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  • Question 1 - A 75-year-old patient with a history of hypertensive retinopathy comes in for an...

    Correct

    • A 75-year-old patient with a history of hypertensive retinopathy comes in for an eye examination. Upon fundoscopy, only retinal arteriole tortuosity is observed without any other abnormalities. Based on the Keith-Wagener classification, what grade of hypertensive retinopathy is most likely represented in this case?

      Your Answer: Grade 1

      Explanation:

      Grade 1 hypertensive retinopathy is characterized by tortuosity and silver wiring on fundoscopy, while Grade 0 would show no abnormal findings despite a diagnosis of hypertension.

      Understanding Hypertensive Retinopathy: Keith-Wagener Classification

      Hypertensive retinopathy is a condition that affects the eyes due to high blood pressure. The Keith-Wagener classification is a system used to categorize the different stages of hypertensive retinopathy. Stage I is characterized by narrowing and twisting of the blood vessels in the eyes, as well as an increased reflection of light known as silver wiring. In stage II, the blood vessels become compressed where they cross over veins, leading to arteriovenous nipping. Stage III is marked by the appearance of cotton-wool exudates, which are white patches on the retina caused by blocked blood vessels. Additionally, there may be flame and blot hemorrhages that can collect around the fovea, resulting in a ‘macular star.’ Finally, stage IV is the most severe stage and is characterized by papilloedema, which is swelling of the optic disc at the back of the eye. Understanding the Keith-Wagener classification can help healthcare professionals diagnose and manage hypertensive retinopathy.

    • This question is part of the following fields:

      • Ophthalmology
      17.9
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  • Question 2 - A 75-year-old woman complains of 'strange spots' affecting her eyesight. She has observed...

    Incorrect

    • A 75-year-old woman complains of 'strange spots' affecting her eyesight. She has observed several flashes and floaters in the visual field of her left eye over the last few days. What could be the probable diagnosis?

      Your Answer: Vitreous haemorrhage

      Correct Answer: Posterior vitreous detachment

      Explanation:

      Retinal tear is a common condition among individuals aged 65 years and above, and it is the most probable diagnosis in this case. Typically, an ophthalmologist will evaluate such patients to determine the likelihood of developing retinal detachment.

      Sudden loss of vision can be a scary symptom for patients, as it may indicate a serious issue or only be temporary. Transient monocular visual loss (TMVL) is a term used to describe a sudden, brief loss of vision that lasts less than 24 hours. The most common causes of sudden, painless loss of vision include ischaemic/vascular issues (such as thrombosis, embolism, and temporal arteritis), vitreous haemorrhage, retinal detachment, and retinal migraine.

      Ischaemic/vascular issues, also known as ‘amaurosis fugax’, have a wide range of potential causes, including large artery disease, small artery occlusive disease, venous disease, and hypoperfusion. Altitudinal field defects are often seen, and ischaemic optic neuropathy can occur due to occlusion of the short posterior ciliary arteries. Central retinal vein occlusion is more common than arterial occlusion and can be caused by glaucoma, polycythaemia, or hypertension. Central retinal artery occlusion is typically caused by thromboembolism or arteritis and may present with an afferent pupillary defect and a ‘cherry red’ spot on a pale retina.

      Vitreous haemorrhage can be caused by diabetes, bleeding disorders, or anticoagulants and may present with sudden visual loss and dark spots. Retinal detachment may be preceded by flashes of light or floaters, which are also common in posterior vitreous detachment. Differentiating between posterior vitreous detachment, retinal detachment, and vitreous haemorrhage can be challenging, but each has distinct features such as photopsia and floaters for posterior vitreous detachment, a dense shadow that progresses towards central vision for retinal detachment, and large bleeds causing sudden visual loss for vitreous haemorrhage.

    • This question is part of the following fields:

      • Ophthalmology
      15
      Seconds
  • Question 3 - An 80-year-old woman presents with complaints of dry, gritty, and painful eyes bilaterally....

    Correct

    • An 80-year-old woman presents with complaints of dry, gritty, and painful eyes bilaterally. She has been experiencing these symptoms for a few years and has found little relief with frequent use of lubricating eye drops. Upon examination, both eyelids were crusted and had irregular margins. The meibomian orifices on both lids were obstructed with oily material. What is the underlying cause of this woman's dry eye condition?

      Your Answer: Meibomian blepharitis

      Explanation:

      When the tarsal glands are chronically infected, they can hinder the production of the precorneal tear film, which is responsible for slowing down the evaporation of tears. This can ultimately lead to dry eyes.

      The tarsal glands, also known as Meibomian glands, produce an oily substance that forms the outer layer of the precorneal tear film. This oily substance helps to prevent tear evaporation, while also improving tear stability and spreading. However, when Meibomian blepharitis occurs, the production of this oil is reduced, causing excessive water from the tear film to evaporate and resulting in dry eyes. None of the other options listed are relevant to this issue, as they do not involve dysfunction of the Meibomian glands.

      Understanding Dry Eye Syndrome

      Dry eye syndrome is a condition that causes discomfort in both eyes, with symptoms such as dryness, grittiness, and soreness that worsen throughout the day. Exposure to wind can also cause watering of the eyes. People with Meibomian gland dysfunction may experience symptoms that are worse upon waking, with eyelids sticking together and redness of the eyelids. In some cases, dry eye syndrome can lead to complications such as conjunctivitis or corneal ulceration, which can cause severe pain, photophobia, redness, and loss of visual acuity.

      Although there may be no abnormalities on examination, eyelid hygiene is the most appropriate management step for dry eye syndrome. This can help control blepharitis, which is a common condition associated with dry eye syndrome. By understanding the symptoms and appropriate management steps, individuals with dry eye syndrome can find relief and improve their overall eye health.

    • This question is part of the following fields:

      • Ophthalmology
      35.9
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  • Question 4 - A 68-year-old man complains of a burning sensation around his left eye. Upon...

    Correct

    • A 68-year-old man complains of a burning sensation around his left eye. Upon examination, a rash with erythematous blisters is visible in the left trigeminal distribution. What is the probable diagnosis?

      Your Answer: Herpes zoster ophthalmicus

      Explanation:

      Herpes Zoster Ophthalmicus: Symptoms, Treatment, and Complications

      Herpes zoster ophthalmicus (HZO) is a condition that occurs when the varicella-zoster virus reactivates in the area supplied by the ophthalmic division of the trigeminal nerve. It is responsible for approximately 10% of shingles cases. The main symptom of HZO is a vesicular rash around the eye, which may or may not involve the eye itself. Hutchinson’s sign, a rash on the tip or side of the nose, is a strong indicator of nasociliary involvement and increases the risk of ocular involvement.

      Treatment for HZO involves oral antiviral medication for 7-10 days, ideally started within 72 hours of symptom onset. Intravenous antivirals may be necessary for severe infections or immunocompromised patients. Topical antiviral treatment is not recommended for HZO, but topical corticosteroids may be used to treat any secondary inflammation of the eye. Ocular involvement requires urgent ophthalmology review to prevent complications such as conjunctivitis, keratitis, episcleritis, anterior uveitis, ptosis, and post-herpetic neuralgia.

      In summary, HZO is a condition caused by the reactivation of the varicella-zoster virus in the ophthalmic division of the trigeminal nerve. It presents with a vesicular rash around the eye and may involve the eye itself. Treatment involves oral antiviral medication and urgent ophthalmology review is necessary for ocular involvement. Complications of HZO include various eye conditions, ptosis, and post-herpetic neuralgia.

    • This question is part of the following fields:

      • Ophthalmology
      18.9
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  • Question 5 - A 65-year-old man visits his GP with a complaint of pain in his...

    Incorrect

    • A 65-year-old man visits his GP with a complaint of pain in his left eye. Upon examination, the sclera appears red and the cornea is hazy with a dilated pupil. What is the probable diagnosis?

      Your Answer: Anterior uveitis

      Correct Answer: Acute angle closure glaucoma

      Explanation:

      Should red eye be attributed to glaucoma or uveitis?
      Glaucoma is characterized by intense pain, haloes, and a partially dilated pupil, while uveitis is indicated by a small, fixed oval pupil and ciliary flush.

      Understanding the Causes of Red Eye

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

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

      Anterior uveitis presents with acute onset, pain, blurred vision, and photophobia. The pupil is small and fixed, and there may be ciliary flush.

      Scleritis is characterized by severe pain and tenderness, which may worsen with movement. It may also be associated with underlying autoimmune diseases such as rheumatoid arthritis.

      Conjunctivitis may be bacterial or viral, with purulent or clear discharge, respectively.

      Subconjunctival haemorrhage may be caused by trauma or coughing bouts.

      Endophthalmitis typically occurs after intraocular surgery and presents with red eye, pain, and visual loss.

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

    • This question is part of the following fields:

      • Ophthalmology
      57
      Seconds
  • Question 6 - A 28-year-old man with ankylosing spondylitis (AS) comes in with photophobia and a...

    Correct

    • A 28-year-old man with ankylosing spondylitis (AS) comes in with photophobia and a painful red eye.
      What is the most probable diagnosis?

      Your Answer: Uveitis

      Explanation:

      Understanding Eye Conditions Associated with Ankylosing Spondylitis

      Ankylosing spondylitis (AS) is a chronic inflammatory disorder that primarily affects the sacroiliac joints and axial skeleton. However, it can also lead to various eye conditions. Uveitis, also known as iritis or iridocyclitis, is the most common extra-articular manifestation of AS, occurring in 20-30% of patients. Acute anterior uveitis is often unilateral and presents with symptoms such as a painful red eye, photophobia, and blurred vision. Patients with uveitis may also have or develop other spondyloarthropathies, including reactive arthritis, undifferentiated spondyloarthropathy, and psoriatic arthritis.

      Acute angle-closure glaucoma, on the other hand, is not associated with AS. It is a medical emergency that needs immediate treatment to prevent vision loss. Conjunctivitis, which is responsible for approximately 30% of all eye complaints, is usually benign and self-limited. Herpes zoster ophthalmicus and keratoconus are also not associated with AS.

      It is important for patients with AS to be aware of these potential eye conditions and seek urgent ophthalmological assessment if they experience any symptoms. Early diagnosis and treatment can prevent vision loss and improve outcomes.

    • This question is part of the following fields:

      • Ophthalmology
      10.5
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  • Question 7 - A 52-year-old woman has recently been diagnosed with raised intraocular pressure (IOP) and...

    Correct

    • A 52-year-old woman has recently been diagnosed with raised intraocular pressure (IOP) and loss of peripheral vision. She also has diabetes.
      Which of the following treatments would ophthalmology have initiated?

      Your Answer: Latanoprost

      Explanation:

      Understanding Chronic Open-Angle Glaucoma and Treatment Options

      Chronic open-angle glaucoma (COAG) is a progressive and irreversible optic neuropathy that can lead to significant visual loss if left untreated. It is the second leading cause of irreversible blindness in developed countries. Patients with COAG may not present with any symptoms until late in the disease course, making early detection and treatment crucial.

      The first-line treatment for COAG is a prostaglandin analogue, such as latanoprost. Other options include pilocarpine, a cholinergic parasympathomimetic agent, and brinzolamide, a carbonic anhydrase inhibitor. More than one agent may be needed concurrently to achieve the target intraocular pressure (IOP).

      Beta-blockers, such as timolol, may also be used as an alternative or adjuvant therapy, but should be avoided in patients with a history of asthma. Sodium cromoglicate eye drops are not effective in the management of COAG or ocular hypertension (OHT).

      OHT is a major risk factor for developing COAG, but COAG can also occur without raised IOP. Age thresholds for treatment recommendations only apply when vision is currently normal and treatment is purely preventative. Patients experiencing peripheral vision loss should be evaluated for COAG regardless of age.

      Early detection and appropriate treatment can help prevent significant visual loss in patients with COAG.

    • This question is part of the following fields:

      • Ophthalmology
      22.1
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  • Question 8 - A 28-year-old male comes to the Emergency Department complaining of a severely painful,...

    Correct

    • A 28-year-old male comes to the Emergency Department complaining of a severely painful, reddened right-eye that has been bothering him for the past 6 hours. He reports experiencing reduced visual acuity and seeing halos around light. The patient has a history of hypermetropia. Upon examination, the right-eye appears red with a fixed and dilated pupil and conjunctival injection. What is the most probable diagnosis?

      Your Answer: Acute closed-angle glaucoma

      Explanation:

      The correct diagnosis is acute closed-angle glaucoma, which is characterized by an increase in intra-ocular pressure due to impaired aqueous outflow. Symptoms include a painful red eye, reduced visual acuity, and haloes around light. Risk factors include hypermetropia, pupillary dilatation, and age-related lens growth. Examination findings typically include a fixed dilated pupil with conjunctival injection. Treatment options include reducing aqueous secretions with acetazolamide and increasing pupillary constriction with topical pilocarpine.

      Anterior uveitis is an incorrect diagnosis, as it refers to inflammation of the anterior portion of the uvea and is associated with systemic inflammatory conditions. A key ophthalmoscopy finding is an irregular pupil.

      Central retinal vein occlusion is also an incorrect diagnosis, as it causes acute blindness due to thromboembolism or vasculitis in the central retinal vein. Severe retinal haemorrhages are seen on ophthalmoscopy.

      Infective conjunctivitis is another incorrect diagnosis, as it is characterized by sore, red eyes with discharge. Bacterial causes typically result in purulent discharge, while viral cases often have serous discharge.

      Glaucoma is a group of disorders that cause optic neuropathy due to increased intraocular pressure (IOP). However, not all patients with raised IOP have glaucoma, and vice versa. Acute angle-closure glaucoma (AACG) is a type of glaucoma where there is a rise in IOP due to impaired aqueous outflow. Factors that increase the risk of AACG include hypermetropia, pupillary dilatation, and lens growth associated with age. Symptoms of AACG include severe pain, decreased visual acuity, haloes around lights, and a hard, red-eye. Management of AACG is an emergency and requires urgent referral to an ophthalmologist. Emergency medical treatment is necessary to lower the IOP, followed by definitive surgical treatment once the acute attack has subsided.

      There are no specific guidelines for the initial medical treatment of AACG, but a combination of eye drops may be used, including a direct parasympathomimetic, a beta-blocker, and an alpha-2 agonist. Intravenous acetazolamide may also be administered to reduce aqueous secretions. Definitive management of AACG involves laser peripheral iridotomy, which creates a small hole in the peripheral iris to allow aqueous humour to flow to the angle. It is important to seek medical attention immediately if symptoms of AACG are present to prevent permanent vision loss.

    • This question is part of the following fields:

      • Ophthalmology
      15.1
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  • Question 9 - A 35-year-old woman came to your GP clinic with a cold sore and...

    Correct

    • A 35-year-old woman came to your GP clinic with a cold sore and left eye discomfort. She reported experiencing a red, painful eye with watering and sensitivity to light for the past 3 days. During fluorescein examination, you observed a dendritic ulcer on the cornea that was stained with fluorescein.

      What is the primary treatment for this condition?

      Your Answer: Topical aciclovir drops

      Explanation:

      The appropriate treatment for herpes simplex keratitis is the use of topical aciclovir. Antibiotics are ineffective against viral infections and should not be used. The use of steroids can worsen the condition and should be avoided. If the patient is already using topical steroids for another eye condition, the dosage should be decreased.

      Understanding Herpes Simplex Keratitis

      Herpes simplex keratitis is a condition that affects the cornea of the eye and is caused by the herpes simplex virus. The most common symptom of this condition is a dendritic corneal ulcer, which can cause a red, painful eye, photophobia, and epiphora. In some cases, visual acuity may also be decreased. Fluorescein staining may show an epithelial ulcer, which can help with diagnosis. One common treatment for this condition is topical aciclovir, which can help to reduce the severity of symptoms and prevent further damage to the cornea.

    • This question is part of the following fields:

      • Ophthalmology
      21.9
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  • Question 10 - A 57-year-old man presents to the Emergency Department with a one-day history of...

    Correct

    • A 57-year-old man presents to the Emergency Department with a one-day history of blurring of vision and headache. He tells you there is no pain on touching the scalp, or when eating and chewing food.
      He has a past medical history of hypertension and type II diabetes mellitus, which is well controlled with metformin.
      He tells you that his uncle died of brain cancer and he is afraid that he may have the same condition.
      On examination, his visual acuity is 6/18 in both eyes. On dilated fundoscopy, you see some arterioles narrower than others. There are also venules being compressed by arterioles. There is optic disc swelling in both eyes with some exudates lining up like a star at the macula. There is also some dot-and-blot and flame-shaped haemorrhages.
      His pulse is 80 beats per minute, while his blood pressure (BP) is 221/119 mmHg. His temperature is 37 °C, while his respiratory rate is 14 breaths per minute. His oxygen saturations are 98% on room air.
      What is the most likely diagnosis?

      Your Answer: Hypertensive retinopathy

      Explanation:

      Differentiating Hypertensive Retinopathy from Other Eye Conditions: A Case Study

      The patient in question presented with a highly raised blood pressure and complained of headache and blurring of vision. Fundoscopy revealed bilateral optic disc swelling, which is a typical feature of hypertensive retinopathy. However, other conditions such as giant-cell arteritis, age-related macular degeneration, intracranial space-occupying lesion, and proliferative diabetic retinopathy were also considered.

      Giant-cell arteritis was ruled out due to the absence of scalp tenderness and jaw claudication. Age-related macular degeneration was also unlikely as there were no drusen or choroidal neovascularisation present. While an intracranial space-occupying lesion was a possibility, the lack of accompanying symptoms such as early-morning vomiting and weight loss made it less likely. Proliferative diabetic retinopathy was also ruled out as there were no new vessels at the disc or elsewhere.

      In conclusion, the patient’s symptoms and fundoscopy findings strongly suggest a diagnosis of hypertensive retinopathy. It is important to differentiate this condition from other eye conditions to ensure appropriate treatment and management.

    • This question is part of the following fields:

      • Ophthalmology
      26.8
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  • Question 11 - A 28-year-old pregnant woman came to your GP clinic complaining of mild pain...

    Incorrect

    • A 28-year-old pregnant woman came to your GP clinic complaining of mild pain and redness in both eyes that had been present for a week. During the examination, you noticed diffuse conjunctival injection with some purulent discharges and crusted eyelids. What is the ONE treatment you should initiate for this patient?

      Your Answer: Chloramphenicol ointment

      Correct Answer: Fusidic acid eye drops

      Explanation:

      Pregnant women with bacterial conjunctivitis should use topical fusidic acid eye drops for treatment. It is not recommended to use chloramphenicol ointment or eye drops in pregnant patients. Oral antibiotics are typically unnecessary for treating bacterial conjunctivitis, and steroid eye drops are not effective. While viral conjunctivitis can be monitored without treatment, bacterial conjunctivitis requires prompt treatment with topical antibiotics to prevent a secondary bacterial infection.

      Conjunctivitis is a common eye problem that is often seen in primary care. It is characterized by red, sore eyes with a sticky discharge. There are two types of infective conjunctivitis: bacterial and viral. Bacterial conjunctivitis is identified by a purulent discharge and eyes that may be stuck together in the morning. On the other hand, viral conjunctivitis is characterized by a serous discharge and recent upper respiratory tract infection, as well as preauricular lymph nodes.

      In most cases, infective conjunctivitis is a self-limiting condition that resolves without treatment within one to two weeks. However, topical antibiotic therapy is often offered to patients, such as Chloramphenicol drops given every two to three hours initially or Chloramphenicol ointment given four times a day initially. Alternatively, topical fusidic acid can be used, especially for pregnant women, and treatment is twice daily.

      For contact lens users, topical fluoresceins should be used to identify any corneal staining, and treatment should be the same as above. During an episode of conjunctivitis, contact lenses should not be worn, and patients should be advised not to share towels. School exclusion is not necessary.

    • This question is part of the following fields:

      • Ophthalmology
      26.8
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  • Question 12 - A 67-year-old man with a history of primary open-angle glaucoma presents with sudden...

    Incorrect

    • A 67-year-old man with a history of primary open-angle glaucoma presents with sudden painless loss of vision in his left eye. Upon examination of the left eye, there are multiple flame-shaped and blot haemorrhages with a swollen optic disc. What is the probable diagnosis?

      Your Answer: Ischaemic optic neuropathy

      Correct Answer: Occlusion of central retinal vein

      Explanation:

      Sudden painless vision loss and severe retinal hemorrhages observed on fundoscopy are indicative of central retinal vein occlusion.

      Understanding Central Retinal Vein Occlusion

      Central retinal vein occlusion (CRVO) is a possible cause of sudden, painless loss of vision. It is more common in older individuals and those with hypertension, cardiovascular disease, glaucoma, or polycythemia. The condition is characterized by a sudden reduction or loss of visual acuity, usually affecting only one eye. Fundoscopy reveals widespread hyperemia and severe retinal hemorrhages, which are often described as a stormy sunset.

      Branch retinal vein occlusion (BRVO) is a similar condition that affects a smaller area of the fundus. It occurs when a vein in the distal retinal venous system is blocked, usually at arteriovenous crossings.

      Most patients with CRVO are managed conservatively, but treatment may be necessary in some cases. For instance, intravitreal anti-vascular endothelial growth factor (VEGF) agents may be used to manage macular edema, while laser photocoagulation may be necessary to treat retinal neovascularization.

      Overall, understanding the risk factors, features, and management options for CRVO is essential for prompt diagnosis and appropriate treatment. Proper management can help prevent further vision loss and improve the patient’s quality of life.

    • This question is part of the following fields:

      • Ophthalmology
      29.4
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  • Question 13 - A 28-year-old male patient complains of a painful rash on his forehead that...

    Incorrect

    • A 28-year-old male patient complains of a painful rash on his forehead that has been present for one day. The patient has no significant medical history. Upon examination, a vesicular rash is observed on the right side in the distribution of the ophthalmic nerve. There is no discharge or pus, and no ocular involvement is present. What is the recommended treatment for this condition?

      Your Answer: Topical acyclovir for 7-10 days

      Correct Answer: Oral acyclovir for 7-10 days

      Explanation:

      In the case of herpes zoster ophthalmicus, topical antiviral treatment is not recommended. The first line of treatment is oral acyclovir, which should be initiated promptly and continued for 7-10 days. If there are any indications of ocular involvement, the patient should be referred to an ophthalmologist immediately. While steroids can be administered concurrently, they do not decrease the likelihood of post-herpetic neuralgia. Topical mupirocin is not an appropriate treatment option.

      Herpes Zoster Ophthalmicus: Symptoms, Treatment, and Complications

      Herpes zoster ophthalmicus (HZO) is a condition that occurs when the varicella-zoster virus reactivates in the area supplied by the ophthalmic division of the trigeminal nerve. It is responsible for approximately 10% of shingles cases. The main symptom of HZO is a vesicular rash around the eye, which may or may not involve the eye itself. Hutchinson’s sign, a rash on the tip or side of the nose, is a strong indicator of nasociliary involvement and increases the risk of ocular involvement.

      Treatment for HZO involves oral antiviral medication for 7-10 days, ideally started within 72 hours of symptom onset. Intravenous antivirals may be necessary for severe infections or immunocompromised patients. Topical antiviral treatment is not recommended for HZO, but topical corticosteroids may be used to treat any secondary inflammation of the eye. Ocular involvement requires urgent ophthalmology review to prevent complications such as conjunctivitis, keratitis, episcleritis, anterior uveitis, ptosis, and post-herpetic neuralgia.

      In summary, HZO is a condition caused by the reactivation of the varicella-zoster virus in the ophthalmic division of the trigeminal nerve. It presents with a vesicular rash around the eye and may involve the eye itself. Treatment involves oral antiviral medication and urgent ophthalmology review is necessary for ocular involvement. Complications of HZO include various eye conditions, ptosis, and post-herpetic neuralgia.

