Medical -Surgical Nursing

Medical Medical -Surgical Nursing Surgical Nursing Surgical Nursing What is hypermetropia? - long sitedness, whereby light ray convergence at a point after the retina, and therfore out of focus. Nearby objects apphear blurry while distant objects are clearer what is myopia? - near/short sightedness, close is clear, far is blurry -usual starts in puberty and gets worse untill eye is fully grown. also in very young children. conditions associated with myopia? - squint- childhood eyes point in diff. directions. lazy eyechildhood, one eye. doesnt develop properly glaucoma - IOC pressure. cataracts - develpoment of cloudy atches inside lense. Retinal detachment - wherby retina pulls awat from the blood vessel that nourish it What is astigmatism? - Failure to converge image at one point on the fovea (likea refraction rather than focusing) Causes of astigmatism? - -Hereditary - corneal or lenticular -Injuries to the cornea, such as infection that scars the cornea keratoconus & kertoglobus - causes bulgin, thinner and shape change. Some conditions of the eyelid others that affect cornea or lense What is presbyopia? - gradual loss of your eyes' ability to focus on nearby objects. It's a natural part of aging 40-65yrs Aetiology of bacterial conjunctivitis? - S.Aureus, Sterp. Pneumo or H.flu also STIs chlamydia trachromatis, N.gonnorheae what is opthalmia neonatorum? - chlamydia or gonorrheae infection from infected birth canal affecting 20-40% What is Episcleritis ? - Inflamationof localiased superficial episclera vascular network, most commonly diffuse (moderate to sever inflam @1-3 month intervals) -Nodular/focal episcleritis (can often present with associated systemic disease) What are the classification of Allergic conjunctivitis? - type 1 hypersensitivity - seasonal (SAC) perrenial - chronic (PAC) Atopic - relates to eczema and athsma gaint pappilary (GPC) Limbal and tarsal kertaoconjuctivitis (VKC) What is gaint pappilary Allergica conjunctivitis - inner lining of the eyelid swells and develops small bumps. Known as papillae, these bumps tend to form after chronic irritation what can cause a corneal abbration? - Direct trauma Foreign body between eyelid and conjunctiva Heat by contact UV radiation (Arc Eye) What can cause corneal ulcer? - can be secondary to abrasive trauma, pentrating injuries or prolonged use of contact lenses What are dendritic ulcers? - Herpes simplex virus (HSV) keratitis is the most frequent cause of corneal blindness. - aggressive treatment - Symptoms of Dendritic ulcers? - Pain Photophobia Blurred vision Tearing Redness - with fluorescein staining and has a delicate branching pattern, Appearance of dendritic ulcer on opthalmoscopy? - - infectious epithelial keratitis (with characteristic dendritic ulcers) -neurotrophic keratopathy -stromal keratitis endotheliitis (classified as disciform, diffuse, or linear) what are the symptoms of keratic precipitates and anterior uveitis - Pain, generally developing over a few hours or days except in cases of trauma: Redness Photophobia Blurred vision Increased lacrimation Chronic anterior uveitis presents primarily as blurred vision and mild redness. pain & photophobia normaly only during acute episode. what are the symptoms of posterior Uveitis? - Blurred vision and floaters Absence of symptoms of anterior uveitis (ie, pain, redness, and photophobia) All parts of the posterior chamber may be affected, including the retina, choroid and optic nerve. It can be caused by bacterial, fungal, viral and parasitic infections. What are the findings of posterior Uveitis upon opthalmoscopy? - posterior uveitis Showing candle wax drippings (white areas) Anterior uventis is linked to which non infectious diseases? - -Ankyolising spondilitis, -behcet syndrom (ulcers eye,mouth & genitals), -IBS, -Juvenile arthritis, sarcoidosis (Granulomatous disease), -seronegative arthropathy Anterior uventis is linked to which infectious diseases? - HSV, SYphilis, TB & varicella zoster Intermediate uventis (Cillary body to retina) is linked to which non-infectious disease? - Lymphoma, MS and sarcoidosis Posterior uventis (Retina, retinavvessels) and Panuverntis (iris, cilliary body and choroid layer) - is linked which non-infectious diseases? - Behcets sydrome, lymphoma, sarcoidosis2 Posterior uventis (Retina, retinavvessels) and Panuverntis (iris, cilliary body and choroid layer) - is linked which infectious diseases? - CMV, endogenous encephalitis, syphalis. TB and varicella zoster Toxicaris & toxoplasmosis Workup for suspected uveitis? - CBC, ESR, Antinuclear antibody (ANA), Rapid plasma reagin (RPR) Venereal disease research laboratory (VDRL) Lyme titer HLA testing for ankylosing spondylarthroses Chest radiography (to assess for sarcoidosis or tuberculosis) Urinalysis (for red blood cells or casts) Infectious workup (eg, HIV, toxoplasmosis), depending on the presentation What is a HYPOpyon - It is a leukocytic exudate, seen in the anterior chamber, usually accompanied by redness of the conjunctiva and the underlying episclera -often co-inside with behcets disease, endophthalmitis, panuveitis/panopthalmitis & Averse drug reactions what are anterior synchiae? - Peripheral anterior synechiae (PAS) Adhesions between the iris and trabecular meshwork PAS result from prolonged appositional contact between the iris and trabecular meshwork PAS may reduce outflow of aqueous humor May lead to raised intraocular pressure What are floaters? - Spots, threads, or fragments of cobwebs, which float slowly before the observer's eyes commony collagen breaking down to fibrils, retinal tears and tear film debris of conjuctival surface what are cateracts and how will a pateint present? - Gradual thickening of the lens. Hx of progressive residual deteriation and disturbance in night & near vision charectoristic of senile cataracts? - -decreased visual acuity -glare -Myopia or myopic shift - monocular diplopia - abnormal curvature of corneal surface , created double vision in 1 eye! What is intracapsular extraction? - Extraction of entire lens, including the posterior capsule and zonules, caries postoperative comlications What is extracapsular extraction - removal of the lens nucleus through an opening in the anterior capsule and a relatively large limbal incision, with retention of the integrity of the posterior capsule What is phacoemulsification - extraction of the lens nucleus through an opening in the anterior capsule; an ultrasonically driven needle is used to fragment the nucleus of the cataract; the lens substrate is then aspirated through a needle port via a small limbal or scleral incision What is optic neuritis? - demyelinating inflammation of the optic nerve that often occurs in association with multiple sclerosis (MS) and neuromyelitis optica (NMO) Signs of optic neuritis? - Decreased pupillary light reaction in the affected eye: Varying degrees of vision reduction: From mild acuity to complete vision loss Abnormal contrast sensitivity and color vision: In almost all patients with adult optic neuritis who have decreased visual acuity Altitudinal field defects Arcuate defects Nasal steps Central scotoma Cecocentral scotoma Papillitis (swollen disc): Found in one third of patients with optic neuritis Symptoms of optical neuritis? - -Preceding viral illness Rapidly impairmed vision in 1 eye or, less commonly, both eyes: -Dyschromatopsia (change in color perception) in the affected eye: sometimes more prominent than decreased vision. Retro-orbital or ocular pain: + vision changes & usually exacerbated by eye movement; the pain may precede vision loss. -Uhthoff phenomenon = vision loss is exacerbated by heat or exercise -Pulfrich phenomenon, in which objects moving in a straight line appear to have a curved trajectory: Presumably caused by asymmetrical conduction between the optic nerves Symptoms of retinitis pigmentosa? - Common symptoms include difficulty seeing at night and a loss of side (peripheral) vision What is retinitis pigmentosa? - rare, genetic disorders