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MENTI CODE 5610 4190 Michael Song ms2521@ic.ac.uk OPHTHALMOLOGY A MedED LECTURE S l i d e s r e f e r e n c e : L a u r e n H i n eSESSION STRUCTURE Conditions Presentations • Acute change / loss of vision • Cataracts • Glaucoma (open / closed) • Diplopia • Conjunctivitis • Ptosis • Uveitis (Anterior / posterior) • Red eye • Cellulitis (periorbital / orbital) • Visual Hallucination • Scleritis • Optic neuritis • Visual field defects J o i n M e n t i 5 61 0 4 1 90 Eye Anatomy https://www.mastereyeassociates.com/eye-anatomyIn practiceVISION LOSSS Orbital/Preorbital cellulitis S Angle closure glaucoma O Painful Uveitis L Optic neuritis N Giant cell arteritis I I V Retinal artery occlusion T Retinal vein occlusion U Painless Age-related macular C degeneration A Migraine* SBA 1 A 65-year-old patient presents to the emergency department with severe eye pain, nausea, vomiting, and a headache. On examination, you note a fixed, mid-dilated pupil. What is the most appropriate initial management? 1. Topical antibiotic eye drops 2. Oral acetazolamide and topical timolol 3. Observation and follow-up in 1 week 4. Immediate surgical intervention 5. anti-VEGF eye drops J o i n M e n t i 5 61 0 4 1 90 SBA 1 A 65-year-old patient presents to the emergency department with severe eye pain, nausea, vomiting, and a headache. On examination, you note a fixed, mid-dilated pupil. What is the most appropriate initial management? 1. Topical antibiotic eye drops 2. Oral acetazolamide and topical timolol 3. Observation and follow-up in 1 week 4. Immediate surgical intervention 5. anti-VEGF eye drops Angle-closure glaucoma Risk factors: CLOSE Acute, severe increase in IOP (>21mmHg) due to closure of irido- Chinese corneal angle preventing outflow of aqueous humour. EMERGENCY – optic nerve Long-sighted damage Old age Shallow anterior chamber Tonometry Ethnicity (East Asian) Gonioscopy + diabetes, COPD, HTN. Anticholinergics, TCAs UNILATERAL ▪ Halos around Female ▪ Mid-dilated lights pupil ▪ Red eye http://eyerounds.org/books/glaucoma_guide/chapter9.html#gsc.tab=0 ▪ Severe eye ▪ Triggered by: pain dim lighting, ▪ Blurry vision dark room IMMEDIATE HOSPITAL ADMISSION + referral to ophthalmologist ▪ Reduced visual Surgical Medical acuity ✶ Acetazolamide +/- timolol (BB) ✶ Peripheral laser iridotomy ▪ Headache + ✶ Pilocarpine ✶ Trabeculectomy if medical Mx fails N&V ✶ IV mannitol if unsuccessful Open-angle Glaucoma OPEN ANGLE GLAUCOMA = CHRONIC GLAUCOMA Raised intraocular pressure causing optic nerve damage (>21mmHg) Wide anterior angle (open) allows aqueous e↓try but drainage → net gain of fl↑IOP→ Risk factors: ↑IOP ▪ Myopia (short-sightedness) ▪ Age >65 ▪ FHx ▪ African-Caribbean ethnicity ▪ HTN ▪ T2DM (secondary glaucoma) OA Glaucoma • BILATERAL • Asymptomatic until significant damage to nerve IOP by tonometer >21mmHg • Halos around lights Fundoscopy: increased cup:disc ratio (cupping) • Peripheral visual field loss Gonioscopy (open) • nasal scotoma progressing to tunnel vision 1. Laser trabeculoplasty • Decrease visual acuity 2. Prostaglandin analogues, e.g. latanoprost 3. Other eye drops: timolol, acetazolamide, brimonidine • Optic disc cupping 4. Surgical trabeculectomy SBA 2 A 78-year-old patient presents to A&E following a fall at home. They claim their vision ‘is not what it was’ and that at nighttime they can barely see in front of them. What are night vision issues most suggestive of? 1. Chronic glaucoma 2. Cataracts 3. Retinal