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Ophthalmology Dr Alexander Wallace & Dr Chantae Reid-AgboolaTopics ● Common eye conditions: Conjunctivitis, keratitis, blepharitis, dry eye ● Glaucoma: Diagnosis, treatment, and management ● Cataracts: Symptoms, diagnosis, and surgery ● Retinal conditions: Diabetic retinopathy, macular degeneration, retinal detachment ● Eye emergencies: Acute angle-closure glaucoma, trauma, uveitis ● Vision loss: Red flags and differential diagnosisQuestion 1 How is this patient best treated? A 8-year old boy present to the GP with a 2 day history of a red and 1. Urgent referral to the eye emergency itchy right eye, his vision has not room been affected. He has had coryzal for the past week. He has not other 2. Watchful waiting past medical history or medications. 3. Chloramphenicol eye drops O/e 4. Sodium chromonate eye drops - 6/6 Snellen chart bilaterally 5. Acyclovir eye drops - IOP 14 mmHg (normal) - Right eye has serous discharge and the conjunctiva is bloodshot. - He has swollen and tender cervical lymph nodesAnswer 1 A 8-year old boy present to the GP How is this patient best treated? with a 2 day history of a red and 1. Urgent referral to the eye emergency itchy right eye, his vision has not been affected. He has had coryzal room for the past week. He has not other 2. Watchful waiting past medical history or medications. O/e 3. Chloramphenicol eye drops 4. Sodium chromonate eye drops - 6/6 Snellen chart bilaterally 5. Acyclovir eye drops - IOP 14 mmHg (normal) - Right eye has serous discharge and the conjunctiva is bloodshot. - He has swollen and tender cervical lymph nodesConjunctivitis Bacteria: tx: topical chloramphenicol - purulent discharge, eyes 'stuck together' in the morning Virus: tx: supportive - serous discharge, recent URTI, preauricular lymph nodes Allergic: tx: topical antihistamines, topical mast cell stabilisers (sodium cromoglicate) Neonatal conjunctivitis (in 30 days of life): gonococcal = urgent ophthalmology referralLid conditions and dryeye disease Blepharitis (whole lid margins): acne rosacea, seborrhoeic dermatitis, staph infection Stye (hordeolum): infected meibomian gland = painful Chalazion (blocked meibomian gland) = not painful Entropion = INWARDS lid rolling Ectropium = OUTWARDS lid rolling Trichiasis: inwards growing eyelash Dry eye disease: usually due to meibomian gland dysfunction or blepharitis. Remember Sjogren's disease - Tx: stop smoking, control allergens, lid hygiene (washing), artificial tearsQuestion 2 A 55-year old man presents to the What is the most likely cause of eye emergency room with a red, painful watery right eye with this presentation? reduced vision. 1. Herpes zoster virus Fluorescein dye is added to the eye 2. Pseudomonas surface and this is seen: 3. Acanthamoeba 4. Staphylococcus aureus 5. Herpes simplex virusAnswer 2 A 55-year old man presents to the What is the most likely cause of this eye emergency room with a red, presentation? painful watery right eye with 1. Herpes zoster virus reduced vision. Fluorescein dye is added to the eye 2. Pseudomonas aeruginosa surface and this is seen: 3. Acanthamoeba 4. Staphylococcus aureus 5. Herpes simplex virusKeratitis Corneal inflammation, can be sight threatening so is an emergency (usually infection) - always refer Contact lenses are a big risk factor as well as neurotrophic Presents with unilateral sudden red, painful eye with reduced vision. Grittiness sensation Ulcers stain yellow with fluorescein Viral: - Herpes simplex virus: dendritic ulcer (corneal epithelium). Tx: topical acyclovir - Herpes zoster virus: Hutchinson sign (vesicular rash on nose - trigeminal nerve), Tx: oral acyclovir if presents within 72 hoursKeratitis Bacterial: staphylococcus aureus (most common), Pseudomonas aeruginosa (contact lens wearers), - Tx: topical chloramphenicol Acanthamoeba (amoebic): fresh water Fungal Non-infective: photokeratitis, contact lens related, exposure keratitis (facial nerve palsy), chemicals, autoimmune Complications: cornea ulcers, scaring and endophthalmitisQuestion 3 A 67-year old male attends the eye A&E Given the likely diagnosis, following a sudden onset right eye pain, what is a risk factor that