Ophthalmology: Past paper questions Flashcards
A 23-year-old man presents to his GP with a 2-day history of pain in his right eye, photophobia, and blurred vision.
He has no past medical history but states that he has had lower back pain that improves with exercise for the last 12 months.
On examination there is hyperaemia of the sclera and yellow crusting on the patient’s eyelashes. He finds it difficult to follow your finger with his eyes on cranial nerve examination due to pain. There is some oedema of his eyelids and miosis of the right pupil.
Given the likely diagnosis, what is the most appropriate next step?
High-dose oral steroids
Ocular steroid drops
Systemic antibiotics
Topical chloramphenicol
Urgent ophthalmology review
Urgent ophthalmology review
This patient is presenting with signs and symptoms of anterior uveitis as evidenced by blurred vision (caused by turbidity of the aqueous), photophobia and miosis (caused by ciliary muscle spasm) and pain (caused by ciliary muscle spasm and or raised intraocular pressures).
Anterior uveitis is an important differential in the acute and painful red eye. In the stem, the patient states he has had lower back pain that improves with exercise, this is a classic feature of ankylosing spondylitis. Anterior uveitis itself is a feature of spondyloarthropathies.
An urgent ophthalmology review is the most appropriate treatment / next step here. Anterior uveitis can have high morbidity and urgent specialist assessment is key. History taking and thorough evaluation are imperative so that underlying causes, if present, can be addressed. The mainstay of treatment for anterior uveitis itself is the use of topical steroids, mydriatics, non-steroidal anti-inflammatory drugs, and cycloplegics. Immunosuppression under specialist guidance can also be used.
A 70-year-old man complains of reduced vision. Fundoscopy reveals the following:
What is the most likely diagnosis?
Primary open angle glaucoma
Hypertensive retinopathy
Optic neuritis
Age-related macular degeneration
Diabetic retinopathy with laser scars
Age-related macular degeneration
Age-related macular degeneration is the most common cause of blindness in the UK. Degeneration of the central retina (macula) is the key feature with changes usually bilateral. ARMD is characterised by degeneration of retinal photoreceptors that results in the formation of drusen which can be seen on fundoscopy and retinal photography. It is more common with advancing age and is more common in females.
**
Patients typically present with a subacute onset of visual loss with:**
a reduction in visual acuity, particularly for near field objects
gradual in dry ARMD
subacute in wet ARMD
difficulties in dark adaptation with an overall deterioration in vision at night
fluctuations in visual disturbance which may vary significantly from day to day
they may also suffer from photopsia, (a perception of flickering or flashing lights), and glare around objects
visual hallucinations may also occur resulting in Charles-Bonnet syndrome
Signs:
distortion of line perception may be noted on Amsler grid testing
fundoscopy reveals the presence of drusen, yellow areas of pigment deposition in the macular area, which may become confluent in late disease to form a macular scar.
in wet ARMD well demarcated red patches may be seen which represent intra-retinal or sub-retinal fluid leakage or haemorrhage.
A 50-year-old man presents with red-eye associated with slight watering and mild photophobia. He reports no pain or tenderness and vision is not affected
What is the most likely diagnosis?
Scleritis
Keratitis
Episcleritis
Anterior Uveitis
Acute angle glaucoma
Episcleritis is a cause of red eye which is classically not painful
Important for meLess important
A 62-year-old man presents to the emergency department with a sudden loss of vision in his right eye. The loss of vision started in the edges and moved towards the centre and had preceding flashes and floaters. There was no antecedent trauma. He denies any headaches or eye redness and has a history of type 2 diabetes mellitus. He wears corrective glasses and occasionally contact lenses, however, he cannot remember his prescription.
What feature increases the risk of this patient developing this condition?
Astigmatism
Contact lens use
Hypermetropia
Presbyopia
Type 2 diabetes mellitus
Diabetes mellitus is a risk factor for retinal detachment
A 52-year-old man attends his GP regarding problems with his vision. For the past few months, he has been having some difficulty driving as he has been struggling to see cars coming toward him from the sides of his vision. He thinks this may also be what’s causing his occasional headaches but reports no pain around his eyes or any current headache.
His past medical history includes peripheral vascular disease, type II diabetes, and short-sightedness, and often does not wear his glasses.
What is the most likely diagnosis?