detachment 4. Central retinal vein occlusion 5. Age-related macular degeneration J o i n M e n t i 5 61 0 4 1 90 SBA 2 A 78-year-old patient presents to A&E following a fall at home. They claim their vision ‘is not what it was’ and that at nighttime they can barely see in front of them. What are night vision issues most suggestive of? 1. Chronic glaucoma 2. Cataracts 3. Retinal detachment 4. Central retinal vein occlusion 5. Age-related macular degeneration Cataracts Most common cause of curable blindness worldwide Denaturing of lens proteins causing cloudy opacity on/within lens Causes ▪ Age >65 ▪ Toxins: steroids, smoking ▪ Trauma: ionising radiation, UV exposure or physical ▪ Systemic disease: marfan’s, neurofibromatosis type 2 ▪ Metabolic: diabetes mellitus ▪ Maternal infection ▪ Hereditary Investigations: Symptoms History Gradual painless loss of vision + blurriness Fundoscopy Increasing myopia – changing prescriptions Slit lamp examination Faded colours IOP testing Night vision issues Treatment Signs: Dependent on impact on ADLs + Eye examination: cloudiness of lens, loss of red reflex suitability for surgery: Lens replacement surgery via Decrease in visual acuity cannot be corrected by refractive phacoemulsification correction Age-related macular degeneration Dry Wet Gradual vision loss (years) Sudden, severe vision loss (months) 90% of AMD 10% of AMD Drusen (yellow spots) Haemorrhage Above + optic disc swelling Oedema, haemorrhage, disciform (papilloedema) scarring, abnormal vessel growth Smoking cessation Smoking cessation Regular eye checks Regular eye checks Risk factors: AREDS2 formula vitamins AREDS2 formula vitamins - Smoking + Anti-VEGF injections - Age >50 - CVD: HTN, hypercholesterolaemia Ptosis Myasthenia gravis: Drooping of the upper eyelid repeated eye movements • Cosmetic effect increase ptosis • Vision impairment • Underlying cause Horner’s syndrome: loss of sympathetic supply to one side of the face/neck Causes: Triad: Ptosis, miosis, ▪ Horner’s syndrome ▪ Stroke anhidrosis ▪ 3 nerve palsy ▪ Giant cell arteritis ▪ Myasthenia gravis ▪ Tumours ▪ Thyroid eye disease ▪ Stye ▪ Orbital cellulitis ▪ Iatrogenic III, IV, VI nerve palsies Neurogenic Multiple sclerosis GBS a Thyroid eye disease p Myogenic Myasthenia Gravis l i Trauma D Orbital Orbital cellulitis Monocular CataractRED EYE Shaemorrhageval Chemical Trauma Foreign body Corneal abrasion y Conjunctivitis E Orbital/periorbital Infection Cellulitis e Blepharitis R Acute angle-closure glaucoma Uveitis Inflammation Keratitis Scleritis Episcleritis SBA 3 A 45-year-old male presents to A&E with a sore, red left eye. This suddenly started this morning, when he awoke to blurry vision. closer inspection the left pupil is fixed and constricted, withe. On widespread injection throughout the eye and no visible discharge. Which is the most likely cause of his eye pain? 1. Conjunctivitis 2. Anterior Uveitis 3. Acute angle closure glaucoma 4. Optic neuritis 5. Posterior Uveitis J o i n M e n t i 5 61 0 4 1 90 SBA 3 A 45-year-old male presents to A&E with a sore, red left eye. He is wearing sunglasses as the lights are giving him a headache.n. On closer inspection the left pupil is fixed and constricted, with widespread injection throughout the eye and no visible discharge. Which is the most likely cause of his eye pain? 1. Conjunctivitis 2. Anterior Uveitis 3. Acute angle closure glaucoma 4. Optic neuritis 5. Posterior Uveitis Uveitis: Anterior AKA iritis Inflammation of the iris and ciliary body (anterior chamber). 