redness and reduced vision. He also has a headache and some nausea. This came on could predispose the patient at 8pm this evening. He has no pass to this condition? ophthalmic history. His prescription is +3.5D bilaterally 1. Hypermetropia O/e: 2. Myopia - Right eye red sclera, pupil is 3. Miotic drops semidilated and non-reactive 4. Black ethnicity - Tonometry 28 mmHg - VA 6/20 (right), 6/6 (left) 5. ConjunctivitisAnswer 3 A 67-year old male attends the eye A&E following a sudden onset right Given the likely diagnosis, eye pain, redness and reduced what is a risk factor that vision. He also has a headache and some nausea. This came on at 8pm could predispose the this evening. He has no pass patient to this condition? ophthalmic history. His prescription is +3.5D bilaterally 1. Hypermetropia O/e: 2. Myopia - Right eye red sclera, pupil is semidilated and non-reactive 3. Miotic drops - Tonometry 28 4. Black ethnicity - VA 6/20 (right), 6/6 (left) 5. ConjunctivitisAcute closed angle glaucoma Sudden IOP secondary to impaired aqueous outflow. Glaucoma is optic nerve damage (neuropathy) mainly due to raised IOP. Risk factors: hypermetropia (long-sightedness, +D prescription), pupillary dilatation (dark, mydriatic drops), co-pathology e.g. lens growth associated with age, neovascularization, asian ethnicity Presentation: sudden onset and unilateral: red (sclera) + painful eye, corneal haze, reduced visual acuity, semi-dilated non-reactive pupil Investigations: slitlamp examination, IOP (tonometry) 11-21mmHg, gonioscope (lens to visualise the angle) Treatment: make pupil small and reduce IOP - supine, pilocarpine (constrict pupil), acetazolamide (CAI), IV mannitol - definitive: laser peripheral iridotomyQuestion 4 A 70-year old female is referred from the optometrist to the general Given the likely diagnosis the patient is ophthalmology clinic due to an started on latanoprost, what side effect intraocular pressure of 26 mmHg should the patient be counselled about? (right eye), 25 mmHg (left eye). She 1. Darkening of the iris has no symptoms or visual acuity 2. Loss of eyelashes reduction. 3. Orange tears O/e 4. Metallic taste in the mouth - Slitlamp: NAD apart from a 5. Possibility of a rash pale optic disc and an optic cup-to-risk ratio of 0.8Answer 4 A 70-year old female is referred from the optometrist to the general ophthalmology clinic due to an Given the likely diagnosis the patient is intraocular pressure of 26 mmHg started on latanoprost, what side effect (right eye), 25 mmHg (left eye). She should the patient be counselled about? has no symptoms or visual acuity 1. Darkening of the iris reduction. 2. Loss of eyelashes O/e 3. Orange tears - Slitlamp: NAD apart from a 4. Metallic taste in the mouth pale optic disc and an optic 5. Possibility of a rash cup-to-disk ratio of 0.8Open angle glaucoma Irreversible, progressive optic neuropathy associated with raised intraocular pressure (but not always). Aqueous humour unable to flow out of the anterior chamber via the trabecular meshwork Presentation: often asymptomatic, picked up by optometrist at routine check. Symptoms can include reduced peripheral VA (central scotoma developing to tunnel vision) IOP >21 mmHg = high Investigations: tonometry (IOP), VA, slit-lamp examination/fundus photograph (disc: cupped (>0.7 C/D), pale), visual fields, OCT scan, gonioscopyOpen angle glaucoma R isk factors: black ethnicity, diabetes, myopia, corticosteroids, hypertension Treatment: - Selective laser trabeculoplasty (SLT) (≥24 mmHg) - latanoprost (prostaglandin analogue) - timolol (B-blocker), dorzolamide (CAI) - brimonidine (sympathetic ~ alpha2-adrenoceptor agonist) - trabeculectomy Medications side effects: - latanoprost = iris pigmentation & lash growth - timolol: b-blockers contraindicated in asthmatics - CAI: sulphonamide-like reactions (allergies/asthma) - alpha2-adrenoceptor agonist: avoid with MAOi/TCA, AE: hyperaemia of scleraQuestion 5 A 75-year old female presents to her GP with worsening vision from her Which of these is not a risk factor for left eye over the last 2 years. On the likely diagnosis? further questioning she mentions 1. Smoking she has noticed halos around lights 2. Diabetes which is more