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  • Question 1 - A 42-year-old diabetic man is seen in the Diabetes Clinic with decreased visual...

    Incorrect

    • A 42-year-old diabetic man is seen in the Diabetes Clinic with decreased visual acuity. When referred to the Eye Clinic, the Ophthalmologist inquires about the patient's risk factors for macular edema.
      What is the most significant risk factor? Choose ONE answer only.

      Your Answer: Low glycosylated haemoglobin

      Correct Answer: Proteinuria

      Explanation:

      Factors Associated with Macular Edema in Diabetes

      In diabetes, macular edema is a common cause of visual loss and can result from various factors such as macular capillary non-perfusion, vitreous hemorrhage, and distortion or traction detachment of the retina. The severity of diabetic retinopathy, male gender, higher glycosylated hemoglobin, proteinuria, higher systolic and diastolic blood pressure, and smoking history are all associated with a higher incidence of macular edema, according to The Wisconsin Epidemiologic Study of Diabetic Retinopathy.

      Contrary to popular belief, low glycosylated hemoglobin is not associated with macular edema. However, hypercholesterolemia and other cardiovascular risk factors can influence the onset and progression of retinopathy and should be monitored. While peripheral vascular disease is a risk factor for diabetes, it is not directly associated with macular edema. Overall, understanding the factors associated with macular edema in diabetes can help healthcare professionals identify and manage patients at risk for this complication.

    • This question is part of the following fields:

      • Eyes And Vision
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  • Question 2 - You are evaluating a patient who is experiencing double vision. When looking straight...

    Incorrect

    • You are evaluating a patient who is experiencing double vision. When looking straight ahead, the patient's right eye is turned upward and outward. When attempting to look to the left, the double vision becomes more severe.

      What is the probable underlying issue?

      Your Answer: Right 6th nerve palsy

      Correct Answer: Right 4th nerve palsy

      Explanation:

      Understanding Fourth Nerve Palsy

      Fourth nerve palsy is a condition that affects the superior oblique muscle, which is responsible for depressing the eye and moving it inward. One of the main features of this condition is vertical diplopia, which is double vision that occurs when looking straight ahead. This is often noticed when reading a book or going downstairs. Another symptom is subjective tilting of objects, also known as torsional diplopia. Patients may also develop a head tilt, which they may or may not be aware of. When looking straight ahead, the affected eye appears to deviate upwards and is rotated outwards. Understanding the symptoms of fourth nerve palsy can help individuals seek appropriate treatment and management for this condition.

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      • Eyes And Vision
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  • Question 3 - A 25-year-old man has a 3-week history of persistent conjunctivitis in his right...

    Incorrect

    • A 25-year-old man has a 3-week history of persistent conjunctivitis in his right eye. He has tried using over-the-counter medication but this has not helped. Of note, he returned from a visit to Amsterdam four weeks ago, following which he was treated for urinary symptoms at the local walk-in centre. On examination, he has some mucopurulent discharge and hyperaemia. The inferior tarsal conjunctival follicles are obvious.
      What is the most likely diagnosis?

      Your Answer: Simple bacterial conjunctivitis

      Correct Answer: Chlamydial conjunctivitis

      Explanation:

      Differentiating Conjunctivitis: Causes and Symptoms

      Conjunctivitis, commonly known as pink eye, is an inflammation of the conjunctiva, the thin membrane that covers the white part of the eye and the inner surface of the eyelids. It can be caused by various factors, including bacteria, viruses, allergens, and sexually transmitted infections. Here are some of the different types of conjunctivitis and their distinguishing features:

      Chlamydial Conjunctivitis: This type of conjunctivitis is transmitted through autoinoculation or eye-to-eye spread and is associated with urethritis or cervicitis. It is caused by Chlamydia trachomatis and can last for up to 12 months if left untreated. It is usually unilateral and presents with chronic follicular conjunctivitis.

      Trachoma: This type of conjunctivitis is caused by poor sanitation and is the third most common cause of blindness in the world. It is caused by serotypes A to C of C. trachomatis and presents with severe conjunctival scarring and secondary corneal ulceration and scarring.

      Allergic Conjunctivitis: This type of conjunctivitis occurs in atopic individuals and presents with itchy, watering eyes.

      Gonococcal Conjunctivitis: This type of conjunctivitis is caused by gonorrhea and presents with a rapid onset of unilateral/bilateral red eyes with a severe purulent discharge and tender preauricular lymph nodes.

      Simple Bacterial Conjunctivitis: This type of conjunctivitis is usually bilateral and should have resolved by three weeks. The discharge is mucopurulent but less copious than in gonococcal conjunctivitis.

      Viral Conjunctivitis: This type of conjunctivitis is usually bilateral and should have resolved by three weeks. The discharge is usually watery, and follicles may be seen on eyelid eversion.

      In summary, the type of conjunctivitis can be determined by the symptoms and the underlying cause. It is important to seek medical attention if symptoms persist or worsen.

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      • Eyes And Vision
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  • Question 4 - A 23-year-old female who is overweight visits her doctor complaining of daily headaches...

    Incorrect

    • A 23-year-old female who is overweight visits her doctor complaining of daily headaches that have been ongoing for two weeks. The headaches are felt on both sides of her forehead, persist throughout the day, and intensify when she bends over. She doesn't experience any aura with the headaches. During a fundoscopy, the doctor notices blurring of the optic disc. What is the probable diagnosis?

      Your Answer: Sinus headache

      Correct Answer: Idiopathic intracranial hypertension

      Explanation:

      Idiopathic intracranial hypertension is a possible diagnosis for a young woman with a high BMI, headache, and visual symptoms, as it is associated with papilloedema. Cluster headaches, migraines, and sinus headaches do not account for papilloedema and have different characteristics.

      Understanding Papilloedema

      Papilloedema is a condition characterized by swelling of the optic disc due to increased pressure within the skull. This condition typically affects both eyes. During a fundoscopy, several signs may be observed, including venous engorgement, loss of venous pulsation, blurring of the optic disc margin, elevation of the optic disc, loss of the optic cup, and Paton’s lines.

      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 be caused by hypoparathyroidism and hypocalcaemia or vitamin A toxicity.

      It is important to diagnose and treat papilloedema promptly, as it can lead to permanent vision loss if left untreated. Treatment typically involves addressing the underlying cause of the increased intracranial pressure, such as surgery to remove a tumor or medication to manage hypertension.

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      • Eyes And Vision
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  • Question 5 - A 32-year-old man complains of itching and burning of his eyelid margins for...

    Incorrect

    • A 32-year-old man complains of itching and burning of his eyelid margins for two weeks. Upon examination, redness and scaling are observed on the edges of his eyelids.

      Which of the following is the correct statement?

      Your Answer:

      Correct Answer: He should be advised to use dilute baby shampoo to clean the eyelids twice a day

      Explanation:

      Understanding and Treating Blepharitis

      Blepharitis is a chronic condition that can be caused by staphylococcal infection, seborrhoeic dermatitis, meibomian gland dysfunction, or a combination of these factors. It is characterized by inflammation of the eyelid margins and can be managed with self-care measures. Good eyelid hygiene is crucial in treating blepharitis, and patients should be advised to clean their eyelids twice a day using dilute baby shampoo.

      While topical or oral antibiotics may be prescribed in certain cases, they should be reserved for second-line use when eyelid hygiene alone is ineffective. Contact dermatitis and acute conjunctivitis are not the same as blepharitis, and treatment with artificial tears is not always necessary.

      In some cases, chronic blepharitis may be a symptom of rosacea and can be treated with oral tetracycline. It is important for patients to understand the causes and treatment options for blepharitis in order to effectively manage their symptoms.

    • This question is part of the following fields:

      • Eyes And Vision
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  • Question 6 - You are conducting a HGV medical examination on a 65-year-old truck driver. He...

    Incorrect

    • You are conducting a HGV medical examination on a 65-year-old truck driver. He reports a decline in his vision but doesn't use corrective lenses. What is the method used to verify if he should be cautioned against driving according to DVLA standards?

      Your Answer:

      Correct Answer: Their visual acuity according to a Snellen chart is 6/7.5 in the best eye and 6/60 in the other eye

      Explanation:

      DVLA Fitness to Drive Standards: Vision Requirements

      According to the DVLA Fitness to Drive Standards, there are specific requirements for vision when driving. These include being able to read a car number plate made after 1 September 2001 from 20 meters away, having a visual acuity of at least decimal 0.5 (6/12) measured on the Snellen scale, and having an adequate field of vision. Lorry and bus drivers have additional requirements, including a visual acuity of at least 0.8 (6/7.5) in their best eye and an uninterrupted horizontal visual field of at least 160 degrees. It is important to note that if you have any problems with your eyesight that affect either eye, you must inform the DVLA. While there are some exceptions for those who held their license before 1 January 1997, it is crucial to meet these standards to ensure safe driving.

    • This question is part of the following fields:

      • Eyes And Vision
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  • Question 7 - A 35-year-old man presents to the Emergency Department claiming to have lost the...

    Incorrect

    • A 35-year-old man presents to the Emergency Department claiming to have lost the vision in his left eye. While sitting at his desk he started to see a shower of black spots in his vision. These rapidly increased, becoming larger and more numerous until he could not see at all. This has persisted over a period of five hours. He has diabetes, which has been very poorly controlled in the past. He previously had laser treatment to both eyes; however, he has not attended follow-up appointments in the last 12 months.
      What is the most likely explanation for this patient's presentation?

      Your Answer:

      Correct Answer: He has had a vitreous haemorrhage due to diabetic retinopathy

      Explanation:

      Differentiating Causes of Visual Disturbances in a Diabetic Patient

      Visual disturbances in diabetic patients can have various causes, and it is important to differentiate between them to provide appropriate treatment. In the case of proliferative diabetic retinopathy, new blood vessels grow in the eyes and can bleed spontaneously, causing visual disturbances. Laser treatment is necessary, and follow-up is crucial to ensure sufficient therapy. Acute retinal detachment requires urgent surgery to prevent further vision loss. Fungal eye infections are rare and usually follow an injury. Visual disturbances due to hypoglycaemia are transient and resolve when blood glucose stabilises. In contrast, persistent and progressive loss of vision suggests a vitreous haemorrhage, as seen in poorly controlled diabetic retinopathy. Proper diagnosis and treatment can prevent further vision loss in diabetic patients.

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      • Eyes And Vision
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  • Question 8 - A 70-year-old man mentions that he has a family history of glaucoma. Which...

    Incorrect

    • A 70-year-old man mentions that he has a family history of glaucoma. Which from the list is most likely to give evidence of primary open-angle glaucoma?

      Your Answer:

      Correct Answer: Visual field testing

      Explanation:

      Visual Field Testing for Glaucoma

      Primary open-angle (chronic) glaucoma is a condition that often goes undetected, with up to 50% of cases remaining unnoticed. By the time symptoms arise, up to 90% of optic nerve fibers may have already been irreversibly damaged. However, routine optician checks can help identify abnormal discs, raised intraocular pressure, or reduced visual fields, which are all potential indicators of glaucoma.

      Visual field testing is a crucial tool in detecting glaucoma. Perimetry machines objectively document what a patient perceives in their peripheral vision. This is more reliable than simple field testing, such as moving wiggling fingers or the end of a hatpin across each quadrant towards the center of the eye.

      Other tests, such as examination of pupillary responses, cover tests, and palpation of the eyes for hardness, are not reliable indicators of glaucoma. Visual acuity testing is also not a reliable indicator, as visual field loss from glaucoma typically spares fixation and visual acuity is preserved until the condition is advanced.

      In conclusion, visual field testing is a crucial tool in detecting glaucoma, and routine optician checks can help identify potential indicators of the condition.

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      • Eyes And Vision
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  • Question 9 - A three-year-old girl, who was otherwise healthy, has been brought in by her...

    Incorrect

    • A three-year-old girl, who was otherwise healthy, has been brought in by her concerned father who noticed her left eye turning inwards for the past two weeks.

      Ocular examination reveals a left esotropia. The eyes are white and the patient appears comfortable.

      What is the best course of action for management?

      Your Answer:

      Correct Answer: Refer to ophthalmology in the near future

      Explanation:

      Causes and Management of Squinting Eyes in Children

      There are various causes of squinting eyes in children, which can be categorized into muscular, neurogenic, inflammatory, and sensory deprivation causes. However, in a healthy child, the most appropriate management would be to refer them to an ophthalmologist immediately to rule out correctable causes, especially sensory deprivation causes like refractive error. This can be easily treated with glasses or contact lenses and possibly patching.

      If the squint is due to correctable sensory deprivation and is not addressed during childhood, it is unlikely that anything can be done to correct the vision in that eye, and amblyopia may develop. This can have a significant impact on the child’s future career and lifestyle. Therefore, early detection and management of squinting eyes in children is crucial to prevent long-term consequences.

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      • Eyes And Vision
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  • Question 10 - During a home visit, a 75-year-old female patient complains of a chesty cough....

    Incorrect

    • During a home visit, a 75-year-old female patient complains of a chesty cough. However, she also mentions experiencing severe and progressive right-sided eye pain since this morning. She has noticed blurry vision in the same eye and has been feeling nauseous, vomiting twice. As she has blue eyes, acute angle-closure glaucoma is suspected. Unfortunately, there will be a delay admitting the patient as the ambulance is at least 45 minutes away. What is the most appropriate method of managing this patient?

      Your Answer:

      Correct Answer: Ask the patient to lie flat, face up with no pillow

      Explanation:

      Acute angle closure glaucoma (AACG) is a type of glaucoma where there is a rise in intraocular pressure (IOP) due to a blockage in the outflow of aqueous humor. This condition is more likely to occur in individuals with hypermetropia, pupillary dilation, and lens growth associated with aging. Symptoms of AACG include severe pain, decreased visual acuity, a hard and red eye, halos around lights, and a semi-dilated non-reacting pupil. AACG is an emergency and requires urgent referral to an ophthalmologist. The initial medical treatment involves a combination of eye drops, such as a direct parasympathomimetic, a beta-blocker, and an alpha-2 agonist, as well as intravenous acetazolamide to reduce aqueous secretions. Definitive management involves laser peripheral iridotomy, which creates a tiny hole in the peripheral iris to allow aqueous humor to flow to the angle.

    • This question is part of the following fields:

      • Eyes And Vision
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  • Question 11 - A 50-year-old man presents to your urgent clinic with a red left eye....

    Incorrect

    • A 50-year-old man presents to your urgent clinic with a red left eye. He reports that he woke up this morning and noticed the redness, which was not present when he went to bed last night. He denies any pain, discharge, or itching in the eye. His visual acuity is 6/6 in both eyes and he doesn't wear contact lenses. He has no significant medical history and takes no regular medications.

      Upon examination, his blood pressure is 128/80 mmHg. There is a uniform area of redness in the medial inferior quadrant of the left eye. The cornea appears normal and the pupil reacts appropriately to light.

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Subconjunctival haemorrhage

      Explanation:

      A painless red eye that occurs suddenly is often caused by subconjunctival haemorrhage. This condition doesn’t affect the cornea and typically resolves on its own within two weeks. However, it is important to check the patient’s blood pressure as subconjunctival haemorrhage can rarely be linked to hypertension. On the other hand, a painful red eye may be caused by conditions such as herpes zoster ophthalmicus, scleritis, or uveitis. Conjunctivitis, which is characterized by a gritty sensation and ocular discharge, usually affects both eyes.

      Subconjunctival haemorrhages occur when blood vessels in the subconjunctival space bleed. These vessels typically supply the conjunctiva or episclera. Trauma is the most common cause, followed by spontaneous idiopathic cases, Valsalva manoeuvres, and several systemic diseases. While subconjunctival haemorrhages can look alarming, they are rarely an indicator of anything serious. They are more common in women than men, and the risk increases with age. Newborns are also more susceptible. The incidence of both traumatic and non-traumatic subconjunctival haemorrhages is 2.6%.

      Risk factors for subconjunctival haemorrhages include trauma, contact lens usage, idiopathic causes, Valsalva manoeuvres, hypertension, bleeding disorders, certain drugs, diabetes, arterial disease, and hyperlipidaemia. Symptoms include a red eye, usually unilateral, and mild irritation. Signs include a flat, red patch on the conjunctiva with well-defined edges and normal conjunctiva surrounding it. The patch’s size can vary depending on the size of the bleed and can involve the whole conjunctiva. Traumatic haemorrhages are most common in the temporal region, with the inferior conjunctiva as the next most commonly affected area. Vision should be normal, including acuity, visual fields, and range of eye movements. On examination, the fundus should be normal.

      The diagnosis of a subconjunctival haemorrhage is clinical. If there is no obvious traumatic cause, check the patient’s blood pressure. If raised, refer the patient appropriately. If the patient is taking warfarin, check the INR. If raised, refer for appropriate adjustments to the dose to bring the INR back into the target range. If you cannot see the whole border of the haemorrhage, it may be associated with an intracranial bleed or an orbital roof fracture. Further appropriate investigations should then be done, including a full cranial nerve exam looking for neurological signs as well as a CT head, after discussion with a senior. Recurrent or spontaneous, bilateral subconjunctival haemorrhages warrant investigations for bleeding disorders or other pathology.

      Reassure the patient that subconjunctival haemorrhages are a benign condition that will resolve on their own in 2 to 3 weeks.

    • This question is part of the following fields:

      • Eyes And Vision
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  • Question 12 - A 70-year-old male patient of yours is confused. He has had nausea and...

    Incorrect

    • A 70-year-old male patient of yours is confused. He has had nausea and vomiting for two days and is now complaining of yellow vision.

      Which of the following is the most likely cause?

      Your Answer:

      Correct Answer: Digoxin

      Explanation:

      Xanthopsia and Digoxin Toxicity

      Confusion, nausea, vomiting, and yellow discoloration of vision are all symptoms that suggest digoxin toxicity. Xanthopsia, or yellow vision, is a rare but possible side effect of digoxin toxicity, particularly in the elderly. Amiodarone can cause corneal deposits and impaired vision, but it doesn’t result in xanthopsia.

      While rotavirus and viral labyrinthitis may cause nausea and vomiting, they do not result in xanthopsia. It is important to note that the elderly are often more susceptible to side effects from medications due to various factors such as declining renal function and rates of gastric emptying.

      If a patient presents with xanthopsia and other symptoms of digoxin toxicity, it is crucial to consider the possibility of digoxin toxicity and take appropriate action. The British National Formulary provides information on digoxin and its potential side effects.

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  • Question 13 - A 52-year-old man with type 2 diabetes mellitus presents for his annual review...

    Incorrect

    • A 52-year-old man with type 2 diabetes mellitus presents for his annual review and is found to have new vessel formation at the optic disc. His visual acuity in both eyes is unaffected (6/9) and his blood pressure is 155/84 mmHg. His HbA1c level is 68 mmol/mol (8.4%). What is the primary intervention that should be taken for this patient?

      Your Answer:

      Correct Answer: Laser therapy

      Explanation:

      An ophthalmologist should be urgently referred for panretinal photocoagulation as the patient is suffering from proliferative diabetic retinopathy.

      Understanding Diabetic Retinopathy

      Diabetic retinopathy is a leading cause of blindness in adults aged 35-65 years-old. The condition is caused by hyperglycemia, which leads to abnormal metabolism in the retinal vessel walls, causing damage to endothelial cells and pericytes. This damage leads to increased vascular permeability, which causes exudates seen on fundoscopy. Pericyte dysfunction predisposes to the formation of microaneurysms, while neovasculization is caused by the production of growth factors in response to retinal ischaemia.

      Patients with diabetic retinopathy are typically classified into those with non-proliferative diabetic retinopathy (NPDR), proliferative retinopathy (PDR), and maculopathy. NPDR is further classified into mild, moderate, and severe, depending on the presence of microaneurysms, blot haemorrhages, hard exudates, cotton wool spots, venous beading/looping, and intraretinal microvascular abnormalities. PDR is characterized by retinal neovascularisation, which may lead to vitreous haemorrhage, 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. For maculopathy, intravitreal vascular endothelial growth factor (VEGF) inhibitors are used if there is a change in visual acuity. Non-proliferative retinopathy is managed through regular observation, while severe/very severe cases may require panretinal laser photocoagulation. Proliferative retinopathy is treated with panretinal laser photocoagulation, intravitreal VEGF inhibitors, and vitreoretinal surgery in severe or vitreous haemorrhage cases. Examples of VEGF inhibitors include ranibizumab, which has a strong evidence base for slowing the progression of proliferative diabetic retinopathy and improving visual acuity.

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      • Eyes And Vision
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  • Question 14 - A 68-year-old with a history of type 2 diabetes mellitus and hypertension comes...

    Incorrect

    • A 68-year-old with a history of type 2 diabetes mellitus and hypertension comes to the clinic complaining of experiencing light flashes in his left eye. He has been experiencing these symptoms for the past 2 days and they seem to occur more at the peripheral part of his vision. There is no pain or redness in the affected eye. His corrected visual acuity is measured as 6/9 in both eyes. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Vitreous detachment

      Explanation:

      If a patient experiences flashes and floaters, it may indicate vitreous detachment, which increases the risk of retinal detachment. Therefore, it is crucial to refer the patient to an ophthalmologist immediately.