    • This question is part of the following fields:

      • Ophthalmology
      13.1
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  • Question 14 - A 25-year-old man, who is typically healthy, arrives at the Emergency Department with...

    Correct

    • A 25-year-old man, who is typically healthy, arrives at the Emergency Department with a three-day history of a red, itchy eye that is only slightly painful when touched over the redness. He had previously visited his General Practitioner and was given chloramphenicol ointment to apply to his eyes four times daily. However, he noticed no improvement in his red eye.
      During the examination, his visual acuities are 6/6 in both eyes. His affected eye displays a red spot on the medial side of the eyeball. After administering phenylephrine 10% eye drops, the redness appeared to have improved.
      What is the most probable diagnosis?

      Your Answer: Episcleritis

      Explanation:

      Differentiating Eye Inflammations: Symptoms and Characteristics

      Episcleritis is a mild inflammation that causes grittiness and tenderness on palpation, with sectorial redness that is deeper than conjunctivitis. Scleritis, on the other hand, causes severe pain, tenderness, and blueish-red tinge due to deeper inflamed vessels in the sclera. Conjunctivitis presents with superficial inflammation and is not tender to palpation. Iritis causes acute pain, photophobia, and circumcorneal redness, while keratitis also causes acute pain and circumcorneal redness, with fluorescein staining indicating corneal epithelial defect. Knowing these symptoms and characteristics can help in accurately diagnosing and treating eye inflammations.

    • This question is part of the following fields:

      • Ophthalmology
      32.3
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  • Question 15 - A 30-year-old male with a history of ankylosing spondylitis presents to his GP...

    Correct

    • A 30-year-old male with a history of ankylosing spondylitis presents to his GP with complaints of eye pain and sensitivity to light. He wears glasses for nearsightedness and this is his first occurrence, affecting only his right eye. Upon examination, his right eye has a visual acuity of 6/6 while his left eye is corrected to 6/18. The left pupil is misshapen and the eye is red, but the cornea appears clear. What is the most likely diagnosis for this patient?

      Your Answer: Anterior uveitis

      Explanation:

      Ankylosing spondylitis is commonly associated with anterior uveitis, which presents with symptoms such as a misshapen pupil, red eye, and reduced vision. This condition involves both eyes and is more likely than other eye conditions. Retinal detachment does not cause eye pain.

      Anterior uveitis, also known as iritis, is a type of inflammation that affects the iris and ciliary body in the front part of the uvea. It is a common cause of red eye and is associated with HLA-B27, which may also be linked to other conditions. Symptoms of anterior uveitis include sudden onset of eye discomfort and pain, small or irregular pupils, intense sensitivity to light, blurred vision, redness, tearing, and the presence of pus and inflammatory cells in the front part of the eye. This condition may be associated with ankylosing spondylitis, reactive arthritis, ulcerative colitis, Crohn’s disease, Behcet’s disease, and sarcoidosis. Urgent review by an ophthalmologist is necessary, and treatment may involve the use of cycloplegics and steroid eye drops.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 16 - A 62-year-old man is referred to Ophthalmology with bilateral cataracts. He reports a...

    Correct

    • A 62-year-old man is referred to Ophthalmology with bilateral cataracts. He reports a gradual decline in his vision over the past few years and has difficulty reading small print. He is placed on the surgical waiting list.
      Which eye structure is most likely to be impacted by this ailment?

      Your Answer: Lens

      Explanation:

      Anatomy of the Eye: Understanding the Different Parts and Their Disorders

      The eye is a complex organ that allows us to see the world around us. It is made up of several parts, each with its own function. Understanding the anatomy of the eye and the disorders that can affect it is important for maintaining good eye health.

      Lens: The lens is a transparent structure located behind the pupil and iris. It helps to focus light onto the retina. Cataracts occur when the lens becomes cloudy or opaque, causing vision problems.

      Cornea: The cornea is the clear dome-shaped surface of the eye that sits over the iris. It plays a role in refracting light. Damage to the cornea can cause pain and light sensitivity.

      Iris: The iris is the colored part of the eye. It can be affected by disorders such as uveitis, which causes inflammation of the uvea (iris, ciliary body, and choroid).

      Retina: The retina is located at the back of the eye and contains rods and cones that process incoming light. Disorders of the retina include retinitis pigmentosa, diabetic retinopathy, and retinal detachment.

      Sclera: The sclera is the white part of the eye. Disorders of the sclera include scleritis, which causes redness, pain, and reduced visual acuity. It can be associated with rheumatoid arthritis.

      Understanding the different parts of the eye and their functions can help you identify potential problems and seek treatment early. Regular eye exams are important for maintaining good eye health and preventing vision loss.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 17 - A 16-year-old girl comes to the eye clinic with a painful red eye...

    Correct

    • A 16-year-old girl comes to the eye clinic with a painful red eye after a minor injury. The doctor diagnoses her with a corneal ulcer in her left eye and prescribes topical antibiotics for treatment. She asks for a prescription of the same numbing eye drops that were used during the examination to use at home. What is the most appropriate pain management for this condition?

      Your Answer: Oral analgesics

      Explanation:

      It is not recommended to prescribe anaesthetic eye drops to patients with corneal ulcers as it can potentially worsen the condition by slowing down the healing process.

      Understanding Corneal Ulcers

      A corneal ulcer is a condition that occurs when there is a defect in the cornea, which is usually caused by an infection. It is important to note that corneal abrasions, on the other hand, are typically caused by physical trauma. There are several risk factors that can increase the likelihood of developing a corneal ulcer, including contact lens use and vitamin A deficiency, which is particularly common in developing countries.

      The pathophysiology of corneal ulcers can vary depending on the underlying cause. Bacterial, fungal, and viral infections can all lead to the development of a corneal ulcer. In some cases, contact lens use can also be associated with a type of infection called Acanthamoeba keratitis.

      Symptoms of a corneal ulcer typically include eye pain, sensitivity to light, and excessive tearing. Additionally, a focal fluorescein staining of the cornea may be present.

    • This question is part of the following fields:

      • Ophthalmology
      22.1
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  • Question 18 - A 32-year-old woman presents to her General Practitioner with a unilateral painful red...

    Correct

    • A 32-year-old woman presents to her General Practitioner with a unilateral painful red eye and photophobia. She has a known diagnosis of ankylosing spondylitis (AS).
      What is the most likely diagnosis?

      Your Answer: Anterior uveitis

      Explanation:

      Anterior uveitis is a common manifestation of AS, occurring in 20-30% of patients, especially those who are HLA-B27 positive. Symptoms include a painful red eye, photophobia, increased lacrimation, and blurred vision. AACG, on the other hand, is characterized by sudden blockage of the anterior chamber angle, causing a sudden rise in intraocular pressure. It is less likely in this case as it is usually seen in patients over 60 years old and has no association with AS. Blepharitis, herpes zoster ophthalmicus, and keratoconus are also unlikely diagnoses as they have different symptoms and no association with AS.

    • This question is part of the following fields:

      • Ophthalmology
      11.3
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  • Question 19 - A 25-year-old woman came to your GP clinic complaining of sudden onset itching,...

    Incorrect

    • A 25-year-old woman came to your GP clinic complaining of sudden onset itching, burning, and watering in both eyes. During the examination, you noticed moderate chemosis in both eyes and conjunctival follicles. You also discovered tender preauricular lymph nodes while palpating her neck. She informed you that her boyfriend had similar symptoms a week ago. What is the most probable diagnosis?

      Your Answer: Bacterial conjunctivitis

      Correct Answer: Adenoviral conjunctivitis

      Explanation:

      Adenoviral conjunctivitis is easily spread from person to person. The patient’s boyfriend had the same condition a week ago, so it’s not surprising that she has it now. This type of viral conjunctivitis is the most common.
      There is no evidence of herpes simplex because there are no cold sores or dendritic ulcers visible with fluorescein uptake.
      Bacterial and chlamydial conjunctivitis are unlikely because there is no pus discharge. Allergic conjunctivitis is also unlikely because there is no history of atopy or itchiness.

      Conjunctivitis is a common eye problem that is often seen in primary care. It is characterized by red, sore eyes with a sticky discharge. There are two types of infective conjunctivitis: bacterial and viral. Bacterial conjunctivitis is identified by a purulent discharge and eyes that may be stuck together in the morning. On the other hand, viral conjunctivitis is characterized by a serous discharge and recent upper respiratory tract infection, as well as preauricular lymph nodes.

      In most cases, infective conjunctivitis is a self-limiting condition that resolves without treatment within one to two weeks. However, topical antibiotic therapy is often offered to patients, such as Chloramphenicol drops given every two to three hours initially or Chloramphenicol ointment given four times a day initially. Alternatively, topical fusidic acid can be used, especially for pregnant women, and treatment is twice daily.

      For contact lens users, topical fluoresceins should be used to identify any corneal staining, and treatment should be the same as above. During an episode of conjunctivitis, contact lenses should not be worn, and patients should be advised not to share towels. School exclusion is not necessary.

    • This question is part of the following fields:

      • Ophthalmology
      35.1
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  • Question 20 - A 54-year-old man presents to his General Practitioner with a three-day history of...

    Incorrect

    • A 54-year-old man presents to his General Practitioner with a three-day history of blurring of vision. He has a past medical history of hypertension, managed with amlodipine, ramipril, and indapamide, and type II diabetes mellitus, which is well controlled with metformin.
      On examination, his visual acuity is 6/18 in both eyes with a reduction in colour vision. There is no relative afferent pupillary defect. On direct fundoscopy, the optic disc's margins are ill-defined and seem to be raised in both eyes. There are also some cotton-wool spots scattered around the retina in both eyes.
      What is the most likely diagnosis?

      Your Answer: Intracranial space-occupying lesion

      Correct Answer: Hypertensive retinopathy

      Explanation:

      Differentiating Hypertensive Retinopathy from Other Eye Conditions

      Hypertensive retinopathy is a serious condition that can lead to vision loss if left untreated. A grade 4 hypertensive retinopathy, as classified by the Keith-Wagener-Barker system, is characterized by bilateral optic disc swelling and cotton-wool spots. This condition can cause a reduction in visual acuity and color vision due to optic neuropathy secondary to hypertension.

      It is important to differentiate hypertensive retinopathy from other eye conditions that may present with similar symptoms. Proliferative diabetic retinopathy, for example, is unlikely if the patient’s type II diabetes is well-controlled. The presence of cotton-wool spots does not indicate diabetic retinopathy.

      An intracranial space-occupying lesion is also not indicated in the patient’s history. Optic neuritis, while it can present with loss of optic nerve function, is more likely to present unilaterally and without cotton-wool spots.

      Pre-proliferative diabetic retinopathy is also unlikely in this case, as the patient’s diabetes is well-controlled. In diabetic retinopathy, optic discs will not be raised.

      In summary, a thorough understanding of the patient’s medical history and symptoms is necessary to accurately diagnose hypertensive retinopathy and differentiate it from other eye conditions.

    • This question is part of the following fields:

      • Ophthalmology
      42.8
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  • Question 21 - During your FY2 rotation in General Practice, you saw a 76-year-old man in...

    Incorrect

    • During your FY2 rotation in General Practice, you saw a 76-year-old man in your GP clinic who had been experiencing blurring of vision in his right eye for the past 5 months. He finally decided to seek medical attention because he felt his vision was becoming increasingly distorted. Upon examination, there were no signs of inflammation in either eye, and both corneas were clear with no fluorescein uptake. However, on dilated fundoscopy, you noticed yellowish deposits in the center of the macula in his right eye. What is the curative treatment for this condition?

      Your Answer: Intravitreal anti-VEGF injection

      Correct Answer: None

      Explanation:

      Dry age-related macular degeneration, characterized by yellowish drusen deposits, currently has no cure. However, high doses of beta-carotene, vitamins C and E, and zinc can be administered to slow down the progression of visual loss. On the other hand, wet AMD can be treated with intravitreal anti-VEGF injections, laser photocoagulation, and photodynamic therapy.

      Age-related macular degeneration (ARMD) is a common cause of blindness in the UK, characterized by the degeneration of the central retina (macula) and the formation of drusen. It is more prevalent in females and is strongly associated with advancing age, smoking, family history, and conditions that increase the risk of ischaemic cardiovascular disease. ARMD can be classified into two forms: dry and wet. Dry ARMD is more common and is characterized by drusen, while wet ARMD is characterized by choroidal neovascularisation and carries a worse prognosis. Clinical features of ARMD include subacute onset of visual loss, difficulties in dark adaptation, and visual disturbances such as photopsia and glare.

      To diagnose ARMD, slit-lamp microscopy and color fundus photography are used to identify any pigmentary, exudative, or haemorrhagic changes affecting the retina. Fluorescein angiography and indocyanine green angiography may also be used to visualize changes in the choroidal circulation. Treatment for dry ARMD involves a combination of zinc with anti-oxidant vitamins A, C, and E, which has been shown to reduce disease progression by around one third. For wet ARMD, anti-VEGF agents such as ranibizumab, bevacizumab, and pegaptanib are used to limit disease progression and stabilize or reverse visual loss. Laser photocoagulation may also be used to slow progression, but anti-VEGF therapies are usually preferred due to the risk of acute visual loss after treatment.

      In summary, ARMD is a common cause of blindness in the UK that is strongly associated with advancing age, smoking, and family history. It can be classified into dry and wet forms, with wet ARMD carrying a worse prognosis. Diagnosis involves the use of various imaging techniques, and treatment options include a combination of zinc and anti-oxidant vitamins for dry ARMD and anti-VEGF agents or laser photocoagulation for wet ARMD.

    • This question is part of the following fields:

      • Ophthalmology
      14.9
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  • Question 22 - A 67-year-old man presents to his Optician for a routine eye check-up. His...

    Incorrect

    • A 67-year-old man presents to his Optician for a routine eye check-up. His intraocular pressure (IOP) is 30 mmHg. On examination, fundoscopy reveals cupping of the optic disc. He is referred for assessment with an Ophthalmologist; he is classed as being at high lifetime risk of visual impairment.
      What is the most appropriate first-line treatment for this patient?

      Your Answer: Sodium cromoglicate

      Correct Answer: Latanoprost

      Explanation:

      Overview of Glaucoma Medications

      Glaucoma is a condition that can lead to vision loss and is often associated with high intraocular pressure (IOP). The first-line treatment recommended by the National Institute for Health and Care Excellence is a prostaglandin analogue such as latanoprost. Patients must meet certain criteria to receive this treatment. Brinzolamide and brimonidine are third-line treatments that may be used if a patient cannot tolerate a prostaglandin analogue or beta-blocker. Sodium cromoglicate eye drops are used for allergic conjunctivitis and do not help manage ocular hypertension. Timolol is a beta-blocker that may be used if a patient cannot tolerate a prostaglandin analogue, but it is not a first-line treatment.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 23 - A 33-year-old man presents to the eye casualty department with an eye injury...

    Incorrect

    • A 33-year-old man presents to the eye casualty department with an eye injury sustained during a game of squash. Upon examination of his right eye, there is evidence of blood in the anterior chamber, proptosis, a stiff eyelid, and a relative afferent pupillary defect, leading to a suspected diagnosis of orbital compartment syndrome. What is the best course of action for management?

      Your Answer: Orbit MRI

      Correct Answer: Immediate canthotomy

      Explanation:

      In cases of ocular trauma, it is important to assess for orbital compartment syndrome as it may require urgent decompression before any imaging is done.

      A man presents with symptoms of orbital compartment syndrome, including blood in the front part of the eye, bulging of the eye, a stiff eyelid, and a pupil defect. This is a medical emergency that requires immediate attention as it can lead to permanent vision loss. The condition is caused by an increase in volume within the orbit, which can be due to bleeding or swelling of the eye. It can be caused by surgical or external trauma, such as a sports injury. In this case, the correct course of action is to perform an immediate canthotomy to relieve the pressure.

      B-scan ultrasonography is not the correct answer. This imaging technique is useful for examining the back part of the eye and is used to diagnose conditions such as retinal detachment or vitreous hemorrhage. It is not helpful in diagnosing orbital compartment syndrome.

      Immediate IV acetazolamide is also not the correct answer. While this medication can be used to reduce intraocular pressure in acute closed-angle glaucoma, it is not the primary treatment for orbital compartment syndrome.

      Non-contrast head CT is not the correct answer either. While this imaging test can help confirm the diagnosis and determine the cause of the condition, it should not be done before immediate surgical decompression is performed due to the severity of the condition.

      Ocular Trauma and Hyphema

      Ocular trauma can lead to hyphema, which is the presence of blood in the anterior chamber of the eye. This condition requires immediate referral to an ophthalmic specialist for assessment and management. The main concern is the risk of raised intraocular pressure due to the blockage of the angle and trabecular meshwork with erythrocytes. Patients with high-risk cases are often admitted and require strict bed rest to prevent the redispersement of blood. Even isolated hyphema requires daily ophthalmic review and pressure checks initially as an outpatient.

      In addition to hyphema, an assessment should also be made for orbital compartment syndrome, which can occur secondary to retrobulbar hemorrhage. This is a true ophthalmic emergency and requires urgent management. Symptoms of orbital compartment syndrome include eye pain and swelling, proptosis, ‘rock hard’ eyelids, and a relevant afferent pupillary defect.

      To manage orbital compartment syndrome, urgent lateral canthotomy is necessary to decompress the orbit. This should be done before diagnostic imaging to prevent further damage. Proper management and prompt referral to an ophthalmic specialist can help prevent vision loss and other complications associated with ocular trauma and hyphema.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 24 - A 62-year-old man presents to the Ophthalmology Clinic with elevated intraocular pressure and...

    Incorrect

    • A 62-year-old man presents to the Ophthalmology Clinic with elevated intraocular pressure and peripheral vision loss. He also has a history of asthma. What is the most suitable course of treatment to begin in this scenario?

      Your Answer: Timolol

      Correct Answer: Latanoprost

      Explanation:

      Medications for Glaucoma: Uses and Contraindications

      Glaucoma is a condition that can lead to vision loss if left untreated. The primary goal of treatment is to lower intraocular pressure. Here are some common medications used for glaucoma and their uses and contraindications:

      1. Latanoprost: This prostaglandin analogue increases scleral permeability to aqueous fluid, reducing intraocular pressure. It is safe to use in asthmatics and is recommended as a first-line medication.

      2. Brinzolamide: This carbonic anhydrase inhibitor also lowers intraocular pressure but is not a first-line medication for glaucoma. It is safe to use in those with concurrent asthma.

      3. Pilocarpine: This muscarinic receptor agonist improves the flow rate of aqueous humour but is not a first-line medication. It is cautioned against use in asthmatics as it can increase bronchial secretions and airway resistance.

      4. Sodium cromoglicate: This mast-cell stabiliser is not usually used in glaucoma but is commonly used in conditions such as allergic rhinitis.

      5. Timolol: This beta-receptor antagonist is contraindicated in asthmatics as it can lead to increased airway resistance through bronchospasm.

      It is important to consult with a healthcare provider to determine the best medication for individual cases of glaucoma, taking into consideration any contraindications or potential side effects.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 25 - A 30-year-old woman with type 1 diabetes mellitus arrives at the emergency department...

    Incorrect

    • A 30-year-old woman with type 1 diabetes mellitus arrives at the emergency department complaining of blurry vision in her left eye. She reports her vision in that eye as 'hazy and faded' which started a few hours ago. She also experiences pain that worsens with eye movement. There are no visible signs of trauma or infection on her eyes, and her recent HbA1c and capillary blood glucose levels are normal. What clinical manifestation is linked to the suspected diagnosis?

      Your Answer: Absent corneal reflex

      Correct Answer: Relative afferent pupillary defect (RAPD)

      Explanation:

      Optic neuritis is a condition that can be caused by multiple sclerosis, diabetes, or syphilis. It is characterized by a decrease in visual acuity in one eye over a period of hours or days, as well as poor color discrimination and pain that worsens with eye movement. Other symptoms include a relative afferent pupillary defect and a central scotoma. The condition can be diagnosed through an MRI of the brain and orbits with gadolinium contrast. Treatment typically involves high-dose steroids, and recovery usually takes 4-6 weeks. If an MRI shows more than three white-matter lesions, the risk of developing multiple sclerosis within five years is approximately 50%.

    • This question is part of the following fields:

      • Ophthalmology
      10.4
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  • Question 26 - In people aged 45-64, what is the most frequent cause of blindness? Choose...

    Incorrect

    • In people aged 45-64, what is the most frequent cause of blindness? Choose ONE option from the list provided.

      Your Answer: Macular degeneration

      Correct Answer: Diabetic retinopathy

      Explanation:

      Common Eye Conditions: Causes and Prevalence

      Diabetes can lead to various ophthalmic complications, including glaucoma, cataracts, and neuropathies, but the most common and potentially blinding is diabetic retinopathy. This condition accounts for 12% of all new cases of blindness in developed countries and is the leading cause of new blindness in people aged 25-64 years. Glaucoma, a group of eye diseases that damage the optic nerve, is more prevalent in the aging population, with up to 15% affected by the seventh decade of life. Age-related macular degeneration (AMD) is the most common cause of irreversible vision loss in the developed world, with non-exudative (dry) AMD comprising more than 90% of patients diagnosed with AMD. Optic atrophy, a sign of many disease processes, can cause changes in the color and structure of the optic disc associated with variable degrees of visual dysfunction. Finally, corneal abrasion, caused by a disruption in the integrity of the corneal epithelium or physical external forces, is the most common eye injury. While most people recover fully from minor corneal abrasions, deeper scratches can cause long-term vision problems if not treated properly.

    • This question is part of the following fields:

      • Ophthalmology
      17.7
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  • Question 27 - A 68-year-old woman visits the general practice clinic with complaints of itchy eyes...

    Incorrect

    • A 68-year-old woman visits the general practice clinic with complaints of itchy eyes and crusting on the eyelids. During examination, the upper lids near the eyelash follicles have small flakes of skin, and the eyelids are slightly swollen.
      What is the most suitable initial treatment for this patient's condition?

      Your Answer: Topical steroids

      Correct Answer: Warm compresses and eyelid hygiene

      Explanation:

      Treatment Options for Blepharitis

      Blepharitis is a common eye condition that causes inflammation of the eyelids. The most appropriate first-line treatment for blepharitis is self-care measures such as eyelid hygiene and warm compresses. This involves cleaning the eyelids with warm water and a diluted cleanser such as baby shampoo twice a day, and applying a warm compress to the closed eyelids for 5-10 minutes once or twice a day.

      Topical steroids are not recommended for the treatment of blepharitis, but may be used by secondary care clinicians to reduce inflammation. Topical chloramphenicol may be prescribed for anterior blepharitis if eyelid hygiene and warm compresses are ineffective, while oral tetracycline may be prescribed for posterior blepharitis with meibomian gland dysfunction and rosacea if self-care measures are ineffective.

      It is important to note that topical ketoconazole is not recommended for the treatment of blepharitis, as it is used for other conditions such as fungal skin infections and candidiasis. If self-care measures and prescribed treatments do not improve symptoms, further treatment or referral may be recommended.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 28 - A 60-year-old man came to your GP clinic complaining of blurred vision for...

    Incorrect

    • A 60-year-old man came to your GP clinic complaining of blurred vision for the past month. He has a history of type 2 diabetes mellitus. During direct ophthalmoscopy, you observed a ring of hard exudates at the fovea, but the rest of the retina appeared normal. What is the probable diagnosis for his vision blurring?

      Your Answer: Vitreous haemorrhage

      Correct Answer: Diabetic maculopathy

      Explanation:

      Diabetic maculopathy refers to any structural anomaly in the macula caused by diabetes. The patient in this case had hard exudates in the macula, which resulted in blurred vision. As there were no abnormalities in the rest of the retina, options 1-3 (background, pre-proliferative and proliferative diabetic retinopathies) are incorrect. Although vitreous hemorrhage can cause blurred vision in cases of proliferative retinopathy, there is no indication of it in the given history.

