Ophthalmology for

finals
Dr Charlotte Smith ~ F1 AFP Research
MBChB
Ophthalmology
The Theory
Anterior chamber: The Posterior chamber: The
anterior chamber is the posterior chamber is
front part of the eye between the iris and lens.
between the cornea and the
iris.
Qu.1

What is the canthus?

Qu.2

What is the function of

the caruncle?

Qu.3 FUN fact

Why does it swell/go

red?
 ● Accommodation: ​when the lens
changes shape to focus on near objects
(ciliary muscles used)
● Acuity: ​how well the eyes see a small
or distinct object
● Amblyopia: ​acuity uncorrected by
lenses. No anatomical defect.
● Ectropion:​eyelid goes out
● Entropion: ​eyelid goes in
Definitions ● Limbus:​the point where the cornea
and the sclera meet
● Macula:​retinal area. This 5mm lateral
Useful for exam questions to the optic disc
● Miotic: ​agent leading to pupil
constriction. E.g. pilocarpine
● Mydriatic: ​agent leading to pupil
dilation. E.g. tropicamide
● Presbyopia: ​age-related reduced near
acuity
Questions: give the muscle,
movement and innervation of the
following labels on this right eye:

1.

2.

5.
Questions: give the muscle,
movement and innervation of the
following labels:

1. Lateral Rectus: abducts the eye

Innervation: Abducens nerve
Questions: give the muscle,
movement and innervation of the
following labels:

1. Lateral Rectus: abducts the eye

Innervation: Abducens nerve

2. Inferior Rectus: depresses,

adducts and extorts the eye.
Innervation: Oculomotor nerve
Questions: give the muscle,
movement and innervation of the
following labels:

1. Lateral Rectus: abducts the eye

Innervation: Abducens nerve

2. Inferior Rectus: depresses,

adducts and extorts the eye.
Innervation: Oculomotor nerve

5. Superior Oblique: Depresses,

abducts and intorts the eye.
Innervation: Trochlear nerve.
Case Study:
Greg a 60 yr old male has been going
to his GPs with recurrent headaches
for the past 3 months. Under his GPs
suggestion he goes to see his optician
who notices he has a bitemporal
hemianopia.

Qu.1 Where is the lesion on this

diagram?

Qu.2 What is the most likely cause of

this?

Qu.3 What other symptoms could he

be having?
Case Study:
Greg a 60 yr old male has been going
to his GPs with recurrent headaches
for the past 3 months. Under his GPs
suggestion he goes to see his optician
who notices he has a bitemporal
hemianopia.

Qu.1. 2

Qu.2 pituitary tumour likely

macroadenoma

Qu.3 any symptoms of pituitary

dysfunction!! I.e any hormones there
can be affected.
Case Study:
Greg a 60 yr old male has been going
to his GPs with recurrent headaches
for the past 3 months. Under his GPs
suggestion he goes to see his optician
who notices he has a bitemporal
hemianopia.

Qu.1. 2

Qu.2 pituitary tumour likely

macroadenoma

Qu.3 any symptoms of pituitary

dysfunction!! I.e any hormones there
can be affected.
Please have a minute to work
out the visual field defects in
the following:

1.

3.

4.

5.
Quadrantanopia explained:

At the lateral geniculate bodies

our optic radiations split into a
further two. To make 4.

Two are superior (lateral)

Two are inferior (medial)

Which is how you get a

superior or inferior
quadrantanopia.
Common Eyelid Diseases
What is this
condition?

What other condition

is this commonly
associated with?

What is the
management of that
condition?
 Normally affects all 4 eyelids.

Pathogenesis:​either anterior blepharitis (staph

infections) or posterior blepharitis (meibomian

Blepharitis
gland dysfunction)

Symptoms:​painful + gritty eyes. Worse first

thing on a morning

Signs: loss of eyelash, recurrent chalazion and

styes.

