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Medicine > Ophthalmology > Flashcards

Ophthalmology Flashcards

1
Q

What are the three layers of the eyeball? Outline the components of each.

A

Fibrous: Sclera (fibrous layer, white) and cornea (transparent, central)

Vascular: Choroid, ciliary body and iris

  • Choroid: CT layer and BVs
  • Ciliary body: ciliary muscle and processes; attach to lens of eye via ciliary processes to control lens shape and formation of (aq) humour
  • Iris: circulator structure which is situated between lens and cornea

Inner: Retina

  • Pigmented (outer) layer: retinal pigment epithelium allowing light absorption, epithelium transport and secretion of growth factors
  • Neural (inner) layer: Photoreceptors
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2
Q

What are the two components of the fibrous layer of the eyeball?

A

Sclera

Cornea

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3
Q

What fibrous layer of the eyeball provides attachment to the extra ocular muscles?

A

Sclera (Tenon’s capsule/Sclera)

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4
Q

What two components make up the ciliary body?

A

Ciliary muscles

Ciliary processes

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5
Q

What is the function of the ciliary body?

A

Change the shape of the lens of the eye to control refraction of light to the retina

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6
Q

What is the function of the iris?

A

Alter the diameter of the pupil (the aperture within the iris)

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7
Q

Functionally, which is the most important layer of the eyeball?

A

Neural layer, bearing the retina

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8
Q

Which fascial sheet surrounds the eye?

What does it connect to anteriorly and posteriorly?

What potential space is between it and the sclera?

A

Tenon’s capsule

Anteriorly: Sclera

Posteriorly: Meninges around the optic nerve

Episcleral space

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9
Q

Which ligament is formed by the tendon sleeve around the tendon of the medial rectus muscle?

Where does it attach to?

A

Medial check ligament

Lacrimal bone

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10
Q

Which ligament is formed by the tendon sleeve around the tendon of the lateral rectus muscle?

Where does it attach to?

A

Lateral check ligament

Zygomatic bone

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11
Q

At what site of the eyeball is the optic nerve perforating the eye?

A

Posterior scleral foramen

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12
Q

At the posterior scleral foramen, what portions of sclera are continuous with the meningeal sheath of the optic nerve?

Which meningeal layer forms the sheath surrounding the optic nerve?

A

2/3 outer of sclera continuous with the dural sheath of optic nerve

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13
Q

What structure is formed by the inner third of the sclera pieced by the fibres of the optic nerve?

A

Lamina cribrosa

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14
Q

What 4 apertures does the sclera contain?

A

4 anterior apertures: Scleral attachments of rectus muscles, transmitting anterior ciliary arteries

4-5 middle apertures: vorticose veins (posterior to equator of eye)

Posterior apertures: passage of long and short ciliary arteries, veins and nerves

Posterior scleral foramen: Optic nerve pierces sclera

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15
Q

What is the term for the point at which the sclera meets the cornea?

A

Corneoscleral junction (CSJ)

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16
Q

What structure lies posterior to the Corneoscleral junction and within the internal surface of the sclera?

A

Canal of Schlemm (internal scleral sulcus)

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17
Q

At which point of the internal scleral sulcus is the ciliary muscle attached to?

A

Scleral spur (anteriorly and inwards)

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18
Q

What are the 3 layers of the sclera?

A

Episclera (connective tissue layer)

Scleral stroma (dense irregular CT - white colour)

Lamina fusca (melanocytes)

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19
Q

What is the potential space between the lamina fascia and choroid termed?

Which structures traverse it?

A

Perichoroidal space

Traversed by long and short posterior ciliary arteries and nerves

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20
Q

Outline the vascular supply to the sclera?

A

Anterior: Episcleral plexus

Posterior: Branches of long and short posterior ciliary arteries

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21
Q

What is the innervation of the sclera?

A

Anterior: Long ciliary nerves

Posterior: Short ciliary nerves

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22
Q

What is the term for the convex surface at the corneoscleral junction?

A

Sulcus sclerae

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23
Q

What are the layers that form the cornea?

A

Corneal epithelium: 5 cell layers (central) - 10 cell layers (peripheral)

Bowman’s membrane: acellular with irregularly arranged collagen fibrils

Substantia propria (corneal stroma): 90% thickness of cornea; parallel-arranged collagen fibres

Descemet’s membrane: basement membrane of underlying cornea endothelium; collagen fibres; peripherally, protrusions projecting into anterior chamber of eye (Hassal-Henle bodies); continuous with meshwork of Schlemm’s canal; line of junction of Descemet’s membrane and trabecular meshwork of Schlemm’s canal is called line of Schwalbe

Corneal endothelium: single layer of endothelial cells; continuous with surface of iris; forms barrier between cornea and surrounding structures; do not undergo mitosis thus if injured, corneal surface is permanently opaque

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24
Q

The protrusions of Descemet’s membrane which project into anterior chamber of eye are termed?

A

Hassal-Henle bodies

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25
Q

At what point do Descemet’s membrane and trabecular meshwork of canal of Schlemm meet?

A

Line of Schwalbe

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26
Q

What supplies blood to the cornea?

A

Cornea is an avascular structure; nourished by nutrients of aqueous humor via endothelial layer

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27
Q

What innervates the cornea?

A

Annular plexus in perichoroidal space (fr. Long Ciliary Nerves)

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28
Q

What structure of the eye has the highest refractory power?

A

Cornea - 42 diopters of light

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29
Q

What is the unit of measurement for refractivity? Explain this

A

Diopters

unit of measurement of the optical power of a lens or curved mirror, which is equal to the reciprocal of the focal length measured in metres

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30
Q

What structures make up the uvea?

A

Choroid, ciliary body and iris

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31
Q

What is the most vascular layer of the eye?

A

Choroid of the vascular layer (uvea)

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32
Q

What are the layers of the choroid?

A

3 layers:

1) Vessel layer: Melanocytes + BVs
2) Capillary layer: melanocytes + branches of BVs
3) Bruch’s membrane: BM of endothelium of capillaries; collagen; elastic fibres and BM of pigmented layer of retina

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33
Q

What innervates the choroid?

A

Long and short ciliary nerves in the perichoroidal space

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34
Q

What is the function of the choroid?

A

Perfusion of outer layers of the retina and between eye

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35
Q

What is the ciliary body continuous with?

A

Choroid posteriorly and iris anteriorly, forming the uvea

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36
Q

What is the roughened base of the ciliary body called?

A

COrona ciliaris

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37
Q

What is the smoothened, posterior surface of the ciliary body called?

A

Orbiculus ciliates

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38
Q

What are the components of the ciliary body?

A

Ciliary epithelium: 2 layers; inner layer is non-pigmented and continuous with retina posteriorly; pigmented cells which are continuous with pigmented epithelium of retina

Ciliary stroma: loose CT and rich in BV

Ciliary muscle: smooth muscle in the ciliary stroma; pulling ciliary body anteriorly leading to loosening of zonular fibres of lens so lens shrinks and becomes more convex to enhance refractive power of lens (in accommodation)

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39
Q

What innervates the ciliary body?

A

Short ciliary nerves (parasympathetic input from CN III)

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40
Q

What are the functions of the ciliary body?

A

Produce aqueous humor

Accommodation of the eye

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41
Q

What structure of the eye represents the border of the anterior and posterior chambers of the eye?

A

Iris

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42
Q

What is the periphery of the iris termed?

A

Ciliary margin

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43
Q

What is the term for the angle formed by iris root (ciliary margin) and cornea?

A

Iridocorneal angle (filtration angle)

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44
Q

Where is the trabecular meshwork, facilitating aq drainage of humor present?

A

At the iridocorneal (filtration) angle of the iris and cornea

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45
Q

Which two muscles does the iris contain?

A

Smooth muscle

Sphincter pupillae muscle

Dilator pupillae

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46
Q

What are Fuch’s crypts?

A

gaps between radial streaks (collagen fibre bands) converging towards the pupil

Present on the anterior surface of the iris

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47
Q

What colour is the posterior surface of the iris?

What does it contain?

A

Black

Radial contraction folds with contraction furrows (several circular lines) marking the ciliary portion

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48
Q

What is the blood supply to the iris?

A

Majort arterial circle (anterior + posterior ciliary arteries)

Radial arteries anastomose to form minor arterial circle of iris (at level of collarette of the iris)

Minor venous circle (veins of pupillary margin which strain into vorticose veins)

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49
Q

What innervates the iris?

A

Long and short ciliary nerves (br. CN V1)

Papillary muscles (autonomic function): 
- Sphincter pupillae (short ciliary nerves of CN III)
  • Dilator pupillae (superior cervical ganglion)
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50
Q

What are the functions of the iris?

Explain how muscle contractions alter the shape of the pupils.

A

Accommodation (refracting light accordingly to see an image)

Contraction of dilator pupillae muscle (Sup. cervical ganglion) causes dilation of the pupil called mydriasis

Contraction of the sphincter pupillae muscle reduces the pupil size called minis

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51
Q

What are the two parts of the retina?

What us the term for the space between these layers?

A

Neurosensory retina (inner)

Retinal pigmented epithelium (outer)

Potential space = sub retinal space

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52
Q

What is the term for the anterior retinal end at its junction with the ciliary body?

A

Ora serrata

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53
Q

What is the non-visual layer of the retina?

A

Ciliary epithelium (as it is continuous with the retina)

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54
Q

What is the site of clearest vision, containing the highest amount of photoreceptor cells?

A

Macula lutea

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55
Q

What is the term for the shallow depression in the centre of the region with the highest amount of photoreceptor cells?

What is this region called?

A

Fovea centralis

Macula lutea

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56
Q

What are the two main types of photoreceptor?

Outline their function and distribution in the retina

A

Rods and Cones

Cones:

  • Cone shaped
  • High-intensity light
  • Colour vision
  • Dense presence at fovea centralis

Rods:

  • Conical shape
  • Low-intensity light
  • Grayscale
  • Peripherally distributed
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57
Q

Which cells synapse with the photoreceptors and transmit an action potential to ganglion cells?

A

Bipolar cells

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58
Q

What are the second order neurones in the visual pathway?

A

Ganglion cells, synapsing with bipolar and amacrine cells

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59
Q

What are the function of horizontal cells?

A

Distributed around the apices of rods and cones, these release GABA which inhibits distant ganglion cells, enabling optic nerve to transmit signals from photoreceptors most excited and contributing to the formation of a clear image

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60
Q

What is the function of the amacrine cells?

A

bipolar cells stimulate the amacrine cells, which in turn stimulate the ganglion cells with which they synapse. Therefore, the amacrine cells are the indirect connection between bipolar and ganglion cells and their function is to modulate the photoreceptive process by ensuring that all the relevant ganglion cells are stimulated

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61
Q

What cells are most abundant in the outer limiting layer? What role do they play?

A

Muller cells (Supporting cells) which connect with photoreceptor cells.

Muller cell processes reach anterior surface of retina with terminal dilation covered by BM which forms the inner limiting membrane.

Other supporting cells:

  • Retinal astrocytes
  • Perivascular glial cells
  • Microglial cells
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62
Q

what are the 10 retinal layers?

A

Mnemonic: In New Generation It Is Only Ophthalmologist Examines Patient’s Retina

Inner Limiting Membrane 
Nerve fibre layer 
Ganglion cell
Inner plexiform layer
Inner Nuclear layer
Outer nuclear layer 
Outer plexiform layer
External limiting membrane 
Photoreceptors
Retinal pigment epithelium
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63
Q

Outline the features of the 10 retinal layers.

A

Inner Limiting Membrane (Muller cell processes)

Nerve fibre layer (axons and ganglion cells)

Ganglion cell (nuclei of ganglion cells)

Inner plexiform layer (synapses of bipolar, amacrine and ganglion cells)

Inner Nuclear layer (nuclei of bipolar, horizontal, amacrine and Muller cells)

Outer nuclear layer (synapses of rods and cones, bipolar and horizontal cells)

Outer plexiform layer (synapses between terminal processes of rods and cones, bipolar and horizontal cells)

External limiting membrane (Muller cells and supporting cells)

Photoreceptors (rods and cones)

Retinal pigment epithelium (cuboidal cells with pigment)

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64
Q

What is the function of the retinal pigment epithelium?

A

1) The cells of the RPE contain a high amount of dark pigment. Their function is to absorb light which passes through the retina and prevent it from reflecting back to the neurosensory layer. This feature is of great importance for a clear vision
2) Additionally, the cells of the RPE contribute to nourishing of the retina and it forms the blood-retinal barrier. The barrier is composed of the tight junctions between the cells of the RPE and its function is to prevent the diffusion of large and/or toxic molecules from the choroid into the retina.

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65
Q

What is the blood supply to the retina?

A

1-6 = central retinal artery

7-10 = choroid

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66
Q

What are the components of the lens?

A

Capsule

Epithelium: SCE deep to lens capsule

Lens fibres: transformed, elongated epithelial cells

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67
Q

What fibres hold the lens in place? Where do they extend from?

A

Zonular fibres which summate to form suspensory ligament of lens

Arise from ciliary processes

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68
Q

What is the anterior concavity adapted to fit with the convexity of the lens called?

A

Hyaloid fossa

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69
Q

What channel extends from the optic disc to the posterior pole of the lens?

What is its relevance?

A

Hyaloid channel

Bears hyaloid artery in foetal life

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70
Q

What is aqueous humor?

A

The aqueous humor is a nutrient-rich fluid that fills the anterior and posterior chambers of the eye. The amount of aqueous humor in a healthy human eye is 200 milliliters. The aqueous humor is produced by the ciliary processes and delivered into the posterior chamber of the eye.

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71
Q

Outline the drainage of aqueous humor.

A

Produced by ciliary processes and delivered into posterior chamber of eye.

Humor passes through zonular fibres and into iris to reach anterior chamber of eye. Flows via trabecular meshwork of Schlemm’s canal and drains into it.

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72
Q

What structure produces aqueous humor?

A

Ciliary body (ciliary epithelium)

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73
Q

What is normal intraocular pressure?

How is this created?

A

10-21mmHg

Resistance to flow through trabecular meshwork into Canal of Schlemm

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74
Q

Outline the pathophysiology in open-angle glaucoma.

A

Gradual increase in resistance via trabecular meshwork thus chronic onset of glaucoma

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75
Q

Outline the pathophysiology in close-angle glaucoma.

A

Iris bulges forward to occlude trabecular meshwork from anterior chamber resulting in accumulation of aq humor and subsequent pressure rise

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76
Q

What is a normal cup-disc ratio?

A

0.4-0.7

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77
Q

What are the clinical features of glaucoma?

