Ophathalmology

Question 1

Features of acute angle-closure glaucoma?

Answer 1

Severe pain in the eye or headache - hard, red eye - haloes around lights - demi-dilated non-reactive pupil - corneal oedema resulting in hazy cornea - decreased visual acuity

Question 2

Pre-disposing factors to acute angle-closure glaucoma?

Answer 2

• Hypermetropia
• Pupillary dilatation
• Lens growth associated with age
• TCA use : Amytriptilline
• Topiramate
• Anticholinergic drug : Atropine

Question 3

Mx of acute angle-closure glaucoma?

Answer 3

• Eye-drop + IV acetazolamide
  No guidelines for eye drops, but a combination of the following can be used: Pilocarpine (direct parasympathomimetic) - Apraclonidine (alpha-2 agonist) - Timolol (B-blocker, avoid in asthma and heart block)
• Surgery is the definitive Mx: laser peripheral iridotomy

Question 4

Causes of acute open-angle glaucoma?

Answer 4

Myopia
Aging Genetics
Afro Caribbean ethnicity
Hypertension
Diabetes mellitus
Corticosteroids

Question 5

Features of acute open-angle glaucoma?

Answer 5

• Peripheral visual field loss - nasal scotomas progressing to ‘tunnel vision’
• Decreased visual acuity
• Optic disc cupping (hallmark of POAG)

Question 6

Mx of POAG?

Answer 6

• 1st line: 360° selective laser trabeculoplasty (SLT) to people with an IOP of ≥ 24 mmHg
• 2nd line: prostaglandin analogue (PGA) eyedrops : Latanoprost
• 3rd line : B-blocker eye drops
  Carbonic anhydrase inhibitor eye drops
  Sympathomimetic eye drops
• Surgery (trabeculoctomy) in refractory cases

Question 7

Classification of age-related macular degeneration?

Answer 7

Dry ARMD (90%)= Drusen
Wet ARMD (10%)= Worst prognosis

Question 8

Diagnosis of ARMD?

Answer 8

Slit-lamp microscopy + colour fundus photography = initial investigation
Fluorescein angiography =

Question 9

Features of ARMD?

Answer 9

• Reduction in visual acuity, particularly for near field objects (gradual in dry ARMD, subacute in wet)
• Difficulty in dark accomodation and deterioriation of night vision
• Fluctuations in visual disturbance which may vary significantly from day to day
• Photopsia and glare around objects
• Charles-Bonnet hallucinations

Question 9

Signs of ARMD?

Answer 9

• Distortion of line perception may be noted on Amsler grid testing
• Fundoscopy =>
  In dry ARMD: presence of drusen, yellow areas of pigment deposition in the macular area, which may become confluent in late disease to form a macular scar.
  In wet ARMD: well demarcated red patches (intra-retinal or sub-retinal fluid leakage or haemorrhage)

Question 10

Mx of dry ARMD?

Answer 10

Zinc + antioxidant vitamins A,C,E, in people with moderate disease (slows progression by a third)

Question 11

Mx of wet ARMD?

Answer 11

• Vascular endothelial growth factor, to be started within 2 months of diagnosis (ranibizumab, bevacizumab and pegaptanib)

Question 12

What are Angioid retinal streaks?

Answer 12

Irregular dark red lines radiating from the optic nerve

Question 13

Causes of angioid retinal streaks?

Answer 13

• Pseudoxanthoma elasticum
• Ehler-Danlos syndrome
• Paget’s disease
• Sickle-cell anaemia
• Acromegaly

Question 13

What are the features of anterior uveitis?

Answer 13

• Acute onset of red painful eye with blurred vision, photophobia (often intense) lacrimation, ciliary flush, hypopion
• Small, fixed, irregular pupil due to sphincter muscle contraction
• Visual acuity initially normal, then gets worse

Question 14

What is anterior uveitis associated with?

Answer 14

Associated with HLA-B27, so:
- Ankylosing spondylitis
- Reactive arthritis
- Ulcerative colitis, Crohn’s disease
- Behcet’s disease
- Sarcoidosis: bilateral disease may be seen

Question 15

Management of anterior uveitis?

Answer 15

• Urgent review by ophthalmology
• Cycloplegics (dilates the pupil which helps to relieve pain and photophobia) e.g. Atropine, - Cyclopentolate
• Steroid eye drops

Question 16

What are the features of retinitis pigmentosa?

Answer 16

Tunnel vision due to loss of peripheral retina and eventual central vision impairment due to photoreceptor degeneration. Night blindness is often first sign.
Fundoscopy: black bone spicule-shaped pigmentation in the peripheral retina, mottling of the retinal pigment epithelium

Question 17

Associations of retinitis pigmentosa?

Answer 17

• Refsum disease: cerebellar ataxia, peripheral neuropathy, deafness, ichthyosis
• Usher syndrome
• Abetalipoproteinemia
• Lawrence-Moon-Biedl syndrome
• Kearns-Sayre syndrome
• Alport’s syndrome

Question 18

Management of Ramsay-Hunt syndrome?

Answer 18

Oral aciclovir and corticosteroids

Question 19

Features of Herpes simplex keratitis?

Answer 19

• Red, painful eye
• Epiphora
• Photophobia
• ↓Visual acquity

Question 20

Diagnosis of Herpes simplex keratitis?

Answer 20

Fluorescein: dendritic pattern of staining

Question 21

Management of Herpes simplex keratitis?

Answer 21

Urgent referral + topical Acyclovir
NO TOPICAL STEROIDS AS THEY EXACERBATE CONDITION

Question 22

Sudden unilateral painless loss of vision + severe haemorrhages seen in fundoscopy (stormy sunset) =?

Answer 22

CRVO Central Retinal Vein Occlusion

Question 23

Mx of Central Retinal Vein Occlusion?

Answer 23

Usually managed conservatively, but treatment is required in : - Macular oedema => intravitreal anti-vascular endothelial growth factor (VEGF) agents - Retinal neovascularization => laser photocoagulation

Question 24

Posterior vitrous detachment symptoms?

Answer 24

Flashes in periphery + Floaters ont temporal side of central vision

Question 25

Vitrous haemorrhage symptoms?

Answer 25

- Large bleeds => sudden visual loss - Moderate bleeds => numerous dark spots - Small bleeds => floaters

Question 26

Retinal detachment symptoms?

Answer 26

- Dense shadow that starts in the periphery and progresses toward central vision - Veil or curtain over FOV - Straight lines appear wavy - Central visual loss

Question 27

Reduced visual acuity + proptosis + painful eye + systemic symptoms =?

Answer 27

Orbital cellulitis = manage with urgent ATBx