passmed

Question 1

what is holmes-adie pupil

Answer 1

dilated pupil
once the pupil has constricted it remains small for an abnormally long time
slowly reactive to accommodation but very poorly (if at all) to light

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

commonly seen in women

Question 2

what is Herpes zoster ophthalmicus (HZO

Answer 2

reactivation of the varicella-zoster virus in the area supplied by the ophthalmic division of the trigeminal nerve

Question 3

features of herpes zoster opthalmicus

Answer 3

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

Question 4

management of hZO

Answer 4

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 5

Complications of HZO

Answer 5

ocular: conjunctivitis, keratitis, episcleritis, anterior uveitis
ptosis
post-herpetic neuralgia

Question 6

entropion?

Answer 6

inturning of the eyelids

Question 7

ectropion?

Answer 7

out-turning of the eyelids

Question 8

types of stye

Answer 8

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 9

causes of adie pupil

Answer 9

damage to parasympathetic innervation of the eye due to viral or bacterial infection.

Question 10

marcus-gunn pupil

Answer 10

Relative afferent pupillary defect, seen during the swinging light examination of pupil response. The pupils constrict less and therefore appear to dilate when a light is swung from unaffected to affected eye.

Question 11

causes for marcus-gunn pupil

Answer 11

damage to the optic nerve or severe retinal disease

Question 12

horners syndrome

Answer 12

Miosis (pupillary constriction), ptosis (droopy eyelid), apparent enophthalmos (inset eyeball), with or without anhidrosis (decreased sweating) occurring on one side

Question 13

cause of horner

Answer 13

damage to the sympathetic trunk on the same side as the symptoms, due to trauma, compression, infection, ischaemia or many others.

Question 14

hutchinson’s pupil?

Answer 14

Unilaterally dilated pupil which is unresponsive to light

Question 15

cause of huthcinsons pupil

Answer 15

A result of compression of the occulomotor nerve of the same side, by an intracranial mass (e.g. tumour, haematoma)

Question 16

argyll-robertson pupil

Answer 16

Bilaterally small pupils that accommodate but don’t react to bright light.

Question 17

causes of argyll-robertson pupil

Answer 17

diabetes mellitus

syphillis

Question 18

contradictions to lumbar puncture

Answer 18

papilloedema

focal neurology such as a cranial nerve III or VI palsy can indicate increased intracranial pressure due to a cerebral mass.

Question 19

CSF findings of a
MS
subarachnoid haemorrhage

Answer 19

MS - oligoclonal bands

subarachnoid haemorrhage - RBCs

Question 20

what is papilloedema

Answer 20

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

Question 21

features of pailloedema on fundoscopy

Answer 21

• 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 22

causes of papilloedema

Answer 22

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

Rare causes include
hypoparathyroidism and hypocalcaemia
vitamin A toxicity

Question 23

causes of tonic or Adie’s pupil

Answer 23

Caused by damage to parasympathetic fibres innervating the pupil constrictor muscle with cell bodies in the ciliary ganglion
Likely cause an unrecognised viral infection

Question 24

acetozolamide

Answer 24

acute angle glaucoma

Question 25

chloramphenicol

Answer 25

bacterial conjunctivitis

Question 26

causes of mydriasis

Answer 26

``` third nerve palsy Holmes-Adie pupil traumatic iridoplegia phaeochromocytoma congenital ```

Question 27

Drug causes of mydriasis

Answer 27

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

Question 28

causes of RAPD

Answer 28

``` optic nerve disorders - MS -optic neuritis - optic nerve tumors - trauma -glaucoma - viral infections - granulomatosis before optic chiasm retina - retinal detachment ```

Question 29

Tx of RAPD

Answer 29

observe | gets better in a few months

Question 30

retinal detachment

Answer 30

fluid in RPE and sensiry retina

Question 31

Tx tear in retina but no fluid separating it out

Answer 31

laser or cryotherapy

Question 32

types of retinal detachment

Answer 32

rhegmatogenous - witha tear U shaped retina, macula on, degenerative changes in neurosensory retina creating a hole allowing to fluid to pass from the virteous to the subretinal space between sensory retina and RPE - trauma exudative - fluid build up in subretinal space due to breakdown of blood- retinal barrier HTN, vasculitis, AMD, tumor tractional retinal detachement - pulling, common miopic

