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Question 1
Correct
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A 78-year-old male presents to the ophthalmology clinic with a recent complaint of difficulty seeing objects up close, particularly at night. His general practitioner referred him for evaluation. During fundoscopy, the doctor observes distinct red patches. The patient has a medical history of hypertension and is a lifelong smoker. What is the most probable diagnosis, and what is the most suitable treatment?
Your Answer: Anti-vascular endothelial growth factor (VEGF)
Explanation:The most effective treatment for wet AMD is anti-VEGF therapy. Wet age-related macular degeneration, also known as exudative or neovascular macular degeneration, is caused by choroidal neovascularization, which can lead to rapid vision loss due to fluid and blood leakage. Symptoms include reduced visual acuity, particularly for near objects, worse vision at night, and red patches visible on fundoscopy indicating fluid leakage or hemorrhage. Anti-VEGF therapy targets vascular endothelial growth factor, a potent mitogen that increases vascular permeability in patients with wet ARMD, reducing leakage. Treatment should begin as soon as possible to prevent further vision loss.
Amaurosis fugax, on the other hand, is treated with aspirin and is caused by a variety of conditions, including large artery disease, small artery occlusive disease, venous disease, and hypoperfusion. It typically presents as a sudden loss of vision, as if a curtain is coming down.
Cataract surgery is the appropriate treatment for cataracts, which cause reduced vision, faded color vision, glare, and halos around lights. A defect in the red reflex may be observed on fundoscopy.
High-dose steroids are used to treat optic neuritis, which presents with unilateral vision loss over hours or days, red desaturation, pain, and scotoma.
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.
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This question is part of the following fields:
- Ophthalmology
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Question 2
Correct
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A 75-year-old man comes to the General Practitioner (GP) complaining of painless sudden vision loss in his eyes. Upon examination, the GP observes a right homonymous superior quadrantanopia. Where is the lesion located that is responsible for this visual field defect?
Your Answer: Left temporal lobe optic radiation
Explanation:Lesions and their corresponding visual field defects
Visual field defects can be caused by lesions in various parts of the visual pathway. Here are some examples:
Left temporal lobe optic radiation
Lesion in this area can cause a left superior quadrantanopia.Optic chiasm
A lesion in the optic chiasm can cause a bitemporal hemianopia.Left occipital visual cortex
A lesion in the left occipital visual cortex can cause a right homonymous hemianopia with macular sparing.Right optic tract
A lesion in the right optic tract can cause a left homonymous hemianopia.Right parietal lobe optic radiation
A lesion in the right parietal lobe optic radiation can cause a left inferior quadrantanopia.Understanding the location of the lesion and its corresponding visual field defect can aid in diagnosis and treatment of visual impairments.
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This question is part of the following fields:
- Ophthalmology
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Question 3
Incorrect
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A 26-year-old woman presents to the Eye Casualty with a sudden onset of painful reduction in vision in her left eye. She denies any other symptoms and has no significant medical history.
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 color vision. Eye movements are normal, but the pain worsens. The swinging torch test reveals left pupil dilation when the torch light swings from the right eye to the left. Dilated fundoscopy shows a swollen optic disc in her left eye.
What is the recommended first-line treatment for this condition?Your Answer: Oral prednisolone
Correct Answer: Intravenous methylprednisolone
Explanation:Treatment Options for Optic Neuritis in Multiple Sclerosis Patients
Optic neuritis is a common symptom of multiple sclerosis (MS) and can cause vision loss or pain. While the condition may improve on its own, treatment with steroids is often recommended. Intravenous methylprednisolone is the preferred route of administration for this medication, although it can cause side effects such as mood changes and weight gain.
Glatiramer acetate and interferon beta are first-line treatments for MS, but are not typically used for isolated episodes of optic neuritis. Natalizumab is a second-line treatment option for MS, but may not be appropriate for all patients.
It is important to note that oral prednisolone alone is not recommended for optic neuritis in MS patients due to an increased risk of recurrence. Overall, treatment options for optic neuritis in MS patients should be carefully considered based on individual patient needs and medical history.
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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 30-year-old man reports experiencing a scratchy sensation in his eyes as the day goes on. He feels that his eyes become tired. These symptoms only occur during weekdays when he works as a computer programmer for a local business. During examination, there is mild conjunctival hyperemia, but the rest of the ocular examination is normal. Which nerve stimulation is linked to tear production?
Your Answer: Chorda tympani
Correct Answer: Intermediate nerve
Explanation:Cranial Nerves and Their Parasympathetic Functions
The cranial nerves play a crucial role in the parasympathetic nervous system, which is responsible for regulating various bodily functions. Here are some of the cranial nerves and their parasympathetic functions:
1. Intermediate Nerve: This nerve supplies secretomotor innervation to the lacrimal gland. The parasympathetic fibers originate from the geniculate ganglion of the facial nerve and travel through the greater petrosal nerve, deep petrosal nerve, Vidian nerve, and maxillary nerve to reach the lacrimal gland.
2. Oculomotor Nerve: The oculomotor nerve provides motor innervation to four of the six ocular muscles and parasympathetic innervation to the ciliary muscle and sphincter pupillae muscle of the iris.
