Passmedicine extras

Question 1

Hypertensive Retinopathy Classification

Answer 1

0- But with diagnosed hypertension?

Question 2

That Herpes Zoster sign

Answer 2

Hutchinson’s sign: rash on the tip or side of the nose. Indicates nasociliary involvement and is a strong risk factor for ocular involvement

Question 3

Argyll-Robertson pupil

Answer 3

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

Question 4

Eyelid problems commonly encountered include:

Answer 4

blepharitis: inflammation of the eyelid margins typically leading to a red eye
stye: infection of the glands of the eyelids

chalazion (Meibomian cyst)

entropion: in-turning of the eyelids
ectropion: out-turning of the eyelids

Question 5

Differentiating posterior vitreous detachment, retinal detachment and vitreous haemorrhage

Answer 5

Posterior vitreous detachment:

Flashes of light (photopsia) - in the peripheral field of vision. Floaters, often on the temporal side of the central vision

Retinal detachment;

Dense shadow that starts peripherally progresses towards the central vision
A veil or curtain over the field of vision
Straight lines appear curved
Central visual loss

Vitreous haemorrhage;

Large bleeds cause sudden visual loss
Moderate bleeds may be described as numerous dark spots
Small bleeds may cause floaters

Question 6

Nice guidlines for open angly glaucoma

Answer 6

NICE guidelines:

first line: prostaglandin analogue (PGA) eyedrop

second line: beta-blocker, carbonic anhydrase inhibitor, or sympathomimetic eyedrop

if more advanced: surgery or laser treatment can be tried2

Reassessment

important to exclude progression and visual field loss

needs to be done more frequently if: IOP uncontrolled, the patient is high risk, or there is progression

Question 7

Age related macular degneration investigations

Answer 7

slit-lamp microscopy

-for a base line and to see changes in the retina

fluorescein angiography

• if neovaculation is suspected to guide anti VEGF therapy

ocular coherence tomography

-used to visualise the retina in three dimensions, because it can reveal areas of disease which aren’t visible using microscopy alone.

Question 8

Periorbital (preseptal) vs Orbital cellulitis:

Answer 8

Absence of painful movements, diplopia and visual impairment indicates the former

Question 9

what can predispose cataracts?

Answer 9

• Down’s Syndrome
• Diabtes Mellitis
• Uveitis
• long term steroid use

Question 10

Cataracts Classification

Answer 10

• Nuclear: change lens refractive index, common in old age
• Polar: localized, commonly inherited, lie in the visual axis
• Subcapsular: due to steroid use, just deep to the lens capsule, in the visual axis
• Dot opacities: common in normal lenses, also seen in diabetes and myotonic dystrophy

Question 11

Age related macular degneration Treatments

Answer 11

• a combination of zinc with anti-oxidant vitamins A,C and E reduced progression of the disease by around one third. (not smokers as increases risk of lung cancer)
• Anti VEGF (ranibizumab, bevacizumab and pegaptanib)
• Laser photocoagulation (but risk of increased acute visual loss)

Question 12

Cataracts Causes

Answer 12

• Smoking
• Increased alcohol consumption
• Trauma
• Diabetes mellitus
• Long-term corticosteroids
• Radiation exposure
• Myotonic dystrophy
• Metabolic disorders: hypocalcaemia

Question 13

Pupil Disorders

Answer 13

• Adie pupil-Tonically dilated pupil, slowly reactive to light with more definite accommodation response. Caused by damage to parasympathetic innervation of the eye due to viral or bacterial infection. Commonly seen in females, accompanied by absent knee or ankle jerks.
• Marcus-Gunn pupil - Relative afferent pupillary defect, seen during the swinging light examination of pupil response. The pupils constrict less and therefore appear to dilate when a light is swung from unaffected to affected eye. Most commonly caused by damage to the optic nerve or severe retinal disease
• Horner’s syndrome- Miosis (pupillary constriction), ptosis (droopy eyelid), apparent enophthalmos (inset eyeball), with or without anhidrosis (decreased sweating) occurring on one side. Caused by damage to the sympathetic trunk on the same side as the symptoms, due to trauma, compression, infection, ischaemia or many others.
• Hutchinson’s - Unilaterally dilated pupil which is unresponsive to light. A result of compression of the occulomotor nerve of the same side, by an intracranial mass (e.g. tumour, haematoma)
• Argyll-Robertson pupil- Bilaterally small pupils that accommodate but don’t react to bright light. Causes include neurosyphilis and diabetes mellitus

Question 14

Amaurosis Fugax

Answer 14

Painless, transient monocular blindness together with the description of a ‘black curtain coming down’ is characteristic of amaurosis fugax

Question 15

Horner’s syndrome

Answer 15

miosis + ptosis + enophthalmos +/- anhydrosis

Question 16

Horners syndrome causes

Answer 16

Question 17

Oribitla cellulitis investigation and management

Answer 17

Investigations (usually just clincial though)

• Full blood count – 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. Most common bacterial causes – Streptococcus, Staphylococcus aureus, Haemophilus influenzae B.

Management

• admission to hospital for IV antibiotics

Question 18

Marcus Gunn pupil

Answer 18

(relative afferent pupillary defect) is diagnosed during the swinging light test. If there is damage to the afferent pathway (retina or optic nerve) of one eye, the pupil of that affected eye will abnormally dilate when a light is shone into it. This is because the consensual pupillary relaxation response from the healthy eye will dominate. Marcus Gunn pupil can be found in patients with multiple sclerosis. Therefore, given the history, this should be ruled out in this patient.

