Gradual change in or loss of vision

Question 1

What is age-related macular degeneration (ARMD)?

Answer 1

ARMD is the most common cause of blindness in the UK, characterized by degeneration of the central retina (macula) and changes that are usually bilateral.

Question 2

What are the key features of ARMD?

Answer 2

ARMD is characterized by degeneration of retinal photoreceptors resulting in the formation of drusen, visible on fundoscopy and retinal photography.

Question 3

What is the greatest risk factor for ARMD?

Answer 3

Advancing age is the greatest risk factor for ARMD.

Question 4

How does age affect the risk of ARMD?

Answer 4

The risk of ARMD increases threefold for patients older than 75 years compared to those aged 65-74.

Question 5

What role does smoking play in ARMD risk?

Answer 5

Current smokers are twice as likely as non-smokers to have ARMD-related visual loss, and ex-smokers have a slightly increased risk (OR 1.13).

Question 6

How does family history affect ARMD risk?

Answer 6

First-degree relatives of a sufferer of ARMD are thought to be four times more likely to inherit the condition.

Question 7

What are other risk factors for ARMD?

Answer 7

Other risk factors include hypertension, dyslipidaemia, and diabetes mellitus.

Question 8

What are the two traditional forms of macular degeneration?

Answer 8

The two forms are dry macular degeneration (90% of cases) and wet macular degeneration (10% of cases).

Question 9

What characterizes dry macular degeneration?

Answer 9

Dry macular degeneration, also known as atrophic, is characterized by drusen, which are yellow round spots in Bruch’s membrane.

Question 10

What characterizes wet macular degeneration?

Answer 10

Wet macular degeneration, also known as exudative or neovascular macular degeneration, is characterized by choroidal neovascularization and can lead to rapid vision loss.

Question 11

What are the clinical features of ARMD?

Answer 11

Patients typically present with subacute onset of visual loss, difficulties in dark adaptation, fluctuations in visual disturbance, photopsia, glare, and possible visual hallucinations.

Question 12

What signs may be noted in ARMD?

Answer 12

Signs include distortion of line perception on Amsler grid testing and the presence of drusen on fundoscopy.

Question 13

What is the initial investigation of choice for ARMD?

Answer 13

Slit-lamp microscopy is the initial investigation of choice to identify changes affecting the retina.

Question 14

What is the purpose of fluorescein angiography in ARMD?

Answer 14

Fluorescein angiography is used if neovascular ARMD is suspected, guiding intervention with anti-VEGF therapy.

Question 15

What did the AREDS trial find regarding treatment for dry ARMD?

Answer 15

The AREDS trial found that a combination of zinc with vitamins A, C, and E reduced progression of dry ARMD by around one third.

Question 16

What is the role of anti-VEGF agents in wet ARMD?

Answer 16

Anti-VEGF agents can limit progression of wet ARMD and stabilize or reverse visual loss, and should ideally be instituted within the first two months of diagnosis.

Question 17

What are examples of anti-VEGF agents?

Answer 17

Examples of anti-VEGF agents include ranibizumab, bevacizumab, and pegaptanib.

Question 18

What is the risk associated with laser photocoagulation in ARMD treatment?

Answer 18

Laser photocoagulation can slow progression of ARMD but carries a risk of acute visual loss, especially in patients with sub-foveal ARMD.

Question 19

What is blurred vision?

Answer 19

Blurred vision may be defined as a loss of clarity or sharpness of vision.

Question 20

What is the most common cause of blurred vision?

Answer 20

Refractive error is the most common cause of blurred vision.

Question 21

What are some other causes of blurred vision?

Answer 21

Other causes include cataracts, retinal detachment, age-related macular degeneration, acute angle closure glaucoma, optic neuritis, and amaurosis fugax.

Question 22

What assessments are used for blurred vision?

Answer 22

Assessments include visual acuity with a Snellen chart, pinhole occluders, visual fields, and fundoscopy.

Question 23

How can pinhole occluders help in assessing blurred vision?

Answer 23

Pinhole occluders are useful to check if the blurred vision is due to a refractive error. If the blurring improves with a pinhole occluder, then the likely cause is a refractive error.