Management: incurable. Lid hygiene, warm

massage +/- tear substitutes or
chloramphenicol ointment

Red Flag:​unilateral blepharitis think is this a

tumour?

Fun fact: Can be associated with Rosacea (treat

with metronidazole)
Eyelid lumps
 Stye: infection at the base of the anterior
eyelash:
● Can be associated with recurrent
blepharitis or diabetes
● It leads to uncomfortable feeling on the
eyelid
Eyelid lumps ● Management: self-limiting, hot flannel, if
recurrent may need to puncture and
drain.

Chalazion: inflammation of the meibomian

glands of the posterior eyelid

● It presents as discomfort and a lump. It

will generally be red and nodule in
appearance
● Management: ​lid massage and if
particularly troublesome surgery
Causes of red eyes
Non emergency presentations
 3 types

Viral: most common type. Likely adenovirus.

Mx reassurance. Likely to get sore throat and
Conjunctivitis: clear eye discharge.

Allergic: acute allergy, meds, hay fever,

Clear mucus eye discharge. Mx
antihistamine eye drops or oral antihistamines

Bacterial: normally staph infections. Can be

STD related. Mx abx drops.

General symptoms: conjunctival blood

vessel dilation. Vision can be affected but
resolves after a blink.

RED FLAGs: one eye, neonate or recurrent

 Name two things that
decrease tear
production:

Keratoconjunctivitis What rheum condition is

associated with dry

sicca (Dry eyes)

eyes?

What ix would you do?

True or False

Decreased tear
production increases
chance of infection?
 Fun fact you have two types of tears: basal
(constant) and reflex (emotion and trauma)

Things that decrease tear production:

Keratoconjunctivitis anticholinergics, conjunctivitis, allergies or blepharitis

Sx : gritty burning eyes. Sensation of a foreign body.

sicca (Dry eyes) Generally gets worse as the day go on.
Can leave the eyes feeling really heavy, blurred and
teary

Ix: fluorescein drops and a slit lamp

Mx: topical lubricant eye drops

Need to rule out Sjogren’s Syndrome. Schirmer’s test!

 What is it?
Sudden onset bright red eye.
Subconjunctival Blood is free to move into the subconjunctival space.
So one small Haemorrhage can spread fast!

Haemorrhage Presentation:
Generally unilateral and asymptomatic

Management: check for signs of trauma. Need to

avoid aspirin + NSAIDs

Question: what blood test would you like to do?

Episcleritis

What are some RED

FLAGs you need to
keep an eye on for
this condition??
 Common in Younger People

What is it?

Episcleritis ●

●
The episcleral is a thin vascular tissue layer
between the conjunctiva and the sclera
Very common condition

Presentation:
● Acute in onset
● Normally affects one eye
● No pain can cause some discomfort
● Very localised superficial red eye

RED FLAG: need to rule out scleritis. Is it painful? Is it a

deep red in colour? Does the patient have any AI
conditions?
Causes of red eyes
EMERGENCY presentations
 Which of the following
Scleritis conditions is not associated
with developing scleritis?

A. Rheumatoid Arthritis
B. Polymyalgia Rheumatic
C. Vasculitis
D. Psoriasis
E. SLE
 Common in Older People with pre-existing
AI conditions

Scleritis Definition: affecting the full thickness of the

sclera. Very rare condition

Associated conditions: systemic vasculitis,

RA and polymyalgia rheumatica

Presentation: severe eye pain. Worse on

movement. Photophobia and reduced visual
acuity with a deep diffuse red sclera.

Mx: URGENT referral. NSAIDs and

immunosuppression and need to treat
underlying disease
What is the most likely cause of
this gentleman’s presentation?

A. Syphilis
B. Periorbital cellulitis
C. Graves’ disease
D. Carotid artery aneurysm
E. Acute angle closure glaucoma
 What is it?

