Eyes and Ears (1)

Question 1

What structure is damaged in noise-induced hearing loss?

Answer 1

Cochlea

* the hearing loss is likely to be temporary but repeated or severe damage can cause permanent hearing loss

Question 2

What structure is most likely involved in the presence of symptoms of ‘world spinning around’ ?

Answer 2

Fluid (endolymph) within semi-circular canal moves around -> spinning sensation

Question 3

What is the danger of use of cotton budts?

Answer 3

Damage to the tympanic membrane -> perforated eardrum -> may heal over time

Question 4

What structure is involved in ‘glue ear’?

Answer 4

Build up of fluid in the middle ear -> otitis media with effusion

Question 5

SImple pathway of vision (from light entering the eye)

Answer 5

Light -> cornea -> lens -> viterous humour -> rods + cons (retina) -> optic n. (CN II) -> visual cortex (occipital lobe)

Question 6

Simple pathway of sound -> hearing (start from sound wave)

Answer 6

sound wave -> pinna -> auditory cannal -> middle ear* -> hair cells (Organ of Corti on Cochlea) -> vestibulochochlear n. (CN VIII) -> auditory cortex

*middle ear structures: tympanic membrane, airspace and ossicles: malleus, incus and stapes

Question 7

What allows the outflow/ drainage of aqueous humour?

Answer 7

Contraction of the ciliary muscle -> opens the Trabecular meshwork -> outflow of Aqueous Humour through the Canal of Schlemm

Question 8

What’s keratitis?

(4) symptoms

Answer 8

Keratitis

• inflammation of the cornea

Symptoms: painful, red eye, photophobia, profuse tearing

Question 9

What’s retinitis pigmentosa?

Answer 9

Retinitis pigmentosa

• inherited condition
• progressive degeneration of photoreceptors
• initially rods, then cones

Question 10

Ambylopia

• other name
• simple pathophysiology
• age
• cause

Answer 10

Amblyopia = lazy eye

• failure of neural connections between brain and eye to develop properly
• development happens in first 7-8 years of life – older than that may never develop proprly even if underyling eye problem is corrected.
• Causes - anything which means one eye is used less than the other (squint, cataract)

Question 11

What happens if a yound child (up to 5 years)is deaf?

Answer 11

Childhood deafness

• young children, up to 5 years or so, who are deaf will not develop normal neural pathways (just like amblyopia)
• even if their hearing is improved (eg cochlear implant) they may still not be able to hear / interpret speech and sounds

Question 12

What are the elements of the examination of the eye? (7)

Answer 12

• Look at the eye
• Evert upper lid (if suspect foreign body)
• Visual acuity (Snellen chart) -> with and without usual glasses / lenses
• Pupils Equal and Reacting to Light and Accommodating? (PERLA)
• Red reflex
• Fundi (fundoscopy)
• Visual fields

Question 13

How to test for visual acuity?

Answer 13

Standard Snellen chart for use at 6 m

Question 14

What instructions to give to the patient while using Snellen chart?

Answer 14

Instructions:

• Cover one eye
• Read the lowest line that you can read
• Any mistakes -> try the line above

Question 15

How to note the results of the Snellen chart?

Answer 15

VA = 6/ n (n = number just above the lowest line they read correctly)

• Top number = distance (in metres) at which the test chart was presented (usually 6m)
• Bottom number = position on the chart of the smallest line read by the ‘patient’

Example: 6/60 means the subject can only see the top letter when viewed at 6m

Question 16

• How does the ‘pin hole’ test work?
• What’s its purpose?

Answer 16

The pin hole removes any refractive error because you only see light that passes straight through the pin hole and lens to the retina – so no refraction is needed

Question 17

What’s Limbus?

Answer 17

Limbus = junction of the cornea and sclera

Question 18

Which eye is it (R of L)? Why?

Answer 18

Right eye - macula in the middle and the optic disc at the nasal side

Question 19

Amsler Grid

• what is it used for?