that involve a breakdown and loss of cells in the retina. Mutations in one of more than 50 genes is involved. There is no cure for retinitis pigmentosa. what is primary open angle glaucoma - most common type, which tends to develop slowly over many years Symtoms of glaucoma? - intense eye pain a red eye a headache tenderness around the eyes seeing rings (halo) around lights blurred vision What is DARC (detection of apoptosing retinal cells) - Real-time imaging of single neuronal cell apoptosis in patients with glaucoma Annexin 5 labelled with fluorescent dye DY-776 (phosphatidylserine exposed on apoptotic cell membranes) what is secondary glaucoma? - caused by an underlying eye condition, such as uveitis (inflammation of the eye) what is childhood glaucoma? - a rare type that occurs in very young children, caused by an abnormality of the eye Risk factor for glaucoma ? - Age - glaucoma becomes more likely as you get older and the most common type affects around 1 in 10 people over 75 Ethnicity - people of African, Caribbean or Asian origin are at a higher risk of glaucoma Family history - you're more likely to develop glaucoma if you have a parent or sibling with the condition High Myopia prostoglandins are most useful in which type of glaucoma - Effective at reducing intraocular pressure in pts with open-angle glaucoma what are Carbonic Anhydrase Inhibitors and how do they treat glaucoma? - reduce eye pressure by decreasing the production of intraocular fluid. The pill form (Acetazolamide)is an alternative for people whose glaucoma is not controlled by medication eye drops. Medical managemnet of glaucoma? - -Prostaglandin analogues, such as latanoprost, bimatoprost, tafluprost and travoprost. -Beta-blockers, such as betaxolol hydrochloride, levobunolol hydrochloride and timolol -Carbonic anhydrase inhibitors, such as brinzolamide and dorzolamide -Sympathomimetics, such as brimonidine tartrate Miotics, such as pilocarpine What are sympathomimetics and how do they treat glaucoma? - Alphagan P has a purite preservative that breaks down into natural tear components and may be more effective for people who have allergic reactions to preservatives in other eye drops. Alphagan is available in a generic form. Use and side effect of beta blockers and how do they treat glaucoma - Relatively inexpensive. Systemic side effects can be minimized by closing the eyes following application or using a technique called punctal occlusion that prevents the drug from entering the tear drainage duct and systemic circulation wht are Carbonic anhydrase inhibitorsand how do they treat glaucoma - (CAIs) reduce eye pressure by decreasing the production of intraocular fluid. whata re miotics and how do they treat glaucoma? - They cause pin point pupils and this flattens the iris, opening the irido-corneal angle. These medications reduce eye pressure by increasing the drainage of intraocular fluid through the trabecular meshwork. what is laser iridectomy? - preventative measure before disease set in, creating a new passage for aqeus humor draining (using laser) Risk factors for Age-related macular degeneration? - Family history of macular degeneration Smoking (past or present) Low macular pigment Having light skin or light eyes Exposure to the sun Poor diet Being overweight Being a woman, as they normally develop AMD at an earlier age than men Symtoms of retinal detachment? - Photopsia (common initially) Visual field defect (developing over time; may help localize detachment) Floaters & flashes Reduced VA distortion curtain field effect what is macular degeneration? how does this impact daily life? - when cnetral vision is disrupted, directly what is infront of you. (peripheral vision is kept!) vision becomes increasingly blurred, which means: Reading becomes difficult Colours appear less vibrant Facial Recognition becomes difficult This sight loss usually happens gradually over time, although it can sometimes be rapid. what is Tractional retinal detachment? - This results from adhesions between the vitreous gel/fibrovascular proliferation and the retina what is DRY AMD? - develops when the cells of the macula become damaged by a build-up of deposits called drusen. It's the most common and least serious type of AMD, accounting for around 9 out of 10 cases. Vision loss is gradual, occurring over many years. However, an estimated 1 in 10 people with dry AMD go on to develop wet AMD. What is wet AMD? - (macular haemorrhages from abnoral leaky vasculature) - develops when abnormal blood vessels form underneath the macula and damage its cells. Wet AMD is more serious than dry AMD. Without treatment, vision can deteriorate within days. What is Pre-proliferative retinopathy? - - more severe and widespread changes affect the blood vessels, including more significant bleeding into the eye what is Rhegmatogenous retinal detachment? - (the most common type) - This results when a hole, tear, or break in the neuronal layer allows fluid from the vitreous to seep between and separate sensory and RPE layers What is Anti- VEGF treatment? - Antibody against VEGF During WET AMD, neovasculisation produces molecules of VEGF that enourages further vascular leak and neovascularisation = further damage what is Exudative retinal detachment? - serous) retinal detachment - This results from exudation of material into the subretinal space from retinal vessels (as in hypertension, central retinal venous occlusion, vasculitis, or papilledema What is diabetic retinopathy - most common cause of blndness 25-65yrs, Hyperglycamia caused increased retina bloodflowand abnormal metabolism in retina vessel walls. Causing precipitats that damage epithelial cells and pericytes What is Proliferative retinopathy? - - scar tissue and new blood vessels, which are weak and bleed easily, develop on the retina - can result in some loss of vision Treatment and managment of Diabetic retinopathy? - Glycaemic control Pharmacological therapies - intravitreal injections of steroids and monoclonal antibodies Laser photocoagulation Vitrectomy Cryotherapy what is Blephritis? - persistent inflammation of the margins of the eyelid) present with eyelids that are red, burn, itch, and stick together. The condition is often associated with seborrhoeic dermatitis or rosacea what are the red flags for eye pain? - Visual changes, Pain, photophobia, pain on movement of the eye and Contact lenses why should tricamide not be put in open angle glaucoma? - Because this dialtes this can cause closed angle glaucoma Hx in a corneal arc Pt - ltraviolet light (e.g. weld ers; reflection from sea, sand or snow; sunlamps; halogen desk lamp). Over-exposure to UV irradiation or a 'corneal flash burn' produces a superficial and painful keratitis what is the onset and symptoms of ARC EYE? - (bilateral ) corneal redness pain intense bilateral lacrimation blepharospasm photophobia blurred vision / signs of reduced visual acuity sensation of a foreign body in the eye. (3-8 hrs after) - what are the common signs and symptoms of blephritis - itching, irritation, burning, discomfort Foreign body sensation Crusting around the eye lashes Lid thickening Loss of lashes Abnormal thickening of meibomian secretions (oil capping) Frothy tear film. Both eyes are usually How do symptoms present in blephritis? - (bi-laterally, intermittent & relapsing over long periods, worse in morning) Causes/classification of blephritis? - Staphylococcal blepharitis Seborrhoeic blepharitis Meibomian blepharitis - Meibomian gland dysfunction Self managment advice for a patient with Blephritis? - improves in 2-3 weeks: -avoid eye make up Apply warm compresses to closed eyelids for 5-10 m inutes. -For posterior blepharitis , massage the eyelid to express Meibomian glands. -Clean the eyelid — wet a cloth or cotton bud with cleanser (e.g. a sodium bicarbonate )and rub along the lid margins. - Many optometrists sell cleaner e.g. blephasol medical mangement of - Consider topical antibiotics (chloramphenicol or fusidic acid) or oral antibiotics (tetracyclines) if there are clear signs of staphylococcal infection or Meibomian gland dysfunction, respectively. NB Antibiotics should usually be reserved for second-line use, when eyelid hygiene alone has proved ineffective Blepharitis frequently causes dry eye: prescribe a rtificial tears or ocular lubricant to relieve symptoms When should you refer blephritis Pt? - -no improvement 6/52 despite maximal treatment -(for secondary care treatment, e.g. corticosteroids). -If patient is staining with fluorescein and keratitis is suspected, -rapid onset of visual loss or an acutely painful red eye . Refer with urgency appropriate to the problem if there is: - Evidence of corneal disease (pain, blurred vision) -Deterioration of vision -Associated disease, such as Sjögren's syndrome or eyelid deformities what are the Symptoms of Cataracts ? - (both eyes simultaneously but one eye may be worse than the other.): dimming/blurring of vision Lights may appear too bright Glare from lamps or the sun Poor night vision Double vision or multiple images in one eye Dulled colour vision Nearsightedness, accompanied by frequent changes in eyeglass prescription What is the onset, etc of cataracts? - Cataracts usually develop gradually, and are not ge nerally associated with pain, eye redness or other acute symptoms unless they are ext remely advanced. When should a cataract patient be referred? - Rapid and/or painful changes in vision are suspicious for other eye diseases and should be referred for specialist opinion. -patients with visual acuity of 6/12 or worse in cataract affects eye after correction (glasses) What is the surgical managment of Cataracts - removing the cloudy lens and replacing it with an intraocular implant under local anaesthetic. Non surgical management of Cataracts? - Reducing glare by wearing a hat or sunglasses in bright light correcting refractive problems with spectacles or contact lenses increasing light levels when working or reading to improve contrast referral for generic management of visual impairment (which may involve social services and provision of accessibility aids) Benfits of cataract surgery - mproved visual acuity. 85-90% of people will have 6/12 best corrected vision (This meets the driving requirements in the UK). However, reading glasses are usually needed after cataract surgery, and some people may require glasses for distance vision who did not previously require them -Improved clarity of vision - Improved colour vision. How will a Pt present with conjunctivits? - Red,eyes, normal, visual aquity and normal cornea What is the initial treatment for irritant conjunctivitis? - Remove/neutralise irritant if possible e.g. a displaced contact lens; foreign body; eye lashes rubbing against the surface of the eye; a chemical splashing, etc Presentation of Allergic conjuctivits? - -Bilateral itchy eyes -Oedema - 'cobblestone' appearance on upper eyelids when inflammation is chronic -Patient also suffers from eczema, allergic rhinitis, or asthma. giant papillary conjunctivitis 1-5% with soft C.lenses 1% of people with hard C.lense symtoms and presentation of bacterial Conjunctivitis? - Sore, swollen sticky/matted eye on waking + photophobic -can be uni/bilateral -acute- yellow purulent discharge -mild- mucopurulent (sticky yellow) - pappilae -palpable pre-auricular nodes -timing- acute or chronic symtoms and presentation of viral Conjunctivitis? - -Feels unwell. -Watery, sticky, gritty, sometimes subconjunctival haemorrhage. - (Bilateral) -H/O upper respiratory tract infection -serous (watery liquid) -follicle & papillae involved - pres auricular node is palpable and tender -Acute onset symtoms and presentation of chylamidial Conjunctivitis? - -Sore and slightly itchy -bi/unilateral -muscoid (stringy white) - large follicles in the fornicies -pre-auricular node palpable and non-tender -chronic symtoms and presentation of allergicConjunctivitis? - Very itchy and sore H/O upper respiratory tract infection -Bilateral -Mucoid -Papillae & thickened lids -pre-auricular node sometimes palpable -acute medical managment of seasonal/allergic conjunctivits? - -First line prescribing: either oral antihistamines -or topical treatment with mast cell stabilisers, sodium cromoglycate QDS for 1/12. Review after 1/52 & oral antihistamines. Second line: opatanol. Common causes of contact dermatoconjunctivtis & giant papillary conjunctivitis? - Commonly reaction to eye drops of contact lenses Drugs & Magment of suspected bacterial Conjunctivits? - occ. chloramphenicol to return if there is no improvement after 3-4 days then stop for 48 hrs & swab A positive bacterial culture — prescribe a topical ocular antibiotic directed by sensitivity results if they are still symptomatic. Positive chlamydial cultures — refer to GUM for testing of sexual contacts and systemic treatment. A negative bacterial and chlamydial culture — consider repeating the test if symptoms persist for longer than 3 weeks - review in 1/52 if no better Drugs & Magment of suspected viral Conjunctivits? - Reassurance - gel tears or viscotears or nothing - can give topical antibiotic cover for 1/52 to prevent secondary bacterial infection -if Pt wears contact lenses refer to optometrist to check cornea When to refer in Conjunctivitis? - If reduced vision or not responding in 2nd care, particularly severe atopic. -adults with Chylamidial inf. -penetrating cause of irritant conjunctivitis -neonatal conjunctivitis - refer to 2ns care and check for chylamidia and & gonnococal causes what can cause Corneal abbrations/Ulcers? - grit, finger nail, foreign body or by a contact lens, injuring the epithelial tissue. Wearing contact lenses incorrectly can also cause injury (e.g. if not clean; if dirt/dust becomes trapped behind a lens; if do not fit properly or are worn for excessively long periods of time). Symtoms of corneal graft? How should you screen it? - -Severe eye pain eye redness photophobia increased tears blurred / distorted vision squinting caused by eye muscle spasm sensation of foreign body in the eye, even if it has been removed. (with flouresin stain) Managment of corneal abrations/ulcers? - • Antibiotic ointment chloramphenicol (QTD for 1/52 ) • oral analgesics •lubricants at night: •ifcorneal erosion occ Lacri-Lube used at night every night for 3 months will resolve 80% and will also help prevent recurrence of erosion Refer corneal abration/ulcer if? - ain does not resolve after use of antibiotic ointment Patient continues to experience blurred vision or a reduction in visual acuity Patient continues to experience considerable pain, despite analgesics Injury/abrasion penetrates beyond the Bowman's membrane into the corneal stroma Symptoms of recurrent erosion persist despite using regular ointment at night. What are the symptoms of developmental glaucoma ? - having large eyes (pressure causes eye to expand) - photophobia - cloudy and/or watery eyes, - jerky eye movement - a squint when should you refer a patient with galucoma? - 1.