Ophthalmology

Cornea

5 layers Epithelium: stratified squamous epithelium (superficial wing cells with microvilli) BM zone: linked by hemidesmosomes. BM and Bowman's layer (strong, thin, avascular). Heals by scarring Stroma: 90% of corneal thickness. specialised ECM. Nutrition from tear film and aqueous humour (avascular) Descemet's membrane Endothelium: monolayer of hexagonal cells. Cells lost with age, compensated by polymegathism. Regulates passage of water through stroma by Na channels 70% of eye's dioptric power. CNVa provides sensation. Avascular

Corneal dystrophies

ANTERIOR Epithelial BM dystrophy (Cogan's microcystic dystrophy): commonest, early adulthood. Defect of hemidesmososmes. B/l asymmetrical recurrent erosions, epithelial maps, dots/microcysts and fingerprints (curvilinear ridges) RX: RCES Reis-Bucklers dystrophy: AD BIGH3 mutation causing Bowman's layer degeneration. B/l recurrent erosions, multiple subepithelial grey reticular opacities starting centrally. Rx: RCES Meesman's dystrophy: AD, CK3/12 mutations (cytoskeleton). Progressive. Mild ocular irritation, photophobia and reduced VA in adulthood w/ discrete clear epithelial vesicles, central -> peripheral sparing limbus. Rx: none STROMAL Lattice dystrophy: amyloid stromal deposition, AD. Tyoe 1: commonest (BIGH3 mutation), 2: familial amyloidosis, 3: rare, japanese. Reduced VA, recurrent erosions, b/l criss-cross refractile lines -> progressive central corneal haze. Ix: Congo red apple green birefringence Rx: RCES Granular dystrophy: AD BIGH3 mutation causes hyaline deposition in stroma. Reduced VA, sometimes recurrent erosions. B/l white crumb-like opacities central->peripheral->coalesce. Ix: stains red with Masson trichome Rx: RCES Avellino dystrophy: v. rare AD dystrophy in those from Avellino (Italy). BIGH3 mutation. Reduced VA< recurrent erosions, b/l granular and lattice-type lines, later corneal haze. Ix: stains for both hyaline and amyloid, Rx: RCES Macular dystrophy: rare AR CHST6 mutation, causing oculospecific MPS (stromal deposition of GAGs). Gradual, painless reduction in VA. B/l focal illdefined grey-white stromal opacities superimposed on diffuse scarring. Ix: alcian blue, colloidal iron, Rx: PK Schnyder's crystalline dystrophy: AD UBIAD1 mutation causing cholesterol and fat deposition in stroma. May be associated with hyperlipidaemia. Reduced VA, glare, central anterior stromal yellow white scintillating crystals, corneal haze, arcus. Ix: stains red with oil red O, Rx: PK Congenital stromal corneal dystrophy: CHSD (H-Hereditary). v. rarae AD DCN mutation causing b/l diffuse snowflake whitish opacities Rx: PK Central cloudy dystrophy: AD, crocodile shagreen appearance Fleck dystrophy: AD, white flecks throughout cornea, insignificant Posterior amorphous corneal dystrophy: AD, grey sheets in deep stroma, rarely visually significant POSTERIOR Fuchs' endothelial dystrophy: Common, female. NKATPase dysfunction in endothelium allowing stromal accumulation of fluid, thickening of Descemet's membrane. Gradual reduction in VA from middle age, may be triggered by surgery. Corneal guttata, 'beaten metal' appearance, stromal oedema (Decemet's folds, epithelial bullae), recurrent corneal erosions (pannus, stromal haze). Ix: specular microscopy (reduced cell count/hexagons with increased cell size and variation), pachymetry: high CCT. Rx: avoid eye surgery. topical hypertony (NaCl), warm air blown onto eyes (eg dryer), ocular HTN, BCL for bullae. Endothelium replacement surgery (DMEK-Descemet's membrane endothelial keratoplasty) Congenital hereditary endothelial dystrophy (CHED): AR - CHED2, b/l marked oedema from birth (3xCCT), severe reduced VA, amblyopia, nystagmus. AD - CHED1 b/l mild oedema from infant, tearing, photophobia, mild reduced VA, progressive. Rx: PK Posterior polymorphous corneal dystrophy (PPCD): PPCD1-3. Clusters/lines of vesicles, irregular broad bands or diffuse haze of posterior cornea, iridocorneal adhesion, corectopia, glaucoma

Dry AMD

AREDS 1: no AMD, few small drusen <63um 2: early AMD, multiple small drusen, few intermediate drusen (63-124um), RPE abnormalities 3: intermediate AMD, extensive intermediate drusen >=1 large drusen (>125um=width of retinal vein), geographic atrophy outside of fovea 4: advanced AMD, geographic atrophy involving fovea, features of neovascular AMD RF: smoking, female, white caucasian, hypermetropia, CVS risks. risk score 0-4, 1 for large drusen, 1 for RPE pigment abnormality, 2 for advanced AMD in c/l eye Dry AMD characterised by drusen deposit between RPE and inner collagenous layer in Bruch's membrane and RPE hyperpigmentation/atrophy Gradually reduced central VA, metamorphopsia, scotomas O/e: hard (well demarcated) or soft (larger, pale yellow, poorly defined, can coalesce, RF for CNV), RPE hyperpigmentation, RPE atrophy (leading to geographic atrophy if underlying choroidal vessels visible) OCT: drusen, RPE abnormalities, reticular pseudodrusen (above RPE) Counselling, link to support groups, refraction aid, Register as visually impaired, Amsler grid regularly for progression Lifestyle: smoking cessation, increased omega3 (oily fish) and macular carotenoids (spinach, cabbage, broccoli) Vitamin: Vit C+E, alpha carotene, zinc. Replace carotene (increase lung ca in smokers) with lutein+zeaxanthin

Retinal necrosis

Acute RN (ARN) Rare, caused by HSV and VZV U/l reduced VA, floaters, discomfort Occlusive arteritis, full-thickness peripheral necrotising retinitis, marked vitritis + AC activity Complications: 75% RD, ischaemic optic neuropathy AC tap/vitreous biopsy PCR IV aciclovir, steroids, aspirin (arterial occlusion) and barrier laser photocoagulation (RD) Progressive outer RN v. rare, caused by VZV in HIV+ve painless very rapid reduced VA Rapidly coalescing white areas of outer retinal necrosis with minimal inflammation Rx: intravitreal foscarnet + IV ganciclovir + foscarnet

Viral conjunctivitis

Adenovirus Incubation 1w, infectious for further 2w Pharyngoconjunctival fever: aerosol transmission in children/young adults. URTI + keratitis in 30% Epidemic keratoconjunctivitis: contact transmission. Keratitis in 80% can be severe Acute watering, burning, itching, keratitis (photophobia, blurred vision). Watery discharge with lid oedema, chemosis, tender preauricular lymphadenopathy. If severe subconjunctival petichial haemorrhage, pseudomembrane, symblepharon Swab for antigen/PCR Supportive + topical Abx to stop 2ndary infection. Frequent handwashing, don't touch eyes or share towels/flannels or shake hands Molluscum contagiosum: contact transmission. If on lash margin, can cause follicular conjunctivitis. Rx removal of pearly umbilicated lid nodule HSV1: blepharokeratoconjunctivitis: burning, FB sensation, u/l follicular conjunctivitis, preauricular lymphadenopathy with lid vesicles and keratitis (dendritic ulcer). Rx topical acyclovir

Chemical injury

Alkali (most domestic chemicals) cause liquefactive necrosis, so penetrate through eye. Acids cause coagulative necrosis, so only affect most anterior layer Corneal involvement will cause opacification. Limbal involvement has corneal stem cells, so damage impairs regenerative capacity (LSCD). Conjunctiva can cause corneal epithelialisation with conjunctiva (conjunctivalisation). Fornix can retain chemicals. Grade by Roper-Hall or Dua classification Conjunctival inflammation (red eye) or ischaemia (white eye), chemosis, haemorrhage, epithelial defects (ulceration, necrosis, complete loss of conjunctiva, perilimbal ischaemia, corneal epitheliopathy/oedema/necrosis), AC activity, traumatic mydriasis, raised IOP. Rarely scleral necrosis, vitritis, necrotic retinopathy COMPLICATIONS Conjunctival scarring: symblepharon, ankyloblepharon, loss of goblet cells, keratinisation LSCD: conjunctivalisation, vascularisation, opacification Full thickness burn: scleritis, retinitis, vitritis, phthisis bulbi Periorbital burns Test pH, instil LA, insert speculum if available, then irrigate with >2L or until pH normalised Topical Abx, cycloplegics and lubricants with PO cocodamol SEVERE INJURY topical steroids, vitC (if alkaline), PO vitC (promotes collagen formation), PO tetracycline (inhibits necrosis - proteinase inhib) Acetazolomide + topical bblocker if high IOP SURGICAL: amniotic membrane Tx with LSC Tx. Pseudopterygiums can be excised, and even obliterated fornices can be opened and reconstructed. For corneal opacity, penetrating keratoplasty (corneal Tx) or keratoprosthesis

Peripheral retinal degenerations

Almost all eyes have some form MODERATE RISK Lattice degeneration: 6% of population, 30% of RRD, commoner in elderly myopes, connective tissue syndromes. Areas of retinal thinning with criss-cross white lines and small white holes within lesion Snailtrack: common in myopes, long circumferential retinal thinning with glistening appearance +/- large round holes LOW RISK Peripheral cystoid degeneration: almost universal in elderly, close-packed tiny cystic spaces in outer plexiform/inner nuclear level +/- retinoschisis Retinoschisis: retina splits at outer plexiform/inner nuclear level, leading to inner leaf ballooning. Usually infratemporal areas of peripheral cystoid degeneration. Can progress to RRD with tears, and mimics RRD (to differentiated OCT and laser uptake - retinoschisis uptakes laser) White without pressure: white peripheral retina, usually in young highly pigmented pts Snowflake degeneration: vitreous attachment to Muller's cells. Diffuse frosted appearance with white dots Meridonal folds: small radial fold of retina in axis of dental process at or serrata, can have small hole at base Retinal tufts: common, have holes, but within vitreous base. White inward projections of retina due to traction MINIMAL RISK (insignificant age-related degeneration) Pavingstone degeneration: elderly myopes, irregularly absent RPE and choriocapillaris, forming windows to large vessels and sclera Cobblestone degeneration: small drusen-like bodies with pigment ring at Bruch's membrane Reticular pigmentary degeneration: honeycomb peripheral pigmentation

Sclera

Almost complete sphere continuous with optic nerve and cornea. thickest post, thinnest at rectal insertions. Consists of many collagen types, opaque but strong. Inner layer = lamina fusca Avascular, but pierced by vessels. Innervated by long and short ciliary nerves. Episclera (covering loose connective tissue layer, heavily vascularised with superficial and deep anterior plexi anastamosing with conjunctival plexi, and posterior episcleral plexus (short posterior ciliary vessels). Provides lubrication) and choroidal vasculature provide nutrition

Blunt trauma

Anterior rupture, posterior rupture (deep AC, low IOP) AC: corneal abrasion/oedema, hyphaema, transient miosis with permenant traumatic mydriasis and irregular pupil (sphincter rupture). Iridodialysis, angle recession, ciliary cleft. Vossius ring, cataract, subluxation of lens PC: PVD/vitreous haemorrhage. Commotio retinae (pale retinal opacity due to photoreceptor outer segment fragmentation. 3/4 resolve without visual loss. If severe can progress to chorioretinitis sclopetaria), retinal dialysis, macular hole, choroidal rupture (can progress to CNV), traumatic optic neuropathy (RAPD)/optic nerve avulsion Globe protection, Abx, tetanus vaccine. CT. REPAIR SURGICALLY

Corneal degeneration

Arcus: common. B/l usually normal, but if arcus juvenilis consider hyperlipidaemia T2. U/l = ocular hypotony or c/l carotid compromise Cornea farinata: b/l symmetrical deep stromal faint flour-like opacities. Don't affect VA Crocodile shagreen: asymptomatic, benign faint reticular netwrok of stromal opacities Vogt's limbal girdle: common b/l chalky white peripheral corneal deposition (3 and 9oclock). Asymptomatic Lipid keratopathy: primary (idiopathic) or secondary to corneal trauma. If primary only yellow-white stromal deposits of cholesterol, fat, phospholipids - asymptomatic. If secondary also corneal vascularisation. Ix: ICG/fluorescein angiography, Rx: occlusion of feeder vessel, PK Band keratopathy: AC inflammation, phthisis bulbi, and systemic causes (familial/primary, senile, ichthyosis, CKD, hyperCa/PO4/uraemia). Asymptomatic, but can have FB sensation, pain, reduced VA. White opacities at 3 and 9 oclock, progressing centrally to form band. Rx: underlying cause, therapeutic CL for symptoms, chemical chelation (EDTA) + mechanical debridement, excimer phototherapeutic laser keratectomy Salzmann nodular degeneration: slowly progressive complication of chronic keratitis, Bowman's layer replaced w/ eosinophilic material. Glare, pain, reduced VA. Well defined grey-white elevated nodules with iron lines. Rx: treat keratitis, lubrication, therapeutic CL, excimer phototherapeutic laser keratectomy

