Opthalmology

Question 1

acute angle-closure glaucoma (AACG) there is a rise

Answer 1

in IOP secondary to an impairment of aqueous outflow.

Question 2

Factors predisposing to AACG include:

acute angle closure glaucoma

Answer 2

Factors predisposing to AACG include:
hypermetropia (long-sightedness)
pupillary dilatation
lens growth associated with age

Question 3

Features
of acute angle closure glaucoma

Answer 3

severe pain: may be ocular or headache
decreased visual acuity
symptoms worse with mydriasis (e.g. watching TV in a dark room)
hard, red-eye
haloes around lights
semi-dilated non-reacting pupil
corneal oedema results in dull or hazy cornea
systemic upset may be seen, such as nausea and vomiting and even abdominal pain

Question 4

ARMD

Answer 4

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.

Question 5

dry macular degeneration

Answer 5

characterised by drusen - yellow round spots in Bruch’s membrane

Question 6

wet macular degeneration

Answer 6

characterised by choroidal neovascularisation

Question 7

a reduction in visual acuity, particularly for near field objects
timeframe in AMRDS TWO SUBTYPES

Answer 7

gradual in dry ARMD
subacute in wet ARMD

Question 8

FUNDOSCOPY IN DRY AMRDS

Answer 8

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.

Question 9

FUNDOSCOPY IN WET AMRDS

Answer 9

in wet ARMD well demarcated red patches may be seen which represent intra-retinal or sub-retinal fluid leakage or haemorrhage.

Question 10

TX FOR DRY AMRDS

Answer 10

combination of zinc with anti-oxidant vitamins A,C and E reduced progression of the disease by around one third. Patients with more extensive drusen seemed to benefit most from the intervention. Treatment is therefore recommended in patients with at least moderate category dry ARMD.

Question 11

TX FOR WET AMRDS

Answer 11

vascular endothelial growth factor (VEGF)
VEGR is a potent mitogen and drives increased vascular permeability in patients with wet ARMD

within the first two months of diagnosis of wet ARMD if possible
examples of anti-VEGF agents include ranibizumab, bevacizumab and pegaptanib,. The agents are usually administered by 4 weekly injection.

Question 12

Anterior uveitis

Answer 12

Features
acute onset
ocular discomfort & pain (may increase with use)
pupil may be small +/- irregular due to sphincter muscle contraction
photophobia (often intense)
blurred vision
red eye
lacrimation
ciliary flush: a ring of red spreading outwards
hypopyon; describes pus and inflammatory cells in the anterior chamber, often resulting in a visible fluid level
visual acuity initially normal → impaired

Question 13

Tx for anterior uvetits

Answer 13

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

Question 14

Argyll-Robertson pupil

Answer 14

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

A mnemonic used for the Argyll-Robertson Pupil (ARP) is Accommodation Reflex Present (ARP) but Pupillary Reflex Absent (PRA)

Question 15

Causes of
Argyll-Robertson pupil

Answer 15

causes
diabetes mellitus
syphilis

Question 16

Blepharitis

Answer 16

Blepharitis is inflammation of the eyelid margins.

It may due to either meibomian gland dysfunction (common, posterior blepharitis) or seborrhoeic dermatitis/staphylococcal infection (less common, anterior blepharitis).

Blepharitis is also more common in patients with rosacea

Question 17

Features OF BLEPHARITIS

Answer 17

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 18

Mx of Blepharitis

Answer 18

softening of the lid margin using hot compresses twice a day
‘lid hygiene’ - mechanical removal of the debris from lid margins
cotton wool buds dipped in a mixture of cooled boiled water and baby shampoo is often used
an alternative is sodium bicarbonate, a teaspoonful in a cup of cooled water that has recently been boiled
artificial tears may be given for symptom relief in people with dry eyes or an abnormal tear film

Question 19

Central retinal artery occlusion

Answer 19

Central retinal artery occlusion is a relatively rare cause of sudden unilateral visual loss. It is due to thromboembolism (from atherosclerosis) or arteritis (e.g. temporal arteritis)

Question 20

Central retinal artery occlusion

features

Answer 20

Features
sudden, painless unilateral visual loss
relative afferent pupillary defect
‘cherry red’ spot on a pale retina

Question 21

Management is difficult and the prognosis is poor

of Central retinal artery occlusion

Answer 21

any underlying conditions should be identified and treated (e.g. intravenous steroids for temporal arteritis)
if a patient presents acutely then Intraarterial thrombolysis may be attempted but currently, trials show mixed results.

Question 22

Central retinal vein occlusion (CRVO) is a differential for sudden painless loss of vision.