      Understanding Diabetic Retinopathy

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

      Patients with diabetic retinopathy are classified into those with non-proliferative diabetic retinopathy (NPDR), proliferative retinopathy (PDR), and maculopathy. NPDR is further classified into mild, moderate, and severe, depending on the presence of microaneurysms, blot hemorrhages, hard exudates, cotton wool spots, venous beading/looping, and intraretinal microvascular abnormalities. PDR is characterized by retinal neovascularization, which may lead to vitreous hemorrhage, and fibrous tissue forming anterior to the retinal disc. Maculopathy is based on location rather than severity and is more common in Type II DM.

      Management of diabetic retinopathy involves optimizing glycaemic control, blood pressure, and hyperlipidemia, as well as regular review by ophthalmology. Treatment options include intravitreal vascular endothelial growth factor (VEGF) inhibitors for maculopathy, regular observation for non-proliferative retinopathy, and panretinal laser photocoagulation and intravitreal VEGF inhibitors for proliferative retinopathy. Vitreoretinal surgery may be necessary in cases of severe or vitreous hemorrhage.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 29 - A 52-year-old woman presents to an eye screening appointment, having been referred by...

    Incorrect

    • A 52-year-old woman presents to an eye screening appointment, having been referred by her General Practitioner. She has a family history of type II diabetes mellitus. At the appointment, there are no signs of diabetic retinopathy.
      What is the most appropriate ongoing eye screening for this patient?

      Your Answer: Attend eye screening only if he experiences a change in vision

      Correct Answer: Annual visual acuity testing and retinal photography

      Explanation:

      The Importance of Annual Eye Screening for Diabetic Patients

      The National Health Service diabetic eye screening programme recommends that patients over the age of 12 with diabetes attend annual eye screening appointments. These appointments include visual acuity testing and retinal photography, which can detect changes consistent with background retinopathy or more severe forms of diabetic retinopathy. Patients with moderate, severe, or proliferative retinopathy will be referred for further assessment and may require more frequent screening following treatment.

      Tonometry, which measures intraocular pressure, is also important in the diagnosis of glaucoma. However, the gold-standard test for diagnosing diabetic retinopathy is dilated retinal photography with or without fundoscopy. Retinal photographs are preferable to fundoscopy because they provide a clear view of the entire retina and can be compared with previous images to monitor disease progression.

      It is important for diabetic patients to attend annual eye screening appointments, even if they have no changes in vision. Vision may be preserved until relatively advanced stages of the disease, and early detection of diabetic retinopathy can prevent irreversible loss of vision. Therefore, patients should not wait for changes in vision to occur before attending screening appointments.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 30 - A 55-year-old man with a history of cytomegalovirus infection presented to the ED...

    Incorrect

    • A 55-year-old man with a history of cytomegalovirus infection presented to the ED complaining of blurred vision, light sensitivity, floaters, and redness in his right eye for the past two weeks. Upon fundus examination, a combination of white and red retinal lesions were observed. What is the probable diagnosis?

      Your Answer: Anterior uveitis

      Correct Answer: Chorioretinitis

      Explanation:

      Chorioretinitis can be identified through a pizza pie appearance on fundoscopy. This occurs when the choroid and retina become inflamed, typically in patients with cytomegalovirus. It is important to note that anterior uveitis will not show any fundal signs. While floaters may suggest retinal detachment, it does not present as a pizza pie appearance on fundoscopy.

      Causes of Chorioretinitis

      Chorioretinitis is a medical condition that affects the retina and choroid, which are the layers of tissue at the back of the eye. There are several causes of chorioretinitis, including syphilis, cytomegalovirus, toxoplasmosis, sarcoidosis, and tuberculosis.

      Syphilis is a sexually transmitted infection caused by the bacterium Treponema pallidum. It can cause chorioretinitis as part of its secondary stage. Cytomegalovirus is a common virus that can cause chorioretinitis in people with weakened immune systems, such as those with HIV/AIDS. Toxoplasmosis is a parasitic infection that can be contracted from contaminated food or water, and it can cause chorioretinitis in some cases.

      Sarcoidosis is a condition that causes inflammation in various parts of the body, including the eyes. It can lead to chorioretinitis in some cases. Tuberculosis is a bacterial infection that can affect the lungs, but it can also spread to other parts of the body, including the eyes. It can cause chorioretinitis as a rare complication.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 31 - An elderly man aged 76 visits the surgery after a visit to his...

    Incorrect

    • An elderly man aged 76 visits the surgery after a visit to his optician who noted raised intra-ocular pressure and decreased peripheral vision. He has a medical history of asthma and type 2 diabetes mellitus. The patient is referred to ophthalmology. What is the probable treatment he will receive for his likely diagnosis?

      Your Answer: Brimonidine

      Correct Answer: Latanoprost

      Explanation:

      Patients with a history of asthma should be prescribed a prostaglandin analogue as the first-line treatment.

      Glaucoma is a condition where the optic nerve is damaged due to increased pressure in the eye. Primary open-angle glaucoma is a type where the iris is clear of the trabecular meshwork, which is responsible for draining aqueous humour from the eye. This results in increased resistance to outflow and raised intraocular pressure. The condition affects 0.5% of people over 40 years old and increases with age. Genetics also play a role, with first-degree relatives having a 16% chance of developing the disease. Symptoms are usually absent, and diagnosis is made through routine eye examinations. Investigations include visual field tests, tonometry, and slit lamp examinations. Treatment involves eye drops to lower intraocular pressure, with prostaglandin analogues being the first line of treatment. Surgery may be considered in refractory cases. Regular reassessment is necessary to monitor progression and prevent visual field loss.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 32 - A 45-year-old with type 2 diabetes is found to have new vessel formation...

    Incorrect

    • A 45-year-old with type 2 diabetes is found to have new vessel formation on the optic disc on fundoscopy.
      Which of the following is the best intervention?

      Your Answer: Lower cholesterol

      Correct Answer: Laser treatment

      Explanation:

      Managing Diabetic Retinopathy: Treatment Options and Risk Factors

      Diabetic retinopathy is a common complication of diabetes that can lead to blindness if left untreated. Laser photocoagulation is a non-invasive treatment option that has a high success rate and low complication rate. Focal laser photocoagulation is used to treat specific microaneurysms, while a grid pattern of laser burns is applied for non-specific leakage. Other important factors in managing diabetic retinopathy include controlling blood pressure, optimizing cholesterol levels, and maintaining HbA1c levels in the 6-7% range. Patients with diabetes should also be monitored for other ophthalmic complications, such as glaucoma and neuropathies. Risk factors for diabetic retinopathy include age at diabetes onset, serum triglyceride and total cholesterol levels, serum creatinine levels, and hypertension. Early detection and treatment of diabetic retinopathy can prevent blindness and improve long-term outcomes for patients with diabetes.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 33 - A mother brings her 8-year-old daughter into the clinic with worries about her...

    Incorrect

    • A mother brings her 8-year-old daughter into the clinic with worries about her eyes. She believes her daughter's left eye is 'turned outwards'. The child reports no changes in her vision. Upon examination, a left exotropia is observed. The child is instructed to cover her right eye while looking at a fixed point, and the left eye moves inward to maintain focus. What is the best course of action for this patient?

      Your Answer: Reassurance with follow up in 6 months

      Correct Answer: Referral to ophthalmology

      Explanation:

      Children with a squint should be referred to ophthalmology for assessment. Exotropia, or an outwardly turned eye, requires evaluation of the type and severity of the squint by a paediatric eye service. Advising the use of a plaster over the good eye before follow-up is not appropriate as the underlying causes of the squint need to be addressed first, such as a space-occupying lesion or refractive error. Optometrists are not medical doctors and a full assessment by an ophthalmologist is necessary to identify and treat any medical or surgical causes, such as retinoblastoma. Reassurance is not appropriate as squints can worsen and lead to amblyopia, which can be prevented with early treatment. Follow-up in 6 months would also be inappropriate.

      Squint, also known as strabismus, is a condition where the visual axes are misaligned. There are two types of squints: concomitant and paralytic. Concomitant squints are more common and are caused by an imbalance in the extraocular muscles. On the other hand, paralytic squints are rare and are caused by the paralysis of extraocular muscles. It is important to detect squints early on as they can lead to amblyopia, where the brain fails to process inputs from one eye and favours the other eye over time.

      To detect a squint, a corneal light reflection test can be performed by holding a light source 30cm from the child’s face to see if the light reflects symmetrically on the pupils. The cover test is also used to identify the nature of the squint. This involves asking the child to focus on an object, covering one eye, and observing the movement of the uncovered eye. The test is then repeated with the other eye covered.

      If a squint is detected, it is important to refer the child to secondary care. Eye patches may also be used to help prevent amblyopia.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 34 - A 28-year-old patient complains of a painful bump on their eyelid. The lump...

    Incorrect

    • A 28-year-old patient complains of a painful bump on their eyelid. The lump has been there for about four days and is gradually getting bigger.

      During the examination, a tender, smooth lump is observed, measuring roughly 2 mm in size, emerging from the outer edge of the left upper eyelid. The eye is not inflamed, and there is no periorbital or orbital redness, and the patient's visual acuity is normal.

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

      Your Answer: Prescribe a 10-day course of oral flucloxacillin

      Correct Answer: Provide advice on application of hot compresses and simple analgesia

      Explanation:

      Management of Stye or Hordeolum

      A stye or hordeolum is an acute and painful swelling of the eyelid caused by inflammation in an eyelash follicle. It usually presents unilaterally and can take a few days to develop. While it does not affect visual acuity, it can cause watery eyes. The first-line management for a stye is the application of warm compresses a few times a day, which can help the stye resolve or drain. However, if symptoms do not improve, referral to Eye Casualty for incision and drainage may be necessary. Topical antibiotics are not recommended in the absence of conjunctivitis, and systemic antibiotics are not indicated unless there are signs of cellulitis over the eyelid. Therefore, simple analgesia and warm compresses are the recommended management for a stye or hordeolum.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 35 - A 10-year-old boy visits his General Practitioner a week after experiencing an upper-respiratory...

    Incorrect

    • A 10-year-old boy visits his General Practitioner a week after experiencing an upper-respiratory tract infection. He reports developing erythema around his left eye and pain on eye movement since waking up this morning.
      Upon examination of his left eye, the boy displays proptosis, restricted eye movements, reduced visual acuity, and a relative afferent pupillary defect (RAPD). However, his right eye appears normal.
      What is the most probable diagnosis?
      Choose the SINGLE most likely diagnosis from the options below.

      Your Answer: Conjunctivitis

      Correct Answer: Orbital cellulitis

      Explanation:

      Eye Infections and Inflammations: Symptoms and Differences

      Eye infections and inflammations can cause a range of symptoms, but it is important to differentiate between them to ensure appropriate treatment. Here are some common eye conditions and their distinguishing features:

      Orbital Cellulitis: This is a serious condition that can cause erythema (redness) around the eye, pain on eye movements, restricted eye movements, proptosis (bulging of the eye), reduced visual acuity, and a relative afferent pupillary defect (RAPD). It is usually caused by the spread of infection from sinuses or trauma to the orbit. Treatment involves antibiotics and surgery if there is an orbital collection.

      Conjunctivitis: This is a common condition that can accompany upper respiratory tract infections. It causes redness and discharge from the eye, but does not usually cause proptosis, restricted eye movements, or a RAPD.

      Anterior Uveitis: This is an inflammation of the iris and ciliary body that causes a painful red eye, photophobia, increased lacrimation, and blurred vision. It does not usually cause erythema or proptosis.

      Preseptal Cellulitis: This is a less serious condition that causes swelling and erythema of the eyelid, but does not cause proptosis, visual changes, or a RAPD. It is often confused with orbital cellulitis, but can be differentiated by the absence of these symptoms.

      Blepharitis: This is an inflammation of the eyelid that causes swelling, erythema, and flakiness or scaliness of the eyelids. It does not usually cause proptosis or visual changes.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 36 - A 55-year-old woman visits her primary care physician with a complaint of right...

    Incorrect

    • A 55-year-old woman visits her primary care physician with a complaint of right eye pain that has been present for 2 days. She reports sensitivity to bright light but denies any history of eye trauma or regular use of contact lenses. The patient has a medical history of Crohn's disease and is currently taking methotrexate.

      During the examination, the patient's vital signs are normal. The right eye appears red and is tearing. Fluorescein staining reveals the presence of a dendritic ulcer.

      What is the recommended treatment for this patient's condition?

      Your Answer: Topical corticosteroids

      Correct Answer: Topical aciclovir

      Explanation:

      The appropriate treatment for herpes simplex keratitis is topical aciclovir. This patient’s symptoms and examination findings suggest herpes simplex keratitis, which is more common in immunosuppressed individuals. Topical aciclovir is the preferred treatment option. Artificial tears are not likely to be helpful as the patient’s eye is already watery. Oral flucloxacillin is not indicated for this condition, as it is typically used for superficial skin infections. Topical chloramphenicol is not appropriate for this patient, as it is used to treat bacterial conjunctivitis, which presents with different symptoms.

      Understanding Herpes Simplex Keratitis

      Herpes simplex keratitis is a condition that affects the cornea of the eye and is caused by the herpes simplex virus. The most common symptom of this condition is a dendritic corneal ulcer, which can cause a red, painful eye, photophobia, and epiphora. In some cases, visual acuity may also be decreased. Fluorescein staining may show an epithelial ulcer, which can help with diagnosis. One common treatment for this condition is topical aciclovir, which can help to reduce the severity of symptoms and prevent further damage to the cornea.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 37 - A mother brings her 6-week-old infant to your clinic suspecting that the baby...

    Incorrect

    • A mother brings her 6-week-old infant to your clinic suspecting that the baby may have a squint. She has observed that the baby's eyes do not always appear to be looking in the same direction. However, she reports that the baby is developing well and there are no concerns regarding their vision.
      What would be the most suitable course of action in this situation?

      Your Answer: Routine referral to ophthalmology

      Correct Answer: Reassure dad that intermittent squint in newborns is normal

      Explanation:

      It is considered normal for newborns under 3 months to have intermittent squint due to their underdeveloped eye muscles. Therefore, there is no need for investigation. However, if the squint persists or there are concerns about the newborn’s vision, referral to secondary care is recommended. In older children, eye patches may be used to prevent lazy eye.

      Squint, also known as strabismus, is a condition where the visual axes are misaligned. There are two types of squints: concomitant and paralytic. Concomitant squints are more common and are caused by an imbalance in the extraocular muscles. On the other hand, paralytic squints are rare and are caused by the paralysis of extraocular muscles. It is important to detect squints early on as they can lead to amblyopia, where the brain fails to process inputs from one eye and favours the other eye over time.

      To detect a squint, a corneal light reflection test can be performed by holding a light source 30cm from the child’s face to see if the light reflects symmetrically on the pupils. The cover test is also used to identify the nature of the squint. This involves asking the child to focus on an object, covering one eye, and observing the movement of the uncovered eye. The test is then repeated with the other eye covered.

      If a squint is detected, it is important to refer the child to secondary care. Eye patches may also be used to help prevent amblyopia.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 38 - A 40-year-old man comes to the clinic complaining of visual difficulties. He reports...

    Incorrect

    • A 40-year-old man comes to the clinic complaining of visual difficulties. He reports having poor vision in low light conditions for a while, but now he is concerned as he is experiencing tunnel vision. He mentions that his grandfather had a similar issue and was declared blind when he was in his 50s. What is the probable diagnosis?

      Your Answer: Vitelliform macular dystrophy

      Correct Answer: Retinitis pigmentosa

      Explanation:

      Understanding Retinitis Pigmentosa

      Retinitis pigmentosa is a condition that primarily affects the peripheral retina, leading to tunnel vision. The initial sign of this condition is often night blindness, which can progress to a loss of peripheral vision. Fundoscopy, a diagnostic test, reveals black bone spicule-shaped pigmentation in the peripheral retina and mottling of the retinal pigment epithelium. Retinitis pigmentosa is often associated with other diseases such as Refsum disease, Usher syndrome, abetalipoproteinemia, Lawrence-Moon-Biedl syndrome, Kearns-Sayre syndrome, and Alport’s syndrome.

      To better understand retinitis pigmentosa, it is important to know that it is a genetic disorder that affects the retina’s ability to respond to light. This condition can lead to the death of photoreceptor cells in the retina, which are responsible for detecting light and transmitting visual information to the brain. As a result, individuals with retinitis pigmentosa may experience difficulty seeing in low light conditions, loss of peripheral vision, and, in severe cases, complete blindness.

      In summary, retinitis pigmentosa is a genetic condition that primarily affects the peripheral retina, leading to tunnel vision. It is often associated with other diseases and can cause night blindness, loss of peripheral vision, and, in severe cases, complete blindness. Early diagnosis and management are crucial in preventing further vision loss.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 39 - A 75-year-old man came to the clinic with painless, blurry vision in his...

    Incorrect

    • A 75-year-old man came to the clinic with painless, blurry vision in his right eye. He reported no other ocular symptoms and had a history of bilateral cataract surgery five years ago. What is the most probable reason for his vision impairment?

      Your Answer: Optic disc swelling

      Correct Answer: Posterior capsule opacification

      Explanation:

      Blurred vision years after cataract surgery may be caused by posterior capsule opacification, which can occur even after the cataract has been removed and an artificial lens has been implanted.

      Understanding Cataracts: Causes, Symptoms, and Management

      A cataract is a common eye condition that affects the lens of the eye, causing it to become cloudy and reducing the amount of light that reaches the retina. This can lead to blurred or reduced vision, making it difficult to see clearly. Cataracts are more common in women and tend to increase in incidence with age. While the normal ageing process is the most common cause, other factors such as smoking, alcohol consumption, trauma, diabetes, and long-term corticosteroid use can also contribute to the development of cataracts.

      Symptoms of cataracts include reduced vision, faded colour vision, glare, and halos around lights. A defect in the red reflex is also a sign of cataracts. Diagnosis is typically made through ophthalmoscopy and slit-lamp examination, which can reveal the presence of a visible cataract.

      In the early stages, age-related cataracts can be managed conservatively with stronger glasses or contact lenses and brighter lighting. However, surgery is the only effective treatment for cataracts and involves removing the cloudy lens and replacing it with an artificial one. Referral for surgery should be based on the presence of visual impairment, impact on quality of life, and patient choice. Complications following surgery can include posterior capsule opacification, retinal detachment, posterior capsule rupture, and endophthalmitis.

      Overall, cataracts are a common and treatable eye condition that can significantly impact a person’s vision. Understanding the causes, symptoms, and management options can help individuals make informed decisions about their eye health.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 40 - A 68-year-old man came to your GP clinic complaining of stiffness and pain...

    Incorrect

    • A 68-year-old man came to your GP clinic complaining of stiffness and pain in his knee joints, painful urination, and a red eye with circumcorneal redness, hypopyon, and photophobia. What is the most probable reason for his red eye?

      Your Answer: Blepharitis

      Correct Answer: Iritis

      Explanation:

      When dealing with reactive arthritis, it is important to keep in mind that anterior uveitis may also be present in addition to conjunctivitis.

      Since reactive arthritis is linked to HLA-B27, it is important to consider the possibility of iritis or anterior uveitis, even though conjunctivitis is more commonly seen as part of the triad of symptoms. The specific description of a red eye with circumcorneal redness and hypopyon suggests iritis rather than conjunctivitis. Conjunctivitis typically causes a more generalized redness of the eye and hypopyon is not commonly observed. Corneal ulceration is unlikely in this case as there is no mention of increased fluorescein uptake on the cornea or a visible ulcer. Scleritis can be ruled out as it does not present with circumcorneal redness or hypopyon. While scleritis is associated with systemic conditions such as rheumatoid arthritis and other collagen/vascular disorders like Wegener’s granulomatosis, polyarteritis nodosa, and systemic lupus erythematosus, it is not associated with reactive arthritis. Blepharitis is also an incorrect diagnosis as there were no eyelid symptoms and blepharitis does not typically cause a red eye with photophobic symptoms.

      Anterior uveitis, also known as iritis, is a type of inflammation that affects the iris and ciliary body in the front part of the uvea. It is a common cause of red eye and is associated with HLA-B27, which may also be linked to other conditions. Symptoms of anterior uveitis include sudden onset of eye discomfort and pain, small or irregular pupils, intense sensitivity to light, blurred vision, redness, tearing, and the presence of pus and inflammatory cells in the front part of the eye. This condition may be associated with ankylosing spondylitis, reactive arthritis, ulcerative colitis, Crohn’s disease, Behcet’s disease, and sarcoidosis. Urgent review by an ophthalmologist is necessary, and treatment may involve the use of cycloplegics and steroid eye drops.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 41 - What is the most frequent ocular manifestation of rheumatoid arthritis, typically seen in...

    Incorrect

    • What is the most frequent ocular manifestation of rheumatoid arthritis, typically seen in patients of all ages?

      Your Answer: Episcleritis

      Correct Answer: Keratoconjunctivitis sicca

      Explanation:

      The symptoms of keratoconjunctivitis sicca include a sensation of dryness, burning, and grittiness in the eyes, which is caused by a reduction in the production of tears.

      Rheumatoid Arthritis and Its Effects on the Eyes

      Rheumatoid arthritis is a chronic autoimmune disease that affects various parts of the body, including the eyes. In fact, ocular manifestations of rheumatoid arthritis are quite common, with approximately 25% of patients experiencing eye problems. These eye problems can range from mild to severe and can significantly impact a patient’s quality of life.

      The most common ocular manifestation of rheumatoid arthritis is keratoconjunctivitis sicca, also known as dry eye syndrome. This condition occurs when the eyes do not produce enough tears, leading to discomfort, redness, and irritation. Other ocular manifestations of rheumatoid arthritis include episcleritis, scleritis, corneal ulceration, and keratitis. Episcleritis and scleritis both cause redness in the eyes, with scleritis also causing pain. Corneal ulceration and keratitis both affect the cornea, with corneal ulceration being a more severe condition that can lead to vision loss.

      In addition to these conditions, patients with rheumatoid arthritis may also experience iatrogenic ocular manifestations. These are side effects of medications used to treat the disease. For example, steroid use can lead to cataracts, while the use of chloroquine can cause retinopathy.

      Overall, it is important for patients with rheumatoid arthritis to be aware of the potential ocular manifestations of the disease and to seek prompt medical attention if they experience any eye-related symptoms. Early diagnosis and treatment can help prevent vision loss and improve overall quality of life.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 42 - A 42-year-old woman presents with a sudden onset of vision loss in her...

    Correct

    • A 42-year-old woman presents with a sudden onset of vision loss in her left eye. She reports experiencing pain with eye movement and a decrease in colour vision. She has no significant medical history and is not taking any medications.

      During the examination, her left eye has a visual acuity of 6/6 while her right eye has a visual acuity of 6/24. A relative afferent pupillary defect is observed in her left eye, and visual field testing reveals a central scotoma in the left eye.

      What is the most probable cause of her symptoms?

      Your Answer: Optic neuritis

      Explanation:

      A central scotoma is a common feature of optic neuritis, along with visual loss, periocular pain, and dyschromatopsia (change in colour perception). Other classic signs on examination include a relative afferent pupillary defect. Unlike open-angle glaucoma, which typically causes painless, gradual loss of peripheral vision, optic neuritis often affects the central vision. Anterior ischaemic optic neuropathy, on the other hand, causes sudden, painless loss of vision and is more common in people over 50. Optic nerve glioma, which is rare after age 20 and may be associated with neurofibromatosis, can cause visual defects and headaches but is not typically associated with eye movement pain or colour desaturation.

