Ophthal Key

Question 1

Anterior uveitis = Iritis = Iridocyclitis
iritis. Anterior uveitis describes inflammation of the anterior

Anterior uveitis is one of the important differentials of a red eye. It is also
referred to as portion of the uvea “iris and ciliary body”.

Answer 1

Features
♦ Acute onset, progressive (over a few hours/ days)
♦ Ocular discomfort & pain (may increase with use)

♦ Pupil may be irregular, distorted, constricted, sluggish to react.
♦ Photophobia (often intense)
♦ Blurred vision
♦ Red eye
♦ Lacrimation (watering)
♦ Ciliary flush

♦ Hypopyon; describes pus and inflammatory cells (flares and cells) in the
anterior chamber, often resulting in a visible fluid level.
♦ Visual acuity initially normal → later, impaired

Question 2

Anterior uveitis = Iritis = Iridocyclitis
iritis. Anterior uveitis describes inflammation of the anterior

Anterior uveitis is one of the important differentials of a red eye. It is also
referred to as portion of the uvea “iris and ciliary body”.

Answer 2

Associated conditions “Often given as a hint to pick iritis”

Ankylosing spondylitis ▐ Reactive arthritis ▐ ulcerative colitis, Crohn’s disease

Note, Rheumatoid arthritis is more associated with scleritis than uveitis.

Management
√ Urgent review by ophthalmology
√ Cycloplegics (eg, Cyclopentolate) → it dilates the pupil which prevents
adhesion between lens and iris and helps to relieve pain and photophobia) eg,
atropine, cyclopentolate.

√ Prednisolone eye drops → reduce inflammation.

Question 3

Acute Iritis

Answer 3

❤️Photophobia Marked

❤️Anterior
chamber
Cells and Flares
“Hypopyon”

❤️Pupil Irregular
constricted, sluggish to light

♦ Atropine,

♦ Prednisolone

❤️Cyclopentolate

❤️Intra-ocular
pressure (IOP)
Variable

❤️Cornea keratitic precipitate

❤️As,RA,IBD

Question 4

Fixed, non-reacting, semi-
dilated, ovoid. Pupil could
also be abnormal in shape.
Glacoma angle closure

Answer 4

♦ Timolol maleate drops √
♦ IV Acetazolamide
♦ beta-blockers, steroids,
analgesics, antiemetics
♦ Peripheral iridotomy (PI)

♦ Pilocarpine drops √

Systemic association eg,
Headache, Nausea and
Vomiting.
√ Hx of being in a dark
room (movie theatre,
ophthalmologist clink).
√ Hx of tropicamide drops(mydriatic)

Cornea

Oedema “Hazy, Dull,
Cloudy”. Coloured haloes.

Iop high

Pupil

Question 6

Painful red eye of 4 days. Sclera and Corneal junction are red with tearing.
Pupil is irregular in shape. Fluorescein staining is normal. Diagnosis?

Answer 6

Anterior uveitis

Question 7

A 36 YO man presents with painful, red, photophobic eye for 24-hours. He
also complains of blurred vision. The pupil is Irregular/ Distorted in shape. He
has Hx of cervical spondylitis and back pain and stiffness for which he is on
NSAIDs for the last 3 years

Answer 7

.
• Likely Dx → → • The affected ocular part → = (Anterior uveitis) = (Iridocyclitis) “any is correct”.
iris

Question 8

A 50 YO man presents with painful, red, photophobic eye with slightly blurred
vision and watering for 2 days.

On slit lamp examination → cells and flare in
the anterior chamber. The pupil is sluggish to react.

Answer 8

→ Acute iritis = (Anterior uveitis) = (Iridocyclitis) “Any is correct”

Question 9

Acute Angle Closure Glaucoma
= Narrow Angle Glaucoma
Mechanism of Acute Angle-Closure Glaucoma
• The root of the iris occludes the anterior chamber angle and prevents the
passage of the aqueous humour from the posterior to the anterior chamber.

• Aqueous cannot reach the outflow pathway and collects in the eyeball.
• The result is a rapid elevation of intraocular pressure (IOP).

• It is an ophthalmic emergency and may cause permanent visual loss unless
managed immediately and properl

Answer 9

Impaired aqueous outflow → ↑ Intra-Ocular Pressure (↑ IOP).
• RFs → Hypermetropia ▐ Pupillary dilatation.

• Features:
♦ Acute severely painful and red eye.
♦ Headache, Blurred vision, Ocular pain.
♦ Seeing coloured “Halos” around lights “this feature is in cataract as well”.
♦ The pupil is semi-dilated, non-reacting (ie, fixed), might look ovoid
(abnormal in shape).
♦ ↑ pupil dilatation (Mydriasis) such as when watching TV in a dark room →
Worsens Symptoms.
♦ OE → Hard globe ▐ Cloudy- dull- hazy cornea “Corneal Oedema” ▐ Shallow
anterior chamber.
♦ Systemic → Nausea, vomiting, headache.
◙ Initial Investigation → Measure intra-ocular pressure using tonometry.

Answer 10

Medical management
The management of AACG is an emergency and should prompt urgent referral
to an ophthalmologist.

Emergency medical treatment is required to lower the IOP with more
definitive surgical treatment given once the acute attack has settled.

√ To reduce aqueous secretions → √ To induce pupillary constriction → topical √ A ß-blocker (eg, eye drops), (↓ aqueous production) since
timolol is a ß-blocker, cautioned in asthmatic patients.

√ Others: Steroids eye drops (eg, prednisolone 15 every 15 minute for 1 hour,
then hourly), analgesics, anti-emetics
√ After stabilising the patient, urgently refer to an ophthalmologist.

◙ Surgical management
√ Laser peripheral iridotomy (PI): “Preferred”.
√ Surgical iridectomy.

Question 11

Example1,
A 47 YO ♀ presents complaining of severe right-sided headache. Her right
eye is painful, red, and watery. She also has intermittent blurred vision and
sees coloured halos. ± Hard globe

Answer 11

√ The likely Dx → Acute Angle Closure Glaucoma

√ The next step → Measure intra-ocular pressure using tonometry.

♦ Do not get tricked thinking that this is a case of cluster headache. Even
though the presentation is similar, cluster headache does not present with
halos around lights.

Also, cluster headache would have a Hx of recurrent
attacks.

Question 12

Example 2,
Acute angle closure glaucoma Coloured Halos.
“to measure IOP”.
“Narrow angle glaucoma”.
After being in a dark room watching a movie with her friends, a girl has been
brought to the ED complaining of sudden severe right eye pain and redness +
nausea and vomiting.

She has Hx of blurred vision and recurrent episodes of
headaches. Her pupil is fixed, dilated, ovoid.

Answer 12

√ The likely Dx → angle closure glaucoma

√ The likely visual symptom → coloured haloes

√ The next step → Ocular tonometry to measure iop

√ The likely affected structure →

√ Rx options
Anterior chamber.

→ Pilocarpine Timolol Acetazolamide, Prednisolone.
drops, drops, IV Note: Timolol maleate eye drops are one of the treatment options of AACG.

They
are ß-blockers, so it should be cautioned in asthmatic patients.

Question 13

◙ Unilateral severe painful, red, watery eye, headache ± hard globe ± sees halos
± blurring of vision

Answer 13

→ Narrow angle glaucoma → Pilocarpine eye drops “one of the lines of Rx”

Question 14

A 47-year-old man had received tropicamide eye for routine eye examination
and then developed acute eye pain and blurry vision in the right eye.

Examinations reveal a mid-dilated pupil, conjunctival injection, and a shallow
anterior chamber in the right eye. What is the most appropriate initial
management?

A) Latanoprost.
B) Atropine sulfate.
C) Timolol maleate.
D) Cyclopentolate hydrochloride.
E) Reassure.

Answer 14

Answer → C.

• Acute eye pain and blurry vision, mid-dilated pupil, conjunctival injection, and a
shallow anterior chamber → Acute angle closure glaucoma (AACG).

• Tropicamide is a mydriatic agent (dilates the pupil) → precipitates and worsens
AACG.

• Rx options of AACG → drops, drops, IV Pilocarpine Timolol Acetazolamide,
Prednisolone

Question 15

This is an example to help you differentiate it from cluster H.,
While he is working at his office, a 31 YO ♂ suddenly developed excruciating
headache to his left side associated with left eye pain.

He experienced similar
episodes 3 months ago. His left eye is red, swollen and with lacrimation.

Answer 15

The likely Dx → Cluster headache.
The Management

◙ Management (Acute phase):
√ 100% O2 for 10-20 minutes.
√ Sumatriptan (Nasal or Subcutaneous).

√ If first time attack → refer to specialist as it may require CT to R/O other DDs.

◙ Prophylaxis: → Calcium Channel Blockers (e.g. Verapamil)

Excruciating = very severe, eye pain swelling redness and with lacrimation are
features of cluster headache.

