Head and Neck/ENT/Ophthalmology Flashcards
Page 330 - Page 375
A 25-year-old woman presents to your practice complaining of a painful lump in her left eyelid. The lesion is shown in the following photograph. Which one of the following is the most likely diagnosis?
A. Stye.
B. Chalazion.
C. Meibomian cyst.
D. Dacryocystitis.
E. Blepharitis.
A. Stye
Acute abscess of a lash follicle or associated glands of the anterior margin of the lid is termed hordeolum (stye). The causative organism is usually Staphylococcus aureus.
The picture shows a red swelling of the upper eyelid which may be seen in both chalazion and stye, but since stye tends to be located more marginally, the lesion is more likely to be an stye. Stye presents with a red tender swelling of the lid margin.
Option B: Chalazion, also termed meibomian abscess/cyst (internal hordeolum), is the result of an obstructed and secondarily infected meibomian gland. Meibomian (tarsal) glands are special kinds of sebaceous glands at the rim of the eyelid inside the tarsal plate. They produce and secret meibum, which is an oily substance that prevents evaporation of the eyes’ tear film and tear spillage onto the cheeks by trapping the tear between the oiled edge and the eyeball. It also makes the closed lids airtight. There are about 50 glands in the upper and 25 in the lower lid. When an acute infection of a meibomian abscess subsides, the abscess within the gland is replaced by granulation tissue, and eventually becomes fibrotic. This will form a small hard nodule in the eyelid.If the lesion was more away from the eyelid margin, chalazion could have been the better bet.
Option B: Dacryocystitis is inflammation of the tear sac often secondary to obstruction of naso-lacrimal duct. It present with inflamed swelling over the medial canthus.
Option E: Blepharitis presents with inflamed margins of the eyelids. It may be caused by Staphylococcus aureus, seborrheic dermatitis, or rosacea, and presents with itching and burning of lid margins.
Management is with removal of crusts from the lids and steroid drops or creams. For blepharitis associated with staph aureus, tetracycline or chloramphenicol ointment is used. Oral doxycycline is indicated in those with blepharitis associated with rosacea.
A 4-year-old boy is brought to the emergency department by his mother because of fever and swelling of his left eye since this morning. Examination reveals an ill child with a fever of 38.5°C and right periorbital swelling. The eyelids are swollen and erythematous. Further assessment reveals that eye movements are preserved in all direction. The visual acuity is intact. There is no nuchal rigidity. Which one of the following is the most appropriate next step in management?
A. Lumbar puncture.
B. Emergency CT scan of the orbital fossa.
C. Topical chloramphenicol ointment.
D. Intravenous flucloxacillin and ceftriaxone.
E. Oral antihistamine and topical corticosteroids.
D. Intravenous flucloxacillin and ceftriaxone
The periorbital edema and erythema and fever are suggestive of either orbital or periorbital cellulitis. With orbital cellulitis, the eye movements are impaired. This leaves periorbital cellulitis as the most likely diagnosis. Periorbital cellulitis should be urgently treated with intravenous broad spectrum antibiotics (e.g. flucloxacillin and ceftriaxone). If the child is vaccinated against Hemophilus influenza, some will advise a narrower-spectrum combination of antibiotics.
In a child of this age, meningitis would be expected to be associated with neck rigidity. Without this finding, or other pointers, meningitis would be unlikely and lumbar puncture (option A) futile. Emergency CT scan of the orbital fossa (option B) to determine the extension prior to surgical intervention is the next best in management of orbital cellulitis.
Periorbital cellulitis requires treatment with intravenous antibiotics. Topical antibiotics (option C) are not effective.
Option E: Antihistamine or corticosteroids has no role in management of periorbital cellulitis.
28-year-old man presents to your practice with redness and purulent discharge of his left eye as illustrated in the accompanying photograph. Which one of the following is the most effective antibiotic for treatment of this patient?
A. Tobramycin.
B. Streptomycin.
C. Chloramphenicol.
D. Penicillin.
E. Tetracycline.
C. Chloramphenicol
The red eye, injection of the conjunctiva and mucopurulent discharge is suggestive of bacterial conjunctivitis as the most likely diagnosis. Suspected bacterial conjunctivitis should be empirically treated with a broad-spectrum topical antibiotic. For this purpose, chloramphenicol is widely used as one of the most appropriate choices. The patient should always be advised about hygienic measures for prevention of spread to the other eye.
Swab culture is not initially indicated and is reserved if the infection persists or recurs despite initial treatment. Specific therapy then is planned based on the culture and susceptibility results.
A 34-year-old woman presents with a painful lump in the right upper eyelid. The lump has developed over a course of 3 days. On examination, there is a 1x1.5cm warm tender lump in the upper eyelid. The visual acuity is intact. The eye movements are completely normal in all directions. The patient is otherwise healthy and afebrile. Which one of the following would be the next best step in management of this patient?
A. CT scan of the orbit.
B. Flucloxacillin and ceftriaxone intravenously.
C. Topical chloramphenicol.
D. Application of heat and massage.
E. Incision and curettage of the lesion under local anesthesia.
D. Application of heat and massage
The painful lump in the eyelid in the presence of normal vision and preserved eye movements can be either stye (external hordeolum) or meibomian abscess (internal hordeolum). Both of these conditions are often managed conservatively with application of heat and massage to allow drainage of infected contents.
This then is followed by oral di/flucloxacillin in meibomian abscess and sometimes by topical chloramphenicol (option C) in stye. Incision and curettage under local anesthesia (option E) is the treatment of last resort or when the abscess is large.
In the AMC handbook of multiple choice question the treatment of meibomian cyst in acute phase has been mentioned to be incision of the lesion. However, in Australian therapeutic guidelines, as well as Murtagh’s general practice and many other references, conservative measures, are mentioned as the initial management.
Intravenous administration of antibiotics (option B) is used if peri-orbital or orbital cellulitis is suspected. Topical chloramphenicol is used for treatment of conjunctvitis and not indicated for this patient. CT scan of the orbit (option A) is an important part of management if orbital cellulitis is suspected.
A 56-year-old man presents to the emergency department with acute right eye pain, redness and blurred vision. On examination, he has eye injection and corneal haziness, and the eye feels hard to palpation. Which one of the following is the most appropriate immediate management?
A. Oral acetazolamide.
B. Topical pilocarpin.
C. Carteolol.
D. Laser iridotomy.
E. Topical corticosteroids.
C. Carteolol.
The clinical findings are a classic description of acute closed-angle glaucoma – an acute rise in the pressure of the anterior chamber. This condition is real emergency and if left untreated catastrophic results can ensue. Treatment of acute closed-angle glaucoma is with immediate application of topical agents that inhibit aqueous production. The following topical agents might be used:
* Topical beta blockers (first-line): timolol, carteolol
* Alpha adrenergic agonists: e.g. apraclonodine
* Topical prostaglandins
Other management options depend on the setting:
* If the patient can be seen within 1 hour of presentation, urgent referral to an ophthalmologist will be the next best step.