      Sudden loss of vision can be a scary symptom for patients, but it can be caused by a variety of factors. Transient monocular visual loss (TMVL) is a term used to describe a sudden, temporary loss of vision that lasts less than 24 hours. The most common causes of sudden painless loss of vision include ischaemic/vascular issues, vitreous haemorrhage, retinal detachment, and retinal migraine.

      Ischaemic/vascular issues, also known as ‘amaurosis fugax’, can be caused by a wide range of factors such as thrombosis, embolism, temporal arteritis, and hypoperfusion. It may also represent a form of transient ischaemic attack (TIA) and should be treated similarly with aspirin 300 mg. 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, and hypertension. Severe retinal haemorrhages are usually seen on fundoscopy. Central retinal artery occlusion, on the other hand, is due to thromboembolism or arteritis and features include afferent pupillary defect and a ‘cherry red’ spot on a pale retina.

      Vitreous haemorrhage can be caused by diabetes, bleeding disorders, and anticoagulants. Features may include sudden visual loss and dark spots. Retinal detachment may be preceded by flashes of light or floaters, which are also symptoms of posterior vitreous detachment. Differentiating between these conditions can be done by observing the specific symptoms such as a veil or curtain over the field of vision, straight lines appearing curved, and central visual loss. Large bleeds can cause sudden visual loss, while small bleeds may cause floaters.

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  • Question 15 - A 40-year-old woman presents with bilateral blurring of vision accompanied by light sensitivity...

    Incorrect

    • A 40-year-old woman presents with bilateral blurring of vision accompanied by light sensitivity and eye pain. Upon examination, you observe that her eyes are injected. She also reports experiencing ankle pain and displays tender erythematous lesions on her shins. A chest X-ray reveals hilar lymphadenopathy. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Uveitis

      Explanation:

      Uveitis in Sarcoidosis: A Common Ocular Manifestation

      Sarcoidosis is a systemic disease that can affect various organs, including the eyes. Uveitis, a type of inflammation in the uvea (the middle layer of the eye), is a common ocular manifestation of sarcoidosis. It typically presents as granulomatous uveitis, which is often bilateral. Conjunctival nodules may also be present. Other ocular manifestations of sarcoidosis include episcleritis and scleritis, although they are less common than uveitis. It is important for patients with sarcoidosis to have regular eye exams to monitor for any ocular complications.

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  • Question 16 - A 32-year-old engineer seeks guidance regarding laser correction of myopia.
    What is the one...

    Incorrect

    • A 32-year-old engineer seeks guidance regarding laser correction of myopia.
      What is the one accurate statement about this treatment?

      Your Answer:

      Correct Answer: Is complicated sometimes by reduced night vision

      Explanation:

      Myths and Facts about Laser Eye Surgery

      Laser eye surgery is a popular procedure for correcting refractive errors, but there are many misconceptions about it. Here are some myths and facts about laser eye surgery:

      Myth: Laser eye surgery can be performed by optometrists without special training.
      Fact: Laser eye surgery should only be performed by ophthalmologists who have received special training and certification.

      Myth: Laser eye surgery is available on the National Health Service for sight improvement.
      Fact: Laser eye surgery is not available on the National Health Service for cosmetic purposes.

      Myth: Laser eye surgery is suitable for anyone over the age of 16 years.
      Fact: Laser eye surgery is not recommended for young people whose eyes are still developing and whose prescription may still change.

      Myth: Laser eye surgery is suitable for patients with keratoconus.
      Fact: Laser eye surgery is not recommended for patients with keratoconus, as it can further thin the cornea.

      Laser eye surgery can be a safe and effective way to correct refractive errors, but it is important to separate fact from fiction before making a decision. Always consult with a qualified ophthalmologist to determine if laser eye surgery is right for you.

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  • Question 17 - A mother brings her 10-week-old child in for review. Since birth, the child's...

    Incorrect

    • A mother brings her 10-week-old child in for review. Since birth, the child's left eye has been watering. The symptoms have worsened over the past few days after the child contracted a mild viral illness. Upon clinical examination, no abnormalities were found. What is the best course of action to take?

      Your Answer:

      Correct Answer: Teach nasolacrimal duct massage

      Explanation:

      Understanding Nasolacrimal Duct Obstruction in Infants

      Nasolacrimal duct obstruction is a common condition that causes persistent watery eyes in infants. It occurs when there is an imperforate membrane, usually at the lower end of the lacrimal duct. This condition affects around 1 in 10 infants, with symptoms typically appearing at around one month of age.

      Fortunately, nasolacrimal duct obstruction can be managed with simple techniques. Parents can be taught to massage the lacrimal duct, which can help to alleviate symptoms. In fact, around 95% of cases resolve on their own by the time the child reaches one year of age.

      However, in cases where symptoms persist beyond this point, it may be necessary to seek further medical intervention. In such cases, it is recommended to refer the child to an ophthalmologist for consideration of probing. This procedure is typically done under a light general anaesthetic and can help to resolve any remaining issues with the nasolacrimal duct.

      Overall, while nasolacrimal duct obstruction can be concerning for parents, it is a manageable condition that typically resolves on its own. By understanding the causes and treatment options for this condition, parents can help to ensure their child’s eyes stay healthy and comfortable.

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  • Question 18 - A 65-year-old woman presents with a 2-day history of a progressively painful left...

    Incorrect

    • A 65-year-old woman presents with a 2-day history of a progressively painful left eye. She reports redness in the eye and increased sensitivity to light, with pain rated at 10/10. She typically wears glasses for reading and doesn't use contact lenses. The affected eye's vision is slightly blurred. The patient has a medical history of rheumatoid arthritis, which is managed with methotrexate. On examination, the left eye is red, the cornea is clear, and the pupil is reactive. Eye movements cause pain. Fundoscopy reveals no abnormalities. Using a pinhole, visual acuity is 6/6 in the right eye and 6/12 in the left eye.

      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Scleritis

      Explanation:

      Scleritis is a serious condition that can be caused by systemic inflammatory diseases such as rheumatoid arthritis. Patients typically experience intense eye pain that worsens with eye movement, as well as sensitivity to light, tearing, and decreased vision. The eye may be tender to the touch. If scleritis is suspected, it is important to seek immediate referral to an ophthalmologist as it can lead to vision loss. Treatment involves the use of nonsteroidal anti-inflammatory drugs and immunosuppressants. Episcleritis, on the other hand, is less painful and causes more localized redness. A simple test involving the use of phenylephrine eye drops can help distinguish between the two conditions. Conjunctivitis and subconjunctival hemorrhage do not typically cause vision loss, while optic neuritis can cause pain with eye movement and decreased vision, but not a red eye.

      Understanding Scleritis: Causes, Symptoms, and Treatment

      Scleritis is a condition that involves inflammation of the sclera, which is the white outer layer of the eye. This condition is typically non-infectious and can cause a red, painful eye. The most common risk factor associated with scleritis is rheumatoid arthritis, but it can also be linked to other conditions such as systemic lupus erythematosus, sarcoidosis, and granulomatosis with polyangiitis.

      Symptoms of scleritis include a red eye, which is often accompanied by pain and discomfort. Other common symptoms include watering and photophobia, which is sensitivity to light. In some cases, scleritis can also lead to a gradual decrease in vision.

      Treatment for scleritis typically involves the use of oral NSAIDs as a first-line treatment. In more severe cases, oral glucocorticoids may be used. For resistant cases, immunosuppressive drugs may be necessary, especially if there is an underlying associated disease.

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  • Question 19 - In a 60-year-old patient presenting with complete homonymous hemianopia (with macular sparing), what...

    Incorrect

    • In a 60-year-old patient presenting with complete homonymous hemianopia (with macular sparing), what is the most likely diagnosis?

      Your Answer:

      Correct Answer: Occipital cortex lesion

      Explanation:

      Understanding Homonymous Hemianopia: Causes and Symptoms

      Homonymous hemianopia is a condition characterized by the loss of part of the field of view on the same side in both eyes. This occurs due to a lesion involving the occipital cortex, which contains temporal fibers from the same side and nasal fibers from the opposite side. It is important to note that there may be macular sparing in this condition.

      It is crucial to differentiate homonymous hemianopia from other conditions that may present with similar symptoms. A lateral geniculate nucleus lesion, for example, can produce complete or partial homonymous defects. Migraine, on the other hand, may present with complex visual phenomena during the aura stage, but it is less likely to cause hemianopia than an occipital lobe lesion.

      An optic chiasm lesion would result in bitemporal hemianopia, as information from the temporal visual field falls on the nasal (medial) retina, and the nasal fibers are compressed in lesions of the chiasm. An optic nerve lesion, on the other hand, usually presents as monocular visual loss.

      In summary, homonymous hemianopia is a condition that results from a lesion involving the occipital cortex. It is important to differentiate it from other conditions that may present with similar symptoms to ensure proper diagnosis and treatment.

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  • Question 20 - A 75-year-old man has recently been diagnosed with diabetes. What is the most...

    Incorrect

    • A 75-year-old man has recently been diagnosed with diabetes. What is the most significant retinal feature that would indicate the presence of proliferative diabetic retinopathy?

      Your Answer:

      Correct Answer: New vessel formation

      Explanation:

      Understanding Diabetic Retinopathy: Symptoms and Stages

      Diabetic retinopathy is a common complication of diabetes that can lead to blindness if left untreated. It affects up to 80% of patients who have had diabetes for ten years or more. The longer a person has diabetes, the higher the chance of developing diabetic retinopathy.

      The exact mechanism by which diabetes leads to retinopathy is not fully understood. However, it is known that microvascular occlusion causes retinal ischaemia, leading to arteriovenous shunts and neovascularisation. Leakage results in intraretinal haemorrhages and localised or diffuse oedema. These are characteristic features that appear at various stages of diabetic retinopathy.

      As retinopathy progresses, it enters an advanced or proliferative stage. At this stage, blood vessels proliferate/grow (neovascularisation). These can bleed, leading to vitreous haemorrhage and blurring of vision.

      There are several symptoms and stages of diabetic retinopathy that should be recognized. Haemorrhages result from rupture of weakened capillaries and appear as small dots or larger blots. Cotton-wool spots are due to a build-up of axonal debris and have a white fluffy appearance. Hard exudates are precipitates of lipoproteins and other proteins leaking from retinal blood vessels. They form white or yellow deposits usually with sharp margins. Microaneurysms are an early feature of diabetic retinopathy appearing at the non-proliferative stage. They appear as red dots.

      General practitioners should be able to use an ophthalmoscope and recognize significant abnormalities. Fundus photography examines larger areas of the fundus and has the advantage of photo documentation for future reference. It is important to monitor and treat diabetic retinopathy to prevent blindness.

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  • Question 21 - A 25-year-old university student comes to the GP clinic complaining of right eye...

    Incorrect

    • A 25-year-old university student comes to the GP clinic complaining of right eye pain, photophobia, and reduced visual acuity that started a day ago. During the examination, fluorescein staining showed a dendritic ulcer on the cornea. The patient wears contact lenses every day but has not been able to since the symptoms began.

      What should be the next course of action in managing this patient?

      Your Answer:

      Correct Answer: Immediate referral to an ophthalmologist

      Explanation:

      If there is suspicion of herpes simplex keratitis, an immediate referral to an ophthalmologist is necessary. This is especially important if there is a dendritic corneal ulcer present. While topical acyclovir is the treatment for herpes simplex keratitis, the urgent specialist referral should be the next step in management. Chloramphenicol and itraconazole are not effective treatments for this condition. Eye lubricants and analgesia alone are not sufficient management options.

      Understanding Herpes Simplex Keratitis

      Herpes simplex keratitis is a condition that primarily affects the cornea 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 aciclovir, which can help to reduce the severity of symptoms and prevent further complications.

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  • Question 22 - A 42-year-old woman with a history of rheumatoid arthritis comes in with a...

    Incorrect

    • A 42-year-old woman with a history of rheumatoid arthritis comes in with a red right eye that has been present for two days. She reports no pain or itching. Upon examination, her pupils are equal and reactive to light, measuring 3mm. Her visual acuity is 6/5 in both eyes. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Episcleritis

      Explanation:

      Episcleritis is not painful, whereas scleritis causes pain.

      Rheumatoid Arthritis and Its Effects on the Eyes

      Rheumatoid arthritis is a condition that affects the joints, but it can also have ocular manifestations. In fact, about 25% of patients with rheumatoid arthritis experience eye problems. The most common ocular manifestation is keratoconjunctivitis sicca, which is dryness and inflammation of the eyes. Other ocular manifestations include episcleritis, which is redness of the outer layer of the eye, and scleritis, which is redness and pain in the white part of the eye. Corneal ulceration and keratitis are also possible.

      In addition to these manifestations, some treatments for rheumatoid arthritis can also have ocular side effects. Steroid use can lead to cataracts, while the use of chloroquine can cause retinopathy. It is important for patients with rheumatoid arthritis to have regular eye exams to monitor for any ocular manifestations or side effects from treatment.

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  • Question 23 - An 80-year-old lady came to the clinic complaining of a one day history...

    Incorrect

    • An 80-year-old lady came to the clinic complaining of a one day history of right temporal headache, jaw claudication, fever and reduced appetite. She stated that her vision had not worsened.
      Upon examination, there was tenderness on palpation of the right scalp at the temporal region and the right temporal artery was palpable and hard. The patient's visual acuity was 6/6 on both eyes according to the Snellen chart.
      What would be the most appropriate next step in managing this patient's condition?

      Your Answer:

      Correct Answer: Start the patient on oral prednisolone

      Explanation:

      Giant Cell Temporal Arteritis: Urgent Management Required

      This patient’s history strongly suggests giant cell temporal arteritis (GCA), a medical emergency that requires urgent management. While ophthalmologists may be involved in the management of GCA, their involvement is only necessary if the condition is affecting the patient’s vision. In this scenario, the patient’s vision is not affected.

      The recommended course of action is to start the patient on 40-60mg of prednisolone per day (for patients without visual symptoms) and refer them urgently to a physician, typically a Rheumatologist. It is important to note that national guidance should be followed, rather than local variations, when assessing patients in an exam setting. Shared care is recommended, and patients may require treatment for several years.

      In addition to steroids, aspirin and PPIs are recommended. However, long-term treatment with oral steroids can increase the risk of osteoporosis, which should be assessed. For more information on national guidance and associated information, CKS provides a comprehensive summary of GCA management.

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  • Question 24 - A 67-year-old woman complains of visual difficulties. She has a history of rheumatoid...

    Incorrect

    • A 67-year-old woman complains of visual difficulties. She has a history of rheumatoid arthritis, depression, and is on medication for hypertension. She has been experiencing headaches and blurred vision for the past few days, and today she noticed a significant decrease in vision in her right eye. During the examination, her right eye appeared red, her pupil was sluggish, and her corrected visual acuity was 6/30. Her medication was recently altered. Which of the following medications is the most probable cause of this occurrence?

      Your Answer:

      Correct Answer: Amitriptyline

      Explanation:

      Anticholinergics and tricyclic antidepressants are drugs that can cause acute glaucoma.

      Acute angle closure glaucoma (AACG) is a type of glaucoma where there is a rise in intraocular pressure (IOP) due to a blockage in the outflow of aqueous humor. This condition is more likely to occur in individuals with hypermetropia, pupillary dilation, and lens growth associated with aging. Symptoms of AACG include severe pain, decreased visual acuity, a hard and red eye, halos around lights, and a semi-dilated non-reacting pupil. AACG is an emergency and requires urgent referral to an ophthalmologist. The initial medical treatment involves a combination of eye drops, such as a direct parasympathomimetic, a beta-blocker, and an alpha-2 agonist, as well as intravenous acetazolamide to reduce aqueous secretions. Definitive management involves laser peripheral iridotomy, which creates a tiny hole in the peripheral iris to allow aqueous humor to flow to the angle.

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  • Question 25 - A 62-year-old lady comes to see you after a routine assessment by her...

    Incorrect

    • A 62-year-old lady comes to see you after a routine assessment by her optician. She has had no visual problems prior to the assessment. The assessment revealed early nuclear sclerotic cataracts bilaterally. Her corrected visual acuity today is 6/5 in the right eye and 6/5 in the left eye.

      What is the most appropriate action to take?

      Your Answer:

      Correct Answer: No action is required

      Explanation:

      Understanding Cataracts and Driving Requirements

      It is common for individuals to develop nuclear sclerotic cataracts as they age. However, there is no need for referral unless there is a visual impairment that affects the patient’s lifestyle. If a person has a visual acuity of 6/5, it means they can read at a distance of six meters what a person with normal vision can read at five meters. Therefore, if a patient has excellent vision, they are unlikely to benefit from new glasses.

      There is no indication for a person to stop driving if they meet the minimum eyesight standard for driving, which is a visual acuity of at least 6/12 measured on the Snellen scale. To drive legally, a person must also be able to read a car number plate made after 1 September 2001 from a distance of 20 meters, with glasses or contact lenses if necessary.

      It is important to note that YAG laser capsulotomy is a procedure carried out for posterior capsular opacification, which can develop after cataract extraction. This procedure is not necessary for a patient with nuclear sclerotic cataracts and would not benefit them.

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  • Question 26 - A 24-year-old man has been experiencing painful redness in his left eye for...

    Incorrect

    • A 24-year-old man has been experiencing painful redness in his left eye for three days, along with blurred vision and sensitivity to light. He finds that the pain worsens when he tries to read. The redness is most prominent around the cornea, and the pupil on the affected side is slightly smaller and irregular compared to the right. Upon investigation, his haemoglobin, white cell count, and platelets are within normal range, but his erythrocyte sedimentation rate is elevated at 40 mm/hour. Additionally, he tests positive for HLA-B27. What is the most likely underlying cause of his eye problems?

      Your Answer:

      Correct Answer: Ankylosing spondylitis

      Explanation:

      The man in question is displaying symptoms of acute anterior uveitis, which can be caused by a variety of underlying systemic diseases or may be idiopathic. Non-granulomatous uveitis is often associated with diseases related to HLA-B27, such as ankylosing spondylitis, inflammatory bowel disease, reactive arthritis, psoriatic arthritis, and Behçet’s disease. Sarcoidosis, syphilis, toxoplasmosis, and tuberculosis can also cause uveitis, but each has its own unique ocular manifestations and symptoms.

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  • Question 27 - A 75-year-old woman who has just been diagnosed with macular degeneration seeks guidance...

    Incorrect

    • A 75-year-old woman who has just been diagnosed with macular degeneration seeks guidance on antioxidant dietary supplements. Is there any reason why such supplements should not be prescribed?

      Your Answer:

      Correct Answer: Current smoker

      Explanation:

      Antioxidant dietary supplements are not recommended for smokers due to the increased risk of lung cancer associated with beta-carotene.

      Age-related macular degeneration (ARMD) is a common cause of blindness in the UK, characterized by degeneration of the central retina (macula) and the formation of drusen. The risk of ARMD increases with age, smoking, family history, and conditions associated with an increased risk of ischaemic cardiovascular disease. ARMD is classified into dry and wet forms, with the latter carrying the worst prognosis. Clinical features include subacute onset of visual loss, difficulties in dark adaptation, and visual hallucinations. Signs include distortion of line perception, the presence of drusen, and well-demarcated red patches in wet ARMD. Investigations include slit-lamp microscopy, colour fundus photography, fluorescein angiography, indocyanine green angiography, and ocular coherence tomography. Treatment options include a combination of zinc with anti-oxidant vitamins for dry ARMD and anti-VEGF agents for wet ARMD. Laser photocoagulation is also an option, but anti-VEGF therapies are usually preferred.

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  • Question 28 - A 30-year-old myopic woman came in with complaints of a red right eye,...

    Incorrect

    • A 30-year-old myopic woman came in with complaints of a red right eye, accompanied by dull ocular pain, photophobia, and blurry vision. The affected eye also had some epiphora, but no ocular discharge was observed. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Acute anterior uveitis

      Explanation:

      Possible Diagnosis: Acute Anterior Uveitis

      The patient’s history doesn’t indicate infective conjunctivitis. Additionally, acute keratitis is unlikely as there are no known risk factors such as contact lens wear or eye injury. Moreover, keratitis typically causes sharp pain rather than a dull ache. The main symptom reported by the patient is vision disturbance, which is a key feature of acute anterior uveitis. Therefore, this condition should be considered as a possible diagnosis.

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  • Question 29 - A 67-year-old man presents to the clinic with a complaint of gradual deterioration...

    Incorrect

    • A 67-year-old man presents to the clinic with a complaint of gradual deterioration of his vision. He has been experiencing difficulty recognizing faces and distinguishing colors for several months. The patient also reports that his central vision appears somewhat blurry. He has a smoking habit of 10 cigarettes per day and a blood pressure of 124/76 mmHg. Recent blood tests, including an HbA1c of 38 mmol/mol, are unremarkable.