The Hx of similar attacks is also important.
Always same side.

Question 16

Arteriovenous nicking, also known as AV nipping, is the phenomenon where,
on examination of the eye, a small artery (arteriole) is seen crossing a small
vein (venule),

which results in the compression of the vein with bulging on
either side of the crossing. It is seen in Hypertensive Retinopathy.

Answer 16

On fundoscopy of hard exudates, dots, and blots, one or more of the following would be a clincher:

Arteriovenous nipping/ Copper or silver wiring/ Flamed shaped hemorrhage
Management → Control HTN.

Note, the Hx of uncontrolled HTN (> 140/90) + dots and blots, ischemic
changes, hard exudates → hypertensive retinopathy

not always be given.

Question 17

◙ Central retinal artery occlusion (CRAO)
√ Sudden (over seconds), painless, unilateral loss of vision, no eye redness.

√ Pale or white retina ▐ Cherry red spots at macula ▐ Vessels attenuation.

• Central retinal artery is a branch of the Ophthalmic artery which is a branch
of the Internal carotid artery.

√ If a patient presents within 100 minutes of the symptoms
may be performed as a trial to dislodge the
→ Firm ocular massage occlusion.
→ Then, Refer

Answer 17

Important,
Central Retinal Artery Occlusion may be associated with Giant Cell Arteritis
(Temporal Arteritis).

It may be given as a hint by mentioning that the patient
complains of unilateral headaches and pain especially on chewing.

Question 18

Optic neuritis
Remember its association with Multiple Sclerosis.

√ Swollen, Pale optic disc.
√ eye pain especially on eye movement
√ Reduced vision.

√ Reduced colour vision (initially red colour vision loss).
√ Sometimes, Hx of remitting and relapsing of symptoms would be given
beside muscle weakness, exaggerated reflexes.

♦ The affected structure is → Optic Nerve.
♦ Management → Corticosteroids

Answer 18

◙ Remember, the management of Multiple Sclerosis

√ In acute cases (during a Relapse) (initial) → Oral or IV Methylprednisolone.

√ Long-term → Glatiramer acetate [or] Interferon-beta.

Question 19

Central Retinal Vein Occlusion has a similar presentation
(Sudden, painless loss of vision). HOWEVER,

Answer 19

√ “Central retinal ARTERY occlusion”, the retina is Pale and the macula shows
Cherry red spots ± Attenuation of vessels.

√ “Central retinal VEIN occlusion”, the retina is haemorrhagic “often flame-
shaped scattered hemorrhages” and the macula is swollen “oedematous”.

◙ Sudden painless loss of vision + Pale retina + Cherry red macula ± Vessels
attenuation
→ CRAO “Central Retinal Artery Occlusion”.

◙ Sudden painless loss of vision + Optic disc and macular edema “swelling” +
retinal hemorrhage (flame-shaped) ± engorged, tortuous veins
→ CRVO “Central Retinal Vein Occlusion”.

Question 20

Important Hints towards [Cataract]
♣ High Myopia → a risk factor.
♣ Long-term Oral Steroid intake (e.g. Asthma, COPD, RA) with progressive loss
of vision/ DM. (Risk Factors).

♣ Glare at night → Lights appear brighter than usual.

♣ Dazzling (halos) around lights.
♣ Frequent change spectacles (glasses) = refraction changes (lens problem).

♣ Exposure to significant amounts of ultra violet light (with no glasses wearing).
♣ Eye trauma can also cause cataract.

Answer 20

♣ On fundoscopy → “Dense opacities = lens has become cloudy; thus,
affecting the vision”.

Example,
A 49 YO asthmatic patient presents with left eye reduced vision and glare
especially at night.

√ The likely Dx →

√ The likely cause →

long-term Steroid Induced Cataract.

“Oral” Steroid intake for asthma. (not inhaled)!

Question 21

Viral conjunctivitis
♦ Redness, no pain, no discharge (or if present, it is watery -serous-), no vision
impairment.
♦ Commonly occurred due to URTI.

♦ The commonest causative organism → Adenovirus.
♦ Rx → Reassure + Supportive (e.g., artificial tears).

Answer 21

Bacterial
♦ Purulent discharge, grittiness “sand” sensation.
conjunctivitis
♦ Eyes may be ‘stuck together’ in the morning.
♦ ± Hx Otitis media

♦ Rx →
√ Initial → Self-care, Clean discharge using cotton wool soaked
in water.

√ Severe/ Prolonged (> 1week)? Topical antibiotics drops
(e.g., Chloramphenicol “first-line”, Fusidic acid).

Viral
• Serous “watery” discharge
conjunctivitis
• Recent URTI
• ± Preauricular lymph nodes
• Rx → Reassurance + Supportive management

Answer 22

Allergic

♠ Bilateral Redness + Itching + Chemosis (swelling of
Conjunctivitis
conjunctiva ± eyelids).

♠ Hx of atopy or seasonal (due to pollen) or perennial (due to
dust mite, washing powder or other allergens

♠ Rx → Topical anti-histamines (first-line)

Question 23

◙ Dots, blots, hard exudates in DM 1 patient. (maybe + Hx of HTN to trick you).
→ non-proliferative “background” retinopathy.

◙ Dots, blots, hard exudates + cotton wool spots in DM 1 patient.
→ Pre-proliferative retinopathy.

Answer 23

◙ The above + neovascularisation “new vessels” in DM 1 patient. (maybe + Hx of
HTN to trick you to choose HTN retinopathy)

→ Proliferative retinopathy (Laser photocoagulation is required).

◙ Hx of uncontrolled HTN + any of: dots, blots, exudates, ischemic changes,

macular edema ± Arteriovenous nipping/ Copper or silver wiring/ Flamed shaped
hemorrhage
→ Hypertensive retinopathy.

◙ Sudden painless loss of vision + Pale retina + Cherry red macula + Vessels
attenuation (maybe + Hx of HTN to trick you to choose HTN retinopathy)

→ CRAO “Central Retinal Artery Occlusion” → (Firm Ocular Massage)

Question 24

◙ Sudden painless loss of vision + Optic disc and macular edema “swelling” +
retinal hemorrhages (flame-shaped) + engorged, tortuous veins (maybe + Hx of
HTN to trick you to choose HTN retinopathy)
→ CRVO “Central Retinal Vein Occlusion”.

◙ Sudden, painless, “transient” loss of vision ± a curtain falling down his vision
→ Amaurosis Fugax. (Transient occlusion of the central retinal artery).

◙ Sudden painless loss of vision + a curtain “black shadow” falling down his vision
± grey opaque retina that balloons forwards ± RFs (e.g. Myopia).
± Fs: Floaters – Flashes – Field visual loss

Answer 24

→ Retinal Detachment → Rx: Scleral Buckling.

◙ Night blindness (difficulty driving, tripping) + Peripheral visual loss + Hereditary
→ Retinitis Pigmentosa → Routine ophthalmologist referral

◙ HIV positive (homosexual, weight loss) + progressive visual deterioration ±
retinal hemorrhages and yellow exudates.
→ CMV retinitis.

◙ Long term steroid intake (oral steroids e.g. in asthma, COPD), Glare at night,
Dazzling “halos” around lights. Others: exposure to UV light excessively without
wearing glasses/ frequently changing spectacles/ high myopia, trauma to eye
→ Cataract. The cause if he is asthmatic or has COPD → Oral Corticosteroids.

◙ A child presents with periorbital redness and edema + Proptosis + Ptosis +
Restricted painful eye movement ± systemic (e.g. Nausea).
→ Orbital Cellulitis → Admit and administer IV antibiotics.

Question 25

◙ Herpes Zoster Ophthalmicus. √ √ Reactivation of Varicella Zoster Virus (VZV) in the nerve (5th CN).

Answer 25

√ Conjunctivitis, Keratitis, pain around an eye, painful Vesicles/ Rash around an eye …etc. √ Rx → Aciclovir. ◙ Careful, the affected nerve → Trigeminal Nerve “the ophthalmic branch”. Note, ♣ Keratitis can be a complication of Herpes Zoster Ophthalmicus. ♣ Keratitis can also be due to Herpes Simplex Keratitis (dendritic corneal ulcer), for which, Topic Aciclovir is used.

Question 26

Retinitis Pigmentosa ◙ It is inherited. ◙ It primarily affects the peripheral retina resulting in tunnel vision. ◙ Features √ Night blindness is often the initial sign √ Tunnel vision due to loss of the peripheral retina (occasionally referred to as tunnel vision)

Answer 26

√ It is progressive, meaning that it will end up with central blindness. ◙ Fundoscopy: black bone spicule-shaped pigmentation in the peripheral retina, mottling of the retinal pigment epithelium. → Routine ophthalmologist referral Hints, Family Hx, gradual loss of “peripheral” vision, especially at night, Difficult night driving, tripping “stumbling” at night.