75% of uveitis ▪ Pain Most commonly linked to autoimmune diseases: ▪ Red eye (ciliary flush) - Rheumatoid arthritis ▪ Anisocoria - Ankylosing spondylitis (HLA-B27) ▪ Irregular and small ▪ Photophobia - SLE ▪ Blurred vision - IBD - MS - Psoriasis Idiopathic makes up around 30-50% of cases Slit lamp examination: 1. Urgent referral to ophthalmologist ▪ Cells in anterior chamber ▪ Acutely: Cycloplegics (atropine) + Prednisolone eye ▪ Keratitic precipitation drops + Mx of underlying disease + simple analgesia ▪ Injection around iris ▪ Long term: triamcinolone eye drops Uveitis: Posterior Inflammation of the choroid. 10% of uveitis ▪ Gradual onset of painless vision loss Most commonly linked to infections: ▪ No signs of anterior chamber - Toxoplasmosis inflammation (redness, pain, - Tuberculosis - Syphillis photophobia or discharge) - HSV, HZV, CMV, EBV, rubella ▪ Floaters ▪ Photopsias (flashes of light) Also linked to autoimmune pathologies: ▪ Typically younger patients - Behcet’s disease - Sarcoidosis Can lead to severe, permanent vision loss if not treated Slit lamp examination: 1. Referral to ophthalmologist ▪ Retinitis • Specialty consultation: Mx of ▪ Choroiditis underlying cause • Cycloplegics and steroid eye drops ▪ Optic nerve oedema (papilloedema) SBA 4 A 36-year-old female presents with sudden onset pain in her right eye. This is worse with eye movement, and her eye appears diffusely red. Visual acuity is 20/20 in both eyes. Her PMH includes T1DM and a recent diagnosis of rheumatoid arthritis. What is the most likely cause of her eye pain? 1. Conjunctivitis 2. Optic neuritis 3. Scleritis 4. Anterior Uveitis 5. Acute angle-closure glaucoma J o i n M e n t i 5 61 0 4 1 90 SBA 4 This is worse with eye movement, and her eye appears diffuselyght eye. red. Visual acuity is 20/20 in both eyes. Her PMH includes T1DM and a recent diagnosis of rheumatoid arthritis. What is the most likely cause of her eye pain? 1. Conjunctivitis 2. Optic neuritis 3. Scleritis 4. Anterior Uveitis 5. Acute angle-closure glaucoma Scleritis Inflammation deep into the sclera. Typically on a background of autoimmune disease: - Rheumatoid arthritis - Wegeners granulomatosis / GPA - SLE ▪ Severe eye pain ▪ Pain on palpation ▪ Redness: non-blanching, adherent Underlying cause: CRP/ESR, FBC, vessels U&Es ▪ Photophobia and watering Phenylephrine drops ▪ Decreased visual acuity ▪ Violet/blue discolouration 1. Same day ophthalmology Complications: referral ▪ Uveitis ▪ Scleral thinning/perforation 2. Oral NSAIDs (ibuprofen) ▪ Keratitis ▪ Permanent vision loss 3. High dose prednisolone ▪ Glaucoma • Treatment of underlying cause ▪ Cataracts Episcleritis Inflammation of the episcleral layer of the sclera (between sclera and conjunctiva). PAINLESS Causes: High occurrence in UC patients (2-5%) RA Idiopathic ▪ PAINLESS ▪ Mild eye redness: diffuse or Self limiting sectoral Lubricating eye drops ▪ Vessels move on palpation ▪ Irritation / grittiness ▪ Mild tenderness on palpation ▪ No visual changes SBA 5 A 9-year-old boy presents to his GP feeling unwell for the past few days. On examination, there is redness, ptosis, oedema around his eye and he has a temperature of 37.5ºC.acuity is reduced in the affected What is the most likely causative pathogen for his presentation? 1. Acanthamoeba 2. Herpes zoster virus 1 3. Adenovirus 4. Staphylococcus aureus 5. Streptococcus pneumoniae J o i n M e n t i 5 61 0 4 1 90 SBA 5 days. On examination, there is redness, ptosis, oedema around hisew right eyelid and proptosis. His visual acuity is reduced in the affected eye and he has a temperature of 37.5ºC. What is the most likely causative pathogen for his presentation? 