Ophthalmology

Question 1

Red eye differentials

Answer 1

• Preserved acuity:
  
  • Painless- subconjunctival haemorrhage, conjunctivitis, dry eyes, hayfever
  • Painful- foreign body, corneal abrasion, episcleritis, keratitis/ corneal ulcer, scleritis (++ pain)
• Loss of visual acuity:
  
  • Painless - nil
  • Painful - anterior uveitis, keratitis, acute. ++ Pain: angle closure glaucome, endophthalmus

Question 2

Key features of acute angle closure glaucoma

Answer 2

• Hx- middle-old age. Long sighted.
  
  • Systemically unwell
  • Blurred vision + halos
• O/E- Significant loss of acuity
  
  • Red injected eye
  • Fix, mid dilated oval shaped pupil
  • Hazy cornea - oedema
  • Raised IOP - firm
• Ix- ?measure IOP
• Tx- REFER
  
  • Med- beta blockers, pilocarpine eye drops, IV acetazolamide
  • Surg- bilat peripheral iridotomy

Question 3

Key features of iritis/ ant. uveitis

Answer 3

• Hx:
  
  • Pain, photophobia
  • Red
  • Reduced acuity
• O/E:
  
  • Unilateral rednress around cornea. Doesn’t blanch on pressure.
  • May get synechiae - adhesions between pupil and lens
• Associations- HLA-B27, IBD, Reiter’s, RA, HSV, sarcoid
• Ix- dilated fundoscopy. Ix underlying cause.
• Tx: Refer!
  
  • Med- high dose pred drops hourly. Cyclopentolate drops

Question 4

Key features of scleritis

Answer 4

• = Inflammation of white of eye. Can be sight threatening!
• Hx- +++ Eye pain. Can’t bear to have globe touches
• O/E- Thin sclera –> blue. Can lead to globe perforation.
• Ix- Phenylephrine drops, Ix AI disease
• Tx- Refer! Systemic NSAIDs/ immunosuppression

Question 5

Key features of episcleritis

Answer 5

• Hx- bruised + tender. Photosensitivity. Globe not painful to touch.
• O/E- Raised nodular appearance.
• Inflammation of vessels in episclera - superficial + can be moved on light tough
• Tx- reassurance, cold compress

Question 6

Key features of keratitis/ corneal ulcer

Answer 6

• High risk in contact lens wearers
• Hx- scattered vision, pain, photophobia, watery eye
• O/E- Hypopeon (pus w/ fluid level)
• Ix- fluoroscein dye –> >60% to ophthalmology
• Tx: ABx drops every 30-60mins
• HSV keratitis- ++ watering. Flurocein- branching dendrite. Tx- aciclovir

Question 7

Key features of corneal abrasion/ foreign body

Answer 7

• Presentation- irritation, feeling of foreign body
• O/E:
  
  • Subtarsal foreign body scratches up and down
  • Rust ring around metal
• Ix: Visualisation w/ fluroscein + slit lamp
• Tx- removal. Irrigation, analgesia –> green needle. ABx.

Question 8

Key features of conjunctivitis

Answer 8

• Types- bacterial, viral, allergic, neonatal
• Presentation;
  
  • Discharge- purulent in bacterial –> crusting
  • Allergic- follicles + cobblestone appearance
  • Bilat- often viral
  • Red and swollen
  • Discomfort
  • Acuity not affected
  • Conjunctival vessels injected, blanche
• Tx:
  
  • Cons- hand washing, no sharing towels, no contacts
  • Bacterial- chloramphenicol
  • Viral- self resolve
  • Allergic- anti-histamine
  • Neonatal- gonorrhoea, chlamydia

Question 9

Key features of subconjunctival haemorrhage

Answer 9

• Causes- cough, sneeze, HTN, blood thinners
• Harmless. Self resolve
• Recurrent - Ix HTN, bleeding

Question 10

Key features of Endophalmitis

Answer 10

• Causes- 2-5d post-op, penetration, cataracts
• Presentation:
  
  • +++ Pain
  • Hypopyon/ hyphema - cells/ blood in ant. chamber
  • Loss of acuity
  • Red conjunctiva/ episclera
• Ix- slit lamp
• Tx: IV ABx, intravitreal steroids, ?surg eg vitreous aspiration

Question 11

Key features of cataracts

Answer 11

• = Opacification of lens
• RF: Age, smoking, DM, systemic corticosteroids
• Congenital eg Down’s
• Presentation:
  
  • Gradual painless loss of vision
  • Difficulty with - reading, TV, bright lights, driving at night, recognising faces
  • Haloes
• O/E- disrupted red light reflex
• Tx- phacoemulsification with intraocular lens insertion. Risks: Endophthalmitis, eye rupture, no improvement in vision.

Question 12

Key features of glaucoma

Answer 12

• = Progressive optic neuropathy due to outflow obstruction of vitreous humour and raise IOP
• Open vs closed (systemically unwell)
• Presentation:
  
  • ASx
  • Peripheral vision loss
  • Light haloes
• Ix- IOP, slit lamp (cupping), visual fields
• Tx:
  
  • Reduce production- topical beta blockers, carbonic anyhydrase inhibitors
  • Increase drainage - prostaglandin analogues, miotic agents, trabeculectomy

Question 13

Key features of vitreous haemorrhage

Answer 13

• Blood into and aroun vitreous humor
• ++ DM
• Sx- sudden painless vision loss, hazy, floaters
• Tx- refer. Retinal laser, vitrectomy

Question 14

Key features of retinal artery occlusion

Answer 14

• Embolic event –> sudden painless visual loss
• CVS RF
• Fund- pale macula with cherry red spot
• Tx: refer

Question 15

Key features of retinal detachment

Answer 15

• Sx- floaters –> shadow/ curtain over vision
• RF: short sighted, trauma, eye surg
• Tx: Surgical eg bubble

Question 16

Hypertensive retinopathy fundoscopic findings

Answer 16

• AV nipping
• Hard exudates
• Macular oeda
• Flame haemorrhage
• Silver wiring
• (Papilloedema)

Question 17

Key feature of age related macular degeneration

Answer 17

• RF: >55y, smoking, HTN, poor diet, FHx, obesity, sunlight
• Presentation:
  
  • Difficulty reading
  • Colours less bright
  • Poor facial recognition
  • Gradual loss of central vision
  • Difficulty driving
• Tx:
  
  • Dry (90%)- Cons- reduce RF, Amsler grid
  • Wet (10%)- Anti-VEGF injections

Question 18

Types of strabismus

Answer 18

• Esotropia- convergent
• Exotropia- divergent
• Hypotropia- divergent
• Hypertropia- upwards
• Cyclotropia- twisting
• Cover-uncover- fix with light at 1/3m. Cover with occluder and obser other eye. Outward movement= esotropia. Repeat at 6m

Question 19

Pathology behind visual field loss

Answer 19