      What is the expected finding on fundoscopy when examining the patient's macula, given the likely diagnosis?

      Your Answer:

      Correct Answer: Drusen

      Explanation:

      Dry macular degeneration, also known as drusen, is a common cause of visual loss in individuals over the age of 50. The accumulation of lipid and protein debris around the macula is a key indicator of this condition. Wet macular degeneration, on the other hand, is characterized by choroidal neovascularization. Hypertensive retinopathy is typically associated with blot hemorrhages and cotton wool spots, while microaneurysms can indicate either hypertensive retinopathy or diabetic retinopathy. However, given the patient’s normal blood pressure and HbA1c levels, it is less likely that these findings are present.

      Age-related macular degeneration (ARMD) is a common cause of blindness in the UK, characterized by degeneration of the central retina (macula) and the formation of drusen. The risk of ARMD increases with age, smoking, family history, and conditions associated with an increased risk of ischaemic cardiovascular disease. ARMD is classified into dry and wet forms, with the latter carrying the worst prognosis. Clinical features include subacute onset of visual loss, difficulties in dark adaptation, and visual hallucinations. Signs include distortion of line perception, the presence of drusen, and well-demarcated red patches in wet ARMD. Investigations include slit-lamp microscopy, colour fundus photography, fluorescein angiography, indocyanine green angiography, and ocular coherence tomography. Treatment options include a combination of zinc with anti-oxidant vitamins for dry ARMD and anti-VEGF agents for wet ARMD. Laser photocoagulation is also an option, but anti-VEGF therapies are usually preferred.

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  • Question 30 - A 48-year-old man presents with complaints of blurred vision, redness and itching of...

    Incorrect

    • A 48-year-old man presents with complaints of blurred vision, redness and itching of the eyes. He reports having this chronic 'eye infection' on and off for the past four years. He has been using chloramphenicol drops without much relief. Upon examination, there is evidence of blepharitis, lid margin telangiectasia and mild conjunctival hyperaemia.
      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Rosacea

      Explanation:

      Common Eye Conditions Associated with Systemic Diseases

      Rosacea is a skin condition that can also affect the eyes, causing chronic blepharitis, meibomian cysts, conjunctivitis, and keratitis. Ocular rosacea symptoms may occur before, during, or after skin symptoms, and may not always match the severity of skin symptoms.

      Ulcerative colitis, an inflammatory bowel disease, can cause scleritis or uveitis, which can lead to eye pain, redness, and vision loss.

      Recurrent herpes simplex can cause a linear branching corneal ulcer, known as a dendritic ulcer, as well as epithelial and disciform keratitis, resulting in foreign-body sensation, light sensitivity, redness, and blurred vision.

      Rheumatoid arthritis may be associated with episcleritis, scleritis, and dry eyes, which can cause eye pain, redness, and irritation.

      Systemic sclerosis, a connective tissue disorder, can cause eyelid tightening and telangiectasia, which are visible blood vessels on the surface of the skin, including the eyelids.

      Overall, it is important for individuals with these systemic diseases to be aware of potential eye complications and to seek prompt medical attention if they experience any changes in their vision or eye health.

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  • Question 31 - A 5-week-old girl presents to your clinic with a three-day history of mild...

    Incorrect

    • A 5-week-old girl presents to your clinic with a three-day history of mild yellow discharge from her right eye and a 9 mm erythematous swelling inferior to the medial canthus of the right eye. Her mother reports that her eyes have always been watery. Upon examination, she has a temperature of 38.3°c. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Dacryocystitis

      Explanation:

      Eye Infections and Obstructions: Understanding the Differences

      Dacryocystitis is an inflammation of the nasolacrimal sac caused by an infection resulting from an obstruction in the nasolacrimal duct. This obstruction leads to the stagnation of tears and can cause systemic illness in infants. If left untreated, the infection can spread and cause orbital cellulitis.

      A chalazion, also known as a meibomian cyst, occurs when the small oil glands around the eyelashes become blocked due to inflammation. This blockage leads to the formation of a small, tender swelling within the eyelid. Chalazions can occur on either the inferior or superior eyelids.

      An external hordeolum, commonly known as a stye, is a localized infection or inflammation of the eyelash follicle. This type of infection is usually caused by a staphylococcal infection.

      While nasolacrimal duct obstruction can contribute to the development of dacryocystitis in infants, it should not cause inflammation and illness on its own. It is important to note that congenital nasolacrimal duct obstruction is common in infants and typically resolves within 12 months.

      Ophthalmia neonatorum caused by Neisseria gonorrhoeae typically occurs within the first five days of birth and is characterized by bilateral purulent discharge. When caused by chlamydial infection, the conjunctivitis may occur after three days but can arise as late as two weeks after birth.

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  • Question 32 - Each of the following can lead to cataract formation except for one. Which...

    Incorrect

    • Each of the following can lead to cataract formation except for one. Which one is it?

      Down's syndrome
      12%
      Hypercalcaemia
      28%
      Diabetes mellitus
      6%
      Long-term steroid use
      6%
      Uveitis
      48%

      Is it true that hypocalcaemia, not hypercalcaemia, is a contributing factor to cataract formation?

      Your Answer:

      Correct Answer: Hypercalcaemia

      Explanation:

      Cataract formation is more likely to occur due to hypocalcaemia rather than hypercalcaemia.

      Understanding Cataracts

      A cataract is a common eye condition that occurs when the lens of the eye becomes cloudy, making it difficult for light to reach the retina and causing reduced or blurred vision. Cataracts are more common in women and increase in incidence with age, affecting 30% of individuals aged 65 and over. The most common cause of cataracts is the normal ageing process, but other possible causes include smoking, alcohol consumption, trauma, diabetes mellitus, long-term corticosteroids, radiation exposure, myotonic dystrophy, and metabolic disorders such as hypocalcaemia.

      Patients with cataracts typically experience a gradual onset of reduced vision, faded colour vision, glare, and halos around lights. Signs of cataracts include a defect in the red reflex, which is the reddish-orange reflection seen through an ophthalmoscope when a light is shone on the retina. Diagnosis is made through ophthalmoscopy and slit-lamp examination, which reveal 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, involving the removal of the cloudy lens and replacement with an artificial one. Referral for surgery should be based on the presence of visual impairment, impact on quality of life, patient choice, and the risks and benefits of surgery. Complications following surgery may include posterior capsule opacification, retinal detachment, posterior capsule rupture, and endophthalmitis. Despite these risks, cataract surgery has a high success rate, with 85-90% of patients achieving corrected vision of 6/12 or better on a Snellen chart postoperatively.

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  • Question 33 - A 35-year-old man comes to the Ophthalmology Clinic with unequal pupils. He has...

    Incorrect

    • A 35-year-old man comes to the Ophthalmology Clinic with unequal pupils. He has been experiencing morning headaches and is currently undergoing investigation. The possibility of third (oculomotor) nerve palsy is being considered as the probable diagnosis.
      Which of the following examination results would provide the strongest evidence for this diagnosis? Choose ONE option only.

      Your Answer:

      Correct Answer: The pupil on the contralateral side reacts normally to light

      Explanation:

      Understanding Third Nerve Palsy: Effects on Pupil Size and Reactivity

      Third nerve palsy is a condition that affects the third cranial nerve, resulting in paralysis of the medial, superior, and inferior rectus muscles and inferior oblique muscles. This causes the affected eye to look down and out. One of the key symptoms of third nerve palsy is a smaller pupil on the affected side, due to the lack of parasympathetic nerve fibers to the iris sphincter. This also results in an inability to constrict in response to light, impairing light reactions to a direct or consensual stimulus. However, the pupil on the contralateral side will still react normally to light detected by the affected eye. Accommodation is also impaired, as the pupil would normally restrict as part of the near response. The size difference between pupils is greater in bright light, as the affected eye fails to constrict in response to light while the contralateral eye constricts as usual. Causes of third nerve palsy include diabetes mellitus, tumours, demyelination, giant cell arteritis, syphilis, posterior communicating artery aneurysm, raised intracranial pressure, and idiopathic aetiology.

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  • Question 34 - A 25-year-old man with ulcerative colitis and chronic lower back pain presents with...

    Incorrect

    • A 25-year-old man with ulcerative colitis and chronic lower back pain presents with a complaint of a red painful eye. What is the most probable feature that will be observed during the examination?

      Your Answer:

      Correct Answer: Photophobia on ophthalmoscopy

      Explanation:

      Understanding the Symptoms of HLA-B27 Associated Uveitis

      HLA-B27 associated uveitis is a condition that affects the eyes and is associated with several symptoms. One of the most common symptoms is photophobia, which is a sensitivity to light that can cause discomfort and pain. Other symptoms include ocular injection, miosis (due to ciliary spasm), normal or near-normal visual acuity, and a normal fundus.

      While retinal and vitreous haemorrhages have been reported with severe uveitis, retinal haemorrhages are not a common symptom. Additionally, a dilated pupil is not typically associated with uveitis, as a small pupil is more common in acute anterior uveitis. Chronic uveitis may cause irregular-shaped pupils due to the presence of synechiae.

      Profound visual loss is not a common symptom of uveitis, although some blurring of vision may occur with anterior uveitis. More severe loss of vision can occur with posterior uveitis and panuveitis. Finally, purulent discharge is not a symptom of uveitis, as it is typically associated with conjunctivitis.

      Overall, understanding the symptoms of HLA-B27 associated uveitis can help individuals recognize the condition and seek appropriate treatment.

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  • Question 35 - A 52-year-old woman presents with sudden-onset, painless visual loss affecting her left eye....

    Incorrect

    • A 52-year-old woman presents with sudden-onset, painless visual loss affecting her left eye. She awoke from sleep to find that she could only perceive light and dark and was unable to drive to work because of this.
      She has a history of recurrent miscarriage, although she has gone on to have one healthy child. Her medical history is otherwise unremarkable. She is anxious and has a blood pressure of 154/89 mmHg; her heart rate is 78 bpm and regular.
      A picture of her left retina is shown below:
      Which of the following is the most useful investigation?

      Your Answer:

      Correct Answer: Thrombophilia screen

      Explanation:

      Differential Diagnosis for Sudden Visual Loss with Flame-Shaped Hemorrhages

      Explanation: Sudden visual loss with extensive flame-shaped hemorrhages on retinal photographs can be indicative of central retinal vein occlusion (CRVO). This may be linked to an underlying thrombophilia, especially in patients with a history of recurrent miscarriage. Therefore, a thrombophilia screen is the most appropriate next step. However, it is important to note that raised intraocular pressure can also be a risk factor for retinal vein occlusion.

      Carotid angiography is not recommended as central retinal artery occlusion presents with a pale retina, not extensive hemorrhages. CT renal angiogram is not indicated unless there are signs and symptoms of uncontrolled hypertension. Intraocular pressure measurement is not useful in this case as it is associated with acute glaucoma, which presents with pain and a firm globe, and is not associated with the retinal picture seen in CRVO. Ultrasound of both kidneys is only useful in the case of hypertensive retinopathy, which is not suggested by sudden visual loss.

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  • Question 36 - An 81-year-old man presents with sudden loss of vision in his left eye....

    Incorrect

    • An 81-year-old man presents with sudden loss of vision in his left eye. On further questioning, he complains of a left-sided headache over the past few weeks, associated with tenderness of his head when he brushes his hair. On examination, his vision is reduced to counting fingers in the left eye. A left relative afferent pupillary defect is present. Fundoscopy reveals a pale, swollen left optic disc with some adjacent flame-shaped haemorrhages. The right eye is entirely normal. An urgent erythrocyte sedimentation rate (ESR) is elevated at 92 mm/h.
      What is the most important initial course of action?

      Your Answer:

      Correct Answer: Administration of high-dose systemic corticosteroids

      Explanation:

      Diagnosis and Treatment of Giant-Cell Arteritis

      Giant-cell arteritis is a serious condition that can lead to sudden, painless loss of vision. It should be suspected in patients over 50 years old who present with symptoms such as headache, scalp tenderness, and an elevated ESR. Other symptoms may include jaw claudication, joint pain, myalgia, anorexia, weight loss, and fever. If giant-cell arteritis is suspected, high-dose systemic corticosteroids should be started immediately to prevent bilateral vision loss, which can occur within 1-2 weeks. A temporal artery biopsy may also be considered to confirm the diagnosis, although it may remain positive for several weeks after starting treatment.

      The initial dose of corticosteroids is typically 60 mg daily for patients with visual symptoms and 40-60 mg daily for others. Aspirin and a proton pump inhibitor should also be started at the same time. Automated visual field assessment may be part of an ophthalmological assessment, but it is not a reliable diagnostic tool. A CT scan of the brain and orbits may be useful in ruling out other causes of vision loss, such as compressive optic nerve tumors.

      After treatment is initiated, an urgent specialist review is recommended, although some patients may be managed solely in primary care. Early diagnosis and treatment are crucial in preventing permanent vision loss in patients with giant-cell arteritis.

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  • Question 37 - A 5-year-old boy comes to the clinic with a two-day history of a...

    Incorrect

    • A 5-year-old boy comes to the clinic with a two-day history of a red, irritated right eye. His father has been wiping away stringy discharge from the eye and the eye has been stuck together in the mornings. He has no light sensitivity. He has no significant past medical history.

      During examination, pupils are equal and reactive to light. The right eye has injected bulbar and tarsal conjunctiva and follicles are present. A tender pre-auricular lymph node is palpable.

      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Viral conjunctivitis

      Explanation:

      Understanding Different Types of Red Eye

      Viral conjunctivitis is a common cause of red eye, characterized by inflamed conjunctiva and itchiness. It is often caused by adenovirus and can follow an upper respiratory tract infection. Anterior uveitis or iritis, on the other hand, presents with unilateral inflamed conjunctiva, pain, and light sensitivity. It can be associated with systemic inflammatory disease and a past medical history of inflammatory arthropathy. Bacterial conjunctivitis, on the other hand, results in purulent discharge with no pre-auricular lymphadenopathy. Episcleritis is usually unilateral and causes segmental injection with no discharge and minimal discomfort. Lastly, scleritis is an inflammatory disease that causes severe ocular pain and is often associated with rheumatoid arthritis or vasculitis. It causes redness of the sclera and conjunctiva. Understanding these different types of red eye can help in proper diagnosis and treatment.

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  • Question 38 - A 65-year-old man presents with a brief history of painless diplopia that he...

    Incorrect

    • A 65-year-old man presents with a brief history of painless diplopia that he first noticed while reading. The images are horizontally and vertically separated, although he notes that the degree of separation varies. During examination, the visual acuities are 6/6 in either eye. There is no pupil abnormality. There is a left ptosis, partially covering the pupil, and reduced abduction and depression of the left eye, both in abduction and adduction, with other ocular movements appearing normal. There is no other abnormality on examination. He reports that his right upper eyelid sometimes droops as well.
      What is the most probable diagnosis? Choose ONE option only.

      Your Answer:

      Correct Answer: Myasthenia gravis

      Explanation:

      Differentiating between Myasthenia Gravis and other eye conditions

      When a patient presents with signs of reduced function in certain eye muscles, it is important to differentiate between various conditions that could be causing the symptoms. In this case, the patient has normal function of the inferior oblique and superior rectus, but reduced function of the lateral rectus, levator palpebrae superioris, inferior rectus, and superior oblique. Additionally, there is a history of ptosis on both sides.

      Third nerve palsy, fourth nerve palsy, sixth nerve palsy, and Horner syndrome are all potential diagnoses that must be ruled out. However, each of these conditions presents with different symptoms than what the patient is experiencing.

      Based on the symptoms and history, it is likely that the patient has myasthenia gravis. This condition causes muscle weakness and fatigue, which can affect various muscles in the body, including the eye muscles. It is important to accurately diagnose myasthenia gravis in order to provide appropriate treatment and management for the patient.

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  • Question 39 - A 50-year-old man presents to your clinic with a red left eye. His...

    Incorrect

    • A 50-year-old man presents to your clinic with a red left eye. His wife noticed it yesterday and urged him to see a doctor. He recalls experiencing similar symptoms a few times before. He denies any significant pain or discomfort and reports no changes in his vision. He works as a landscaper and takes co-codamol for back pain and laxatives for constipation. He has no other medical history.

      During the examination, you observe a well-defined area of redness in his left eye. His pupils and visual acuity are normal. After staining his eye, you find no abnormalities.

      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Subconjunctival haemorrhage

      Explanation:

      Subconjunctival haemorrhage typically manifests as a localized, well-defined area of bleeding in one eye and may be associated with a history of constipation. This individual is taking co-codamol, which can contribute to constipation. Blepharitis, on the other hand, is characterized by inflammation of the eyelid margin and typically presents with burning, itching, and both eyelids sticking together. Conjunctivitis, whether due to allergy or infection, typically causes itching. Gardeners are at risk of corneal abrasions and foreign bodies, as organic matter can enter the eye during activities such as strimming. However, patients usually report a sensation of a foreign body in the eye and may have a visible abrasion upon staining.

      Subconjunctival haemorrhages occur when blood vessels in the subconjunctival space bleed. These vessels typically supply the conjunctiva or episclera. Trauma is the most common cause, followed by spontaneous idiopathic cases, Valsalva manoeuvres, and several systemic diseases. While subconjunctival haemorrhages can look alarming, they are rarely an indicator of anything serious. They are more common in women than men, and the risk increases with age. Newborns are also more susceptible. The incidence of both traumatic and non-traumatic subconjunctival haemorrhages is 2.6%.

      Risk factors for subconjunctival haemorrhages include trauma, contact lens usage, idiopathic causes, Valsalva manoeuvres, hypertension, bleeding disorders, certain drugs, diabetes, arterial disease, and hyperlipidaemia. Symptoms include a red eye, usually unilateral, and mild irritation. Signs include a flat, red patch on the conjunctiva with well-defined edges and normal conjunctiva surrounding it. The patch’s size can vary depending on the size of the bleed and can involve the whole conjunctiva. Traumatic haemorrhages are most common in the temporal region, with the inferior conjunctiva as the next most commonly affected area. Vision should be normal, including acuity, visual fields, and range of eye movements. On examination, the fundus should be normal.

      The diagnosis of a subconjunctival haemorrhage is clinical. If there is no obvious traumatic cause, check the patient’s blood pressure. If raised, refer the patient appropriately. If the patient is taking warfarin, check the INR. If raised, refer for appropriate adjustments to the dose to bring the INR back into the target range. If you cannot see the whole border of the haemorrhage, it may be associated with an intracranial bleed or an orbital roof fracture. Further appropriate investigations should then be done, including a full cranial nerve exam looking for neurological signs as well as a CT head, after discussion with a senior. Recurrent or spontaneous, bilateral subconjunctival haemorrhages warrant investigations for bleeding disorders or other pathology.

      Reassure the patient that subconjunctival haemorrhages are a benign condition that will resolve on their own in 2 to 3 weeks.

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  • Question 40 - A 60-year-old woman has been recently diagnosed with chronic open-angle glaucoma. The Ophthalmologist...

    Incorrect

    • A 60-year-old woman has been recently diagnosed with chronic open-angle glaucoma. The Ophthalmologist also comments that she has mild bilateral cataracts. When light from a pen torch is shone into the left eye, both pupils constrict. When the torch is moved to the right eye, both pupils appear to be more dilated.
      Which of the following most correctly identifies the significance of this finding?

      Your Answer:

      Correct Answer: There is already optic nerve damage in the right eye

      Explanation:

      Understanding the Afferent Pupillary Defect in Glaucoma

      The afferent pupillary defect is a key diagnostic tool in glaucoma. It refers to differences in the afferent pathway between the two eyes, indicating retinal or optic nerve disease. This defect can be detected even if visual field testing is not positive, making it a valuable tool in diagnosing glaucoma.

      Contrary to popular belief, the presence of neurosyphilis doesn’t necessarily indicate an afferent pupillary defect. Instead, the Argyll Robertson pupils, which are small, irregular pupils that constrict during accommodation but not in response to light, are a hallmark of neurosyphilis.

      It is also important to note that the density of a cataract or intraocular pressure doesn’t affect the presence of an afferent pupillary defect. Even with a dense cataract or corneal scar, a positive test can still be obtained as long as the retina and optic nerve are healthy.

      Finally, while miotic drugs like pilocarpine can be used to treat glaucoma, they do not cause an afferent pupillary defect. This defect is a result of underlying retinal or optic nerve disease and should be carefully evaluated by a healthcare professional.

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  • Question 41 - A 65-year-old man has been diagnosed with primary open angle glaucoma. He inquires...

    Incorrect

    • A 65-year-old man has been diagnosed with primary open angle glaucoma. He inquires about the potential impact on his vision if the condition is left untreated.

      Your Answer:

      Correct Answer: Impairs peripheral visual fields

      Explanation:

      The main impact of glaucoma is on the patient’s visual field, as it causes an optic neuropathy. This typically starts with peripheral vision loss and can progress to tunnel vision if left untreated. While visual acuity may also be affected, it is not as commonly impacted as the visual field.