A 
Vision loss: Tunnel vision 
Eye pain
Headaches
Blurred vision
Halos around lights
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78
Q

How may you measure IO pressure in an emergency?

A

Tanometry (non-contact or Goldmann application)

CT-Ocular

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79
Q

What is the gold-standard way of measuring intraocular pressure?

A

Goldmann application tanometry

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80
Q

How do you manage open-angle glaucoma?

A

PG analogue: Latanoprost

2nd
ß-blockers: Timolol

Sympathomimetic: Brimonidine

CAi: Acetazolamide

Miotics: Pilocarpine

Surgery: Trabeculectomy

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81
Q

What is the MOA of latanoprost in Glaucoma?

A

Increase uveoscleral outflow

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82
Q

What are the side effects of latanoprost?

A

Eyelash growth

Eyelid pigmentation

Iris pigmentation

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83
Q

What is the MOA of ß-blockers in glaucoma?

A

Reduce aq humor production

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84
Q

What is the MOA of CA-i in glaucoma?

A

Reduce aq humor production

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85
Q

What is the MOA of Briminodine in glaucoma?

A

Sympathomimetic (a2 agonist) thus reduce aq production and increase outflow

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86
Q

What surgery may be able to treat Open-Angle glaucoma refractors to eye drops?

A

Trabeculectomy surgery may be required where eye drops are ineffective. This involves creating a new channel from the anterior chamber, through the sclera to a location under the conjunctiva.

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87
Q

Which patients should not receive Timolol?

A

Asthmatics

Heart block

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88
Q

What are the side effects of Brimonidine?

A

Hyperaemia

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89
Q

What are the side effects of pilocarpine?

A

Miosis
Headache
Blurred vision

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90
Q

What are the clinical features of acute angle closure glaucoma?

A

severe pain: may be ocular or headache
decreased visual acuity
symptoms worse with mydriasis (e.g. watching TV in a dark room)
hard, red-eye
haloes around lights
semi-dilated non-reacting pupil
corneal oedema results in dull or hazy cornea
systemic upset may be seen, such as nausea and vomiting and even abdominal pain

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91
Q

What is the management of acute angle closure glaucoma?

A

Pilocarpine
Timolol
Acetazolamide

Surgical: Laser peripheral iridotomy

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92
Q

What is the most common cause of blindness in the UK?

A

ARMD

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93
Q

What are the risk factors for Age Related Macular Degeneration?

A

Age
Smoking
FHx
Arteriopath

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94
Q

What form of macular degeneration os most commonly seen?

A

90% is Dry Macular Degeneration

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95
Q

What are the clinical features of macular degeneration?

A 
Reduced visual acuity 
Central scotoma 
Distortion of straight lines 
Visual changes
Photopsia (flickering/flashing lights)

Drusen
Red patches with fluid leak or haemorrhage

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96
Q

How is ARMD managed?

A

Dry:
Supportive: Stop smoking; BP control; Vitamin supplementation

Wet: Randibizumab
±
Laser photocoagulation

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97
Q

Outline the pathophysiology of diabetic retinopathy.

A

Chronic hyperglycaemia leads to AGEPs which damages the endothelial cells resulting in increased vascular permeability; micro aneurysms; exudates and axonal damage (cotton wool spots) and neovascularisation due to aberrant healing

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98
Q

What are the two main types of Diabetic Retinopathy?

A

Non-Proliferative

Proliferative

Maculopathy

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99
Q

What are the severities of non-proliferative diabetic retinopathy?

A

Mild: Microaneurysms

Moderate: Microaneurysms, blot haemorrhages, exudates, cotton wool spots, venous beading

Severe: Blot haemorrhages and micro aneurysms in all 4 quadrants; venous beading in 2 quadrants and intraretinal microvascular abnormality in any quadrant

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100
Q

How do you manage diabetic retinopathy?

A

Supportive: Glycaemic control; hypertension control; dyslipidaemia control; ophthalmology review

± Non-proliferative
- Observation

If severe:
- Laser photocoagulation

± Proliferative:
- Laser photocoagulation
+
- Intravitreal VEGFi: Randabizumab

Maculopathy:
- VEGFi: Randabizumab

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101
Q

What component of the eye produces aqueous humor?

A

Pars plicata of the ciliary body

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102
Q

What investigation allows direct visualisation of the chamber angle?

A

Gonioscopy

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103
Q

In which condition is a Sampaolesi line commonly seen?

What is observed?

A

Pseudoexfoliation (Pigment dispersion syndrome)

Abundance of pigment at Schwalbe’s line (collagen tissue condensation at the edge of Descemet’s membrane)

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104
Q

Outline the structures seen at the anterior angle?

A

Mnemonic: I Can See This Stuff

Iris

Ciliary body

Scleral spur

Trabecular meshwork

Schwalbe’s line

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105
Q

By what process does do ganglion cells die in Glaucoma?

A

Apoptosis

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106
Q

What are the thickest portions of the neuroretinal rim?

A

Mnemonic: ISNT

Inferior > Superior > Nasal > Temporal

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107
Q

In which ethnicities is Primary Angle Closure Glaucoma most common?

A

Asian

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108
Q

In which ethnicities is Primary Open Angle Glaucoma more common?

A

European

African

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109
Q

What are the risk factors of POAG?

A 
Increasing age
Afro-caribbean ethnicity 
European heritage 
Myopia
Hypertension
Diabetes Mellitus
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110
Q

What are the potential side effects of Dorzolamide?

A

Sulphonamide-like reactions

Mnemonic: SULPHONAMIDES

SJS 
Urinary stones 
Lyell's Syndrome (TEN)
Photosensitivity
Haematological/Hepatic 
Ocular side effects 
Neonatal jaundice 
Antimetabolites (inhibit THF reductase)
Miscarriage 
Intolerance 
Dermatitis 
Eosinophilia
Serum sickness
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111
Q

What relation may central cornea thickness have to glaucoma risk?

A

A thinner cornea may be a risk factor for patients with OHT due to poor measurement of IOP (reads lower cf actual) and potentially less rigid support structure around optic nerve head

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112
Q

What other investigation may be used to assess the anterior chamber angle in conjunction with Gonioscopy?

A

Van Herick test - looks at ratio of anterior chamber depth cf corneal thickness

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113
Q

What is the management of primary open angle glaucoma?

A

Vision loss is irreversible, aim to halt the progression

Supportive: Patient education; Annual Review (set target for IOP lowering)
+
Medical: Topical Latanoprost > Timolol > CAi

±
Surgery: Laser trabeculoplasty OR Trabeculectomy

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114
Q

Describe pseudoexfoliation syndrome.

A

Exfoliation (pseudoexfoliation) Syndrome is characterized by the fibrillar deposits in the anterior segment of the eye.

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115
Q

What are the risk factors for Pseudoexfoliation syndrome?

A

Advanced age: 50+

Scandinavian heritage

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116
Q

What extracellular matrix products are deposited in high quantities in Pseudoexfoliation syndrome?

A

Fibrillin
alpha-Elastin
Laminin

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117
Q

What are the clinical features of Pseudoexfoliation syndrome?

A

Relatively asymptomatic

Increased IOP
Possible glaucomatous damage to optic nerve
Sampaolesi line (increased pigment) of trabecular meshwork
Fibrillar flaky deposits on anterior lens capsule

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118
Q

How is pseudoexfoliation syndrome managed?

A

Supportive: Review examination; glaucoma monitoring

± Glaucomatous changes
- Timolol

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119
Q

What is a posterior synechiae?

A

Posterior joining of the iris to the ciliary body, preventing aqueous humor draining from the anterior of the eye into the posterior chamber

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120
Q

What are the three routes for aqueous humor to drain from the anterior to posterior chamber?

A

Trabecular

Uveoscleral outflow

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121
Q

What are 3 risk factors for PACG?

A 
Advancing age 
Hyperopia 
FHx 
Female gender 
Asian descent 
Shallow anterior chamber depth 
Thicker lens
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122
Q

What is the gold-standard for diagnosing primary closed angle glaucoma?

A

Gonioscopy

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123
Q

What are the clinical features of PACG?

A 
Visual loss: Tunnel vision (arcuate distribution of temporal retinal fibres) 
Blurred vision 
Rainbows
Halos around lights 
Eye pain 
Nausea and vomiting

Raised IOP
Mid-dilated pupil (iris sphincter ischaemia) -> Sectoral iris atrophy
Optic nerve atrophy -> Cupping

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124
Q

How is PACG managed?

A

Vision loss is irreversible, a medical emergency

Medical: topical Timolol + topical Latanoprost + Topical Pilocarpine + IV Acetazolamide

±

Surgery: Laser peripheral iridotomy

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125
Q

Describe Pigment Dispersion Syndrome.

A

spectrum of the same disease characterized by excessive pigment liberation throughout the anterior segment of the eye

Triad: Dense trabecular meshwork pigmentation + Iris transillumination defects + Central cornea posterior surface pigment deposition

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126
Q

What is the purported aetiology of pigmented dispersion syndrome?

A

concave iris contour which causes rubbing of the posterior iris surface against the anterior lens zonules bundles during physiological pupil movement, leading to disruption of the iris pigment epithelial cell membrane and release of pigment granule

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127
Q

What are the risk factors for Pigment Dispersion Syndrome?

A 
Male gender 
Advanced age 
Myopia 
African ancestry 
Concave iris 
Flat cornea 
FHx
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128
Q

What are the clinical features of Pigment Dispersion syndrome?

A

Haloes; Blurry vision

Krukenberg spindles (vertical corneal pigmentation) + TM pigmentation + Transillumination defects

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129
Q

How is Pigment Dispersion Syndrome managed?

A

Latanoprost

or

Timolol

or

Pilocarpine

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130
Q

What causes 100 day glaucoma? Outline the pathophysiology behind this.

A

Diabetes mellitus; Carotic occlusive disease; Central Retinal Vein Occlusion with glaucoma forming due to neovascularisation

This occurs in the aforementioned diseases whereby retinal ischaemia occurs, resulting in VEGF production which supports new vessel growth on the iris. The new vessels have surrounding fibrovascular membranes which produce radial traction resulting in peripheral anterior synechiae (iris with TM) which results in open angle glaucoma which may progress to angle closure glaucoma.

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131
Q

How is Neovascular Glaucoma (NVG) managed?

A

Surgical: Pan-retinal photocoagulation (PRP)

± Medical
Medical: ß-blockers/CAi/PG analogues/Cholinergics

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132
Q

What are the drugs that cause cataract?

A

Amiodarone
Busulfan
Chlorpromazine/ Corticosteroids
Dexamethasone

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133
Q

What are the boundaries of the orbit?

A

Roof: Front-Less (Frontal + Lesser wing of Sphenoid)

Lateral: Great-Z (Greater wing of Sphenoid + Zygomatic

Medial: SMEL (Sphenoid + Maxilla + Ethmoid + Lacrimal)

Floor: My Zipped Pants (Maxialla + Zygomatic + Palatine)

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134
Q

Outline the structures present at the superior orbital fissure.

A

Use common tendinous ring as a reference point

Outside ring:
LFTs - Lacrimal nerve (CNV1) + Frontal Nerve (CNV1) + Trochlear nerve (CN IV)

CN III (Superior and Inferior)
Abducens nerve (lateral) 
Nasociliary nerve (medial) 
Ophthalmic art. 
Ophthalmic nerve (CN I)
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135
Q

What is the cause of Thyroid Eye disease?

A

Hyperthyroidism (90%) cases in which elevated T3 and T4 may exert effects on orbital fibroblasts

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136
Q

What are the risk factors for Thyroid Eye Disease?

A

Female
Hyperthyroidism (Grave’s)
Smoking
Stress/Infection

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137
Q

What is the main risk factor for Thyroid Eye Disease?

A

Smoking

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138
Q

What is the most common muscle affected by Thyroid Eye Disease?

A

Inferior Rectus (CN III)

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139
Q

What are the clinical features of thyroid eye disease?

A 
Gritty eyes
Photophobia 
Lacrimation
Dry eyes
Protrusion of the eye (Exomthalmos) 
Vision changes: Blurred; Double vision 
Eyelid retraction (Dalrymple's sign) 
Lid lag (Kocher sign)
Exompthalmos 
Eye muscle involvement (IM SLOw) 
Compressive optic neuropathy (fulminant visual loss)
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140
Q

What is the refractive index of the lens?

A

1.4

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141
Q

What are the 3 portions of the lens?

A

Capsule

Cortex

Nucleus

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142
Q

What collagen type makes up the capsule?

A

Type 4

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143
Q

What type of epithelia is present on the lens?

A

Simple cuboidal cells

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144
Q

What structures connect the ciliary body to the lens nucleus?

What is it made of?

A

Zonules of Zinn make up the Zones

Fibrillin

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145
Q

What type of cataracts give you a myopic shift with second sight of the aged?

A

Nuclear sclerotic cataract

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146
Q

What gives the nuclear sclerotic cataract its yellow colour?

A

Urochrome deposition

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147
Q

You observe a cataract with a wedge-shape opacity? What type of age-related cataract is it?

A

Cortical cataract

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148
Q

What type of cataracts cause significant visual defect with glare?

A

Subcapsular cataracts

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149
Q

What type of cataracts are observed in myotonic dystrophy?

A

Iridescent cortical opacities

Star-shaped cortical opacities

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150
Q

What type of cataracts are seen in Atopic dermatitis?

A

Shield-like, dense anterior plaques

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151
Q

What is the most common cause of secondary cataracts?

A

Chronic uveitis

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152
Q

What type of cataract is observed in acute congestive angle closure?

A

Glaucomflecken - small, anterior grey-white sub capsular opacities

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153
Q

Which of the following IOLs are especially prone to the development of posterior capsular opacification?

A

​

Polymethylmethacrylate (PMMA) IOLs.

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154
Q

What bacterium is the cause of post-op endophthalmitis?

A

S epidermidis

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155
Q

What is the most common late complication of cataract surgery?

A

Posterior capsular opacification (PCO)

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156
Q

Which form of lens in cataract surgery is associated with posterior capsular opacification?

A

PMMA IOLs

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157
Q

What are the clinical features of posterior capsular opacification?

A

Persistently slowly worsening blurring & glare. ​
Reduced VA. ​
Vacuolated (pearl-type) PCO – consists of proliferating swollen lens epithelial cells. ​
Fibrosis-type PCO – due to fibroblastic metaplasia of epithelial cells. ​
Soemmering ring – a whitish annular or doughnut-shaped proliferation of residual cells that classically forms at the periphery of the capsular bag following older methods of cataract surgery. ​

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158
Q

How is posterior capsular opacification managed?

A

Posterior capsulotomy – create an opening in the posterior capsule using a Nd-YAG laser.