Cortical Cavernous
Condition that likely follows a carotid aneurysm
rupture. Causing a reflux of blood into the
cavernous sinus.
Fistula Aetiology:
Surgery, trauma or spontaneous

Presentation: normally unilateral

● Engorged eye vessels, lid and conjunctival
oedema, bilateral proptosis and diplopia.
● Pulsatile loud bruit over the eye/ sensation of
tinnitus

Investigations: MRI arteriography.

Management: Surgery
 NOTE: very serious but rare

Common pathogens:
Pseudomonas and Staph organisms

Bacterial Keratitis Note all contact lens related infections will be

Gram -ve so pseudomonas

RF:
Contact lens wearer, smoker, poor hygiene,
immunocompromised or trauma

Presentation:
● Normally unilateral
● Moderate to severe pain
● Rapid onset
● Red eye
● Photophobia and poor vision
● Eye discharge

Now name 3 signs you can see

Signs include
Epiphora
Lid oedema
Hypopyon

Management:
● Corneal scrap for culture and sensitivities.
● Start abx immediately

Note: marginal keratitis presents with a sore red

eye. But no visual symptoms. Mx is with steroids
and abx
How do you
investigate this
condition?

What is the name

given to this sign?

What is the
management?

What is CRUCIAL to
avoid in this
condition?
 ● Common in children and is normally
HSV Keratitis ●
unilateral.
Tend to have vesiculobullous eruptions
across the body preceding pain and
erythema
● The patient can have eye discomfort,
photophobia, light sensitivity

● Investigation:​fluorescein drops
(dendritic)
● Management:​acyclovir. NO STEROIDS
Acute Anterior What 3 things make
up the uvea?
Uveitis/Iritis
What will you see on slit
lamp?

How do you manage

the condition?
 Uvea: is the iris, ciliary bodies and choroid

Aetiology: Seronegative arthritis, sarcoidosis

Symptoms:

● Generally unilateral and appears acute

● There is an intensely painful red eye
Acute Anterior ● Reduced vision and photophobia

Signs:
Uveitis/Iritis ● Intense global redness
● Irregular pupil
● Variable intraocular pressure (often is low)

Investigation: On slit lamp: fibrin clot in the anterior

chamber. These are keratic precipitates (WCC deposits).

Management:

● Need to determine the cause (bloods, antibodies,

CXR etc)
● Treat with eye dilation (cyclopentolate) and
prednisolone drops
Orbital and Periorbital
Label picture A + B
cellulitis either orbital or
periorbital
cellulitis
 Periorbital

Sx: fever, erythema, tenderness and oedema,

normally unilateral

Orbital and Periorbital Cause: H influenzae or s pneumonia

cellulitis Mx: prompt treatment w/ iv abx to prevent orbital

cellulitis

Orbital cellulitis:

Sx: proptosis, painful eye movement and reduced

visual acuity

Mx: CT to assess for spread, LP to exclude

meningitis, abx IV cefotaxime
 Gladys a 72 yr old with hypermetropia. She went
to the local pot luck meal at the village hall last
How would you night. But has been vomiting since the early hours
treat this? of the morning.

She has a headache but put this down to being

dehydrated and the vomiting bug.

When she tried to get out of bed her left eye

became very painful and she had to double check
√ to see if she was wearing glasses her vision was
so bad!

What’s the most likely diagnosis?

A. A. Chronic open angle Glaucoma

B. B. Acute open angle glaucoma

C. C. Acute closed angle glaucoma

D. D. Chronic closed angle glaucoma

 Rare but important cause of red eye

RF: ​old and long-sighted

Symptoms: ​unilateral eye pain, red eye,

headache, nausea and vomiting and poor
vision
Glaucoma Signs: ​corneal oedema, mid dilated pupil
Acute Angle Closure
Investigations: ​tonometer

Management: ​Reduce IOP with oral

acetazolamide and IV mannitol. Give
Pilocarpine drops to constrict the eye and BB
drops (timolol). Surgery can be done on to
prevent second occurrence (iridotomy)
Causes of sudden visual
loss
What condition is
shown in A?

