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Question 1
Correct
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A 25-year-old male with a history of ankylosing spondylitis presents to the emergency department with a painful red eye, photophobia, lacrimation, and reduced visual acuity. On examination, an irregularly shaped pupil is noted. What is the most suitable approach to manage this patient's current condition?
Your Answer: Steroid and cycloplegic (mydriatic) eye drops
Explanation:Anterior uveitis, also known as iritis, is a type of inflammation that affects the iris and ciliary body in the front part of the uvea. It is a common cause of red eye and is associated with HLA-B27, which may also be linked to other conditions. Symptoms of anterior uveitis include sudden onset of eye discomfort and pain, small or irregular pupils, intense sensitivity to light, blurred vision, redness, tearing, and the presence of pus and inflammatory cells in the front part of the eye. This condition may be associated with ankylosing spondylitis, reactive arthritis, ulcerative colitis, Crohn’s disease, Behcet’s disease, and sarcoidosis. Urgent review by an ophthalmologist is necessary, and treatment may involve the use of cycloplegics and steroid eye drops.
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This question is part of the following fields:
- Ophthalmology
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Question 2
Incorrect
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A 52-year-old woman presents to an eye screening appointment, having been referred by her General Practitioner. She has a family history of type II diabetes mellitus. At the appointment, there are no signs of diabetic retinopathy.
What is the most appropriate ongoing eye screening for this patient?Your Answer: Attend eye screening only if he experiences a change in vision
Correct Answer: Annual visual acuity testing and retinal photography
Explanation:The Importance of Annual Eye Screening for Diabetic Patients
The National Health Service diabetic eye screening programme recommends that patients over the age of 12 with diabetes attend annual eye screening appointments. These appointments include visual acuity testing and retinal photography, which can detect changes consistent with background retinopathy or more severe forms of diabetic retinopathy. Patients with moderate, severe, or proliferative retinopathy will be referred for further assessment and may require more frequent screening following treatment.
Tonometry, which measures intraocular pressure, is also important in the diagnosis of glaucoma. However, the gold-standard test for diagnosing diabetic retinopathy is dilated retinal photography with or without fundoscopy. Retinal photographs are preferable to fundoscopy because they provide a clear view of the entire retina and can be compared with previous images to monitor disease progression.
It is important for diabetic patients to attend annual eye screening appointments, even if they have no changes in vision. Vision may be preserved until relatively advanced stages of the disease, and early detection of diabetic retinopathy can prevent irreversible loss of vision. Therefore, patients should not wait for changes in vision to occur before attending screening appointments.
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This question is part of the following fields:
- Ophthalmology
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Question 3
Incorrect
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An 80-year-old woman presents with complaints of dry, gritty, and painful eyes bilaterally. She has been experiencing these symptoms for a few years and has found little relief with frequent use of lubricating eye drops. Upon examination, both eyelids were crusted and had irregular margins. The meibomian orifices on both lids were obstructed with oily material. What is the underlying cause of this woman's dry eye condition?
Your Answer: Ectropion
Correct Answer: Meibomian blepharitis
Explanation:When the tarsal glands are chronically infected, they can hinder the production of the precorneal tear film, which is responsible for slowing down the evaporation of tears. This can ultimately lead to dry eyes.
The tarsal glands, also known as Meibomian glands, produce an oily substance that forms the outer layer of the precorneal tear film. This oily substance helps to prevent tear evaporation, while also improving tear stability and spreading. However, when Meibomian blepharitis occurs, the production of this oil is reduced, causing excessive water from the tear film to evaporate and resulting in dry eyes. None of the other options listed are relevant to this issue, as they do not involve dysfunction of the Meibomian glands.
Understanding Dry Eye Syndrome
Dry eye syndrome is a condition that causes discomfort in both eyes, with symptoms such as dryness, grittiness, and soreness that worsen throughout the day. Exposure to wind can also cause watering of the eyes. People with Meibomian gland dysfunction may experience symptoms that are worse upon waking, with eyelids sticking together and redness of the eyelids. In some cases, dry eye syndrome can lead to complications such as conjunctivitis or corneal ulceration, which can cause severe pain, photophobia, redness, and loss of visual acuity.
Although there may be no abnormalities on examination, eyelid hygiene is the most appropriate management step for dry eye syndrome. This can help control blepharitis, which is a common condition associated with dry eye syndrome. By understanding the symptoms and appropriate management steps, individuals with dry eye syndrome can find relief and improve their overall eye health.