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159
Q

What type of clinical sign is a centra oil droplet cataract pathognomonic of?

A

Congenital cataract

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160
Q

How do you manage bilateral dense cataracts?

A

urgery between 4-10 weeks to prevent development of stimulus deprivation amblyopia.

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161
Q

How do you manage unilateral dense cataracts?

A

4-6 weeks

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162
Q

What is the most common cause of proptosis in adults?

A

Thyroid Eye Disease

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163
Q

How may Thyroid Eye Disease be classified?

A

Mild vs Moderate-Severe

Mild:

  • Lid retraction <2mm
  • Exophthalmos <3mm
  • Transient/absent diplopia
  • Mild soft tissue involvement

Moderate-Severe:

  • Lid retraction >2mm
  • Exophthalmos >3mm
  • Diplopia
  • Moderate-severe soft tissue involvement
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164
Q

When do you conduct an orbital decompression in moderate-severe active thyroid eye disease?

A

6/12

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165
Q

What are the features of sight-threatening thyroid eye disease?

A

Optic neuropathy

Corneal breakdown

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166
Q

How do you manage a patient with dysthyroid optic neuropathy?

A

High dose IV glucocorticoids – treatment of choice. ​

Orbital decompression – if GC response poor after 1-2 weeks or GC side effects intolerable

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167
Q

What type of cellulitis most commonly follows a sinus infection?

A

Orbital cellulitis

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168
Q

What clinical features are fundamentally different in preseptal and orbital cellulitis?

A

Proptosis, VA reduced, ophthalmoplegia and diplopia

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169
Q

What is the gold-standard investigation in Orbital Cellulitis?

A

CT-Orbit

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170
Q

What is the most common cause o a direct carotid cavernous fistula?

A

Trauma

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171
Q

A patient presents following a head injury. They have a pulsatile proptosis and conjunctival chemosis. They say they can hear a whooshing noise in the head.

O/E there is optic disc swelling and ophthalmoplegia.

What is your DDx?

A

Direct carotid cavernous fistula

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172
Q

What is the gold-standard investigation for Carotid Cavernous Fistula?

A

Digital subtraction angiography

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173
Q

How do you manage a carotid cavernous fistula?

A

Direct: Transarterial repair

Indirect: Transvenous occlusion

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174
Q

A child presents with a bright red, superficial cutaneous lesion on the eyelid.

What is your DDx?

A

Capillary haemangioma

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175
Q

What is your Tx for a Capillary Haemangioma?

A

Oral propanolol

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176
Q

What is the most common orbital tumour in adults?

A

Cavernous haemangioma

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177
Q

Where is a cavernous haemangioma most commonly found?

A

Lateral portion of muscle cone behind the globe

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178
Q

How do you manage a cavernous haemangioma?

A

Observe if asymptomatic ​

Surgical removal if symptomatic.

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179
Q

How is aqueous humor secreted?

A

Active transport

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180
Q

What is the main route by which aqueous humor travels out of the eye?

A

Trabecular outflow

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181
Q

From posterior to anterior, what are the AC angle structures that can be seen on gonioscopy?

A

Iris process -> ciliary body -> scleral spur -> trabeculum -> Schwalbe line.

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182
Q

Which visual field defects is not typically seen in glaucoma?

A

Central scotoma

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183
Q

Which of the following is not a side effect of Timolol?

A. Bronchospasm

B. Tachyphylaxis

C. Heart block

D. Paraesthesia

A

D. Paraesthesia

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184
Q

Which of the following is not a side effect of Timolol?

A. Bronchospasm

B. Tachyphylaxis

C. Increased urination

D. Heart block

A

C. Increased urination

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185
Q

Which of the following is not a side effect of Dorzolamide?

A. Stinging sensation

B. Bitter taste

C. Paraesthesia

D. Dermatitis

A

C. Paraesthesia

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186
Q

Which of the following is not a side effect of pilocarpine?

A. Miosis

B. Brow ache

C. Conjunctival hyperaemia

D. Myopia

A

C. Conjunctival hyperaemia

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187
Q

Which of the following is not a side effect of Latanoprost?

A. Eyelash growth

B. Brow ache

C. Conjunctival hyperaemia

D. Hyperpigmentation of iris

A

B. Brow ache

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188
Q

Which region has the highest incidence of Pseudoexfoliation Syndrome?

A

Scandinavia

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189
Q

A young myopic man has blurry vision on exertion. Slit lamp examination shows spoke-like iris transillumination defects. What is the most likely diagnosis?

(A) Pseudoexfoliation syndrome ​
​
(B) Pigment dispersion syndrome. ​
​
(C) Acute angle closure glaucoma. ​
​
(D) Neovascular glaucoma.
A

(B) Pigment dispersion syndrome.

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190
Q

What is the refractive index of the cornea?

A

1.376​

​

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191
Q

Where is the thickest portion of the cornea?

A

Thickest towards the periphery

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192
Q

How many layers are there of the cornea?

Outline them and their contents

A

A-E

Epithelium (above): SSE; can regenerate

Bowman: Acellular

Stroma (C): Type I collagen

Descemet: elastic Type IV collagen; can regenerate

Endothelium: polygonal cells; pump excess fluids out of stroma - keep cornea dehydrated and transparent

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193
Q

What is the most important risk factor for developing bacterial keratitis?

A. Contact lens wear. ​
​
B. Eye trauma. ​
​
C. Pre-existing corneal ulcer. ​
​
D. Immunosuppression.
A

A. Contact lens wear. ​

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194
Q

Which pathogen predominantly causes Bacterial Keratitis?

A. S. aureus

B. Streptococci

C. Klebsiella

D. P. aeruginosa

A

D. P. aeruginosa

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195
Q

What investigation do you use in a suspected case of bacterial keratitis?

A

Corneal draping for MC+S

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196
Q

How do you manage a case of bacterial keratitis?

A

Supportive: Stop CL wearing
+
Medical: Topical Ciprofloxacin + Cyclopentolate

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197
Q

Why do you prescribe Cyclopentolate in a case of Bacterial Keratitis?

A

prevent formation of posterior synechiae & reduce pain. ​

​

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198
Q

A patient presents with unilateral eye redness, pain and photophobia. On examination with fluorescein, you note the following stellate fluorescent shapes. What is the diagnosis?

A

Herpes Simplex Keratitis

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199
Q

What strain of Herpes Simplex is associated with blepharoconjunctivitis?

A

HSV-1

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200
Q

A patient presents with unilateral eye redness, pain and photophobia. On examination with fluorescein, you note the following stellate fluorescent shapes.

What is your management?

A

Topical aciclovir 3%

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201
Q

In severe herpes simplex keratitis, the union of multiple dendritic ulcers is called?

A

Geographic ulcer

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202
Q

Why do you not use topical steroids in Herpes Simplex Keratitis?

A

​

Do not use topical steroids – risk of corneal perforation. ​

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203
Q

A 52 y/o M presents with malaise and fever for 5/7; facial pruritus and the presence of some vesicles on the left side of the nose. The rash was maculopapular just yesterday. Fluorescein dye shows dendritic epithelial lesions with tapered ends. Slit-lamp shows iris atrophy.

What is your DDx?

What is the cause of this condition?

What sign is associated with this condition?

How do you manage this condition?

A

Herpes Zoster ophthalmic

VZV affecting CNV1

Hutchinson Sign

Tx:
Medical: Oral acyclovir 5 times a day within 72 hours of rash
+
VZV vaccine

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204
Q

What layer of the cornea is affected in Interstitial Keratitis?

A

Corneal stroma

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205
Q

A patient presents with a reduced vision. They had a history of failure to thrive and maculopapular rash as a neonate.

O/E you see a saddle-shaped nose deformity. On slit-lamp examination, you notice a pink salmon patch with deep stromal vascularisation.

What is your diagnosis?

A. Herpes simplex keratitis

B. Interstitial keratitis

C. Bacterial keratitis

D. Acanthamoeba keratitis

A

B. Interstitial keratitis

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206
Q

Which of the following signs is pathognomonic for acanthamoeba keratitis?

A. Perineural infiltrates. ​
​
B. Ring abscess. ​
​
C. Anterior stromal infiltrates. ​
​
D. Eye pain out of proportion of clinical findings.
A

A. Perineural infiltrates.

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207
Q

A patient presents with blurry vision and eye pain which is disproportional to what the GP observed. O/E there is dVA. Slit-lamp examination shows perineurial infiltrates.

What is your management for this condition?

A. Chlorhexidine

B. PMHB

C. Oxifloxacin

D. Fusidic Acid

A

B. PMHB

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208
Q

What condition is most commonly associated with peripheral corneal infiltration, ulceration or thinning?

A. OA

B. Sjogren’s

C. RA

D. SLE

A

C. RA

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209
Q

A patient presents with reduced vision 2/52. They describe pain, redness, tearing and photophobia. O/E you see crescentic ulceration.

What is your DDx?

A. Herpes simplex keratitis

B. Peripheral ulcerative keratitis

C. Bacterial keratitis

D. Acanthamoeba keratitis

A

B. Peripheral ulcerative keratitis

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210
Q

A patient presents with reduced vision 2/52. They describe pain, redness, tearing and photophobia. O/E you see crescentic ulceration.

What is your Tx?

A. Chlorhexidine

B. PMHB

C. Oral steroids

D. Fusidic Acid

A

C. Oral steroids

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211
Q

A patient presents with reduced vision over the past few months. They describe their vision is not what it used to be.

O/E you see an apical protrusion of the cornea. You notice an ‘oil droplet’ red reflex.

Slit-lamp shows fine vertical stromal lines.

What are the clinical features observed?

A

Oil droplet red reflex

Vogt lines

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212
Q

A patient presents with reduced vision over the past few months. They describe their vision is not what it used to be.

O/E you see an apical protrusion of the cornea. You notice an ‘oil droplet’ red reflex.

Slit-lamp shows fine vertical stromal lines.

What condition is this?

A

Keratoconus

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213
Q

A patient presents with reduced vision over the past few months. They describe their vision is not what it used to be.

O/E you see an apical protrusion of the cornea. You notice an ‘oil droplet’ red reflex.

Slit-lamp shows fine vertical stromal lines.

What is your management of this?

A. Fusidic acid topical

B. Deep anterior lamellar keratoplasty

C. Steroids

D. Laser iridotomy

A

B. Deep anterior lamellar keratoplasty

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214
Q

Corneal oedema which causes worsening vision, irregular warts on the Descemet membrane and a beaten metal endothelial appearance are signs of?

A

Fuchs endothelial corneal dystrophy

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215
Q

Corneal oedema which causes worsening vision, irregular warts on the Descemet membrane and a beaten metal endothelial appearance are signs of?

How would you manage this?

A

Fuchs Endothelial Corneal Dystrophy

Descemet membrane endothelial keratoplasty

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216
Q

What are the layers of the eyelid?

A

Anterior to Posterior

Skin

Fat

Fascia

Orbicularis oculi

Orbital septum

Levator palpebral superioris

Muller muscle

Conjunctiva

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217
Q

What nerve innervates orbicularis oculi?

A

CN VII - Facial Nerve, temporal and zygomatic divisions

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218
Q

What nerve innervates levator palpebral superioris?

A

Superior division of CN III (Oculomotor nerve)

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219
Q

A patient presents with an enlarging nodule around the eyelid. The nodule has been enlarging over a few week. It is red, painful and hard.

What is your management?

A

Supportive: Observation (often resolves; hot compresses

± Medical: Oral ABX

± Surgery: Incision and curettage

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220
Q

A patient presents with a skin lesion on their eyelid. The lesion is shiny, firm and has a pearly appearance. The centre is ulcerated and around it there are some dilated blood vessels.

What is your DDx?

A

BCC

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221
Q

A patient presents with a skin lesion on their eyelid. The lesion is shiny, firm and has a pearly appearance. The centre is ulcerated and around it there are some dilated blood vessels.

What is your management?

A

Mohs micrographic surgical excision

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222
Q

What proportion of SCC metastasises to regional lymph nodes?

A. 30%

B. 20%

C. 40%

D. 50%

A

B. 20%

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223
Q

A 68 year old patient presents with a skin lesion around the eye. The lesion appears hyperkeratotic, with crusting, erosions and fissures. It has grown very quickly, over a matter of weeks.

What is your DDx?

A

SCC

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224
Q

A 68 year old patient presents with a skin lesion around the eye. The lesion appears hyperkeratotic, with crusting, erosions and fissures. It has grown very quickly, over a matter of weeks.

What is your management?

A

Mohs surgical excision

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225
Q

A 68 year old patient presents with a skin lesion around the eye. The lesion appears yellow on the upper eyelid. The eyelid margin has been thickened with some eyelash distortion.

What is your DDx?

A. BCC

B. SCC

C. Meiobian Cyst

D. Sebaceous Gland Carcinoma

A

D. Sebaceous Gland Carcinoma

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226
Q

Which of the following is not a condition associated with blepharitis?

A. Acne rosacea. ​
​
B. Seborrhoeic dermatitis. ​
​
C. Atopic dermatitis. ​
​
D. Acne vulgaris.
A

D. Acne vulgaris.

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227
Q

What is the difference between anterior and posterior blepharitis?

A

Anterior: inflammation of eyelid skin around bases of eyelash

Posterior: meibomian gland dysfunction with altered secretion

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228
Q

Which condition is associated more with staphylococcal blepharitis?

A. Demodex folliculorum

B. Acne rosacea

C. Atopic dermatitis

D. Seborrheic dermatitis

A

C. Atopic dermatitis

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229
Q

Which condition is associated more with posterior blepharitis?

A. Demodex folliculorum

B. Acne rosacea

C. Atopic dermatitis

D. Seborrheic dermatitis

A

B. Acne rosacea

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230
Q

Which condition is associated more with seborrheic blepharitis?

A. Demodex folliculorum

B. Acne rosacea

C. Atopic dermatitis

D. Seborrheic dermatitis

A

D. Seborrheic dermatitis

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231
Q

What is the main management for blepharitis?

A

Supportive: Lid hygiene

± Topical ABX

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232
Q

A 43 year old patient presents with hard scales and crusting around the eyelash. The lid margins appear hypaeamix and greasy. Lashes are adhering to each other.

What is your ddx?

What is your ddx?

A. Staphylococcal blepharitis

B. Posterior blepharitis

C. Anterior blepharitis

D. Seborrheic blepharitis

A

D. Seborrheic blepharitis

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233
Q

A 49 year old patient presents with oil globules seen at meibomian gland orifices and unstable tear film.

What is your ddx?

