Notes in ophthalmology

MCQ ,OSCE ,SLID.

Bahcet”s disease
 Idiopathic , recurrent ,
 More common in male ( 20-30 yrs)
 Bilateral iridocyclitis with hypopyon + post. Uveitis
General lesion:-
 Oral & genital ulcer.
 Erythema nodosum.
 Acniform.
 Arthritis
 Gastritis& gastric ulcer.
+ve pathergy test
 TTT:-
o Topical& systemic steroid& sub conj. Injection.
o Atropine 1% 3tim/ day E.D

Toxoplasmosis
 Toxoplasma gondi is intracellular protozoa.
 The cat is the definitive host.& other animals are intermediate host.
 Fundus change:-
 Chorioretinal atrophy & scar with pigmented border.
 Bilateral vitritis , vasculitis , papillitis
 Investigation:- ELISA test.
 TTT:-
 Clindamycin 300mg
 Septrin tab
 Systemic steroid .

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 Duane syndrome :- ( mcq only)
 It is retraction globe & limitation of ocular motility.
 Contraction of medial recti ms.& lateral recti ms.
 Some children have associated congenital defect ( deafness with speech
disorder)
Classification:-
Type I:-
 most common , limitation or abscent of abduction.
 Normal adduction. Slight esotropia in primary position.
Type II:-
 Least common , limitation or abscent of adduction .
 Normal or limitation of abduction.
 Slight exotropia in 1ry position.
Type III:-
 Limitation adduction & abduction . straight or slight esotropia in 1ry
position.
Other feature:-
 Narrowing of palpebral fissure in abduction.
 Up- shoot or down- shoot in adduction is seen in some PT.

Giant cell arteritis :- ( GCA)

 Is granulomatous necrotizing arteritis  superficial temporal a.
 Common age 70 -80 yrs.
 Scalp tenderness , headache .
 Jaw claudication.
 Superficial temporal arteritis.
Investigation:-
 ESR.
 C-reactive protein. High.
 Platelet counts .
 Temporal artery biopsy.

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 Complication:-
1- Amourosis fugax ( transient ischaemic attacks).
2- Central retinal artery occlusion .
3- Ocular ischaemic syndrome .
4- Cortical blindness.
TTT:- systemic steroid.

Collagen diseases:- ( R.A. , SLE,):-

Ocular menifastation :-
1- Keratocojunctivitis sicca ( xerosis)
2- Keratomalacia.
3- Ant. Uveitis
4- Scleritis & episclertitis.
5- scleromalacia

AIDS:- (Ocular menifastation )

 retinopathy.
 Posterior uveitis ( choroiditis)
 Kaposi sarcoma.

Systemic hypertension:-
1- Hypertension retinopathy.
2- Sub-conj. Hge.
3- CRAO ,CRVO.
4- Ocular motor n. palsy.
5- Ischemic optic neropathy.

Vitamin A deficiency:-
1- Xerosis.
2- Keratomalacia.
3- Night blindness.
4- Corneal ulcer.
5- Madarosis.

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 Ocular pharmacology
Mydriatics & cycloplegia
1- Parasympatholytics:-
o Atropine 1% ( duration of action 15 -20 days)
o Homatropine 1%
o Hyoscine 0.25%
o Cyclopentolate 1% short duration
o Tropicamide ( mydriacyl) 1%
2- Sympathomimetics:-
o Phenyl – ephrine . 2.5 – 10 %
o Adrenaline ( sub- conj. Injection)
 Action:-
1- Pupillary dilation
2- Loss of accommodation.
3- Prevent post. Synechia & break any new synechia.
4- Decrease pain.
 Indications:-
1- Corneal ulcer‫ز‬
2- Uvitis  atropine  long duration
3- Accommodative squint in children < 3 yrs.
4- Before fundus examinationtropicamide  short duration
5- Before laser for fundus.
6- Before F.A. & fundus camera
7- Before YAG laser capsulotomy
8- Before retinoscopy in children < 10 yrs.
9- Pre- operative  cataract , & retinal surgery.
10- Used in cases amblyopia .

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 Side effects:-
1- Atropine toxicity :-  due to systemic absorption.
*c/p:- fever , flushing face , fits , fast heart (tachycardia) ,dry
mouth & skin.
*TTT:- cold compressors + antipyretics.
Pilocarpine 10 mg. IM.
2- Atropine sensitivity  use cyclopentolate.
NB:- not used in shallow A/C lead to CAG.
3- Increase IOP.

