Ophthalmology for 5th Year Exams

Clark Stevenson - Ophthalmology Registrar

Visual Acuity
Snellen chart measures minimum angle of resolution. Larger angle means
low-resolution vision. Visual acuity requires:
1. Light transmission
2. Image formation
3. Transduction into electrical signal
4. Transmission to visual cortex
5. Cortical processing

Visual fields

1. Single eye or optic nerve

2. Altitudinal defect from partial optic
nerve damage
3. Bitemporal hemianopia (pituitary
macroadenoma)
4. Homonymous hemianopia not sparing
macula (usually optic tract)
5. Superior homonymous quadrantopia
(damage to inferior part of optic radiation;
can have inferior quadrantopia if damage
to superior part)
6. Homonymous hemianopia sparing
macula (visual cortex damage from
stroke; macula spared due to dual blood
supply with partial supply from middle
cerebral artery)

Eye movements

Know:
- Third cranial nerve palsy (eye down and out, ptosis, dilated pupil) =
posterior communicating artery aneurysm
- Fourth nerve palsy = vertical diplopia, head tilt if torsion
- Sixth nerve palsy = horizontal diplopia
Pupils

Pupil reflexes:
- Direct and consensual
reflexes
- Near reflex (triad = miosis/
pupil constriction,
convergence, lens
accommodation)
- Swinging light test (for
relative afferent pupillary
defect/Marcus Gunn pupil)

Pathology:
- Marcus Gunn pupil
- Argyll-Robertson pupil (light-
near dissociation)
- Adie’s tonic pupil (idiopathic
degeneration of ciliary
ganglion)
- Holmes-Adie syndrome
(Adie’s + absent reflexes)

Anisocoria: is it worse in the

light (big pupil is abnormal) or
dark (small pupil is abnormal)?
- Small: old Adies pupil,
Horner’s syndrome (triad = miosis/pupil constriction, ptosis due to
paralysis of Muller’s muscle, anhidrosis, know signs of Pancoast tumour)
- Large: third cranial nerve palsy
Eyelids and lashes

- Orbital cellulitis = infection

spread past the orbital
septum. Symptoms/signs are
proptosis/globe protrusion,
painful or restricted eye
movement, diplopia if eye is
pushed out of alignment,
systemically unwell, may
have reduced vision due to
pressure and tension on optic
nerve. Patient needs
immediate IV antibiotics and
CT head.
- Stye = infected sebaceous
gland at base of eyelash
(“hordeolum”), conservative
treatment
- Chalazion = blocked
meibomian gland, not infected, treat with hot compresses
- Infected chalazion (also called “hordeolum”!!)
- Blepharitis = dry uncomfortable eye, worse in the morning, ongoing for
months
- Basal cell carcinoma; “madarosis” refers to focal eyelash loss due to
invasive lesion
Conjunctiva and Sclera
Subconjunctival hemorrhage
Dry eye

Conjunctivitis: discomfort, red eye, no loss of visual acuity

- Bacterial conjunctivitis: purulent exudate, usually unilateral, treat
with chloramphenicol
- Chlamydia: sexually transmitted or vertical transmission to
newborns. Worse conjunctivitis than typical bacterial, can last many
months if untreated. Consider concomitant gonorrhoea/other STIs.
- Must be treated in newborns to prevent blindness
- Viral conjunctivitis: weeping red eyes, quite itchy and
uncomfortable, typical history is a few days after patient has an
upper respiratory tract infection. Extremely contagious, lasts around
2 weeks. Contagious while eye is weeping. Consider
chloramphenicol to prevent secondary bacterial infection. Hand
hygiene very important.
- Allergic conjunctivitis: seen in patients with atopic triad (asthma,
eczema, hayfever). Affects both eyes immediately, often with lid
swelling and other associated features of hayfever. If it’s bad
enough it can cause a shield ulcer on the cornea where the rough
inflamed surface of the eyelids causes epithelial damage.

Episcleritis: the episclera is the outer layer of the connective tissue

sclera, you can get idiopathic inflammation in this layer. Painless or
mild discomfort, no loss of acuity.

Scleritis: inflammation of the sclera itself, usually related to systemic

autoimmune disease (e.g. rheumatoid arthritis). Severely painful red
eye, reduced vision, photophobia. MCQ tip: to differentiate from
uveitis, they would mention a blue/purple hue of the sclera (suggestive
of scleral thinning) and a deep, aching pain.

Pingueculum: benign deposition of protein, fat, or calcium on the

conjunctiva. No treatment required. Related to sun exposure.