1. Acanthamoeba 2. Herpes zoster virus 1 3. Adenovirus 4. Staphylococcus aureus 5. Streptococcus pneumoniae Orbital Cellulitis MEDICAL EMERGENCY Infection within the orbit of the eye – including the muscles and fat Usually extends from sinus infection into orbit S. Aureus + strep. pneumoniae Kids > adults Systematically unwell: fever 5Ps: 1. Eye Pain (deep/boring) 2. Proptosis +/- ophthalmoplegia 3. Periocular swelling (eyelid oedema) 4. Pupillary involvement - RAPD 5. Palsy - decreased movement due to swelling Urgent hospital admission IV antibiotics e.g.cefotaxime, clindamycinPeriorbital Cellulitis Infection within the soft tissues anterior to the orbital septum Usually from local insect bite/trauma S. Aureus + strep. pneumoniae Kids > adults ▪ Eyelid swelling ▪ Eye pain (mild) ▪ Decreased vision due to swelling ▪ Red eye Observation, consider hospital referral if high risk Oral antibiotics e.g. co-amoxiclav/clarithromycin SBA 6 A 50-year-old female presents with bilateral redness and irritation in her eyes. She reports a gritty sensation and excessive tearing. On examination, there is conjunctival injection and follicular reaction in both eyes. Visual acuity is unaffected. What is the most likely diagnosis? 1. Optic neuritis 2. Scleritis 3. Conjunctivitis 4. Anterior uveitis 5. Central retinal artery occlusion J o i n M e n t i 5 61 0 4 1 90 SBA 6 her eyes. She reports a gritty sensation and excessive tearing. Onn in examination, there is conjunctival injection and follicular reaction in both eyes. Visual acuity is unaffected. What is the most likely diagnosis? 1. Optic neuritis 2. Scleritis 3. Conjunctivitis 4. Anterior uveitis 5. Central retinal artery occlusionConjunctivitis • Acute red eye • Itching • Grittiness/foreign body feeling • Tearing Clinical diagnosis • Discharge • Visual acuity not affected Allergic Viral Bacterial Hayfever, pollen, dust Adenovirus, HSV, molluscum Staph. Aureus, strep. Pneumo, gonococcal Bilateral Unilateral or bilateral Can spread between eyes Itchy, red eyes Gritty, crusting, red Gritty, crusting, red Stringy discharge Watery discharge Purulent discharge None Lymphadenopathy + coryzal Typically none Sx Topical Antihistamines Observation, lubricant, Topical Abx: hygiene chloramphenicol/fusidic acid drops Keratitis + Blepharitis Keratitis Blepharitis Inflammation of cornea Chronic inflammation of eyelids Eye pain, blurred vision, photophobia, excessive tearing, Eye irritation, itching, crusting or flakingof foreign body sensation, red eye eyelids/eyelashes in morning, redness Bacterial (s.aureus, strep. Pseudomonas) viral (HSV), Seborrheic dermatitis, rosacea, eczema, allergies fungal or acanthamoeba (most serious) Contact lens use, dry eyes, poor contact lens hygiene Age >50, poor hygiene, dermatological diseases Slit lamp assessment Slit lamp examination Fluorescin staining: dendritic corneal ulcer in herpetic Antibiotic eyedrops Eyelid hygiene, Mx underlying disease, artificial tears Herpetic: urgent assessment by ophthalmology Corneal abrasions, perforation, vision loss Styes, conjunctivitis, chalazia (meibomian cyst), potential vision loss Haemorrhages Retrobulbar Subconjunctival Aetiology Blood poolsBEHIND eyeball Blood poolsunder CONJUNCTIVA Risk factors Anaesthetic injections Post-surgery Trauma / Anticoagulant use perforations