      Glaucoma is a condition where the optic nerve is damaged due to increased intraocular pressure (IOP). Primary open-angle glaucoma (POAG) is a type of glaucoma where the peripheral iris doesn’t cover the trabecular meshwork, which is responsible for draining aqueous humour from the eye. POAG is more common in older individuals, with up to 10% of those over 80 years of age affected. Genetics, Afro-Caribbean ethnicity, myopia, hypertension, diabetes mellitus, and corticosteroid use are all risk factors for POAG. POAG may present with peripheral visual field loss, decreased visual acuity, and optic disc cupping, which can be detected during routine optometry appointments.

      Fundoscopy signs of POAG include optic disc cupping, optic disc pallor, bayonetting of vessels, and cup notching. Optic disc cupping occurs when the cup-to-disc ratio is greater than 0.7, indicating a loss of disc substance. Optic disc pallor indicates optic atrophy, while bayonetting of vessels occurs when vessels have breaks as they disappear into the deep cup and reappear at the base. Cup notching usually occurs inferiorly where vessels enter the disc, and disc haemorrhages may also be present.

      The diagnosis of POAG is made through a series of investigations, including automated perimetry to assess visual field, slit lamp examination with pupil dilatation to assess optic nerve and fundus for a baseline, applanation tonometry to measure IOP, central corneal thickness measurement, and gonioscopy to assess peripheral anterior chamber configuration and depth. The risk of future visual impairment is assessed using risk factors such as IOP, central corneal thickness (CCT), family history, and life expectancy. If POAG is suspected, referral to an ophthalmologist is necessary for further evaluation and management.

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  • Question 42 - A 19-year-old male presents to your clinic with a painful, red left eye...

    Incorrect

    • A 19-year-old male presents to your clinic with a painful, red left eye that has been bothering him for the past week. He denies any history of trauma to the eye, but the pain has been progressively worsening. The pain is exacerbated by eye movement and he is experiencing photophobia. He also reports a possible decrease in vision in the affected eye. The patient has no significant medical history.

      Upon examination, the left eye appears diffusely red and is tearing. Visual acuity is decreased in the left eye, but there are no abnormalities on staining. The left pupil reaction is slower than the right, but the shape appears normal. The anterior chamber appears normal.

      What is the most appropriate management plan for this patient, given the likely diagnosis?

      Your Answer:

      Correct Answer: Same day urgent referral to an ophthalmologist

      Explanation:

      Understanding Scleritis: Causes, Symptoms, and Treatment

      Scleritis is a condition that involves inflammation of the sclera, which is the white outer layer of the eye. This condition is typically non-infectious and can cause a red, painful eye. The most common risk factor associated with scleritis is rheumatoid arthritis, but it can also be linked to other conditions such as systemic lupus erythematosus, sarcoidosis, and granulomatosis with polyangiitis.

      Symptoms of scleritis include a red eye, which is often accompanied by pain and discomfort. Other common symptoms include watering and photophobia, which is sensitivity to light. In some cases, scleritis can also lead to a gradual decrease in vision.

      Treatment for scleritis typically involves the use of oral NSAIDs as a first-line treatment. In more severe cases, oral glucocorticoids may be used. For resistant cases, immunosuppressive drugs may be necessary, especially if there is an underlying associated disease.

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  • Question 43 - A 35-year-old mother of a one-year-old baby boy presented to your clinic with...

    Incorrect

    • A 35-year-old mother of a one-year-old baby boy presented to your clinic with a sharp pain and redness in her right eye, following a scratch from her baby. Upon examination, a central oval-shaped fluorescent uptake of the right cornea was observed, indicating a corneal abrasion. What would be the most appropriate next step in managing this patient's condition?

      Your Answer:

      Correct Answer: Start the patient on chloramphenicol eye ointment, QID for 5 days

      Explanation:

      Treatment for Simple Corneal Abrasion

      From the patient’s history and examination, it can be concluded that they have a simple corneal abrasion caused by a scratch. The recommended treatment for this condition is a topical ocular antibiotic. The abrasion should heal quickly, and no follow-up is necessary. It is important to avoid using topical ocular steroids as they can slow down the healing process.

      It is worth noting that GPs can treat simple corneal abrasions, and there is no need for ophthalmology referral. Topical prophylactic antibiotics, such as chloramphenicol 1%, can be used to manage corneal abrasions. By following these guidelines, patients can receive effective treatment for their condition and avoid unnecessary referrals or complications.

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  • Question 44 - A 75-year-old man who had a right cataract surgery two weeks ago comes...

    Incorrect

    • A 75-year-old man who had a right cataract surgery two weeks ago comes to see you to ask for help, as he has lost/mislaid the postoperative (post-op) medication given to him after the surgery, sometime in the last 24 hours. He says that he has a post-op ophthalmology clinic appointment scheduled for four weeks' after surgery.

      Which one of the following would be the best next step in managing this man's condition?

      Your Answer:

      Correct Answer: Give her a new set of post-op medication (same as given before) for another two weeks and advise her to keep the ophthalmology clinic appointment

      Explanation:

      Duration of Post-Op Topical Ocular Medication after Cataract Surgery

      It is a widely accepted practice that patients who undergo cataract surgery should use post-op topical ocular medication for four weeks, which includes an antibiotic and a steroid or a combination of both. This medication helps prevent infection and inflammation, which are common complications after surgery.

      In the scenario mentioned, the patient has already completed two weeks of post-op medication. To ensure proper healing and prevent any complications, it is recommended that the patient continues using the same medication for another two weeks. It is important to note that changing post-op medications without the advice of the ophthalmologist should be avoided.

      In summary, patients who undergo cataract surgery should follow the recommended duration of post-op topical ocular medication to ensure proper healing and prevent complications.

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  • Question 45 - An 80-year-old woman comes to the clinic with a complaint of blurred vision...

    Incorrect

    • An 80-year-old woman comes to the clinic with a complaint of blurred vision in her right eye for the past few months. She also reports seeing crooked or wavy lines in the center of her right visual field. The left eye appears to be unaffected, and she has never used glasses or contact lenses. During the examination, a central scotoma is observed in the right eye.

      What is the MOST probable diagnosis?

      Your Answer:

      Correct Answer: Age related macular degeneration

      Explanation:

      Macular degeneration causes loss of vision in the central field, while primary open-angle glaucoma results in loss of vision in the peripheral field.

      Age-related macular degeneration (ARMD) is a common cause of blindness in the UK, characterized by degeneration of the central retina (macula) and the formation of drusen. The risk of ARMD increases with age, smoking, family history, and conditions associated with an increased risk of ischaemic cardiovascular disease. ARMD is classified into dry and wet forms, with the latter carrying the worst prognosis. Clinical features include subacute onset of visual loss, difficulties in dark adaptation, and visual hallucinations. Signs include distortion of line perception, the presence of drusen, and well-demarcated red patches in wet ARMD. Investigations include slit-lamp microscopy, colour fundus photography, fluorescein angiography, indocyanine green angiography, and ocular coherence tomography. Treatment options include a combination of zinc with anti-oxidant vitamins for dry ARMD and anti-VEGF agents for wet ARMD. Laser photocoagulation is also an option, but anti-VEGF therapies are usually preferred.

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  • Question 46 - This 65-year-old individual with diabetes is experiencing a decline in their ability to...

    Incorrect

    • This 65-year-old individual with diabetes is experiencing a decline in their ability to read newsprint. The lens clouding is making it difficult to visualize the retina on fundoscopy.
      What is the probable reason for this person's vision impairment?

      Your Answer:

      Correct Answer: Rubeosis iridis

      Explanation:

      Premature Cataracts and Diabetic Retinopathy

      Cataracts can develop prematurely due to various factors such as diabetes, steroid therapy, Cushing’s syndrome, and trauma. When this happens, it is important to treat the cataract to assess the back of the eye for any signs of diabetic retinopathy. Diabetic retinopathy is a complication of diabetes that affects the blood vessels in the retina, leading to vision loss. By treating the cataract, doctors can examine the retina and determine if any further treatment is necessary to prevent or manage diabetic retinopathy. Therefore, it is crucial for individuals with diabetes or other risk factors for premature cataracts to have regular eye exams to detect and address any potential issues early on.

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  • Question 47 - A 54-year-old man contacts his GP reporting visual alterations in his left eye....

    Incorrect

    • A 54-year-old man contacts his GP reporting visual alterations in his left eye. He has been observing flashes/floaters and spider webs for the last 48 hours, and now there is some darkening on the periphery of vision. Additionally, he has noticed that straight lines appear somewhat jagged. There is no associated pain or injury. The patient is in good health and has no chronic medical conditions.

      What is the probable diagnosis for the aforementioned symptoms?

      Your Answer:

      Correct Answer: Retinal detachment

      Explanation:

      If you experience peripheral vision loss accompanied by spider webs and flashing lights, it could be a sign of retinal detachment. This condition is often described as a curtain coming down over your vision and requires immediate attention from an ophthalmologist. Additionally, you may notice floaters or string-like shapes, and straight lines may appear distorted due to the retina detaching from the choroid.

      Sudden loss of vision can be a scary symptom for patients, but it can be caused by a variety of factors. Transient monocular visual loss (TMVL) is a term used to describe a sudden, temporary loss of vision that lasts less than 24 hours. The most common causes of sudden painless loss of vision include ischaemic/vascular issues, vitreous haemorrhage, retinal detachment, and retinal migraine.

      Ischaemic/vascular issues, also known as ‘amaurosis fugax’, can be caused by a wide range of factors such as thrombosis, embolism, temporal arteritis, and hypoperfusion. It may also represent a form of transient ischaemic attack (TIA) and should be treated similarly with aspirin 300 mg. 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, and hypertension. Severe retinal haemorrhages are usually seen on fundoscopy. Central retinal artery occlusion, on the other hand, is due to thromboembolism or arteritis and features include afferent pupillary defect and a ‘cherry red’ spot on a pale retina.

      Vitreous haemorrhage can be caused by diabetes, bleeding disorders, and anticoagulants. Features may include sudden visual loss and dark spots. Retinal detachment may be preceded by flashes of light or floaters, which are also symptoms of posterior vitreous detachment. Differentiating between these conditions can be done by observing the specific symptoms such as a veil or curtain over the field of vision, straight lines appearing curved, and central visual loss. Large bleeds can cause sudden visual loss, while small bleeds may cause floaters.

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  • Question 48 - A 16-year-old female complains of an itchy eye with watery discharge on one...

    Incorrect

    • A 16-year-old female complains of an itchy eye with watery discharge on one side. She reports feeling generally healthy with no changes to her vision or fever. The patient wears contact lenses but has not had an optician appointment recently.

      During the examination, the patient displays injected conjunctiva in the affected eye, but there is no apparent redness or swelling around the eye. The application of topical fluorescein doesn't reveal any corneal staining.

      What would be the best course of action for managing this patient's condition?

      Your Answer:

      Correct Answer: Advise she should not wear contact lenses for the duration of her symptoms

      Explanation:

      It is not recommended to wear contact lenses when experiencing conjunctivitis, which is likely the case for this 15-year-old with viral conjunctivitis. While it is possible that her prescription may not be up to date, this doesn’t affect her susceptibility to infection or more severe conditions. Warm compresses are more effective for treating styes or chalazion, which present as lumps on the eyelid, rather than viral conjunctivitis. Since the fluorescein test did not show any corneal stains, there is no need for ophthalmology referral. However, if a contact lens wearer with these symptoms had staining, they would require a visit to eye casualty as this would indicate a corneal injury. While topical antihistamine eye drops may be used for allergic conjunctivitis, the unilateral nature of the presentation makes this diagnosis less likely. Topical chloramphenicol is the preferred treatment for bacterial conjunctivitis, but the watery discharge suggests viral conjunctivitis instead.

      Infective conjunctivitis is a common eye problem that is often seen in primary care. It is characterized by red, sore eyes that are accompanied by 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 on its own within one to two weeks. However, patients are often offered topical antibiotic therapy, such as Chloramphenicol or topical fusidic acid. Chloramphenicol drops are given every two to three hours initially, while chloramphenicol ointment is given four times a day initially. Topical fusidic acid is an alternative and should be used for pregnant women. For contact lens users, topical fluoresceins should be used to identify any corneal staining, and treatment should be the same as above. It is important to advise patients not to share towels and to avoid wearing contact lenses during an episode of conjunctivitis. School exclusion is not necessary.

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  • Question 49 - A 42-year-old woman, who is typically healthy, presents to the clinic with complaints...

    Incorrect

    • A 42-year-old woman, who is typically healthy, presents to the clinic with complaints of itchy and sticky eyelids, particularly in the morning. She denies any pain or vision changes and has not attempted any self-treatment. Upon examination, there are red, inflamed, and crusted eyelid margins, but no asymmetry. Visual acuity is normal. What is the best course of action for managing her symptoms?

      Your Answer:

      Correct Answer: Eyelid hygiene

      Explanation:

      Blepharitis is a chronic condition that can be effectively managed with good lid hygiene techniques. Referral to a specialist is not usually necessary, but immediate ophthalmological assessment is recommended if there are symptoms of corneal disease, sudden onset visual loss, or persistent localised disease despite optimal treatment. Antibiotics should only be prescribed if there are clear signs of staphylococcal infection, and corticosteroids should only be initiated by an ophthalmologist in secondary care due to their potential adverse effects. It is important for healthcare professionals to be aware of both common and less common eye conditions that require urgent action.

      Understanding Blepharitis

      Blepharitis is a condition characterized by inflammation of the eyelid margins. It can be caused by dysfunction of the meibomian glands or seborrhoeic dermatitis/staphylococcal infection. Patients with rosacea are more prone to developing blepharitis. The meibomian glands secrete oil to prevent rapid evaporation of the tear film, and any problem affecting these glands can lead to dry eyes and irritation.

      Symptoms of blepharitis are usually bilateral and include grittiness and discomfort around the eyelid margins, sticky eyes in the morning, and redness of the eyelid margins. Staphylococcal blepharitis may cause swollen eyelids, styes, and chalazions. Secondary conjunctivitis may also occur.

      Management of blepharitis involves softening the lid margin using hot compresses twice a day and mechanical removal of debris from the lid margins through lid hygiene. A mixture of cooled boiled water and baby shampoo or sodium bicarbonate in cooled boiled water can be used for cleaning. Artificial tears may also be given for symptom relief in patients with dry eyes or an abnormal tear film.

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  • Question 50 - A 65-year-old woman has been experiencing a shift in her eyesight in recent...

    Incorrect

    • A 65-year-old woman has been experiencing a shift in her eyesight in recent weeks. She is unable to read small text, even with her regular reading glasses. There is a constant slight blurriness in the center, and lines always appear distorted instead of straight.
      Which retinal indication is most likely linked to this condition? Choose ONE option only.

      Your Answer:

      Correct Answer: Drusen

      Explanation:

      Common Retinal Abnormalities and Their Characteristics

      Retinal abnormalities can cause vision problems and may be indicative of underlying health conditions. Here are some common retinal abnormalities and their characteristics:

      Drusen: These are yellow or white accumulations of extracellular material that accumulate in the retina. Large numbers of drusen are a sign of age-related macular degeneration.

      Disc swelling: Unilateral swelling may be due to demyelinating optic neuritis, non-arteritic anterior ischaemic optic neuropathy, retinal vein occlusion, or diabetic papillopathy. Bilateral swelling may be due to papilloedema, toxic optic neuropathy, or malignant hypertension.

      Cotton-wool spots: These appear as fluffy white patches on the retina and are caused by poor axonal metabolism due to ischaemia. Diabetes and hypertension are the two most common diseases that cause these spots.

      Flame haemorrhages: These are intraretinal haemorrhages that may be ‘dot’ or ‘blot’ shaped or flame-shaped, depending on their depth within the retina. They are most commonly due to hypertension, retinal vein occlusion, and diabetes.

      Vitreous haemorrhage: This occurs when blood is seen as a cloud in the vitreous. It may be an early sign of retinal tears and detachment but is most commonly seen in patients with proliferative diabetic retinopathy.

      Understanding these common retinal abnormalities and their characteristics can help with early detection and treatment of underlying health conditions.

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  • Question 51 - A 55-year-old woman has newly diagnosed diabetes. You examine her retina.
    Which of the...

    Incorrect

    • A 55-year-old woman has newly diagnosed diabetes. You examine her retina.
      Which of the following represents the earliest sign of diabetic retinopathy?

      Your Answer:

      Correct Answer: Dot haemorrhage

      Explanation:

      Understanding the Stages of Diabetic Retinopathy

      Diabetic retinopathy is a condition that affects the eyes of individuals with diabetes. While the exact mechanism behind its development is not fully understood, it is known that microvascular occlusion leads to retinal ischaemia, which in turn causes arteriovenous shunts and neovascularisation. This process results in the characteristic features seen at various stages of diabetic retinopathy.

      The earliest lesions to be detected in diabetic retinopathy are usually dot haemorrhages, which are capillary microaneurysms. Cotton-wool spots and hard exudates usually appear later than microaneurysms. Cotton-wool spots are due to a build-up of axonal debris, while hard exudates are precipitates of lipoproteins and other proteins leaking from retinal blood vessels that form well-defined yellow patches.

      New blood vessels on the optic disc characterise proliferative retinopathy. They are an attempt by the residual healthy retina to re-vascularise hypoxic retinal tissue. However, these vessels are poorly and hastily built, and they bleed spontaneously or with minimal trauma. Advanced disease then follows with pre-retinal haemorrhage, vitreous haemorrhage, retinal detachment, macular oedema, and ischaemic maculopathy.

      Venous loops and venous beading frequently occur adjacent to areas of non-perfusion. They indicate increasing retinal ischaemia, and their occurrence is a significant predictor of progression to proliferative diabetic retinopathy.

      Understanding the stages of diabetic retinopathy is crucial for early detection and treatment. Regular eye exams are recommended for individuals with diabetes to monitor their eye health and prevent vision loss.

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  • Question 52 - A 3-day-old baby develops severe conjunctivitis in both eyes. The eyes are red...

    Incorrect

    • A 3-day-old baby develops severe conjunctivitis in both eyes. The eyes are red and the baby is unwell.

      Which of the following is the single true statement?

      Your Answer:

      Correct Answer: The disease is not a notifiable disease

      Explanation:

      Understanding Ophthalmia Neonatorum: Myths and Facts

      Ophthalmia neonatorum is a type of conjunctivitis that occurs in infants within the first 28 days of life. While most cases are mild, it can be a serious condition if caused by gonococcal infection. Unfortunately, as of April 2010, ophthalmia neonatorum is no longer a notifiable disease.

      There are several myths surrounding ophthalmia neonatorum that need to be debunked. Firstly, it is not true that most cases are due to nasolacrimal duct blockage. While this is a common occurrence, it doesn’t cause redness in the eye or distress in the baby. Secondly, it is not true that only the baby needs to be treated. The mother will also need to be seen and tested for infections.

      Another myth is that ophthalmia neonatorum is usually due to a coliform infection. In reality, it is commonly caused by bacterial infections such as Chlamydia trachomatis, Neisseria gonorrhoeae, Staphylococcus aureus, Streptococcus pneumoniae, and other organisms. Viral infections such as herpes simplex virus can also be a cause, although less frequently.

      Lastly, it is not true that treatment involves lid cleaning only. While this may be appropriate for nasolacrimal duct blockage, other causes require different treatments. For example, gonococcal infection requires urgent referral and treatment with antibiotics.

      In conclusion, it is important to understand the facts and myths surrounding ophthalmia neonatorum. This will help ensure that infants receive the appropriate treatment and prevent serious complications.

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  • Question 53 - Which of the following is not a factor that increases the risk of...

    Incorrect

    • Which of the following is not a factor that increases the risk of primary open-angle glaucoma?

      Your Answer:

      Correct Answer: Hypermetropia

      Explanation:

      Hypermetropia is linked to acute angle closure glaucoma, while myopia is linked to primary open-angle glaucoma.

      Glaucoma is a condition where the optic nerve is damaged due to increased intraocular pressure (IOP). Primary open-angle glaucoma (POAG) is a type of glaucoma where the peripheral iris doesn’t cover the trabecular meshwork, which is responsible for draining aqueous humour from the eye. POAG is more common in older individuals, with up to 10% of those over 80 years of age affected. Genetics, Afro-Caribbean ethnicity, myopia, hypertension, diabetes mellitus, and corticosteroid use are all risk factors for POAG. POAG may present with peripheral visual field loss, decreased visual acuity, and optic disc cupping, which can be detected during routine optometry appointments.

      Fundoscopy signs of POAG include optic disc cupping, optic disc pallor, bayonetting of vessels, and cup notching. Optic disc cupping occurs when the cup-to-disc ratio is greater than 0.7, indicating a loss of disc substance. Optic disc pallor indicates optic atrophy, while bayonetting of vessels occurs when vessels have breaks as they disappear into the deep cup and reappear at the base. Cup notching usually occurs inferiorly where vessels enter the disc, and disc haemorrhages may also be present.

