Opthalmology

Question 1

Glaucoma vs Uveitis for Acute Painful Red Eye
How to differentiate ?

Answer 1

Glaucoma -
Dilated, Haloes

Uveitis -
Constricted Oval Pupil

Question 2

Horners Syndrome

1. Central Lesions
2. Pre-Ganglionic
3. Post-Ganglionic

Answer 2

1. Anhydrosis of Face Arms Trunk

Stroke
Syringomyelia
Multiple sclerosis
Tumour
Encephalitis

2. Anhydrosis of Face

Pancoast Tumour
Thyroidectomy
Trauma

3. Post Ganglionic - No Anhydrosis

Carotid artery dissection
Carotid aneurysm
Cavernous sinus thrombosis
Cluster headache

Question 3

What drug is used for Dilating Pupils in Horner’s Syndrome ?

Answer 3

Apraclonidine drops (an alpha-adrenergic agonist)

causes pupillary dilation in Horner’s syndrome due to denervation supersensitivity but produces mild pupillary constriction in the normal pupil by down-regulating the norepinephrine release at the synaptic cleft

Question 4

Keith-Wagener’s Classification

Answer 4

Grade 1 – Silver wiring  

Grade 2 – + AV nicking 

Grade 3 – + flamed shape, dot and blot haemorrhages and cotton wool exudates 

Grade 4 – + papilloedema 

Question 5

How to differentiate 1st/2nd order from 3rd order in Horner’s Syndrome ?

Answer 5

Apraclonidine drops 1st which will cause ipsilateral dilation and contralateral constriction = Confirming Horner

Then Hydroxyamphetamine drops will dilate pupils for 1st/2nd order

Question 6

Glaucoma Pharmacology !!!

Watch Medicosis Video if needed

Answer 6

Alpha 1 Agonist –> Vasoconstriction so less Plasma filtered to make Aqueous Humor

Beta Blocker —> Prevent formation of Aqueous Humor by Panacinar Cells

OR Alpha 2 (Anti-sympathetic) which causes Less Noradrenaline release which will inturn not stimulate Beta Receptors so technically Beta Blockade

Alpha 2 agonist (Primary MOA)
OR PGF2 alpha (-prost) —> Dilate the Eye and Increase the Angle

Carbonic Anhydrase acts on PCT reduced water absorption and reduce plasma formation

Parasympathomimetic (Pilocarpine) which is a Muscarinic Agonist (M3) –> Increases the Angle and Promotes Drainage

1. Any inhibitor / blocker –> reduce production
2. Any agonist
   –> Increase outflow

Brimonidine (alpha 2 agonist) does both

Question 7

Side Effects of Prostaglandin Analogues

Answer 7

Long Eye Lashes
Brown Iris Pigmentation

Question 8

When not to give Alpha 2 Agonist ?

Answer 8

MOAI and TCA co-use

Question 9

Diabetic Retinopathy Classification

NPDR
PDR
Maculopathy

Answer 9

1. Mild NPDR

1 or more microaneurysm

2. Moderate NPDR

microaneurysms

blot hemorrhages

hard exudates

cotton wool spots (‘soft exudates’ - represent areas of retinal infarction)

venous beading/looping

intraretinal microvascular abnormalities (IRMA) less severe than in severe NPDR

4. Severe NPDR

blot haemorrhages and microaneurysms in 4 quadrants

venous beading in at least 2 quadrants

IRMA in at least 1 quadrant

4. PDR

Neovascularization
Common in T1 DM

5. Maculopathy

Macular oedema
Common in T2 DM

Question 10

Treatment for NPDR PDR and Maculopathy

Answer 10

PDR

Neovascularization - Laser photocoagulation 

a. 50% experience reduction in Peripheral Vision
b. Decrease in NIGHT VISION)

Maculopathy

intravitreal VEGF inhibitors

Question 11

Drugs that Precipitate Glaucoma

Answer 11

Anti-Cholinergic and TCA

Question 12

Flashes in Which Conditions ?

Answer 12

Flashes in

Vitreous detachment (Flashes often on Temporal Side & Diabetics) + Weiss Ring

Retinal detachment (Peripheral to Central Shutdown)

Cataract

Question 13

Holmes-Adie pupil

Answer 13

Dilated
Absent Knee Reflexes
Absent Eye Reflex

Answer 14

Marcus Gunn Pupil-Relative afferent pupillary defect-
defect is found by the ‘swinging light test’. It is caused by a lesion anterior to the optic chiasm i.e. optic nerve or retina, lesion btw optic chiasma & LGB is congruous defect and lesion posterior to LGB & occipital area is incongruous defect.
Finding: the affected and normal eye appears to dilated rather constricting when light is throw on the affected & constrict when light throw into the healthy eye.
Causes: retina: detachment, optic nerve: optic neuritis e.g. MS
Pathway of pupillary light reflex:
afferent: retina → optic nerve → lateral geniculate body(LGB) → midbrain
efferent: Edinger-Westphal nucleus (midbrain) → oculomotor nerve

Question 15

Does Viral URTI associate with Blepharitis ?