      Optic neuritis is a condition that can be caused by multiple sclerosis, diabetes, or syphilis. It is characterized by a decrease in visual acuity in one eye over a period of hours or days, as well as poor color discrimination and pain that worsens with eye movement. Other symptoms include a relative afferent pupillary defect and a central scotoma. The condition can be diagnosed through an MRI of the brain and orbits with gadolinium contrast. Treatment typically involves high-dose steroids, and recovery usually takes 4-6 weeks. If an MRI shows more than three white-matter lesions, the risk of developing multiple sclerosis within five years is approximately 50%.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 43 - A 56-year-old woman visits the emergency GP service with a red and painful...

    Incorrect

    • A 56-year-old woman visits the emergency GP service with a red and painful eye that has been bothering her for a few hours. Upon examination, the doctor notices a dilated pupil and a significant decrease in vision.
      What is the most probable diagnosis?

      Your Answer: Uveitis

      Correct Answer: Acute angle-closure glaucoma

      Explanation:

      Common Eye Conditions: Symptoms and Characteristics

      Acute angle-closure glaucoma, Conjunctivitis, Foreign body, Optic neuritis, and Uveitis are some of the most common eye conditions that individuals may experience. Each condition has its own set of symptoms and characteristics that can help in identifying the underlying cause.

      Acute angle-closure glaucoma is characterized by sudden onset symptoms such as blurred vision, seeing haloes around lights, red eye, pain, headache, and nausea and vomiting. It is an ophthalmic emergency that requires urgent specialist assessment to prevent blindness.

      Conjunctivitis is one of the most common non-traumatic eye complaints resulting in presentation to A&E. It is characterized by redness, profuse discharge, irritation, and rarely photophobia. Most causes are benign, with a self-limited process.

      Foreign body in the cornea is characterized by pain, foreign body sensation, photophobia, tearing, and red eye. A visible foreign body may be present on physical examination.

      Optic neuritis is characterized by rapidly developing impairment of vision in one eye, dyschromatopsia, retro-orbital or ocular pain, Uhthoff’s phenomenon, and Pulfrich’s phenomenon. It often occurs in association with multiple sclerosis (MS) and neuromyelitis optica (NMO).

      Uveitis is characterized by inflammation of the uveal tract or adjacent ocular structures. It is often autoimmune in nature, and the aetiology remains elusive in most cases. Symptoms vary depending on the location of the inflammation, with acute anterior uveitis being the most common form of intraocular inflammation, causing a painful red eye.

      Understanding the symptoms and characteristics of these common eye conditions can help in identifying the underlying cause and seeking appropriate treatment.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 44 - An older patient with Bell's palsy presented to the emergency department with complaints...

    Incorrect

    • An older patient with Bell's palsy presented to the emergency department with complaints of a sore and gritty right eye. Despite occasional blurring of vision, the patient's visual acuity remained unaffected. The patient was unable to close their right eye and had not been compliant with taping the eyelid at night or using the lubricating ointment provided by their GP a week prior. An ophthalmologist performed a slit lamp examination, which revealed a normal-appearing cornea and anterior chamber. The examination was then continued with the addition of fluorescein dye on the eye. What findings would the doctor anticipate during this examination?

      Your Answer: Foreign body on the medial part of cornea

      Correct Answer: Punctate fluorescein staining of cornea

      Explanation:

      Patients with dry eyes often exhibit punctate fluorescein staining of the cornea, which is a common occurrence in those with Bell’s palsy. This condition impairs the ability to blink or close the eye, leading to a lack of moisture on the cornea and subsequent dryness. It is important to note that keratic precipitates and foreign bodies can be observed without the use of fluorescein dye, and keratic precipitates are typically associated with anterior uveitis rather than the dry eye syndrome seen in Bell’s palsy. Additionally, corneal abrasions typically result in decreased visual acuity, which is not a symptom of dry eyes in this context.

      Understanding Dry Eye Syndrome

      Dry eye syndrome is a condition that causes discomfort in both eyes, with symptoms such as dryness, grittiness, and soreness that worsen throughout the day. Exposure to wind can also cause watering of the eyes. People with Meibomian gland dysfunction may experience symptoms that are worse upon waking, with eyelids sticking together and redness of the eyelids. In some cases, dry eye syndrome can lead to complications such as conjunctivitis or corneal ulceration, which can cause severe pain, photophobia, redness, and loss of visual acuity.

      Although there may be no abnormalities on examination, eyelid hygiene is the most appropriate management step for dry eye syndrome. This can help control blepharitis, which is a common condition associated with dry eye syndrome. By understanding the symptoms and appropriate management steps, individuals with dry eye syndrome can find relief and improve their overall eye health.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 45 - A 65-year-old man presented to the GP surgery multiple times with a persistent...

    Incorrect

    • A 65-year-old man presented to the GP surgery multiple times with a persistent conjunctivitis in one eye. Despite being treated with chloramphenicol and steroid eye drops, the symptoms did not improve. After three weeks, he visited the eye casualty with a constantly teary, painless, and red right eye. Upon examination, it was found that he had decreased visual acuity and mild proptosis in the affected eye. What is the probable diagnosis for this patient?

      Your Answer: Scleritis

      Correct Answer: Orbital lymphoma

      Explanation:

      If a patient has chronic unilateral conjunctivitis that is not responding to treatment, it could be a sign of orbital lymphoma.

      Orbital lymphoma typically has a slow onset of symptoms, which is why it is the most appropriate answer in this situation. If the red eye persists despite treatment, it is important to investigate further to rule out any serious underlying conditions. The other options listed are not applicable as they are associated with a painful red eye.

      Conjunctivitis is a common eye problem that is often seen in primary care. It is characterized by red, sore eyes with a sticky discharge. There are two types of infective conjunctivitis: bacterial and viral. Bacterial conjunctivitis is identified by a purulent discharge and eyes that may be stuck together in the morning. On the other hand, viral conjunctivitis is characterized by a serous discharge and recent upper respiratory tract infection, as well as preauricular lymph nodes.

      In most cases, infective conjunctivitis is a self-limiting condition that resolves without treatment within one to two weeks. However, topical antibiotic therapy is often offered to patients, such as Chloramphenicol drops given every two to three hours initially or Chloramphenicol ointment given four times a day initially. Alternatively, topical fusidic acid can be used, especially for pregnant women, and treatment is twice daily.

      For contact lens users, topical fluoresceins should be used to identify any corneal staining, and treatment should be the same as above. During an episode of conjunctivitis, contact lenses should not be worn, and patients should be advised not to share towels. School exclusion is not necessary.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 46 - A 72-year-old retired teacher visits the doctor with a painless gradual loss of...

    Incorrect

    • A 72-year-old retired teacher visits the doctor with a painless gradual loss of vision. She reports difficulty reading as the words on the page are becoming harder to see. Additionally, she notices that straight lines in her artwork are appearing distorted, which is confirmed by Amsler grid testing. What is the probable diagnosis?

      Your Answer: Cataracts

      Correct Answer: Dry age-related macular degeneration

      Explanation:

      The most likely diagnosis for this patient’s gradual central loss of vision and difficulty reading is dry age-related macular degeneration. This subtype accounts for the majority of cases of macular degeneration and typically presents with a gradual loss of vision. Glaucoma and retinal detachment are unlikely diagnoses as they present with different symptoms such as peripheral vision loss and sudden vision loss with flashes and floaters, respectively.

      Age-related macular degeneration (ARMD) is a common cause of blindness in the UK, characterized by the degeneration of the central retina (macula) and the formation of drusen. It is more prevalent in females and is strongly associated with advancing age, smoking, family history, and conditions that increase the risk of ischaemic cardiovascular disease. ARMD can be classified into two forms: dry and wet. Dry ARMD is more common and is characterized by drusen, while wet ARMD is characterized by choroidal neovascularisation and carries a worse prognosis. Clinical features of ARMD include subacute onset of visual loss, difficulties in dark adaptation, and visual disturbances such as photopsia and glare.

      To diagnose ARMD, slit-lamp microscopy and color fundus photography are used to identify any pigmentary, exudative, or haemorrhagic changes affecting the retina. Fluorescein angiography and indocyanine green angiography may also be used to visualize changes in the choroidal circulation. Treatment for dry ARMD involves a combination of zinc with anti-oxidant vitamins A, C, and E, which has been shown to reduce disease progression by around one third. For wet ARMD, anti-VEGF agents such as ranibizumab, bevacizumab, and pegaptanib are used to limit disease progression and stabilize or reverse visual loss. Laser photocoagulation may also be used to slow progression, but anti-VEGF therapies are usually preferred due to the risk of acute visual loss after treatment.

      In summary, ARMD is a common cause of blindness in the UK that is strongly associated with advancing age, smoking, and family history. It can be classified into dry and wet forms, with wet ARMD carrying a worse prognosis. Diagnosis involves the use of various imaging techniques, and treatment options include a combination of zinc and anti-oxidant vitamins for dry ARMD and anti-VEGF agents or laser photocoagulation for wet ARMD.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 47 - An 80-year-old woman comes in for a routine eye exam and is found...

    Incorrect

    • An 80-year-old woman comes in for a routine eye exam and is found to have a reproducible peripheral vision defect in her left eye. She reports no noticeable changes in her vision. Tonometry shows intraocular pressure of 17 mmHg in the left eye and 19 mmHg in the right eye (normal range is 10-21 mmHg). Direct ophthalmoscopy reveals a cup-to-disc ratio of 0.8 (increased) in the left eye. Gonioscopy is normal and she has no significant medical history. What is the most likely diagnosis?

      Your Answer: Optic neuritis

      Correct Answer: Chronic open-angle glaucoma

      Explanation:

      The correct diagnosis for this patient is chronic open-angle glaucoma, which can sometimes occur even with normal intraocular pressure. The patient’s symptoms, such as gradual peripheral vision loss, and the increased cup-to-disc ratio seen on investigations point towards this diagnosis. Gonioscopy also revealed a normal drainage angle, confirming that this is open-angle glaucoma.

      Dry age-related macular degeneration is an incorrect diagnosis in this case, as it typically presents with central vision loss and drusen on ophthalmoscopy, not changes in the cup-to-disc ratio.

      Hypertensive retinopathy is also an unlikely diagnosis, as it is often asymptomatic and associated with a medical history of hypertension. Additionally, it has a characteristic appearance on ophthalmoscopy that does not include changes in the cup-to-disc ratio.

      Optic neuritis is another incorrect diagnosis, as it typically presents with painful vision loss and other symptoms such as loss of color vision or acuity. It is also often associated with multiple sclerosis, which would present with additional symptoms such as sensory or motor deficits or other cranial nerve palsies.

      Glaucoma is a condition where the optic nerve is damaged due to increased pressure in the eye. Primary open-angle glaucoma (POAG) is a type of glaucoma where the peripheral iris is clear of the trabecular meshwork, which is important in draining aqueous humour from the eye. POAG is more common in older individuals and those with a family history of the condition. It may present insidiously with symptoms such as peripheral visual field loss, decreased visual acuity, and optic disc cupping. Diagnosis is made through a series of investigations including automated perimetry, slit lamp examination, applanation tonometry, central corneal thickness measurement, and gonioscopy. It is important to assess the risk of future visual impairment based on factors such as IOP, CCT, family history, and life expectancy. Referral to an ophthalmologist is typically done through a GP.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 48 - A 78-year-old man comes to the clinic complaining of a swollen left upper...

    Correct

    • A 78-year-old man comes to the clinic complaining of a swollen left upper eyelid that has been bothering him for the past 3 months. He recalls noticing a bump on the eyelid that was uncomfortable at first, but it gradually grew into a hard lump. He denies any pain at present and has not experienced any vision problems. Upon examination, the eye appears to be in good health. What is the probable diagnosis?

      Your Answer: Chalazion

      Explanation:

      A painless, firm lump in the eyelid is indicative of a chalazion or Meibomian cyst. This occurs when the Meibomian gland becomes blocked, resulting in the formation of a cyst. It is often a consequence of an internal stye (hordeolum internum). Although cysts may resolve on their own, they may require topical antibiotics if they become infected. The absence of pain and the prolonged history suggest that it is not an internal or external stye. Blepharitis and ectropion are unlikely to cause a lump in the eyelid.

      Eyelid problems are quite common and can include a variety of issues. One such issue is blepharitis, which is inflammation of the eyelid margins that can cause redness in the eye. Another problem is a stye, which is an infection of the glands in the eyelids. Chalazion, also known as Meibomian cyst, is another eyelid problem that can occur. Entropion is when the eyelids turn inward, while ectropion is when they turn outward.

      Styes can come in different forms, such as external or internal. An external stye is an infection of the glands that produce sebum or sweat, while an internal stye is an infection of the Meibomian glands. Treatment for styes typically involves hot compresses and pain relief, with topical antibiotics only being recommended if there is also conjunctivitis present. A chalazion, on the other hand, is a painless lump that can form in the eyelid due to a retention cyst of the Meibomian gland. While most cases will resolve on their own, some may require surgical drainage.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 49 - A 28-year-old male patient visits his GP with complaints of progressive tunnel vision...

    Incorrect

    • A 28-year-old male patient visits his GP with complaints of progressive tunnel vision and difficulty seeing at night for the past year. He recalls his grandfather experiencing similar symptoms but is unsure of the cause. During fundus examination, bone-spicule pigmentation is observed in the peripheral retina. What is the probable diagnosis?

      Your Answer: Macular degeneration

      Correct Answer: Retinitis pigmentosa

      Explanation:

      The presence of black bone-spicule pigmentation on fundoscopy is a classic sign of retinitis pigmentosa, an inherited retinal disorder that causes tunnel vision and night blindness by affecting the peripheral retina.

      Understanding Retinitis Pigmentosa

      Retinitis pigmentosa is a condition that primarily affects the peripheral retina, leading to tunnel vision. The initial sign of this condition is often night blindness, which can progress to a loss of peripheral vision. Fundoscopy, a diagnostic test, reveals black bone spicule-shaped pigmentation in the peripheral retina and mottling of the retinal pigment epithelium. Retinitis pigmentosa is often associated with other diseases such as Refsum disease, Usher syndrome, abetalipoproteinemia, Lawrence-Moon-Biedl syndrome, Kearns-Sayre syndrome, and Alport’s syndrome.

      To better understand retinitis pigmentosa, it is important to know that it is a genetic disorder that affects the retina’s ability to respond to light. This condition can lead to the death of photoreceptor cells in the retina, which are responsible for detecting light and transmitting visual information to the brain. As a result, individuals with retinitis pigmentosa may experience difficulty seeing in low light conditions, loss of peripheral vision, and, in severe cases, complete blindness.

      In summary, retinitis pigmentosa is a genetic condition that primarily affects the peripheral retina, leading to tunnel vision. It is often associated with other diseases and can cause night blindness, loss of peripheral vision, and, in severe cases, complete blindness. Early diagnosis and management are crucial in preventing further vision loss.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 50 - A 42-year-old man visits his doctor, reporting crusting of both eyelids that is...

    Incorrect

    • A 42-year-old man visits his doctor, reporting crusting of both eyelids that is more severe in the morning and accompanied by an itchy feeling. He states that he has not experienced any changes in his vision.
      During the eyelid examination, the doctor observes crusting at the eyelid margins, which are inflamed and red. The conjunctivae seem normal, and the pupils react equally to light.
      What is the probable diagnosis?

      Your Answer: Hordeolum

      Correct Answer: Blepharitis

      Explanation:

      Common Eye Conditions and Their Symptoms

      Blepharitis: This condition presents with crusting of both eyelids, redness, swelling, and itching. It can be treated with eyelid hygiene and warm compress. If necessary, chloramphenicol ointment can be used.

      Conjunctivitis: Patients with conjunctivitis have watery/discharging eyes, a gritty sensation, and conjunctival erythema. Most cases resolve on their own, but some may require topical antibiotics.

      Chalazion: A painless swelling or lump on the eyelid caused by a blocked gland. Patients report a red, swollen, and painless area on the eyelid that settles within a few days but leaves behind a firm, painless swelling. Warm compresses and gentle massaging can help with drainage.

      Entropion: The margin of the eyelid turns inwards towards the surface of the eye, causing irritation. It is more common in elderly patients and requires surgical treatment.

      Hordeolum: An acute-onset localised swelling of the eyelid margin that is painful. It is usually localised around an eyelash follicle, and plucking the affected eyelash can aid drainage. Styes are usually self-limiting, but eyelid hygiene and warm compress can help with resolution.

      Understanding Common Eye Conditions and Their Symptoms

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 51 - A 26-year-old man presents to the emergency department with complaints of left eye...

    Incorrect

    • A 26-year-old man presents to the emergency department with complaints of left eye pain. He has been unable to wear his contact lenses for the past day due to the severity of the pain. He describes the pain as intense and wonders if there is something lodged in his eye. Upon examination, diffuse hyperemia is observed in the left eye. The left cornea appears hazy, and there is a hypopyon present. Pupillary reaction is normal, but visual acuity is reduced on the left side, and the patient experiences some photophobia. What is the most probable diagnosis?

      Your Answer: Acute angle closure glaucoma

      Correct Answer: Keratitis

      Explanation:

      A hypopyon in anterior uveitis can be seen, but a normal pupillary reaction and contact lens use suggest a diagnosis of keratitis.

      Understanding Keratitis: Inflammation of the Cornea

      Keratitis is a condition that refers to the inflammation of the cornea. While conjunctivitis is a common eye infection that is not usually serious, microbial keratitis can be sight-threatening and requires urgent evaluation and treatment. The causes of keratitis can vary, with bacterial infections typically caused by Staphylococcus aureus and Pseudomonas aeruginosa commonly seen in contact lens wearers. Fungal and amoebic infections can also cause keratitis, with acanthamoebic keratitis accounting for around 5% of cases. Parasitic infections such as onchocercal keratitis can also cause inflammation of the cornea.

      Other factors that can cause keratitis include viral infections such as herpes simplex keratitis, environmental factors like photokeratitis (e.g. welder’s arc eye), and exposure keratitis. Clinical features of keratitis include a red eye with pain and erythema, photophobia, a foreign body sensation, and the presence of hypopyon. Referral is necessary for contact lens wearers who present with a painful red eye, as an accurate diagnosis can only be made with a slit-lamp examination.

      Management of keratitis involves stopping the use of contact lenses until symptoms have fully resolved, as well as the use of topical antibiotics such as quinolones. Cycloplegic agents like cyclopentolate can also be used for pain relief. Complications of keratitis can include corneal scarring, perforation, endophthalmitis, and visual loss. Understanding the causes and symptoms of keratitis is important for prompt diagnosis and treatment to prevent serious complications.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 52 - A 26-year-old man presents to the eye casualty department on his own accord....

    Incorrect

    • A 26-year-old man presents to the eye casualty department on his own accord. He mentions that he rarely visits doctors but decided to seek medical attention for his current issue. The patient has a medical history of ulcerative colitis.
      Upon initial examination, the doctor notes inflammation in either the episclera or the sclera and proceeds to perform a slit lamp examination.
      What is the classic distinguishing feature between the two diagnoses based on the history and examination?

      Your Answer: Redness of eyes

      Correct Answer: Pain

      Explanation:

      Distinguishing between scleritis and episcleritis cannot be based solely on the redness of the eyes, as both conditions result in visible redness.

      Rheumatoid Arthritis and Its Effects on the Eyes

      Rheumatoid arthritis is a chronic autoimmune disease that affects various parts of the body, including the eyes. In fact, ocular manifestations of rheumatoid arthritis are quite common, with approximately 25% of patients experiencing eye problems. These eye problems can range from mild to severe and can significantly impact a patient’s quality of life.

      The most common ocular manifestation of rheumatoid arthritis is keratoconjunctivitis sicca, also known as dry eye syndrome. This condition occurs when the eyes do not produce enough tears, leading to discomfort, redness, and irritation. Other ocular manifestations of rheumatoid arthritis include episcleritis, scleritis, corneal ulceration, and keratitis. Episcleritis and scleritis both cause redness in the eyes, with scleritis also causing pain. Corneal ulceration and keratitis both affect the cornea, with corneal ulceration being a more severe condition that can lead to vision loss.

      In addition to these conditions, patients with rheumatoid arthritis may also experience iatrogenic ocular manifestations. These are side effects of medications used to treat the disease. For example, steroid use can lead to cataracts, while the use of chloroquine can cause retinopathy.

      Overall, it is important for patients with rheumatoid arthritis to be aware of the potential ocular manifestations of the disease and to seek prompt medical attention if they experience any eye-related symptoms. Early diagnosis and treatment can help prevent vision loss and improve overall quality of life.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 53 - A 67-year-old man with a 14 year history of type 2 diabetes mellitus...

    Incorrect

    • A 67-year-old man with a 14 year history of type 2 diabetes mellitus presents with complaints of blurred vision and poor eyesight. Upon examination using a Snellen chart, his visual acuity is found to be reduced to 6/12 in the left eye and 6/18 in the right eye. Fundoscopy reveals the presence of yellow deposits in the right eye, consistent with drusen formation, albeit to a lesser extent. Similar changes are observed in the left eye. What is the most probable diagnosis?

      Your Answer: Pre-proliferative diabetic retinopathy

      Correct Answer: Dry age-related macular degeneration

      Explanation:

      Dry macular degeneration is characterized by the presence of drusen.

      Age-related macular degeneration (ARMD) is a common cause of blindness in the UK, characterized by the degeneration of the central retina (macula) and the formation of drusen. It is more prevalent in females and is strongly associated with advancing age, smoking, family history, and conditions that increase the risk of ischaemic cardiovascular disease. ARMD can be classified into two forms: dry and wet. Dry ARMD is more common and is characterized by drusen, while wet ARMD is characterized by choroidal neovascularisation and carries a worse prognosis. Clinical features of ARMD include subacute onset of visual loss, difficulties in dark adaptation, and visual disturbances such as photopsia and glare.

      To diagnose ARMD, slit-lamp microscopy and color fundus photography are used to identify any pigmentary, exudative, or haemorrhagic changes affecting the retina. Fluorescein angiography and indocyanine green angiography may also be used to visualize changes in the choroidal circulation. Treatment for dry ARMD involves a combination of zinc with anti-oxidant vitamins A, C, and E, which has been shown to reduce disease progression by around one third. For wet ARMD, anti-VEGF agents such as ranibizumab, bevacizumab, and pegaptanib are used to limit disease progression and stabilize or reverse visual loss. Laser photocoagulation may also be used to slow progression, but anti-VEGF therapies are usually preferred due to the risk of acute visual loss after treatment.

      In summary, ARMD is a common cause of blindness in the UK that is strongly associated with advancing age, smoking, and family history. It can be classified into dry and wet forms, with wet ARMD carrying a worse prognosis. Diagnosis involves the use of various imaging techniques, and treatment options include a combination of zinc and anti-oxidant vitamins for dry ARMD and anti-VEGF agents or laser photocoagulation for wet ARMD.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 54 - A 60-year-old man presents with a sudden onset of vision loss in his...

    Correct

    • A 60-year-old man presents with a sudden onset of vision loss in his left eye upon waking up this morning. He reports no pain in his eye. His medical history includes diabetes mellitus and hypertension. Upon fundoscopic examination, the right eye appears normal, but the left eye shows multiple retinal haemorrhages. What is the most probable diagnosis?

      Your Answer: Central retinal vein occlusion

      Explanation:

      The sudden painless loss of vision and severe retinal haemorrhages observed on fundoscopy in this patient are indicative of central retinal vein occlusion. Amaurosis fugax, which is caused by atheroembolism from the carotid arteries, results in temporary vision loss that resolves within a few minutes. In contrast, this patient’s vision loss is persistent. While central retinal artery occlusion also causes acute painless vision loss, it is characterized by a loss of relative afferent pupillary defect, a cherry-red macula, and a white/pale retina on fundoscopy. Hypertensive retinopathy may cause flame-shaped haemorrhages and cotton wool spots on the retina, but it does not result in sudden vision loss.