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This question is part of the following fields:
- Ophthalmology
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Question 4
Incorrect
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A 21-year-old man visits his General Practitioner (GP) with a lump on his eyelid that he has noticed for two days. The GP diagnoses it as a chalazion. What is the most suitable course of action?
Your Answer: Watch and wait
Correct Answer: Apply heat and massage daily
Explanation:Managing Chalazion: Options and Recommendations
Chalazion, also known as meibomian cyst, is a painless inflammatory lesion of the eyelid that contains meibomian secretions. While it is a self-limiting condition, it may become infected and require medical attention. Here are some management options and recommendations for chalazion:
Apply Heat and Massage Daily: The best way to manage chalazion is to apply heat and massage daily to release the oil. This treatment option is effective and usually improves the condition without the need for antibiotics.
Refer to Ophthalmology Urgently: While GPs can manage chalazion, referrals to ophthalmology should be made if the lesion does not improve with treatment or if the GP feels the lesion might be suspicious.
Surgical Incision: If medical management has been unsuccessful, chalazions can be removed surgically by incision and curettage.
Topical Antibiotics: There is no indication for the use of antibiotics in the treatment of chalazion.
Watch and Wait: While chalazions can sometimes resolve with time without treatment, they usually require medical attention. As such, watch and wait is not an appropriate management option.
In summary, applying heat and massage daily is the best way to manage chalazion. Referrals to ophthalmology should be made if necessary, and surgical incision may be required if medical management is unsuccessful. Topical antibiotics are not recommended, and watch and wait is not an appropriate management option.
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This question is part of the following fields:
- Ophthalmology
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Question 5
Incorrect
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A 15-year-old boy presents with a history of seasonal 'watering eyes' for the past 2 years. His symptoms have worsened this year. He complains of bilateral itchy eyes and difficulty in doing school work due to excessive tearing. There is no history of nasal symptoms, asthma or eczema. On examination, there is conjunctival redness, bulging tarsal conjunctivae and mild eyelid swelling. What is the initial management approach for this patient?
Your Answer: Topical corticosteroid
Correct Answer: Topical antihistamines
Explanation:The symptoms exhibited by this patient are indicative of allergic conjunctivitis. The initial treatment approach for this condition involves the use of topical antihistamines. In case of additional symptoms like rhinosinusitis, oral antihistamines may also be prescribed.
Understanding Allergic Conjunctivitis
Allergic conjunctivitis is a condition that can occur on its own, but is often associated with hay fever. It is characterized by bilateral symptoms such as conjunctival erythema and swelling, as well as itchiness and swelling of the eyelids. Those with a history of atopy may be more prone to developing allergic conjunctivitis, which can be seasonal (due to pollen) or perennial (due to exposure to dust mites, washing powder, or other allergens).
When it comes to managing allergic conjunctivitis, first-line treatment typically involves the use of topical or systemic antihistamines. If these prove ineffective, second-line treatment options such as topical mast-cell stabilizers like Sodium cromoglicate and nedocromil may be recommended. By understanding the symptoms and treatment options for allergic conjunctivitis, individuals can take steps to manage their condition and reduce discomfort.
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This question is part of the following fields:
- Ophthalmology
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Question 6
Incorrect
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A 60-year-old man came to your GP clinic complaining of blurred vision for the past month. He has a history of type 2 diabetes mellitus. During direct ophthalmoscopy, you observed a ring of hard exudates at the fovea, but the rest of the retina appeared normal. What is the probable diagnosis for his vision blurring?
Your Answer: Background diabetic retinopathy
Correct Answer: Diabetic maculopathy
Explanation:Diabetic maculopathy refers to any structural anomaly in the macula caused by diabetes. The patient in this case had hard exudates in the macula, which resulted in blurred vision. As there were no abnormalities in the rest of the retina, options 1-3 (background, pre-proliferative and proliferative diabetic retinopathies) are incorrect. Although vitreous hemorrhage can cause blurred vision in cases of proliferative retinopathy, there is no indication of it in the given history.