3. Glossopharyngeal Nerve: This nerve provides secretomotor innervation to the parotid gland. The parasympathetic fibers travel through the tympanic branch of the glossopharyngeal nerve, tympanic plexus, lesser petrosal nerve, and auriculotemporal nerve to reach the parotid gland.
4. Vagus Nerve: The vagus nerve provides parasympathetic innervation to the heart, lung, and gastrointestinal tract.
5. Chorda Tympani: This branch of the facial nerve contains preganglionic parasympathetic fibers that synapse at the submandibular ganglion attached to the lingual nerve. The postganglionic parasympathetic fibers reach the submandibular and sublingual glands via the branches of the lingual nerve.
Understanding the parasympathetic functions of these cranial nerves is essential in diagnosing and treating various medical conditions.
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This question is part of the following fields:
- Ophthalmology
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Question 5
Correct
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A 29-year-old man visits his General Practitioner (GP) with complaints of painful red eye on one side. Upon examination, the GP observes reduced visual acuity, photophobia, eye watering, and a poorly reactive pupil. The patient is suspected to have uveitis. What is the most suitable course of action for managing this patient?
Your Answer: Same-day referral to an Ophthalmologist
Explanation:Management of Acutely Painful Red Eye with Suspected Uveitis
Explanation:
When a patient presents with an acutely painful red eye and suspected uveitis, it is crucial to refer them for same-day assessment by an Ophthalmologist. A slit-lamp examination is necessary to confirm the diagnosis, which cannot be performed by a GP. Non-infective anterior uveitis is treated with a combination of steroids and cycloplegics to reduce inflammation and ciliary spasm. In cases of infective uveitis, antimicrobials are also added.Chloramphenicol is used in the treatment of conjunctivitis, but it is not appropriate for uveitis. Conservative management with pain relief alone is not sufficient for this condition. Topical steroids are required to reduce inflammation, along with a cycloplegic such as atropine to reduce ciliary spasm. However, topical steroids should not be initiated in primary care, and patients require urgent assessment in secondary care.
Referral within two weeks is not appropriate for a patient with an acutely painful red eye and suspected uveitis. Any delay in treatment can result in adhesions within the eye and long-term damage. Therefore, same-day referral to an Ophthalmologist is necessary for prompt diagnosis and treatment.
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This question is part of the following fields:
- Ophthalmology
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Question 6
Correct
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A 28-year-old man presents with a 5-day history of increasing pain, blurry vision and lacrimation in the left eye. He also feels a foreign body sensation in the affected eye. He had been doing some DIY work at home without wearing any goggles for the past few days prior to the onset of pain.
On examination, his visual acuities are 6/18 in the left and 6/6 in the right. The conjunctiva in the left is red. The cornea is tested with fluorescein and it shows an uptake in the centre of the cornea which looks like a dendrite. On examination of his face, there are some small vesicles at the corner of his mouth as well.
What is the most likely diagnosis?Your Answer: Viral keratitis
Explanation:Possible Eye Conditions and Diagnosis for a Patient with Corneal Ulcer
Upon examination of a patient with a corneal ulcer, several possible eye conditions can be considered. However, based on the presence of a dendritic ulcer and a history of cold sores, a viral keratitis, specifically herpes simplex keratitis, is likely. A corneal abrasion is unlikely as there is no history of eye injury. A corneal foreign body is also unlikely as there is no visible foreign object on the cornea. Fungal keratitis is unlikely as there are no risk factors present. Microbial keratitis is a possibility, but it typically presents with a round-shaped ulcer. Overall, a viral keratitis diagnosis seems most probable.
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This question is part of the following fields:
- Ophthalmology
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Question 7
Incorrect
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Mrs Green is a 58-year-old woman who comes to eye casualty with sudden vision loss in her left eye. She reports having observed some dark spots in her vision over the past few days. She is not in any pain and has a medical history of diet-controlled type 2 diabetes mellitus and hypertension. What is the most probable cause of her visual impairment?
Your Answer: Retinal detachment
Correct Answer: Vitreous haemorrhage
Explanation:Understanding Vitreous Haemorrhage
Vitreous haemorrhage is a condition where there is bleeding into the vitreous humour, which can cause sudden painless loss of vision. This disruption to vision can range from floaters to complete visual loss. The bleeding can come from any vessel in the retina or extend through the retina from other areas. Once the bleeding stops, the blood is typically cleared from the retina at a rate of approximately 1% per day.
The incidence of spontaneous vitreous haemorrhage is around 7 cases per 100,000 patient-years. The incidence by age and sex varies according to the underlying causes. The most common causes, which collectively account for 90% of cases, include proliferative diabetic retinopathy, posterior vitreous detachment, and ocular trauma (which is the most common cause in children and young adults).
Patients with vitreous haemorrhage typically present with an acute or subacute onset of painless visual loss or haze, a red hue in the vision, or floaters or shadows/dark spots in the vision. Signs of the condition include decreased visual acuity (depending on the location, size, and degree of vitreous haemorrhage) and visual field defects if the haemorrhage is severe.
