Ophthalmology

Question 1

Eye with
- Reduced vision
- Pain
- Corneal opacity + epithelial erosion
- Hyperaemia
- Hypolacrimation
+/- mucopurulent discharge, hypopyon

Diagnosis, causes:

Answer 1

Keratitis

neurotropic keratopathy, rheumatoid arthritis, dry eye, corneal infection (Staph, Strep, HSV, VZV, EBV, CMV), FB/contact lens abrasion

Question 2

Eye with:
- Pain - not relieved with tetracaine
- Photophobia
- Decreased vision
- Watery discharge
- Hyperaemia
- Miosis

Diagnosis, causes, slit lamp findings, management:

Answer 2

Iritis/Anterior uveitis

Blunt trauma, syphilis, herpesvirus, TB, VZV, toxoplasmosis, spondyloarthropathies (HLA-B27), sarcoid, juvenile RA, ulcerative colitis, Kawasaki, Behcet, Reiter’s

• Ciliary/perilimbal injection
• Cells and flare
• Hypopyon
• Keratic precipitates

Discuss with opthlamology - steroid and dilating drops
Consider bloods: CBC, ANA, HLA-B27, ESR, syphilis screen, chlamydia/gonorrhoea

Question 3

Eye with:
- Violaceous hue
- Globe tender to touch
- Focal scleral injection
- Referred piercing pain to jaw/forehead
+/- corneal ulcers

Diagnosis, cause

Answer 3

Scleritis

Idiopathic, HSV, TB, syphilis, collagen vascular diseases, Wegener’s granulomatosis, sarcoidosis, RA, reactive arthritis, IBD

Question 4

Eye with:
- Mild pain
- Isolated mild focal injection
- Acute onset
- Normal visual acuity

Diagnosis, cause

Answer 4

Episcleritis

Idiopathic, may be associated with collagen vascular disease

Question 5

Eye with:
- well demarcated bright red patch on sclera
- Normal vision
- No corneal involvement

Diagnosis, cause

Answer 5

Subconjunctival haemorrhage

Trauma, valsalva, coughing, bleeding disorder, HTN, Kaposi sarcoma

Question 6

Differentiating between allergic, viral, bacterial conjunctivitis

Management

Answer 6

Allergic - Atopy/hayfever, itch, grittiness, watery discharge
Viral - preceding URTI, watery discharge
Bacterial - Mucopurulent discharge

Cold compress
Artificial tears
Good hand hygiene
If bacterial - antibacterial drops if still ongoing after 2-3 days good hand hygiene

Question 7

High risk conjunctivitis and treatment

Answer 7

Neonates <28 days
- Suspect maternal STI, acute referral to paeds, treat with erythromycin or azithromycin
- Possible pneumonia with neonatal chlamydia

Chlamydia conjunctivitis (suspect if pre auricular lymph node swelling)
- Opthalmology advice, treat with doxycycline, contact tracing
- Risk for trachoma

Gonorrhoea conjunctivitis (suspect if acute onset profuse purulent discharge)
- Acute ophthalmology referral, contact tracing

Acute referral for all with corneal involvement

Question 8

Preseptal vs orbital cellulitis symptoms + management

Answer 8

Orbital septum - tissue from orbital rim to eyelids
Preseptal cellulitis - redness, minimal eyelid swelling
Staphylococcus aureus, Streptococcus pyogenes, Haemophilus influenzae - augmentin

Orbital cellulitis - redness, eyelid swelling, painful ocular movement, ptosis, proptosis, diplopia, pupillary changes, visual changes in late stage
- Acute ophthalmology referral

Question 9

Herpes zoster ophthalmicus symptoms

Answer 9

Flu-like prodrome 1/52
Rash on forehead - erythema macules > papules and vesicles > pustules
Photophobia suggests corneal involvement
Hutchinson’s sign - vesicular lesions on tip of nose
Eye - blepharitis + ptosis, reduced visual acuity, redness (episcleritis)
Secondary bacterial infection

Cornea - punctate epithelial keratitis (day 1-2) > dendritic keratitis (1/52) > anterior stromal keratitis (weeks) > deep stromal keratitis (months) > neurotropic keratopathy (years)
Uveitis (2 weeks-years)
Acute retinal necrosis, optic neuritis, oculomotor palsy

Question 10

Management of herpes zoster ophthalmicus

Answer 10

Ophthalmology advice
Analgesia
Valaciclovir 1g tds
- in immunocompromised until 2 days after last lesion crusted
Avoid contact with pregnant women, immunocompromised people, children naive to chickenpox until last lesion has crusted

Question 11

Risks for acute angle closure glaucoma

Answer 11

Increasing age
Female
Hypermetropia
Asian
FHx angle closure glaucoma
Anticholinergics

Question 12

Symptoms + signs of acute angle closure glaucoma

Answer 12

**Acute onset unilateral painful red eye
**Decreased vision
Nausea and vomiting
First onset at low lighting
Unilateral headache
Halos around vision
Photophobia

**Mid dilated, poorly reactive pupil
Rock hard globe + increased IOP (normal 12-21mmHg)
**Hazy cornea

Question 13

Management of acute angle closure glaucoma

Answer 13

Urgent ophthalmology referral
Sit upright to reduce IOP
Well lit room to prevent pupil dilation

Ophthalmology management:
Acetazolamide 500mg PO/IV
500mL Mannitol 15% IV
Topical beta-blocker + cholinergic
Laser iridotomy

Question 14

High risk mechanisms for penetrating eye injury

Answer 14

Exposure to fast projectile, sharp, penetrating objects
Metal on metal exposure (hammering, grinding)
MVA
Fall while holding sharp object
Airguns/firearms

