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  • Question 1 - A 65-year-old woman comes to the Emergency Department with multiple facial lesions that...

    Correct

    • A 65-year-old woman comes to the Emergency Department with multiple facial lesions that appeared suddenly 24 hours ago and are painful to the touch. She experienced burning pain on her forehead a week ago. Upon examination, she has tenderness on the left side of her forehead and several 4-6mm vesicles on the left side. Hutchinson's sign is positive. What aspect of her condition necessitates an immediate evaluation by an ophthalmologist?

      Your Answer: Lesions on the tip of the nose

      Explanation:

      Hutchinson’s sign is a strong indicator of ocular involvement in shingles, characterized by vesicles extending to the tip of the nose. This patient is presenting with herpes zoster ophthalmicus, which is caused by the reactivation of herpes zoster affecting the ophthalmic branch of the trigeminal nerve. Urgent ophthalmological review is necessary due to the presence of lesions on the tip of the nose. Management involves oral antivirals and, if there is secondary inflammation of the eye, topical steroids may be given. Lesions above the eyebrow can also occur if the ophthalmic branch of the trigeminal nerve is affected, but this has no association with ocular involvement. Pain over the affected area is a common symptom preceding the eruption of the vesicles, but it is not indicative of ocular involvement. Lesions on the top eyelid can also occur if the ophthalmic branch of the trigeminal nerve is affected.

      Herpes Zoster Ophthalmicus: Symptoms, Treatment, and Complications

      Herpes zoster ophthalmicus (HZO) is a condition that occurs when the varicella-zoster virus reactivates in the area supplied by the ophthalmic division of the trigeminal nerve. It is responsible for approximately 10% of shingles cases. The main symptom of HZO is a vesicular rash around the eye, which may or may not involve the eye itself. Hutchinson’s sign, a rash on the tip or side of the nose, is a strong indicator of nasociliary involvement and increases the risk of ocular involvement.

      Treatment for HZO involves oral antiviral medication for 7-10 days, ideally started within 72 hours of symptom onset. Intravenous antivirals may be necessary for severe infections or immunocompromised patients. Topical antiviral treatment is not recommended for HZO, but topical corticosteroids may be used to treat any secondary inflammation of the eye. Ocular involvement requires urgent ophthalmology review to prevent complications such as conjunctivitis, keratitis, episcleritis, anterior uveitis, ptosis, and post-herpetic neuralgia.

      In summary, HZO is a condition caused by the reactivation of the varicella-zoster virus in the ophthalmic division of the trigeminal nerve. It presents with a vesicular rash around the eye and may involve the eye itself. Treatment involves oral antiviral medication and urgent ophthalmology review is necessary for ocular involvement. Complications of HZO include various eye conditions, ptosis, and post-herpetic neuralgia.

    • This question is part of the following fields:

      • Ophthalmology
      14.2
      Seconds
  • Question 2 - A 65-year-old man presents with sudden vision loss in his right eye and...

    Correct

    • A 65-year-old man presents with sudden vision loss in his right eye and dark floaters over the past few weeks. Fundoscopy is challenging due to patches of redness obscuring the fundus. He has a 20-year history of type 2 diabetes mellitus, hypercholesterolaemia, and proliferative diabetic retinopathy, and takes metformin, pioglitazone, atorvastatin, and dapagliflozin. He is concerned about having a stroke, as his father had one in the past. What is the most probable diagnosis?

      Your Answer: Vitreous haemorrhage

      Explanation:

      Retinal detachment and vitreous haemorrhage are the two main causes of sight loss in proliferative diabetic retinopathy.

      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 nonproliferative 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 nonproliferative retinopathy, and panretinal laser photocoagulation and intravitreal VEGF inhibitors for proliferative retinopathy. Vitreoretinal surgery may be necessary in cases of severe or vitreous hemorrhage.

    • This question is part of the following fields:

      • Ophthalmology
      22.8
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  • Question 3 - A 52-year-old man presents to the Emergency Department with a 2-day history of...

    Correct

    • A 52-year-old man presents to the Emergency Department with a 2-day history of an increasingly painful and swollen right eye. He complains of blurring of vision and pain, especially with eye movements, which are quite restricted.
      On examination, the visual acuity is 6/18 in the right eye and 6/6 in the left. The periorbital area of the right eye is very swollen and erythematosus. The eye itself is red and proptosed. The conjunctiva was chemosed. Eye movements in the right eye are quite restricted in all directions. There is relative afferent pupillary defect on the right.
      Vital observations were as follows:
      Blood pressure 120/70 mmHg
      Heart rate 75 bpm
      Respiratory rate 18 per minute
      Oxygen saturation 98% on air
      Temperature 37.9 °C
      What is the most important step in your management plan to determine the cause of this patient’s eye problem?

      Your Answer: Computed tomography (CT) scan of the orbit, sinuses, and brain

      Explanation:

      Diagnostic Steps for Orbital Cellulitis: CT Scan of the Orbit, Sinuses, and Brain

      Orbital cellulitis is commonly caused by ethmoidal sinusitis and requires prompt diagnosis and management. While blood culture and normal blood tests can be helpful, they are not the most important steps in determining the cause of the infection. Instead, a CT scan of the orbit, sinuses, and brain is the most effective diagnostic tool. This scan can reveal diffuse orbital infiltrate, proptosis, sinus opacity, or even orbital abscesses. Once diagnosed, management often involves ENT assessment for sinus drainage and/or subperiosteal abscess. Intravenous cefuroxime and metronidazole or flucloxacillin are necessary to control the infection, but do not aid in determining the cause.

    • This question is part of the following fields:

      • Ophthalmology
      33.1
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  • Question 4 - A 75-year-old man with a history of hypertension and type II diabetes complains...

    Correct

    • A 75-year-old man with a history of hypertension and type II diabetes complains of sudden, painless vision loss in his right eye. Upon examination, his left eye has 6/6 visual acuity, but he can only perceive finger movement in his right eye. Fundoscopy reveals significant retinal hemorrhages originating from the disc. What is the probable cause of his vision loss?

      Your Answer: Central retinal vein occlusion

      Explanation:

      The correct answer is central retinal vein occlusion, which presents with sudden painless loss of vision and severe retinal haemorrhages on fundoscopy. This condition is associated with risk factors such as increasing age, hypertension, high cholesterol, diabetes, smoking, glaucoma, and polycythaemia. The blockage of the vein causes excess fluid and blood to leak into the retina, resulting in the appearance of severe haemorrhages that resemble a cheese and tomato pizza.

      Central retinal artery occlusion shares similar risk factors with retinal vein occlusion, but its appearance on fundoscopy is different. In central retinal artery occlusion, the retina appears pale, and the macula appears red (cherry-red spot).

      Non-arteritic ischaemic optic neuropathy also causes sudden painless loss of vision, but it is characterized by a hyperaemic, oedematous optic disc with a small cup to disc ratio.

