Day 3 Ophthalmology

Question 1

Which eye condition is common in diabetics, causing sudden loss of vision?

Answer 1

Vitreous haemorrhage

Question 2

Nasolacrimal duct obstruction treatment

Answer 2

nasolacrimal duct massage

Question 3

In which condition do you see central scotoma

Answer 3

optic neuritis

Question 4

Which condition is associated with hypermetropia?

Which condition is associated with myopia?

Answer 4

Acute angle closure glaucoma is associated with hypermetropia,

Primary open-angle glaucoma is associated with myopia

Question 5

A 49-year-old woman who is known to have multiple sclerosis presents to see her GP. Her partner has noticed a change in the appearance of her eyes over the past few weeks. On examination she has a ptosis on the left side associated with a small left pupil. Fundoscopy is nomal. What is the most likely diagnosis?

Answer 5

Horner’s

Question 6

define Mydriasis

Answer 6

Anisocoria is unequal pupil size.

Commonly caused by third nerve palsy

Question 7

A 65-year-old man with a history of primary open-angle glaucoma presents with sudden painless loss of vision in his right eye. On examination of the right eye the optic disc is swollen with multiple flame-shaped and blot haemorrhages. What is the most likely diagnosis?

Answer 7

Central retinal vein occlusion

Question 8

Which infective organism causes acute penumonia most in COPD

Answer 8

Haemophilus influenzae

Question 9

Define Heuristic

Answer 9

A technique, is any approach to problem solving or self-discovery that employs a practical method that is not guaranteed to be optimal

Question 10

What are The Cardiff Acuity Test and LogMar charts?

Answer 10

alternative methods for testing visual acuity

Question 11

A 79-year-old gentleman presents with a 3 months history of a red swollen left upper eyelid. He remembers initially developing a bump on the eyelid which was uncomfortable but then got bigger forming a hard lump. He reports no pain currently and has not noted any problems with his vision and the eye itself appears healthy.

Answer 11

A meibomian cyst presents as a firm painless lump in the eyelid

Question 12

Which of the following is the strongest risk factor for subcapsular cataracts?

Answer 12

steroid use

Question 13

A 6-year-old girl presents to your general practice surgery with her father.

He describes that for the past year, she develops intermittent flares of red, itchy eyelids.

This appears to bother her most in the mornings.

These episodes normally self-resolve with no intervention, but this flare has been particularly protracted - lasting over a month - and he would like some advice.

She has never experienced any visual changes.

Answer 13

Blepharitis - hot compresses to both eyes

Question 14

Treatment of ARMD

Answer 14

• vascular endothelial growth factor (VEGF)
• laser photocoagulation

Question 15

A 22-year-old woman presents with a red painful eye.

She describes the pain as tearing. When asked to scale the degree of pain, she gave a score of 7 out of 10.

She also reported that she uses contact lenses frequently.

Answer 15

microbial keratitis

Contact lens wearers who present with a red painful eye should be referred to eye casualty to exclude microbial keratitis

Question 16

What is Argyll-Robertson syndrome?

Answer 16

Argyll-Robertson pupil is one of the classic pupillary syndromes.

It is sometimes seen in neurosyphilis.

Typically the pupil accommodates but doesn’t react.

A mnemonic used for the Argyll-Robertson Pupil (ARP) is Accommodation Reflex Present (ARP) but Pupillary Reflex Absent (PRA)

Question 17

Sympathomimetics (e.g. brimonidine, an alpha2-adrenoceptor agonist)

Mechanism of action?

Notes?

Answer 17

Reduces aqueous production and increases outflow

Avoid if taking MAOI or tricyclic antidepressants

Adverse effects include hyperaemia

Question 18

Which conditions can cause an RAPD?

(3)

Answer 18

Large retinal detachment

central retinal artery/vein occlusion

optic nerve ischaemia

Question 19

A 50-year-old man presents with red-eye associated with slight watering and mild photophobia. He reports no pain or tenderness and vision is not affected

What is the most likely diagnosis?