Investigations for vitreous haemorrhage include dilated fundoscopy, slit-lamp examination, ultrasound (useful to rule out retinal tear/detachment and if haemorrhage obscures the retina), fluorescein angiography (to identify neovascularization), and orbital CT (used if open globe injury is suspected).
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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 30-year-old female patient visits her GP complaining of a severe throbbing headache that is most intense in the morning. Despite taking paracetamol, the symptoms have persisted for several weeks. She also experiences vomiting in the mornings and has noticed blurry vision. Upon examination, her pupils are equal and reactive, and there are no abnormalities in her systemic examination. What would you anticipate observing during fundoscopy?
Your Answer: Prominent optic cup
Correct Answer: Blurring of optic disc margin
Explanation:Papilloedema is characterized by a blurry appearance of the optic disc margin during fundoscopy.
The patient in question is experiencing elevated intracranial pressure, the cause of which is uncertain. Their symptoms, including a morning headache, vision impairment, and vomiting, are indicative of papilloedema. As such, it is expected that their fundoscopy would reveal signs of this condition, such as a blurred optic disc margin.
Other potential indicators of papilloedema include a loss of optic cup and venous pulsation. However, increased arterial reflex is more commonly associated with hypertensive retinopathy, while retinal pigmentation is a hallmark of retinitis pigmentosa.
Understanding Papilloedema: Optic Disc Swelling Caused by Increased Intracranial Pressure
Papilloedema is a condition characterized by swelling of the optic disc due to increased pressure within the skull. This condition is typically bilateral and can be identified through fundoscopy. During this examination, venous engorgement is usually the first sign observed, followed by loss of venous pulsation, blurring of the optic disc margin, elevation of the optic disc, loss of the optic cup, and the presence of Paton’s lines, which are concentric or radial retinal lines cascading from the optic disc.
There are several potential causes of papilloedema, including space-occupying lesions such as tumors or vascular abnormalities, malignant hypertension, idiopathic intracranial hypertension, hydrocephalus, and hypercapnia. In rare cases, papilloedema may also be caused by hypoparathyroidism and hypocalcaemia, or vitamin A toxicity.
Overall, understanding papilloedema is important for identifying potential underlying conditions and providing appropriate treatment to prevent further complications.
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This question is part of the following fields:
- Ophthalmology
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Question 9
Correct
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A 55-year-old man visits his optometrist for a check-up. He has hyperopia and his current prescription is +3/+3.25 without any astigmatism or myopia. What is the primary eye condition that this patient is susceptible to with his present eye condition?
Your Answer: Acute angle-closure glaucoma
Explanation:Hypermetropia is linked to acute angle-closure glaucoma, while myopia is associated with primary open-angle glaucoma. This is because those with hypermetropia have smaller eyes, shallower anterior chambers, and narrower angles. The connection between myopia and primary open-angle glaucoma is not as clear, but it may be due to the optic nerve head being more vulnerable to damage from increased intraocular pressure. Cataracts are commonly linked to aging and severe short-sightedness, while central retinal artery occlusion is associated with aneurysms, arterial disease, and emboli.
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.
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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 65-year-old man visits the clinic with complaints of vision problems that have persisted for the past month. He reports difficulty reading words in books and blurry vision. The patient's visual acuity is 20/30 in both eyes upon examination. He currently takes amlodipine and ramipril for hypertension and smokes 30 cigarettes per day. The patient is concerned about losing his vision, as his father experienced a similar issue.
During fundoscopy, amber material deposits are observed under the retinal pigment epithelium in both eyes, without neovascularisation present. What is the most appropriate next step in diagnosing the patient's condition?Your Answer: Fluorescein angiography
Correct Answer: Test with Amsler grid
Explanation:The Amsler grid test is a useful tool for assessing patients suspected of having age-related macular degeneration (AMD) as it checks for distortion of line perception. In this case, the patient has dry AMD, which is confirmed by the presence of drusen on fundoscopy. Patients with AMD typically see distorted lines instead of straight ones. Fluorescein angiography would not be appropriate for this patient as it assesses the vascular supply to the retina and choroid, which is not relevant in this case. Measuring intraocular pressure is also not useful in diagnosing AMD as it is associated with glaucoma. Similarly, a slit lamp examination of the anterior chamber is not relevant in diagnosing AMD as it is used to diagnose other eye conditions such as injuries, corneal infections, or cataracts.
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.
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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 68-year-old woman comes to the eye casualty department complaining of a gradual decline in her vision over the past 8 years. She reports difficulty reading books due to this issue. Upon examination, a central visual impairment is observed, and the patient displays metamorphopsia when using an Amsler grid. Fundoscopy reveals small yellow deposits in the macula. What is the most suitable medical treatment for this patient, given the most probable diagnosis?
Your Answer: Monthly intravitreal anti-VEGF injections
Correct Answer: Vitamin supplementation
Explanation:Medical treatment cannot cure dry AMD. However, administering high doses of beta-carotene, vitamins C and E, and zinc can help slow down the progression of visual impairment.
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.