- 21mmHg for patients younger than 65 years; 24mmHg for patients age 65-80 years; -25mmHg for patients over 80 years AND 2. there is optic disc change consistent with glaucoma in either eye; 3. Visual field defect is found consistent with gla ucoma in either eye; 4. Narrow drainage angle on van Herrick with signif icant risk of closure; 5. Signs often associated with glaucoma e.g. pigmen t dispersion or pseudoexfoliation what is a hordeola/Stye? - an acute, localized abscess situated on the eyelid, usually caused by staphylococcal infection. Patients typically present with a painful, tender, localized eyelid swelling that has developed over several days. Symtoms of Hordeola/Styes - Swelling generally affects only one eyelid (althou gh both eyes could be affected) More than one stye may be present If there is associated periorbital cellulitis (causing the eyelid to become very oedematous), the localized swelling may not be obvious Vision is unaffected If the stye is external (along the edge of the eyelid)- caused by infection of eyelash follicle or associated sebaceous or apocrine gland. How does this present? - Is located at the eyelid margin (upper or lower) Is usually localized around an eyelash follicle Points anteriorly through the skin. A small, yello w, pus-filled spot may be visible Is painful on palpation If the stye is internal - meibomian stye - on the conjunctival surface of the eyelid -(infected meibomian gland): how would this presnet? - More prolonged/more painful than an external stye localized, red swelling on the externa eyelid (although the whole eyelid affected), tender to touch. An internal stye is usually further from the lid margin compared with an external stye. Everting the eyelid (can be extremely painful), shows localized swelling within the tarsal plate. Stye usually points toward the conjunctiva How can a internal stye can be differentiated from a Meibomian cyst/chalazion, although initial management is the same: - Meibomian cyst is a chronic inflammatory granuloma, caused by obstruction of a meibomian gland, situated on the posterior eyelid Palpitation of meibomian cyst generally produces no pain/tenderness Managment ofHorseola/stye - Reassure - styes are self-limiting and rarely cause complications Epilate eyelash from the infected follicle (to facilitate drainage) If very painful, or obstructing vision, for appropriate patients consider : -incising and draining. This should only be undertaken by suitably experienced healthcare professionals. Topical antibiotics should not be prescribed for styes unless there is evidence of conjunctivitis If there are signs of conjunctivitis refer to the section for management Manage any blepharitis to reduce the risk of future episodes of styes. Self management of Hordeola/Styes - apply a warm compress (e.g. clean flannel rinsed i n hot water) to the affected eye for 5-10 minutes, repeating 3-4 times daily until the stye drains or resolves Avoid excessively hot compresses (to avoid scalding, particularly in children) take paracetamol or ibuprofen to relieve pain, if required patient should not attempt to puncture an external stye themselves maintain lid hygiene once the stye resolves What do you do if a suspected Hordeola/Stye could be preseptal cellulitis? - refer and seek opthalmologist for systemic medication When should you refer a Hordeola/Stye? - If the stye does not improve or resolve with conservative treatment, or if alarge and painful (rare for external styes), refer to an ophthalmologist for incision and drainage When do you need to urgerntl refer a Hordeola/stye? and Red flags for hospital admission - if there is significant preseptal cellulitis if the patient presents with signs or symptoms of orbital cellulitis (rare) Red flags for hospital admission include: Lid (periorbital) swelling. Protrusion of the eyeball (proptosis). Double vision (diplopia) or impairment of eye move ment (ophthalmoplegia). Reduced visual acuity. Reduced light reflexes or abnormal swinging light test. Systemically unwell. Central nervous system signs or symptoms (for example drowsiness, vomiting,headache, seizure, or cranial nerve lesion). what is a meibomian cyst/chalazion? - A Meibomian cyst (MC) (also known as a chalazion) i s a sterile, chronic, inflammatory granuloma caused by the obstruction of a Meibomian gland, that manifests as a swelling on the inside of an eyelid. MCs can occur spontaneously or may develop from an internal stye (hordeolum) or due to dysfunction of the Meibomian gland what are the causes/predispositions to meibomian cysts? - -poor eyelid hygiene -seborrhoea -acne rosacea -chronic blepharitis -hyperlipidaemia -leishmaniasis -tuberculosis -immune deficiencies -viral infections -rarely, carcinoma what are the charectoristics of a meibomian cyst? - a nodule that ard, painless, palpable (but can cause pain, e.g. pressure on the eyeball, and larger MCs may be tender secondary to their size - may grow up to 8mm) -non-erythematous and non-fluctuant -develop over several weeks -usually 2-8 mm in diameter -are often with associated conjunctival injection, more common on the upper eyelid , one or both eyes can be affected and more than one MC may be present MCs can occur at any age What will meibomiam cyst "patient history" commonly present with - history of recent eyelid discomfort sometimes fo llowed by acute inflammation (e.g. redness, tenderness, swelling) but normally settling / painless and non-tender a history of previous episodes (MCs recur in predisposed individuals) MC may have been present for weeks / months. Rarely, MC may become secondarily infected; the in fection can spread or cause preseptal cellulitis. How would you diagnose a meibomian cyst? - Eversion of the eyelid shows a discrete, immobile, round, yellowish lump (lipogranuloma) which may appear inflamed, tender, and erythematous in the acute phase normal, freely mobile skin over the cyst, while th e MC is adherent to the tarsal plate no associated ulceration, bleeding, telangiectasia, tenderness, or discharge. Vision should be normal unless MC is excessively large - the latter can cause astigmatism and visual disturbance (including vision loss) and ptosis. what is the managment of Meibomian cyst? - can take 1-6 months to resolve apply a warm compress (clean flannel rinsed in hot water) for 15-30 minutes twice a day to the affected eye (to help liquefy the lipid content of the MC, thus encouraging drainage) massage eye lid as follows: After a bath or shower, arm hand under hot water and work up a lather using a drop of baby shampoo. Place the index finger over the closed lids at the lid margin and vigorously (but carefully) massage the lid back and forth for a total of 10 times. Repeat procedure using the middle, ring and little finger. Clean affected eyelid/lashes twice daily (to clear debris and oily secretions). When to refer a meibomian cyst? - GP = is 16 years old or over: C has not responded to conservative management and is present for more than three months; MC interferes with vision; MC is source of regular infection (2 or more episo des within three-month period) requiring medical treatment; or Excessive pain. 2nd care = for routine treatment ONLY if: S/he is 15 years old or under Pt unsuitable for local anaesthetic Pt is on anti-coagulants MC is located too close to the punctum / the site of the lesion or lashes means specialist intervention necessary what is a pinguecula? - common, non-malignant, slow-growing proliferations of conjunctival connective tissue in the eye, associated with high exposure to UV/sunlight. Pinguecula can be distinguished from pterygia which extend over the cornea (conjuctival vascularised thickening , often triangular) What are the symptoms of pinguecula? - fleshy lumps on the conjunctiva may be yellow, gray, white or colourless are almost always to one side of the iris (not abo ve or below), usually on the side closest to the nose. are common in adults (incidence increases with age) and those who have been exposed to high levels of sunlight normally asymptomatic - normal aquity, normal corneal apphearance but, may report dry eyes. Management of pinguecula ? - Reassure patient: pinguecula grow slowly and almost never cause significant damage. Suggest wearing sunglasses in sunny conditions to prevent further development of pinguecula and pterygia Suggest using artificial tears to lubricate the eye, to protect against dryness and relieve the sensation of a foreign body in the eye. In severe cases, non-steroidal eye drops may be used to reduce any swelling orinflammation. When should you refer a pinguecula? - f pingueculm has become infected (pingueculitis) - very painful, inflamed, sore, and causing irritation pingueculum not settling. What are the charectoristics & symptoms of a subconjunctival heamorrhage? - traumatic, spontaneous, or related to systemic illness -symptomatic -Deep red patch on the globe -Sudden onset -Normal vision. What are the causes of subconjunctival heamorrhage? - -iopathic -Valsalva (e.g. coughing, straining, vomiting) - particularly