Ophthalmology

Question 1

Causes of sudden, painless vision loss

Answer 1

Central retinal artery occlusion
Central retinal vein occlusion
Vitreous haemorrhage
Retinal detachment
TIA/Stroke
Temporal arteritis
Optic neuritis

Question 2

What is a relative afferent pupillary defect (RAPD)?

Answer 2

Suggests retinal or optic nerve pathology
Pupil constricts normally during consensual response but not during direct light (gives appearance of
paradoxical pupil dilation)
Seen in:
* CRAO
* CRVO
* Retinal detachment
* Stroke/TIA

Question 3

45F with sudden-onset, painless vision loss. Diagnosis and cause.

Answer 3

Vitreous haemorrhage
Due to proliferative diabetic retinopathy

Question 4

65M progressively painful eye with temporal headache. Description and likely diagnosis

Answer 4

Conjunctival injection with peri-limbal (ciliary) flush, constricted irregular pupil and hypopyon

Anterior uveitis

Question 5

Clinical findings in anterior uveitis

Answer 5

Conjunctival injection with perilimbal flush
Direct and consensual photophobia
Aching pain, may involve temporal region
Pupil may be small, normal or irregular
Muddy iris
Slit lamp - cell and flare in anterior chamber
Posterior synechiae
Hypopyon (develops over days)

Question 6

Orbital vs periorbital cellulitis - Differentiating signs and symptoms

Answer 6

• Loss of vision
• Ophthalmoplegia
• Pain on eye movement
• Proptosis
• Conjunctival oedema

Question 7

Orbital cellulitis - Routes of contraction and common organisms

Answer 7

Extension from peri-orbital structures: sinuses, face, globe, lacrimal sac
Direct innoculation of orbit from trauma or sugery
Haematogenous spread

Strep pneumo, pyogenes
Staph aureus
Haemophilus influenzae

Question 8

Features of orbital compartment syndrome

Answer 8

x Proptosis
x Rock hard eyeball palpated with eyelid closed
x Visual acuity. Significantly decrease, rapidly dropping to light perception only
x Inability to open eye
x Severe eye pain
x Limited eye movements
x Raised IOP >40 mm Hg. Rock hard eye ball to palpation compared to the other side
x RAPD

Question 9

Indications for lateral canthotomy

Answer 9

Blunt eye trauma with suspected retrobulbar haematoma

PLUS any of:

Decreased VA
Raised IOP >40 mmHg
RAPD
Proptosis

OR

CT findings of orbital compartment syndrome:
- Stretching of optic nerve
- Tenting of glob
- Retrobulbar haemorrhage with proptosis

Question 10

Methods of tonometry

Answer 10

Tonopen (electronic indentation)
Impression (Schiotz) tonometry
Applanation tonometry with slit lamp (Goldmann)
Rebound tonometry
Pneumato-tonometry

Question 11

Conditions associated with anterior uveitis

Answer 11

Inflammatory bowel disease
Ankylosing spondylitis
Sarcoidosis
Psoriasis
Reiter syndrome
SLE

Question 12

Complications of anterior uveitis

Answer 12

Synechiae
Glaucoma
Cataracts
Retinitis
Band keratopathy
Vision loss

Question 13

Treatment of globe rupture

Answer 13

• Urgent referral to Opthalmology
• Lie patient flat
• Avoid external pressure on the eye
• Tetanus update
• IV antibiotics (cephazolin 2gm IV +/- gentamicin)
• Eye shield – not pad
• Analgesia – appropriate opiate-based analgesia
• IV anti-emetic
• Sinus precautions

Question 14

28M struck in eye with cricket ball. Description of findings

Answer 14

Haemorrhage in anterior chamber inferiorly
Iridodialysis (iris separation from ciliary body) inferiorly
Pupillary distortion - damage to sphincter ?traumatic mydriasis

Question 15

Management of traumatic hyphema

Answer 15

• Analgesia (avoiding NSAIDs, aspirin)
• Eye patch
• Bed rest and head elevated 30 deg to aid settling of hyphema
• Topical cycloplegics - homatropine/tropicamide
• Seek and treat complications
• Raised IOP - acetazolamide/topical timolol
• Traumatic iridocyclitis - steroids, cycloplegics
• Seek and treat assoc. injuries incl.:
• Lens dislocation
• Globe rupture
• Orbital wall fracture
• Retinal detachment