Ophthalmology

Question 1

How does dry age-related macular degeneration present?

Answer 1

Patients suffer a progressive loss of central vision over years/decades.
The typical patient presents complaining of difficulty in reading text, recognizing faces and problems with vision in dim light.
Visual fluctuation is a classic feature, day by day vision may appear to deteriorate and improve unpredictably.
Fundoscopy shows drusen (protein deposits) at the macula.

Question 2

How does wet age-related degeneration present?

Answer 2

Patients suffer a progressive loss of central vision over months.
The typical patient may complain of difficult reading text, recognizing faces and seeing in dim light.
Visual fluctuation is another feature that may present.
Fundoscopy shows macular oedema.

Question 3

When do we need to treat amblyopia by?

Answer 3

Treatment of amblyopia must be started at an early age and the critical period is up to 8 years old. The good eye is normally patched. Amblyopia treatment is rarely successful in the second decade of life.

Question 4

How does keratitis present?

Answer 4

Keratitis presents with an acute-onset of eye pain, watering, photophobia and reduced vision. It is commonly caused by trauma or viral infection e.g. herpes simplex.

Question 5

How do we manage keratitis?

Answer 5

Keratitis requires rapid treatment to reduce the risk of permanent visual loss. Keratitis caused by viral infection may be treated with topical antiviral drops. Traumatic keratitis requires referral to ophthalmology for consideration of corticosteroid treatment.

Question 6

How does Bell’s Palsy present?

Answer 6

It is characterised by:

Acute (but not sudden) onset, unilateral, lower motor neuron facial weakness, sparing the extraocular muscles and muscles of mastication.
Mild-moderate postauricular otalgia (which may precede paralysis).
Hyperacusis (actually quite uncommon).
Nervus intermedius symptoms (altered taste and dry eyes/mouth).
It should be noted that, while there are no objective facial somatosensory disturbances, patients may describe “numbness” or “heaviness”.

Question 7

What is blepharitis? How does it present?

Answer 7

Blepharitis is a common condition describing eyelid inflammation.

Common causes are Staphylococcus, Seborrheic dermatitis and Rosacea.

Patients often present with sore, itchy eyelid margins with a crusty appearance at the base of the eyelashes.

The condition cannot be cured, but it very rarely causes damage to eyesight.

Treatment is aimed at controlling the symptoms with good eyelid hygiene.

Warm compresses should be applied twice daily to clean debris from the eyelid margins.

Question 8

Give two complications of cataract surgery

Answer 8

Endophthalmitis is the most dangerous complication and the first thing any doctor should rule out when presented with a patient complaining of visual symptoms following intraocular surgery. Patients typically present within days of surgery with severe pain, loss of vision and hyperaemia. They should be admitted and seen immediately by an ophthalmologist.

Posterior lens capsule opacification is a relatively common complication of cataract surgery that usually occurs a few weeks following the operation. The typical patient complains of blurry vision as if their cataract has returned, and a white opacity may be visible on observation. The condition can be treated easily with a simple laser procedure which can be carried out as an outpatient.

Question 9

How does central retinal vein occlusion present?

Answer 9

Sudden, painless loss of vision

Question 10

How does central retinal vein occlusion appear on fundoscopy?

Answer 10

The classic view on fundoscopy is that of widespread hyperaemia and haemorrhages, often likened to a ‘stormy sunset’

Question 11

What is chronic open-angle glaucoma? How does it present?

Answer 11

Chronic open angle glaucoma refers to optic neuropathy with death of optic nerve fibres, with or without raised intraocular pressure.

Assessment of visual fields reveals loss of peripheral fields as well as a central scotoma in advanced disease. Fundoscopy may reveal optic disc cupping, where the cup appears large in relation to the optic disc.

Question 12

What is corneal acrus?

Answer 12

Corneal arcus occurs as a result of lipid deposition in the periphery of the cornea and appears as a white, blue or grey opaque ring.

Common in hyperlipidaemia or hypercholesterolaemia

Question 13

How does diabetic retinopathy present on fundoscopy?

Answer 13

The fundoscopy signs are important to recognise.

Signs that signify milder disease are: ‘dots’ (microaneurysms), hard exudates (lipid deposits) and ‘blots’ (haemorrhages).

Signs that signify significant ischaemia and thus more severe disease are: engorged tortuous veins, cotton wool spots, and large ‘blot’ haemorrhages.

Question 14

Give five differentials of gradual visual loss

Answer 14

Cataract
AMD
Chronic open angle glaucoma
Diabetic maculopathy

Question 15

How do we treat endopthalmitis?

Answer 15

IV vanc as most common causative bugs are gram positive

Question 16

How do we distinguish between episcleritis and scleritis?

Answer 16

Clinical features include a deep boring pain that wakes the patient up at night combined with a severely red eye.

As the inflammation affects the superficial episcleral as well as the deep scleral vessels, topical vasoconstrictors such as 10% phenylephrine do not cause blanching of the eye and this can be used to help distinguish episcleritis from scleritis.