Trauma Valsalva manouvres (coughing/vomiting – esp in kids) Spontaneous Symptoms Excruciatingly painful Asymptomatic, harmless Significant reduction in visual acuity Proptosis Reduced eye movements Increased IOP Mx CT scan + lateral cantholysis Reassure, resolution in >2wkEYE PAIN eye movementsy Optic neuritis Blepharitis Dry eye N itchy, gritty Conjunctivitis I Allergy A Thyroid eye disease P GCA Periocular Migraine E Orbital cellulitis Y Uveitis E Scleritis Sharp severe Keratitis Acute angle-closure glaucoma Corneal abrasion eye movementsy Optic neuritis Blepharitis Dry eye N itchy, gritty Conjunctivitis I Allergy A Thyroid eye disease P GCA Periocular Migraine E Orbital cellulitis Y Uveitis E Scleritis Sharp severe Keratitis Acute angle-closure glaucoma Corneal abrasion SBA 7 A 30-year-old male complains of sudden vision loss in his right eye. He describes pain with eye movement and visual disturbances. On relative afferent pupillary defect is noted. Fundoscopy reveals optic disc swelling. What is the most likely diagnosis? 1. Optic neuritis 2. Scleritis 3. Conjunctivitis 4. Anterior uveitis 5. Acute angle-closure glaucoma J o i n M e n t i 5 61 0 4 1 90 SBA 7 He describes pain with eye movement and visual disturbances. On eye. examination, there is decreased visual acuity in the right eye, and a relative afferent pupillary defect is noted. Fundoscopy reveals optic disc swelling. What is the most likely diagnosis? 1. Optic neuritis 2. Scleritis 3. Conjunctivitis 4. Anterior uveitis 5. Acute angle-closure glaucomaOptic neuritis Inflammation of optic nerve Common in females 20-40 years Causes - Demyelination (MS) - Diabetes - Idiopathic - Infectious (syphilis) - SLE/sarcoidosis MRI of optic nerve/orbits - GCA (ischaemia) FBC, ESR, CRP (inflammation markers) UNILATERAL 1. Red colour desaturation 2. Ophthalmoplegia ROD 3. Decrease in visual acuity Immediate: High dose IV methylprednisolone ▪ RAPD Oral prednisolone week after ▪ Central scotoma ▪ Blurry visionMISC/NICHE Lewy Body Dementiae Neurological Migraine s Epilepsy n l t Schizophrenia u n Psychiatric Mood disorders i c V l Ocular Macular degeneration a H Delirium Systemic Narcolepsy Substance use SBA 8 A 58-year-old man presents to the GP having suddenly lost vision in his left eye. He reports no pain, with only the left eye affected. He normally uses glasses to correct short-sightedness. On fundoscopy, you find a cherry red macula. What is the most likely cause of this condition? 1. Hypertension 2. Diabetes 3. Trauma 4. Myopia 5. Atherosclerosis J o i n M e n t i 5 61 0 4 1 90 SBA 8 A 58-year-old man presents to the GP having suddenly lost vision in his left eye. He reports no pain, with only the left eye affected. He normally uses glasses to correct short-sightedness. On fundoscopy, you find a cherry red macula. What is the most likely cause of this condition? 1. Hypertension 2. Diabetes 3. Trauma 4. Myopia 5. Atherosclerosis Vessel occlusions Type Symptoms RFs Signs Mx Appearance Central Sudden, Atherosclerosis RAPD Urgentreferral to TIA Cherryred spot retinal profound, entire DM Retinal oedema clinic + eye casualty artery vision loss HTN Pale retina - Bagrebreathing occlusion (blindness) CV disease Cherryred spot (vasodilation) + ocular (CRAO) Giant cell Carotid bruits massage Unilateral arteritis Often irreversible Central Blurred, Atherosclerosis RAPD Refer to eye casualty retinal widespread DM Retinal oedema “Stormy sunset” vein vision loss HTN Papilloedema MxCV risk factors occlusion Glaucoma