Transcript OPHTHALMOLOGY REVIEW

OPHTHALMOLOGY REVIEW
OCTOBER 2009
History
• 2% of all GP presentations
• History cannot be underestimated
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Contact lens use
Sticky discharge/ itching/ pain/ redness
Unilateral/ bilateral
Others affected
Trauma
Previous history
Systemic disease
Examination
• Visual acuity with Snellen chart
• Eyelids and anterior segment
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Swelling
Conjunctivitis
Ciliary/ limbal injection
Corneal ulcers/ foreign body
Cloudy cornea
Examination cont….
• Corneal integrity (fluorescein stain)
• Eversion of lid for foreign bodies
• For patients with blurred vision
– Visual field
– Pupillary light reaction (direct/ consensual)
– Dilated fundoscopy
Snellen Chart
Assessing acuity…
• Snellen chart – Test at 6 metres
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The largest letter on chart is 60; i.e. vision is 6/60
6/12 is equivalent to the driving standard
If can only read top letter at 1 metre, vision is 1/60
If can only count fingers CF (60cm)
• Sight impaired (partially sighted)
– 3/60 to 6/60 if full visual field or higher acuity with diminished field
• Severely sight impaired (blind)
– 3/60 or worse with full field or high acuity with diminished field
• Illiterate chart – point in direction of letter E…
Colour blindness – Ishihara Chart
No 12
No 6
Dummy number
Referral
• Acute Referral
Sudden loss of vision
Injuries
Sudden onset diplopia
Acute glaucoma
Retinal tear
Wet ARMD
• PEARS (Primary Eyecare Acute Referral Scheme)
Lids/ Lashes/ Tears
Red eyes
Flashes/ floaters
Dry/ unsure ARMD
• Others
Cataract/ glaucoma/ squints etc refer via C&B.
NB there is a dedicated lid clinic
DRSS for patients with diabetes
Refractive errors
MYOPIA
Image focussed in front of retina, eyeball too long, short-sightedness
Concave spectacle lens
HYPERMETROPIA
Image focussed behind the retina, eyeball too short, long-sightedness
Convex lens
PRESBYOPIA
Lens becomes stiffer with age, decreased range of focussing/
accommodation
45 and above, usually stable by 60
Weak convex lens
ASTIGMATISM
Difference in curvature in different medians ie rugby ball vs football
Distortion of image
HORNER’S SYNDROME
Features are miosis, ptosis, enophthalmos, anhydrosis
Heterochromia seen in congenital disorder
Anhydrosis of face, arm, trunk (central lesions):
Stroke, syringomyelia, MS, tumour, encephalitis
Anhydrosis of face (pre-ganglionic lesions):
Pancoast tumour, thyroidectomy, trauma, cervical rib
No anhydrosis (post-gangionlic lesions):
Caroid artery dissection/ aneurysm, cavernous sinus thrombosis
• ARGYLL ROBERTSON PUPIL
– Usually asymptomatic
– Small irregular pupils
– React poorly to light but constrict normally in convergence ie
accommodation
– Tertiary syphilis
• HOLMES ADIE PUPIL
– Difference in pupil size, blurred near vision, photophobia,
asymptomatic
– Irregular dilated pupil with minimal/ no reactivity to light, slow
constriction on convergence, slow redilation
– Typically young females
– May be associated with diminished reflexes
– Most idiopathic
– Orbital trauma/ surgery/ HZ infection/ early syphilis/ parvo B19/
HSV/ Lyme disease/ endometriosis/ seminomas/ Sjogrens
BLEPHARITIS
Chronic bilateral inflammation of the lid margins often
exhibiting crust formation.
Blepharoconjunctivitis if associated with chronic
conjunctivitis.
Can be:
Staphylococcal
Seborrhoeic
Contact dermatitis
Related to acne rosacea
Symptoms
• Irritation
• Burning
• Itching
• Sometimes loss of lashes (madarosis)
Management
• Warm, wet compresses to soften crusts then removal of
crusts with cotton buds soaked in solution of bicarbonate
of soda/ baby shampoo in cool boiled water.