Miotics:- parasympathomimetics( pilocarpine 1- 4% )

 Indications :-
1- TTT of POAG.
2- TTT of same cases of accommodative squint.
3- Used before *goniotomy . * keratoplasty * iridotomy (YAG laser)
4- Used before  trabeculectomy.
5- Used after  goniotomy to prevent synechia.
 Side effects:-
1- Headache , bradycardia , GIT disturbance.
2- Myopia.
3- Visual field defects.
4- Cystic iris.
5- Cataract .

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 Corticosteroids:-
 Action :-
o Anti- inflammatory.
o Anti – Allergic.
o Anti- fibroblastic .
 Indications :-
o Lid:- dermatitis , insect bites . small chalazion.
o Conj:- allergic conjunctivitis , spring catarrh , prevent
symblepharon.
o Anter. Segment:- interstitial keratitis , episcleritis ,
scleritis.
Iridocyclitis , chemical bruns.
o Post cataract operation .
o Post keratoplasty.
NB:- all above used topical steroid.( E.D & E.O)
o Posterior segment :- use topical & systemic steroids.
 Post . uveitis.
 Optic neuritis.
 Sympathetic ophthalmitis.
 Used with avastin injection for ischemic retina( PDR &
CRVO)
 Dangers of local steroid :-
1- Steroid induced glaucoma.
2- Steroid induced cataract ( post. Subcapsular)
3- Increasing susceptibility to infection .
4- Reactivation of organisms H.S , H.Z.
5- Delaying wound healing.
 Dangers of systemic steroids ( prolonged use)
1- Peptic ulceration.
2- Induced diabetis.
3- Hypertension due to salt & water retention.
4- Induced cataract.
5- Osteoporosis.
6- Cushingoid state.
7- Psychic disturbances.
N.B:- sudden stoppage after prolonged use leading to acute
adrenal insufficiency.

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  Avastin:- ( anti vasogenic factor)( anti- VEGF)
 Use :- for regression of new BVs of retina
 Intravitreal injection at pars plana by insulin needle.
 Indication:-CRVO, PDR.
 Local anesthesia:- E.D  novacin .
 Indications :-
1- Any instrument touch the cornea :-
o Tonometry.
o Goniolens
o Removal of F.body.
o Removal of suture.
2- Dilatation & sac syringing .
3- Cataract extraction( phaco).
 Flourescine staining:- (water soluble)
 Indications :-
1- Stain base of corneal ulcer.
2- Applanation tonometry. ( diagnosis of case glaucoma)
3- Hard contact lens fitting. (Hard CL)
4- Break up time (BUT ) test ( dry eye).
5- Jones test( evaluation of lacrimal drainage system)
6- Siedel”s test ( wound leakage).
7- Flourescine angiography.( F.A)
Use in diagnosis of :-
a- CRVO & BRVO.
b- CRAO & BRAO.
c- DR.
d- Hypertensive retinopathy.
e- Macular disease.
f- Papillodema.
g- Age related macular degeneration.
h- Befor fundus laser( argon or diode laser)

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  Rose Bengal stain:-
rose in color & painful  stain dead & infected epith.
 Indications :-
1- Edges of corneal ulcer .
2- Dry eye.
 TTT of dead cell ( epith) debridement or excimer laser.

 Drug induced cataract:-

1- Steroid  systemic & topical.
2- Gold.
3- Allopurinol.
4- Miotics.
5- Amiodarone.
6- Busulphan( myleran).
7- Chlorpromazine.

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 Differential diagnosis
 D.D of deep A/C
1. Aphakia.
2. High myopia.
3. Hypermature cataract.
4. Buphthalmos.
5. Keratoconus.
6. Keratoglobus.
7. Total posterior synechia.
 D.D of shallow A/C
1. hypermetropia .
2. microphthalmia.
3. Acut angle closure glaucoma.
4. Iris bombe.
5. Intumescent cataract.
6. Wound leakage.
7. Plana cornea.

 D.D of irregular depth of A/C

1. Leucoma adherent.
2. Sublaxation of lens.
3. Peripheral anterior synechia or anterior staphyloma.
4. Tumor of iris .& keratectasia.

