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Question 1
Incorrect
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A 3-year-old boy is brought in by his father with a red and itchy right eye. On examination, there is mild redness of the conjunctiva, and small bumps are visible on the inside of the eyelid. The eyelid is swollen, and there are a few small red spots on the white part of the eye. The eye is watery, and there is no pus. He recently had a mild cold. You diagnose him with viral conjunctivitis.
According to the current NICE guidance, which of the following should NOT be included in the management of this patient?Your Answer: Antibiotic prescription should be avoided
Correct Answer: The child should be excluded from school until the infection has resolved
Explanation:When it comes to managing viral conjunctivitis, it’s important to reassure the patient that most cases are self-limiting and don’t require antimicrobial treatment. In fact, viral conjunctivitis usually resolves on its own within one to two weeks. However, there are some self-care measures that can help ease symptoms. These include cleaning the eyelids with cotton wool soaked in sterile saline or boiled and cooled water, applying cool compresses around the eye area, and using lubricating drops or artificial tears. It’s also important to avoid prescribing antibiotics if possible.
It’s crucial to inform the person that infective conjunctivitis is contagious and they should take steps to prevent spreading the infection to their other eye and other people. This includes washing hands frequently with soap and water, using separate towels and flannels, and avoiding close contact with others, especially if they are a healthcare professional or child-care provider. It’s worth noting that the infection can be contagious for up to 14 days from onset.
According to Public Health England, there is no recommended exclusion period from school, nursery, or childminders unless there is an outbreak or cluster of cases. It’s important to provide written information to the patient, explain the red flags for an urgent review, and advise them to seek further help if symptoms persist beyond 7 days. If the person returns with symptoms of conjunctivitis, it may be necessary to consider sending swabs for viral PCR and bacterial culture, as well as prescribing empirical topical antibiotics if they haven’t already been prescribed. If symptoms persist for more than 7-10 days after initiating treatment, it may be necessary to discuss with or refer to ophthalmology.
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This question is part of the following fields:
- Ophthalmology
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Question 2
Incorrect
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A 60-year-old woman comes in with severe left eye pain and loss of vision in the left eye. She has experienced vomiting multiple times. During the examination, there is noticeable left-sided circumcorneal erythema, and the left pupil is mid-dilated and unresponsive to light.
What would be the most suitable initial investigation in this case?Your Answer:
Correct Answer: Applanation tonometry
Explanation:This patient has presented with acute closed-angle glaucoma, which is a serious eye condition requiring immediate medical attention. It occurs when the iris pushes forward and blocks the fluid access to the trabecular meshwork, leading to increased pressure within the eye and damage to the optic nerve.
The main symptoms of acute closed-angle glaucoma include severe eye pain, decreased vision, redness around the cornea, swelling of the cornea, a fixed semi-dilated pupil, nausea, vomiting, and episodes of blurred vision or seeing haloes.
To confirm the diagnosis, tonometry is performed to measure the intraocular pressure. Normal pressure ranges from 10 to 21 mmHg, but in acute closed-angle glaucoma, it is often higher than 30 mmHg. Goldmann’s applanation tonometer is commonly used in hospitals for this purpose.
Management of acute closed-angle glaucoma involves providing pain relief, such as morphine, and antiemetics if the patient is experiencing vomiting. Intravenous acetazolamide is administered to reduce intraocular pressure. Additionally, a topical miotic medication like pilocarpine is started about an hour after initiating other treatments to help constrict the pupil, as it may initially be paralyzed and unresponsive.
Overall, acute closed-angle glaucoma is a medical emergency that requires prompt intervention to alleviate symptoms and prevent further damage to the eye.
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This question is part of the following fields:
- Ophthalmology
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Question 3
Incorrect
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A 30-year-old construction worker comes in with intense pain in his right eye following an incident at the job site where a significant amount of cement dust entered his right eye.
What is the potential pathological condition that this patient's eye may be susceptible to?Your Answer:
Correct Answer: Colliquative necrosis
Explanation:Cement contains lime, which is a powerful alkali, and this can cause a serious eye emergency that requires immediate treatment. Alkaline chemicals, such as oven cleaner, ammonia, household bleach, drain cleaner, oven cleaner, and plaster, can also cause damage to the eyes. They lead to colliquative necrosis, which is a type of tissue death that results in liquefaction. On the other hand, acids cause damage through coagulative necrosis. Common acids that can harm the eyes include toilet cleaners, certain household cleaning products, and battery fluid.
The initial management of a patient with cement or alkali exposure to the eyes should be as follows:
1. Irrigate the eye with a large amount of normal saline for 20-30 minutes.
2. Administer local anaesthetic drops every 5 minutes to help keep the eye open and alleviate pain.
3. Monitor the pH every 5 minutes until a neutral pH (7.0-7.5) is achieved. Briefly pause irrigation to test the fluid from the forniceal space using litmus paper.After the initial management, a thorough examination should be conducted, which includes the following steps:
1. Examine the eye directly and with a slit lamp.
2. Remove any remaining cement debris from the surface of the eye.
3. Evert the eyelids to check for hidden cement debris.
4. Administer fluorescein drops and check for corneal abrasion.
5. Assess visual acuity, which may be reduced.
6. Perform fundoscopy to check for retinal necrosis if the alkali has penetrated the sclera.
7. Measure intraocular pressure through tonometry to detect secondary glaucoma.Once the eye’s pH has returned to normal, irrigation can be stopped, and the patient should be promptly referred to an ophthalmology specialist for further evaluation.
Potential long-term complications of cement or alkali exposure to the eyes include closed-angle glaucoma, cataract formation, entropion, keratitis sicca, and permanent vision loss.
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This question is part of the following fields:
- Ophthalmology
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Question 4
Incorrect
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A 12-year-old boy presents to the eye clinic with a sudden onset of acute follicular conjunctivitis in his right eye. He complains of severe eye pain and has blurred vision with a lot of watery discharge. During the examination, pseudomembrane formation is observed in his eye, and he has preauricular lymphadenopathy on the right side. The doctor informs him that he has been diagnosed with 'epidemic keratoconjunctivitis'.