      Understanding Central Retinal Vein Occlusion

      Central retinal vein occlusion (CRVO) is a possible cause of sudden, painless loss of vision. It is more common in older individuals and those with hypertension, cardiovascular disease, glaucoma, or polycythemia. The condition is characterized by a sudden reduction or loss of visual acuity, usually affecting only one eye. Fundoscopy reveals widespread hyperemia and severe retinal hemorrhages, which are often described as a stormy sunset.

      Branch retinal vein occlusion (BRVO) is a similar condition that affects a smaller area of the fundus. It occurs when a vein in the distal retinal venous system is blocked, usually at arteriovenous crossings.

      Most patients with CRVO are managed conservatively, but treatment may be necessary in some cases. For instance, intravitreal anti-vascular endothelial growth factor (VEGF) agents may be used to manage macular edema, while laser photocoagulation may be necessary to treat retinal neovascularization.

      Overall, understanding the risk factors, features, and management options for CRVO is essential for prompt diagnosis and appropriate treatment. Proper management can help prevent further vision loss and improve the patient’s quality of life.

    • This question is part of the following fields:

      • Ophthalmology
      24.9
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  • Question 55 - During your FY2 rotation in General Practice, you saw a 75-year-old man in...

    Incorrect

    • During your FY2 rotation in General Practice, you saw a 75-year-old man in your GP clinic who complained of blurred vision in his right eye for the past 4 months. He finally decided to come to see you because he felt his vision was now very distorted. On dilated fundoscopy, the left eye appeared normal, but you could see drusen at the macula in the right eye. You suspect age-related macular degeneration.
      What is the ONE next step in management for this patient?

      Your Answer: Prescribe atorvastatin 40mg

      Correct Answer: Refer to ophthalmology urgently within 1 week

      Explanation:

      It is essential to refer patients suspected of having AMD to ophthalmology urgently within 1 week for a formal diagnosis. This is because if the diagnosis is wet AMD, anti-VEGF injections can be administered, which will improve the patient’s long-term visual outcome. Even if drusen is present, which is more indicative of dry AMD, an urgent referral should still be made within 1 week. Delaying the referral for a month will postpone the formal diagnosis and treatment commencement for the patient. While multi-vitamins may be beneficial for dry AMD, it is not the next step in management. Atorvastatin is used to lower blood cholesterol levels and is not effective in treating drusen.

      Age-related macular degeneration (ARMD) is a common cause of blindness in the UK, characterized by the degeneration of the central retina (macula) and the formation of drusen. It is more prevalent in females and is strongly associated with advancing age, smoking, family history, and conditions that increase the risk of ischaemic cardiovascular disease. ARMD can be classified into two forms: dry and wet. Dry ARMD is more common and is characterized by drusen, while wet ARMD is characterized by choroidal neovascularisation and carries a worse prognosis. Clinical features of ARMD include subacute onset of visual loss, difficulties in dark adaptation, and visual disturbances such as photopsia and glare.

      To diagnose ARMD, slit-lamp microscopy and color fundus photography are used to identify any pigmentary, exudative, or haemorrhagic changes affecting the retina. Fluorescein angiography and indocyanine green angiography may also be used to visualize changes in the choroidal circulation. Treatment for dry ARMD involves a combination of zinc with anti-oxidant vitamins A, C, and E, which has been shown to reduce disease progression by around one third. For wet ARMD, anti-VEGF agents such as ranibizumab, bevacizumab, and pegaptanib are used to limit disease progression and stabilize or reverse visual loss. Laser photocoagulation may also be used to slow progression, but anti-VEGF therapies are usually preferred due to the risk of acute visual loss after treatment.

      In summary, ARMD is a common cause of blindness in the UK that is strongly associated with advancing age, smoking, and family history. It can be classified into dry and wet forms, with wet ARMD carrying a worse prognosis. Diagnosis involves the use of various imaging techniques, and treatment options include a combination of zinc and anti-oxidant vitamins for dry ARMD and anti-VEGF agents or laser photocoagulation for wet ARMD.

    • This question is part of the following fields:

      • Ophthalmology
      19
      Seconds
  • Question 56 - A 26-year-old female contact lens wearer arrives at the emergency department complaining of...

    Incorrect

    • A 26-year-old female contact lens wearer arrives at the emergency department complaining of eye pain. She reports experiencing severe pain, watery eyes, and sensitivity to light in her left eye. Upon examination, her left eye appears red, but her pupil seems normal. After applying fluorescein dye, you observe a distinct area of green fluorescence under a blue light. What is the probable diagnosis?

      Your Answer: Anterior uveitis

      Correct Answer: Corneal ulcer

      Explanation:

      If there is corneal uptake of fluorescein, along with symptoms of ocular pain, tearing, and photophobia, it is likely that the individual has a corneal ulcer. Fluorescein, an orange dye, is applied to the surface of the eye and will appear green/yellow under a blue light if it is taken up by the corneal epithelium. While dry eye can also cause fluorescence, it typically appears as a diffuse, speckled pattern known as superficial punctate staining.

      Understanding Corneal Ulcers

      A corneal ulcer is a condition that occurs when there is a defect in the cornea, which is usually caused by an infection. It is important to note that corneal abrasions, on the other hand, are typically caused by physical trauma. There are several risk factors that can increase the likelihood of developing a corneal ulcer, including contact lens use and vitamin A deficiency, which is particularly common in developing countries.

      The pathophysiology of corneal ulcers can vary depending on the underlying cause. Bacterial, fungal, and viral infections can all lead to the development of a corneal ulcer. In some cases, contact lens use can also be associated with a type of infection called Acanthamoeba keratitis.

      Symptoms of a corneal ulcer typically include eye pain, sensitivity to light, and excessive tearing. Additionally, a focal fluorescein staining of the cornea may be present.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 57 - A 42-year-old woman visits her General Practitioner with a red right eye. She...

    Incorrect

    • A 42-year-old woman visits her General Practitioner with a red right eye. She reports experiencing photophobia, blurred vision and excessive tearing of the eye for the last three days. She has a history of eczema and takes oral corticosteroids for it. She is referred to an ophthalmologist and fluorescein staining reveals the presence of a dendritic ulcer.

      What is the most probable diagnosis?

      Your Answer: Corneal abrasion

      Correct Answer: Herpes simplex keratitis

      Explanation:

      Differential Diagnosis of a Dendritic Ulcer in the Eye

      A dendritic ulcer in the eye is a characteristic finding of herpes simplex keratitis, caused by the herpes simplex virus type 1. It may occur as a primary infection in children or as a reactivation in response to triggers such as stress or immunosuppression. The affected eye may present with redness, pain, photophobia, blurred vision, and increased tearing. However, other conditions may mimic the appearance of a dendritic ulcer on fluorescein staining, such as corneal abrasion, herpes zoster ophthalmicus, bacterial conjunctivitis, and cytomegalovirus (CMV) retinitis. A thorough differential diagnosis is necessary to determine the underlying cause and appropriate management.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 58 - Cataracts are usually not associated with which of the following conditions? Please select...

    Incorrect

    • Cataracts are usually not associated with which of the following conditions? Please select only one option from the list below.

      Your Answer: Rubella

      Correct Answer: Thyrotoxicosis

      Explanation:

      Common Causes of Cataracts and Their Associated Symptoms

      Cataracts are a common eye condition that can cause visual impairment. While ageing is the most common cause, there are several other factors that can contribute to cataract development. Here are some of the common causes of cataracts and their associated symptoms:

      1. Thyrotoxicosis: This condition involves excess synthesis and secretion of thyroid hormones, leading to the hypermetabolic condition of thyrotoxicosis. Symptoms include sympathetic activation in younger patients and cardiovascular symptoms and unexplained weight loss in older patients. Approximately 50% of patients with Graves-thyrotoxicosis have mild thyroid ophthalmopathy, which can cause periorbital edema, conjunctival edema, poor lid closure, extraocular muscle dysfunction, and proptosis.

      2. Diabetes mellitus: Patients with diabetes are at risk of developing several ophthalmic complications, including cataracts. Epidemiological studies have shown that cataracts are the most common cause of visual impairment in patients with older-onset diabetes. Hyperglycemia is associated with loss of lens transparency, and rapid decline of serum glucose levels in patients with marked hyperglycemia may induce temporary lens opacification and swelling.

      3. Myotonic dystrophy: This chronic genetic disorder affects muscle function and can cause gradually worsening muscle atrophy and weakness. Other symptoms include cataracts, intellectual disability, and heart conduction abnormalities. Myotonic dystrophy may cause a cortical cataract with a blue dot appearance or a posterior subcapsular cataract.

      4. Rubella: Congenital cataracts are usually diagnosed at birth and can be associated with ocular abnormalities, trauma, or intrauterine infection, particularly rubella. Congenital rubella infection may result in growth delay, learning disability, hearing loss, congenital heart disease, and eye, endocrinological, and neurological abnormalities.

      5. Hypoparathyroidism: This condition is characterized by hypocalcemia, hyperphosphatemia, and low or inappropriately normal levels of parathyroid hormone. Patients may present with hypocalcemia, mental changes, and neuromuscular excitability or tetany. Anatomical abnormalities, although not readily apparent, include deposition of calcium in soft tissues, including intracranial calcifications and cataract formation.

      In addition to these causes, cataracts can also be caused by trauma

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 59 - A 45-year-old man visits his GP complaining of burning and itching of his...

    Incorrect

    • A 45-year-old man visits his GP complaining of burning and itching of his eyelids, particularly in the mornings. He reports feeling dryness and grittiness in his eyes and has stopped using contact lenses, opting for glasses instead. Upon examination, the GP notes redness, crusting, and slight swelling of the eyelid margins, as well as a small chalazion on the lower right lid. The patient's visual acuity remains unchanged and both conjunctivae are clear. What is the recommended first-line treatment?

      Your Answer: Steroid eye drops

      Correct Answer: Regular lid hygiene

      Explanation:

      The initial and most important treatment for blepharitis, a common and chronic condition, is regular lid hygiene. Although there are different types of blepharitis, lid hygiene is the first-line treatment for all of them. The goal is to clear out any stagnant oily secretions, unblock meibomian glands, remove bacteria and flakes of skin, and soothe the eyelids. Patients should practice lid hygiene twice daily, which involves warmth, massage, and cleansing. There are many patient information leaflets available online that explain the process. Oral tetracycline is not the first-line treatment for blepharitis and is usually unnecessary if lid hygiene measures are followed. If symptoms persist, a course of oral tetracycline may be considered, especially in cases where meibomian gland dysfunction is prominent and there is associated rosacea. Sodium cromoglicate eye drops are not used in the management of blepharitis, as they are intended for allergic eye disease. Steroid eye drops are not a primary care treatment option for blepharitis and are not first-line, although they may be considered by specialists in cases resistant to other treatment measures.

      Blepharitis is a condition where the eyelid margins become inflamed. This can be caused by dysfunction of the meibomian glands (posterior blepharitis) or seborrhoeic dermatitis/staphylococcal infection (anterior blepharitis). It is more common in patients with rosacea. The meibomian glands secrete oil to prevent rapid evaporation of the tear film, so any problem affecting these glands can cause dryness and irritation of the eyes. Symptoms of blepharitis are usually bilateral and include grittiness, discomfort around the eyelid margins, sticky eyes in the morning, and redness of the eyelid margins. Styes and chalazions are also more common in patients with blepharitis, and secondary conjunctivitis may occur.

      Management of blepharitis involves softening the lid margin with hot compresses twice a day and practicing lid hygiene to remove debris from the lid margins. This can be done using cotton wool buds dipped in a mixture of cooled boiled water and baby shampoo or sodium bicarbonate in cooled boiled water. Artificial tears may also be given for symptom relief in people with dry eyes or an abnormal tear film.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 60 - A 25-year-old male with a history of ankylosing spondylitis presents to the emergency...

    Incorrect

    • A 25-year-old male with a history of ankylosing spondylitis presents to the emergency department with a painful red eye, photophobia, lacrimation, and reduced visual acuity. On examination, an irregularly shaped pupil is noted. What is the most suitable approach to manage this patient's current condition?

      Your Answer: Acetazolamide and pilocarpine eye drops

      Correct Answer: Steroid and cycloplegic (mydriatic) eye drops

      Explanation:

      Anterior uveitis, also known as iritis, is a type of inflammation that affects the iris and ciliary body in the front part of the uvea. It is a common cause of red eye and is associated with HLA-B27, which may also be linked to other conditions. Symptoms of anterior uveitis include sudden onset of eye discomfort and pain, small or irregular pupils, intense sensitivity to light, blurred vision, redness, tearing, and the presence of pus and inflammatory cells in the front part of the eye. This condition may be associated with ankylosing spondylitis, reactive arthritis, ulcerative colitis, Crohn’s disease, Behcet’s disease, and sarcoidosis. Urgent review by an ophthalmologist is necessary, and treatment may involve the use of cycloplegics and steroid eye drops.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 61 - Which one of the following features is not present in pre-proliferative retinopathy in...

    Correct

    • Which one of the following features is not present in pre-proliferative retinopathy in elderly diabetic patients?

      Your Answer: Neovascularisation

      Explanation:

      Proliferative retinopathy is characterized by the presence of retinal neovascularization.

      Understanding Diabetic Retinopathy

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

      Patients with diabetic retinopathy are classified into those with non-proliferative diabetic retinopathy (NPDR), proliferative retinopathy (PDR), and maculopathy. NPDR is further classified into mild, moderate, and severe, depending on the presence of microaneurysms, blot hemorrhages, hard exudates, cotton wool spots, venous beading/looping, and intraretinal microvascular abnormalities. PDR is characterized by retinal neovascularization, which may lead to vitreous hemorrhage, and fibrous tissue forming anterior to the retinal disc. Maculopathy is based on location rather than severity and is more common in Type II DM.

      Management of diabetic retinopathy involves optimizing glycaemic control, blood pressure, and hyperlipidemia, as well as regular review by ophthalmology. Treatment options include intravitreal vascular endothelial growth factor (VEGF) inhibitors for maculopathy, regular observation for non-proliferative retinopathy, and panretinal laser photocoagulation and intravitreal VEGF inhibitors for proliferative retinopathy. Vitreoretinal surgery may be necessary in cases of severe or vitreous hemorrhage.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 62 - A 46-year-old male patient presented to the emergency department with sudden onset of...

    Incorrect

    • A 46-year-old male patient presented to the emergency department with sudden onset of pain, photophobia, and redness in his left eye. During examination, an irregularly sized left pupil and hypopyon in the anterior chamber were observed. The patient has a history of a condition marked by stiffness and back pain. What is the most probable diagnosis for his eye issue?

      Your Answer: Scleritis

      Correct Answer: Anterior uveitis

      Explanation:

      Anterior uveitis is frequently observed in conditions linked to HLA-B27, such as ankylosing spondylitis, reactive arthritis, and psoriatic arthritis. This type of uveitis can cause an irregular pupil due to the formation of posterior synechiae, which occurs when inflammation within the eye causes the iris to stick to the anterior lens surface. However, intermediate and posterior uveitis are not associated with HLA-B27 and do not typically cause pain, irregular pupil size, or hypopyon. Scleritis and episcleritis also do not present with an irregular pupil or hypopyon.

      Anterior uveitis, also known as iritis, is a type of inflammation that affects the iris and ciliary body in the front part of the uvea. It is a common cause of red eye and is associated with HLA-B27, which may also be linked to other conditions. Symptoms of anterior uveitis include sudden onset of eye discomfort and pain, small or irregular pupils, intense sensitivity to light, blurred vision, redness, tearing, and the presence of pus and inflammatory cells in the front part of the eye. This condition may be associated with ankylosing spondylitis, reactive arthritis, ulcerative colitis, Crohn’s disease, Behcet’s disease, and sarcoidosis. Urgent review by an ophthalmologist is necessary, and treatment may involve the use of cycloplegics and steroid eye drops.

    • This question is part of the following fields:

      • Ophthalmology
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      Seconds
  • Question 63 - Which of the following is not a recognized feature of Horner's syndrome? ...

    Incorrect

    • Which of the following is not a recognized feature of Horner's syndrome?

      Your Answer: Ptosis

      Correct Answer: Mydriasis

      Explanation:

      Horner’s syndrome is a medical condition that is characterized by a set of symptoms including a small pupil (miosis), drooping of the upper eyelid (ptosis), sunken eye (enophthalmos), and loss of sweating on one side of the face (anhidrosis). The presence of heterochromia, or a difference in iris color, is often seen in cases of congenital Horner’s syndrome. Anhidrosis is also a distinguishing feature that can help differentiate between central, pre-ganglionic, and post-ganglionic lesions. Pharmacologic tests, such as the use of apraclonidine drops, can be helpful in confirming the diagnosis of Horner’s syndrome and localizing the lesion.

      Central lesions, pre-ganglionic lesions, and post-ganglionic lesions can all cause Horner’s syndrome, with each type of lesion presenting with different symptoms. Central lesions can result in anhidrosis of the face, arm, and trunk, while pre-ganglionic lesions can cause anhidrosis of the face only. Post-ganglionic lesions, on the other hand, do not typically result in anhidrosis.

      There are many potential causes of Horner’s syndrome, including stroke, syringomyelia, multiple sclerosis, tumors, encephalitis, thyroidectomy, trauma, cervical rib, carotid artery dissection, carotid aneurysm, cavernous sinus thrombosis, and cluster headache. It is important to identify the underlying cause of Horner’s syndrome in order to determine the appropriate treatment plan.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 64 - A 82-year-old man comes to the clinic complaining of sudden loss of vision...

    Incorrect

    • A 82-year-old man comes to the clinic complaining of sudden loss of vision in his left eye since this morning. He denies any associated eye pain or headaches and is otherwise feeling well. His medical history includes ischaemic heart disease. Upon examination, the patient has no vision in his left eye. The left pupil shows poor response to light, but the consensual light reaction is normal. Fundoscopy reveals a red spot over a pale and opaque retina. What is the most probable diagnosis?

      Your Answer: Vitreous haemorrhage

      Correct Answer: Central retinal artery occlusion

      Explanation:

      Central Retinal Artery Occlusion: A Rare Cause of Sudden Vision Loss

      Central retinal artery occlusion is a rare condition that can cause sudden, painless loss of vision in one eye. It is typically caused by a blood clot or inflammation in the artery that supplies blood to the retina. This can be due to atherosclerosis or arteritis, such as temporal arteritis. Symptoms may include a relative afferent pupillary defect and a cherry red spot on a pale retina. Unfortunately, the prognosis for this condition is poor, and management can be difficult. Treatment may involve identifying and addressing any underlying conditions, such as intravenous steroids for temporal arteritis. In some cases, intraarterial thrombolysis may be attempted, but the results of this treatment are mixed. Overall, central retinal artery occlusion is a serious condition that requires prompt medical attention.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 65 - A 50-year-old woman presents to the Emergency Department with sudden, painless loss of...

    Incorrect

    • A 50-year-old woman presents to the Emergency Department with sudden, painless loss of vision in her right eye. On examination, fundoscopy reveals a pale retina with a cherry-red spot at the macula in her right eye. Her left eye is normal.
      What is the most likely diagnosis?

      Your Answer: Age-related macular degeneration (AMD)

      Correct Answer: Central retinal-artery occlusion (CRAO)

      Explanation:

      Differentiating Eye Conditions: A Brief Overview

      Central retinal-artery occlusion (CRAO) is characterized by a sudden loss of vision due to the lack of blood supply to the inner layer of the retina. On fundoscopy, the retina appears pale with a ‘cherry-red spot’ at the macula.

      Age-related macular degeneration (AMD) is the most common cause of irreversible vision loss in the developed world. However, deterioration in vision is usually gradual in AMD unless there is a retinal haemorrhage, which would be seen on fundoscopy.

      Central retinal-vein occlusion (CRVO) results in retinal hypoxia and is characterized by tortuous vessels, retinal-vein engorgement, haemorrhages, cotton-wool spots, and optic disc swelling.

      Glaucoma is a progressive optic neuropathy that can result in irreversible loss of nerve fibres if left untreated. On fundoscopy, you may see ‘cupping of the optic disc or an increased cup-to-disc ratio.

      Retinal detachment refers to the separation of the inner layers of the retina from the underlying retinal pigment epithelium. It may present with four Fs: floaters, flashing lights (photopsia), field loss, and fall in visual acuity. Retinal detachment is one of the most time-critical eye emergencies encountered in the emergency setting.

      In summary, understanding the different presentations and fundoscopic findings of these eye conditions is crucial in making an accurate diagnosis and providing appropriate management.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 66 - A 42-year-old woman arrived at the Emergency Department complaining of a painful and...

    Correct

    • A 42-year-old woman arrived at the Emergency Department complaining of a painful and red eye with watering and mild sensitivity to light. The diagnosis was uncertain, but it was suspected to be either episcleritis or scleritis. The on-call ophthalmologist was contacted, and they requested that a specific eye drop be administered to differentiate between the two conditions.

      Which of the following eye drops is capable of distinguishing between episcleritis and scleritis?

      Your Answer: Phenylephrine eye drops

      Explanation:

      Distinguishing between episcleritis and scleritis can be achieved using eye drops. By administering the drops, it is possible to observe whether the redness in the eye blanches or not. If it does, then the condition is episcleritis, but if it doesn’t, then it is scleritis. This skill is particularly valuable for those working in an Emergency Medicine rotation. None of the other options are useful for distinguishing between these two conditions.

      Understanding Episcleritis

      Episcleritis is a condition that involves the sudden onset of inflammation in the episclera of one or both eyes. While the majority of cases are idiopathic, there are some associated conditions such as inflammatory bowel disease and rheumatoid arthritis. Symptoms of episcleritis include a red eye, mild pain or irritation, watering, and mild photophobia. However, unlike scleritis, episcleritis is typically not painful.

      One way to differentiate between the two conditions is by applying gentle pressure on the sclera. If the injected vessels are mobile, it is likely episcleritis. In contrast, scleritis involves deeper vessels that do not move. Phenylephrine drops may also be used to distinguish between the two conditions. If the eye redness improves after phenylephrine, a diagnosis of episcleritis can be made.

      Approximately 50% of cases of episcleritis are bilateral. Treatment for episcleritis is typically conservative, with artificial tears sometimes being used. Understanding the symptoms and differences between episcleritis and scleritis can help individuals seek appropriate treatment and management for their eye condition.

    • This question is part of the following fields:

      • Ophthalmology
      23.8
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  • Question 67 - A 48-year-old male patient comes to the GP clinic complaining of pain and...

    Incorrect

    • A 48-year-old male patient comes to the GP clinic complaining of pain and redness on his left upper eyelid. Upon examination, a tender papule with erythema is found at the left eyelid margin, with a small area of pus discharge. Additionally, there is slight redness of the conjunctiva. What is the probable diagnosis?

      Your Answer: Acne vulgaris

      Correct Answer: Hordeolum externum

      Explanation:

      The individual is experiencing an infection in the glands of their external eyelid, which is classified as a type of stye known as hordeolum externum. It should be noted that a chalazion, also referred to as a meibomian cyst, typically occurs on the internal eyelid. Blepharitis, on the other hand, is characterized by inflammation of the eyelid margins and does not typically result in a lump. Ectropion refers to the outward turning of the eyelids, while acne vulgaris does not typically impact the eyelids.

