Presentations/passmed

Question 1

What presents with PAINLESS loss of vision?

Answer 1

Retinal detachment - associated with an area of visual loss, usually described as a falling curtain
Floaters and flashing lights

Posterior vitreous detachment
Floaters and flashing lights

Central retinal artery occlusion -

Central retinal vein occlusion

Question 2

What eye problems are associated with flashing lights and floaters?

Answer 2

Retinal detachment

Posterior vitreous detachment

Question 3

A 40-year-old man presents to the eye hospital with a one-day history of bilateral red eyes around the corneal limbus. Both eyes are very painful, especially when trying to read the newspaper. On further questioning, he reports photosensitivity and blurry vision. He has a generalised headache, as well as back pain that is worse in the morning and improves over the course of a day.

On examination, his pupils are small, oval-shaped and fixed. There is no hypopyon, but they are very watery.

What is the most appropriate management plan?

Answer 3

The patient has Anterior uveitis!

Anterior uveitis is most likely to be treated with a steroid + cycloplegic (mydriatic) drops

Question 4

When would you give high flow oxygen and sumatriptan?

Answer 4

In cluster headaches

Question 5

What is a hypopyon?

Answer 5

This describes pus and inflammatory cells in the anterior chamber, often resulting in a visible fluid level.

Question 6

A 67-year-old woman presents to an out-of-hours general practitioner with a painful, red left eye and nausea. She noticed the symptoms starting when she was at the cinema with her granddaughter and since then her vision has worsened. On examination, she has a left-sided, semi-dilated pupil that does not react to light with some surrounding conjunctival injection.

Which of the following is the most appropriate management option?

Answer 6

Pilocarpine eye drops (constrict the pupil) and oral acetazolamide (to reduce the aqueous humour production) should be administered
Lay the patient flat

Question 7

For acute angle closure glaucoma, the patient is given pilocarpine eye drops and acetazolamide, what are the roles of these medications?

Answer 7

Pilocarpine eye drops are a mitotic agent (patients with acute angle closure glaucoma present with a fixed dilated pupil) and also causes ciliary muscle contraction.

Acetazolamide is a carbonic anhydrase inhibitor and reduces the production of aqueous humour.

Question 8

What is the definitive management of Acute angle closure glaucoma?

Answer 8

Laser iridotomy

This makes a hole in the iris

Question 9

What is transient monocular visual loss?

Answer 9

A sudden transient loss of vision that lasts less than 24 hours

Question 10

Give the differentials for sudden painless visual loss?

Answer 10

Ischaemic/vascular
Vitreous haemorrhage
Retinal detachment
Retinal migraine

Question 11

What are the reasons for ischaemic optic neuropathy?

Answer 11

Occlusion of the short posterior ciliary arteries which causes damage to the optic nerve.

Question 12

What field defects are seen in ischaemic/vascular sudden loss of vision?

Answer 12

Currain coming down

Question 13

What are the causes of vitreous haemorrhage?

Answer 13

Diabetes
Bleeding disorders
Anticoagulants

Question 14

How do you differentiate between posterior vitreous detachment, retinal detachment and vitreous haemorrhage?

Answer 14

Posterior vitreous detachment- flashes of light, photopsia in the peripheral field of vision
Floaters (often on the temporal side of central vision

In retinal detachment you will get a dense shadow that starts peripherally progresses towards the central vision
A veil or curtain over the field of vision
Straight lines will appear curved
Central visual loss

Vitreous haemorrhage- large bleeds will cause sudden visual loss, moderate bleeds will be described as a numerous dark spots

Small bleeds will cause floaters

Question 15

A 73-year-old man attends the emergency department with sudden-onset visual loss in the left eye. He reports no pain or headache, and there was no history of preceding trauma. There are no neurological symptoms.

He has a past medical history of poorly-controlled type 2 diabetes, and hypertension.

On examination, he his just about able to distinguish light from dark with the left eye. His red reflex is absent. You are unable to gain any view of the retina with fundoscopy. His neurological examination is otherwise normal.

What is the most likely cause of his visual loss?

Answer 15

Vitreous haemorrhage
The retina may be obscured on fundoscopy with the presence of vitreous haemorrhage

As well vitreous haemorrhage is associated with type 2 diabetes

Question 16

A 63-year-old man presents to his GP complaining of pain in his right eye. On examination the sclera is red and the pupil is dilated with a hazy cornea. What is the most likely diagnosis?

Answer 16

Red eye - glaucoma or uveitis?

glaucoma: severe pain, haloes, ‘semi-dilated’ pupil, hazy cornea
uveitis: small, fixed oval pupil, ciliary flush

Question 17

How can squints be classified?

Answer 17

the nose: esotropia

temporally: exotropia
superiorly: hypertropia
inferiorly: hypotropia

Question 18

Squints can be divided into concomitant (common) and paralytic (rare), what does this mean?

Answer 18

Concomitant= due to imbalance in the extraocular muscles
Convergent is more common than divergent

Paralytic= due to paralysis of the extraocular muscles

Question 19

How is detection of a squint made?