in children -Traumatic - including remote injury and surgery -Hypertension or arteriosclerosis Blood dyscrasias (if recurrent or in young patients without history of trauma or infection) • Antibiotics, drugs/chemicals. Management of subconjunctival heamorrhage? - If onset is spontaneous, check patient's blood pres sure and reassure patient that it will resolve in 2/52. OTC artificial tears can be used 4 times per day for mild irritation Discourage use of aspirin products or NSAIDs until subcon haemorrhage resolved What is keratitis? - Keratitis is an inflammation of the cornea — the clear, dome-shaped tissue on the front of your eye that covers the pupil and iris. somtimes infection involving bacteria, viruses, fungi or parasites. Noninfectious , contact lenses & other noninfectious diseases What are the symptoms of keratitis? - Eye redness Eye pain Excess tears or other discharge from your eye Difficulty opening your eyelid because of pain or irritation Blurred vision Decreased vision Sensitivity to light (photophobia) A feeling that something is in your eye what are the Complications of keratitis - Chronic corneal inflammation Chronic or recurrent viral infections of your cornea Open sores on your cornea (corneal ulcers) Corneal swelling and scarring Temporary or permanent reduction in your vision Blindness what methods should Pt use to Prevent keratitis - Usual Good care for contact lenses , ont wear when swimming & Preventing viral outbreaks. How is keratinitis classified - Exposure keratitis — due to dryness of the cornea caused by incomplete eyelid closure photo-keratinitis - due to UV e.g. snow or welders Contact elnse acute red eye - non ulcerative moderte- superficial punctate keratitis - lumps on conrea bilaterally) severe- ulcerative keratitis - disruption (infect/inflam) of its epithelial layer with involvement of the corneal stroma. What is orbital cellulitis? - extension of infection from the nasal sinuses or the skin of the face although in children, there may be haematogenous spread from a more distant site. (normally Haemophilus influenzae, Streptococcus pneumoniae, and staphylococci.) how is keratitus treated? - depends on the cause of the keratitis. can progress rapidly, requires urgent antibacterial, antifungal, or antiviral therapy. Abx solutions include levofloxacin, gatifloxacin, moxifloxacin, ofloxacin. what are the symptoms and charectoristics of orbital cellulitis? - The condition is characterised by acute swelling of the orbital tissues, proptosis, oedema and limited eye movement. Complication of orbital cellulitis - cavernous sinus thrombosis as indicated by neurological signs, visual loss, muscle paresis and papilloedema. Erosion of orbital bones may result in brain abscess and meningitis. When should you refer orbital cellulitis? and how do you treat it? - This condition requires urgent referral. Immediate treatment is necessary and before the causative organism is known. obtain cultlures from any facial lesions or CSF - beta lactamase resistant antibiotics for staphylococci, amoxicillin and augmentin for haemophilus. Post-traumatic cellulitis should be covered for gram-negative and gram- positive bacilli. Hot compresses help localise the inflammatory reaction. Nasal decongestants and vasoconstrictors help drain the sinuses. Surgical drainage is indicated in suppurative preseptal cellulitis. What is the lacrimal gland? - located in the supratemporal orbit. Two lobes exist, the orbital and the palpebral. The palpebral lobe is visualized easily by upper lid eversion. This eccrine secretory gland is responsible for the formation of the aqueous layer of the tear film. What is dacryoadenitis? - infectious dacryoadenitis is thought to be caused by ascension of an inciting agent from the conjunctiva through the lacrimal ductules into the lacrimal gland. What are the ophthalmic physical signs of acute dacryoadenitis? - Chemosis (conjunctival swelling) Conjunctival injection Mucopurulent discharge Erythema of eyelids Lymphadenopathy (submandibular) Swelling of the lateral third of the upper lid (S-shaped lid) Proptosis Ocular motility restriction Globe displacement inferiorly and medially Increased severity of signs and symptoms with orbital lobe involvement Acanthamoeba keratitis associated (rarely) dacryoadenitis patient presentation - Unilateral, severe pain, redness, and pressure in the supratemporal region of the orbit Rapid onset (hours to days) Chronic dacryoadenitis is characterized by the following: Can be bilateral, painless enlargement of the lacrimal gland present for more than a month More common than acute dacryoadenitis What are the Systemic physical signs of acute dacryoadenitis - Parotid gland enlargement Fever Upper respiratory infection Malaise What are the Systemic physical signs of chronic dacryoadenitis - Less severe presentation than acute dacryoadenitis No pain (usually) Enlarged gland but mobile Minimal ocular signs Mild ptosis secondary to enlargement of the gland (possible) Mild-to-severe dry eyes What are the viral causes of dacryoadenitis? - Mumps (most common, especially in childhood) Epstein-Barr virus Herpes zoster Mononucleosis Cytomegalovirus Echoviruses Coxsackievirus A What are the bacterial causes of dacryoadenitis? - Staphylococcus aureus and Streptococcus Neisseria gonorrhoeae Treponema pallidum Chlamydia trachomatis Mycobacterium leprae Mycobacterium tuberculosis Borrelia burgdorferi What are the fungal causes of dacryoadenitis? - Histoplasmosis Blastomycosis Parasite (rare) Schistosoma haematobium Protozoa (rare) Acanthamoeba keratitis associated What are the inflamatory causes of dacryoadenitis? - Sarcoidosis Graves disease Sjögren syndrome [3] Orbital inflammatory syndrome Benign lymphoepithelial lesion Treatment of acute dacryoadentis? - Viral (most common) - Self-limiting, supportive measures (eg, warm compresses, oral nonsteroidal anti-inflammatories) Bacterial - cephalexin or cephazolin until culture results are obtained. Protozoan or fungal related - Treat the underlying infection accordingly with specific antiamoebic or antifungal agents. Inflammatory (noninfectious) - Investigate for systemic etiology, and treat accordingly What is an ectropion? - abnormal eversion (outward turning) of the lid margin away from the globe. Without normal lid globe apposition, corneal exposure, tearing, keratinization of the palpebral conjunctiva, and visual loss may result. Ectropion usually involves the lower lid and often has a component of horizontal lid laxity. Which conditions cause Nontraumatic transient (24h) monocular vision loss - amaurosis fugax (usually minutes) — usually embolic or thrombotic; can occur secondary to hypoperfusion states, hyperviscosity or vasospasm. migraine (can be without headache) one eye closed! Uncommon causes include: -papilloedema (may be associated with visual loss lasting seconds) -other causes of ischemic optic neuropathy, e.g. giant cell arteritis -impending central retinal vein occlusion (CRVO) glaucoma -posterior reversible encephalopathy syndrome (PRES) -large vessel occlusion or dissection, e.g. ocular ischemic syndrome (carotid occlusive disease), vertebrobasilar insufficiency, and carotid or vertebral artery dissection -functional visual loss, e.g. hysteria, malingering Which conditions cause "Painless" acute persistent loss of vision? - central retinal artery occlusion (CRAO) central retinal vein occlusion (CRVO) retinal detachment or hemorrhage vitreous hemorrhage optic or retrobulbar neuritis internal carotid artery occlusion Which conditions cause "Painful" acute loss of vision? - acute glaucoma endophalmitis uveitis keratoconus (vision can deteriorate rapidly and is associated with photophobia) which conditions cause a " transient" Nontraumatic causes of acute binocular loss of vision? - migraine vertebrobasilar insufficiency (transient) which conditions cause a " prolonged" Nontraumatic causes of acute binocular loss of vision? - Stroke poisons/ toxic optic neuropathy (e.g. methanol, quinine, ethambutol, ergot