      Eyelid problems are quite common and can include a variety of issues. One such issue is blepharitis, which is inflammation of the eyelid margins that can cause redness in the eye. Another problem is a stye, which is an infection of the glands in the eyelids. Chalazion, also known as Meibomian cyst, is another eyelid problem that can occur. Entropion is when the eyelids turn inward, while ectropion is when they turn outward.

      Styes can come in different forms, such as external or internal. An external stye is an infection of the glands that produce sebum or sweat, while an internal stye is an infection of the Meibomian glands. Treatment for styes typically involves hot compresses and pain relief, with topical antibiotics only being recommended if there is also conjunctivitis present. A chalazion, on the other hand, is a painless lump that can form in the eyelid due to a retention cyst of the Meibomian gland. While most cases will resolve on their own, some may require surgical drainage.

    • This question is part of the following fields:

      • Ophthalmology
      22.5
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  • Question 68 - A 75-year-old woman with age-related macular degeneration (AMD) presented to the emergency department...

    Incorrect

    • A 75-year-old woman with age-related macular degeneration (AMD) presented to the emergency department with a painless bloodshot right eye. She was very worried about her condition. The previous day, she had received an intravitreal injection for the treatment of AMD. Upon examination, her visual acuity had not decreased further, but there was bleeding under the conjunctiva around the injection site. What is the probable diagnosis?

      Your Answer: Endophthalmitis

      Correct Answer: Subconjunctival haemorrhage

      Explanation:

      It is important to inform patients about the possibility of developing subconjunctival haemorrhage after receiving intravitreal injections, as it is a common iatrogenic complication. This condition causes a red eye but is not painful and typically resolves within a couple of weeks.

      Understanding Subconjunctival Haemorrhage

      Subconjunctival haemorrhage occurs when blood vessels bleed into the subconjunctival space, usually those that supply the conjunctiva or episclera. Trauma is the most common cause, followed by spontaneous idiopathic cases, Valsalva manoeuvres, and several systemic diseases. Although subconjunctival haemorrhages can look alarming, they are rarely an indicator of anything sinister.

      Subconjunctival haemorrhages are more common in women than in men when there has been no history of trauma. The annual incidence of non-traumatic subconjunctival haemorrhages is 0.6%, and the risk increases with age as the risk factors are more common in elderly patients. Newborns are also more susceptible. The incidence of both traumatic and non-traumatic subconjunctival haemorrhages is 2.6%.

      The most common causes of subconjunctival haemorrhages are trauma and contact lens usage, which are often the sole risk factor in younger patients. Other risk factors include idiopathic causes, Valsalva manoeuvre, hypertension, bleeding disorders, drugs such as aspirin, NSAIDs and anticoagulants, diabetes, arterial disease, and hyperlipidaemia.

      Subconjunctival haemorrhages are mostly asymptomatic, but patients may experience mild irritation. The main sign is a flat, red patch on the conjunctiva with well-defined edges and normal conjunctiva surrounding it. Traumatic haemorrhages are most common in the temporal region, with the inferior conjunctiva as the next most commonly affected area. Vision should be normal, including acuity, visual fields, and range of eye movements. On examination, the fundus should be normal.

      The diagnosis of a subconjunctival haemorrhage is a clinical one. If there is no obvious traumatic cause, check the patient’s blood pressure. If raised, refer the patient appropriately. If the patient is taking warfarin, check the INR. If raised, refer for appropriate adjustments to the dose to bring the INR back into the target range. Recurrent or spontaneous, bilateral subconjunctival haemorrhages warrant investigations for bleeding disorders or other pathology.

      Reassure the patient that subconjunctival haemorrhage is a benign condition that will resolve on its own in 2 to

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 69 - A 42-year-old woman visits her GP clinic with a blistering rash around her...

    Incorrect

    • A 42-year-old woman visits her GP clinic with a blistering rash around her right eye that developed overnight. Upon examination, the eye appears to be unaffected. The GP promptly contacts the nearby hospital rapid access eye clinic for guidance.
      What is the most suitable course of treatment?

      Your Answer: Topical aciclovir

      Correct Answer: Oral aciclovir

      Explanation:

      Herpes Zoster Ophthalmicus: Symptoms, Treatment, and Complications

      Herpes zoster, commonly known as shingles, is a reactivation of the varicella-zoster virus that causes chickenpox. Herpes zoster ophthalmicus (HZO) occurs when the virus affects the trigeminal nerve, resulting in eye involvement in about 50% of cases. Symptoms include patchy erythema and grouped herpetiform vesicles, which may extend to the tip of the nose. Other ophthalmic manifestations include conjunctivitis, scleritis, keratitis, and optic neuritis. Urgent referral to ophthalmology is necessary in the presence of eye involvement, as it poses a risk to vision. Treatment involves oral aciclovir and topical aciclovir for severe eye infection. There is no recommendation for the use of carbamazepine in the management of post-herpetic neuralgia. Topical steroids are not indicated for herpes zoster infection. Complications of HZO include post-herpetic neuralgia and scarring. Aggressive treatment and follow-up monitoring are required for HZO due to the possibility of eye involvement.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 70 - A 57-year-old male presents to eye casualty with a one-day history of a...

    Incorrect

    • A 57-year-old male presents to eye casualty with a one-day history of a painful red eye. He has a past medical history of hypertension and type II diabetes mellitus. He wears glasses for his hypermetropia.

      Upon examination of the right eye, a ciliary injection accompanies a fixed mid-dilated pupil. The pain is exacerbated when assessing pupillary reaction, which is non-reactive. His visual acuity is markedly reduced in his right eye compared to his left.

      Gonioscopy was performed, and the trabecular meshwork was not visualised. What is the first-line management for this likely diagnosis?

      Your Answer: Prescribe cyclopentolate eye drops

      Correct Answer: Administer pilocarpine, timolol, and brimonidine eye drops

      Explanation:

      The appropriate treatment for a patient with acute angle closure glaucoma (AACG) is to administer pilocarpine, timolol, and brimonidine eye drops. This condition is characterized by ocular pain, decreased visual acuity, worsened symptoms with mydriasis, and haloes around lights. AACG is more common in individuals with hypermetropia. The presence of a fixed mid-dilated pupil and inability to visualize the trabecular meshwork are consistent with AACG. Pilocarpine, timolol, and brimonidine are all used to reduce intra-ocular pressure (IOP) and protect the optic nerve.

      Administering gentamicin eye drops is not appropriate for this patient as it is an antibiotic used to treat eye infections such as microbial keratitis. The patient does not have risk factors for an eye infection and the examination findings are more consistent with AACG.

      Prescribing prednisolone eye drops is also not appropriate as it is a steroid used to manage inflammatory eye diseases such as anterior uveitis. While anterior uveitis may present with a painful red eye, the examination findings for this patient are more suggestive of angle closure.

      Similarly, prescribing cyclopentolate eye drops is not appropriate as it is a mydriatic eye drop that may worsen the patient’s symptoms by reducing the angle. Mydriatic eye drops may be used in the management of anterior uveitis, but the examination findings for this patient are more consistent with AACG.

      Glaucoma is a group of disorders that cause optic neuropathy due to increased intraocular pressure (IOP). However, not all patients with raised IOP have glaucoma, and vice versa. Acute angle-closure glaucoma (AACG) is a type of glaucoma where there is a rise in IOP due to impaired aqueous outflow. Factors that increase the risk of AACG include hypermetropia, pupillary dilatation, and lens growth associated with age. Symptoms of AACG include severe pain, decreased visual acuity, haloes around lights, and a hard, red-eye. Management of AACG is an emergency and requires urgent referral to an ophthalmologist. Emergency medical treatment is necessary to lower the IOP, followed by definitive surgical treatment once the acute attack has subsided.

      There are no specific guidelines for the initial medical treatment of AACG, but a combination of eye drops may be used, including a direct parasympathomimetic, a beta-blocker, and an alpha-2 agonist. Intravenous acetazolamide may also be administered to reduce aqueous secretions. Definitive management of AACG involves laser peripheral iridotomy, which creates a small hole in the peripheral iris to allow aqueous humour to flow to the angle. It is important to seek medical attention immediately if symptoms of AACG are present to prevent permanent vision loss.

    • This question is part of the following fields:

      • Ophthalmology
      9.6
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  • Question 71 - A 52-year-old man reports a sudden painless loss of vision which occurred yesterday...

    Correct

    • A 52-year-old man reports a sudden painless loss of vision which occurred yesterday evening. He describes this as a veil dropping over his left eye. The symptoms have since resolved and his vision is currently normal.
      What is the most probable diagnosis?

      Your Answer: Amaurosis fugax

      Explanation:

      Amaurosis fugax, or transient vision loss, is a common complaint that typically lasts from seconds to hours and may have an identifiable cause. It often presents as a grey curtain moving from the periphery towards the center of vision. Ischemic causes, such as giant cell arteritis, cerebrovascular ischemia, and retinal arteriolar emboli, are more common in patients over 45 years old. A monocular visual disturbance, as seen in this patient, is more likely to be due to a circulatory disturbance of the anterior circulation, such as the carotid artery.

      Retinal detachment is a time-critical eye emergency that presents with floaters, flashing lights, field loss, and a fall in visual acuity. Patients with high myopia are at high risk. Over time, a shadow may appear in the peripheral visual field, which, if ignored, may spread to involve the entire visual field in a matter of days.

      Age-related macular degeneration (AMD) is the most common cause of irreversible vision loss in the developed world and usually manifests after age 50. The disease is often bilateral and may be asymmetrical. Peripheral visual acuity is preserved in all forms of dry AMD, but the advanced, non-exudative form is associated with severe central visual-field loss.

      Central retinal artery occlusion results in inner layer oedema and pyknosis of the ganglion cell nuclei, leading to ischaemic necrosis and opacification of the retina. The most common presenting complaint is an acute, persistent, painless loss of vision. A history of amaurosis fugax may be present.

      Central retinal vein occlusion presents with variable visual loss, retinal haemorrhages, dilated tortuous retinal veins, cotton-wool spots, macular oedema, and optic disc oedema. Visual loss can be sudden or gradual, over a period of days to weeks, and ranges from mild to severe. Photophobia, pain, and eye redness may also be present.

    • This question is part of the following fields:

      • Ophthalmology
      27
      Seconds
  • Question 72 - A 62-year-old female presents with a red eye on one side that is...

    Incorrect

    • A 62-year-old female presents with a red eye on one side that is watering but not causing any pain. She has a history of well-managed Crohn's disease and reports feeling generally healthy. Her vital signs are normal. Upon examination, a small area of redness is observed, but there is no vision impairment, and the patient does not display any sensitivity to light. Eye drops are given, resulting in a brief whitening of the blood vessels. What is the probable diagnosis?

      Your Answer: Retrobulbar haemorrhage

      Correct Answer: Episcleritis

      Explanation:

      Episcleritis is a condition that can cause redness in the eye, but it is typically not accompanied by pain.

      Both episcleritis and scleritis can cause unilateral redness in the eye, tearing, and no sensitivity to light. However, a key difference between the two is that the use of phenylephrine or neosynephrine eye drops will cause the blood vessels in episcleritis to become pale, while this will not occur in scleritis.

      In contrast, closed-angle glaucoma often presents with a painful, red eye that is unilateral. The cornea may appear hazy, and the pupil may be mid-dilated. Patients may also experience nausea, vomiting, and see halos around lights.

      A stye, or hordeolum, is a bacterial infection of one of the glands in the eyelid. This can cause a tender, red bump on the edge of the eyelid.

      Retrobulbar hemorrhage can occur due to various factors, such as AV malformation, trauma, or increased venous pressure. Symptoms include a painful, red eye that may protrude, particularly at night. Patients may also experience reduced vision, nausea, vomiting, and double vision.

      Understanding Episcleritis

      Episcleritis is a condition that involves the sudden onset of inflammation in the episclera of one or both eyes. While the majority of cases are idiopathic, there are some associated conditions such as inflammatory bowel disease and rheumatoid arthritis. Symptoms of episcleritis include a red eye, mild pain or irritation, watering, and mild photophobia. However, unlike scleritis, episcleritis is typically not painful.

      One way to differentiate between the two conditions is by applying gentle pressure on the sclera. If the injected vessels are mobile, it is likely episcleritis. In contrast, scleritis involves deeper vessels that do not move. Phenylephrine drops may also be used to distinguish between the two conditions. If the eye redness improves after phenylephrine, a diagnosis of episcleritis can be made.

      Approximately 50% of cases of episcleritis are bilateral. Treatment for episcleritis is typically conservative, with artificial tears sometimes being used. Understanding the symptoms and differences between episcleritis and scleritis can help individuals seek appropriate treatment and management for their eye condition.

    • This question is part of the following fields:

      • Ophthalmology
      48.6
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  • Question 73 - A 28-year-old woman presents to the Emergency Department with a 4-day history of...

    Incorrect

    • A 28-year-old woman presents to the Emergency Department with a 4-day history of an increasingly painful and swollen right eye. She complains of blurring of vision and pain, especially with eye movements, which were quite restricted. She has a past medical history of asthma and is allergic penicillin. On examination, the visual acuity is 6/24 in the right, 6/6 in the left. The periorbital area of the right eye is very swollen and erythematous. The eye itself is red and proptosed. The conjunctiva is chemosed. Eye movements in the right eye are quite restricted in all directions. There is relative afferent pupillary defect on the right. Fundoscopy shows a swollen optic disc in the right eye. Computed tomography (CT) scan shows diffuse orbital infiltrate and proptosis. Vital observations are as follows: Blood pressure 130/80 mmHg Heart rate 80 bpm Respiratory rate 20 per minute Oxygen saturation 97% on air Temperature 38.2 °C What is first-line management for this patient?

      Your Answer: Drainage of the orbit

      Correct Answer: Clindamycin and ciprofloxacin IV

      Explanation:

      Orbital Cellulitis in Penicillin-Allergic Patients

      When treating orbital cellulitis in a patient with a penicillin allergy, it is important to choose the right antibiotics. Cefuroxime IV alone is not enough and should be combined with metronidazole. Co-amoxiclav IV is not appropriate for penicillin-allergic patients. Tazocin® IV should also be avoided. The best option is a combination of clindamycin and ciprofloxacin IV. It is important to note that drainage of the orbit is not necessary unless there are signs of an abscess. By choosing the right treatment, we can effectively manage orbital cellulitis in penicillin-allergic patients.

    • This question is part of the following fields:

      • Ophthalmology
      66.8
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  • Question 74 - A 28-year-old individual who wears contact lenses was referred to a casualty ophthalmology...

    Incorrect

    • A 28-year-old individual who wears contact lenses was referred to a casualty ophthalmology clinic by their GP due to complaints about their left eye. The patient reports experiencing redness, pain, and a gritty sensation in the affected eye, as well as increased sensitivity to light. There is no discharge present. What is the probable diagnosis?

      Your Answer: Blepharitis

      Correct Answer: Keratitis

      Explanation:

      Keratitis is characterized by symptoms such as a red eye, sensitivity to light, and a feeling of grittiness in the eye.

      Understanding Keratitis: Inflammation of the Cornea

      Keratitis is a condition that refers to the inflammation of the cornea. While conjunctivitis is a common eye infection that is not usually serious, microbial keratitis can be sight-threatening and requires urgent evaluation and treatment. The causes of keratitis can vary, with bacterial infections typically caused by Staphylococcus aureus and Pseudomonas aeruginosa commonly seen in contact lens wearers. Fungal and amoebic infections can also cause keratitis, with acanthamoebic keratitis accounting for around 5% of cases. Parasitic infections such as onchocercal keratitis can also cause inflammation of the cornea.

      Other factors that can cause keratitis include viral infections such as herpes simplex keratitis, environmental factors like photokeratitis (e.g. welder’s arc eye), and exposure keratitis. Clinical features of keratitis include a red eye with pain and erythema, photophobia, a foreign body sensation, and the presence of hypopyon. Referral is necessary for contact lens wearers who present with a painful red eye, as an accurate diagnosis can only be made with a slit-lamp examination.

      Management of keratitis involves stopping the use of contact lenses until symptoms have fully resolved, as well as the use of topical antibiotics such as quinolones. Cycloplegic agents like cyclopentolate can also be used for pain relief. Complications of keratitis can include corneal scarring, perforation, endophthalmitis, and visual loss. Understanding the causes and symptoms of keratitis is important for prompt diagnosis and treatment to prevent serious complications.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 75 - A 38-year-old male patient visits the GP clinic complaining of redness in his...

    Incorrect

    • A 38-year-old male patient visits the GP clinic complaining of redness in his left eye for the past week. During the examination, a tender papule is observed at the margin of the lower eyelid on the left side. Additionally, the conjunctiva of the left eye appears red. What is the best course of action for this patient?

      Your Answer: Warm compress and analgesia only

      Correct Answer: Warm compress, analgesia and topical antibiotic

      Explanation:

      If there is conjunctivitis present with the stye, topical antibiotics are recommended along with warm compress and pain relief. Cold compress should not be used. Oral antibiotics should only be considered if the infection persists despite topical treatment.

      Eyelid problems are quite common and can include a variety of issues. One such issue is blepharitis, which is inflammation of the eyelid margins that can cause redness in the eye. Another problem is a stye, which is an infection of the glands in the eyelids. Chalazion, also known as Meibomian cyst, is another eyelid problem that can occur. Entropion is when the eyelids turn inward, while ectropion is when they turn outward.

      Styes can come in different forms, such as external or internal. An external stye is an infection of the glands that produce sebum or sweat, while an internal stye is an infection of the Meibomian glands. Treatment for styes typically involves hot compresses and pain relief, with topical antibiotics only being recommended if there is also conjunctivitis present. A chalazion, on the other hand, is a painless lump that can form in the eyelid due to a retention cyst of the Meibomian gland. While most cases will resolve on their own, some may require surgical drainage.

    • This question is part of the following fields:

      • Ophthalmology
      30.5
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  • Question 76 - A 56-year-old man visits his GP with complaints of bilateral gritty and sore...

    Correct

    • A 56-year-old man visits his GP with complaints of bilateral gritty and sore eyes that have persisted for several weeks. He denies any history of trauma and has not experienced any discharge. He has not noticed any blurred vision. The patient's medical history is significant only for back pain, which he is managing with paracetamol and amitriptyline. During the examination, his visual acuity is 6/6 corrected bilaterally, and there are no apparent corneal or pupillary abnormalities. His eyes are not red, and eye movements are normal. What is the most probable diagnosis?

      Your Answer: Dry eye syndrome

      Explanation:

      Dry eye syndrome is a common cause of bilateral sore eyes with a gritty or burning sensation. This can be treated with topical lubrication, such as hypromellose. While an examination may appear normal, fluorescein staining can reveal superficial punctate staining and Schirmer’s test may indicate reduced tear production. It is important to consider allergic conjunctivitis as a possible differential diagnosis, especially if symptoms persist for a prolonged period of time and there are no signs of conjunctival involvement.

      Understanding Dry Eye Syndrome

      Dry eye syndrome is a condition that causes discomfort in both eyes, with symptoms such as dryness, grittiness, and soreness that worsen throughout the day. Exposure to wind can also cause watering of the eyes. People with Meibomian gland dysfunction may experience symptoms that are worse upon waking, with eyelids sticking together and redness of the eyelids. In some cases, dry eye syndrome can lead to complications such as conjunctivitis or corneal ulceration, which can cause severe pain, photophobia, redness, and loss of visual acuity.

      Although there may be no abnormalities on examination, eyelid hygiene is the most appropriate management step for dry eye syndrome. This can help control blepharitis, which is a common condition associated with dry eye syndrome. By understanding the symptoms and appropriate management steps, individuals with dry eye syndrome can find relief and improve their overall eye health.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 77 - A 55-year-old female patient arrived at the emergency department complaining of intense pain...

    Incorrect

    • A 55-year-old female patient arrived at the emergency department complaining of intense pain in her left eye, along with redness and sensitivity to light. Upon examination, her intraocular pressure was found to be elevated at 30 mmHg, and her pupil was mid-dilated. After diagnosing her with acute angle closure glaucoma, you promptly administered IV acetazolamide and topical pilocarpine. What is the definitive treatment for this condition?

      Your Answer: Topical carbonic anhydrase inhibitors in both eyes

      Correct Answer: Laser peripheral iridotomy in both eyes

      Explanation:

      The definitive treatment for acute angle-closure glaucoma is laser peripheral iridotomy, which creates an additional pathway in the iris for aqueous to flow from the posterior chamber to the anterior chamber and be drained into the angle. While topical beta blockers, alpha agonists, prostaglandin analogues, and carbonic anhydrase inhibitors can all help control intraocular pressure in glaucoma patients, they are not considered definitive treatments for AACG.

      Glaucoma is a group of disorders that cause optic neuropathy due to increased intraocular pressure (IOP). However, not all patients with raised IOP have glaucoma, and vice versa. Acute angle-closure glaucoma (AACG) is a type of glaucoma where there is a rise in IOP due to impaired aqueous outflow. Factors that increase the risk of AACG include hypermetropia, pupillary dilatation, and lens growth associated with age. Symptoms of AACG include severe pain, decreased visual acuity, haloes around lights, and a hard, red-eye. Management of AACG is an emergency and requires urgent referral to an ophthalmologist. Emergency medical treatment is necessary to lower the IOP, followed by definitive surgical treatment once the acute attack has subsided.

      There are no specific guidelines for the initial medical treatment of AACG, but a combination of eye drops may be used, including a direct parasympathomimetic, a beta-blocker, and an alpha-2 agonist. Intravenous acetazolamide may also be administered to reduce aqueous secretions. Definitive management of AACG involves laser peripheral iridotomy, which creates a small hole in the peripheral iris to allow aqueous humour to flow to the angle. It is important to seek medical attention immediately if symptoms of AACG are present to prevent permanent vision loss.

    • This question is part of the following fields:

      • Ophthalmology
      60.1
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  • Question 78 - A 25-year-old man comes to you complaining of severe, stabbing pain in his...

    Incorrect

    • A 25-year-old man comes to you complaining of severe, stabbing pain in his right eye that has been occurring once a day for the past few weeks. The pain lasts for about 30 minutes and he is often seen pacing around and shouting during these episodes. His wife reports that his right eye appears red and he has clear nasal discharge during the episodes. Based on this presentation, what advice would you give the patient to prevent further episodes?

      Your Answer: Excessive exercise

      Correct Answer: Alcohol

      Explanation:

      Cluster headaches are often triggered by alcohol, and they typically affect individuals of a certain age and gender.

      Cluster headaches are a type of headache that is known to be extremely painful. They are called cluster headaches because they tend to occur in clusters that last for several weeks, usually once a year. These headaches are more common in men and smokers, and alcohol and sleep patterns may trigger an attack. The pain typically occurs once or twice a day, lasting between 15 minutes to 2 hours. The pain is intense and sharp, usually around one eye, and is accompanied by redness, lacrimation, lid swelling, and nasal stuffiness. Some patients may also experience miosis and ptosis.

      To manage cluster headaches, 100% oxygen or subcutaneous triptan can be used for acute treatment, with response rates of 80% and 75% respectively within 15 minutes. Verapamil is the drug of choice for prophylaxis, and a tapering dose of prednisolone may also be effective. It is recommended to seek specialist advice from a neurologist if a patient develops cluster headaches, especially with respect to neuroimaging. Some neurologists use the term trigeminal autonomic cephalgia to group a number of conditions including cluster headache, paroxysmal hemicrania, and short-lived unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT). Patients with these conditions should be referred for specialist assessment as specific treatment may be required, such as indomethacin for paroxysmal hemicrania.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 79 - A 40-year-old man complains of pain in his right eye that worsens with...

    Correct

    • A 40-year-old man complains of pain in his right eye that worsens with movement. Upon examination, a relative afferent pupillary defect is observed. What is the most probable reason for his symptoms?