A. Staphylococcal blepharitis

B. Posterior blepharitis

C. Anterior blepharitis

D. Seborrheic blepharitis

A

B. Posterior blepharitis

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234
Q

Describe the Marcus-Gunn jaw-winking phenomenon.

A

retraction of a ptotic lid when ipsilateral pterygoid muscles are activated (eg chewing, opening the mouth).​

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235
Q

What is Gradenigo syndrome?

A

Ear pain + inability to abduct eye (CN6 palsy)

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236
Q

What is the usual position of the upper lid?

A

2mm below the superior limbus

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237
Q

What forms the tarsal plates?

A

Orbital septum

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238
Q

Which 3 muscles retract the eyelid?

A

Levator palpebral superioris (CN III)

Muller’s Muscle (sympathetic)

Frontalis (CN VIII)

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239
Q

Which muscle is responsible for eyelid closure?

A

Orbicularis oculi (CN VII)

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240
Q

The corneal limb of the blink reflex is conducted via which nerve?

A. CN V1

B. CN VI

C. CN II

D. CN VIII

A

A. CN V1

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241
Q

The light stimulus of the blink reflex is conducted via which nerve?

A. CN V1

B. CN VI

C. CN II

D. CN VIII

A

C. CN II

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242
Q

The auditory stimulus of the blink reflex is conducted via which nerve?

A. CN V1

B. CN VI

C. CN II

D. CN VIII

A

D. CN VIII

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243
Q

A patient demonstrates globe rotation up and out during forced lid closure. What is this called?

A

Bell’s Phenomenon

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244
Q

How many canthal tendons are there?

A

2 per orbit: medial and lateral

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245
Q

In what order is the eyelid repaired in a deep laceration, penetrating other lamellae?

A

Both posterior and anterior lamellae require construction; posterior (tarsus and conjunctiva) before anterior (skin and orbicularis)

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246
Q

What pathogen is typically associated with Blepharitis?

A

Staphylococcal

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247
Q

How may blepharitis be classified?

A

Anterior: Staph or Seborrheic

Posterior: Meibomian glands

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248
Q

What ABX can be used to treat blepharitis?

What is the MOA?

A

Tetracyclines limit fatty acid production which can decrease the inflammatory secretions

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249
Q

A patient presents with foamy tear film, crusty eyelashes.

What is your DDx?

A

Meibomian Gland Dysfunction (secondary to chronic posterior blepharitis)

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250
Q

A patient presents with foamy tear film, crusty eyelashes.

What is the gold-standard investigation for this?

A

Tear film breakup time <5 seconds

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251
Q

How do you manage Meibomian Gland Dysfunction?

A

Based on clinical features.

Supportive: diet; lid hygiene

± Mild discomfort
- Topical lubricants

± Inflammatory changes
- Orał doxycycline

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252
Q

How is trichiasis managed?

A

Epilation

Lash destruction (only a few abnormal lashes)

Surgery (pentagon excision to remove focal groups)

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253
Q

What is a stye?

A

A painful lid abscess caused by Staphylococcus infection.

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254
Q

How may a hordeolum be classified?

A

Hordeolum is classified according to the affected gland:
External (anterior lamella): abscess of Zeis or Moll glands

Internal (posterior lamella): abscess of Meibomian gland

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255
Q

What is the fundamental difference between a hordeolum and a chalazion?

A

Chalazion = painless

Hordeolum = painful

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256
Q

A chronic translucent cyst is present in the anterior lamella glands.

What type is it?

A

Cyst of Moll

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257
Q

A chronic non-translucent cyst is present in the anterior lamella glands.

What type is it?

A

Cyst of Zeis

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258
Q

In a patient who cannot have a BCC resected, what management is recommended?

A. Vismodegib

B. Cisplatin

C. FU

D. Prednisolone

A

A. Vismodegib

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259
Q

Where does a melanoma metastasise to?

A

Liver

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260
Q

A recurrent unilateral blepharitis should raise suspicion of?

A

Sebaceous gland carcinoma

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261
Q

What is the most common form of ectropion?

A. Cicatrical

B. Paralytic

C. Congenital

D. Involutional

A

D. Involutional

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262
Q

Ectropion due to shortage of skin is?

A. Cicatrical

B. Paralytic

C. Congenital

D. Involutional

A

C. Congenital

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263
Q

Ectropion due to orbicularis weakness is called ?

A. Cicatrical

B. Paralytic

C. Congenital

D. Involutional

A

B. Paralytic

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264
Q

Ectropion due to shortened anterior lamellar due to chronic dermatitis is called?

A. Cicatrical

B. Paralytic

C. Congenital

D. Involutional

A

A. Cicatrical

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265
Q

A patient presents with an outward turned eyelid. It is deemed to be an involutional ectropion, with horizontal lid laxity.

What is your management?

A. Lateral tarsal strip

B. Diamond excision

C. Graft and flap

D. Ocular lubricant only

A

A. Lateral tarsal strip

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266
Q

A patient presents with an outward turned eyelid. There is a shortened, inflamed anterior lamella due to chronic inflammation.

What is your management?

A. Lateral tarsal strip

B. Diamond excision

C. Graft and flap

D. Ocular lubricant only

A

C. Graft and flap

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267
Q

What is the most common form of entropion?

A. Cicatricial

B. Involutional

C. Paralytic

D. Idiopathic

A

B. Involutional

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268
Q

What is of the following is not a management for entropion of the involutional kind?

A. Transverse tarsotomy

B. Jones procedure

C. Everting sutures

D. Membrane graft

A
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269
Q

A patient presents with a Ptosis following a history of Myaesthenia Gravis.

What type of ptosis is this?

A. Involutional

B. Neurogenic

C. Congenital

D. Pseudoptosis

A

B

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270
Q

A patient presents with a Ptosis in addition to abnormal eye movements and a mydriatic pupil.

What type of ptosis is this?

A. Involutional

B. Neurogenic

C. Congenital

D. Pseudoptosis

A

B, CN III palsy

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271
Q

A patient presents with a Ptosis which is deemed to be organic following exclusion of other causes.

What type of ptosis is this?

A. Involutional

B. Neurogenic

C. Congenital

D. Pseudoptosis

A

A. Involutional

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272
Q

The spread of ethmoid cellulitis to orbital cellulitis is via which membrane?

A

Lamina papyracea of the medial wall of the orbit

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273
Q

What are the contents of the optic foramen?

A

Transmits the optic nerve and the ophthalmic artery

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274
Q

What are the contents of the superior orbital fissure?

A

LFTs

Lacrimal (CNV1)

Frontal (CNV1)

Trochlear (CN4)

Common tendinous ring:

  • Superior and inferior Occulomotor nerves
  • Nasociliary nerve (CNV1)
  • Abducens nerve (CN 6)
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275
Q

What are the contents of the

A
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276
Q

What are the contents of the inferior orbital fissure?

A 
Infraorbital nerve (CNV2)
Zygomatic nerve (CNV2) 
Inferior ophthalmic vein
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277
Q

What pathogen commonly causes preseptal cellulitis?

A. S. pneumoniae

B. Haemophilus

C. S. aureus

D. Klesiella

A

C

278
Q

What pathogen commonly causes orbital cellulitis?

A

S pneumoniae

279
Q

What is the gold-standard investigation for orbital cellulitis?

A

CT-Orbit

280
Q

What is the most common cause of axial proptosis in adults?

A. TED

B. Cavernous haemangioma

C. Optic nerve glioma

D. Lacrimal gland pathology

A

A

281
Q

What causes lid retraction in TED?

A. Parasympathetic stimulation of Muller’s Muscle

B. Stimulation of superior levator palpebrae

C. Sympathetic Muller’s muscle stimulation

D. Proptosis

A
282
Q

What causes lid retraction in TED?

A. Parasympathetic stimulation of Muller’s Muscle

B. Stimulation of superior levator palpebrae

C. Sympathetic Muller’s muscle stimulation

D. Proptosis

A

B

283
Q

The occurrence of headache, ophthalmoplegia and periorbital sensory loss is seen in?

A. Sarcoidosis

B. Tolosa-Hunt Syndrome

C. Granulomatosis with polyangiitis

D. TED

A

B

284
Q

A patient with positive cANCA and orbital inflammation is most likely to have?

A. Sarcoidosis

B. Tolosa-Hunt Syndrome

C. Granulomatosis with polyangiitis

D. TED

A

C

285
Q

A patient presenting with orbital inflammation on a b/g of noncaseating granulomas present in the lung as well as elevated serum ACEi is most likely to have?

A. Sarcoidosis

B. Tolosa-Hunt Syndrome

C. Granulomatosis with polyangiitis

D. TED

A

A

286
Q

What is the gold-standard investigation to diagnose Tolosa-Hunt syndrome?

What are the clinical features of this condition?

A

MRI/Biopsy

Headache + Periorbital sensory loss + Ophthalmoplegia

287
Q

What is the commonest primary childhood orbital malignancy?

A. Neuroblastoma

B. Rhabdomyosarcoma

C. Capillary haemangioma

D. Optic nerve glioma

A

B

288
Q

A child presents with a lump present in the supers-nasal orbit which is causing a unilateral proptosis which is painless.

What is the diagnosis?

A. Neuroblastoma

B. Rhabdomyosarcoma

C. Capillary haemangioma

D. Optic nerve glioma

A

B

289
Q

A child presents with an eye lump which shows Homer-wright rosettes on histology.

What is the DDx?

A. Neuroblastoma

B. Rhabdomyosarcoma

C. Capillary haemangioma

D. Optic nerve glioma

A

A

290
Q

A child presents with an eye lump which has blanching and a red unilateral lesion of the upper eyelid.

What is the DDx?

A. Neuroblastoma

B. Rhabdomyosarcoma

C. Capillary haemangioma

D. Optic nerve glioma

A

C

291
Q

A child presents with an eye lump is causing a unilateral proptosis and RAPD O/E.

What is the DDx?

A. Neuroblastoma

B. Rhabdomyosarcoma

C. Capillary haemangioma

D. Optic nerve glioma

A

D

292
Q

A 57 year old presents with vision loss in one eye. The vision loss is painless.

O-CT shows a thick optic nerve sheath.

What is your DDx?

A. Neuroblastoma

B. Optic nerve sheath meningioma

C. Cavernous haemangioma

D. Optic nerve glioma

A

B

293
Q

A 57 year old presents with reduced visual acuity and slow progressing axial proptosis.

O-CT shows a lesion within the common tendinous ring.

What is your DDx?

A. Neuroblastoma

B. Optic nerve sheath meningioma

C. Cavernous haemangioma

D. Optic nerve glioma

A

C

294
Q

A patient presents with an ocular bruit, hearing a whooshing sound. O/E there are visual defects.

What is your DDx?

A. Indirect CCF

B. Direct CCF

C. Cavernous sinus thrombosis

D. Orbital varices

A

B

295
Q

A patient presents with an irritated eye and corkscrew epibulbar vessels shown.

What is your DDx?

A. Indirect CCF

B. Direct CCF

C. Cavernous sinus thrombosis

D. Orbital varices

A

A

296
Q

A patient presents with a sudden onset headache. They feel nauseous and have double vision. What is your diagnosis?

A. Central retinal vein occlusion

B. Central retinal artery occlusion

C. Cavernous Sinus Thrombosis

D. Orbital varices

A

C

297
Q

Which eye movement will be affected first in a cavernous sinus thrombosis?

A. Eye abduction

B. Eye adduction

C. Eye moving inferiorly

D. Eye moving superiorly

A

A - CN 6 is affected first

CN6 is first affected because it travels within the sinus as opposed to CN3 and CN4 which travel within the walls of the sinus.

298
Q

What is the most ocular toxic heavy metal commonly used?

A. Copper

B. Iron

C. Aluminium

D. Zinc

A

A

299
Q

A foreign body is propelled into the orbit. A CT-Orbit shows the deposits to be present in the cornea.

How would you remove the foreign body?

A. Fine forceps

B. 26G needle

C. Scleral trapdoor approach

D. Electromagnetic removal

A

B

300
Q

A foreign body is propelled into the orbit. Following slit-lamp examination and CT-Orbit, the deposits are deemed to be present in the anterior chamber.

How would you remove the foreign body?

A. Fine forceps

B. 26G needle

C. Scleral trapdoor approach

D. Electromagnetic removal

A

A

301
Q

A foreign body is propelled into the orbit. Following slit-lamp examination and CT-Orbit, the deposits are deemed to be present in the angle of the anterior chamber.

How would you remove the foreign body?

A. Fine forceps

B. 26G needle

C. Scleral trapdoor approach

D. Electromagnetic removal

A

C

302
Q

A foreign body is propelled into the orbit. Following slit-lamp examination and CT-Orbit, the deposits are deemed to be present in the ciliary body.

How would you remove the foreign body?

A. Fine forceps

B. Intraocular magnet

C. Scleral trapdoor approach

D. Electromagnetic removal

A

D

303
Q

A foreign body is propelled into the orbit. Following slit-lamp examination and CT-Orbit, the deposits are deemed to be present in the posterior segment.

How would you remove the foreign body?

A. Fine forceps

B. Intraocular magnet

C. Scleral trapdoor approach

D. Electromagnetic removal

A

B

304
Q

Which is worse, alkali or acid burn?

A

Alkali > Acid as causes liquefactive necrosis

305
Q

What is the initial management of a chemical burn in the eye?

A. Irrigation

B. Topical steroids

C. Doxycycline

D. Ascorbic acid

A

A

306
Q

Which of the following work by aiding collagen formation in an alkali burn?

A. Irrigation

B. Topical steroids

C. Doxycycline

D. Ascorbic acid

A

D

307
Q

Which of the following treatments are contraindicated in an acid burn?

A. Irrigation

B. Topical steroids

C. Doxycycline

D. Ascorbic acid

A

D

308
Q

A 23 year old man presents following a fist fight where he has been punched multiple times in the face. O/E there is periorbital bruising and vertical diplopia.

Which muscle is the cause for the vertical diplopia?

A. LR

B. IR

C. SO

D. IO

A

B

309
Q

A 34 year old Rangers fan presents following punching himself in the face. There is a painful loss of vision, a rigid proptosis and a RAPD on examination. Furthermore, there are restricted ocular movements.

What is your DDx?

A. Orbital floor fracture

B. Retrobulbar haemorrhage

C. Hyphema

D. Foreign body

A

B

310
Q

A 34 year old Rangers fan presents following punching himself in the face. There is a painful loss of vision, a rigid proptosis and a RAPD on examination. Furthermore, there are restricted ocular movements.

How should you manage this?

A

A. IV mannitol + IV Acetazolamide

B. IV mannitol + IV Acetazolamide + Topical Latanoprost

C. IV mannitol

D. IV mannitol + IV Acetazolamide + IV Methylprednisolone

311
Q

Describe the conjunctiva.