pronounced in the 3. Hypercalcemia dark. The GP uses an ophthalmoscope to 4. Steroid use examine the eyes. 5. Myotonic dystrophy Right eye NAD Left eye lens is cloudyAnswer 5 A 75-year old female presents to her GP with worsening vision from her left eye over the last 2 years. On Which of these is not a risk further questioning she mentions factor for the likely diagnosis? she has noticed halos around lights 1. Smoking which is more pronounced in the dark. 2. Diabetes 3. Hypercalcemia The GP uses an ophthalmoscope to examine the eyes. 4. Steroid use Right eye NAD 5. Myotonic dystrophy Left eye lens is cloudyCataract Common condition where the lens becomes opacified, normal aging process Leading cause of blindness worldwide. Risk factors: AGE, smoking, diabetes, steroid use, trauma, metabolic conditions (hypocalcemia), radiation exposure, myotonic dystrophy Presentation: gradual, painless blurred vision (unilateral/bilateral), halos around lights, glare, loss of red reflexCataract Nuclear sclerotic Cortical Posterior subcapsular Tx: - Watchful waiting - Phacoemulsification (surgery) - Complications: - Endophthalmitis - Retinal detachment - Posterior capsule rupture - Posterior capsule opacification (treat with YAG capsulotomy)Question 6 72 year old female attends ED after a What features increase the risk of sudden loss in vision in their left eye. developing the condition? The symptoms noted were flashes and floaters that progressed to vision loss at the peripheries, then A. Type 2 diabetes mellitus the centre. The pt denies any recent B. Hypermetropia trauma. C. Hypertension D. Female sex No red eye, denies any pain. E. Contact lens Pt has hypermetropia and frequently wears contact lens.Question 6 72 year old female attends ED after a What features increase the risk of sudden loss in vision in their left eye. developing the condition? The symptoms noted were flashes and floaters that progressed to vision loss at the peripheries, then A. Type 2 diabetes mellitus the centre. The pt denies any recent B. Hypermetropia trauma. C. Hypertension D. Female sex No red eye, denies any pain. E. Contact lens Pt has hypermetropia and frequently wears contact lens.Retinal detachment - Detachment in neurosensory tissue at the Ddx: back of the eye - Vitreous haemorrhage> does not result in vision loss - It is an ophthalmic emergency where pts need to be seen <24 hours - Condition is normally reversible providing Mx - Urgent <24hr referral to that an urgent referral is made ophthalmology - Examination under slit lamp Risk factors - USS to help r/o vitreous - Diabetes mellitus> diabetic retinopathy haemorrhage if view obscured - Myopia - Age - Recent traumaQuestion 7 A 61-year-old man presents to his optometrist complaining of gradual changes to his vision in his right eye. PMH: Type 2 diabetes mellitus, hypertension and hypercholesterolaemia. Which diagnosis is most likely? A. Wet macular degeneration B. Proliferative diabetic retinopathy C. Non-proliferative diabetic retinopathy D. Optic neuritis E. Dry macular degenerationQuestion 7 A 61-year-old man presents to his optometrist complaining of gradual changes to his vision in his right eye. PMH: Type 2 diabetes mellitus, hypertension and hypercholesterolaemia. Which diagnosis is most likely? A. Wet macular degeneration B. Proliferative diabetic retinopathy C. Non-proliferative diabetic retinopathy D. Optic neuritis E. Dry macular degeneration DiabeticRetinopathy - Classified into: proliferative, Severe NPDR non-proliferative, macuolopathy - blot haemorrhages and microaneurysms in Mild NPDR 4 quadrants - 1 or more microaneurysm - venous beading in at least 2 quadrants Moderate NPDR Proliferative diabetic retinopathy - Microaneurysms - neovascularization - blot haemorrhages - fibrous tissue forming anterior to retinal - hard exudates disc - cotton wool spots ● more common in DM e I DM, 50% blind in 5 - venous beading/looping yearsDiabeticRetinopathy Mx - Diabetic control - NPDR> close observation - Changes in visual acuity then VEGF inhibitors - Panretinal laser photocoagulation (can cause up to 50% of pts to notice reduction in visual fieldQuestion 8 A 28 year old male attends ED after getting A. 48hr OP appointment