Acute angle-closure glaucoma
Age-related macular degeneration
Cataracts
Primary open-angle glaucoma
Scleritis
primary open-angle glaucoma
A 25-year-old man is visiting his GP for a new patient check-up. He is fit and well, with no concerns. On enquiry about illnesses that run in the family he reveals that both his mother and grandfather both suffer from glaucoma.
What advice should you give him regarding glaucoma?
Glaucoma has no hereditary component
He should have an annual screening commencing now
He should get annual screening from age 60 years
Due to his high risk treatment for glaucoma should be commenced now
He should get annual screening from age 40 years
He should get annual screening from age 40 years
A 76-year-old woman complains of blurred vision. She has not been to the doctors for many years and describes her self as being otherwise fit and well. Fundoscopy reveals the following:
Similar changes are seen in both eyes. What is the most likely diagnosis?
Primary open angle glaucoma
Retinal tear
Diabetic retinopathy with laser scars
Optic neuritis
Age-related macular degeneration
Age-related macular degeneration is the most common cause of blindness in the UK. Degeneration of the central retina (macula) is the key feature with changes usually bilateral. ARMD is characterised by degeneration of retinal photoreceptors that results in the formation of drusen which can be seen on fundoscopy and retinal photography. It is more common with advancing age and is more common in females.
Argyll-Robertson pupil
Argyll-Robertson pupil is one of the classic pupillary syndrome. It is sometimes seen in neurosyphilis. A mnemonic used for the Argyll-Robertson Pupil (ARP) is Accommodation Reflex Present (ARP) but Pupillary Reflex Absent (PRA)
Features
small, irregular pupils
no response to light but there is a response to accommodate
Causes
diabetes mellitus
syphilis
A 30-year-old male presents with sudden onset loss of vision. He denies any preceding warning signs or head trauma, and does not complain of any pain. You perform a fundoscopy and find severe retinal haemorrhages on fundoscopy.
Which of the following is the most likely diagnosis?
Optic neuritis
Retinal detachment
Posterior vitreous detachment
Central retinal artery occlusion
Central retinal vein occlusion
Central retinal vein occlusion - sudden painless loss of vision, severe retinal haemorrhages on fundoscopy
fundoscopy: central retinal vein occlusion
Central retinal vein occlusion is the correct answer. Fundoscopy reveals severe flame shaped retinal haemorrhages, described as a cheese and tomato pizza appearance.
fundoscopy: central retinal artery occlusion
Central retinal artery occlusion presents with acute visual loss. The typical fundoscopy finding is a pale retina with a ‘cherry red’ spot.
A 6-year-old girl presents to your general practice surgery with her father.
He describes that for the past year, she develops intermittent flares of red, itchy eyelids. This appears to bother her most in the mornings. These episodes normally self-resolve with no intervention, but this flare has been particularly protracted - lasting over a month - and he would like some advice. She has never experienced any visual changes.
On examination, she is playful and smiling. The eyelids appear slightly red bilaterally, and there is a small amount of foamy discharge on the lid margins, with matting of the eyelashes. The medial canthus on the superior lid of her left eye has a small, discrete, red lump which is mildly tender on palpation. The eye itself is not red, nor is it painful. Examination is otherwise normal, and she is apyrexial.
Which of the following is the single best initial management option for this girl?
Hot compresses to both eyes
Oral doxycycline
Topical chloramphenicol drops to both eyes
Topical dexamethasone drops to both eyes
Same-day referral to an ophthalmologist
1st line of treatment for blepharitis is hot compresses
A 3-year-old boy is referred to the optometrist by the GP after his mother brought him in concerned about a squint. He is otherwise fit and well.
After an initial assessment by the optometrist, he is diagnosed with exotropia. He is offered appointments to discuss treatment including intermittent eye patching.
During the interim, they move to a different part of the country and miss these appointments. The mother does not seek further attention regarding his exotropia.
What is the child particularly at increased risk of developing in the future?
Amblyopia
Esotropia
Hypermetropia
Hypertropia
Hypotropia
Failure to correct childhood squints may lead to amblyopia
A 72-year-old man presents to his GP complaining of a ‘droopy’ eyelid. The symptoms started yesterday and do not seem to improve. He has a past medical history of poorly controlled type two diabetes mellitus and hypertension, which cause him recurrent foot ulcers. He is a life-long smoker.