Answer 19

Testing for macular degeneration -> to monitor patient’s central visual field

Question 20

How to use Amsler grid (instruction and abnormal result)

Answer 20

How to use the Amsler grid:

• wear your reading glasses
• hold the Amsler grid at normal reading distance (about 35cm)
• cover one eye at a time with the palm of your hand
• stare at the centre dot of the chart at all times (don’t let your eye drift)

Abnormal = any lines crooked / wavy / missing / blurry / discoloured or any boxes different in size or shape from others

Abnormality = sign of macular disease eg, ARMD or diabetic macular oedema

Question 21

Answer 21

a. Increased cup: disc ratio. (= cupping). Normal is 0.3. (occ up to 0.7). Increase in ratio over time is usually glaucoma

b. Glaucoma

Question 22

Answer 22

a. Drusen – yellow or white deposits of lipid around the macula

b. Around the macula

c. Age Related Macular Degeneration

Question 23

• What’s drusen?
• Is it normal?
• Hard vs soft drusen

Answer 23

Dursen - yellow/ white deposits of lipid around the macula

• A few (once aged > 40) are normal -> possibly caused by eye’s failure to eliminate waste products
• Hard drusen (small, discrete, well separated from each other) – more likely to be normal
• Soft drusen (larger, softer edge, closer together - like these) are usually associated with ARMD

Question 24

Answer 24

a. Cataract
b. haloes, diplopia, glare or dazzle when night driving, failure to recognise faces

Question 25

Answer 25

**a**. Cotton wool spots -\> damage to nerve fibres (result of accumulations of axoplasmic material within the nerve fiber layer) **b**. hypertensive and diabetic retinopathy

Question 26

Answer 26

**a.** hard exudates -\> diabetic macular oedema (derived from leaking retinal vessels) **b.** hypertensive and diabetic retinopathy

Question 27

Answer 27

**a.** *Proliferative retinopathy* – lots of new vessels elsewhere (NVE), and some on disc. **b.** *Diabetes* **c.** Control of BP (most important) + glycaemic control and statins help

Question 28

Answer 28

**7. *Severe glaucoma*** (macular sparing) **8. *Cataract*** (generalised blurring) **9. *ARMD*** (peripheral vision preserved)

Question 29

Stages (4) of ***hypertensive retinopathy*** \*what can be seen?

Answer 29

Question 30

A 65 year old woman visits her GP complaining of a gradual reduction in her vision over the last 6 months. On further questioning, she reports that her central vision is distorted, she finds the text in the newspaper appears as “wavy lines” and she’s given up reading books with small print. However, it seems that her peripheral vision is intact. **a. What is the most likely diagnosis?** **b. What test would you perform for 'wavy lines' symptom?**

Answer 30

a. Age Related Macular Degeneration b. Amsler grid

Question 31

(2) possible findings on the fundoscopy of the patients with ***Age-Related Macular Degeneration***

Answer 31

* **Drusen** – tiny white or yellow accumulations of extracellular material (lipid and protein). Usually concentrated in the area of the macula in ARMD * **New vessel formation –** immature blood vessels that grow in the choroidal layer

Question 32

What's ***Bruch's membrane*** and what is its association with ***Age-Related Macular Degeneration***?

Answer 32

Drusen (extracellular deposits) form deep in Bruch’s membrane Bruch’s membrane is the thin layer that separates the retina from the underlying choroidal blood supply * Blockage -\> nutrition from the choroid cannot get to the retina * blockage photoreceptor waste products from draining down into the choroidal bed

Question 33

What happens to the Bruch's membrane in ***wet/neovascular ARMD?***

Answer 33

**Neovascular“wet”ARMD** If a break occurs in **Bruch's membrane** **-\>** vessels can grow up out of the deep choroidal circulation directly up into the retina **-\>** this is dangerous, as this neovascularization can bleed, create edema, and rapidly destroy vision

Question 34

What's the general management of ***Age-Related Macular Degeneration***

Answer 34

* Supportive – magnifiers, bright reading lamps, rehabilitation * Stop smoking! Reduces risk of progression. * Diet – leafy, green veg and fruit – may improve concentration of macular pigment, but no firm evidence it slows progression * Antioxidants and zinc -\> may prevent progression in those with medium ARMD

Question 35

Management of Wet ARMD (apart from lifestyle etc)

Answer 35

**Wet Rx:** intravitreal injections of ***anti-vascular endothelial growth factor (anti-VEGF)***; VEGF promotes new blood vessel growth. Initially monthly x 3. About 1/3 get some improvement in vision, most stay same.

