Head and Neck/ENT/Ophthalmology Flashcards

Question

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.

Answer 1

**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.

Answer 2

**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.

Answer 3

**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

Answer 4

**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](https://emedicine.medscape.com/article/1229174-overview?form=fpf), 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.`

Answer 5

**D. Uveitis.** A red eye is a finding in many ophthalmological diseases such as those of the conjunctiva (e.g. conjunctivitis), cornea (e.g. corneal ulcers), inflammation of the eye chambers (e.g. anterior uveitis), or episclera and sclera. Each condition, however, often has specific features with which the differential diagnoses could be narrowed down. The cornea is normal in this patient and the red reflex is intact. These findings make acute closed-angle glaucoma an unlikely diagnosis. In patients with acute closed-angle glaucoma, the cornea is hazy and the pupil is partially or fully dilated and unresponsive to light. The red reflex is lost. Other accompanying features include hardness of the orbit, ipsilateral headache and nausea and vomiting. Chronic closed-angle glaucoma does not cause a red eye. There is also no clear or purulent discharge in the history. These make conjunctivitis (bacterial, viral or allergic) (option B) a less likely diagnosis as well. In conjunctivitis, the eye is red but not painful. The vision is preserved and there is no corneal or pupillary abnormalities. Blepharitis (option C) is the inflammation of the eyelids. The condition is associated with inflamed and often itchy eyelids. If there is any abnormal eye finding, it will be related to concomitant conjunctivitis. Keratitis (option E) is the inflammation of the cornea due to infection (e.g. herpes simplex, herpes zoster) or other inflammatory processes. There are corneal abnormalities such as circumcorneal dendritic ulceration in herpes infection. Features of keratitis include redness, pain and a sense of foreign body or grittiness, photophobia, and lacrimation. The vision and pupillary reflexes are normal. In fact, in this patient with such constellation of signs and symptom, anterior uveitis is 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](https://emedicine.medscape.com/article/1229174-overview?form=fpf), Lyme disease, tuberculosis, sarcoidosis, herpes simplex and herpes zoster infections, juvenile rheumatic arthritis disease, or trauma. Acute anterior uveitis presents with eye pain and redness. Eye pain generally develops over a course of few hours or days unless the cause is trauma, in which case it develops almost immediately. There is 360o perilimbal injection, which increases in intensity as it approaches the limbus. This pattern is different from the redness in conjunctivitis, in which the injection decreases as it approaches the perilimbal area. Visual acuity may or may not be decreased in the affected eye. On pupillary examination, the patient may experience direct photophobia when the light is shone into the affected eye, or consensual photophobia when the light is directed into the unaffected eye. Consensual photophobia is very helpful in distinguishing the photophobia due to iritis from superficial photophobia such as seen in conjunctivitis. Hypopyon, the white cells precipitate in the anterior chamber, is another feature that may be seen in anterior uveitis. Pupil may be irregular due to adhesion of the iris to the anterior aspect of the lens. Chronic anterior uveitis presents primarily with blurred vision, mild redness, and no or little pain or photophobia except during an acute exacerbation.