Answer 19

Episcleritis

Question 20

Patient has sudden painless loss of vision, severe retinal haemorrhages on fundoscopy

Answer 20

Central retinal vein occlusion

retinal haemorrhages on fundoscopy, due to increased venous pressure following downstream occlusion.

Question 21

most common cause of persistent watery eye in infants??

Answer 21

Nasolacrimal duct obstruction

Question 22

A 67-year-old woman presents to an out-of-hours general practitioner with a painful, red left eye and nausea.

On examination, she has a left-sided, semi-dilated pupil that does not react to light with some surrounding conjunctival injection.

Answer 22

Acute closed-angle glaucoma presents with a fixed dilated pupil with conjunctival injection

Question 23

A 25-year-old female patient presents to her GP due to a severe throbbing headache which is worst first thing in the morning. This has been happening for several weeks with no response to paracetamol. She has also been vomiting on most mornings and feels that her vision has been blurry.

Her pupils are equal and reactive and systemic examination is normal.

Which of the following would you expect to see on fundoscopy?

Answer 23

Increased intracranial pressure

Papilloedema is associated with blurring of optic disc margin on fundoscopy

Question 24

How does primary open-angle glaucoma present/?

Answer 24

Primary open-angle glaucoma does not typically present acutely and has a more insidious onset.

Most cases are asymptomatic and if symptoms are noted, it will present as loss of peripheral vision. Pupillary changes are not seen in this case.

Question 25

A 36-year-old female teacher presents to emergency eye casualty with unilateral right-sided red eye which is acutely painful. She complains of burning pain around the eye, photophobia and you note her eye is tearing excessively. Fluorescein staining shows a linear, branching epithelial defect. She is not a contact lens wearer and she has no past medical history of note. Which option below is the most appropriate management?

Answer 25

Treatment for herpes simplex keratitis is topical aciclovir

Question 26

Patient presents with eye pain, and often pain on eye movements.

Answer 26

Optic neuritis

Question 27

A 75-year-old woman presents to surgery complaining of 'blurry' vision in her right eye for the past few months. She also notes that straight lines appear crooked or wavy. This only seem to affect the centre of her right visual field and no problems are noted with the left eye. She has never worn glasses or contact lens. On examination a central scotoma is noted in the right eye.

Answer 27

ARMD

Question 28

What is Topical sodium cromoglicate used for?

Answer 28

Mast cell stabilizers in allergies

Question 29

How does Horner's syndrome present in eyes?

Answer 29

ptosis + constricted pupil = Horner's

Question 30

A 75-year-old lady, who has been a diabetic for over 25 years attend her regular follow-up sessions. During the consultation, the lady mentions to her GP that she has had difficulty with her vision over the past few months, especially in the left eye. She described it as a blurry vision and also reported seeing round figures around lights at night. The lady has never had problems with her vision in the past. She currently also takes medications to manage her blood pressure and cholesterol levels. Physical examination is otherwise unremarkable.

Answer 30

This patient has a classic presentation of cataract. The long history of diabetes mellitus in an elderly presentation along with unilateral blurry vision and halos surrounding light sources are strongly suggestive of a diagnosis of cataract.

Question 31

Miotics (e.g. pilocarpine, a muscarinic receptor agonist) Mechanism of action? Notes?

Answer 31

Increases uveoscleral outflow Adverse effects included a constricted pupil, headache and blurred vision

Question 32

In ophthalmology, what is Aciclovir used to treat?

Answer 32

viral keratitis

Question 33

What is "wet ARMD"?

Answer 33

* 10% of cases * also know as exudative or neovascular macular degeneration * characterised by choroidal neovascularisation * leakage of serous fluid and blood can subsequently result in a rapid loss of vision * carries worst prognosis

Question 34

An 84-year-old man presents with loss of vision in his left eye since the morning. He is otherwise asymptomatic and of note has had no associated eye pain or headaches. His past medical history includes ischaemic heart disease but he is otherwise well. On examination he has no vision in his left eye. The left pupil responds poorly to light but the consensual light reaction is normal. Fundoscopy reveals a red spot over a pale and opaque retina. What is the most likely diagnosis?

