-
Question 1
Correct
-
A 9-year-old girl presents to the emergency department with increasing redness and swelling around her left eye over the past 48 hours. During the examination, she reports pain and double vision when her eye movements are assessed. There is also tenderness and erythema over the left eyelid. Her temperature is 38°C. Based on the probable diagnosis, what is the most suitable course of treatment?
Your Answer: Intravenous cefotaxime
Explanation:Orbital cellulitis can be distinguished from preseptal cellulitis by the presence of symptoms such as reduced visual acuity, proptosis, and pain when moving the eyes. If a person experiences painful eye movements and visual disturbances along with a red, swollen, and tender eye, it is a cause for concern and may indicate orbital cellulitis. In such cases, it is crucial to administer urgent empirical intravenous antibiotics that cover gram-positive and anaerobic organisms, such as Intravenous cefotaxime or clindamycin. On the other hand, preseptal cellulitis can be managed with oral co-amoxiclav and close monitoring. Unlike orbital cellulitis, preseptal cellulitis does not cause painful eye movements or visual disturbances and is less likely to cause fever.
In rare cases, subperiosteal or orbital abscess may complicate orbital cellulitis, leading to symptoms such as proptosis, headache (facial, throbbing), and reduced visual acuity. In such cases, surgical drainage may be necessary, but intravenous empirical antibiotics would still be an essential part of the treatment. It is worth noting that these conditions are more likely to occur as a complication of sinusitis rather than orbital cellulitis.
Bacterial keratitis, which is more common in contact lens users, can be treated with topical ciprofloxacin. This condition presents with symptoms such as eye pain, watering, and photophobia but does not cause eyelid swelling, diplopia, or fever.
Understanding Orbital Cellulitis: Causes, Symptoms, and Management
Orbital cellulitis is a serious infection that affects the fat and muscles behind the orbital septum within the orbit, but not the globe. It is commonly caused by upper respiratory tract infections that spread from the sinuses and can lead to a high mortality rate. On the other hand, periorbital cellulitis is a less severe infection that occurs in the superficial tissues anterior to the orbital septum. However, it can progress to orbital cellulitis if left untreated.
Risk factors for orbital cellulitis include childhood, previous sinus infections, lack of Haemophilus influenzae type b (Hib) vaccination, recent eyelid infections or insect bites, and ear or facial infections. Symptoms of orbital cellulitis include redness and swelling around the eye, severe ocular pain, visual disturbance, proptosis, ophthalmoplegia, eyelid edema, and ptosis. In rare cases, meningeal involvement can cause drowsiness, nausea, and vomiting.
To differentiate between orbital and preseptal cellulitis, doctors look for reduced visual acuity, proptosis, and ophthalmoplegia, which are not consistent with preseptal cellulitis. Full blood count and clinical examination involving complete ophthalmological assessment are necessary to determine the severity of the infection. CT with contrast can also help identify inflammation of the orbital tissues deep to the septum and sinusitis. Blood culture and microbiological swab are also necessary to determine the organism causing the infection.
Management of orbital cellulitis requires hospital admission for IV antibiotics. It is a medical emergency that requires urgent senior review. Early diagnosis and treatment are crucial to prevent complications and reduce the risk of mortality.
-
This question is part of the following fields:
- Ophthalmology
-
-
Question 2
Correct
-
A 72-year-old patient with poorly controlled type 2 diabetes mellitus arrives at the emergency department complaining of sudden visual disturbance that has been present for the past 2 hours. He describes dark spots obstructing his vision in his right eye, with a yellowish tint to his vision. What is the probable diagnosis?
Your Answer: Vitreous haemorrhage
Explanation:Understanding Vitreous Haemorrhage
Vitreous haemorrhage is a condition where there is bleeding into the vitreous humour, which can cause sudden painless loss of vision. This disruption to vision can range from floaters to complete visual loss. The bleeding can come from any vessel in the retina or extend through the retina from other areas. Once the bleeding stops, the blood is typically cleared from the retina at a rate of approximately 1% per day.
The incidence of spontaneous vitreous haemorrhage is around 7 cases per 100,000 patient-years. The incidence by age and sex varies according to the underlying causes. The most common causes, which collectively account for 90% of cases, include proliferative diabetic retinopathy, posterior vitreous detachment, and ocular trauma (which is the most common cause in children and young adults).