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This question is part of the following fields:
- Ophthalmology
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Question 12
Incorrect
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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: Intravenous (IV) acyclovir
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.
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This question is part of the following fields:
- Ophthalmology
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Question 13
Correct
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A 75-year-old man comes to the General Practitioner (GP) complaining of painless sudden vision loss in his eyes. Upon examination, the GP observes a right homonymous hemianopia with macular sparing. Where is the lesion located that is responsible for this visual field defect?
Your Answer: Left occipital visual cortex
Explanation:Lesions and their corresponding visual field defects
Lesions in different areas of the visual pathway can cause specific visual field defects. A lesion in the left occipital visual cortex can result in a right homonymous hemianopia with macular sparing. This is because the visual cortex typically presents with macular sparing. On the other hand, a lesion in the left temporal lobe optic radiation can cause a right superior quadrantanopia. An optic chiasm lesion can lead to bitemporal hemianopia, while a right optic tract lesion can cause a left homonymous hemianopia. Finally, a right parietal lobe optic radiation lesion can result in a left inferior quadrantanopia. Understanding these different visual field defects can aid in localizing the site of a lesion in the visual pathway.
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This question is part of the following fields:
- Ophthalmology
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Question 14
Correct
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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: 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.
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This question is part of the following fields:
- Ophthalmology
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Question 15
Correct
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A 67-year-old man presents to the eye clinic with a 12-hour history of flashers and floaters in his left eye. The patient denies any other vision problems and is in good health, except for a history of hypertension, ischaemic heart disease, and bilateral cataracts. He lives alone, does not smoke, and wears glasses. On examination of the left eye using a slit lamp, a small tear is observed in the inferior part of the retina, with the surrounding area appearing crinkled. What is the primary risk factor associated with this condition?
Your Answer: Myopia
Explanation:Retinal detachment can be caused by various risk factors, including diabetes mellitus, ageing, previous eye surgery, eye trauma, and myopia. In this case, a 73-year-old man presented with flashers and floaters in his right eye, which were indicative of retinal detachment. Myopia, which is characterized by an elongated eyeball, can increase the tension on the retina and is therefore a risk factor for this condition. It is important to note that blocked trabecular meshwork, cataract formation, and hyperopia are not associated with retinal detachment.
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.
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This question is part of the following fields:
- Ophthalmology
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Question 16
Correct
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A 65-year-old patient is receiving medical treatment for primary open-angle glaucoma and experiences side effects of increased eyelash length, iris, and periocular pigmentation. What medication class is responsible for these effects?
Your Answer: Prostaglandin analogues
Explanation:Prostaglandin analogues can cause hyperaemia, increased eyelash growth, periocular skin pigmentation, and increased iris pigmentation as side effects. On the other hand, beta-blockers have the potential to exacerbate asthma and heart block, unlike the other options mentioned.
Glaucoma is a condition where the optic nerve is damaged due to increased pressure in the eye. Primary open-angle glaucoma is a type where the iris is clear of the trabecular meshwork, which is responsible for draining aqueous humour from the eye. This results in increased resistance to outflow and raised intraocular pressure. The condition affects 0.5% of people over 40 years old and increases with age. Genetics also play a role, with first-degree relatives having a 16% chance of developing the disease. Symptoms are usually absent, and diagnosis is made through routine eye examinations. Investigations include visual field tests, tonometry, and slit lamp examinations. Treatment involves eye drops to lower intraocular pressure, with prostaglandin analogues being the first line of treatment. Surgery may be considered in refractory cases. Regular reassessment is necessary to monitor progression and prevent visual field loss.
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This question is part of the following fields:
- Ophthalmology
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Question 17
Correct
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A 73-year-old man visits the optician after hearing that individuals over 70 can receive a complimentary eye exam. He has been wearing glasses for his entire adult life due to being long-sighted. His doctor recently informed him that he has pre-diabetes, but he feels fine and hasn't noticed any issues with his vision. During the eye exam, the optometrist discovers that he has high intraocular pressure and advises him to see a specialist for further testing.
What symptom is he most likely to encounter based on the probable diagnosis?Your Answer: Reduced peripheral vision
Explanation:The patient’s optic nerve fibers may have suffered irreversible damage, putting her at increased risk of developing glaucoma due to her age, pre-diabetes, and raised intraocular pressure. The optometrist detected this pressure, which is caused by impaired drainage of aqueous fluid within the eye. However, the patient is asymptomatic and therefore unlikely to have closed-angle glaucoma, which causes intense eye pain, redness, headaches, halos around lights, and nausea. Cloudy vision is more likely to be caused by cataracts, but there are no other features to suggest this diagnosis. Open-angle glaucoma can sometimes cause color blindness, but it more commonly affects the visual fields. It does not cause dry eyes, which can be caused by autoimmune conditions such as Sjogren’s syndrome and systemic lupus erythematosus.
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.
