Ophthalmology

Question 1

Epidemiology of anterior uveitis

Answer 1

Associated with HLA-B27 protein
Associated w/ conditions including IBD, reactive arthritis, ankylosing spondylitis, sarcoidosis and Behcet’s disease

Question 2

What is anterior uveitis?

Answer 2

Inflammation of the iris and ciliary body

Question 3

Symptoms of anterior uveitis

Answer 3

Red eye
Acute onset eye pain
Small irregular pupils

Question 4

Stages of Chronic Kidney Disease

Answer 4

CKD 1 = eGFR >90; normal function
CKD 2 = eGFR 60-89; mild reduction
CKD 3a = eGFR 45-59; mild-moderate reduction
CKD 3b = eGFR 30-44; mod-severe reduction
CKD 4 = eGFR 15-29; severe reduction
CKD 5 = eGFR <15; kidney failure

Question 5

First line treatment CKD

Answer 5

ACEi/ARB
- need to have baseline eGFR and potassium, discontinue if dropping
- should not be combined due to risk of hyperkalaemia

Question 6

What is Acute Kidney Injury (AKI)?

Answer 6

Sudden decrease of kidney function
rise in creatinine and urea, fall in eGFR and urine output

Question 7

Pre-renal causes of AKI

Answer 7

Volume loss (haemorrhage, V+D, dehydration, etc)
Hypotension (sepsis, shock)
Decreased effective arterial volume
Renal artery stenosis
Medications: NSAIDs. ACEi, Cyclosporine and tacrolimus

Question 8

Intra-renal causes of AKI

Answer 8

Acute tubular necrosis
Nephrotoxic agents
Intratubular obstruction
Pyelonephritis
Thrombotic Microangiopathies
Glomerulonephritis:
–> Nephritic syndrome (IgA nephropathy, post-strep, vasculitis)
–> Nephrotic syndrome (MCD, Membranous, Amyloid, Diabetic)

Question 9

What is acute tubular necrosis?

Answer 9

Damage to the tubular epithelial cells within the renal tubules of the kidney due to either ischaemia or direct toxicity

Question 10

Causes of acute tubular necrosis

Answer 10

Ischaemia
–> hypotension, shock, direct vascular injury
Nephrotoxicity
–> contrast
–> drugs e.g. aminoglycosides (gentamicin), cisplatin (& other chemos), methotrexate, NSAIDs, ACEi. ARBs, statins

Question 11

Presentation of acute tubular necrosis

Answer 11

Oliguria (reduced urine output)
Uraemia (build up of toxins in blood)
Electrolyte imbalance

Brown urine

Urine microscopy shows muddy brown casts

Question 12

Management for acute tubular necrosis

Answer 12

correction of underlying cause (e.g. fluid resus)
removal of nephrotoxins
may require haemofiltration or haemodialysis

Question 13

What is acute interstitial nephritis?

Answer 13

Inflammation of the extra-glomerular tissue, thought to be mediated by an interstitial hypersensitivity reaction

Question 14

Presentation of acute interstitial nephritis

Answer 14

Typically delayed presentation (2-40 days) after triggering medication
Rash, fever, AKI (oliguria, uraemia, EI), and eosinophilia

High Eosinophils

Question 15

Causes of acute interstitial nephritis

Answer 15

Abx: rifampicin, penicillins, cephalosporins, quinolones
NSAIDs
Diuretics
PPIs
Acyclovir
Methotrexate
Infections (strep, mycoplasma, EBV, CMV, TB, Legionella)
Autoimmunity
SLE

Question 16

Cause of IgA Nephropathy

Answer 16

IgA complexes deposit in the glomerulus
–> inflammation (type 3 hypersensitivity reaction)

Question 17

Presentation of IgA nephropathy

Answer 17

recurrent haematuria 1-2 days after an URTI/GI infection/strenuous exercise
Sometimes mild proteinuria

Question 18

Ix for IgA nephropathy

Answer 18

Urinalysis: +ve for blood +/- protein
Urine microscopy, culture & sensitivities (MC&S): RBCs (normally dysmorphic suggesting bleeding from glomerulus), WBCs

Gold standard = renal biopsy
–> shows IgA deposits within the mesangium (sub-endothelium) causing proliferation and inflammation

Question 19

Management of IgA nephropathy

Answer 19

Symptom control
Optimising and monitoring fluid balance
Steroids if renal function starts deteriorating

Question 20

Indications for dialysis (AKI)

Answer 20

AEIOU

Acidosis: severe pH<7.20
Electrolyte imbalance: persistent hyperkalaemia of >7mmol)
Intoxication: poisoning
Oedema: refractory pulmonary oedema
Uraemia: encephalopathy or pericarditis

Question 21

Stages of AKI

Answer 21

Stage 1: creatinine rise of 1.5x compared to baseline or urine output <0.5 ml/kg/hour for 6 hours.
Stage 2: creatinine rise of 2x compared to baseline or urine output <0.5 ml/kg/hour for 12 hours.
Stage 3: creatinine rise of 3x compared to baseline or urine output <0.3 ml/kg/hour for 24 hours (or anuria for 12 hours) or serum creatinine >354umol/dl