Pigmented conjunctival lesions

BENIGN Conjunctival epithelial melanosis: congenital racial common pigmentation. Can be b/l. Flat and patchy, can be diffuse or focal (eg Axenfield loop around intrascleral nerve) Conjunctival freckle: congenital common tiny flat freely moving pigmented ara Melanocytoma: rare black pigmentation, fixed, slowly growing Acquired: mascara deposits in fornix, coal dust tattoos, adrenochrome from adrenaline administration PREMALIGNANT Primary acquired melanosis (PAM): uncommon, rare in afrocaribbeans. U/l flat irregular brown pigmentation. If nodules within, siggests melanoma. Ix: histology to differentiate PAM without atypia (benign melanocytic proliferation) from PAM with atypia (50% risk of melanoma transformation by 5y). Rx: if atypia, excision + cryotherapy/RT Conjunctival naevus: uncommon, v. low risk. Most common at limbus, invasion of cornea = transformation Congenital ocular melanocytosis: subconjunctival flat grey lesions with u/l hyperpigmentation of face and iris hyperchromia/mamillations and glaucoma. Naevus of Ota (oculodermal melanocytosis) most common, but also limited ocular or dermal forms MALIGNANT Melanoma: first consideration for abnormal conjunctival pigmentation. Usually from atypical PAM. Solitary grey/black vascularised nodule fixed to episclera, usually at limbus. Mets to LN, lung, liver, brain. MALIGNANCY MORE LIKELY if elevated, irregular, with symptoms (bleeding, itchy, painful, inflammed) Rx: wide local excision + cryotherapy, or exenteration

Lid tumours

BENIGN Papillomas: v. common, asociated with HPV SK: common in elderly Keratoacanthoma: uncommon tumour that grows rapidly for 2-6w. Non-pigmented protrusion with keratin-filled centre. May require excision as mimics SCC Naevi Capillary haemangiomas (strawberry naevi), port wine stain, etc Pyogenic granuloma: abnormal response to injury. Red highly vascular mass MALIGNANT BCC: 90% of lid malignancies. Usually lower lid, sun exposure + age RFs. Locally invasive. Firm nodule with rolled pearly edges and surface ulceration. Can also just be reddish scaly plaques. Rx Moh's surgery. Alternatives: cryotherapy, topical imiquimod, PDT, Vismodegib SCC: rare, usually lower lid. Metastatic. Rx Moh's surgery, exenteration. Alternatives as above for Bowen's disease Sebaceous gland carcinoma: arises from MG or Zeis glands. Uncommon, usually upper lid, females. Resembles chalazion. Rx wide local excision, exenteration Melanoma: rare. Wide excision Rx Kaposi's Sarcoma Merkel cell carcinoma: non-tender purple nodule on upper lid

Episcleritis

Benign recurrent inflammation of episclera, 10% associated with systemic disease Simple episcleritis: sudden onset mild discomfort, tearing, photophobia. Sectoral (sometimes diffuse) non-tender redness which blanches with topical vasoconstrictor (phenylephrine), spontaneously resolves in 1-2w Nodular episcleritis: sudden onset FB sensation, discomfort, tearing, photophobia. Red nodule in episclera which can be moved seperately from sclera and conjunctiva. Non-tender, blanches w/ phenylephrine, does not stain w/ fluorescein. Resolves in 5-6w Rx: reassurance, cold compress, topical lubricants. Check for systemic disease

HSV keratitis

Blepharoconjunctivitis: primary, then becomes latent in trigeminal ganglion Epithelial keratitis: superficial punctate keratitis -> stellate erosion -> dendritic ulcer -> geographic ulcer, stains with fluorescein). Dx clinical. Rx topical/PO aciclovir Stromal keratitis: multiple opacities w/ corneal vascularisation, lipid exudation, scarring, AC activity, high IOP. Rx aciclovir Disciform keratitis: endothelitis. Painless with haloes. Descemet's folds, Wessely ring, keratoprecipitates VZV (Herpes zoster ophthalmicus) ACUTE Epithelial: pseudodendrites, infiltrates Stromal: nummular keratitis + granular deposits. Rarely necrotising interstitial keratitis CHRONIC Disciform: endotheliitis, Descemet's folds, KPs Neurotrophic: can lead to thinning and perforation Mucus plaques: linear grey elevations Rx: topical aciclovir, lubricants, steroids, mucolytics (as appropriate)

Acanthamoeba keratitis

CL associated keratitis, severe loss of vision in 25%. Swimming with CL is rf. Almost always due to poor CL hygeine Dendritic ulcers. ALL DENDRITIC ULCERS IN CL USERS are acanthamoeba until proven otherwise In vivo confocal microscopy visualises cysts Corneal scrapes CL, lenses, solution MC&S Stop CL, admit, topical anti-amoebics (biguanide + aromatic diamidine) + tpoical bblocker (attacks cysts), analgaesia/cycloplegics. Consider steroids

Other lid disorders

CONGENITAL Epiblepharon: horizontal fold of skin of lower lid, can cause inversion/pseudotrichiasis Epicanthic folds: Epicanthus palpebraris is normal in children, tarsalis (upper) is normal in oriental, inversus (lower) is downs and blepharophimosis, superciliaris is above brow rare Telecanthus: long distance between medial canthi but normal IPD Cryptophthalmos: skin is continuous over eyes, poor visual prognosis Ankyloblepharon: fusion of eyelids Coloboma: full thickness defect of eyelid. Medial in upper lid, lateral in lower ACQUIRED Floppy eyelid syndrome: excessively lax upper lid everts during sleep causing exposure conjunctivitis. Associated with obesity/OSA

Central serous chorioretinopathy

CSC, choroidal hyperpermeability causes sub-RPE/retinal fluid accumulation. Risks: men 20-59, psychosocial stress, Cushing's, drugs (steroids) U/l sudden reduced VA, positive central scotoma, metamorphopsia, hypermetropia Shallow detachment of retina with PED and pigmentary changes at posterior pole FFA: leakage/pooling, smoke-stack/inkblot pattern OCT: RD with small areas of PED, EDI-OCT shows choroidal thickening + dilated large vessels (pachychoroid - hallmark) Conservative: spontaneous remission common (80%, 2mo post-partum) If >6mo, recurrences or occupational need Argon laser: mild burns to areas of leakage PDT: half-dose/low-dose Medical: eplerenone may have an effect

Lacrimal infections

Canaliculitis: due to actinomyces israelli (also Nocardia, fungi and viruses) U/l epiphora, recurrent nasal conjunctivitis with pouting of punctum and discharge from punctum (sulfur granules if A. israelli) Rx: surgery (1-snip procedure) + irrigation and topical Abx Acute dacryocystitis: staph or strep in pts with nasolacrimal obstruction. URGENT - can cause spreading cellulitis pain around sac, with worsening epiphora and tender erythematous lump inferior to medial canthus that expresses pus from punctae on compression. May have preseptal cellulitis send discharge for MC&S Rx: PO + topical Abx, warm compress + gentle massage. May require formal incision + drainage, and obstruction will require DCR either immediately or delayed Chronic dacryocystitis: due to nasolacrimal obstruction. Recurrent u/l conjunctivitis, epiphora and a mucocele Syringing causes expression of mucus Rx: DCR, or dacryocystectomy in old pts

Burn

Cigarette ash injury is a common cause. Range from punctate defects to stromal melting, perforation (usually molten metal) and opacification. Exposure keratopathy may occur 2ndary to lid damage Immediate cool irrigation. Topical Abx, cycloplegics, lubricants, steroids with PO cocodamol. For more severe cases consider VitC, tetracycline, as for chemical LIDS 1st deg: cool compress, lubrication 2/3: topical Abx with occlusion dressing, trim singed eyelashes. Temporary tarsorrhaphy (+lateral canthotomy and cantholysis) may be required to prevent exposure keratopathy Overlying skin 1st degree: erythema, oedema, but dry, mild pain. Heals well 2nd degree: erythema, oedema, weeping with blisters, severe pain. Heals with pigmentary changes 3rd degree: dry, inflexible, leathery skin, numb. Scars Liase with burns unit. Estimate %BSA, give fluid resuscitation accordingly. Air-fluidised bed with reverse barrier nursing, sterile dressings and simple emollients COMPLICATIONS Lid cicatrisation: entropion/ectropion, trichiasis, exposure keratopathy Epiphora: lacrimal duct damage Conjunctival burns: symblepharon, dry eye (loss of goblet cells/Mebomium glands) LSCD

Posterior segment imaging

Colour fundus photography: can capture 80% of retina on non-dilated eye with ultra-widefield imaging. Can be light or scanning laser ophthalmoscopy (SLO - confocal) Fundus autofluorescence (FAF) imaging: using innate fluorescence of back of eye. Monitoring AMD + other retinal degeneration. Light or SLO Scanning laser tomography: using SLO confocal tech to form stack of cs images of optic nerve head Scanning laser polarimetry: RNFL is birefrigent. Using scattering of polarised light, RNFL thickness can be mapped Adaptive optics: compensates for lense and corneal optics and uses confocal tech to obtain cellular level images of back of eye Optical coherence tomography (OCT): like USS but with low coherence light. Gives series of cs images, each pixel determined by reflectivity OCT angiography: no need for IV contrast, put poor field of vision and just coming into clinics Ocular USS: Piezoelectric crystals. Can detect detachment, foreign bodies, tumours, etc. Orbital USS can look at orbit (lower freq), corneal ultrasonic pachymetry can give estimation of corneal thickness. Ultrasound biomicroscopy (UBM) can give detailed anterior segment images. Colour doppler imaging (CDI) can give information about blood flow Fundus fluorescein angiography(FFA): light or SLO, fluorescein used as contrast. Multiple pictures taken quickly after contrast injection to see different filling phases (choroidal, arterial, capillary, venous, late) Indocyanine green (ICG) angiography: performed in association with FFA to carefully assess choroidal circulation, to diagnose CNV, IPCV, choroidal tumours (haemangioma). Retinal (FFA) and choroidal (ICG) blood flow can be calculated, and research is going into retinal oximetry

LSCD

Congenital: aniridia Trauma: chemical, thermal, UV, RT, CL wear, preservative toxicity Onc: Ocular surface malignancy Neur: neurotrophic cornea Inf: peripheral ulcerative keratitis, OcMMP, atopic keratoconjunctivitis, SJS/TEN (scarring keratitis) COnjunctivalisation, opaque/irregular/thickened corneal epithelium, corneal vasularisation Impression cytology to diagnose keratolimbal allo/autograft, AM graft, or even cultuvated cells from cadaveric limbus

Ophthalmia neonatorum

Conjunctivitis in first month of life, potentially sight threatening Gonococcal: 1-3d of birth (hyperacute), severe purulent discharge, lid oedema, chemosis +/- pseudomembrane, keratitis. Conjunctival swab/scrape MC&S, Rx Cefotaxime IM single dose, frequent saline irrigation of discharge, mum to GUM. Chlamydial: 4-28d (subacute) w/ mucopurulent discharge, papillae. Can be haemorrhagic +/- preseptal cellulitis. Ix Prewet swabs/conjunctival scrape for Giemsa stain. Rx erythromycin 2w PO, mum to GUM HSV: 1-14d (acute) vesicular lid lesions, mucoid discharge +/- dendritic keratitis, anterior uveitis, cataract, retinitis, optic neuritis. Can have systemic problems. Rx acyclovir drops +/- IV acyclovir

CNV

Degenerative: AMD, pathological myopia (lacquer crack), angioid streaks Trauma: choroidal rupture, laser Inflammation: POHS, multifocal choroiditis, serpiginous choroidopathy, birdshot choroidopathy, punctate inner choroidopathy, VKH Dystophy: Best's disease Other: Chorioretinal scar, tumour Idiopathic

Submacular haemorrhage

Devastating complication of CVN (rarely angioid streaks, trauma, retinal macroaneurysm) causing permanent visual loss due to release of iron Sudden painless loss of vision with drusen, known AMD and risk factors for macroaneurysm. O/E: large subretinal haemorrhage OCT Intravitreal anti-VEGF + rtPA Pneumatic displacement of blood with posturing or vitrectomy + intravitreal rtPA + gas RAPID treatment saves vision

Ocular neuropathic pain

Due to nerve damage. Can cause severe corneal pain 1st: PO gabapentin 2nd: PO amitryptiline/pregabalin 3rd: PO Duloxetine/carbamezapine/tramadol

Exudative retinal detachment

ERD, rare. Damage to outer blood-retinal barrier allows fluid into subretinal space, splitting retina from RPE Congenital: nanophthalmos, MPS, FEVR Vascular: Wet AMD, Coat's disease, CSC, vasculitis, malignant HTN, pre-eclampsia Tumours: Choroidal Inflammatory: posterior uveitis/scleritis, post-op, extensive PRP, orbital cellulitis VF defect, visual distortion, metamorphopsia (Amsler) and reduced VA if macula involved O/e: smooth convex dome. Shallow or bullous (fluid moves quickly to most dependent position) Ix: BP, urinalysis Rx: treat underlying disease, surgery rarely required