Understanding Diabetic Retinopathy
Diabetic retinopathy is a leading cause of blindness among adults aged 35-65 years old. The condition is caused by hyperglycemia, which leads to abnormal metabolism in the retinal vessel walls and damage to endothelial cells and pericytes. This damage causes increased vascular permeability, resulting in exudates seen on fundoscopy. Pericyte dysfunction predisposes to the formation of microaneurysms, while neovascularization is caused by the production of growth factors in response to retinal ischemia.
Patients with diabetic retinopathy are classified into those with non-proliferative diabetic retinopathy (NPDR), proliferative retinopathy (PDR), and maculopathy. NPDR is further classified into mild, moderate, and severe, depending on the presence of microaneurysms, blot hemorrhages, hard exudates, cotton wool spots, venous beading/looping, and intraretinal microvascular abnormalities. PDR is characterized by retinal neovascularization, which may lead to vitreous hemorrhage, and fibrous tissue forming anterior to the retinal disc. Maculopathy is based on location rather than severity and is more common in Type II DM.
Management of diabetic retinopathy involves optimizing glycaemic control, blood pressure, and hyperlipidemia, as well as regular review by ophthalmology. Treatment options include intravitreal vascular endothelial growth factor (VEGF) inhibitors for maculopathy, regular observation for non-proliferative retinopathy, and panretinal laser photocoagulation and intravitreal VEGF inhibitors for proliferative retinopathy. Vitreoretinal surgery may be necessary in cases of severe or vitreous hemorrhage.
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This question is part of the following fields:
- Ophthalmology
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Question 7
Correct
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A 25-year-old man comes to you complaining of severe, stabbing pain in his right eye that has been occurring once a day for the past few weeks. The pain lasts for about 30 minutes and he is often seen pacing around and shouting during these episodes. His wife reports that his right eye appears red and he has clear nasal discharge during the episodes. Based on this presentation, what advice would you give the patient to prevent further episodes?
Your Answer: Alcohol
Explanation:Cluster headaches are often triggered by alcohol, and they typically affect individuals of a certain age and gender.
Cluster headaches are a type of headache that is known to be extremely painful. They are called cluster headaches because they tend to occur in clusters that last for several weeks, usually once a year. These headaches are more common in men and smokers, and alcohol and sleep patterns may trigger an attack. The pain typically occurs once or twice a day, lasting between 15 minutes to 2 hours. The pain is intense and sharp, usually around one eye, and is accompanied by redness, lacrimation, lid swelling, and nasal stuffiness. Some patients may also experience miosis and ptosis.
To manage cluster headaches, 100% oxygen or subcutaneous triptan can be used for acute treatment, with response rates of 80% and 75% respectively within 15 minutes. Verapamil is the drug of choice for prophylaxis, and a tapering dose of prednisolone may also be effective. It is recommended to seek specialist advice from a neurologist if a patient develops cluster headaches, especially with respect to neuroimaging. Some neurologists use the term trigeminal autonomic cephalgia to group a number of conditions including cluster headache, paroxysmal hemicrania, and short-lived unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT). Patients with these conditions should be referred for specialist assessment as specific treatment may be required, such as indomethacin for paroxysmal hemicrania.
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This question is part of the following fields:
- Ophthalmology
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Question 8
Incorrect
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A 75-year-old man presents to his GP with a decline in his vision. He describes a gradual onset of dark floaters in his vision over the past few months and has recently experienced some episodes of flashing lights when outside in bright sunlight. The patient has a history of hypertension, which is managed with 5mg ramipril daily. He has a smoking history of 45 pack-years, does not consume alcohol, and is able to perform his daily activities independently. What is the most probable diagnosis for this patient's vision changes?
Your Answer: Macular degeneration
Correct Answer: Vitreous detachment
Explanation:The patient has flashers and floaters associated with vitreous detachment, which can lead to retinal detachment. This is not central retinal artery occlusion, ischaemic optic neuropathy, macular degeneration, or temporal arteritis.
Sudden loss of vision can be a scary symptom for patients, as it may indicate a serious issue or only be temporary. Transient monocular visual loss (TMVL) is a term used to describe a sudden, brief loss of vision that lasts less than 24 hours. The most common causes of sudden, painless loss of vision include ischaemic/vascular issues (such as thrombosis, embolism, and temporal arteritis), vitreous haemorrhage, retinal detachment, and retinal migraine.
