Ophthalmology: Past paper questions Flashcards
A 23-year-old man presents to his GP with a 2-day history of pain in his right eye, photophobia, and blurred vision.
He has no past medical history but states that he has had lower back pain that improves with exercise for the last 12 months.
On examination there is hyperaemia of the sclera and yellow crusting on the patient’s eyelashes. He finds it difficult to follow your finger with his eyes on cranial nerve examination due to pain. There is some oedema of his eyelids and miosis of the right pupil.
Given the likely diagnosis, what is the most appropriate next step?
High-dose oral steroids
Ocular steroid drops
Systemic antibiotics
Topical chloramphenicol
Urgent ophthalmology review
Urgent ophthalmology review
This patient is presenting with signs and symptoms of anterior uveitis as evidenced by blurred vision (caused by turbidity of the aqueous), photophobia and miosis (caused by ciliary muscle spasm) and pain (caused by ciliary muscle spasm and or raised intraocular pressures).
Anterior uveitis is an important differential in the acute and painful red eye. In the stem, the patient states he has had lower back pain that improves with exercise, this is a classic feature of ankylosing spondylitis. Anterior uveitis itself is a feature of spondyloarthropathies.
An urgent ophthalmology review is the most appropriate treatment / next step here. Anterior uveitis can have high morbidity and urgent specialist assessment is key. History taking and thorough evaluation are imperative so that underlying causes, if present, can be addressed. The mainstay of treatment for anterior uveitis itself is the use of topical steroids, mydriatics, non-steroidal anti-inflammatory drugs, and cycloplegics. Immunosuppression under specialist guidance can also be used.
A 70-year-old man complains of reduced vision. Fundoscopy reveals the following:
What is the most likely diagnosis?
Primary open angle glaucoma
Hypertensive retinopathy
Optic neuritis
Age-related macular degeneration
Diabetic retinopathy with laser scars
Age-related macular degeneration
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. It is more common with advancing age and is more common in females.
**
Patients typically present with a subacute onset of visual loss with:**
a reduction in visual acuity, particularly for near field objects
gradual in dry ARMD
subacute in wet ARMD
difficulties in dark adaptation with an overall deterioration in vision at night
fluctuations in visual disturbance which may vary significantly from day to day
they may also suffer from photopsia, (a perception of flickering or flashing lights), and glare around objects
visual hallucinations may also occur resulting in Charles-Bonnet syndrome
Signs:
distortion of line perception may be noted on Amsler grid testing
fundoscopy reveals the 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 may be seen which represent intra-retinal or sub-retinal fluid leakage or haemorrhage.
A 50-year-old man presents with red-eye associated with slight watering and mild photophobia. He reports no pain or tenderness and vision is not affected
What is the most likely diagnosis?
Scleritis
Keratitis
Episcleritis
Anterior Uveitis
Acute angle glaucoma
Episcleritis is a cause of red eye which is classically not painful
Important for meLess important
A 62-year-old man presents to the emergency department with a sudden loss of vision in his right eye. The loss of vision started in the edges and moved towards the centre and had preceding flashes and floaters. There was no antecedent trauma. He denies any headaches or eye redness and has a history of type 2 diabetes mellitus. He wears corrective glasses and occasionally contact lenses, however, he cannot remember his prescription.
What feature increases the risk of this patient developing this condition?
Astigmatism
Contact lens use
Hypermetropia
Presbyopia
Type 2 diabetes mellitus
Diabetes mellitus is a risk factor for retinal detachment
A 52-year-old man attends his GP regarding problems with his vision. For the past few months, he has been having some difficulty driving as he has been struggling to see cars coming toward him from the sides of his vision. He thinks this may also be what’s causing his occasional headaches but reports no pain around his eyes or any current headache.
His past medical history includes peripheral vascular disease, type II diabetes, and short-sightedness, and often does not wear his glasses.
What is the most likely diagnosis?
Acute angle-closure glaucoma
Age-related macular degeneration
Cataracts
Primary open-angle glaucoma
Scleritis
primary open-angle glaucoma
A 25-year-old man is visiting his GP for a new patient check-up. He is fit and well, with no concerns. On enquiry about illnesses that run in the family he reveals that both his mother and grandfather both suffer from glaucoma.
What advice should you give him regarding glaucoma?
Glaucoma has no hereditary component
He should have an annual screening commencing now
He should get annual screening from age 60 years
Due to his high risk treatment for glaucoma should be commenced now
He should get annual screening from age 40 years
He should get annual screening from age 40 years
A 76-year-old woman complains of blurred vision. She has not been to the doctors for many years and describes her self as being otherwise fit and well. Fundoscopy reveals the following:
Similar changes are seen in both eyes. What is the most likely diagnosis?
Primary open angle glaucoma
Retinal tear
Diabetic retinopathy with laser scars
Optic neuritis
Age-related macular degeneration
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. It is more common with advancing age and is more common in females.
Argyll-Robertson pupil
Argyll-Robertson pupil is one of the classic pupillary syndrome. It is sometimes seen in neurosyphilis. A mnemonic used for the Argyll-Robertson Pupil (ARP) is Accommodation Reflex Present (ARP) but Pupillary Reflex Absent (PRA)
Features
small, irregular pupils
no response to light but there is a response to accommodate
Causes
diabetes mellitus
syphilis
A 30-year-old male presents with sudden onset loss of vision. He denies any preceding warning signs or head trauma, and does not complain of any pain. You perform a fundoscopy and find severe retinal haemorrhages on fundoscopy.
Which of the following is the most likely diagnosis?
Optic neuritis
Retinal detachment
Posterior vitreous detachment
Central retinal artery occlusion
Central retinal vein occlusion
Central retinal vein occlusion - sudden painless loss of vision, severe retinal haemorrhages on fundoscopy
fundoscopy: central retinal vein occlusion
Central retinal vein occlusion is the correct answer. Fundoscopy reveals severe flame shaped retinal haemorrhages, described as a cheese and tomato pizza appearance.
fundoscopy: central retinal artery occlusion
Central retinal artery occlusion presents with acute visual loss. The typical fundoscopy finding is a pale retina with a ‘cherry red’ spot.
A 6-year-old girl presents to your general practice surgery with her father.
He describes that for the past year, she develops intermittent flares of red, itchy eyelids. This appears to bother her most in the mornings. These episodes normally self-resolve with no intervention, but this flare has been particularly protracted - lasting over a month - and he would like some advice. She has never experienced any visual changes.
On examination, she is playful and smiling. The eyelids appear slightly red bilaterally, and there is a small amount of foamy discharge on the lid margins, with matting of the eyelashes. The medial canthus on the superior lid of her left eye has a small, discrete, red lump which is mildly tender on palpation. The eye itself is not red, nor is it painful. Examination is otherwise normal, and she is apyrexial.
Which of the following is the single best initial management option for this girl?
Hot compresses to both eyes
Oral doxycycline
Topical chloramphenicol drops to both eyes
Topical dexamethasone drops to both eyes
Same-day referral to an ophthalmologist
1st line of treatment for blepharitis is hot compresses
A 3-year-old boy is referred to the optometrist by the GP after his mother brought him in concerned about a squint. He is otherwise fit and well.
After an initial assessment by the optometrist, he is diagnosed with exotropia. He is offered appointments to discuss treatment including intermittent eye patching.
During the interim, they move to a different part of the country and miss these appointments. The mother does not seek further attention regarding his exotropia.
What is the child particularly at increased risk of developing in the future?
Amblyopia
Esotropia
Hypermetropia
Hypertropia
Hypotropia
Failure to correct childhood squints may lead to amblyopia
A 72-year-old man presents to his GP complaining of a ‘droopy’ eyelid. The symptoms started yesterday and do not seem to improve. He has a past medical history of poorly controlled type two diabetes mellitus and hypertension, which cause him recurrent foot ulcers. He is a life-long smoker.
An eye examination shows ptosis of the left palpebra with a constricted pupil, visual acuity 6/6 in both eyes, normal colour vision, intact central and peripheral fields. A similar episode happened to him after a motorbike accident, he was diagnosed with ‘a nerve palsy’ which later resolved.
What is the most likely diagnosis?
Abducens nerve palsy
Horner’s syndrome
Lateral medullary syndrome
Oculomotor nerve palsy
Trochlear nerve palsy
Horners
Ptosis + dilated pupil = third nerve palsy;
ptosis + constricted pupil = Horner’s
An 83-year-old male is referred to the ophthalmology clinic by his general practitioner with a new-onset inability to see objects near to him, especially at night. On fundoscopy, the doctor notices well-demarcated red patches. He has a past medical history of hypertension and he is a life-long smoker.
Given the most likely diagnosis, which one of the following is the most appropriate treatment?
Anti-vascular endothelial growth factor (VEGF)
Aspirin
Cataract surgery
High-dose steroids
Laser photocoagulation
Anti-VEGF
Definitive treatment for wet AMD is anti-VEGF
hypertensive retinopathy staging
Hypertensive retinopathy
The table below shows the Keith-Wagener classification of hypertensive retinopathy
**I **
- Arteriolar narrowing and tortuosity
- Increased light reflex - silver wiring
II
- Arteriovenous nipping
III
- Cotton-wool exudates
- Flame and blot haemorrhages
- These may collect around the fovea resulting in a ‘macular star’
IV
- Papilloedema
