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Question 1
Correct
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A 73-year-old man visits the optician after hearing that individuals over 70 can receive a complimentary eye exam. He has been wearing glasses for his entire adult life due to being long-sighted. His doctor recently informed him that he has pre-diabetes, but he feels fine and hasn't noticed any issues with his vision. During the eye exam, the optometrist discovers that he has high intraocular pressure and advises him to see a specialist for further testing.
What symptom is he most likely to encounter based on the probable diagnosis?Your Answer: Reduced peripheral vision
Explanation:The patient’s optic nerve fibers may have suffered irreversible damage, putting her at increased risk of developing glaucoma due to her age, pre-diabetes, and raised intraocular pressure. The optometrist detected this pressure, which is caused by impaired drainage of aqueous fluid within the eye. However, the patient is asymptomatic and therefore unlikely to have closed-angle glaucoma, which causes intense eye pain, redness, headaches, halos around lights, and nausea. Cloudy vision is more likely to be caused by cataracts, but there are no other features to suggest this diagnosis. Open-angle glaucoma can sometimes cause color blindness, but it more commonly affects the visual fields. It does not cause dry eyes, which can be caused by autoimmune conditions such as Sjogren’s syndrome and systemic lupus erythematosus.
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.
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This question is part of the following fields:
- Ophthalmology
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Question 2
Correct
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A 70-year-old man with a lengthy history of hypertension is undergoing an eye examination. He has been experiencing deteriorating headaches and reduced visual acuity over the past few weeks. Upon fundoscopy, he displays flame haemorrhages, cotton wool spots, arteriovenous nipping, and papilloedema. What level of hypertensive retinopathy does this correspond to?
Your Answer: Grade IV
Explanation:Grade IV hypertensive retinopathy is indicated by papilloedema, which is a severe manifestation that requires immediate attention due to its association with high morbidity and mortality. The various grades of hypertensive retinopathy have distinct characteristics, which are outlined below.
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.
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This question is part of the following fields:
- Ophthalmology
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Question 3
Correct
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An 80-year-old man presents to the clinic with an 8-month history of uncorrectable poor vision. He has a medical history of hypertension, allergic conjunctivitis, and type 1 diabetes mellitus, and has been a heavy smoker for the past 20 years. On examination, his right eye has a visual acuity of 6/30 while the left eye is normal. Fundoscopy reveals increased retinal blood vessels, blot haemorrhages, and hard exudates in the nasal upper quadrant of the right eye. He denies any sudden visual loss or ocular trauma. What is the most likely diagnosis?
Your Answer: Proliferative diabetic retinopathy
Explanation:The most likely diagnosis for this patient is proliferative diabetic retinopathy, as evidenced by the presence of neovascularisation, microaneurysms, and hard exudates on fundoscopy. This condition is more common in type 1 diabetes mellitus. Dry age-related macular degeneration and hypertensive retinopathy are less likely diagnoses, as they do not explain all of the patient’s symptoms and findings.
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 nonproliferative 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 nonproliferative retinopathy, and panretinal laser photocoagulation and intravitreal VEGF inhibitors for proliferative retinopathy. Vitreoretinal surgery may be necessary in cases of severe or vitreous hemorrhage.
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This question is part of the following fields:
- Ophthalmology
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Question 4
Correct
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A 22-year-old woman comes to the General Practitioner (GP) complaining of redness, watering, and burning in both eyes for the past week. Upon examination, her vision is 6/6 in both eyes, but the conjunctivae are diffusely injected. Tender preauricular lymphadenopathy is noticeable when the face and neck are palpated. Further questioning reveals that she also has a sore throat and a stuffy nose. What is the initial treatment for this patient's eye issue?
Your Answer: Supportive measures with cool compresses and artificial tears
Explanation:Treatment Options for Viral Conjunctivitis
Viral conjunctivitis, also known as pink eye, is a common condition that can cause redness, itching, and discharge in the eyes. While there is no cure for viral conjunctivitis, there are several treatment options available to help manage the symptoms.
The first-line treatment for viral conjunctivitis is supportive care, which typically involves using cool compresses and artificial tears to soothe the eyes. These measures can help reduce inflammation and relieve discomfort, and the condition will usually resolve on its own over time.
While an eye shield is not typically necessary for viral conjunctivitis, some doctors may recommend using topical chloramphenicol eye drops to prevent secondary bacterial infections. However, this is not a first-line treatment and is not always necessary.
Topical steroids, such as prednisolone and dexamethasone eye drops, are not recommended for the treatment of viral conjunctivitis. While these medications can help reduce inflammation, they can also increase the risk of complications and should only be used under the guidance of a healthcare professional.
In summary, the best course of action for treating viral conjunctivitis is to focus on supportive care with cool compresses and artificial tears. If necessary, your doctor may recommend additional treatments to help manage your symptoms and prevent complications.
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This question is part of the following fields:
- Ophthalmology
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Question 5
Correct
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A 68-year-old man is referred to Ophthalmology with bilateral cataracts. He reports gradual worsening of his vision over many years and struggles with night-time driving due to glare. He is put on the waiting list for surgical repair.
What structure in the eye is affected by cataract formation?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.
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This question is part of the following fields:
- Ophthalmology
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Question 6
Incorrect
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A 78-year-old woman visits her GP with a complaint of gradual loss of peripheral vision over the past 4 months and a decline in overall visual acuity. She reports experiencing tunnel vision. The patient has a medical history of hypertension and type 2 diabetes mellitus and wears corrective glasses for her myopia. Upon fundoscopy, the doctor observes optic disc cupping and hemorrhages. What is the probable diagnosis?
Your Answer: Diabetic retinopathy
Correct Answer: Primary open-angle glaucoma
Explanation:The main effect of glaucoma is the development of defects in the visual field.
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.