Choroidal detachment

Effusion: hypotony (glaucoma filtration/cyclodestructive surgery), PRP, cryo, posterior uveitis, uveal effusion syndrome, nanophthalmos Haemorrhage: intra-op, trauma, spontaneous Smooth dark convex dome on retina arising from extreme periphery (ora serrata visible). 2 can touch (kissing choroidals) causing retinal adhesion/detachment Ix USS, Rx underlying disease Uveal effusion syndrome: ERD, combined choroidal detachments, scleral thickening and nanophthalmos, due to impaired posterior segment thickening. Rx: surgical scleral windows to decompress vortex veins + MMC

Primary angle closure glaucoma

Elderly chinese female. 2 mechanisms Pupillary block: hypermetropic eye causes apposition of iris and lens, causing aqueous humour build-up in posterior chamber, anterior bowing of peripheral iris and angle closure Plateau iris: ciliary body + iris anteriorly placed, blocking flow through trabecular network Primary angle closure (PAC): narrow angles, iridotrabecular contact, and >=1 of: raised IOP, peripheral ant synechiae, symptoms of acute. Rx: prophylactic Nd-YAG PI, lens extraction can cure, only do if catarct PAC glaucoma (PACG): PAC + evidence of glaucomatous optic neuropathy. Rx: Nd-YAG PI, medical as for POAG. Lens extraction option ACUTE periocular/head/abdo pain, reduced VA, haloes, N+V. O/E: red eye, corneal oedema, i/l closed angle with c/l narrow angle, fixed semi-dilated pupil, glaukomflecken. IOP 50-80 Acetazolamide IV stat Topical: bblocker (timolol stat), sympathomimetic (apraclonidine stat), steroid (pred stat), pilocarpine (once IOP<50) Admit, consider corneal indentation Check IOP hourly, mannitol if not improving DEFINITIVE: Nd-YAG or surgical peripheral iridotomy. Others include argon laser iridoplasy, paracentesis, cyclodiode photocoagulation

Electrodiagnostic tests

Electroretinogram (ERG): contact lens electrodes used to detect retinal response. Bright light shone into eyes, electrodes pick up response. Light intensity modified to have cone-only or rod-only response. Initial negative a wave (photoreceptors), then +ve b wave (bipolar/Muller cells), with oscillatory potentials (OP-amacrine cells) throughout Pattern ERG (PERG): uses reversing chequerboard a stimulus, tests macular cones multiple field ERG (mfERG): uses small stimuli to map out 2d map of retinal function electrooculogram (EOG): involves eye movements, used to diagnose Best's disease Visual evoked potentials (VEP): either flash of light or reversing chequerboard given, response seen in occipital lobe. Good to show functional visual loss, objective measure Dark adaptometry (DA): Goldmann-Weekers. Bright light blanches photoreceptors, then lights of increasing intensities used until perception. Used to test vit A deficiency night blindness and rhosopsin metabolism abnormalities

Lid lumps

External hordeolum: aka stye, acute abscess in lash follicle. Tender lump w/ inflammation due to staph infection. Rx warm compresses, PO Abx if preseptal cellulitis Cysts of Moll: translucent cyst due to blockage of Moll glands. Rx surgery Cysts of Zies: poorly translucent, opaque white contents due to blockage of Zies glands Xanthelasma: deposition of lipids in perivascular xanthoid cells Molluscum contagiosim: HIV Internal hordeolum: acute abscess within MG. Same as external Chalazion: most common of all lid lumps. Chronic lipogranulomatous inflammation of blocked MGs, usually on upper lid of pts with blepharitis, rosacea or SD. Hot compress, surgery (incision and curettage) if persistent

Corneal abrasion

FB Usually metallic (no infection). Stone ceramic or organic FBs cause infection Photophobia, pain, injection, lacrimation, blurred vision. Hx of not using PPI while working ONLY REMOVE under slit lamp with LA and needle. Remove rust ring Topical Abx, cycloplegic, PO NSAIDs No FB innocuous but cause severe pain due to exposition of stromal nociceptors (+ photophobia, lacrimation) Slit lamp, Seidel's test. Check for microbial keratitis or recurrent corneal erosion syndrome (RCES) Topical Abx, cycloplegic, NSAIDs. NO PATCHING (delays healing)

AC angle

FROM ANT -> POST Schwalbe's line: termination of Descemet's membrane at peripheral cornea Trabecular meshwork: reticulated band of fibrocellular sheets, with triangular c/s base as scleral spur Scleral spur: firm fibrous projection forming base of Schlemm's canal, separating trabecular network from ciliary body Ciliary body: Pars plana (post) and pars plicata (ant, containing ciliary processes). Inner Ciliary cuboidal bilayer epithelium continuous with RPE and retina Schlemm's canal: septate drain outer to trabecular meshwork Aqueous production: 2.5microl/min by ciliary epithelial Na/K/Cl pumps. Low gluc/protein, high VitC Aqueous drainage Trabecular/conventional route: through trabecular network, into Schlemm's canal (via pressure-dependent giant vacuole mediated transcellular channels) and out through collector channels, draining into episcleral veins Uveoscleral/unconventional root (30%): passes via iris root -> ciliary body -> supracilliary/suprachoroidal space -> choroidal circulation Flow out = C(IOP-Pv) + U C=pressure sensitive outflow facility, Pv=episcleral venous pressure, U=pressure independent outflow via uvea, IOP = intraocular pressure (normal 11-21, diurnal variation of 5

Slit lamp examination

Goldmann applanation Tonometry: fluorescein + blue light for IOP. Tonometer attached and when two semicircles touch record Seidel's test: if fluorescein is diluted quickly, AC leak Gonioscopy: to view angle. Can be direct (Koeppe) or indirect (Zeiss - differentiate between appositional closure and synechial closure, Goldmann - most common). Angle classified by Shaffer or Spaeth grades Fundoscopy: to view fundus. Image inverted and reversed. Goldmann 3-mirror lense can be used to see periphery. Both this and above use handheld lenses Schirmer's test/tear film breakup time (TFBUT) Van Herick method: peripheral AC depth Pachymeter: central AC depth AC flare/haze indicates AC inflammation. Moving dots indicate inflammatory cells Watzke-Allen test: slit lamp over fovea. If pt sees gap in line, full-thickness macular defect Indirect fundoscopy: head light with hand-held lense and scleral depressor to view extremes of peripheral retina Amsler grid: fixate on central dot, see if lines distorted (AMD)

Epiretinal membrane

IDIOPATHIC fibrocellular avascular layer arising from retinal glial cells that break through ILM, probably through PVD-induced defects Asymptomatic. May have metamorphopsia or reduced VA. Membrane may be transparent -> white, retinal striae, may have abnormal vessels OCT Rx: severely symptomatic can have vitrectomy + membrane peel but 70% will have cataract has complication in 2y 75% stable after diagnosis w/o surgery OTHER CAUSES retinal detachment surger, cryo, photocoagulation, trauma Posterior uveitis Persistent vitreal haemorrhage Retinal vascular disease (BVO)

Cystoid macular oedema

INflammatory: post-op/laser/cryo, uveitis Vascular (retinal): RVO, DR, HTN, RT, OIS, retinal vascular telangiectasia Vascular (choroidal): CNV Drugs: nicotinic acid, topical adrnealine, PGA, chemo, glitazones Congenital: RP, AD CMO Vitreoretinal: vitreomacular traction syndrome, ERM CNII: optic disc pit/coloboma Tumours Idiopathic Asymptomatic, may have severe reduced VA, metamorphopsia, scotomas Loss of foveal contour, retinal thickening, cystoid spaces, central yellow spot. Occassionally small haemorrhages/telangiectasia FFA: leakage into cystoid spaces OCT DM/RVO: antiVEGF inhereted: carbonic anhydrase inhibitors Inflammatory: topical steroid+NSAID, 2nd line periocular steroid, 3rd line intravitreal/systemic steroids

Penetrating trauma

IOFB must be excluded with extensive imaging Mechanical: as before Infection: endophthalmitis, panophthalmitis Toxicity Siderosis: ferrous FB. Iron deposits in RPE causing photoreceptor death. Injection, heterochromia (red-brown iris), red-brown anterior capsular cataract, retinal detatchment, humour staining. ERG may show nerve loss Chalcosis: copper FB. Rapid fulminant endophthalmitis. Alloys cause Wilson-type signs (K-F rings, anterior sunflower cataract, yellow retinal plaques) Sympathetic ophthalmia: rare b/l granulomatous panuveitis caused by trauma to one eye. Prevent by rapid primary repair. Usually 1-12mo after trauma. Presentation and Rx identical to VKH. Prophylactic enucleation only for blind eye. Enucleation may help at start of disease Globe protection, Abx, tetanus vaccine. CT, USS, ERG. REPAIR SURGICALLY

Ocular hypertension

IOP>21 with healthy optic disc and normal VF. Over 5y, 9.5% (or 4.4% treated) progress to POAG. Low CCT (which causes tonometers to underestimate IOP) and old age are risk factors Following should receive Rx IOP>27 IOP>21 and suspicious disc IOP>21 and low CCT Monitoring: every 6-12mo IOP, fundoscopy, perimetry, OCT

Acute anterior uveitis

Idiopathic (50%): u/l pain, photophobia, redness, reduced VA. O/e: circumlimbal injection, KP in inferior Arlt's triangle, AC flare, synechiae, cells HLA-B27 related (50%): more severe AC inflammation sometimes even with hypopyon. Can cause CMO after resolution. Associated with all sero-ve SpA Rx: frequent topical steroids, pupillary dilation to break synechiae and ease pain Other causes (rare) HSV/VZV/CMV Posner-Schlossman syndrome Systemic: DM, sarcoidosis, carotid artery stenosis (Anterior segment ischaemia), Kawasaki (1st week) Renal: TINU, IgA nephropathy Rheum: JIA Viral: patchy iris atrophy w/ TI (HSV+VZV) defects and concomitant keratitis and commonly glaucoma (open angle). Treat uveitis with topical steroids, keratitis with antivirals. CMV does not cause iris atrophy, but causes corneal endotheliitis. Retinitis in HIV+ve. Rx oral valganciclovir ANY UVEITIS IN IVDU IS CANDIDA UNTIL PROVEN OTHERWISE Anterior segment ischaemia: dull u/l ache with AC flare/cells, sluggish pupil. May have signs of OIS. Ix carotid doppler Rx vascular surgery TINU: rare association of tubulointerstitial nephritis with uveitis, usually 2ndary to infection or drugs. Anterior b/l, after systemic disease. Ix: renal biopsy, U+E, UM JIA: b/l, asymptomatic white eye w/ band keratopathy, small KPs, AC cells/flare/PS, cataract, 2ndary glaucoma, CMO. Screened until 12yo. Rx: systemic + topical steroid, steroid-sparing agents

Choroidal folds

Idiopathic/congenital (typically young, healthy, hypermetropic w/b/l folds) Orbital: TED, retrobulbar mass, idiopathic orbital inflammatory disease Ocular: hypotony, posterior scleritis, choroidal scars/tumours, uveitis Intracranial: raised ICP, may come before papilloedema Usually asymptomatic, but signifies underlying disease FFA: alternating streaks of hyper and hypofluorescence OCT: differentiates from retinal striae Orbital USS, CT, MRI: exclude orbital or intracranial pathology

Epiphora

Increased production: drugs, high parasympathetic drive, reactive (any chronic irritation) Rx: if irritation/kCS, ocular lubricants (paradoxical). If crocodile tears, upper lid botulinum Pump failure: lid laxity, OO weakness, ectropion Rx appropriate surgery Reduced drainage: congenital (punctal atresia), Idiopathic stenosis (elderly), idiopathic fibrosis, any scarring process (trachoma, RT), lacrimal sac obstruction (mass - lymphoma/primary, granulomas - sarcoidosis/syphilis), delayed canalisation (congenital) Rx dacryocystorhinostomy (drill new bony canal into nasal mucosa!) - comp include haemorrhage + epistaxis, ostium closure, infection

Intermediate uveitis

Inflammation of vitreous. Usually b/l Floaters, reduced VA (CMO), or asymptomatic. Vitritis (cells, snowballs), exudation at inferior ora serrata (snowbanking), peripheral periphlebitis, rarely vitreous haemorrhage, some AC activity common COMPLICATIONS CMO, cataract, glaucoma, cyclitic membrane, TRD, retinal tears, ERM, retinal neovascularisation, retinoschisis Idiopathic: pars planitis Systemic: MS, sarcoidosis, IBD, CNS/intraocular lymphoma Infective: Toxocara, Lyme, HTLV-1 Observation if mild Topical steroids + mydriatics if AC activity. If CMO or visually disabling floaters, periocular or intravitreal steroids. For b/l resistant disease, systemic steroids +/- steroid sparing agents SURGERY Vitrectomy + intravitreal steroids Cataract and glaucoma surgery

