Eyes and vision

Question 1

Risk factors cataracts

Answer 1

Increasing age
Diabetes
Smoking
Long exposure UV light
Long-term corticosteroids
Previous eye injuries
FHx

Question 2

Red flags for eye problems in children

Answer 2

Same day ophthalmology:
Red reflex absent or very dull, white, or markedly asymmetric in a young child (urgent ref if>3m)
Signs of preseptal or orbital cellulitis, corneal ulcer, corneal haze or opacity
New, sudden onset strabismus or binocular diplopia in the older child
Purulent eye discharge in a neonate
Complete ptosis
hyphaema (blood in front of iris).
penetrating eye injury or eyelids swollen shut.
aged 6 years or younger with herpes simplex keratitis or herpes zoster ophthalmicus.

Same days paeds if: orbital/preseptal cellulitis

urgent optometry assessment if:
anterior uveitis.
glaucoma.
new-onset of strabismus.

Question 3

What could purulent eye discharge in a neonate indicate?

Answer 3

Toxoplasma, others (syphilis, varicella-zoster, parvovirus B19), rubella, cytomegalovirus, herpes (TORCH) infections in pregnancy

Question 4

How to assess children’s vision at different ages

Answer 4

0 to 3 months – visual interest and fixation is variable.
4 to 12 months – should be interested in your face and fixate on a toy well.
1 to 2 years – should fixate on toys and pictures, a container of hundreds and thousands (cake decoration) at 50 cm.
2 years+ – vision can be measured using appropriate paediatric eye charts. This is done by an optometrist who can organise an onward referral to an orthoptist if necessary

Question 5

Horner’s syndrome

Answer 5

More than 2 mm difference in pupil size and mild ptosis on the side of the smaller pupil, hemifacial anhidrosis

Question 6

Corneal ulcer vs abrasion

Answer 6

Painful, red, photophobic eye.-> urgent optometry

Ulcer:
Loss of corneal epithelium with positive fluorescein staining, not caused by trauma.
Sight‑threatening.
The affected area has an opaque appearance.
Abrasion:
An area in which the cornea is devoid of its surface epithelium due to ocular trauma.
Common.
cornea clear.

Question 7

Risk factors for corneal ulcers

Answer 7

Dry eyes
Bell’s palsy
Ectropion
Immunocompromised
Contact lens wearer (microbial keratitis)

Question 8

Signs/symptoms herpes zoster ophthalmicus

Answer 8

Pain around the eye.
Rash in VI dermatome, spreads into hairline.
Eyelid swollen.
Vesicular lesions on the tip of the nose are high‑risk for more serious ocular involvement (nasociliary branch of the VI nerve innervates the globe, Hutchinson’s sign).
Early conjunctivitis, and occasional faint, patchy fluorescein staining of the cornea
If iritis/keratitis: redcued vision, severe pain, photophobia, hazy iris, irregular pupil

Question 9

Management herpes zoster ophthalmicus

Answer 9

Treat immediately with aciclovir tablets 800 mg, five times a day for 7 days
Lubricant drops
+ urgent optometry (or admit ophthalmology if endophthalmitis)

Question 10

Pterygium vs Pinguecula

Answer 10

Pterygium:
A triangular wedge of fibrovascular conjunctival tissue that typically starts medially on the nasal conjunctiva and extends laterally onto the cornea.
Associated with chronic sun exposure.
Pinguecula:
A degenerative eye condition
A yellowish, slightly raised conjunctival lesion.
Remains confined to the conjunctiva without corneal involvement.

Eye drops, refer routine optometry if cornea affected by>3mm by pterygium

Question 11

Management ectropion

Answer 11

Apply bland moisturiser to lower lid with upward massage
Copious lubricant drops, gels, ointments
Routine ophthalmology referral

Question 12

Management entropion

Answer 12

Use tape to stabilise lid
Copious lubricant drops, gels, ointments
Urgent referral

Question 13

Common benign eyelid lesions and appearances

Answer 13

Chalazion: meibonian gland blockage, inner eyelid red lump
Cyst of Moll: blocked gland of Moll at base of an eyelash, papule/nodule
Eyelid skin papilloma: overgrowth skin, no lash loss or destruction of tissue