Tortous veins + (CRVO) Unilateral Coagulopathies flame Manage complications haemorrhages e.g neovascularization Cotton wool spots /macular oedema Hypertensive retinopathy Grading Features Grade 1 Subtle arterial narrowing, copper/silver wiring Grade 2 Arteriovenous nipping, vessel constriction Grade 3 Cotton wool spots, flame haemorrhages, exudates Grade 4(malignant) optic disc swelling (illoedema )Please fill out the feedback form ☺SBA PRACTICE SBA 9 A 35-year-old man presents with a painful red eye, photophobia, and blurred vision. On examination, you note ciliary flush and cells in the anterior chamber. What gene is most commonly associated with the condition described? 1. HLA-B27 2. HLA-B34 3. BRCA-2 4. HLA-DR3 5. HLA-DR2 J o i n M e n t i 5 61 0 4 1 90 SBA 9 A 35-year-old man presents with a painful red eye, photophobia, and blurred vision. On examination, you note ciliary flush and cells in the anterior chamber. What gene is most commonly associated with the condition described? 1. HLA-B27 2. HLA-B34 3. BRCA-2 4. HLA-DR3 5. HLA-DR2 SBA 10 A 42-year-old woman presents with a red, painful eye, photophobia, and blurred vision. On examination, you note scleral inflammation with violaceous discoloration. What is the most likely underlying cause or associated condition? 1. Staphylococcus aureus infection 2. Rheumatoid arthritis 3. Trauma to the face 4. Herpes zoster virus 1 5. Diabetes mellitus J o i n M e n t i 5 61 0 4 1 90 SBA 10 A 42-year-old woman presents with a red, painful eye, photophobia, and blurred vision. On examination, you note scleral inflammation with violaceous discoloration. What is the most likely underlying cause or associated condition? 1. Staphylococcus aureus infection 2. Rheumatoid arthritis 3. Trauma to the face 4. Herpes zoster virus 1 5. Diabetes mellitus SBA 11 A 24-year-old patient presents with bilateral eye redness, itchiness and watery discharge. Which is the most appropriate initial treatment? 1. Topical antihistamine 2. Topical timolol 3. Topical gentamicin 4. Oral antihistamine 5. Topical acyclovir J o i n M e n t i 5 61 0 4 1 90 SBA 11 A 24-year-old patient presents with bilateral eye redness, itchiness and watery discharge. Which is the most appropriate initial treatment? 1. Topical antihistamine 2. Topical timolol 3. Topical gentamicin 4. Oral antihistamine 5. Topical acyclovir SBA 12 A 35-year-old man presents with a painful, red left eye, photophobia and blurred vision for the past four days. Upon further questioning, he has been experiencing bloody diarrhoea for the last month. Which is the most appropriate initial treatment? 1. Topical antibiotic eye drops 2. Oral acyclovir 3. Topical cycloplegic eye drops 4. IV prednisolone 5. Oral methylprednisolone J o i n M e n t i 5 61 0 4 1 90 SBA 12 A 35-year-old man presents with a painful, red left eye, photophobia and blurred vision for the past four days. Upon further questioning, he has been experiencing bloody diarrhoea for the last month. Which is the most appropriate initial treatment? 1. Topical antibiotic eye drops 2. Oral acyclovir 3. Topical Cycloplegic eye drops 4. IV prednisolone 5. Oral methylprednisolone SBA 13 A 67-year-old patient presents with gradual, painless vision loss over the past few years. On examination, you note the following findings bilaterally: • Increased intraocular pressure • Optic nerve cupping • Reduced visual acuity Which of the following statements is correct regarding the potential conditions causing these findings? 