alkaloids, salicylates) posterior reversible encephalopathy (PRES) optic or retrobulbar neuritis hysteria malingering Post-traumatic causes of loss of vision? - From 'front to back': lid injury orbital blow-out fracture corneal abrasion, irregularity or laceration hyphema traumatic mydriasis traumatic iritis ruptured globe traumatic cataract lens dislocation commotio retinae retinal detachment retinal or vitreous hemorrhage intra-ocular foreign body traumatic optic neuropathy or optic nerve avulsion CNS injury What cahnges occur in glaucoma that are evident on fundoscopy? - Large cup to disc ratio Progressive cupping Vertical cupping Asymmetric optic nerve head cupping Notching of the neuroretinal rim Disc hemorrhage What is gonioscopy? - normally used in conjunction with a slit lamp or operating microscope to gain a view of the iridocorneal angle, or the anatomical angle formed between the eye's cornea and iris. What is tonometry? - Tonometry is the procedure an instrument is placed in contact with the cornea to determine the intraocular pressure (IOP), the fluid pressure inside the eye. what is strabismus? - Strabismus is misalignment of the eyes such that both eyes are not simultaneously directed at the same object. what would be the cause of a patient with paralytic strabismus? - A problem with the extra occular muscles or the nerves innovating them which three nerves are involved in innervating the extraoccular muscles? - CN: III, IV & VI what defining symptom would an impairment in An impairment of cranial nerve III likely cause? - associated eye to deviate down and out and may or may not affect the size of the pupil. what defining symptom and possible cause would an impairment in An impairment of cranial nerve IV likely be? - can be congenital, causes the eye to drift up and perhaps slightly inward what defining symptom would an impairment in An impairment of cranial nerve VI likely cause? - causes the eyes to deviate inward and has many causes due to the relatively long path of the nerve. can raised ICP cause strabismus - yes, y compressing the nerve that runs between Clivus & briain stem Why must we be careful using forceps during newbornes during birthing, what can happen during, if not careful? .. and cause strabismus - Twisting the babies neck during delivery can damage CN VI What would likely be the cause in a pt that has strabismus wihtout cranial nerve stigmata? - Involvement of the visual cortex what is Esotropia? - Esotropia is a type of strabismus characterized by an inward deviation of one eye relative to the other eye what is accomodative esotropa - an esodeviation due to normal accommodation in uncorrected hyperopia what is ambyloyia - refers to a unilateral or bilateral decrease of vision, in one or both eyes, caused by abnormal vision development in childhood or infancy is amblyopia permanent? - no, It is a common vision problem in children and is the leading cause of decreased vision among children. Most vision loss is preventable or reversible with the right kind of intervention. what are the important causes for ambylopia? - Anisometropia or refractive errors Strabismus Strabismic anisometropia Visual deprivation Organic lesions what will Pt with ectropion usually tell you ? - Patients often complain of irritated or red eyes with tearing. They may constantly wipe their eyes, thereby exacerbating lid laxity and the ectropion. what is the differnece between esotropia and exotropion? - the first, designates a convergent horizontal strabismus; and the second : designates a divergent horizontal strabismus what is a common previous encounter in the history of pt with a current ectropion - facial burns, lid surgery, or lid trauma What further questions should you ask in a patient with cicatrical ectropion or periocular skin rash? - history of facial skin cancer and topical and systemic medication use should be ascertained e.g.? maybe basal cell carcinoma or parotid tumor (+ lid paralysis) can facial nerve palsy cause ectropions? - yes, Acute is consistent with Bell palsy. Chronic, insidious progressive facial nerve palsy may indicate a mass lesion. for a patient with facial nerve palsy should be ascertain for examples from a care giver? - as about lagoopthalmous, if so may require slit lamp and corneal teasting of sensation Medical mangement of Ectropion? - Lubrication and moisture shields (if significant corneal exposure exists from the ectropion then use plastic dressings sometimes taping inferolateral canthal skin suptertemporaly can provides relief especial new onset 7th nerve pauls general & self-management/advice for ectropion - early puntal or incipient types should be wiped upwards to avoid making worse. Cicarical following trauma or surger can be massaged to stretch scaring +/- Steroid Surgical management of Ectropion - Horizontal lid laxity is often seen with ectropion and usually can be corrected with a lateral tarsal strip procedure. Mild-to-moderate cases of medial ectropion may respond to a medial conjunctival spindle procedure. Tarsal ectropion requires reinsertion of the lower lid retractors. Augmentation of the anterior lamellae (along with excision of any cicatrix) is required for cicatricial ectropion. what is an entropion - malposition resulting in inversion of the eyelid margin, resulting iin ocullar irritation and damage Presentation of congenital entropions - Dysgenesis of the lower eyelid retractors may be present creating instability in the eyelid with consequent entropion, or a paucity of tissue may be present vertically in the posterior lamella of the eyelid. OR Structural defects in the tarsal plate Presentation of Acute spastic entropion - Spastic closure of the eyelids allows the orbicularis oculi muscle to overwhelm the oppositional action of the lower eyelid retractors, resulting in an inturning of the eyelid margin and further irritation of the ocular surface from the inturned eyelashes. Most of these patients often have an involutional component as well. Presentation of Involutional entropion - The patient may exhibit horizontal laxity of the medial and/or lateral canthal tendons what is the snap test? - a useful diagnostic maneuver. The eyelid margin is pulled away from the globe, with poor resultant snap back to the globe surface. Presentation of Cicatricial entropion - usually will display scar tissue of the conjunctiva, usually a result of trauma, chemical burns, Stevens-Johnson syndrome, ocular cicatricial pemphigoid (OCP), infections, or Mx. Digital eversion of the eyelid margin is difficult in cases of cicatricial entropion Cuases of congenital Entropion? - may arise due to a number of underlying developmental abnormalities, usually in the lower eyelid. Facial nerve paralysis in the pediatric population has been shown to be associated with lower lid entropion Cuases of spastic Entropion? - usually occurs as a result of ocular irritation, which may be due to infectious, inflammatory, or traumatic (eg, surgical) processes Cuases of Involutional entropion - usually is due to a constellation of problems. Cuases of Cicatricial entropion? - a result of scarification of the palpebral conjunctiva, with consequent inward rotation of the eyelid margin. what is epiblepharon ? - congenital condition in which the pretarsal orbicularis muscle and the skin covering the eyelid override the eyelid margin and push the eyelashes vertically or inwards. The eyelid margin in these cases actually is in a normal position. (common in asian , tends to resolve as face matures) what is Trichiasis - a very common lid abnormality, is defined as the misdirection of eyelashes toward the globe. The misdirected lashes may be diffuse across the entire lid or in a small segmental distribution What may you see during fundoscopic examination of a Pt with diabetic retinopathy? - Small microaneurism + hard exudates, due to damage of peri-retinal (from hyperglycemia), leaky micovasculature and osmotic damage from incomplete (glucose metabolism - sorbate) What are hard