to into a physical altercation. They have ophthalmology. noticeable swelling to their left eye. He B. Surgical drainage reports sever pain and is unable to open their eye. C. CT Head D. Pack and dressing the eye O/E: Proptosis of eye, tender to touch, E. Urgent lateral canthotomy erythema, hard on palpation of periorbital area. Given the diagnosis, what is the next appropriate management step?Question 8 A 28 year old male attends ED after getting A. 48hr OP appointment to into a physical altercation. They have ophthalmology. noticeable swelling to their left eye. He B. Surgical drainage reports sever pain and is unable to open their eye. C. CT Head D. Pack and dressing the eye O/E: Proptosis of eye, tender to touch, E. Urgent lateral canthotomy erythema, hard on palpation of periorbital area. Given the diagnosis, what is the next appropriate management step?Orbital compartment syndrome - Compartment syndrome due to retrobulbar haemorrhage. - Raised intraocular pressure can develop due to the blockage of the angle and trabecular meshwork - Strict bed rest advised> blood can be redistributed and cause increase sxQuestion 9 An 79 year old woman reports reduced vision. Fundoscopy examination reveals: What is the most likely diagnosis? A. Diabetic retinopathy with photocoagulation scarring B. Hypertensive retinopathy C. Acute closed angle glaucoma D. Age related macular degeneration E. Proliferative diabetic retinopathyQuestion 9 An 79 year old woman reports reduced vision. Funodscopy examination reveals: What is the most likely diagnosis? A. Diabetic retinopathy with photocoagulation scarring B. Hypertensive retinopathy C. Acute closed angle glaucoma D. Age related macular degeneration E. Proliferative diabetic retinopathyMacular degeneration - Most common cause of blindness in UK - Characterised by drusen in bruch’s membrane - Two types ‘dry’ and ‘wet’: neovascularisation - 90% of cases in UK are dry ARMD - Dry= Gradul onset - Wet= subacute onset - Typical reduction in vision in near field objects - Difficult with night vision - Photopsia Risk factors - Age (>75 3x more risk) - Smoking - Family history - Cardiovascular disease, DM, HTNQuestion 10 A 28-year-old man presents to the What is the next appropriate step in managing the ophthalmology clinic with a 2-day history of a patient's condition? painful red right eye. He describes A. Oral acyclovir photophobia and blurred vision. There is no discharge. His past medical history includes B. Topical corticosteroids and cycloplegic agents ankylosing spondylitis. C. Oral corticosteroids D. Intravitreal antibiotics On examination, visual acuity is 6/9 in the E. Topical antihistamines right eye and 6/6 in the left. Slit-lamp examination reveals ciliary injection, small, irregular pupil, and cells in the anterior chamberQuestion 10 A 28-year-old man presents to the What is the next appropriate step in managing the ophthalmology clinic with a 2-day history of a patient's condition? painful red right eye. He describes A. Oral acyclovir photophobia and blurred vision. There is no discharge. His past medical history includes B. Topical corticosteroids and cycloplegic ankylosing spondylitis. agents C. Oral corticosteroids On examination, visual acuity is 6/9 in the D. Intravitreal antibiotics right eye and 6/6 in the left. Slit-lamp E. Topical antihistamines examination reveals ciliary injection, small, irregular pupil, and cells in the anterior chamberAnterior Uveitis ● Unilateral painful red eye ● Photophobia, blurred vision, watery eye ● Ciliary injection, not conjunctival ● Small, irregular pupil (posterior synechiae) ● Anterior chamber cells & flare (slit-lamp) ● Possible hypopyon in severe cases Risk Factors / Associations Management ● HLA-B27 diseases: Ankylosing spondylitis, IBD, ● Topical corticosteroids (e.g., prednisolone Psoriatic arthritis acetate) ● Infections: HSV, VZV, TB, Syphilis ● Cycloplegics (e.g., cyclopentolate) – ● Systemic autoimmune: Sarcoidosis, JIA prevent synechiae, relieve pain ● Idiopathic (~50% of cases) ● Treat underlying cause if identified ● Urgent ophthalmology referral SEEYOUNEXT https://linktr.ee/medtic.teaching THURSDAY! 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