Eye

Question 1

Blepharitis

Answer 1

Group of conditions characterised by inflammation of the eyelid margin.
Anterior - primarily affects the lashes. Posterior - involves the meibomian glands.
C: Staphylococcal infection, seborrhoeic dermatitis, meibomian gland dysfunction, or any combination of these factors. Also demodex mite infestation.
S: Eyes are sore or gritty, itching, burning, eyelids may stick together, exacerbations and remissions, may have watery eyes, blurred vision, dry eyes, reddened, visible crusting or scaling.
D: Clinical examination of the lid skin, lashes, lid margin, tear film, conjunctiva, cornea. Swabbing may be needed.
T: Avoid contact lens, eyeliner, use warm compresses, lid massage, lid cleansing. Topical antibiotics (Chloramphenicol ointment) if staphylococcal infection. Systemic antibiotics - doxycycline, lymecycline, tetracycline and oxytetracycline if no response to topical treatment. Artificial tears and lubricants for dry eye. Dietary supplementation (omega-3 fatty acids found in fish oils).

Question 2

Conjunctivitis

Answer 2

Inflammation of the conjunctiva. Can be infectious or non-infectious.
C: Viral (adenovirus, HSV, HZV, Molluscum contagiosum, MMR, mononucleosis, varicella and HIV), bacterial (Staphylococcus spp., Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis). Other - gonorrhea, chlamydia, lyme disease, allergic, mechanical/irritative/toxic, immune-mediated and neoplastic.
S: Red eye, irritation, grittiness, discomfort, discharge which may be watery, mucoid, sticky or purulent, oedema, papillae on the inside of the eyelid.
D: Eye exam, visual acuity, refer to a specialist for further investigations if no response, unclear aetiology, neonatal.
T: Bacterial - usually self-limiting 1-2 weeks, infection control, lubricant eye drops, Chloramphenicol as first-line, Fusidic acid as second-line.
Viral - usually self-limiting 4-6 weeks, infection control, lubricant eye drops. No antibiotics!
Allergic - eye baths, lubricants, cool compresses. Topical mast cell stabilisers - sodium cromoglycate. Topical ocular antihistamines, antazoline, azelastine, and emedastine. Also diplofenac eye drops.

Question 3

Corneal abrasion

Answer 3

Abrasion on the thin, transparent dome that covers your eye’s iris and pupil.
C: Flying dust, specks of metal, grains of sand, a fingernail, an animal claw, or other foreign objects. Contact lens.
S: Pain, uncomfortable feeling, rapid eye blinking, redness.
D: Corneal examination - eye drops to relax your eye muscles and widen your pupil and fluorescein drops to highlight imperfections in the surface of your cornea. Give analgesia before this test.
T: Rinsing with clean water or saline solution, analgesia, Ocular lubricants, topical antibiotics (proxymetacaine or oxybuprocaine).

Question 4

Keratitis

Answer 4

Inflammation of the cornea. May be infectious or non-infectious.
C: Injury to the cornea, contaminated contact lens (particularly the microscopic parasite acanthamoeba), viral infection (herpes simplex and herpes zoster), bacterial (gonorrhea), contaminated water (particularly in oceans, rivers, lakes and hot tub).
S: Red eye, eye pain, excess tears or discharge, difficulty opening the eye, blurred/decreased vision, photophobia.
D: Eye exam, slit lamp, sample of tears or some cells from your cornea for laboratory analysis.
T: Non-infectious keratitis - artificial tear drops, 24 hour patch
Bacterial - artificial tear drops, oral antibiotics
Fungal - antifungal eyedrops and oral antifungal medication
Viral - antiviral eyedrops and oral antiviral medications

Question 5

Foreign body

Answer 5

Something that enters the eye from outside the body.
C: Eyelash, dried mucus, sawdust, dirt, sand, cosmetics, contact lens, metal particles, glass shards.
S: Feeling of pressure or discomfort, sensation that something is in your eye, eye pain, extreme tearing, photophobia, excessive blinking, redness.
D: Eye exam, Fluorescein dye­, Magnifier to locate and remove any foreign objects, CT scan.
T: Bandage the eye using a clean cloth or gauze, removed with a moist cotton swab or flushed out with water. Needles or other instruments may be used. If it has caused abrasion, an antibiotic ointment may be given to prevent infection. Acetaminophen to treat pain from larger corneal abrasions.

