is otherwise well. On examination he reaction is normal. Fundoscopy reveals a red spot over a pale and opaque retina. What is theght most likely diagnosis? A Vitreous Hamorrhage B Retinal detachment C Ischaemic optic neuropathy D CRVA E CRAO Acute Visual Loss Transient Painful Red Eye Acute Glaucoma TIA Optic Neuritis Acute Glaucoma Unilateral Bilateral RAPD CRAO Optic Neuritis CRVO ION TIA CRAO Retinal detachment CRVO Acute Glaucoma Optic Neuritis Retinal Detachment Trans Ischaemic Attack Amaurosis Fugax: transient loss of vision due compromised blood flow to the retina •Sudden onset, homonymous visual field loss, painless, other neurological Symptoms symptoms •lasts between 15 seconds to several minutes •hypertension, peripheral vascular disease, diabetes, and hyperlipidaemia •Note may amaurosis fugax may be due to inflammatory conditions: CGA, SLE, Risk Factors MS Management •Refer to stroke team manage as TIA CRVO & CRAO Central Retinal Vein Occlusion Central Retinal Artery Occlusion Symptoms Acute Monocular Painless Central Vision Loss Acute monocular Painless Central Vision loss RAPD RAPD Fundoscopy Cherry Red Spot Severe Retinal Haemorrhage – stormy Sunset Passmedicine.com Management CRAO | Wills Eye Hospital Stroke team assessment If Macular Oedema + Prophylactic Aspirin Neovasc 1 line = VEGF If Carotid Stenosis – endarterectomy Retinal Detachment Presentation Management •Visual field loss progressing towards centre •Emergency--> Immediate surgical •History: ‘dark curtain’, flashes, floaters consultation to avoid permanent vision loss if the central retina is •RAPD not yet detached drdigvijaysingh.com •Loss of red reflex •Pale retinal folds /wrinkled Risk Trauma / Age / Cataract surgery/ FmHx/ Myopia Vitreous Haemorrhage Presentation •Sudden onset of floaters followed by diffuse vision loss •Monocular, painless American Academy of Ophthalmology History •Associated with retinal neovascularisation (diabetic retinopathy 50%), trauma Management •Blood slowly clears from vitreous •If retinal break cryotherapy or laser photocoagulation •Treat neovascularisation (laser + anti- VEGF) A 66-year-old woman, Mumtaz, presents to the emergency department with painless visual loss in her left eye. Her vision suddenly disappeared in the left eye 2 hours ago whilst she was poorly controlled diabetes mellitus and proliferative diabetic retinopathy. Over the past month she has noticed the appearance of cobwebs partially obscuring her vision in the left eye. On examination visual acuity is 6/12 in the right eye and there is complete visual loss in the left eye. What is the most likely diagnosis? A Acute closed angle glaucoma B Amaurosis fugax C CRAO D Retinal Detachment E Vitreous Haemorrhage A 66-year-old woman, Mumtaz, presents to the emergency department with painless visual loss in her left eye. Her vision suddenly disappeared in the left eye 2 hours ago whilst she was poorly controlled diabetes mellitus and proliferative diabetic retinopathy. Over the past month she has noticed the appearance of cobwebs partially obscuring her vision in the left eye. On examination visual acuity is 6/12 in the right eye and there is complete visual loss in the left eye. What is the most likely diagnosis? A Acute closed angle glaucoma B Amaurosis fugax C CRAO D Retinal Detachment E Vitreous HaemorrhageAyan is a 25 year old male who has a sudden decrease in VA (visual acuity since this morning when he woke up from his left eye. He complains of pain when moving his eye . On examination you observe RAPD, Optic disk swelling and a central scotoma. He was diagnosed with Multiple sclerosis 5 months ago. What is the most likely diagnosis? A Ischaemic Optic Neuropathy B Retinal detachment C Optic Neuritis D granulomatosis with polyangiitis E Vitreous HaemorrhageAyan is a 25 year old male who has a sudden decrease in VA (visual acuity since this morning when he woke up from his left eye. He complains of pain when moving his eye . On examination you observe RAPD, Optic disk swelling and a central scotoma. He was diagnosed with Multiple sclerosis 5 months ago. What is the most likely diagnosis? A Ischaemic Optic Neuropathy B Retinal detachment C Optic Neuritis D granulomatosis with polyangiitis E Vitreous Haemorrhage Optic Neuritis Causes Presentation Multiple Sclerosis Diabetes , Syphilis •Unilateral decrease in visual acuity (hours to days), central scotoma •Colour vision affected ‘red desaturation’ •Pain worse on eye movement •RAPD, optic disc swelling, Central Scotoma Management • High dose steroids (methylprednisolone) healthjade.com Ischaemic Optic Neuropathy / GCA Presentation Investigation •Sudden, monocular