 Abnormal contents of A/C:-

1- Blood ( hyphema).
2- Pus ( hypopyon)
3- IOL or lens
4- F.body.
5- Silicon oil .( inverted hypopyon)
6- Air bubble  post cataract operation
7- Protein ( aqueous flare)
8- Inflammatory cells .
9- Vitreous.

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  D.D of hypopyon ( pus in A/C):- ( endophthalmitis)
1- Post –operative.
2- Post – traumatic.
3- Active iridocyclitis.
4- Behcet syndrome.
5- Intraocular tumor.
6- Retained intraocular F. body.
7- Corneal abscess
.
 D.D of hyphema ( blood in A/C).
1- Trauma (most common)
2- Rubeosis iridis.
3- Acute herpes iridocyclitis.
4- Blood diseases.
5- Intraocular tumor.( Retinoblastoma.)
6- Drugs ( heparin , aspirin)

 D.D of hypotony:-
1- Trauma
2- Cyclitis.
3- Cyclodestruction .
4- Retinal detachment.
5- Post. Trabeculectomy.
6- Phthisis bulbi.

 D.D of enophthalmos :- ( small globe)

1- Congenital .
2- Senile .
3- Traumatic.
4- Horner syndrome.
5- Rubella syndrome.
6- Phthisis bulbi.

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  D.D of heterochromia:-
1- Xalatan. ( antiglaucoma drug)
2- Horner syndrome
3- Nevus of ota.
4- Melanoma of iris .
5- Congenital.
6- Steurge weber syndrome.
7- Sidrosis bulbi.
8- Rubeosis iridis.

 D.D of Giant papillary conjunctivitis :- ( causes)

1- Exposure suture .
2- Ocular prostasis. ( corneal prostasis)
3- Hard C.L wear.
4- Spring catarrh.

 D.D of megalo-cornea ( large ):- > 13 mm

1- Marfan syndrome.
2- Buphthalmos .
3- High myopia.
4- Physiological.
 D.D of micro- cornea (small):-< 11mm
1- Hypermetropia .
2- Microphthalmos.
3- Physiological.

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 Red eye

Types :-
1- Ciliary injection:-(hyperaemic at limbus)  painful.
2- Conjunctival injection :- ( at bulbar conj. & fornix) painless.
3- Sub conjunctival Hge.  painless.

D.D of ciliary injection +/_ conjunctival injection:- ( painful redness)

1. Corneal ulcer.
2. Corneal F .body.
3. Corneal graft rejection.
4. Acute iridocyclitis.
5. Acut congestive glaucoma.
6. Endophthalmitis & panophthalmitis.
7. Episcleritis & scleritis.
8. Orbital cellulitis.

D.D of sub- conjunctival Hge. :-

1. Post- operative.
2. Post – traumatic. ( head & ocular )
3. Increased systemic hypertension.
4. Blood diseases.
5. Increased intra abdominal pressure ( constipation , during labour)
6. Increased intra thoracic pressure ( cough).
7. Conjunctivitis  viral infection.
8. Sub conjunctival injection  insulin needle.

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 D.D of conjunctival injection :- conjunctivitis only & painless.

N.B:- effect of adrenaline E.D on BVs:-

 Conjunctival injection :- vessels are constricted early.
 Ciliary injection :-vessels are constricted after 1hr.
 Episcleritis & scliritis :- vessels are constricted late ( after 3-4 hrs)

D.D of discoloration of sclera:-

Blue sclera:-
1. Staphyloma.
2. Marfan syndrome.
3. Buphthalmos .
4. High myopia.
5. Osteogensis imperfecta.
6. Physiological in infant.

Brown sclera:-
1. Nevus .
2. Malignant melanoma.
3. Capillary perforation.