* If the referral is delayed, the patient should be given acetazolamide PO (250mg x2) (option A). After one hour of treatment, topical pilocarpine (option B) can be started as well (2 doses 15 minutes apart).
NOTE - The most frequently drug group in the emergency department is topical beta blockers (timolol, carteolol) and intravenous acetazolamide. Of the given options, carteolol is the most appropriate management option.
Option D: Laser iridotomy will be the definite treatment of closed-angle glaucoma and is considered after the acute attack subsides. This procedure is not applicable in acute setting.
Option E: Topical corticosteroids have shown no benefit in an acute attack but might be helpful in reducing the corneal inflammation after the acute phase has subsided.
A 65-year-old woman presents to the emergency department with sudden onset decrease in visual acuity and floaters in the visual field of her right eye. The eye appears normal on inspection, and is not painful. Which one of the following could be the most likely diagnosis?
A. Age-related macular degeneration.
B. Closed-angle glaucoma.
C. Cataract.
D. Retinal detachment.
E. Presbyopia.
D. Retinal detachment.
The symptoms are highly suggestive of retinal detachment. In retinal detachment, the retina peels away from its underlying layer of support tissue. Initial detachment may be localized or broad, but without emergency treatment the entire retina may detach and result in loss of vision.
Retinal detachment presents with sudden onset of visual impairment, floaters and flashes. The patient describes black dots in the visual field. The patient may describe the visual loss as a curtain coming down in front of the eyes. Visual field will be completely lost if macula is detached.
If the detachment is not repaired within 24-72 hours, permanent damage may occur.
Risk factors for retinal detachment include:
* Aging
* Congenital eye diseases
* Cataract surgery
* Diabetic retinopathy
* Focal retinal atrophy
* Family history of detachment
* Hereditary vitreoretinopathy
* Myopia (axial)
* Prematurity
* Trauma Uveitis
Option A: Age-related macular degeneration presents with slowly progressive visual loss in an elderly. There are no floaters or flashes and compared to acute-onset of symptoms in retinal detachment, the visual impairment occurs insidiously.
Option B: Open-angle glaucoma is associated with gradual vision impairment that often initially affects the peripheral vision, progressing to involve the entire visual field.
Option C: Cataract is the opacification of the lens. The patient will have difficulty in seeing both far and near objects with the affected eye. Dazzling is a common complaint and vision is worse in bright light.
Option E: In presbyopia, the lens becomes stiff and less easy to accommodate, resulting in declining ability to focus on near objects. Presbyopia presents with eye strain, difficulty seeing in dim light, and problems in focusing on small objects and fine prints.
A 47-year-old man presents to the emergency department with acute onset of pain in his right eye, associated with lacrimation, nausea and severe unilateral headache. Further assessment establishes the diagnosis of acute closed-angle glaucoma. The patient is managed initially with timolol drop, intravenous acetazolamide and pilocarpine eye drop. Which one of the following would be to most appropriate long-term management of this patient?
A. Laser iridotomy.
B. Laser trabeculectomy.
C. Topical cortisone.
D. Topical pilocarpine 4%.
E. Topical carbonic anhydrase inhibitor.
A. Laser iridotomy.
Long term management of closed-angle glaucoma is with iridotomy, either by laser or surgery. A small piece of iris is removed at 12 o’clock, allowing free drainage of aqueous.
Option B: Laser trabeculectomy is treatment of choice in patients with chronic open angle glaucoma with failed conservative management. The procedure includes establishing a pressure valve at the limbus, so that aqueous can flow freely into a conjunctival bleb.
Option C: Corticosteroids are not used for treatment of glaucoma.
Option D: Topical pilocarpine is used, in conjunction with intravenous acetazolamide, for urgent decompression in acute closed-angle glaucoma.
Option E: Carbonic anhydrase inhibitors such as topical acetazolamide and dorzolamide, or oral acetazolamide are used in pharmacological management of chronic simple glaucoma. Oral acetozolamide is also used in pre-referral management of acute closed-angle glaucoma.
A 60-year-old man presents to the emergency department with painful red right eye and photophobia. On examination, the right eye pupil has normal reaction to light. Which one of the following is the most likely diagnosis?
A. Acute iritis.
B. Acute close-angle glaucoma.
C. Acute keratitis.
D. Bacterial conjunctivitis.
E. Viral conjunctivitis.
C. Acute keratitis.
The clinical picture is consistent with acute keratitis (inflammation of the cornea) as the most likely diagnosis.
Acute keratitis or corneal ulcer presents with:
* Red eye
* Eye pain
* Reflex lacrimation
* Photophobia
* Normal reactive pupils
Option A: Acute iritis is associated with a red painful eye and irregular constricted pupil. Photophobia can be a feature. The cornea is often normal, but the vision is usually blurry.
Option B: Acute closed-angle glaucoma presents with a painful red eye, which is hard to touch. There is photophobia and haziness of the cornea, as well as headache, nausea and vomiting. The pupils are dilated fixed and not reactive to light or accommodation. Light reflex is absent.
Option D and E: Conjunctivitis (either bacterial or viral) is characterized by red eye(s), normal cornea and normal reactive pupils. There is no visual abnormality or photophobia.
A 32-year-old man presents to your office following trauma to his left eye. On slit-lamp examination, hyphema in the anterior chamber is noted. Which one of the following is the most appropriate next step in management?
A. Immediate referral to ophthalmologist.
B. Give antibiotics and arrange follow-up in a week.
C. Advise ice packs and review in the emergency department tomorrow.
D. Prescribe NSAIDs and follow up in 3 days.
E. Drain the hyphema in the emergency department.
Hyphema is the medical term for bleeding inside your eye.
A. Immediate referral to ophthalmologist.
Hyphema is the presence of blood in the anterior chamber. It occurs usually after trauma to the eye. If there is no history of trauma, non-accidental injury in children or coagulation disorders should be suspected.
According to Australian therapeutic guidelines, an urgent ophthalmology review on the same day of the presentation is mandatory and the most appropriate management option. While awaiting an ophthalmology review, the patient should be instructed to rest in bed with the head elevated 30 to 45° and be given an eye shield to protect the eye from further trauma. Intraocular pressure must be monitored regularly.
Hyphema is associated with recurrent bleeding, glaucoma, and blood staining of the cornea. Any of these three may result in permanent vision loss.
Option B: Antibiotics are not indicated in the treatment of hyphema.
Option C: ‘Ice packs and review’ is not appropriate. Urgent referral should be arranged as the most appropriate step.
Option D: Oral or topical NSAIDs are contraindicated, as they may cause re-bleeding.
Option E: Draining a hyphema in the emergency department is not recommended. It should be performed by an ophthalmologist in the operation room.
Which one of the following conditions is most consistent with the funduscopic findings shown in the accompanying photograph?