      Retinal detachment is another condition that causes painless loss of vision, but patients usually report preceding flashes or floaters. Risk factors for retinal detachment include increasing age, eye injury, or extreme myopia.

      Finally, a vitreous haemorrhage can also cause painless loss of vision, but fundoscopy is not useful in this case as the vitreous is filled with blood, obscuring the view of the retina.

      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.

    • This question is part of the following fields:

      • Ophthalmology
      49.4
      Seconds
  • Question 5 - A 53-year-old male presents to the acute medical admissions unit with a one-day...

    Correct

    • A 53-year-old male presents to the acute medical admissions unit with a one-day history of left-sided headache, retro-orbital pain, and dull facial pain on the left side. He has a medical history of hypertension and migraine and is currently taking ramipril 2.5mg. Upon examination, he displays partial ptosis and enophthalmos of the left eye, with anisocoria and miosis of the same eye. His visual acuity is 6/6 in both eyes, and the rest of his neurological exam is unremarkable, with normal sweating bilaterally. What is the most likely cause of these symptoms?

      Your Answer: Carotid artery dissection

      Explanation:

      Horner’s syndrome is a condition that typically presents with ptosis, miosis, and anhidrosis on the same side of the body. The degree of anhidrosis can help determine the location of the lesion along the sympathetic pathway. In cases where anhidrosis is absent, it may indicate a postganglionic lesion, such as in the case of carotid artery dissection. This condition can cause a partial Horner’s syndrome with ptosis and miosis, but without anhidrosis. While this is a rare presentation of carotid artery dissection, it is important to recognize to prevent further neurological complications, such as an ischemic stroke. Preganglionic lesions, such as a cervical rib or Pancoast tumor, can cause anhidrosis of just the face, while central lesions, such as a stroke or syringomyelia, can cause anhidrosis of the head, arm, and trunk in addition to ptosis and miosis.

      Horner’s syndrome is a medical condition that is characterized by a set of symptoms including a small pupil (miosis), drooping of the upper eyelid (ptosis), sunken eye (enophthalmos), and loss of sweating on one side of the face (anhidrosis). The presence of heterochromia, or a difference in iris color, is often seen in cases of congenital Horner’s syndrome. Anhidrosis is also a distinguishing feature that can help differentiate between central, Preganglionic, and postganglionic lesions. Pharmacologic tests, such as the use of apraclonidine drops, can be helpful in confirming the diagnosis of Horner’s syndrome and localizing the lesion.

      Central lesions, Preganglionic lesions, and postganglionic lesions can all cause Horner’s syndrome, with each type of lesion presenting with different symptoms. Central lesions can result in anhidrosis of the face, arm, and trunk, while Preganglionic lesions can cause anhidrosis of the face only. postganglionic lesions, on the other hand, do not typically result in anhidrosis.

      There are many potential causes of Horner’s syndrome, including stroke, syringomyelia, multiple sclerosis, tumors, encephalitis, thyroidectomy, trauma, cervical rib, carotid artery dissection, carotid aneurysm, cavernous sinus thrombosis, and cluster headache. It is important to identify the underlying cause of Horner’s syndrome in order to determine the appropriate treatment plan.

    • This question is part of the following fields:

      • Ophthalmology
      28.4
      Seconds
  • Question 6 - A 75-year-old male with type 2 diabetes mellitus presents for his annual diabetic...

    Incorrect

    • A 75-year-old male with type 2 diabetes mellitus presents for his annual diabetic eye screening. He was previously diagnosed with mild nonproliferative diabetic retinopathy (NPDR) when micro-aneurysms were observed during retinal examination. However, during this visit, cotton wool spots are also detected in both eyes. What is the underlying pathophysiology of this new discovery?

      Your Answer: Thinning of the neuroretinal rim

      Correct Answer: Pre-capillary arteriolar occlusion

      Explanation:

      Cotton wool spots in diabetic retinopathy are caused by pre-capillary arteriolar occlusion, leading to retinal infarction. This is the reason why the patient is presenting with new cotton wool spots, indicating the progression of their NPDR. Central retinal vein occlusion, lipid deposition in the retina, and thickening of the walls of retinal arterioles are not the underlying causes of cotton wool spots in diabetic retinopathy.

      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 nonproliferative 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 nonproliferative retinopathy, and panretinal laser photocoagulation and intravitreal VEGF inhibitors for proliferative retinopathy. Vitreoretinal surgery may be necessary in cases of severe or vitreous hemorrhage.

    • This question is part of the following fields:

      • Ophthalmology
      31.6
      Seconds
  • Question 7 - A 48-year-old woman comes to the clinic with a gradual onset of left-sided...

    Incorrect

    • A 48-year-old woman comes to the clinic with a gradual onset of left-sided visual issues. She reports no discomfort or itching in the affected area. During the examination, left-sided ptosis and miosis are observed. When the lights are dimmed, the right pupil dilates, but the left pupil does not. She has a history of smoking for 8 years. What is the probable diagnosis?

      Your Answer: Chalazion

      Correct Answer: Squamous cell carcinoma of the lung

      Explanation:

      Horner’s syndrome is a medical condition that is characterized by a set of symptoms including a small pupil (miosis), drooping of the upper eyelid (ptosis), sunken eye (enophthalmos), and loss of sweating on one side of the face (anhidrosis). The presence of heterochromia, or a difference in iris color, is often seen in cases of congenital Horner’s syndrome. Anhidrosis is also a distinguishing feature that can help differentiate between central, Preganglionic, and postganglionic lesions. Pharmacologic tests, such as the use of apraclonidine drops, can be helpful in confirming the diagnosis of Horner’s syndrome and localizing the lesion.

      Central lesions, Preganglionic lesions, and postganglionic lesions can all cause Horner’s syndrome, with each type of lesion presenting with different symptoms. Central lesions can result in anhidrosis of the face, arm, and trunk, while Preganglionic lesions can cause anhidrosis of the face only. postganglionic lesions, on the other hand, do not typically result in anhidrosis.

      There are many potential causes of Horner’s syndrome, including stroke, syringomyelia, multiple sclerosis, tumors, encephalitis, thyroidectomy, trauma, cervical rib, carotid artery dissection, carotid aneurysm, cavernous sinus thrombosis, and cluster headache. It is important to identify the underlying cause of Horner’s syndrome in order to determine the appropriate treatment plan.

    • This question is part of the following fields:

      • Ophthalmology
      12.1
      Seconds
  • Question 8 - A 7-year-old girl presents to the emergency department with complaints of swelling around...

    Incorrect

    • A 7-year-old girl presents to the emergency department with complaints of swelling around her left eye. She has been experiencing this for the past 2 days and has also been feeling feverish and lethargic. The patient denies any history of trauma or vision loss.
      Upon examination, the patient has a temperature of 38.2ºC and is found to have left-sided proptosis. All eye movements are painful and reduced in the affected eye. Fundoscopy is normal, and the patient has a visual acuity of 6/6 in the right eye and 6/12 in the left eye.
      What is the most likely diagnosis?