Yellow sclera:- Jaundice . ( upper part of sclera)

D.D of sudden loss of vision:-

1. Central retinal artery occlusion. ( CRAO)
2. Central retinal vein occlusion.( CAVO) ischemic type
3. Hysterical , malingeres. painless
4. Amaurosis fugax.
5. Rupture globe  massive vit. Hge. ( painful)

D.D of rapid decrease of vision :-

1. In few hours:- Vit. Hge.

2. CRVO  non ischemic type . (painless)

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 3. Acut congestive glaucoma.( painful)
4. Commotio retina ( painless)

In few days:-
1. Corneal ulcer.
2. Acute Iridocyclitis. painful
3. Optic neuritis.
4. RD. & choroiditis. ( painless)

D.D of Gradual painless diminution of vision:- ( within months or

years)
1. Keratoconus.
2. POAG.
3. senile Cataract.
4. Age – related macular degeneration.
5. Vit. Opacity .
6. R.P.
7. Retinopathies ( DR)
8. 1ry optic nerve atrophy.
9. Amblyopia
10. High myopia.
11. Papilledema

D.D of Transient loss of vision:- ( amaurosis fugax)

1. CRAO
2. Giant cell arteritis.
3. Carotid artery disease.
4. Papilledema.
5. Migraine.
6. Severe hypertension

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 Main causes of painful decrease of vision:-
1- Corneal ulcer.
2- Acute iridocyclitis.
3- ACG.
4- Endophthalmitis& panophthalmitis.
Main causes of diminution of vision in infants:-
1- Congenital glaucoma.
2- Congenital cataract.
3- Progressive myopia.

Photopsia = flashing of light:-

Causes: Retinitis , choroiditis , high myopia , RD.

D.D of Photophopia: ( can’t see in light)

Causes:-
1- Corneal ulcer.
2- Acute iridocyclitis.
3- Endophthalmitis.
4- Orbital cellulitis.
5- Acute congestive glaucoma.
6- Albinism ( trans-illumination)
7- Viral conjunctivitis.
8- Spring catarrh.

D.D of Night blindness:- ( it means difficulty to see in dim illumination)

1. vit .A Deficiency.
2. POAG.
3. Sidrosis bulbi.
4. PRP. ( pan retinal photocoagulation).
5. Cortical cataract.
6. R.P.
7. High myopia.
8. Congenital (rare).
9. Drugs toxicity ( phenothiazine).

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 D.D of day blindness:- ( it means difficulty to see in bright illumination)
(Central scotoma)
1. Central corneal opacity .
2. Nuclear cataract.
3. Post. Subcapsular cataract.
4. Macular lesion.

D.D of Colour blindness:-

1. Congenital ( most common cause , common in male)
2. Acquired :-
a- Papilledema.  blue
b- Papillitis.  red & green.
c- Macular lesion.
d- Drugs:- digoxin , chloraquine
NB:- test of color vision  ishahara test slide ,mcq

D.D of decrease of near vision :-( loss of accommodation)

1. Presbyopia
2. Psudophakia.
3. POAG.
4. Mydriatics & cycloplegics.
5. Trauma ( paralysis of ciliary body).

D.D of monocular diplopia:- (uniocular diplopia)

1. Sublaxation lens. Except if hypermature cataract was the cause.
2. Iridocyclitis.
3. Large peripheral iridectomy.
4. Polycoria.
5. Immature cataract.

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 D.D of binocular diplopia:-
1. Paralytic squint ( 4th , 6th n . palsy )
2. Myasthenia gravis.
3. Symblepharon.
4. Blow out fracture (fracture of floor of orbit up gaze
5. Proptosis. ( graves’ disease)
6. Pterygium.
7. Psudo-tumor.
8. Anisometropia  with glasses anisokonia.

D.D of corneal odema:- 3P + 1C

1. Post – operative.
2. Post- traumatic. Damage corneal endothelium.
3. High –IOP
4. Corneal ulcer.  damage corneal epith.
Ttt:-hypertonic saline solution E.D 5%. & bandage CL.
 D.D of loss of corneal sensation:-
1. Herpes simplex & zoster infection. (viral keratitis)
2. Neuroparalytic keratitis. (trigeminal damage)
3. Corneal edema.
4. Acute & absolute glaucoma.
5. DM.

 D.D of corneal discolouration:-

1. Band shaped keratopathy  calcium deposition .(white)
2. Arcus senilis  lipid deposition. (White)
3. Fleisher ring  iron deposition. (Brown)
4. Kayser – fleischer ring  copper deposition. (Gold)
5. Hyphema  boold stain. ( green)
 D.D of all spots in eye :-
1. Tranta spot  spring catarrh.
2. Bitot spot  dry eye.
3. Herbret spots  trachoma.
4. Cherry red spot CRAO
Commotion retina
Amoratic family(TAY- sack”s disease)

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 Quinine poising
5. Cotton wool spot ( soft exudates).
 DR.
 CRVO
 Hypertnsive retinopathy.