Patients with vitreous haemorrhage typically present with an acute or subacute onset of painless visual loss or haze, a red hue in the vision, or floaters or shadows/dark spots in the vision. Signs of the condition include decreased visual acuity (depending on the location, size, and degree of vitreous haemorrhage) and visual field defects if the haemorrhage is severe.
Investigations for vitreous haemorrhage include dilated fundoscopy, slit-lamp examination, ultrasound (useful to rule out retinal tear/detachment and if haemorrhage obscures the retina), fluorescein angiography (to identify neovascularization), and orbital CT (used if open globe injury is suspected).
-
This question is part of the following fields:
- Ophthalmology
-
-
Question 3
Incorrect
-
A 35-year-old man visits his GP complaining of a painful and red right eye with photophobia for the past 2 days. He usually wears contact lenses but has been using glasses since the onset of pain. The patient has a medical history of allergic rhinitis and takes cetirizine daily.
During the examination, the doctor observes dilated conjunctival and episcleral vessels, mild eyelid swelling, and increased tearing in the right eye. The left eye appears normal, and the patient's corrected visual acuity is 6/6 in the left eye and 6/12 in the right eye.
What is the most appropriate course of action for this patient?Your Answer: Prescribe chloramphenicol drops and advise the patient to avoid contact lenses until his symptoms have resolved
Correct Answer: Refer urgently to eye casualty
Explanation:If a person wearing contact lenses experiences a painful red eye, it is important to refer them to an eye casualty department to rule out the possibility of microbial keratitis.
Understanding Keratitis: Inflammation of the Cornea
Keratitis is a condition that refers to the inflammation of the cornea. While conjunctivitis is a common eye infection that is not usually serious, microbial keratitis can be sight-threatening and requires urgent evaluation and treatment. The causes of keratitis can vary, with bacterial infections typically caused by Staphylococcus aureus and Pseudomonas aeruginosa commonly seen in contact lens wearers. Fungal and amoebic infections can also cause keratitis, with acanthamoebic keratitis accounting for around 5% of cases. Parasitic infections such as onchocercal keratitis can also cause inflammation of the cornea.
Other factors that can cause keratitis include viral infections such as herpes simplex keratitis, environmental factors like photokeratitis (e.g. welder’s arc eye), and exposure keratitis. Clinical features of keratitis include a red eye with pain and erythema, photophobia, a foreign body sensation, and the presence of hypopyon. Referral is necessary for contact lens wearers who present with a painful red eye, as an accurate diagnosis can only be made with a slit-lamp examination.
Management of keratitis involves stopping the use of contact lenses until symptoms have fully resolved, as well as the use of topical antibiotics such as quinolones. Cycloplegic agents like cyclopentolate can also be used for pain relief. Complications of keratitis can include corneal scarring, perforation, endophthalmitis, and visual loss. Understanding the causes and symptoms of keratitis is important for prompt diagnosis and treatment to prevent serious complications.
-
This question is part of the following fields:
- Ophthalmology
-
-
Question 4
Correct
-
A 28-year-old man presents with a 5-day history of increasing pain, blurry vision and lacrimation in the left eye. He also feels a foreign body sensation in the affected eye. He had been doing some DIY work at home without wearing any goggles for the past few days prior to the onset of pain.
On examination, his visual acuities are 6/18 in the left and 6/6 in the right. The conjunctiva in the left is red. The cornea is tested with fluorescein and it shows an uptake in the centre of the cornea which looks like a dendrite. On examination of his face, there are some small vesicles at the corner of his mouth as well.
What is the most likely diagnosis?Your Answer: Viral keratitis
Explanation:Possible Eye Conditions and Diagnosis for a Patient with Corneal Ulcer
Upon examination of a patient with a corneal ulcer, several possible eye conditions can be considered. However, based on the presence of a dendritic ulcer and a history of cold sores, a viral keratitis, specifically herpes simplex keratitis, is likely. A corneal abrasion is unlikely as there is no history of eye injury. A corneal foreign body is also unlikely as there is no visible foreign object on the cornea. Fungal keratitis is unlikely as there are no risk factors present. Microbial keratitis is a possibility, but it typically presents with a round-shaped ulcer. Overall, a viral keratitis diagnosis seems most probable.