A. Age-related macular degeneration.
B. Central retinal artery occlusion (CRAO).
C. Chronic simple glaucoma.
D. Acute angle glaucoma.
E. Diabetic retinopathy.
C. Chronic simple glaucoma.
The photograph shows an increased ratio of the optic cup (light yellow circle) to the optic disc (orange circle). Also, the retinal vessels seem to be cut when they enter the optic disc. These findings are characteristics of chronic simple glaucoma.
Normal optic cups occupy less than 50% of the optic disk. The median cup-to-disc ratio is 0.2 to 0.3 (20-30%). With chronically increased intraocular pressure (IOP), this ration increases. In chronic simple glaucoma, the cup size increases (especially along the vertical axis); therefore, this ratio increases as a result. Individuals with a cup-to-disc ration of over 50% need further evaluation.
As damage progresses ,the optic disc becomes pale (atrophied) and the disc widens and becomes deeper, so the blood vessels of the disc appear to be broken as they enter the cup and disappear, then appear at the base again.
Option A: The retina in age-related macular degeneration has drusen in dry type, and vascular proliferation in wet type.
Option B: In central retinal artery occlusion, the retina becomes pale and there is cherry-red discoloration of the macula (cherry-red spot).
Option D: Acute closed-angle glaucoma is not associated with significant retinal changes.
Option E: Diabetic retinopathy presents with microaneurysms, exudates, cotton-wool spots and flame hemorrhages on funduscopy.
Which one of the following is the most appropriate definite management of cataract?
A. Intraocular lens(IOL).
B. Phaecoemulsification.
C. Use of protective measures such as sunglasses.
D. Topical corticosteroids.
E. Pilocarpine drop.
A. Intraocular lens (IOL).
Nothing can be done for an opacified lens and it should be removed and replaced with a synthetic intraocular lens. The best method for lens replacement is phaecoemulsification.
Option B: Phaecoemulsification is a modern cataract surgery for lens replacement, in which the lens is emulsified with an ultrasonic handpiece and aspirated from the eye. Aspirated fluids are replaced with irrigation of balanced salt solution, maintaining the anterior chamber, as well as cooling the handpiece. Phaecoemulsification and extracapsular cataract extraction (ECCE) is the best method for intraocular lens replacement.
Option C: Protective measures such as wearing sunglasses are advised to prevent further damage to the lens, but not for treatment.
Option D: Short-term topical corticosteroid may be used for management of post-operative inflammation. Corticosteroids are not useful for treatment of cataract itself.
Option E: Pilocarpine drop causes pupil constriction, and is used for initial management of closed-angle glaucoma or long-term medical management of chronic simple glaucoma.
Five days after phaecoemulsification surgery and intraocular lens replacement due to cataract, a 68-year-old man presents with redness and blurred vision of the treated eye. The eye is illustrated in the accompanying photograph. Which one of the following is the condition shown in the photograph?
A. Hyphema.
B. Hypopyon.
C. Retinal detachment.
D. Central retinal artery occlusion.
E. Keratitis.
B. Hypopyon.
Phaecoemulsification, the current standard procedure for lens replacement in cataract, has a number of potential post-operative complications. Anterior uveitis is one of such complications. Anterior uveitis presents with eye pain and redness (conjunctiva and episclera in a circumcorneal fashion), blurred vision, photophobia, and reflex lacrimation. The pupil is often constricted but regular unless adhesions develop. Hypopyon is a feature that could be seen in anterior uveitis, and is accumulation of leukocytic exudate in the anterior chamber. The exudate settles at the dependent aspect of the eye due to gravity. The eye illustrated in the photograph has collection of exudate material at the bottom of the anterior chamber due to gravity, characteristics of hypopyon.
The most common post-operative complication associated with phaecoemulsification is thickening of the posterior capsule. During the surgery, the posterior part of the capsule is deliberately left to make the surgery safer. Over a few months to few years, this capsule opacifies in 5-30% of the patients and resembles the recurrence of the cataract. This condition is simply treated with capsulotomy with Yag laser in an outpatient setting.
Few patients may have post-operative irritation and inflammation. A short course of topical corticosteroids will take care of the problem. Other very rare complications include vitreous hemorrhage, retinal detachment, glaucoma and endophthalmitis. Central retinal artery occlusion is not a complication of phaecoemulsification.
A 66-year-old woman presents with sudden decrease of vision in her right eye 45 minutes ago. She has a 15-year history of type II diabetes mellitus and hypertension for the past five years, for which she is on enalapril. On examination, the visual acuity of the left eye is 12/18, and that of the right eye is limited to only finger counting. Fundoscopic examination of the right eye is shown in the following photograph. Which one of the following is the most likely diagnosis?
A. Central retinal artery occlusion (CRAO).
B. Central retinal vein occlusion (CRVO).
C. Age-related macular degeneration.
D. Diabetic retinopathy.
E. Hypertensive retinopathy.
A. Central retinal artery occlusion (CRAO).
The findings in the photograph are a pale retina and a cherry-red macula (cherry-red spot) associated with central retinal artery occlusion (CRAO).
Option B: Central retinal vein occlusion (CRVO) has a more insidious onset, unless the vein has acutely undergone complete obstruction. The fundoscopic findings in CRVO are tortuous retinal vessels, edema of the optic nerve and diffuse hemorrhages in all the four quadrants of the retina.
Option C, D and E: Age-related macular degeneration, diabetic retinopathy and hypertensive retinopathy are not usually associated with sudden onset of visual loss. Moreover, funduscopy will show different patterns.
A patient presents to your practice with gradual loss of vision. The accompanying photograph is the fundus of one of his eyes on funduscopic exam. Which one of the following is the most likely diagnosis?
A. Diabetic retinopathy.
B. Hypertensive retinopathy.
C. Age-related macular degeneration.
D. Central retinal artery occlusion.
E. Central retinal vein occlusion.
B. Hypertensive retinopathy.
Findings on funduscopic examination are papilledema (C-shaped head of the optic nerve), straightening of the vessels, thickened opacified vessel walls (copper-wiring) and arteriorvenous nicking. These findings are suggestive of hypertensive retinopathy.
Straightening and constriction of vessels due to arteriosclerosis is the first funduscopic finding in hypertensive retinopathy. This is followed by arteriorvenous nicking - when the sclerotic arteriole presses against the thin wall of an adjacent venule, the venule will appear as hourglass.
Further progression of hypertensive retinopathy will lead to:
* Retinal hemorrhages (either flame or dot-blot)
* Cotton-wool spots
* Optic nerve edema
* Star-shaped macula and hard exudates
Option A: Some features of hypertensive retinopathy can be seen in diabetic retinopathy, as well as vascular proliferation in proliferative diabetic retinopathy, but arteriorvenous nicking, copper-wiring and more importantly papilledema are characteristic of hypertensive retinopathy.