      Your Answer: Iritis

      Correct Answer: Orbital cellulitis

      Explanation:

      Orbital cellulitis is characterized by sudden swelling of one eye, accompanied by proptosis and limited eye movement. Pain and visual changes may also occur depending on the severity of the condition. Diagnosis is usually based on clinical examination, but in severe or resistant cases, microbiology and imaging techniques such as CT may be used. Conjunctivitis and iritis can cause red eyes, but they do not typically result in orbital swelling. Retinoblastoma is a type of cancer that primarily affects children under the age of 5 and is usually detected during routine fundoscopy or due to a decline in vision.

      Understanding Orbital Cellulitis: Causes, Symptoms, and Management

      Orbital cellulitis is a serious infection that affects the fat and muscles behind the orbital septum within the orbit, but not the globe. It is commonly caused by upper respiratory tract infections that spread from the sinuses and can lead to a high mortality rate. On the other hand, periorbital cellulitis is a less severe infection that occurs in the superficial tissues anterior to the orbital septum. However, it can progress to orbital cellulitis if left untreated.

      Risk factors for orbital cellulitis include childhood, previous sinus infections, lack of Haemophilus influenzae type b (Hib) vaccination, recent eyelid infections or insect bites, and ear or facial infections. Symptoms of orbital cellulitis include redness and swelling around the eye, severe ocular pain, visual disturbance, proptosis, ophthalmoplegia, eyelid edema, and ptosis. In rare cases, meningeal involvement can cause drowsiness, nausea, and vomiting.

      To differentiate between orbital and preseptal cellulitis, doctors look for reduced visual acuity, proptosis, and ophthalmoplegia, which are not consistent with preseptal cellulitis. Full blood count and clinical examination involving complete ophthalmological assessment are necessary to determine the severity of the infection. CT with contrast can also help identify inflammation of the orbital tissues deep to the septum and sinusitis. Blood culture and microbiological swab are also necessary to determine the organism causing the infection.

      Management of orbital cellulitis requires hospital admission for IV antibiotics. It is a medical emergency that requires urgent senior review. Early diagnosis and treatment are crucial to prevent complications and reduce the risk of mortality.

    • This question is part of the following fields:

      • Ophthalmology
      42.7
      Seconds
  • Question 9 - A 65-year-old man visits his GP complaining of a gradual onset of dry,...

    Incorrect

    • A 65-year-old man visits his GP complaining of a gradual onset of dry, itchy right eye and associated blurring of his vision. The patient and his family have also observed that he has difficulty completely closing his eyelid. The patient has a history of hypertension and type 2 diabetes but has never been hospitalized or had any eye problems before.

      During the examination, the patient displays signs of miosis, partial ptosis, anhidrosis of the face, and enophthalmos.

      What is the probable cause of this patient's presentation?

      Your Answer: Cavernous sinus thrombosis

      Correct Answer: Pancoast tumour

      Explanation:

      Horner’s syndrome is a condition that occurs when there is a lesion in the sympathetic nerve trunk, resulting in symptoms such as miosis, partial ptosis, enophthalmos, and anhidrosis on the same side as the lesion. The location of the lesion can be determined by the presence and location of anhidrosis. If anhidrosis is present only in the face, it indicates a Preganglionic lesion, which can be caused by conditions such as Pancoast tumors, cervical rib, and thyroid issues. On the other hand, a postganglionic lesion, which can be caused by carotid artery dissection or cavernous sinus thrombosis, results in Horner’s syndrome without anhidrosis. Central lesions, such as those caused by stroke or syringomyelia, result in Horner’s syndrome with anhidrosis of the face, arm, and trunk on the affected side.

      Horner’s syndrome is a medical condition that is characterized by a set of symptoms including a small pupil (miosis), drooping of the upper eyelid (ptosis), sunken eye (enophthalmos), and loss of sweating on one side of the face (anhidrosis). The presence of heterochromia, or a difference in iris color, is often seen in cases of congenital Horner’s syndrome. Anhidrosis is also a distinguishing feature that can help differentiate between central, Preganglionic, and postganglionic lesions. Pharmacologic tests, such as the use of apraclonidine drops, can be helpful in confirming the diagnosis of Horner’s syndrome and localizing the lesion.

      Central lesions, Preganglionic lesions, and postganglionic lesions can all cause Horner’s syndrome, with each type of lesion presenting with different symptoms. Central lesions can result in anhidrosis of the face, arm, and trunk, while Preganglionic lesions can cause anhidrosis of the face only. postganglionic lesions, on the other hand, do not typically result in anhidrosis.

      There are many potential causes of Horner’s syndrome, including stroke, syringomyelia, multiple sclerosis, tumors, encephalitis, thyroidectomy, trauma, cervical rib, carotid artery dissection, carotid aneurysm, cavernous sinus thrombosis, and cluster headache. It is important to identify the underlying cause of Horner’s syndrome in order to determine the appropriate treatment plan.

    • This question is part of the following fields:

      • Ophthalmology
      15.3
      Seconds
  • Question 10 - A 29-year-old individual arrives at the emergency department complaining of sensitivity to light...

    Incorrect

    • A 29-year-old individual arrives at the emergency department complaining of sensitivity to light and a red right eye that began an hour ago. Upon examination, the right eye is painful, red, and has an irregularly-shaped pupil, while the left eye appears normal. The patient is referred to ophthalmology for further evaluation. What is the probable medical treatment that the patient received?

      Your Answer: Steroid and pilocarpine drops

      Correct Answer: Steroid and cycloplegic drops

      Explanation:

      The most common treatment for anterior uveitis involves using a combination of steroid and cycloplegic (mydriatic) drops. This is because the symptoms of photophobia and a small, irregularly-shaped pupil are indicative of anterior uveitis. Steroids are administered to reduce inflammation, while cycloplegics such as atropine or cyclopentolate are used to dilate the pupil and alleviate pain and sensitivity to light. Chloramphenicol is an antibiotic that is typically used to treat bacterial conjunctivitis without the need for steroids. Acetazolamide, on the other hand, is a carbonic anhydrase inhibitor that is used to manage acute angle-closure glaucoma. Pilocarpine, a muscarinic receptor agonist, is used to treat primary open-angle glaucoma and acute closed angle glaucoma.

      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.

    • This question is part of the following fields:

      • Ophthalmology
      32.3
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  • Question 11 - A 56-year-old man on your contact list reports experiencing two small floaters that...

    Incorrect

    • A 56-year-old man on your contact list reports experiencing two small floaters that have appeared in his left eye, partially obstructing his vision over the past 24 hours. He has been working on computer screens more frequently than usual over the past week and wears glasses for myopia. He denies any pain or injury to either eye and has not visited an optometrist in several years. What is the best course of action for managing this situation?