-
This question is part of the following fields:
- Ophthalmology
-
-
Question 5
Incorrect
-
A 48-year-old woman comes to the clinic with a gradual onset of left-sided visual issues. She reports no discomfort or itching in the affected area. During the examination, left-sided ptosis and miosis are observed. When the lights are dimmed, the right pupil dilates, but the left pupil does not. She has a history of smoking for 8 years. What is the probable diagnosis?
Your Answer: Multiple sclerosis
Correct Answer: Squamous cell carcinoma of the lung
Explanation:Horner’s syndrome is a medical condition that is characterized by a set of symptoms including a small pupil (miosis), drooping of the upper eyelid (ptosis), sunken eye (enophthalmos), and loss of sweating on one side of the face (anhidrosis). The presence of heterochromia, or a difference in iris color, is often seen in cases of congenital Horner’s syndrome. Anhidrosis is also a distinguishing feature that can help differentiate between central, Preganglionic, and postganglionic lesions. Pharmacologic tests, such as the use of apraclonidine drops, can be helpful in confirming the diagnosis of Horner’s syndrome and localizing the lesion.
Central lesions, Preganglionic lesions, and postganglionic lesions can all cause Horner’s syndrome, with each type of lesion presenting with different symptoms. Central lesions can result in anhidrosis of the face, arm, and trunk, while Preganglionic lesions can cause anhidrosis of the face only. postganglionic lesions, on the other hand, do not typically result in anhidrosis.
There are many potential causes of Horner’s syndrome, including stroke, syringomyelia, multiple sclerosis, tumors, encephalitis, thyroidectomy, trauma, cervical rib, carotid artery dissection, carotid aneurysm, cavernous sinus thrombosis, and cluster headache. It is important to identify the underlying cause of Horner’s syndrome in order to determine the appropriate treatment plan.
-
This question is part of the following fields:
- Ophthalmology
-
-
Question 6
Correct
-
During duty surgery (urgent care), you encounter a 55-year-old woman who is experiencing excruciating pain around her right eye. She has tried over-the-counter drops from the chemist, but they have not provided any relief. Although she has no significant medical history, she has been working 12-hour night shifts as a bank nurse. Upon examination, you notice a mild vesicular rash on the conjunctiva, but the eye itself appears normal under direct vision. Her visual acuity is normal, and fundoscopy reveals no abnormalities.
What would be the most appropriate next step?Your Answer: Oral acyclovir and urgent ophthalmology referral
Explanation:The recommended course of action for suspected herpes zoster ophthalmicus is urgent referral to an ophthalmologist and a 7-10 day course of oral antivirals such as acyclovir. Prescribing high dose oral steroids or topical dexamethasone is not the appropriate treatment for this condition. While direct referral to the emergency department may result in eventual referral to ophthalmology and treatment, it is not the most efficient or effective approach.
Herpes Zoster Ophthalmicus: Symptoms, Treatment, and Complications
Herpes zoster ophthalmicus (HZO) is a condition that occurs when the varicella-zoster virus reactivates in the area supplied by the ophthalmic division of the trigeminal nerve. It is responsible for approximately 10% of shingles cases. The main symptom of HZO is a vesicular rash around the eye, which may or may not involve the eye itself. Hutchinson’s sign, a rash on the tip or side of the nose, is a strong indicator of nasociliary involvement and increases the risk of ocular involvement.
Treatment for HZO involves oral antiviral medication for 7-10 days, ideally started within 72 hours of symptom onset. Intravenous antivirals may be necessary for severe infections or immunocompromised patients. Topical antiviral treatment is not recommended for HZO, but topical corticosteroids may be used to treat any secondary inflammation of the eye. Ocular involvement requires urgent ophthalmology review to prevent complications such as conjunctivitis, keratitis, episcleritis, anterior uveitis, ptosis, and post-herpetic neuralgia.
In summary, HZO is a condition caused by the reactivation of the varicella-zoster virus in the ophthalmic division of the trigeminal nerve. It presents with a vesicular rash around the eye and may involve the eye itself. Treatment involves oral antiviral medication and urgent ophthalmology review is necessary for ocular involvement. Complications of HZO include various eye conditions, ptosis, and post-herpetic neuralgia.