Entropion

Inversion of eyelid (usually lower). Eyelashes cause corneal abrasion (FB sensation, photophobia, blepharospasm, epiphora), pseudotrichiasis, keratopathy, pannus formation Involutional: commonest, inferior lid retractor dysfunction (pretarsal>preseptal OO) with increased tissue laxity. May have reduced lower lid movement on downgaze, high lid laxity. Rx Surgery (or botox) Cicatricial: cicatrizing conjunctivitis (trachoma, can affect upper lid), pemphigoid, chemical injuries/trauma, RT, severe blepharitis can cause scarring and shortening of posterior lamella. May have sym/ankyloblepharon, with loss of plica semilunaris. Rx medical or surgery Congenital: rare, usually self-limiting, due to pretarsal OO hypertrophy

Uveal tract

Iris: arises from AC angle to pupil. Divided by colarette into central/peripheral. Contains anterior connective tissue layer, sphincter pupillae (parasympathetic short ciliary n ribres from CNIII), posterior epithelial bilayer. Anterior layer has radial myoepithelial processes of dilator pupillae (sympathetic long ciliary n fibres from CNVa), posterior layer heavily pigmented. Continuous w/ ciliary body Ciliary body: Ciliary muscle and ciliary epithelium, split into pars plana and pars plicata containing ciliary processes Choroid: from ora serrata to optic disc. from deep to superficial, Bruch's membrane (RPE BM, collagen, elastin, collagen, choriocapillaris BM), choriocapillaris (capillary layer), stroma (Sattler's layer - medium vessels, Haller's layer - large vessels), suprachoroid (potential space

Other corneal ectasias

Keratoglobus: b/l global corneal thickening and fragility. Acquired (endstage keratoconus) or congenital (EDS/brittle cornea syndrome). Rx: CL, PK Pellucid marginal degeneration: b/l inferior crescenteric corneal thinning w/ astigmatism. 30-50yo with painless visual distortion. Rx: hard CL Posterior keratoconus: non-progressive congenital abnormal steepening of post cornea with normal anterior. Usually u/l, no Rx required

Imaging

Keratometry: anterior part of cornea (3mm diameter). Helmholtz or Javal Schiotz keratometers. Manual or automatic Corneal topography: Allow imaging of whole cornea + corneal thickness and posterior corneal. Light scattering (scanning slit .videokeratoscopy) or Scheimpflug imaging Colour map (of curvature or keratometric dioptres) used. Cornea can be round, oval, symmetric/asymmetric bow tie or irregular Scheimpflug imaging produces 3d model from 50 cross-sections In vivo confocal microscopy: visualises individual cells and nerve fibres (microstructure). For detection of infectious keratitis, corneal deposits Anterior segment OCT: interferometry with low-coherence light. can visualise AC angle

Corneal procedures

Keratoplasty: PK for whole cornea, Anterior lammellar keratoplasty for ant, endothelial keratoplasty for post. Vascularisation + high risk. Risks: failure (<2w), rejection (>2w), infection (endophthalmitis), haemorrhage (wound leak, raised IOP), Urrets-Zavalia syndrome (fixed dilated pupil due to iris ischaemia), worsened vision/astigmatism, recurrence. Post-op visual rehabilitation + topical Abx/steroid. Don't remove sutures for 1y Triple procedure: PK with 'open sky' cataracts operation Procedure: enucleation of donor eye, then corneoscleral discs removed in cabinet. Endothelial cell count tested (high = low risk of failure) and regularly tested for infection. Suspended in media at 34deg REJECTION Epithelial rejection: graft epithelium replaced with host, demarcation line Stromal rejection: subepithelial infiltrates Endothelial rejection: corneal oedema, KPs, AC activity, Khodadoust line RX: TOPICAL STEROIDS can save graft Corneal collagen cross linking: stabilises keratoconus. Remove epithelium, give riboflavin topically then expose to UVA. Low complication + failure rate AM Tx: never rejected. Can be used to support LSCs, conjunctival reconstruction, corneal defects. Anti-inflammatory and anti-bacterial

Tear anatomy

Lacrimal gland: almond shaped, palpebral and orbital sections spolit by LPS aponeurosis. 12 ducts open into superolateral fornix. Innervted by parasympathetic fibres of lacrimal nerve Drainage: superior/inferior punctae/canalliculi. Canaliculi fuse to form common canaliculus -> lacrimal sac -> nasolacrimal duct. 2/3 in bony canal, 1/3 in nasal mucosa, opens beneath inferior turbinate. System has valves, OO produces suction MGs produce outer layer (prevents evaporation). glands of Krause and Wolfring in conjunctiva produce middle layer. Goblet cells and lacrimal gland produce base layer

Pupil

Light response: CNIIn -> pretectal n -> E-W n -> CNIII n -> cilliary ganglion -> short ciliary n Accommodation: BA19 -> FEF -> CNIII/EW nn -> ciliary ganglion -> short ciliary n DUE TO SEPERATION, only one can be affected Sympathetic: sup cervical ganglion -> nasociliary branch of CNV (via ICA) -> long ciliary n Pilocarpine: muscarininc agonist. Normal pupil constricts at 1%. If constricts at 0.125% denervation hypersensitivity (Holmes-Adie syndrome) Apraclonidine: weak a1 agonist. No effect usually, dilation in Horner's Cocaine: inhibits NorA reuptake. Dilation in normal eye, nothing in Horner's Hydroxyamfetamine: stimulates release of preformed NorA. If Horner's of postganglionic n (3rd degree), then no effect. If further down pathway, dilation Hirschberg test: for strabismus. Lit pentorch in front of pt. Look for symmetrical corneal reflections (just nasal of centre) Krimsky test: use prism bar to normalise corneal reflection - measures degree of strabismus Cover-uncover test: fix on target. Then cover each eye in turn, looking for movement in the other (off alignment). Then uncover, looking for movement in that eye Alternate cover test: repeatedly cover each eye for 3s w/o allowing binocular vision. If deviates outwards after uncovering, eye has drifted inwards (esophoric) Prism cover test: alternate cover test with prism to assess degree (at correct prism strength no movement observed) Maddox testing: maddox rod (red eyepeice with pentorch, line wshould be on light) maddox wing (near vision) or double maddox rod (torsion) test strabismus. Strength of prism to normalise determines degree of strabismus, apart from maddox wing (has scale) Parks-Bielschowsky 3-step test: vertical deviation due to single muscle. 1-which pupil higher, 2-worse on L/R gaze, 3-worse on L/R head tilt (superior muscles intort, inferior extort). Best at diagnosing CNIV palsies Caloric test: head back at 60deg. Water in ear causes nystagmus. Direction=COWS (cold opposite warm same)

Retina

Look up anatomy picture. Muller cells are glial cells that make up ILM and ELM. umbo (red, green) -> peri (blue cones) -> parafovea -> fovea. Multilayered ganglion/bipolar cell layers with high cone density. Continuous with nonpigmented ciliary epithelium RPE: continuous with pigmented ciliary epithelium and CNII. tight junctions form blood-retinal barrier. Melanin prevents visualisation of underlying choroidal vessels, but depigments with age causing tessellated/tigroid fundus Bruch's membrane Choroid lamina fusca Sclera Ophthalmic artery branches into posterior ciliary a (choroidal plexi, outer 1/3) and central retinal a (inner 2/3), watershed outer plexiform layer. central retinal arcades run in NFL, but give superficial (ganglion cell layer) and deep (INL) capillary networks with nonfenestrated endothelium Cones have iodopsins, rods rhodopsin, ionise with photons Ganglion cells can be magnocellular (peripheral, coarse) or parvocellular (central, VA/colour) RPE stores vit a

White dot syndromes

Manifest as visible white dots on fundus Multiple evanescent white dot syndome (MEWDS) Acute posterior multifocal placoid pigment epitheliopathy (APMPPE) Acute retinal pigment epitheliitis (ARPE, Krill disease) Acute zonal occult outer retinopathy (AZOOR) Birdshot chorioretinopathy (BCR) Multifocal choroiditis with panuveitis (MCP) Punctate inner choroidopathy Serpiginous choroidopathy Do OCT and FFA to confirm

Peripheral keratopathies

Marginal keratitis: reaction to staph exotoxin, associated with atopy, rosacea and chronic blepharitis. Sterile white subepithelial peripheral corneal infiltrate at 2/4/8/10oclock, spreading circumferentially with perilimbal sparing. Rx: topical steroid + abx Rosacea-associated keratitis: begins as inferior punctate epithelial erosions, progresses to perforation/thinning. Rx: PO/topical abx + steroids Phlyctenulosis: solitary limbal lesion (phlycten). Can also be conjunctival or corneal. Usually in Africa. Hypersensitivity to staph or mycobacteria. Rx: steroid Dellen: non-ulcerative corneal thinning adjactent to raised limbal lesions due to dry eyes. Rx: lubrication Terrien's marginal degeneration: middle aged males. yellow lipid deposition w/ fine vascularisation of superior marginal cornea and thinning between lipid and limbus (astigmatism). Rx: astigmatism, PK

Orbital #

Maxillary: most common, due to object <5cm (tennis ball, fist). Periorbital bruising, surgical emphysema. Vertical diplopia due to mechanical movement restriction. Enophthalmos, infraorbital anaesthesia. Beware white eye blowout # in children, where no signs but diplopia due to inferior rectus being entrapped in flap of bone Ethmoidal: Afro-Carribeans. Horizontal diplopia (medial rectus tethering) Frontal: children brow injury. Superior conjunctivitis with no posterior limit, inferior globe displacement with pulsative globe + bruit (communication with CSF -> meningitis) Zygomatic: v. strong, only in severe facial trauma Orbital compartment syndrome: soft tissue oedema + retrobulbar haemorrhage cause sudden rise in IOP, causing ischaemic ON damage and blindness. "Tense Orbit" - resistance to retropulsion with tight eyelids, painful proptosis, reduced VA, restricted EOM and retinal artery pulsations. Elevated IOP Immediate lateral canthotomy + lower/upper cantholysis to release lateral canthal tendon Then: IV mannitol + acetazolomide Then: orbital septum incision, formal orbital decompression No nose blowing (can cause surgical emphysema, herniation, or URTI spread Abx: co-amox Trap door type should be surgically repaired within 48h (children), 14d (adults). Full repair within 1m Immediate repair if persistent oculocardiac reflex, white eye #, or huge enophthalmos/hypoglobus

Ptosis

May have high upper lid crease, compensatory brow lift Involutional: disinsertion of LPS. Very common. RF: ophthalmic surgery (excessive speculum traction), trauma, chronic CL use, periocular steroids. Rx Anterior levator advancement (or Mullerectomy) Neurogenic: CNIII (commonly spontaneously recovers in 6mo) or Horner's (partial but persistent) MG: Rx medically, no surgery Myopathic: chronic progressive external ophthalmoplegia (CPEO) causes b/l symmetric ptosis. Usually surgery delayed Mechanical: masses of upper lid can cause ptosis Congenital: myopathies Rx surgery (anterior levator resection), blepharophimosis syndrome (AD, less wide palpebral fissures, telecanthus, b/l ptosis, epicanthus inversus and ectropia - Rx Surgery), Marcus-Gunn jaw-winking syndrome Pseudoptosis: brow ptosis (lowering of eyebrow due to frontalis dysfunction), dermatochalasis (excess of skin on upper lid), blepharochalasis ('cigarette paper' lids with multiple skin folds) Beware enophthalmos, phthisis bulbi and contralateral pathology

Lens abnormalities

Microphakia: Lowe syndrome Microspherophakia: Marfans, Alports, Congenital Rubella, Hyperlysinaemia, Weill-Marchesani syndrome, Peter's anomaly, Familial microspherophakia Coloboma: giant retinal tears, iris/choroid colobomata Anterior lenticonus: Alport Posterior lenticonus: U/l sporadic, b/l familial or Lowes syndrome Lentiglobus: posterior polar cataract Ectopia lentis Congenital: familial ectopia lentis, ectopia lentis et pupillae, Marfans, Homocystinuria, Weill-Marchesani syndrome, hyperlysineamia, sulfite oxidase deficiency Acquired: trauma, myopia, hypermature cataract, PXF, buphthalmos, ciliary body tumour Can be complete (dislocation) or partial (subluxation). If anterior can cause glaucoma, otherwise refractive error Rx: CL/spectacles, dislocation (YAG zonulysis)/lensectomy + aphakic correction

Vogt-Koyanagi-Harada syndrome

Multisystem sutoimmune response to melanocyte antigens. Dark-skinned race women 30-49 with HLA-DR4, usually with hx of cutaneous injury (liberating antigen) Prodrome: fevere, meningism, auditory symptoms Ophthalmic: b/l granulomatous anterior uveitis, posterior uveitis with multifocal RD, ERD, choroidal depigmentation (sunset glow fundus), Dalen Fuchs' nodules (peripheral yellow-white choroidal granulomas, subretinal fibrosis Cutaneous: vitiligo, alopecia, poliosis Auditory: tinnitus, deafness, vertigo Neuro: sterile meningitis, encephalitis, cranial neuropathies OCT: ERDs FFA: leakage and delay USS: choroidal thickening LP: lymphocytosis Rx: high-dose systemic steroids, steroid sparing agents