Question 36

Long term prognosis for ARMD

Answer 36

Variable loss of central vision (dry is very slow but wet can cause serious visual loss over days or weeks) **-\>** peripheral vision will be preserved

Question 37

1. A 75 year old man has noticed gradual reduction in his vision. It is particularly difficult driving at night as he finds he is dazzled by the glare of car headlights. 1. **What is likely diagnosis?** 1. **Apart from testing visual acuity, what two things can a GP do to confirm this diagnosis?**

Answer 37

**A.** Cataracts **B. Tests to confirm:** * Red reflex will be lost * Lens may appear white or brown (ophthalmoscopy - though sometimes can see the white lens with naked eye).

Question 38

Risks factors for ***cataracts***

Answer 38

Age, smoking, DM, systemic steroids. eye trauma, female, uveitis, UV exposure, poor nutrition, lower social class, alcohol, drugs of abuse, genetics (congenital cataracts), intra-uterine rubella, inflammation and degenerative eye diseases

Question 39

Treatment of ***cataracts*** | (name and outline the procedure)

Answer 39

***Phacoemulsification*** ## Footnote There is no absolute threshold of visual acuity at which surgery is indicated. It depends upon the impact of the cataract on the patient's quality of life * Incision approximately 3 mm in diameter is made in the sclera. * Round hole of approximately 5 mm diameter is made in lens capsule. * Hard lens nucleus is liquefied by ultrasonic probe inserted through the hole and extracted. * Soft lens fibres are aspirated. * Replacement lens is placed folded into the now empty capsular bag where it unfolds. * Hole heals without sutures. This can be performed on day-case basis either with a locally injected anaesthetic or even anaesthetic eye drops. Post-operative care includes use of topical antibiotics and steroids with avoidance of strenuous activity.

Question 40

1. A 61 year old woman is concerned that she may have an eye problem - something to do with the pressure in the eye she thinks. Her vision is fine but her Mum had some problem and her brother and sister have both been diagnosed with the same condition: they told her she should get checked. **What condition is she talking** **about ?**

Answer 40

Glaucoma (open angle)

Question 41

Risk factors for ***open-angle glaucoma***

Answer 41

_Risks for ***open angle***_: * age * fam history (x3) * DM (x2) * black (x2 or more), (and reduced x0.5 if Asian) * Myopia * retinal disease * hypertension

Question 42

Risk factors for ***narrow-angle*** ***glaucoma***

Answer 42

**_Risks for**_ _**closed angle_****_:_** * age * female (4:1) * hypermetropic (long sight) * FH * ethnicity (SE Asian and Chinese, Inuit) * Pupillary dilatation (topical mydriatics or some systemic drugs that dilate the eye - eg. anticholinergics, antihistamines, antidepressants, CNS stimulants like cocaine, methylphenidate, amphetamines) can push iris into angle and precipitate angle closure in people with narrow angles

Question 43

How would the optician test for open angle glaucoma?

Answer 43

* **Tonometry** - check intra-ocular pressure. (NB Glaucoma ≠ raised IOP !!) * **Examine optic discs** – ratio of diameters of cup (pale centre) to whole disc \*normal cup:disc = 0.3 (but up to 0.7 can be normal).increase in cupping over time suggests glaucoma. * **Visual fields** – may have scotoma (partial loss of vision)

Question 44

Patient presents with ***flashes*** and ***floaters*** ***- prognosis*** ***- is referral needed?*** ***- what to advice (safety netting)***

Answer 44

85% need minimal, if any, intervention * vision loss **-\>** same day referral to ophthalmology * no vision loss **-\>** detailed retinal examination within 2w (eg optician). * Tell patients if symptoms progress (eg signs of retinal detachment - slowly enlarging curtain or shadow), they should seek urgent advice

Question 45

Patient presents with ***'haloes'*** - what is halo? - possible cause

Answer 45

***Haloes*** Excess water in or on surface of eye **-\>** rainbow like coloured rings around lights / bright objects **Causes**: acute angle closure, excess tears, chronic open angle glaucoma, cataracts (headlights glare at night so night driving impossible), drugs (digoxin, chloroquine).

Question 46

When to suspect ***retinal detachment***?

Answer 46

**_When to suspect retinal detachment_** * New onset floaters or flashes * Sudden painless visual field loss * reduction VA or blurred/distorted vision * Loss of red reflex, vitreous opacities * detached retinal folds (pale, opaque, wrinkled)