exudates? - Deposits of protein a lipid caued from microvascular leakage, creating yellow/white deposition on retina what is the hallmark of proliferative retinopathy? and what medaites it? - (this stage is advanced thus wil normally present with blurry vision & floaters) Vascular Proliferation of the peri-retinal microculature due VEGF realeased in reponse to ischaemia What are the complication of proliferative retinopathy? - Vitreous Heamorrhage, retinal detachment (sight threatening- unprediatable) Treatment for DM without retinopathy? - early and aggressive control of blood sugar & yearly dilted eye exam (preventive) Treatment for DM without retinopathy - early eye exam & control lood sugar + anti-VEGF +treat symptoms treatment of proliferative diabetic retinopathy - patients can be treated with laser photosoagulation, this is not necesisarily therputic as such but slows the progression and chance on complixations e.g. retinal detachment, vitrous heamorhage,etc what is diabetic retinopathy? - DM, disease of retina ,slow progressive comlication (regulate blood glucose!) What is supplied with blood from retinal pigment epithelium? - outer 1/3 of cones (outer portion) what is retinal detchment - speration of the multilayer nerosensory retina from the RPE, resulting in ischemia and rapid progressive photoreceptor death What is passive retinal detachment? - accumulation of fluid between the two layers what is active retinal detachment? - vitreous traction of the retina what is rhegmatogenous retinal detachment? - cause by underlying breaks/wholes in the retina, What is non-rhegmatogenous retinal detachment? - caused by leakage exudation or vitreous traction pathophysiology (rhegmatogenous) posterior vitreous detachment - strong vitreoetical connection leading to a full thickness tear or hole, fluid percolates though = retinal detachment pathophysiology of (rhegmatogenous) Traumatic retinal detachment - trauma can cause a retinal break & subretinal migration of liquid vitreus and development of RD pathophysiology of (non-rhegmatogenous) Tractional retinal detachment - strong attahment of the retina (seen in DM patient) with vitromacular traction sydrome, ROP & sickle cell retinopathy pathophysiology of (non-rhegmatogenous) exudative retinal detachent? - Accumulation of fluid beneeath the retina (inflammatorry conditions) pathophysiology of lattice degeneration (Non -rhegmatogenous) - Focal retinal thinning in periphery with overlying vitreous liquification pathophysiology of psuedoretinal detacchment (Non -rhegmatogenous) - Peripheral senile: retinoschisis: splitting of a peripheral retina wiht an elevated retinal layer (partial removeal from RPE) Risk factors for retinal detachments? - Myopia, cataract surgery PVD (90% u get in other eye) What is the clinical presentation of retinal detachment - increased floaters, flahses of light (tug on surface of retina causing mechanical depolarisation of axons), curtain like shadow over vidual ield & blurred vision what are the the different types of non rhegmatogenous RD? - tractional , lattice and pseudaopseudoretinal detachment what are the causes of Rhegmatogenous RD? - PVD, traumatic, retinal detachment diagnosis of retinal detachment? - Slit lamp (pigmented behind the lense (- vitrous haemorrhage get B san) & 360 degreee scleral depression exam treatment for patient with only posterior vitreous detachment? (vitrous liquification but no retinal detachment) - nothing but if worsening flashes, more floaters,+ with loss of peripheral vision or central vision warant evaluation for RD treatment for patient with retinal hole or tear w/o detachment? - Laser retinopexy (welding the retina around a tear, the risk of retinal detachment can be minimised) or cryotinopexy (same as above but with freeze) treatment for patient with large peripheral rhegmatogenous retinal detachment - pneumatic retinoplext, temporary peribulbular baloon, scleral bucke (belt wraps round tars like a belt to hold in place) or pars plana vitrectomy (removal of vetrous gel) what is penumaticretinopexy procedure? sucess rate? - ryotherapy followed y intravetreal gas buble - bubble rises and pushes retina again RPE (used for superior retinal tears) 70-80% what is scleral buckle procedure? success rate? - surgicall make indentation in wall and close to retainal break, then a belt-like items is placed round the eye to hold eye and sclera together and in place. 70-80% (used for types other than superior tears) whit is a viterectomy procedure ? sucess rate? - surgically take out vitroeus humor in contact with retina (pullin it aaway) 80-90% how long does it take retinal degeneration to occure after RD - approximately 12 hours thus swift intervention is needed presnetation of central vein occlusions? - +sudden painless loss of vision +retinal heamorhage (bth superficial flames and deep blot) in all 4 quadrnt of fundus with tortuous retinal venous system + optic nerve head swelling, cotton wool spots, splinter heamorhage and macular oedema are common + sometime vitreous heamorrhage clinical fature of retinal vein occlusion? - With time retinal heamorrhage may decreae of resolve: - macular oedema often chronic -epiretinal membrane may form -optocilliar shunt vessels neovascularisation of disc,etc may results in vitreous hemorhage or tractional retinal detachment pathophysiology of retinal vein occlusion? - can lead to macular oeadema due to an increase in vascaulr permeability caused by the formation of a thrombus in retinal veins, VEGF_A play role with endothelial cells. increases turbulent flow and retrograde intrvascular pressure = dmage of tigh junction between endothelial cell, content spils out in retina = macular odema = blurred central vission from the internal corrotid artery, which vessels split off to supply blood to the eye? which structure does it supply specifically ? - opthalmic artery central retinal artey inner retina and surface of optic nerve normal etiolgoy of retinal artery occlusion, in atrisk groups e.g. DM,Smoker & HTN ? why is it helpful to know this? - carrotid artery artherosclerosis - important due to furutre event risk -thus carotid endoartherectomy reduced further stroke risk in pt with retinal artery occlusion Normal etiology of retinal artery occlusion in pt 40yrs? - Cardiac emoboli e.g. A-fib - important as pt may need chronic anticoagulation what are the less common eitiologies of Retina Artey Ocllusion ? - -small artery diseas (local artheroma in central retinal artery -other vacsular e.e.g carotid artery diseaction, radiation injury to carotid and fribromuscular dysplasia -haematologi causes: sickle cell, hypercoagulable disorder and leukemia/lymhoma what are the most important inflamatory cause of retinal artery occlusion? - Giant cell arteritis (50years + w/o visible emboli) - lupus, polyarteritis nodosa and wegeners Clinical manifestations of Of central retinal artery occlusion? and whaat is seen on PEx? - acute vision loss (painless) - Visuall aquity of hand motion may be normal - cheery red macular a pale surroundings clinical manifestation of branch retinal artery occlusion ? and what is seen on PEx - monocular vision loss (restircted to part of visual feild) 50% with BRAO have imparrire Visual aquity sectorial patten o retinal opacification retinal emboli and more frequently seen Diagnosis of RAO/BRAO? - rarely requires confirmatory testing -flouresin angiography (good when atypical) ESR and CRP: in all patient w/o retinal emboli Prognosis of RAO or BRAO - BRAO - 80'% Central RAO - rarely improves during ROA/CROA how long can retina go without blood supply - 90-100 mins = no injury, 240 minute massive irreversible injury do corticosteroids improve outcome in Giant cell arthitis? - yes paitnets with CRAO due to GCA benefit from such treatment conservative treatments in RAO - occular massage increase aques outflow vi schlem canal acetazolamid, mannitol reduce iop nitroglycerines can dialte artery and dislodge clot more distaly and thus preseve more vision 95% o2/ 5% co2 : vasodilator