Answer 34

Central retinal artery occlusion

Question 35

What is this?

Answer 35

A **chalazion** (Meibomian cyst) is a retention cyst of the Meibomian gland. It presents as a firm **painless lump** in the eyelid. The majority of cases resolve spontaneously but some require surgical drainage

Question 36

Patient complains of "flashes and floaters" with no pain

Answer 36

Retinal detachment

Question 37

A 73-year-old female presents to her GP with left shoulder and arm pain which came on quite suddenly a week ago and has been worsening. The pain is now unmanageable with regular co-codamol. The GP also notes that the patient's left pupil is smaller than the other side and the eyelid is lagging slightly.

Answer 37

Pancost's

Question 38

characteristics of uveitis | (3)

Answer 38

small, fixed oval pupil, ciliary flush

Question 39

investigation for cellulitis

Answer 39

Where orbital cellulitis is suspected, a **contrast enhanced-CT scan of the orbits**, sinuses and brain should be considered to support the diagnosis and to search for possible complications such as abscess which may require surgical drainage.\*

Question 40

A 42-year-old man is diagnosed with syphilis following months of ill health. On examination he is noted to have bilateral small pupils which accommodate but do not respond to light. What is the most likely diagnosis?

Answer 40

Argyll-Robertson pupil

Question 41

Why might digoxin levels be higher than prescribed?

Answer 41

Digoxin is excreted by the kidneys, CKD patients will build up

Question 42

Patient presents with a triad of a painful eye, vision loss and impaired colour vision.

Answer 42

optic neuritis

Question 43

Which condition is associated with hypermetropia? Which condition is associated with myopia?

Answer 43

Acute angle closure glaucoma is associated with hypermetropia primary open-angle glaucoma is associated with myopia

Question 44

Characteristics of Central retinal artery occlusion (3)

Answer 44

1. causes sudden unilateral visual loss 2. due to thromboembolism (from atherosclerosis) or arteritis (e.g. temporal arteritis) 3. features include afferent pupillary defect, 'cherry red' spot on a pale retina

Question 45

A 25-year-old lady presents to the GP with itchy eyes. She describes a gritty feeling in both her eyes and has noticed that they stick together in the morning. The grittiness is also worst first thing when she wakes up. She complains of no other symptoms. Given her presentation what is the most likely diagnosis?

Answer 45

blepharitis

Question 46

Carbonic anhydrase inhibitors (e.g. Dorzolamide) Mechanism of action? Notes?

Answer 46

Reduces aqueous production Systemic absorption may cause sulphonamide-like reactions

Question 47

Patient complains of multiple dark spots in her vision, as well as sudden vision loss she has diabetes she has ben in an accident

Answer 47

vitreous haemorrhage

Question 48

What is a LBBB

Answer 48

**Delayed depolarisation of the left ventricle** ## Footnote One of the most common ways to remember the difference between LBBB and RBBB is WiLLiaM MaRRoW in LBBB there is a 'W' in V1 and a 'M' in V6 in RBBB there is a 'M' in V1 and a 'W' in V6

Question 49

Which infection of the eye presents with dendritic ulceration?

Answer 49

HSV

Question 50

What is Adie pupil?

Answer 50

Tonically dilated pupil, slowly reactive to light with more definite accommodation response. Caused by damage to parasympathetic innervation of the eye due to viral or bacterial infection. Commonly seen in females, accompanied by absent knee or ankle jerks.

Question 51

A 30-year-old male presents with sudden onset loss of vision. He denies any preceding warning signs or head trauma, and does not complain of any pain. You perform a fundoscopy and find severe retinal haemorrhages on fundoscopy. Which of the following is the most likely diagnosis?

Answer 51

Central retinal vein occlusion sudden painless loss of vision, severe retinal haemorrhages on fundoscopy

Question 52

Which condition is associated with short-sightedness?

Answer 52

Cataracts are associated with aging and high myopia (severe short-sightedness)

Question 53

A 71-year-old patient with a background of hypertensive retinopathy presents for an eye check. Fundoscopy demonstrates retinal arteriole tortuosity with nil other abnormalities noted. According to the Keith-Wagener classification, which grade of hypertensive retinopathy is this most likely to represent?

Answer 53

grade 1

Question 54

How is Anterior uveitis is most likely to be treated?

Answer 54

with a steroid + cycloplegic (mydriatic) drops

Question 55

28-year-old patient presents to the emergency department with a right **red eye** and **sensitivity to light** that **started 1 hour ago**. Examination of the right eye reveals a **painful, red eye, with a small and irregularly-shaped pupil**.

Answer 55

Anterior uveitis

Question 56

Prostaglandin analogues (e.g. latanoprost) Mode of action? Side effects?

Answer 56

Increases uveoscleral outflow Adverse effects include brown pigmentation of the iris, increased eyelash length

Question 57

Causes pupillary constriction, blurred vision and headaches

Answer 57

Pilocarpine

Question 58

A 67-year-old man presents as he has developed a painful blistering rash around his right eye. On examination a vesicular rash covering the right trigeminal nerve dermatome is seen.

Answer 58

HSV

Question 59

Risk factors for vitreous haemorrhage include: (5)

Answer 59

Diabetes Trauma Anticoagulants Coagulation disorders Severe short sightedness

Question 60

In which conditions do you see haloes?

Answer 60

cataracts, glaucoma

Question 61

What is Hutchinson's pupil?

Answer 61

Unilaterally dilated pupil which is unresponsive to light. A result of compression of the occulomotor nerve of the same side, by an intracranial mass (e.g. tumour, haematoma)

Question 62

On examination, the boy appears unsettled and is crying constantly. His temperature is 38°C and other vital signs are normal. On examination of the affected eye, the eyelid is erythematous and oedematous. Proptosis of the left eye is noted and there seems to be limited ocular movement as well.

Answer 62

orbital cellulitis

Question 63

In which condition would you see leukoria

Answer 63

retinoblastoma

Question 64

Treatments for acute angle-closure glaucoma

Answer 64

**_combination of eye drops, for example:_** * a direct parasympathomimetic (e.g. pilocarpine, causes contraction of the ciliary muscle → opening the trabecular meshwork → increased outflow of the aqueous humour) * a beta-blocker (e.g. timolol, decreases aqueous humour production) * an alpha-2 agonist (e.g. apraclonidine, dual mechanism, decreasing aqueous humour production and increasing uveoscleral outflow) **intravenous acetazolamide** * reduces aqueous secretions **_Definitive management_** * laser peripheral iridotomy * creates a tiny hole in the peripheral iris → aqueous humour flowing to the angle

Question 65

Adverse effects include brown pigmentation of the iris

Answer 65

Latanoprost59

Question 66

A 72-year-old man presents with a painful, red eye to the Emergency Department. Due to the severity of his symptoms and reduced visual acuity he is referred on to ophthalmology who make a diagnosis of acute glaucoma. Which of the following should be the aims of treatment?

Answer 66

Reducing aqueous secretion + inducing pupillary constriction

Question 67

A 30-year-old woman presents with a 2 day history of a painless red eye. She is otherwise well and has not noticed a decrease in her vision. The patient has no past medical history of note and is not on any long-term medications. On examination, her eyes are red and injected bilaterally. Upon applying light pressure on her eye with a cotton bud, you notice that the injected vessels seem to move.

Answer 67

Episcleritis

Question 68

What kind of drug is Amiloride?

Answer 68

potassium sparing diuretic

Question 69

Acetazolamide is a carbonic anhydrase inhibitor that is used in managing what?