Answer 19

Detection of a squint may be made by the corneal light reflection test - holding a light source 30cm from the child’s face to see if the light reflects symmetrically on the pupils

The cover test is used to identify the nature of the squint
ask the child to focus on an object
cover one eye
observe movement of uncovered eye
cover other eye and repeat test

Question 20

What are the following treatments used for?

IV acetazolamide

Pilocarpine drops

Steroid and chloramphenicol onitment

Steroid and cycloplegic drops

Steroids and pilocarpine drops

Answer 20

Steroids are given to reduce inflammation and cycloplegics (atropine or cyclopentolate) dilate the pupil which helps with pain relief and photophobia.

Chloramphenicol is an antibiotic used in treating bacterial conjunctivitis without the need for steroids.

Acetazolamide is a carbonic anhydrase inhibitor that is used in managing acute angle-closure glaucoma.

Pilocarpine is a muscarinic receptor agonist and can be used in managing primary open-angle glaucoma and acute close angle glaucoma.

Question 21

Contact lens wearers who present with a painful red eye should be referred to eye casualty to exclude microbial keratitis, how should microbial keratitis be differentiated from conjunctivitis?

Answer 21

Slit lamp examination is required.

Question 22

What is the keith wagener classification of hypertensive retinopathy?

Answer 22

Stage 1= arteriolar narrowing and tortuosity
Increased light reflex- silver wiring

Stage 2= arteriovenous nipping

Stage 3= cotton wool exudates
Flame and blot haemorrhages

Stage 4= papilloedema

Question 23

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?

Answer 23

Carotid artery dissection

Question 24

What is a hyphema?

Answer 24

This is a condition which occurs when blood enters the front chamber of the eye, between the iris and the cornea

Question 25

A 30-year-old man has presented to the eye emergency department after being hit across the face with a baseball bat. On examination, the right eye has blood in the anterior chamber.

What is he at risk of?

Answer 25

Glaucoma

Blunt ocular trauma with associated hyphema is a high risk scenario of raised intra ocular pressure

This is due to the blood causing a blockage in the drainage of the aqueous humour, it is important to closely monitor the intraocular pressure of such patients

Question 26

What eye problems are associated with blunt trauma?

Answer 26

Cataract
Ectopia lentis (displacement of the eyes lens from its normal location)
Glaucoma

Question 27

What is herpes zoster opthalmicus?

Answer 27

This describes the reactivation of the varicella zoster virus in the area which is supplied by the ophthalmic division of the Trigeminal nerve.

It accounts for around 10%of shingle cases

Question 28

What are the features of herpes zoster opthalmicus?

Answer 28

Vesicular rash around the eye, which may or may not involve the actual eye itself
Hutchinsons sign- rash on the tip or side of the nose, this indicates nasociliary involvement and is a strong risk factor for ocular involvement

Question 29

What is the management of herpes zoster opthalmicus?

Answer 29

Oral antiviral treatment for 7-10 days
Ideally the oral antiviral treatment should be started within 72 hours
IV antivirals may be given for very severe infection or if the patient is immunocompromised

Topical corticosteroids may be used to treat any secondary inflammation of the eye

Ocular involvement requires urgent opthalmology review

Question 30

What are the complications of herpes zoster opthalmicus?

Answer 30

Ocular- conjunctivitis, keratitis, episcleritis, anterior uveitis
Ptosis
Post herpetic neuralgia

Question 31

A 22-year-old medical student is complaining of severe right eye pain after recently returning from an elective placement in the US. On further questioning, he revealed that he went swimming in fresh water with his contact lens on. On examination, his right eye seemed slightly red but no other major clinical findings were noted.

What is the most likely causative organism of his presentation?

Answer 31

Acanthamoeba

Pain out of proportion of clinical presentation, contact lens and recent freshwater swimming is classical of acanthamoebic keratitis.

Question 32

What is a relative afferent pupillary defect?

Answer 32

This is also known as the marcus gunn pupil a relative afferent pupillary defect which is found by the swinging light test. if is caused by a lesion anterior to the optic chiasm- optic nerve or retina

Both the affected and normal eye appear to dilate when light is shone on the affected

Question 33

What is the pathway of the pupillary light reflex?

Answer 33

Afferent=

Retina which goes to the optic nerve which goes to the lateral geniculate body and then to the midbrain

Efferent=

Edinger- westphal nucleus (midbrain) to the oculomotor nerve

Question 34

What are the causes of Relative afferent pupillary defect/ marcus gunn pupil?

Answer 34

Retina= Retinal detachment

Optic nerve= optic neuritis ie: multiple sclerosis

Question 35

What is a holmes aide pupil?

Answer 35

A dilated pupil which poorly (if at all) reacts to direct light, however it does slowly react to accomodation.

Question 36

What is an argyll robertson pupil?

Answer 36

A constricted pupil which doesn’t respond to light but responds to accommodation, it is usually bilateral and is often associated with neurosyphilis.