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This question is part of the following fields:
- Ophthalmology
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Question 7
Incorrect
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A 58-year-old woman has been referred by her optician to the eye clinic. She has been experiencing vision problems and is concerned about her eye health. On examination, her external eye, including the pupil, appears normal.
Investigations:
Slit-lamp: Quiet anterior chamber
Intra-ocular pressure: 30 mmHg
Fundoscopy: Optic disc appears slightly cupped
Visual field testing: Arcuate scotoma
Which of the following diagnoses is most likely based on this clinical presentation?Your Answer: Acute angle closure glaucoma
Correct Answer: Primary open angle glaucoma
Explanation:Differentiating Ophthalmic Conditions: A Guide
Primary Open Angle Glaucoma: This condition is characterized by unnoticed visual loss, which becomes apparent only after impaired vision is demonstrated. Patients with POAG develop a visual field defect due to loss of nerve fibers at the optic disc, resulting in the appearance of ‘cupping’ of the optic disc. Increased intraocular pressures are the most common cause of optic disc fiber damage.
Retinal Detachment: Patients with retinal detachment typically present with a history of flashing lights and floaters in their vision. The three most common causes of retinal detachment are rhegmatogenous, tractional, and exudative. The history and examination findings are not typical of retinal detachment.
Acute Angle Closure Glaucoma: This is an ophthalmology emergency that presents with an acutely painful red eye, usually with associated vomiting. The pupil is fixed and mid-dilated, and there is corneal edema. This condition occurs when the angle between the lens and iris becomes blocked off, causing an acute pressure rise. The high pressure can cause permanent damage to the optic nerve if not treated quickly. Although this patient has a high intraocular pressure, the history is not suggestive of an acute painful attack.
Central Retinal Vein Occlusion: This condition causes sudden painless loss of vision due to reduced blood flow to the retina. The patient in this case gives a history of slow, progressive visual loss, which is not typical of central retinal vein occlusion. This condition is also unlikely to cause a rise in intraocular pressure.
Anterior Uveitis: A quiet anterior chamber indicates that anterior uveitis (iritis) is unlikely to be the cause of the patient’s symptoms. Cells in the anterior chamber are a sign of ocular inflammation, which is not present in this case.
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This question is part of the following fields:
- Ophthalmology
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Question 8
Incorrect
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A 50-year-old woman presents to the eye emergency department with complaints of blurred vision and sensitivity to bright lights. She has a medical history of asthma, polymyalgia rheumatica, and gout. During the examination, the ophthalmologist identifies a subcapsular cataract in her left eye, located just beneath the lens in the visual axis.
What is the most significant risk factor for subcapsular cataracts?Your Answer: Allopurinol
Correct Answer: Steroids
Explanation:Steroid use may be linked to the development of subcapsular cataracts, which are located behind the capsule in the visual axis and have a rapid progression. These cataracts are often accompanied by glare from bright lights and appear as a central granular lens opacity during examination. Dot cataracts are associated with myotonic dystrophy, while nuclear cataracts are linked to myopia. Nuclear cataracts with a stellate morphology are typically associated with ocular trauma, but this depends on the mechanism of the injury.
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.
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This question is part of the following fields:
- Ophthalmology
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Question 9
Correct
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A 50-year-old male visits his GP complaining of bilateral sore eyes that feel gritty. He has tried using over-the-counter eye drops, but the symptoms returned the next day. During the examination, the doctor notices erythematosus eyelid margins and a small stye on the right side. The patient has no known allergies. What is the initial management that should be taken?
Your Answer: Hot compress and mechanical removal of debris
Explanation:The patient is displaying symptoms that are typical of blepharitis, such as bilateral grittiness. This condition is caused by inflammation of the eyelid margins due to meibomian gland dysfunction, seborrhoeic dermatitis, or infection. Common symptoms include sticky eyes, erythematosus eyelid margins, and an increased risk of styes, chalazions, and secondary conjunctivitis.
To manage blepharitis, hot compresses should be applied to soften the eyelid margin, and debris should be removed with cotton buds dipped in cooled boiled water. Artificial tears may also be used if the patient reports dry eyes.
If the patient were suffering from allergic conjunctivitis, topical sodium cromoglycate would be appropriate. This condition would present with bilateral red eyes, itchiness, swelling, rhinitis, and clear discharge. On the other hand, if the patient had anterior uveitis, topical steroids would be indicated. This condition would present with rapid onset blurred vision, photosensitivity, floaters, eye pain, and redness in one or both eyes.
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.
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This question is part of the following fields:
- Ophthalmology
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Question 10
Correct
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A 48-year-old man visits his doctor complaining of vision problems. He has been experiencing difficulty while driving for the past few months, as he is unable to see cars approaching him from the sides of his vision. He suspects that this may also be the cause of his occasional headaches, but he does not report any pain around his eyes or any current headache. The patient has a history of peripheral vascular disease, type II diabetes, and short-sightedness, and he often neglects to wear his glasses. What is the most probable diagnosis?
Your Answer: Primary open-angle glaucoma
Explanation:The patient is likely suffering from primary open-angle glaucoma, which causes gradual loss of peripheral vision. This is supported by the patient’s symptoms and risk factors, such as diabetes and myopia. The headaches are likely due to eye strain from not wearing glasses. Acute angle-closure glaucoma, age-related macular degeneration, and cataracts are unlikely causes as they present with different symptoms and risk factors.
Age-related macular degeneration (ARMD) is a common cause of blindness in the UK, characterized by the degeneration of the central retina (macula) and the formation of drusen. It is more prevalent in females and is strongly associated with advancing age, smoking, family history, and conditions that increase the risk of ischaemic cardiovascular disease. ARMD can be classified into two forms: dry and wet. Dry ARMD is more common and is characterized by drusen, while wet ARMD is characterized by choroidal neovascularisation and carries a worse prognosis. Clinical features of ARMD include subacute onset of visual loss, difficulties in dark adaptation, and visual disturbances such as photopsia and glare.
