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Question 1
Incorrect
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A 25-year-old patient comes in with a painful and red left eye. Upon examination, you observe conjunctival erythema and the presence of mucopurulent discharge and lid crusting. Based on these findings, you diagnose the patient with bacterial conjunctivitis. However, the patient cannot use the first-line treatment due to a previous reaction. According to the current NICE guidance, what is the recommended second-line antibiotic for managing bacterial conjunctivitis?
Your Answer: Ciprofloxacin 0.3% drops
Correct Answer: Fusidic acid 1% drops
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 2
Correct
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A 40-year-old woman comes in with bitemporal hemianopia resulting from a meningioma.
Where in the visual pathway has this lesion occurred?Your Answer: Optic chiasm
Explanation:The optic chiasm is situated just below the hypothalamus and is in close proximity to the pituitary gland. When the pituitary gland enlarges, it can impact the functioning of the optic nerve at this location. Specifically, the fibres from the nasal half of the retina cross over at the optic chiasm to form the optic tracts. Compression at the optic chiasm primarily affects these fibres, resulting in a visual defect that affects peripheral vision in both eyes, known as bitemporal hemianopia. There are several causes of optic chiasm lesions, with the most common being a pituitary tumor. Other causes include craniopharyngioma, meningioma, optic glioma, and internal carotid artery aneurysm. The diagram below provides a summary of the different visual field defects that can occur 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 3
Correct
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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: 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 4
Correct
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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: 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 5
Incorrect
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A child who was diagnosed with bacterial conjunctivitis seven days ago presents with ongoing symptoms. During their last visit, they were reassured and given advice on general measures, but no antibiotics were prescribed. The symptoms have now worsened, and the eye is extremely sticky and crusted.
What is the most suitable course of action in managing this child's condition?Your Answer: Prescribe empirical topical antibiotics, swabs unnecessary
Correct Answer: Send swabs for viral PCR and bacterial culture and prescribe empirical topical antibiotics
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 6
Correct
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A child who was diagnosed with viral conjunctivitis ten days ago presents with persistent symptoms of painful, red eyes. During their previous visit, they were reassured and given advice on general measures, but no antibiotics were prescribed. The symptoms have now worsened, and the eye is extremely sticky and crusted.
What is the most suitable course of action for managing this patient?Your Answer: Send swabs for viral PCR and bacterial culture and prescribe empirical topical antibiotics
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 7
Correct
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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: 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 8
Correct
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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: 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 9
Correct
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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: 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 10
Correct
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A 32-year-old artist returns from a vacation in Thailand with a severely painful, red right eye. The symptoms appeared rapidly within a day, and now there is excessive 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 while in Thailand.
What is the SINGLE most probable organism responsible for this condition?Your Answer: Neisseria gonorrhoea
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 11
Correct
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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: 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 12
Incorrect
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A 60-year-old woman comes in with intense pain and vision loss in her left eye. She has experienced multiple episodes of vomiting. Upon examination, there is noticeable redness around the left side of the cornea, and the left pupil is dilated and unresponsive to light.
What is the most suitable initial treatment for this patient?Your Answer: Topical pilocarpine
Correct Answer: Intravenous acetazolamide
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 13
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: Advise that no school exclusion is necessary
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 14
Correct
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A 12-year-old boy comes in with complaints of double vision. He is holding his head tilted to the left-hand side. During the examination of his eye movements, it is observed that both eyes can look normally to the right, but on looking to the left, his left eye cannot turn outwards past the midline. The right eye is unaffected when looking to the left.
Which muscle is the MOST likely to be involved in this case?Your Answer: Lateral rectus
Explanation:This patient is experiencing a condition called right-sided abducens nerve palsy, which means that their sixth cranial nerve is paralyzed. As a result, the lateral rectus muscle, which is responsible for moving the eye outward, is also paralyzed. This means that the patient’s right eye is unable to turn outward. This can lead to a condition called convergent strabismus, where the eyes are not aligned properly, and diplopia, which is double vision. To compensate for the double vision, patients often tilt their head towards the side of the paralyzed muscle.
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This question is part of the following fields:
- Ophthalmology
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Question 15
Correct
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A 22-year-old individual comes in with a painful, itchy, red left eye. During the examination, there is noticeable redness in the conjunctiva, and follicles are observed on the inner eyelid when it is turned inside out. They recently had a mild and short-lived upper respiratory tract infection, but there are no other significant medical history.