-
This question is part of the following fields:
- Ophthalmology
-
-
Question 7
Incorrect
-
A 67-year-old woman presents with a complaint of seeing an 'arc of white light and some cobwebs' in her vision with eye movements in her left eye for the past week. She also reports that her vision in the left eye is now very blurry. She denies any recent trauma and has a history of myopia in both eyes. Her past medical history is unremarkable. On examination, her left eye has a visual acuity of 6/18 while her right eye has a visual acuity of 6/6. Both anterior segments appear normal. However, on dilated fundoscopy, the view of the left fundus is blocked by some red and grey matter in the vitreous while the right fundus is unremarkable. What is the next most appropriate management step to determine the underlying cause of the findings in the left fundus?
Your Answer: Examine the entire fundus with a slit lamp and Volk lenses
Correct Answer: Ultrasound B-scan of the eye
Explanation:The Importance of Ultrasound B-Scan in Diagnosing Vitreous Haemorrhage
Vitreous haemorrhage is a condition that requires prompt diagnosis and treatment. While it may present with symptoms such as floaters and blurred vision, it is important to rule out any underlying causes such as retinal detachment. The most effective way to do this is through an ultrasound B-scan of the eye.
A CT scan of the head is not recommended as it exposes the patient to unnecessary radiation and does not provide useful information in diagnosing vitreous haemorrhage. Similarly, examining the fundus with a slit lamp, Volk lenses, or scleral indentation will not yield results as the haemorrhage obstructs the view.
An optical coherence tomography (OCT) of the macula may not be effective in ruling out important causes of vitreous haemorrhage due to the presence of the haemorrhage itself.
In conclusion, an ultrasound B-scan of the eye is the most effective way to diagnose vitreous haemorrhage and rule out any underlying causes such as retinal detachment. It is important to prioritize this diagnostic tool to ensure prompt and accurate treatment.
-
This question is part of the following fields:
- Ophthalmology
-
-
Question 8
Incorrect
-
Please rewrite the question while maintaining the paragraph structure.
Your Answer: Left inferior homonymous quadrantanopia – right temporal cortex
Correct Answer: Left homonymous scotoma – right occipital cortex
Explanation:Understanding Visual Field Defects and their Corresponding Brain Lesions
Visual field defects can occur due to various brain lesions. The location of the lesion determines the type of visual field defect. Here are some examples:
– Left homonymous scotoma – right occipital cortex: If the tip of the occipital cortex is affected, it can cause a contralateral scotoma, affecting the central vision. However, if the whole occipital lobe is affected, it will cause a homonymous hemianopia.
– Bitemporal hemianopia – optic chiasm: Bitemporal hemianopia occurs with a lesion of the optic chiasm, not the occipital cortex.
– Right superior homonymous quadrantanopia – left temporal cortex: Superior quadrantanopia occurs with temporal lesions, not parietal lesions.
– Left inferior homonymous quadrantanopia – right parietal cortex: Inferior quadrantanopia occurs with parietal lesions, not temporal lesions.
– Right monocular anopia – right optic nerve injury: Monocular anopia occurs with damage to the optic nerve on that same side, rather than damage to the occipital cortex.Understanding the relationship between visual field defects and their corresponding brain lesions can aid in diagnosis and treatment of neurological conditions affecting vision.
-
This question is part of the following fields:
- Ophthalmology
-
-
Question 9
Incorrect
-
A 35-year-old woman visits her General Practitioner, reporting crusting of both eyelids that is more severe in the morning and accompanied by an itchy feeling. She states that she has not experienced any changes in her vision. Upon examining her eyelids, the doctor observes crusting at the eyelid edges that are inflamed and red. The conjunctivae seem normal, and the pupils react equally to light. What is the probable diagnosis?
Your Answer: Conjunctivitis
Correct Answer: Blepharitis
Explanation:Common Eye Conditions and Their Symptoms
Blepharitis: This condition presents with crusting of both eyelids, redness, swelling, and itching. It can be treated with eyelid hygiene and warm compress. If these measures are not effective, chloramphenicol ointment can be used.
Chalazion: A painless swelling or lump on the eyelid caused by a blocked gland. Patients report a red, swollen, and painful area on the eyelid, which settles within a few days but leaves behind a firm, painless swelling. Warm compresses and gentle massaging can encourage drainage.
Conjunctivitis: Patients with conjunctivitis present with conjunctival erythema, watery/discharging eye, and a gritty sensation. Most cases are self-limiting, but some patients will require topical antibiotics if symptoms have not resolved.