      The diagnosis of POAG is made through a series of investigations, including automated perimetry to assess visual field, slit lamp examination with pupil dilatation to assess optic nerve and fundus for a baseline, applanation tonometry to measure IOP, central corneal thickness measurement, and gonioscopy to assess peripheral anterior chamber configuration and depth. The risk of future visual impairment is assessed using risk factors such as IOP, central corneal thickness (CCT), family history, and life expectancy. If POAG is suspected, referral to an ophthalmologist is necessary for further evaluation and management.

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  • Question 54 - A 25-year-old woman comes to the clinic with a 6-month history of dermatitis...

    Incorrect

    • A 25-year-old woman comes to the clinic with a 6-month history of dermatitis on her right eyelid only. She denies any other symptoms of allergy and her serum IgE level is within normal limits. She doesn't use any eye makeup products. What is the most likely allergen causing her dermatitis?

      Your Answer:

      Correct Answer: Nail varnish

      Explanation:

      Unilateral Eyelid Contact Dermatitis: Causes and Symptoms

      Unilateral eyelid contact dermatitis is a type IV hypersensitivity reaction that occurs when a substance comes into contact with the skin. This reaction is often caused by agents transferred to one eye from the hands, such as nail polish, artificial nails, hand moisturizers, and soaps. The symptoms of this condition include asymmetrical and unilateral eyelid dermatitis, sometimes accompanied by linear areas of dermatitis on the face and neck caused by absent-minded habitual rubbing of these areas with freshly painted fingernails.

      Egg white, house dust mite, peanut, and shampoo are not likely to cause unilateral eyelid contact dermatitis. Eggs may produce urticaria or dermatitis and systemic symptoms, while house dust mite causes upper respiratory symptoms and conjunctivitis. Peanut causes a type I hypersensitivity reaction that can result in anaphylaxis, and shampoo may cause bilateral itching and swelling of the skin on the scalp or contact irritant dermatitis.

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  • Question 55 - A 60-year-old woman presents to you with sudden loss of vision in her...

    Incorrect

    • A 60-year-old woman presents to you with sudden loss of vision in her left eye while shopping. She reports two similar episodes in the past month that resolved within minutes. She has no other symptoms and is generally healthy, with a history of hypertension and ischaemic heart disease. Her vision is reduced to counting fingers. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Central retinal artery occlusion

      Explanation:

      Visual Disturbances: Causes and Management

      Visual disturbances can be caused by various conditions, including retinal transient ischaemic attack (TIA), central retinal artery occlusion, retinal vein occlusion, middle cerebral artery infarct, and migraine. Amaurosis fugax, or transient monocular blindness, may precede a central retinal artery occlusion or a stroke. Urgent referral to ophthalmology is necessary within the first 24 hours, and methods such as anterior chamber paracentesis, intravenous Diamox®, ocular massage, and breathing into a paper bag may help restore vision. Retinal vein occlusion causes sudden painless unilateral loss of vision, while middle cerebral artery infarct produces a wide variety of neurological deficits, including visual consequences such as gaze preference towards the side of the lesion and contralateral homonymous hemianopia. Migraine visual aura consists of an area that is not well seen, surrounded by shimmering zig-zag lines, that gradually enlarges and then breaks up over a period of 15-30 minutes. Proper management and investigation are necessary to prevent further complications and ensure appropriate treatment.

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  • Question 56 - A 40-year-old man comes in for a routine check-up due to concerns about...

    Incorrect

    • A 40-year-old man comes in for a routine check-up due to concerns about his friend's recent diagnosis of type two diabetes mellitus. He has no symptoms, medical history, or smoking history. His mother has open-angle glaucoma and his father was diagnosed with prostate cancer at age 75. During the examination, his BMI is 24 kg/m² and blood pressure is 124/76 mmHg. What is the recommended health screening for this patient?

      Your Answer:

      Correct Answer: Intraocular pressure screening for glaucoma

      Explanation:

      Individuals with a family history of glaucoma should undergo annual screening from the age of 40. As this patient is over 40 and has a mother with glaucoma, this is the most appropriate health screening to initiate.

      Routine chest X-ray screening for lung cancer is not recommended for asymptomatic individuals, and as this patient is a non-smoker with no symptoms, it is not the most appropriate option.

      Faecal immunochemical screening for bowel cancer is typically initiated at age 60 unless there are concerning symptoms or a family history. As this patient has neither, this is not the most appropriate screening to commence.

      While PSA screening for prostate cancer is controversial, the patient’s father’s diagnosis at age 75 would not significantly increase his risk. It could be discussed with the patient and initiated at age 50, but it is not necessary at this time.

      Although blood tests to check HbA1c could be considered, the patient has no symptoms, no family history of diabetes, and is at a healthy weight. Therefore, this is not the most important health screening to initiate.

      Glaucoma is a condition where the optic nerve is damaged due to increased intraocular pressure (IOP). Primary open-angle glaucoma (POAG) is a type of glaucoma where the peripheral iris doesn’t cover the trabecular meshwork, which is responsible for draining aqueous humour from the eye. POAG is more common in older individuals, with up to 10% of those over 80 years of age affected. Genetics, Afro-Caribbean ethnicity, myopia, hypertension, diabetes mellitus, and corticosteroid use are all risk factors for POAG. POAG may present with peripheral visual field loss, decreased visual acuity, and optic disc cupping, which can be detected during routine optometry appointments.

      Fundoscopy signs of POAG include optic disc cupping, optic disc pallor, bayonetting of vessels, and cup notching. Optic disc cupping occurs when the cup-to-disc ratio is greater than 0.7, indicating a loss of disc substance. Optic disc pallor indicates optic atrophy, while bayonetting of vessels occurs when vessels have breaks as they disappear into the deep cup and reappear at the base. Cup notching usually occurs inferiorly where vessels enter the disc, and disc haemorrhages may also be present.

      The diagnosis of POAG is made through a series of investigations, including automated perimetry to assess visual field, slit lamp examination with pupil dilatation to assess optic nerve and fundus for a baseline, applanation tonometry to measure IOP, central corneal thickness measurement, and gonioscopy to assess peripheral anterior chamber configuration and depth. The risk of future visual impairment is assessed using risk factors such as IOP, central corneal thickness (CCT), family history, and life expectancy. If POAG is suspected, referral to an ophthalmologist is necessary for further evaluation and management.

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  • Question 57 - A 30-year-old female patient visits her general practitioner with a complaint of visual...

    Incorrect

    • A 30-year-old female patient visits her general practitioner with a complaint of visual disturbance. Upon examination, the doctor observes a left inferior homonymous quadrantanopia. What is the most probable location of the lesion?

      Your Answer:

      Correct Answer: Right parietal lobe

      Explanation:

      A visual field defect known as left homonymous hemianopia indicates a loss of vision to the left side, which is caused by a lesion in the right optic tract. Homonymous quadrantanopias, which affect the parietal-inferior and temporal-superior areas, are also a type of visual field defect. Incongruous defects are caused by optic tract lesions, while congruous defects are caused by lesions in the optic radiation or occipital cortex.

      Understanding Visual Field Defects

      Visual field defects can occur due to various reasons, including lesions in the optic tract, optic radiation, or occipital cortex. A left homonymous hemianopia indicates a visual field defect to the left, which is caused by a lesion in the right optic tract. On the other hand, homonymous quadrantanopias can be categorized into PITS (Parietal-Inferior, Temporal-Superior) and can be caused by lesions in the inferior or superior optic radiations in the temporal or parietal lobes.

      When it comes to congruous and incongruous defects, the former refers to complete or symmetrical visual field loss, while the latter indicates incomplete or asymmetric visual field loss. Incongruous defects are caused by optic tract lesions, while congruous defects are caused by optic radiation or occipital cortex lesions. In cases where there is macula sparing, it is indicative of a lesion in the occipital cortex.

      Bitemporal hemianopia, on the other hand, is caused by a lesion in the optic chiasm. The type of defect can indicate the location of the compression, with an upper quadrant defect being more common in inferior chiasmal compression, such as a pituitary tumor, and a lower quadrant defect being more common in superior chiasmal compression, such as a craniopharyngioma.

      Understanding visual field defects is crucial in diagnosing and treating various neurological conditions. By identifying the type and location of the defect, healthcare professionals can provide appropriate interventions to improve the patient’s quality of life.

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  • Question 58 - A 31-year-old man visits his General Practitioner with complaints of recurrent burning and...

    Incorrect

    • A 31-year-old man visits his General Practitioner with complaints of recurrent burning and itching in his eyes. He frequently wakes up with red, sticky eyes and has received treatment for conjunctivitis multiple times, but with no lasting improvement. During the examination, the doctor observes red and inflamed lid margins and mild conjunctival injection.
      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Blepharitis

      Explanation:

      Common Eye Conditions and Their Symptoms

      Blepharitis: This condition is commonly seen in adults and can be divided into anterior and posterior blepharitis. Anterior blepharitis affects the skin and eyelashes, while posterior blepharitis involves the meibomian glands. Symptoms include red and swollen eyelids, crusts at the base of eyelashes, a gritty or burning sensation in the eyes, and excessive watering. Regular lid cleaning with baby shampoo is key to effective management, and topical antibiotics may be used if there is an infection.

      Viral Conjunctivitis: Those with viral conjunctivitis typically have a recent history of upper respiratory tract infection or contact with a sick individual. Symptoms include redness, watering, and discharge from the eyes. This condition usually settles in 1-2 weeks and is not chronic.

      Chlamydial Conjunctivitis: This condition is characterized by chronic low-grade conjunctivitis that may persist for 3-12 months if left untreated. Symptoms include a green stringy discharge in the morning. Recurrent conjunctivitis in sexually active patients should raise the possibility of chlamydia.

      Contact Dermatitis: Excessive eye makeup use can lead to contact dermatitis. Symptoms include redness, itching, and swelling in the periorbital area. A history of new cosmetics or makeup use should be explored.

      Meibomianitis: Symptoms of meibomianitis include dry and gritty eyes, skin flaking around the eyes, and crusty eyes after sleeping. This condition responds to long courses of systemic antibiotics. However, the symptoms described here are more consistent with blepharitis than meibomianitis.

      Understanding Common Eye Conditions and Their Symptoms

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  • Question 59 - A 75-year-old Caucasian lady comes to the clinic with a complaint of left...

    Incorrect

    • A 75-year-old Caucasian lady comes to the clinic with a complaint of left vision becoming wavy and blurry for the past week. She reports that her venetian blinds appear distorted with her left eye. She has no other medical issues. What would be the most appropriate next step in managing her condition?

      Your Answer:

      Correct Answer: Urgent ophthalmology referral

      Explanation:

      Macular Degeneration: A Common Cause of Distorted Vision in Elderly Patients

      An elderly patient complaining of wavy distorted vision should raise suspicion of macular degeneration, a common age-related eye condition. There are two types of macular degeneration: dry and wet. Unfortunately, there is no treatment for the dry type, but patients can be advised on good lighting and the use of magnifying glasses to aid their vision. However, patients should be aware that there is a 10% chance of the dry type converting into the more aggressive wet type.

      The wet type of macular degeneration can be treated with anti-vascular endothelial growth factor (anti-VEGF) injections, which are given directly into the eye. This treatment aims to stabilize the condition and prevent further loss of central vision. While it is not a cure, a large minority of patients may experience some improvement in their vision. Therefore, it is crucial to refer patients with suspected macular degeneration to an ophthalmologist urgently, as delays may impact the prognosis.

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  • Question 60 - A 72-year-old man had cataract surgery seven months ago. Initially, this seemed very...

    Incorrect

    • A 72-year-old man had cataract surgery seven months ago. Initially, this seemed very successful but he has recently become aware of blurring of his vision and glare when driving at night. He wonders if his cataracts have grown back. Examination of his eye reveals no abnormality of the pupils or fundus.
      What is the single most likely diagnosis?

      Your Answer:

      Correct Answer: Posterior capsular opacification

      Explanation:

      Visual Disturbances: Possible Causes and Treatments

      Visual disturbances can be caused by various conditions, and it is important to identify the underlying cause to provide appropriate treatment. One possible cause is posterior capsular opacification, which can occur after cataract surgery. This condition is characterized by visual disturbance and is caused by the thickening of the lens capsule where the artificial lens is placed. It can be treated with outpatient laser treatment using a YAG laser to create a clear area for light to enter the eye.

      Migraine can also cause visual disturbances, which are characterized by an area that is not well seen, surrounded by shimmering zig-zag lines that gradually enlarge and then break up over a period of 15-30 minutes.

      Acute angle-closure glaucoma causes rapid onset loss of vision and eye pain, which is not present in this patient. Chronic glaucoma, on the other hand, causes gradual loss of vision usually spreading from the periphery, which is also unlikely in this patient.

      Lastly, recurrence of cataract is not possible after cataract surgery since the natural lens, which causes the opacification, is removed and replaced with an artificial lens that doesn’t form cataracts.

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  • Question 61 - A 60-year-old man comes to see you having been diagnosed with cataract by...

    Incorrect

    • A 60-year-old man comes to see you having been diagnosed with cataract by a local optician.
      Which of the following statements about cataracts is correct?

      Your Answer:

      Correct Answer: They may cause similar symptoms to macular degeneration

      Explanation:

      Myths and Facts About Cataracts

      Cataracts are a common eye condition that can cause vision loss and other symptoms. However, there are many myths and misconceptions about cataracts that can lead to confusion and misinformation. Here are some common myths and the facts that debunk them:

      Myth: Cataracts only cause painless loss of vision similar to macular degeneration.
      Fact: While painless loss of vision is a symptom of cataracts, they can also cause defects in the red reflex and monocular diplopia.

      Myth: Cataracts only affect elderly people.
      Fact: While age is a common factor in cataract development, other factors such as malnutrition, illness, and excess UV exposure can also contribute. Children can also develop cataracts.

      Myth: Cataracts in the elderly are unaffected by other disease processes.
      Fact: Cataracts can develop after eye surgery, in people with diabetes or other health problems, and can be linked to steroid use and smoking.

      Myth: Recurrence of symptoms after cataract surgery is unusual.
      Fact: Posterior capsule opacification can occur in up to 40% of cases, but can be treated with laser capsulotomy.

      By understanding the facts about cataracts, individuals can better manage their eye health and seek appropriate treatment when necessary.

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  • Question 62 - A 42-year-old woman visits the GP clinic complaining of feeling easily fatigued. Upon...

    Incorrect

    • A 42-year-old woman visits the GP clinic complaining of feeling easily fatigued. Upon further inquiry, it is discovered that she experiences double vision towards the end of the day and that her level of tiredness increases with physical activity. During the examination, she reports that her hands feel exhausted after repeatedly opening and closing them for 5 minutes. What is the most conclusive test for diagnosing this condition?

      Your Answer:

      Correct Answer: Anti-acetylcholine receptor antibodies

      Explanation:

      Myasthenia gravis is a condition that affects a significant number of patients and is often associated with the presence of Antimuscarinic antibodies. Thymomas are typically linked to the presence of anti-striational receptor antibodies. While MRI scanning is important in ruling out other potential causes of symptoms, it is not a diagnostic tool. Lumbar puncture is not useful in diagnosing myasthenia gravis, but it can help eliminate infection as a potential cause when there is a mixed clinical presentation.

      Myasthenia gravis is an autoimmune disorder that results in muscle weakness and fatigue, particularly in the eyes, face, neck, and limbs. It is more common in women and is associated with thymomas and other autoimmune disorders. Diagnosis is made through electromyography and testing for antibodies to acetylcholine receptors. Treatment includes acetylcholinesterase inhibitors and immunosuppression, and in severe cases, plasmapheresis or intravenous immunoglobulins may be necessary.

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  • Question 63 - A 75-year-old woman with a history of polymyalgia rheumatica presents to her General...

    Incorrect

    • A 75-year-old woman with a history of polymyalgia rheumatica presents to her General Practitioner with a sudden loss of vision in her right eye. For the previous few days, she had been suffering from right-sided temporal headache, muscle aches and tiredness. She also noticed her jaw was getting painful after a few minutes of chewing.
      What single investigation would most strongly support the most likely diagnosis?

      Your Answer:

      Correct Answer: Giant cell infiltrate on temporal artery biopsy

      Explanation:

      Understanding the Diagnostic Features of Giant Cell Arteritis

      Giant cell arteritis (GCA) is a type of vasculitis that affects medium- and large-sized arteries. The gold standard for diagnosing GCA is a biopsy of the temporal artery, which will show vasculitis characterized by a predominance of mononuclear cell infiltration or granulomatous inflammation, usually with multinucleated giant cells. A positive biopsy is a strong indicator of GCA.

      While there are other tests that may be performed, such as the Treponema pallidum haemagglutination (TPHA) test for syphilis and the C-reactive protein (CRP) level test, these are not specific to GCA. However, an erythrocyte sedimentation rate (ESR) is often elevated in GCA, with levels usually exceeding 50 mm/hour and sometimes exceeding 100 mm/hour.

      One of the most concerning symptoms of GCA is homonymous hemianopia, a visual field defect that affects either the two right or two left halves of the visual fields of both eyes. This is caused by lesions in the retrochiasmal visual pathways, which are located anterior to the optic chiasm in GCA patients.

      Overall, understanding the diagnostic features of GCA is crucial for accurate diagnosis and effective treatment.

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  • Question 64 - A 50-year-old female patient of yours has a history of bilateral dry eyes...

    Incorrect

    • A 50-year-old female patient of yours has a history of bilateral dry eyes and was prescribed hypromellose in the past. She now reports persistent discomfort and grittiness in her eyes despite using hypromellose for over three months.

      What would be your next course of action in managing her symptoms?

      Your Answer:

      Correct Answer: Stop the hypromellose and try her on another type of ocular lubricant

      Explanation:

      The Importance of Addressing Dry Eye in General Practice

      Dry eye is a common condition that is often overlooked as a trivial problem. However, it can be an under-treated condition that causes discomfort and visual debility for patients. Unfortunately, many clinicians do not take the time to explore the patient’s genuine concerns and the impact of dry eyes on their mental health.

      It is important to note that not all ocular lubricants are suitable or agreeable to all patients. Therefore, if one lubricant is not working, there are many others that can be tried before referring the patient to ophthalmology. This condition must be treated on a case-by-case basis to ensure the best possible outcome for the patient.

      In conclusion, addressing dry eye in general practice is crucial to improving the quality of life for patients. By taking the time to understand their concerns and exploring different treatment options, clinicians can help alleviate discomfort and improve visual function.

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  • Question 65 - A 56-year-old man on your telephone list reports experiencing two small floaters that...

    Incorrect

    • A 56-year-old man on your telephone list reports experiencing two small floaters that have appeared in his left eye, partially obstructing his vision over the past day. 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 optician in several years.

      What would be the most suitable course of action for managing this situation?

      Your Answer:

      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. In this case, the patient’s new-onset floaters could be a sign of retinal detachment, which requires immediate attention to prevent loss of sight. Therefore, the optician’s assessment of her glasses prescription should be delayed until after the ophthalmology review. Irrigation and antibiotic cover are unnecessary since there is no history of a foreign body or pain in the eye. It is important to prioritize the urgent ophthalmology review and not delay it by arranging a face-to-face assessment the following day. Additionally, blaming the use of computer screens for the floaters is unlikely and observing for further time is not a sufficient response to potential sight-threatening causes.

      Retinal detachment is a condition where the tissue at the back of the eye separates from the underlying pigment epithelium. It can cause reversible visual loss if detected and treated before it affects the macula. However, if left untreated and symptomatic, it can lead to permanent visual loss. Risk factors for retinal detachment include diabetes mellitus, myopia, age, previous cataract surgery, and eye trauma such as boxing.

      Symptoms of retinal detachment include new onset floaters or flashes, sudden painless visual field loss progressing from the periphery to the center of the visual field, and reduced peripheral visual fields. If the macula is involved, central visual acuity and outcomes become much worse. The swinging light test may reveal a relative afferent pupillary defect if the optic nerve is affected. Fundoscopy can show the loss of the red reflex and retinal folds appearing as pale, opaque, or wrinkled forms. However, if the break is small, it may appear normal.

      Management of retinal detachment involves urgent referral to an ophthalmologist for assessment with a slit lamp and indirect ophthalmoscopy for pigment cells and vitreous hemorrhage. Any patients with new onset flashes and floaters should be referred within 24 hours to prevent permanent visual loss.

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  • Question 66 - Which of the following is not a cause of a mydriatic pupil? ...

    Incorrect

    • Which of the following is not a cause of a mydriatic pupil?

      Your Answer:

      Correct Answer: Argyll-Robertson pupil

      Explanation:

      The Argyll-Robertson pupil is a well-known pupillary syndrome that can be observed in cases of neurosyphilis. This condition is characterized by pupils that are able to accommodate but do not react to light. A helpful mnemonic for remembering this syndrome is Accommodation Reflex Present (ARP) but Pupillary Reflex Absent (PRA). Other features of the Argyll-Robertson pupil include small and irregular pupils. The condition can be caused by various factors, including diabetes mellitus and syphilis.

