Ophthalmological Conditions

Question 1

Acute chlamydial conjunctivitis (presentation, cause, diagnosis, treatment)

Answer 1

Presentation: Acute or subacute unilateral conjunctivitis with mucopurulent discharge or as a chronic conjunctivitis.
Cause: Exposure to STI (mother-to-child transmission, accidental transmission, or sexual abuse).
Diagnosis: Chlamydia PCR.
Treatment: Systemic treatment.
● > 1 month old - azithromycin 1 g (child 20 mg/kg) PO STAT
● Neonate - azithromycin 20 mg/kg PO for 3 days

Question 2

Bacterial keratitis (symptoms, examination, management)

Answer 2

Epidemiology: 95% secondary to contact lens infection
Symptoms: Usually begin within 24 hours of infection.
● Red eye
● Reduced visual acuity
● Pain
● Eyelid swelling
● Photophobia
Examination: Corneal epithelial defect highlighted on fluorescein staining (common). Other - yellow or white stromal
infiltrates, corneal oedema.
Management:
● Immediate referral for corneal scraping and initiation of topical treatment is essential
● If referral is delayed or vision is threatened, start topical treatment ASAP.
○ Ciprofloxacin 0.3% eye drops 1-2 drops every 15 minutes for 6 hours, then hourly for 48 hours,
then every 4 hours until healed.

Question 3

Cataracts (definition, terminology, RF, presentation, Ex, management)

Answer 3

Definition: Opacity of the lens that may cause blurred or distorted vision, glare problems or in advanced cases,
blindness.
Terminology:
● Immature cataract = view of the retina and transmission of red reflex still present.
● Mature cataract = red reflex is lost.
Risk factors: age, smoking, alcohol, sunlight, diabetes, systemic high-dose corticosteroids.
Presentation: problems with night driving, short-sighted.
Examination: Ensure eye is dilated for fundoscopy.
Cataract surgery: low-risk procedure. Indicated in interferes with ADLs.
● Optimise BP control
● Aspiring or anticoagulants can be continued for most patients
Complications: Risk for intraoperative floppy iris syndrome in patients on duodart or some antipsychotics (i.e. inform
surgeon).
Post-operative: Review by surgeon at 1 week and 1 month post-surgery. Minimal evidence for restriction of physical
activity.

Question 4

71M, barber, presenting with difficulty driving at night because of the glare from street lights and oncoming headlights.
Associated with decline in vision. O/E: Bilateral visual loss especially distance vision, red reflexes diminished, view
limited on fundoscopy. What is the likely diagnosis?

Answer 4

Cataracts

Question 5

Chalazion (cause, prognosis, presentation, examination, management)

Answer 5

Cause: Obstruction of Zeis or meibomian glands.
Prognosis: Small ones resolve without intervention over days or weeks.
Presentation: Plainless localised eyelid swelling.
Examination: Non-tender rubbery nodule of the inner eyelid.
Management:
● Warm compresses for 15 minutes about 4 times a day.
● Refer to an ophthalmologist if persistent.

Question 6

Conjunctivitis (types)

Answer 6

Viral
- Red, irritated eyes with gritty sensation
- May have follicular appearance
- History of URTI, rapid progression over days, presence of mucopurulent discharge
Bacterial
- Redness and purulent discharge (follicle formation rare)
- Discharge appears at the lid margins and corners of eyes
- More often appears within minutes of wiping discharge
Allergic
- Red, irritated, itchy eyes
- Often have associated atopy, eczema, hay fever or asthma
Hypersensitivity
- Exposure to drugs, eye cosmetics, soaps or other chemicals

Question 7

Allergic conjunctivitis (general advice, medication options)

Answer 7

General advice: Do not rub eyes, discontinue the use of contact lenses during symptomatic periods, apply cool
compresses, liberally use refrigerated artificial tears during the day, avoidance of allergens.
Medication options: antihistamine and mast cell stabilisers.
- Combination: Olopatadine (Patanol) 0.1% BD
- Antihistamine: Levocabastine 0.05% 2-4 times a day
- Mast cell stabilisers: Lodoxamide 0.1% QID
** Vasoconstrictor eye drops are not recommended because extended use can cause rebound ocular redness.