An eye examination shows ptosis of the left palpebra with a constricted pupil, visual acuity 6/6 in both eyes, normal colour vision, intact central and peripheral fields. A similar episode happened to him after a motorbike accident, he was diagnosed with ‘a nerve palsy’ which later resolved.
What is the most likely diagnosis?
Abducens nerve palsy
Horner’s syndrome
Lateral medullary syndrome
Oculomotor nerve palsy
Trochlear nerve palsy
Horners
Ptosis + dilated pupil = third nerve palsy;
ptosis + constricted pupil = Horner’s
An 83-year-old male is referred to the ophthalmology clinic by his general practitioner with a new-onset inability to see objects near to him, especially at night. On fundoscopy, the doctor notices well-demarcated red patches. He has a past medical history of hypertension and he is a life-long smoker.
Given the most likely diagnosis, which one of the following is the most appropriate treatment?
Anti-vascular endothelial growth factor (VEGF)
Aspirin
Cataract surgery
High-dose steroids
Laser photocoagulation
Anti-VEGF
Definitive treatment for wet AMD is anti-VEGF
The patient is suffering from wet age-related macula degeneration, also known as exudative or neovascular macular degeneration.
It is due to choroidal neovascularisation which serous fluid and blood leakage can subsequently result in a rapid loss of vision. This patient has the characteristic signs and symptoms: a reduction in visual acuity, particularly for near field objects, worse at night and red patches representing intra-retinal or sub-retinal fluid leakage or haemorrhage visible on fundoscopy. VEGF is a potent mitogen and drives increased vascular permeability in patients with wet ARMD, decreasing the leakage. This treatment should start as soon as possible.
amaurosis fugax treatment
ocular massage
300mg aspirin
A 40-year-old man presents to their emergency department with sudden unilateral left eye pain and nausea. The patient said they were sitting at home watching tv when the eye pain came on suddenly.
The patient reports reduced vision in the affected eye. The left pupil is dilated on examination and unreactive to light.
There is no significant past medical history. The patient mentions he wears glasses to read.
Tonometry is carried out.
What other investigation is required to confirm the diagnosis?
B-scan ultrasound
Gonioscopy
Ishihara plates
Snellen chart
Visual Fields
Gonioscopy
gonioscopy
Gonioscopy involves using a special lens on the slit lamp which allows visualisation of the anterior chamber angle. This can highlight any blockages that may have resulted in this increasing rise in pressure.
Alongside tonometry, measuring the intra-ocular pressure will confirm the diagnosis of acute angle-closure glaucoma.
B-scan ultrasound
is used to visualise the patient’s retina and is carried out when retinal detachment is suspected. This patient requires a gonioscopy to confirm the diagnosis.
An 18-year-old man presents to the GP with a 4-day history of a red, irritated left eye with associated wateriness and discharge. In the morning, he feels his eyes are matted shut and has noticed thick yellowish mucoid material. He denies any exposure to anyone who has been ill or had any similar symptoms and has not had a recent upper respiratory tract infection.
There is a past medical history of allergic rhinosinusitis, asthma, and eczema, and he takes loratadine, a salbutamol inhaler, a beclometasone inhaler, and topical emollients. He wears contact lenses.
What is the most likely diagnosis?
Allergic conjunctivitis
Bacterial conjunctivitis
Blepharitis
Keratitis
Viral conjunctivitis
A bacterial conjunctivitis is associated with a purulent discharge
A 28-year-old contact lens wearer attends the emergency department with pain in his right eye. He reports a gritty sensation like something is stuck in the eye.
The eye is globally erythematous and he struggles to look at lights. On slit-lamp assessment, a hypopyon is present and there are focal white infiltrates on the cornea.
What is the most likely underlying organism?
Neisseria gonorrhoea
Pseudomonas aeruginosa
Acanthamoeba
Herpes simplex
Onchocerca volvulus
Pseudomonas infection should be suspected in contact lens associated keratitis
A 45-year-old man with poorly treated tertiary syphilis is being screened for complications of neurosyphilis. On questioning, he reports a right-sided loss of visual acuity and decreased colour vision. He denies any headaches or changes to vision with coughing.
On examination, there is no evidence of eye movement abnormalities or gaze abnormality. He does have a relative afferent pupillary defect and fundoscopy shows right-sided optic disc swelling.
Given the likely diagnosis, what other visual abnormality may be expected?