      Mydriasis, which is the enlargement of the pupil, can be caused by various factors such as third nerve palsy, Holmes-Adie pupil, traumatic iridoplegia, phaeochromocytoma, and congenital conditions. Additionally, certain drugs like topical mydriatics such as tropicamide and atropine, sympathomimetic drugs like amphetamines and cocaine, and anticholinergic drugs like tricyclic antidepressants can also cause mydriasis. It is important to note that anisocoria, which is the unequal size of pupils, can also lead to apparent mydriasis when compared to the other pupil.

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  • Question 67 - A 21-year-old woman presented with a three week history of bilateral crusting of...

    Incorrect

    • A 21-year-old woman presented with a three week history of bilateral crusting of her eyelids in the morning. She did not complain of any ocular pain or discharge.

      What is the next most appropriate step after taking a proper history?

      Your Answer:

      Correct Answer: Check for visual acuity

      Explanation:

      Importance of Checking Visual Acuity in Ocular Examinations

      Regardless of the presenting complaints related to the eyes, the first step in any ocular examination is to check and document the patient’s visual acuity (VA). This can be done using a Snellen chart or any other acceptable form of VA measurement.

      Checking VA is crucial as it provides a baseline for future assessments and helps in determining the progression of any ocular condition. It is also important to document VA as it can have medico-legal implications in some cases.

      Therefore, before attempting any other form of ocular examination, it is essential to check and document the patient’s VA. This simple step can provide valuable information for the diagnosis and management of ocular conditions.

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  • Question 68 - A 56-year-old woman complains of a continuous watery left eye that has been...

    Incorrect

    • A 56-year-old woman complains of a continuous watery left eye that has been bothering her for the last 4 days. Upon examination, there is redness and puffiness in the inner corner of her left eye. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Dacryocystitis

      Explanation:

      Lacrimal Duct Problems: Dacryocystitis and Congenital Obstruction

      Lacrimal duct problems can manifest in two ways: dacryocystitis and congenital obstruction. Dacryocystitis is an infection of the lacrimal sac that causes a watering eye (epiphora) and swelling and redness at the inner corner of the eye. Treatment involves systemic antibiotics, and intravenous antibiotics may be necessary if there is associated periorbital cellulitis.

      On the other hand, congenital lacrimal duct obstruction affects 5-10% of newborns and is bilateral in 20% of cases. It causes a watering eye, even when the baby is not crying, and may lead to secondary infections. However, in 99% of cases, symptoms resolve by the time the baby reaches 12 months of age.

      It is important to identify and manage lacrimal duct problems promptly to prevent complications and ensure proper eye health.

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  • Question 69 - A 65-year-old man visits his doctor with a complaint of blurred vision in...

    Incorrect

    • A 65-year-old man visits his doctor with a complaint of blurred vision in his left eye for the past week. Upon examination, his right eye has a visual acuity of 6/6 and his left eye has a visual acuity of 6/18. No pupillary defect is observed. Dilated fundal examination shows extensive retinal haemorrhages in all quadrants of the left retina, along with dilated tortuous retinal veins. The right fundus appears normal. The patient has not seen his doctor in the last ten years. He describes himself as healthy and is not taking any regular medication. However, his blood pressure is 185/100 and his random blood sugar is 12 mmol/l. What is the most probable ocular diagnosis?

      Your Answer:

      Correct Answer: Central retinal vein occlusion

      Explanation:

      Understanding Central Retinal Vein Occlusion

      Central retinal vein occlusion (CRVO) is a common type of retinal vascular disorder that can lead to vision loss. It occurs when the vein that carries blood away from the retina becomes blocked, usually due to thickening of the adjacent arteriole. Risk factors for CRVO include arteriosclerosis and hyperviscosity.

      Symptoms of CRVO include painless and unilateral visual loss, with more severe cases presenting with widespread retinal haemorrhages, engorged veins, retinal oedema, and a swollen optic disc. However, less severe cases may also occur.

      It is important to differentiate CRVO from other retinal disorders, such as diabetic retinopathy, branch retinal vein occlusion, hypertensive retinopathy, and ocular ischaemic syndrome. Diabetic retinopathy is associated with retinal haemorrhages, but these are unlikely to be unilateral. Branch retinal vein occlusion affects only part of the retina, while hypertensive retinopathy should be bilateral and accompanied by other changes. Ocular ischaemic syndrome is a rare condition associated with severe carotid artery occlusive disease, causing dot-and-blot haemorrhages within the mid-periphery and dilated retinal veins.

      In summary, understanding the symptoms and risk factors of CRVO can help with early detection and treatment, preventing further vision loss.

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  • Question 70 - You come across a 20-year-old art student who complains of a painful, red...

    Incorrect

    • You come across a 20-year-old art student who complains of a painful, red right eye. The symptoms started four days ago with a sensation of something being stuck in her eye, but she cannot see anything. Her eyelids are now slightly swollen, and her eye is watering. She experiences blurred vision and sensitivity to light. She is generally healthy and wears contact lenses daily, with no history of cold sores.

      Upon examination, you observe a diffusely red right eye. Her pupil reaction is normal, but her visual acuity is slightly reduced. Staining reveals a small, circular area on the cornea that takes up the dye.

      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Corneal ulcer

      Explanation:

      When a patient who wears contact lenses experiences a foreign body sensation in their eye, along with a red eye and an ulcer on staining, it is a classic presentation of a corneal ulcer. However, it is important to rule out herpes simplex keratitis as a differential diagnosis, especially if the patient has a history of herpes. Anterior uveitis, episcleritis, and scleritis would not show any abnormalities on staining the eye.

      A corneal ulcer is a condition where there is a defect in the cornea, usually caused by an infection. This is different from a corneal abrasion, which is a defect in the cornea caused by physical trauma. Risk factors for corneal ulcers include using contact lenses and having a vitamin A deficiency, which is more common in developing countries.

      The pathophysiology of corneal ulcers can be caused by bacterial, fungal, viral, or Acanthamoeba infections. Bacterial keratitis, fungal keratitis, and viral keratitis (such as herpes simplex or herpes zoster) can lead to a dendritic ulcer. Acanthamoeba keratitis is often associated with contact lens use.

      Symptoms of a corneal ulcer include eye pain, sensitivity to light, and watering of the eye. The cornea may also show focal fluorescein staining.

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  • Question 71 - A 68-year-old man presents to his GP with complaints of blurred vision in...

    Incorrect

    • A 68-year-old man presents to his GP with complaints of blurred vision in his left eye and difficulty reading, with lines appearing wavy. The GP suspects age-related macular degeneration. How urgently should the patient be referred for further assessment?

      Your Answer:

      Correct Answer: Urgent - seen with 1 week

      Explanation:

      Urgent Referral for Age-Related Macular Degeneration

      If there is suspicion of age-related macular degeneration, it is crucial to refer the patient urgently for further assessment. Ideally, they should be seen within one week of referral, especially if they present with rapid visual distortion. The assessment should be conducted by a macular clinic, a local hospital eye service, or an optometrist who can refer to an ophthalmologist.

      According to Clinical Knowledge Summaries, if there is a delay of more than one week in being seen by an optometrist or ophthalmologist, or if symptoms worsen while waiting to be seen, the patient should attend eye casualty, if available, as soon as possible, or seek other immediate medical attention to expedite urgent specialist assessment.

      Once neovascular age-related macular degeneration is confirmed, treatment in secondary care should be given as soon as possible to prevent any visual loss. Therefore, urgent referral and assessment are crucial in managing age-related macular degeneration.

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  • Question 72 - A 68-year-old lady came to the clinic complaining of bilateral grittiness in both...

    Incorrect

    • A 68-year-old lady came to the clinic complaining of bilateral grittiness in both eyes for the past two weeks. Her visual acuity was 6/6 in both eyes on Snellen chart. There was no ocular discharge and her eyes appeared white. What would be the most appropriate next step in managing her condition?

      Your Answer:

      Correct Answer: Start this patient on an ocular lubricant

      Explanation:

      Treatment for Dry Eyes or Tear Film Dysfunction

      If you are experiencing symptoms such as burning, itching, or a gritty sensation in your eyes, but your vision is not affected and your eyes do not appear inflamed, you may be suffering from dry eyes or tear film dysfunction. Fortunately, this condition can be easily treated with ocular lubricants. Steroids and antibiotics are not appropriate for this type of condition.

      Only if your symptoms persist despite adequate lubrication should you consider referral to an ophthalmologist. In most cases, however, simple lubrication is enough to alleviate discomfort and restore normal eye function. So if you are experiencing dry eyes or tear film dysfunction, don’t hesitate to try ocular lubricants and see if they can help you feel better.

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  • Question 73 - A 68-year-old man complains of painless vision loss in one eye. What is...

    Incorrect

    • A 68-year-old man complains of painless vision loss in one eye. What is the most indicative of a central retinal artery occlusion diagnosis?

      Your Answer:

      Correct Answer: Fundoscopy reveals a bright red spot at the centre of the macula

      Explanation:

      Understanding Fundoscopy Findings in Central Retinal Artery Occlusion

      Fundoscopy is a diagnostic tool used to examine the retina and its blood vessels. In cases of central retinal artery occlusion, fundoscopy reveals a bright red spot at the center of the macula due to the intact underlying choroid vessels supplying it. Additionally, the retina appears pale and opaque with narrow thread-like arteries, and there may be segmentation of the blood column in the arteries.

      Contrary to popular belief, complete loss of vision is not the norm in central retinal artery occlusion. Instead, vision is usually reduced to counting fingers. Complete visual loss would suggest involvement of the ophthalmic artery, while segmental visual loss would indicate only a branch retinal artery is involved.

      Furthermore, the pupil on the affected side doesn’t react normally to light. A relative afferent pupillary defect is observed during the swinging flashlight test, where both pupils constrict less when a bright light is swung from the unaffected eye to the affected eye. This indicates differences between the two eyes in the afferent pathway to the brain along the optic nerve due to retinal or optic nerve disease.

      Finally, it is important to note that visual loss in central retinal artery occlusion is sudden, occurring over seconds, rather than gradual over several hours. Understanding these fundoscopy findings can aid in the diagnosis and management of central retinal artery occlusion.

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  • Question 74 - A 59-year-old woman presents to your clinic with a lump on her upper...

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    • A 59-year-old woman presents to your clinic with a lump on her upper eyelid that she has noticed recently. The lump is not causing any discomfort. Upon examination, a 6mm firm lump is observed that distorts the eyelid margin and causes loss of eyelashes. The lump appears to be slightly ulcerated. What would be the most suitable course of action for her management?

      Your Answer:

      Correct Answer: Arrange a 2 week referral

      Explanation:

      A possible meibomian cyst is suggested by the patient’s history. These cysts typically develop slowly over several weeks, resulting in a firm, localized swelling of the eyelid. While there may be initial discomfort, pain and tenderness are usually absent. Meibomian cysts are most commonly found on the upper eyelid and are typically 2-8 mm in diameter.

      When the eyelid is turned inside out, a meibomian cyst appears as a distinct, immobile, circular, yellowish lump (lipogranuloma). In the acute phase, it may appear inflamed, tender, and red. The skin overlying the cyst is usually normal and freely movable, while the meibomian cyst itself adheres to the tarsal plate. There should be no associated ulceration, bleeding, telangiectasia, or discharge.

      Warm compresses and massage are the first-line treatments for meibomian cysts. Topical or oral antibiotics should not be used.

      If a malignant eyelid tumor is suspected, such as if the meibomian cyst has an unusual appearance (such as distortion of the eyelid margin, loss of eyelashes, ulceration, or bleeding) or if a suspected meibomian cyst recurs in the same location, NICE recommends arranging a 2-week wait referral. As a result, the correct answer is a 2-week referral.

      Source: CKS

      According to the April 2016 feedback report, candidates should be familiar with the presentation and management of common eye conditions, as well as less common eye conditions that require urgent attention.

      Eyelid problems are quite common and can include a variety of issues such as blepharitis, styes, chalazions, entropion, and ectropion. Blepharitis is an inflammation of the eyelid margins that can cause redness in the eye. Styes are infections that occur in the glands of the eyelids, with external styes affecting the sebum-producing glands and internal styes affecting the Meibomian glands. Chalazions, also known as Meibomian cysts, are retention cysts that present as painless lumps in the eyelid. While most cases of chalazions resolve on their own, some may require surgical drainage.

      When it comes to managing styes, there are different types to consider. External styes are usually caused by a staphylococcal infection in the glands of Zeis or Moll, while internal styes are caused by an infection in the Meibomian glands. Treatment typically involves hot compresses and pain relief, with topical antibiotics only recommended if there is an associated conjunctivitis.

      Overall, eyelid problems can be uncomfortable and even painful, but with proper management and treatment, they can be resolved effectively. It’s important to seek medical attention if symptoms persist or worsen.

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  • Question 75 - A 50-year-old man with poorly controlled type II diabetes presents with sudden onset...

    Incorrect

    • A 50-year-old man with poorly controlled type II diabetes presents with sudden onset of visual loss in one eye. Examination of his eye reveals loss of red reflex, acuity of 6/24 in the affected eye (6/6 in the good eye) and blood in the posterior chamber of the eye. What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Vitreous haemorrhage

      Explanation:

      Common Causes of Visual Impairment: A Comparison of Vitreous Haemorrhage, Central Retinal Artery Occlusion, Branch Retinal Vein Occlusion, Commotio Retinae, and Vitreous Detachment

      Vitreous Haemorrhage: Patients with vitreous haemorrhage often experience floaters and a red hue, and the blood appears as a cloud in the vitreous. This condition is commonly seen in patients with proliferative diabetic retinopathy, as well as those who have experienced trauma or have other causes of proliferative retinopathy. It may also be an early sign of retinal tears and detachment.

      Central Retinal Artery Occlusion: Sudden loss of vision is the hallmark of central retinal artery occlusion. Fundoscopy reveals a pale retina due to retinal ischaemia, with the centre of the macula appearing as a cherry-red spot.

      Branch Retinal Vein Occlusion: Fundoscopy reveals superficial haemorrhages, retinal oedema, and cotton-wool spots in a sector of retina drained by the affected vein. The obstructed vein is dilated and tortuous. Visual loss largely depends on the compromise to macular drainage, and peripheral occlusions may be asymptomatic.

      Commotio Retinae: Commotio retinae, or Berlin’s oedema, is caused by blunt injury to the eye. Decreased vision in the injured eye occurs a few hours after the injury. The retina appears opaque and white in colour in the periphery, but the blood vessels are normal. It is usually self-limiting.

      Vitreous Detachment: Vitreous detachment is the most common cause of light flashes and floaters, but not visual loss. A slit-lamp examination is mandatory to exclude retinal tears, which are present in about 10% of cases.

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  • Question 76 - A 21-year-old man comes to see his doctor with concerns about his vision....

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    • A 21-year-old man comes to see his doctor with concerns about his vision. He has been having trouble differentiating between red and green colours and feels that this has gotten worse over time. His brother also experiences similar issues, but his sister and parents do not. What is the best advice you can give to this patient?

      Your Answer:

      Correct Answer: Failure of red-green discrimination is the most common feature of his condition

      Explanation:

      Understanding Color Blindness: Causes, Symptoms, and Implications for Daily Life

      Color blindness is a condition that affects a person’s ability to distinguish certain colors. The most common form is the failure of red-green discrimination, which is caused by a hereditary X-linked recessive gene. While rare, failure of blue-yellow discrimination can also occur and is more commonly acquired. Monochromatic defects are even rarer, affecting only about 1 in 30,000 people.

      Ageing can exacerbate pre-existing color vision deficiencies, but color blindness itself is not affected by ageing. Diagnosis of color blindness requires specialist referral in most cases, as the commonly used Ishihara plate test is limited in its ability to detect more complex diagnoses.

      Color blindness can have implications for daily life, particularly in certain occupations. While drivers do not need to notify the Driver and Vehicle Licensing Agency, people with color vision deficiency may be prohibited from working in roles that require color-coded wires, reading dashboards correctly, or operating machinery.

      Late-stage optic nerve disease can also affect color vision, but this symptom is usually noticed relatively late in the progression of the disease. Therefore, it is important to test color vision in suspected optic nerve lesions and thyroid eye disease, which can drive progressive optic neuropathy.

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  • Question 77 - A 35-year-old woman with rheumatoid arthritis takes oral steroids. She complains of watering...

    Incorrect

    • A 35-year-old woman with rheumatoid arthritis takes oral steroids. She complains of watering of both eyes and occasional blurred vision while working on a computer.
      What is the probable diagnosis?

      Your Answer:

      Correct Answer: Dry eyes

      Explanation:

      Understanding the Possible Eye Conditions Caused by Corticosteroid Treatment

      Corticosteroid treatment can cause various eye conditions, including dry eyes, cataracts, and glaucoma. Dry eye syndrome is characterized by a burning or gritty sensation, dryness, intermittent blurring of vision, redness, itching, and photosensitivity. Cataracts caused by corticosteroids are typically posterior and subcapsular, leading to gradually progressive blurring of vision. Glaucoma may also occur due to raised intraocular pressure, resulting in optic nerve damage and peripheral vision loss. However, any optic nerve damage is irreversible. In contrast, corticosteroid eye drops may be used to manage inflammatory eye disorders associated with dry eyes. Fluctuating blood sugar levels caused by corticosteroids can also result in osmotic swelling of the lens, leading to intermittent blurring of vision. Finally, a transient ischaemic attack may cause acute transient loss of vision or transient diplopia, but it is not related to corticosteroid treatment.

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  • Question 78 - A 28 year old woman with no pre-existing medical conditions comes to you...

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    • A 28 year old woman with no pre-existing medical conditions comes to you after discovering she is expecting. During your discussion about pregnancy supplements, she inquires if she can simply continue taking her regular over-the-counter multivitamin tablet. Can you inform her which vitamin, when consumed in excessive amounts, can be harmful to the developing fetus?

      Your Answer:

      Correct Answer: Vitamin A

      Explanation:

      To prevent birth defects, pregnant women should not consume more than 10,000IU of vitamin A per day as it can be harmful in high doses. It is recommended that they avoid taking any supplements that contain vitamin A, including regular multivitamins, during pregnancy. In the UK, supplements are now restricted to a maximum of 6,000IU of vitamin A, so if a pregnant woman has been taking one, there is no need to worry. Additionally, liver should be avoided as it contains high levels of vitamin A.

      Vitamin A, also known as retinol, is a type of fat soluble vitamin that plays several important roles in the body. One of its key functions is being converted into retinal, which is a crucial visual pigment. Additionally, vitamin A is essential for proper epithelial cell differentiation and acts as an antioxidant to protect cells from damage.

      When the body lacks sufficient vitamin A, it can lead to a condition known as night blindness. This is because retinal is necessary for the eyes to adjust to low light conditions, and a deficiency can impair this process. Therefore, it is important to ensure adequate intake of vitamin A through a balanced diet or supplements to maintain optimal health.

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  • Question 79 - A six-year-old girl presents to your clinic with a two-day history of red...

    Incorrect

    • A six-year-old girl presents to your clinic with a two-day history of red eyes. There was no known injury to her eyes. She has clear discharge from both eyes and no symptoms of a cold. Upon examination, her visual acuity is normal, but both upper eyelids are swollen and the conjunctiva is red bilaterally. There is no lymphadenopathy and she is not running a fever. You suspect she has acute infective conjunctivitis.

      What is the best course of treatment for this patient?

      Your Answer:

      Correct Answer: Advise his symptoms should improve within 7 days without treatment

      Explanation:

      Antimicrobial treatment is often unnecessary for most cases of infective conjunctivitis, regardless of whether it is caused by a virus or bacteria. It can be challenging to differentiate between the two, although bacterial conjunctivitis may present with purulent discharge instead of watery discharge. Patients can alleviate symptoms with self-care measures such as cold compresses and ocular lubricants. If symptoms persist after seven days, patients should seek further medical attention. In severe cases of suspected bacterial conjunctivitis, chloramphenicol ointment can be purchased over the counter, while fusidic acid may be used as a second-line antimicrobial. Herpetic conjunctivitis, which causes a painful red eye with vesicular eyelid lesions, can be treated with aciclovir. Swabs are not useful in diagnosing conjunctivitis.

      Infective conjunctivitis is a common eye problem that is often seen in primary care. It is characterized by red, sore eyes that are accompanied by 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 on its own within one to two weeks. However, patients are often offered topical antibiotic therapy, such as Chloramphenicol or topical fusidic acid. Chloramphenicol drops are given every two to three hours initially, while chloramphenicol ointment is given four times a day initially. Topical fusidic acid is an alternative and should be used for pregnant women. For contact lens users, topical fluoresceins should be used to identify any corneal staining, and treatment should be the same as above. It is important to advise patients not to share towels and to avoid wearing contact lenses during an episode of conjunctivitis. School exclusion is not necessary.

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  • Question 80 - A 55-year-old woman urgently presented with a three-hour history of severe headache and...

    Incorrect

    • A 55-year-old woman urgently presented with a three-hour history of severe headache and diplopia.

      Examination revealed her left eye to be 'down and out' on primary gaze, with a dilated left pupil.

      What would be the best next step in managing this woman's condition?