Question 8

Episcleritis (key points, prognosis, presentation, management)

Answer 8

Key points
● Majority do not have an underlying infectious (rheumatic disease, herpes zoster) or systemic inflammatory
disease (rheumatoid arthritis, inflammatory bowel disease, vasculitis, systemic lupus erythematosus)

Prognosis: Good. Minimal discomfort, self-resolving after a few weeks.

Presentation: Aching or awareness (not usually pain).

Management: NSAIDs

Question 9

Gonococcal conjunctivitis (presentation, diagnosis, complications, management)

Answer 9

Key point
● Requires advice from ophthalmologist urgently

Causative agent: Neisseria gonorrhoea

Presentation:
● Adult - Acute onset of copious, purulent discharge
● Neonate - As above ~ 2-5 days after birth

Diagnosis: Gonorrhoea PCR

Complications: Ulceration and perforation of the cornea

Management: Treat concurrently for Chlamydia
> 1 month = Ceftriaxone 1g (child 50 mg/kg) IM STAT
Plus Azithromycin 1 g (child 20 mg/kg) PO single dose
Neonates = Cefotaxime 100 mg/kg IM as a single dose
Plus Azithromycin 20 mg/kg PO for 3 days

Question 10

Herpes simplex keratitis (key point, ocular manifestations, significance, examination, treatment)

Answer 10

Key point
● Prompt referral to ophthalmologist is recommended with suspected herpes simplex keratitis.

Ocular manifestations: blepharitis, conjunctivitis, keratitis, iritis and retinitis.

Significance: can result in corneal scarring and loss of vision.

Examination: Fluorescein staining. Can be confirmed on PCR.

Treatment:
● Aciclovir 3% eye ointment, 5 times a day, for 10-14 days OR
● Valaciclovir 500mg PO BD for 7-10 days (if ointment nor available)

Question 11

Herpes zoster ophthalmicus (key points, treatment)

Answer 11

Key point
● Antiviral therapy aims to reduce pain.
● Can be started after 72 hours (ideally <72 hours) if there are active vesicles present or in
immunocompromised or elderly patients to reduce the risk of ocular complications.
● Concerning symptoms include red eye, visual loss and photophobia.

Treatment: Topical acyclovir has no role.
1. Valaciclovir 1g (child 20 mg/kg) PO, 8 hourly for 7 days

Question 12

Hyphema - significance, management

Answer 12

Significance: Risk of secondary glaucoma.
● Ruptured vessels could fill the anterior chamber with blood, blocking the escape of aqueous humour and
causing a severe secondary glaucoma.

Management: Complete bed rest.
● Exclude penetrating eye injury
● Eye shield over affected eye
● Elevate patient’s head to 30 degrees and main patient at bed rest
● Dilate pupil
● Symptomatic management for nausea and topical pain control

Question 13

Lens care and use

Answer 13

Length of lens use and wear
● Soft lenses allow only a limited time of safe and health usage
● Prescribed for use during waking hours only and not while sleeping
Monitor for: pain, redness, blurred vision, photophobia.
Complications:
● Increased risk of microbial keratitis with overnight use
● Corneal ulcers
● Corneal abrasions

Question 14

Macular degeneration (presentation, fundocscopy)

Answer 14

Clinical presentation: Sudden fading of central vision. Others - distortion of vision, straight lines may seem wavy and
objects distorted, peripheral fields normal.
Fundoscopy: white exudates, haemorrhages in retina. Macula may look normal or raised.

** Refer to page 203 of GP Study Notes for picture

Question 15

Marginal keratitis (cause, association, presentation, management)

Answer 15

Cause: Inflammation of the cornea.
Associated with: Blepharitis.
Presentation: Foreign body sensation or pain, epiphora, photophobia and occasionally reduced visual acuity.
Management: Warm compresses, lid massage, lid scrubs +/- antibiotic and steroid drops or ointments.