What is the MOST LIKELY diagnosis for this patient?Your Answer: Viral conjunctivitis
Explanation:Conjunctivitis is the most common reason for red eyes, accounting for about 35% of all eye problems seen in general practice. It occurs when the conjunctiva, the thin layer covering the white part of the eye, becomes inflamed. Conjunctivitis can be caused by an infection or an allergic reaction.
Infective conjunctivitis is inflammation of the conjunctiva caused by a viral, bacterial, or parasitic infection. The most common type of infective conjunctivitis is viral, with adenoviruses being the main culprits. Bacterial conjunctivitis is also common and is usually caused by Streptococcus pneumoniae, Staphylococcus aureus, or Haemophilus influenzae.
The symptoms of infective conjunctivitis include sudden redness of the conjunctiva, discomfort described as a gritty or burning sensation, watering of the eyes, and discharge that may temporarily blurry vision. It can be challenging to differentiate between viral and bacterial conjunctivitis based on symptoms alone.
Here are some key features that can help distinguish between viral and bacterial conjunctivitis:
Features suggestive of viral conjunctivitis:
– Mild to moderate redness of the conjunctiva
– Presence of follicles on the inner surface of the eyelids
– Swelling of the eyelids
– Small, pinpoint bleeding under the conjunctiva
– Pseudomembranes (thin layers of tissue) may form on the inner surface of the eyelids in severe cases, often caused by adenovirus
– Less discharge (usually watery) compared to bacterial conjunctivitis
– Mild to moderate itching
– Symptoms of upper respiratory tract infection and swollen lymph nodes in front of the earsFeatures suggestive of bacterial conjunctivitis:
– Purulent or mucopurulent discharge with crusting of the eyelids, which may cause them to stick together upon waking
– Mild or no itching
– Swollen lymph nodes in front of the ears, which are often present in severe bacterial conjunctivitis
– If the discharge is copious and mucopurulent, infection with Neisseria gonorrhoeae should be considered.By considering these distinguishing features, healthcare professionals can better diagnose and manage cases of conjunctivitis.
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This question is part of the following fields:
- Ophthalmology
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Question 16
Correct
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A 35-year-old man is diagnosed with anterior uveitis.
Which SINGLE statement regarding this condition is FALSE?Your 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 17
Correct
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A 42-year-old woman comes in with a suddenly painful right eye and sensitivity to light. The eye feels sandy and is visibly watery. The patient has been experiencing a mild cold for the past few days. You administer fluorescein drops to her eye, and this exposes the existence of a dendritic ulcer.
What is the PRIMARY probable causative organism?Your Answer: Herpes simplex virus (type 1)
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 aciclovir 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 18
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: Hypermetropia is a significant risk factor
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 19
Incorrect
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A 70-year-old woman experiences a sudden onset of vision loss in her left eye. She is later diagnosed with central retinal vein occlusion (CRVO).
Your Answer: Approximately 25% of patients have hypertension
Correct Answer: Chronic glaucoma is a recognised risk factor
Explanation:Central retinal vein occlusion (CRVO) typically leads to painless, one-sided vision loss. When examining the retina, it may appear similar to a ‘pizza thrown against a wall’, with swollen retinal veins, swelling of the optic disc, multiple flame-shaped hemorrhages, and cotton wool spots. Hypertension is present in about 65% of CRVO patients, and it is more common in individuals over the age of 65. Other known risk factors include being elderly, having chronic glaucoma, arteriosclerosis, and polycythemia.
In contrast, central retinal artery occlusion (CRAO) is characterized by a pale retina and a ‘cherry-red spot’ in the macula’s center, which is spared due to its blood supply from the underlying choroid. It is important to differentiate between CRVO and CRAO based on these distinct features.
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This question is part of the following fields:
- Ophthalmology
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Question 20
Correct
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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 onset of the irritation has been gradual. There has been mild mucopurulent discharge present in the eye for the past two weeks, and he states that he has to clean the eye regularly. On examination, you note the presence of right-sided, nontender pre-auricular lymphadenopathy. On further questioning, he admits to visiting a sex worker during his visit to Thailand.
Which of the following antibiotics would be most appropriate to prescribe for this patient?Your Answer: Doxycycline
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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