Pterygium: pingueculae can grow onto the corneal surface as a ‘wing’

of tissue. Generally don’t need treatment unless the tissue grows over
where the pupil is and affects visual acuity.
Cornea

Chemical injury: can cause immediate blindness. IRRIGATE with

≥10L of water or saline, check conjunctival fornices for any
remaining particulate matter. Alkali worse than acid because
acid causes coagulative necrosis and stops itself, whereas alkali
causes liquefactive and eats into the cornea and can lead to
perforation.

Bacterial Keratitis: history of contact lens use, pain, red eye,

reduced vision, corneal opacity. Needs hospital admission.

Dendritic/branching ulcer: herpes simplex keratitis, do not give

steroids

Anterior chamber

Angle closure glaucoma: extremely painful eye (vomiting from

pain), age over 50, fixed mid-dilated pupil, hazy cornea, reduced visual
acuity. Give lots of eye drops and oral acetazolamide (Diamox, carbonic
anhydrase inhibitor) to reduce pressure. Immediate referral to
ophthalmology, can cause blindness within hours.

Uveitis

Uvea = iris, ciliary body, choroid (vascular coat of eye)

Anterior uveitis: red painful eye with reduced vision and

photophobia, usually in someone with a history of systemic
autoimmune/inflammatory condition.

Ophthalmic herpes zoster: conjunctivitis, keratitis, or uveitis

along with a painful crusting rash along the trigeminal
V1 dermatome (20% of all shingles!).
> Hutchinson’s sign: area of crusting on the ipsilateral
tip of the nose indicates nasociliary nerve involvement
which makes it much more likely that the cornea is
involved.
Lens
Cataract: gradual reduced vision over months to years,
yellow tint to vision, problems with glare especially when
driving at night. Faster formation in diabetes or with long-
term corticosteroid use. Cataracts do NOT cause RAPD.

Vitreous
Posterior vitreous detachment: occasional floater. If sudden detachment
can be many more floaters and can cause flashes due to traction on the
retina, which should be assumed to be a retinal tear until proven otherwise.

Vitreous haemorrhage: sudden shower of brownish floaters (retinal tear

until proven otherwise)

Endophthalmitis: usually post-surgical or after penetrating eye injury.

Intense pain, photophobia, red eye, markedly reduced vision, hazy cornea,
hypopyon (pus in anterior chamber).

Retina

Central retinal artery occlusion: sudden painless loss of vision,

history of hypertension, cherry red spot on fundoscopy. This is a
stroke and patient should be assessed for cardiovascular risk
factors and started on aspirin if indicated.

Central retinal vein occlusion: sudden painless loss of vision,

history of hypertension. “Blood and thunder” appearance of
fundus.

Hypertensive retinopathy: silver/copper wiring, cotton wool

spots, retinal haemorrhages, high blood pressure.

Age-related macular degeneration: loss of central vision in older

people. Dry type is slow loss; wet type has faster loss over
hours-days due to bleeding or fluid accumulation. Treated with
anti-vascular endothelial growth factor (VEGF) agents.

Retinal detachment: flashes and floaters, black curtain coming

down over vision that doesn’t go away. Risk factor is myopia/
short sightedness.

Non-proliferative diabetic retinopathy: haemorrhages,

microaneurysms, venous beading, microvascular abnormalities.
No symptoms!

Proliferative diabetic retinopathy: growth of new blood vessels

over the disc or macula, 50% risk of blindness from retinal
detachment, vitreous hemorrhage, scarring. Treated with anti-
VEGF, panretinal laser photocoagulation, and ensuring diabetes
is controlled.
Optic nerve

Cup/disc ratio: bigger cup means smaller rim of axons,

axons have died from glaucoma

Optic nerve swelling: transient visual loss, RAPD,

blurred disc edges. Note that this is not papilloedema
necessarily, should be symptoms of raised intracranial
pressure to call it papilloedema (headache, nausea/
vomiting). Optic neuritis is another cause of swelling
and will also cause pain on eye movements.

Glaucoma

Causes death of axons as they exit the eye to form the

optic nerve. No symptoms until advanced and all
peripheral vision lost. Causes arcuate scotomas.
Screen from 50, or 35 if family history.

Reduce aqueous Increase aqueous

production absorption
Beta blockers Prostaglandin
(timolol) analogues
(latanoprost/
Alpha agonist
(brimonidine)
Carbonic
anhydrase
inhibitor

Refractive error

Emmetropia = no refractive error

Myopia: light focused in front of retina, usually

due to longer eye. Higher risk of retinal
detachment.

Hypermetropia/hyperopia: light focused

behind retina due to shorter eye, higher risk of
angle closure due to narrow angles.