Question 14

Red flags eyelid lesion

Answer 14

Progressive enlargement over months
Distortion or destruction of normal lid architecture, e.g. lashes missing, notch or dip in lid contour
Pearly solid lump, sometimes with a depression in the centre (rodent ulcer), lower lid and medial canthus – typical BCC

Inflammation + tissue distortion and ulceration – SCC or aggressive BCC

Question 15

Management chalazion

Answer 15

Hot compress 2-3x daily for 5-10 mins
If purulent, chloramphenicol eye drops for 7 days
If >6 weeks refer routine ophthalmology

Question 16

Meibomianitis

Answer 16

Inflammation is centred around the openings of the meibomian glands, located posterior to the eyelashes.
Heat is needed to soften the oil blocking the glands so it can be cleaned away:
Apply a hot compress to closed eye for a few minutes
Massage the eyelids with the tip of the index finger using firm downward strokes on the upper lid, and upward strokes on the lower lid.
Bathe the eye with cooled boiled water and cotton wool or cotton buds to remove excess oily material and any crusts on the lashes.

Question 17

Glaucoma eye drops

Answer 17

Beta blockers- timolol- risk wheeze/hypotension
Carbonic anhydrase inhibitors- acetazolamide- lethargy
a2-agonists- brimonidine- hypotension
Muscarinic agonists- pilocarpine- myopia
Prostaglandin analogues- latanoprost- lash growth, iris pigmentation

Question 18

Symptoms and signs of acute angle closure glaucoma

Answer 18

Narrowing or closure of the anterior chamber angle and a rapid rise of intraocular pressure
Red severely painful eye, nausea and vomiting, halos around light, blurring of vision
Eyeball hard on palpation
Unreactive semi-dilated pupil
Redness around hazy cornea
Cornea cloudy (oedematous)

Question 19

Diagnosis? Sudden unilateral blurred vision. headache, tender scalp

Answer 19

temporal arteritis
+ jaw claudication

ESR/CRP raised, plts raised

Treat with steroids, bone protection

Question 20

Symptoms retinal detatchment

Answer 20

Floaters
Flashes
Curtain being drawn across vision
Distortion if macula is involved
If due to traction in diabetes it is gradual vision loss

Question 21

Treatment retinal artery occlusion

Answer 21

Rule out temporal arteritis
Screen for cardiovascular risk factors
Fluorescein angiography
Aim to reduce intra-ocular pressure (acetazolamide, aspirin, hyperventilate)

Question 22

Treatment retinal vein occlusion

Answer 22

Investigate for cardiovascular risk factors
Autoimmune disease/clotting disorders/glaucoma screening
Monitor regularly
Low dose aspirin
Treat risk factors

Question 23

Signs and symptoms central retinal artery occlusion

Answer 23

Thromboembolic blockage causing retinal infarction
Painless sudden visual loss
RAPD
Retina pale with cherry red spot of macula

Question 24

Signs and symptoms retinal vein occlusion

Answer 24

Thrombosis of retinal veins, branch is more common than central
Causes painless visual loss unilaterally, retinal flame haemorrhages and cotton wool spots. Vitreous haemorrhage, swollen optic disc, tortuous vessels

Question 25

Signs of hypertensive retinopathy

Answer 25

Retinal damage due to chronic hypertension
Cotton wool spots, flame haemorrhages, papilloedma is advanced/malignant hypertension
* Acute ischaemia in choroid
* Optic disc swelling
Chronic hypertension
* Arteriosclerosis (copper wiring)
* AV nipping

Question 26

What is thyroid eye disease

Answer 26

Autoimmune
Anti-TSH receptor antibodies target extraocular muscles
Irritable red eyes
Aching
Pain on eye-movement
Double vision

Question 27

Signs thyroid eye disease

Answer 27

Proptosis
Lid retraction
Lid lag on downward gaze
Systemic signs (tremor, low BMI, heat intolerance)
Thyroid function tests, anti TSH antibodies, CT scan for extraocular swelling

Question 28

What is uveitis associated with? Treatment?