What is the sign?

What condition is
shown in B?

Retinal Artery occlusion
Retinal Artery Occlusion
● RF:​AF, smoking, Hyperlipidaemia, HTN and
Diabetes
● Aetiology​: occurs due to an atherosclerotic plaque,
emboli or GCA.
● Symptoms:​sudden often a ​total loss ​of vision (in
central artery​occlusion), in a ​branch artery​you
are likely to ​get altitudinal loss​(superior/inferior).
● The patient will have a ​relative afferent pupillary
defect
● Fundoscopy will show a cherry-red spot .
● Management:​to reduce the chance of any CVS
events.
You need to prescribe aspirin and start on BP medication
and a statin. ​Note: ​if the patient presents and has
retinal oedema you need to do ​ocular massage​and
then surgery. 3 months after the episode
 Retinal Vein Occlusion: 2nd most common cause of
blindness

● Aetiology: ​HTN, polycythaemia, diabetes and

HTN/atherosclerosis.

In a ​branch vein occlusion​, you get symptoms

such as blurring of vision and a field defect. On
fundoscopy, you will see flame haemorrhages

Retinal Vein Occlusion

in the region that the occlusion is at.

In a ​central vein occlusion​, you get symptoms

Retinal Vein Occlusion
such as blurring of vision but you may also get
more vision loss. You may also have a relative
afferent pupillary defect. In this condition, you
are likely to get ​widespread flame
haemorrhages and optic disc swelling.

● Management:​pan-retinal photocoagulation. If
oedema /neovascularization Anti-vEGF and
dexamethasone implants
● Investigations: ​fundus fluorescein angiogram
 Secondary to central RVO or branch RVO.

Vitreous Haemorrhage ● This leads to neovascularization, retinal detachment

and tears
● These produce floaters or full vision obscured
● Generally get better on their own but may require
vitrectomy
Anterior Ischaemic Optic Anterior ischaemic optic neuropathy (AION)

Neuropathy (AION) This can be arteritic and non-arteric. Crucial to ask about
GCA symptoms!

There is a sudden profound loss of vision, swollen pale

optic disc and a relative afferent pupillary defect.

● Investigations:​CRP , ESR and FBC

● Management:​give steroids
Causes of gradual loss
of vision
 What is the angle? ​The space between the posterior
surface cornea and the anterior surface of the iris. This is
where the aqueous leaves the eye.

Problems at the angle. Leads to the formation of

glaucoma.

The most common type of glaucoma is chronic open-angle

glaucoma.
Glaucoma What is optic disc cupping?

● The cup is the area of the disc that doesn’t have any
nerves or blood in it.
● This is a telltale sign that someone may have
glaucoma.
● A normal eye will have <half of the disc diameter
without nerve/blood.

Raised IOP is more than 21 mmHg.

 Chronic Open-Angle Glaucoma:​is the most
common type of optic neuropathy and leads to
enlargement of the optic disc cup and progressive
loss of visual fields causes tunnel vision.

Identification: ​generally people are asymptomatic and

Chronic Open Angle are picked up at a screening. You are deemed at

higher risk if you are black, >35, FH, high myopia or
steroid use
Glaucoma Management:
● Medical therapy (eye drops) BB timolol, Alpha
Agonist Brimonidine. Prostaglandin analogue
latanoprost.
● Laser therapy (laser iridotomy)
 Macular Degeneration:

● This is a condition that leads to the gradual loss of

sight
● The macula is found lateral to the optic disc and is
part of the retina and is the site of
the highest acuity. At the centre of the macula, you
have the fovea (cone heavy)

Macular Degeneration
Pathophysiology of Macular Degeneration:

● When we get older there is a development of drusen

(waster from photoreceptors) in the retina. This
accumulates in the RPE
● If you have drusen you have poorly functioning RPE
● Furthermore: Dry AMD is atrophy of the retina
● Wet AMD: you get new vessel growth under the
retina
 ● Dry AMD: ​atrophy pf the REP, choroid and retina. ​
This leads to a central scotoma
with OK peripheral vision​.​
Management: v​it A, E and zinc