Option C: Age-related macular degeneration presents with drusen, pigment and sometimes hemorrhage of the macula in dry type, and proliferation of vessels from choroid into the neurosensory retina and macular hemorrhages and exudates in macule in wet type.
Option D: Central retinal artery occlusion (CRAO) gives a different picture with pale retina and the cherry-red spot.
Option E: Retinal vein occlusion gives tortuous congested veins and hemorrhage as the typical picture.
A 60-year-old woman presents to your practice, complaining of visual problems. She describes the gradual loss of the ability to see clearly and that the center of her vision is blurry. Furthermore, she sees horizontal lines wavy. Which one of the following would be the next best step in management?
A. Referral to ophthalmologist.
B. Pilocarpine drops.
C. Laser emulsification.
D. Duplex Doppler sonography of the carotid artery.
E. Iridectomy.
A. Referral to ophthalmologist.
Central visual impairment is characteristic of macular degeneration, as is the distortion of objects such as seeing straight lines wavy. Once the diagnosis of macular degeneration is suspected, urgent referral to ophthalmologist would be the next best step in management.
Age-related macular degeneration is the leading cause of blindness in the elderly population in developed countries. There are two types of ARMD:
- Dry ARMD
It comprises 90% of AMD cases, and is characterized by drusen, pigmentation and sometimes hemorrhages at macula. The progression is slow.
Drusen (singular, ‘druse’) are tiny yellow or white accumulation of extracellular material that build up between Bruch’s membrane (a layer of retina) and the retinal pigment epithelium. The presence of a few small drusen is normal with advancing age, and most people over 40 years have some hard drusen. The presence of large and multiple drusen in the macula is pathologic and a common early finding in AMD.
- Wet ARMD
Wet ARMD occurs when abnormal vessels grow from the choroid into the neurosensory retina and leak at macula. It is associated with rapid deterioration in vision and visual distortion.
A 50-year-old man presents to you complaining of difficulty in reading books and seeing in dim light. His problem started six months ago and has worsened progressively. His sight improves when he look through a 1 mm pinhole. Which one of the following would be the most likely diagnosis?
A. Myopia.
B. Presbyopia.
C. Hypermetropia.
D. Cataract.
E. Chronic simple glaucoma.
B. Presbyopia.
The history and the age are suggestive of presbyopia. Presbyopia is a Greek word meaning ‘the eye of an old man’. This condition is almost always seen after age 40 and is completed at 60. With age, the lens becomes stiff and less easy to accommodate. The ability to focus on near objects continuously declines from 50 mm in a child to 100 mm at the age of 25 and eventually to only 1-2 meters at 60 years of age.
Presbyopia presents with the following:
* Eye strain
* Difficulty seeing in dim light
* Problems in focusing on small objects and/or fine prints
Option A: A person with myopia has not difficulty seeing near objects, but vision for distant objects is diminished.
Option C: Although persons with hypermetropia have the same presentation as this clinical scenario, the late age of onset is more suggestive of presbyopia. Hypermetropia usually occurs at younger ages.
Option D: Patients with bilateral cataract have difficulty in seeing both far and near objects. Furthermore, they tend to be visually impaired in bright rather than dim light.
Option E: Chronic simple glaucoma presents differently with impaired peripheral visual fields initially. The vision may be completely lost as the disease progresses continuously. The following photograph shows characteristic visual field impairment in chronic simple glaucoma. A similar pattern would be seen in those with retinitis pigmentosa and hysteria.
A 27-year-old woman presents to your practice with sudden onset of pain, redness and tearing of her right eye as illustrated in the following photograph. Further inquiry reveals that she also has had pain and stiffness of her lower back for the past 1 year that she attributes to bad sitting at work. Her brother has similar back pain. On examination, she is found to be photophobic. Limited ability to bend forward is the other significant finding. Which one of the following would be the next best step in management?
A. Anti-double stranded DNA antibody.
B. HLA-B27.
C. X-ray of the lumbosacral spine.
D. Anti-nuclear antibody (ANA).
E. Check ESR and CRP.
C. X-ray of the lumbosacral spine.
The photograph shows an eye with 360-degree perilimbal congestion that is more intense at limbus. There is also an iris with irregular contour. These findings, along with symptoms of acute onset of pain, redness, photophobia and tearing, establish the diagnosis of anterior uveitis with high certainty.
Anterior uveitis is caused by several conditions such as trauma, seronegative spondyloarthropathies (i.e. ankylosing spondylitis, reactive arthritis, psoriatic arthritis and inflammatory bowel disease), idiopathic juvenile arthritis, and very rarely infections such as herpes, syphilis and tuberculosis. In 50% of cases, no clear cause is found (idiopathic).
The presence of low back pain and stiffness and the family history of similar condition in this patient’s brother make ankylosing spondylitis (AS) the most likely underlying etiology of the anterior uveitis. When AS is suspected, X-ray of the lumbosacral spine is always the next best step in management.
The findings on X-ray include the following:
* Sacroiliitis evident by haziness of the sacroiliac joint (the earliest finding)
* Fusion of sacroiliac joint (a late finding)
* Bamboo spine and squaring of the vertebral bodies (a late finding)
Option A and D: As the name seronegative implies, serologic tests such as ANA, anti-double stranded DNA antibody, rheumatoid factor (RF), etc. are negative in seronegative.
Option B: Although HLA-B27 is positive in 90% of patients with AS, it is not used as a diagnostic tool because it is also positive in 10% of people without AS.
Option E: Seronegative arhtropathies are inflammatory; therefore, ESR and CRP are expected to be elevated. However, normal values do not exclude AS. On the other hand, positive levels can be found in several other conditions and are not diagnostic for AS or other seronegative arhtropathies.
A 75-year-old woman presents with a 16-hour history of a painful tender swelling under the right side of the jaw. The accompanying photograph shows the intraoral appearance. On examination, the swelling is exquisitely tender to palpation. Which one of the following would be the appropriate investigation to confirm the diagnosis?
A. Ultrasonography of the submandibular area.
B. Intraoral plain X-ray.
C. CT scan of the head and neck.
D. MRI of the head and neck.
E. Sialogram of the submandibular salivary duct.
B. Intraoral plain X-ray.
The unilateral erythema and the tender swelling shown in the photograph are characteristic of acute sialadenitis in the setting of salivary duct calculi.
Salivary duct calculi are composed predominantly of calcium salts, and form due to stasis and ductal inflammation. More than 80% of salivary duct stones occur in the submandibular gland due to its long and torturous course. Another reason that most salivary stones form in the in submandibular glands is the mixed mucous and serous composition of the saliva in this gland compared to other salivary glands.
For submandibular calculi, plain X-ray is the most useful intial study, as 80% are radio-opaque. In contrast, most parotid duct calculi are radiolucent. It is important to note that X-ray is considered the choice if bases on clinical findings, stones are highly suspected. Otherwise, CT scan or ultrasound are used for initial assessment.