Ischaemic/vascular issues, also known as ‘amaurosis fugax’, have a wide range of potential causes, including large artery disease, small artery occlusive disease, venous disease, and hypoperfusion. Altitudinal field defects are often seen, and ischaemic optic neuropathy can occur due to occlusion of the short posterior ciliary arteries. Central retinal vein occlusion is more common than arterial occlusion and can be caused by glaucoma, polycythaemia, or hypertension. Central retinal artery occlusion is typically caused by thromboembolism or arteritis and may present with an afferent pupillary defect and a ‘cherry red’ spot on a pale retina.
Vitreous haemorrhage can be caused by diabetes, bleeding disorders, or anticoagulants and may present with sudden visual loss and dark spots. Retinal detachment may be preceded by flashes of light or floaters, which are also common in posterior vitreous detachment. Differentiating between posterior vitreous detachment, retinal detachment, and vitreous haemorrhage can be challenging, but each has distinct features such as photopsia and floaters for posterior vitreous detachment, a dense shadow that progresses towards central vision for retinal detachment, and large bleeds causing sudden visual loss for vitreous haemorrhage.
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This question is part of the following fields:
- Ophthalmology
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Question 9
Incorrect
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A 28-year-old woman presents to the Emergency Department with a 4-day history of an increasingly painful and swollen right eye. She complains of blurring of vision and pain, especially with eye movements, which were quite restricted. She has a past medical history of asthma and is allergic penicillin. On examination, the visual acuity is 6/24 in the right, 6/6 in the left. The periorbital area of the right eye is very swollen and erythematous. The eye itself is red and proptosed. The conjunctiva is chemosed. Eye movements in the right eye are quite restricted in all directions. There is relative afferent pupillary defect on the right. Fundoscopy shows a swollen optic disc in the right eye. Computed tomography (CT) scan shows diffuse orbital infiltrate and proptosis. Vital observations are as follows: Blood pressure 130/80 mmHg Heart rate 80 bpm Respiratory rate 20 per minute Oxygen saturation 97% on air Temperature 38.2 °C What is first-line management for this patient?
Your Answer: Cefuroxime intravenously (IV)
Correct Answer: Clindamycin and ciprofloxacin IV
Explanation:Orbital Cellulitis in Penicillin-Allergic Patients
When treating orbital cellulitis in a patient with a penicillin allergy, it is important to choose the right antibiotics. Cefuroxime IV alone is not enough and should be combined with metronidazole. Co-amoxiclav IV is not appropriate for penicillin-allergic patients. Tazocin® IV should also be avoided. The best option is a combination of clindamycin and ciprofloxacin IV. It is important to note that drainage of the orbit is not necessary unless there are signs of an abscess. By choosing the right treatment, we can effectively manage orbital cellulitis in penicillin-allergic patients.
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This question is part of the following fields:
- Ophthalmology
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Question 10
Incorrect
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A 52-year-old man reports a sudden painless loss of vision which occurred yesterday evening. He describes this as a veil dropping over his left eye. The symptoms have since resolved and his vision is currently normal.
What is the most probable diagnosis?Your Answer: Age-related macular degeneration
Correct Answer: Amaurosis fugax
Explanation:Amaurosis fugax, or transient vision loss, is a common complaint that typically lasts from seconds to hours and may have an identifiable cause. It often presents as a grey curtain moving from the periphery towards the center of vision. Ischemic causes, such as giant cell arteritis, cerebrovascular ischemia, and retinal arteriolar emboli, are more common in patients over 45 years old. A monocular visual disturbance, as seen in this patient, is more likely to be due to a circulatory disturbance of the anterior circulation, such as the carotid artery.
Retinal detachment is a time-critical eye emergency that presents with floaters, flashing lights, field loss, and a fall in visual acuity. Patients with high myopia are at high risk. Over time, a shadow may appear in the peripheral visual field, which, if ignored, may spread to involve the entire visual field in a matter of days.
Age-related macular degeneration (AMD) is the most common cause of irreversible vision loss in the developed world and usually manifests after age 50. The disease is often bilateral and may be asymmetrical. Peripheral visual acuity is preserved in all forms of dry AMD, but the advanced, non-exudative form is associated with severe central visual-field loss.
Central retinal artery occlusion results in inner layer oedema and pyknosis of the ganglion cell nuclei, leading to ischaemic necrosis and opacification of the retina. The most common presenting complaint is an acute, persistent, painless loss of vision. A history of amaurosis fugax may be present.