● Wet AMD: ​leaking vessels below the retina resulting

Macular Degeneration in retinal scarring. There are

exudates and haemorrhages. ​You notice a more
rapid change in vision with objects becoming
smaller and lines not appearing straight.
Management: photodynamic lasers, IV
photosensitive drugs and intravitreal injections of
anti-TNF beta

Ways to investigate:
● Slit lamps
● Colour fundus photography
● Ocular coherence tomography: to give a cross-
section of the retina
 ● Causes ocular ischaemia. This leads to new blood
vessel formation on the iris.
● Causing less aqueous liquid lto leave the eye. RF for
glaucoma
● The lens has increased glucose uptake. RF for
cataracts
● These blood vessels then bleed and increase the
risk of retinal detachments.

Signs commonly seen: cotton wool spots, oedema or flare

Diabetic Eyes
haemorrhage all due to vascular leakage

Types:

● Non-proliferative: microaneurysms, haemorrhages,

Leading cause of blindness in hard exudate and cotton wool spots.

● Proliferative: fine new vessels appear. Leads to
vitreous haemorrhages -> maculopathy -> oedema
the developed world -> vision threatened

Management:

● BP management + good BM control

● If maculopathy or proliferative retinopathy use laser
photocoagulation and anti-vEGF.
 Emergency Ophthalmology:
An ophthalmic emergency is when a delay in treatment
will lead to a poor prognosis/loss of vision and have
consequences

The number one cause is ​Trauma: foreign bodies.​

Emergency Sx: ​subconjunctival haemorrhages and

corneal lacerations.

Ophthalmology You need to investigate with US and X-Ray. ​

Management: remove item + abx

Another common cause is blunt trauma. ​These

include assaults and accidents where the eyelid
and eye are affected. Common symptoms are:​
hyphema (blood pool in anterior chamber),
raised ICP and loss of vision.​Need to rule out
lens dislocation, macular oedema or ON
compression.
 Retinal Detachments:

● There is a potential space between photoreceptors

and retinal pigment epithelium (RPE), If fluid enters
this space the retina is lifted or detached from the
RPE producing a field defect

Risk Factors: High Myopia, Eye surgery + Diabetes

Types of detachment:

● Rhegmatogenous: occurs due to a retinal

Retinal Detachments ●
tear/break
Tractional occurs due to tissue attachments to the
vitreous and pulls the retina from the RPE.
● Exudative: detachment due to fluid build-up.

Symptoms: 3 Fs● Flashes, Floaters and Field Defects

Signs: may have RAPD

● Investigations: ​fundoscopy
● Management: ​if you get a superior retinal
detachment you get an inferior field defect To fix a
retinal tear (horseshoe-shaped) seal with lasers.
Retinal detachment: gas/laser therapy or surgery.
 Definition: ​opacity or clouding of the lens

Pathophysiology:​the lens is made out of ectoderm and

continues to enlarge with life. The lens changes shape and allows
for accommodation. Loss of ability to change shape is
presbyopia. Anatomically the lens is connected to zonules which
are in turn connected to ciliary muscles.

Types of Cataracts:

● Posterior subcapsular cataract: good vision when the pupil

Cataracts: leading cause is dilated i.e. in dim light. But in bright light, it constricts
and you get profound vision loss.
● Cortical cataract: good visual acuity as the central lens is

of gradual sight loss clear. May complain of a halo of light and glare.
● Trauma-related: forms a sunflower shape
● Congenital (zonular) cataract:

Clinical Presentation:

● White pupil (leucocoria)

● Visual loss

Management: Either Phacoemulsification and an intraocular lens

put inside. Or alternatively, use surgery + ultrasound
Pupil Defects
 What’s the most
important thing to
remember for exams?
To look after yourself 
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