Entropion: This condition is when the margin of the eyelid turns inwards towards the surface of the eye, causing irritation. It is more common in elderly patients and requires surgical treatment.
Hordeolum: An acute-onset localised swelling of the eyelid margin that is painful. It is usually localised around an eyelash follicle, in which case plucking the affected eyelash can aid drainage. Styes are usually self-limiting, but eyelid hygiene and warm compress can help with resolution.
Understanding Common Eye Conditions and Their Symptoms
-
This question is part of the following fields:
- Ophthalmology
-
-
Question 10
Correct
-
A 57-year-old man presents with painful weeping rashes on his right upper eyelid and forehead, accompanied by acute punctate keratopathy. He had undergone chemotherapy for non-Hodgkin's lymphoma about a year ago. No other abnormalities are observed. What is the most probable diagnosis?
Your Answer: Herpes zoster
Explanation:Increased Risk of Herpes Zoster in Immunocompromised Patients
Immunosuppressed individuals who have undergone organ transplantation, as well as those with cancer, leukaemia, and AIDS, are more susceptible to developing herpes zoster. This condition, commonly known as shingles, is caused by the reactivation of the varicella-zoster virus, which remains dormant in the body after a previous chickenpox infection.
In cases of herpes zoster ophthalmicus, where the virus affects the eye and surrounding areas, the presence of the Hutchinson sign – a rash on the tip of the nose supplied by the external nasal nerve – indicates a higher risk of developing uveitis, an inflammation of the eye uvea. It is important for immunocompromised patients to be aware of this increased risk and seek prompt medical attention if they experience any symptoms of herpes zoster.
-
This question is part of the following fields:
- Ophthalmology
-
-
Question 11
Correct
-
A 40-year-old woman comes to the Emergency Department complaining of left eye pain for the third time. She reports experiencing blurred vision and a sensation of something being stuck in her eye each time. She typically wears contact lenses and has accidentally scratched her eye multiple times in the past.
Investigations reveal an epithelial defect with surrounding corneal edema on slit lamp examination, as well as an area of increased uptake on fluorescein examination. What is the most likely diagnosis based on these findings?Your Answer: Corneal ulcer
Explanation:Diagnosing Corneal Ulcers in Contact Lens Wearers
Corneal ulcers are a common complication in contact lens wearers, caused by bacteria adhering to the lens surface and infecting the cornea. Symptoms include pain, photophobia, foreign body sensation, and most importantly, blurred vision. Treatment involves avoiding contact lenses for a few days, re-education on proper application, and topical antibiotics.
Other potential diagnoses, such as bacterial conjunctivitis, traumatic corneal abrasion, Fuchs’ endothelial dystrophy, and keratitis sicca, can be ruled out based on the patient’s history and examination findings. It is important to accurately diagnose and treat corneal ulcers in contact lens wearers to prevent further complications and vision loss.
-
This question is part of the following fields:
- Ophthalmology
-
-
Question 12
Correct
-
A 72-year-old man visits his GP complaining of a sudden onset of unilateral ptosis on the left side. During the examination, the doctor observes anisocoria with miosis of the left pupil and anhidrosis of his left face, arm, and trunk. The patient reports no pain in the left arm or scapular region. He has a history of smoking for 45 pack-years. A chest X-ray is performed, but it shows no abnormalities. What is the probable cause of this condition?
Your Answer: Stroke
Explanation:Causes of Horner Syndrome: A Differential Diagnosis
Horner syndrome is a rare condition that affects the nerves that control the pupil, eyelid, and sweat glands in the face. It is characterized by a drooping eyelid, a constricted pupil, and decreased sweating on one side of the face. Here are some possible causes of Horner syndrome and their distinguishing features:
1. Stroke: A central type Horner syndrome is often caused by a stroke, especially in patients with a history of smoking.
2. Carotid artery dissection: This condition can cause a postganglionic or third-order Horner syndrome, which is characterized by neck pain, headache around the eye, pulsatile tinnitus, and Horner syndrome. Unlike the central and preganglionic types, there is no anhidrosis in postganglionic Horner syndrome.
3. Cavernous sinus thrombosis: This condition can also cause a postganglionic Horner syndrome, but it is usually accompanied by unilateral periorbital edema, headache, photophobia, and proptosis. Patients may also exhibit signs of sepsis due to the infective cause of this condition.