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This question is part of the following fields:
- Ophthalmology
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Question 18
Incorrect
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A 36-year-old swim instructor arrives at the Emergency Department complaining of severe pain in his right eye and feeling like there is something foreign in it, even though he has already removed his contact lenses. Upon examination, the right eye shows conjunctival injection, and the patient experiences photophobia, tearing, and discharge. His visual acuity is 6/6 in the left eye and 6/12 in the right eye, with intact ocular reflexes. A slit lamp inspection reveals mild, regular ulceration in the right eye. What is the most probable diagnosis?
Your Answer:
Correct Answer: Acanthamoeba keratitis
Explanation:Wearing contact lenses increases the risk of acanthamoeba infection, which can cause keratitis. This is especially true for individuals who are frequently exposed to bodies of water, such as swimmers and lifeguards. Symptoms of acanthamoeba keratitis include eye pain, reduced visual acuity, redness, photophobia, and discharge. Treatment typically involves a combination of antiamoebic medications such as biguanides and diamidines. Anterior uveitis, conjunctivitis, and herpes simplex virus keratitis are less likely causes of the patient’s symptoms, given the history of contact lens use and occupation as a lifeguard.
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 19
Incorrect
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A 62-years-old-man presents to the pulmonology clinic with a recent onset of ptosis in his right upper lid. He has been experiencing a chronic cough for the past three months, accompanied by streaks of blood. Upon radiological examination, an opacification is observed in the upper right part of his chest. The patient appears cachexic and unwell, with a BMI of 18 kg/m² and a fasting blood sugar level of 8.3 mmol/L. What other clinical findings may be present in this patient?
Your Answer:
Correct Answer: Right upper limb pain
Explanation:Patients with Pancoast tumours may experience shoulder pain and upper limb neurological signs, in addition to Horner’s syndrome, due to the tumour proximity to the brachial plexus. Therefore, the correct answer is right upper limb pain. Kussmaul breathing is an incorrect option as it is associated with metabolic acidosis, which is not present in this case. Lupus pernio is also an incorrect answer as it is more commonly seen in sarcoidosis rather than lung cancer. Opsoclonus-myoclonus syndrome is another incorrect option as it is a paraneoplastic syndrome typically associated with neuroblastoma in children.
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.
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This question is part of the following fields:
- Ophthalmology
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Question 20
Incorrect
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Which one of the following statements regarding the management of conjunctivitis is incorrect?
Your Answer:
Correct Answer: Contact lens may be worn once topical antibiotic treatment has been started
Explanation:It is not advisable to wear contact lenses while experiencing conjunctivitis.
Conjunctivitis is a common eye problem that is often seen in primary care. It is characterized by red, sore eyes with a sticky discharge. There are two types of infective conjunctivitis: bacterial and viral. Bacterial conjunctivitis is identified by a purulent discharge and eyes that may be stuck together in the morning. On the other hand, viral conjunctivitis is characterized by a serous discharge and recent upper respiratory tract infection, as well as preauricular lymph nodes.
In most cases, infective conjunctivitis is a self-limiting condition that resolves without treatment within one to two weeks. However, topical antibiotic therapy is often offered to patients, such as Chloramphenicol drops given every two to three hours initially or Chloramphenicol ointment given four times a day initially. Alternatively, topical fusidic acid can be used, especially for pregnant women, and treatment is twice daily.
For contact lens users, topical fluoresceins should be used to identify any corneal staining, and treatment should be the same as above. During an episode of conjunctivitis, contact lenses should not be worn, and patients should be advised not to share towels. School exclusion is not necessary.
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This question is part of the following fields:
- Ophthalmology
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Question 21
Incorrect
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A 9-year-old girl presents to the emergency department with increasing redness and swelling around her left eye over the past 48 hours. During the examination, she reports pain and double vision when her eye movements are assessed. There is also tenderness and erythema over the left eyelid. Her temperature is 38°C. Based on the probable diagnosis, what is the most suitable course of treatment?
Your Answer:
Correct Answer: Intravenous cefotaxime
Explanation:Orbital cellulitis can be distinguished from preseptal cellulitis by the presence of symptoms such as reduced visual acuity, proptosis, and pain when moving the eyes. If a person experiences painful eye movements and visual disturbances along with a red, swollen, and tender eye, it is a cause for concern and may indicate orbital cellulitis. In such cases, it is crucial to administer urgent empirical intravenous antibiotics that cover gram-positive and anaerobic organisms, such as Intravenous cefotaxime or clindamycin. On the other hand, preseptal cellulitis can be managed with oral co-amoxiclav and close monitoring. Unlike orbital cellulitis, preseptal cellulitis does not cause painful eye movements or visual disturbances and is less likely to cause fever.
In rare cases, subperiosteal or orbital abscess may complicate orbital cellulitis, leading to symptoms such as proptosis, headache (facial, throbbing), and reduced visual acuity. In such cases, surgical drainage may be necessary, but intravenous empirical antibiotics would still be an essential part of the treatment. It is worth noting that these conditions are more likely to occur as a complication of sinusitis rather than orbital cellulitis.
Bacterial keratitis, which is more common in contact lens users, can be treated with topical ciprofloxacin. This condition presents with symptoms such as eye pain, watering, and photophobia but does not cause eyelid swelling, diplopia, or fever.
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.