Question 33

presentation of retinal detachment

Answer 33

preceded by Floaters flashes peripheral field loss initially -> A veil or curtain over the field of vision loss of red reflex loss of central vision at a later stage detached retina appears grey on fundoscopy Straight lines appear curved Central visual loss Field loss - sudden painless curtain like loss of peripheral visual loss fall in acuity

Question 34

other causes of retinal detachment

Answer 34

proliferative diabetic retinopathy uveitis intraocular tumours

Question 35

prognosis of retinal detachment

Answer 35

time to give definitive treatment site and extent of detachment nature of underlying pathology

Question 36

DD for retinal detachment

Answer 36

migraine retinal artery occlusion post vitreous detachment vitreous haemorrhages - diabetes

Question 37

Mx of retinal detachment

Answer 37

superior tear - lie them flat inferior tear - 30 degrees 2) surgery - vitreoctomy -> to remove traction of the vitreous, cryotherapy/laser photocoagulation stick retina back on

Question 38

causes of tunnel vision

Answer 38

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

Question 39

causes of painless loss of vision

Answer 39

- optic neuritis - retinal detachment - posterior vitreous detachment - vitreous haemorrhage - retinal migraine - CRA occlusion - CRV occlusion

Question 40

define transient monocular visual loss

Answer 40

sudden, transient loss of vision that lasts less than 24 hours.

Question 41

differentials for amaurosis fugax

Answer 41

- large artery disease (atherothrombosis, embolus, dissection), - small artery occlusive disease (anterior ischemic optic neuropathy, vasculitis e.g. temporal arteritis), venous disease and hypoperfusion

Question 42

causes of central retinal vein occlusion

Answer 42

glaucoma, polycythaemia, hypertension

Question 43

fundoscopy finding of CRVO

Answer 43

severe retinal haemorrhages chees pizza appearance

Question 44

causes of vitreous haemorrhage

Answer 44

proliferative diabetic retinopathy (over 50%) posterior vitreous detachment ocular trauma: the most common cause in children and young adults , bleeding disorders, anticoagulants

Question 45

features of vitreous haemorrhage

Answer 45

sudden visual loss | dark spots

Question 46

features of posterior vitreous detachment

Answer 46

Flashes of light (photopsia) - in the peripheral field of vision Floaters, often on the temporal side of the central vision

Question 47

features of vitreous haemorrhage

Answer 47

painless visual loss or haze (commonest) red hue in the vision floaters or shadows/dark spots in the vision Large bleeds cause sudden visual loss Moderate bleeds may be described as numerous dark spots Small bleeds may cause floaters

Question 48

signs of vitreous haemorrhage

Answer 48

decreased visual acuity: variable depending on the location, size and degree of vitreous haemorrhage visual field defect if severe haemorrhage

Question 49

Ix for vitreous haemorrhage

Answer 49

- 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 50

what is post vitreous detachment

Answer 50

separation of the vitreous membrane from the retina

Question 51

risk factors of post vitreous detachment

Answer 51

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 52

symptoms of post vitreous detachment

Answer 52

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 53

signs of post vitreous detachment

Answer 53

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

Question 54

Ix for post vitreous detachment

Answer 54

All patients with suspected vitreous detachment should be examined by an ophthalmologist within 24hours to rule out retinal tears or detachment.

Question 55

Mx for post vitreous detachment

Answer 55

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 56

features of horners

Answer 56

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

Question 57

what is retinitis pigmentosa

Answer 57

affects the peripheral retina resulting in tunnel vision

Question 58

features of retinitis pigmentosa

Answer 58

night blindness is often the initial sign | tunnel vision due to loss of the peripheral retina (occasionally referred to as funnel vision)

Question 59

fundoscopy finding of retinitis pigmentosa

Answer 59

black bone spicule-shaped pigmentation in the peripheral retina, mottling of the retinal pigment epithelium

Question 60

ass diseases of retinitis pigmentosa

Answer 60

``` Refsum disease: cerebellar ataxia, peripheral neuropathy, deafness, ichthyosis Usher syndrome abetalipoproteinemia Lawrence-Moon-Biedl syndrome Kearns-Sayre syndrome Alport's syndrome ```

Question 61

define anisocoria

Answer 61

different pupil size

Question 62

anisocoria worse in the light

Answer 62

parasympahteitc issue | ciliary ganglion