To diagnose ARMD, slit-lamp microscopy and color fundus photography are used to identify any pigmentary, exudative, or haemorrhagic changes affecting the retina. Fluorescein angiography and indocyanine green angiography may also be used to visualize changes in the choroidal circulation. Treatment for dry ARMD involves a combination of zinc with antioxidant vitamins A, C, and E, which has been shown to reduce disease progression by around one third. For wet ARMD, anti-VEGF agents such as ranibizumab, bevacizumab, and pegaptanib are used to limit disease progression and stabilize or reverse visual loss. Laser photocoagulation may also be used to slow progression, but anti-VEGF therapies are usually preferred due to the risk of acute visual loss after treatment.
In summary, ARMD is a common cause of blindness in the UK that is strongly associated with advancing age, smoking, and family history. It can be classified into dry and wet forms, with wet ARMD carrying a worse prognosis. Diagnosis involves the use of various imaging techniques, and treatment options include a combination of zinc and antioxidant vitamins for dry ARMD and anti-VEGF agents or laser photocoagulation for wet ARMD.
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This question is part of the following fields:
- Ophthalmology
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Question 11
Correct
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As an FY-2 doctor in ophthalmology, you encounter a 59-year-old male patient who complains of pain in his right eye, accompanied by tearing and reduced vision. Upon examination, you diagnose a corneal ulcer. What is the most probable cause of this condition?
Your Answer: Steroid eye drops
Explanation:Fungal infections and subsequent corneal ulcers can be caused by the use of steroid eye drops. These drops are designed to reduce inflammation, but they can also weaken the immune response to infections, leaving the cornea vulnerable to bacteria, fungi, or protists. Treatment for corneal ulcers typically involves targeted eye drops to address the specific organism causing the infection, such as antibacterial or antifungal drops. Saline or lubricant eye drops, on the other hand, are sterile and do not pose a risk for corneal ulcers.
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.
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This question is part of the following fields:
- Ophthalmology
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Question 12
Incorrect
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A 62-years-old-man presents to the pulmonology clinic with a recent onset of ptosis in his right upper lid. He has been experiencing a chronic cough for the past three months, accompanied by streaks of blood. Upon radiological examination, an opacification is observed in the upper right part of his chest. The patient appears cachexic and unwell, with a BMI of 18 kg/m² and a fasting blood sugar level of 8.3 mmol/L. What other clinical findings may be present in this patient?
Your Answer: Kussmaul breathing
Correct Answer: Right upper limb pain
Explanation:Patients with Pancoast tumours may experience shoulder pain and upper limb neurological signs, in addition to Horner’s syndrome, due to the tumour proximity to the brachial plexus. Therefore, the correct answer is right upper limb pain. Kussmaul breathing is an incorrect option as it is associated with metabolic acidosis, which is not present in this case. Lupus pernio is also an incorrect answer as it is more commonly seen in sarcoidosis rather than lung cancer. Opsoclonus-myoclonus syndrome is another incorrect option as it is a paraneoplastic syndrome typically associated with neuroblastoma in children.
Horner’s syndrome is a medical condition that is characterized by a set of symptoms including a small pupil (miosis), drooping of the upper eyelid (ptosis), sunken eye (enophthalmos), and loss of sweating on one side of the face (anhidrosis). The presence of heterochromia, or a difference in iris color, is often seen in cases of congenital Horner’s syndrome. Anhidrosis is also a distinguishing feature that can help differentiate between central, Preganglionic, and postganglionic lesions. Pharmacologic tests, such as the use of apraclonidine drops, can be helpful in confirming the diagnosis of Horner’s syndrome and localizing the lesion.
Central lesions, Preganglionic lesions, and postganglionic lesions can all cause Horner’s syndrome, with each type of lesion presenting with different symptoms. Central lesions can result in anhidrosis of the face, arm, and trunk, while Preganglionic lesions can cause anhidrosis of the face only. postganglionic lesions, on the other hand, do not typically result in anhidrosis.
There are many potential causes of Horner’s syndrome, including stroke, syringomyelia, multiple sclerosis, tumors, encephalitis, thyroidectomy, trauma, cervical rib, carotid artery dissection, carotid aneurysm, cavernous sinus thrombosis, and cluster headache. It is important to identify the underlying cause of Horner’s syndrome in order to determine the appropriate treatment plan.
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This question is part of the following fields:
- Ophthalmology
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Question 13
Correct
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A 65-year-old woman came to her GP with a complaint of painless blurring and distortion of central vision and difficulty with night vision that has been going on for 2 years. She reports that her vision is sometimes poor and sometimes better. During the examination using a direct ophthalmoscope, yellow deposits were observed at the macula. What is the initial treatment for this patient's eye condition?
Your Answer: Vitamin supplementation
Explanation:Vitamin supplementation containing vitamins C and E, beta-carotene, and zinc can delay the progression of dry age-related macular degeneration (AMD) from intermediate to advanced stages. However, there is no other treatment available for dry AMD, and management is mainly supportive. Pan-retinal photocoagulation is not used for either dry or wet AMD. Anti-vascular endothelial growth factor (VEGF) intravitreal injection is reserved for wet AMD, where there is choroidal neovascularization. This treatment stops abnormal blood vessels from leaking, growing, and bleeding under the retina. Focal laser photocoagulation is sometimes used in wet AMD, but anti-VEGF injections are now the preferred treatment. Photodynamic therapy can be used in wet AMD when anti-VEGF is not an option or for those who do not want repeated intravitreal injections. The patient in question has dry AMD, with metamorphopsia as a symptom and yellow deposits at the macula known as drusen.
