Ophthalmology

Question 1

Ophthalmoscopy | Pathology

Answer 1

Increased cup:disc ratio; glaucoma
Pale optic disc; optic atrophy
Blurry contour; papilloedema in raised ICP

Question 2

AMD | Clinical features

Answer 2

Gradual loss of vision
Painless
Central vision only, peripheral vision spared

Wet AMD; sudden central vision loss, distortion

Question 3

AMD | Types

Answer 3

Dry AMD, 90%; drusen, RPE atrophy

Wet AMD, 10%; haemorrhage, exudate, neovascularisation, pigment epithelial detachment

Question 4

AMD | Management

Answer 4

Dry AMD; observation, RF modification

Wet AMD; urgent ophthalmology referral, intravitreal antiVEGF injections, RF modification

Question 5

Primary open angle glaucoma | Clinical features

History
Triad

Answer 5

Gradual loss of vision
Painless
Peripheral vision
Haloes, eye ache
Scotoma

1. Visual field defect
2. Abnormal disc
3. Raised IOP

Question 6

Glaucoma | Investigations

Answer 6

Goldmann tonometry; for IOP

Normal range 10-20mmHg
Ocular hypertension (OHT) >21mmHg
AACG >40mmHg

Question 7

Primary open angle glaucoma (POAG) | Management

Medical

Implications for driving
SEs

Patient counselling

Answer 7

[Medical]
Topical prostaglandin analogues; travoprost
Topical beta-blockers; timolol
Topical carbonic anhydrase inhibitors; acetazolamide
Topical alpha2-adrenergic agonists

[Implications for driving]
Inform of driving standards
If glaucoma affects both eyes, must inform DVLA

[Patient counselling]
Effect of drops
SEs
Importance of compliance
Probability of lifetime treatment
That they will not notice any day-to-day benefit

Question 8

AMD | RFs

Answer 8

Age >50yrs
Smoking
FH +ve

Question 9

Acute angle closure glaucoma (AACG) | Clinical features

History
Signs

Answer 9

Sudden onset loss of vision
Painful
Eye redness
Fixed semi-dilated pupil
Corneal oedema; cloudy appearance due to waterlogged cornea

Deep, dull, periorbital headache
Nausea/vomiting
Haloes around lights

Question 10

Acute angle closure glaucoma (AACG) | RFs

Answer 10

Female
Hypermetropia; long-sighted, smaller eye, shallower anterior chamber, more likely to occlude
Cataracts; thicker lens, shallow chamber
Previous AACG in fellow eye
Asian ethnicity

Question 11

Acute angle closure glaucoma (AACG) | Management

PLAN

Medical
Surgical

Answer 11

[PLAN]
Admit patient to hospital
Check IOP hourly until under adequate control

[Medical]
TOPICAL
Carbonic anhydrase inhibitors + beta-blockers
1. Dorzolamide + timolol drops
2. + pupil contstriction
(Brinzolamide)
(Timolol 0.5% 1 drop BD)

SYSTEMIC carbonic anhydrase inhibitors
1. IV/PO acetazolamide

[Surgical]
Laser peripheral iridotomy (LPI)
Prophylaxis of contralateral eye with LPI
Cataract surgery, artificial ‘pseudophakic’ lens thinner allowing deepening of anterior chamber

Question 12

Occular emergencies

Answer 12

Acute angle closure glaucoma (AACG)
Central retinal artery occlusion (CRAO)
Retinal detachment
Wet AMD

Orbital cellulitis
Postoperative infective endophthalmitis

Question 13

Central retinal artery occlusion (CRAO) | Clinical features

History
Signs

Answer 13

Sudden onset loss of vision
Painless
Unilateral
RAPD

Cherry red spot in the macula
Pale swollen retina
Emboli

Question 14

Central retinal artery occlusion (CRAO) | RFs

Atherosclerotic
Embolic
Inflammatory

Answer 14

[Atherosclerotic]
HTN, DM
Hypercholesterolaemia
Smoking

[Embolic]
Carotid artery disease; TIA/stroke
Arrhythmias; AF
Valve vegetations; infective endocarditis

[Inflammatory]
Vasculitis; GPA, giant cell arteritis (GCA)

Question 15

Central retinal artery occlusion (CRAO) | Investigations

Answer 15

BP, FBC, BM, blood cultures
Lipid profile
Coagulation profile

MUST r/o GCA in >50yrs; FBC, CRP, ESR, temporal artery biopsy

Carotid Doppler USS; carotid artery plaques/stenosis

Vasculitis autoantibodies; ANA, ANCA, DNA, RF

To r/o infective endocarditis; ECG, echocardiogram, blood cultures

Question 16

Central retinal artery occlusion (CRAO) | Management

PLAN

Medical

Answer 16

Urgent ophthalmology referral within hours; retinal ischaemia similar to ‘stroke’, may restore vision

[Medical]
IV acetazolamide

Question 17

Retinal detachment | Clinical features

History
Signs

Answer 17

Sudden onset loss of vision
Painless
Preceded by flashes of light, floaters, or ‘curtain’ visual field defect

If macula is involved central vision is affected, otherwise peripheral loss

Demarcation lines ‘high tide marks’ / tear
Retinal thinning
Pale detached retina
Loss of RPE peripheral markings

Question 18

Retinal detachment | RFs

Answer 18

Myopia
Trauma
Previous ophthalmic surgery

Question 19

Retinal detachment | Management

Surgery

Answer 19

[Surgery]