      Your Answer: Avoid computer screens and call back in 48 hours if no resolution

      Correct Answer: Arrange same-day ophthalmology assessment

      Explanation:

      If a patient presents with new-onset flashes or floaters, it is crucial to refer them urgently for assessment by an ophthalmologist within 24 hours. This is because the floaters could be a symptom of a retinal detachment, which requires immediate attention to prevent loss of sight. Therefore, the ophthalmology team may need to perform an urgent operation if a detachment is detected.

      In this case, the patient has new-onset floaters, and there is no history of a foreign body or pain in her eye. Therefore, irrigation and antibiotic cover are unlikely to be helpful. While it is important to see her optician to ensure her glasses are the correct prescription, an urgent ophthalmology review should be organized first.

      It is inappropriate to delay referral to ophthalmology by arranging a face-to-face assessment the following day. Additionally, the use of computer screens is an unlikely cause for floaters, and observing for further time does not adequately address potential sight-threatening causes.

      Retinal detachment is a condition where the tissue at the back of the eye separates from the underlying pigment epithelium. This can cause vision loss, but if detected and treated early, it can be reversible. Risk factors for retinal detachment include diabetes, myopia, age, previous cataract surgery, and eye trauma. Symptoms may include new onset floaters or flashes, sudden painless visual field loss, and reduced peripheral and central vision. If the macula is involved, visual outcomes can be much worse. Diagnosis is made through fundoscopy, which may show retinal folds or a lost red reflex. Urgent referral to an ophthalmologist is necessary for assessment and treatment.

    • This question is part of the following fields:

      • Ophthalmology
      23.8
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  • Question 12 - A 57-year-old man presented to the Emergency Department with a 1-day history of...

    Incorrect

    • A 57-year-old man presented to the Emergency Department with a 1-day history of blurring of vision and headache. He does not complain of any pain when touching the scalp or any pain when eating and chewing food.
      Past medical history includes hypertension and type 2 diabetes mellitus, which is well controlled with metformin.
      On further history taking, he tells you that he has a family history of brain cancer and he is afraid that this could be relevant to his symptoms.
      On examination, his visual acuity is 6/18 in both eyes. On dilated fundoscopy, you could see some arterioles narrower than others. You also see venules being compressed by arterioles. There are also some dot-and-blot and flame-shaped haemorrhages, as well as some cotton-wool spots.
      His vital observations are as follows:
      Heart rate 80 bpm
      Blood pressure 221/119 mmHg
      Oxygen saturation 98% on room air
      Respiratory rate 14 per minute
      Temperature 37 °C
      According to the Keith-Wagener-Barker classification of hypertensive retinopathy, what grade of hypertensive retinopathy is this?

      Your Answer: Grade 5

      Correct Answer: Grade 3

      Explanation:

      Stages of Diabetic Retinopathy

      Diabetic retinopathy is a condition that affects the eyes of people with diabetes. It is important to detect and treat it early to prevent vision loss. There are different stages of diabetic retinopathy, each with its own set of features.

      Grade 1 is characterized by arteriolar narrowing. Grade 2 includes features of grade 1 and arteriovenous nipping. Grade 3 includes features of grade 2 and microaneurysms, dot-and-blot haemorrhages, flame-shaped haemorrhages, cotton-wool spots, and hard exudates. Grade 4 includes features of grade 3 and optic disc swelling.

      It is important to have regular eye exams if you have diabetes to detect any signs of diabetic retinopathy early. With proper management and treatment, vision loss can be prevented or delayed.

    • This question is part of the following fields:

      • Ophthalmology
      9.3
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  • Question 13 - A 50-year-old woman arrives at the emergency department complaining of vision issues. She...

    Incorrect

    • A 50-year-old woman arrives at the emergency department complaining of vision issues. She reports seeing a red tint in her vision and dark spots in her right eye. The physician sends her to the eye casualty department where they suspect a vitreous haemorrhage.
      What factors could potentially increase the likelihood of developing this condition?

      Your Answer: Use of steroid eye drops

      Correct Answer: Use of warfarin

      Explanation:

      The use of blood thinning agents such as warfarin is a predisposing factor for vitreous haemorrhage, which is characterized by red-tinged vision and dark spots. Other risk factors include diabetes, trauma, coagulation disorders, and severe short sightedness.

      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 arthritis), 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 arthritis 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.

    • This question is part of the following fields:

      • Ophthalmology
      54.5
      Seconds
  • Question 14 - A 29-year-old woman presents to an ophthalmologist with complaints of vision problems. She...

    Incorrect

    • A 29-year-old woman presents to an ophthalmologist with complaints of vision problems. She reports experiencing blackouts in her peripheral vision and severe headaches. Upon examination, the ophthalmologist notes bitemporal hemianopia in her visual fields. Where is the likely site of the lesion in her optic pathway?

      Your Answer: Primary visual cortex

      Correct Answer: Optic chiasm

      Explanation:

      Understanding the Effects of Lesions in the Visual Pathway

      The visual pathway is a complex system that allows us to perceive and interpret visual information. However, lesions in different parts of this pathway can result in various visual field defects. Here is a breakdown of the effects of lesions in different parts of the visual pathway:

      Optic Chiasm: Lesions in the optic chiasm can cause bitemporal hemianopia or tunnel vision. This is due to damage to the fibers that receive visual stimuli from the temporal visual fields.

      Optic Nerve: Lesions in the optic nerve can result in monocular blindness of the ipsilateral eye. If only one eye has a visual field defect, then the lesion cannot be further back than the optic nerve.

      Optic Tract: Lesions in the optic tract can cause homonymous hemianopia of the contralateral visual field. This means that a lesion of the left optic tract causes loss of the right visual field in both eyes.

      Lateral Geniculate Nucleus: Any lesions after the optic chiasm will result in a homonymous hemianopia.

      Primary Visual Cortex: Lesions in the primary visual cortex can also result in homonymous hemianopia, but with cortical lesions, there is usually macular sparing because of the relatively large cortical representation of the macula. Less extensive lesions are associated with scotoma and quadrantic field loss.

      Understanding the effects of lesions in the visual pathway is crucial in diagnosing and treating visual field defects.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 15 - A 50-year-old welder comes to the Emergency Department with a metal splinter in...

    Incorrect

    • A 50-year-old welder comes to the Emergency Department with a metal splinter in his eye. What is the most effective course of action that can be provided in this setting?