Secondary closed angle glaucoma

NEOVASCULAR posterior segment ischaemia causes neovascularisation of iris and drainage angle, which eventually contract to form posterior synechiae Ischaemic CRVO: 50% progress to NVG Diabetic retinopathy: PDR Other vascular: OIS, CRAO, BRVO Other retinal: chronic retinal detachment, sickle cell retinopathy Malignant: retinal/choroidal tumours Severe pain, iris rubeosis, AC flare, hyphaema, ectropion uvea Gonioscopy: abnormal vessels in angle, fibrovascular membrane overlying trabecular network (open angle) or synechial angle closure (closed angle) Rx: antiVEGF, treat underlying cause OTHER Inflammatory: seclusio pupillae (360deg posterior synechiae) causes iris bombe and angle closure. Rapid Rx of uveitis, and multiple or large PI. Angle can also close due to anterior synechiae, Rx POAG Phacomorphic glaucoma: intumescent enlarged lens cause pupillary block. Can also be due to normal age-related lens increase in highly hypermetropic eye. Sigma sign on gonioscopy. Rx: PACG, cataract removal Lens subluxation/dislocation: pupillary block. Lenticular astigmatism, variable refraction. Rx: dilate, lie pt supine, then constrict to relocate lens. If fails, surgery Iridoschisis: b/l splitting + atrophy of anterior iris sheath in elderly. Associated w/ nanophthalmos Iridocorneal endothelial syndrome (ICE): abnormal corneal endothelium migrates across angle, trabecular meshwork and anterior iris, 20-40yo male, 50% glaucoma. U/l pain, reduced VA, fine corneal guttata ('beaten metal'), corneal oedema, iris atrophy, corectopia, pseudopolycoria. Ix: specular microscopy Posterior polymorphous dystrophy (PPD): b/l abnormal corneal endothelium causes extensive anterior synechiae in childhood Epithelial downgrowth: deranged healing response, corneal epithelium moves down wound and colonises endothelial layer, growing over trabecular network and forming synechiae Fuch's endothelial dystrophy: severe corneal oedema may cause angle closure Aqueous misdirection syndrome (malignant glaucoma): posterior misdirection of aqueuous causes anterior displacement of vitreous, ciliary processes and lens, causing angle closure. Usually due to surgery. No pupillary block. Rx as PCAG. If medical treatment + PI fails, posterior hyaloidotomy/capsulotomy with laser or surgery to form unichamber eye Post-op: due to gases, vitreoelastic, etc. Rx: prophylactic single dose of acetazolomide

Retinal artery occlusion

Ocular emergency. Male, age. hypoxia -> coagulative necrosis within 100min CRAO Sudden painless reduced VA to CF or less White swollen retina, cherry red spot at macula, arteriolar attenuation + cattle-trucking, RAPD, visible emboli (20%) 30% have cilioretinal artery protecting papillomacular bundle and preserving sight Complications: NVI/NVD/NVG, optic atrophy, OIS If chronic may be hard to identify, but OCT will show inner retinal atrophy Check for: GCS!, CVS risks, carotid bruit AFFECTED EYE: IV acetazolomide, ocular massage and AC paracentesis Other eye: steroids for GCA, carotid endartectomy, etc 1/3 show improvement, 18% NVI BRAO Sudden painless u/l altitudinal VF defect White swollen retina along branch arteriole, branch arteriolar attenuation + cattle trucking, 60% visible emboli (eg Hollenhorst cholesterol plaque) Complications (NV) rare OCT APLS causes multiple BRAO. Susac syndrome with SNHL (rare) No Rx Ophtlamic artery occlusion: similar to CRAO but also profound choroidal ischaemia (no cherry red spot) and NPL vision CRAO+CRVO: whitening + venous haemorrhage. APLS Purtscher's retinopathy: due to head/compressive chest trauma, acute pancreatitis, fat emboli. b/l polygonal retinal whitening between arteriole + venule, CWS with minimal haemorrhage Paracentral acute middle maculopathy (PAMM): hyperreflectivity on OCT of middle retinal layers suggesting ischaemia of intermediate/deep plexi - nonspecific

Ocular ischaemic syndrome

Ocular hypoperfusion due to carotid stenosis. Can be due to Takayasu's Subacute reduced VA in affected eye (can be abrupt with cherry red spot). 10% have aumorosis fugax hx (may be light-induced). 40% have dull periorbital ache (periorbital angina) May hav prominent collaterals on forehead Ant: atrophic iris, poorly reactive pupil, AC activity, NVI (but no high IOP due to hypoperfusion) Post: Narrowed retinal arterioles, dilated (not tortuous) veins, haemorrhages, microaneurysms, CWS, NVD/NVE, spontaneous arterial pulsation with lid pressure FFA: delayed filling, prolonged transit time, leakage and vessel wall staining Carotid doppler Carotid endartectomy: may stabilise/improve VA NV: PRP

Cicatricial conjunctivitis

Ocular mucous membrane pemphigoid (MMP): >60yo T2HR to hemidesmosomes of BM. Papillary conjunctivitis, subconjunctival bullae, ulceration, scarring, dry eye, 2ndary microbial keratitis, LSCD, corneal neovascularisation Rx: treat any blepharitis/infection. Then topical steroids, PO dox (MMP inhib). Mild-dapsone, moderate-MMF/methotrexate, severe-cyclophosphamide/IV steriods SJS/TEN: mild-eyelid oedema, injection, chemosis. More severe forms have keratitis (ulceration, defects) then scarring (sym/ankylobelpharon). Ocular signs can occur years after disease occurence. Rx: burns unit. Orbital lubricant/hygiene, topical steroid + prophylactic Abx. Surgery for scarring (controversial) FOR BOTH, a radical solution is osteo-odonto-keratoprosthesis Trauma, anterior blepharitis (Staph aureus), infective conjunctivitis, Drugs (eg penicillamine), congenital (ectodermal dysplasia, epidermolysis bullosa), systemic (rosacea, Sjogrens, GVHD - acute is like SJS/TEN, chronic like KCS), neoplastic (sebaceous cell carcinoma, conjunctival ca, SCC)

Rhegmatogenous retinal detachment

Ophthalmic emergency. Vitreous liquefaction + retinal break allow fluid to enter subretinal space and detach retina from RPE Flashes (temporal), floaters, curtain type VF defect, reduced VA (macular involvement) BEWARE that if RRD originates from holes or dialysis, no hx of PVD so asymptomatic until reduced VA from macular involvement Vitreous: PVD +/- vitreous 'tobacco dust' pigment +/- blood Retinal breaks: usually tears, but can be large holes or dialysis Retinal detachment: u/l corrugated convex dome of retina and loss of RPE markings Chronic: retinal thinning, demarcation lines (3mo), intraretinal cysts (1y), proliferative vitreoretinopathy USS: highly reflective irregular convex membrane SURGERY Macula-on detachment with u-tear requires urgent referal. If macula-off, can wait for <1w Posture to reduce traction towards macula Vitrectomy: most common. Posterior segment entered, vitreous replaced with saline, SRF aspirated laser/cryopexy fixes tear in place, then gas bubble used to hold Scleral buckling: if no pre-existing PVD. After retinopexy a band is placed around eye to push RPE into retina. Risks failure, diplopia, refractive change/worse vision, infection, haemorrhage, explant extrusion, glaucoma, ERM/CMO/choroidal detachment Pneumatic retinopexy: lower success rate, used for small superior detachments. Post-op posturing vital, works by tamponading break after cryo or retinopexy. risks infection, haemorrhage, repeat procedure, acutely raised IOP

Posterior vitreous detachment

PVD. Synersis (liquification of vitreous) occurs with age (also myopia, trauma, inflammation, connective tissue diseases), leaving empty lacunae and reduced shock absorption. Break in cortical vitreous allows vitreal fluid to flow into retrohyaloid space and separate vitreous and retina. Very common, 10% have retinal tear, mimics retinal detachment Flashes (arc of light in temporal field), floaters (ring, cobwebs. Wobble w/ movement, black specs=haemorrhage/retinal tear) O/E: Weiss ring (detachment at optic disc), wrinkly posterior hyaloid face, rarely vitreous haemorrhage, retinal detachment, retinal break Reassure, safety-net for retinal detachment IF vitreous haemorrhage: Indirect fundoscopy required to identify small retinal breaks. Must look at whole ora serrata. If not possible USS. F/u frequently until haemorrhage cleared IF TEAR Laser retinopexy: heat adheres retina to RPE. 80% success rate, 20% need retreatment, 9% detach despite Rx. Rarely retinal/vitreous haemorrhage, and post-op ERM/CMO/RRD. Can use slit lamp (post-equatoral) or indirect fundoscopy (pre-equatoral) Cryopexy: usually for pre-equatorial. Freezes retina to RPE. Success rates and comps above

Angioid streaks

PXE (by far most common association) EDS Pagets Acromegaly Haemoglobinopathies Hereditary spherocytosis Abetalipoproteinaemia Idiopathic (50%) PXE: AR ABCC6 mutation causing degeneration + calcification of elastic fibres in skin eye and CVS. Skin examined for plucked chicken/cobblestone-like appearance Asymptomatic, may have reduced VA, metamorphopsia Angioid streaks: narrow irregular red-dark brown streaks radiating from peripapillary ring with peripapillary chorioretinal atrophy, RPE mottling ('peau-d'orange'), disc/subretinal drusen Complications: CNV, choroidal rupture (with minor trauma), subfoveal haemorrhage, macular atrophy FFA: CNV, angioid streaks hyperfluoresce Conservative: avoid contact spots (choroidal rupture) CNV: intravitreal antiVEGF foveal CNV: PDT or argon laser

Microbial keratitis

Pain, FB sensation, redness, photophobia, tearing, discharge, blurriness Injection + white opacities within cornea, oedema COmplications: anterior uveitis, corneal perforation with endophthalmitis (rare) CORNEAL SCRAPE send CL, solutions, cases for culture. If due to CL reportable Sterilisation phase: intensive topical Abx for 72h (PO if limbal involvement or perforation). Cycloplegics and analgaesics for pain Repair phase: consider topical steroids If persistent consider PO tetracyclines and vit c Corneal perforation: therapeutic CL to facilitate repair, tissue adhesives (enbucrilate), surgical reconstruction: AM or keratoplasty

Non-pigmented conjunctival lesions

Papilloma: pedunculated (young, HPV infection) or sessile form (middle age, u/l and solitary). Rx: resolve spontaneously. Excise/cryo if symptomatic Epibulbar choristoma: dermoid (associated with Goldenhar syndrome, children. Soft u/l yellow limbal mass, may encircle limbus), lipodermoid (adults, soft white mass at lateral canthus), ectopic lashes (rare, subconjunctival cilia) Pyogenic granuloma: red vascular mass after trauma PREMALIGNANT Conjunctival intraepithelial neoplasia: >50yo, fleshy, freely moving mass at limbus with tufted vessels. Can transform to SCC. Rx excision + MMC + cryotherapy, followed by chemo eye drops MALIGNANT Ocular surface squamous neoplasia (OSSN): >50yo, UV light and HPV, may have Hx of CIN. Persistent u/l keratoconjunctivitis, limbal gelatinous mass, may infiltrate cornea, sclera, penetrate globe, but doesn't met. Excision + MMC + cryo + topical chemo. Exenteration rarely required Conjunctival Kaposi's sarcoma: HHV8 bright red mass in inferior fornix, can mimic subconjunctival haemorrhage. Rx RT Conjunctival lymphoma: salmon pink subconjunctival infiltrate in fornices. Rx excision + cryo + RT Mucoepidermoid carcinoma: v. rare aggressive, mimics pterygium, arising from mucus-secreting conjunctival cells

Acuity

Pinhole if <6/9 or <0.2 logMAR: corrects refractive error, differentiates between optical and pathological causes Adult literate: snellen, logMAR (ETDRS) Adult illiterate: Sheridan Gardiner/Tumbling E, Kay picture test, Keeler logMAR Children >=3: logMAR, Kay 2-3: Cardiff cards Babies/infants: preferential looking tests (cardiff cards), electrodiagnostic tests (VEPs in response to alternating chequerboard), fixation tests logMAR: 1.0U - 0.1U per correct line - 0.02U per correct word. 1.0=6/60, 0=6/6 <0.5/60 means not able to CF, so go straight to HM Near vision: Test type N chart (in NA M and J exist) Binocular vision: Worth's lights, Bagolini Glasses test, stereoacuity tests Contrast vision: Vistech, Pelli-Robson, Cambridge chart Colour vision: Ishihara (screening), Hardy-Rand-Rittler, Holmes Wright (military), Farnsworth D15, Farnsworth-Munsell 100-Hue test (gold standard)

