Opthalmology

Question 1

features of acute angle closure glaucoma

Answer 1

severe pain: may be ocular or headache
decreased visual acuity
symptoms worse with mydriasis
hard, red-eye
haloes around lights
semi-dilated non-reacting pupil
corneal oedema results in dull or hazy cornea

Question 2

causes of acute angle closure glaucoma

Answer 2

raised intraocular pressure (IOP) secondary to an impairment of aqueous outflow:

hypermetropia (long-sightedness)
pupillary dilatation
lens growth associated with age

Question 3

management of acute angle closure glaucoma

Answer 3

emergency - urgent ophthalmologist referral

must lower IOP

eye drops
direct parasympathomimetic (pilocarpine) to contract ciliary muscle
beta blocker - timolol to reduce aq humor production
alpha2 agonist -

IV acetazolamide - reduce aq secretions

laser peripheral iridotomy - creates hole in peripheral iris

Question 4

risk factors for age-related macular degeneration

Answer 4

advancing age
smoking
family history
increased risk of ischaemic cardiovascular disease, such as hypertension, dyslipidaemia and diabetes mellitus.

Question 5

pathophysiology of age related macular degeneration

Answer 5

most common cause of blindness in the UK

bilateral degeneration of the central retina (macula)

ARMD is characterised by degeneration of retinal photoreceptors - results in the formation of drusen which can be seen on fundoscopy and retinal photography

Question 6

features of dry macular degeneration

Answer 6

90% of cases
also known as atrophic
characterised by drusen - yellow round spots in Bruch’s membrane

Question 7

features of wet macular degeneration

Answer 7

10% of cases
also known as exudative or neovascular macular degeneration
characterised by choroidal neovascularisation
leakage of serous fluid and blood can subsequently result in a rapid loss of vision
carries the worst prognosis

Question 8

presentation of age related macular degeneration

Answer 8

subacute visual loss with reduced visual acuity - gradual (dry) and subacute (wet)
poor dark adaptation, poor night vision
fluctuant visual disturbance
photopsia
visual hallucinations - charles bonnet syndrome

Question 9

investigation findings in age related macular degeneration

Answer 9

distorted line perception on amsler grid testing
fundoscopy - drusen, yellow areas of pigment deposition in the macular
wet ARMD - well demarcated red patches - intra retinal / sub retinal fluid leakage or haemorrhage

slit-lamp microscopy - identify any pigmentary, exudative or haemorrhagic changes affecting the retina

fluorescin angiography - can guide anti VEGF

Question 10

treatment of age related macular degeneration

Answer 10

zinc + vitamins ACE

anti-VEGF vascular endothelial growth factor
4 weekly injection

laser photocoagulation if new vessel formation present

Question 11

features of allergic conjunctivitis

Answer 11

Bilateral symptoms conjunctival erythema, conjunctival swelling (chemosis)
Itch is prominent
the eyelids may also be swollen
May be a history of atopy
May be seasonal (due to pollen) or perennial (due to dust mite, washing powder or other allergens)

Question 12

management of allergic conjunctivitis

Answer 12

first-line: topical or systemic antihistamines
second-line: topical mast-cell stabilisers, e.g. Sodium cromoglicate and nedocromil

Question 13

features of anterior uveitis

Answer 13

inflammation of the anterior portion of the uvea - iris and ciliary body

acute onset painful red eye
pupil may be small +/- irregular due to sphincter muscle contraction
photophobia (often intense)
lacrimation
ciliary flush: a ring of red spreading outwards
hypopyon; describes pus and inflammatory cells in the anterior chamber
impaired visual acuity and blurriness

Question 14

associated conditions with anterior uveitis

Answer 14

ankylosing spondylitis
reactive arthritis
ulcerative colitis, Crohn’s disease
Behcet’s disease
sarcoidosis: bilateral disease may be seen

Question 15

management of anterior uveitis

Answer 15

urgent review by ophthalmology
cycloplegics (dilates the pupil which helps to relieve pain and photophobia) e.g. Atropine, cyclopentolate
steroid eye drops

Question 16

features of argyll robertson pupil

Answer 16

Accommodation Reflex Present (ARP) but Pupillary Reflex Absent (PRA)

small, irregular pupils
no response to light but there is a response to accommodate

due to diabetes and syphilis

Question 17

causes of blepharitis

Answer 17

meibomian gland dysfunction (common, posterior blepharitis)

seborrhoeic dermatitis/staphylococcal infection (less common, anterior blepharitis)

common in pt with rosacea

Question 18

features of blepharitis

Answer 18

symptoms are usually bilateral
grittiness and discomfort, particularly around the eyelid margins
eyes may be sticky in the morning
eyelid margins may be red. Swollen eyelids may be seen in staphylococcal blepharitis
styes and chalazions are more common in patients with blepharitis
secondary conjunctivitis may occur