Question 15

Slit lamp signs of penetrating eye injury

Answer 15

Uveal/retinal prolapse
Vitreous extrusion
Hyphaema
Irregular/peaked pupil shape
Deep or shallow anterior chamber
Subconjunctival haemorrhage
Seidel positive

Question 16

Management of penetrating eye injury

Answer 16

Refer acutely
Do no apply pressure
- Apply rigid protective cover
Do no apply eye drops
Do not force eyelid open
Do no attempt FB removal
Oral analgesia
Antiemetic
Update tetanus
NBM
Consider abx if delayed transfer

Question 17

Injuries in blunt eye trauma

Answer 17

Hyphaema - gross/microscopic
Traumatic iritis
Traumatic mydriasis (damage to pupillae sphincter muscles)
Eyelid, lacrimal apparatus injury
Orbital blow out fracture

Globe rupture
Retrobulbar haematoma
Retinal detachment
Iridodialysis - tear of iris root
Lens dislocation
Vitreous haemorrhage
Commotio retinae (traumatic retinopathy) - oedema in retina

Question 18

Structures injured in medial eye lid lacerations
How to investigate?

Answer 18

Superior/inferior lacrimal punctums and lacrimal canals
Lacrimal sac and nasolacrimal canal

Instill fluorescein in eye, look for dye in the wound

Question 19

What to avoid in suturing of lid laceration?
Removal of sutures time?
Patient advice?

Answer 19

Avoid vertical tension - risk of lid retraction, ectropion, lagophthalmos (inability to close eyelids completely)

Lid sutures - 4-6 days
Lid margins + periorbital skin - 5-7 days

Limit sun + water exposure
No makeup 2-3 weeks

Question 20

Referral criteria for lid lacerations

Answer 20

Within 6-8mm of medial canthus, or medial to punctum
Involving inner surface
Involving lid margin
Deep to tarsal plate
Tissue avulsion
Ptosis (levator palpebrae involvement)
Orbital fat exposure (orbital septum, levator palpebrae)

Question 21

Management of chemical ocular burns

Answer 21

Alkali worse than acidic
Oral analgesia + repeated tetracaine
Irrigate ASAP - deterioration within seconds
At least 1L Hartmanns > NaCl/sterile water
Evert eyelid, sweep fornices
Ophthalmology advice
Urgent assessment for alkali burns, hazy cornea, corneal defects

Question 22

UV keratoconjunctivitis
Cause, presentation, management

Answer 22

Excess UV-B and UV-C light exposure to eye
30mins-24hrs post exposure - photophobia, FB sensation, watering, conjunctivitis, blurred vision
Punctate epithelial staining on fluroescein

Self-limiting 24-48 hours - cold compress, sunglasses

Question 23

Causes of transient bilateral vision loss

Answer 23

Papilloedema
- Elevated ICP, haemorrhages, tumours, venous obstruction, infection, hydrocephalus.
- Refer for neuroimaging/LP

Vertebrobasilar insufficiency
- Reduced posterior cerebral blood flow
- embolic disease, atherosclerosis, hypercoagulability, hyperviscosity, vasculitis
- Good control of cardiac/vascular risk factors

Migraine
- Retinal vasospasm
- Headache within 60 mins of vision loss
- Do not use triptans, ergots, beta blockers

Question 24

Management of transient unilateral vision loss

Answer 24

Amaurosis fugax
Carotid artery disease, atherosclerosis, embolic disease, hypercoagulability, hyperviscosity, arteritis, cocaine
Manage as TIA
Refer acutely for USS carotids, MRA/CTA of neck, echocardiogram
Management of cardiac risk factors

Question 25

3 types of retinal detachment

Answer 25

Symptoms - flashes, floaters, reduced peripheral vision, blurred vision

Rhegmatogenous (most common)
- vitreoretinal traction
- Risks - age, myopia, trauma, cataract surgery
- Surgical management

Tractional
- Fibrosis from prev retinal tears, surgery, trauma, proliferative retinopathy
- Surgical excision of fibrosis

Exudative (serous)
- Inflammation (sarcoid uveitis), severe acute HTN, neoplasm
- Manage underlying condition

Question 26

2 causes of painless unilateral persistent vision loss, various severity

Answer 26

Retinal artery occlusion
- Embolism atherosclerosis, giant cell arteritis, hypercoagulability, collagen vascular disease

Retinal vein occlusion
- venous stasis > oedema, haemorrhage, ischaemia
- Embolism, atherosclerosis, hypercoagulability, collagen vascular disease, glaucoma

Manage HTN, hyperlipidaemia, smoking cessation, diabetes.

Question 27

Progressive unilateral vision loss over days, pain with eye movements, reduced light intensity and colour brightness

Diagnosis? Cause?

Answer 27

Optic neuritis

Middle aged women
Demyelinating disease (MS), infection (syphilis, Lyme, viral), granulomatous (sarcoidosis)

Refer acutely for neuro-imaging, IV steroids

Question 28

Painless vision loss, altitudinal visual defect, reduced colour vision

2 types that can cause these symptoms?

Answer 28

Anterior ischaemic optic neuropathy
- Unilateral
- Idiopathic, nocturnal hypotension, abnormal autoregulation of optic nerve blood flow.
- Giant cell arteritis
- Risk factors - atherosclerosis, HTN, smoking, diabetes, sleep apnoea, amiodarone, phosphodiesterase inhibitors (sildenafil)

Posterior ischaemic optic neuropathy
- Unilateral or bilateral
- Intraoperative hypotension, anaemia, prolonged Trendelenburg, lengthy abdominal/cardiac/spine surgeries
- Risks - atherosclerosis