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This question is part of the following fields:
- Ophthalmology
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Question 22
Incorrect
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A 70-year-old man, with a history of atrial fibrillation, hypertension and type 2 diabetes mellitus, presents to the Emergency Department with a sudden painless loss of vision in his left eye that lasted for a few minutes. He describes the loss of vision as a curtain coming into his vision, and he could not see anything out of it for a few minutes before his vision returned to normal.
Upon examination, his acuity is 6/9 in both eyes. On dilated fundoscopy, there is a small embolus in one of the vessels in the left eye. The rest of the fundus is normal in both eyes.
What is the most likely diagnosis?Your Answer:
Correct Answer: Amaurosis fugax
Explanation:Differentiating Causes of Vision Loss: Amaurosis Fugax, Anterior Ischaemic Optic Neuropathy, CRAO, CRVO, and Retinal Detachment
When a patient presents with vision loss, it is important to differentiate between various causes. In the case of a transient and painless loss of vision, a typical diagnosis is amaurosis fugax. This is often seen in patients with atrial fibrillation and other vascular risk factors, and a small embolus may be present on fundoscopy. Treatment involves addressing the underlying cause and treating it as an eye transischaemic attack (TIA).
Anterior ischaemic optic neuropathy, on the other hand, is caused by giant-cell arthritis and presents with a sudden, painless loss of vision. However, there is no evidence of this in the patient’s history.
Central retinal artery occlusion (CRAO) is another potential cause of vision loss, but it does not present as a transient loss of vision. Instead, it causes long-lasting damage and may be identified by a cherry-red spot at the macula. The small embolus seen on fundoscopy is not causing a CRAO.
Similarly, central retinal vein occlusion (CRVO) presents with multiple flame haemorrhages, which are not present in this case.
While the patient did mention a curtain-like loss of vision, this does not necessarily indicate retinal detachment. Retinal detachment typically presents with flashes and floaters, and vision is worse if the detachment is a macula-off detachment.
In summary, careful consideration of the patient’s history and fundoscopic findings can help differentiate between various causes of vision loss.
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This question is part of the following fields:
- Ophthalmology
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Question 23
Incorrect
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A 50-year-old woman presents to the eye emergency department with complaints of blurred vision and sensitivity to bright lights. She has a medical history of asthma, polymyalgia rheumatica, and gout. During the examination, the ophthalmologist identifies a subcapsular cataract in her left eye, located just beneath the lens in the visual axis.
What is the most significant risk factor for subcapsular cataracts?Your Answer:
Correct Answer: Steroids
Explanation:Steroid use may be linked to the development of subcapsular cataracts, which are located behind the capsule in the visual axis and have a rapid progression. These cataracts are often accompanied by glare from bright lights and appear as a central granular lens opacity during examination. Dot cataracts are associated with myotonic dystrophy, while nuclear cataracts are linked to myopia. Nuclear cataracts with a stellate morphology are typically associated with ocular trauma, but this depends on the mechanism of the injury.
Understanding Cataracts: Causes, Symptoms, and Management
A cataract is a common eye condition that affects the lens of the eye, causing it to become cloudy and reducing the amount of light that reaches the retina. This can lead to blurred or reduced vision, making it difficult to see clearly. Cataracts are more common in women and tend to increase in incidence with age. While the normal ageing process is the most common cause, other factors such as smoking, alcohol consumption, trauma, diabetes, and long-term corticosteroid use can also contribute to the development of cataracts.
Symptoms of cataracts include reduced vision, faded colour vision, glare, and halos around lights. A defect in the red reflex is also a sign of cataracts. Diagnosis is typically made through ophthalmoscopy and slit-lamp examination, which can reveal the presence of a visible cataract.
In the early stages, age-related cataracts can be managed conservatively with stronger glasses or contact lenses and brighter lighting. However, surgery is the only effective treatment for cataracts and involves removing the cloudy lens and replacing it with an artificial one. Referral for surgery should be based on the presence of visual impairment, impact on quality of life, and patient choice. Complications following surgery can include posterior capsule opacification, retinal detachment, posterior capsule rupture, and endophthalmitis.
Overall, cataracts are a common and treatable eye condition that can significantly impact a person’s vision. Understanding the causes, symptoms, and management options can help individuals make informed decisions about their eye health.
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This question is part of the following fields:
- Ophthalmology
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Question 24
Incorrect
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A 35-year-old man has arrived at the eye emergency department following a blow to the face with a baseball bat. During the examination, it was observed that there is blood in the anterior chamber of his left eye. What is the primary risk associated with the presence of blood in the anterior chamber?
Your Answer:
Correct Answer: Glaucoma
Explanation:Blunt trauma to the eye that results in hyphema can lead to increased intraocular pressure, which is a high-risk situation for the patient.
The blockage of aqueous humour drainage caused by the presence of blood can result in glaucoma, which is a serious complication that requires close monitoring of intraocular pressure. While cataracts and ectopia lentis can be associated with blunt trauma, they are not typically associated with hyphema. Endophthalmitis, on the other hand, is usually caused by infection, post-surgery, or penetrating ocular trauma.