Question 24

What is the management for blurred vision?

Answer 24

Management depends on the suspected underlying cause. If gradual onset is corrected by a pinhole occluder and there are no other associated symptoms, an optician review is the next step.

Question 25

When should a patient with blurred vision be seen by ophthalmology?

Answer 25

Patients should be seen by ophthalmology if there are associated symptoms such as visual loss or pain; this should be urgent.

Question 26

What is a cataract?

Answer 26

A cataract is a common eye condition where the lens of the eye gradually opacifies, becoming cloudy, which makes it difficult for light to reach the retina, causing reduced or blurred vision. Cataracts are the leading cause of curable blindness worldwide.

Question 27

Who is more likely to develop cataracts?

Answer 27

Cataracts are more common in women than in men.

Question 28

How does age affect the incidence of cataracts?

Answer 28

The incidence of cataracts increases with age. One study found that 30% of individuals aged 65 and over had a visually-impairing cataract in either one or both eyes.

Question 29

What is the most common cause of cataracts?

Answer 29

The normal ageing process is the most common cause of cataracts.

Question 30

What are other possible causes of cataracts?

Answer 30

Other possible causes include smoking, increased alcohol consumption, trauma, diabetes mellitus, long-term corticosteroids, radiation exposure, myotonic dystrophy, and metabolic disorders like hypocalcaemia.

Question 31

What are typical symptoms of cataracts?

Answer 31

Patients typically present with a gradual onset of reduced vision, faded colour vision, glare, and halos around lights.

Question 32

What is a sign of cataracts during examination?

Answer 32

A defect in the red reflex is a sign of cataracts, as cataracts prevent light from reaching the retina.

Question 33

What investigations are used to diagnose cataracts?

Answer 33

Investigations include ophthalmoscopy (normal fundus and optic nerve findings) and slit-lamp examination (visible cataract).

Question 34

What are the classifications of cataracts?

Answer 34

Cataracts can be classified as nuclear, polar, subcapsular, and dot opacities.

Question 35

How are early-stage cataracts managed non-surgically?

Answer 35

In early stages, age-related cataracts can be managed conservatively with stronger glasses/contact lenses or brighter lighting to optimize vision.

Question 36

What is the surgical treatment for cataracts?

Answer 36

Surgery involves removing the cloudy lens and replacing it with an artificial one. Referral for surgery depends on visual impairment, quality of life impact, and patient choice.

Question 37

What should patients be advised about after cataract surgery?

Answer 37

Patients should be advised on the use of eye drops and eyewear, what to do if vision changes, and the management of other ocular problems.

Question 38

What is the success rate of cataract surgery?

Answer 38

Cataract surgery has a high success rate, with 85-90% of patients achieving 6/12 corrected vision postoperatively.

Question 39

What are common complications following cataract surgery?

Answer 39

Complications can include posterior capsule opacification, retinal detachment, posterior capsule rupture, and endophthalmitis.

Question 40

What is optic atrophy?

Answer 40

Optic atrophy is seen as a pale, well demarcated disc on fundoscopy. It is usually bilateral and causes a gradual loss of vision. ## Footnote Strictly speaking, optic atrophy is a descriptive term; it is the optic neuropathy that results in visual loss.

Question 41

What are the acquired causes of optic atrophy?

Answer 41

Acquired causes include: multiple sclerosis, papilloedema (longstanding), raised intraocular pressure (e.g. glaucoma, tumour), retinal damage (e.g. choroiditis, retinitis pigmentosa), ischaemia, toxins (e.g. tobacco amblyopia, quinine, methanol, arsenic, lead), and nutritional deficiencies (e.g. vitamin B1, B2, B6, and B12 deficiency).

Question 42

What are the congenital causes of optic atrophy?

Answer 42

Congenital causes include: Friedreich's ataxia, mitochondrial disorders (e.g. Leber's optic atrophy), and DIDMOAD syndrome (the association of cranial Diabetes Insipidus, Diabetes Mellitus, Optic Atrophy, and Deafness).