What is the SINGLE most likely causative organism in this case?Your Answer:
Correct Answer: Adenovirus
Explanation:Epidemic keratoconjunctivitis is a type of viral conjunctivitis that is primarily caused by adenoviruses. This highly contagious condition tends to occur in outbreaks. It is a common cause of acute conjunctivitis and has distinct clinical features. These include the sudden onset of acute follicular conjunctivitis, severe pain in the affected eye, a significant amount of watery discharge, the presence of subconjunctival hemorrhages, potential visual changes, hyperemia and chemosis, and the possibility of membranes and pseudomembranes forming. Additionally, ipsilateral preauricular lymphadenopathy may be observed.
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This question is part of the following fields:
- Ophthalmology
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Question 5
Incorrect
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A 32-year-old woman comes in with a painful, red left eye. She is also experiencing bilateral knee discomfort. Her medical history includes frequent and recurring mouth and genital ulcers. Upon examination of her eye, there is circumlimbal redness and a hypopyon is visible. Her left pupil has a poor reaction to light.
What is the SINGLE most probable diagnosis?Your Answer:
Correct Answer: Behçet’s syndrome
Explanation:Behçet’s syndrome is a systemic vasculitis that is mediated by the immune system. It is characterized by various symptoms, including polyarthritis, which primarily affects large joints. Additionally, patients with Behçet’s syndrome often experience recurrent oral and genital ulcers. Ocular disease is also common, with manifestations such as uveitis, hypopyon, and iridocyclitis. Furthermore, neurological involvement can occur, leading to demyelination, parkinsonism, and dementia. In this particular case, the patient’s eye examination reveals features consistent with anterior uveitis and the presence of a hypopyon. While several conditions can cause anterior uveitis, the patient’s history of joint pain in large joints and recurrent oral and genital ulcers strongly suggest Behçet’s syndrome as the most likely diagnosis.
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This question is part of the following fields:
- Ophthalmology
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Question 6
Incorrect
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A 65-year-old man has experienced a stroke affecting the blood vessels in his brain. Testing of his visual field reveals that he has a quadrantanopia in the lower left side of his vision.
Where in the visual pathway has this injury occurred?Your Answer:
Correct Answer: Upper optic radiation
Explanation:Homonymous quadrantanopia occur when there are lesions in the optic radiation. The optic tract passes through the posterolateral angle of the optic chiasm, running alongside the cerebral peduncle and inside the uncus of the temporal lobe. Eventually, it reaches the lateral geniculate body (LGN) in the thalamus. Acting as a relay center, the LGN sends axons through the optic radiation to the primary visual cortex in the occipital lobe. The upper optic radiation carries fibers from the superior retinal quadrants (which corresponds to the lower half of the visual field) and travels through the parietal lobe. On the other hand, the lower optic radiation carries fibers from the inferior retinal quadrants (which corresponds to the upper half of the visual field) and travels through the temporal lobe. Consequently, lesions in the temporal lobe can lead to superior homonymous quadrantanopia, while lesions in the parietal lobe can cause inferior homonymous quadrantanopia. The diagram below provides a summary of the different visual field defects resulting from lesions at various points in the visual pathway.
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This question is part of the following fields:
- Ophthalmology
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Question 7
Incorrect
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A 60-year-old man comes in with decreased vision and floaters in his right eye. Upon fundoscopy, you observe a section of sensory retina protruding towards the center of the eye. A diagnosis of retinal detachment is confirmed.
Which of the following statements about retinal detachment is correct?Your Answer:
Correct Answer: A retina which remains fixed at six months post-surgical repair is unlikely to become detached again
Explanation:Retinal detachment is a condition where the retina separates from the retinal pigment epithelium, resulting in a fluid-filled space between them. This case presents a classic description of retinal detachment. Several risk factors increase the likelihood of developing this condition, including myopia, being male, having a family history of retinal detachment, previous episodes of retinal detachment, blunt ocular trauma, previous cataract surgery, diabetes mellitus (especially if proliferative retinopathy is present), glaucoma, and cataracts.
The clinical features commonly associated with retinal detachment include flashes of light, particularly at the edges of vision (known as photopsia), a dense shadow in the peripheral vision that spreads towards the center, a sensation of a curtain drawing across the eye, and central visual loss. Fundoscopy, a procedure to examine the back of the eye, reveals a sheet of sensory retina billowing towards the center of the eye. Additionally, a positive Amsler grid test, where straight lines appear curved or wavy, may indicate retinal detachment.
Other possible causes of floaters include posterior vitreous detachment, retinal tears, vitreous hemorrhage, and migraine with aura. However, in this case, the retinal appearance described is consistent with retinal detachment.
It is crucial to arrange an urgent same-day ophthalmology referral for this patient. Fortunately, approximately 90% of retinal detachments can be successfully repaired with one operation, and an additional 6% can be salvaged with subsequent procedures. If the retina remains fixed six months after surgery, the likelihood of it becoming detached again is low.
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This question is part of the following fields:
- Ophthalmology
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Question 8
Incorrect
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A 45-year-old woman comes in with a painful red eye accompanied by sensitivity to light, excessive tearing, and reduced vision. The on-call ophthalmology team is consulted, and they diagnose her with anterior uveitis.
Which of the following is the SINGLE LEAST probable underlying cause?Your Answer:
Correct Answer: Lymphoma
Explanation:Anterior uveitis refers to the inflammation of the iris and is characterized by a painful and red eye. It is often accompanied by symptoms such as sensitivity to light, excessive tearing, and a decrease in visual clarity. In less than 10% of cases, the inflammation may extend to the posterior chamber. The condition can also lead to the formation of adhesions between the iris and the lens or cornea, resulting in an irregularly shaped pupil known as synechia. In severe cases, pus may accumulate in the front part of the eye, specifically the anterior chamber, causing a condition called hypopyon.
There are various factors that can cause anterior uveitis, including idiopathic cases where no specific cause can be identified. Other causes include trauma, chronic joint diseases like spondyloarthropathies and juvenile chronic arthritis, ankylosing spondylitis, inflammatory bowel disease, psoriasis, sarcoidosis, and infections such as Lyme disease, tuberculosis, leptospirosis, herpes simplex virus (HSV), and varicella-zoster virus (VZV). It is worth noting that approximately 50% of patients with anterior uveitis have a strong association with the HLA-B27 genotype.