Vitreomacular traction

Posterior hyaloid adheres to ILM at macula. AP traction distorts macular architecture Asymptomatic, but can have metamorphopsia, reduced VA. Slight change in foveal contour/reflex OCT MACULAR HOLE Idiopathic: vitreomacular traction Trauma, CMO, ERM, RRD, Laser injury, pathological myopia, HTN, DR Small yellow foveolar spot, loss of foveolar contour, yellow foveal ring. Eventually full thickness defect. Watzke Allen test to confirm OCT Medical: enzymatic vitreolysis (ocriplasmin) for small holes Suregry: vitrectomy + ILM peel and gas tamponade. Must be performed within 6mo

Peripheral Ulcerative Keratitis

Primary (idiopathic) Systemic: GPA/MPA/EGPA, RA, SLE, Sjogrens, Relapsing polychondritis, PAN, sarcoid Other: T1DM, mycobacteria Aggressive sight-threatening keratitis. pain, redness, reduced VA w/ peripheral corneal ulceration, epithelial defects, stromal thinning and associated limbal inflammation and scleritis Mooren's ulcer: associated w/ hepC. ulcer advances centrally and circumferencially with underlying stromal melt and grey infiltrate at advancing margin Rx: prevent dry eye, systemic immunosuppression for underlying condition, treat any infection or persistent epithelial defects

Retinal vasculitis

Primary: birdshot chorioretinopathy, VKH, sympathetic ophthalmia Infective: HSV/VZV/CMV/HTLV-1/HIV, Toxoplasmosis/Lyme/Cat-scratch, Syphilis/Whipple's Systemic: Leukaemia/lymphoma, SLE/APLS, Behcets/sarcoidosis, GPA/EGPA/PAN Reduced VA, floaters, positive scotomata (asymptomatic if peripheral) O/e: perivascular sheathing of arteries/veins/capillaries, retinal haemorrhages, vitritis signs, disc swelling, CMO Complications: B/CRVO, neovascularisation, vitreous haemorrhage, ischaemic maculopathy, TRD FFA (widespread leakage with enlarged FAZ) to diagnose. Rx underlying condition, otherwise as intermediate uveitis

Keratoconus

Progressive ectasia causing conical distortion of cornea. ?Due to recurrent trauma (eye rubbing) w/ underlying connective tissue disease b/l asymmetric progressive irregular astigmatism with reduced VA. Stabilises by mid 30s. O/E: corneal steepening/thinning, Vogt's striae (vertical stromal lines disappearing on pressure), Fleischer ring (iron deposition at base of cone), Munson's sign (conical distortion of lower lid on downward gaze), Rizutti's sign (abnormal slit lamp focus when looking obliquely through cone), scissoring reflex on retinoscopy, oil droplet reflex on ophthalmoscopy COMPLICATIONS: acute hydrops (Descemet's membrane rupture -> corneal oedema), scarring Corneal topography/videokeratography Mild: Spectacle/CL Moderate: RGP CL. If CL-intolerant, insert intracorneal ring segments (ICRS) to flatten cornea Severe: lamellar/PK Hydrops: intracameral air injection, topical steroids/lubricant/cycloplegics Progression: corneal collagen cross-linking (ribovarin + UV light) - new

Genetic open angle glaucoma

Pseudoexfoliation syndrome: Associated w/ LOX1 mutation, heat/IR damage. Systemic condition causing whitish dandruff-like deposits over AC, skin, heart, lungs, kidneys and meninges. Elderly, female, scandanavia (prevalence 20%!). O/E: deposits on pupillary border, anterior lens capsule and in AC + corneal endothelium. Peripupillary transillumination defects, poor mydriasis and iridodonesis/phacodonesis. Gonioscopy: narrow open angle with irregular pigment deposition in trabeculum and anterior to Schwalbe's line and PXF deposition in angle Glaucoma Capsulare: 25% of PXF Rx as for POAG. Can do SLT for affected areas Pigment dispersion syndrome Release of pigment from posterior mid-iris due to rubbing against zonules (reverse pupillary block configuration). AD. Myopic caucasian male 20-40yo O/E: pigment on corneal endothelium (Krukenberg spiral), post lense capsule (Zentmayer's line), anterior hyaloid-capsular ligament (Egger's line). Middle spoke-like transillumination defects Gonioscopy: open angle, concave iris with homogenous trabecular pigmentation and pigment anterior to schwalbe's line inferiorly Pigmentary glaucoma: 50%, usually asymptomatic Rx: Topical meds, ALT/SLT, trabeculectomy as for POAG, but no PI

Diabetic retinopathy

R0: none. Rx-annual screening R1: background (microaneurysms, retinal haemorrhages, venous loop, exudates, CWS) Rx-annual screening + inform DM team R2: pre-proliferative (venous beading/reduplication, IRMA, multiple deep, round, blot haemorrhages), Rx-refer to HES<=13w (4-6moly review, PRP in select cases) R3a: active proliferative (NVD, NVE, preretinal/vitreous haemorrhage, preretinal fibrosis, TRD), Rx-fast track referral to HES for immediate PRP R3s: stabel/post-Rx proliferative (evidence of PRP + no changes since post-Rx photo), Rx-annual screening M1: maculopathy (exudate/thickening/haemorrhage within 1DD of centre of fovea), Rx-refer to HES<=13w (PRP and/or antiVEGF) P1: evidence of PRP

Fungal keratitis

Rare, needs trauma, immunosuppression or organic FB. Candida, Fusarium, Aspergillus Feathery branching infiltrate with satellite lesions, hypopyon/AC activation Scrape Topical antifungals. If severe PO. 12w

Other

Red for central VF testing (when does it appear red) Inattention with red (any difference between colours) - early chiasmal disease Formal perimetry gold standard Lid Upper margin reflex distance Levator function (thumb on frontalis to inhibit) Lagophthalmos/Bell's sign Fatiguability: hold target superiorly, fixate for 1min, look for ptosis. If noted, test surrounding muscles and Ice-pack test Cogan's twitch: MG, rapid elevation from downgaze to primary position causes eyelid overshoot Jaw winking: synkinesis Exophtalmometry: measures degree of exophthalmos (Hertel exophtlamometer) 2 ruler test: for horizontal or vertical orbital displacement TEARS Dye disappearance test: fluorescein should drain by 2min Probing: LA, straight lacrimal cannula into lower canaliculus. Soft stop if obstruction at canaliculus (regurgitates only through canaliculus enterd) or common canaliculus (regurgitates through both). If hard stop nasolacrimal duct obstruction Jones testing: both of above, but with nasendoscopy for dye recovery REFRACTION Retinoscopy: using retinoscope and lenses to see movement of red reflex and test for astigmatism and refraction objectively Autorefractors: analyse deviation of light to get Back-vertex distance (BVD). Lens strength in diopters (= 1/BVD) Subjective refraction: snellen chart with lenses Focimetry: can be automated or manual. Uses green light to determine strength of lenses. Can determine cylindricle lenses too (used for astigmatism, have different powers in different axis) Asthenopia: refractive discomfort/eye strain. Usually due to overcorrecting lenses, causing pt to constantly accommodate

Retinal break

Retinal hole: full thickness retinal defect due to atrophy, associated with retinal degeneration Rx: none if small and asymptomatic Operculated hole: retinal hole caused by PVD with free flowing operculum Retinal tear: full thickness U-shaped defect due to PVD. Associated with abnormal vitreous adhesions (lattice degeneration). Ongoing traction causes progression to RRD. Rx laser photocoagulation or cryo Giant retinal tear: >3 clock hours in extent. Peripheral retina, due to PVD. Associated with connective tissue disease, trauma, myopia Dialysis: full-thickness circumferential disinsertion of retina from ora serrata. Spontaneous or after trauma, not with PVD. Rx scleral buckling (detachment) or laser/cryo (no/limited detachment)

Retinal vein occlusion

Risk: all VTE risks + age. BRVO>CRVO CRVO (non-ischaemic) mild/moderate painless reduced VA with metamorphopsia Dilated tortuous retinal veins, retinal haemorrhages in all 4 quadrants, occasional CWS, mild optic disc oedema Complications: CMO CRVO (ischaemic) severe painless reduced VA As before + RAPD, extensive haemorrhage, widespread CWS. Rarely vitreous haemorrhage, ERD Chronic: venous sheathing, resorption of haemorrhages, macular pigment disturbance, CMO, neovascularisation (NVI>NVD>NVE>NVG) FFA: slow AV phase acutely, non-ischaemic - vein wall staining, microaneurysms, dilated optic disc capillaries. Ischaemic - same + capillary closure with hypofluorescence, leakage with NV or CMO OCT: for CMO Discontinue HRT and OCP CMO: anti-VEGF NV: urgent PRP, review at 2w, consider antiVEGF NVA/NVI with NVG: urgent PRP + cyclodiode laser therapy BRVO (or HRVO involving whole hemisphere) Most commonly u/l superotemporal Asymptomatic, or reduced VA, metamorphopsia, classically altitudinal VF defect Retinal haemorrhages (dot/blot/flame), CWS, oedema in distribution of dilated tortuous vein (typically superotemporal arcade, arising from AV crossing) Chronic: venous sheathing, exudates, pigment disturbance, collateral vessels. CMO, NVE>NVD>NVI, recurrent vitreous haemorrhage FFA, OCT: CMO respecting horizontal raphe CMO: antiVEGF NV: PRP

Primary open angle glaucoma

Risks: age, Afro-caribbean, FHx (1/8), Steroids Asymptomatic: rarely eye ache, halos VF defects: focal on horizontal meridian (nasal step, baring of blind spot, paracentral scotomas, arcuate/altitudinal defects), or generalised depression IOP > 21 Disc changes: C/D asymmetry/high ratio, vertical cup elongation, Neuro-retinal rim notching (ISNT rule of thickness), disc haemorrhage, vessel bayoneting, peripapillary atrophy in beta zone (dark zones surrounding disc due to chorioretinal thinning and RPE disruption ) This is the glaucoma triad NTG: variant with IOP<21, elderly japanese. May have other vascular dysregulation (migraine, Raynauds, exaggerated nocturnal hypotension) Counselling: lifetime Rx, compliance, driving Medical: topical PGA, bblocker, a2agonist or carbonic anhydrase inhibitor (in order of preference) Surgical: laser trabeculoplasty (50% failure at 5y), trabeculectomy with anti-scarring MMC. New surgeries include MIGS, deep sclerectomy and viscoanalostomy

Lid anatomy

SUPERFICIAL TO DEEP Skin with no subcut fat with 150 hairs in 2-3rows on upper (75 on lower), with apocrine sweat glands (of Moll) and modified sebaceous glands (of Zeis) Orbicularis oculi: eye closure and lacrimal drainage. Orbital and palpebral (preseptal and pretarsal) regions. Originates from medial canthal tendon, inserts in lateral canthal tendon. Horner's muscle is the part surrounding lacrimal sac, pushing tears out Orbital septum: originates from orbital ridge, thickening at palpebral margin to form tarsal plate. Contains 25-35 mebomian glands (lipid part of tear film). Inserts into medial and lateral canthal tendons Preaponeurotic fat pads Lid retractors: Originates from orbital apex (sphenoid), runs over transverse ligament of Whitnall and steeply downwards to insert into tarsus/septum (CNIII). Muller's muscle is accessory, and innervated sympathetically. Lower lid retractors analagous but rudimentry Conjunctiva: stratified squamous epithelium (non-keratinised) w/ goblet cells Lower lid infraorbital n (Vb), upper lid Va Arterial arcades from medial palpebral a (terminal ophthalmic a) to lateral palpebral a (lacrimal a). Drain to parotid glands, submandibular glands and anterior cervical chain. Superficial temporal, ophthalmic and angular veins

Bacterial Conjunctivitis

Staph epidermidis, Staph aureus, Strep pneumoniae, H. influenzae (classically children), M. lacunata Acute red gritty sticky eye, usually sequentially b/l. Purulent dischargw, crusted lids, injected conjunctiva with papillae, chemosis Only swab if recurrent/refractory or immunosuppressed Topical chloramphenicol. Frequent handwashing, don't touch eyes or share towels/flannels or shake hands If chronic or recurrent, probably resevoir. Consider: staphylococcal blepharitis, chronic dacryocystitis, giant fornix syndrome (in elderly) N. gonococcus: rare, STI or neonatal. 3-5d incubation. Hyperacute <24h onset w/ severe purulent discharge, marked lid swelling/chemosis, papillae, preauricular lymphadenopathy, pseudomembrane and keratitis (ulceration, perforation, endophthalmitis) Swab for MC&S Topical Abx (ofloxacin), with QDS saline irrigation of discharge. If keratitis admit, add IV ceftriaxone Chlamydial. trachomatis: STI. Subacute (2-3w) usually u/l onset of mucopurulent discharge, lid oedema, ptosis, papillae/follicles, non-tender lymphadenopathy, superior pannus. Signs predominantly on upper lid/bulbar conjunctiva. Keratitis w/ punctate epithelial erosions Swab for PCR/ELISA/IHC Topical chloramphenicol (bacteriostatic) Trachoma: spread by flies in poor overcrowded environments. Follicular conjunctivits with scarring (Arlt lines, trichiasis, entropion, KCS, limbal follicles -> Herbert pits), pannus Swabs SAFE: Surgery (for lashes), Abx (azithromycin PO), Facial cleanliness and Environmental improvement