Answer 15

Nope !!!

Question 16

Pupils Dilated in which conditions ?

HoT COP ATTACK with a GUN

Answer 16

Holmes Adie
Traumatic Iridoplegia
Congenital
Oculomotor nerve palsy
Pheochromocytoma
Atropine
Tropicamide
TCA
Amphetamine
Cocaine
Marcus gun/RAPD

Question 17

Dacryocystitis Treatment

Answer 17

Systemic Abx –> IV if Periorbital Cellulitis

Question 18

Pinguecula ?
What does it Progress into ?

Answer 18

Benign yellow-white thickening which is usually bilateral and caused by ultraviolet (UV) exposure.

Progresses into Pterygium Surfers Eye - raised, fleshy, triangular-shaped growth that starts in the corner of your eye

Question 19

What’s a Chalazion ?

Answer 19

Meibomian cyst - Painless

Question 20

Most Common Ocular Manifestation in RA ?

Answer 20

Keratoconjunctivitis Sicca

Question 21

Herpes Simplex Keratitis Investigation ?

Answer 21

Fluorescein Staining –> Dendritic Ulcers

Question 22

1st line for Chronic Open Angle Glaucoma ?

Answer 22

Lantanoprost
Prostaglandin Analogues !!!!!!!

vs Open Angle if Acute
IV Carbonic Anhydrase and Timolol

Question 23

Treatment of ARMD ?

Investigations ?

Answer 23

If Dry - Watch and Wait
If Wet - Anti VEGF

Slit Lamp is the Investigation of Choice +/- Colour fundus photography

Once Wet ARMD suspected –> fluorescein angiography +/- indocyanine green angiography

Optical coherence tomography - To show 3D Retina

Question 24

Hypermetria or Myopia

Risk Factor for Acute vs Chronic Open Angle Glaucoma ?

Answer 24

Acute - Asians / Hypermetria / Anti Cholinergic or Antidepressants / 55-70

Chronic - Africans / Myopia / >40

Question 25

Strongest Risk Factor for ARMD ?

Answer 25

Smoking !!!

Question 26

Retinitis Pigmentosa

Answer 26

Night Blindness + Tunnel Vision Fundoscopy - black bone spicule-shaped pigmentation in the peripheral retina, mottling of the retinal pigment epithelium Associated diseases Refsum disease: cerebellar ataxia, peripheral neuropathy, deafness, ichthyosis Usher syndrome abetalipoproteinemia Lawrence-Moon-Biedl syndrome Kearns-Sayre syndrome Alport's syndrome

Question 27

Optic Neuritis 1. Features 2. Investigation of Choice 3. Treatment

Answer 27

Red Saturation + Central Scotoma + Ophthalmoplegia + RAPD NO VISION LOSS !!!!! MRI with Gadolinium Contrast Steroids

Question 28

What pathologies cause Tunnel Vision (CHOP P GR)

Answer 28

Choroidoretinitis Hysteria Optic Atrophy 2ry to tabes dorsalis Papilloedema Glaucoma Retinitis pigmentosa

Question 29

Pathologies about Angloid Retinal Streaks

Answer 29

SPACE sickle-cell anaemia Paget's disease pseudoxanthoma elasticum acromegaly calcification and breaks in Bruch's membrane Ehler-Danlos syndrome

Question 30

CRVO vs CRAO Fundocopy Changes

Answer 30

CRVO - Stormy Sunset - Multiple Hemorrhages CRAO - Cherry Red Spot

Question 31

Orbital Cellulitis Tx

Answer 31

1. IV antibiotics --> risk of cavernous sinus thrombosis and intracranial spread

Question 32

Orbital Cellulitis Risk Factors

Answer 32

Risk Factor 1. Lack of Hemophilus influenzae type b (Hib) vaccination

Question 33

Preseptal vs Orbital Cellulitis

Answer 33

Reduced visual acuity, proptosis, ophthalmoplegia/pain with eye movements in Orbital Cellulitis

Question 34

Angloid Retinal Streaks on Fundoscopy

Answer 34

Irregular dark red lines radiating from the optic nerve.

Question 35

Vitamin AC and E are given in ARMD. So when is it contraindicated to give this ?

Answer 35

In SMOKERS but its not ACE its only Beta-Carotene

Question 36

Herpes Zoster Opthamicus 1. Treatment 2. Predictor of Ocular Involvement

Answer 36

1. Oral Acyclovir 2. Hutchinson's Sign

Question 37

Optic Atrophy

Answer 37

Acquired MS papilloedema (longstanding) raised intraocular pressure (e.g. glaucoma, tumour) retinal damage (e.g. choroiditis, retinitis pigmentosa) ischaemia toxins: tobacco amblyopia, quinine, methanol, arsenic, lead nutritional: vitamin B1, B2, B6 and B12 deficiency Congenital causes Friedreich's ataxia mitochondrial disorders e.g. Leber's optic atrophy DIDMOAD - the association of cranial Diabetes Insipidus, Diabetes Mellitus, Optic Atrophy and Deafness (also known as Wolfram's syndrome)