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OPHTHALMOLOGY PAUL CALLEJALearning Objectives • Understand the anatomy of the anterior chamber, including the production, flow, and drainage of aqueous humour, as well as neurovascular supply to anterior eye structures. • Introduce a clinical framework for approaching eye pathologies, focusing on pattern recognition and systematic assessment. • Differentiate between important and emergency ophthalmic conditions, highlighting key features, investigations, and management.Anatomical Divisions of the Eye External Eye Orbit • Eyelids • Orbital Bones • Eyelashes • Extraocular Muscles • Conjunctiva • Orbital Fat • Orbital Septum Lacrimal • Lacrimal Apparatus Gland • Optic Nerve (CN II) Anterior Segment Posterior Segment • Cornea • Vitreous Body • Anterior Chamber • Posterior Chamber Iris • Retina • Pupil • Macula • Lens • Fovea • Ciliary Body • Optic Disc • Trabecular Meshwork • Optic Nerve • Choroid • Schlemm’s Canal • ScleraEyeball Anatomy (layers) Retina Foveaa Optic Disc Retinal Arteries Retinal Veins Uvea Choroid Ciliary body Iris ScleraAnterior Segment AnatomyClinical Framework Lacrimal Eyelashes Glands Swelling Eyelid Conjunctiva External Vision Lesions Orbital Eye Septa Cornea Orbital Anterior Fat Chamber Anatomical Anterior Pain Presenting Discharg Orbit Structure Segment Complaint e Extraocul ar Lens Muscles Orbital Trabecular Bones Posterior Meshwork Segment Pupil Dryness Retinal Retina Vein Red Eye Retinal Optic Artery NerveQuestion 1 A 72-year-old woman presents to the Emergency Department with sudden onset severe right eye pain, nausea, and vomiting. Examination reveals a red eye with a mid-dilated, fixed pupil and a cloudy cornea. Visual acuity is reduced. Which of the following is the most appropriate initial management? A. Oral Prednisolone B. IV Acetazolamide C. Intravitreal Anti-VEGF D. Lubricating Eye Drops E. Cycloplegics Correct Answer: B. Oral AcetazolamideImportant Differentials 1 • Pain • Severe Eye Pain • Photophobia • Blurred Vision • Blurred Vision • Headache • Redness • Redness • Small, irregular pupil • Mid-dilated, fixed pupil • Cloudy Cornea Anterior Uveitis Acute Angle-Closure Glaucoma (ACAG) Description Inflammation of the anterior uveal tract (iris andSudden rise in intraocular pressure (IOP) due ciliary body). to blocked aqueous drainage. Breakdown of blood-ocular barrier causing Mechanical obstruction of trabecular meshwork Pathophysiology immune-mediated inflammation. by the peripheral iris. Idiopathic, autoimmune (HLA-B27 related), Hypermetropia, age, medications, family Causes trauma, infections. history, Asian ethnicity. Investigations Slit-lamp exam: cells and flare, hypopyon Tonometry: High IOP (>30 mmHg), possible. Gonioscopy: Closed angle. Topical steroids (e.g., prednisolone), Management (NICE/RCOpth) cycloplegics (e.g., cyclopentolate, atropine), Acetazolamide, pilocarpine, timolol, laser ophthalmology referral. iridotomy, urgent referral to ophthalmology. Complications Posterior synechiae, cataract, glaucoma, cystoid Optic nerve damage, permanent vision loss, macular oedema, vision loss. chronic glaucoma. Referral Requirement Ophthalmology referral always required. Emergency referral to ophthalmology.Question 2 A 45-year-old woman with a history of rheumatoid arthritis presents with severe eye pain, worse on eye movements, radiating to her jaw. Examination reveals redness with a bluish hue and reduced visual acuity. What is the most likely diagnosis? A. Episcleritis B. Blepharitis C. Scleritis D. Conjunctivitis E. Keratitis Correct Answer: C. ScleritisImportant Differentials 2 • Severe pain • Redness • Mild discomfort • Redness • Photophobia • No vision loss • Tearing • Decreased vision • No pain or tenderness (mild • Eye tenderness irritation only) Scleritis Episcleritis Inflammation of the sclera, often Description associated with systemic autoimmune Benign, self-limiting inflammation of the diseases. episcleral layer, usually idiopathic. Pathophysiology Immune-mediated inflammation involving Non-granulomatous inflammation of deep scleral vessels and tissues. superficial episcleral vessels. Autoimmune conditions (RA, SLE), Idiopathic, occasionally linked to systemic Causes infections, trauma. conditions. NSAIDs, steroids (oral or topical), Lubricants, NSAIDs, topical steroids if Management (NICE/RCOpth) immunosuppressants if severe. symptomatic and persistent, usually resolves spontaneously. Complications Vision loss, scleral thinning, globe Rare; generally self-limiting. perforation, secondary glaucoma. Always requires referral to Referral Requirement ophthalmology. Referral only if persistent or recurrent.Question 3 A 32-year-old man presents following blunt trauma to the right eye. He complains of pain, blurred vision, and reduced eye movement. Examination reveals proptosis, reduced visual acuity, and a positive RAPD. What