Complications that can arise from uveitis include the development of cataracts, glaucoma, band keratopathy (a condition where calcium deposits form on the cornea), and even blindness.
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This question is part of the following fields:
- Ophthalmology
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Question 9
Incorrect
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A one-week-old infant presents with eyelid swelling and a mucopurulent discharge from both eyes shortly after birth. The diagnosis of ophthalmia neonatorum is made. What is the most probable causative organism in this case?
Your Answer:
Correct Answer: Chlamydia trachomatis
Explanation:Ophthalmia neonatorum refers to any cause of conjunctivitis during the newborn period, regardless of the specific organism responsible.
Conjunctivitis is the most frequent occurrence of Chlamydia trachomatis infection in newborns. Chlamydia is now the leading cause, accounting for up to 40% of cases. Neisseria gonorrhoea, on the other hand, only accounts for less than 1% of reported cases. The remaining cases are caused by non-sexually transmitted bacteria like Staphylococcus, Streptococcus, Haemophilus species, and viruses.
Gonorrhoeal ophthalmia neonatorum typically presents within 1 to 5 days after birth. It is characterized by intense redness and swelling of the conjunctiva, eyelid swelling, and a severe discharge of pus. Corneal ulceration and perforation may also be present.
Chlamydial ophthalmia neonatorum, on the other hand, usually appears between 5 to 14 days after birth. It is characterized by a gradually increasing watery discharge that eventually becomes purulent. The inflammation in the eyes is usually less severe compared to gonococcal infection, and there is a lower risk of corneal ulceration and perforation.
The second most common manifestation of Chlamydia trachomatis infection in newborns is pneumonia. Approximately 5-30% of infected neonates will develop pneumonia. About half of these infants will also have a history of ophthalmia neonatorum.
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This question is part of the following fields:
- Ophthalmology
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Question 10
Incorrect
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A 60-year-old woman comes in with severe left eye pain and loss of vision in the left eye. After conducting a comprehensive examination and measuring the intraocular pressure, you diagnose her with acute closed-angle glaucoma.
Which of the following statements about acute closed-angle glaucoma is correct?Your Answer:
Correct Answer: intraocular pressures are often greater than 30 mmHg
Explanation:This patient has presented with acute closed-angle glaucoma, which is a medical emergency in the field of ophthalmology. It occurs when the iris bows forward and blocks the fluid access to the trabecular meshwork, which is located at the entrance to Schlemm’s canal. As a result, the intraocular pressure rises and leads to glaucomatous optic neuropathy.
The main clinical features of acute closed-angle glaucoma include severe eye pain, loss of vision or decreased visual acuity, congestion and redness around the cornea, corneal swelling, a fixed semi-dilated oval-shaped pupil, nausea and vomiting, and preceding episodes of blurred vision or seeing haloes.
The diagnosis can be confirmed by tonometry, which measures the pressure inside the eye. The normal range of intraocular pressure is 10-21 mmHg, but in acute closed-angle glaucoma, it is often higher than 30 mmHg. Goldmann’s applanation tonometer is commonly used in hospitals for this purpose.
Management of acute closed-angle glaucoma should include providing pain relief, such as morphine, and antiemetics if the patient is experiencing vomiting. Intravenous administration of acetazolamide 500 mg is recommended to reduce intraocular pressure. Treatment with a topical miotic, like pilocarpine 1% or 2%, should be initiated approximately one hour after starting other measures, as the pupil may initially be paralyzed and unresponsive.
On the other hand, chronic open-angle glaucoma is a more common presentation than acute closed-angle glaucoma. It affects approximately 1 in 50 people over the age of 40 and 1 in 10 people over the age of 75. In this condition, there is a partial blockage within the trabecular meshwork, which hinders the drainage of aqueous humor and gradually increases intraocular pressure, leading to optic neuropathy. Unlike acute closed-angle glaucoma, chronic open-angle glaucoma does not cause eye pain or redness. It presents gradually with a progressive loss of peripheral vision, while central vision is relatively preserved.
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This question is part of the following fields:
- Ophthalmology
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Question 11
Incorrect
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A 42-year-old woman comes in with a painful, red left eye and sensitivity to light. She also reports seeing floaters and experiencing a dull, throbbing headache. She is currently being evaluated by the rheumatology team for persistent pain and stiffness in her upper back and discomfort in her buttocks and thighs. Her eye appears red, and a hypopyon is visible.
What is the SINGLE most probable UNDERLYING diagnosis?Your Answer:
Correct Answer: Ankylosing spondylitis
Explanation:The most probable diagnosis in this case is anterior uveitis. Anterior uveitis refers to the inflammation of the iris and typically manifests as a painful and red eye. It is often accompanied by symptoms such as sensitivity to light, excessive tearing, and decreased visual clarity. In some instances, there may be the presence of pus in the front part of the eye known as hypopyon.
Anterior uveitis can have various causes, including idiopathic (no known cause), trauma, chronic joint diseases like spondyloarthropathies and juvenile chronic arthritis, inflammatory bowel disease, psoriasis, sarcoidosis, and infections such as Lyme disease, tuberculosis, leptospirosis, herpes simplex virus (HSV), and varicella-zoster virus (VZV). Additionally, certain malignancies like non-Hodgkin lymphoma, ocular melanoma, and retinoblastoma can also be associated with anterior uveitis.
A significant association has been observed between the HLA-B27 genotype and anterior uveitis, with approximately 50% of patients having this genetic marker. In this particular case, the likely underlying diagnosis is ankylosing spondylitis, a condition characterized by chronic pain and stiffness in the middle spine area and sacroiliitis. It is worth noting that around 30% of men with unilateral uveitis will be found to have ankylosing spondylitis.
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This question is part of the following fields:
- Ophthalmology
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Question 12
Incorrect
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A 60-year-old woman comes in with intense left eye pain and vision loss in the left eye. She has experienced multiple episodes of vomiting. During the examination, there is noticeable redness around the left side of the cornea, and the left pupil is dilated and does not react to light.
What is the SINGLE most probable diagnosis?Your Answer:
Correct Answer: Closed-angle glaucoma
Explanation:Acute closed-angle glaucoma is a serious eye condition that requires immediate medical attention. It occurs when the iris pushes forward and blocks the fluid from reaching the trabecular meshwork, which is responsible for draining the eye. This blockage leads to increased pressure inside the eye and can cause damage to the optic nerve.