Central scotoma
Flashes and floaters
Haloes
Homonymous hemianopia
Leukocoria
A central scotoma is a feature of optic neuritis
neurosyphilis and the eye
Tertiary syphilis is fortunately very rare, but the neurosyphilis complications represent classical findings.
There may be many forms of ocular involvement,
- Uveitis (most common)
- Optic neuritis (optic papilitis)
A 40-year-old man has come to the emergency department with severe pain in his left eye, especially when looking at light, along with blurred vision. He has a history of Crohn’s disease which is currently controlled by azathioprine. On examination there is conjunctival injection at the junction of the cornea and sclera with increased lacrimation. The pupil also appears smaller on his left eye compared to his right.
What treatment is required for this patient?
Antibiotic drops
Antihistamine drops
NSAID drops
Pilocarpine and β-blocker drops
Steroid and cycloplegic drops
Anterior uveitis is most likely to be treated with a steroid + cycloplegic (mydriatic) drops
Steroid and cycloplegic drops
Anterior uveitis is most likely to be treated with a steroid + cycloplegic (mydriatic) drops
management of anterior uveitis
Steroid drops are required to reduce inflammation. Cycloplegic drops are required to prevent adhesions between the lens and iris, and to relieve spasms of the ciliary body.
hypertensive retinopathy staging
Hypertensive retinopathy
The table below shows the Keith-Wagener classification of hypertensive retinopathy
**I **
- Arteriolar narrowing and tortuosity
- Increased light reflex - silver wiring
II
- Arteriovenous nipping
III
- Cotton-wool exudates
- Flame and blot haemorrhages
- These may collect around the fovea resulting in a ‘macular star’
IV
- Papilloedema
A 75-year-old gentleman with a long history of hypertension is having his eyes checked. He has reduced visual acuity and headaches which have been worsening over the last few weeks.
On fundoscopy, he has flame haemorrhages, cotton wool spots, arteriovenous nipping and papilloedema.
What grade of hypertensive retinopathy does this correspond to?
Grade I
Grade II
Grade III
Grade IV
Grade V
Papilloedema indicates **grade IV **hypertensive retinopathy
Important for meLess important
This is the most serious manifestation of hypertensive retinopathy and should be taken seriously as it is associated with high morbidity and mortality.
See below for the characteristics of the different grades of hypertensive retinopathy.
A 65-year-old man with a 16 year history of type 2 diabetes mellitus presents complaining of poor eye sight and blurred vision. Visual acuity measured using a Snellen chart is reduced to 6/12 in the right eye and 6/18 in the left eye. Fundoscopy reveals a number of yellow deposits in the left eye consistent with drusen formation. Similar changes but to a lesser extent are seen in the right eye. What is the most likely diagnosis?
Wet age-related macular degeneration
Pre-proliferative diabetic retinopathy
Chronic open angle glaucoma
Proliferative diabetic retinopathy
Dry age-related macular degeneration
Drusen = Dry macular degeneration
A 43-year-old man attends his GP with pain and facial swelling after an upper respiratory tract infection. On examination, erythema and swelling surround the right eye and there is pain on eye movements. Visual acuity is 6/6 on the left and 6/24 on the right.
What is the most appropriate course of action?
Admit to hospital for IV antibiotics
Prescribe high-dose oral steroids and check thyroid function
Prescribe high-dose oral steroids and refer urgently to Rheumatology
Supportive management and nasal decongestants
Urgent referral to maxillofacial surgeons for debridement
IV antibiotics in hospital
Patients with orbital cellulitis require admission to hospital for IV antibiotics due to the risk of cavernous sinus thrombosis and intracranial spread
A 75-year-old man has progressively worsening vision in both eyes. He is finding it difficult to read and make out faces, and has fallen multiple times as edges of objects such as stairs are difficult to discern. A slit-lamp examination shows amber retinal deposits but no signs of neovascularisation.
There is a past medical history of hypertension and type 2 diabetes mellitus and takes amlodipine and metformin. He has smoked 30 cigarettes a day for the past 40 years but does not drink alcohol.
Given the likely diagnosis, which treatment option is best for this patient?