Question 6

Pterygium

Answer 6

Growth of the conjunctiva or mucous membrane that covers the white part of your eye over the cornea. Like a ‘wedge’.
C: Unknown. Exposure to UV light, pollen, sand, smoke and wind.
S: Redness, blurred vision, eye irritation, burning, itchiness, can interfere with vision.
D: Eye exam, visual acuity, Corneal topography, photo documentation to track growth.
T: Shouldn’t require treatment. Eye drops or eye ointments that contain corticosteroids to reduce inflammation.
Surgery is also done when a pterygium causes a loss of vision or astigmatism.

Question 7

Chalazion

Answer 7

A chalazion, or meibomian cyst, is a focus of granulomatous inflammation in the eyelid arising from a blocked meibomian gland.
C: Disorders which cause abnormally thick meibum predispose to chalazia, which can therefore be multiple or recurrent.
S: Gradually enlarging roundish, firm lesion in either the upper or lower lid, may be tender, can cause blurred vision, swelling.
D: Clinical diagnosis
T: Can resolve spontaneously, twice-daily (minimum) warm compresses for 10 mins, massage the lids. Incision of the cyst via surgery, followed by ocular chloramphenicol for a week. Triamcinolone injection for softer smaller lesions. Large lesions - curetting and steroid injection.

Question 8

Periorbital cellulitis

Answer 8

Sight-threatening and life-threatening ophthalmic emergency characterised by infection of the soft tissues behind the orbital septum.
C: Extension of ethmoid sinusitis, intermediary maxillary sinusitis, preseptal cellulitis. Direct inoculation of the orbit from trauma. Post-surgery. Haematogenous spread from distant bacteraemia.
Usually, Streptococcus pneumoniae, Staphylococcus aureus, Streptococcus pyogenes and Haemophilus influenzae, MRSA.
S: Eyelid oedema, erythema, chemosis, decreased visual acuity, proptosis, blurred/double vision, fever, malaise, pain, involvement of optic nerve would cause papilloedema or neuritis.
D: Clinical diagnosis, FBC, swabs of discharge, CT of the sinuses and orbit ± brain, LP.
T: Hospital admission. Co-amoxiclav is the first-choice antibiotic (or clindamycin with metronidazole). If MRSA, IV vancomycin or teicoplanin. Optic function should be monitored 4-hourly.
Surgery is indicated where there is CT evidence of an orbital collection.

Question 9

Dacryoadenitis

Answer 9

Inflammation of the lacrimal gland.
C: Viral - adenovirus, EBV and mumps, infectious mononucleosis, HZV, HSV, rhinovirus, cytomegalovirus, coxsackievirus A, echovirus. Bacterial - Staph. Aureus, Streptococcus, Haemophilus influenzae, Klebsiella pneumoniae, Pseudomonas. Fungal - Histoplasmosis or Blastomycosis, Protozoal - acanthamoeba, idiopathic, autoimmune, Lymphoproliferative.
S: Swelling of lateral third of the upper lid, redness, pain, conjunctival swelling and redness, mucopurulent discharge, bulging of the eye ball, difficulty in eye movements.
D: Clinical diagnosis. Culture and sensitivity of the discharge. Blood cultures. CT scan.
T: Viral - warm compresses, NSAIDs, bacterial - broad-spectrum antibiotics (such as cephalosporins), await sensitivities.

Question 10

Non-paralytic strabismus

Answer 10

Any misalignment of the eyes. As a result the retinal image is not in corresponding areas of both eyes.
C: Usually congenital
S: Children - close one eye in sunlight, motor skills may be reduced, compensatory head tilt or chin lift.
Adults - double vision, asthenopia (ocular discomfort) with ‘eye strain’ or headaches, pulling sensation.
D: Gross inspection, red reflex, ophthalmoscopy, visual acuity. Hirschberg’s test.
T: Correction of refractive errors, prisms, surgical alignment,

Question 11

Paralytic strabismus

Answer 11

Any misalignment of the eyes. As a result the retinal image is not in corresponding areas of both eyes.
C: Acquired through damage to the extraocular muscles or their nerves
S: CNIII, CNIV, CNVI palsies, ocular myositis, ocular myopathy, myasthenia gravis.
D: Orthoptic confirmation of the paralytic squint, blood tests and imaging.
T: Treat the underlying cause. If no cause found, prisms or surgery.

Question 12

Cataracts

Answer 12

Lens opacities that can become large enough to block light and obstruct vision.
C: Aging, congenital, smoking, DM, systemic corticosteroids, eye trauma, alcohol, metabolic disorders, inflammatory and degenerative eye diseases.
S: Gradual painless loss of vision, difficulties with reading, failure to recognise faces, diplopia in one eye, halos in one eye,
D: Opacities can be seen as defects in the red reflex obtained when the ophthalmoscope is held 60 cm from the eye. This is best seen with a dilated pupil.
T: Surgical removal of the cataract is the only effective treatment to restore or maintain vision. Replaced with artificial lens. Postoperative care includes the use of topical antibiotics and steroids with avoidance of strenuous activity.