4. Multiple sclerosis: While multiple sclerosis can cause central Horner syndrome, it is not the most common cause. Patients with this condition should also present with other features of multiple sclerosis.
5. Pancoast tumor: Although this patient is a chronic heavy smoker, a Pancoast tumor is not necessarily the cause of Horner syndrome. This type of tumor causes a preganglionic Horner syndrome, which presents with ptosis, miosis, and anhidrosis on the face. Additionally, a Pancoast tumor significant enough to cause Horner syndrome would be visible on a chest X-ray.
In conclusion, Horner syndrome can have various causes, and a thorough differential diagnosis is necessary to determine the underlying condition.
-
This question is part of the following fields:
- Ophthalmology
-
-
Question 13
Incorrect
-
As part of a learning exercise, an elderly person drew a small black square and a black circle, 4 inches horizontally apart, on a piece of white paper. The elderly person then held the paper at arm’s length and closed their left eye, while focusing on the black square, which was to the left of the black circle, with their right eye. They moved the paper slowly towards them until the black circle disappeared.
Which of the following anatomical structures is responsible for the disappearance of the black circle?Your Answer: Fovea centralis
Correct Answer: Optic disc
Explanation:Anatomy of the Eye: Optic Disc, Macula Lutea, Fovea Centralis, Dilator Pupillae, and Sphincter Pupillae
The eye is a complex organ that allows us to see the world around us. Within the eye, there are several important structures that play a role in vision. Here are five key components of the eye and their functions:
1. Optic Disc: This is the area where the optic nerve exits the retina. It lacks photoreceptor cells, creating a blind spot in our visual field. The optic disc is lighter in color than the surrounding retina and is the point from which branches of the central retinal artery spread out to supply the retina.
2. Macula Lutea: This small, yellow-colored area is located next to the optic disc. It has a higher visual sensitivity than other areas of the retina.
3. Fovea Centralis: This is the central depression of the macula lutea and contains the largest number of densely compact cone photoreceptors. It has the highest visual sensitivity of any area of the retina.
4. Dilator Pupillae: This structure is found in the iris and is innervated by sympathetic fibers. It dilates the pupillary opening.
5. Sphincter Pupillae: Also found in the iris, this structure is innervated by parasympathetics and constricts the pupillary opening.
Understanding the anatomy of the eye and how these structures work together is essential for maintaining good vision and identifying potential problems.
-
This question is part of the following fields:
- Ophthalmology
-
-
Question 14
Correct
-
A 42-year-old man comes to his General Practitioner complaining of erythema around his right eye and limited eye movements for the past 2 days. He has been experiencing sinusitis symptoms for the last week. During the examination of his right eye, the doctor observes erythema around the eye, proptosis, painful and restricted eye movements, and decreased visual acuity. The examination of his left eye is normal.
What is the most suitable test to perform?Your Answer: Computed tomography (CT) orbit, sinuses and brain
Explanation:Imaging and Diagnostic Tools for Orbital Cellulitis
Orbital cellulitis is a serious condition that requires prompt diagnosis and treatment. To evaluate patients with suspected orbital cellulitis, a computed tomography (CT) scan of the orbit, sinuses, and brain is necessary if they have central nervous system involvement, proptosis, eye movement restriction or pain, reduced visual acuity, or other symptoms. If patients do not improve after 36-48 hours of IV antibiotics, surgical drainage may be required, making imaging crucial for evaluation.
Ophthalmic ultrasound is not useful in the diagnosis or assessment of orbital cellulitis, but it is used in the evaluation of intra-ocular tumors. Optical coherence photography (OCT) is also not used in the assessment of orbital cellulitis, but it is useful in the diagnosis and assessment of other eye conditions such as glaucoma and macular degeneration.
An X-ray of the skull bones is not useful in the assessment of orbital cellulitis and is typically used in cases of suspected non-accidental injury in children. Overall, proper imaging and diagnostic tools are essential for the accurate diagnosis and treatment of orbital cellulitis.
-
This question is part of the following fields:
- Ophthalmology
-
-
Question 15
Correct
-
A 50-year-old woman with uncontrolled diabetes visits her doctor reporting sudden vision loss in her right eye without any pain. She also mentions seeing flashes of light in the periphery of her vision. What could be the possible diagnosis?