      Your Answer: Topical antibiotic

      Correct Answer: Immediate ophthalmology referral

      Explanation:

      Immediate Referral and Management of Corneal Foreign Body

      If a patient presents with a suspected corneal foreign body, immediate referral to the emergency eye service is necessary. High-velocity injuries or injuries caused by sharp objects should be treated as penetrating injuries until proven otherwise. Once referred, the foreign body can be removed under magnification with a slit lamp and a blunted needle, using a topical anaesthetic to the cornea. Topical antibiotics are given, and the eye is covered with an eye pad. Chemical injuries require eye wash, but this will not remove a corneal foreign body. Retinoscopy is not relevant to this scenario. While topical antibiotics may play a role in management, the most important first step is to remove the foreign body to prevent corneal ulceration, secondary infection, and inflammation.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 16 - A 60-year-old woman visits her GP complaining of painless, gradual vision loss in...

    Incorrect

    • A 60-year-old woman visits her GP complaining of painless, gradual vision loss in both eyes. During the examination, the GP observes bitemporal hemianopia. Where is the lesion located that is causing this visual field defect?

      Your Answer: Left occipital visual cortex

      Correct Answer: Optic chiasm

      Explanation:

      Visual Field Defects and their Corresponding Lesions

      Visual field defects can provide important clues to the location of lesions in the visual pathway. A bitemporal hemianopia, for example, is typically caused by a lesion at the optic chiasm, such as a pituitary tumor or a craniopharyngioma. A left occipital visual cortex lesion, on the other hand, will cause a right homonymous hemianopia with macular sparing. Similarly, a left temporal lobe optic radiation lesion will result in a right superior quadrantanopia, while a right optic tract lesion will cause a left homonymous hemianopia. Finally, a right parietal lobe optic radiation lesion will produce a left inferior quadrantanopia. Understanding these relationships can aid in the diagnosis and management of visual field defects.

    • This question is part of the following fields:

      • Ophthalmology
      15.8
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  • Question 17 - An 80-year-old man presents with complaints of blurred vision. Upon fundoscopy, drusen, retinal...

    Incorrect

    • An 80-year-old man presents with complaints of blurred vision. Upon fundoscopy, drusen, retinal epithelial changes, and macular neovascularisation are noted. The clinician suspects age-related macular degeneration. What would be the most suitable follow-up investigation?

      Your Answer: Ocular tonometry

      Correct Answer: Fluorescein angiography

      Explanation:

      Age-related macular degeneration (ARMD) is a common cause of blindness in the UK, characterized by the degeneration of the central retina (macula) and the formation of drusen. It is more prevalent in females and is strongly associated with advancing age, smoking, family history, and conditions that increase the risk of ischaemic cardiovascular disease. ARMD can be classified into two forms: dry and wet. Dry ARMD is more common and is characterized by drusen, while wet ARMD is characterized by choroidal neovascularisation and carries a worse prognosis. Clinical features of ARMD include subacute onset of visual loss, difficulties in dark adaptation, and visual disturbances such as photopsia and glare.

      To diagnose ARMD, slit-lamp microscopy and color fundus photography are used to identify any pigmentary, exudative, or haemorrhagic changes affecting the retina. Fluorescein angiography and indocyanine green angiography may also be used to visualize changes in the choroidal circulation. Treatment for dry ARMD involves a combination of zinc with antioxidant vitamins A, C, and E, which has been shown to reduce disease progression by around one third. For wet ARMD, anti-VEGF agents such as ranibizumab, bevacizumab, and pegaptanib are used to limit disease progression and stabilize or reverse visual loss. Laser photocoagulation may also be used to slow progression, but anti-VEGF therapies are usually preferred due to the risk of acute visual loss after treatment.

      In summary, ARMD is a common cause of blindness in the UK that is strongly associated with advancing age, smoking, and family history. It can be classified into dry and wet forms, with wet ARMD carrying a worse prognosis. Diagnosis involves the use of various imaging techniques, and treatment options include a combination of zinc and antioxidant vitamins for dry ARMD and anti-VEGF agents or laser photocoagulation for wet ARMD.

    • This question is part of the following fields:

      • Ophthalmology
      69.7
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  • Question 18 - A 24-year-old woman is attending her first appointment with her GP. She reports...

    Incorrect

    • A 24-year-old woman is attending her first appointment with her GP. She reports feeling healthy and has no current health concerns. However, when asked about her family medical history, she mentions that her mother and grandfather have both been diagnosed with glaucoma.

      As her GP, what advice would you give her regarding glaucoma?

      Your Answer: He should get annual screening from age 60 years

      Correct Answer: He should get annual screening from age 40 years

      Explanation:

      Individuals who have a positive family history of glaucoma are recommended to undergo annual screening from the age of 40. This is because glaucoma has a strong genetic component, and having a first-degree relative with the condition increases one’s risk. The NHS offers free examinations for those who meet this criteria. It is important to note that glaucoma often has no symptoms in its early stages, making regular screening crucial in detecting and treating the condition before it causes significant visual impairment. Opticians can typically perform these screenings.

      Glaucoma is a condition where the optic nerve is damaged due to increased pressure in the eye. Primary open-angle glaucoma (POAG) is a type of glaucoma where the peripheral iris is clear of the trabecular meshwork, which is important in draining aqueous humour from the eye. POAG is more common in older individuals and those with a family history of the condition. It may present insidiously with symptoms such as peripheral visual field loss, decreased visual acuity, and optic disc cupping. Diagnosis is made through a series of investigations including automated perimetry, slit lamp examination, applanation tonometry, central corneal thickness measurement, and gonioscopy. It is important to assess the risk of future visual impairment based on factors such as IOP, CCT, family history, and life expectancy. Referral to an ophthalmologist is typically done through a GP.

    • This question is part of the following fields:

      • Ophthalmology
      67.8
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  • Question 19 - An 80-year-old man arrives at the emergency department with a complaint of severe...

    Incorrect

    • An 80-year-old man arrives at the emergency department with a complaint of severe headache. He has a medical history of hypertension and takes Ramipril 10 mg and Amlodipine 10 mg. During the full workup, fundoscopy is conducted and reveals scattered cotton wool spots, tortuous vessels throughout, and AV nipping in both eyes. According to the Keith-Wagener classification, what stage of hypertensive retinopathy does this patient have?

      Your Answer: Stage 2

      Correct Answer: Stage 3

      Explanation:

      Hypertensive retinopathy can be detected through fundoscopy, which may reveal end organ damage. This condition can progress through stages 1 to 3, and is often tested on as a final exam question. Diabetic retinopathy is also a commonly tested topic.

      Understanding Hypertensive Retinopathy: Keith-Wagener Classification

      Hypertensive retinopathy is a condition that affects the eyes due to high blood pressure. The Keith-Wagener classification is a system used to categorize the different stages of hypertensive retinopathy. Stage I is characterized by narrowing and twisting of the blood vessels in the eyes, as well as an increased reflection of light known as silver wiring. In stage II, the blood vessels become compressed where they cross over veins, leading to arteriovenous nipping. Stage III is marked by the appearance of cotton-wool exudates, which are white patches on the retina caused by blocked blood vessels. Additionally, there may be flame and blot hemorrhages that can collect around the fovea, resulting in a ‘macular star.’ Finally, stage IV is the most severe stage and is characterized by papilloedema, which is swelling of the optic disc at the back of the eye. Understanding the Keith-Wagener classification can help healthcare professionals diagnose and manage hypertensive retinopathy.