Question 13

Congenital cataracts

Answer 13

Lens opacity which is present at birth.
C: Hereditary/genetic, metabolic (eg, galactosaemia), in-utero infection (toxoplasmosis, other, rubella, cytomegalovirus, herpes simplex (TORCH)).
S: Infant doesn’t seem to be visually aware of the world around them, gray or white cloudiness of the pupil, nystagmus.
D: Opacities can be seen as defects in the red reflex obtained when the ophthalmoscope.
T: Surgery as early as 6–8 weeks of age. During the procedure, the ophthalmologist removes the cloudy part of the lens and may put in a flexible plastic artificial lens.

Question 14

Macular degeneration

Answer 14

Ageing changes without any other obvious precipitating cause that occur in the central area of the retina (macula) in people aged 55 years and older.
Can be dry (gradual visual disturbance) or wet/neovascular (central visual blurring and distortion, develops quickly).
C: Environmental and genetic. Risk factors - age, smoking, family history, AMD in one eye, diet, obesity, UV, Caucasian ethnicity.
S: Reduction in visual acuity, loss in contrast sensitivity, size or colour of objects appearing different in different eyes, abnormal dark adaptation, photopsia, light glare.
D: Slit-lamp biomicroscopy, Colour fundus photography, Fluorescein angiography if neovascular, Ocular coherence tomography.
T: Dry - No cure. Lifestyle advice. Make the most of remaining sight using optical aids (such as magnifiers) and advice on lighting, tactile aids, electronic aids and other non-optical aids.
Wet - Intravitreal injections of anti-vascular endothelial growth factor (ranibizumab, bevacizumab and aflibercept), given monthly for 3 months and then variably.

Question 15

Ectropion

Answer 15

When part or all of the lower eyelid turns outwards away from the eye.
C: Age (muscles become weak), scarring of the eyelid or near the eyelid, condition which causes weakness of the facial muscles.
S: Inner lining of the eyelid that droops, may be dry and sore, constantly watery, may cause corneal ulcers to develop.
D: Eye exam
T: An operation to tighten the skin and muscles around the eyelid. May require a skin graft to help support the lower lid. Lubricating eye ointment and patches at night.

Question 16

Entropion

Answer 16

An eyelid turns inwards towards the eye, usually the lower lid.
C: Aging (muscles become weak), trachoma, congenital, eye infections or damage.
S: Irritation and pain on the front of the eye, watery eye. May develop a corneal ulcer.
D: Eye exam
T: Taping the eyelid to the cheek, injecting the muscles of the eyelid with botulinum toxin, lubricating eye ointment whilst underlying cause heals. Or surgery is used to turn the eyelid back to its normal position.

Question 17

Glaucoma

Answer 17

A group of eye conditions that lead to damage to the optic nerve head with progressive loss of retinal ganglion cells and their axons. Often associated with increased IOP.
C: Risk factors - raised IOP, myopia, DM, family history, female, ethnicity, long-term use of steroids, eye trauma, uveitis, hypertension.
S: Intense eye pain, nausea and vomiting, red eye, tenderness around the eye, seeing rings around the eyes, blurred vision.
D: Gonioscopy - measure the angle between the cornea and the iris to assess whether the glaucoma is open-angle or closed-angle. Corneal thickness, Tonometry (measures IOP), Optic disc examination, visual fields.
T: Eye drops to lower IOP - latanoprost, timolol, brimonidine, pilocarpine, dorzolamide.
Trabeculectomy surgery.
Other procedures - Canaloplasty, laser surgery, drainage implants, sclerectomy.

Question 18

Diabetic retinopathy

Answer 18

A chronic progressive, potentially sight-threatening disease of the retinal microvasculature, associated with the prolonged hyperglycaemia.
Includes microaneurysms, hard exudates, haemorrhages, cotton wool spots, neovascularisation.
C: Prolonged hyperglycaemia, hypertension and other cardiovascular risk factors, renal disease, intraocular surgery.
S: Painless gradual loss of central vision, dark, painless floaters which may resolve over several days caused by haemorrhages.
D: Slit-lamp magnification of the fundus. Gold standard - dilated retinal photography with accompanying ophthalmoscopy.
T: Good glycaemic and blood pressure control. Lipid-lowering therapy. Good diet and exercise. Smoking cessation. Laser treatment to induce regression of blood vessels. Fluocinolone acetonide intravitreal implant. Vitrectomy.