The main symptoms of acute closed-angle glaucoma include severe eye pain, vision loss or decreased visual acuity, redness and congestion around the cornea, swelling of the cornea, a fixed semi-dilated pupil, and nausea and vomiting. Some individuals may also experience episodes of blurred vision or seeing haloes before the onset of these symptoms.
On the other hand, chronic open-angle glaucoma is a more common form of the condition. It affects about 1 in 50 people over the age of 40 and 1 in 10 people over the age of 75. In this type of glaucoma, there is a partial blockage in the trabecular meshwork, which gradually restricts the drainage of fluid from the eye. As a result, the pressure inside the eye gradually increases, leading to optic nerve damage. Unlike acute closed-angle glaucoma, chronic open-angle glaucoma does not cause eye pain or redness. Instead, it presents slowly with a gradual loss of peripheral vision, while central vision is relatively preserved.
It is important to seek medical attention if you experience any symptoms of glaucoma, as early diagnosis and treatment can help prevent further vision loss.
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This question is part of the following fields:
- Ophthalmology
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Question 13
Incorrect
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A 7-year-old girl presents with a 4-day history of blurred vision in her left eye. She is also experiencing eye pain and fatigue. On examination, her temperature is 38.0°C, but her other vital signs are normal. There is significant redness in the conjunctiva, and a collection of pus (hypopyon) is present in her left eye. Her visual acuity in that eye is reduced to counting fingers. She recently received a kitten as a pet from her parents.
What is the SINGLE most likely causative organism?Your Answer:
Correct Answer: Toxocara canis
Explanation:Toxocariasis is a rare infection caused by the parasitic roundworm Toxocara canis. The main way it spreads to humans is through contact with dog feces. However, practicing good hand hygiene can help prevent transmission. While most people who come into contact with Toxocara canis don’t show any symptoms, a small number may experience a mild flu-like illness.
The most common presentation of toxocariasis is in children, who may experience unilateral visual loss. This loss of vision is typically caused by conditions such as vitritis, macular edema, and tractional retinal detachment. It is believed that these lesions occur due to a toxic or immunoallergic reaction to the larval antigens.
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This question is part of the following fields:
- Ophthalmology
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Question 14
Incorrect
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A 3-year-old boy is brought in by his father with a red and painful right eye. On examination, you note the presence of conjunctival erythema. There is also mucopurulent discharge and lid crusting evident in the eye. You make a diagnosis of bacterial conjunctivitis.
With reference to the current NICE guidance, which of the following should NOT be included in your management plan for this patient?Your Answer:
Correct Answer: Topical antibiotics should be prescribed routinely
Explanation:Here is a revised version of the guidance on the management of bacterial conjunctivitis:
– It is important to inform the patient that most cases of bacterial conjunctivitis will resolve on their own within 5-7 days without any treatment.
– However, if the condition is severe or if there is a need for rapid resolution, topical antibiotics may be prescribed. In some cases, a delayed treatment strategy may be appropriate, and the patient should be advised to start using topical antibiotics if their symptoms have not improved within 3 days.
– There are several options for topical antibiotics, including Chloramphenicol 0.5% drops (to be applied every 2 hours for 2 days, then 4 times daily for 5 days) and Chloramphenicol 1% ointment (to be applied four times daily for 2 days, then twice daily for 5 days). Fusidic acid 1% eye drops can also be used as a second-line treatment, to be applied twice daily for 7 days.
– It is important to note that there is no recommended exclusion period from school, nursery, or childminders for isolated cases of bacterial conjunctivitis. However, some institutions may have their own exclusion policies.
– Provide the patient with written information and explain the red flags that indicate the need for an urgent review.
– Arrange a follow-up appointment to confirm the diagnosis and ensure that the symptoms have resolved.
– If the patient returns with ongoing symptoms, it may be necessary to send swabs for viral PCR (to test for adenovirus and Herpes simplex) and bacterial culture. Empirical topical antibiotics may also be prescribed if they have not been previously given.
– Consider referring the patient to ophthalmology if the symptoms persist for more than 7 to 10 days after initiating treatment.For more information, you can refer to the NICE Clinical Knowledge Summary on Infective Conjunctivitis.
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This question is part of the following fields:
- Ophthalmology
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Question 15
Incorrect
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You evaluate the pupillary light reflex in a patient with a cranial nerve impairment. Upon shining the light into the left eye, there is no alteration in pupil size in either the left or right eye. However, when the light is directed into the right eye, both the left and right pupils constrict.
What is the location of the lesion in this scenario?Your Answer:
Correct Answer: Left optic nerve
Explanation:The pupillary light reflex is a reflex that regulates the size of the pupil in response to the intensity of light that reaches the retina. It consists of two separate pathways, the afferent pathway and the efferent pathway.
The afferent pathway begins with light entering the pupil and stimulating the retinal ganglion cells in the retina. These cells then transmit the light signal to the optic nerve. At the optic chiasm, the nasal retinal fibers cross to the opposite optic tract, while the temporal retinal fibers remain in the same optic tract. The fibers from the optic tracts then project and synapse in the pretectal nuclei in the dorsal midbrain. From there, the pretectal nuclei send fibers to the ipsilateral Edinger-Westphal nucleus via the posterior commissure.
On the other hand, the efferent pathway starts with the Edinger-Westphal nucleus projecting preganglionic parasympathetic fibers. These fibers exit the midbrain and travel along the oculomotor nerve. They then synapse on post-ganglionic parasympathetic fibers in the ciliary ganglion. The post-ganglionic fibers, known as the short ciliary nerves, innervate the sphincter muscle of the pupils, causing them to constrict.
The result of these pathways is that when light is shone in one eye, both the direct pupillary light reflex (ipsilateral eye) and the consensual pupillary light reflex (contralateral eye) occur.
Lesions affecting the pupillary light reflex can be identified by comparing the direct and consensual reactions to light in both eyes. If the optic nerve of the first eye is damaged, both the direct and consensual reflexes in the second eye will be lost. However, when light is shone into the second eye, the pupil of the first eye will still constrict. If the optic nerve of the second eye is damaged, the second eye will constrict consensually when light is shone into the unaffected first eye. If the oculomotor nerve of the first eye is damaged, the first eye will have no direct light reflex, but the second eye will still constrict consensually. Finally, if the oculomotor nerve of the second eye is damaged, there will be no consensual constriction of the second eye when light is shone into the unaffected first eye.