Question 17

In what condition do you see dendritic ulcers?

Answer 17

Pathognomonic for herpes simplex keratitis

Presents with pain, photophobia and epiphora

Question 18

What are the four grades of hypertensive retinopathy?

Answer 18

Grade I – Vascular attenuation (or narrowing of the retinal arteries)
Grade II – Above + AV nipping
Grade III – Above + retinal haemorrhages, hard exudates and cotton wool spots
Grade IV – Above + optic nerve oedema

Question 19

Who is idiopathic intracranial htn most common in? How do we treat it?

Answer 19

Most common in obese women

First line management of idiopathic intracranial hypertension (and the only intervention supported by good evidence) is weight loss.

Failing this, patients often try carbonic anhydrase inhibitors, such as acetazolamide, but its extensive profile of side effects (peripheral paraesthesia, anorexia and metallic dysgeusia) mean that it is poorly tolerated. Topiramate and furosemide are also commonly tried.

Question 20

What is the first line ix for an intra-ocular foreign body?

Answer 20

CT scan

Question 21

How does ischaemic optic neuropathy present?

Answer 21

Generally, patients present with sudden onset monocular vision loss and colour blindness.

On examination, a relative afferent pupillary defect is often elicited.

Optic disc swelling or pale optic disc on fundoscopy

Question 22

What is the most common cause of arteritic anterior ischaemic optic neuropathy (AION)

Answer 22

GCA

Question 23

Where do you see a classic “pizza pie” appearance on fundoscopy?

Answer 23

Cytomegalovirus retinitis, most common ocular opportunistic infection seen in HIV

Question 24

Give four important differentials of ocular pain

Answer 24

Acute angle closure glaucoma
Anterior uveitis
Scleritis
Corneal ulcer

Question 25

How does acute angle-closure glaucoma present?

Answer 25

Patients typically present as systemically unwell with nausea and headaches. In some, but not all, there is severe ocular pain associated with blurred vision and haloes around lights. The pupil is typically in a fixed-dilated position. Acute angle-closure glaucoma is an emergency, patients must be referred to ophthalmology immediately to prevent the progression of visual loss.

Question 26

How does anterior uveitis present?

Answer 26

Patients typically present with red eye, pain, blurred vision and photophobia. The pupil may be irregular due to adhesions between the lens and iris (termed synechiae).

Question 27

How does scleritis present?

Answer 27

Severe inflammation of the sclera, patients complain of severe pain in the orbit and pain on eye movement. ~50% of patients are systemically ill with associated rheumatological conditions such as rheumatoid arthritis or granulomatosis with polyangiitis, so look for systemic symptoms.

Question 28

How does corneal ulcer present?

Answer 28

Patients may present with pain, photophobia and excessive lacrimation. Slit lamp examination with fluorescein application is important to visualise the ulcer. Ulcers may be traumatic, bacterial, viral, fungal, protozoal, or vasculitic. Always ask about contact lens use.

Question 29

Give four ocular SEs of steroids

Answer 29

Raised intraocular pressure
Glaucoma
Accelerated cataract formation
Worsening of corneal ulcers

Question 30

What does optic disc pallor show?

Answer 30

Optic disc pallor is the characteristic sign of optic atrophy. It is an end stage to many disease processes that result in damage to the optic nerve cells (known as optic neuropathy).

Question 31

How does optic neuritis present?

Answer 31

Visual loss
Periocular pain
Dyschromatopsia

Question 32

How does orbital cellulitis present? How is it treated?

Answer 32

The typical patient is a child with an erythematous swollen eyelid, mild fever and erythema surrounding the orbit.

Treat with intravenous empirical antibiotics. If there is doubt over the diagnosis, treat it as orbital cellulitis.

Question 33

How does primary closed angle glaucoma present?

Answer 33

In primary closed angle glaucoma, patients typically present as systemically unwell with nausea and headaches.
In some, but not all, there is severe ocular pain associated with blurred vision and halos around lights.
The pupil is typically in a fixed-dilated position.
Primary closed angle glaucoma is an emergency, patients must be referred to ophthalmology immediately to prevent the progression of visual loss.

Question 34

How does central retinal artery occlusion present? How is it seen on fundoscopy?

Answer 34

In central retinal artery occlusion (CRAO) patients present with sudden onset painless loss of vision that typically occurs over seconds.

Pale retina with a cherry red spot at the macula

Question 35

How does thyroid eye disease present?

Answer 35

Signs include lid retraction, proptosis, lid lag and red, watery eyes.

Question 36

What is trachoma?

Answer 36

Trachoma is a bacterial keratoconjunctivitis caused by Chlamydia trachomatis. It is common in children and adults with poor hygiene e.g, in resource poor areas of the world. Repeated or untreated infection can lead to conjunctival scarring and corneal abrasion. It is easily treated with oral antibiotics, typically Azithromycin as a one-off dose.