      Your Answer: Multiple sclerosis

      Explanation:

      Optic neuritis is a condition that can be caused by multiple sclerosis, diabetes, or syphilis. It is characterized by a decrease in visual acuity in one eye over a period of hours or days, as well as poor color discrimination and pain that worsens with eye movement. Other symptoms include a relative afferent pupillary defect and a central scotoma. The condition can be diagnosed through an MRI of the brain and orbits with gadolinium contrast. Treatment typically involves high-dose steroids, and recovery usually takes 4-6 weeks. If an MRI shows more than three white-matter lesions, the risk of developing multiple sclerosis within five years is approximately 50%.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 80 - You assess a patient in the Emergency Department who was admitted after a...

    Incorrect

    • You assess a patient in the Emergency Department who was admitted after a motorcycle accident. He is a diabetic patient, with multiple recent hospitalizations due to non-adherence to insulin therapy. Both of his pupils are small, responsive to accommodation, but unresponsive to light.
      What is the most appropriate description of this situation?

      Your Answer: Horner's syndrome

      Correct Answer: Argyll-Robertson pupil

      Explanation:

      – Adie pupil: A condition where the pupil is constantly dilated and reacts slowly to light, but responds better to accommodation. It is caused by damage to the parasympathetic innervation of the eye due to viral or bacterial infection. It is more commonly seen in females and is often accompanied by absent knee or ankle jerks.
      – Marcus-Gunn pupil: A relative afferent pupillary defect that is observed during the swinging light examination of pupil response. The pupils constrict less and appear to dilate when a light is swung from the unaffected to the affected eye. This condition is most commonly caused by damage to the optic nerve or severe retinal disease.
      – Horner’s syndrome: A condition characterized by miosis (pupillary constriction), ptosis (droopy eyelid), apparent enophthalmos (inset eyeball), with or without anhidrosis (decreased sweating) occurring on one side. It is caused by damage to the sympathetic trunk on the same side as the symptoms, due to trauma, compression, infection, ischaemia, or other causes.
      – Hutchinson’s pupil: A condition where the pupil on one side is unilaterally dilated and unresponsive to light. It is caused by compression of the occulomotor nerve on the same side, usually by an intracranial mass such as a tumor or hematoma.

      Argyll-Robertson Pupil: A Classic Pupillary Syndrome

      The Argyll-Robertson Pupil (ARP) is a classic pupillary syndrome that is sometimes observed in neurosyphilis. It is characterized by small, irregular pupils that do not respond to light but do respond to accommodation. A useful mnemonic for remembering this syndrome is Accommodation Reflex Present (ARP) but Pupillary Reflex Absent (PRA).

      The ARP can be caused by various factors, including diabetes mellitus and syphilis. It is important to note that the presence of an ARP may indicate underlying neurological or systemic disease and should prompt further evaluation and management. Proper diagnosis and treatment of the underlying condition can help prevent further complications and improve patient outcomes.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 81 - A 32-year-old female patient comes to the clinic with a chief complaint of...

    Correct

    • A 32-year-old female patient comes to the clinic with a chief complaint of headaches. During the examination, it is observed that when a light is shone in her right eye, both pupils constrict, but when the light is immediately moved to the left eye, both pupils appear to dilate. What is the probable diagnosis?

      Your Answer: Left optic neuritis

      Explanation:

      The ‘swinging light test’ can detect a relative afferent pupillary defect, which is indicated by less constriction of the pupils on one side. In this case, the left side is affected, suggesting an underlying condition such as multiple sclerosis causing optic neuritis. Symptoms of optic neuritis may include a dull ache around the eye that worsens with movement, which is common in patients of this age group.

      Understanding Relative Afferent Pupillary Defect

      A relative afferent pupillary defect, also known as the Marcus-Gunn pupil, is a condition that can be identified through the swinging light test. This condition is caused by a lesion that is located anterior to the optic chiasm, which can be found in the optic nerve or retina.

      When conducting the swinging light test, the affected eye will appear to dilate when light is shone on it, while the normal eye will not. This is due to the fact that the afferent pathway of the pupillary light reflex is disrupted. The pathway starts from the retina, then goes through the optic nerve, lateral geniculate body, and midbrain. The efferent pathway, on the other hand, starts from the Edinger-Westphal nucleus in the midbrain and goes through the oculomotor nerve.

      There are various causes of relative afferent pupillary defect, such as retina detachment and optic neuritis, which is commonly associated with multiple sclerosis. Understanding this condition is important in diagnosing and treating patients who may be experiencing vision problems.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 82 - A 45-year-old woman presents to the Ophthalmology department with a 3-day history of...

    Incorrect

    • A 45-year-old woman presents to the Ophthalmology department with a 3-day history of an increasingly painful and swollen left eye. She complains of blurring of vision and pain, especially with eye movements.
      On examination, visual acuity is 6/24 in the left and 6/6 in the right. The periorbital area of the left eye is very swollen and erythematous. The eye itself is red and proptosed. The conjunctiva is chemosed. Eye movements in the left eye are quite restricted in all directions. There is relative afferent pupillary defect on the left. Fundoscopy shows a swollen optic disc in the left eye. Vital observations are as follows:
      Blood pressure 130/80 mmHg
      Heart rate 80 bpm
      Respiratory rate 20 per minute
      Oxygen saturation 97% on air
      Temperature 38.2 °C
      Computed tomography (CT) scan shows some opacities in the ethmoid sinuses.
      What is the definitive treatment for this eye problem?

      Your Answer: Co-amoxiclav IV

      Correct Answer: Drainage of the ethmoid sinuses

      Explanation:

      Treatment Options for Ethmoidal Sinusitis and Orbital Cellulitis

      Ethmoidal sinusitis is a common cause of orbital cellulitis, which requires prompt treatment to prevent complications. The most effective treatment for ethmoidal sinusitis is surgical drainage of the sinuses to remove the pus and debris. Antibiotics are also necessary to aid recovery, but they should be administered after the drainage procedure.

      While there are several antibiotics that can be used to treat orbital cellulitis, such as cefuroxime, metronidazole, co-amoxiclav, and Tazocin®, they are not sufficient to address the underlying cause of the condition. Therefore, drainage of the ethmoid sinuses is the definitive treatment for ethmoidal sinusitis and orbital cellulitis.

      In summary, the treatment options for ethmoidal sinusitis and orbital cellulitis include surgical drainage of the sinuses followed by antibiotics. Antibiotics alone are not enough to treat the condition, and the choice of antibiotic may vary depending on the patient’s age and other factors.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 83 - A 65-year-old man presents to the ophthalmology clinic with a complaint of gradual...

    Incorrect

    • A 65-year-old man presents to the ophthalmology clinic with a complaint of gradual vision loss. During tonometry, his intraocular pressure is found to be 26mmHg and optic disc cupping is observed on fundoscopy. Visual field examination reveals peripheral visual loss. The physician prescribes timolol eye drops to be used twice daily. What is the mechanism of action of this medication?

      Your Answer: Increase production of aqueous fluid

      Correct Answer: Decrease production of aqueous fluid

      Explanation:

      Timolol, a beta blocker, is effective in treating primary open-angle glaucoma by reducing the production of aqueous fluid. This condition is characterized by increased intraocular pressure due to inefficient drainage of fluid in the eye’s trabecular meshwork. Symptoms include gradual loss of vision, particularly in the peripheral fields. Brimonidine, an alpha-adrenergic agonist, also reduces aqueous fluid production and increases uveoscleral outflow. However, drugs that decrease uveoscleral outflow or increase aqueous fluid production would worsen the patient’s condition. Glucocorticoids can cause reduced drainage of aqueous humour and are implicated in causing open-angle glaucoma. Latanoprost, a prostaglandin analogue, increases uveoscleral outflow.

      Glaucoma is a condition where the optic nerve is damaged due to increased pressure in the eye. Primary open-angle glaucoma is a type where the iris is clear of the trabecular meshwork, which is responsible for draining aqueous humour from the eye. This results in increased resistance to outflow and raised intraocular pressure. The condition affects 0.5% of people over 40 years old and increases with age. Genetics also play a role, with first-degree relatives having a 16% chance of developing the disease. Symptoms are usually absent, and diagnosis is made through routine eye examinations. Investigations include visual field tests, tonometry, and slit lamp examinations. Treatment involves eye drops to lower intraocular pressure, with prostaglandin analogues being the first line of treatment. Surgery may be considered in refractory cases. Regular reassessment is necessary to monitor progression and prevent visual field loss.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 84 - A 25-year-old woman presents to her General Practitioner (GP) with a 1-day history...

    Correct

    • A 25-year-old woman presents to her General Practitioner (GP) with a 1-day history of itching and watery discharge from both eyes.
      On examination, the vision is 6/9 in both eyes. Both pupils are equally reactive to light. The conjunctivae are both chemosed with mild diffuse injection. The eyelids are slightly oedematous.
      Her past medical history includes eczema. Her vital observations are as follows:
      Blood pressure 110/70 mmHg
      Heart rate 65 bpm
      Respiratory rate 12
      Temperature 36.7 °C
      Oxygen saturation 99% on air
      What is the most likely diagnosis?

      Your Answer: Allergic conjunctivitis

      Explanation:

      Distinguishing Different Types of Eye Infections: A Case Study

      The presentation points towards the diagnosis of allergic conjunctivitis. This is due to the patient’s history of itchiness, watery discharge, slightly swollen eyelids, and atopy. It was ruled out that the patient had bacterial conjunctivitis, as it typically presents with more purulent discharges bilaterally. Orbital cellulitis was also ruled out, as the eyelids and orbit would be very swollen and red with restriction and pain in eye movements, and the vital observations were normal. Preseptal cellulitis can present with oedematous eyelids, but the eye itself should be quiet and white. While viral conjunctivitis can present with watery discharges, the patient’s history of atopy and itchiness made allergic conjunctivitis the more likely diagnosis.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 85 - An 80-year-old man presents to you with a complaint of blurred vision that...

    Correct

    • An 80-year-old man presents to you with a complaint of blurred vision that has been worsening over the past 3 months. He has a medical history of type 2 diabetes and takes metformin. During the examination, you observe a shadow in the red reflex. What is the most probable diagnosis?

      Your Answer: Cataract

      Explanation:

      Understanding Cataracts: Causes, Symptoms, and Management

      A cataract is a common eye condition that affects the lens of the eye, causing it to become cloudy and reducing the amount of light that reaches the retina. This can lead to blurred or reduced vision, making it difficult to see clearly. Cataracts are more common in women and tend to increase in incidence with age. While the normal ageing process is the most common cause, other factors such as smoking, alcohol consumption, trauma, diabetes, and long-term corticosteroid use can also contribute to the development of cataracts.

      Symptoms of cataracts include reduced vision, faded colour vision, glare, and halos around lights. A defect in the red reflex is also a sign of cataracts. Diagnosis is typically made through ophthalmoscopy and slit-lamp examination, which can reveal the presence of a visible cataract.

      In the early stages, age-related cataracts can be managed conservatively with stronger glasses or contact lenses and brighter lighting. However, surgery is the only effective treatment for cataracts and involves removing the cloudy lens and replacing it with an artificial one. Referral for surgery should be based on the presence of visual impairment, impact on quality of life, and patient choice. Complications following surgery can include posterior capsule opacification, retinal detachment, posterior capsule rupture, and endophthalmitis.

      Overall, cataracts are a common and treatable eye condition that can significantly impact a person’s vision. Understanding the causes, symptoms, and management options can help individuals make informed decisions about their eye health.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 86 - You are a foundation doctor working in general practice. You review a sixty-five-year-old...

    Incorrect

    • You are a foundation doctor working in general practice. You review a sixty-five-year-old gentleman with a facial rash. On examination you note a vesicular rash extending to the tip of the nose. Observations are unremarkable.
      What is your primary concern?

      Your Answer: Associated pain

      Correct Answer: Possible involvement of the cornea

      Explanation:

      The presence of vesicles extending to the tip of the nose, known as Hutchinson’s sign, is strongly linked to shingles affecting the eyes. This is because the trigeminal nerve branch that supplies the cornea and nasal tip is affected. While pneumonia can be associated with herpes, this patient does not exhibit any respiratory symptoms. Despite the potential for post-herpetic neuralgia from the painful rash of shingles, the primary concern for this patient is the ocular involvement indicated by Hutchinson’s sign.

      Herpes Zoster Ophthalmicus: Symptoms, Treatment, and Complications

      Herpes zoster ophthalmicus (HZO) is a condition that occurs when the varicella-zoster virus reactivates in the area supplied by the ophthalmic division of the trigeminal nerve. It is responsible for approximately 10% of shingles cases. The main symptom of HZO is a vesicular rash around the eye, which may or may not involve the eye itself. Hutchinson’s sign, a rash on the tip or side of the nose, is a strong indicator of nasociliary involvement and increases the risk of ocular involvement.

      Treatment for HZO involves oral antiviral medication for 7-10 days, ideally started within 72 hours of symptom onset. Intravenous antivirals may be necessary for severe infections or immunocompromised patients. Topical antiviral treatment is not recommended for HZO, but topical corticosteroids may be used to treat any secondary inflammation of the eye. Ocular involvement requires urgent ophthalmology review to prevent complications such as conjunctivitis, keratitis, episcleritis, anterior uveitis, ptosis, and post-herpetic neuralgia.

      In summary, HZO is a condition caused by the reactivation of the varicella-zoster virus in the ophthalmic division of the trigeminal nerve. It presents with a vesicular rash around the eye and may involve the eye itself. Treatment involves oral antiviral medication and urgent ophthalmology review is necessary for ocular involvement. Complications of HZO include various eye conditions, ptosis, and post-herpetic neuralgia.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 87 - A 21-year-old man visits his General Practitioner (GP) with a lump on his...

    Correct

    • A 21-year-old man visits his General Practitioner (GP) with a lump on his eyelid that he has noticed for two days. The GP diagnoses it as a chalazion. What is the most suitable course of action?

      Your Answer: Apply heat and massage daily

      Explanation:

      Managing Chalazion: Options and Recommendations

      Chalazion, also known as meibomian cyst, is a painless inflammatory lesion of the eyelid that contains meibomian secretions. While it is a self-limiting condition, it may become infected and require medical attention. Here are some management options and recommendations for chalazion:

      Apply Heat and Massage Daily: The best way to manage chalazion is to apply heat and massage daily to release the oil. This treatment option is effective and usually improves the condition without the need for antibiotics.

      Refer to Ophthalmology Urgently: While GPs can manage chalazion, referrals to ophthalmology should be made if the lesion does not improve with treatment or if the GP feels the lesion might be suspicious.

      Surgical Incision: If medical management has been unsuccessful, chalazions can be removed surgically by incision and curettage.

      Topical Antibiotics: There is no indication for the use of antibiotics in the treatment of chalazion.

      Watch and Wait: While chalazions can sometimes resolve with time without treatment, they usually require medical attention. As such, watch and wait is not an appropriate management option.

      In summary, applying heat and massage daily is the best way to manage chalazion. Referrals to ophthalmology should be made if necessary, and surgical incision may be required if medical management is unsuccessful. Topical antibiotics are not recommended, and watch and wait is not an appropriate management option.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 88 - A 27-year-old female patient complains of a painful and red left eye that...

    Correct

    • A 27-year-old female patient complains of a painful and red left eye that has been bothering her for a day. She reports continuous tearing from the affected eye and experiences photophobia. Upon examination, fluorescein staining reveals a small, feathery area of abnormal uptake. However, her visual acuity is 6/6 in both eyes. What is the best course of action for management?

      Your Answer: Refer immediately to ophthalmology

      Explanation:

      The patient’s symptoms suggest the possibility of a corneal abrasion or dendritic corneal ulcer, with photophobia being a key indicator. However, the feathery pattern observed is more indicative of herpes simplex keratitis. Urgent review by an ophthalmologist is necessary, and caution should be exercised in prescribing topical steroids as they may exacerbate the infection.

      Understanding Herpes Simplex Keratitis

      Herpes simplex keratitis is a condition that affects the cornea of the eye and is caused by the herpes simplex virus. The most common symptom of this condition is a dendritic corneal ulcer, which can cause a red, painful eye, photophobia, and epiphora. In some cases, visual acuity may also be decreased. Fluorescein staining may show an epithelial ulcer, which can help with diagnosis. One common treatment for this condition is topical aciclovir, which can help to reduce the severity of symptoms and prevent further damage to the cornea.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 89 - A 28-year-old male with a history of Marfan's syndrome arrives at the emergency...

    Incorrect

    • A 28-year-old male with a history of Marfan's syndrome arrives at the emergency department reporting a sudden, painless loss of vision in his left eye. He did not experience any symptoms beforehand and did not sustain any injuries.

      What is the probable diagnosis?

      Your Answer: Cataract

      Correct Answer: Lens dislocation

      Explanation:

      In Marfan’s syndrome, painless loss of vision in one eye may be caused by lens dislocation, which is a common ocular symptom of the condition. The dislocation usually occurs in the upper outer part of the eye and can affect one or both eyes. While retinal detachment can also cause sudden vision loss without pain, it is less common than lens dislocation and is often preceded by visual disturbances such as flashes, floaters, or blind spots.

      Causes of Lens Dislocation

      Lens dislocation can occur due to various reasons. One of the most common causes is Marfan’s syndrome, which causes the lens to dislocate upwards. Homocystinuria is another condition that can lead to lens dislocation, but in this case, the lens dislocates downwards. Ehlers-Danlos syndrome is also a known cause of lens dislocation. Trauma, such as a blow to the eye, can also cause the lens to dislocate. Uveal tumors and autosomal recessive ectopia lentis are other potential causes of lens dislocation. It is important to identify the underlying cause of lens dislocation to determine the appropriate treatment plan. Proper diagnosis and management can help prevent complications and improve outcomes for patients.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 90 - A 35-year-old female patient presents to the eye hospital emergency department with a...

    Correct

    • A 35-year-old female patient presents to the eye hospital emergency department with a 1-week history of blurred vision and right eye pain worse on movement. The patient also reports a missing area of the visual field in the right eye. On examination, there is decreased visual acuity and impaired colour vision in the right eye and a right relative afferent pupillary defect. Fundoscopy reveals mildly swollen right optic disc. Intraocular pressure is 18 mmHg in the right eye. Her past medical history includes type 1 diabetes mellitus and hypertension. What is the most likely diagnosis for this 35-year-old female patient with blurred vision and right eye pain?

      Your Answer: Optic neuritis

      Explanation:

      Optic neuritis is the likely cause of this patient’s symptoms, which may be idiopathic or secondary to multiple sclerosis. One of the common symptoms of optic neuritis is a reduction in colour vision, along with pain around the eye during movement. Visual field defects, particularly central scotoma, may also occur. If only one eye is affected, there may be a relative afferent pupillary defect. While the patient has some risk factors for stroke, stroke would not cause eye pain or affect colour vision. Anterior ischaemic optic neuropathy typically causes painless visual loss and is more common in individuals over 50 years of age. The patient’s intraocular pressure is within the normal range, ruling out acute angle closure glaucoma. Additionally, the patient does not have papilloedema, as only one optic disc is swollen.

      Optic neuritis is a condition that can be caused by multiple sclerosis, diabetes, or syphilis. It is characterized by a decrease in visual acuity in one eye over a period of hours or days, as well as poor color discrimination and pain that worsens with eye movement. Other symptoms include a relative afferent pupillary defect and a central scotoma. The condition can be diagnosed through an MRI of the brain and orbits with gadolinium contrast. Treatment typically involves high-dose steroids, and recovery usually takes 4-6 weeks. If an MRI shows more than three white-matter lesions, the risk of developing multiple sclerosis within five years is approximately 50%.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 91 - A 67-year-old woman presents to her general practitioner (GP) complaining of a headache...

    Incorrect

    • A 67-year-old woman presents to her general practitioner (GP) complaining of a headache and painless loss of vision in her left eye lasting for 5 minutes. Two days later, she developed sudden-onset, right-sided weakness affecting both upper and lower limbs and lasting for 30 minutes. Her past medical history includes mild hyperlipidemia. She is a non-smoker. There are no neurological abnormalities. Her blood pressure is 150/85 mmHg and heart rate 80 bpm. There are no audible carotid bruits.
      Which of the following is the most likely diagnosis?

      Your Answer: TIA secondary to cardioembolism

      Correct Answer: Transient ischaemic attack (TIA) secondary to carotid artery disease

      Explanation:

      Understanding Transient Ischaemic Attack (TIA) and its Possible Causes

      Transient ischaemic attack (TIA) is a medical condition that occurs when blood flow to the brain is temporarily disrupted, leading to neurological symptoms that usually last for less than an hour. One of the most common causes of TIA is carotid artery disease, which accounts for up to 90% of cases. Symptoms of TIA due to carotid artery disease include contralateral motor and sensory disturbance, ipsilateral visual disturbance, and amaurosis fugax (monocular blindness). A carotid artery bruit in the neck may also be present.

      Migraine equivalents are another possible cause of TIA, but they are characterized by absent headache and slow spread of symptoms from one body part to the next. Unlike migraines, TIA episodes are sudden-onset and resolved within an hour.

      TIA can also be caused by cardioembolism, which accounts for 5-10% of cases. However, this is unlikely in the absence of atrial fibrillation or significant cardiac disease.

      Small-vessel disease is another possible cause of TIA, but it is unlikely to account for both hemiparesis and visual loss. Giant cell arteritis (GCA) can also be associated with transient visual loss, but hemiparesis is not a feature. Prodromal symptoms such as malaise, weight loss, and characteristic temporal headache are commonly present in GCA.

      In summary, TIA is a serious medical condition that requires prompt evaluation and treatment. Understanding the possible causes of TIA can help healthcare providers make an accurate diagnosis and provide appropriate care.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 92 - A 78-year-old woman visits her GP complaining of a gradual loss of vision...

    Correct

    • A 78-year-old woman visits her GP complaining of a gradual loss of vision over the past 2 years. She reports difficulty seeing objects up close, particularly at dusk and in the early morning when walking her dog. Amsler grid testing reveals distorted line perception. The patient has a history of osteoarthritis in her knees, which she treats with paracetamol as needed. What is the probable observation on fundoscopy?

      Your Answer: Drusen

      Explanation:

      The patient’s symptoms and clinical findings suggest a diagnosis of dry macular degeneration, which is characterized by the presence of drusen – small yellowish deposits of lipids under the retina. The patient is experiencing a gradual loss of central vision, difficulty seeing in the dark, and distorted line perception on Amsler grid testing.

      Hypertensive retinopathy can cause AV nicking, which is visible on fundoscopy, but it is unlikely to be the cause of this patient’s symptoms. Cotton wool spots, which are associated with hypertensive and diabetic retinopathy, are also an unlikely cause as the patient has no history of hypertension or diabetes, and these spots do not typically cause changes in vision. Cupping of the optic disc, seen in glaucoma, is also an unlikely diagnosis as the patient’s symptoms do not match those typically seen in glaucoma.

      Age-related macular degeneration (ARMD) is a common cause of blindness in the UK, characterized by the degeneration of the central retina (macula) and the formation of drusen. It is more prevalent in females and is strongly associated with advancing age, smoking, family history, and conditions that increase the risk of ischaemic cardiovascular disease. ARMD can be classified into two forms: dry and wet. Dry ARMD is more common and is characterized by drusen, while wet ARMD is characterized by choroidal neovascularisation and carries a worse prognosis. Clinical features of ARMD include subacute onset of visual loss, difficulties in dark adaptation, and visual disturbances such as photopsia and glare.