      Your Answer:

      Correct Answer: Refer to a neurosurgeon urgently

      Explanation:

      Warning Signs of a Berry Aneurysm

      The presence of severe headache and diplopia, accompanied by a dilated pupil and a misaligned eye on primary gaze, should raise concerns about a berry aneurysm located around the posterior communicating artery of the Circle of Willis. This condition requires immediate referral to a neurosurgeon for appropriate intervention. Once the danger phase has passed, the diplopia can be managed accordingly.

      It is important to recognize the warning signs of a berry aneurysm, as this condition can be life-threatening if left untreated.

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  • Question 81 - A 48-year-old woman presents to the ophthalmology clinic. Both intra-ocular pressures are within...

    Incorrect

    • A 48-year-old woman presents to the ophthalmology clinic. Both intra-ocular pressures are within normal limits. There are open anterior chamber angles, normal visual fields, and healthy optic discs in both eyes. What is the most suitable term/diagnosis to summarize these results?

      Your Answer:

      Correct Answer: Normal findings

      Explanation:

      Understanding Glaucoma and Ocular Hypertension

      The intra-ocular pressures are normal and the additional findings are all in keeping with a normal examination. Normal pressure glaucoma (NTG) is a form of open-angle glaucoma characterized by glaucomatous optic neuropathy in patients with consistently lower IOP measurements. On the other hand, ocular hypertension is defined as consistently or recurrently elevated IOP greater than 21 mmHg with open anterior chamber angles, normal visual fields, and healthy optic discs.

      If there is a visual field defect, open-angle glaucoma should be suspected. Ophthalmoscopy may reveal cupping of the optic discs. It is important to diagnose and treat these conditions early to prevent vision loss. The American Academy of Ophthalmology and NICE CKS provide guidelines for the diagnosis and treatment of normal-tension glaucoma and glaucoma and ocular hypertension. Regular eye exams and monitoring of IOP are crucial in maintaining good eye health.

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  • Question 82 - A 78-year-old man presents to you with complaints of vision problems in his...

    Incorrect

    • A 78-year-old man presents to you with complaints of vision problems in his right eye. He has been experiencing crooked edges on his door and occasional blurring of his vision. He has noticed that he tends to turn slightly while driving, but his peripheral vision remains unaffected. He denies any pain in his eye. Upon examination, his visual acuity is normal and his fundi appear unremarkable. However, when asked to look at a lined piece of paper, he reports seeing breaks in the lines. What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Age-related macular degeneration

      Explanation:

      Understanding Eye Conditions: A Guide for General Practitioners

      Ophthalmology is a crucial aspect of a general practitioner’s work, yet it is often under-taught. It is essential to be aware of diagnoses and to categorize routine and urgent eye conditions. This guide aims to provide a brief overview of some common eye conditions.

      Age-related macular degeneration is a condition that can often be asymptomatic, and visual loss is usually mild. Patients may experience visual distortions, blurring of vision, and difficulty reading. There may also be a difference in size and color between both eyes.

      Retinal vein occlusion causes sudden, painless unilateral visual loss. Primary closed-angle glaucoma and uveitis usually present with severe and progressive eye pain, along with blurred vision. Amaurosis fugax refers to transient retinal ischemia and symptoms include rapid onset of blindness developing over seconds, as if a curtain was drawn across the eye, and lasts seconds or minutes.

      It is important for general practitioners to be familiar with these conditions and to refer patients to ophthalmologists when necessary. By understanding these eye conditions, general practitioners can provide better care for their patients and ensure that they receive appropriate treatment.

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  • Question 83 - A 35-year-old lady, who has a history of hay fever, visited your clinic...

    Incorrect

    • A 35-year-old lady, who has a history of hay fever, visited your clinic complaining of bilateral itchy, watery, and red eyes that have been bothering her for the past three days. She reported no discharge and no changes in her vision. You prescribed topical ocular mast cell stabilizers, but she returned two days later, stating that her symptoms have not improved. What would be the most appropriate next step in managing this patient's condition?

      Your Answer:

      Correct Answer: Continue with the same treatment

      Explanation:

      Vernal Conjunctivitis and Treatment Options

      A patient with a history of hay fever who presents with itchy, red, and watery eyes may be suffering from vernal conjunctivitis, which is often associated with hay fever or atopy. In such cases, topical mast cell stabilizers are a good option for treatment. However, it is important to inform the patient that the drops may not take immediate effect and may take a few days to work. Ocular topical antibiotics would not be appropriate for vernal conjunctivitis. If the condition worsens despite treatment, ophthalmology referral should be considered. It is important to note that vernal conjunctivitis is a chronic condition that requires long-term management, and patients should be advised accordingly. By providing appropriate treatment and advice, clinicians can help patients manage their symptoms and improve their quality of life.

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  • Question 84 - A mother brings in her four-week-old baby for review. She has noticed that...

    Incorrect

    • A mother brings in her four-week-old baby for review. She has noticed that the baby's eyes have been watering a lot over the last few days. She describes clear fluid running out of both eyes. The baby was born at term by vaginal delivery and is doing well. On examination, the baby's sclerae are white, corneas are clear, and red reflex is present bilaterally. The conjunctiva is not inflamed and there is no purulent discharge.

      What is the most probable reason for the baby's watery eyes?

      Your Answer:

      Correct Answer: Delayed development of the nasolacrimal ducts

      Explanation:

      Babies often experience watery eyes due to the delayed development of their nasolacrimal ducts. This typically occurs 1-2 weeks after birth when tear production begins. Instead of draining properly, tears overflow and run out of the eye. Fortunately, this condition usually resolves by the time the baby reaches 12 months of age. Massaging the side of the nose gently can help to open the nasolacrimal duct. It is rare for babies to experience allergic conjunctivitis, which would involve inflammation of the conjunctiva. Watery eyes are not a symptom of amblyopia, although squinting is common in young babies and should be monitored until it resolves by 4 months of age. Ophthalmia neonatorum, on the other hand, causes severe conjunctivitis with eyelid swelling and purulent discharge.

      Understanding Nasolacrimal Duct Obstruction in Infants

      Nasolacrimal duct obstruction is a common condition that causes persistent watery eyes in infants. It occurs when there is an imperforate membrane, usually at the lower end of the lacrimal duct. This condition affects around 1 in 10 infants, with symptoms typically appearing at around one month of age.

      Fortunately, nasolacrimal duct obstruction can be managed with simple techniques. Parents can be taught to massage the lacrimal duct, which can help to alleviate symptoms. In fact, around 95% of cases resolve on their own by the time the child reaches one year of age.

      However, in cases where symptoms persist beyond this point, it may be necessary to seek further medical intervention. In such cases, it is recommended to refer the child to an ophthalmologist for consideration of probing. This procedure is typically done under a light general anaesthetic and can help to resolve any remaining issues with the nasolacrimal duct.

      Overall, while nasolacrimal duct obstruction can be concerning for parents, it is a manageable condition that typically resolves on its own. By understanding the causes and treatment options for this condition, parents can help to ensure their child’s eyes stay healthy and comfortable.

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  • Question 85 - A 32-year-old woman visits her General Practitioner complaining of sudden discomfort in her...

    Incorrect

    • A 32-year-old woman visits her General Practitioner complaining of sudden discomfort in her right eye. She describes it as feeling 'gritty' and notices watering. She also experienced some discharge from the eye upon waking up in the morning. Upon examination, the conjunctiva appears red and inflamed. What is the most appropriate management for this patient's condition?

      Your Answer:

      Correct Answer: Topical antibiotics can be withheld

      Explanation:

      Understanding Conjunctivitis: Topical Antibiotics and Treatment Options

      Conjunctivitis, commonly known as pink eye, is a condition characterized by inflamed conjunctiva, discharge, and gritty eye discomfort. While most cases are self-limiting and resolve spontaneously within 5-7 days, severe symptoms or rapid resolution may require the use of topical antibiotics such as chloramphenicol and fusidic acid. However, NICE guidelines recommend withholding antibiotics unless necessary. Bacterial and viral forms of conjunctivitis can be differentiated clinically, with purulent discharge indicating a positive bacterial culture. Mucopurulent discharge with crusting is suggestive of bacterial conjunctivitis, while pruritis and petechial subconjunctival hemorrhages suggest a viral cause. While antibiotics can improve rates of clinical and microbiological remission, most cases resolve spontaneously. Referral to ophthalmology should be considered if symptoms persist for longer than 5-7 days. Serious complications from untreated infective conjunctivitis are rare but can include epidemic keratoconjunctivitis, keratitis, and corneal perforation.

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  • Question 86 - A 6-week-old baby is brought in for her first routine check-up in the...

    Incorrect

    • A 6-week-old baby is brought in for her first routine check-up in the practice. She has had no problems except for a persistent sticky right eye despite two courses of antibiotic drops. On examination, she has some discharge at the medial canthus but her eyes look normal. Swabs sent previously showed normal upper respiratory tract flora.
      What is the single most likely diagnosis?

      Your Answer:

      Correct Answer: Nasolacrimal duct obstruction

      Explanation:

      Common Eye Conditions in Newborns

      The nasolacrimal duct may not be fully developed in 5-10% of newborns, but it typically resolves on its own by 12 months. Cleaning the medial canthus is usually sufficient, and antibiotics are not effective unless an infection occurs. Surgery is rarely necessary.

      Ophthalmia neonatorum is a type of conjunctivitis that occurs within the first 28 days of life. It can be caused by bacteria such as Chlamydia trachomatis, Neisseria gonorrhoeae, Staphylococcus aureus, and Streptococcus pneumoniae, as well as viruses like herpes simplex virus. If left untreated, it can lead to serious eye damage.

      Allergic conjunctivitis is uncommon in infants under 1 year old, but viral and bacterial conjunctivitis can occur. Both eyes are typically affected, and in addition to eye discharge, the conjunctiva will appear inflamed.

      Understanding Eye Conditions in Newborns

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  • Question 87 - A 65-year-old woman with type 2 diabetes mellitus presents with complaints of bumping...

    Incorrect

    • A 65-year-old woman with type 2 diabetes mellitus presents with complaints of bumping into things since the morning. She has also noticed some 'floating spots in her eyes' over the past two days. Upon examination, it is found that she has lost vision in her right eye. The red reflex on the right side is difficult to elicit and the retina on the right side cannot be visualised during fundoscopy. However, changes consistent with pre-proliferative diabetic retinopathy are observed in the left fundus. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Vitreous haemorrhage

      Explanation:

      Based on the patient’s medical history and symptoms, it is likely that they are experiencing vitreous haemorrhage. This is supported by the complete loss of vision in the affected eye and the inability to see the retina. To distinguish between vitreous haemorrhage and retinal detachment, please refer to the table provided below.

      Sudden loss of vision can be a scary symptom for patients, but it can be caused by a variety of factors. Transient monocular visual loss (TMVL) is a term used to describe a sudden, temporary loss of vision that lasts less than 24 hours. The most common causes of sudden painless loss of vision include ischaemic/vascular issues, vitreous haemorrhage, retinal detachment, and retinal migraine.

      Ischaemic/vascular issues, also known as ‘amaurosis fugax’, can be caused by a wide range of factors such as thrombosis, embolism, temporal arteritis, and hypoperfusion. It may also represent a form of transient ischaemic attack (TIA) and should be treated similarly with aspirin 300 mg. 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, and hypertension. Severe retinal haemorrhages are usually seen on fundoscopy. Central retinal artery occlusion, on the other hand, is due to thromboembolism or arteritis and features include afferent pupillary defect and a ‘cherry red’ spot on a pale retina.

      Vitreous haemorrhage can be caused by diabetes, bleeding disorders, and anticoagulants. Features may include sudden visual loss and dark spots. Retinal detachment may be preceded by flashes of light or floaters, which are also symptoms of posterior vitreous detachment. Differentiating between these conditions can be done by observing the specific symptoms such as a veil or curtain over the field of vision, straight lines appearing curved, and central visual loss. Large bleeds can cause sudden visual loss, while small bleeds may cause floaters.

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  • Question 88 - A 76-year-old woman presents to your clinic with a gradual onset of visual...

    Incorrect

    • A 76-year-old woman presents to your clinic with a gradual onset of visual disturbance. She reports difficulty in recognizing facial details and increasing difficulty in reading. She also experiences bending of road edges while driving and sees a floating grey patch in her vision. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Age related macular degeneration

      Explanation:

      The most probable diagnosis for this description is age-related macular degeneration (ARMD). In the initial stages, patients may experience difficulty in reading or identifying details. A common symptom of ARMD is the perception of straight lines appearing bent or distorted, as mentioned in the description. This can be assessed in a clinical setting using an Amsler grid.

      Age-related macular degeneration (ARMD) is a common cause of blindness in the UK, characterized by degeneration of the central retina (macula) and the formation of drusen. The risk of ARMD increases with age, smoking, family history, and conditions associated with an increased risk of ischaemic cardiovascular disease. ARMD is classified into dry and wet forms, with the latter carrying the worst prognosis. Clinical features include subacute onset of visual loss, difficulties in dark adaptation, and visual hallucinations. Signs include distortion of line perception, the presence of drusen, and well-demarcated red patches in wet ARMD. Investigations include slit-lamp microscopy, colour fundus photography, fluorescein angiography, indocyanine green angiography, and ocular coherence tomography. Treatment options include a combination of zinc with anti-oxidant vitamins for dry ARMD and anti-VEGF agents for wet ARMD. Laser photocoagulation is also an option, but anti-VEGF therapies are usually preferred.

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  • Question 89 - A 32-year-old pregnant woman presents to your clinic with a red eye. She...

    Incorrect

    • A 32-year-old pregnant woman presents to your clinic with a red eye. She complains of gradual onset of one-sided redness with severe, boring pain that radiates to her forehead. The pain worsens with eye movements and disrupts her sleep. She also experiences watering of the eye and sensitivity to light, but her vision is unaffected. She has no prior history of this condition and is generally healthy. Upon examination, her visual acuity is normal, but her left eye shows diffuse redness and tenderness. Both pupils react normally. What is the next appropriate step in managing her condition?

      Your Answer:

      Correct Answer: Same day specialist assessment

      Explanation:

      The patient has red eye and a working diagnosis of scleritis, which requires a same day specialist assessment. Features of serious causes of red eye include moderate to severe eye pain or photophobia, marked redness of one eye, and reduced visual acuity. Oral cetirizine may be useful in allergic conjunctivitis, while chloramphenicol drops are used in severe infective conjunctivitis. Fusidic acid drops are an alternative treatment option for infective conjunctivitis. Episcleritis is a possible differential diagnosis but is unlikely due to the patient’s severe pain.

      Understanding the Causes of Red Eye

      Red eye is a common condition that can be caused by various factors. It is important to identify the underlying cause of red eye to determine the appropriate treatment. Some causes of red eye require urgent referral to an ophthalmologist. Here are some key distinguishing features of different causes of red eye:

      Acute angle closure glaucoma is characterized by severe pain, decreased visual acuity, and a semi-dilated pupil. The patient may also see haloes and have a hazy cornea.

      Anterior uveitis has an acute onset and is accompanied by pain, blurred vision, and photophobia. The pupil is small and fixed, and there may be ciliary flush.

      Scleritis is characterized by severe pain and tenderness, which may be worse on movement. It may be associated with an underlying autoimmune disease such as rheumatoid arthritis.

      Conjunctivitis may be bacterial or viral. Bacterial conjunctivitis is characterized by purulent discharge, while viral conjunctivitis has a clear discharge.

      Subconjunctival haemorrhage may be caused by trauma or coughing bouts.

      Endophthalmitis typically occurs after intraocular surgery and is characterized by a red eye, pain, and visual loss.

      By understanding the different causes of red eye and their distinguishing features, healthcare professionals can provide appropriate treatment and referral when necessary.

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  • Question 90 - A 65-year-old man presents to the eye casualty with a recent change in...

    Incorrect

    • A 65-year-old man presents to the eye casualty with a recent change in vision in his right eye. He first noticed flashes of light, followed by a large cobweb-like obstruction in his vision. After a slit lamp examination, the ophthalmologist determines no further intervention is necessary.
      What is a risk factor for the condition affecting this patient?

      Your Answer:

      Correct Answer: Myopia

      Explanation:

      Understanding Eye Conditions: Posterior Vitreous Detachment, Refractive Errors, and Other Symptoms

      A posterior vitreous detachment is a condition where the vitreous humor, the gel-like substance in the eye, separates from the retina. Myopia, or short-sightedness, is a risk factor for this condition as well as retinal detachment and tears. Refractive errors such as astigmatism and hypermetropia can also affect vision, causing blurred vision at near and far distances. Miosis, or a constricted pupil, can occur for various reasons including senile miosis, opioid toxicity, and Horner’s syndrome. Ptosis, or drooping of the upper eyelid, can also affect vision and is a feature of Horner’s syndrome, which has a triad of symptoms including miosis, ptosis, and anhidrosis. Understanding these eye conditions and symptoms can help individuals seek appropriate medical attention and treatment.

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  • Question 91 - A 28-year-old man, who is typically healthy, visits his primary care physician complaining...

    Incorrect

    • A 28-year-old man, who is typically healthy, visits his primary care physician complaining of bilateral watery discharge from his eyes over the past three days. He reports a burning sensation in both eyes, but his vision remains unaffected. Upon examination, both conjunctivae appear inflamed, but the sclera is white. No vesicles or pus are observed. What is the most probable causative agent?

      Your Answer:

      Correct Answer: Adenovirus

      Explanation:

      Common Causes of Eye Infections and Their Ocular Presentations

      Viral conjunctivitis is a common, self-limiting condition that is typically caused by adenovirus. Other viruses that can cause conjunctival infection include herpes simplex virus, varicella zoster virus, picornavirus, poxvirus, and human immunodeficiency virus (HIV). Congenital rubella can cause cataract, microphthalmos, iris abnormalities, and pigmentary retinopathy. Primary infection with herpes simplex can present as blepharoconjunctivitis, while recurrent herpes can cause a linear branching corneal ulcer. Toxoplasma gondii can cause chorioretinitis with reduced visual acuity and floaters. Ocular tuberculosis is rare and would present as a discrete mass on examination.

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  • Question 92 - A 29-year-old woman comes to the clinic complaining of headaches, nausea and vomiting,...

    Incorrect

    • A 29-year-old woman comes to the clinic complaining of headaches, nausea and vomiting, and blurred vision that have been going on for two days.

      She has been wearing glasses since she was a child due to her long-sightedness. She has a history of severe migraines and was recently prescribed a prophylactic medication by her GP.

      During the examination, both of her eyes appear red, and her pupils are mid-dilated and unreactive in both eyes.

      What is the probable medication responsible for this presentation?

      Your Answer:

      Correct Answer: Topiramate

      Explanation:

      Topiramate: Mechanisms of Action and Contraceptive Considerations

      Topiramate is a medication primarily used to treat seizures. It can be used alone or in combination with other drugs. The drug has multiple mechanisms of action, including blocking voltage-gated Na+ channels, increasing GABA action, and inhibiting carbonic anhydrase. The latter effect results in a decrease in urinary citrate excretion and the formation of alkaline urine, which favors the creation of calcium phosphate stones.

      Topiramate is known to induce the P450 enzyme CYP3A4, which can reduce the effectiveness of hormonal contraception. Therefore, the Faculty of Sexual and Reproductive Health (FSRH) recommends that patients taking topiramate consider alternative forms of contraception. For example, the combined oral contraceptive pill and progestogen-only pill are not recommended, while the implant is generally considered safe.

      Topiramate can cause several side effects, including reduced appetite and weight loss, dizziness, paraesthesia, lethargy, and poor concentration. However, the most significant risk associated with topiramate is the potential for fetal malformations. Additionally, rare but important side effects include acute myopia and secondary angle-closure glaucoma. Overall, topiramate is a useful medication for treating seizures, but patients should be aware of its potential side effects and contraceptive considerations.

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  • Question 93 - A 30-year-old teacher presents to the out-of-hours General Practice with complaints of conjunctivitis....

    Incorrect

    • A 30-year-old teacher presents to the out-of-hours General Practice with complaints of conjunctivitis. She wears contact lenses. She has been using over-the-counter Brolene® drops for the last two days to try to treat the problem herself, but now finds her vision blurred in the affected eye. On examination, she has florid keratoconjunctivitis and visual acuity of 6/36 in her affected eye. Fluorescein stain is taken up centrally.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Corneal ulcer

      Explanation:

      Differential Diagnosis for a Unilateral Eye Condition

      One possible diagnosis for a patient with a unilateral eye condition is a corneal ulcer, which can be caused by contact lens use and may lead to serious complications if left untreated. However, other conditions should also be considered. Viral conjunctivitis, which is typically bilateral and accompanied by copious discharge, may follow a viral upper respiratory tract infection. Chlamydial conjunctivitis, on the other hand, is not usually unilateral and doesn’t involve fluorescein uptake. A dendritic ulcer, caused by herpes simplex virus, is characterized by small branching epithelial dendrites and doesn’t exhibit central fluorescein uptake. Finally, a foreign body may cause similar symptoms, but would typically be visible upon examination and not involve central fluorescein staining. A thorough differential diagnosis is necessary to accurately diagnose and treat a patient’s eye condition.