Your Answer: Retinal detachment
Explanation:The patient’s symptoms suggest retinal detachment, which is characterized by a painless loss of vision over several hours and the presence of flashes and floaters. Acute closed-angle glaucoma, optic neuritis, diabetic retinopathy, and central retinal artery occlusion are less likely causes as they do not fit the patient’s presentation or symptoms.
Sudden loss of vision can be a scary symptom for patients, as it may indicate a serious issue or only be temporary. Transient monocular visual loss (TMVL) is a term used to describe a sudden, brief loss of vision that lasts less than 24 hours. The most common causes of sudden, painless loss of vision include ischaemic/vascular issues (such as thrombosis, embolism, and temporal arthritis), vitreous haemorrhage, retinal detachment, and retinal migraine.
Ischaemic/vascular issues, also known as ‘amaurosis fugax’, have a wide range of potential causes, including large artery disease, small artery occlusive disease, venous disease, and hypoperfusion. Altitudinal field defects are often seen, and ischaemic optic neuropathy can occur due to occlusion of the short posterior ciliary arteries. Central retinal vein occlusion is more common than arterial occlusion and can be caused by glaucoma, polycythaemia, or hypertension. Central retinal artery occlusion is typically caused by thromboembolism or arthritis and may present with an afferent pupillary defect and a ‘cherry red’ spot on a pale retina.
Vitreous haemorrhage can be caused by diabetes, bleeding disorders, or anticoagulants and may present with sudden visual loss and dark spots. Retinal detachment may be preceded by flashes of light or floaters, which are also common in posterior vitreous detachment. Differentiating between posterior vitreous detachment, retinal detachment, and vitreous haemorrhage can be challenging, but each has distinct features such as photopsia and floaters for posterior vitreous detachment, a dense shadow that progresses towards central vision for retinal detachment, and large bleeds causing sudden visual loss for vitreous haemorrhage.
-
This question is part of the following fields:
- Ophthalmology
-
-
Question 16
Correct
-
A 54-year-old woman presents with a sudden onset of severe pain and redness in her right eye. She denies any history of foreign body injury and has not experienced any cold-like symptoms. The patient has a medical history of systemic lupus erythematosus, which is currently being managed with hydroxychloroquine. She has no fever and upon examination, her sclera is erythematous and injected with a bluish hue. Her pupils are equal and reactive, and her visual acuity is normal in both eyes. There is no significant discharge present. What is the most likely diagnosis in this case?
Your Answer: Scleritis
Explanation:The patient’s autoimmune history, painful red-eye, and bluish hue suggest scleritis, which is a medical emergency requiring urgent ophthalmology review. Episcleritis, which is not painful and presents with a different type of redness, is unlikely. Acute angle closure glaucoma and foreign body injury are also possible differentials, but the patient’s clear and reactive pupils and lack of eye discharge make these less likely. In any case, intraocular pressure should be checked to rule out acute glaucoma.
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. Patients may also experience watering and photophobia, as well as 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. With proper treatment, most patients with scleritis can achieve relief from their symptoms and prevent further complications.
-
This question is part of the following fields:
- Ophthalmology
-
-
Question 17
Correct
-
A 72-year-old man comes to the clinic complaining of intense pain around his left eye and vomiting. Upon examination, his left eye appears red and there is a noticeable decrease in visual acuity. What is the best initial course of action for this patient?
Your Answer: Refer immediately to hospital
Explanation:Glaucoma is a group of disorders that cause optic neuropathy due to increased intraocular pressure (IOP). However, not all patients with raised IOP have glaucoma, and vice versa. Acute angle-closure glaucoma (AACG) is a type of glaucoma where there is a rise in IOP due to impaired aqueous outflow. Factors that increase the risk of AACG include hypermetropia, pupillary dilation, and lens growth associated with age. Symptoms of AACG include severe pain, decreased visual acuity, halos around lights, and a hard, red-eye. Management of AACG is an emergency and requires urgent referral to an ophthalmologist. Emergency medical treatment is necessary to lower the IOP, followed by definitive surgical treatment once the acute attack has subsided.
There are no specific guidelines for the initial medical treatment of AACG, but a combination of eye drops may be used, including a direct parasympathomimetic, a beta-blocker, and an alpha-2 agonist. Intravenous acetazolamide may also be administered to reduce aqueous secretions. Definitive management of AACG involves laser peripheral iridotomy, which creates a small hole in the peripheral iris to allow aqueous humour to flow to the angle. It is important to seek medical attention immediately if symptoms of AACG are present to prevent permanent vision loss.