visual loss, age >60 years •Systemic symptoms: unilateral headache, scalp • Elevated ESR>50 /CRP elevated tenderness, jaw claudication, proximal muscle • temporal artery biopsy (note skip lesions) weakness • Normal CCK and EMG •RAPD, swollen optic disc, cotton wool spots Management Causes • Urgent high dose glucocorticoids BEFORE biopsy • Affects aorta and large branches – external • high dose prednisolone (IV 1g carotid arteries methylprednisolone), same day referral to • Associated with Polymyalgia Rheumatica ophthalmology • Sometimes low dose asprin given Herpes Zoster Ophthalmicus Herpes zoster ophthalmicus (HZO) describes the reactivation of the varicella-zoster virus in the area supplied by the ophthalmic division of the trigeminal nerve. It accounts for around 10% of case of shingles. Symptoms Management Oral antiviral treatment for 7-10 days • Vesicular Rash around eye • ideally started within 72 hours • intravenous antivirals may be given for • Hutchinson’s sign – rash very severe infection or if the patient is immunocompromised on tip of nose • topical antiviral treatment is not given in HZO Hutchinson's sign nose and nail •topical corticosteroids may be used to treat any (healthjade.net) secondary inflammation of the eye •ocular involvement requires urgent ophthalmology review Pre septal/Periorbital & Orbital Cellulitis Pre septal : infection of soft tissues anterior to septum (eyelid, skin , subcut face (not orbit content) Orbital : infection of fat and muscle posterior to orbital septum (not globe) Symptoms Investigation Management PRESEPTAL red, swollen, painful eye - Secondary Care of acute onset. They are FBC ,WCC referral likely to have symptoms Examination associated with fever. CT with CONTRAST - Oral antibiotics Blood culture (staph aureus ( co-amoxiclav) •Redness and swelling - Children may around the eye ,staph epidermis , strep) require •Severe ocular pain admission ORBITAL •Visual disturbance •Proptosis FBC ,WCC with eye movementsain Examination •Eyelid oedema and ptosis CT with CONTRAST - Admission for •Drowsiness +/- Nausea/vomiting in Blood culture broad spectrum meningeal involvement (streptococcus , staph IV abx (Rare) aureus , HiB)Source: passmedicine.comAnam a 70 year old women has recently had an infarct in the right parietal lobe. What is the visual field defect would be seen in this patient? A. Left Superior Quadrantanopia B. Right Superior Quadrantanopia C. Left Inferior Quadrantanopia D. Right Superior Quadrantanopia E. Bitemporal HemianopiaAnam a 70 year old women has recently had an infarct in the right parietal lobe. What is the visual field defect would be seen in this patient? A. Left Superior Quadrantanopia B. Right Superior Quadrantanopia C. Left Inferior Quadrantanopia D. Right Superior Quadrantanopia E. Bitemporal HemianopiaVisual Pathways forum.facmedicine.comVisual Pathways step1.medbullets.com Innervation of eye Nerve Muscle Action CN3 (Oculomotor) SR, IR,MR, IO All of them do what their names say IO- upwards and outwards CN 4 (Trochlear) SO Downwards and outwards CN 6 (Abducens) LR AbductionHuda a 6o year old suffered a thunderclap headache and visited her local emergency department. On examination, the junior doctor found a down and out eye and ptosis. What is the other finding on examination that he will elicit? A. Mydriasis B. Irregular pupil C. Blurred vision D. Miosis E. hyperhidrosisHuda a 6o year old suffered a thunderclap headache and visited her local emergency department. On examination, the junior doctor found a down and out eye and ptosis. What is the other finding on examination that he will elicit? A. Mydriasis B. Irregular pupil C. Blurred vision D. Miosis E. hyperhidrosis PALSY https://fpnotebook.com/neuro/anatomy/CrnlNrv6.htm Cheat sheet 1. Anterior uveitis- HLA b27 conditions/autoimmune. Also irregular shape of pupil due to post synechiae 2. Episcleritis vs scleritis- not painful vs painful and phenylephrine blanches the conjunctival and episcleral vessels 3. Glaucoma- acute - Sudden onset N+V, intense eye pain, Hx of exposure to dark. 4. Cataract- glare around object particularly at night 5. Keratitis- contact lens use? Think pseudomonas 6. Dry AMD- drusen 7. CN3 palsy- down and out eye 8. Sudden onset visual loss- Think CRAO- cherry red spot 9. Sudden onset blurring vision with diabetic/ CVD hx – think CRVO- Haemorrhage in quadrants 10. Sudden onset flashers/ floaters- vitreous/ retinal detachment (100s) 11. R.D- curtain in visual field 12. Blepharitis- Sticky eyes, might also have HX of itchy scalp (Seborrheic dermatitis) FEEDBACK FORM Thank you! FEEDBACK FORM for Slides Go and ACE! and Recordings Those exams.