Question 19

management of blepharitis

Answer 19

hot compresses twice a day

‘lid hygiene’

artificial tears

Question 20

causes of blurred vision

Answer 20

refractive error: most common
cataracts
retinal detachment
age-related macular degeneration
acute angle closure glaucoma
optic neuritis
amaurosis fugax

Question 21

testing for blurred vision

Answer 21

visual acuity with a Snellen chart
if the blurring improves with a pinhole occluder then likely cause is a refractive error
visual fields
fundoscopy

Question 22

causes of cataract

Answer 22

lens of the eye gradually opacifies

Normal ageing process: most common cause
Smoking, alcohol
Trauma
Diabetes mellitus
Long-term corticosteroids
Radiation exposure
Myotonic dystrophy
Metabolic disorders: hypocalcaemia

more common in women

Question 23

presentation of cataracts

Answer 23

a gradual onset of:
Reduced vision
Faded colour vision: making it more difficult to distinguish different colours
Glare: lights appear brighter than usual
Halos around lights

defective red reflex - due to cataracts preventing light from getting to the retina

Question 24

classification of cataracts

Answer 24

Nuclear: change lens refractive index, common in old age
Polar: localized, commonly inherited, lie in the visual axis
Subcapsular: due to steroid use, just deep to the lens capsule, in the visual axis
Dot opacities: common in normal lenses, also seen in diabetes and myotonic dystrophy

Question 25

management of cataracts

Answer 25

surgery - to remove cloudy lens and replace with artificial one consider side effects Posterior capsule opacification: thickening of the lens capsule Retinal detachment Posterior capsule rupture Endophthalmitis: inflammation of aqueous and/or vitreous humour

Question 26

features of central retinal artery occlusion

Answer 26

rare cause of sudden unilateral visual loss - due to thromboembolism or arteritis sudden, painless unilateral visual loss relative afferent pupillary defect 'cherry red' spot on a pale retina

Question 27

features of central retinal vein occlusion

Answer 27

sudden, painless reduction or loss of visual acuity, usually unilaterally fundoscopy widespread hyperaemia severe retinal haemorrhages - 'stormy sunset'

Question 28

features of branch retinal vein occlusion

Answer 28

when a vein in the distal retinal venous system is occluded and is thought to occur due to blockage of retinal veins at arteriovenous crossings - more limited area of fundus is affected

Question 29

management of central retinal vein occlusion

Answer 29

conservative indications for treatment - macular oedema - antiVEGF retinal neovascularisation - laser photocoagulation

Question 30

indications for referral to ophthalmology in corneal foreign body

Answer 30

suspected penetrating eye injury due to high velocity injury significant orbital/periocular trauma chemical injury (irrigate 20-30min before referring) organic material neare centre of cornea red flags e.g. severe pain; irregular, dilated or non-reactive pupils; significant reduction in visual acuity.

Question 31

risk factors and causes of corneal ulcers

Answer 31

defect in cornea 2* to infective cause (usually) RF - contact lenses, vitamin A deficiency abacterial keratitis fungal keratitis viral keratitis: herpes simplex, herpes zoster - may lead to a dendritic ulcer Acanthamoeba keratitis: associated with contact lens use

Question 32

features of corneal ulcers

Answer 32

eye pain photophobia watering of the eye focal fluorescein staining of the cornea

Question 33

pathophysiology of diabetic retinopathy

Answer 33

damage to cells due to increased blood flow and abnormal metabolism in retinal vessel walls --> increased vascular permeability - exudates on fundoscopy can be non-proliferative or proliferative

Question 34

features of non-proliferative diabetic retinopathy

Answer 34

microaneurysms blot haemorrhages hard exudates cotton wool spots 'soft exudates' - retinal infarction severe NPDR blot haemorrhages and microaneurysms in 4 quadrants venous beading in at least 2 quadrants IRMA in at least 1 quadrant

Question 35

features of proliferative diabetic retinopathy

Answer 35

retinal neovascularisation - may lead to vitrous haemorrhage fibrous tissue forming anterior to retinal disc more common in Type I DM, 50% blind in 5 years