Option A: Ultrasound is increasingly used, as it is able to give information about the gland, the presence of duct dilation and can identify stones as small as 1mm; however, it is difficult to perform in submandibular area, especially where the lesion is away from the mandible. It is best used for parotid gland problems.
Option C: CT is complementary and can provide superior images in complex cases or in patients with recurrent disease. However, in some patients artefacts from dental implants may limit the usefulness of CT scan. In most cases, CT scan and MRI are unnecessary.
Option D: MRI is not routinely used for diagnosis of sialadenitis and sialolethiasis.
Option E: A Sialogram is a useful study for delineating the exact size and location of stones in a salivary gland duct. The stone will be visualized as a filling defect within the duct. Active infection of salivary gland is a contraindication for sialography because it can exacerbate the extent of the infection. While other means such as X-ray or CT-scan can be used, sialograms are less frequently used these days.
The parents of a 6-week-old baby has brought her to your clinic after they noticed a swelling on the right side of her neck. She is otherwise healthy, is being breastfed, and is gaining weight appropriately. Which one of the following should not be considered in the differential diagnosis of the lateral cervical swelling in this child?
A. Acute cervical adenitis.
B. Branchial cleft cyst.
C. Cystic hygroma.
D. Sternocleidomastoid muscle hematoma.
E. Thyroglossal duct cyst.
E. Thyroglossal duct cyst.
Of the given options, thyroglossal duct cyst is invariably in the midline (or just slightly off of it) and not seen on the lateral aspect of the neck.
Option A: Cervical adenitis (lymphadenitis) is defined as enlarged, inflamed, and tender lymph node(s) of the neck. Cervical lymph nodes are distributed along the course of the sternocleidomastoid muscle, in the posterior neck, supraclavicular, or submandibular region.
Option B: A branchial cleft cyst is a congenital epithelia cyst that arises on the lateral part of the neck due to failure of obliteration of the second branchial cleft (or failure of fusion of the second and third branchial arches) during embryonic development. A branchial cyst can also be among differential diagnoses of a lateral neck swelling in children.
Option C: Cystic hygroma, also known as cystic lymphangioma or macrocystic lymphatic malformation, is a congenital multiloculated lymphatic lesion that can arise anywhere, but is classically found in the left posterior triangle of the neck (especially left side) and axillary regions. It can cause a swelling observed in the lateral side of the neck.
Option D: Hematomas of the sternocleidomastoid present with lateral swellings along the course of the muscle.
A 52-year-old man presents to the emergency department with sudden-onset right-sided vision loss. His medical history is remarkable for right-sided headache of 2 weeks duration, which is exacerbated by chewing. Fundoscopic exam is performed with the findings shown in the following photograph. Which one of the following is the most likely cause of the visual loss?
A. Central retinal artery occlusion (CRAO).
B. Branch retinal artery occlusion (BRAO).
C. Central retinal vein occlusion (CRVO).
D. Branch retinal vein occlusion (BRCO).
E. Circumciliary vein occlusion.
A. Central retinal artery occlusion (CRAO).
The photograph shows a pale retina and a red macula. This fundoscopic picture is most consistent with CRAO.
A majority of patients with CRAO develop unilateral sudden-onset and significant vision loss. The vision loss is often painless. CRAO almost never occurs in both eyes simultaneously. Occasionally, CRAO is preceded by transient monocular blindness, or there is a stuttering or fluctuating course. The vision loss is severe, and most affected patients can see only hand motions and rarely can count fingers.
On fundoscopic examination, ischemic retinal whitening is seen immediately after an occlusion of the central retinal artery. A “cherry red spot” appears in the macula, where the retina is thinner and the retinal pigment epithelium and choroidal vasculature can be seen more easily as the ischemic retina becomes less translucent.
Common causes of CRAO include:
* Atherosclerotic changes of the carotid artery
* Emboli from the heart
* Atheroma within the central retinal artery
* Hematologic diseases such as polycythemia, sickle cell disease, leukemia and lymphoma
* Inflammatory processes such as giant cell arteritis, Wegener’s granulomatosis, polyarteritis nodosa, lupus, etc.
With history of right-sided headaches aggravated by chewing, and now sudden-onset loss of vision, giant cell arteritis (GCA) is most likely to have caused this visual loss.
GCA is a chronic vasculitis of large- and medium-sized arteries, occurring among people over the age of 50 years. It is more common in women than men. The vascular involvement can be generalized; however, cranial branches of the arteries branching from the aortic arch are most prominently involved.
GCA can present with headache, temporal region tenderness, weak pulses of the temporal artery, or jaw claudication. Arm claudication may occur in a minority of patients as a result of subclavian or axillary arteries involvement. Polymyalgia rheumatica can be an association.
Visual symptoms in GCA are common and if not managed promptly, may have devastating outcomes such as permanent loss of vision.
Visual manifestations of GCA is due to ischemia of central or branch retina artery occlusion and ischemia, ischemia of choroid, retina or a combination of these conditions. In many patients amaurosis fugax (transient monocular loss of vision) precedes acute vision loss.
Despite effective therapy, visual loss remains common in GCA and permanent partial or complete loss of vision in one or both eyes occurs in 15-20% of cases. This is due to the fact that visual loss is the presenting feature in many patients who could have been treated if diagnosed earlier based on other presenting symptoms.
Option B: BRAO presents differently on fundoscopic exam with whitening and paleness of the retina only and in segments that are supplied by the occluded branch of the retinal artery.
Option C and D: Fundus examination in CRVO and BRVO reveals retinal hemorrhage, edema and dilated retinal veins. This pattern is generalized in CRVO and focal in BRVO.
Option E: Circumciliary vein occlusion is seen in glaucoma. Glaucoma has a different fundoscopic exam appearance.
Which one of the following is the most appropriate management option for the eye abnormality shown in the accompanying photograph?
A. CT scan of the head and the orbit.
B. Warm compress.
C. Anesthetic eye drops.
D. Antibiotic eye drops.
E. Corticosteroid eye drops.
B. Warm compress.
The photograph shows a diffuse beefy red discoloration of the sclera not crossing the limbus (the border or the cornea and sclera). This is typical for subconjunctival hemorrhage. Subconjunctival hemorrhage can be caused by trauma to the eye, a sudden increase in intrathoracic pressure such as during sneezing or coughing, anti-coagulation disorders or medications, or spontaneously (idiopathic). The condition is usually asymptomatic, unless caused by trauma, in which case pain can be a feature. In non-traumatic cases, mild irritation can be feature at occasions.
NOTE - Subconjunctival hemorrhage is directly related to hypertension but measuring the blood pressure to reassure the patient is worth doing.
In cases of subconjunctival hemorrhage with no history of trauma, no active treatment is required. Artificial tears can be applied if irritation is a complaint. It is important to note that use of aspirin and NSAIDs should be avoided due to increased risk of rebleeding. Like a bruise, the hemorrhage may become green or yellow with time. The discoloration usually disappears within 2 weeks. Application of warm compress, after cold compress for the first 24 to 48 hours, several times a day, can facilitate the process.
