Opthalmology

Question 1

Viral conjunctivitis - features, mx.

Answer 1

Watery discharge, preauricular lymphadenopathy, follicular pattern of conjunctiva. Cold compress, lubricants, worse day 5-6 then slowly resolves.

Question 2

Allergic conjunctivitis - features, management.

Answer 2

Cobblestoning on conjunctiva. Avoid rubbing, avoid lenses. Use cool compress, refrigerated fake tears. 1stline antihistamine (zyrtec drop, for 6+), patanol mast cell stabiliser 3+, eyezep - azelastine does both 4+

Question 3

Features and management of gonococcal + chalmydial conjunctivitis. Risks.

Answer 3

G: acute copious discharge. Take PCR swab, STAT cefotaxime IV/IM + azith, opthal emergency, seen in neonates. C: Azith 1g oral STAT, face washing and treating household contacts.

Question 4

Fx and Mx of periorbital + orbital cellulitis.

Answer 4

Fever, pain and swelling alone - oral fluclox (keflex or clinda if allergy), ensure improving 48hr. If sinusitis use augmentin. If proptosis, diplopia or painful eye movements risk orbital - CT, IV abx (cefotaxime), blood cultures.

Question 5

What are 6 history questions in someone presenting with a red eye?

Answer 5

Vision affected, photophobia, trauma, contact lenses, discharge, foreign body sensation (grittiness likely viral/allergic/dry).

Question 6

Acute angle closure glaucoma - 5 features, 5 mx

Answer 6

Severe pain, nausea/vomiting, see halos around lights, mix-dilated poorly reactive pupil, cloudy cornea. Emergency opthal, lie flat, NBM, IV morph/ondansetron, no eye patch.

Opthal will do eye drops like timolol

Question 7

What are 4 possible causes of transient vision loss? What tests are considered?

Answer 7

Ischaemia from cartoid disease, giant cell arteritis - headache, retinal vasospasm in young pt, migraine -bilateral w aura. If >50, do ESR + CRP, carotid U/S and opthal review. Consider MRI, cardiac workup.

Question 8

Chalazion and stye - cause, appearance, management. DDx.

Answer 8

C: meibomian cyst/clogged gland. Not tender. Warm compress, eyelid hygiene, gentle massage, improve in 1mo. Stye/hordeolum - infection of gland of Zeiss or meibomian. Warm compress. Abx only if cellulitis. DDx: BCC.

Question 9

Cataract - cause, RF, symptoms, mx.

Answer 9

Lens opacity. Age, smoking, alcohol, sunlight exposure, diabetes ?steroids. Painless, bluriness, halos around lights, fading colours, worse at night. Low risk surgery under local when symptoms bothersome.

Question 10

What are some causes of flashes + floaters (both + separate)? 2 differentials

Answer 10

Posterior vitreous detachment, retinal detachment, retinal tear, posterior uveitis. Flash only: retinitis. Float: vitreous haemorrhage, PVD. DDx: migraine, occipital lobe pathology.

Question 11

How does a retinal detachment present? RF? DDx?

Answer 11

Painless vision loss, recent flash/float. RF: trauma/surgery, age >50, Fhx, near sightedness. Other painless loss: vitreous haemorrhage, central artery/vein occlusion, temporal arteritis, optic neuritis.

Question 12

Open angle glaucoma - risk factors, findings.

Answer 12

Age, Fhx, OSA, diabetes, HTN, vasospam/migraines. Can be asx. Cupping of optic disc - increased size/ratio of cup to disc and vessels pushed out.

Question 13

Open angle glaucoma - treatment options (3) w examples, SE. SE of eye drops.

Answer 13

Prostagland analogue 1st latanoprost - hypertrichosis, pigmentation skin/iris. Beta: timolol - bronchoconstrict, bradyarrythmia, hypotension. Use in morning. Alpha agonist: brimonidine - conjunctivitis. Preservatives can cause chronic red gritty eyes

Question 14

Macular degeneration - sx, RF, mx.