is the most appropriate immediate management? A. Observation B. Topical Lubricants C. Lateral Canthotomy and cantholysis D. Oral Antibiotics E. Intravitreal Steroids Correct Answer: C. Lateral CanthotomyImportant Differentials 3 • Severe Pain • Painless • Proptosis • Red patch on sclera • Restricted eye • Normal vision movements • Reduced vision • RAPD Subconjunctival Haemorrhage RetrobulbarHaemorrhage Description Bleeding undertheconjunctiva. Bleeding within theorbit, causing compression of optic nerve. Increasedorbital pressurefrom blood Pathophysiology Ruptureof conjunctival bloodvessels. accumulation. Causes Trauma, coughing, anticoagulantuse, Trauma, surgery, orbital fractures. idiopathic. Painless, bright redpatch on sclera, normSeverepain, proptosis, restricted eye Presentation vision. movements, decreasedvision, RAPD. Conservative; reassurance; resolves in 1-2mergency decompression (lateral Management (NICE/RCOpth) weeks. canthotomy with cantholysis), imaging, urgentreferral. Permanentvision loss, optic nerveatrophy, Complications Rare; generally harmless. globe rupture. Referral Requirement Not usually required unless recurrent. Always requires immediate referral to ophthalmology.Question 4 A 10-year-old child presents with right-sided periorbital swelling, pain, and fever following a recent upper respiratory tract infection. Examination reveals proptosis, reduced eye movements, and decreased vision. What is the most appropriate next step? A. Oral Antibiotics B. Warm Compresses C. Urgent CT Scan D. Topical Steroids E. Artificial Tears Correct Answer: C. Urgent CT ScanImportant Differentials 4 • Eyelid swelling • Eyelid swelling • Redness • Pain • Pain • Proptosis • No proptosis • Restricted movements • Normal eye movements • Decreased vision • No vision loss • Fever Preseptal Cellulitis Orbital Cellulitis Infection of tissues anterior to the orbitalInfection of tissues posterior to the orbital Description septum; commonly following trauma, insect septum, often secondary to sinusitis or bites, or sinusitis. trauma. Localised infection not involving the globe orread of infection to orbital tissues, Pathophysiology optic nerve. potentially affecting the optic nerve and ocular muscles. Sinusitis (especially ethmoid), trauma, post- Causes Trauma, insect bites, sinusitis, skin infectsurgical, dental infection. IV antibiotics: Ceftriaxone + Metronidazole. Management Oral antibiotics: Co-amoxiclav. Surgical drainage if abscess present. Urgent (NICE/RCOpth) Monitor for progression to orbital cellulitiENT opinion Complications Rare; can progress to orbital cellulitis if Cavernous sinus thrombosis, meningitis, untreated. permanent vision loss. Referral Requirement Only if symptoms worsen or do not improve Emergency referral to ophthalmology and with treatment. Most kids require review. ENT.Question 5 A 65-year-old man presents with sudden, painless loss of vision in his left eye. Fundoscopy reveals a pale retina with a cherry-red spot at the macula. What is the most likely diagnosis? A. Retinal Detachment B. Central Retinal Vein Occlusion C. Central Retinal Artery Occlusion D. Diabetic Retinopathy E. Optic Neuritis Correct Answer: C. Central Retinal Artery Occlusion Important Differentials 5 • Sudden, painless, vision loss • Sudden, painless, vision loss • Blurred or reduced visual acuity • Severely reduced visual acuity • Visual field defect (partial or diffuse) • RAPD • Visual field defect (central or diffuse) • Mild pain • Fundoscopy Findings: • Fundoscopy Findings: • Dilated, tortuous retinal veins • Pale retina • Widespread retinal haemorrhages • Cherry-red spot at the macula • Narrowed retinal arteries • Cotton wool spots • Retinal oedema • Macular oedema • Optic disc swelling (if severe) Central Retinal ArteryOcclusion(CRAO) Central Retinal VeinOcclusion(CRVO) Suddenblockageofthecentral retinal artery, Blockageofthecentral retinal vein, leading to Description causing ischemia totheretina. venous congestionand retinal haemorrhages. Embolismor thrombosis ofcentral retinal Thrombosis ofthecentral retinal vein; Pathophysiology artery; oftenrelated toatherosclerosis or associated withhypertension, diabetes, carotid arterydisease. hyperlipidaemia. Causes Atherosclerosis, emboli(e.g., carotid plaque, Hypertension, diabetes, hyperlipidaemia, cardiacthrombus), giant cell arteritis. glaucoma, coagulopathies. Emergencyreferral to ophthalmology; Management paracentesis, ocular massage, carbogen Referral to ophthalmology; treat underlying (NICE/RCOpth) inhalation, reducing IOP, thrombolysis inselect cause, intravitreal anti-VEGF(e.g., cases. ranibizumab), laser photocoagulationifneeded. Complications Permanent visionloss, neovascularisation, Neovascular glaucoma, macular oedema, neovascular glaucoma. permanent visionloss. Immediateemergencyreferral to Referral Requirement ophthalmology. Urgentreferral to ophthalmology.