Patients should be advised to return if the bruise-like appearance does not resolve completely, if pain ensues, or if there is rebleeding.
CT scan of the orbit may be indicated in patients with subconjunctival hemorrhage following trauma to exclude orbit fractures or other possible associated injuries.
A 67-year-old man presents to your practice complaining of difficulty seeing in daylight. He explains that when he is out in the daytime, the light is dazzling. He, however, does not have any problem in reading or watching TV. He has the history of type II diabetes mellitus and hypertension, for which he is on metformin and enalapril, respectively. Which one of the following could be the most likely diagnosis?
A. Cataract.
B. Chronic simple glaucoma.
C. Hypertensive retinopathy.
D. Presbyopia.
E. Retinal detachment.
A. Cataract.
The presentation is most consistent with diagnosis of cataract. Cataract is a term used for any lens opacity. The prevalence of cataract increases with age. Sixty five percent of those aged 50 to 59 years and all people older than 80 years will have lens opacities.
Cataract presents with gradual loss of vision with preserved direct pupillary light reflex. Unilateral cataract may remain unnoticed, but the mono-ocular impaired vision may affect distance judgment due to stereopsis. Bilateral cataracts lead to gradual vision loss that can cause frequent change of glasses.
Dazzling, especially in sunlight is seen initially. With bilateral cataract difficulty in reading, recognizing faces, watching TV and driving, particularly at night, become the more prominent symptoms.
Option B: Chronic glaucoma presents with gradual loss of vision often starting with blurring in the peripheiry of the visual field, progressing to invlove the central vision. Dazzling is not a problem.
Option C: Hypertensive retinopathy leads to vision loss and retinal hemorrhage, but dazzling is an unusual feature.
Option D: Presbyopia is associated with ageing and is characterized by the progressively diminishing ability to focus clearly on an object close to the eye. The first symptom of presbyopia is eyestrain. Others incluse difficulty seeing in dim light, problems focusing on small objects and fine print that are usually noticed between the ages of 40 and 50. There is no dazzling.
Option E: Retinal detachment is associated with floaters and flashes, but no dazzling
Three days after a successful lens replacement in a 67-year-old man due to the cataract of his right eye, he wakes up in the morning with a painful red eye and photophobia. On examination, the affected eye has decreased and blurry vision. Funduscopic exam is normal on both sides. The picture of his eye is illustrated in the following photograph. Which one of the following is the most likely diagnosis?
A. Hypopyon.
B. Conjunctivitis.
C. Acute glaucoma.
D. Uveitis.
E. Suture infection and abscess.
D. Uveitis.
The photograph shows a red eye with constricted and more importantly a deposit of white matter in the anterior chamber. These alongside the eye pain, photophobia, and blurred vision, make anterior uveitis the most likely diagnosis.
The uvea is the pigmented part of the eye including iris, ciliary body, and choroid. The iris and ciliary body are called the anterior uvea. Iris inflammation invariably involves the ciliary body too; so the inflammation is best referred to as anterior uveitis rather than iritis. Anterior uveitis is idiopathic in 50% of cases. The remaining half are caused by an underlying condition such as seronegative spondyloarthropathies, Behçet disease, Lyme disease, tuberculosis, sarcoidosis, herpes simplex and herpes zoster infections, juvenile rheumatic arthritis disease, or trauma.
Clinical features suggestive of anterior uveitis include the following:
* Red eye: the redness in anterior uveitis is circumcorneal, meaning that there is 360° injection around the limbus. The injection has the highest intensity in the perilimbus and decreases towards the periphery. The injection in conjunctivitis is reverse.
* Pain
* Blurred vision
* Photophobia (both direct and consensual) on examination
* Constricted pupil – there might be pupil irregularities due to adhesion of the iris to the anterior aspect of the lens
* Lacrimation
Anterior uveitis can also be a complication of cataract or other eye surgeries. Currently, phacoemulsification is the standard procedure for lens replacement in people with cataract. This procedure is associated with a number of complications and anterior uveitis being one of them. The eye illustrated in the photograph has collection of exudate material at the bottom of the anterior chamber due to gravity, namely hypopyon, a feature seen in anterior uveitis.
Option A: Hypopyon is accumulation of leukocytic exudate in the anterior chamber. The exudate settles at the dependent aspect of the eye due to gravity. Although this patient has hypopyon in the affected eye, this is a sign seen in anterior uveitis not a diagnosis.
Option B: Conjunctivitis presents with conjunctival redness giving rise to a red eye; however, the condition is not a cause of blurred vision, pupil abnormalities. Superficial photophobia can be a feature though.
Option C: Acute closed-angle glaucoma presents with acute eye pain and ipsilateral headache, nauseas and vomiting, hazy cornea and an irregular dilated pupil. The orbit is hard to palpation. This patient does not have clinical features of acute glaucoma.
Option E: Suture infection, if occurs, is most likely to cause endophthalmitis (the infection of the entire orbit including both the anterior and posterior chambers) with a different presentation especially on fundoscopic exam.
NOTE - Patients with anterior uveitis need urgent referral for review by an ophthalmologist and follow up to prevent damage from prolonged inflammation including disruption to aqueous flow inside the eye that can result in glaucoma and adhesions between the iris and lens. Treatment incudes topical corticosteroids such as prednisolone eye drop that significantly reduces the inflammation, and subsequently, the pain and redness. Cyclopentolate drop is often considered as well to keep the pupil dilated and prevent from lens-iris adhesions.
A 26-year-old woman presents with red right eye since this morning. For the past few hours she also has had mild discomfort and irritation of the eye. She denies any discharge or itchiness. On examination, eye movements, orbital pressure and visual acuity are normal. Cornea shows no abnormality and has preserved light and red reflexes. A funduscopic exam reveals no retinal abnormality either. She has unaffected visual acuity. There is a patchy redness of the sclera as shown in the following photograph. Which one of the following would be the most appropriate eye drop to consider for her?
A. Ketotifen.
B. Hypomellose.
C. Sodium cromoglycate.
D. Prednisolone.
E. Chloramphenicol.
B. Hypomellose.
The clinical presentation, as well as the appearance of the eye (a patchy redness) makes epicscleritis the most likely diagnosis.
Epicscleritis is the inflammation of the episclera, the tissue that lies between the conjunctiva and the sclera. The condition is usually mild and self-limiting but often recurrent. Two- thirds of the cases are idiopathic and the remaining one-third can have an underlying systemic condition such as infections (tuberculosis, syphilis, Lyme disease or cat scratch disease) or a rheumatologic disorder (e.g. rheumatoid arthritis, polyarteritis nodosa, seronegative spondyloarthropathies, etc.). In patients with epicscleritis, visual acuity and fields are unaffected. Mild photophobia and lacrimation might exist; however, these are not significant findings in most patients.