    • This question is part of the following fields:

      • Ophthalmology
      5.5
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  • Question 20 - A 75-year-old woman presents with sudden visual loss in her right eye. She...

    Incorrect

    • A 75-year-old woman presents with sudden visual loss in her right eye. She reports experiencing flashes and floaters. The patient has a history of myopia and has worn glasses since her early teenage years. Additionally, she has a medical history of hypertension, recurrent deep vein thrombosis, and osteoporosis. Her current medications include amlodipine 5mg once daily, apixaban 2.5mg twice daily, and alendronic acid 70mg once weekly. Upon examination, her visual acuity in the affected eye is 6/12. Fundoscopy reveals a normal optic disc and retinal vessels. What is the most likely diagnosis?

      Your Answer: Vitreous haemorrhage

      Correct Answer: Posterior vitreous detachment

      Explanation:

      Patients with PVD have a high likelihood of developing a retinal tear, which increases their risk of retinal detachment. As a result, it is crucial for these patients to be evaluated by an ophthalmologist within 24 hours.

      Understanding Posterior Vitreous Detachment

      Posterior vitreous detachment is a condition where the vitreous membrane separates from the retina due to natural changes in the vitreous fluid of the eye with ageing. This is a common condition that does not cause any pain or loss of vision. However, it is important to rule out retinal tears or detachment as they may result in permanent loss of vision. Posterior vitreous detachment occurs in over 75% of people over the age of 65 and is more common in females. Highly myopic patients are also at increased risk of developing this condition earlier in life.

      Symptoms of posterior vitreous detachment include the sudden appearance of floaters, flashes of light in vision, blurred vision, and cobweb across vision. If there is an associated retinal tear or detachment, the patient will require surgery to fix this. All patients with suspected vitreous detachment should be examined by an ophthalmologist within 24 hours to rule out retinal tears or detachment.

      The management of posterior vitreous detachment alone does not require any treatment as symptoms gradually improve over a period of around 6 months. However, it is important to monitor the condition and seek medical attention if any new symptoms arise. The appearance of a dark curtain descending down vision indicates retinal detachment and requires immediate medical attention. Overall, understanding posterior vitreous detachment and its associated risks is important for maintaining good eye health.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 21 - A 32-year-old female complains of fatigue and frequent headaches. During the swinging light...

    Incorrect

    • A 32-year-old female complains of fatigue and frequent headaches. During the swinging light test, an abnormality is noticed in her eyes. Both pupils appear to dilate as the light is moved from the left to the right eye. However, the pupillary response to accommodation is normal bilaterally. Fundoscopy also reveals normal findings bilaterally. The patient has a medical history of type one diabetes and hypertension. What is the probable cause of this patient's symptoms?

      Your Answer: Diabetic eye disease

      Correct Answer: Marcus-Gunn Pupil (relative afferent pupillary defect) on the right

      Explanation:

      The swinging light test can diagnose Marcus Gunn pupil (also known as relative afferent pupillary defect). If there is damage to the afferent pathway (retina or optic nerve) of one eye, the affected eye’s pupil will abnormally dilate when a light is shone into it because the healthy eye’s consensual pupillary relaxation response will dominate. This condition can be found in patients with multiple sclerosis, so it should be ruled out in this patient based on the history. However, the history and examination findings do not suggest raised intracranial pressure, which typically presents with symptoms such as a headache, vomiting, bilateral blurred vision, and seizures, and often shows bilateral papilloedema on fundoscopy. Although the patient is diabetic, diabetic eye disease typically does not affect pupillary light responses, and some abnormality on fundoscopy would be expected. The information provided does not match Holmes-Aide’s pupil, which is a dilated pupil that poorly reacts to direct light but slowly reacts to accommodation. The history also does not suggest Argyll Robertson pupil, which is characterised by a constricted pupil that does not respond to light but responds to accommodation and is often associated with neurosyphilis.

      Understanding Relative Afferent Pupillary Defect

      A relative afferent pupillary defect, also known as the Marcus-Gunn pupil, is a condition that can be identified through the swinging light test. This condition is caused by a lesion that is located anterior to the optic chiasm, which can be found in the optic nerve or retina.

      When conducting the swinging light test, the affected eye will appear to dilate when light is shone on it, while the normal eye will not. This is due to the fact that the afferent pathway of the pupillary light reflex is disrupted. The pathway starts from the retina, then goes through the optic nerve, lateral geniculate body, and midbrain. The efferent pathway, on the other hand, starts from the Edinger-Westphal nucleus in the midbrain and goes through the oculomotor nerve.

      There are various causes of relative afferent pupillary defect, such as retina detachment and optic neuritis, which is commonly associated with multiple sclerosis. Understanding this condition is important in diagnosing and treating patients who may be experiencing vision problems.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 22 - Which statement about childhood squints is accurate? ...

    Incorrect

    • Which statement about childhood squints is accurate?

      Your Answer: Divergent squints are more common than convergent squints

      Correct Answer: The corneal light reflection test is a suitable screening test

      Explanation:

      Both paralytic and non-paralytic squints can lead to the development of amblyopia.

      Squint, also known as strabismus, is a condition where the visual axes are misaligned. There are two types of squints: concomitant and paralytic. Concomitant squints are more common and are caused by an imbalance in the extraocular muscles. On the other hand, paralytic squints are rare and are caused by the paralysis of extraocular muscles. It is important to detect squints early on as they can lead to amblyopia, where the brain fails to process inputs from one eye and favours the other eye over time.

      To detect a squint, a corneal light reflection test can be performed by holding a light source 30cm from the child’s face to see if the light reflects symmetrically on the pupils. The cover test is also used to identify the nature of the squint. This involves asking the child to focus on an object, covering one eye, and observing the movement of the uncovered eye. The test is then repeated with the other eye covered.

      If a squint is detected, it is important to refer the child to secondary care. Eye patches may also be used to help prevent amblyopia.

    • This question is part of the following fields:

      • Ophthalmology
      15
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  • Question 23 - A 25-year-old woman presents to the Eye Casualty with a sudden onset of...

    Incorrect

    • A 25-year-old woman presents to the Eye Casualty with a sudden onset of pain and reduced vision in her left eye over the past few hours. She denies any other symptoms.
      Upon examination, her right eye has a visual acuity of 6/6 while her left eye has a visual acuity of 6/36 with reduced colour vision. Eye movements are normal, but the pain worsens. The swinging torch test reveals left pupil dilation when the torch light is swung from the right eye to the left.
      A dilated fundoscopy shows normal optic discs in both eyes. An MRI scan of the head reveals white matter lesions in two different areas of the brain. An LP and CSF analysis show oligoclonal bands.
      What is the most likely diagnosis for this patient?