Features

Answer 22

loss of visual acuity, usually unilaterally
fundoscopy
widespread hyperaemia
severe retinal haemorrhages - ‘stormy sunset’

Question 23

Central retinal vein occlusion

Answer 23

Management
the majority of patients are managed conservatively
indications for treatment in patients with CRVO include:
macular oedema - intravitreal anti-vascular endothelial growth factor (VEGF) agents
retinal neovascularization - laser photocoagulation

Question 24

Non-proliferative diabetic retinopathy

Mild
mod
severe

Answer 24

Mild NPDR
1 or more microaneurysm

Moderate NPDR
microaneurysms
blot haemorrhages
hard exudates
cotton wool spots, venous beading/looping and intraretinal microvascular abnormalities (IRMA) less severe than in severe NPDR

Severe NPDR
blot haemorrhages and microaneurysms in 4 quadrants
venous beading in at least 2 quadrants
IRMA in at least 1 quadrant

Question 25

Proliferative diabetic retinopathy Key features

Answer 25

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 26

Non-proliferative retinopathy mx

Answer 26

Non-proliferative retinopathy regular observation if severe/very severe consider panretinal laser photocoagulation

Question 27

Proliferative retinopathy mx

Answer 27

oliferative retinopathy panretinal laser photocoagulation following treatment around 50% of patients develop a noticeable reduction in their visual fields due to the scarring of peripheral retinal tissue other complications include a decrease in night vision (rods are predominantly responsible for vision in low light conditions, the majority of rod cells are located in the peripheral retina), a generalised decrease in visual acuity and macular oedema intravitreal VEGF inhibitors often now used in combination with panretinal laser photocoagulation examples include ranibizumab strong evidence base suggests they both slow progression of proliferative diabetic retinopathy and improve visual acuity if severe or vitreous haemorrhage: vitreoretinal surgery

Question 28

Herpes simplex keratitis most commonly presents with a dendritic corneal ulcer. features

Answer 28

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

Question 29

Herpes simplex keratitis Mx

Answer 29

Management immediate referral to an ophthalmologist topical aciclovir

Question 30

Herpes zoster ophthalmicus (HZO) describes the reactivation of the varicella-zoster virus in the area supplied by the ophthalmic division of the trigeminal nerve. It accounts for around 10% of case of shingles. vesicular rash around the eye, which may or may not 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 Mx

Answer 30

Management oral antiviral treatment for 7-10 days ideally started within 72 hours intravenous antivirals may be given for very severe infection or if the patient is immunocompromised topical antiviral treatment is not given in HZO topical corticosteroids may be used to treat any secondary inflammation of the eye ocular involvement requires urgent ophthalmology review

Question 31

Holmes-Adie pupil is a benign condition most commonly seen in women. It is one of the differentials of a

Answer 31

dilated pupil. association of Holmes-Adie pupil with absent ankle/knee reflexes

Question 32

Horner's syndrome features

Answer 32

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

Question 33

Hypertensive retinopathy stages anf features Keith-Wagener classification of hypertensive retinopathy

Answer 33

Stage Features 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 34

Keratitis featurs

Answer 34

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

Question 35

amoebic keratitis

Answer 35

amoebic acanthamoebic keratitis accounts for around 5% of cases increased incidence if eye exposure to soil or contaminated water pain is classically out of proportion to the findings

Question 36

Bacterial keratitis

Answer 36

bacterial typically Staphylococcus aureus Pseudomonas aeruginosa is seen in contact lens wearers

Question 37

Management of keratitis

Answer 37

stop using contact lens until the symptoms have fully resolved topical antibiotics typically quinolones are used first-line cycloplegic for pain relief e.g. cyclopentolate

Question 38

Congenital lacrimal duct obstruction affects around 5-10% of newborns. It is bilateral in around 20% of cases features

Answer 38

watering eye (even if not crying) secondary infection may occur

Question 39

Dacryocystitis is infection of the lacrimal sac features

Answer 39

watering eye (epiphora) swelling and erythema at the inner canthus of the eye

Question 40

Drug causes of mydriasis

Answer 40

topical mydriatics: tropicamide, atropine sympathomimetic drugs: amphetamines, cocaine anticholinergic drugs: tricyclic antidepressants

Question 41

Optic neuritis features

Answer 41

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 42

Investiagtion of Opric neuritis mx

Answer 42

MRI of the brain and orbits with gadolinium contrast is diagnostic in most cases management high-dose steroids recovery usually takes 4-6 weeks

Question 43

Differentiating orbital from preseptal cellulitis

Answer 43

reduced visual acuity, proptosis, ophthalmoplegia/pain with eye movements are NOT consistent with preseptal cellulitis

Question 44

Blood culture and microbiological swab to determine the organism. Most common bacterial causes - for orbitial cellulitis

Answer 44

Blood culture and microbiological swab to determine the organism. Most common bacterial causes - Streptococcus, Staphylococcus aureus, Haemophilus influenzae B.

Question 45

imaging for orbital cellultis

Answer 45

CT with contrast - Inflammation of the orbital tissues deep to the septum, sinusitis.

Question 46

Papilloedema

Answer 46

Papilloedema describes optic disc swelling that is caused by increased intracranial pressure. It is almost always bilateral.

Question 47

Causes of papilloedema

Answer 47

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

Question 48

Posterior vitreous detachment

Answer 48

Posterior vitreous detachment is the separation of the vitreous membrane from the retina. This occurs due to natural changes to the vitreous fluid of the eye with ageing. Posterior vitreous detachment is a common condition that does not cause any pain or loss of vision.

Question 49

Symptoms of posterior vitrous detachment

Answer 49

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 50

PVD signs Posterior vitreous detachment

Answer 50

Weiss ring on ophthalmoscopy (the detachment of the vitreous membrane around the optic nerve to form a ring-shaped floater).

Question 51

Management of Posterior vitreous detachment

Answer 51

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 52

IOP of ≥ 24 mmHg NICE tx

Answer 52

offer 360° selective laser trabeculoplasty (SLT) first-line to people with an IOP of ≥ 24 mmHg NICE

Question 53

Prostaglandin analogues (e.g. latanoprost)

Answer 53

Increases uveoscleral outflow

Question 54

Beta-blockers (e.g. timolol, betaxolol)

Answer 54

Reduces aqueous production Should be avoided in asthmatics and patients with heart block

Question 55

Sympathomimetics (e.g. brimonidine, an alpha2-adrenoceptor agonist)

Answer 55

Reduces aqueous production and increases outflow Avoid if taking MAOI or tricyclic antidepressants

Question 56

Carbonic anhydrase inhibitors (e.g. Dorzolamide)

Answer 56

Reduces aqueous production

Question 57

Miotics (e.g. pilocarpine, a muscarinic receptor agonist)

Answer 57

Increases uveoscleral outflow Adverse effects included a constricted pupil, headache and blurred vision

Question 58

RED EYE AAS CSE CAASES

Answer 58

Acute angle closure glaucoma severe pain (may be ocular or headache) decreased visual acuity, patient sees haloes semi-dilated pupil hazy cornea Anterior uveitis acute onset pain blurred vision and photophobia small, fixed oval pupil, ciliary flush Scleritis severe pain (may be worse on movement) and tenderness may be underlying autoimmune disease e.g. rheumatoid arthritis Conjunctivitis purulent discharge if bacterial, clear discharge if viral Subconjunctival haemorrhage history of trauma or coughing bouts Endophthalmitis typically red eye, pain and visual loss following intraocular surgery

Question 59

Relative afferent pupillary defect FINDING IN A SWINGING LIGHT TEST

Answer 59

the affected and normal eye appears to dilate when light is shone on the affected

Question 60

Relative afferent pupillary defect CAUSES

Answer 60

retina: detachment optic nerve: optic neuritis e.g. multiple sclerosis

Question 61

Retinitis pigmentosa Retinitis pigmentosa primarily affects the peripheral retina resulting in tunnel vision It may be autosomal recessive, dominant, X-linked or sporadic. FESTURES

Answer 61

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 62

Fundus examination RETINITIS PIGMITOSA

Answer 62

Fundus examination reveals a triad of a waxy optic disc, bone-spicule pigmentation and arteriolar attenuation.

Question 63

The most common causes of a sudden painless loss of vision are as follows:

Answer 63

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 64

Vitreous haemorrhage

Answer 64

causes: diabetes, bleeding disorders, anticoagulants features may include sudden visual loss, dark spots

Question 65

Retinal detachment

Answer 65

features of vitreous detachment, which may precede retinal detachment, include flashes of light or floaters (see below)

Question 66

Differentiating posterior vitreous detachment, retinal detachment and vitreous haemorrhage

Answer 66

Posterior vitreous detachment Retinal detachment Vitreous haemorrhage 1. Flashes of light (photopsia) - in the peripheral field of vision Floaters, often on the temporal side of the central vision 2. Dense shadow that starts peripherally progresses towards the central vision A veil or curtain over the field of vision Straight lines appear curved Central visual loss 3. Large bleeds cause sudden visual loss Moderate bleeds may be described as numerous dark spots Small bleeds may cause floaters

Question 67

Tunnel vision

Answer 67

Causes papilloedema glaucoma retinitis pigmentosa choroidoretinitis optic atrophy secondary to tabes dorsalis hysteria