The initial management usually starts with artificial lubricants (tear) such as Hypomellose or Artelac 4 to 6 times a day. For more discomfort and irritation not responsive to this measure, topical NSAIDs such as diclofenac would be the next line of treatment. Topical corticosteroids are reserved for those not responding to the above. Over 80% of the patients will respond to topical corticosteroids.
Option A and C: There is no itchiness or discharge as pointers towards allergic conjunctivitis to justify the application of drugs used for treatment of the condition. Ketotifen is an antihistamine and sodium cromoglycate a mast cell inhibitor. These drugs have no role in management of epicscleritis.
Option D: Prednisolone can be a choice if the condition does not show a satisfactory response to artificial tear drops and topical NSAIDs.
Option E: Chloramphenicol is an antibiotic used for treatment of bacterial conjunctivitis. The absence of purulent discharge and/or sticky eyelids, especially on waking up, excludes bacterial conjunctivitis.
NOTE - A distinction between epicscleritis and scleritis is very important because while the former is a mild self-limiting condition, the latter can result in serious damage to the eye and sight. Unlike epicscleritis, scleritis is associated with severe penetrating pain in the eye that radiates to the jaw, eyebrows, forehead or sinuses. Eyeball tenderness is also characteristic of scleritis and absent in epicscleritis. Scleritis is almost always associated with an underlying systemic disease. In scleritis, redness increases gradually over a course of several days. There is a bluish red tinge which is best seen in the natural light rather than through the slit lamp. The discoloration can be focal or involve the entire sclera. The interpalpebral area is the most common site. The discoloration does not blanch with application of sympathomimetic dilating drugs.
A 75-year-old man presents to your practice with complaint of persistent right ear pain for the past few weeks. He has been a heavy smoker for the past 50 years. He denies any recent hearing loss. Physical examination, including a full otoscopic exam, is unremarkable. No significant hearing loss is noted. Which one of the following could be the most likely diagnosis?
A. Cholesteatoma.
B. Chronic otitis media.
C. Tongue cancer.
D. Acoustic neuroma.
E. Ramsay-Hunt syndrome.
C. Tongue cancer.
Ear pain (otalgia) is a common complaint and comprise approximately 4% of general practice setting encounters alone.
The nerve supply for sensation in ear originates from several cranial nerves including the trigeminal nerve (CN-V), facial nerve (CN-VII), glossopharyngeal nerve (CN-IX), and vagus nerve (CN-X) as well as branches from the cervical plexus (mostly C2 and C3). These nerves also supply multiple head and neck structures; therefore, in many cases with ear pain, pain is referred from somewhere else. This may pose a diagnostic challenge.
The etiology of ear pain can be primary or secondary. Primary otalgia originates from the ear structures itself while secondary otalgia is the pain felt in the ear but in fact referred from other structures. In children, primary otalgia is more common while in adults ear pain is often due to a secondary cause.
The following table outlines the primary and secondary causes of ear pain: (see table)
Primary otalgia often has benign causes that at experienced hands are often diagnosed through history and physical examination. With negative ear findings on examination, secondary causes of ear pain should be considered and investigated. Odontogenic problems, especially those of posterior teeth, are the most common cause of secondary otalgia accounting for approximately 63% of cases.
Temporomandibular joint (TMJ) dysfunction is the second most common cause of secondary ear pain. Vertigo and tinnitus are other possible presentations of TMJ dysfunction. Pain related to chewing or other jaw movements is often a clue in history.
Trigeminal neuralgia usually has other associated symptoms such as unilateral attacks of abrupt onset that last up to 2 minutes and are excruciating.
All cancers of the head and neck, usually squamous cell carcinomas, can cause secondary otalgia in patients who have an otherwise normal otology history and examination. Of importance are neoplasms in the oropharyngeal region (soft palate, posterior pharyngeal wall, palatine tonsil or tongue base), which can present with deep, intense otalgia. Patients with cancers in this region may have additional symptoms of dysphagia, odynophagia, and sore throat, or may be otherwise asymptomatic. The presence of risk factors for these cancers such as chronic alcohol use and tobacco exposure is a red flag and a clue to the diagnosis. In advanced stages, cervical lymphadenopathy is a common examination finding.
Given this patient’s age, normal ear examination, presence of heavy smoking in the history, and lack of clues for other secondary causes of ear pain, squamous cell carcinoma of the tongue is the most likely explanation for this presentation. This patient need referral to an otolaryngologist for further assessment and management.
Option A: A cholesteatoma consists of squamous epithelium that is trapped within the skull base and can erode and destroy important structures within the temporal bone. Its potential for causing central nervous system (CNS) complications (e.g., brain abscess, meningitis) makes it a potentially fatal lesion. Hearing loss is also a common symptom of cholesteatomas. Large cholesteatomas fill the middle ear space with desquamated epithelium, with or without associated mucopurulent discharge, interfering with sound transmission. Ossicular damage is frequently present and can cause conductive hearing loss. In this patient, normal exam findings are inconsistent with cholesteatoma as diagnosis.
Option B: Chronic otitis media presents with purulent ear discharge and often conductive hearing loss. Otoscopy shows perforated tympanic membrane and pus in the ear canal. This patient has none of these findings. Moreover, the condition is usually seen in children.
Option D: Acoustic neuromas are intracranial tumors arising from the Schwann cell sheath of either the vestibular or cochlear nerve. As acoustic neuromas grow, they eventually occupy a large portion of the cerebellopontine angle. Unilateral hearing loss is the most common symptom present at the time of diagnosis. Other symptoms of acoustic neuroma include headaches, and imbalance. Absence of unilateral hearing loss in this patient, and ear pain rather than headache make such diagnosis very unlikely.
Option E: Ramsay Hunt syndrome (herpes zoster oticus) is the viral infection of the facial nerve and presents with ear pain, vesicles involving pinna/external auditory meatus and facial nerve palsy. The absence of vesicles as well as other features of facial nerve involvement make such diagnosis unlikely.
A 37-year-old woman with a history of recurrent oral and genital ulcers presents with a red eye as illustrated in the following photograph. Which one of the following is the most appropriate action to take?
A. Oral corticosteroids.
B. Topical corticosteroids.
C. Oral fluconazole.
D. Referral to ophthalmologist.
E. Topical antibiotics.
D. Referral to ophthalmologist.
The photograph shows conjunctival redness and congestion which is more intense at the limbus, iris with irregular contour, and more importantly a collection of exudate material at the bottom of the anterior chamber due to gravity, characteristics of hypopyon. The presence of recurrent oral ulcers, genital ulcers, and uveitis in this patient makes the Behcet syndrome the most likely diagnosis.
Patients with anterior uveitis need an urgent referral for review by an ophthalmologist and follow-up to prevent damage due to inflammation, including disruption to aqueous flow inside the eye that can result in glaucoma and adhesion between the iris and lens. Behcet syndrome itself is also a condition requiring prompt referral for an ophthalmological opinion, which may be sight-saving.