and improved 02 How can you diagnose the etiology of ROA - iarotid imaging: carotid US, cervical MRI/CTA GCA - ESR, CRP Cardiac evaluation : holter monitor, baseline ECG and ECHO Hypercoagulation testing what is retinoblastoma? - neuroectodermal malignancy arising from retinal cells; a small round blue tumour of childhood. linked to RB1 located on 13q14 can be heritable or via acquired somatic mutations what is the two hit hypothesis of retinoblastoma - hild is born with one retinoblastoma mutation and acquires another after birth 90% spontaneously and 10% inherited from parents what is endophytic growth (classification of retinoblastoma) - when the tumor breaks through the internal limiting membrane and has an ophthalmic appearance of a white-to-cream mass showing either no surface vessels or small irregular tumor vessels. This growth pattern is typically associated with vitreous seeding, wherein small fragments of tissue become separated from the main tumor, thus a metastasis risk what is exophytic growth (classification of retinoblastoma) - occurs in the subretinal space. This growth pattern is often associated with subretinal fluid accumulation and retinal detachment. The tumor cells may infiltrate through the Bruch membrane into the choroid and then invade either blood vessels or ciliary nerves or vessels. Retinal vessels are noted to increase in caliber and tortuosity as they overlie the mass. what is diffuse infiltrating growth (classification of retinoblastoma) - It is characterized by a relatively flat infiltration of the retina by tumor cells but without a discrete tumor mass. The obvious white mass seen in typical retinoblastoma rarely occurs. It grows slowly compared with typical retinoblastoma. what questions should be asked during the history taking in retinoblastoma? - history of eye tumors, previous enucleation, or any malignancy in childhood in any of the family members what are the presenting symptoms of retinoblstoma? - *white relfex, *strabismus (eso/exotropia), red painful eye wit galucoma, poor vision. -Orbbital cellulitis, unilateral mydriasis , heterochroma iridis, hyphema, nystagmus, white spots on iris and anorexia/failure to thrive What secondary chagnes to the eye can occur in retinoblastoma? - glaucoma, retinal detachment and inflamation due to tumor necrosis what is a rare presentation of retinoblastoma? - pseudouveitis, with red eye pain hypopyon and hyphema. - charectoristic of an infiltrating RB in which tumour cells invade terina difuself w/o froming a discrete tumour mass or orbital inflamation mimicking orbital cellulitis may occur in eyes with necrotis tumour and does not necissarily imply extraoccular extension DDx for retinal blastoma ? - Congenital Cataract Exudative Retinal Detachment Pediatric Tuberculosis Retinopathy of Prematurity Uveitis, Anterior, Childhood Vitreous Hemorrhage relevant work-up in retinoblastoma? - -lab studies of LFT & urinalysis to exlude other Dx -DNA studies from tumor cell sof leukocytes, look for ss confirmational polyorphismor direct swequecing +PCR -assays of aques humour enxymes: LDH 1.0 -imaging: CT .MRI -ultrasonography : detec calcifications to distinguish RB from non-neoplastic conditions -immunohistopathological : S-antigen + interphotoreceptor retinoid binding protein (IRBP) What tretments are available for retinoblastoma w/o vitreous seeding ? -or children with progression of disease while undergoing chemoreduction - or tumours extending up to beyond the cut margin of optic nerve and what are the risks? - external beam radiation therapy- -cessation of bone growth causing midface hypoplasia, yonger the patient worse impact -Can increase risk of scondary cancer What tretments are available for retinoblastoma -large tumour or limited moderately sized tumoue (3) in non-critical area? and what are the risks? - Radioactive isotope plaques -advantages: local treatment, minimizing radiation to normal tissue -disadvantage - incomplete treatment, high doe to sclera, signif. less radiation for anterior lesion and difficulty placing posterior plaques When is chemotherapy indicated for RB patients? - -treatment for eyes in intraocular groups C and D. -Prophylactic if a tumor is in the optic nerve past the lamina cribrosa -neoadjuvant chemotherapy reduced posibilty of ERBT-related comlpications when is surgical care indicated in retinoblastoma patients? - removal of the tumor has been the standard management of very unfavorable retinoblastoma cases. when is enucleationg indicated in retinoblastoma patients? - performed when there is no chance of preserving useful vision in an eye. Patients generally requiring enucleation are those who present with total retinal detachments and/or the posterior segment is full of the tumor, in which case it is clear the patient cannot retain any form of useful vision. cause orbital growth retardation What tretments are available for small anterioryl located tumour, remote from the disc and macular or after reccurence from chemo? - Cryotherapy, it is performed transsclerally. Under direct visualization, freezing is carried out until the ice ball incorporates the entire tumor. A refreeze-thaw cycle is repeated 3-4 times. untill complete dissaoearance o tumor with flatpigmented scar (sign of success) Medical management of retinoblstoma? -antineoplastics? - Vincristine (blcoks mitosis in metaphase, by binding microtubular proteins) - & Carboplatin (inhibit DNA & RNA synthesis) -Etoposide (blocks cells in the late S-G2 cell cycle) Medical management of retinoblstoma? -immunosupressive? - cyclosporine (suppresses some humoral immunity and, to a greater extent, cell-mediated immune reactions such as delayed hypersensitivity, allograft rejection, experimental allergic encephalomyelitis) RB: classic regression patterns : type 1 - A ceoncession of tumour lump calcified mass "cottage cheese apphearance" RB: classic regression patterns : type 2 - change in charector of the tumour from a solid-looking, pink, vascuar, opaque tumour to a grayish less vascular translucent tissue "fish flesh" appearance RB: classic regression patterns : type 3 - combination of type 1 & 2 RB: classic regression patterns : type 4 - total loss of tuor, retina and choroid leaving bare sclera PEx of optic neuritis? - -Decreased pupillary light reaction in the affected eye: + (RAPD) or Marcus Gunn pupil commonly is found. In bilateral cases, the RAPD may not be apparent. -Varying degrees of vision reduction: from a mild decrease in visual acuity to complete vision loss,(often monocular but can be binocular) -Abnormal contrast sensitivity and color vision: nearly all Pt with decreased visual acuity. -Field defects: May include altitudinal, arcuate, nasal step, central scotoma, cecocentral scotoma. -Initially, the optic nerve head may appear normal. Papillitis (swollen disc) may be seen in one third of patients with optic neuritis Diagnosis of Optic neuritis. to rule out other neuopathies? - -MRI,*VEPS -ESR, throid function, anti-nuclear antibodiesm ACE enzyme, rapid plasma reagin & mitochondrial DNA mutation studies. Managent of Pt with optical neuritis? - -visual function improves post 1 week. -residual colour and contract defects are common -corticosteroids to decrease demyelinating inflamation, and thus vision loss -IV corticosteroid used in sever bi-lateral presentation What are the "traditional classification" for background retinopathy? - • microaneurysms (dots) • blot haemorrhages (=3) • hard exudates What are the "traditional classification" for pre-proliferative retinopathy? - • cotton wool spots (soft exudates; ischaemic nerve fibres) • 3 blot haemorrhages • venous beading/looping • deep/dark cluster haemorrhages • more common in Type I DM, treat with laser photocoagulation What are the "NPDR classification" for mild NPDR? - 1 or more aneurisms What are the "NPDR classification" for moderate NPDR? - • microaneurysms • blot haemorrhages • hard exudates • cotton wool spots, venous beading/looping and intraretinal microvascular abnormalities