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This question is part of the following fields:
- Ophthalmology
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Question 16
Incorrect
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A 25-year-old patient complains of a red and painful right eye. Upon examination, you observe conjunctival erythema. There is also mucopurulent discharge and lid crusting present in the eye. Based on the current NICE guidance, what is the recommended first-line antibiotic for treating bacterial conjunctivitis?
Your Answer:
Correct Answer: Chloramphenicol 1% ointment
Explanation:When it comes to managing bacterial conjunctivitis, NICE provides some helpful guidance. It is important to inform the patient that most cases of bacterial conjunctivitis will resolve on their own within 5-7 days without any treatment. However, in severe cases or situations where a quick resolution is necessary, topical antibiotics may be necessary. In some cases, it may be appropriate to delay treatment and advise the patient to start using topical antibiotics if their symptoms have not improved within 3 days.
There are a few options for topical antibiotics that can be used. One option is Chloramphenicol 0.5% drops, which should be applied every 2 hours for 2 days and then 4 times daily for 5 days. Another option is Chloramphenicol 1% ointment, which should be applied four times daily for 2 days and then twice daily for 5 days. Fusidic acid 1% eye drops can also be used as a second-line treatment and should be applied twice daily for 7 days.
By following these guidelines, healthcare professionals can effectively manage bacterial conjunctivitis and provide appropriate treatment options for their patients.
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This question is part of the following fields:
- Ophthalmology
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Question 17
Incorrect
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A 45-year-old man presents with a red, painful right eye. He describes the pain as being excruciating, and it radiates to his forehead. His eyes are excessively watery, and he prefers to stay in a dark room at home because light exacerbates the pain. On examination, his eye appears very red, and there is tenderness upon palpation of the eyeball. His visual acuity is decreased. He was recently diagnosed with ankylosing spondylitis.
What is the SINGLE MOST likely diagnosis?Your Answer:
Correct Answer: Scleritis
Explanation:Scleritis is a serious condition characterized by inflammation of the sclera, the white outer layer of the eye. It often affects both eyes, with bilateral involvement seen in about half of the cases. While the cause of scleritis can be unknown (idiopathic), it is associated with systemic inflammatory diseases like rheumatoid arthritis in approximately one-third of patients. In fact, scleritis can sometimes be the initial manifestation of these inflammatory conditions.
The clinical features of scleritis include moderate to severe pain, which can be felt in the brow or jaw. The pain worsens with eye movement and may disrupt sleep. The onset of symptoms is typically gradual. Other common symptoms include sensitivity to light (photophobia), excessive tearing (epiphora), and redness of both the superficial and deep episcleral vessels. The affected eye may also be tender to touch, and there may be a decrease in visual acuity. Some individuals may have a history of previous episodes of scleritis.
In summary, scleritis is a serious inflammatory disease of the sclera that can be associated with systemic inflammatory conditions. It presents with significant pain, often referred to the brow or jaw, and worsened by eye movement. Other symptoms include photophobia, excessive tearing, and redness of the episcleral vessels. It is important to recognize scleritis as it can be the first sign of underlying inflammatory diseases.
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This question is part of the following fields:
- Ophthalmology
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Question 18
Incorrect
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A 70-year-old man experiences a sudden loss of vision in his left eye. He is later diagnosed with central retinal artery occlusion (CRAO).
Which ONE statement about this condition is accurate?Your Answer:
Correct Answer: The pupil on the affected side is usually poorly reactive to light with a normal consensual light reaction
Explanation:Central retinal artery occlusion (CRAO) is characterized by sudden and painless loss of vision in the affected eye. It can occur due to emboli from atheromatous carotid arteries, thrombosis caused by arteriosclerosis or hypertension, or vasospasm resulting from giant cell arteritis. The pupil on the affected side typically shows poor reactivity to light, but the consensual light reaction remains normal. The typical retinal findings in CRAO include a pale retina due to edema, narrowed blood vessels, segmentation of blood columns in arteries (resembling cattle-trucking), and a cherry red spot indicating sparing of the macular center supplied by the underlying choroid. Over several weeks, optic atrophy may develop. Immediate referral to an eye specialist is necessary as CRAO is an ophthalmological emergency.
On the other hand, central retinal vein occlusion (CRVO) leads to painless and unilateral visual loss. The retina in CRVO has a distinct appearance likened to a pizza thrown against a wall. Fundoscopic examination reveals engorged retinal veins, disc edema, multiple flame-shaped hemorrhages, and cotton wool spots.
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This question is part of the following fields:
- Ophthalmology
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Question 19
Incorrect
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A 60-year-old man presents with decreased visual acuity and 'floaters' in his right eye. You conduct a fundoscopy and observe a sheet of sensory retina bulging towards the center of the eye. A diagnosis of retinal detachment is made.
Which of the following statements about retinal detachment is NOT true?Your Answer:
Correct Answer: Hypermetropia is a significant risk factor
Explanation:Retinal detachment is a condition where the retina separates from the retinal pigment epithelium, resulting in a fluid-filled space between them. This case presents a classic description of retinal detachment. Several risk factors increase the likelihood of developing this condition, including myopia, being male, having a family history of retinal detachment, previous episodes of retinal detachment, blunt ocular trauma, previous cataract surgery, diabetes mellitus (especially if proliferative retinopathy is present), glaucoma, and cataracts.
The clinical features commonly associated with retinal detachment include flashes of light, particularly at the edges of vision (known as photopsia), a dense shadow in the peripheral vision that spreads towards the center, a sensation of a curtain drawing across the eye, and central visual loss. Fundoscopy, a procedure to examine the back of the eye, reveals a sheet of sensory retina billowing towards the center of the eye. Additionally, a positive Amsler grid test, where straight lines appear curved or wavy, may indicate retinal detachment.
Other possible causes of floaters include posterior vitreous detachment, retinal tears, vitreous hemorrhage, and migraine with aura. However, in this case, the retinal appearance described is consistent with retinal detachment.