      To diagnose ARMD, slit-lamp microscopy and color fundus photography are used to identify any pigmentary, exudative, or haemorrhagic changes affecting the retina. Fluorescein angiography and indocyanine green angiography may also be used to visualize changes in the choroidal circulation. Treatment for dry ARMD involves a combination of zinc with anti-oxidant vitamins A, C, and E, which has been shown to reduce disease progression by around one third. For wet ARMD, anti-VEGF agents such as ranibizumab, bevacizumab, and pegaptanib are used to limit disease progression and stabilize or reverse visual loss. Laser photocoagulation may also be used to slow progression, but anti-VEGF therapies are usually preferred due to the risk of acute visual loss after treatment.

      In summary, ARMD is a common cause of blindness in the UK that is strongly associated with advancing age, smoking, and family history. It can be classified into dry and wet forms, with wet ARMD carrying a worse prognosis. Diagnosis involves the use of various imaging techniques, and treatment options include a combination of zinc and anti-oxidant vitamins for dry ARMD and anti-VEGF agents or laser photocoagulation for wet ARMD.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 93 - A 72-year-old man comes in for a check-up. He has just been diagnosed...

    Incorrect

    • A 72-year-old man comes in for a check-up. He has just been diagnosed with dry age-related macular degeneration. What is the most efficient way to slow down the advancement of this condition?

      Your Answer: Reduce alcohol intake

      Correct Answer: Stop smoking

      Explanation:

      Smoking has been identified as a risk factor for macular degeneration, while consuming a well-balanced diet rich in fresh fruits and vegetables may help to slow down its progression. Ongoing studies are exploring the potential benefits of additional antioxidants in this regard.

      Age-related macular degeneration (ARMD) is a common cause of blindness in the UK, characterized by the degeneration of the central retina (macula) and the formation of drusen. It is more prevalent in females and is strongly associated with advancing age, smoking, family history, and conditions that increase the risk of ischaemic cardiovascular disease. ARMD can be classified into two forms: dry and wet. Dry ARMD is more common and is characterized by drusen, while wet ARMD is characterized by choroidal neovascularisation and carries a worse prognosis. Clinical features of ARMD include subacute onset of visual loss, difficulties in dark adaptation, and visual disturbances such as photopsia and glare.

      To diagnose ARMD, slit-lamp microscopy and color fundus photography are used to identify any pigmentary, exudative, or haemorrhagic changes affecting the retina. Fluorescein angiography and indocyanine green angiography may also be used to visualize changes in the choroidal circulation. Treatment for dry ARMD involves a combination of zinc with anti-oxidant vitamins A, C, and E, which has been shown to reduce disease progression by around one third. For wet ARMD, anti-VEGF agents such as ranibizumab, bevacizumab, and pegaptanib are used to limit disease progression and stabilize or reverse visual loss. Laser photocoagulation may also be used to slow progression, but anti-VEGF therapies are usually preferred due to the risk of acute visual loss after treatment.

      In summary, ARMD is a common cause of blindness in the UK that is strongly associated with advancing age, smoking, and family history. It can be classified into dry and wet forms, with wet ARMD carrying a worse prognosis. Diagnosis involves the use of various imaging techniques, and treatment options include a combination of zinc and anti-oxidant vitamins for dry ARMD and anti-VEGF agents or laser photocoagulation for wet ARMD.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 94 - Each of the following can cause a mydriatic pupil, except for what? ...

    Incorrect

    • Each of the following can cause a mydriatic pupil, except for what?

      Your Answer: Traumatic iridoplegia

      Correct Answer: Argyll-Robertson pupil

      Explanation:

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

      Mydriasis, which is the enlargement of the pupil, can be caused by various factors. These include third nerve palsy, Holmes-Adie pupil, traumatic iridoplegia, pheochromocytoma, and congenital conditions. Additionally, certain drugs can also cause mydriasis, such as topical mydriatics like tropicamide and atropine, sympathomimetic drugs like amphetamines and cocaine, and anticholinergic drugs like tricyclic antidepressants. It’s important to note that anisocoria, which is when one pupil is larger than the other, can also result in the appearance of mydriasis.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 95 - A 54-year-old man presented to the Emergency Department with a 1-day history of...

    Incorrect

    • A 54-year-old man presented to the Emergency Department with a 1-day history of blurring of vision and headache. He does not complain of any pain when touching the scalp or any pain when eating and chewing food.
      Past medical history includes hypertension and type 2 diabetes mellitus, which is well controlled with metformin.
      On further history taking, he tells you that he has a family history of brain cancer and he is afraid that this could be relevant to his symptoms.
      On examination, his visual acuity is 6/18 in both eyes. On dilated fundoscopy, you could see some arterioles narrower than others. You also see venules being compressed by arterioles. There are also some dot-and-blot and flame-shaped haemorrhages, as well as some cotton-wool spots. There is no optic disc swelling.
      His vital observations are as follows:
      Heart rate 80 bpm
      Blood pressure 221/119 mmHg
      Oxygen saturation 98% on room air
      Respiratory rate 14 per minute
      Temperature 37 °C
      According to the Keith-Wagener-Barker classification of hypertensive retinopathy, what grade of hypertensive retinopathy is this?

      Your Answer: Grade 1

      Correct Answer: Grade 3

      Explanation:

      Stages of Diabetic Retinopathy

      Diabetic retinopathy is a condition that affects the eyes of people with diabetes. It is important to detect and treat it early to prevent vision loss. There are different stages of diabetic retinopathy, each with its own set of features.

      Grade 1 is characterized by arteriolar narrowing. Grade 2 includes features of grade 1 and arteriovenous nipping. Grade 3 includes features of grade 2 and microaneurysms, dot-and-blot haemorrhages, flame-shaped haemorrhages, cotton-wool spots, and hard exudates. Grade 4 includes features of grade 3 and optic disc swelling.

      It is important to have regular eye exams if you have diabetes to detect any signs of diabetic retinopathy early. With proper management and treatment, vision loss can be prevented or delayed.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 96 - A 67-year-old man visits his doctor with a complaint of a rash on...

    Correct

    • A 67-year-old man visits his doctor with a complaint of a rash on his face. Upon examination, the doctor observes a vesicular rash around the left orbit and on the bridge of the nose. The patient reports experiencing pain. The eye appears unaffected and is not inflamed. The doctor suspects shingles.
      What would be the best course of action?

      Your Answer: Urgent referral to ophthalmology and start oral aciclovir

      Explanation:

      Immediate ophthalmological assessment and a 7-10 day course of oral antivirals are necessary for the treatment of herpes zoster ophthalmicus. Hutchinson’s sign, which involves the tip of the nose, is a strong indicator of ocular involvement and warrants urgent referral to an ophthalmologist. While oral corticosteroids may help alleviate pain, they are not as crucial as antivirals or ophthalmological evaluation.

      Herpes Zoster Ophthalmicus: Symptoms, Treatment, and Complications

      Herpes zoster ophthalmicus (HZO) is a condition that occurs when the varicella-zoster virus reactivates in the area supplied by the ophthalmic division of the trigeminal nerve. It is responsible for approximately 10% of shingles cases. The main symptom of HZO is a vesicular rash around the eye, which may or may not involve the eye itself. Hutchinson’s sign, a rash on the tip or side of the nose, is a strong indicator of nasociliary involvement and increases the risk of ocular involvement.

      Treatment for HZO involves oral antiviral medication for 7-10 days, ideally started within 72 hours of symptom onset. Intravenous antivirals may be necessary for severe infections or immunocompromised patients. Topical antiviral treatment is not recommended for HZO, but topical corticosteroids may be used to treat any secondary inflammation of the eye. Ocular involvement requires urgent ophthalmology review to prevent complications such as conjunctivitis, keratitis, episcleritis, anterior uveitis, ptosis, and post-herpetic neuralgia.

      In summary, HZO is a condition caused by the reactivation of the varicella-zoster virus in the ophthalmic division of the trigeminal nerve. It presents with a vesicular rash around the eye and may involve the eye itself. Treatment involves oral antiviral medication and urgent ophthalmology review is necessary for ocular involvement. Complications of HZO include various eye conditions, ptosis, and post-herpetic neuralgia.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 97 - A 50-year-old man comes to the emergency department complaining of left eye pain,...

    Incorrect

    • A 50-year-old man comes to the emergency department complaining of left eye pain, headache, and blurred vision that started 3 hours ago. He denies any history of eye disease or trauma.
      During the examination, the left eye appears red and watery, while the right pupil reacts normally to light, but the left pupil remains dilated and unresponsive.
      What is the probable diagnosis?

      Your Answer: Scleritis

      Correct Answer: Acute closed-angle glaucoma

      Explanation:

      The most likely diagnosis for this patient is acute closed-angle glaucoma, which is characterized by sudden onset of unilateral eye pain and visual loss, often accompanied by a headache. Examination findings consistent with glaucoma include an erythematous globe with a fixed and dilated pupil and a hazy cornea. Anterior uveitis, conjunctivitis, and keratitis are unlikely diagnoses as they present with different symptoms and examination findings.

      Glaucoma is a group of disorders that cause optic neuropathy due to increased intraocular pressure (IOP). However, not all patients with raised IOP have glaucoma, and vice versa. Acute angle-closure glaucoma (AACG) is a type of glaucoma where there is a rise in IOP due to impaired aqueous outflow. Factors that increase the risk of AACG include hypermetropia, pupillary dilatation, and lens growth associated with age. Symptoms of AACG include severe pain, decreased visual acuity, haloes around lights, and a hard, red-eye. Management of AACG is an emergency and requires urgent referral to an ophthalmologist. Emergency medical treatment is necessary to lower the IOP, followed by definitive surgical treatment once the acute attack has subsided.

      There are no specific guidelines for the initial medical treatment of AACG, but a combination of eye drops may be used, including a direct parasympathomimetic, a beta-blocker, and an alpha-2 agonist. Intravenous acetazolamide may also be administered to reduce aqueous secretions. Definitive management of AACG involves laser peripheral iridotomy, which creates a small hole in the peripheral iris to allow aqueous humour to flow to the angle. It is important to seek medical attention immediately if symptoms of AACG are present to prevent permanent vision loss.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 98 - A 35-year-old woman presents to the Emergency Department complaining of right-eye pain. She...

    Incorrect

    • A 35-year-old woman presents to the Emergency Department complaining of right-eye pain. She suspects that something may be stuck in her eye as she has been unable to wear her contact lenses for the past day due to the pain.
      On examination, there is diffuse hyperaemia of the right eye. The right cornea appears hazy, and the pupillary reaction is normal. Visual acuity is reduced on the right side and a degree of photophobia is noted. A hypopyon is also seen.
      Given the likely diagnosis, which of the following management procedures should be done immediately?
      Select the SINGLE most appropriate management from the list below.

      Your Answer: Stop using contact lens

      Correct Answer: Urgent referral to an eye specialist

      Explanation:

      Urgent Referral and Management of Keratitis: Importance of Eye Specialist Review

      Keratitis is the inflammation of the cornea, which can be potentially sight-threatening if left untreated. Microbial keratitis requires urgent evaluation and treatment, as an accurate diagnosis can only be made with a slit-lamp. Therefore, an immediate referral to an eye specialist is crucial to rule out this condition.

      Topical antibiotics, such as quinolones eye drops, are used as first-line treatment for keratitis and corneal ulcers. However, this is not as crucial as an immediate review by the eye specialist. Cyclopentolate eye drops are used for pain relief, but again, an eye specialist review is more important.

      It is crucial to stop using contact lenses until the symptoms have fully resolved, but this is not as crucial as an immediate review by the eye specialist. Timolol drops, which are used to reduce raised intraocular pressure in glaucoma, have no role in keratitis treatment.

      In summary, an urgent referral to an eye specialist is crucial in the management of keratitis, as an accurate diagnosis and immediate treatment can prevent potential sight-threatening complications.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 99 - A 15-year-old boy presents with a history of seasonal 'watering eyes' for the...

    Incorrect

    • A 15-year-old boy presents with a history of seasonal 'watering eyes' for the past 2 years. His symptoms have worsened this year. He complains of bilateral itchy eyes and difficulty in doing school work due to excessive tearing. There is no history of nasal symptoms, asthma or eczema. On examination, there is conjunctival redness, bulging tarsal conjunctivae and mild eyelid swelling. What is the initial management approach for this patient?

      Your Answer: Topical vasoconstrictor

      Correct Answer: Topical antihistamines

      Explanation:

      The symptoms exhibited by this patient are indicative of allergic conjunctivitis. The initial treatment approach for this condition involves the use of topical antihistamines. In case of additional symptoms like rhinosinusitis, oral antihistamines may also be prescribed.

      Understanding Allergic Conjunctivitis

      Allergic conjunctivitis is a condition that can occur on its own, but is often associated with hay fever. It is characterized by bilateral symptoms such as conjunctival erythema and swelling, as well as itchiness and swelling of the eyelids. Those with a history of atopy may be more prone to developing allergic conjunctivitis, which can be seasonal (due to pollen) or perennial (due to exposure to dust mites, washing powder, or other allergens).

      When it comes to managing allergic conjunctivitis, first-line treatment typically involves the use of topical or systemic antihistamines. If these prove ineffective, second-line treatment options such as topical mast-cell stabilizers like Sodium cromoglicate and nedocromil may be recommended. By understanding the symptoms and treatment options for allergic conjunctivitis, individuals can take steps to manage their condition and reduce discomfort.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 100 - A 5-year-old girl presented to the eye clinic with swollen and red upper...

    Incorrect

    • A 5-year-old girl presented to the eye clinic with swollen and red upper and lower eyelids on her right eye. Upon further examination, it was found that she had decreased visual acuity, conjunctival hyperaemia, mild proptosis, and pain during eye movements. The mother reported that the girl had a severe cold for a week before the onset of these symptoms. What is the most probable diagnosis for this girl?

      Your Answer: Orbital cellulitis secondary to otitis externa

      Correct Answer: Orbital cellulitis secondary to ethmoidal sinusitis

      Explanation:

      The most common cause of orbital cellulitis in children is an infection of the ethmoidal sinus, which has a relatively thin medial wall that allows for easy spread of infection to the orbital cavity. In this case, the patient’s symptoms of proptosis, decreased visual acuity, and ocular motility indicate a diagnosis of orbital cellulitis rather than preseptal cellulitis. The patient’s history of a prolonged cold suggests that ethmoidal sinusitis is the likely cause of the infection. Otitis externa is not relevant to this case as there are no associated symptoms of earache or discharge, and there is no indication of atopy or seasonal predilection to suggest allergic rhinitis.

      Understanding Orbital Cellulitis: Causes, Symptoms, and Management

      Orbital cellulitis is a serious infection that affects the fat and muscles behind the orbital septum within the orbit, but not the globe. It is commonly caused by upper respiratory tract infections that spread from the sinuses and can lead to a high mortality rate. On the other hand, periorbital cellulitis is a less severe infection that occurs in the superficial tissues anterior to the orbital septum. However, it can progress to orbital cellulitis if left untreated.

      Risk factors for orbital cellulitis include childhood, previous sinus infections, lack of Haemophilus influenzae type b (Hib) vaccination, recent eyelid infections or insect bites, and ear or facial infections. Symptoms of orbital cellulitis include redness and swelling around the eye, severe ocular pain, visual disturbance, proptosis, ophthalmoplegia, eyelid edema, and ptosis. In rare cases, meningeal involvement can cause drowsiness, nausea, and vomiting.

      To differentiate between orbital and preseptal cellulitis, doctors look for reduced visual acuity, proptosis, and ophthalmoplegia, which are not consistent with preseptal cellulitis. Full blood count and clinical examination involving complete ophthalmological assessment are necessary to determine the severity of the infection. CT with contrast can also help identify inflammation of the orbital tissues deep to the septum and sinusitis. Blood culture and microbiological swab are also necessary to determine the organism causing the infection.

      Management of orbital cellulitis requires hospital admission for IV antibiotics. It is a medical emergency that requires urgent senior review. Early diagnosis and treatment are crucial to prevent complications and reduce the risk of mortality.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 101 - An 80-year-old man presents to ophthalmology with complaints of progressive vision loss over...

    Incorrect

    • An 80-year-old man presents to ophthalmology with complaints of progressive vision loss over the past few months, which has worsened suddenly in the last week. On visual field testing, a central scotoma is noted, and fundoscopy reveals well-defined red patches on the retina. What is the most probable diagnosis?

      Your Answer: Dry age-related macular degeneration

      Correct Answer: Wet age-related macular degeneration

      Explanation:

      If a patient experiences a gradual decline in vision over several months, along with metamorphopsia and a central scotoma, it is highly likely that they have wet age-related macular degeneration (ARMD). This condition is characterized by a sudden deterioration in vision, red patches on the retina during fundoscopy, and leakage of serous fluid and blood. Acute angle-closure glaucoma, on the other hand, presents with severe headaches, vomiting, and mid-dilated or irregularly shaped pupils. Dry ARMD also causes a slow decline in vision, but it does not result in sudden deterioration or red patches on the retina. Retinal detachment causes a painless loss of vision that starts peripherally and progresses centrally, while vitreous hemorrhage is a common cause of sudden visual loss in diabetics, characterized by dark spots in the vision and a hemorrhage within the vitreous cavity during fundoscopy.

      Age-related macular degeneration (ARMD) is a common cause of blindness in the UK, characterized by the degeneration of the central retina (macula) and the formation of drusen. It is more prevalent in females and is strongly associated with advancing age, smoking, family history, and conditions that increase the risk of ischaemic cardiovascular disease. ARMD can be classified into two forms: dry and wet. Dry ARMD is more common and is characterized by drusen, while wet ARMD is characterized by choroidal neovascularisation and carries a worse prognosis. Clinical features of ARMD include subacute onset of visual loss, difficulties in dark adaptation, and visual disturbances such as photopsia and glare.

      To diagnose ARMD, slit-lamp microscopy and color fundus photography are used to identify any pigmentary, exudative, or haemorrhagic changes affecting the retina. Fluorescein angiography and indocyanine green angiography may also be used to visualize changes in the choroidal circulation. Treatment for dry ARMD involves a combination of zinc with anti-oxidant vitamins A, C, and E, which has been shown to reduce disease progression by around one third. For wet ARMD, anti-VEGF agents such as ranibizumab, bevacizumab, and pegaptanib are used to limit disease progression and stabilize or reverse visual loss. Laser photocoagulation may also be used to slow progression, but anti-VEGF therapies are usually preferred due to the risk of acute visual loss after treatment.

      In summary, ARMD is a common cause of blindness in the UK that is strongly associated with advancing age, smoking, and family history. It can be classified into dry and wet forms, with wet ARMD carrying a worse prognosis. Diagnosis involves the use of various imaging techniques, and treatment options include a combination of zinc and anti-oxidant vitamins for dry ARMD and anti-VEGF agents or laser photocoagulation for wet ARMD.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 102 - A 28-year-old woman visits her GP complaining of a red left eye. She...

    Incorrect

    • A 28-year-old woman visits her GP complaining of a red left eye. She experiences a gritty sensation and feels the need to blink frequently to clear her vision. There is no pain or photophobia, and her pupil size is normal. She reports a significant amount of discharge from the affected eye and recently had a cold. What is the probable diagnosis?

      Your Answer: Acute glaucoma

      Correct Answer: Conjunctivitis

      Explanation:

      Conjunctivitis is a common condition that can be identified by symptoms such as redness in the eye, a gritty sensation, swollen conjunctivae, and discharge that crusts the eyelashes. However, if a patient presents with severe eye pain, photophobia, a small or abnormal shaped pupil, or blurred vision, it may indicate iritis and require urgent referral to an ophthalmologist. Similarly, acute glaucoma can cause severe eye pain, halos, blurred vision, nausea, and vomiting, while keratitis can cause a painful, red eye with tearing, discharge, and decreased vision, particularly in contact lens wearers.

      Conjunctivitis is a common eye problem that is often seen in primary care. It is characterized by red, sore eyes with a sticky discharge. There are two types of infective conjunctivitis: bacterial and viral. Bacterial conjunctivitis is identified by a purulent discharge and eyes that may be stuck together in the morning. On the other hand, viral conjunctivitis is characterized by a serous discharge and recent upper respiratory tract infection, as well as preauricular lymph nodes.

      In most cases, infective conjunctivitis is a self-limiting condition that resolves without treatment within one to two weeks. However, topical antibiotic therapy is often offered to patients, such as Chloramphenicol drops given every two to three hours initially or Chloramphenicol ointment given four times a day initially. Alternatively, topical fusidic acid can be used, especially for pregnant women, and treatment is twice daily.

      For contact lens users, topical fluoresceins should be used to identify any corneal staining, and treatment should be the same as above. During an episode of conjunctivitis, contact lenses should not be worn, and patients should be advised not to share towels. School exclusion is not necessary.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 103 - In the UK, what is the primary reason for irreversible blindness in individuals...

    Incorrect

    • In the UK, what is the primary reason for irreversible blindness in individuals over the age of 65?

      Your Answer: Glaucoma

      Correct Answer: Macular degeneration

      Explanation:

      Common Eye Diseases and Conditions

      Age-related macular degeneration, diabetic retinopathy, glaucoma, senile cataract, and corneal abrasion are some of the most common eye diseases and conditions that affect people worldwide.

      Macular Degeneration

      Macular degeneration is a leading cause of irreversible vision loss in developed countries. The non-exudative (dry) form of the disease is the most common, characterized by the presence of drusen in the macular region. Dry AMD progresses slowly over decades, while the exudative (wet) form can cause rapid central visual loss and distortion.

      Diabetic Retinopathy

      Diabetic retinopathy is a complication of diabetes that can lead to blindness. It is the most common cause of new blindness in people aged 25-64 years globally. Proliferative diabetic retinopathy is rare within the first decade of a diagnosis of type 1 diabetes mellitus, but increases with disease duration.

      Glaucoma

      Glaucoma is a group of eye diseases that damage the optic nerve and can cause specific visual field defects over time. Open-angle glaucoma is the most common type, and it is described as a chronic, progressive, and irreversible optic neuropathy. Glaucoma is the second leading cause of irreversible blindness in developed countries.

      Senile Cataract

      Senile cataract is an age-related disease that causes gradual progressive thickening of the lens of the eye. It is the world’s leading cause of treatable blindness.

      Corneal Abrasion

      Corneal abrasion is a common eye injury that occurs due to a disruption in the integrity of the corneal epithelium or because of physical external forces. Most people recover fully from minor corneal abrasions, but deeper scratches can cause corneal infections, erosion, or scarring, leading to long-term vision problems.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 104 - You assess a patient's eye and discovered that both pupils constrict when focusing...

    Incorrect

    • You assess a patient's eye and discovered that both pupils constrict when focusing on a nearby object but fail to narrow when exposed to bright light. What is the most frequent reason for this pupillary response in the United Kingdom?

      Your Answer: Chlamydia

      Correct Answer: Diabetes mellitus

      Explanation:

      In the UK, diabetes mellitus is now the most frequent cause of Argyll-Robertson pupil, as neurosyphilis is no longer commonly observed due to effective antibiotic treatment. This condition is not caused by sexually transmitted diseases such as chlamydia or gonorrhoea, nor is it associated with optic neuritis, which instead causes a Marcus Gunn pupil or Relative afferent pupillary defect.

      Argyll-Robertson Pupil: A Classic Pupillary Syndrome

      The Argyll-Robertson Pupil (ARP) is a classic pupillary syndrome that is sometimes observed in neurosyphilis. It is characterized by small, irregular pupils that do not respond to light but do respond to accommodation. A useful mnemonic for remembering this syndrome is Accommodation Reflex Present (ARP) but Pupillary Reflex Absent (PRA).

      The ARP can be caused by various factors, including diabetes mellitus and syphilis. It is important to note that the presence of an ARP may indicate underlying neurological or systemic disease and should prompt further evaluation and management. Proper diagnosis and treatment of the underlying condition can help prevent further complications and improve patient outcomes.

    • This question is part of the following fields:

      • Ophthalmology