Intravitreal anti-VEGF agents
Laser photocoagulation
Omega 3 and 6 supplementation
Prostaglandin analogue eyedrops
Vitamins C+E and beta-carotene supplementation
Vitamins C+E and beta-carotene supplementation
There is no curative medical treatment for dry AMD. High dose of beta-carotene, vitamins C and E, and zinc can be given to slow deterioration of visual loss
A 52-year-old male is admitted to the acute medical admissions unit with a 1-day history of a left-sided headache, retro-orbital pain, and dull left-sided facial pain. He has a history of hypertension and migraine and takes ramipril 2.5mg.
On examination, he has a partial ptosis and enophthalmos of the left eye. Pupil examination demonstrates anisocoria with miosis of the left eye. His visual acuity is 6/6 bilaterally and the remainder of neurological examination is normal with normal sweating bilaterally.
What is the single most likely cause of these symptoms?
Carotid artery dissection
Cervical rib
Pancoast’s tumour
Stroke
Syringomyelia
Carotid artery dissection
Horner’s syndrome - anhydrosis determines site of lesion:
head, arm, trunk = central lesion: stroke, syringomyelia
just face = pre-ganglionic lesion: Pancoast’s, cervical rib
absent = post-ganglionic lesion: carotid artery
A 43-year-old man presents to the emergency department complaining of nausea, vomiting, headache, and severe pain in his eye. He has no significant past medical history and is not on any regular medication. On examination his eye is red, the pupil is fixed and dilated and the cornea has a hazy appearance.
What can be used in the initial management of this condition?
Artificial tears
Cyclopentolate
Pan-retinal photocoagulation laser
Peripheral iridotomy
Timolol
Timolol
A combination of eye drops is often used in the initial emergency medical management of acute angle-closure glaucoma
example of initial management of closed angle glaucoma
There are no guidelines for the initial medical treatment emergency treatment. An example regime would be:
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)
- a beta-blocker (e.g. timolol, decreases aqueous humour production)
- an alpha-2 agonist (e.g. apraclonidine, dual mechanism, decreasing aqueous humour production and increasing uveoscleral outflow)
- intravenous acetazolamide
reduces aqueous secretions
A 68-year-old man with a history of type 2 diabetes mellitus presents with worsening eye sight. Mydriatic drops are applied and fundoscopy reveals pre-proliferative diabetic retinopathy. A referral to ophthalmology is made. Later in the evening whilst driving home he develops pain in his left eye associated with decreased visual acuity. What is the most likely diagnosis?
Keratitis secondary to mydriatic drops
Proliferative diabetic retinopathy
Acute angle closure glaucoma
Central retinal artery occlusion
Vitreous haemorrhage
Acute angle closure glaucoma
Mydriatic drops are a known precipitant of acute angle closure glaucoma. This scenario is more common in exams than clinical practice.
A 24-year-old male presents to the emergency department with an acutely painful red eye, which is associated with photophobia, lacrimation and reduced visual acuity. He has a past medical history of ankylosing spondylitis. Examination identifies a small, irregularly shaped pupil.
Which is the most appropriate management of this patient’s presenting condition?
Acetazolamide and cycloplegic (mydriatic) eye drops
Acetazolamide and pilocarpine eye drops
Chloramphenicol eye drops
Oral steroids and pilocarpine eye drops
Steroid and cycloplegic (mydriatic) eye drops
Anterior uveitis is most likely to be treated with a steroid + cycloplegic (mydriatic) drops
A 50-year-old man attends a regular optometry appointment for a general eye-health check-up. He has a history of diabetes with poor adherence to medication, and he does not frequently check his blood sugar levels. On fundoscopy, diffuse neovascularisation was noted, as well as cotton wool spots.
What following treatment pathway would be most beneficial for this patient?
Intravitreal VEGF inhibitors + pan-retinal photocoagulation laser
Intravitreal VEGF inhibitors only
Macular laser therapy
Pan-retinal photocoagulation laser only
Watchful waiting in combination with regular optometry visits
Intravitreal VEGF inhibitors may be used in addition to panretinal laser photocoagulation to treat proliferative diabetic retinopathy
Red eye - glaucoma or uveitis?
glaucoma: severe pain, haloes, ‘semi-dilated’ pupil
uveitis: small, fixed oval pupil, ciliary flush
Acute angle closure glaucoma is associated with …………., where as primary open-angle glaucoma is associated with …………..
Acute angle closure glaucoma is associated with hypermetropia, where as primary open-angle glaucoma is associated with myopia