Central retinal vein occlusion presents with variable visual loss, retinal haemorrhages, dilated tortuous retinal veins, cotton-wool spots, macular oedema, and optic disc oedema. Visual loss can be sudden or gradual, over a period of days to weeks, and ranges from mild to severe. Photophobia, pain, and eye redness may also be present.
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This question is part of the following fields:
- Ophthalmology
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Question 11
Incorrect
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A 76-year-old man comes to his General Practitioner with one-sided visual loss. During the examination, a relative afferent pupillary defect is observed. Fundoscopy reveals a 'cherry-red spot' with a red centre of the macula and a pale surrounding of the retina.
What is the most suitable next step in managing this patient, considering the probable diagnosis?Your Answer: Start patient on topical antibiotics and anti-inflammatories
Correct Answer: Send patient to the Eye Hospital for immediate review by an Ophthalmologist
Explanation:Central Retinal-Artery Occlusion: An Ocular Emergency
Central retinal-artery occlusion (CRAO) is a serious condition that requires immediate attention from an ophthalmologist. It is diagnosed through a dilated eye examination that reveals a cherry-red spot in the center of the macula, surrounded by pale retina due to lack of blood flow. Other signs include segmentation of the blood column in the arteries and cattle-trucking.
CRAO is an ocular emergency because the retinal damage becomes irreversible with time, and urgent management is necessary to protect the other eye and the cardiovascular and cerebrovascular systems. The primary goal of management is to re-perfuse ischaemic tissue as quickly as possible and to institute secondary prevention early.
If giant-cell arteritis is suspected, immediate treatment is necessary, including intravenous steroids followed by oral steroids.
Referral under the 2-week-wait rule is necessary when there is a suspicion of cancer, but no signs of a tumor from history or fundoscopy findings.
It is crucial to refer the patient for urgent brain imaging and immediate review by an eye specialist. Starting the patient on topical antibiotics and anti-inflammatories would be inappropriate since there are no signs of an infection process.
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This question is part of the following fields:
- Ophthalmology
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Question 12
Correct
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A 57-year-old man presents to the Emergency Department with a one-day history of blurring of vision and headache. He tells you there is no pain on touching the scalp, or when eating and chewing food.
He has a past medical history of hypertension and type II diabetes mellitus, which is well controlled with metformin.
He tells you that his uncle died of brain cancer and he is afraid that he may have the same condition.
On examination, his visual acuity is 6/18 in both eyes. On dilated fundoscopy, you see some arterioles narrower than others. There are also venules being compressed by arterioles. There is optic disc swelling in both eyes with some exudates lining up like a star at the macula. There is also some dot-and-blot and flame-shaped haemorrhages.
His pulse is 80 beats per minute, while his blood pressure (BP) is 221/119 mmHg. His temperature is 37 °C, while his respiratory rate is 14 breaths per minute. His oxygen saturations are 98% on room air.
What is the most likely diagnosis?Your Answer: Hypertensive retinopathy
Explanation:Differentiating Hypertensive Retinopathy from Other Eye Conditions: A Case Study
The patient in question presented with a highly raised blood pressure and complained of headache and blurring of vision. Fundoscopy revealed bilateral optic disc swelling, which is a typical feature of hypertensive retinopathy. However, other conditions such as giant-cell arteritis, age-related macular degeneration, intracranial space-occupying lesion, and proliferative diabetic retinopathy were also considered.
Giant-cell arteritis was ruled out due to the absence of scalp tenderness and jaw claudication. Age-related macular degeneration was also unlikely as there were no drusen or choroidal neovascularisation present. While an intracranial space-occupying lesion was a possibility, the lack of accompanying symptoms such as early-morning vomiting and weight loss made it less likely. Proliferative diabetic retinopathy was also ruled out as there were no new vessels at the disc or elsewhere.
In conclusion, the patient’s symptoms and fundoscopy findings strongly suggest a diagnosis of hypertensive retinopathy. It is important to differentiate this condition from other eye conditions to ensure appropriate treatment and management.
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This question is part of the following fields:
- Ophthalmology
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Question 13
Incorrect
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A 25-year-old woman comes in with recurring headaches. During the cranial nerve examination, it is observed that her right pupil is 3 mm while the left pupil is 5 mm. The right pupil reacts to light, but the left pupil is slow to respond. The peripheral neurological examination is normal except for challenging to elicit knee and ankle reflexes. What is the probable diagnosis?
