Ophthalmology

Question 1

What are the causes of sudden painful visual loss?

How do you differentiate them clinically

Answer 1

Closed angle glaucoma: Red eye, hazy cornea, dilated pupil

Anterior uveitis: flush, iris pus, fixed oval pupil

Optic neuritis: central loss, colour loss, RAPD, worse on movement

Giant cell arteritis: Painful jaw/ scalp

Question 2

What are causes of painless sudden visual loss?

How do you distinguish them?

Answer 2

Amaurosis fugax: ‘curtain coming down’,

Central retinal artery occlusion: RAPD, ‘cherry red’ spot on pale retina

Central retinal vein occlusion: retinal haemorrhages

Vitreous haemorrhage: Dark spots, diabetics, anticoagulants

Posterior vitreous detachment: Flashes and floaters

Retinal detachment: Dense shadows peripheral to central; curtain over visual field

Question 3

Name and distinguish the causes of gradual visual loss?

Answer 3

Cataracts: ‘starbursts’ at night, red reflex loss

ARMD: central field loss, wavy appearance to straight lines

Diabetic retinopathy: blurred, blotched vision, ‘cotton wool’ spots

Chronic open angle glaucoma: peripheral loss, halos, can be painful

Question 4

How do you manage acute angle closure glaucoma?

Answer 4

Urgent referral to ophtho

Improve flow: pilocarpine and apraclonidine

Reduce secretions: B-blocker IV acetazolamide

*Blockers/inhibitors block production, agonists improve flow, a–agonists do both)

Question 5

How do you manage anterior uveitis

Answer 5

Urgent Ophtho review

Dilate eye with atropine, cyclopentate

Steroid eye drops for inflammation

Question 6

How do you manage optic neuritis

Answer 6

Give high dose steroids

MRI for white matter lesions (>3 measns 50% MS risk in 5 yrs)

Question 7

How do you treat giant cell arteritis?

Answer 7

Give high dose glucocorticoids (IV methylprednisilone if evolving changes prior to pred)

Optho review same day

Artery biopsy

Question 8

How do you treat amaurosis fugax?

Answer 8

Aspirin 300mg as per stroke

Question 9

How do you manage

CRVO

Answer 9

CRVO

Macular oedema: Anti-VEGF

Neovascularisation: Lasering

Question 10

How are vitreous haemorrahge and retinal detachment managed?

Answer 10

Urgent Ophtho review

Question 11

How are cataracts managed?

Answer 11

If visual impairment, QOL and patient choice are fitting, lens replacement

Question 12

How is age related macular degeneration investigated and managed?

Answer 12

Investigations

1st: Slit lamp

+ fluoreiscin angiography if neovascular suspected

Management

vitamins A, C, E

VEGF if wet/neovascular

+ laser photocoagulation to slow progression

Question 13

How is diabetic retinopathy categorised?

Answer 13

Non-proliferative

Mild: >=1 microaneurysm

Moderate: Cotton wool spots, hard exudates

Severe: Blot haemorrhages in 4 quadrants, venous bleeds in 2

Proliferative

neovascularisation

Maculopathy

Question 14

How do you manage diabetic retinopathy?

Answer 14

All: Optimise cardiac risk factors, regular review

Non-proliferative: Observe, laser photocoag if severe

Proliferative: laser coagulation

Maculopathy: VEGF if visual acuity change

Question 15

How do you investigate primary open angle glaucoma?

Answer 15

Fundoscopy: cup/disc 0.7 pallor and bayonetting of vessels

Slit lamp, tonometry to confirm

Question 16

How do you tell the difference between keratitis and conjunctivitis?

Answer 16

Keratitis // Conjuncitvitis

hypopyon, contact lense // discharge if infective, seasonal, atopic history if allergic

Question 17

How do you manage keratitis?

Answer 17

Refer to Ophtho same day for slit lamp

Stop contact lenses

Quinilone antibiotics

Cycloplegics for pain

Question 18

How do you investigate and treat herpes simplex keratitis?

Answer 18

Immediate referral to Ophtho

Fluoreiscin staining shows corneal ulcer

give oral aciclovir

Question 19

What organism is responsible for keratitis that is

Bacterial

Fungal

Viral

Answer 19

Bacterial: S. aureus, P. aeringuosa (contacts)

Fungal: Acanthomoebic (soil, contaminated water)

Viral: Herpes simplex

Question 20

How do viral, bacterial and allergic conjunctivitis differ

Demographic

Symptoms

Treatment

Pathogen

Answer 20

Viral // Bacterial // allergic

Adults // Children // equal

Watery discharge, URTI // Thick discharge // watery discharge, itch

Self-limiting 1-2w // if 5-7d, chloramphenicol // antihistamine –> mast cell stabilisers

adeno, HSV // S. aureus, chlamydia, gonorrhea // NA

Question 21

What is the difference between esophoric and exophoric ambylopia?

How are they managed

Answer 21

Eso: Inward, Exo: Outwards

Covering good eye causes other to move opposite way

Refer for Ophtho

Specs/patch good eye/corrective surgery

*tropia if all the time, phoria if sometimes*

Question 22

Which ophtho meds cause

brown pigmentation, eyelash growing

Hyperaemia, adversity in MAOIs or TCAs

Headaches, blurred vision

Answer 22

PGE analogues (lantaprost)

sympathomimetics (brimonidine)

pilocarpine

Question 23

What nerve damage causes the following

Down + out eye, dilated eye

Up and outward rotation, vertical diplopia

Eye cannot abduct

Answer 23

3rd nerve (oculomotor)

4th nerve (superior oblique)

6th nerve (abducens)

Question 24

What is the difference between a Holmes-Adie pupil and Argyll-Robertson?

Answer 24

HA: Unilateral dilation, slow dilation following constriction; will get smaller over time. +/- ankle and knee reflex loss

AR: Constricted pupil that accomodates but does not react. Neurosyphilis.

Question 25

Name the location of the lesion and the associated pathologies

Answer 25

1. Optic nerve: ipsilateral loss (neuritis, ischaemia, trauma)
2. Optic chiasm central: bitemporal hemianopia (adenoma, suprasellar aneurysm)
3. Optic chiasm lateral: ipsilateral monocular hemianopia (3rd ventricle distension, IC/PCA atheroma)

4. Optic tract: contralateral homonymous hemianopia (MCA stroke and tumours)

5. Occipital cortex: contralateral homonymous hemianopia with macular sparing (PCA stroke, trauma)

Question 26

Contralateral homonymous quandrantopia is associated with

Answer 26

MCA stroke, tumour and trauma

Question 27

What’s this?

Answer 27

Normal retina

Question 28

Whats this?

Answer 28

Central retinal artery occlusion

Question 29

Whats this

Answer 29

Central retinal vein occlusion

Question 30

Whats this?

Answer 30

Maculopathy

Advanced diabetic retinopathy

Question 31

Whats this?

Answer 31

ARMD