Answer 28

Ankylosing spondylitis
Psoriatic arthritis
IBD
Sarcoidosis
Syphilis
Treated with steroids

Question 29

Differences between scleritis and episcleritis

Answer 29

Scleritis: subacute severe pain,, worse on eye movement, immobile hyperaemic vessels, associated with rhematoid/SLE/IBD/vasculitis-> globe perforation (acute ophthalm)
Episcleritis: common, acute mild pain, mobile hyperaemic vessels, self limiting

Question 30

5 non emergency causes of red eye

Answer 30

Subconjunctival haemorrhage
Dry eyes
Conjunctivitis
Corneal abrasion
Keratitis

Question 31

8 causes acute visual loss

Answer 31

Painless:
Central retinal artery occlusion
Vitreous haemorrhage (retinal vein occlusion/diabetic retinopathy)
Anterior ischaemic optic neuropathy (after temporal arteritis)
Retinal detachment
Stroke/TIA
Painful:
Acute angle closure glaucoma
Optic neuritis

Question 32

3 causes flashers/floaters

Answer 32

Posterior vitreous detachment
Migraine with aura
Retinal detachment (risk after trauma, myopia, recent cataract/laser surgery)- acute optometry if<6 weeks

Question 33

What is optic neuritis?

Answer 33

Autoimmune demyelination of the optic nerve
1st presentation of MS
Blurred optic disc, RAPD, reduced visual acuity, pain on eye movement, colour perception impaired (red desaturates)

Question 34

Features of macula degeneration

Answer 34

Central vision loss, distortion, smokers incr risk
Dry: retinal atrophy with drusen
Wet: neovascularisationm haemorrhages distorting macula. Can be treated with anti-VEGF

Question 35

What is amblyopia?

Answer 35

Squint causing double vision
Brain ignores one side-> abnormal development if not corrected by age 7
Corrected with temporary patching of good eye

Question 36

What visual loss can you still drive with?

Answer 36

6/12 in at least 1 eye (read reg plate at 20m)

Question 37

4 types of allergic conjunctivitis

Answer 37

seasonal- pollen.
perennial- dust mites or pets.
contact dermatoconjunctivitis – eye drops or cosmetics.
giant papillary conjunctivitis – contact lenses.

Question 38

Topical treatment allergic conjunctivitis

Answer 38

Mast cell stabilisers (e.g. sodium cromoglicate) to prevent symptoms before they occur as they can take 6 weeks to show an effect- OTC
Combined antihistamine and mast cell stabiliser (e.g. olopatadine)

Question 39

What is anterior uveitis and endomphthalmitis? + risk factors

Answer 39

Anterior uveitis encompasses iritis (inflammation of the iris) and iridocyclitis (inflammation of the iris and ciliary body).

Endophthalmitis is an inflammation of the internal eye tissues, most commonly caused by an infection. It occurs after surgery and is a genuine ophthalmological emergency

Recent eye surgery – endophthalmitis
Previous iritis, ank spond, reactive arthritis, IBD

Question 40

Symptoms + signs endophthalmitis / iritis

Answer 40

Endophthalmitis-> acute opthalmology:
Short history of unilateral red eye and deep aching pain.
Significant sensitivity to light.
Blurred vision.
Eyelid swelling, chemosis, and and discharge.
Sluggish pupil reflex or reduced red reflex, cells in the anterior chamber (exudate or hypopyon)

Iritis-> acute optometry:
Poorly reactive pupil/unreactive disorted pupil

Question 41

Risk factors for acute angle closure glaucoma

Answer 41

Older age
Female
Asian
FHx
Short hyperopic eyes
Antidepressants – safe in open‑angle glaucoma or who have had a cataract removed. If a patient has angle‑closure glaucoma, antidepressants can be used with caution and advised if symptoms of eye pain, reduced vision or nausea, they should get optometry assessment.

Question 42

Causes of transient monocular vision loss

Answer 42

giant cell arteritis.
amaurosis fugax: embolic retinal disease, usually originating in the carotid artery/carotid stenosis, painless, curtain closes over few secs, lasts few minutes- treat as TIA
optic neuropathy.
carotid artery dissection- pulsatile tinnitus, stroke
retinal migraine.

Question 43

Management dry AMD

Answer 43

Diet rich in vitamins A, C, E
antioxidants (AREDS2 combination)
Stop smoking, modify CV risk factors