Your Answer: Migraine
Correct Answer: Holmes-Adie syndrome
Explanation:Understanding Holmes-Adie Pupil
Holmes-Adie pupil is a condition that is more commonly observed in women and is considered a benign condition. It is one of the possible causes of a dilated pupil. In about 80% of cases, it affects only one eye. The main characteristic of this condition is a dilated pupil that remains small for an unusually long time after it has constricted. The pupil also reacts slowly to accommodation but poorly or not at all to light.
Holmes-Adie syndrome is a condition that is associated with Holmes-Adie pupil. It is characterized by the absence of ankle and knee reflexes. This condition is not harmful and does not require any treatment.
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This question is part of the following fields:
- Ophthalmology
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Question 14
Incorrect
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A 35-year-old female patient presents to the eye hospital emergency department with a 1-week history of blurred vision and right eye pain worse on movement. The patient also reports a missing area of the visual field in the right eye. On examination, there is decreased visual acuity and impaired colour vision in the right eye and a right relative afferent pupillary defect. Fundoscopy reveals mildly swollen right optic disc. Intraocular pressure is 18 mmHg in the right eye. Her past medical history includes type 1 diabetes mellitus and hypertension. What is the most likely diagnosis for this 35-year-old female patient with blurred vision and right eye pain?
Your Answer: Stroke
Correct Answer: Optic neuritis
Explanation:Optic neuritis is the likely cause of this patient’s symptoms, which may be idiopathic or secondary to multiple sclerosis. One of the common symptoms of optic neuritis is a reduction in colour vision, along with pain around the eye during movement. Visual field defects, particularly central scotoma, may also occur. If only one eye is affected, there may be a relative afferent pupillary defect. While the patient has some risk factors for stroke, stroke would not cause eye pain or affect colour vision. Anterior ischaemic optic neuropathy typically causes painless visual loss and is more common in individuals over 50 years of age. The patient’s intraocular pressure is within the normal range, ruling out acute angle closure glaucoma. Additionally, the patient does not have papilloedema, as only one optic disc is swollen.
Optic neuritis is a condition that can be caused by multiple sclerosis, diabetes, or syphilis. It is characterized by a decrease in visual acuity in one eye over a period of hours or days, as well as poor color discrimination and pain that worsens with eye movement. Other symptoms include a relative afferent pupillary defect and a central scotoma. The condition can be diagnosed through an MRI of the brain and orbits with gadolinium contrast. Treatment typically involves high-dose steroids, and recovery usually takes 4-6 weeks. If an MRI shows more than three white-matter lesions, the risk of developing multiple sclerosis within five years is approximately 50%.
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This question is part of the following fields:
- Ophthalmology
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Question 15
Incorrect
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A 30-year-old woman with type 1 diabetes mellitus arrives at the emergency department complaining of blurry vision in her left eye. She reports her vision in that eye as 'hazy and faded' which started a few hours ago. She also experiences pain that worsens with eye movement. There are no visible signs of trauma or infection on her eyes, and her recent HbA1c and capillary blood glucose levels are normal. What clinical manifestation is linked to the suspected diagnosis?
Your Answer: Inferolateral deviation of the affected eye
Correct Answer: Relative afferent pupillary defect (RAPD)
Explanation:Optic neuritis is a condition that can be caused by multiple sclerosis, diabetes, or syphilis. It is characterized by a decrease in visual acuity in one eye over a period of hours or days, as well as poor color discrimination and pain that worsens with eye movement. Other symptoms include a relative afferent pupillary defect and a central scotoma. The condition can be diagnosed through an MRI of the brain and orbits with gadolinium contrast. Treatment typically involves high-dose steroids, and recovery usually takes 4-6 weeks. If an MRI shows more than three white-matter lesions, the risk of developing multiple sclerosis within five years is approximately 50%.
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This question is part of the following fields:
- Ophthalmology
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Question 16
Correct
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An 80-year-old female visits her GP 4 days after undergoing cataract surgery in her left eye. She reports that the procedure went smoothly and she was discharged on the same day. However, she is currently experiencing pain in the operated eye and notes that it appears redder than before. Her right eye has a corrected visual acuity of 6/6, while her left eye has a corrected visual acuity of 6/18. There are no abnormalities in her pupillary reactions or eye movements. What is the most appropriate course of action at this point?