Answer 6

**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.`

Answer 7

**E. Posterior vitreous detachment.** Flashes (photopsias) refer to the perception of light in the absence of external light stimuli. Flashes are typically described as a momentary arc of white light, similar to a bolt of lightning or a camera flash. They are more noticeable in dim lighting, may be triggered by eye movement and are usually in the temporal visual field. Flashes can be generated anywhere along the visual pathway. In the eye, flashes are the result of mechanical stimulation of the retina by vitreoretinal traction. Floaters refer to the sensation of dark spots. These spots are caused either by opacities in the vitreous, which cast shadows on the retina, or by light bending at the junction between fluid pockets and the vitreous. Floaters may be caused by vitreous debris from infection, inflammation and hemorrhage, but are typically due to the age-related degeneration of the vitreous that forms condensations of collagen fibers. Floaters are often described by patients as ‘flies’, ‘cobwebs’ or ‘worms’ that are more pronounced against light backgrounds. Floaters may also result from hemorrhage of retinal vessels into the vitreous and may be described as small black or red spots. `NOTE - The most common cause of vitreous hemorrhage is proliferative diabetic retinopathy.` The most common cause of flashes and floaters in elderly patients is posterior vitreous detachment (PVD). PVD is present in approximately 66% of patients over the age of 70 years. PVD is age-related vitreous degeneration, shrinkage and separation from the retina. During separation, the vitreous may tug and cause mechanical stimulation of the retina that will results in flashes. Patients with PVD often have normal vision and visual fields otherwise. There is no afferent pupillary defect, and patients have normal pupillary light reflex. `NOTE - Patient with PVD are be at higher risk of retinal detachment if PVD is associated with vitreous hemorrhage. Near 70% of these patients have been found to have at least one retinal tear.` Option A: Vitreous hemorrhage is mainly associated with floaters. Flashes are less common. On the other hand, compared with PVD, vitreous hemorrhage is less common. Option B: Retinal detachment is also associated with flashes and floaters, especially of sudden onset. Compared with PVD, retinal detachment is a rare condition (1 in 10,000 people per year). Furthermore, patients with retinal detachment often have visual acuity and visual fields abnormalities. Option C: Depression can cause a variety of somatic symptoms. However, flashes and floaters are unlikely to be somatic presentation of depression. Option E: Optic neuritis can be associated with flashes, especially on eye movements. Floaters are not a feature because the pathology is limited to the optic nerve and does not affect the vitreous. Moreover, retro-orbital pain, worse on eye movements, is a common presentation of optic neuritis which is absent in this patient. `TOPIC REVIEW` Differential diagnosis of flashes and floaters: **Flashes** * Ophthalmic Posterior vitreous detachment Retinal tear/hole Retinal detachment Optic neuritis – photopsia on eye movement, retrobulbar pain * Non-ophthalmic Migraine – scintillating (sparkling or shining) scotomas, colored lights, bilateral, evolves over 5 to 30 minutes before resolving with onset of a headache, normal visual acuity Postural hypotension – bilateral temporary dimming of vision and light-headedness Occipital tumors Vertebrobasilar transient ischemic attacks **Floaters** * Ophthalmic Vitreous syneresis Vitreous hemorrhage Posterior vitreous detachment Retinal detachment Vitritis Tear film debris `NOTE - There is no non-ophthalmic cause for floaters.` | RACGP - Flashes and Floaters

Answer 8

**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.

Answer 9

**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

Answer 10

**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.

Answer 11

**D. Using a new preserving solution for her contact lenses.** The clinical picture of bilateral itchy and watery eyes is consistent with either viral or allergic conjunctivitis. With erythematous eyelids, an allergic reaction would be the most likely diagnosis. Allergic conjunctivitis may be the response of a previously sensitized individual to an allergen, including but not limited to the following: * Household dust * Pollen from trees or grass * Mold spores * Animal dander * Chemical perfumes * Contact lens solutions * Certain medications (systemic or topical) This woman has used a new contact lens solution that is very likely to have caused an allergic reaction. Option A and E: A mucopurulent discharge will be consistent with bacterial conjunctivitis which is unlikely in this scenario. A previous history of bacterial conjunctivitis is unrelated to the current presentation. Option B: A lump in the upper eyelid is a finding in stye or chalazion, which have quite different presentations. Option C: Conjunctivitis does not affect vision. If vision is impaired, some other diagnoses other than conjunctivitis must be considered. | Allergic Conjunctivitis

Answer 12

**C. Refer the patient to an ophthalmologist.** Any embedded foreign body **should be removed by an ophthalmologist**, and the next best step in management would be a referral to an ophthalmologist. Option B: An X-ray of the orbital area is required if a foreign body is suspected, but it is not visible on examination. Option D: No evidence supports the usefulness of an eye patch when the foreign body is still in the eye. After removal, however, padding the eye for 24 hours is often recommended. Option A and E: Stuck foreign bodies of the eye should be removed by an **ophthalmologist**. Moreover, removal of an embedded foreign body usually does not require application of anesthetics or general anesthesia.

Answer 13

**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

Answer 14

**B. Irrigation with water.** In chemical injuries of the eye, the most important initial step is irrigation with plenty amount of water to wash out the offending agent, followed by urgent referral to an ophthalmologist for further management. Option A: While the eye might have been seriously damaged, the application of topical anesthetics and padding are inappropriate actions. The anesthetic agent might have a chemical interaction with the offending agent and cause more injury. Application of topical anesthetic should be considered after thorough irrigation of the eye if the patient still has pain. Option C: Neutralizing agents should never be used in this situation, as they can result in heat production and more damage caused by thermal injury. Option D: Topical antibiotics may be considered by the ophthalmologist for further management, but they have no role in initial management. Option E: Urgent referral to ophthalmologist is the most appropriate next step after vigorous irrigation.