      Your Answer: Giant-cell arthritis

      Correct Answer: Multiple sclerosis

      Explanation:

      Possible Diagnoses for a Patient with Optic Neuritis

      Optic neuritis is a condition that involves inflammation of the optic nerve, which can cause vision loss, pain, and other symptoms. When a patient presents with optic neuritis, there are several possible underlying diagnoses that could be considered.

      One of the most likely diagnoses is multiple sclerosis, which can cause optic neuritis as a secondary symptom. To confirm this diagnosis, another MRI should be done at a later time to show that there are white matter plaques that are disseminated in time and space. However, the signs and examination findings are consistent with multiple sclerosis. It’s worth noting that if the optic disc is spared from inflammation, it can result in retrobulbar neuritis, which would not involve optic disc swelling.

      Another possible diagnosis is giant-cell arthritis, which can cause a condition called anterior ischemic optic neuropathy (AION). This can result in a relative afferent pupillary defect (RAPD) and reduced visual acuity. However, the fundoscopy, MRI, and CSF findings are not consistent with AION.

      Internuclear ophthalmoplegia is an ophthalmic sign that can be found in multiple sclerosis, but it is not a diagnosis in and of itself. It occurs when there is an injury or dysfunction to the medial longitudinal fasciculus.

      Myasthenia gravis is another possible diagnosis, but it typically presents with variable diplopia or ptosis, which worsens in the evening or with exercise. There would not be any optic neuropathy signs.

      Finally, post-viral demyelination is a type of atypical optic neuritis that is often bilateral and occurs a few weeks after a viral illness or vaccination. However, there is no history of any viral illnesses in this patient, making this diagnosis less likely.

    • This question is part of the following fields:

      • Ophthalmology
      11.9
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  • Question 24 - A 7-year-old girl visits her GP complaining of a swollen left eye. She...

    Incorrect

    • A 7-year-old girl visits her GP complaining of a swollen left eye. She noticed it while playing outside in the park. Her mother is concerned because she is having difficulty reading her books. The girl has no medical history, and this has never happened before.

      During the examination, the left eyelid is warm and red, and the eye seems to be bulging. The girl's eye movements are limited in all directions. The right eye appears normal. Her heart rate is 120 beats/minute, and her temperature is 37.9ºC.

      What is the most probable diagnosis?

      Your Answer: Minimal change disease

      Correct Answer: Orbital cellulitis

      Explanation:

      Orbital cellulitis can be distinguished from preseptal cellulitis based on the presence of reduced visual acuity, proptosis, and pain with eye movements. This classic presentation is accompanied by fever and tachycardia, indicating an infection. While preseptal cellulitis can also cause a swollen eye, it does not result in the same symptoms as orbital cellulitis. Other conditions, such as minimal change disease, mastoiditis, and bilateral periorbital edema, may cause swelling and fever, but they do not typically result in unilateral swelling with restricted eye movements and raised temperature.

      Understanding Orbital Cellulitis: Causes, Symptoms, and Management

      Orbital cellulitis is a serious infection that affects the fat and muscles behind the orbital septum within the orbit, but not the globe. It is commonly caused by upper respiratory tract infections that spread from the sinuses and can lead to a high mortality rate. On the other hand, periorbital cellulitis is a less severe infection that occurs in the superficial tissues anterior to the orbital septum. However, it can progress to orbital cellulitis if left untreated.

      Risk factors for orbital cellulitis include childhood, previous sinus infections, lack of Haemophilus influenzae type b (Hib) vaccination, recent eyelid infections or insect bites, and ear or facial infections. Symptoms of orbital cellulitis include redness and swelling around the eye, severe ocular pain, visual disturbance, proptosis, ophthalmoplegia, eyelid edema, and ptosis. In rare cases, meningeal involvement can cause drowsiness, nausea, and vomiting.

      To differentiate between orbital and preseptal cellulitis, doctors look for reduced visual acuity, proptosis, and ophthalmoplegia, which are not consistent with preseptal cellulitis. Full blood count and clinical examination involving complete ophthalmological assessment are necessary to determine the severity of the infection. CT with contrast can also help identify inflammation of the orbital tissues deep to the septum and sinusitis. Blood culture and microbiological swab are also necessary to determine the organism causing the infection.

      Management of orbital cellulitis requires hospital admission for IV antibiotics. It is a medical emergency that requires urgent senior review. Early diagnosis and treatment are crucial to prevent complications and reduce the risk of mortality.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 25 - A 25-year-old woman presents to her General Practitioner (GP) with a 1-day history...

    Incorrect

    • A 25-year-old woman presents to her General Practitioner (GP) with a 1-day history of itching and watery discharge from both eyes.
      On examination, the vision is 6/9 in both eyes. Both pupils are equally reactive to light. The conjunctivae are both chemosed with mild diffuse injection. The eyelids are slightly oedematous.
      Her past medical history includes eczema. Her vital observations are as follows:
      Blood pressure 110/70 mmHg
      Heart rate 65 bpm
      Respiratory rate 12
      Temperature 36.7 °C
      Oxygen saturation 99% on air
      What is the most likely diagnosis?

      Your Answer: Preseptal cellulitis

      Correct Answer: Allergic conjunctivitis

      Explanation:

      Distinguishing Different Types of Eye Infections: A Case Study

      Upon examination of a patient with eye symptoms, it was determined that the presentation pointed towards the diagnosis of allergic conjunctivitis. This was due to the patient’s history of itchiness, watery discharge, slightly swollen eyelids, and atopy. It was ruled out that the patient had bacterial conjunctivitis, as it typically presents with more purulent discharges bilaterally. Orbital cellulitis was also ruled out, as the eyelids and orbit would be very swollen and red with restriction and pain in eye movements, and the vital observations were normal. Preseptal cellulitis can present with oedematous eyelids, but the eye itself should be quiet and white. While viral conjunctivitis can present with watery discharges, the patient’s history of atopy and itchiness made allergic conjunctivitis the more likely diagnosis.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 26 - As an FY-2 doctor in ophthalmology, you encounter a 59-year-old male patient who...

    Incorrect

    • As an FY-2 doctor in ophthalmology, you encounter a 59-year-old male patient who complains of pain in his right eye, accompanied by tearing and reduced vision. Upon examination, you diagnose a corneal ulcer. What is the most probable cause of this condition?

      Your Answer: Anti-fungal eye drops

      Correct Answer: Steroid eye drops

      Explanation:

      Fungal infections and subsequent corneal ulcers can be caused by the use of steroid eye drops. These drops are designed to reduce inflammation, but they can also weaken the immune response to infections, leaving the cornea vulnerable to bacteria, fungi, or protists. Treatment for corneal ulcers typically involves targeted eye drops to address the specific organism causing the infection, such as antibacterial or antifungal drops. Saline or lubricant eye drops, on the other hand, are sterile and do not pose a risk for corneal ulcers.