The treatment of Behcet syndrome is high-dose steroids and specific ulcer treatment. Ocular manifestations require systematic, not topical corticosteroids (option B).
Fluconazole (option C) is an antifungal medicine, and topical antibiotics (option E) are used for bacterial infections, none of which is the case in this scenario.
Although oral corticosteroids (option A) are the treatment of choice, they should be started by the specialist after a thorough assessment of the patient.
References:
* Dermnet NZ – Behcet Disease
* Murtagh’s General Practice, John Murtagh, 8th Edition, p.212
A 78-year-old male comes to your general practice clinic complaining of seeing wavy lines whenever he tries to directly look at his grandchildren. He is otherwise well and only wears corrective lenses for his myopia. Fundoscopy findings are shown below.
Which of the following could be the best diagnostic test for this patient?
A. Amsler grid.
B. Visual field testing.
C. Optical coherence tomography.
D. Fluorescein angiography.
E. Digital tonometry.
A. Amsler grid.
The history and clinical findings, including the fundoscopic exam, suggest age-related macular degeneration (ARMD).
Fundoscopy findings show the characteristic drusen. Drusen are extracellular deposits made of lipids, proteins, and cellular debris under the retina. They appear as yellow or whitish spots on fundoscopy. Having drusen increases an individual’s risk of developing ARMD and is considered a sign if the patient develops characteristic symptoms. Other fundoscopy findings in ARMD include the following:
* retinal edema and localized elevation
* detachment of the retinal pigment epithelium (RPE)
* a gray-green discoloration under the macula.
ARMD is the leading cause of vision loss in Australians over 50 years of age. It is a chronic, painless disease that mainly affects the retinal pigment epithelium.
Symptoms can include the following:
* difficulty reading or any other activity which requires fine vision (despite wearing glasses)
* distortion, where wavy lines appear bent
* difficulty distinguishing faces
* dark or blurred patches in the center of the vision
The Amsler grid is the best initial test to screen and monitor the progression of symptoms for ARMD. The patient can be given a piece of paper and asked to check for distortions in the lines.
Below is a sample of an individual with normal eyesight next to that of a patient with ARMD. (See photo)
Option B and C: Visual field testing and optical computed tomography are ancillary procedures to check for the integrity of the RPE but are not required to diagnose ARMD.
Option D: Fluorescein angiography is used in the evaluation of ARMD to check for the vascular integrity of the retinal vessels. This involves dye injection and a highly specialized camera. This may help in the detection of early disease but is not the initial step.
Option E: Digital tonometry has no role in the evaluation of ARMD and is indicated if glaucoma is suspected.
A 38-year-old woman presents to the emergency department after getting hit in her right eye with a squash ball in a match. On examination, the visual acuity of the affected eye is decreased. The eye is shown in the accompanying photograph. Which one of the following is the most appropriate next step in management?
A. Application of an eye patch.
B. Topical antibiotics.
C. Urgent referral to an ophthalmologist.
D. Evacuation of the blood under local anesthesia.
E. Reassurance as it resolves within 5 to 7 days.
C. Urgent referral to an ophthalmologist.
The photograph shows blood in the anterior chamber consistent with the diagnosis of hyphema.
Causes of hyphema include:
* Trauma – Trauma is the most common cause of hyphema. Of all traumatic hyphemas, most occur in sports. In traumatic hyphema, the impact forces the globe inward and instantaneously increases the pressure of the anterior chamber. This pressure pushes the lens, iris, and ciliary bodies backward and disrupts the vasculature with tearing of and bleeding from the blood vessels.
* Blood clotting disturbances
* Medications – anticoagulants
* Neovascularization – such as in diabetic retinopathy, previous eye surgery, etc.
* Melanoma or retinoblastoma
* Abnormal vasculature
Hyphema is not usually painful unless it is caused by trauma. Visual acuity is often impaired in the affected eye. The presence of blood in the anterior chamber is characteristic.
Every patient with hyphema should be urgently assessed by an ophthalmologist as the most appropriate step in management. In the meanwhile, the eye should be protected from more damage (e.g. by application of eye patches or shields), the head elevated and the patient advised about restricted physical activity.
Although most hyphemas resolve in 5 to 7 days, reassurance is not an appropriate action, as there may be serious complications without prompt assessment and treatment.
Topical antibiotics are not part of the management plan in hyphema.
NOTE - The following conditions require urgent referral to an ophthalmologist as the most appropriate management:
* Significant trauma to the eye / penetrating trauma/chemical burns (severe) /embedded foreign body in the cornea or intraocular foreign body
* Hyphema (>3mm)/hypopyon
* Corneal ulcer
* Severe conjunctivitis
* Uveitis/acute iritis
* Behçet syndrome
* Acute glaucoma
* Giant cell arteritis
* Acute dacryocystitis
* Endophthalmitis
* Herpes zoster ophthalmicus – when the tip of the nose is involved, consider the possibility of the internal eye involvement as well
A 56-year-old man presents to the emergency department with acute-onset pain in the left eye associated with headache and nausea. He has a bluury vision in the left eye. On examination, the left eye is red, with an irregular and unresponsive pupil. The accompanying photograph shows the affected eye. Which one of the following is the most likely diagnosis?
A. Acute iritis.
B. Bacterial conjunctivitis.
C. Acute closed-angle glaucoma.
D. Chronic open-angle glaucoma.
E. Cataract.
C. Acute closed-angle glaucoma.
The sign and symptoms found on exam are suggestive of acute closed-angle glaucoma as the most likely diagnosis.
Acute closed-angle glaucoma presents with sudden onset unilateral eye pain, ipsilateral headache and, nausea and vomiting. The attack is often preceded by blurred vision or halos around lights, at night time. Pupil dilatation in dim light results in more increased pressure of the anterior chamber and worsens the symptoms.
Findings on examination include the following:
* Red eye
* Irregular semi-dilated fixed pupil. The pupil may look vertically ovoid
* Hazy cornea
* The affected eye feels hard to touch, as the intraocular pressure has risen to over 60 mmHg (normal 15-20 mmHg)
* Decreased visual acuity
Option A: Acute iritis, better termed anterior uveitis, presents with acute pain, photophobia (not found in acute closed-angle glaucoma), lacrimation, circumcorneal redness, and a constricted pupil.
Option B: Conjunctivitis may present with pain and photophobia, but the rest of the exam is normal. Visual acuity is preserved and cornea and pupil look normal.
Option D: Chronic open-angle (simple) glaucoma is optic nerve damage caused by chronically increased intraocular pressure. Patients, if symptomatic, will complain of gradual loss of visual fields; first, the nasal and superior, and eventually the temporal. Simple glaucoma is not painful and the pupil and iris are normal. The eye is not red.
Option E: Cataract is neither painful nor associated with red eye or pain. The lens is hazy on exam.
Topic Review (Page 375)
The following table compares differentiating features of different underlying aetiologies of a redy eye:
