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MRCP Part 1 > Ophthalmology #4 > Flashcards

Ophthalmology #4 Flashcards

1
Q

A 64yo woman with T2DM presents as she has started to bump into things since the morning. Over the previous 2 days, she had noticed some ‘floating spots in her eyes’. Examination reveals no vision in her right eye. The red reflex on the right side is difficult to elicit and you are unable to visualise the retina on the right side during fundoscopy.
Examination of the left funds reveals changes consistent with pre-proliferative diabetic retinopathy. What is the most likely diagnosis?

A

Vitreous haemorrhage

The history of diabetes, complete loss of vision in the affected eye, and inability to visualise the retina point towards a diagnosis of vitreous haemorrhage.

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2
Q

A 64yo woman presents with bilateral sore eyelids. She also complains of her eyes being dry all the time. On examination, her eyelid margins are erythematous but not swollen.
What is the most appropriate initial management?

A

Hot compresses + mechanical removal of lid debris.

Artificial tears may also be given for symptom relief of blepharitis.

Note: Blepharitis is also more common in patients with rosacea.

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3
Q

A 54yo man with T2DM is found on annual review to have new vessel formation at the optic disc.
Visual acuity in both eyes is not affected (6/9). Blood pressure is 155/84. HbA1c is 68mmol/mol (8.4%).
What is the most important intervention in this patient?
- Follow up Ophthalmoscopy in 3 months
- Add aspirin
- Blood pressure control
- Tight glycaemic control
- Laser therapy

A

Laser therapy: the patient has proliferative diabetic retinopathy and therefore urgent referral to an ophthalmologist for pan-retinal photocoagulation is indicated.

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4
Q

A patient has mild Non-proliferative diabetic retinopathy. What would you see on fundoscopy?

A

1 or more microaneurysm (dots)

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5
Q

A patient has mild Non-proliferative diabetic retinopathy. What would you see on fundoscopy?

A
  • Microaneurysms (dots)
  • Blot haemorrhages
  • Hard exudates
  • Cotton wool spots, venous beading / looping and intraretinal microvascular abnormalities (IRMA) less severe than in Severe NDPR.
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6
Q

A patient has severe Non-proliferative diabetic retinopathy. What would you see on fundoscopy?

A
  • Blot haemorrhages and microaneurysms (dots) in 4 quadrants
  • Venous beading in at least 2 quadrants
  • Intraretinal microvascular abnormalities (IRMA) in at least 1 quadrant.
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7
Q

A patient has Proliferative Retinopathy. What would you see on fundoscopy, and what is the epidemiology?

A
  • Retinal neovascularisation => may lead to vitreous haemorrhage
  • Fibrous tissue forming anterior to retinal disc.
  • More common in Type 1 Diabetes Mellitus, 50% blind in 5 years.
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8
Q

What is meant by ‘maculopathy’?

A
  • Based on location, rather than severity; anything is potentially serious.
  • Hard exudates and other ‘background’ changes on macula
  • Check the patient’s visual acuity
  • More common in T2DM.
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9
Q

71yo female with dry age-related macular degeneration is reviewed. Her eyesight has deteriorated over the past 6 months. She has never smoked and is taking antioxidant supplements. What is the most appropriate next step?

A

Explain that there are currently no other medical therapies available.

  • Laser photocoagulation does slow progression of ARMD where there is new vessel formation, although there is a risk of acute visual loss after treatment.
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10
Q

A 39yo female with a history of rheumatoid arthritis presents with a 2-day history of a red right eye. There is no itch or pain. Pupils are 3mm, equal and reactive to light. Visual acuity is 6/5 in both eyes. What is the most likely diagnosis?

A

Episcleritis

Note: Scleritis is painful. Episcleritis is NOT painful.

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11
Q

A 70yo male is investigated for blurred vision. Fundoscopy reveals drusen, retinal epithelial and macular neovascularisation. A diagnosis of Age-Related Macular Degeneration is suspected. What is the most appropriate next investigation?

  • Vitreous fluid sampling
  • MRI Orbits
  • Ocular tonometry
  • Fluorescein angiography
  • Kinetic perimetry
A

Fluorescein angiography.

Investigations:
- Slit lamp microscopy + colour fundus photography (to provide a baseline against which changes can be identified over time)

  • Fluorescein angiography: used is neovascular ARMD is suspected, as this can guide intervention with anti-VEGF therapy
  • Ocular coherence tomography is used to visualise the retina in three dimensions (this can reveal areas of disease which aren’t visible using microscopy alone).
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12
Q

Which of the following is not a risk factor for Primary Open-Angle Glaucoma?

  • Diabetes Mellitus
  • Family History
  • Hypertension
  • Afro-Caribbean ethnicity
  • Hypermetropia
A

Hypermetropia

-> Acute angle closure glaucoma is associated with hypermetropia, where as primary open angle glaucoma is associated with myopia.

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13
Q

Patient has a 1 day history of redness, puffiness and pain on eye movement of the left eye. Vision is restricted due to an inability to open the eye.
There is oedema surrounding the upper and lower eyelids with erythema and proptosis.
Intraocular pressure is mildly raised.
He has been taking intranasal corticosteroids for sinusitis.
What is the diagnosis and appropriate management?

A

Diagnosis: Orbital Cellulitis

Management: Admit for IV antibiotics due to the risk of Cavernous Sinus Thrombosis and intracranial spread.

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14
Q

A patient presents with Periorbital Cellulitis.

What signs might the patient have / develop?

A
  • Proptosis
  • Relative Afferent Pupillary Defect
  • Raised intraocular pressure
  • Globe displacement with resistance to retropulsion
  • Recent sinus infection or sinusitis is a risk factor for orbital cellulitis.
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15
Q

What is ‘Orbital Cellulitis’?

A

Orbital Cellulitis is the result of an infection affecting the fat and muscles posterior to the orbital septum, within the orbit but not involving the globe.

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16
Q

What is Orbital Cellulitis usually caused by?

A

Usually caused by a spreading Upper Respiratory Tract Infection from the sinuses.
It carries a high mortality rate.

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17
Q

What is periorbital cellulitis?

A

Periorbital (preseptal) cellulitis is a less serious superficial infection anterior to the orbital septum, resulting from a superficial tissue injury (chalazion, insect bite).
Periorbital cellulitis can progress to Orbital Cellulitis.

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18
Q

What is the mean age of hospitalisation for people with Orbital Cellulitis?

A

7 - 12 years

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19
Q

What are the risk factors for Orbital Cellulitis?

A
  • Childhood
  • Previous sinus infection
  • Lack of Hib (H. influenzae B) vaccination
  • Recent eyelid infection / insect bite on eyelid (Peri-orbital cellulitis)
  • Ear or facial infection
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20
Q

How might Orbital Cellulitis present?

A
  • Redness and swelling around the eye
  • Severe ocular pain
  • Visual disturbance
  • Proptosis
  • Ophthalmoplegia / pain with eye movements
  • Eyelid oedema and ptosis
  • Drowsiness +/- nausea/vomiting in meningeal involvement (RARE!!)
21
Q

How would you differentiate Orbital Cellulitis from Peri-Orbital Cellulitis?

A

Reduced visual acuity, proptosis, ophthalmoplegia/pain with eye movements are NOT consistent with peri-orbital cellulitis

22
Q

What investigations should you request if you suspected Orbital Cellulitis?

A
  • FBC: WBC elevated, raised inflammatory markers
  • Clinical examination involving complete ophthalmological assessment: Decreased vision, afferent pupillary defect, proptosis, dysmotility, oedema, erythema
  • CT with contrast: inflammation of the orbital tissues deep to the septum, sinusitis
  • Blood culture and microbiological swab to determine the organism.
23
Q

Which are the most common bacterial causes of Orbital Cellulitis?

A
  • Streptococcus
  • Staphylococcus aureus
  • Haemophilus influenzae B
24
Q

What should your immediate management plan be if someone presents with Orbital Cellulitis?

A

Admission to hospital for IV antibiotics.

25
Q

A 67yo male presents with sudden onset painless loss of vision in the right eye. He describes it as having a dense shadow over the vision, progressing from the periphery to the centre.
He has no Past Medical History of note.
What is the most likely diagnosis?

A

Retinal Detachment

  • causes sudden painless loss of vision
  • characterised by a dense shadow starting peripherally and progressing centrally.
26
Q

A 71yo male presents with a burning sensation around his right eye. On examination, an erythematous blistering rash can be seen in the right trigeminal distribution. What is the most likely diagnosis?

A

Herpes Zoster Ophthalmicus

27
Q

What is Herpes Zoster Ophthalmicus?

A

HZO describes the reactivation of the Varicella-Zoster Virus in the area supplied by the Ophthalmic division of the trigeminal nerve.

It accounts for around 10% of cases of Shingles.

28
Q

What are the features of Herpes Zoster Ophthalmicus?

A
  • Vesicular rash around the eye, which may or may not involve the actual eye itself
  • Hutchinson’s sign: rash on the tip or side of the nose. Indicates nasociliary involvement and is a strong risk factor for ocular involvement.
29
Q

What is the management of Herpes Zoster Ophthalmicus?

A
  • Oral antiviral for 7 - 10 days.
    > Ideally started within 72 hours
    > IV antivirals may be given for very severe infection or if the patient is immunocompromised
    > topic antiviral treatment is NOT given in HZO
  • Topical corticosteroids may be used to treat any secondary inflammation of the eye.
  • Ocular involvement requires urgent Ophthalmology review
30
Q

What are the complications of Herpes Zoster Ophthalmicus (HZO)?

A
  • Ocular: conjunctivitis, keratitis, episcleritis, anterior uveitis
  • Ptosis
  • Post-herpetic neuralgia
31
Q

A 25yo female presents with a 1 day history of a painful and red left eye. She describes how her eye is continually streaming tears

On examination she exhibits a degree of photophobia in the affected eye.
Application of fluorescein demonstrates a dendritic pattern of staining.
Visual acuity is 6/6 in both eyes.
What is the diagnosis?
What is the most appropriate management?

