Eye presentations - spot diagnosis

Question 1

7 year old with an acutely painful, hot, red, swollen area around the left eye. No visual changes, eye movements non-painful.

a) likely diagnosis
b) how is this different to the main differential

Answer 1

a) Peri-orbital cellulitis

b) Orbital cellulitis: suspect if there is vision loss, painful eye movements, chemosis, proptosis or RAPD

Question 2

85 year old 5 days post-cataract surgery presents with sudden decrease in vision and eye pain. Eye is red and discharging. You notice an exudate with a fluid level in the anterior chamber of the eye.

a) likely diagnosis
b) sign found o/e (exudate)
c) management

Answer 2

a) Endophthalmitis
b) Hypopyon

c) - Urgent (24h) ophthalmology review
- Confirm with slit lamp examination and microbiological sample
- Treat with ABx

Question 3

32 year old patient with ankylosing spondylitis presents with a red eye, photophobia and headache

a) this is the classic triad of…?
b) Management

Answer 3

a) Anterior uveitis

b) - Urgent (24h) ophthalmology review
- Cycloplegic/mydriatic drug (cyclophenolate)
- Steroids (topical or systemic)
- Add ciclosporin/tacrolimus if necessary

Question 4

45 year old watching television, sudden and progressive unilateral eye pain, associated with headache, nausea, vomiting and red eye.

a) diagnosis
b) Management

Answer 4

a) AACG

b) - Urgent ophthalmology review
- In the meantime, give all topical glaucoma meds (timolol, prednisolone, pilocarpine) + IV acetazolamide + analgesia/ antiemetics
- If no response, give IV mannitol
- Surgery likely required (peripheral iridotomy)

Question 5

34 year old woman with no PMHx presents with acute unilateral vision loss, pain around the eye, worse on eye movement, and washing out of colours

a) Likely diagnosis
b) What sign o/e would support this
c) Possible causes and investigations
d) Management

Answer 5

a) Optic neuritis
b) RAPD

c) MS, inflammatory (sarcoid, SLE, NMO), infection, GCA, metabolic, etc.
- Bloods: FBC, ESR, UEs, TFTs, auto-antibodies (eg. NMO-IgG, anti-dsDNA)
- Special test: LP/MRI for MS

d) IV methylprednislone
- Ophthalmology review/ neuro

Question 6

24 year old woman presents with jagged lines in her vision that coincide with a headache

Answer 6

Migraine

Question 7

60 year old with sudden onset of a shower of floaters, so many as to be uncountable. Also has flashers, with som

a) Likely diagnosis
b) Pathogenesis
c) Why does this require urgent assessment?

Answer 7

a) Vitreous haemorrhage
b) Usually secondary to posterior vitreous detachment (caused by shrinking of the vitreous with age, causing it to detach from the retina); this then snags a blood vessel
c) Can lead to retinal detachment; presentation is very similar

Question 8

Down syndrome - what finding in the iris?

Answer 8

Brushfield spots

Question 9

Wilson disease - finding

Answer 9

Kayser-Fleischer rings

Question 10

Neurofibromatosis type 1 - finding

Answer 10

Lisch nodules

Question 11

Vitamin A deficiency - finding

Answer 11

Bitot’s spots

Question 12

Hypercalcaemia - finding

Answer 12

Band keratopathy

Question 13

54 year old; asymptomatic, routine eye screen. Increased optic cup:risk ratio (>0.6) present

a) Likely diagnosis
b) Other tests to perform

Answer 13

a) Chronic open-angle glaucoma

b) - Goniometry: irido-corneal angle measurement
- Tonometry: assess IOP

Question 14

65 year old presents with sudden onset flashers and floaters; on slit-lamp examination there are vitreous opacities and haemorrhages, and detached retinal folds

Answer 14

Retinal detachment

Question 15

Family history of blindness, impaired night vision and progressive peripheral vision loss

Answer 15

Retinitis pigmentosa

Question 16

Family history of blindness, gradual loss of acuity, colour vision

Answer 16

Retinal dystrophy