Secondary open angle glaucoma

Steroid induced (common) Red cell glaucoma: due to hyphaema, red cells block trabecular network. Avoid CAi in SCA Ghost cell glaucoma: vitreous haemorrhage causes degenerate RBCs to infiltrate trabecular network 2-4w later (tan-coloured as no Hb) Angle recession: blunt trauma causes angle recession, trabecular damage. If known angle recession, monitor IOP regularly (10% at 10y glaucomatous) Raised episcleral venous pressure: SW syndrome, orbital varices, cavernous sinud fistula, SVCO. Engorged episcleral veins, chemosis, proptosis, blood in Schlemm's canal Tumours: infiltrate and clog trabecular network. 20% of malignant melanoma Schwartz-Matsuo syndrome: anterior segment inflammation and open angle raised IOP due to RRD Inflammatory: acute trabeculitis (HSV/VZV). May have signs of uveitis + keratitis. Treat infection, beware can scar and become chronic, requiring POAG Rx (avoid PGA as reactivate HSV Posner-Schlossman syndrome: recurrent u/l painless high IOP in white eye, young males. Though to be due to HSV trabeculitis. Reduced VA, haloes, but no pain. Rx topical steroid Fuchs' heterochromic uveitis: mild chronic u/l anterior uveitis, iris heterochromia, cataract. 30% glaucoma. Young adults, associated with rubella virus. Often asymptomatic, may have cataract symptoms, floaters. White eye, white stellate KPs over corneal endothelium, iris atrophy (moth-eaten appearance) with transillumination defects, rubeosis, heterochromia (becomes bluer), iris nodules, cataract, vitritis, raised IOP. Rx POAG, cataract removal. NOT topical steroids Phacolytic glaucoma: hypermature cataract loses lens proteins which clog trabecular network. Rx catarct removal Phacoanaphylactic uveitis: sensitised immune system can attack other eye. AC flare, cells, hypopyon, KP, synechiae. Rx: topical steroids, removal of lens fragments

Hereditary vitreoretinal degeneration

Stickler syndrome: T2collagen mutation. Aka hereditary arthro-ophthalmopathy. Commonest cause of hereditary RRD. High myopia with perivascular lattice-like pigmented degeneration and giant retinal tears (70% RRD). Also epiphyseal dysplasia, cleft palate, bifid uvula, mid-facial flattening, Pierre-Robin sequence, SNHL, MVP. Rx: prophylactic retinopexy XL juvenile retinoschisis: NFL retinal splitting, male children. Foveal schisis with spoke-like folds separating cystoid spaces. Later progresses to retinal schisis with vitreous veils. RRD in 5%. Ix: VF loss with schisis, OCT Rx: dorzolamide Goldmann-Favre syndrome: v. rare, like XLJR but increased blue light sensitivity FEVR: abrupt cessation of peripheral retinal vessels at equator with vitreous bands at peripheral, causing CNV and ERD

Degenerative myopia

Subset who constantly progress (pathological myopia), major in East Asia Increasing myopia, reduced VA, metamorphopsia, photopsia Fundus: tessellated, lacquer cracks (rarely CNV), spontaneous macular haemorrhage + Forster-Fuchs' spot (pigmented scar), posterior staphyloma, lattice degeneration Disc: tilted with temporal atrophy (temporal crescent), peripapillary choroidal cavitation (surrounding yellow-orange thickening) Vitreous syneresis, PVD, macular holes, peripheral retinal tears, RRD< macular retinoschisis Increased time outdoors, antiVEGF for CNV

Dry eyes

Tear film instability (evaporative): by far most common cause. posterior blepharitis (MGD), vit A deficiency, etc Sjogren syndrome Lacrimal gland deficiency: Age-related dry eye, congenital alacrima, infiltration (sarcoidosis, lymphoma, GVHD), gland ablation Gland obstruction: cicatricial conjunctivitis Reflex hyposecretion: CL wear, DM, VIIn damage, neurotrophic keratitis Burning, itching, blurred vision (corneal involvement) Mucus strands, no tear meniscus, punctate epithelial defects, mucus plaques, TBUT <10s, Schirmer test SICCA OSS uses lissamine green for conjunctiva and fluorescein for cornea to score severity Omega 3, lubricants (less viscous = less blurriness, but need to reapply more), lid hygeine/warm compress. Next: punctal occlusion devices, moisture chamber goggles. Abx for anterior blepharitis, topical immunosuppressants, secretagogoues, LFA-1 agonists. PO dox Next: therapeutic CLs, AM grafts, surgery (punctal occlusion, salivary gland transposition), serum eye drops

Cataracts

Thought to be due to oxidative damage-mediated protein denaturation SUTURAL Congenital: non-progressive Concussion: flower-shaped ant+post Storage disorder: start posteriorly. Fabry disease, mannosidosis Deposition: start anterior. Cu, Au, Ag, Fe, chlorpromazine NUCLEAR Congenital: non-progressive. Cataracta centralis pulverulenta Age-related: increased white scatter and brunescence (brown chromophores) POLAR (congenital) Anterior: capsular + AC abnormalities w/ persistent pupillary membrane, anterior lenticonus, Peter's anomaly Posterior: capsular + PC abnormalities w/ persistent hyperplastic primary vitreous, Mittendorf dots, posterior lenticonus DIFFUSE Congenital: Focal blue dot opacities. Lowe syndrome carriers Age-related: Christmas tree cataracts OTHER Lamellar: congenital/infantile. Rubella, DM, hypocalcaemia, galactosaemia Coronary: sporadic, round 'crown' cortical opacities Cortical: age-related 'spoke-like' opacities in superficial cortex Subcapsular: granular material just beneath capsule, more commonly posterior. DM, steroids, uveitis, RT Immature: incomplete opacification Mature: complete Hypermature: cortical lysis leads to lense shrinkage Morgagnian: total cortical lysis allows hard nucleus to fall inferiorly into intact capsule Reduced VA, contrast sensitivity, colour vision. Glare, monocular diplopia, polyplopia, ghosting Refraction changes (typically myopic shift), difficulty obtaining fundal view UNCOMMON phacomorphic glaucoma: enlarged lense may cause anterior iris bowing and 2ndary angle closure phacolytic glaucoma: soluble lense proteins lost, causing trabecular obstruction and 2ndary open angle glaucoma phacoanaphylactic uveitis: inflammatory response to lens protein, either due to traumatic capsular rupture or post-op lens retention SURGERY RISKS INTRAOP Floppy iris syndrome: miosis + iris prolapse in op due to use of prostatic alpha blockers Post capsule rupture (3%): remove all vitreous, place ACIOL AC problems: capsulorhexis 'runs out' Loss of nuclear fragment posteriorly (0.3%): will require pars plana vitrectomy, as v. proinflammatory Choroidal haemorrhage (0.1%): sudden increase in IOP, AC shallowing, iris prolapse. Poor prognosis, RF: HTN POSTOP Corneal oedema (10%): topical Rx Elevated IOP (5%): acetazolomide + topicals. Paracentesis if severe AC inflammation (4%): topical steriods. Can be due to toxic anterior segment syndrome (TASS) - acute emergency postop inflammation due to introduction of toxins to AC (iodine, contaminated/denature fluid). 12-24h post op corneal oedema, severe AC activity (hypopyon), high IOP (toxic to trabecular network). Intensive topical steroids with IOP monitoring Wound leak/iris prolapse (2%): Pos Seidel's. Return to theatre, abscise any nonviable iris and suture closed Endophthalmitis: Staph epidermidis/aureus and Strep. Emergency 1-7d postop. Pain, worsening VA, hypopyon/AC/PC activity. Vitreal biopsy/AC tap + intravitreal abx (vanc) POSTOP LATE Posterior capsule opacification (PCO 10% by 2y): YAG posterior capsulotomy if symptomatic Cystoid macular oedema (7%): Irvine-Gass syndrome. Excellent vision postop for days, then decline. O/E - loss of foveal contour, retinal thickening, central yellow spot. OCT - cystoid spaces. FFA- dye leakage in parafoveal cystoid spaces and optic disc. Topical steroid + NSAID AC retained epinuclear fragment: has to be removed Retinal detachment (0.7%): high risk in myopes and vitreous loss. Refer to vitreoretinal surgeon Chronic endophthalmitis: 1w-months postop. Propionibacterium acnes, S. epidermidis, fungi. Chronic postop inflammation recurring with steroid tapering. P. acnes = white plaque on posterior capsule. AC tap MC&S. Intravitreal vanc or amphotericin Refractive surprise: ametropia postop. Common in astigmatism. Can trial spectacles/CL, piggyback IOL or laser refractive surgery. If quickly identified, IOL exchange can be performed If ametropic, anisometropia with the emmotropic operated eye can cause aniseikonia, so do 2nd eye within 1w Pre-op: mydriasis. Wrong IOL is never event. Biometry (USS) used to calculate corneal refractive power, axial length and so IOL needed. Aim for emmetropia Procedure: small corneal incisions or scleral tunneling. On meridian incisions if previous astigmatism. AC filled with viscoelastic. Continuous curvilinear capsulorhexis (anterior capsulectomy via cystotome, stain with tryptan blue) performed. Hydrodissection (injection of viscoelastic below remnant of anterior capsule) splits cortex and nucleus. Phacoemulsification + aspiration and irrigation, then IOL introduction. Topical Abx, no sutures FSL: femtosecond lasers may help with each steo but expensive Manual small incision surgery (MSICS): nucleus removed via large scleral incision where phacoemulsification is available Toric IOL: for astigmatism Pseudoaccomodative IOL: multifocal Accomodative IOL: focal length changes with AP capsule movement. Not great due to high rate of capsular fibrosis ACIOL: used if capsule rupture

Other keratopathy

Thygeson's superficial punctate keratopathy Rare, young adult idiopathic B/l FB sensation (recurrent) with photophobia and tearing. Coarse stellate grey-white epithelial opacities in normal eye. NON-STAINING Rx: topical steriods, therapeutic CL Recurrent corneal erosion syndrome (RCES) Failure of epithelial-BM readhesion Recurrent episodes of severe pain, photophobia, starting on opening eyes after sleep. Worse on blinking, resolves within hours. Usually hx of corneal trauma (often forgotten). If caught during episode, will have epithelial irregularities (eg defects) Rx: lubricants, cycloplegics, NSAIDs, therapeutic CL, treat epithelial interruption Surgery: mechanical debridement of nonfunctional epithelium, alcohol delamination, excimer laser phototherapeutic keratectomy Treatment for persistent epithelial defect (>2w): due to LSCD, neurotrophia, chemical injury, keratitis, etc Topical chloramphenicol, lubricants, paraffin ointment (only at night as blurs vision), serum eye drops (if severe), steroids (if indicated) Systemic: dox, vit C, to promote stromal formation CL: therapeutic to help closure Grafts: AM Tx (used as BM substitute), LESC Tx, Gunderson flap, buccal mucous membrane graft

Other conjunctival lesions

Toxic conjunctivitis: topical aminoglycosides, antivirals, CL solutions cause inferior papillary conjunctivitis, that can scar. Rx discontinue agent Parinaud oculoglandular syndrome: u/l conjunctivitis w/ granulomatous nodules on palpebral conjunctiva, ipsilateral preauricular/submandibular lymphadenopathy, systemic upset. Due to cat-scratch disease (Bartonella henselae). Confirm with serology Ligneous conjunctivitis: rare idiopathic, in young girls characterised by pseudomembranes of palpebral conjunctiva and oropharynx. Rx topical cyclosporin Pinguecula: very common yellow-white patch on bulbar conjunctiva just next to limbus due to degeneration of collagen. Rx reassurance Pterygium: triangular pink-white fibrovascular band from nasal limbus, growing across cornea. Usually stops before interfering with vision. Stability shown by Stocker line. Rx: excise only if affecting vision, as recurrence tends to be more aggressive Concretions: conjunctival lithiasis, most common in elderly with chronic blepharitis (palpebral conjunctiva, can break through to cause FB sensation). Rx remove with needle under slit lamp Retention cyst: conjunctival cyst. Rx puncture with needle under slit lamp, excise if recurrence

Lens

Transparent avascular biconvex structure Capsule: thick BM. Thicker anteriorly and peripherally Epithelium: just deep to anterior capsule, cuboidal/non-mitotic centrally, columnar mitotic peripherally. Lose organelles to be transparent Lens fibres: main bulk. Arranged into central (fetal and embryonic old fibres) nucleus, and cortex (outer newer fibres). Sutures between fibres (Y anterior, lamda posterior) Zonules: suspensory fibrillin fibres that arise at ciliary body and attach to lense Low water content and high protein (crystallin) content allow for refraction Combination of glutathione and vitc prevent oxidative damage