1. The findings are suggestive of open-angle glaucoma only. 2. The findings are suggestive of cataracts only. or a combination of both.due to either open-angle glaucoma or cataracts, cataracts.dings are not consistent with either open-angle glaucoma or J o i n M e n t i 5 61 0 4 1 90 SBA 13 past few years. On examination, you note the following findings bilaterally: • Increased intraocular pressure • Optic nerve cupping • Reduced visual acuity Which of the following statements is correct regarding the potential conditions causing these findings? 1. The findings are suggestive of open-angle glaucoma only. 2. The findings are suggestive of cataracts only. 3. The findings could be due to either open-angle glaucoma or cataracts, or a combination of both. 4. The findings are not consistent with either open-angle glaucoma or cataracts.SUMMARY SLIDESOrbital and Periorbital Cellulitis Clinical Feature Periorbital Orbital Eyelid swelling +/- erythema Y Y Aetiology: Eye pain Sometimes Y - deep Orbital: Periorbitalaka preseptal Infection/inflammation Inflammation of eyelid Pain on eye movement N Y of orbit content but not (ophthalmoplegia) +/- diplopia globe (muscles etc) superficial to orbit From underlying From superficial insult Proptosis N Y (subtle) sinusitis e.g insect bite Vision impairment N Y – afferent Progression to ✶ Staph.Aureus pupillary defect vision loss/brain ✶ Strep. Pneumo Fever N Y abscess ORBITAL MGMT PERIORBITAL MGMT Differentials: Risk factors: ✶ IMMEDIATE Anaphylaxis Kids > adults ✶ Consider hospital HOSPITAL Recent sinus infection or referral orbit trauma REFERRAL Investigations: Complications: Clinical diagnosis ✶ Oral co-amoxiclav (with specialist advice) ✶ Oral clarithromycin (if penicillin allergic) ✶ Loss of vision ✶ Brain abscessOptic neuritis Presentation: Investigations: Aetiology: Examination: ✶ Sharp eye pain MRI: orbits/optic nerve exacerbated by (swelling, enhancement, Inflammation of ✶ Central scotoma movements optic nerve. ✶ Decreased visual ✶ Colour ?white matter lesions in MS) acuity desaturation (red) ✶ Idiopathic ✶ Unilateral ✶ RAPD Bloods: FBC, ESR, CRP ✶ Autoimmune: ✶ Papilloedema ✶ Central scotoma (inflammation markers) ✶ Other neuro deficits Multiple sclerosis, e.g numbness (MS) SLE, sarcoidosis Complications: ✶ Infection: ✶ Younger Pts syphilis, HSV, ✶ Unilateral ✶ Visual loss mumps Differentials: Management: ✶ Immediate: IV methylprednisolone (pulse-dose) ✶ Giant cell ✶ Week after: oral prednisolone arteritis ✶ Migraine Co-prescribe omeprazole for gastroprotectionGlaucoma: open angle Aetiology: Differentials: Risk factors: Investigations: Increased IOP ✶ Cataracts ✶ Age >65 caused by defective ✶ Afro-Caribbean Reduced visual acuity drainage of aqueous ethnicity humour. IOP >21mmHg ✶ Myopia Fundoscopy: optic disc cupping Damage to optic ✶ Family history Gonioscopy (open) nerves from raised ✶ T2DM IOP. ✶ CVD History: Management: Complications: ✶ Blindness Medical: ✶ Progressive ✶ Latanoprost vision loss ✶ Timolol ✶ Acetazolamide / brimonidine Surgical: ✶ Laser trabeculoplasty ✶ Surgical trabeculectomyGlaucoma: acute angle-closure Presentation: Risk factors: Aetiology: ✶ Unilateral vision loss CLOSE: ✶ Red eye Chinese ✶ Severe pain Long-sighted EMERGENCY ✶ Headache, N&V Narrow anterior angle Old age becomes suddenly Differentials: ✶ Triggered by entering a dark Shallow anterior chamber blocked, stopping room Ethnicity (EastAsian) drainage. Sudden ✶ Scleritis ✶ Prodromal halos around increased IOP causes lights pain and vision loss. ✶ Anterior uveitis ✶ Older Pts Examination: Management: Complications: ✶ Sudden ✶ IMMEDIATE HOSPITALADMISSION ✶ Permanent vision loss increased IOP: Medical ✶ Acetazolamide +/- timolol (BB) >30mmHg ✶ Pilocarpine ✶ Red eye ✶ IV mannitol if unsuccessful ✶ Cloudy cornea ✶ Fixed, mid- Surgical dilated pupil ✶ Peripheral laser iridotomy ✶ Trabeculectomy if medical Mx failsConjunctivitis Allergic Viral Bacterial Hayfever, pollen, dust Adenovirus, HSV, Staph. Aureus, strep. Aetiology: Examination: molluscum Pneumo, gonococcal Inflammation of Bilateral Unilateral or bilateral Can spread between eyes conjunctiva – very ✶ Diffuse red eye common (esp in kids) ✶ Discomfort Itchy, red eyes Gritty, crusting, red Gritty, crusting, red ✶ Normal vision Stringy discharge Watery discharge Purulent discharge ✶ Allergic ✶ Some ✶ Viral None Lymphadenopathy + Typically none ✶ Bacterial photophobia coryzal Sx PO Antihistamines Observation, Topical Abx: History: Differentials: lubricant, hygiene chloramphenicol/fusi dic acid drops ✶ Acute onset Investigations: Complications: ✶ Kids > adults ✶ Discomfort/ ✶ Dry eyes ✶ Corneal abrasion ✶ Unlikely: vision loss Grittiness ✶ Foreign body ✶ Clinical ✶ Seasonal diagnosis (allergic) ✶ Slit lampScleritis Investigations: Aetiology: Investigation: Clinical diagnosis: Inflammation of sclera ✶ Slit lamp Low threshold for clinical (all layers) – form of suspicion uveitis Differentials: ✶ Autoimmune (SLE, sarcoidosis), ✶ Episcleritis rheumatoidA ✶ Infectious (rare, ✶ Acute angle- male) closure glaucoma History: Management: Complications: ✶ SEVERE PAIN: worse on eye ✶ SAME DAY OPHTHALMOLOGY REFERRAL movements ✶ Peripheral keratitis Medical ✶ Uveitis ✶ Blurry vision ✶ Cataracts ✶ Photophobia ✶ Oral NSAIDs (ibuprofen) ✶ Glaucoma ✶ Eye watering ✶ High dose prednisolone ✶ Violet hue to ✶ Vision loss if untreated ✶ Treatment of underlying cause irisUveitis Aetiology: Examination: Differentials: Anterior: acute glaucoma, optic Inflammation of ANTERIOR Anterior: Cells in uvea:Anterior: ✶ Autoimmune: UC, anterior chamber neuritis iris, ciliary body RA, SLE, anky Posterior: choroid spond Posterior: Posterior: chronic glaucoma POSTERIOR ✶ Idiopathic retinitis/papilloede ✶ Infection ma Investigations: Slit lamp examination History History: Management: Anterior ✶ Red, painful eye Complications: ✶ Constricted pupil ✶ Anterior: Prednisolone eye drops, Mx of ✶ Photophobia underlying cause ✶ Vision loss Posterior ✶ Gradual onset vision loss ✶ Posterior: specialty consultation, Mx of ✶ Floaters / flashes of light underlying causeCataracts Investigations: Aetiology: Examination: Causes: ✶ History Opacity of lens due ✶ Cloudy opacity ✶ Slit lamp assessment ✶ Loss of red ✶ Age to liquefaction of reflex ✶ Trauma lens content. Most ✶ Metabolic – diabetes common cause of Differentials: ✶ Toxins – incl smoking blindness ✶ Steroids worldwide ✶ Retinal detachment ✶ Hereditary ✶ Open angle ✶ Maternal infection History: glaucoma ✶ Systemic disease ✶ Gradual vision blurring Management: Complications: ✶ Increasing myopia Initial patient assessment: ✶ Major cause of falls in ✶ Eye health in both eyes, suitability for surgery, elderly -> lens ✶ Colour fading replacement ✶ Glare/halos biometry around bright lights/poor night Surgical vision ✶ Phacoemulsification w lens replacementTHANK YOU FOR COMING! PLEASE FILL IN THE FEEDBACK FORM! Recommended resources: BMJ best practice Quesmed + Passmed ‘Clinical specialties: medical student revision guide’ – Rebecca Richardson + Ricky Ellis