Question 16

Optic neuritis (definition, significance, acute features)

Answer 16

Definition: Inflammatory, demyelinating condition that causes acute (usually monocular) visual loss.
Significance: Occurs in 50% of patients with multiple sclerosis at some point in time.
Acute features: Vision loss over a period of hours to days and eye pain (most common).
● Other - flickering or flashes of light, retrobulbar neuritis, loss of colour vision.

Question 17

31F, presenting with a sudden appearance of large black spots obstructing central vision of the left eye with some discomfort associated. Fundoscopy normal.

Answer 17

Optic neuritis

Question 18

Orbital cellulitis (RF, presentation)

Answer 18

Risk factor: Infection from paranasal sinuses. Children under 4 years.
Presentation: Reduced vision, limited or painful eye movements, diplopia, proptosis or chemosis (swelling of the eye
surface membranes because of fluid accumulation).

Question 19

Periorbital cellulitis (definition, presentation, complications, management)

Answer 19

Definition: Cellulitis involving the soft tissue of the eyelids.

Presentation: Vision and eye movements are normal and the patient is systemically well.

Complications: Children under 4 years are at a higher risk of orbital cellulitis due to incomplete orbital septum.

Management:
1. Investigate for orbital cellulitis if there are systemic symptoms
2. If mild - moderate: Treat with oral antibiotics and review in 48 hours to ensure improvement
● Flucloxacillin 500 mg (child 12.5 mg/kg) 6 hourly for 7 days
3. If severe: Treat with IV antibiotics

Question 20

Photokeratitis (definition, prognosis, presentation, examination, prevention, treatment)

Answer 20

Definition: Acute syndrome causing severe eye pain 6-12 hours after exposure to ultraviolet light

Prognosis: Resolution of symptoms in 24-72 hours.

Presentation: Foreign body sensation, eye injection and oedema, facial and lid erythema.

Examination: Fluorescein.

Prevention: Protective eyewear.

Treatment: Supportive.
● Antibiotic ointment - chlorsig
● Oral analgesia

** Topical anaesthetics should not be prescribed for ongoing management.

Question 21

Pinguecula (definition, epidemiology, prognosis, complication, treatment)

Answer 21

Definition: Yellowish elevated nodular growth on either side of the cornea.

Epidemiology: > 35 years.

Prognosis: Generally status and not requiring treatment.

Complication: Pingueculitis (inflammation of the growth).

Treatment:
● Excision is indicated if they are large and uncomfortable.
● If irritating, topical astringent drops such as naphazoline compound drops can give relief.

Question 22

Posterior vitreous detachment (epidemiology, timeframe, presentation, case)

Answer 22

Epidemiology: 50-75 years.
Timeframe: Usually over one week but can take up to 3 months to completely develop.
Presentation: New onset of cobweb-like floaters and/or increased floaters.
Case: 62F, Aboriginal with T2DM, seeing ants crawling on the toilet that aren’t there. Associated with flashing light in
the same eye. Symptoms worsening.

Question 23

Pterygium (definition, epidemiology, treatment)

Answer 23

Definition: Overgrowth of the conjunctiva onto the nasal side of the cornea.
Epidemiology: Adults living in dry, dusty, windy areas.
Treatment:
● Excision by specialist indicated if it is likely to interfere with vision or becomes red/uncomfortable/disfiguring.

Question 24

Red eye - differentials

Answer 24

Conjunctivitis (bacterial, viral, allergic, contact hypersensitivity)
Subconjunctival haemorrhage
Herpes simplex keratitis 
Corneal ulcer 
Scleritis/episcleritis 
Acute uveitis/iritis 
Acute glaucoma 

** Refer to page 251 of GP Study Notes

Question 25

Red eye and levels of care

Answer 25

GP management
- Stye
- Chalazion
- Blepharitis
- Subconjunctival haemorrhage
- Conjunctivitis (bacterial, viral, allergic)
- Corneal abrasion
● Urgent f/u if not better in
1-2 days
- Corneal foreign body
● Urgent f/u if not better in
1-2 days
- Contact lens overwear
● Urgent f/u if not better in
1-2 days
- Dry eye syndrome
- Episcleritis