Answer 14

Painless bilatera visual loss - central scotoma, distorted lines. RF: Smoking, HTN, Fhx, northern europe. Omega 3 fatty acids, eye vitamin supplement, support groups, amsler grid at home. Can be dry or wet, wet use anti-vegf. Chronic disease.

Question 15

What are the fundoscopic features of hypertensive + diabetic retinopathy? Retinal vein and artery occlusions.

Answer 15

HTN: silver wiring, AV nipping, haemorrhage. DM: cotton wool spots, exudates, neovascularisation, haemorrhage. Vein: sunset storm (brnach or central). Artery: pale retina, cherry red spot.

Question 16

What are the differentials for diplopia?

Answer 16

Mono: cataract/astigmatism. Binocular: cranial nerve palsy (from aneurysm/tumour ICP), myasthenia gravis, thyroid eye disease, tumour, trauma.

Question 17

What signs of an orbital fracture need immediate referral? How are they managed in the interim?

Answer 17

Proptosis (blood behind), tear shaped pupil - globe rupture, RAPD, painful/limited eye movements, hyphaema, compartment syndrome - tight orbit. No nose blowing 2 weeks, icepack 2hrly for first 2 days, no air travel 2 weeks, CT and surgery.

Question 18

Dacrocytitis - presentation, mx.

Answer 18

Watery eye then painful swelling from obstructed drain system. Analgesia, warm compress, use keflex if infected.

Question 19

Exam features of optic neuritis - 5.

Answer 19

Usually monocular. Central scotoma, loss of colour vision, RAPD, normal fundoscopy or disc swell/blur.

Question 20

How does uveitis present? Mx

Answer 20

Painful red eye, photophobia, bluriness over days. Pupil constricted, cells in anterior chamber, redness all the way to iris. Urgent opthal review in 48hr.

Question 21

Features of anterior and posterior blepharitis. Assoc conditions. Mx for both and separate.

Answer 21

Eyelid inflammation - ant shows scaly debris, swelling of lid margin. Post: cloudy secretion, chalazion. Mx: warm compress 2-5min then gentle scrub w baby shampoo. Ant: chlorsig ointment. Posterior: doxycycline.

Question 22

Features and management of pingueculum and pterygium

Answer 22

Pingueculum: yellow/white from limbus (some space before cornea), benign from sun exposure. Won’t affect cornea. Pterygium - grows from medial side, wedge shaped film, remove if going over cornea.

Question 23

Episcleritis vs scleritis

Answer 23

Epi: local inflammation over one part of sclera - congested vessel, mild discomfort, no visual change. Reassure. Scleritis: much more inflammation, pain severe and photophobia.

Question 24

Fx and mx of HSV keratitis + photokeratitis

Answer 24

Dendritic ulcer, topical aciclovir, see opthal within 1 day for depth. Photo from UV - welding, pain 6-12hr post exposure; exposed nerve endings - punctate widespread uptake on staining. Self resolve 1-3 days, topical abx and oral analgesia, no patch.

Question 25

Bacterial keratitis - fx, cause, mx.

Answer 25

Painful red eye w photophobia, swelling, blurriness. 95% associated w contact lenses. Ophtal ED - abx to treat avoid ulceration and vision loss.

Question 26

How is hyphaema managed? Risk

Answer 26

Eye shield, bed rest w head at 30 degrees, dilate pupil, control pain and nausea, opthal review within 1-2 days. Risk of glaucoma.

Question 27

What is the natural history of retinitis pigmentosa? Cause?

Answer 27

Night blindness as a child, visual field narrowing, blind by adolescence. Genetic - melanin cells move superficially and affect rods and cones.

Question 28

How are eye chemical injuries managed?

Answer 28

Local anaesthetic, irrigate with 1L normal saline - 15 minutes. Wait 5 mins then check pH, aim for 6.5-8.5. Opthal review.