It is crucial to arrange an urgent same-day ophthalmology referral for this patient. Fortunately, approximately 90% of retinal detachments can be successfully repaired with one operation, and an additional 6% can be salvaged with subsequent procedures. If the retina remains fixed six months after surgery, the likelihood of it becoming detached again is low.
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This question is part of the following fields:
- Ophthalmology
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Question 20
Incorrect
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A 30-year-old construction worker comes in with intense pain in his left eye following an incident at the job site where a significant amount of cement dust entered his left eye.
Which of the following long-term complications is the LEAST probable to develop?Your Answer:
Correct Answer: Open-angle glaucoma
Explanation:Cement contains lime, which is a powerful alkali, and this can cause a serious eye emergency that requires immediate treatment. Alkaline chemicals, such as oven cleaner, ammonia, household bleach, drain cleaner, oven cleaner, and plaster, can also cause damage to the eyes. They lead to colliquative necrosis, which is a type of tissue death that results in liquefaction. On the other hand, acids cause damage through coagulative necrosis. Common acids that can harm the eyes include toilet cleaners, certain household cleaning products, and battery fluid.
The initial management of a patient with cement or alkali exposure to the eyes should be as follows:
1. Irrigate the eye with a large amount of normal saline for 20-30 minutes.
2. Administer local anaesthetic drops every 5 minutes to help keep the eye open and alleviate pain.
3. Monitor the pH every 5 minutes until a neutral pH (7.0-7.5) is achieved. Briefly pause irrigation to test the fluid from the forniceal space using litmus paper.After the initial management, a thorough examination should be conducted, which includes the following steps:
1. Examine the eye directly and with a slit lamp.
2. Remove any remaining cement debris from the surface of the eye.
3. Evert the eyelids to check for hidden cement debris.
4. Administer fluorescein drops and check for corneal abrasion.
5. Assess visual acuity, which may be reduced.
6. Perform fundoscopy to check for retinal necrosis if the alkali has penetrated the sclera.
7. Measure intraocular pressure through tonometry to detect secondary glaucoma.Once the eye’s pH has returned to normal, irrigation can be stopped, and the patient should be promptly referred to an ophthalmology specialist for further evaluation.
Potential long-term complications of cement or alkali exposure to the eyes include closed-angle glaucoma, cataract formation, entropion, keratitis sicca, and permanent vision loss.
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This question is part of the following fields:
- Ophthalmology
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Question 21
Incorrect
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A 42-year-old woman comes in with a suddenly painful right eye and sensitivity to light. She describes her eye as feeling gritty and it is noticeably watery. The patient has been experiencing a mild cold for the past few days. You administer fluorescein drops to her eye, which reveal the presence of a dendritic ulcer.
What is the most suitable treatment for this patient?Your Answer:
Correct Answer: Acyclovir ointment
Explanation:There are two types of infectious agents that can lead to the development of a dendritic ulcer. The majority of cases (80%) are caused by the herpes simplex virus (type I), while the remaining cases (20%) are caused by the herpes zoster virus. To effectively treat this condition, the patient should follow a specific treatment plan. This includes applying acyclovir ointment topically five times a day for a duration of 10 days. Additionally, prednisolone 0.5% drops should be used 2-4 times daily. It is also recommended to take oral high dose vitamin C, as it has been shown to reduce the healing time of dendritic ulcers.
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This question is part of the following fields:
- Ophthalmology
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Question 22
Incorrect
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A 60-year-old woman presents with intense pain in her left eye and sudden vision loss in the same eye. She has experienced multiple episodes of vomiting. After conducting a comprehensive examination and measuring the intraocular pressure, you diagnose her with acute closed-angle glaucoma. You provide analgesics and administer IV acetazolamide as the initial treatment.
What other treatment option could potentially benefit this patient?Your Answer:
Correct Answer: Topical pilocarpine
Explanation:This patient has presented with acute closed-angle glaucoma, which is a serious eye condition requiring immediate medical attention. It occurs when the iris pushes forward and blocks the fluid access to the trabecular meshwork, leading to increased pressure within the eye and damage to the optic nerve.
The main symptoms of acute closed-angle glaucoma include severe eye pain, decreased vision, redness around the cornea, swelling of the cornea, a fixed semi-dilated pupil, nausea, vomiting, and episodes of blurred vision or seeing haloes.
To confirm the diagnosis, tonometry is performed to measure the intraocular pressure. Normal pressure ranges from 10 to 21 mmHg, but in acute closed-angle glaucoma, it is often higher than 30 mmHg. Goldmann’s applanation tonometer is commonly used in hospitals for this purpose.
Management of acute closed-angle glaucoma involves providing pain relief, such as morphine, and antiemetics if the patient is experiencing vomiting. Intravenous acetazolamide is administered to reduce intraocular pressure. Additionally, a topical miotic medication like pilocarpine is started about an hour after initiating other treatments to help constrict the pupil, as it may initially be paralyzed and unresponsive.
Overall, acute closed-angle glaucoma is a medical emergency that requires prompt intervention to alleviate symptoms and prevent further damage to the eye.
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This question is part of the following fields:
- Ophthalmology
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Question 23
Incorrect
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You evaluate the pupillary light reflex in a patient with a cranial nerve impairment. When the light is directed into the left eye, there is no alteration in pupil size in either the left or right eye. However, when the light is directed into the right eye, both the left and right pupils constrict.
What is the location of the lesion in this scenario?Your Answer:
Correct Answer: Left optic nerve
Explanation:The pupillary light reflex is a reflex that regulates the size of the pupil in response to the intensity of light that reaches the retina. It consists of two separate pathways, the afferent pathway and the efferent pathway.
The afferent pathway begins with light entering the pupil and stimulating the retinal ganglion cells in the retina. These cells then transmit the light signal to the optic nerve. At the optic chiasm, the nasal retinal fibers cross to the opposite optic tract, while the temporal retinal fibers remain in the same optic tract. The fibers from the optic tracts then project and synapse in the pretectal nuclei in the dorsal midbrain. From there, the pretectal nuclei send fibers to the ipsilateral Edinger-Westphal nucleus via the posterior commissure.