Your Answer: Urgent ophthalmological referral
Explanation:If a patient experiences redness in the eye, pain, and a decrease in vision after intraocular surgery, it is important to seek urgent ophthalmic evaluation as these symptoms may indicate endophthalmitis, a serious infection within the eye. Treatment options include antibiotics administered systemically or directly into the eye.
Understanding the Causes of Red Eye
Red eye is a common condition that can be caused by various factors. It is important to identify the underlying cause of red eye to determine the appropriate treatment. In some cases, urgent referral to an ophthalmologist may be necessary. Here are some of the key distinguishing features of the different causes of red eye:
Acute angle closure glaucoma is characterized by severe pain, decreased visual acuity, and haloes. The pupil may also be semi-dilated and the cornea hazy.
Anterior uveitis presents with acute onset, pain, blurred vision, and photophobia. The pupil is small and fixed, and there may be ciliary flush.
Scleritis is characterized by severe pain and tenderness, which may worsen with movement. It may also be associated with underlying autoimmune diseases such as rheumatoid arthritis.
Conjunctivitis may be bacterial or viral, with purulent or clear discharge, respectively.
Subconjunctival haemorrhage may be caused by trauma or coughing bouts.
Endophthalmitis typically occurs after intraocular surgery and presents with red eye, pain, and visual loss.
By understanding the different causes of red eye and their distinguishing features, healthcare professionals can provide appropriate management and referral when necessary.
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This question is part of the following fields:
- Ophthalmology
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Question 17
Incorrect
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A 67-year-old man presents to his Optician for a routine eye check-up. His intraocular pressure (IOP) is 30 mmHg. On examination, fundoscopy reveals cupping of the optic disc. He is referred for assessment with an Ophthalmologist; he is classed as being at high lifetime risk of visual impairment.
What is the most appropriate first-line treatment for this patient?Your Answer: Brimonidine
Correct Answer: Latanoprost
Explanation:Overview of Glaucoma Medications
Glaucoma is a condition that can lead to vision loss and is often associated with high intraocular pressure (IOP). The first-line treatment recommended by the National Institute for Health and Care Excellence is a prostaglandin analogue such as latanoprost. Patients must meet certain criteria to receive this treatment. Brinzolamide and brimonidine are third-line treatments that may be used if a patient cannot tolerate a prostaglandin analogue or beta-blocker. Sodium cromoglicate eye drops are used for allergic conjunctivitis and do not help manage ocular hypertension. Timolol is a beta-blocker that may be used if a patient cannot tolerate a prostaglandin analogue, but it is not a first-line treatment.
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This question is part of the following fields:
- Ophthalmology
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Question 18
Correct
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A 60-year-old man presents with a sudden onset of vision loss in his left eye upon waking up this morning. He reports no pain in his eye. His medical history includes diabetes mellitus and hypertension. Upon fundoscopic examination, the right eye appears normal, but the left eye shows multiple retinal haemorrhages. What is the most probable diagnosis?
Your Answer: Central retinal vein occlusion
Explanation:The sudden painless loss of vision and severe retinal haemorrhages observed on fundoscopy in this patient are indicative of central retinal vein occlusion. Amaurosis fugax, which is caused by atheroembolism from the carotid arteries, results in temporary vision loss that resolves within a few minutes. In contrast, this patient’s vision loss is persistent. While central retinal artery occlusion also causes acute painless vision loss, it is characterized by a loss of relative afferent pupillary defect, a cherry-red macula, and a white/pale retina on fundoscopy. Hypertensive retinopathy may cause flame-shaped haemorrhages and cotton wool spots on the retina, but it does not result in sudden vision loss.
Understanding Central Retinal Vein Occlusion
Central retinal vein occlusion (CRVO) is a possible cause of sudden, painless loss of vision. It is more common in older individuals and those with hypertension, cardiovascular disease, glaucoma, or polycythemia. The condition is characterized by a sudden reduction or loss of visual acuity, usually affecting only one eye. Fundoscopy reveals widespread hyperemia and severe retinal hemorrhages, which are often described as a stormy sunset.
Branch retinal vein occlusion (BRVO) is a similar condition that affects a smaller area of the fundus. It occurs when a vein in the distal retinal venous system is blocked, usually at arteriovenous crossings.