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  • Question 94 - A 68-year-old man visits his doctor with complaints of deteriorating vision. He reports...

    Incorrect

    • A 68-year-old man visits his doctor with complaints of deteriorating vision. He reports seeing flashing lights and experiencing difficulty with near vision. The patient has a medical history of hypertension and a 25-pack-year history of smoking. Upon fundoscopy, yellow pigment deposition is observed around the macula. Amsler grid testing reveals distorted perception of straight lines. The intraocular pressure is 15 mmHg.

      What is the most suitable course of action based on the probable diagnosis?

      Your Answer:

      Correct Answer: Referral to ophthalmology urgently

      Explanation:

      An urgent referral to an ophthalmologist is necessary within one week for this patient suspected of having age-related macular degeneration (AMD). The patient is experiencing worsening vision, photopsia, and has drusen on fundoscopy, all of which are consistent with AMD. It is important to rule out wet AMD, which can lead to preventable blindness. Referring to an optometrist or prescribing medication such as latanoprost or vitamins is not appropriate at this stage. The patient requires urgent ophthalmological intervention.

      Age-related macular degeneration (ARMD) is a common cause of blindness in the UK, characterized by degeneration of the central retina (macula) and the formation of drusen. The risk of ARMD increases with age, smoking, family history, and conditions associated with an increased risk of ischaemic cardiovascular disease. ARMD is classified into dry and wet forms, with the latter carrying the worst prognosis. Clinical features include subacute onset of visual loss, difficulties in dark adaptation, and visual hallucinations. Signs include distortion of line perception, the presence of drusen, and well-demarcated red patches in wet ARMD. Investigations include slit-lamp microscopy, colour fundus photography, fluorescein angiography, indocyanine green angiography, and ocular coherence tomography. Treatment options include a combination of zinc with anti-oxidant vitamins for dry ARMD and anti-VEGF agents for wet ARMD. Laser photocoagulation is also an option, but anti-VEGF therapies are usually preferred.

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  • Question 95 - A 40-year-old man visits his General Practitioner with a complaint of worsening vision...

    Incorrect

    • A 40-year-old man visits his General Practitioner with a complaint of worsening vision in his right eye. He has a history of being human immunodeficiency virus (HIV) positive. During the examination, the doctor observes a few distinct, raised, yellowish growths with unclear edges close to the optic disc of his right eye. What is the probable reason for the lesion observed in this individual?

      Your Answer:

      Correct Answer: Tuberculosis

      Explanation:

      Ocular Manifestations of Infectious Diseases

      Choroidal tubercles, toxocariasis, Kaposi’s sarcoma, syphilis, and toxoplasmosis are all infectious diseases that can manifest in the eye. Choroidal tubercles are a common presentation of intraocular tuberculosis, while toxocariasis is caused by roundworm larvae migration and can lead to ocular larva migrans. Kaposi’s sarcoma presents as highly vascular lesions on the eyelids, conjunctiva, caruncle, and lacrimal sac. Syphilis can cause optic neuritis, uveitis, and interstitial keratitis, while toxoplasmosis can lead to chorioretinitis and vitreous inflammation. It is important to consider these infectious diseases in patients presenting with ocular symptoms and to evaluate for systemic involvement.

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  • Question 96 - A 64-year-old man presents with left-sided shoulder pain. He has a medical history...

    Incorrect

    • A 64-year-old man presents with left-sided shoulder pain. He has a medical history of hypertension, osteoarthritis, and COPD. During the examination, he shows good range of motion in the shoulder but experiences pain on the lateral aspect of the shoulder that radiates down to the upper arm and forearm. Additionally, he has some muscle wasting in his hand and a left-sided ptosis and miosis. What is the most suitable investigation to request next?

      Your Answer:

      Correct Answer: Chest x ray

      Explanation:

      Horner’s Syndrome and Shoulder Pain in a Patient with COPD

      This patient with COPD, likely due to significant cigarette smoking, presents with shoulder pain, small muscle wasting in the hand, and Horner’s syndrome. These symptoms suggest a lesion affecting the cervical sympathetic plexus, which could be caused by an apical lung tumor invading the area. Therefore, an urgent chest x-ray should be requested to confirm the diagnosis of Pancoast’s syndrome.

      In addition to Horner’s syndrome, the clinician should also be alert to the presence of a hoarse voice and bovine cough, which may indicate invasion of the recurrent laryngeal nerve and vocal cord paralysis. While brainstem disease can also cause Horner’s syndrome, CT or MRI scanning of the head would only be useful in such instances.

      A plain film of the shoulder may reveal adjacent lung apex and reveal a tumor, but it is not designed to pick up chest pathology. Therefore, a chest x-ray is necessary based on the overall clinical picture. Syringomyelia can also cause Horner’s syndrome and wasting and weakness of the hands and arms, along with loss of pain and temperature sensation over the trunk and arms. An MRI scan can confirm this diagnosis. Nerve conduction studies have no role in this instance.

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  • Question 97 - Which one of the following statements regarding visual impairment is inaccurate? ...

    Incorrect

    • Which one of the following statements regarding visual impairment is inaccurate?

      Your Answer:

      Correct Answer: The patients registered GP needs to make an application to social services for blind registration

      Explanation:

      To apply to social services, it is necessary for a consultant ophthalmologist to do so instead of a GP.

      Visual impairment, specifically blindness, is characterized by having a vision of less than 3/60 in the better eye. In England, registration for this condition is not mandatory. However, individuals who are considered blind can avail of extra benefits such as a disabled parking badge, reduced television license fee, and talking books. To apply for these benefits, a consultant ophthalmologist must submit an application to social services.

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  • Question 98 - A 70-year-old emmetropic gentleman comes to you with a gradual decrease in vision...

    Incorrect

    • A 70-year-old emmetropic gentleman comes to you with a gradual decrease in vision in his left eye for the past four months. He reports no other ocular symptoms.
      Upon examination, the red reflex in the right eye is better than that in the left eye. The patient's visual acuity on Snellen chart is 6/6 unaided in the right eye and 6/18 unaided, improving to 6/9 on pinhole in the left eye. This is now affecting his ability to drive and read with confidence.
      What would be your next best course of action?

      Your Answer:

      Correct Answer: Refer patient to ophthalmologist

      Explanation:

      Cataract as a Cause of Reduced Acuity

      A patient with reduced acuity that improves with pinhole may have a refractive error caused by cataract. If the red reflex is duller in one eye, cataract in that eye should be considered as a possible diagnosis. Cataracts that significantly affect quality of life should be referred to ophthalmology for evaluation of cataract surgery and future visual rehabilitation.

      It is important to note that referral guidance may vary by region, but for the purpose of examination questions, candidates should answer based on national consensus opinion.

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  • Question 99 - A 55-year-old, seemingly healthy woman presents to your clinic reporting that she was...

    Incorrect

    • A 55-year-old, seemingly healthy woman presents to your clinic reporting that she was surprised to find her left eye filled with blood when she woke up this morning. She denies any ocular discomfort and states that her vision is unaffected. There is no discharge from the eye and no active bleeding. Upon examination, you note the presence of a subconjunctival hemorrhage.
      What is the most appropriate course of action to take next?

      Your Answer:

      Correct Answer: Reassure the patient and check her blood pressure and blood glucose level

      Explanation:

      Understanding Subconjunctival Haemorrhage

      Subconjunctival haemorrhage can be a frightening sight, but it is usually not a cause for concern. This condition occurs when a blood vessel in the eye bursts, causing blood to pool under the conjunctiva. While it can be caused by rubbing the eye or minor trauma, it can also be associated with underlying health conditions such as hypertension and diabetes mellitus.

      If you experience subconjunctival haemorrhage, it is important to have your blood pressure and blood glucose levels checked. This will help determine if there are any underlying health issues that need to be addressed. However, in most cases, reassurance and time are all that is needed for the blood to be reabsorbed and the eye to return to normal. So, while it may be alarming to look at, subconjunctival haemorrhage is usually a minor issue that can be easily managed.

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  • Question 100 - A 65-year-old man presents with an acute red eye.

    Of the following conditions which...

    Incorrect

    • A 65-year-old man presents with an acute red eye.

      Of the following conditions which is the most likely cause?

      Your Answer:

      Correct Answer: Closed angle glaucoma

      Explanation:

      Causes of Acute Red Eye

      There are several causes of acute red eye, with glaucoma being the most likely to present with this symptom. Other possible causes include anterior uveitis, corneal ulcers, conjunctivitis, scleritis and episcleritis, and subconjunctival haemorrhage. It is important to note that optic neuritis presents with a specific type of central visual loss known as a central scotoma, while retinal vein occlusion, retinal detachment, and vitreous haemorrhage typically present as visual loss or disturbance. Understanding the various causes of acute red eye can help healthcare professionals make an accurate diagnosis and provide appropriate treatment.

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  • Question 101 - A 55-year-old man presents to your urgent clinic with a red eye that...

    Incorrect

    • A 55-year-old man presents to your urgent clinic with a red eye that he noticed upon waking up this morning. He reports that his eye appeared normal before going to bed last night and denies any pain, discharge, or itching. He has no history of regular medication use and has no visual acuity issues or contact lens use.

      During examination, his blood pressure is measured at 132/88 mmHg. The medial inferior quadrant of his eye shows uniform redness, but his cornea and pupil are unaffected. Based on these findings, you suspect a subconjunctival haemorrhage. The patient expresses concern about the healing time as he has an important business meeting scheduled for next week.

      How long can the patient expect for his subconjunctival haemorrhage to resolve?

      Your Answer:

      Correct Answer: 2 weeks

      Explanation:

      Subconjunctival haemorrhages typically clear up on their own within two weeks and do not require any treatment. However, it is important to check the patient’s blood pressure as these haemorrhages can be linked to high blood pressure. Additionally, it should be noted that the cornea is not affected by a subconjunctival haemorrhage.

      Subconjunctival haemorrhages occur when blood vessels in the subconjunctival space bleed. These vessels typically supply the conjunctiva or episclera. Trauma is the most common cause, followed by spontaneous idiopathic cases, Valsalva manoeuvres, and several systemic diseases. While subconjunctival haemorrhages can look alarming, they are rarely an indicator of anything serious. They are more common in women than men, and the risk increases with age. Newborns are also more susceptible. The incidence of both traumatic and non-traumatic subconjunctival haemorrhages is 2.6%.

      Risk factors for subconjunctival haemorrhages include trauma, contact lens usage, idiopathic causes, Valsalva manoeuvres, hypertension, bleeding disorders, certain drugs, diabetes, arterial disease, and hyperlipidaemia. Symptoms include a red eye, usually unilateral, and mild irritation. Signs include a flat, red patch on the conjunctiva with well-defined edges and normal conjunctiva surrounding it. The patch’s size can vary depending on the size of the bleed and can involve the whole conjunctiva. Traumatic haemorrhages are most common in the temporal region, with the inferior conjunctiva as the next most commonly affected area. Vision should be normal, including acuity, visual fields, and range of eye movements. On examination, the fundus should be normal.

      The diagnosis of a subconjunctival haemorrhage is clinical. If there is no obvious traumatic cause, check the patient’s blood pressure. If raised, refer the patient appropriately. If the patient is taking warfarin, check the INR. If raised, refer for appropriate adjustments to the dose to bring the INR back into the target range. If you cannot see the whole border of the haemorrhage, it may be associated with an intracranial bleed or an orbital roof fracture. Further appropriate investigations should then be done, including a full cranial nerve exam looking for neurological signs as well as a CT head, after discussion with a senior. Recurrent or spontaneous, bilateral subconjunctival haemorrhages warrant investigations for bleeding disorders or other pathology.

      Reassure the patient that subconjunctival haemorrhages are a benign condition that will resolve on their own in 2 to 3 weeks.

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  • Question 102 - A 29-year-old woman presents to the clinic with epiphora. There are no reported...

    Incorrect

    • A 29-year-old woman presents to the clinic with epiphora. There are no reported symptoms of infection or foreign body in the eye. After waiting for five minutes, the eye is re-examined. If there is an overproduction of tears, what is the most probable finding?

      Your Answer:

      Correct Answer: A diluted appearance of fluorescein

      Explanation:

      Interpreting Fluorescein Staining Results in Ophthalmology

      Fluorescein staining is a common diagnostic tool used in ophthalmology to assess the health of the cornea and tear film. The appearance of the fluorescein can provide valuable information about the underlying condition. Here are some interpretations of fluorescein staining results:

      Diluted Appearance of Fluorescein:
      If the fluorescein appears diluted, it may indicate overproduction of tears. This can be caused by various factors such as lid or eyelash malposition, lid margin disease, tear film deficiency, corneal foreign body or disease, conjunctivitis, inflammatory disease, or punctal malposition.

      Diffuse Tiny Green Spots on the Cornea:
      The presence of diffuse tiny green spots on the cornea may indicate punctate epithelial erosion in a dry eye.

      Area of Green Staining on the Central Cornea:
      A larger area of green staining on the central cornea may indicate the presence of ulcers or abrasions caused by injury or infection.

      Positive Seidel Test:
      A positive Seidel test indicates the presence of globe rupture and is used to diagnose corneal perforation.

      Undiluted Fluorescein in the Tear Film:
      If the fluorescein remains undiluted, it may indicate impaired tear drainage caused by congenital nasolacrimal duct obstruction, lacrimal sac mass or mucocele, dacryocystitis, lacrimal pump failure, nasal obstruction, or previous surgery or trauma.

      In conclusion, fluorescein staining is a valuable tool in ophthalmology that can provide important information about the health of the cornea and tear film. Understanding the different interpretations of fluorescein staining results can aid in the diagnosis and treatment of various eye conditions.

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  • Question 103 - A 21-year-old man visits his General Practitioner complaining of visual disturbance. He experienced...

    Incorrect

    • A 21-year-old man visits his General Practitioner complaining of visual disturbance. He experienced a temporary loss of vision for approximately one hour, but his vision has since returned to normal. He did not report any headache. Upon evaluation and examination, the doctor suspects a diagnosis of retinal migraine.
      What is a characteristic feature of this condition?

      Your Answer:

      Correct Answer: Visual aura affecting only one eye

      Explanation:

      Understanding Retinal Migraine: Symptoms and Features

      Retinal migraine is a type of migraine that primarily affects vision in one eye. Unlike a typical migraine aura, which affects both eyes, retinal migraine causes recurrent attacks of unilateral visual disturbance or blindness lasting from minutes to one hour, often with minimal or no headache. The visual disturbance typically starts as a mosaic pattern of scotomata that gradually enlarges, leading to total unilateral visual loss.

      Bilateral aura is not usually considered a feature of retinal migraine, and other diagnoses should be considered if both eyes are affected. Loss of consciousness and facial weakness are also not typical symptoms of retinal migraine and may indicate other underlying conditions.

      However, transient aphasia, a feature of classical migraine, may occur in patients who suffer from visual aura. It usually resolves within an hour or two, with complete resolution to normal function.

      It is important to rule out eye disease or vascular disease, mainly carotid artery disease, especially when risk factors for arteriosclerosis exist, particularly if there is a weakness of the facial muscles. Understanding the symptoms and features of retinal migraine can help with proper diagnosis and treatment.

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  • Question 104 - A 26-year-old construction worker presents with a painful and red right eye. He...

    Incorrect

    • A 26-year-old construction worker presents with a painful and red right eye. He reports feeling like there is something in his eye for the past four days but cannot recall how it happened. He works in a dusty environment and doesn't always wear eye protection. He notes that his vision in the right eye is blurry. Otherwise, he is healthy.

      Upon examination, the patient has a red and watery right eye. His visual acuity is slightly diminished in the right eye compared to the left. Pupil reactions are normal and equal. A foreign body is visible in the centre of the cornea over the iris, appearing superficial.

      What is the most appropriate management plan for this patient, given his history and examination findings?

      Your Answer:

      Correct Answer: Immediate referral to ophthalmology for assessment

      Explanation:

      Immediate referral to ophthalmology is necessary for assessment of foreign bodies in or near the center of the cornea. Signs of a corneal foreign body may include visible foreign material on the eye’s surface or linear scratches on the cornea. Removal of foreign bodies is crucial to prevent permanent scarring and vision loss. If the foreign body is loose and superficial, experienced individuals with the appropriate equipment can remove it. Saline irrigation and topical ocular anesthetics can be used, and metallic foreign bodies may require follow-up and removal by ophthalmology. Patients with suspected penetrating eye injuries, significant orbital or peri-ocular trauma, chemical injuries, organic material foreign bodies, or red flag symptoms should receive urgent assessment by an ophthalmologist rather than FB removal in primary care. Ocular lubricants and analgesia can be prescribed for symptom control, and follow-up appointments should be arranged.

      Corneal foreign body is a condition characterized by eye pain, foreign body sensation, photophobia, watering eye, and red eye. It is important to refer patients to ophthalmology if there is a suspected penetrating eye injury due to high-velocity injuries or sharp objects, significant orbital or peri-ocular trauma, or a chemical injury has occurred. Foreign bodies composed of organic material should also be referred to ophthalmology as they are associated with a higher risk of infection and complications. Additionally, foreign bodies in or near the centre of the cornea and any red flags such as severe pain, irregular pupils, or significant reduction in visual acuity should be referred to ophthalmology. For further information on management, please refer to Clinical Knowledge Summaries.

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  • Question 105 - A 23-year-old woman presents with a red left eye. She reports experiencing an...

    Incorrect

    • A 23-year-old woman presents with a red left eye. She reports experiencing an itchy, gritty sensation in the left eye for the past 24 hours. She notes some grey-green discharge at the lid margins and mentions using an eye bath she purchased from the pharmacy to clear it this morning. Her visual acuity is 6/6 in both eyes, and both pupils are equal and reactive with no other abnormalities detected. Fluorescein staining shows no focal lesion. She has no history of eye problems and doesn't wear contact lenses. What is the most appropriate course of action?

      Your Answer:

      Correct Answer: Prescribe a regular ocular lubricant

      Explanation:

      Antibiotic Stewardship in the Management of Acute Infective Conjunctivitis

      In the management of acute infective conjunctivitis, it is important to consider good antibiotic stewardship and follow national guidance from NICE. While it can be difficult to differentiate between bacterial and viral conjunctivitis, most cases are self-limiting and resolve within 1-2 weeks without the need for antibiotics. Lubricant eye drops can help reduce discomfort, and patients should clean away infected secretions with a cotton wool ball soaked in water. Additionally, up to 10% of patients may experience adverse reactions to topical antibiotics.

      According to the NICE Clinical Knowledge summary, treatment with topical antibiotics should be reserved for severe cases where other serious causes have been ruled out, for schools and childcare organizations requiring treatment before allowing a child to return, and for patients who understand the limitations of treatment but still prefer it. If patients prefer early treatment with antibiotics, they should consider delaying treatment to see if the condition resolves spontaneously within 7 days.

      If a patient presents with an acute red eye and normal visual acuity without any red flag features, immediate eye casualty referral is not necessary. Management in primary care is the most appropriate approach at this stage. However, if the patient experiences reduced visual acuity, immediate referral for further specialist assessment is warranted. By following these guidelines, healthcare providers can ensure appropriate management of acute infective conjunctivitis while promoting antibiotic stewardship.

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  • Question 106 - A 60-year-old patient on your morning telephone appointment list reports a painful watering...

    Incorrect

    • A 60-year-old patient on your morning telephone appointment list reports a painful watering left eye after mowing the lawn. His daughter can see a grass seed visibly stuck near his cornea.

      What is the best course of action for managing this situation?

      Your Answer:

      Correct Answer: Refer to ophthalmology immediately for assessment that day

      Explanation:

      If a patient has an organic foreign body in their eye, such as a grass seed, it is crucial to refer them immediately to ophthalmology for assessment due to the risk of infection. The removal of the foreign body should also be done on the same day as the assessment, as this type of injury is often caused by high-velocity incidents during activities like grass cutting. Attempting to remove the foreign body in primary care or delaying the removal until the following day is not acceptable and may increase the risk of infection. Irrigation and antibiotics should not be used without proper assessment, as this may cause the foreign body to remain in the eye for a longer period of time and increase the risk of infection. It is important to note that, since the foreign body is organic material, it is necessary for the patient to be seen by the ophthalmology department on the same day rather than attempting to remove it at the practice.

      Corneal foreign body is a condition characterized by eye pain, foreign body sensation, photophobia, watering eye, and red eye. It is important to refer patients to ophthalmology if there is a suspected penetrating eye injury due to high-velocity injuries or sharp objects, significant orbital or peri-ocular trauma, or a chemical injury has occurred. Foreign bodies composed of organic material should also be referred to ophthalmology as they are associated with a higher risk of infection and complications. Additionally, foreign bodies in or near the centre of the cornea and any red flags such as severe pain, irregular pupils, or significant reduction in visual acuity should be referred to ophthalmology. For further information on management, please refer to Clinical Knowledge Summaries.

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