A

The conjunctiva is a thin transparent membrane that lines the surface of the sclera and the underside of the eyelid. It can be thought of as a modified layer of skin.

312
Q

What are the three portions of the conjunctiva?

A

Bulbar

Palpebral

Conjunctival fornix

313
Q

An enlargement of the conjunctival vessels is known as?

A. Cicatrization

B. Chemosis

C. Hyperaemia

D. Follicles

A

C

314
Q

A transparent swelling of the conjunctiva is known as?

A. Cicatrization

B. Chemosis

C. Hyperaemia

D. Follicles

A

B

315
Q

Scarring of the conjunctiva is known as?

A. Cicatrization

B. Chemosis

C. Hyperaemia

D. Follicles

A

A

316
Q

Which is the predominant cause of bacterial conjunctivitis in warm climates?

A. H aegyptius

B. H influenzae

C. S aureus

D. S pneumoniae

A

A

317
Q

Which is the predominant cause of bacterial conjunctivitis in children?

A. H aegyptius

B. H influenzae

C. S aureus

D. S pneumoniae

A

B

318
Q

A 7 year old child presents with red sticky eyes. There is purulent discharge coming out. The patient says their eyes are stuck together.

Swabs are positive for H influenzae.

What is your management?

A. Chloramphenicol topical

B. Oral doxycycline

C. Ceftriaxone

D. Co-amoxiclav

A

D

319
Q

A 17 year old presents with red sticky eyes. There is purulent discharge coming out. The patient says their eyes are stuck together.

What is your management?

A. Chloramphenicol topical

B. Oral doxycycline

C. Ceftriaxone

D. Co-amoxiclav

A

A

320
Q

A 17 year old presents with red sticky eyes. There is purulent discharge coming out. The patient says their eyes are stuck together. Additionally they have some urethritis.

A urethral swab and conjunctival swab are positive for gram negative diplococci.

What is your management?

A. Chloramphenicol topical

B. Oral doxycycline

C. Ceftriaxone

D. Co-amoxiclav

A

C

321
Q

Serotypes D-K cause which complication of chlamydia in the eyes?

A

Inclusion Body Chlamydial Conjunctivitis

322
Q

Serotypes A-C cause which complication of chlamydia in the eyes?

A

Trachoma

323
Q

A patient presents with an inferior follicular conjunctivitis with mucopurulent discharge.

Swabs and PCR are positive for a gram negative, rod-shaped obligate organism.

What is your diagnosis?

A. Bacterial conjunctivitis

B. Inclusion Body Chlamydial Conjunctivitis

C. Trachoma

D. Gonococcal conjunctivitis

A

B

324
Q

What is the leading cause of preventable blindness worldwide?

A

Trachoma

325
Q

A patient from Eritrea presents with superior follicular conjunctivitis. A thick band of scar tissue is seen in the conjunctiva.

What is your differential diagnosis?

What is your management?

A

Trachoma

Mnemonic: SAFE 
Surgery for trichiasis 
Azithromycin 1mg PO 
Facial hygiene 
Environmental improvement
326
Q

What is the treatment of gonococcal conjunctivitis?

A

Topical ofloxacin + Ceftriaxone 1mg STAT

327
Q

Describe ophthalmia neonatorum.

A

Conjunctivitis within <30 days of life

328
Q

A neonate aged 8 days old is found to have ophthalmia neonatorum. Swabs show a gram negative rod-shaped bacteria.

What is the management?

A. Erythromycin PO

B. IM Ceftriaxone and IV Penicillin

C. IV Acyclovir

D. Topical chloramphenicol

A

A

329
Q

A neonate aged 8 days old is found to have ophthalmia neonatorum. Swabs show a gram negative diplococci.

What is the management?

A. Erythromycin PO

B. IM Ceftriaxone and IV Penicillin

C. IV Acyclovir

D. Topical chloramphenicol

A

B

330
Q

A neonate aged 8 days old is found to have ophthalmia neonatorum. Swabs are positive for HSV.

What is the management?

A. Erythromycin PO

B. IM Ceftriaxone and IV Penicillin

C. IV Acyclovir

D. Topical chloramphenicol

A

C

331
Q

A neonate aged 8 days old is found to have ophthalmia neonatorum. Swabs show a cluster of gram negative bacteria.

What is the management?

A. Erythromycin PO

B. IM Ceftriaxone and IV Penicillin

C. IV Acyclovir

D. Topical chloramphenicol

A

D

332
Q

What is the most common cause of viral conjunctivitis?

A

Adenovirus

333
Q

Which serovar of adenovirus does not cause Pharyngoconjunctival Fever?

A. 3

B. 8

C. 4

D. 7

A

B

334
Q

What is the difference between perennial and seasonal conjunctivitis?

A

All year round; both type 1

335
Q

What are the key features of vernal keratoconjunctivitis?

A

Teenage boys

Type 1 -> Type 4 hypersensitivity

Summer

Upper conjunctiva with cobblestone appearance

336
Q

Which conditions is atopic keratoconjunctivitis associated with?

A

Atopy:

Allergic rhinitis

Eczema

Asthma

337
Q

In ocular mucous membrane pemphigoid, antibodies target which membrane?

A

Basement membrane of mucosal surfaces

338
Q

What is the main difference between a pterygium and a pinguecula?

A

They key difference is that pterygium invades into the cornea, pinguecula does not.

339
Q

What type of collagen makes up Descemet’s membrane?

A

Type 4

340
Q

What structure of the eye has the highest refractive power?

A

45D

341
Q

What investigation may be used to measure cornea thickness?

A. Pachymetry

B. OCT

C. Fluorescein staining

D. Specular microscopy

A
342
Q

What is the commonest cause of bacterial keratitis in contact lens wearers?

A

P aeruginosa

343
Q

What do you use to treat a fungal keratitis caused by candida?

A

Voriconazole or Amphotericin

344
Q

What do you use to treat a fungal keratitis caused by candida?

A

Voriconazole or Amphotericin

345
Q

What do you use to treat a fungal keratitis caused by candida?

A

Natamycin drops

346
Q

Marginal keratitis is an autoimmune reaction against which toxin?

A. S epidermidis

B. H influenzae

C. M tuberculosis

D. Acanthamoeba

A

A

347
Q

Which nerve does HSV lie dormant in to cause a herpes simplex keratitis?

A. CN VI

B. CN VII

C. CN IV

D. CN V

A

D

348
Q

What clinical finds would be suggestive of filamentary keratitis?

A

Comma shaped lesions which move whilst blinking following rose bengal staining

349
Q

What is the management for filamentary keratitis?

A

Acetylcysteine drops

350
Q

What is the most common epithelial dystrophy?

A. Cogan

B. Meesman

C. Reis-Buckler

D. Meretoja

A

A

351
Q

Histology shows a thickened basement membrane over Bowman’s layer. What epithelial dystrophy is this?

A. Cogan

B. Meesman

C. Reis-Buckler

D. Meretoja

A

A

352
Q

Histology shows cysts. What epithelial dystrophy is this?

A. Cogan

B. Meesman

C. Reis-Buckler

D. Meretoja

A

B

353
Q

Histology shows replacement of bowman’s by connective bands. What epithelial dystrophy is this?

A. Cogan

B. Meesman

C. Bowmans

D. Meretoja

A

C

354
Q

Outline the stromal dystrophies and their corresponding stain.

A

Mnemonic: Marilyn Monroe Always; Gets Her Men; in L.A. County

Macular - Mucopolysaccharide - Alcian blue

Granular - Hyaline - Masson trichome

Lattice - Amyloid - Congo red

355
Q

Why are symptoms worse in the morning for Fuchs Endothelial Dystrophy?

A

Symptoms are worse in the morning because the eyes are shut overnight and corneal fluid evaporation in limited. The endothelial pump is dysfunctional so fluid accumulation occurs. Throughout the day the eyes are open and blinking, this allows better clearing of the accumulated fluid.

356
Q

What visual defect does keratoconus lead to?

A

Irregular astigmatism

357
Q

What are the clinical features of keratoconus?

A

Typically bilateral and presents in adolescents.

Munson sign - lower lid protrudes on downward gaze

Vogt striae - corneal stromal striations seen on slit lamp

358
Q

How do you manage a Keratoconus?

A

Dependent on severity (<48D vs >54D)

Mild (<48D):
- Rigid contact lenses

Severe (>54D):
- Keratoplasty

359
Q

Corneal topography shows a butterfly pattern in a child with bilateral blurring of vision over time.

What is your DDx?

A

Pellucid Marginal Degeneration

360
Q

A patient presents with reduced corneal sensation on a background of corneal ulceration.

What is your Ddx?

A

Neurotrophic keratopathy

361
Q

What is the cause for exposure keratopathy?

A

Lagophthalmos

362
Q

What is the management for a patient presenting with Kayser-Fleischer rings in the descet membrane?

A

Penicillamine-D

363
Q

What two divisions of the ciliary body are there?

A

Anterior functional - pars plicate

Posterior non-functional - pars plant

364
Q

Which layer of the choroid produces aqueous? Is it pigmented?

A

Non-pigmented and produces aqueous

365
Q

What is the fundamental discriminator between episcleritis and scleritis?

A

Additional of 10% phenylephrine makes the red eye blanche

Scleritis is potentially blinding thus requires high dose steroids and taper down

366
Q

What do stellate KPs indicate in anterior uveitis?

A

Non-granulomatous inflammation

367
Q

What do mutton fat KPs indicate in anterior uveitis?

A

Granulomatous

368
Q

What haplotype is associated with Behcet’s Disease?

A

HLAB51

369
Q

Outline the flow of tears.

A
  1. Secretion by lacrimal gland
  2. Channeled medially via orbicularis pump
  3. Drains into nasolacrimal system via upper and lower puncta
  4. Flow through upper and lower cannaliculi into common cannaliculi
  5. Flows via nasolacrimal sac into duct into inferior meatus and into nasolacrimal canal
370
Q

What are the layers of tear film?

A

Lipid (Meibomian)

Aqueous (lacrimal gland)

Mucin (conjunctival goblet cells)

371
Q

What is the sensorimotor innervation of the lacrimal gland?

A

Parasympathetic of CN VII

372
Q

What is the sensory innervation of the lacrimal gland?

A

Lacrimal nerve (CN V1)

373
Q

What are the difference between the accessory lacrimal glands?

A

Krause glands found in conjunctival fornices which are more abundant in upper fornix

Wolfring glands are less numerous but bigger found in the tarsal plate

374
Q

What is the criteria for a positive Schirmer test?

A

<5mm

375
Q

What is the criteria for an abnormal tear film-break up time test?

A

<5 seconds

376
Q

What us the first line treatment for dry eyes?

A

Lubrication and artificial tears

377
Q

What antibodies are present in Sjogren Syndrome?

A

Anti-Ro

Anti-La

378
Q

What is the cause of xerophthalmia?

A

Vitamin A deficiency

379
Q

What are the two main mechanisms of epiphora?

A

1) Nasolacrimal drainage failure

2) Hypersecretion

380
Q

What is the cause of a congenital nasolacrimal duct obstruction?

A

Imperforate membrane over valve of Hasner

381
Q

How do you manage a congenital nasolacrimal duct obstruction?

A

> 12 months:

1) Syringing and probing
2) Silicone stent intubation
3) DCR

382
Q

How do you treat punctal stenosis?

A

Punctoplasty

383
Q

How do you treat punctual eversion?

A

Cautery

384
Q

How do you treat orbicularis pump failure?

A

Lower lid tightening with LTS

385
Q

How do you treat nasolacrimal duct obstruction?

A

DCR

386
Q

How do you treat a canalicular obstruction?

A

DCR with retrograde intubation

387
Q

Which groups of patients tend to have dermatochalasis?

A

Elderly

Obese

388
Q

How is dermatochalasis treated?

A

Upper lid blepharoplasty

389
Q

A patient presents with painful upper lateral lid. There is a swelling and medial hyoglobus.

What is your diagnosis and management?

A

Dacryoadenitis

Oral NSAID/Steroids

390
Q

what is the most common cause of canaliculitis?

A

Actinomyces

391
Q

What is the management for chronic dacryocystitis?

A

Dacryocystorhinostomy

392
Q

What antioxidants are present in the lens, stopping deterioration?

A

Glutathione

Ascorbic acid

393
Q

What type of collagen makes up the lens?

A

Type 4 collagen

394
Q

Which fibres arise from the ciliary body and attach as a sheet to the lens capsule?

A

Zonular fibres

395
Q

What are the zonular fibres made of?

A

Fibrillin

396
Q

What is the refractive index of the adult lens?

A

1.4

397
Q

Outline the Helmholtz Theory of Accommodation.

A 
Ciliary muscles contract 
Ciliary body becomes larger and moves closer to the lens 
Zonular fibres relax
Lens thickens (increases power)
Pupils constrict and converge
Choroid and ora errata stretch forward
398
Q

What is the loss of refractive index power with ageing referred to as?

A

Presbyopia

399
Q

What is the pathophysiology of glaucoma?

A

Ageing, reduced biochemical activities and loss of antioxidants (glutathione and ascorbic acid) cause lens to become thicker.

Alpha and gamma crystallins are reduced and beta crystallins become dispersed

400
Q

A cataract appears yellow with a central lens affected and myopic shift.

What type of age-related cataract is this?

A. Nuclear sclerotic

B. Cortical

C. Anterior subcapsular

D. Posterior sub capsular

A

A

401
Q

A cataract appears wedge-shaped and affects the peripheral lens.

What type of age-related cataract is this?

A. Nuclear sclerotic

B. Cortical

C. Anterior subcapsular

D. Posterior sub capsular

A

B

402
Q

A cataract appears to be associated with blunt trauma.

What type of age-related cataract is this?

A. Nuclear sclerotic

B. Cortical

C. Anterior subcapsular

D. Posterior sub capsular

A

C

403
Q

A cataract appears following corticosteroid usage.

What type of age-related cataract is this?

A. Nuclear sclerotic

B. Cortical

C. Anterior subcapsular

D. Posterior sub capsular

A

D

404
Q

A cataract appears following chloroquine usage.

What type of age-related cataract is this?

A. Nuclear sclerotic

B. Cortical

C. Anterior subcapsular

D. Posterior sub capsular

A

D

405
Q

A Christmas tree cataract is seen.

What condition is this associated with?

A. Myotonic dystrophy

B. Down Syndrome

C. Rubella

D. Wilson’s disease

A

A

406
Q

A blue dot cataract is seen.

What condition is this associated with?

A. Myotonic dystrophy

B. Down Syndrome

C. Rubella

D. Wilson’s disease

A

B

407
Q

A Sunflower cataract is seen.