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This question is part of the following fields:
- Ophthalmology
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Question 14
Correct
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A 57-year-old man comes to the Emergency Department complaining of a headache and blurred vision that started 1 day ago. He reports no pain when touching his scalp or eating and chewing food. He has a medical history of hypertension and type 2 diabetes mellitus, which he manages with metformin. He also mentions that his uncle died of brain cancer, and he is worried that he may have the same condition.
During the examination, his visual acuity is 6/18 in both eyes. Dilated fundoscopy reveals some arterioles narrower than others, with venules being compressed by arterioles. There is optic disc swelling in both eyes, with some exudates lining up like a star at the macula. Additionally, there are some dot-and-blot and flame-shaped haemorrhages.
His vital signs are as follows: heart rate 80 bpm, blood pressure 221/119 mmHg, oxygen saturation 98% on room air, respiratory rate 14 per minute, and temperature 37 °C.
What is the most likely diagnosis?Your Answer: Hypertensive retinopathy
Explanation:Diagnosis of Hypertensive Retinopathy: A Case Study
The patient in question presented with a highly raised blood pressure and complained of headache and blurring of vision. Fundoscopy revealed typical features of hypertensive retinopathy, including bilateral optic disc swelling. Although the patient had a family history of intracranial space-occupying lesions, there were no accompanying symptoms such as early-morning vomiting and weight loss, making this diagnosis unlikely. Additionally, there was no evidence of drusen or choroidal neovascularisation, ruling out age-related macular degeneration. The absence of scalp tenderness and jaw claudication made giant-cell arthritis an unlikely diagnosis as well. Finally, the lack of new vessels at the disc and elsewhere ruled out proliferative diabetic retinopathy. In conclusion, the patient’s symptoms and fundoscopy findings point towards a diagnosis of hypertensive retinopathy.
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This question is part of the following fields:
- Ophthalmology
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Question 15
Correct
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An 80-year-old man arrives at the emergency department with a complaint of severe headache. He has a medical history of hypertension and takes Ramipril 10 mg and Amlodipine 10 mg. During the full workup, fundoscopy is conducted and reveals scattered cotton wool spots, tortuous vessels throughout, and AV nipping in both eyes. According to the Keith-Wagener classification, what stage of hypertensive retinopathy does this patient have?
Your Answer: Stage 3
Explanation:Hypertensive retinopathy can be detected through fundoscopy, which may reveal end organ damage. This condition can progress through stages 1 to 3, and is often tested on as a final exam question. Diabetic retinopathy is also a commonly tested topic.
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.
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This question is part of the following fields:
- Ophthalmology
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Question 16
Correct
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A 23-year-old female patient visits the GP complaining of visual symptoms. She states that her left eye's vision has significantly deteriorated in the last two days. Additionally, she experiences pain behind her left eye when moving it. The patient is healthy otherwise, without medical history, allergies, or regular medication intake. During the examination, a relative afferent pupillary defect is observed, and her left eye's visual acuity is lower than the right. What other symptom is she likely to mention?
Your Answer: Reduced colour vision
Explanation:The patient in the brief is a young female with acute unilateral vision loss and painful eye movements. Given her age and symptoms, optic neuritis is the most likely diagnosis. This is especially true since she does not have any other symptoms commonly associated with temporal arthritis, such as new headaches, general malaise, weight loss, and jaw claudication. Additionally, temporal arthritis typically affects older patients and does not cause painful eye movements.
While optic neuritis can result in any pattern of visual field defect, the most common one is central scotoma. Therefore, peripheral vision loss with central sparing is less likely to be reported. It is important to note that this patient is not likely to have optic neuritis associated with SLE, as this is a rare occurrence. Instead, she is more likely to have idiopathic optic neuritis or optic neuritis associated with multiple sclerosis.
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%.
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This question is part of the following fields:
- Ophthalmology
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Question 17
Incorrect
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A 22-year-old woman, a known type 1 diabetic, visited the GP clinic with a complaint of decreased vision. Her left eye has a vision of 6/6, while her right eye has a vision of 6/18.
Your GP placement supervisor requested you to conduct a dilated direct fundoscopy on her eyes. During the examination, you observed exudates forming a ring around a dot haemorrhage near the fovea.
What is the probable diagnosis of the patient's eye condition?Your Answer: Pre-proliferative diabetic retinopathy
Correct Answer: Diabetic maculopathy
Explanation:Understanding the Different Stages of Diabetic Retinopathy
Diabetic retinopathy is a condition that affects the eyes of people with diabetes. It is caused by damage to the blood vessels in the retina, which can lead to vision loss if left untreated. There are different stages of diabetic retinopathy, each with its own set of features.
The first stage is background diabetic retinopathy, which is characterized by microaneurysms, small blot haemorrhages, hard exudates, and occasional cotton-wool spots. The next stage is pre-proliferative diabetic retinopathy, which includes intraretinal microvascular abnormalities (IRMA), venous beading or loops, clusters of large blot haemorrhages, and multiple cotton-wool spots.
Proliferative diabetic retinopathy is the most advanced stage and includes all the features of pre-proliferative retinopathy, as well as new vessels at the disc or elsewhere in the retina. Finally, proliferative diabetic retinopathy with maculopathy is when there are any features of diabetic retinopathy but existing at the macula, such as a ring of exudates and a dot haemorrhage near the fovea.
It is important for people with diabetes to have regular eye exams to detect and treat diabetic retinopathy early on. With proper management, vision loss can be prevented or minimized.
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This question is part of the following fields:
- Ophthalmology
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Question 18
Correct
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A 35-year-old man presents to the emergency department complaining of intense pain in his left eye, particularly when exposed to light, and blurred vision. He has a medical history of Crohn's disease, which is being managed with azathioprine. Upon examination, there is conjunctival injection at the cornea-sclera junction, increased tearing, and a smaller pupil in the left eye compared to the right. What is the necessary treatment for this patient?