-
This question is part of the following fields:
- Ophthalmology
-
-
Question 18
Incorrect
-
A 68-year-old male with dry age-related macular degeneration is evaluated. Regrettably, his vision has worsened in the last six months. He has never smoked and is currently using antioxidant supplements. What would be the most suitable course of action?
Your Answer: Retinal transplant
Correct Answer: Explain no other medical therapies currently available
Explanation:Age-related macular degeneration (ARMD) is a common cause of blindness in the UK, characterized by the degeneration of the central retina (macula) and the formation of drusen. It is more prevalent in females and is strongly associated with advancing age, smoking, family history, and conditions that increase the risk of ischaemic cardiovascular disease. ARMD can be classified into two forms: dry and wet. Dry ARMD is more common and is characterized by drusen, while wet ARMD is characterized by choroidal neovascularisation and carries a worse prognosis. Clinical features of ARMD include subacute onset of visual loss, difficulties in dark adaptation, and visual disturbances such as photopsia and glare.
To diagnose ARMD, slit-lamp microscopy and color fundus photography are used to identify any pigmentary, exudative, or haemorrhagic changes affecting the retina. Fluorescein angiography and indocyanine green angiography may also be used to visualize changes in the choroidal circulation. Treatment for dry ARMD involves a combination of zinc with antioxidant vitamins A, C, and E, which has been shown to reduce disease progression by around one third. For wet ARMD, anti-VEGF agents such as ranibizumab, bevacizumab, and pegaptanib are used to limit disease progression and stabilize or reverse visual loss. Laser photocoagulation may also be used to slow progression, but anti-VEGF therapies are usually preferred due to the risk of acute visual loss after treatment.
In summary, ARMD is a common cause of blindness in the UK that is strongly associated with advancing age, smoking, and family history. It can be classified into dry and wet forms, with wet ARMD carrying a worse prognosis. Diagnosis involves the use of various imaging techniques, and treatment options include a combination of zinc and antioxidant vitamins for dry ARMD and anti-VEGF agents or laser photocoagulation for wet ARMD.
-
This question is part of the following fields:
- Ophthalmology
-
-
Question 19
Incorrect
-
A 25-year-old woman comes to the clinic with a painless, firm lump on her right upper eyelid. She mentions that it has been present for approximately two weeks and initially started as a small, tender swelling. There are no indications of infection and her vision remains unaffected.
What is the probable diagnosis?Your Answer: Stye
Correct Answer: Meibomian cyst
Explanation:The patient is experiencing a painless swelling or lump on their eyelid, most likely a meibomian cyst (chalazion). This is caused by a blocked gland and typically appears as a firm, painless swelling away from the margin of the eyelid. While a hordeolum (stye) can present similarly in the initial stages, it is usually painful and self-limiting. Blepharitis, which causes crusting, redness, swelling, and itching of both eyelids, is not present in this case. An epidermal inclusion cyst is a less likely cause given the short history of only two weeks.
-
This question is part of the following fields:
- Ophthalmology
-
-
Question 20
Incorrect
-
Which statement about childhood squints is accurate?
Your Answer: Divergent squints are more common than convergent squints
Correct Answer: The corneal light reflection test is a suitable screening test
Explanation:Both paralytic and non-paralytic squints can lead to the development of amblyopia.
Squint, also known as strabismus, is a condition where the visual axes are misaligned. There are two types of squints: concomitant and paralytic. Concomitant squints are more common and are caused by an imbalance in the extraocular muscles. On the other hand, paralytic squints are rare and are caused by the paralysis of extraocular muscles. It is important to detect squints early on as they can lead to amblyopia, where the brain fails to process inputs from one eye and favours the other eye over time.
To detect a squint, a corneal light reflection test can be performed by holding a light source 30cm from the child’s face to see if the light reflects symmetrically on the pupils. The cover test is also used to identify the nature of the squint. This involves asking the child to focus on an object, covering one eye, and observing the movement of the uncovered eye. The test is then repeated with the other eye covered.
If a squint is detected, it is important to refer the child to secondary care. Eye patches may also be used to help prevent amblyopia.
-
This question is part of the following fields:
- Ophthalmology
-
00
Correct
00
Incorrect
00
:
00
:
00
Session Time
00
:
00
Average Question Time (
Mins)