Opthalmology

Question 1

Dx:
Red eye
Not painful/mild pain
\+/- Watering & photophobia
May be bilateral

Answer 1

Episcleritis

Question 2

Management of episcleritis

Answer 2

Self limiting usually

Conservative- may use artificial tears

Question 3

How to differentiate episcleritis vs scleritis

Answer 3

Phenylephrine drops- if redness improves with drop then dx episcleritis

(phenylephrine blanches the conjunctival and episcleral vessels but not the scleral vessels)

Question 4

Features of age related macular degeneration

Answer 4

Drusen (collections of lipids/protein beneath RPE and within Bruch’s membrane)
RPE hypo/hyperpigmentation
RPE atrophy
Neovascular AMD- abnormal new blood vessels which easily bleed/leak

Question 5

Risk factors for age related macular degeneration

Answer 5

SMOKING

Increasing age
Family Hx/Genetic factors

Possible risk factors; HTN, CV disease, excessive sunlight, cataract surgery, long sighted, high alcohol intake, obesity

Question 6

AMD classification

Answer 6

No AMD- no/few small drusen less than 63 micrometers diameter

Early AMD- multiple small drusen, few intermediate drusen or mild abnormalities of RPE

Intermediate AMD- any one of; numerous intermediate drusen, at least 1 large drusen (125 micrometres diameter at least), or geographic atrophy not involving central fovea

Advanced AMD- Geographic atrophy involving central fovea and/or neovascular AMD

Question 7

These are features of…
Painless deterioration of central vision
Usually 55yrs+
Metamorphopsia (distorted vision where straight lines appear bent)
Scotoma (black/grey patch affecting central vision)

Others:
Light glare
Loss of contrast sensitivity
Abnormal dark adaptation
Photopsia (flickering/flashing lights)
Charles Bonnet syndrome (hallucinations)

Answer 7

AMD

Question 8

What would you find on examination in a patient with AMD?

Answer 8

Normal or ↓ visual acuity
Drusen
Pigmentary/exudative/haemorrhagic/atrophic changes of macula

Question 9

In GP if AMD suspected need to

Answer 9

Refer urgently to ophthalmology (within 1 week)

Question 10

Investigations for AMD

Answer 10

Slit lamp biomicroscopy
Colour fundus photography
Ocular coherence tomography
Fluorescein angiography

Question 11

Management of AMD

Answer 11

Slow progression by stopping smoking, healthy diet, supplements

In neovascular AMD- anti-angiogenic therapies e.g. anti VEGF drugs (ranibizumab, bevacizumab, afilbercept)

Question 12

Red, swollen, painful eye- acute onset
Fever
Erythema and oedema of eyelids
Ptosis of eye
Lack of orbital signs

Answer 12

Preseptal cellulitis (preorbital cellulitis)

Question 13

Management of preseptal cellulitis

Answer 13

Admit ophthalmology

Oral co-amoxiclav

Question 14

Eyelid erythema and oedema
Chemosis (oedema of conjunctiva)
Proptosis
Gaze restriction
Blurred/double vision
Fever

Answer 14

Orbital cellulitis

Question 15

Management of orbital cellulitis

Answer 15

Admit ophthalmology
IV abx e.g. cefotaxime and flucloxacillin 7-10d
Surgery if CT shows orbital collection

Question 16

Investigations for preseptal/orbital cellulitis

Answer 16

FBC- leukocytosis
Blood cultures
Swab any skin breaks
CT sinuses and orbit +/- brain

Question 17

Itchy eyes
Watery/mucoid discharge
Conjunctival redness
Chemosis
Oedema of eyelid

Answer 17

Conjunctivitis

Question 18

Ophthalmology red flags

Answer 18

Reduced visual acuity
Marked eye pain, headache or photophobia
Inability to open eye or keep it open
Red sticky eye in neonate (within 30d of birth)
Hx of trauma or possible foreign body
Copious rapidly progressive discharge (may indicate gonococcal infection)
Possible herpes virus infection (herpes simplex may present as unilateral red eye + vesicles on eyelid, herpes zoster - lesions on tip of nose)
Soft contact lens use with corneal sx e.g. photphobia/watering

Question 19

Management of conjunctivitis

Answer 19

Avoid allergens and do not rub eyes
Cold compresses/saline/artificial tears
Topical antihistamine (Emedastine)
OR dual mast cell stabiliser + antihistamine (Azelastine, Epinastine, Ketotifen, Olopatadine)

Question 20

Bilateral eye grittiness and discomfort, esp. at eyelid margins
Eyes may be sticky in the morning
Eyelid margins may be red

Answer 20

Blepharitis

Question 21

Management of blepharitis

Answer 21

Hot compresses BD
Mechanical removal of debris from lid margins
Artificial tears if dry eyes/abnormal tear film

Question 22

Severe pain- ocular or headache
Decreased visual acuity
Hard, red eye
Symptoms worse with mydriasis (e.g. watching TV in dark room)
Haloes around lights
Semi-dilated non-reacting pupil
Dull/hazy cornea
May have systemic upset e.g. nausea, vomiting, abdo pain

Answer 22

Acute angle closure glaucoma

Question 23

Management of acute angle closure glaucoma

Answer 23

Urgent referral ophthalmology
Patient to lie flat with face up, no pillow, to relieve pressure
Pilocarpine eye drops
Acetazolamide 500mg orally (reduces production of aqueous humour)
Analgesia
Anti-emetic

In secondary care- laser iridotomy

Question 24

Increased intraocular pressure
Visual field defects
Cupped optic disc

Answer 24

Primary open angle glaucoma

Question 25

Treatment of primary open angle glaucoma

Answer 25

Mild- monitoring

Reduce intraocular pressure with a topical prostaglandin analogue or prostamide, or a topical beta-blocker

Question 26

Features of Horner’s syndrome

Answer 26

Miosis (small pupil)
Ptosis (drooping of upper eyelid)
Enopthalmos (sunken eye)
Anhidrosis (loss of sweating on one side)