A

Herpes Simplex Kertatitis most commonly presents with a dendritic corneal ulcer.

Topical Aciclovir and Ophthalmology review is required.

32
Q

How does Herpes Simplex Keratitis present?

A

Most commonly presents with a dendritic corneal ulcer

33
Q

What are the features of a dendritic corneal ulcer (seen with Herpes Simplex Keratitis)?

A
  • Red, painful eye
  • Photophobia
  • Epiphora
  • Visual acuity may be decreased
  • Fluorescein staining may show an epithelial ulcer
34
Q

What is the management of a dendritic corneal ulcer (seen with Herpes Simplex Keratitis)?

A
  • Immediate referral to an Ophthalmologist

- Topical Aciclovir

35
Q

Which of the following features is not characteristic of optic neuritis?

  • Eye pain worse on movement
  • Relative Afferent Pupillary Defect
  • Poor discrimination of colours, ‘red desaturation’
  • Sudden onset visual loss
  • Central scotoma
A

Sudden onset visual loss.

Visual loss typically occurs over days rather than hours.

36
Q

List 3 causes of Optic Neuritis.

A
  • Multiple Sclerosis
  • Diabetes
  • Syphilis
37
Q

What are the features of Optic Neuritis?

A
  • Unilateral decrease in visual acuity over hours or days
  • Poor discrimination of colours, ‘red desaturation’
  • Pain worse on eye movement
  • Relative Afferent Pupillary Defect
  • Central Scotoma
38
Q

What is the management of Optic Neuritis?

A
  • High dose steroids

- Recovery usually takes 4-6 weeks

39
Q

How is Optic Neuritis prognosticated?

A

MRI: if >3 white matter lesions, 5-year risk of developing Multiple Sclerosis is 50%.

40
Q

A 24 yo man presents to the emergency department complaining of left eye pain. The pain is severe. He has not been able to wear his contact lenses for the past 24hrs due to pain. On examination, there is diffuse hyperaemia of the left eye.
The left cornea appears hazy and pupillary reaction is normal.
Visual acuity is reduced on the left side and a degree of photophobia is noted.
A hypopyon is also seen.
What is the most likely diagnosis?

A

Keratitis
Whilst a hypopyon can be seen in anterior uveitis, the combination of a normal pupillary reaction and contact lens use make a diagnosis of keratitis more likely.

41
Q

What is ‘Keratitis’?

A

Inflammation of the Cornea.
- Microbial keratitis is not like conjunctivitis - it is potentially sight threatening and should therefore be urgently evaluated and treated.

42
Q

What are the causes of Keratitis?

A
  • Bacterial: S. aureus, Pseudomonas aeruginosa (in contact lens wearers)
  • Fungal
  • Amoebic: acanthamoebic keratitis (increased incidence if eye exposure to soil or contaminated water)
  • Parasitic: onchocercal keratitis (‘river blindness’)
43
Q

List some viral and Environmental causes of Keratitis.

A

Viral: Herpes Simplex Keratitis

Environmental:

  • Photokeratitis: Welder’s arc eye
  • Exposure keratitis
  • Contact Lens Acute Red Eye (CLARE)
44
Q

List the clinical features of Keratitis.

A
  • Red eye: pain and erythema
  • Photophobia
  • Foreign body, gritty sensation
  • Hypopyon may be seen
45
Q

Management of Keratitis in contact lens wearers.

A
  • Stop using contact lens until the symptoms have fully resolved
  • Topical antibiotics: usually quinolones
  • Cycloplegic for pain relief e.g cyclopentolate
46
Q

Complications of keratitis?

A

Complications include:

  • Corneal scarring
  • Perforation
  • Endophthalmitis
  • Visual loss
47
Q

72yo female presents with a vesicular rash around her left eye. The eye is red and there is a degree of photophobia.
What is the diagnosis?
Who are you going to refer her to?
What treatment should she receive?

A

Herpes Zoster Ophthalmicus

Refer to Ophthalmology

Give Oral Aciclovir

48
Q

A 65yo male with 16-year history of T2DM presents complaining of poor eye sight and blurred vision.
Visual acuity is reduced to 6/12 in the right eye and 6/18 in the left eye.
Fundoscopy reveals yellow deposits in the left eye consistent with drusen formation.
Similar changes are seen in the right eye.
What is the most likely diagnosis?

A

Dry age-related macular degeneration.

49
Q

A 65yo man with a history of primary open-angle glaucoma presents with sudden painless loss of vision in his right eye. On examination of the right eye, the optic disc is swollen with multiple flame-shaped and blot haemorrhages. What is the most likely diagnosis?

A

Occlusion of central retinal vein:

  • Sudden painless loss of vision
  • Severe retinal haemorrhages on fundoscopy

MRCP Part 1 (16 decks)

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