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  • Question 1 - You evaluate the pupillary light reflex in a patient with a cranial nerve...

    Incorrect

    • 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: Bilateral oculomotor nerves

      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.

    • This question is part of the following fields:

      • Ophthalmology
      16.1
      Seconds
  • Question 2 - A 60-year-old woman comes in with severe left eye pain and loss of...

    Incorrect

    • 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: Slit lamp examination

      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.

    • This question is part of the following fields:

      • Ophthalmology
      19.3
      Seconds
  • Question 3 - You assess a patient who is experiencing difficulty in closing their right eye...

    Incorrect

    • You assess a patient who is experiencing difficulty in closing their right eye due to a nerve injury. Currently, the eye is dry and necessitates regular administration of eye drops. Your consultant informs you that the orbicularis oculi muscle is solely responsible for closing the eye and suggests that if the symptoms cannot be improved, the patient may require surgical closure of the eye.
      Which nerve has been affected in this scenario?

      Your Answer: Trigeminal nerve

      Correct Answer: Facial nerve

      Explanation:

      The orbicularis oculi muscle encircles the eye socket and extends into the eyelid. It is composed of two parts: the orbital part, which forcefully closes the eye, and the palpebral part, which gently closes the eye. The innervation of the orbicularis oculi muscle is provided by the facial nerve. In the event of facial nerve damage, the orbicularis oculi muscle loses its functionality. As the sole muscle responsible for closing the eyelids, this can have significant clinical implications. The inability to shut the eye can lead to dryness of the cornea and the development of exposure keratitis. While mild cases can be managed with regular use of eye drops, severe cases may require surgical closure of the eye.

    • This question is part of the following fields:

      • Ophthalmology
      28.4
      Seconds
  • Question 4 - A 42-year-old woman presents with right eye pain and sensitivity to light. She...

    Incorrect

    • 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: Scleritis

      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.

    • This question is part of the following fields:

      • Ophthalmology
      18.6
      Seconds
  • Question 5 - A 55-year-old man presents with sudden onset of vision loss in his right...

    Incorrect

    • A 55-year-old man presents with sudden onset of vision loss in his right eye over the past few hours. On fundoscopic examination, you observe that the entire retina appears pale and a cherry red spot is visible in the macular region.

      What is the SINGLE most likely diagnosis?

      Your Answer: Circumciliary vein occlusion

      Correct Answer: Central retinal artery occlusion

      Explanation:

      Central retinal artery occlusion (CRAO) is characterized by sudden, painless, and unilateral loss of vision. The appearance of the retina in CRAO is distinct from that of CRVO. It shows a pale retina with narrowed blood vessels. A notable feature is the presence of a ‘cherry-red spot’ at the center of the macula, which is supplied by the underlying choroid. Additionally, examination often reveals an afferent pupillary defect.

      On the other hand, branch retinal artery occlusion (BRAO) typically affects only one quadrant of the retina, leading to visual field deficits in that specific area rather than complete loss of vision.

    • This question is part of the following fields:

      • Ophthalmology
      11.9
      Seconds
  • Question 6 - A 30-year-old construction worker comes in with intense pain in his left eye...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Ophthalmology
      13.3
      Seconds
  • Question 7 - A 42-year-old woman comes in with a painful, red left eye and sensitivity...

    Incorrect

    • 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: Rheumatoid arthritis

      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.

    • This question is part of the following fields:

      • Ophthalmology
      16.9
      Seconds
  • Question 8 - A 35-year-old woman comes in with a painful, red right eye. She has...

    Correct

    • 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.

    • This question is part of the following fields:

      • Ophthalmology
      11.1
      Seconds
  • Question 9 - A 32-year-old artist returns from a vacation in Thailand with a severely painful,...

    Correct

    • 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.

    • This question is part of the following fields:

      • Ophthalmology
      18.2
      Seconds
  • Question 10 - A 30-year-old construction worker comes in with intense pain in his left eye...

    Incorrect

    • 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: Entropion

      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.

    • This question is part of the following fields:

      • Ophthalmology
      19.6
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Ophthalmology (3/10) 30%
Passmed