What condition is this associated with?

A. Myotonic dystrophy

B. Down Syndrome

C. Rubella

D. Wilson’s disease

A

D

408
Q

A Pearly nuclear sclerotic cataract is seen.

What condition is this associated with?

A. Myotonic dystrophy

B. Down Syndrome

C. Rubella

D. Wilson’s disease

A

C

409
Q

A shield cataract is seen.

What condition is this associated with?

A. Myotonic dystrophy

B. Down Syndrome

C. Rubella

D. Atopic dermatitis

A

D

410
Q

What inheritance pattern is mainly present in congenital cataracts?

A

Autosomal dominant

411
Q

When should unilateral congenital cataracts be removed?

A

6 weeks

412
Q

When should bilateral congenital cataracts be removed?

A

10 weeks

413
Q

What investigations is used to determine the type of lens to be implanted in a cataract surgery?

A

Biometry - determines axial length, corneal curvature, anterior chamber depth

414
Q

What are the two main types of IOL?

A

Rigid vs Flexible

415
Q

Which of the following IOLs is associated with glare?

A. Silicone

B. PMMA

C. Acrylic hydrophobic

D. Acrylic hydrophilic

A

C

416
Q

Which of the following IOLs is associated with the best biocompatibility?

A. Silicone

B. PMMA

C. Acrylic hydrophobic

D. Acrylic hydrophilic

A

D

417
Q

What is the most common intra-operative complication of cataract surgery?

A

Posterior capsular rupture with vitreous loss

418
Q

What is the most common post-operative complication of cataract surgery?

A

Posterior capsular opacification - 10% in 2 years

419
Q

What is the gold standard operation technique in cataract surgery?

A

Phacoemulsification

420
Q

What step is taken to prevent endophthalmitis during cataract surgery?

A

5% povidone-iodine

Intracameral cefuroxime

421
Q

What frequency does the phaco-tip vibrate at?

A

30-60kHz

422
Q

Describe the process of phacoemulsification.

A

cataract broken with direct contact of the ultrasound tip on the nucleus and fragments asperitated

423
Q

What medication is associated with floppy iris syndrome?

A

Tamsulosin

424
Q

What risk of choroidal haemorrhage is there in cataract surgery?

How do you manage choroidal haemorrhage?

A

0.1% risk

Suture wound + IV acetazolamide + Topical steroids

425
Q

A patient presents with painless blurry vision several weeks after cataract surgery. OCT shows retinal layers being raised.

What is your DDx?

A. Posterior capsular opacification

B. Endophthalmitis

C. Cystoid Macular Oedema

D. Zonular dehiscence

A

C

426
Q

How is posterior capsular opacification treated?

A

Nd:YAG laser capsulotomy

427
Q

Which of the following conditions is associated with glaucoma?

A. Familial ectopia lentis

B. Marfan syndrome

C. Homocystinuria

D. Weill-Marchesani Syndrome

A

D, anterior inferior displacement of ectopic lentis which obstructs normal aqueous flow

428
Q

How do you manage a major ectopia lentis?

A

Lensectomy

429
Q

In which condition do you see anterior lenticonus?

A

Alport Syndrome

430
Q

What sign would you see on lentiglobus?

A

Retroillumination with slit lamp shows classic oil droplet sign

431
Q

What is the critical angle?

A

The critical angle (θc) is the angle of incidence at which light is first reflected instead of refracted

432
Q

What is the critical angle for normal spectacles?

A

41 degrees

433
Q

Define total internal reflection.

A

Angle of incidence exceeds the critical angle thus light is not refracted but reflected back into the medium

434
Q

A plus lens has what effect on vergence?

A

Converges light as mergence is measured in D;

D = 1/f(m)

Thus a +2 = +1/2m

435
Q

A minus lens has what effect on vergence?

A

Diverges light as mergence is measured in D;

D = 1/f(m)

Thus a -2 = -1/2m

436
Q

Light from an object 2m away is travelling to a +2D lens. At what distance is the image going to be formed?

A

U + D = V

U = 1/2 = 0.5; light from natural object is divergent (minus) thus -0.5

D = +2

V = -0.5 + 2 = +1.5D

D = 1/f(m)

Thus

1.5 = 1/f(m)

= 1/1.5 = 0.67m

Thus image will form on 0.67m on the other side

437
Q

What image quality is produced by a minus lens?

A

Virtual, erect and diminished

438
Q

What is the most common investigation used to test visual acuity?

A

Retinoscopy

439
Q

What is the minimum driving requirement?

A

6/12

440
Q

In a Duochrome test, if a red background makes it clearer, what is occurring?

A

Red has a longer wavelength and focuses behind the retina thus the patient has a hyperopia.

441
Q

In a Duochrome Test, is a green background makes the letters clearer, what is occurring?

A

Green is a shorter wavelength, focussing light onto the retina thus the patient has myopia.

442
Q

In Retinoscopy, if the red reflex moves against the direction of the light, what is noted?

A

Myopia

443
Q

In Retinoscopy, if the red reflex moves with the direction of the light, what is noted?

A

Hyperopia

444
Q

At what age is colour vision developed?

A

6 months

445
Q

At 6 months, what should the snellen score be?

A

6/30

446
Q

What are the 3 types of ametropia?

A

Myopia

Hyperopia

Astigmatism

447
Q

Describe the pathophysiology of Myopia.

A

Eye has a higher refractive power than normal

Increased refractive power causes a reduced focal length so image is focused in front of the retina thus they are short-sighted

448
Q

Outline the pathophysiology of Hyperopia.

A

Eye has a lower refractive power than normal

Power reduced thus focal length increases and image is focused behind the retina.

An object further away allows them to see the image clearer as this pulls the point of focus from behind the retina.

449
Q

What is the visible spectrum of light in humans?

A

380-750nm

450
Q

What type of lens would you use in myopia?

A

Minus lens as they are concave and diverge light

451
Q

What type of lens would you use in presbyopia?

A

Plus lenses which are convex and converge light

452
Q

What type of lens would you use in astigmatism?

A

Toric lenses

453
Q

How is astigmatism classified?

A

Regular

  • WTR (90 degrees perp)
  • ATR (180 degrees)

Irregular

454
Q

How is irregular astigmatism treated?

A

Rigid gas permeable contact lenses (RGP CLs)

455
Q

How is regular astigmatism treated?

A

Toric lenses

456
Q

which of the following statements are true?

A. Stimulation of beta-2 receptors increase secretion and inhibition of alpha-2 receptors increase secretion of aqueous humor

B. Stimulation of beta-2 receptors increase secretion and stimulation of alpha-2 receptors increase secretion of aqueous humor

C. Inhibition of beta-2 receptors increase secretion and stimulation of alpha-2 receptors increase secretion of aqueous humor

D. Inhibition of beta-2 receptors increase secretion and inhibition of alpha-2 receptors increase secretion of aqueous humor

A

A

457
Q

Which part of the TM bears the greatest resistance to normal AQH outflow via conventional route?

A

Juxtacanalicular meshwork

458
Q

What is the normal range of IOP?

A

11-21mmHg

459
Q

When does IOP peak?

A

In the morning

460
Q

What optic disc changes are seen in glaucomatous disease processes?

A

Neuroretinal rim reduces - retinal neuronal cells die off

Neuroretinal rim does not follow ISNT rule

Cup to disc ratio is increased

461
Q

What is the best test for monitoring glaucoma?

A

Humphrey 24-2 perimetry

462
Q

What is the order of use of medication in glaucoma?

A

Latanoprost
Timolol
Brinzolamide
Brimonidine

463
Q

Which eye drops are used to treat glaucoma in pregnancy?

A

No eye drops licensed for use in pregnancy

Briminodine in 1st trimester

Timolol in 3rd trimester

464
Q

Which of the following is not a side effect of
latanoprost?

A. Iris pigmentation

B. Lash lengthening

C. Lacrimation

D. Macular oedema

A

C

465
Q

Which of the following is not a side effect of
latanoprost?

A. Iris pigmentation

B. Lash lengthening

C. Uveitis

D. Diarrhoea

A

D

466
Q

Which of the following is not a side effect of
Beta blockers?

A. Exacerbates asthma

B. Bradycardia

C. Macular oedema

A

C

467
Q

Which of the following ß-blockers is selective for ß1?

A. Timolol

B. Bisoprolol

C. Carteolol

D. Betaxolol

A

D

468
Q

Why should you be cautious of using Briminodine in young children?

A

A2 selective blockers are lipophilic thus cross BBB which may result in respiratory depression

469
Q

What is the MOA of Briminodine when used in Glaucoma?

A

Reduced aq production + increased uveosacral outflow

470
Q

Which alpha 2 agonist is A2 selective?

A

Briminodine

471
Q

When medications fail to control chronic glaucoma, what is the next management?

A

Trabeculectomy - fistula from AC to subtenant space

Use antimetabolites to reduce risk of bleb failure - 5-FU; Mitomycin C

472
Q

Which of the following is used in a peripheral iridoplasty?

A. Argon

B. ND:YAG

C. Frequency doubled Q-switched ND:YAG

D. Trabeculectomy

A

A

473
Q

Which of the following is used in a peripheral iridotomy?

A. Argon

B. ND:YAG

C. Frequency doubled Q-switched ND:YAG

D. Trabeculectomy

A

B

474
Q

Which of the following is used in a selective laser trabeculoplasty (SLT)?

A. Argon

B. ND:YAG

C. Frequency doubled Q-switched ND:YAG

D. Trabeculectomy

A

C

475
Q

Which of the following is not a risk factor for primary open angle glaucoma?

A. Myopia

B. Afro-caribbean race

C. Increased age

D. Migraine history

A

D

476
Q

What is the first line management for a patient with primary open angle glaucoma?

A

Topical Latanoprost

If no IOP reduction, try alt. first line

If no IOP reduction, combine medications

477
Q

What surgical procedure may be used in a patient with Primary Open Angle Glaucoma who has failed medical management?

A

Selective Laser Trabeculoplasty

478
Q

Which anti-epileptic medication is associated with bilateral PACG?

A

Topiramate

479
Q

What are the essential clinical features to diagnose primary angle closure glaucoma?

A

AC angle closure + Sudden pain + blurred vision + nausea + red eye + glaucomatous changes

480
Q

How do you manage PACG?

A

IV Acetazolamide + Timolol + Apraclonidine + Steroids + Pilocarpine + lay supine
+
Bilateral peripheral iridotomy

481
Q

Primary congenital glaucoma is associated with which gene mutation?

A

CYP1B1

482
Q

What is the normal range for infant IOP?

A

10-12mmHg

483
Q

What is the surgical management of primary congenital glaucoma in infants?

A

Goniotomy (cornea clear)

OR

Trabeculectomy (cornea cloudy)

484
Q

Can glaucoma occur with a normal IOP?

A

Yes, in Normal Tension Glaucoma (NTG)

IOP ≤ 21mmHg

485
Q

What is Ocular Hypertension?

A

Raised IOP (>21mmHg) without glaucomatous damage

486
Q

Which of the following is not a risk factor for conversion of ocular hypertension to primary open angle glaucoma?

A. Older

B. Higher IOP

C. Larger cup:disc ratio

D. Thicker cornea

A

D

487
Q

A 20 year old male presents with unilateral, blurred vision. O/E he has a white eye and IOP is 40-80mmHg. Additionally, gonioscopy shows an open angle with no synechiae.

What is your differential?

A. Pseudoexfoliation Syndrome

B. Posner-Schlossman Syndrome

C. Pigment Dispersion Syndrome

D. Phacolytic Glaucoma

A

B

488
Q

What is the management for Posner-Schlossman Syndrome?

A

Topical steroids

489
Q

What mutation gives rise to Pseudoexfoliation Syndrome?

A

LOX1

490
Q

A 52 year old Scandinavian female presents with reduced peripheral vision. O/E there is raised IOP and a sampaolesi line noted

What is your differential?

A. Pseudoexfoliation Syndrome

B. Posner-Schlossman Syndrome

C. Pigment Dispersion Syndrome

D. Phacolytic Glaucoma

A

A

491
Q

A patient presents with blurry vision. They say the vision gets blurry when they are exerting themselves carrying boxes.

O/E there is elevated IOP and cupping. TM pigmentation is noted with Krukenberg spindles noted.

What is your differential?

A. Pseudoexfoliation Syndrome

B. Posner-Schlossman Syndrome

C. Pigment Dispersion Syndrome

D. Phacolytic Glaucoma

A

C

492
Q

A patient presents with a painful red eye. O/E there are foamy macrophages present in a AC tap. Slit lamp shows a hyper mature cataract.

What is your DDx?

A. Pseudoexfoliation Syndrome

B. Posner-Schlossman Syndrome

C. Pigment Dispersion Syndrome

D. Phacolytic Glaucoma

A

D

493
Q

What is the main risk factor for angle recession glaucoma?

A

Blunt ocular trauma

494
Q

A finding of irregular widening of the ciliary body upon Gonioscopy is suggestive of which diagnosis?

A. Pseudoexfoliation Syndrome

B. Angle recession Glaucoma

C. Pigment Dispersion Syndrome

D. Phacolytic Glaucoma

A

B

495
Q

What is the difference between red cell and ghost glaucoma?

A

Red cell shows fresh, red cells blocking the T which occurs acutely after hyphaema and blunt trauma.

Ghost cell are degenerated old red cells blocking the TM which occur after a few weeks following vitreous haemorrhage

496
Q

In which condition are tan coloured red cells seen in the anterior chamber?

A. Red Cell Glaucoma

B. Posner-Schlossman Syndrome

C. Pigment Dispersion Syndrome

D. Ghost Cell Glaucoma

A

D

497
Q

A patient presents with unilateral eye pain and blurry vision. O/E there is a port wine stain on the same side. They have a history of seizures.

What is your DDx?

A. Pseudoexfoliation Syndrome

B. Posner-Schlossman Syndrome

C. Sturge-Weber Syndrome

D. Phacolytic Glaucoma

A

C

498
Q

A finding of rubeosis iridis, elevated IOP and blurry vision is suggestive of?

A. Possner-Schlossman Syndrome

B. Aqueous Misdirection Syndrome

C. Iridocorneal Endothelial Syndrome

D. Neovascular Glaucoma

A

D

499
Q

What is the management for Neovascular Glaucoma?

A

PRP ± Intravitral anti-VEGF

500
Q

Why should you not give Pilocarpine in Neovascular Glaucoma?

A

May worsen synechial angle closure

501
Q

What is the management for a lens subluxation glaucoma?

A

Lie supine + Miotics

502
Q

What are the clinical features of Aqueous Misdirection Syndrome?