Ocular Trauma and Hyphema
Ocular trauma can lead to hyphema, which is the presence of blood in the anterior chamber of the eye. This condition requires immediate referral to an ophthalmic specialist for assessment and management. The main concern is the risk of raised intraocular pressure due to the blockage of the angle and trabecular meshwork with erythrocytes. Patients with high-risk cases are often admitted and require strict bed rest to prevent the disbursement of blood. Even isolated hyphema requires daily ophthalmic review and pressure checks initially as an outpatient.
In addition to hyphema, an assessment should also be made for orbital compartment syndrome, which can occur secondary to retrobulbar hemorrhage. This is a true ophthalmic emergency and requires urgent management. Symptoms of orbital compartment syndrome include eye pain and swelling, proptosis, ‘rock hard’ eyelids, and a relevant afferent pupillary defect.
To manage orbital compartment syndrome, urgent lateral canthotomy is necessary to decompress the orbit. This should be done before diagnostic imaging to prevent further damage. Proper management and prompt referral to an ophthalmic specialist can help prevent vision loss and other complications associated with ocular trauma and hyphema.
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This question is part of the following fields:
- Ophthalmology
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Question 25
Incorrect
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A 25-year-old female patient complains of a painful red eye with a tearing sensation. On a scale of 1 to 10, she rates the pain as 7. She mentions that she wears contact lenses regularly. What would be the most suitable course of action?
Your Answer:
Correct Answer: Same-day ophthalmology referral
Explanation:If a contact lens wearer experiences a painful red eye, it is important to refer them to an eye casualty immediately to rule out microbial keratitis. Due to the complexity of assessing red eye in contact lens wearers, a specialist should assess the patient on the same day to determine the cause and provide appropriate treatment. While acyclovir is effective in treating viral keratitis, other microbes may be responsible for this condition. Therefore, specialist referral is necessary. The patient should be advised to temporarily discontinue contact lens use and practice good hygiene. Reassurance is not appropriate as microbial keratitis can lead to vision loss if left untreated. It is important to make an urgent referral, which is typically offered to suspected cancer patients within two weeks.
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 26
Incorrect
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A 28-year-old man presents with an acutely red right eye. He also has dull aching pain affecting the eye, and he is photosensitive, with light severely worsening the pain in the eye. There is no mucopurulent discharge and he has mild blurring of vision. The left eye is not affected. Other past history of note includes intermittent diarrhoea, which he says looked bloody on a couple of occasions, but he put this down to food poisoning. On examination, his blood pressure is 125/72 mmHg; he looks thin, with a body mass index of 19.
Investigations:
Investigation Result Normal value
Haemoglobin 119 g/l 135–175 g/l
White cell count (WCC) 8.1 × 109/l 4–11 × 109/l
Platelets 204 × 109/l 150–400 × 109/l
Erythrocyte sedimentation rate (ESR) 35 mm/h 0–10mm in the 1st hour
Sodium (Na+) 141 mmol/l 135–145 mmol/l
Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l
Creatinine 130 μmol/l 50–120 µmol/l
Intraocular pressure: reduced in the affected eye, with numerous cells seen within the aqueous.
Which of the following is the most likely diagnosis?Your Answer:
Correct Answer: Anterior uveitis
Explanation:Differential Diagnosis for a Red, Painful Eye with Photophobia: Anterior Uveitis
Anterior uveitis is a possible diagnosis for a patient presenting with a red, painful eye and photophobia. The condition can be idiopathic or associated with systemic inflammatory diseases, such as ulcerative colitis. The presence of inflammatory cells in the aqueous is a hallmark of anterior uveitis. Treatment typically involves cyclopentolate for ocular pain relief and corticosteroids to reduce inflammation. Tapering of corticosteroid therapy is guided by the degree of clinical response.
Other potential diagnoses, such as conjunctivitis and herpetic ulcer, can be ruled out based on the absence of certain symptoms and risk factors. Acute glaucoma is also unlikely as intraocular pressures are low in anterior uveitis, whereas they would be expected to be raised in acute glaucoma. Anterior scleritis is another possibility, but it is less likely in this case as the examination findings do not mention intense redness of the anterior sclera.
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This question is part of the following fields:
- Ophthalmology
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Question 27
Incorrect
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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:
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.
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This question is part of the following fields:
- Ophthalmology
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Question 28
Incorrect
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A 35-year-old female accountant comes to the emergency eye clinic with a painful red eye on the right side. She reports a burning sensation around the eye, sensitivity to light, and excessive tearing. Fluorescein staining reveals a linear, branching epithelial defect. She has no history of wearing contact lenses and no significant medical history. What is the best course of action for management?
Your Answer:
Correct Answer: Topical acyclovir
Explanation:Topical acyclovir is the treatment for herpes simplex keratitis, which presents with a painful red eye, photophobia, and abnormal fluorescein staining. Artificial tears are used for dry eyes, while topical chloramphenicol is used for bacterial conjunctivitis.
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.
