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13.03.13 Ophthalmology tutorial

Top 4 key causes
  • Acute red eye
    • Conjunctivitis
    • Keratitis
    • Uveitis
    • Acute angle closure glaucoma
  • Acute visual loss
    • CVA
    • Giant cell arteritis
    • Central retinal artery/vein occlusion
    • Retinal detachment
    • Vitreous haemorrhage
  • Chronic visual loss
    • Cataract
    • Open angle glaucoma
    • AMD
    • Diabetes

Acute red eye


 Redness
Pain
Vision loss
Discharge
Photophobia
Notes
Conjunctivitis
Diffuse
No
No
Lots
Watery/sticky
No
Infective: Treat with chloramphenicol
Allergic
Keratitis
(Corneal ulcer)
Around ulcer
+++
Depends where it is
Sticky/watery
+++
Viral: HSV1
Bacterial: Gram -ves (from contact lenses)
Uveitis/Iritis
Ciliary flush
(Spreads from cornea)
+
+/-
No
++
Autoimmune (IBD, SLE, sarcoid, Ank Spond)
Steroids + Dilators to break up stickiness
Acute angle closure glaucoma
Diffuse
Unilateral
+++
Also headache
+++
Watery
+
Fixed mid-dilated pupil, Headache, Vomiting
Treat with pilocarpine, acetazolamide, iridotomy


Keratitis
  • AKA corneal ulcer
  • Contact lens use is highly suggestive
  • Treat with a fluoroquinolone
    • Levofloxacin
    • NB Ciprofloxacin is also in this class (cf C. diff risk)


History

  • Ask about three key things in the first 30 seconds:
    • Visual changes
    • Pain
    • Redness
  • Don't forget their AGE!
  • Photophobia?
  • Discharge?


Visual field testing

  • Cover one eye
  • Look at my nose
    • Any bits of my face blurred or missing?
  • Look at my eye 
    • Hold up 1 or two fingers (clearly) in each quadrant


Notes
  • Conjunctivitis is not painful
  • Keratoconus: Degenerative disorder in which structural changes within the cornea cause it to thin and change to a more conical shape
  • Old people don't get migraines - Consider other causes
  • Vitreous haemorrhage from proliferative diabetic retinopathy
  • Rods are lost first in retinitis pigmentosa => Peripheral vision lost first
  • Small bowel resection => Vitamin A malabsorption => Visual loss
  • Optic radiations
    • Superior visual fields travel through the temporal lobe
    • Inferior visual fields travel through the parietal lobe
  • Some people have collateral supply to the foveal parts of the occipital lobe from the MCA => PCA strokes can spare central vision
  • Onset is acute if they can remember what they were doing at the time
  • Glaucoma starts with a arcuate scotoma which progresses to tunnel vision
  • Intraoccular pressure rises from 10-21 mm Hg to 60-70 mm Hg in glaucoma
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