A

Acute highly raised IOP + Shallow AC + no pupil block

503
Q

What viral infection is believed to be related to Iridocorneal Endothelial Syndrome?

A

HSV infection

504
Q

A 32 year old woman presents with unilateral pain and blurred vision.

Slit lamp shows corneal oedema, corneal guttate. Gonioscopy shows peripheral anterior synechiae.

The tissue is shown to be corneal.

What is your DDx?

A. Cogan-Reese Syndrome

B. Neovascular Glaucoma

C. Aqueous Misdirection Syndrome

D. Chandler Syndrome

A

D

505
Q

A 32 year old woman presents with unilateral pain and blurred vision.

Slit lamp shows corneal oedema, corneal guttate. Gonioscopy shows peripheral anterior synechiae.

The tissue is shown to be nodular following iris stromal tissue change.

What is your DDx?

A. Cogan-Reese Syndrome

B. Neovascular Glaucoma

C. Aqueous Misdirection Syndrome

D. Chandler Syndrome

A

A

506
Q

Outline the physiological process of Meiosis.

A

Light/near convergence as stimuli

1) Light –> retinal ganglion cells –> Optic nerve –> Chiasm –> Exit at optic tract before LGN –> Enter dorsal midbrain –> Synapse with ipsilateral pretectal nucleus –> projections to bilateral Edinger-Westphal nuclei –> CN3 innervates the ciliary ganglion which causes sphincter pupillae and ciliary body contraction via short ciliary nerves
2) Near reflex –> visual cortex/ CN3 –> Frontal lobe eye fields –> CN3/Edinger-Westphal nucleus –> Medial recti convergence + Ciliary body contracts ciliary muscle with zonular relaxation thus lens thickens

507
Q

Outline the physiological pathway of pupillary dilation.

A

1st order fibres start in hypothalamus and project down spinal cord to C8-T10

2nd order preganglionic fibres leave spinal cord, traverse over lung apex and synapse at superior cervical ganglion at carotid bifurcation

3rd order post-ganglionic fibres traverse the wall of internal carotid artery and enter globe via long ciliary nerve to innervate dilator pupillae

508
Q

What is the shortest division of the optic nerve?

A

Intraocular

509
Q

What is the longest division of the optic nerve?

A

Intra-orbital

510
Q

What is the blood supply of the optic nerve?

A

Short posterior ciliary artery to the intraocular division

Ophthalmic artery (Pial vessels) supplies the rest

511
Q

Which fibres give rise to Willebrand’s Knee?

A

Inferonasal fibres of optic nerve notch forward into contralateral optic nerve before going posteriorly into contralateral tract

512
Q

Pathology of Willebrand’s knee gives rise to which type of visual defect?

A

Junctional scotoma

513
Q

A middle chasmal lesion results in which visual defect?

A

Bitemporal hemianopia

514
Q

Posterior chasmal lesions cause which visual field defect?

A

Paracentral scotoma

515
Q

Where do the optic tracts project to?

A

LGN

516
Q

Which fibres do the optic tracts carry?

A

Ipsilateral temporal fibres and contralateral nasal fibres

517
Q

A lesion of the left optic tract causes which visual field defect?

A

Right homonymous hemianopia

518
Q

What are the two divisions of the optic radiations?

A

Dorsal loop - travels through parietal lobe carrying inferior visual fields to primary visual cortex

Meyer’s Loop - travels through temporal lobe carrying superior visual fields to primary visual cortex

519
Q

A lesion of the left temporal lobe causes what visual field defect?

A

Right superior homonymous quadrantopia

520
Q

A lesion of the right parietal lobe in Dorsal loop gives rise to which visual field defect?

A

Right inferior homonymous quandrantopia

521
Q

What visual field defect occurs in a posterior cerebral artery occlusion?

A

Homonymous hemianopia with macular sparing

522
Q

Which visual field defect is caused by a systemic hypoperfusion?

A

Homonymous hemianopia with central scotoma

523
Q

Which visual stream is responsible for localising vision?

A

Dorsal stream –> Parietal lobe

524
Q

Which visual stream is responsible for visual identification?

A

Ventral stream -> Temporal lobe

525
Q

What investigation is used to assess visual fields?

A

Perimetry

526
Q

In which directions does the visual fields extend in each area?

A

Superior = 50

Nasal = 60

Inferior = 70

Temporally = 90

Mnemonic: SNIT

527
Q

An enlargement of the blindspot is termed a?

A

Seidel scotoma

528
Q

What is the difference between Humphrey and Goldman?

A

Humphrey is automated and static cf Goldman is manual and kinetic

529
Q

In which types of conditions are red-green loss seen?

A

Optic nerve problems

530
Q

In which conditions is blue-yellow vision loss seen?

A

Macular problems

Glaucoma

531
Q

What does Sherrington’s Law state?

A

Increased innervation of an agonist results in a decreased innervation of its antagonist

532
Q

What does Hering’s Law state?

A

yolk muscles receive equal innervation. I.e contraction of left LR will simultaneously produce equal contraction of the right MR

533
Q

What is the origin of SO?

A

Lesser wing of sphenoid

534
Q

What is the origin of IO?

A

Orbital floor

535
Q

What is the origin of LR?

A

Common tendinous ring

536
Q

What is the origin of MR?

A

Common tendinous ring

537
Q

Which extra ocular muscle inserts closest to the limbus?

A

Medial rectus

538
Q

What is the innervation of LR?

A

CN 6

539
Q

What is the innervation of SO?

A

CN IV

540
Q

What is the innervation of all recti muscles?

A

CN III

541
Q

What is the innervation of IO?

A

CN III

542
Q

Which muscles control elevation?

A

SR and IO

543
Q

Which muscles control depression of the eye?

A

IR + SO

544
Q

Which muscles control Adduction of the eye?

A

MR + SR + IR

545
Q

Which muscles control abduction?

A

LR + SO + IO

546
Q

Which muscle controls intorsion?

A

SO

547
Q

Which muscle of the eye controls extortion?

A

IO

548
Q

Where are voluntary saccades initiated?

A

Frontal lobe, on opposite side to direction of saccade

549
Q

Outline the process of a left saccade.

A

Originates in right frontal lobe frontal eye field (FEF) –> impulse reaches PONS –> activates PPRF and CN6 Nucleus –> impulse splits down to CN6 acting on ipsilateral lateral rectus (abduction) and CN3 contralaterally to medial rectus (abduction)

550
Q

Testing the dolls head reflex and it showing as intact suggests what?

A

Internuclear pathways intact

551
Q

An upbeat nystagmus shows?

A

Medullary lesions

552
Q

A downbeat nystagmus shows?

A

Arnold-Chiari malformations

553
Q

A latest horizontal nystagmus when one eye covered suggests?

A

Infantile esotropia

554
Q

A vestibular nystagmus suggests?

A

Vestibular lesion thus nystagmus towards the lesion

555
Q

What are the 3 types of optic neuritis pathologies?

A

Papillitis: Inflammation of the optic disc. Typically presents in post-viral children with flame hemorrhages and an oedematous optic nerve

Retrobulbar neuritis: disc is spared but the segment behind the eyeball is affected. The disc looks normal in this acute setting. More common in adults

Neuroretinitis: The disc and retina are both involved. Occurs in lyme disease and cat scratch

556
Q

What visual field defect occurs in papilloedema?

A

Loss of the inferior nasal quadrant of vision

557
Q

A patient is seen with a history of headaches and tenderness, sudden onset painful loss of vision unilaterally.

O/e the disc is chalky white.

ESR is elevated.

What is your diagnosis?

What is your management?

A

Anterior Ischaemic Optic Neuropathy secondary to GCA

Intravitreal Methylprednisolone

558
Q

What is the pathophysiology of MS?

A

T-cell mediated type 4 autoimmune neurodegenerative disorder of myelin in the central nervous system, which leads to inflammation and sclerosis.

559
Q

Which of the following is a mitochondrially inherited condition which affects the retinal ganglions?

A. MS

B. Leber Hereditary Optic Neuropathy

C. Neuromyelitis Optica

D. Miller-Fischer Syndrome

A

B

560
Q

A fundoycopic triad of pseudo oedema, telangiectasia and tortuous vessels are seen in a young man with painless, worsening central scotoma.

What is your diagnosis?
A. MS

B. Leber Hereditary Optic Neuropathy

C. Neuromyelitis Optica

D. Miller-Fischer Syndrome

A

B

561
Q

A patient presents with severe retrobulbar neuritis and muscle weakness and spasms.

IgG bodies are present against astrocytic AQP4.

What is your diagnosis?

A. MS

B. Leber Hereditary Optic Neuropathy

C. Neuromyelitis Optica

D. Miller-Fischer Syndrome

A

C

562
Q

A patient presents with ataxia, areflexia, ophthalmoplegia and facial diplegia.

It is associated with GQ1B auto-antibody.

What is your diagnosis?

A. MS

B. Leber Hereditary Optic Neuropathy

C. Neuromyelitis Optica

D. Miller-Fischer Syndrome

A

D

563
Q

Light to the left eye causes both eyes to constrict.

Light to the right eye does not cause constriction but if light is swung to the right, both eyes are seen to dilate.

What pathology is seen?

A

A right Marcus-Gunn pupil

564
Q

Light to the left eye causes both eyes to constrict.

Light to the right eye does not cause constriction but if light is swung to the right, both eyes are seen to dilate.

Where is the lesion?

A

Lesion of Optic nerve between the retina and pretectal nucleus thus no light stimulus

565
Q

A bilateral, irregular meiosis that does not react to light but accommodates suggests what lesion?

A

Dorsal midbrain lesion

566
Q

A bilateral, irregular meiosis that does not react to light but accommodates suggests what type of pupil defect?

A

Argyll-Robertson Pupil

567
Q

A unilateral dilated pupil that does not react to light and has a vermiform iris to movements is termed?

A

Adie’s pupil (the dilated)

Mnemonic: aDie’s pupil is Dilated

568
Q

A unilateral dilated pupil that does not react to light and has a vermiform iris to movements is caused by what type of lesion?

A

Lesion of the post ciliary ganglion parasympathetic fibres

569
Q

How do you test for an Adie’s pupil?

A

0.1% Pilocarpine which dilates the pupil

thus treatment is low dose pilocarpine to both eyes which causes denervation hypersensitivity constriction of the Adie pupil

570
Q

What is Holmes-Adie syndrome?

A

Holmes-adie syndrome is: Aldie pupil + decreased lower limb reflexes

571
Q

What is the triad of Horner Syndrome?

A

Ptosis + Anhidrosis + Miosis

572
Q

A lesion of the brain and spinal cord causing a Horner’s Syndrome is which order?

A

1st

573
Q

A pan coast tumour causing Horner’s syndrome is what order?

A

2nd

574
Q

A horner syndrome without anhidrosis caused by a CCF is what order?

A

3rd

575
Q

Why is there no anhidrosis in 3rd order Horner Syndrome?

A

secretomotor fibers that supply the sweat glands of the face leave this pathway before the third order neuron. Therefore, lesion of the third neuron will not affect sweat gland function.

576
Q

Which of the following will cause the normal pupil to dilate via NA-reuptake can be used to confirm a Horner Syndrome?

A. Cocaine

B. Apraclonidine

C. Hydroxyamphetamine

D. Dilute adrenaline

A

A - blocks NA reuptake thus enhances sympathetic effect and causes mydriasis in normal people.

Horner pupil will not dilate but normal will

577
Q

Which of the following will cause the Horner pupil to dilate via hypersensitivity can be used to confirm a Horner Syndrome?

A. Cocaine

B. Apraclonidine

C. Hydroxyamphetamine

D. Dilute adrenaline

A

B - sympathetic pathway broken thus effector muscles at end of pathway are hypersensitive thus Horner eye dilates more than normal eye

578
Q

Which of the following will cause the Horner pupil not to dilate thus can be used to confirm a 3rd order Horner Syndrome?

A. Cocaine

B. Apraclonidine

C. Hydroxyamphetamine

D. Dilute adrenaline

A

C

579
Q

Which of the following will cause the Horner pupil to dilate thus can be used to confirm a 3rd order Horner Syndrome?

A. Cocaine

B. Apraclonidine

C. Hydroxyamphetamine

D. Dilute adrenaline

A

D

580
Q

What condition may present as Painful Horner Syndrome?

A

Carotid dissection

581
Q

What is a surgical CN3 lesion?

A

A lesion that affects the pupil - not reacting to light

582
Q

Why do medical CN3 lesions tend to spare the pupils?

A

Microvascular problems are unlikely to effect these superficial fibers because of rich blood supply via pial vessels. Hence the pupil reflexes are spared in medical CN3 lesions.

583
Q

What is the presentation of a CN3 lesion?

A

Ptosis
Ophthalmoplegia (only abduction preserved)
Down and out eye
Dilated pupil (if surgical)

584
Q

What are the features of Weber’s Stroke?

A

CN3 palsy and contralateral hemiparesis

585
Q

How does a CN4 nerve lesion present?

A

Vertical diplopia and hypertrophia

586
Q

What test is used to identify a CN4 lesion?

A

Park’s Test

587
Q

If the left eye has a CN4 lesion, what head movements exacerbate this?

A

Diplopia is worse on right gaze (contralateral direction)

Diplopia is worse on left head tilt (ipsilateral head tilt)

588
Q

What is the most common cause of CN6 lesion?

A

Microvascular disease causing nerve ischaemia

589
Q

How does a CN6 nerve lesion present?

A

Horizontal diplopia and esotropia (eye inwards)

Reduced abduction

590
Q

Infection of ear and CN6 palsy is termed?

A

Gradenigo Syndrome

591
Q

What is the communication between the CN6 nucleus and the opposite CN3 nucleus?

A

Median Longitudinal Fasciculus (MLF)

592
Q

How is internuclear ophthalmoplegia caused?

A

Damage to the MLF q

593
Q

On attempted left gaze, the patient is unable to adduct the right eye and there is abducting nystagmus of the left eye.

Attempted right gaze is normal.

What is the lesion?

A

Right MLF lesion - resulting in reduced connection between the MLF of the CN6 and CN3

594
Q

What causes a bilateral INO?

A

Both MLF damaged

595
Q

On attempted Left gaze, there is abducting nystagmus of the left eye and unable to adduct the right eye.

On attempted right gaze, there is abducting nystagmus of the right eye and unable to adduct the left eye.

What lesion is present?

A

BINO

596
Q

What is the cause of one and a half syndrome?

A

Horizontal gaze palsy due to lesion of CN 6 nucleus or PPRF which stops functioning of ipsilateral abduction or adduction but allows contralateral abduction (as CN6 nucleus on opposite side is intact)

597
Q

A patient presents with double vision. On attempted right gaze, the right eye does not move, nor does the left eye.