Answer 15

**D. Acute closed-angle glaucoma.** The clinical picture of a **painful red eye and headache, blurred vision and decreased visual acuity and a hard orbit** is highly suggestive of acute closed-angle glaucoma. Acute-angle glaucoma results from an **obstruction preventing the aqueous humor from being circulated normally**; this leads to **increased pressure** within the orbit. It is a genuine emergency and hesitation in prompt treatment can result in permanent loss of vision. Option A and B: Acute retinal artery and vein thrombosis can cause sudden loss of vision, but they are painless. Option C: Open-angle glaucoma presents with gradual painless visual loss. It does not develop acutely. Option E: Cataract is opacification of lens. It develops gradually. Cataract is not painful.

Answer 16

**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:

Answer 17

**B. Vitreous hemorrhage.** Floaters refer to the sensation of dark spots in the vision, which are caused either by opacities in the vitreous that cast shadows on the retina, or by light bending at the junction between fluid pockets and the vitreous. Patients often describe floaters as “flies”, “cobwebs” or “worms” that are more pronounced against light backgrounds. **Hemorrhage from adjacent retinal vessels into the vitreous body leads to floaters**, a sudden onset of decreased visual acuity (bumping into objects since this morning), and a darkened or diminished red reflex consistent with this patient’s symptoms. **The most common cause of vitreous hemorrhage is proliferative diabetic retinopathy**. As this patient has long-standing diabetes mellitus and her left eye presents retinal changes consistent with pre-proliferative diabetic retinopathy, it is very likely that her right eye also has diabetic retinopathy with vitreous hemorrhage that leads to these symptoms. Though vitreous hemorrhage is the right diagnosis with proliferative retinopathy (option A) being the most likely underlying pathophysiology for that in this case. Occlusion of the central retinal vein (option C) presents with variable visual loss and has an insidious onset unless the vein is acutely and completely obstructed. The fundoscopy will reveal retinal hemorrhage, dilated tortuous retinal veins, cotton-wool spots, macular edema, and optic disc edema. Retinal detachment (option D) presents with sudden onset of visual impairment, floaters, and flashes. Patients describe black dots in their visual fields and visual loss as a curtain coming down in front of their eyes. The visual field will be completely lost if the macula is detached. Ophthalmoscopy may show detached and floating retinal folds as a large grey shadow in the vitreous. Dulling of the red reflex may be seen in retinal detachment. Cataract (option E) often presents with a history of gradual progressive visual deterioration and disturbance in the night and near vision. Patients may also complain of decreased visual acuity, glare, myopic shift, and monocular diplopia.

Answer 18

**A. Fine needle aspiration (FNA).** Neck masses in adults are a common presentation for head and neck cancer. Head and neck cancer accounts for 3.4% of all malignancies in Australia, and the incidence of oropharyngeal squamous cell carcinoma is rising. Early diagnosis is essential to prevent worsening prognosis. **All neck masses should be considered malignant until proven otherwise**. Detailed history and examination is crucial in the initial work-up. It is of paramount importance to notice the presence of any red flag symptoms and risk factor for head and neck malignancies in the history. `Red flag symptoms for head and neck cancer include:` * a mass that has been present for >2 weeks * a recent change in the voice * dysphagia or odynophagia * ipsilateral otalgia, nasal obstruction, or epistaxis * unexplained weight loss or loss of appetite Risk factors for head and neck cancer include: * smoking * alcohol use * age >40 years * past history of previous head and neck malignancy * past history of head and neck cutaneous lesions In physical examination, assessment of assessing the location of a neck mass is essential as it provides clues to the etiology. Characteristic features of the lump such as size, shape, consistency, compressibility, mobility, changes in overlying skin, are very important and must be documented thoroughly. In terms of investigations, **fine-needle aspiration (FNA) of the mass for cytology** and **computed tomography of the neck with contrast** are the mainstay of **first-line investigation**. CT scan of chest (option B), colonoscopy (option E) and gastroscopy, CT scan of the brain (option C), and mammography (option D) , are considered for further investigation to detect a primary malignancy in case initial assessments suggest the lump to be a metastatic lesion.

Head and Neck/ENT/Ophthalmology Flashcards

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