Question 36

management of diabetic retinopathy

Answer 36

optimise glycaemic control, blood pressure and hyperlipidemia regular review by ophthalmology Non-proliferative retinopathy regular observation if severe/very severe consider panretinal laser photocoagulation Proliferative retinopathy panretinal laser photocoagulation intravitreal VEGF inhibitors - if change in visual acuity severe or vitreous haemorrhage: vitreoretinal surgery

Question 37

pathophysiology of episcleritis

Answer 37

acute onset of inflammation in the episclera of one or both eyes usually idiopathic inflammatory bowel disease rheumatoid arthritis

Question 38

features of episcleritis

Answer 38

red eye 50% bilateral mild pain/irritation watering and mild photophobia may be present episcleritis - injected vessels are mobile when gentle pressure - blanched by phenylephrine scleritis - vessels are deeper, dont move

Question 39

common eyelid problems

Answer 39

blepharitis: inflammation of the eyelid margins typically leading to a red eye stye: infection of the glands of the eyelids chalazion (Meibomian cyst) entropion: in-turning of the eyelids ectropion: out-turning of the eyelids

Question 40

types of stye

Answer 40

external (hordeolum externum): infection (usually staphylococcal) of the glands of Zeis (sebum producing) or glands of Moll (sweat glands) internal (hordeolum internum): infection of the Meibomian glands. May leave a residual chalazion (Meibomian cyst)

Question 41

common presentations of herpes simplex keratitis

Answer 41

dendritic corneal ulcer Features red, painful eye photophobia epiphora visual acuity may be decreased fluorescein staining may show an epithelial ulcer

Question 42

management of herpes simplex keratitis

Answer 42

immediate referral to an ophthalmologist topical aciclovir

Question 43

features of herpes zoster ophthalmicus

Answer 43

Herpes zoster ophthalmicus (HZO) - reactivation of the varicella-zoster virus in the area supplied by the ophthalmic division of the trigeminal nerve vesicular rash around the eye - may involve the actual eye itself Hutchinson's sign: rash on the tip or side of the nose. Indicates nasociliary involvement and is a strong risk factor for ocular involvement

Question 44

management of herpes zoster ophthalmicus

Answer 44

oral antiviral treatment for 7-10 days start

Question 45

features of holmes-adie pupil

Answer 45

benign condition in females - unilateral dilated pupil slowly reactive to accomodation

Question 46

features of horner's sydrome

Answer 46

miosis (small pupil) ptosis enophthalmos* (sunken eye) anhidrosis (loss of sweating one side)

Question 47

sites of lesions causing horners and subsequent effects

Answer 47

central lesions - anhidrosis of face, arm, trunk stroke, syringomyelia, MS tumour, encephalitis pre-ganglionic - anhidrosis of face pancoast tumour, thyroidectomy, trauma, cervical rib post-ganglionic lesions - no anhidrosis carotid artery/aneurysm, cavernous sinus thrombosis, cluster headache

Question 48

classification of hypertensive retinopathy

Answer 48

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

Question 49

bacterial vs viral conjunctivitis

Answer 49

common eye problem- sore, red eyes with sticky discharge Bacterial conjunctivitis Purulent discharge Eyes may be 'stuck together' in the morning) Viral conjunctivitis Serous discharge Recent URTI Preauricular lymph nodes

Question 50

management of infective conjunctivitis

Answer 50

normal self-limiting condition topical antibiotic therapy e.g., chloramphenicol topical fusidic acid for women

Question 51

causes of keratitis

Answer 51

inflammation of the cornea bacterial - Staphylococcus aureus, Pseudomonas aeruginosa in contact lens wearers fungal amoebic - acanthamoebic keratitis parasitic: onchocercal keratitis ('river blindness') viral - herpes simplex keratitis environmental - photokeratitis, exposure keratitis, contact lens acute red eye

Question 52

clinical features of keratitis

Answer 52

red eye: pain and erythema photophobia foreign body, gritty sensation hypopyon may be seen

Question 53

management of keratitis

Answer 53

stop using contact lenses topical antibiotics - quinolones cycloplegic - for pain relief

Question 54

causes of mydriasis

Answer 54

third nerve palsy Holmes-Adie pupil traumatic iridoplegia phaeochromocytoma congenital topical mydriatics: tropicamide, atropine sympathomimetic drugs: amphetamines, cocaine anticholinergic drugs: tricyclic antidepressants

Question 55

features of nasolacrimal duct obstruction

Answer 55

most common cause of a persistent watery eye in an infant. It is caused by an imperforate membrane, usually at the lower end of the lacrimal duct. Around 1 in 10 infants have symptoms at around one month of age

Question 56

causes of optic neuritis

Answer 56

multiple sclerosis: the commonest associated disease diabetes syphilis

Question 57

features of optic neuritis

Answer 57

unilateral decrease in visual acuity over hours or days poor discrimination of colours, 'red desaturation' pain worse on eye movement relative afferent pupillary defect central scotoma

Question 58

management of optic neuritis

Answer 58

high-dose steroids recovery usually takes 4-6 weeks

Question 59

pathophysiology of orbital cellulitis

Answer 59

infection affecting the fat and muscles posterior to the orbital septum, within the orbit but not involving the globe caused by a spreading URTI from the sinuses and carries a high mortality rate a medical emergency requiring hospital admission and urgent senior review

Question 60

risk factors for orbital cellulitis

Answer 60

Childhood - mean age of hospitalisation 7-12 years Previous sinus infection Lack of Haemophilus influenzae type b (Hib) vaccination Recent eyelid infection/ insect bite on eyelid (periorbital cellulitis) Ear or facial infection

Question 61

presentation of orbital cellulitis

Answer 61

Redness and swelling around the eye Severe ocular pain 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

Question 62

fundoscopy findings in papilloedema

Answer 62

venous engorgement: usually the first sign loss of venous pulsation: although many normal patients do not have normal pulsation blurring of the optic disc margin elevation of optic disc loss of the optic cup Paton's lines: concentric/radial retinal lines cascading from the optic disc

Question 63

causes of papilloedema

Answer 63

space-occupying lesion: neoplastic, vascular malignant hypertension idiopathic intracranial hypertension hydrocephalus hypercapnia

Question 64

describe posterior vitreous detachment

Answer 64

separation of the vitreous membrane from the retina due to natural changes to the vitreous fluid of the eye with ageing common condition, does not cause any pain or loss of vision. may sometimes lead to tears and detachment of the retina. must rule out retinal tears or retinal detachment in anyone with suspected posterior vitreous detachment, as they may result in permanent loss of vision.

Question 65

risk factors of posterior vitreous detachment

Answer 65

As people age, the vitreous fluid in the eye becomes less viscous, and thus, does not hold its shape as well. Therefore, it pulls the vitreous membrane away from the retina towards the centre of the eye. Highly myopic (near-sighted) patients are also at increased risk of developing posterior vitreous detachment earlier in life. This is because the myopic eye has a longer axial length than an emmetropic eye.

Question 66

features of posterior vitreous detachment

Answer 66

The sudden appearance of floaters (occasionally a ring of floaters temporal to central vision) Flashes of light in vision Blurred vision Cobweb across vision The appearance of a dark curtain descending down vision (means that there is also retinal detachment)

Question 67

management of posterior vitreous detachment

Answer 67

examination by an ophthalmologist within 24hours to rule out retinal tears or detachment. Posterior vitreous detachment alone does not cause any permanent loss of vision. Symptoms gradually improve over a period of around 6 months and therefore no treatment is necessary. If there is an associated retinal tear or detachment the patient will require surgery to fix this.

Question 68

management of primary open angle glaucoma

Answer 68

prostaglandin analogues - latanoprost - increase uveoscleral outflow beta blockers - timolol - reduce aq production sympathomimetics - brimoniodine - reduce aq production, increases outflow carbonic anhydrase inhibitors - dorzolamide - reduce aq production miotics - pilocarpine - increase uveoscleral outflow

Question 69

fundoscopy of primary open angle glaucome

Answer 69

1. Optic disc cupping - cup-to-disc ratio >0.7 (normal = 0.4-0.7), occurs as loss of disc substance makes optic cup widen and deepen 2. Optic disc pallor - indicating optic atrophy 3. Bayonetting of vessels - vessels have breaks as they disappear into the deep cup and re-appear at the base 4. Additional features - Cup notching (usually inferior where vessels enter disc), Disc haemorrhages

Question 70

investigation findings in primary open angle glaucoma

Answer 70

automated perimetry to assess visual field slit lamp examination applanation tonometry to measure IOP central corneal thickness measurement gonioscopy

Question 71

describe a relative afferent pupillary defect

Answer 71

Marcus-Gunn pupil, caused by a lesion anterior to the optic chiasm the affected and normal eye appears to dilate when light is shone on the affected eye causes retina: detachment optic nerve: optic neuritis e.g. multiple sclerosis

Question 71

causes of red eye

Answer 71

Acute angle closure glaucoma Anterior uveitis Scleritis Conjunctivitis Subconjunctival haemorrhage Endophthalmitis

Question 72

pathway of pupillary light reflex

Answer 72

afferent: retina → optic nerve → lateral geniculate body → midbrain efferent: Edinger-Westphal nucleus (midbrain) → oculomotor nerve

Question 73

describe retinal detachment

Answer 73

occurs when the neurosensory tissue that lines the back of the eye comes away from its underlying pigment epithelium reversible cause of visual loss if recognised and treated before the macula is affected f left untreated and symptomatic, retinal detachment will inevitably lead to permanent visual loss.

Question 74

risk factors for retinal detachment

Answer 74

diabetes mellitus myopia age previous surgery for cataracts (accelerates posterior vitreous detachment) eye trauma e.g. boxing

Question 75

features of retinal detachment

Answer 75

new onset floaters or flashes sudden onset, painless and progressive visual field loss - a curtain, or shadow progressing to the centre of the visual field from the periphery if macula is involved = central visual acuity, visual outcomes become much worse reduced peripheral visual fields

Question 76

fundoscopy findings in retinal detachment

Answer 76

the red reflex is lost and retinal folds may appear as pale, opaque or wrinkled forms if the break is small, however, it may appear normal.

Question 77

features of retinitis pigmentosa

Answer 77

primarily affects the peripheral retina resulting in tunnel vision night blindness is often the initial sign tunnel vision due to loss of the peripheral retina (occasionally referred to as funnel vision) fundoscopy: black bone spicule-shaped pigmentation in the peripheral retina, mottling of the retinal pigment epithelium

Question 78

ocular manifestations of rheumatoid arthritis

Answer 78

keratoconjunctivitis sicca (most common) episcleritis (erythema) scleritis (erythema and pain) corneal ulceration keratitis

Question 79

risk factors of scleritis

Answer 79

rheumatoid arthritis: the most commonly associated condition systemic lupus erythematosus sarcoidosis granulomatosis with polyangiitis

Question 80

causes and types of strabismus

Answer 80

Squint (strabismus) = misalignment of the visual axes. concomitant (common) - due to imbalanced extraocular muscles, convergent>divergent paralytic (rare) - due to paralysis of extra-ocular muscles uncorrected may lead to amblyopia (the brain fails to fully process inputs from one eye and over time favours the other eye).

Question 81

features of scleritis

Answer 81

scleritis = full thickness inflammation of sclera, causes red, painful eye red eye classically painful (in comparison to episcleritis), but sometimes only mild pain/discomfort is present watering and photophobia are common gradual decrease in vision

Question 82

investigation of squint

Answer 82

corneal light reflection test - holding a light source 30cm from the child's face to see if the light reflects symmetrically on the pupils The cover test is used to identify the nature of the squint ask the child to focus on an object cover one eye observe movement of uncovered eye cover other eye and repeat test

Question 83

causes of sudden vision loss

Answer 83

ischaemic/vascular (e.g. thrombosis, embolism, temporal arteritis etc). This includes recognised syndromes e.g. occlusion of central retinal vein and occlusion of central retinal artery vitreous haemorrhage retinal detachment retinal migraine

Question 84

causes of tunnel vision

Answer 84

due to concentric diminution of the visual fields papilloedema glaucoma retinitis pigmentosa choroidoretinitis optic atrophy secondary to tabes dorsalis hysteria

Question 85

features of vitreous haemorrhage

Answer 85

painless visual loss or haze (commonest) red hue in the vision floaters or shadows/dark spots in the vision decreased visual acuity: variable depending on the location, size and degree of vitreous haemorrhage visual field defect if severe haemorrhage

Question 86

causes of vitreous haemorrhage

Answer 86

proliferative diabetic retinopathy (over 50%) posterior vitreous detachment ocular trauma

Question 87

investigation findings in vitreous haemorrhage

Answer 87

dilated fundoscopy: may show haemorrhage in the vitreous cavity slit-lamp examination: red blood cells in the anterior vitreous ultrasound: useful to rule out retinal tear/detachment and if haemorrhage obscures the retina fluorescein angiography: to identify neovascularization orbital CT: used if open globe injury

Question 88

management of corneal foreign body

Answer 88

suspected penetrating eye injury due to high-velocity injuries Significant orbital or peri-ocular trauma chemical injury - irrigate 20-30mins organic foreign bodies red flag sx