Question 19

timolol mode of action

Answer 19

Beta blockers such as timolol work in primary open-angle glaucoma by reducing aqueous production

Question 20

causes of pappilodema

Answer 20

• space-occupying lesion: neoplastic, vascular
• malignant hypertension
• idiopathic intracranial hypertension
• hydrocephalus
• hypercapnia

Rare causes include

• hypoparathyroidism and hypocalcaemia
• vitamin A toxicity

Question 21

Management of infective conjunctivitis

Answer 21

• normally a self-limiting condition that usually settles without treatment within 1-2 weeks
• topical antibiotic therapy is commonly offered to patients, e.g. Chloramphenicol. Chloramphenicol drops are given 2-3 hourly initially where as chloramphenicol ointment is given qds initially
• topical fusidic acid is an alternative and should be used for pregnant women. Treatment is twice daily
• contact lens should not be worn during an episode of conjunctivitis
• advice should be given not to share towels
• school exclusion is not necessary

Question 22

Management of anterior uveitis

Answer 22

• urgent review by ophthalmology
• cycloplegics (dilates the pupil which helps to relieve pain and photophobia) e.g. Atropine, cyclopentolate
• steroid eye drops

Question 23

Most likely complication of herpes zoster ophthalmicus (HZO).

Answer 23

Anteriror Uveitis

Question 24

Causes of Papilloedema

Answer 24

• space-occupying lesion: neoplastic, vascular
• malignant hypertension
• idiopathic intracranial hypertension
• hydrocephalus
• hypercapnia

Question 25

Causes of optic neuritis

Answer 25

• multiple sclerosis
• diabetes
• syphilis

Question 26

Herpes simplex keratitis feature and management

Answer 26

Features

• red, painful eye
• photophobia
• epiphora
• visual acuity may be decreased
• fluorescein staining may show an epithelial ulcer

Management

• immediate referral to an ophthalmologist
• topical aciclovir

Question 27

Management of allergic conjunctivitis

Answer 27

• first-line: topical or systemic antihistamines
• second-line: topical mast-cell stabilisers, e.g. Sodium cromoglicate and nedocromil

Question 28

Open angle glaucoma investigaitons and treatment

Answer 28

Investigations:

• automated perimetry to assess visual field
• slit lamp examination with pupil dilatation to assess optic neve and fundus for a baseline
• applanation tonometry to measure IOP
• central corneal thickness measurement
• gonioscopy to assess peripheral anterior chamber configuration and depth
• Assess risk of future visual impairment, using risk factors such as IOP, central corneal thickness (CCT), family history, life expectancy

The majority of patients with primary open-angle glaucoma are managed with eye drops. These aim to lower intra-ocular pressure which in turn has been shown to prevent progressive loss of visual field.

NICE guidelines:

• first line: prostaglandin analogue (PGA) eyedrop
• second line: beta-blocker, carbonic anhydrase inhibitor, or sympathomimetic eyedrop
• if more advanced: surgery or laser treatment can be tried2

Question 29

Scleritis Features

Answer 29

• red eye
• classically painful (in comparison to episcleritis), but sometimes only mild pain/discomfort is present
• watering and photophobia are common
• gradual decrease in vision

Question 30

Diabetic Retinopath Classification

Answer 30

Mild NPDR

• 1 or more microaneurysm

Moderate NPDR

• microaneurysms
• blot haemorrhages
• hard exudates
• cotton wool spots, venous beading/looping and intraretinal microvascular abnormalities (IRMA) less severe than in severe NPDR

Severe NPDR

• blot haemorrhages and microaneurysms in 4 quadrants
• venous beading in at least 2 quadrants
• IRMA in at least 1 quadrant

Proliferative retinopathy

• retinal neovascularisation - may lead to vitrous haemorrhage
• fibrous tissue forming anterior to retinal disc
• more common in Type I DM, 50% blind in 5 years

Maculopathy

• based on location rather than severity, anything is potentially serious
• hard exudates and other ‘background’ changes on macula
• check visual acuity
• more common in Type II DM

Question 31

The most common causes of a sudden painless loss of vision

Answer 31

• ischaemic/vascular (e.g. thrombosis, embolism, temporal arteritis etc). This includes recognised syndromes e.g. occlusion of central retinal vein and occlusion of central retinal artery
• vitreous haemorrhage
• retinal detachment
• retinal migraine

Question 32

Retinitis Pigmentosa Features

Answer 32

• night blindness is often the initial sign
• tunnel vision due to loss of the peripheral retina (occasionally referred to as funnel vision)
• fundoscopy: black bone spicule-shaped pigmentation in the peripheral retina, mottling of the retinal pigment epithelium

Question 33

Blepharitis features and management

Answer 33

Features

• symptoms are usually bilateral
• grittiness and discomfort, particularly around the eyelid margins
• eyes may be sticky in the morning
• eyelid margins may be red. Swollen eyelids may be seen in staphylococcal blepharitis
• styes and chalazions are more common in patients with blepharitis
• secondary conjunctivitis may occur

Management

• softening of the lid margin using hot compresses twice a day
• mechanical removal of the debris from lid margins - cotton wool buds dipped in a mixture of cooled boiled water and baby shampoo is often used*
• artificial tears may be given for symptom relief in people with dry eyes or an abnormal tear film