Perimetry

Traquair's island: 50deg sup, 60 nasal, 70 inf, 90 temporal Goldmann: kinetic perimetry, light moved around to form isopter threshold curves for different light sizes/intensities Humphrey: static perimetry. Used for automated perimetry - lights shine at differing intensities at different areas. Pt presses buzzer when they see light. Value for each area tested Fixation losses: if light shone in blind spot but seen, fixation lost. >20% disregard test FP: responds even when no light seen (trigger happy) FN: stops responding to light previously seen (fatigue) p value Will give a numerical and greyscale display (in dB), then a comparison to age-appropriate controls (total deviation) and pattern deviation (stops overall loss of sensitivity from obscuring patterns in results) Automated protocols: SITA, Esterman grid (binocular version used by DVLA), short wavelength (blue on yellow background, more sensitive for glaucoma damage) EMGT progression analysis uses several VF tests in series to detect glaucoma progression Altutudinal defect: ION, hemibranch occlusion, glaucoma Arcuate scotoma: ION, glaucoma, drusen Binasal: functional, glaucoma, outer CNII compression, RP Bitemporal HA: chiasmal lesion, tilted optic disc, sectoral RP Central scotoma: macular lesion, optic neuritis/atrophy homonymous hemianopia: optic tract lesions Tunnel vision: glaucoma, RP, b/l PRP, CRAO, b/l occipital lobe lesions, papilloedema, functional (spiralling/crossing of isopters) Enlarged blind spot: papilloedema, glaucoma, CNII drusen/coloboma/myelinated fibres, myopic disc Pie in the sky: superior homonymous quadrantopia - temporal lesion Pie in the floor: inferior homonymous quadrantopia - parietal lesion

Eyelash disorders

Trichiasis Misdirected eyelashes: arise from normal position, but point posteriorly due to minor scarring Distichiasis: lashes arise from MG (or just posterior). Uncommon congenital (Meige syndrome) or acquired (meibomitis, trauma, cicatrising conjunctivitis) Pseudotrichiasis: misdirected eyelashes due to entropion Prevent! Epilation. Lash electrolysis, cryotherapy, trephination, photo/laserablation can remove small no of lashes, but can cause scarring. Surgical correction for entropion Lash infestation: lice cause itching, blepharitis and follicular conjunctivitis. Lice and eggs seen on slit lamp. Cryotherapy, malathion or permethrin. Can be Phthiriasis (crabs) or pediculosis Madarosis: chronic anterior blepharitis, alopecia, psoriasis, hypothyroidism, Leprosy. Loss of lashes Poliosis: whitening of lids. Sympathetic ophthalmia, VKH syndrome, Waardenburg syndrome, hypogonadism

Blepharitis

UNILATERAL BLEPHARITIS may be sebaceous cell carcinoma MGD Intrinsic (meibomian oil deficiency, low blink rate, drugs), extrinsic (vit A deficiency, eye drop preservatives) Stagnation of oils in MGs cause pro-inflammatory oil make-up with staph spp colonisation of lid margin (lipase and esterase secretion, leading to characteristic "tear foam", chronic inflammation, lid margin hyperkeratinisation, cicatrisation and irreversible MG blockage Mebomianitis: predominantly inflammation, associated with rosacea. Burning, worse in morning with inflammed MG openings -> chalazia -> internal hordeolum Bacterial blepharitis: anterior. Usually staphs, but also strep, Propionibacterium acnes and Moraxella. Burning, gritty, crusted with injected lid margins, scales at lash base and external hordeolum Seborrhoeic blepharitis: excessive MG secretions (associated with SD of scalp). Burning, gritty, crusted lids with lashes stuck together by soft scales and "tear foam" Mild discomfort, itching, photophobia, altered secretions with lid margin vascularity, telangiectasia and orifice plugging, conjunctival inflammation and corneal staining Omega 3, lid hygiene, warm compress with lid warming devices (warm flannel, then expression by running cotton bud down lid). Ocular lubricants. Topical Abx/anti-inflammatories (consider oral if severe)

Posterior scleritis

Uncommon sight-threatening scleritis, 1/3 systemic Deep pain referred to brow or jaw, reduced VA, diplopia, photopsia, hypermetropia. White eye, lid oedema, proptisis, restricted motility, choroidal folds, annular choroidal/exudative retinal detatchment (may cause ciliary body rotation, AC shallowing and glaucoma), macular/disc oedema USS: T sign from scleral thickening (can be seen on CT/MRI) with fluid in Tenon's space PO NSAIDs, steroid (IV if not controlled)

Anterior scleritis

Uncommon, potentially blinding (causes astigmatism if necrosis) scleral inflammation, 50% systemic connective tissue disease, 50% b/l severe, boring, retrobulbar pain radiating to forehead/temporal, can mimic GCA/trigeminal neuralgia, can wake patient from sleep. Globe tender to touch, pt has hand over eye and dreads examination Diffuse: 1w subacute onset, pain, redness, tearing, photophobia with diffuse injection of deep episcleral vascular plexi not blanching with phenylephrine Nodular: Diffuse symptoms + FB sensation. Red nodule in sclera, cannot be moved seperately from underlying tissue, no blanching with phenylephrine Necrotising: 3-4d onset with severe pain. White avascular areas surrounded by injected oedematous sclera -> translucency with black-blue uveal tissue revealed. May advance to anterior uveitis, PUK. Most have systemic disease Scleromalacia perforans: severe chronic RA. Asymptomatic, small yellow areas of necrotic sclera coalesce to reveal large areas of underlying uvea. Rest of eye quiet. VA gradually reduces due to astigmatism Extensive bloods for systemic disease (RF, CCO, ANA, ANCA, ACE, VDRL). Anterior segment fluorescein angiography (ASFA)/ICG angiography may predict progression to necrosis by identifying areas of ischaemia PO NSAID, steroids if refractory. Topical steroid are only symptomatic Rx. Subconjunctival steroid may be an option Necrotising: rapid IV immunosuppression, maintenance with steroid sparing agents

Hyphaema

Usually due to blunt trauma. Surgery (iris manipulation) Spontaneous: iris neovascularisation, haematological disease, tumour (juvenile xanthogranuloma), UGH syndrome Ranges from "8-ball" hyphaema (AC completely filled) to microscopic hyphaema (RBCs on slit lamp) COMPLICATIONS: rebleeds, corneal staining, red cell glaucoma Admit if high risk. Bed rest, globe protection, topical steroid + cycloplegia. Avoid antiplatelets, anticoagulants and NSAIDs Annual IOP checks for angle recession glaucoma If severe IOP: topical acetazolomide + bblocker, else AC paracentesis + washout, else trabeculectomy

Esoteric viral uveitis

WNV: 80% asymptomatic, 20% self-limited febrile illness. Ocular: 80% b/l multifocal chorioretinitis. Ix: serology, Rx supportive Chikungunya: self-limiting febrile illness lasting days-wks, arthralgia/arthritis, skin rash, low back pain. Ocular: anterior uveitis and posterior w/ reduced VA/colour vision, central/centrocecal scotoma, peripheral VF defects, retinitis, choroiditis, neuroretinitis, optic neuritis. Ix: serology, Rx: topical steroid, dilation Subacute sclerosing panencephalitis: SSPE, rare neurodegenration after Measles infection. Retinitis w/ focal foveal pigmentary changes, papilloedema or optic atrophy HTLV: leukaemia, tropical spastic paraparesis. Isolated uveitis or associated with leukaemia

Ophthalmic radiology

XR orbit: occipitomental and lateral views. Only used for foreign bodies now Dacryocystography/dacryoscintigraphy (DCG/DSG): old techniques, fluoroscopy of tear ducts CT/CTA MRI/MRA MRV: CVST diagnosis, so used in investigation of papilloedema

Tractional retinal detachment

contracting retinal membranes and vitreous changes with abnormal vitreous attachments pull on retina. Usually 2ndary to fibrovascular responses: PDR, ROP, Sickle cell retinopathy, familial exudative vitreoretinopathy (FEVR), vitreomacular traction syndrome, incontinentia pigmenti, retinal dysplasia Asymptomatic, may have VF defect, visual distortion, metamorphopsia (Amsler) and reduced VA if macula involved O/E: concave tenting of retina, immobile +/- macular ectopia. Slowly progressive. Can produce break and mix with RRD Surgery challenging - vitrectomy + membrane peel + gas tamponade. Usually delayed until macular involvement

Ectropion

eversion of eyelid (usually lower) away from globe, causing irritation of ocular surface. Epiphora, recurrent infections, conjunctival irritation/keratinisation Involutional: commonest, age-related laxity (can test by pulling lids). Rx Surgery Cicatrical: trauma, burns, RT, dermatitis cause scarring/shortening of anterior lamella Rx surgery Mechanical: mass displaces lid. Remove mass Paralytic: VIIn weakness (may have Vn palsy preventing corneal sensation). Rx ocular lubricants, tape eye shut, surgery (eg tarsorrhaphy) Congenital: Down's, blepharophimosis syndrome. Due to lack of skin

Deposition keratopathies

exposure keratopathy: VIIn lesion, nocturnal lagophthalmos (commonest), ectropion (floppy eyelid syndrome), proptosis/TED Wilson's (hepatolenticular degeneration): KF ring + sunflower cataract Vortex keratopathy (cornea verticillata): Drugs (amiodarone, suramin, indometacin, tamoxifen, chlorpromazine, atovaquone), systemic (Fabry's disease). Asymptomatic, swirling grey lines radiating from infracentral cornea Crystalline keratopathy: feathery stromal opacities. Can be biofilm (S. viridans, S. epidermidis, P. aeruginosa, Candida) or non-organic (chrysiasis, Ig, urate, cysteine, lipids) MPS keratopathy: GAG deposition in stroma causing corneal clouding

Wet AMD

neovascular AMD. New capillaries grow from choriocapillaris up through Bruch's membrane into subRPE/subretinal space. Can haemorrhage, scar, ERD. 15% have retinal angiomatous proliferation (RAP, NV of retinal vasculature). Polypoidal choroidal vasculopathy (PCV) common in asian/african, polypoidal dilatation of choroidal vasculatue with serosanguineous PEDs Can be sudden onset, reduced central VA, metamorphopsia, scotoma O/E: grey membrane, subretinal/subRPE haemorrhage/exudation, PED/RD, CMO, subretinal fibrosis FFA, OCT Type 2 (classic) CNV: FFA - well demarcated lacy early hyperfluorescence/progressive leakage. OCT shows subretinal hyperreflective material Type 1 (occult - may remain quiescent for long time) CNV: FFA - fibrovascular PED, late leakage with no clear source. OCT - irregular broad RPE elevation, separated from Bruch's membrane Type 3(RAP) CNV: FFA - as for 1. OCT - outer retinal hyperreflective foci with CMO For PCV, ICG required. Early subretinal early hyperfluorescence Supportive + lifestyle as for dry 1: Anti-VEGF. Reduces vessel permeability (stopping subretinal fluid) and prevents CNV. Pegaptanib (no longer in use), ranibizumab, bevacizumab, aflibercept (higher affinity fusion protein). Must have VA 6/12-96, no permenant foveal damage, lesion <=12 disc areas in diameter, evidence of recent progression. maintain and improve. Risks: always vitreous floaters (advise), warn for endophthalmitis 2: Photodynamic therapy: activates verteporfin, concentrates in neovascular vessels 3: Laser photocoagulation (only extrafoveal)

Allergic conjunctivitis

rhinoconjunctivitis: T1HR, seasonal or perennial. Itching, watery discharge, chemosis/lid oedema and injection with Hx of atopy. Skin prick/RAST. Rx allergen avoidance, ocular lubricants (dilute allergen), topical + PO anti-H, topical mast cell stabiliser. If severe, short course of topical steroid Vernal keratoconjunctivitis: Thought to be allegic, Hx of atopy. Itching, thick mucus discharge, typically young female in Spring Tarsal - flat topped giant 'cobblestone' papillae on superior tarsus Limbal - limbal papillae, white Trantas dots Keratitis - superior punctate erosions, venal ulcer with adherent mucus plaque/shield ulcer, pseudogerontoxon Rx: topical mast cell stabiliser (cromoglicate), steroid (for acute episodes), cyclosporin (steroid sparing during tapering), mucolytic (acetylcysteine) Atopic keratoconjunctivitis: 25-30yo, Hx of atopy, with severe lid desease (eczema/staph). Itching, red eye w/ keratitis (photophobia+blurred vision). Small tightly packed papillae, chemosis, limbal hyperaemia, may scar. Punctate epithelial erosions, shield ulcers, pannus in cornea Rx: as with VKC. PO immunosuppression if severe, surgery for severe keratitis. Treat lid desease

Conjunctiva anatomy

stratified squamous (palpebral, limbal) or columnar with microvilli that stabilise tear film (bulbar). Goblet cells throughout, with BM and stroma (lymphoid tissue) below attached to episclera/Tenon's layer Palpebral: crypts of Henle (mucin) Forniceal: glands of Krause and Wolfring (aqueous) Bulbar: glands of Manz (mucin) (tear film is epithelium, mucin, aqueous and lipid - inf to sup)