Vitrectomy within 24hrs

Question 20

Orbital cellulitis | Clinical features

Answer 20

Paediatric ocular pain
Loss of vision
Painful limited EOM
Proptosis
Periorbital erythema, swelling/oedema, warmth, tenderness
Unilateral

Fever, malaise

Question 21

Orbital cellulitis | RFs

Answer 21

Children, male
Recent sinusitis; H. influenzae
Lack of HiB vaccination
Recent eyelid surgery

Question 22

Orbital cellulitis | Management

PLAN

Medical

Answer 22

[PLAN]
Admit to hospital
Urgent referral to oculoplastics/ENT

[Medical]
Abx; IV cefuroxime/ceftriaxone

Question 23

Post-operative infective endophthalmitis | Clinical features

History triad

Answer 23

Sudden onset loss of vision
Painful
Inflamed red eye; injected conjunctiva
Hypopyon; pus in anterior chamber

Fixed unreactive pupil
Abnormal red reflex

1. Painful sudden vision loss
2. Recent ocular surgery within 1/52 ago
3. Poorly controlled DM; immunocompromised

Question 24

Post-operative infective endophthalmitis | Investigations & Management

PLAN

Medical

Answer 24

Vitreous tap; intraocular fluid sample

PLAN
Immediate referral to ophthalmology
Intravitreal abx injection

Question 25

Conjunctivitis | Clinical features Bacterial Viral Allergic Chlamydial HSV-1 Fungal

Answer 25

Bacterial; red, sticky, mucopurulent, gritty Gonococcus Viral; red, watery, gritty Recent cold/flu-like sx Adenovirus Allergic; red, itchy, swelling, watery/mucoid, bilateral Chlamydial; red, persistent mucopurulent discharge, unilateral Neonates HSV-1; dendritic ulcer Fungal; immunocompromised

Question 26

Conjunctivitis | Investigations

Answer 26

Conjunctival swabs; Gram-stain, culture, PCR PCR; unresponsive chlamydial/viral infection Corneal scrape Fluorescein staining; dendritic ulcers, corneal abrasion, bacterial keratitis (severe may increase risk of corneal perforation)

Question 27

Conjunctivitis | Management Non-pharmacological Pharmacological

Answer 27

[Non-pharmacological] Self-limiting, resolve within 5/7 Bathing/cleaning eye with clean water/sterile wipes Avoid contact lens wear with topical treatment Contact lens wear should be discontinued until at least 48hrs after complete resolution of sx Reduce risk of transmission; good hand hygiene, avoid sharing towels ``` [Pharmacological] Bacterial; topical chloramphenicol Viral; topical acyclovir Chlamydial/gonococcal; immediate referral to ophthalmology as risk of corneal scarring Allergic; topical/PO antihistamine ```

Question 28

Anterior uveitis | Clinical features & RFs

Answer 28

``` Sudden onset loss of vision Painful Red eye Photophobia Without discharge (watery) ``` RFs; HLA-B27 gene association, IBD, psoriasis, spondyloarthritides (PsA, AS, JIA)

Question 29

Anterior uveitis | Management

Answer 29

Referral to ophthalmology Topical corticosteroid; topical prednisolone 1% Pupillary dilation if synechiae; topical cyclopentolate

Question 30

Abducens palsy, CN6 | Clinical features, Investigations & Management

Answer 30

Horizontal diplopia Worse on ipsilateral gaze and in the distance Limited abduction of ipsilateral eye Inv; CT/MRI head to r/o head injury, raised ICP, or compressive lesions (SOL) Tx; referral to orthoptics, fresnel prism

Question 31

Occulomotor palsy, CN3 | Clinical features, Investigations & Management

Answer 31

``` Horizontal and vertical diplopia Unilateral ptosis Fixed dilated pupils; complete loss of parasympathetic supply 'Down and out' gaze Limited EOM up and inwards ``` [Investigations] CT/MRI; to r/o trauma, aneurysm, SOL, stroke Dilation implies external compression of parasympathetic nerve; PCA aneurysm If supply is spared, indicates vascular cause Tx; ?neurosurgery depending on underlying cause

Question 32

Trochlear palsy, CN4 | Clinical features & Management

Answer 32

Vertical diplopia Worse with near vision Torsion of images Tx; referral to orthoptics, prisms, surgical correction

Question 33

'Blowout' fracture | Clinical features & Management

Answer 33

Periorbital bruising, oedema, haemorrhage, pain Upward gaze diplopia Limited upward gaze Enopthalmos [Management] Advise not to blow their nose, communication with sinuses may cause orbital infection PO abx Maxillofacial surgery

Question 34

Myasthenia gravis | Clinical features, Investigations & Management

Answer 34

Variable and fatiguable sx Diplopia Ptosis Inv; antiACh antibodies, edrephonium test, CT/MRI CXR; thymoma, thyroid disease Tx; referral to neurology to assess extent of systemic involvement Anticholinesterases

Question 35

Paediatric ophthalmology | Conditions RB Congenital cataract ROP

Answer 35

``` [Retinoblastoma] Leukocoria Abnormal red reflex Raised mass involving macula Tx; urgent ophthalmology referral ``` ``` [Congenital cataract] Leukocoria Abnormal red reflex Amblyopia Tx; urgent paediatric cataract surgery ``` [Retinopathy of prematurity] Vitreous haemorrhage Retinal detachment Inv; ROP postnatal screening at 4-7wks of age Laser photocoagulation