Answer 69

acute angle-closure glaucoma

Question 70

stye treatment

Answer 70

analgesia + warm compress

Question 71

A 64-year-old woman with type 2 diabetes mellitus presents as she has started to bump into things since the morning. Her medications include metformin, simvastatin and aspirin. Over the previous two days she had noticed numerous 'dark spots' over the vision in her right eye. Examination reveals she has no vision in her right eye. The red reflex on the right side is difficult to elicit and you are unable to visualise the retina on the right side during fundoscopy. Examination of the left fundus reveals changes consistent with pre-proliferative diabetic retinopathy. What is the most likely diagnosis?

Answer 71

The history of diabetes, aspirin use, complete loss of vision in the affected eye and inability to visualise the retina point towards a diagnosis of vitreous haemorrhage.

Question 72

How is an RAPD diagnosed?

Answer 72

Both pupils will dilate when light is swung to the affected eye

Question 73

Beta-blockers (e.g. timolol, betaxolol) mode of action? notes?

Answer 73

Reduces aqueous production Should be avoided in asthmatics and patients with heart block

Question 74

What medicine is likely to have caused his eyelashes to grow in length?

Answer 74

Key side effects of prostaglandin analogues include increased **eyelash length, iris pigmentation and periocular pigmentation**

Question 75

glaucoma characteristics | (3)

Answer 75

severe pain, haloes, 'semi-dilated' pupil

Question 76

A 45-year-old woman attends eye casualty complaining of blurred vision and glare from bright lights. She has a history of asthma, polymyalgia rheumatica and gout. The ophthalmologist finds a lens opacity in her left eye that is located just deep to the lens in the visual axis.

Answer 76

cateracts

Question 77

How does Latanoprost work?

Answer 77

Latanoprost is a prostaglandin analog used in glaucoma. It works by increasing uveoscleral outflow

Question 78

in which condtions do you see Homonymous hemianopia

Answer 78

It is a visual field defect that arises from the optic tract, which is after the optic chiasm

Question 79

What is Argyll-Robertson pupil?

Answer 79

Bilaterally small pupils that accommodate but don't react to bright light. Causes include neurosyphilis and diabetes mellitus

Question 80

differences between orbital and periorbital cellulitis

Answer 80

Periorbital (preseptal): Absence of painful movements, diplopia and visual impairment indicates the former

Question 81

On fundoscopy, a 'cherry red spot' can often be seen in the macula where the retina is thinner.

Answer 81

Central retinal artery occlusion

Question 82

Patient presents with no pain, describes curtain over vision + spider webs + flashing lights in vision

Answer 82

retinal detachment

Question 83

Which condition presents with a fixed dilated pupil with conjunctival injection

Answer 83

**Acute closed-angle glaucoma**

Question 84

The most common causes of a sudden painless loss of vision are: (3)

Answer 84

ischaemic/vascular vitreous haemorrhage retinal detachment

Question 85

A 63-year-old gentleman is diagnosed with primary open angle glaucoma. He asks how untreated glaucoma is most likely to affect vision?

Answer 85

Glaucoma primarily causes visual field defects Glaucoma causes an optic neuropathy, that most frequently affects patients visual field. This tends to commence in the peripheries, and if untreated, eventually leads to tunnel vision.

Question 86

Investigation for ARMD

Answer 86

**slit-lamp microscopy** is the initial investigation of choice, to identify any pigmentary, exudative or haemorrhagic changes affecting the retina which may identify the presence of ARMD. This is usually accompanied by colour fundus photography to provide a baseline against which changes can be identified over time. **fluorescein angiography** is utilised if neovascular ARMD is suspected, as this can guide intervention with anti-VEGF therapy. This may be complemented with indocyanine green angiography to visualise any changes in the choroidal circulation. **ocular coherence tomography** is used to visualise the retina in three dimensions, because it can reveal areas of disease which aren't visible using microscopy alone.

Question 87

70-year-old man is investigated for **blurred vision**. Fundoscopy reveals **drusen**, **retinal epithelial** and **macular** **neovascularisation**.

Answer 87

age related macular degeneration

Question 88

Which test is most suitable to investigate for a refractive error?

Answer 88

A pinhole occluder is useful to identify refractive errors as the cause of blurred vision

Question 89

What kind of drug is Bumetanide?