Your Answer: Steroid and cycloplegic drops
Explanation:The most appropriate treatment for anterior uveitis is a combination of steroid and cycloplegic (mydriatic) drops. This patient’s history of Crohn’s disease increases their risk of developing acute uveitis. Steroid drops are necessary to reduce inflammation, while cycloplegic drops prevent adhesions between the lens and iris and relieve spasms of the ciliary body. Antibiotic drops are not indicated for anterior uveitis, as they are used to treat bacterial conjunctivitis. Antihistamine drops are used for allergic conjunctivitis, topical NSAID drops for episcleritis, and pilocarpine and β-blocker drops for acute closed angle glaucoma.
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.
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This question is part of the following fields:
- Ophthalmology
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Question 19
Correct
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A 56-year-old male visits his general practitioner complaining of a painless red left eye accompanied by tearing for the past three days. He reports no changes in his vision. The patient has a medical history of rheumatoid arthritis. Upon examination, the doctor notes a red left eye but finds nothing else unusual. What is the most probable diagnosis?
Your Answer: Episcleritis
Explanation:Episcleritis is the likely diagnosis for this patient’s painless red left eye of acute onset, which is associated with lacrimation. The absence of pain, visual impairment, or significant examination findings distinguishes it from scleritis. Episcleritis is an inflammation of the episclera that typically resolves within 2-3 weeks.
Anterior uveitis is not the correct diagnosis as it presents with an acutely painful red eye associated with photophobia and reduced visual acuity, and requires urgent referral to ophthalmology.
Bacterial conjunctivitis is also unlikely as it is characterized by a sore, red-eye with a purulent discharge, which is not present in this case.
Scleritis is not the correct diagnosis as it presents with a subacute onset of red-eye associated with pain that is exacerbated by eye movement, and may also have scleral thinning.
Understanding Scleritis: Causes, Symptoms, and Treatment
Scleritis is a condition that involves inflammation of the sclera, which is the white outer layer of the eye. This condition is typically non-infectious and can cause a red, painful eye. The most common risk factor associated with scleritis is rheumatoid arthritis, but it can also be linked to other conditions such as systemic lupus erythematosus, sarcoidosis, and granulomatosis with polyangiitis.
Symptoms of scleritis include a red eye, which is often accompanied by pain and discomfort. Patients may also experience watering and photophobia, as well as a gradual decrease in vision.
Treatment for scleritis typically involves the use of oral NSAIDs as a first-line treatment. In more severe cases, oral glucocorticoids may be used. For resistant cases, immunosuppressive drugs may be necessary, especially if there is an underlying associated disease. With proper treatment, most patients with scleritis can achieve relief from their symptoms and prevent further complications.
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This question is part of the following fields:
- Ophthalmology
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Question 20
Correct
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A 49-year-old man comes to the emergency department complaining of sudden painless loss of vision on the left side. He reports experiencing dark 'floaters' in his vision and a 'red hue' before losing vision completely on the affected side. The symptoms were most severe when lying flat. The patient has a medical history of poorly controlled type 1 diabetes, proliferative diabetic retinopathy, hypertension, and a metallic aortic valve for which he takes warfarin. What is the probable diagnosis?
Your Answer: Vitreous haemorrhage
Explanation:Vitreous haemorrhage should be considered as a possible cause of sudden visual loss in diabetic patients. This patient’s symptoms, including painless loss of vision with floaters and a red hue, are typical of vitreous haemorrhage. The worsening of symptoms when lying flat is also consistent with this diagnosis. The patient has several risk factors for vitreous haemorrhage, such as proliferative retinal disease, hypertension, and anticoagulant use.
Acute angle-closure glaucoma, which presents with painful loss of vision, red-eye, halos around lights, and a semi-dilated non-reactive pupil, is less likely in this case as the patient denies pain and there is no mention of a red eye.
Central retinal vein occlusion is unlikely as it does not typically present with floaters and a red hue preceding sudden loss of vision. Additionally, symptoms would not worsen when lying flat.
Posterior vitreous detachment, which presents with flashes of light and floaters in the peripheral field of vision, does not cause loss of sight.
Understanding Vitreous Haemorrhage
Vitreous haemorrhage is a condition where there is bleeding into the vitreous humour, which can cause sudden painless loss of vision. This disruption to vision can range from floaters to complete visual loss. The bleeding can come from any vessel in the retina or extend through the retina from other areas. Once the bleeding stops, the blood is typically cleared from the retina at a rate of approximately 1% per day.
The incidence of spontaneous vitreous haemorrhage is around 7 cases per 100,000 patient-years. The incidence by age and sex varies according to the underlying causes. The most common causes, which collectively account for 90% of cases, include proliferative diabetic retinopathy, posterior vitreous detachment, and ocular trauma (which is the most common cause in children and young adults).
Patients with vitreous haemorrhage typically present with an acute or subacute onset of painless visual loss or haze, a red hue in the vision, or floaters or shadows/dark spots in the vision. Signs of the condition include decreased visual acuity (depending on the location, size, and degree of vitreous haemorrhage) and visual field defects if the haemorrhage is severe.
Investigations for vitreous haemorrhage include dilated fundoscopy, slit-lamp examination, ultrasound (useful to rule out retinal tear/detachment and if haemorrhage obscures the retina), fluorescein angiography (to identify neovascularization), and orbital CT (used if open globe injury is suspected).
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This question is part of the following fields:
- Ophthalmology
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Question 21
Correct
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A 43-year-old man presents to the emergency department with complaints of a headache on the right side of his head, localized at the eye, and neck pain. He reports that the pain started suddenly over an hour. The patient has a medical history of hypertension and a 20-year pack history of smoking. He appears to be in significant pain, with sweat on his forehead.