Question 19

Hypertensive retinopathy

Answer 19

High blood pressure can cause damage to the retina’s blood vessels, limit the retina’s function, and put pressure on the optic nerve, causing vision problems.
C: Risk factors - uncontrolled hypertension, heart disease, atherosclerosis, diabetes, smoking, high cholesterol, obesity, heavy alcohol consumption.
S: May be asymptomatic, reduced vision, eye swelling, bursting of a blood vessel, double vision, headaches.
D: Ophthalmoscope, Fluorescein Angiography.
T: Lifestyle advice.
Diuretics, beta blockers, or ACE inhibitors to treat the blood pressure.

Question 20

Retinal detachment

Answer 20

The neurosensory layer of the retina separating off from the underlying retinal pigment epithelium.
C: Rhegmatogenous RD - age-related degenerative liquefaction and shrinkage of the vitreous. Exudative - accumulation of serous and/or haemorrhagic fluid in the subretinal space because of hydrostatic factors, inflammation, neoplastic effusions. Tractional RD - fibrotic tissue from previous haemorrhage, injury, surgery, infection, or inflammation.
S: New onset of floaters, new onset of flashes, sudden-onset painless, usually progressive, visual field loss (dark curtain or shadow).
D: Pupillary reflexes, visual acuity, visual fields, dilated fundal examination.
T: Retinal tears and holes are treated with cryotherapy or laser photocoagulation. Vitrectomy to help flatten the retina. Scleral buckling - silicone material placed on the scleral surface, encouraging re-attachment. Pneumatic retinopex - gas bubble to close retinal break, allowing fluid to be pumped out and retina to reattach.

Question 21

Retinal vascular occlusion

Answer 21

Occlusion can cause blood or other fluids to build up and prevent the retina from properly filtering light.
C: Unknown. Risk factors - atherosclerosis, blood clots, arrthymias, diabetes, hypertension, high cholesterol, obesity, IV drug use, age, glaucoma, smoking, macular oedema.
S: Sudden change in vision - blurry vision, or a partial or complete loss of vision. Usually unilateral.
D: Eye exam, BP, Optical coherence tomography, ophthalmoscope, fluorescein angiography.
T: There are usually permanent changes to vision. Medication such as blood thinners or injections into the eye, including antivascular endothelial growth factor (anti-VEGF) drugs such as aflibercept and ranibizumab or corticosteroid drugs.
Laser therapy.

Question 22

Retinoblastoma

Answer 22

An embryonal tumour of the retina and is the most common malignancy of the eye in children. Usually 0-5 years old.
C: Hereditary mutation on chromosome 13, called the retinoblastoma 1 (Rb1) gene or sporadic.
S: Leukocoria (white-to-cream mass), deterioration of vision, red and irritated eye, faltering growth/development, systemically well.
D: Examination under anaesthesia with a maximally dilated pupil is required, bi-dimensional ocular ultrasound and MRI, genetics.
T: Photocoagulation can be used to treat selected small tumours. Cryotherapy. Transpupillary thermotherapy. Plaque radiotherapy. Systemic chemotherapy. Enucleation (eye removed). External beam radiotherapy.

Question 23

Optic neuritis

Answer 23

Inflammation of the optic nerve.
C: Giant cell arteritis, optic neuropathy, autoimmune diseases, including sarcoidosis, SLE, post-vaccination, TB, syphilis, MS, RTIs, periorbital infection, Vitamin B12 deficiency, medications, inherited.
S: Triad - reduced vision (of varying severity), eye pain (particularly on movement) and impaired colour vision. Light flashes, altered perception of the direction of movement, fatigue, decreased pupillary light reaction, abnormal contrast sensitivity.
D: Full ophthalmological and neurological examination. Blood tests - FBC, ESR, TFTs, autoantibodies and syphilis serology. MRI brain. CXR. LP.
T: Refer to an ophthalmologist and/or neurologist. Consider corticosteroids during the acute phase - methylprednisolone 1 g daily for three days.