 D.D of chemosis :- ( conjunctival edema)

1) Conjunctivitis.
2) Myasis.
3) Orbital cellulitis.
4) Graves’ disease.
5) Endophthalmitis & panophthalmitis.
6) Trauma.

 D.D of mass at the limbus:-

1- Apex of pterygium.
2- Pinguecula.
3- Foreign body.
4- Tumor ( dermolipoma , epithelioma , melanoma, hemangioma)
5- Phlycten.
6- Episcleritis.

 D. D of irregular pupil:-
1- posterior synechia.
2- leucoma adherent.
3- coloboma of iris .
4- post operative.
5- post. Traumatic.
6- Iridodialysis . (D-shape pupil).
7- argyll- Robertson pupil.

 D.D of semi – dilated pupil:-

1- acut congestive glaucoma. ( vertical oval)

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  D.D of fixed dilated pupil :-
1- optic nerve atrophy. (& its causes)
2- Coma ( subdural Hge.)
3- Blunt trauma.
4- Adie’s pupil.
5- 3rd near palsy  surgical type.
6- Myopia.
7- Buphthalmos.
 D.D of miosis pupil :-
1- Mild blunt trauma.
2- Miotic drugs.
3- Acute iridocyclitis.
4- Hypotony.
5- Hypermetropia.
6- Horner syndrome.
7- Argyll robertson pupil.
8- Pontine Hge.
 D.D of indications of peripheral iridectomy.
1- Trabeculectomy.
2- Sub –acute closed angle glaucoma.
3- Follow eye in case of acute congestive glaucoma.
4- Aphakia.
5- IOL A/C.

 D.D of indications of peripheral iridotomy:- ( YAG laser )

1- Iris bombe.
2- Sub –acute closed angle glaucoma.
3- Follow eye in case of acute congestive glaucoma.
4- Aphakia.
5- IOL A/C.

 D.D of indications of IOL A/C:-

1- Rupture of post. Capsule  ECCE , phaco,
2- Phakic IOL ( artisan lens ) .
3- ICCE.

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  D.D of anisocoria :-
1- Horner’s syndrome.
2- Adie’s pupil.
3- 3rd nerve palsy  surgical type.
4- Unilateral :  acut iridocyclitis.
 Blunt truma.
 Drugs ( miotics Or mydriatics)
 D.D of iridodenesis :-
1- Aphakia.
2- Posterior dislocation of lens.
3- hypermature cataract.
4- Subluxation lens.
5- Buphthalmos.
6- High myopia.

 D.D of Leukocoria (white pupil):-

1- Retinoblastoma.
2- Retinopathy of prematurity ( R.O.P)
3- Congenital cataract.
4- Coats disease.
5- Coloboma of choroid.
6- Persistent hyperplastic primary vitreous.
7- Ocular toxocariasis.
8- Ocular toxoplasmosis.
9- Endophthalmitis & panophthalmitis.

 D.D of swollen optic disc :-

1- Papilledema.(& its causes)
2- Papillitis.
3- Hypotony.
4- Graves’ disease.

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  D.D of head tilting:-
1- Paralytic squint ( except 3rd n. palsy)
2- Astigmatism .
3- Unilateral ptosis.
 D.D of vitreous floaters ( musca folitans ) :-
1- Vit. Hge
2- Post. Uveitis.
3- R.D
4- High myopia.
5- Intra-ocular tumor ( tumor cells).
6- Vit. Opacity.
7- Old age .
8- Congenital.
9- Physiological.
 D.D of cyctoid macular oedema (CMO) :-
1- D . retinopathy.
2- Hypertensive retinopathy.
3- Post . lens extraction.
4- Hypotony.
5- Uveitis.
DX:- OCT

N.B:-
 when we do not operate for cataract ?
o no PL .
o bad projection of light.

 What are main causes of loss of vision 2nd day after cataract
Extraction?
o IOL is tilting or Wrong calculations.
o Vit. Hge.
o Choroidal detachment .
o Wrong pre-operative assessment of ( optic N. , macula ,
peripheral retina.)

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