ED management

• Angle-closure glaucoma
• Hyphema
• Hypopyon (white cells in anterior chamber)
• Bacterial infectious keratitis

Urgent referral

• Iritis
• Viral infectious keratitis
• Scleritis

Question 26

Red eye - assessment questions

Answer 26

Visual acuity 
Foreign body sensation
Photophobia
Discharge 
Pain

Question 27

48M, carpenter, red right eye with discomfort and gritty sensation over the last 10 days. Trialled chlorsig with minimal effect. PHx of rosacea.

1. What are the 3 most likely differential diagnoses for his red eye?
2. On further assessment you also notice inflammation of his eyelids. What are your two non-pharmacological
   management options for his eyelid condition? (i.e. blepharitis)

Answer 27

What are the 3 most likely differential diagnoses for his red eye?
● Marginal keratitis
● Corneal ulcer/abrasion
● Corneal foreign body
● Herpes simplex keratitis
● Episcleritis
On further assessment you also notice inflammation of his eyelids. What are your two non-pharmacological
management options for his eyelid condition? (i.e. blepharitis)
● Eyelid hygiene with warm compress
● Eyelid firm massage
● Scrubbing the inside of the eyelid

Question 28

Retinal detachment (history, fundoscopy)

Answer 28

History:
● Painless loss of vision
● Flashes and floaters
● Curtain moving over the visual field
Fundoscopy: Detached retina appears corrugated and
partially opaque. Appears out of focus.

Question 29

Retinitis pigmentosa (process, typical features, examination)

Answer 29

Process: Degeneration of rods and cones associated with displacement of melanin-containing cells from the pigment
epithelium into the more superficial parts of the retina.
Typical features:
● Night blindness in childhood
● Concentrically narrowed visual fields
● Irreversible course
Examination: Irregular patches of dark pigment, especially at the periphery. Optic atrophy.

Question 30

Scleritis (key point, prognosis, presentation, history)

Answer 30

Key point
● Painful +++
● Usually associated with connective tissue disorder
Prognosis: Potentially blinding disorder that may involve the cornea, adjacent episclera, and underlying uveal tract.
Presentation: Highly symptomatic. Intense ocular pain, photophobia, and deep-red or purplish scleral hue.
History: Severe, constant pain. Worse at night or early in the morning hours.
● +/- headache, watering of the eyes, ocular redness, photophobia.

Question 31

Stye (definition, types, prognosis, complication, management)

Answer 31

AKA Hordeolum
Definition: Abscess of the eyelid that presents as a localised painful and erythematous swelling.
Types:
● Internal
○ Inflammation of the meibomian gland
● External
○ Arises from glands in the eyelash follicle or lid-margin
Prognosis: Generally resolves in 1 month.
Complication: Periorbital cellulitis.
Management: Warm compresses.

Question 32

Subconjunctival haemorrhage - potential causes

Answer 32

Potential causes:
● Blunt trauma (need to rule out potential globe rupture)
● Minor trauma or complications from contact lens use
● History of elevated venous pressure (Valsalva, coughing, vomiting)
● Hypertension
● Diabetes mellitus
● Coagulopathy

Question 33

Uveitis (key point, symptoms. associated conditions)

Answer 33

Key point
● Occurs in association with other systemic medical conditions (especially infections and inflammatory
diseases)
Symptoms
● Anterior uveitis: pain and redness
● Posterior or intermediate uveitis: painless, floaters and/or some degree of visual loss
Associated conditions: Spondyloarthritis, inflammatory bowel disease, sarcoidosis, juvenile idiopathic arthritis. Less
likely multiple sclerosis.

Question 34

44F, presenting with 2 days of photophobia in R) eye with pain. Visual acuity R) eye is 6/18.

What is the likely diagnosis?

Answer 34

R) eye uveitis