Question 24

Optic atrophy

Answer 24

The loss of some or all of the nerve fibres in the optic nerve.
C: Chronic glaucoma, optic neuritis, traumatic optic neuropathy, lesions compressing the optic nerve, central retinal artery/vein occlusion, hereditary optic neuropathies, retinal degeneration, radiation neuropathy, syphilis.
S: Reduction or loss of vision, loss of contrast or colour vision, decreased perception of brightness, double vision, facial pain.
D: Fundoscopy and may be confirmed with optical coherence tomography, neuroimaging of the brain.
T: Treat underlying disease

Question 25

Blowout fracture

Answer 25

Orbital blowout fractures occur when there is a fracture of one of the walls of orbit but the orbital rim remains intact.
C: Direct blow to the central orbit from a fist or ball which causes a sudden increase in infraorbital pressure. Decompression then occurs by fracture of one or more of the bounding walls of the orbit.
S: Extensive soft tissue swelling, posterior displacement of the eyeball within the orbit, double vision, orbital emphysema, malar region numbness, hypoglobus.
D: X-ray, CT scan.
T: Initial post-traumatic diplopia or extraocular muscle impairment may improve over time, as oedema or muscle injury resolves. If severe diplopia, emphysema, muscle entrapment or large fracture - surgery.

Question 26

Thyroid eye disease

Answer 26

An organ-specific idiopathic autoimmune disease. It usually begins with an active inflammatory orbital phase lasting 6-24 months, then deterioration before spontaneously improving.
C: An autoimmune reaction to thyroid-stimulating hormone (TSH) receptors. Risk factors - smoking, female, middle age, autoimmune thyroid disease, uncontrolled thyroid dysfunction, radio-iodine therapy.
S: Ocular irritation, red eyes, eye ache, diplopia, staring or bulging eyes, dry or watery eyes, photophobia, swelling, difficulty in moving eyes. Concurrent thyrotoxicosis.
D: TSH, T3, T4. Thyroid auto-antibodies.
Thyroid uptake scan or orbital biopsy may be helpful.
T: Mild TED - artificial tears, ointment and prisms
Moderate TED - Ciclosporin and corticosteroids.
Severe TED - Urgent orbital decompression surgery and intravenous corticosteroid therapy.

Question 27

Horner’s syndrome

Answer 27

A rare condition that results from disruption of the sympathetic nerves supplying the eye.
C: First order nerve lesion - CVA, MS, tumours, basal meningitis, neck trauma. Second order nerve lesion - apical lung tumour, lymphadenopathy, aortic aneurysm, neuroblastoma, mandibular dental abscess. Third order nerve lesion - cluster headaches or migraines, Herpes zoster infection, internal carotid artery dissection, temporal arteritis.
S: Partial ptosis (upper eyelid drooping), Miosis (pupillary constriction) leading to anisocoria (difference in size of the pupils), Hemifacial anhidrosis (absence of sweating). Orbital pain/headache.
D: CXR, CT/MRI, CT angiography/carotid ultrasound, cocaine eye drops (should dilate but no response in HS).
T: Management involves diagnosis of the underlying condition and treatment as appropriate.

Question 28

Third nerve palsy

Answer 28

Palsy of CNIII, which controls superior rectus, inferior rectus, medial rectus, inferior oblique, and levator palpebrae superioris muscles.
C: Congenital. Acquired - head injury, infection, vaccination, migraine, brain tumour, aneurysm, diabetes, or high blood pressure.
S: Double vision, ptosis, “Down and out” ocular positioning - abduction, slight depression, and intorsion, may have an enlarged pupil.
D: Neuro exam, MRI/CT.
T: No cure for congenital. 6 months after onset for possible spontaneous improvement (patches and prisms). Relief of pressure on the third nerve from a tumour or blood vessel (aneurysm) with surgery may improve the third nerve palsy.

Question 29

Holmes-Adie pupil

Answer 29

A rare neurological disorder, which causes patients to have a pupil which is larger than normal and slow to react in response to direct light.
C: Idiopathic, trauma, surgery, ischaemia, infection.
S: Affected pupil is dilated all the time, cannot constrict in response to light, ovally distorted, blurry vision, photophobia, headache, facial pain.
D: Clinical diagnosis. Eye exam. Pilocarpine eye drops (eyes would not normally constrict, will constrict).
T: Glasses to correct blurred vision, sunglasses for photophobia, dilute pilocarpine may improve poor depth perception and relieve glare.

Question 30

Hyphaema

Answer 30

A pooling or collection of blood inside the anterior chamber of the eye.
C: Eye trauma, abnormal blood vessels on the surface of the iris, eye infection caused by the herpes virus, hemophilia and sickle cell anemia, problems with intraocular lens, cancer of the eye.
S: Visible blood in the front of the eye, photophobia, pain, blurry, cloudy, blocked vision.
D: Eye examination, eye pressure check, CT scan.
T: If mild, it can heal spontaneously over a week. Analgesia. Eye drops (steroid drops to limit inflammation and/or dilating drops to help with pain). Eye patches. Bed rest. Head elevated at least 40 degrees when sleeping.