Question 27

Papilloedema → Optic disc swelling that is caused by increased intracranial pressure. It is almost always bilateral. Some important causes: √ Space-occupying lesions (hematoma, tumour, abscess). √ Malignant hypertension. ♦ The first sign is usually → venous engorgement.

Answer 27

So, if a patient was found to have papilledema on fundoscopy, the affected part is → Optic Disc. √ ◙ Remember, in Optic neuritis where fundoscopy would show a swollen pale optic disc with painful eye especially on movement ± reduced colour vision especially for Red ± features of MS, the affected part is → Optic nerve. √

Question 27

Retinitis Pigmentosa ◙ It is inherited. ◙ It primarily affects the peripheral retina resulting in tunnel vision. ◙ Features √ Night blindness is often the initial sign √ Tunnel vision due to loss of the peripheral retina (occasionally referred to as tunnel vision)

Answer 27

√ It is progressive, meaning that it will end up with central blindness. ◙ Fundoscopy: black bone spicule-shaped pigmentation in the peripheral retina, mottling of the retinal pigment epithelium. → Routine ophthalmologist referral Hints, Family Hx, gradual loss of “peripheral” vision, especially at night, Difficult night driving, tripping “stumbling” at night.

Question 28

Retinal detachment ◙ Hints: √ Sudden painless loss of vision. √ Floaters – Flashes – Field visual loss – Fall in visual acuity → Retinal Detachment. √ “A curtain falling down” or “Dark shadow over my vision”. ◙ Important Risk factors may be given → Myopia ▐ Extraction of cataracts surgically ▐ Hx of trauma a few days earlier. ◙ Direct ophthalmoscope → Grey, Opalescent “Opaque” retina, Ballooning forward. However, optic disc may appear normal.

Answer 28

√ Head to be tilted backward. √ Surgical or mechanical reattachment (eg, photocoagulation, cryotherapy, injection of expansile gas into the vitreal cavity). (belt around the sclera) “ important √” √ Scleral buckling Important Note, Amaurosis Fugax may present similarly “painless unilateral loss of vision with a sensation that a black curtain has come down over my vision”. However, Amaurosis Fugax is “transient”; usually resolves in 5-30 minutes. It is due to temporary retinal ischemia “transient occlusion of the central retinal artery”

Question 30

Example 1, A 55 YO myopic man presents with unilateral sudden painless visual loss. He says that he felt as a black curtain was coming down his vision. Ophthalmoscope reveals grey opaque retina that balloons forward. ♦ The likely Dx → Retinal detachment. ♦ Appropriate management → Scleral buckling.

Question 31

53 YO ♀ has floaters and flashed of light over the past 6 days in her left visual field. She has difficulty driving as she finds it difficult to see with her left eye. There is no pain or redness in her eyes and no Hx of trauma. Her visual acuity with glasses is 6/6 on the right and 6/24 on the left eye. The likely Dx → Retinal Detachment. √ Floaters – Flashes – Field visual loss – Fall in visual acuity → Retinal Detachment. √ RF → Myopia

Answer 31

Remember, ♦ In Cataract → Glare at night ▐ Dazzling (halos) around lights. ♦ In Retinitis Pigmentosa → Night blindness (difficulty driving, tripping at night) + Peripheral visual loss + Hereditary

Question 32

HIV patient with eye/ retinal manifestations (e.g. progressive visual impairment). → think Cytomegalovirus retinitis (the causative organism is CMV) ♦ The question may not directly tell you that the patient is HIV positive. They may rather give you some hints towards HIV. Such common hints are → Homosexual ± Weight loss.

Answer 32

Another hint towards CMV retinitis: Fundoscopy → retinal hemorrhage + yellow-white areas of exudates

Question 33

Example, A homosexual man with weight loss presents with progressive visual impairment. His fundoscopy shows retinal hemorrhage with white-yellow areas of exudates. ♦ The likely causative organism → Cytomegalovirus.

Question 34

Refresh Your Memory Remember that many opportunistic infections may develop in a HIV-positive patient (immunocompromised). The following are important examples: CD4 > 200 cells/mm3: √ Oral thrush → Candida albicans. √ Shingles → Herpes zoster. √ Hairy leucoplakia → Epstein-Barr Virus (EBV).

Answer 34

Kaposi sarcoma → HHV-8 “Human Herpes Virus 9”. CD4 < 200 cells/mm3: √ Pneumocystis Jirovecii (Carinii) pneumonia. √ Cerebral Toxoplasmosis. √ Oesophageal Candidiasis → Candida albicans. √ Cytomegalovirus retinitis → CMV (especially if CD 4 < 50)

Question 35

Kaposi sarcoma → HHV-8 “Human Herpes Virus 9”. CD4 < 200 cells/mm3: √ Pneumocystis Jirovecii (Carinii) pneumonia. √ Cerebral Toxoplasmosis. √ Oesophageal Candidiasis → Candida albicans. √ Cytomegalovirus retinitis → CMV (especially if CD 4 < 50

Question 36

Subconjunctival Hemorrhage (Bloodshot Eye)

Answer 36

♦ Symptomless (painless, does not affect vision). ♦ It occurs due to small bleed from a minor conjunctival vessel on the eye surface. ♦ It occurs either spontaneously (most commonly) or post-trauma, coughing, sneezing, lifting heavy stuff. √ Check Blood Pressure → to rule out systemic hypertension. √ If the patient is on anticoagulant (eg, warfarin) → Check INR. √ If spontaneous, no history of trauma or anticoagulation therapy → Reassure. It is usually benign and resolves spontaneously within 2 weeks.

Question 37

◙ Sudden painless loss of vision + Pale retina + Cherry red macula

Answer 37

CRAO “Central Retinal Artery Occlusion”. ◙ Sudden painless loss of vision + Optic disc and macular edema “swelling” + retinal hemorrhage (flame-shaped) + engorged, tortuous veins → CRVO “Central Retinal Vein Occlusion

Question 38

Eye signs of Grave’s disease, what to do? → TFT (Thyroid Function Tests are superior to Autoantibodies as we need to establish the diagnosis of hyperthyroidism before looking for its aetiology). ♦ Thyroid “Grave’s” Ophthalmopathy √ Lid lag. √ Lid retraction. √ Exophthalmos. √ Diplopia. √ Restricted eye movements (Ophthalmoplegia).

Answer 38

Other manifestation of Grave’s “Thyrotoxicosis” e.g. tachycardia, weight loss, sweating, agitation and nervousness, intolerance to hot weather…etc. The most appropriate investigation → Thyroid function tests (TFT).

Answer 39

Careful not to mix Grave’s ophthalmopathy up with Oculomotor nerve palsy (3rd nerve palsy) → Diplopia, PtOsis, Mydriasis “Fixed dilated pupil”, outward and downward eye deviation. In such a case, request → CT angiography (to R/O Posterior communicating artery aneurysm). Others, space-occupying lesions.

Question 40

Very Important, In Optic Neuritis, √ Generally, and a more commonly association → Central Scotoma. √ If associated with RAPD “Relative afferent pupillary defect” → pick “Monocular visual field loss” instead of Central Scotoma. Notes, - Central scotoma is also seen in Macular degeneration. - Monocular visual field loss is also seen in Amaurosis Fugax. - In optic neuritis (MS), if there is RAPD → Monocular visual field loss. - In optic neuritis (MS), if there is No RAPD → Central scotoma.

Answer 40

Relative afferent pupillary defect (RAPD) √ Also known as the Marcus-Gunn pupil. √ Relative afferent pupillary defect is found by the ‘swinging light test’ . √ It is caused by a lesion anterior to the optic chiasm i.e. optic nerve or retina. Finding ♦ Both the affected and the normal eye appear to dilate (instead of to constrict) when light is shone on the affected eye. ♠ Firstly, Light to the intact eye → both pupils constrict. ♠ Then immediately, Light to the affected eye → both pupils appear to dilate. Causes (Lesion anterior to optic chiasm; retina, optic nerve) ♦ Retina → Retinal detachment ♦ Optic nerve: → Optic neuritis e.g. in multiple sclerosis (a commonly given hint).

Question 41

Acute angle closure glaucoma → coloured halos.

Answer 41

Remember: in pituitary adenoma and acromegaly → bitemporal hemianopia. Important Note: Bitemporal hemianopia is a type of heteronymous hemianopia. Heteronymous hemianopia refers to visual field defects that involve opposite halves of the visual field in each eye. Specifically: o Binasal hemianopia: Loss of the nasal (inner) halves of the visual field in both eyes. o Bitemporal hemianopia: Loss of the temporal (outer) halves of the visual field in both eyes, which is typically caused by compression of the optic chiasm, such as from a pituitary adenoma. Be aware that the term "bitemporal homonymous hemianopsia" is incorrect and not a recognised medical term. The correct term for the visual field defect caused by a pituitary adenoma is bitemporal hemianopia, which falls under the category of heteronymous hemianopia. Therefore, if scenario mentions that the patient has pituitary adenoma, and asks about the most likely type of visual field defect, and there are 2 options: bitemporal homonymous hemianopsia and Heteronymous hemianopia, → Heteronymous hemianopia would be the correct answer. This is because there is the term "bitemporal homonymous hemianopsia" is not recognised in ophthalmology and does not exist. The correct term is "bitemporal hemianopia", which is a type of Heteronymous hemianopia. So, in such an example, pick Heteronymous hemianopia.

Question 42

Do not confuse/ mix up the management of these conditions: ◙ Dots, blots exudates + neovascularisation “new vessels” in DM 1 patient. (maybe + Hx of HTN to trick you to choose HTN retinopathy) is required). → Proliferative retinopathy (Laser photocoagulation ◙ Sudden painless loss of vision + Pale retina + Cherry red macula + Vessels attenuation (maybe + Hx of HTN to trick you to choose HTN retinopathy)

Answer 42

→ CRAO “Central Retinal Artery Occlusion” → (Firm Ocular Massage). ◙ Sudden painless loss of vision + a curtain “black shadow” falling down his vision ± grey opaque retina that balloons forwards ± RFs (e.g. Myopia). → Rx: → Retinal Detachment Scleral Buckling. ◙ Unilateral severe painful, red, watery eye, headache ± hard globe ± sees halos ± blurring of vision → Narrow (closed) angle glaucoma → Pilocarpine eye drops “one of the lines of Rx” ◙ Itchy, dry, mildly painful eyes + Reduced lacrimation (Schirmer’s test < 10 mm) → Keratoconjunctivitis Sicca Artificial tears → Use eg, Any of which would be a valid answer!

Question 43

Acute Dacryocystitis An infection of the “lacrimal sac” (at the nasal side of the lower lid

Answer 43

√ Watering eye (epiphora). √ Swelling, pain, and erythema at the inner canthus of the eye that can extend over the neighbouring areas. √ ± Mucoid discharge can be expressed from the lacrimal sac. ◙ Management is with systemic antibiotics. √ Intravenous antibiotics are indicated if there is associated periorbital celluli

Question 44

22 YO male presents complaining of a 3-day burning, redness and stickiness of his right eye associated with greenish discharge. The likely part affected → Conjunctive “Bacterial Conjunctivitis”

Answer 44

♦ If < 7 days wool soaked in water. ♦ If > 7 days → Self-care, including gently cleaning the discharges with cotton → Topical antibiotic drops eg, Chloramphenicol “which is bacteriostatic to both gram +ve and -ve organisms. (Topical fusidic acid in pregnancy)

Question 45

◙ Sudden painless loss of vision + Optic disc and macular edema “swelling” + scattered multiple retinal hemorrhages (flame-shaped) ± engorged, tortuous veins

Answer 45

→ CRVO “Central Retinal Vein Occlusion”.

Question 46

Diabetic retinopathy The important concept to know is that once there is neovascularisation, it is proliferative retinopathy which needs → Laser Photocoagulation.

Answer 46

Diabetic Retinopathy, (especially seen DM 1), Fundoscopy findings: 1) Non-proliferative retinopathy (background retinopathy) Dots (microaneurysms) ▐ Blots (hemorrhages) ▐ Hard exudates 2) Pre-proliferative retinopathy The above + Cotton wool spots 3) Proliferative retinopathy ♦ The above + Neovascularisation (New vessel formation) ♦ This type requires → Laser photocoagulation. ♦ Progress rapidly to blindness. ♦ Floaters in vision.m

Question 48

Orbital Cellulitis √ Common in Children ◙ Presentation √ Redness and swelling around the eye (Periorbital redness and edema) √ Severe ocular pain

Answer 48

√ Visual disturbance √ Proptosis √ Ophthalmoplegia/pain with eye movements √ Eyelid oedema and ptosis √ Drowsiness +/- Nausea/vomiting in meningeal involvement (Rare) ◙ Differentiating orbital from preseptal cellulitis Reduced visual acuity, proptosis, ophthalmoplegia/pain with eye movements are NOT consistent with preseptal cellulitis. ◙ Management → Admission to hospital for IV antibiotics

Question 49

Seeing Halos → Think Cataract or Acute Angle Closure Glaucoma. Key 26 Itchy, dry, mildly painful eyes + Reduced lacrimation (Schirmer’s test < 10 mm) → Keratoconjunctivitis Sicca

Answer 49

→ Use Artificial tears eg, Hypromellose drops, NaCl, Sodium hyaluronate. Any of which would be a valid answer!

Answer 50

Important eye association! ◙ Ankylosing spondylitis (morning back pain and stiffness) → Iritis “the affected part is iris” ◙ Rheumatoid arthritis (morning stiffness and pain of SMALL joints) → Scleritis/ episcleritis (Acute red painful eye) “the affected part → Sclera” In RA, the commonest eye association is Keratoconjunctivitis Sicca. → Steroid-induced cataract Note, as RA patients are usually on long-term steroids, they may also develop “Look for cataract features such as Glare at night Dazzling (halos) around lights, Frequently changing eye glasses.

Question 51

OTA

Answer 51

O (Oculomotor) 3rd CN T (Trochlear) 4th CN A (Abducens) 6th CN Same side Opposite side Same side Dilated pupil, ptOsis Diplopia on Downgaze Diplopia on Lateral gaze O T A Oculomotor (3rd), Trochlear (4th), Abducens (6th) Same, Opposite, Same Ptosis, Downward gaze, Lateral Gaze

Question 52

Progressive ↓ in visual acuity and peripheral visual field in an elderly (>60 YO), Myopic (Short-sightedness) and with increased cup-to-disc ratio. → Primary open-angle Glaucoma (POAG). Also called: Chronic Glaucoma. First-line treatment → Prostaglandin analogues, eg, latanoprost, bimatoprost. ◙ Features of open angle glaucoma: √ (↓) peripheral visual field (nasal scotoma → tunnel vision). √ (↓) visual acuity. √ (↑) Intra-ocular pressure. √ Seeing halos around light. √ Optic disc cupping (ie, increased cup-to-disc ratio). √ Family history, Black people, Myopia, usually > 60 YO.

Answer 52

◙ When to consider cataract? ♠ If there is a history of steroid intake (e.g. Asthma, COPD, RA). ♠ Glare at night ▐ Dazzling (halos) around lights. ♠ Frequent change of spectacles. ♠ Exposure to significant amounts of ultraviolet light.

Question 53

Important Ophthalmology Collection ◙ Cases Associated with Myopia → • Primary open-angle Glaucoma (POAG): “Progressive ↓ visual acuity and peripheral field vision in elderly ± disc cupping, ↑ IOP”. First-line Treatment: Prostaglandin analogues (e.g., latanoprost, bimatoprost). • Cataract: “Glare, Dazzling – halos – History of long-term oral steroid use, frequently changing glasses”. Treatment: Surgical lens replacement (phacoemulsification) when vision impairment affects quality of life

Answer 53

• Retinal Detachment: “Sudden onset of floaters and flashes of light, followed by a sensation of a ‘black shadow’ or curtain falling over the vision ± grey, opaque, ballooning retina”. Treatment: Surgical intervention (e.g., scleral buckling, vitrectomy, laser photocoagulation, or pneumatic retinopexy) depending on the case. ◙ Cases Associated with Hypermetropia → • Acute Angle-Closure Glaucoma: (Headache, Halos, Semi-dilated pupil, Hard globe, Corneal Oedema, ± nausea and vomiting). Treatment: Acetazolamide and topical beta-blockers like timolol to quickly lower intraocular pressure. Pilocarpine is used later to open the angle. Laser iridotomy is often needed for definitive treatment.

Question 54

Mooren’s ulcer is NOT a degenerative corneal Disease.

Answer 54

Mooren’s ulcer is NOT a degenerative corneal Disease. Some Degenerative corneal diseases: √ Band Keratopathy. √ Keratoconus. √ Pellucid marginal degeneration. √ Terrien marginal degeneration.

Answer 55

Headache, vomiting, painful eye → Acute close angle glaucoma Acute Iritis Acute Angle Closure Glaucoma (AACG) (Anterior Uveitis) Photophobia Marked Mild Anterior chamber Cells and Flares “Hypopyon” √ Shallow anterior chamber √ Hard globe on palpation Pupil Irregular “distorted”, constricted, sluggish to react Semi dilated, ovoid. Pupil could Non react, fixed also be abnormal in shape. Intra-ocular pressure (IOP) Variable High Cornea Keratitic precipitates Oedema “Hazy, Dull, Cloudy”. Coloured haloes. Associations Ankylosing Spondylitis Reactive Arthritis √ Systemic association eg, Headache, Nausea and Vomiting.

Answer 56

IBD (UC, CD). √ Hx of being in a dark room (movie theatre, ophthalmologist clink). √ Hx of tropicamide drops use (mydriatic agent). Acute iritis Rx ♦ Cyclopentolate, ♦ Atropine, ♦ Prednisolone Acute angle closure glaucoma Pilocarpine Timolol ♦ IV Acetazolamide ♦ beta-blockers, steroids, analgesics, antiemetics ♦ Peripheral iridotomy (PI)

Question 57

middle age female comes complaining of sudden painless loss of vision + Floaters and Flashes with Field visual loss. → Retinal Detachment Rx: Scleral Buckling.

Question 58

Chalazion refer to an ophthalmologist (esp. if large and symptomatic)

Answer 58

Chalazion √ 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 (conservative) but some require surgical drainage. √ Initially → Conservative Rx e.g. → Apply warm compresses to the affected eye. √ 4 weeks after conservative management (e.g. applying warm compresses) if the chalazion still present:

Question 59

On fundoscopy of hard exudates, dots and blots, macular oedema one or more of the following would be a clincher: Arteriovenous nipping/ Copper or silver wiring/ Flame shaped hemorrhage Management → Control HTN

Answer 59

Note, the Hx of uncontrolled HTN (> 140/90) + dots and blots, ischemic changes, hard exudates → not always be given. Hypertensive retinopathy.

Question 60

After being in a dark room watching a movie with her friends, a girl has been brought to the ED complaining of sudden severe right eye pain and redness + nausea and vomiting. She has Hx of blurred vision and recurrent episodes of headaches. Her pupil is fixed, dilated, ovoid. √ The likely Dx → Acute angle closure glaucoma “Narrow angle glaucoma”.

Answer 60

Pilocarpine eye drops, Timolol √ Rx → asthma), eye drops (ß-blocker; cautioned in IV acetazolamide, steroids, anti-emetics. Then → urgent referral to an ophthalmologist. √ The likely visual symptom → Coloured Halos. √ The next step → Ocular tonometry “measure IOP”. √ The likely affected structure → Anterior chamber.

Question 61

♣ Frequent change of spectacles (glasses) but always come back again for error of refraction = refraction changes (lens problem) + Myopia Suspect → Cataract. Important Collection ◙ Myopia → ♠ Open angle Glaucoma, vision in an elderly ± disc cupping” “Progressive ↓ visual acuity and peripheral filed ♠ Cataract “Glare, Dazzling – halos-, Hx of long steroid intake, Hx of Changing glasses

Answer 61

♠ Retinal detachment “Floaters and Flashes ± Curtain falling over vision” . ◙ Hypermetropia → ♠ Acute Angle Closure Glaucoma (Headache, Halos, pupil is semi-dilated, Hard globe, Corneal Oedema, Nausea and vomiting

Question 62

question on woman with eyes defect came back from a travel to ‘Turkey’ with visual acuity of 6/12 and 6/18 for L/R respectively. She is hypertensive with BP of 156/90 and also has DM type 2. Fundoscopy attached What is the diagnosis? (IMAGE BASED Q)

Answer 62

Arteriovenous nicking, also known as AV nipping, is the phenomenon where, on examination of the eye, a small artery (arteriole) is seen crossing a small vein (venule), which results in the compression of the vein with bulging on either side of the crossing . It is seen in Hypertensive Retinopathy. The Hx of travel here may indicate that the patient was not following up his HTN lately.

Question 63

Hypertensive retinopathy

Answer 63

On fundoscopy of hard exudates, dots and blots, one or more of the following would be a clincher: Arteriovenous nipping/ Copper or silver wiring/ Flamed shaped hemorrhage Management → Control HTN. Note, the Hx of uncontrolled HTN (> 140/90) + dots and blots, ischemic changes, hard exudates → not always be given

Question 64

30yr old having progressive painless peripheral visual loss of 6 months duration. Worse at night. Similar history in father. What to do?

Answer 64

◙ Night blindness (difficulty driving, tripping) + Peripheral visual loss + Hereditary → Retinitis Pigmentosa. → Routine ophthalmologist referral √ Vitamin A may help. However, a routine referral to an ophthalmologist is to be done.

Question 65

A patient in depression. Switched from fluoxetine to citalopram. Presents with painful right red eye with visual blurring. A. fusidic acid eye drop B. Urgent referral to psychiatric C. D. clomipramine Urgent referral to ophthalmology

Answer 65

√ Citalopram (a SSRI) is associated with acute angle-closure glaucoma as one of the side-effects. √ Untreated closure angle glaucoma can cause permanent loss of vision

Question 66

Painful red eye of 4 days. Sclera and Corneal junction are red with tearing. Pupil is irregular shape. Fluorescein staining is normal. Diagnosis?

Answer 66

Normal fluorescein stain rules out corneal ulcer and keratitis.

Question 67

Patient with dry eyes. Schirmer’s test shows 8mm (N > 15). (+) ANA. Management

Answer 67

Itchy, dry, mildly painful eyes + Reduced lacrimation (Schirmer’s test < 10 mm) → Keratoconjunctivitis Sicca → Use Artificial tears eg, Hypromellose drops, NaCl, Sodium hyaluronate. Any of which would be a valid answer!

Question 69

Sjogren’ s syndrome SLE, rheumatoid arthritis or other ◘ Sjogren’s syndrome is an autoimmune disorder affecting exocrine glands resulting in dry mucosal surfaces. ◘ It may be primary (PSS) or secondary to connective tissue disorders ◘ Sjogren’s syndrome is much more common in females (ratio 9:1).

Answer 69

√ Dry eyes → keratoconjunctivitis sicca “The patient may have itchy eyes, a sandy sensation under their eyes -due to low lacrimal production” ♦ Schirmer’s test → ↓ tear production. ♦ Rose Bengal stain → may show Corneal ulcerations “2ry to dry eyes”. √ Dry mouth: “They may complain of difficulty in swallowing food – due to low saliva” √ Recurrent Parotitis → Bilateral enlargement of Parotid glands. √ Others: vaginal dryness, arthralgia, Raynaud’s, myalgia, sensory polyneuropathy, renal tubular acidosis (usually subclinical)

Question 70

Investigation √ Schirmer’s test: filter paper near conjunctival sac to measure tear formation → decreased tear production. √ Rose Bengal stain → may show Corneal ulcerations “2ry to dry eyes”. √ Rheumatoid factor (RF) positive in nearly 100% of patients.

Answer 70

√ Anti-Ro (SSA) antibodies in 70%. √ anti-La (SSB) antibodies in 30%. Management ♦ No Cure. ♦ Give artificial saliva and tears (eg, Hypromellose drops).

Question 71

question on woman with eyes defect came back from a travel to ‘Turkey’ with visual acuity of 6/12 and 6/18 for L/R respectively. She is hypertensive with BP of 156/90 and also has DM type 2. Fundoscopy attached What is the diagnosis? (IMAGE BASED Q

Answer 71

The Hx of travel here may indicate that the patient was not following up his HTN lately. Arteriovenous nicking, also known as AV nipping, is the phenomenon where, on examination of the eye, a small artery (arteriole) is seen crossing a small vein (venule), which results in the compression of the vein with bulging on either side of the crossing. It is seen in Hypertensive Retinopathy.

Question 72

Hypertensive retinopathy

Answer 72

On fundoscopy of hard exudates, dots and blots, macular oedema one or more of the following would be a clincher: Arteriovenous nipping/ Copper or silver wiring/ Flamed shaped hemorrhage Management → Control HTN. Note, the Hx of uncontrolled HTN (> 140/90) + dots and blots, ischemic changes, hard exudates → not always be given. Hypertensive retinopathy.

Question 74

A 54 yr old man with left sided facial pain and painful rash extending from forehead to the left eyelid. He had complained of headache 2 weeks prior with no cause found. What is the affected structure?

Answer 74

Ophthalmic nerve is a branch of trigeminal nerve (5th CN); not to be confused with optic nerve (2nd CN)!

Question 75

Herpes zoster Ophthalmicus

Answer 75

◙ Herpes Zoster Ophthalmicus. √ √ Reactivation of Varicella Zoster Virus (VZV) in the Ophthalmic branch of the Trigeminal nerve (5th CN). √ Conjunctivitis, Keratitis, Painful Vesicles around the eye (unilateral facial painful rash) …etc. √ Rx → Oral Aciclovir (antiviral) + Corticosteroids (eg, prednisolone

Question 76

Ramsay hunt syndrome

Answer 76

◙ Ramsay Hunt Syndrome (Herpes Zoster Oticus) √ √ Reactivation of Varicella Zoster Virus (VZV) in the geniculate ganglion of the facial nerve (7th CN) → Facial palsy (ipsilateral facial palsy, loss of taste). √ Otalgia “ear pain” “First symptom”, Tinnitus, Vertigo, Unilateral Hearing loss, Painful rash/ vesicles/ blisters around the ear or on the auditory canal. √ Rx → First → √ If lasted for > 3 months, it is called (post-herpetic neuralgia). If this occurs Give → Amitriptyline or Pregabalin or gabapentin or duloxetine.

Question 77

Ramsay hunt syndrome mng

Answer 77

Important Note: Prednisolone should be started within 2 weeks of symptoms. If The rash and pain persist for more than 2 weeks, it is better to add on a neuropathic agent eg, amitriptyline, or gabapentin or pregabalin or duloxetine . (They would be more beneficial than prednisolone after 2 weeks of the onset of symptoms). So: Aciclovir → up to 2 weeks, add prednisolone → > 2 weeks and still pain → one of the following: Amitriptyline or Pregabalin or gabapentin or duloxetine.

Question 78

Orbital cellulitis • Orbital cellulitis is the result of an infection affecting the fat and muscles posterior to the orbital septum, within the orbit but not involving the globe. • It is usually caused by a spreading upper respiratory tract infection from the sinuses (esp. ethmoid) and carries a high mortality rate. • Orbital cellulitis is a medical emergency requiring hospital admission and urgent senior review. • Periorbital (preseptal) cellulitis is a less serious superficial infection anterior to the orbital septum, resulting from a superficial tissue injury (chalazion, insect bite etc…). Periorbital cellulitis can progress to orbital cellulitis

Answer 78

◙ Epidemiology Mean age of hospitalisation 7-12 years. ◙ Risk factors √ Childhood √ Recent Hx of URTI √ Previous sinus infection √ Lack of Haemophilus influenzae type b (Hib) vaccination √ Recent eyelid infection/ insect bite on eyelid (Peri-orbital cellulitis) √ Ear or facial infection

Question 79

◙ Presentation orbital cellulitis √ Redness and swelling around the eye √ Severe ocular pain √ Visual disturbance (Not Always!). √ Proptosis √ Ophthalmoplegia (limited eye movements) /pain with eye movements √ Eyelid oedema and ptosis √ Drowsiness +/- Nausea/vomiting in meningeal involvement (Rare)

Answer 79

◙ Differentiating orbital from preseptal cellulitis reduced visual acuity, proptosis, ophthalmoplegia/pain with eye movements are NOT consistent with preseptal cellulitis ◙ Investigations • Full blood count – WBC elevated, raised inflammatory markers. • Clinical examination involving complete ophthalmological assessment – Decreased vision, afferent pupillary defect, proptosis, dysmotility, oedema, erythema. • CT with contrast of the sinus, orbit and brain – Inflammation of the orbital tissues deep to the septum, sinusitis, excludes abscess formation. • Blood culture and microbiological swab to determine the organism. Most common bacterial causes – Streptococcus, Staphylococcus aureus, Haemophilus influenzae B.

Question 80

Orbital cellulitis • Orbital cellulitis is the result of an infection affecting the fat and muscles posterior to the orbital septum, within the orbit but not involving the globe. • It is usually caused by a spreading upper respiratory tract infection from the sinuses (esp. ethmoid) and carries a high mortality rate. • Orbital cellulitis is a medical emergency requiring hospital admission and urgent senior review. • Periorbital (preseptal) cellulitis is a less serious superficial infection anterior to the orbital septum, resulting from a superficial tissue injury (chalazion, insect bite etc…). Periorbital cellulitis can progress to orbital cellulitis

Answer 80

◙ Management √ Admission to hospital for broad spectrum IV antibiotics. √ CT scan of the sinus, orbit and brain. √ May require drainage of abscess and decompression.

Question 82

◙ Epidemiology Mean age of hospitalisation 7-12 years. ◙ Risk factors √ Childhood √ Recent Hx of URTI √ Previous sinus infection √ Lack of Haemophilus influenzae type b (Hib) vaccination √ Recent eyelid infection/ insect bite on eyelid (Peri-orbital cellulitis) √ Ear or facial infection

Answer 82

◙ Presentation √ Redness and swelling around the eye √ Severe ocular pain √ Visual disturbance (Not Always!). √ Proptosis √ Ophthalmoplegia (limited eye movements) /pain with eye movements √ Eyelid oedema and ptosis √ Drowsiness +/- Nausea/vomiting in meningeal involvement (Rare) ◙ Differentiating orbital from preseptal cellulitis reduced visual acuity, proptosis, ophthalmoplegia/pain with eye movements are NOT consistent with preseptal cellulitis

Question 83

◙ Investigations of orbital cellulitis • Full blood count – WBC elevated, raised inflammatory markers. • Clinical examination involving complete ophthalmological assessment – Decreased vision, afferent pupillary defect, proptosis, dysmotility, oedema, erythema. • CT with contrast of the sinus, orbit and brain – Inflammation of the orbital tissues deep to the septum, sinusitis, excludes abscess formation. • Blood culture and microbiological swab to determine the organism. Most common bacterial causes – Streptococcus, Staphylococcus aureus, Haemophilus influenzae B.

Answer 83

◙ Management √ Admission to hospital for broad spectrum IV antibiotics. √ CT scan of the sinus, orbit and brain. √ May require drainage of abscess and decompression.

Question 85

A 9 YO girl is brough to the ED by her mother complaining of left eye pain of 3 days that has been worsening. She also has malaise. There is no Hx of trauma. Her mother mentions that the girl had runny nose, fever and cough 10 days ago. On examination, the left eye shows redness, swelling, protrusion, restricted and painful eye movements. Her visual acuity is 6/6. Her temperature is 39. What is the most appropriate initial investigation?

Answer 85

→ CT scan of the orbit, sinus and brain. → Admit to hospital for broad spectrum IV antibiotics (eg, IV ceftriaxone).

Question 87

A patient on TCA “Tricyclic antidepressant” e.g., clomipramine develops painful and red eye with blurry vision + nausea and headache. What should be done? → Urgent referral to ophthalmology.

Answer 87

One of the side effects of TCA (e.g., clomipramine) and SSRIs (e.g., citalopram) is Acute angle closure glaucoma which needs an urgent referral to an ophthalmologist.

Question 88

Charles Bonnet syndrome Charles Bonnet syndrome causes a person whose vision has started to deteriorate to see things that aren’t real (visual hallucinations). The hallucinations may be simple patterns, or detailed images of events, people or places. They’re only visual and don’t involve hearing things or any other sensations. It’s important to be aware that hallucinations associated with Charles Bonnet syndrome are caused by failing eyesight. They’re not caused by a mental health problem or dementia. People with Charles Bonnet syndrome are usually aware that the visions aren’t real, even if they’re vivid. Always see your GP if you’re experiencing hallucinations so they can investigate the cause. Investigations usually start with an eye examination which starts with slit- lamp examination.

Answer 88

Types of hallucination There are 2 main types of hallucination that people with Charles Bonnet syndrome tend to experience. They may see: • simple repeated patterns • complex images of people, objects or landscapes Simple repeated patterns can take the form of grids, shapes or lines, which can appear in bright or vivid colours. The patterns may lay across or cover everything the person sees. More complex hallucinations can involve people, places, animals and insects. Most people don’t see hallucinations of people they know or past events they have experienced. The hallucinations aren't usually unpleasant or threatening, but may be slightly frightening when first experienced. They can sometimes occur out of the blue, and can last for a few minutes or several hours.a They may be moving or static.

Question 89

Visual field defects The main points for the exam are: • Left homonymous hemianopia means visual field defect to the left, i.e. Lesion of right optic tract. • Homonymous quadrantanopias: PITS (Parietal-Inferior, Temporal- Superior). • Incongruous defects = optic tract lesion; congruous defects = optic radiation lesion or occipital corte A congruous defect simply means complete or symmetrical visual field loss and conversely an incongruous defect is incomplete or asymmetric.

Answer 89

❤️Homonymous hemianopia • Incongruous defects: lesion of optic tract. • Congruous defects: lesion of optic radiation or occipital cortex. • Macula sparing: lesion of occipital cortex. ❤️Homonymous quadrantanopias • Superior: lesion of the inferior optic radiations in the temporal lobe (Meyer's loop) • Inferior: lesion of the superior optic radiations in the parietal lobe • mnemonic = PITS (Parietal-Inferior, Temporal-Superior). ❤️Bitemporal hemianopia • Lesion of optic chiasm. • Upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour. • Lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma.

Question 90

Example: A 66 YO man presents to a GP surgery complaining of seeing coloured patterns, faces and animals. He is aware that they are not real. This has started around 4 months ago. He has no auditory hallucinations. His vision has been declining rapidly over the past year. Cranial nerve examinations are normal. What is the likely diagnosis and the next step of investigations?

Answer 90

The likely Dx → The next step → Charles Bonnet Syndrome (CBS). Refer for a slit lamp examination.

Question 92

A 40 YO woman is unable to see the cars that are coming on the left of her car. She says that her both eyes are having difficulties with left vision.

Answer 92

The likely Dx → Left homonymous hemianopsia. The likely affected structure → Right optic tract.

Question 93

Orbital cellulitis is a severe infection of the soft tissues behind the orbital septum, typically caused by bacterial infections spreading from adjacent sinuses, especially the ethmoid sinus. It can arise from organisms like Staphylococcus aureus, Streptococcus pneumoniae, or Streptococcus pyogenes

Answer 93

Clinical Features: • Pain. • Redness around the eye. • Proptosis (bulging eye). • Restricted eye movements. • Periorbital swelling and erythema. • Fever. ◙ Management: The patient needs hospital admission as prompt treatment with intravenous antibiotics is essential to prevent complications, including vision loss and intracranial extension. Broad-spectrum antibiotics (e.g., IV ceftriaxone) are typically initiated. A CT scan is often performed to rule out abscess formation, and surgical drainage may be required if an abscess is present. Note: IV ceftriaxone (broad spectrum) is usually given together with IV metronidazole (for anaerobic bacteria).

Question 94

Blepharitis is a frequent ophthalmic condition involving inflammation of the eyelids, specifically targeting the eyelid margins. It presents with symptoms such as irritation, itching, and noticeable redness. Inflammation can be linked to various underlying causes, including bacterial infection, skin conditions (like seborrheic dermatitis), or dysfunction of the oil glands in the eyelids (meibomian gland dysfunction). Common patient complaints include a burning sensation, grittiness, and a feeling that there is something in the eye (foreign body sensation). Physical examination may reveal swelling and redness of the eyelid margins, along with crusting at the base of the eyelashes.

Answer 94

Examination: The diagnosis of blepharitis is primarily clinical. It’s important to closely inspect the eyelid margins and eyelashes, often aided by a slit-lamp examination for a detailed view. Management: The initial approach to managing blepharitis generally focuses on regular lid hygiene to control symptoms and reduce inflammation. First-line treatments include: • Warm compresses: Applied to closed eyes for 5 to 10 minutes to help soften and remove crusting and improve gland function. • Lid massage: To help express the oil glands and reduce blockage. • Lid cleaning (hygiene): Using a cotton bud dipped in diluted baby shampoo or commercially available eyelid cleansers.

Question 95

52-year-old woman presents with chronic eye discomfort, describing a gritty, burning sensation in both eyes that worsens in the mornings. She also notes redness of her eyelid margins and crusting around her eyelashes, particularly. upon waking. Examination reveals swelling and crusting of the eyelid margins with no other significant eye findings. Her vision is unaffected.

Answer 95

• The most likely diagnosis → Blepharitis. • Initial management → Lid hygiene, massage + warm compresses.

Question 96

1. Scenario: A 40-year-old woman is unable to see cars coming from the left while driving, affecting both eyes. o Likely Diagnosis: o Likely Affected Structure: Left homonymous hemianopsia. Right optic tract. 2. Scenario: A 55-year-old man has difficulty seeing the upper left quadrant in both eyes and bumps into objects on his left side. o Likely Diagnosis: o Likely Affected Structure: Left superior quadrantanopia. Right Meyer's loop (inferior optic radiations) in the temporal lobe.

Answer 96

3. Scenario: A 30-year-old woman experiences vision loss in the outer (temporal) visual fields of both eyes, accompanied by headaches and hormonal imbalances. MRI shows a mass at the optic chiasm. o Likely Diagnosis: o Likely Affected Structure: Bitemporal hemianopia. Optic chiasm, possibly due to a pituitary tumour. 4. Scenario: A 60-year-old man reports sudden loss of vision in the lower right quadrant of his visual field in both eyes. He has a history of hypertension and recent transient ischemic attacks. o Likely Diagnosis: o Likely Affected Structure: Right inferior quadrantanopia. Left superior optic radiations in the parietal lobe. 5. Scenario: A 45-year-old woman complains of difficulty seeing the lower left quadrant in both eyes. She has a history of a recent head injury. o Likely Diagnosis: o Likely Affected Structure: Left inferior quadrantanopia. Right superior optic radiations in the parietal lobe.

Question 97

Scenario: A 50-year-old man complains of vision loss in the upper right quadrant of both eyes. He has no significant medical history. o Likely Diagnosis: o Likely Affected Structure: Right superior quadrantanopia. Left Meyer's loop (inferior optic radiations) in the temporal lobe.

Answer 97

7. Scenario: A 35-year-old woman presents with headaches and visual disturbances over the past six months. An MRI reveals a 2 cm pituitary adenoma. She reports difficulty seeing objects on the outer edges of her vision in both eyes. What is the most likely type of visual field defect in this patient? Options: A) Bitemporal homonymous hemianopsia. B) Heteronymous hemianopia. Answer → Explanation: √ The term "bitemporal homonymous hemianopsia" is incorrect and not recognised in medical terminology. √ The correct term for the visual field defect caused by a pituitary adenoma, which involves loss of the outer (temporal) visual fields in both eyes, is "bitemporal hemianopia." √ This falls under the category of heteronymous hemianopia. Therefore, the correct answer is "heteronymous hemianopia."

Question 98

❤️Visual Field Defects: Key Points for Exams (Revised) Left Homonymous Hemianopia: • Visual field defect on the left side. • Indicates a lesion in the right optic tract. ❤️Homonymous Quadrantanopias: • Superior Quadrantanopia: Lesion in the inferior optic radiations (Meyer's loop) in the temporal lobe. • Inferior Quadrantanopia: Lesion in the superior optic radiations in the parietal lobe. • Mnemonic → PITS (Parietal-Inferior, Temporal-Superior). ❤️Congruous vs. Incongruous Defects: • Congruous Defects: Symmetrical and complete visual field loss, typically due to lesions in the optic radiation or occipital cortex. • Incongruous Defects: Asymmetrical or incomplete visual field loss, typically due to lesions in the optic tract.

Answer 98

❤️Homonymous Hemianopia: • Incongruous Defects: Lesion in the optic tract. • Congruous Defects: Lesion in the optic radiation or occipital cortex. • Macula Sparing: Lesion in the occipital cortex. ❤️Bitemporal Hemianopia: • Caused by a lesion in the optic chiasm. • Upper Quadrant Defect > Lower Quadrant Defect: Inferior chiasmal compression, commonly a pituitary tumour. • Lower Quadrant Defect > Upper Quadrant Defect: Superior chiasmal compression, commonly a craniopharyngioma.

Question 99

Pituitary Adenoma and Its Related Visual Field Defect • The pituitary gland is located near the optic chiasm, where the optic nerves from each eye cross . A pituitary adenoma can compress the optic chiasm, particularly affecting the decussating fibres from the nasal halves of both retinas, leading to a specific pattern of visual field loss known as

Answer 99

→ Bitemporal hemianopia. This pattern is characterised by the loss of vision in the outer (temporal) visual fields of both eyes. Important Note: Bitemporal hemianopia is a type of heteronymous hemianopia. Heteronymous hemianopia refers to visual field defects that involve opposite halves of the visual field in each eye. Specifically: o Binasal hemianopia: Loss of the nasal (inner) halves of the visual field in both eyes. o Bitemporal hemianopia: Loss of the temporal (outer) halves of the visual field in both eyes, which is typically caused by compression of the optic chiasm, such as from a pituitary adenoma. Be aware that the term "bitemporal homonymous hemianopsia" is incorrect and not a recognised medical term. The correct term for the visual field defect caused by a pituitary adenoma is bitemporal hemianopia, which falls under the category of heteronymous hemianopia.

Question 100

Heteronomous hemianopia

Answer 100

Therefore, if scenario mentions that the patient has pituitary adenoma, and asks about the most likely type of visual field defect, and there are 2 confusing options: A) Bitemporal homonymous hemianopsia and B) Heteronymous hemianopia, → would be the correct answer. This is because there is the term "bitemporal homonymous hemianopsia" is not recognised in ophthalmology and does not exist. The correct term is "bitemporal hemianopia", which is a type of Heteronymous hemianopia. So, in such an example, pick Heteronymous hemianopia.

Question 102

Retrobulbar neuritis

Answer 102

Retrobulbar neuritis “Similar to optic neuritis”: • Inflammation of the optic nerve that can cause acute sudden vision loss and pain on movement of the affected eye. “The optic nerve behind the eye”. • It is often associated with multiple sclerosis (MS). That is why there is often a history of transient neurological symptoms in the same patient. • Management → Corticosteroids.

Question 103

68-year-old man presents complaining of visual hallucination (shapes, people, distorted figures). He is aware that his hallucinations are not real. This has been ongoing for the last 3 months. He has had a rapid decline in his vision over the last year. His cranial nerve examination is normal. Slit lamp examination of his eyes is also normal. What is the most appropriate next investigation?

Answer 103

→ Optical tomography.

Question 104

Charles-Bonnet syndrome (CBS) • Charles-Bonnet syndrome is characterised by persistent or recurrent complex hallucinations (usually visual or auditory), occurring in clear consciousness (ie, the patient is aware that his hallucinations are not real). • This is generally associated with visual impairment (although visual impairment is not mandatory for a diagnosis). Insight is usually preserved.

Answer 104

This must occur in the absence of any other significant neuropsychiatric disturbance. • Risk factors include: √ Advanced age. √ Peripheral visual impairment. √ Social isolation. √ Sensory deprivation. √ Early cognitive impairment. • Charles-Bonnet syndrome is equally distributed between sexes and does not show any familial predisposition. The most common ophthalmological conditions associated with this syndrome are age-related macular degeneration, followed by glaucoma and cataract. • The investigation to aid in diagnosis → Optical tomography. Investigations start with eye examination which include slit lamp. Further investigations such as optical tomography need to be done. It may help in many eye conditions such as age-related macular degeneration, glaucoma, retinopathy.

Question 105

A patient cannot see the objects on the outer halves in both eyes. He can only see the inner halves in both eyes. Dx → Bitemporal hemianopsia.

Answer 105

The likely affected structure → Optic chiasm.

Question 107

When suspecting a cranial nerve palsy/ space-occupying lesion (Eg, a patient with diplopia, difficulty in eye abduction, headaches, blurry vision). What is the most appropriate investigation?

Answer 107

→ MRI of the head. (Also, to rule out space-occupying lesion). • MRI is better than CT in visualising soft tissue. • However, CT is also useful and is requested if MRI is contraindicated. ◙ Space-occupying lesions (eg, Abscess, Tumour, Hematoma) can cause headaches, blurry vision, diplopia (CN palsy), papilledema, nausea and vomiting, and can also seizures.

Question 108

53-year-old man presents to the urgent ophthalmology clinic complaining of painful red right eye and mild headache that started 24 hours ago. He also has nausea and vomiting. He has intermittent blurry vision with halos on his right eye. The right pupil is abnormal in shape. There is no history of trauma and the patient’s medical history is insignificant. What is the most appropriate management among the following? A) Cyclopentolate hydrochloride eye drops. B) Hypromellose eye drops. C) Timolol maleate eye drops. D) Panretinal photocoagulation. E) Chloramphenicol eye drops. Answer → C. This is a case of acute angle closure glaucoma (acute red painful eye + systemic symptoms eg, headache, nauseas, vomiting + coloured halos + abnormally shaped pupil -could be ovoid-).

Answer 108

Management of AACG includes: • Medical: √ Pilocarpine eye drops (induces pupillary constriction → opens trabecular meshwork → ↑ passage -outflow- of aqueous humour → ↓IOP). √ Timolol eye drops -ß-blockers- (↓ aqueous secretion). √ IV acetazolamide (↓aqueous secretion). √ Others: steroids -prednisolone- eyedrops, anti-emetics, analgesics. √ After stabilising the patient, urgently refer to an ophthalmologist. Surgical management: √ Laser peripheral iridotomy (PI) “Definitive”.

Question 109

Scenario on a Previous Topic: A 53-year-old man presents to the urgent ophthalmology clinic complaining of painful red right eye and mild headache that started 24 hours ago. He also has nausea and vomiting. He has intermittent blurry vision with halos on his right eye. The right pupil is abnormal in shape. There is no history of trauma and the patient’s medical history is insignificant. What is the most appropriate management among the following? C

Answer 109

A) Cyclopentolate → used in acute anterior uveitis = Iritis = Iridocyclitis. Other lines in acute uveitis: atropine, prednisolone eye drops. B) Hypromellose eye drops → Artificial tears (as NaCl, sodium hyaluronate). Used in dry eye (eg, Keratoconjunctivitis Sicca, Sjogren’s syndrome). C) Timolol maleate eye drops: One of the treatment lines of acute angle closure glaucoma. Other lines: Pilocarpine eye drops, IV acetazolamide. → used to treat diabetic proliferative retinopathy (neovascularisation “new vessels” on the retina). Photocoagulation can also be tried in the management of retinal detachment, but Scleral buckling is preferred. D) Panretinal photocoagulation E) Chloramphenicol eye drops → A topical antibiotic, can be used in bacterial conjunctivitis (only when conjunctivitis is severe and lasts > 7 days. Otherwise: self-care, clean discharge using cotton wool soaked in water, supportive only.

Question 110

Periorbital Cellulitis = Preseptal Cellulitis. • Acute onset of swelling, redness, tenderness, and warmth of the eyelid and the skin around the eye. • Fever is often present. • It is commonly seen in children. • Rx → Oral co-amoxiclav. √

Answer 110

Complication → Orbital cellulitis. √ Orbital cellulitis occurs if the infection spreads to the orbital contents. There would be orbital signs: painful eye movements, proptosis, gaze restriction. √ Orbital cellulitis is an emergency which requires → IV co-amoxiclav.

Question 112

Periorbital Cellulitis = Preseptal Cellulitis. • Acute onset of swelling, redness, tenderness, and warmth of the eyelid and the skin around the eye. • Fever is often present. • It is commonly seen in children. • Rx → Oral co-amoxiclav. √

Answer 112

• Complication → Orbital cellulitis. √ Orbital cellulitis occurs if the infection spreads to the orbital contents. There would be orbital signs: painful eye movements, proptosis, gaze restriction. √ Orbital cellulitis is an emergency which requires → IV co-amoxiclav.

Question 114

A man cannot see the objects on his left side and he is aware that his visual field is affected. When he looks to the left, he cannot see the left side “same side” in both eyes. He was diagnosed with homonymous hemianopsia.

Answer 114

◙ The likely affected structure is → Optic tract (right optic tract in this case).

Question 115

After a stroke, a patient has become unaware of objects or people on one side. He is unaware of his problem. He was asked to draw a clock and this was the result:

Answer 115

◙ The likely Dx → ◙ The likely affected structure → Hemineglect Syndrome. (Neglect Syndromes). “important”. Parietal lobe

Question 116

In case of herpes zoster Ophthalmicus → aciclovir

Answer 116

In case of herpes zoster Ophthalmicus → aciclovir Generally given orally, However, if the tip of nose is involved “+ve Hutchinson’s sing” in an immunocompromised patient “ e.g., DM, or a patient with Crohn’s disease who is on immunosuppressant medications e.g., azathioprine” → Admit for IV aciclovir. Another medication to add on → Prednisolone.

Question 117

When you see “dendritic ulcers” on the cornea seen on fluorescein dye Think → HSV keratitis “Herpes simplex keratitis”.

Answer 117

Keratitis: red painful eye, blurred vision, photophobia, FB sensation in eye. Herpes simplex keratitis → dendritic ulcers are seen on fluorescein dye.

Question 118

Difficulty to see/ drive especially at night + Fundoscopy shows → fundus is obscured by dense opacities.

Answer 118

Cataract. Think → “Dense opacities = lens has become cloudy; thus, affecting the vision”.

Question 119

An 82 YO man presents complaining of deterioration of his vision over the last 6 months. He has difficulties in reading and driving at night. He sees straight lines as bending. He finds the colours more dull than usual. His optician has examined his eyes and found that there are no abnormalities that can be corrected with glasses. His cornea and conjunctiva appear normal.

Answer 119

The likely Dx → Age-related macular degeneration.

Question 121

Age-related macular degeneration is the most common cause of blindness in the UK. • Degeneration of the central retina (macula) is the key feature with changes usually bilateral. • ARMD is characterised by degeneration of retinal photoreceptors that results in the formation of drusen which can be seen on fundoscopy and retinal photography. However, the initial investigation is the slit-lamp microscopy that could 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.

Answer 121

Age-related macular degeneration (ARMD) is one of the most common irreversible causes of visual loss in elderly persons in the developed world. • Traditionally two forms of macular degeneration are seen: √ Dry (90% of cases, geographic atrophy) macular degeneration: characterised by drusen - yellow round spots in Bruch's membrane. √ Wet (10% of cases, exudative, 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. • Recently there has been a move to a more updated classification: √ Early age-related macular degeneration (non-exudative, age-related maculopathy): drusen and alterations to the retinal pigment epithelium (RPE) √ Late age-related macular degeneration (neovascularisation, exudative)

Question 122

Armd

Answer 122

Clinical Picture: √ Mostly > 70 YO. √ Visual disturbance or loss particularly at night. √ Loss of contrast in vision. √ Difficulty in recognising faces. √ Micropsia (objects appear smaller than they are). √ Metamorphopsia (straight lines appear wavy)

Question 123

A 40 YO woman is unable to see the cars that are coming on the left of her car. She says that her both eyes are having difficulties with left vision.

Answer 123

The likely Dx → Left homonymous hemianopsia. The likely affected structure → Right optic tract.