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This question is part of the following fields:
- Ophthalmology
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Question 29
Incorrect
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A 63-year-old woman comes to the emergency department with sudden vision loss, redness, and pain in her left eye. She reports experiencing some discomfort and redness earlier in the day, which worsened over the next two hours. She has no history of trauma or other visual problems. Her medical history includes osteoarthritis, left eye cataract surgery three days ago, and no significant family history.
Upon examination, the left eye appears hyperemic with hypopyon, and eye movements are painful. Visual acuity is severely impaired, while the right eye appears normal. What is the most probable diagnosis?Your Answer:
Correct Answer: Endophthalmitis
Explanation:Post-operative endophthalmitis is a rare but serious complication that can occur after cataract surgery and requires immediate treatment.
If a patient experiences sudden pain, redness, and vision loss shortly after eye surgery, it may indicate post-operative endophthalmitis. This infection affects the aqueous and vitreous humor of the eye and is a rare complication of any eye surgery.
While anterior uveitis can also cause a painful red eye, it is less likely in this case due to the patient’s history of cataract surgery. Additionally, there is no mention of an irregularly-shaped pupil or any systemic disease associated with anterior uveitis.
A corneal ulcer is another possibility, but it typically presents with a sensation of a foreign body in the eye and discharge. It is also more common in contact lens wearers who have been exposed to water.
Retinal detachment is less likely because it usually causes visual disturbances such as floaters, flashes of light, and a curtain descending over the peripheral visual field. Although ocular surgery is a risk factor for retinal detachment, it would not cause the intense redness and hypopyon seen in post-operative endophthalmitis.
Understanding Cataracts: Causes, Symptoms, and Management
A cataract is a common eye condition that affects the lens of the eye, causing it to become cloudy and reducing the amount of light that reaches the retina. This can lead to blurred or reduced vision, making it difficult to see clearly. Cataracts are more common in women and tend to increase in incidence with age. While the normal ageing process is the most common cause, other factors such as smoking, alcohol consumption, trauma, diabetes, and long-term corticosteroid use can also contribute to the development of cataracts.
Symptoms of cataracts include reduced vision, faded colour vision, glare, and halos around lights. A defect in the red reflex is also a sign of cataracts. Diagnosis is typically made through ophthalmoscopy and slit-lamp examination, which can reveal the presence of a visible cataract.
In the early stages, age-related cataracts can be managed conservatively with stronger glasses or contact lenses and brighter lighting. However, surgery is the only effective treatment for cataracts and involves removing the cloudy lens and replacing it with an artificial one. Referral for surgery should be based on the presence of visual impairment, impact on quality of life, and patient choice. Complications following surgery can include posterior capsule opacification, retinal detachment, posterior capsule rupture, and endophthalmitis.
Overall, cataracts are a common and treatable eye condition that can significantly impact a person’s vision. Understanding the causes, symptoms, and management options can help individuals make informed decisions about their eye health.
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This question is part of the following fields:
- Ophthalmology
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Question 30
Incorrect
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A 23-year-old woman presents to the emergency department with complaints of hand clumsiness and photophobia that started a day ago. Her colleagues have noticed her struggling to find words for the past two weeks, but she hasn't noticed it herself. She had a dry cough two weeks ago, which has since resolved. She has no known allergies, no regular medications, and no past medical history.
During the examination, some double vision is observed when assessing the right peripheral visual field. Other than that, there are no significant findings. Due to her photophobia, limited fundoscopy is performed, which reveals blurring of the optic disc margin and venous engorgement.
What further tests or procedures should be conducted at this point?Your Answer:
Correct Answer: CT head
Explanation:The presence of papilloedema in this patient suggests an increase in intracranial pressure, making a lumbar puncture contraindicated. Her symptoms, including hand clumsiness, difficulty with word-finding, and acute photophobia, are consistent with a space-occupying lesion. A CT or MRI scan of the head should be urgently performed, and the patient should be referred to a neurosurgeon. Acetazolamide, a carbonic anhydrase inhibitor used to treat idiopathic intracranial hypertension, is not appropriate for this patient as her symptoms are not consistent with IIH. Broad-spectrum antibiotics and blood cultures are not necessary as the patient does not exhibit any signs of infection. The focus should be on promptly identifying any potential space-occupying lesions causing mass effect.
Understanding Papilloedema: Optic Disc Swelling Caused by Increased Intracranial Pressure
Papilloedema is a condition characterized by swelling of the optic disc due to increased pressure within the skull. This condition is typically bilateral and can be identified through fundoscopy. During this examination, venous engorgement is usually the first sign observed, followed by loss of venous pulsation, blurring of the optic disc margin, elevation of the optic disc, loss of the optic cup, and the presence of Paton’s lines, which are concentric or radial retinal lines cascading from the optic disc.
There are several potential causes of papilloedema, including space-occupying lesions such as tumors or vascular abnormalities, malignant hypertension, idiopathic intracranial hypertension, hydrocephalus, and hypercapnia. In rare cases, papilloedema may also be caused by hypoparathyroidism and hypocalcaemia, or vitamin A toxicity.
Overall, understanding papilloedema is important for identifying potential underlying conditions and providing appropriate treatment to prevent further complications.
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This question is part of the following fields:
- Ophthalmology
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