Answer 89

loop diuretic

Question 90

Contact lens wearers who present with a red painful eye should be referred to eye casualty to exclude what?

Answer 90

microbial keratitis

Question 91

how does an oculomotor nerve lesion present?

Answer 91

"down and out" eye Ptosis + **dilated** pupil

Question 92

A 60-year old man presents with a one month history of worsening visual acuity. He describes blurring of the smaller words in the newspaper and has noticed that straight lines, such as those on the wallpaper in his lounge appear 'curvy'. He has also started to see a grey patch in his central field of vision. On examination his acuity is 20/30 bilaterally. Ophthalmoscopy demonstrates choroidal neovascularisation. What is the most likely diagnosis?

Answer 92

ARMD

Question 93

What is azathioprine used for?

Answer 93

Crohn's

Question 94

What is Bronchiolitis?

Answer 94

Bronchiolitis is a common lower respiratory tract infection that affects babies and young children under two years old

Question 95

most common infection for swimmers wearing contact lenses

Answer 95

Acanthamoeba

Question 96

Chloramphenicol is an antibiotic used in treating what?

Answer 96

Bacterial conjunctivitis without the need for steroids?

Question 97

Patient presents with a **painful eye** and examination findings of a **fixed pupil, hazy cornea** and increased **ocular pressures**

Answer 97

Acute glaucoma

Question 98

What causes "bilateral gritty-ness"?

Answer 98

Bilateral grittiness - think blepharitis

Question 99

What is Hutchinson's sign

Answer 99

Presence of the rash on the tip of his nose

Question 100

A 24-year-old male presents to the emergency department with an acutely painful red eye, which is associated with photophobia, lacrimation and reduced visual acuity. He has a past medical history of ankylosing spondylitis. Examination identifies a small, irregularly shaped pupil.

Answer 100

anterior uveitis treat with steroids + mydriatic

Question 101

A 47-year-old man presents to the emergency department with sudden painless loss of vision on the left side. This was preceded by dark 'floaters' in his vision and a 'red hue' prior to total loss of vision on the affected side. This was worst when lying flat. He has a history of poorly controlled type 1 diabetes, proliferative diabetic retinopathy, hypertension and a metallic aortic valve for which he is on warfarin.

Answer 101

Vitreous haemorrhage is an important differential for sudden visual loss in diabetics

Question 102

What is treated with a steroid + cycloplegic (mydriatic) drops?

Answer 102

Anterior uveitis

Question 103

Pilocarpine is a muscarinic receptor agonist and can be used in managing what?

Answer 103

**primary open-angle glaucoma** and **acute close angle glaucoma**

Question 104

A 55-year-old lady presents to the emergency department with problems with her vision. She describes a red hue of her vision along with some dark spots in her right eye. The doctor refers her to eye casualty where they suspect a vitreous haemorrhage.

Answer 104

Vitreous haemorrhage

Question 105

A 27-year-old male attends the emergency department with a sudden onset painful left eye and slightly blurred vision. He has no past medical history of note and does not wear glasses or contact lenses. His family history includes type 2 diabetes and Crohn's disease. He is wearing sunglasses in the department as he finds the lighting too bright. On removal, you note his left eye is red and his complaint of photophobia is so severe he cannot tolerate ophthalmoscopy. On close inspection, you see a white fluid level visible in the inferior part of the anterior chamber and his pupil appears small and irregular. Due to these findings, you urgently contact ophthalmology - what is your working diagnosis?

Answer 105

Anterior uveitis

Question 106

dorzolamide eye drops. What is the mechanism of action of this drug?

Answer 106

carbonic anhydrase inhibitor

Question 107

Stages of diabetic retinopathy (5)

Answer 107

1. Mild NPDR 2. Moderate NPDR 3. Severe NPDR 4. Proliferative retinopathy 5. Maculopathy

Question 108

A 31-year-old man presents with a painful swelling of his right upper eyelid for the past 3 days. On lifting the eyelid a yellow head pointing at the lid margin can be seen.

Answer 108

Stye