      Understanding Corneal Ulcers

      A corneal ulcer is a condition that occurs when there is a defect in the cornea, which is usually caused by an infection. It is important to note that corneal abrasions, on the other hand, are typically caused by physical trauma. There are several risk factors that can increase the likelihood of developing a corneal ulcer, including contact lens use and vitamin A deficiency, which is particularly common in developing countries.

      The pathophysiology of corneal ulcers can vary depending on the underlying cause. Bacterial, fungal, and viral infections can all lead to the development of a corneal ulcer. In some cases, contact lens use can also be associated with a type of infection called Acanthamoeba keratitis.

      Symptoms of a corneal ulcer typically include eye pain, sensitivity to light, and excessive tearing. Additionally, a focal fluorescein staining of the cornea may be present.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 27 - A 56-year-old female patient complains of photophobia and a painful, red left eye....

    Incorrect

    • A 56-year-old female patient complains of photophobia and a painful, red left eye. During examination, a dendritic corneal ulcer is observed. The patient has recently finished taking oral prednisolone for an asthma flare-up. What is the recommended treatment for this condition?

      Your Answer: Topical cyclopentolate

      Correct Answer: Topical acyclovir

      Explanation:

      The most suitable treatment for herpes simplex keratitis is topical acyclovir. This patient’s symptoms, including a dendritic corneal ulcer, suggest herpes simplex keratitis, which may have been triggered by their recent use of oral prednisolone. Therefore, the most appropriate medication would be topical antivirals, such as acyclovir. It is important to note that acyclovir should be given topically rather than intravenously. Topical ciprofloxacin would be appropriate for bacterial or amoebic keratitis, which is more common in patients who wear contact lenses. Topical chloramphenicol would be suitable for a superficial eye infection like conjunctivitis, but it would not be appropriate for this patient, who likely has a viral cause for their symptoms.

      Understanding Herpes Simplex Keratitis

      Herpes simplex keratitis is a condition that affects the cornea of the eye and is caused by the herpes simplex virus. The most common symptom of this condition is a dendritic corneal ulcer, which can cause a red, painful eye, photophobia, and epiphora. In some cases, visual acuity may also be decreased. Fluorescein staining may show an epithelial ulcer, which can help with diagnosis. One common treatment for this condition is topical acyclovir, which can help to reduce the severity of symptoms and prevent further damage to the cornea.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 28 - Which one of the following statements regarding macular degeneration is true? ...

    Incorrect

    • Which one of the following statements regarding macular degeneration is true?

      Your Answer: Asian ethnicity is a risk factor

      Correct Answer: Wet macular degeneration carries the worst prognosis

      Explanation:

      Age-related macular degeneration (ARMD) is a common cause of blindness in the UK, characterized by the degeneration of the central retina (macula) and the formation of drusen. It is more prevalent in females and is strongly associated with advancing age, smoking, family history, and conditions that increase the risk of ischaemic cardiovascular disease. ARMD can be classified into two forms: dry and wet. Dry ARMD is more common and is characterized by drusen, while wet ARMD is characterized by choroidal neovascularisation and carries a worse prognosis. Clinical features of ARMD include subacute onset of visual loss, difficulties in dark adaptation, and visual disturbances such as photopsia and glare.

      To diagnose ARMD, slit-lamp microscopy and color fundus photography are used to identify any pigmentary, exudative, or haemorrhagic changes affecting the retina. Fluorescein angiography and indocyanine green angiography may also be used to visualize changes in the choroidal circulation. Treatment for dry ARMD involves a combination of zinc with antioxidant vitamins A, C, and E, which has been shown to reduce disease progression by around one third. For wet ARMD, anti-VEGF agents such as ranibizumab, bevacizumab, and pegaptanib are used to limit disease progression and stabilize or reverse visual loss. Laser photocoagulation may also be used to slow progression, but anti-VEGF therapies are usually preferred due to the risk of acute visual loss after treatment.

      In summary, ARMD is a common cause of blindness in the UK that is strongly associated with advancing age, smoking, and family history. It can be classified into dry and wet forms, with wet ARMD carrying a worse prognosis. Diagnosis involves the use of various imaging techniques, and treatment options include a combination of zinc and antioxidant vitamins for dry ARMD and anti-VEGF agents or laser photocoagulation for wet ARMD.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 29 - A 14-year-old boy with a family history of short-sightedness visits his General Practice...

    Incorrect

    • A 14-year-old boy with a family history of short-sightedness visits his General Practice Clinic, reporting difficulty seeing distant objects. He is interested in the underlying pathophysiology of his condition as he is passionate about science. What is the most appropriate explanation for the pathophysiology of his myopia?

      Your Answer: Reduced axial length of the eye, meaning the focal point is posterior to the retina

      Correct Answer: Increased axial length of the eye, meaning the focal point is anterior to the retina

      Explanation:

      Understanding Refractive Errors: Causes and Effects

      Refractive errors are common vision problems that occur when the shape of the eye prevents light from focusing properly on the retina. This can result in blurry vision at various distances. Here are some common types of refractive errors and their effects:

      Myopia: This occurs when the axial length of the eye is increased, causing the focal point to be anterior to the retina. Myopia gives clear close vision but blurry far vision.

      Hyperopia: This occurs when the axial length of the eye is reduced, causing the focal point to be posterior to the retina. Hyperopia results in blurry close vision but clear far vision.

      Astigmatism: This occurs when the cornea has an abnormal curvature, resulting in two or more focal points that can be anterior and/or posterior to the retina. Astigmatism hinders refraction and leads to blurred vision at all distances.

      Understanding the causes and effects of refractive errors can help individuals seek appropriate treatment and improve their vision.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 30 - Which of the following is not a recognized cause of tunnel vision? ...

    Incorrect

    • Which of the following is not a recognized cause of tunnel vision?

      Your Answer:

      Correct Answer: Macular degeneration

      Explanation:

      Understanding Tunnel Vision and Its Causes

      Tunnel vision is a condition where the visual fields become smaller and more concentrated. This means that the person affected can only see what is directly in front of them, while the peripheral vision is diminished. There are several causes of tunnel vision, including papilloedema, glaucoma, retinitis pigmentosa, chorioretinitis, optic atrophy secondary to tabes dorsalis, and hysteria.

      Papilloedema is a condition where there is swelling of the optic nerve head, which can cause pressure on the surrounding tissues. Glaucoma is a condition where there is damage to the optic nerve, which can lead to vision loss. Retinitis pigmentosa is a genetic disorder that affects the retina, causing progressive vision loss. Chorioretinitis is an inflammation of the choroid and retina, which can cause vision loss. Optic atrophy secondary to tabes dorsalis is a condition where there is damage to the optic nerve due to syphilis. Hysteria is a psychological condition that can cause physical symptoms, including tunnel vision.

    • This question is part of the following fields:

      • Ophthalmology
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