Observations reveal a heart rate of 102 bpm, blood pressure of 158/89 mmHg, and a Glasgow coma scale of 15/15. On examination, the right pupil is small, and the eyelid is drooping. The sclera is white, and there is no swelling of the eyelid. The left eye appears normal.
What is the most probable cause of these symptoms?Your Answer: Carotid artery dissection
Explanation:A localised headache, neck pain, and neurological signs such as Horner’s syndrome are indicative of carotid artery dissection. This is a crucial diagnosis to consider when dealing with such symptoms. The presence of a localised headache, neck pain, and Horner’s syndrome suggest carotid artery dissection. The patient’s right eye is showing signs of loss of sympathetic innervation, such as a small pupil and drooping eyelid. The presence of sweat on the forehead indicates that the lesion causing Horner’s syndrome is postganglionic. A carotid artery dissection is the most likely cause of these symptoms, given the patient’s risk factors of smoking and hypertension. Cluster headache, encephalitis, and subarachnoid haemorrhage are less likely diagnoses, as they do not fit with the patient’s symptoms and presentation.
Horner’s syndrome is a medical condition that is characterized by a set of symptoms including a small pupil (miosis), drooping of the upper eyelid (ptosis), sunken eye (enophthalmos), and loss of sweating on one side of the face (anhidrosis). The presence of heterochromia, or a difference in iris color, is often seen in cases of congenital Horner’s syndrome. Anhidrosis is also a distinguishing feature that can help differentiate between central, Preganglionic, and postganglionic lesions. Pharmacologic tests, such as the use of apraclonidine drops, can be helpful in confirming the diagnosis of Horner’s syndrome and localizing the lesion.
Central lesions, Preganglionic lesions, and postganglionic lesions can all cause Horner’s syndrome, with each type of lesion presenting with different symptoms. Central lesions can result in anhidrosis of the face, arm, and trunk, while Preganglionic lesions can cause anhidrosis of the face only. postganglionic lesions, on the other hand, do not typically result in anhidrosis.
There are many potential causes of Horner’s syndrome, including stroke, syringomyelia, multiple sclerosis, tumors, encephalitis, thyroidectomy, trauma, cervical rib, carotid artery dissection, carotid aneurysm, cavernous sinus thrombosis, and cluster headache. It is important to identify the underlying cause of Horner’s syndrome in order to determine the appropriate treatment plan.
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This question is part of the following fields:
- Ophthalmology
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Question 22
Correct
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A 72-year-old myopic man with a history of hypertension arrives at the clinic complaining of a sudden, painless decrease in his vision. He reports a dense shadow obstructing his left eye, which began in the periphery and has advanced towards the center of his vision.
During the examination, he can only perceive hand movements in his left eye, while his right eye has a visual acuity of 6/6. What is the probable reason for the vision loss?Your Answer: Retinal detachment
Explanation:Retinal detachment is a condition that can cause sudden and painless loss of vision. It is characterized by a dense shadow that starts from the periphery and progresses towards the center of the visual field.
Central retinal artery occlusion, on the other hand, is caused by a blockage of blood flow due to thromboembolism or arthritis. This condition can also cause sudden and painless loss of vision, but it does not typically present with a peripheral-to-central progression. Instead, it is characterized by an afferent pupillary defect and a cherry red spot on a pale retina.
Central retinal vein occlusion is more common than arterial occlusion and is often seen in older patients, particularly those with glaucoma. This condition can also cause sudden and painless loss of vision, but it can affect any venous territory and is associated with severe retinal hemorrhages.
Retinal detachment is often seen in people with myopia and can be preceded by flashes and floaters. It typically presents with a shadow in the visual field that starts from the periphery and progresses towards the center.
Optic neuritis can also cause sudden visual loss, but this is usually temporary and is often accompanied by painful eye movement.
Vitreous hemorrhage, on the other hand, causes a dark spot in the visual field where the hemorrhage is located, rather than a shadow that progresses towards the center.
Sudden loss of vision can be a scary symptom for patients, as it may indicate a serious issue or only be temporary. Transient monocular visual loss (TMVL) is a term used to describe a sudden, brief loss of vision that lasts less than 24 hours. The most common causes of sudden, painless loss of vision include ischaemic/vascular issues (such as thrombosis, embolism, and temporal arthritis), vitreous haemorrhage, retinal detachment, and retinal migraine.
Ischaemic/vascular issues, also known as ‘amaurosis fugax’, have a wide range of potential causes, including large artery disease, small artery occlusive disease, venous disease, and hypoperfusion. Altitudinal field defects are often seen, and ischaemic optic neuropathy can occur due to occlusion of the short posterior ciliary arteries. Central retinal vein occlusion is more common than arterial occlusion and can be caused by glaucoma, polycythaemia, or hypertension. Central retinal artery occlusion is typically caused by thromboembolism or arthritis and may present with an afferent pupillary defect and a ‘cherry red’ spot on a pale retina.
Vitreous haemorrhage can be caused by diabetes, bleeding disorders, or anticoagulants and may present with sudden visual loss and dark spots. Retinal detachment may be preceded by flashes of light or floaters, which are also common in posterior vitreous detachment. Differentiating between posterior vitreous detachment, retinal detachment, and vitreous haemorrhage can be challenging, but each has distinct features such as photopsia and floaters for posterior vitreous detachment, a dense shadow that progresses towards central vision for retinal detachment, and large bleeds causing sudden visual loss for vitreous haemorrhage.
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This question is part of the following fields:
- Ophthalmology
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Question 23
Correct
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A 7-year-old girl visits her GP complaining of a swollen left eye. She noticed it while playing outside in the park. Her mother is concerned because she is having difficulty reading her books. The girl has no medical history, and this has never happened before.
