Ophthalmology

Question 1

Symptoms of cataracts?
Signs of cataracts?

Answer 1

Symptoms:
Gradual painless loss of vision
Difficulty reading/watching television
Difficulty recognising faces
Haloes around lights, particularly at night
In children, cataracts may present with a squint

Signs:
Loss of red reflex
Primary investigation- Brown/white appearance of the lens upon slit-lamp bio-microscopy

Question 2

Complications of cataract surgery?

Answer 2

Endophthalmitis
Posterior lens capsule opacification

Rare- retinal detachment, macular oedema, glaucome

Question 3

What is optic neuritis?
Symptoms?

Answer 3

Inflammation and demyelination of the optic nerve

Symptoms:
-sudden onset VA loss, unilateral, over hours/ days
-painful eye movements
-headaches
-changes in colour vision
-RAPD positive
-central scotoma

Question 4

Associations with optic neuritis?

Answer 4

Multiple sclerosis- most common
Syphilis- can be infective
Diabetes

Question 5

Investigations for optic neuritis?

Answer 5

Full eye exam + Ishihara
MRI head and spine with contrast- GOLD-STANDARD

Question 6

Optic neuritis management?

Answer 6

Oral/ IV steroids- methylprednisolone
Immunosuppressant

Question 7

Common causes for periorbital cellulitis?

Answer 7

> in winter from a URTI
S. aureus

Question 8

Common causes for orbital cellulitis?

Answer 8

> in children
lack of Hib vaccine
previous sinus infection
URTI
Insect bite
dental abscess
recent eye surgery

Question 9

Signs and symptoms of periorbital cellulitis?

Answer 9

Painful eye and eyelid/ skin
Fever
warmth
red eye

NO CHEMOSIS
NO PAINFUL EYE MOVEMENTS
NO PROPTOSIS
NORMAL OPTIC NERVE FUNCTION

Question 10

Signs and symptoms of orbital cellulitis?

Answer 10

Painful red eye
eyelid swelling
painful eye movements
chemosis
proptosis
fevers
drowsiness +/- N&V

Question 11

Investigations for orbital and periorbital cellulitis?

Answer 11

Blood- FBC, CRP, ESR, cultures
Eye swabs and cultures
CT-orbit- GOLD-STANDARD

Question 12

Management for periorbital/ orbital cellulitis?

Answer 12

Hospitalisation (may not be needed for periorbital cellulitis)
IV Abx- co-amoxiclav
NSAIDs
Fluid management
Abscess drainage
Warm compress

Question 13

Complications of orbital/ periorbital cellulitis?

Answer 13

-Permanent VA loss/ impairment
-Meningitis
-Cavernous sinus thrombosis (blood clot in the cavernous sinus)
-Brain abscess

Question 14

Signs on fundoscopy for diabetic retinopathy?

Answer 14

Mild disease
-microaneurysms
-hard exudates
-blot haemorrhages

Severe disease
-engorged tortuous veins
-cotton wool spots
-large blot haemorrhages

Proliferative diabetic retinopathy
-neovascularisation near the retina/ optic disc

Question 15

Management of diabetic retinopathy?

Answer 15

-Blood sugar control
-Laser photocoagulation
-Anti-VEGF injections (aimed at neovascularisation)
-vitrectomy surgery (for advanced cases)

Question 16

Grades of hypertensive retinopathy?

Answer 16

GRADE 1
-vascular attenuation

GRADE 2
-above + AV nipping

GRADE 3
-above + retinal haemorrhages, cotton wool spots and hard exudates

GRADE 4
-above + papilloedema + silver wiring

Question 17

Management for acute closed-angle glaucoma?

Answer 17

Aim is to lower IOP

Combination of eye drops, for example:
a direct parasympathomimetic (e.g. pilocarpine, causes contraction of the ciliary muscle → opening the trabecular meshwork → increased outflow of the aqueous humour)

Beta-blocker (e.g. timolol, decreases aqueous humour production)

Alpha-2 agonist (e.g. apraclonidine, dual mechanism, decreasing aqueous humour production and increasing uveoscleral outflow)

Intravenous acetazolamide- reduces aqueous secretions

NSAIDs
Anti-emetics

Definitive treatment: laser iridotomy

Question 18

Acute management of amaurosis fugax?

Answer 18

-aspirin
-stroke referral

Question 19

Signs and symptoms of retinal detachment?

Answer 19

-new onset flashes and floaters
-sudden onset painless VA field loss
-swinging light test -> RADP
-red light reflex may be lost

Question 20

Investigations for GCA?
Initial management of GCA?

Answer 20

Bloods- ESR (50mm/hr) , CRP, LFTs
Temporal artery biopsy
Duplex USS-> halo sign and stenosis of carotid artery

High-dose oral steroids (prednisolone)
If evolving VA lass -> IV methylprednisolone
Urgent ophthalmology review

Question 21

How to differ episcleritis and scleritis?

Answer 21

Episcleritis
-red eye
-typically not painful
-watering and photophobia
-phenylephrine drops blanch conjunctival and episcleral vessels
-in episcleritis, the injected vessels are mobile when gentle pressure is applied on the sclera
-if the eye redness improves after phenylephrine a diagnosis of episcleritis can be made

Scleritis
-red eye
-classically painful (in comparison to episcleritis), but sometimes only mild pain/discomfort is present
-watering and photophobia are common
-gradual decrease in vision
-vessels do not blanch with with phenylephrine