Most patients with CRVO are managed conservatively, but treatment may be necessary in some cases. For instance, intravitreal anti-vascular endothelial growth factor (VEGF) agents may be used to manage macular edema, while laser photocoagulation may be necessary to treat retinal neovascularization.
Overall, understanding the risk factors, features, and management options for CRVO is essential for prompt diagnosis and appropriate treatment. Proper management can help prevent further vision loss and improve the patient’s quality of life.
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This question is part of the following fields:
- Ophthalmology
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Question 19
Incorrect
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A 28-year-old individual who wears contact lenses was referred to a casualty ophthalmology clinic by their GP due to complaints about their left eye. The patient reports experiencing redness, pain, and a gritty sensation in the affected eye, as well as increased sensitivity to light. There is no discharge present. What is the probable diagnosis?
Your Answer: Acute angle-closure glaucoma
Correct Answer: Keratitis
Explanation:Keratitis is characterized by symptoms such as a red eye, sensitivity to light, and a feeling of grittiness in the eye.
Understanding Keratitis: Inflammation of the Cornea
Keratitis is a condition that refers to the inflammation of the cornea. While conjunctivitis is a common eye infection that is not usually serious, microbial keratitis can be sight-threatening and requires urgent evaluation and treatment. The causes of keratitis can vary, with bacterial infections typically caused by Staphylococcus aureus and Pseudomonas aeruginosa commonly seen in contact lens wearers. Fungal and amoebic infections can also cause keratitis, with acanthamoebic keratitis accounting for around 5% of cases. Parasitic infections such as onchocercal keratitis can also cause inflammation of the cornea.
Other factors that can cause keratitis include viral infections such as herpes simplex keratitis, environmental factors like photokeratitis (e.g. welder’s arc eye), and exposure keratitis. Clinical features of keratitis include a red eye with pain and erythema, photophobia, a foreign body sensation, and the presence of hypopyon. Referral is necessary for contact lens wearers who present with a painful red eye, as an accurate diagnosis can only be made with a slit-lamp examination.
Management of keratitis involves stopping the use of contact lenses until symptoms have fully resolved, as well as the use of topical antibiotics such as quinolones. Cycloplegic agents like cyclopentolate can also be used for pain relief. Complications of keratitis can include corneal scarring, perforation, endophthalmitis, and visual loss. Understanding the causes and symptoms of keratitis is important for prompt diagnosis and treatment to prevent serious complications.
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This question is part of the following fields:
- Ophthalmology
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Question 20
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A 42-year-old woman arrived at the Emergency Department complaining of a painful and red eye with watering and mild sensitivity to light. The diagnosis was uncertain, but it was suspected to be either episcleritis or scleritis. The on-call ophthalmologist was contacted, and they requested that a specific eye drop be administered to differentiate between the two conditions.
Which of the following eye drops is capable of distinguishing between episcleritis and scleritis?Your Answer:
Correct Answer: Phenylephrine eye drops
Explanation:Distinguishing between episcleritis and scleritis can be achieved using eye drops. By administering the drops, it is possible to observe whether the redness in the eye blanches or not. If it does, then the condition is episcleritis, but if it doesn’t, then it is scleritis. This skill is particularly valuable for those working in an Emergency Medicine rotation. None of the other options are useful for distinguishing between these two conditions.
Understanding Episcleritis
Episcleritis is a condition that involves the sudden onset of inflammation in the episclera of one or both eyes. While the majority of cases are idiopathic, there are some associated conditions such as inflammatory bowel disease and rheumatoid arthritis. Symptoms of episcleritis include a red eye, mild pain or irritation, watering, and mild photophobia. However, unlike scleritis, episcleritis is typically not painful.
One way to differentiate between the two conditions is by applying gentle pressure on the sclera. If the injected vessels are mobile, it is likely episcleritis. In contrast, scleritis involves deeper vessels that do not move. Phenylephrine drops may also be used to distinguish between the two conditions. If the eye redness improves after phenylephrine, a diagnosis of episcleritis can be made.
Approximately 50% of cases of episcleritis are bilateral. Treatment for episcleritis is typically conservative, with artificial tears sometimes being used. Understanding the symptoms and differences between episcleritis and scleritis can help individuals seek appropriate treatment and management for their eye condition.
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This question is part of the following fields:
- Ophthalmology
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