On the other hand, the efferent pathway starts with the Edinger-Westphal nucleus projecting preganglionic parasympathetic fibers. These fibers exit the midbrain and travel along the oculomotor nerve. They then synapse on post-ganglionic parasympathetic fibers in the ciliary ganglion. The post-ganglionic fibers, known as the short ciliary nerves, innervate the sphincter muscle of the pupils, causing them to constrict.
The result of these pathways is that when light is shone in one eye, both the direct pupillary light reflex (ipsilateral eye) and the consensual pupillary light reflex (contralateral eye) occur.
Lesions affecting the pupillary light reflex can be identified by comparing the direct and consensual reactions to light in both eyes. If the optic nerve of the first eye is damaged, both the direct and consensual reflexes in the second eye will be lost. However, when light is shone into the second eye, the pupil of the first eye will still constrict. If the optic nerve of the second eye is damaged, the second eye will constrict consensually when light is shone into the unaffected first eye. If the oculomotor nerve of the first eye is damaged, the first eye will have no direct light reflex, but the second eye will still constrict consensually. Finally, if the oculomotor nerve of the second eye is damaged, there will be no consensual constriction of the second eye when light is shone into the unaffected first eye.
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This question is part of the following fields:
- Ophthalmology
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Question 24
Incorrect
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A 35-year-old woman comes in with a painful, red right eye. She has a history of ankylosing spondylitis (AS).
What is the MOST frequently occurring eye complication associated with AS?Your Answer:
Correct Answer: Uveitis
Explanation:Uveitis is the most prevalent eye complication that arises in individuals with ankylosing spondylitis (AS). Approximately one out of every three patients with AS will experience uveitis at some stage. The symptoms of uveitis include a red and painful eye, along with photophobia and blurred vision. Additionally, patients may notice the presence of floaters. The primary treatment for uveitis involves the use of corticosteroids, and it is crucial for patients to seek immediate attention from an ophthalmologist.
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This question is part of the following fields:
- Ophthalmology
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Question 25
Incorrect
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A 42-year-old woman presents with right eye pain and sensitivity to light. She reports that the eye pain worsens when she reads or uses her computer. Her eye is excessively watery. During the examination, her right pupil is constricted, and there is noticeable redness around the iris. Her visual acuity is measured and found to be 6/6. She has a history of ankylosing spondylitis and takes a non-steroidal anti-inflammatory medication.
What is the MOST LIKELY diagnosis for this patient?Your Answer:
Correct Answer: Anterior uveitis
Explanation:Anterior uveitis refers to the inflammation of the middle layer of the eye, which includes the iris and the ciliary body. If left untreated, it can lead to permanent damage and vision loss due to the development of conditions like glaucoma, cataract, or retinal edema.
There are various causes of anterior uveitis, including eye trauma from being hit or having a foreign object in the eye. It can also be associated with inflammatory disorders such as ankylosing spondylitis.
The clinical features of anterior uveitis are characterized by a red and sore eye, accompanied by pain that worsens when the ciliary muscles contract. Other symptoms include watering of the eye, blurred vision, sensitivity to light (photophobia), and a constricted or distorted pupil. The visual acuity may be normal or reduced.
Overall, anterior uveitis is a condition that requires prompt attention and treatment to prevent further complications and preserve vision.
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This question is part of the following fields:
- Ophthalmology
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Question 26
Incorrect
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A 32-year-old artist returns from a vacation in Thailand with a severely painful and red right eye. The symptoms appeared rapidly within a day, and the eye now has excessive mucopurulent discharge and swelling of the eyelid. During the examination, tender pre-auricular lymphadenopathy is observed on the right side. Upon further inquiry, the patient confesses to having visited a sex worker during their trip to Thailand.
Which of the following antibiotics would be the most suitable to prescribe for this individual?Your Answer:
Correct Answer: Ceftriaxone
Explanation:Sexually transmitted eye infections can be quite severe and are often characterized by prolonged mucopurulent discharge. There are two main causes of these infections: Chlamydia trachomatis and Neisseria gonorrhoea. Differentiating between the two can be done by considering certain features.
Chlamydia trachomatis infection typically presents with chronic low-grade irritation and mucous discharge that lasts for more than two weeks in sexually active individuals. It may also be accompanied by pre-auricular lymphadenopathy. This type of infection is usually unilateral but can sometimes affect both eyes.
On the other hand, Neisseria gonorrhoea infection tends to develop rapidly, usually within 12 to 24 hours. It is characterized by copious mucopurulent discharge, eyelid swelling, and tender preauricular lymphadenopathy. This type of infection carries a higher risk of complications, such as uveitis, severe keratitis, and corneal perforation.
Based on the patient’s symptoms, it appears that they are more consistent with a Neisseria gonorrhoea infection. The rapid onset, copious discharge, and tender preauricular lymphadenopathy are indicative of this type of infection.
Treatment for gonococcal conjunctivitis in adults is typically based on limited research. However, a study has shown that all 12 patients responded well to a single 1 g intramuscular injection of ceftriaxone, along with a single episode of ocular lavage with saline.
In summary, sexually transmitted eye infections can be caused by either Chlamydia trachomatis or Neisseria gonorrhoea. Differentiating between the two is important in order to provide appropriate treatment. The patient in this case exhibits symptoms that align more closely with a Neisseria gonorrhoea infection, which carries a higher risk of complications. Treatment options for gonococcal conjunctivitis are limited, but a single injection of ceftriaxone has shown positive results in previous studies.
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This question is part of the following fields:
- Ophthalmology
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Question 27
Incorrect
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A one-month-old infant develops eyelid swelling and a mucopurulent discharge from both of his eyes approximately two weeks after birth. His mother is currently being treated for a chlamydia infection.
What is the baby's highest risk of complications?Your Answer:
Correct Answer: Pneumonia
Explanation:Conjunctivitis is the most frequent occurrence of Chlamydia trachomatis infection in newborns. Ophthalmia neonatorum refers to any cause of conjunctivitis during the newborn period, regardless of the specific organism responsible. Chlamydia is now the leading cause, accounting for up to 40% of cases. Neisseria gonorrhoea, on the other hand, only accounts for less than 1% of reported cases. The remaining cases are caused by non-sexually transmitted bacteria like Staphylococcus, Streptococcus, Haemophilus species, and viruses.