During the examination, the left eyelid is warm and red, and the eye seems to be bulging. The girl's eye movements are limited in all directions. The right eye appears normal. Her heart rate is 120 beats/minute, and her temperature is 37.9ºC.
What is the most probable diagnosis?Your Answer: Orbital cellulitis
Explanation:Orbital cellulitis can be distinguished from preseptal cellulitis based on the presence of reduced visual acuity, proptosis, and pain with eye movements. This classic presentation is accompanied by fever and tachycardia, indicating an infection. While preseptal cellulitis can also cause a swollen eye, it does not result in the same symptoms as orbital cellulitis. Other conditions, such as minimal change disease, mastoiditis, and bilateral periorbital edema, may cause swelling and fever, but they do not typically result in unilateral swelling with restricted eye movements and raised temperature.
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.
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This question is part of the following fields:
- Ophthalmology
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Question 24
Incorrect
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A 60-year-old man comes in with a painful red eye. What feature would not indicate a diagnosis of acute angle closure glaucoma?
Your Answer: Vomiting
Correct Answer: Small pupil
Explanation:Glaucoma is a group of disorders that cause optic neuropathy due to increased intraocular pressure (IOP). However, not all patients with raised IOP have glaucoma, and vice versa. Acute angle-closure glaucoma (AACG) is a type of glaucoma where there is a rise in IOP due to impaired aqueous outflow. Factors that increase the risk of AACG include hypermetropia, pupillary dilation, and lens growth associated with age. Symptoms of AACG include severe pain, decreased visual acuity, halos around lights, and a hard, red-eye. Management of AACG is an emergency and requires urgent referral to an ophthalmologist. Emergency medical treatment is necessary to lower the IOP, followed by definitive surgical treatment once the acute attack has subsided.
There are no specific guidelines for the initial medical treatment of AACG, but a combination of eye drops may be used, including a direct parasympathomimetic, a beta-blocker, and an alpha-2 agonist. Intravenous acetazolamide may also be administered to reduce aqueous secretions. Definitive management of AACG involves laser peripheral iridotomy, which creates a small hole in the peripheral iris to allow aqueous humour to flow to the angle. It is important to seek medical attention immediately if symptoms of AACG are present to prevent permanent vision loss.
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This question is part of the following fields:
- Ophthalmology
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Question 25
Incorrect
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A 70-year-old man, who has been a diabetic for over 20 years, visits his GP for a routine check-up. During the appointment, he mentions to his doctor that he has been experiencing difficulty with his vision in his right eye for the past few months. He describes it as blurry vision and seeing halos around lights at night. The man has never had any vision problems before. He is currently taking medications for his high blood pressure and cholesterol levels. Other than his vision, his physical examination is unremarkable. What is the most likely diagnosis for the man's symptoms?
Your Answer: Diabetic retinopathy
Correct Answer: Cataract
Explanation:The patient’s symptoms and medical history strongly suggest a diagnosis of cataract. Their elderly age, long-standing diabetes mellitus, and unilateral blurry vision with halos around light sources are all classic signs of cataract. There is no indication of steroid use, which can also increase the risk of cataract development.
While primary open-angle glaucoma is a possibility, it is less likely given the patient’s symptoms. This condition typically presents with peripheral visual field loss rather than blurry vision. Acute angle-closure glaucoma is also a possibility, but it is more commonly associated with halos than primary open-angle glaucoma.
Uveitis is unlikely given the absence of pain and redness in the eye. Additionally, it is not typically associated with diabetes. Diabetic retinopathy is another possibility in this patient, but it is often asymptomatic or presents with hemorrhage.
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.
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This question is part of the following fields:
- Ophthalmology
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Question 26
Incorrect
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An ophthalmology clinic is treating a 75-year-old man with bilateral primary open-angle glaucoma. Despite using latanoprost eye drops, his intraocular pressures remain high. The ophthalmologist now needs to add a second topical agent to reduce intraocular pressure by decreasing the rate of aqueous humour production. What class of drug should be considered next?
Your Answer: Prostaglandin analogue
Correct Answer: Beta-blocker
Explanation:Beta blockers, like timolol, are effective in treating primary open-angle glaucoma by reducing the production of aqueous humour. They are commonly used as a first-line or second-line treatment, either alone or in combination with a prostaglandin analogue. Topical antimuscarinics should not be used as they can increase IOP, while pilocarpine can be used to reduce it. Carbonic anhydrase inhibitors are available for glaucoma treatment, but not carbonic anhydrase analogues. Topical corticosteroids are not used for glaucoma. If a patient is not responding well to their current treatment, guidelines recommend trying a drug from a different therapeutic class rather than adding a second prostaglandin analogue.
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.
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This question is part of the following fields:
- Ophthalmology
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Question 27
Correct
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A 6-year-old girl presents to the hospital with a 3 days history of painful swelling in the right eye.
On examination, the girl appears agitated and is crying continuously. Her temperature is 38.5°C and other vital signs are within normal limits. On examination of the affected eye, the eyelid is swollen and red. Proptosis of the right eye is observed, and there seems to be limited ocular movement as well. The globe is unaffected, and the other eye is normal. There are no signs of systemic involvement.
What imaging modality should be performed to confirm the most probable diagnosis and assess for potential complications?Your Answer: Contrast enhanced-CT scan of the orbits, sinuses and brain
Explanation:If there is suspicion of orbital cellulitis, a CT scan with contrast should be conducted to evaluate the potential spread of infection to the posterior region. The presence of symptoms such as limited ocular movement and proptosis indicates a higher likelihood of orbital cellulitis rather than periorbital cellulitis. In cases where orbital cellulitis is suspected, a contrast-enhanced CT scan of the sinuses, brain, and orbits should be considered to confirm the diagnosis and identify any potential complications, such as abscesses that may require surgical drainage. Plain skull X-rays are typically used to detect facial bone fractures or metallic foreign bodies in trauma cases. Optical coherence tomography (OCT) is not relevant in this scenario as it is a non-invasive imaging test used to take cross-sectional images of the retina. Ultrasound scans of the eye and orbit are commonly used in cases of eye area injury or trauma. CT venography is performed when cavernous sinus thrombosis is suspected.