On left gaze, the left eye can abduct but the right eye will not move.

What is your diagnosis?

A. CN6 palsy

B. INO

C. BINO

D. One and a Half Syndrome

A

D. One and a half syndrome.

598
Q

Bilateral lid retraction, up gaze paresis and convergence retraction nystagmus are signs of?

A. Parinaud Syndrome

B. BINO

C. INO

D. CN 6 palsy

A

A

599
Q

A patient presents with diplopia towards the end of the day. Repetitive movements worsen fatigue and weakness.

What is your diagnosis?

A

Myaesthenia Gravis

600
Q

A patient presents with diplopia towards the end of the day. Repetitive movements worsen fatigue and weakness.

What is your management?

A

ACEase inhibitors - Neostigmine

601
Q

What gene mutation causes Myotonic Dystrophy?

A

CTG trinucleotide expansion on DMPK gene

602
Q

A patient presents with a bilateral ptosis and ophthalmoplegia.

The report muscle weakness with delayed relaxation.

O/E you see christmas tree cataracts and confirmation of the ophthalmoplegia.

What is your diagnosis?

A

Myotonic Dystrophy

603
Q

At birth there is a bilateral ptosis and pigmentary salt and pepper retinopathy.

What is your diagnosis?

A. Kearns-Sayre Syndrome

B. NF 1

C. Myaesthenia

D. Myotonic Dystrophy

A

A

604
Q

What gene is Type 2 NF found in?

A

Feurofibromin 2 gene on Chromosome 22

605
Q

What are the ophthalmological features of NF Type 1?

A

Optic nerve gliomas

Iris hamartomas

606
Q

What is the difference between a tropia and phoria?

A

A tropia is when the eyes are always deviated (manifest deviation)

A phoria is a more subtle deviation which is hidden by binocular fusion, and becomes apparent when this is broken during testing.

607
Q

What is esotropia associated with?

A

Hypermetropia

608
Q

What is exotropia associated with?

A

Myopia

609
Q

Outline how a Hirschberg test detects a right exotropia.

A

Ophthalmoscope shone and corneal light reflex located.

Corneal light reflex of right eye located more medial to pupil thus outward deviation of the eyeball

610
Q

In esotropia of the right eye, what would a cover test show?

A

Cover L eye, R eye moves outwards to return to normal position.

Uncover L eye = R eye moves back to esotropic position

611
Q

In esophoria of the right eye, what would a cover test show?

A

Cover L eye = no change to R eye

Move cover from L eye to right eye = no movement of L eye

Moving cover from right eye back to left eye causes the right eye to move out. This is to correct the esophoria which was occurring when the right eye was covered and binocular vision was broken.

612
Q

Duane Syndrome is caused by?

A

aberrant co-innervation of both the LR and MR by CN3

613
Q

What is the most common type of Duane Syndrome? What signs are seen?

A

Duane 1

Abduction + Esotropia

614
Q

Upgaze causes a clicking sensation, what is your diagnosis?

What causes this?

A

Brown Syndrome

Mechanical restriction of SO

615
Q

Shortening of the muscle to strengthen to treat strabismus is what type of technique?

A. Resection

B. Recession

C. Advancement

D. Tucking

A

A

616
Q

Loosening of the muscle to weaken to treat strabismus is what type of technique?

A. Resection

B. Recession

C. Advancement

D. Tucking

A

B

617
Q

Strengthening of the muscle which is previously recessed to treat strabismus is what type of technique?

A. Resection

B. Recession

C. Advancement

D. Tucking

A

C

618
Q

Strengthening the superior oblique muscle is what type of technique?

A. Resection

B. Recession

C. Advancement

D. Tucking

A

D

619
Q

How do you manage amblyopia?

A

Occlusion (of good eye)

Atropine penalisation (to good eye)

620
Q

What blood vessels supply the retina?

A

Inner 2/3 retina = Central retinal artery

Outer 1/3 retina = Choroidal vessels

Retinal drainage by central retinal vein

621
Q

What artery forms an anastomosis between the central retinal artery and the choroidal vessels?

A

Cilioretinal artery

622
Q

Where is the blind spot located?

A

Optic disc

623
Q

How many layers does the retina have?

What are they?

Which are neurosensory?

A

10

Internal limiting membrane
Nerve fiber (contains ganglion cell axons)
Ganglion cell layer (contains cell bodies of ganglion cells)
Inner plexiform
Inner nuclear (contains cell bodies of glial cells and bipolar cells)
Outer plexiform
Outer nuclear (contains cell bodies of photoreceptors)
External limiting membrane
Photoreceptors

Mnemonic: In New Generation It Is Only Ophthalmologists Examine Patient Retina’s

9 neurosensory; 1 RPE

624
Q

What is the main visual pigment in rod cells?

A

Rhodopsin

625
Q

Where is the highest concentration of cones?

A

Fovea

626
Q

Which type of pigment is not found in the fovea?

A

Short iodopsin

627
Q

What is long iodopsin responsible for?

A

Red vision

628
Q

What is medium iodopsin responsible for?

A

Green

629
Q

What is syneresis?

A

Vitreous gel becomes increasingly runny with age thus small pools of fluid within the vitreous thus can cause posterior vitreous detachment from the retina

630
Q

How is Diabetic Retinopathy classified?

A

Non-Proliferative: micro aneurysms; retinal haemorrhages; venous looping

Proliferative: Any neovascularisation; vitreous haemorrhage; pre-retinal haemorrhage

Macular oedema: significant macular oedema

631
Q

How is non-proliferative diabetic retinopathy managed?

A

Monitoring

632
Q

How is proliferative diabetic retinopathy managed?

A

PRP

633
Q

How is clinically significant maculopathy managed?

A

Macular grid laser

634
Q

What are the stages of Hypertensive retinopathy?

A

Arteriolar narrowing

AV nipping OR silver wiring

Flame hemorrhages OR cotton wool spots

Disc swelling OR hard exudates OR retinal oedema

635
Q

How do you manage hypertensive retinopathy?

A

Control systemic hypertension - if papilloedema/malignant hypertension, conduct emergency assessment

636
Q

A patient presents with sudden, painless loss of vision.

RAPD and a pale retina is seen as well as a cherry red spot in the macula.

What is your diagnosis?

A

CRAO

637
Q

A patient experiences a sudden painless visual field defect at altitude. You see a swollen white vessel across the retina.

What is your diagnosis?

A

BRAO

638
Q

A patient presents with sudden painless loss of vision, dilation of the branches of a vessel and dot/flame haemorrhages in all 4 quadrants.

The optic disc looks swollen.

What is your diagnosis?

A

CRVO without ischaemia

639
Q

A patient presents with sudden painless loss of vision, dilation of the branches of a vessel and dot/flame haemorrhages in all 4 quadrants.

The optic disc looks swollen. A RAPD is seen as well as rubeosis iridis.

What is your diagnosis?

A

CRVO with ischaemia

640
Q

A patient presents with reduced painless vision, an altitudinal visual field defect and retinal haemorrhages seen in the superotemporal quadrant.

What is your diagnosis?

A

BRVO

641
Q

What is the management of CRAO?

A 
Ocular massage 
\+
IV Acetazolamide 
\+ 
AC paracentesis
642
Q

What is ocular ischaemic syndrome?

A

Angina of the eye caused by carotid obstruction secondary to atherosclerosis

643
Q

A patient presents with painful, gradual reduction in vision with episodes of transient vision loss and orbital aching pain.

There is a flare shown in the AC.

What is your diagnosis?

A

Ocular Ischaemic Syndrome

644
Q

What genotype of Sickle Cell is most associated with ocular disease?

A

HbSC

645
Q

How is diagnosis of Sickle cell made?

A

Haemoglobin electrophoresis

646
Q

What is used to treat Sickle Cell Retinopathy?

A

Scatter laser photocoagulation

647
Q

A young Indian male presents with some neovascularisation and a vitreous haemorrhage.

What is the diagnosis?

A

Eales Disease

648
Q

A patient presents with strabismus, retinal telangiectasia and intraretinal exudation.

What is your diagnosis?

A

Coats Disease

649
Q

Which investigations should you consider in suspected macular degeneration due to a patient with a central scotoma?

A

OCT = shows druse and sub retinal fluid

FFA = neovascularisation

650
Q

How do you treat Dry ARMD?

A

AREDS2 diet (Vitamin C + E + Lutein + Zeaxanthin + Zinc)

651
Q

How do you treat Wet ARMD?

A

Anti-VEGF Intravitreal injections

652
Q

A patient presents with a scotoma and blurry vision. They say straight lines appear curved.

What is your diagnosis?

A

Cystoid Macular Oedema

653
Q

How is CMO diagnosed?

A

OCT

654
Q

How is CMO managed?

A

Steroids

± > 1/12
- Periorbital steroid injection

± >2/12
- Intravitreal or systemic steroids

±
CAi
/
anti-VEGF

655
Q

A 50 year old man presents with sudden unilateral reduction in vision and a blindspot.

What investigation will you order?

A

OCT

656
Q

A 50 year old man presents with sudden unilateral reduction in vision and a blindspot.

OCT shows sub retinal fluid.

What is your management?

A

Argon laser this patient has a central serous chorioretinopathy

657
Q

What is pseudoxanthoma elasticum associated with?

A

Angioid streaks - atrophied streaks from the optic disc to the outer retina

658
Q

Which conditions are associated with angioid streaks?

A

Mnemonic PEPSI

Pseudoxanthoma elastic; Paget’s; Sickle Cell; Idiopathic

659
Q

What is protective to degenerative myopia?

A

Time spent outdoors

660
Q

What is degenerative myopia classically associated with?

A

Connective tissue disorders

661
Q

What is the most common inheritance of Retinitis Pigmentosa?

A

AD

662
Q

The worst forms of Retinitis Pigmentosa are inherited in which manner?

A

X-Linked

663
Q

What is the most common gene mutation for Retinitis Pigmentosa?

A

Rhodopsin gene on Chromosome 3

664
Q

Otoscopy shows a waxy disc with bony spicules and arteriolar attenuation.

ERG is electronegative.

What is your diagnosis?

A

RP

665
Q

The presence of RP and sensorineural deafness and blindness are part of?

A. Usher Syndrome

B. Refsum Syndrome

C. Barder-Biedl Syndrome

D. Bassen Kornzweig Syndrome

A

A

666
Q

The presence of RP and anosmia, peripheral neuropathy and ichthyosis are part of?

A. Usher Syndrome

B. Refsum Syndrome

C. Barder-Biedl Syndrome

D. Bassen Kornzweig Syndrome

A

B

667
Q

RP associated with polydactyly and obesity is part of?

A. Usher Syndrome

B. Refsum Syndrome

C. Barder-Biedl Syndrome

D. Bassen Kornzweig Syndrome

A

C

668
Q

The presence of RP featuring spinocerebellar ataxia and acanthocytosis is part of?

A. Usher Syndrome

B. Refsum Syndrome

C. Barder-Biedl Syndrome

D. Bassen Kornzweig Syndrome

A

D

669
Q

A patient presents with salt and pepper retinopathy and a bulls eye maculopathy.

What is your diagnosis?

A

Leber Congenital Amaurosis

670
Q

A patient presents with bilateral egg yolk macular.

ERG is normal but EOG is abnormal.

What is your diagnosis?

A

Best Disease

671
Q

A patient presents with reading difficulties at the age of 14. A FFA shows a dark choroid and a beaten bronze macula.

What is your diagnosis?

A

Stargardt Disease

672
Q

A patient presents with reduced visual acuity, nystagmus and iris hypopigmentation.

What is your diagnosis?

A

Albinism

673
Q

On fundoscopy, a zig-zag white line is seen and small round holes can be seen.

Which form of peripheral retinal degeneration is this?

Who is it more common in?

A

Lattice Degeneration

Myopes and CT disorders

674
Q

On fundoscopy, in the inferotemporal region of the fundus, a smooth elevation of the retina is seen.

What form of peripheral retinal degeneration is this?

Who is ti most common in?

A

Degenerative retinoschisis

Hyperopes and bilateral

675
Q

What are the types of retinal tear?

A

U-shaped

Giant = extend more than 1/4

Retinal dialysis = tear of retina at ora errata

676
Q

What is the location of retinal dialysis due to trauma?

A

Superonasal

677
Q

What is the form of retinal dialysis which is idiopathic?

A

Inferotemporally

678
Q

Which type of retinal tear has the highest risk to retinal detachment?

A

Giant

679
Q

How is retinal dialysis treated?

A

Scleral buckling

680
Q

How are U-shaped and giant retinal tears managed?

A

Retinopexy

681
Q

What is the most common form of retinal detachment?

A

Rhegmatogenous retinal detachment

682
Q

Which form of retinal detachment is usually seen in Diabetic Retinopathy?

A

Tractional

683
Q

What is the pathophysiology retinal detachment?

A

NSR separates from the RPE - fluid (rhegmatogenous); traction (tractional) or failure of BRB (fluid accumulation and retinal detachment)

684
Q

What are Shaffer Sign pathognomonic of?

A

Tobacco dust in the anterior vitreous following a PVD

685
Q

What is the management of PVD?

A

Vigilance for RD

686
Q

What are the management options in a vitreous haemorrhage?

A

Fundal view present –> PRP

Obstructed fundal view –> Intravitreal anti-VEGF

Persistent haemorrhage or associated RD –> Pars plan vitrectomy

687
Q

What gene is associated with Retinoblastoma?

A

RB1 on Ch13

688
Q

A child who is 3 presents with leukocoria, strabismus and reduced visual acuity.

O/E a white round mass is seen in the fundus.

How is this managed?

A

This is Retinoblastoma and the treatment is enucleation

689
Q

A premature infant who weighs 1kg and experienced some hypoxia presents.

They were born at 28 weeks.

When should they be screened?

A

32 weeks

27-32 weeks or >32 weeks + <1500g = screen 4 weeks postnatally

690
Q

A premature infant who weighs 1kg and experienced some hypoxia presents.

They were born at 26 weeks.

When should they be screened?

A

Screen at 30 weeks

691
Q

A premature infant who weighs 1kg and experienced some hypoxia presents.

They are screened at 30 weeks and retinal vessels are noted to reach between the edge of the disc to the ora serrata.

What is your diagnosis?

What is your management?

A

Zone 2 Retinopathy of Prematurity

Zone 1 → radius 2x distance from disc to fovea with disc at centre
Zone 2 → Edge of 1 to nasal ora serrata
Zone 3 → From 2 to remaining retina

Transpupillary diode laser within 48 hours

Medicine (18 decks)

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