Gonorrhoeal ophthalmia neonatorum typically presents within 1 to 5 days after birth. It is characterized by intense redness and swelling of the conjunctiva, eyelid swelling, and a severe discharge of pus. Corneal ulceration and perforation may also be present.
Chlamydial ophthalmia neonatorum, on the other hand, usually appears between 5 to 14 days after birth. It is characterized by a gradually increasing watery discharge that eventually becomes purulent. The inflammation in the eyes is usually less severe compared to gonococcal infection, and there is a lower risk of corneal ulceration and perforation.
The second most common manifestation of Chlamydia trachomatis infection in newborns is pneumonia. Approximately 5-30% of infected neonates will develop pneumonia. About half of these infants will also have a history of ophthalmia neonatorum.
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This question is part of the following fields:
- Ophthalmology
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Question 28
Incorrect
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A 35-year-old man is diagnosed with anterior uveitis.
Which SINGLE statement regarding this condition is FALSE?Your Answer:
Correct Answer: It most commonly involves the posterior chamber
Explanation:Anterior uveitis refers to the inflammation of the iris and is characterized by a painful and red eye. It is often accompanied by symptoms such as sensitivity to light, excessive tearing, and a decrease in visual clarity. In less than 10% of cases, the inflammation may extend to the posterior chamber. The condition can also lead to the formation of adhesions between the iris and the lens or cornea, resulting in an irregularly shaped pupil known as synechia. In severe cases, pus may accumulate in the front part of the eye, specifically the anterior chamber, causing a condition called hypopyon.
There are various factors that can cause anterior uveitis, including idiopathic cases where no specific cause can be identified. Other causes include trauma, chronic joint diseases like spondyloarthropathies and juvenile chronic arthritis, ankylosing spondylitis, inflammatory bowel disease, psoriasis, sarcoidosis, and infections such as Lyme disease, tuberculosis, leptospirosis, herpes simplex virus (HSV), and varicella-zoster virus (VZV). It is worth noting that approximately 50% of patients with anterior uveitis have a strong association with the HLA-B27 genotype.
Complications that can arise from uveitis include the development of cataracts, glaucoma, band keratopathy (a condition where calcium deposits form on the cornea), and even blindness.
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This question is part of the following fields:
- Ophthalmology
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Question 29
Incorrect
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A 35-year-old traveler returns from a trip to Thailand with a painful, red right eye. The eye has been bothering him for the past two and a half weeks, and the irritation has gradually increased. He has noticed mild mucopurulent discharge in the eye for the past two weeks and has been cleaning it regularly. During the examination, nontender pre-auricular lymphadenopathy is observed on the right side. Upon further questioning, he admits to engaging in sexual activity with a sex worker during his visit to Thailand.
What is the SINGLE most likely causative organism?Your Answer:
Correct Answer: Chlamydia trachomatis
Explanation:Sexually transmitted eye infections can be quite severe and are often characterized by prolonged mucopurulent discharge. The two main causes of these infections are Chlamydia trachomatis and Neisseria gonorrhoea. Differentiating between the two can be done by considering certain features.
Chlamydia trachomatis infection typically presents with chronic low-grade irritation and mucous discharge that lasts for more than two weeks in sexually active individuals. Pre-auricular lymphadenopathy, or swelling of the lymph nodes in front of the ear, may also be present. Most cases of this infection are unilateral, affecting only one eye, but there is a possibility of it being bilateral, affecting both eyes.
On the other hand, Neisseria gonorrhoea infection tends to develop rapidly, usually within 12 to 24 hours. It is characterized by copious mucopurulent discharge, swelling of the eyelids, and tender preauricular lymphadenopathy. This type of infection carries a higher risk of complications, such as uveitis, severe keratitis, and corneal perforation.
Based on the patient’s symptoms, it appears that they are more consistent with a Chlamydia trachomatis infection, especially considering the slower and more gradual onset of their symptoms.
There is ongoing debate regarding the most effective antibiotic treatment for these infections. Some options include topical tetracycline ointment to be applied four times a day for six weeks, oral doxycycline to be taken twice a day for one to two weeks, oral azithromycin with a single dose of 1 gram followed by 500 mg orally for two days, or oral erythromycin to be taken four times a day for one week.
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This question is part of the following fields:
- Ophthalmology
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Question 30
Incorrect
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A 30-year-old construction worker comes in with intense pain in his left eye following an incident at the job site where a significant amount of cement dust blew into his eye.
What should be utilized as an irrigation solution for the affected eye?Your Answer:
Correct Answer: 0.9% normal saline
Explanation:Cement contains lime, which is a powerful alkali, and this can cause a serious eye emergency that requires immediate treatment. Alkaline chemicals, such as oven cleaner, ammonia, household bleach, drain cleaner, oven cleaner, and plaster, can also cause damage to the eyes. They lead to colliquative necrosis, which is a type of tissue death that results in liquefaction. On the other hand, acids cause damage through coagulative necrosis. Common acids that can harm the eyes include toilet cleaners, certain household cleaning products, and battery fluid.
The initial management of a patient with cement or alkali exposure to the eyes should be as follows:
1. Irrigate the eye with a large amount of normal saline for 20-30 minutes.
2. Administer local anaesthetic drops every 5 minutes to help keep the eye open and alleviate pain.
3. Monitor the pH every 5 minutes until a neutral pH (7.0-7.5) is achieved. Briefly pause irrigation to test the fluid from the forniceal space using litmus paper.After the initial management, a thorough examination should be conducted, which includes the following steps:
1. Examine the eye directly and with a slit lamp.
2. Remove any remaining cement debris from the surface of the eye.
3. Evert the eyelids to check for hidden cement debris.
4. Administer fluorescein drops and check for corneal abrasion.
5. Assess visual acuity, which may be reduced.
6. Perform fundoscopy to check for retinal necrosis if the alkali has penetrated the sclera.
7. Measure intraocular pressure through tonometry to detect secondary glaucoma.Once the eye’s pH has returned to normal, irrigation can be stopped, and the patient should be promptly referred to an ophthalmology specialist for further evaluation.
Potential long-term complications of cement or alkali exposure to the eyes include closed-angle glaucoma, cataract formation, entropion, keratitis sicca, and permanent vision loss.
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This question is part of the following fields:
- Ophthalmology
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