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.
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This question is part of the following fields:
- Ophthalmology
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Question 28
Correct
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A 57-year-old man comes to the emergency department complaining of sudden visual loss. He reports no eye redness, ocular trauma, or headaches. The loss of vision began from the outside and progressed inward, accompanied by flashes and floaters. He wears corrective glasses and sometimes contact lenses, but he cannot recall his prescription. What characteristic raises the likelihood of this patient developing this condition?
Your Answer: Myopia
Explanation:Myopia increases the likelihood of retinal detachment, which should be suspected if a patient experiences gradual vision loss starting from the periphery and moving towards the centre. This may be accompanied by the sensation of a curtain or veil descending over their vision, preceded by flashes and floaters caused by the vitreous humour tugging at the retina. Myopia elongates the eyeball, stretching the retina and making it more susceptible to tearing and detachment. Astigmatism, a refractive error caused by an irregularly shaped eyeball, does not increase the risk of RD. Contact lens use is not associated with RD but may increase the risk of infection. Hypermetropia, or farsightedness, does not increase the risk of RD but is associated with acute angle-closure glaucoma, which presents with severe ocular pain, visual blurring, a hard and red eye, and systemic symptoms such as nausea and vomiting.
Retinal detachment is a condition where the tissue at the back of the eye separates from the underlying pigment epithelium. This can cause vision loss, but if detected and treated early, it can be reversible. Risk factors for retinal detachment include diabetes, myopia, age, previous cataract surgery, and eye trauma. Symptoms may include new onset floaters or flashes, sudden painless visual field loss, and reduced peripheral and central vision. If the macula is involved, visual outcomes can be much worse. Diagnosis is made through fundoscopy, which may show retinal folds or a lost red reflex. Urgent referral to an ophthalmologist is necessary for assessment and treatment.
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This question is part of the following fields:
- Ophthalmology
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Question 29
Correct
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A 63-year-old woman comes to the emergency department with sudden vision loss, redness, and pain in her left eye. She reports experiencing some discomfort and redness earlier in the day, which worsened over the next two hours. She has no history of trauma or other visual problems. Her medical history includes osteoarthritis, left eye cataract surgery three days ago, and no significant family history.
Upon examination, the left eye appears hyperemic with hypopyon, and eye movements are painful. Visual acuity is severely impaired, while the right eye appears normal. What is the most probable diagnosis?Your Answer: Endophthalmitis
Explanation:Post-operative endophthalmitis is a rare but serious complication that can occur after cataract surgery and requires immediate treatment.
If a patient experiences sudden pain, redness, and vision loss shortly after eye surgery, it may indicate post-operative endophthalmitis. This infection affects the aqueous and vitreous humor of the eye and is a rare complication of any eye surgery.
While anterior uveitis can also cause a painful red eye, it is less likely in this case due to the patient’s history of cataract surgery. Additionally, there is no mention of an irregularly-shaped pupil or any systemic disease associated with anterior uveitis.
A corneal ulcer is another possibility, but it typically presents with a sensation of a foreign body in the eye and discharge. It is also more common in contact lens wearers who have been exposed to water.
Retinal detachment is less likely because it usually causes visual disturbances such as floaters, flashes of light, and a curtain descending over the peripheral visual field. Although ocular surgery is a risk factor for retinal detachment, it would not cause the intense redness and hypopyon seen in post-operative endophthalmitis.
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.
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This question is part of the following fields:
- Ophthalmology
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Question 30
Correct
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A 30-year-old female patient visits her GP complaining of a severe throbbing headache that is most intense in the morning. Despite taking paracetamol, the symptoms have persisted for several weeks. She also experiences vomiting in the mornings and has noticed blurry vision. Upon examination, her pupils are equal and reactive, and there are no abnormalities in her systemic examination. What would you anticipate observing during fundoscopy?
Your Answer: Blurring of optic disc margin
Explanation:Papilloedema is characterized by a blurry appearance of the optic disc margin during fundoscopy.
The patient in question is experiencing elevated intracranial pressure, the cause of which is uncertain. Their symptoms, including a morning headache, vision impairment, and vomiting, are indicative of papilloedema. As such, it is expected that their fundoscopy would reveal signs of this condition, such as a blurred optic disc margin.
Other potential indicators of papilloedema include a loss of optic cup and venous pulsation. However, increased arterial reflex is more commonly associated with hypertensive retinopathy, while retinal pigmentation is a hallmark of retinitis pigmentosa.
Understanding Papilloedema: Optic Disc Swelling Caused by Increased Intracranial Pressure
Papilloedema is a condition characterized by swelling of the optic disc due to increased pressure within the skull. This condition is typically bilateral and can be identified through fundoscopy. During this examination, venous engorgement is usually the first sign observed, followed by loss of venous pulsation, blurring of the optic disc margin, elevation of the optic disc, loss of the optic cup, and the presence of Paton’s lines, which are concentric or radial retinal lines cascading from the optic disc.
There are several potential causes of papilloedema, including space-occupying lesions such as tumors or vascular abnormalities, malignant hypertension, idiopathic intracranial hypertension, hydrocephalus, and hypercapnia. In rare cases, papilloedema may also be caused by hypoparathyroidism and hypocalcaemia, or vitamin A toxicity.
Overall, understanding papilloedema is important for identifying potential underlying conditions and providing appropriate treatment to prevent further complications.
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This question is part of the following fields:
- Ophthalmology
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