• Topical antibiotics
• Oral tetracyclines for 6-8 weeks
STYES
Common eyelid gland infection
Staph aureus usually
External
• Commonest, staph infection of a lash follicle +/- glands of
Zeis/ Moll
• Pain, redness, localised swelling, pus point often seen,
point outwards
• Treat with warm compresses, topical antibiotic
Internal = Chalazion
CHALAZION/ MEIBOMIAN CYST
Retention cyst of Meibomian gland
• May become infected or develop into a sterile chronic
granuloma
• Most point towards conjunctival surface
• May result in astigmatism because of pressure on eyeball
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If infected, treat as stye
1/3 resolve spontaneously
Most resorb within 2 years
Consider I&C if troublesome
ENTROPION
Turning in of the eyelids
Senile entropion always affects lower lid, elicit by asking pt
to squeeze eyelids shut
Cicatricial may involve either lid eg burns, Stevens- Johnson
Congenital rare
Irrespective of cause, lash irritation of cornea and conjunctiva
is the main problem
Lubricants/ surgical correction are mainstay treatments
ECTROPION
Sagging and eversion of the lower lid
Commonest is senile which is frequently bilateral, loss of
muscle tone and orbital fat
Cicatricial following burns/ irradiation
Epiphora/ irritation
Surgical correction
BASAL CELL CARCINOMA
Locally invasive
Rarely metastasizes
Commonest skin cancer
Middle age/ elderly, caucasians mainly
Related to sunlight exposure
2 male : 1 female
Pearly white appearance, rolled edges if ulcerated
Surgery, cautery, radiotherapy
DACROCYSTITIS
Infection of lacrimal sac
Infants/ over 40’s
Post-menopausal women
Staph aureus, beta haemolytic strep, strep pneumoniae,
candida albicans
Epiphora, swelling, redness at inner canthus
Antibiotics/ dacrocystorhinostomy (DCR)
Conjunctivitis
• Bacterial
– Mucopurulent discharge, mild discomfort/grittiness
– Commonly caused by Staph aureus,
H. influenzae, N.gonorrhoeae,
Strep pneumoniae,
Chlamydia trachomatis.
– Treat with G Choramphenicol, G Fucithalmic, G
Ofloxacin
– Refer conjunctivitis not responding to above, suspected
Chlamydia infections, ophthalmia neonatorum (with
red eyes)
Conjunctivitis
• Viral
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Non purulent watery discharge, often bilateral
No response to antibiotics
Commonly due to adenovirus, occurs in epidemics
Lower fornix follicles (pale elevations)
Associated with fine punctate corneal ulcers and pre
auricular lymphadenopathy
– Usually lasts 2-3 weeks but may persist for months
– Refer if corneal complications suspected
Conjunctivitis
• Allergic
– History of atopy/allergy
– Itching, bilateral, appears and subsides rapidly
• Seasonal allergic
– Follicles may be present in lower conjunctival fornices
• Vernal
– Seen in atopic children/young adults
– Cobblestone papillae (vascular elevations) on upper
tarsal conjunctiva
– Corneal complications common so refer
Subconjunctival haemorrhage
• Presentation
– Spontaneous/ traumatic
• Examination
– Blood under conjunctiva
– Eye is quiet
– Normal VA
• Management
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Looks worse than it is
Reassure
Check BP
Warn may get worse before better
Refer if traumatic
Consider stopping aspirin/ warfarin
Episcleritis
Autoimmune disorder of unknown cause
• Presentation
– Localised sectoral patch of redness, variable discomfort
– Both sexes
• Examination
– VA normal
– No discharge
• Management
– Self-limiting
– If uncomfortable try acular (ketorolac)/ oral NSAID
– May need referral for topical steroids
SCLERITIS
Rare
Severe, deep pain and potential for tissue destruction
Commoner in women
4th-5th decade
Autoimmune/ infectious/ degenerative/ metabolic/
hypersensitivity
Assoc with RA, ankylosing spondylitis/ herpes zoster/ TB/
syphylis/ gout/ Reiter’s disease
Early referral, NSAIDs, steroids
Keratitis
• Corneal inflammation
– Bacterial, marginal, viral
– FB or trauma
– Exposure or toxic reaction
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Moderate pain and photophobia
Vision may be affected
Loss of corneal clarity
Cornea stains with fluorescein
Corneal abrasion
• Injury to the cornea involving the epithelium
• Present with pain, photophobia, lacrimation and
blepharospasm
• Confirm by staining with fluorescein
• Examination easier if anaesthetise with G.
Proxymethacaine 0.5%
• Exclude FB in conjunctival fornices and eversion
of upper lid
• Treat with Oc. Chlor qds for a week then at night
for 3/52
• G. Cyclopentolate 1% tds if extensive abrasion
Recurrent Corneal Erosion
• May occur after apparently trivial corneal injury
• Following healing of the initial abrasion patients
wakes with pain immediately after opening the
eye
• Due to unstable epithelium being shed on first
opening the eye
• Treat with Oc Chlor qds for a week then lubricant
ointment at night eg. Lacri-lube for 1-2 months
Chemical injury
• Alkali injuries cause more damage
• Irrigate immediately with at least 1l normal
saline (or water if not available)
• Refer to eye clinc for grading and treatment
of injury
HYPHAEMIA
Foreign Bodies
• Usually clear history
• Apply local anaesthetic (Proxymethacaine 0.5%)
• If loosely adherent remove with cotton bud or a
sterile green needle
• If metallic FB a rust ring may remain. Use Oc
Chlor for 2-3 days before referral to eye clinic for
removal of ring
• Continue Oc Chlor qds for 4-5 days after removal
of FB
HYPOPYON
Bacterial Keratitis
• Painful, photophobic, watery eye
• Grey area of oedema and opacity may be seen
before staining
• Pus in the anterior chamber (hypopyon) –
indication for urgent referral
• Fluorescein demarcates the edges of the ulcer
• Cultures to be taken before starting treatment so
refer
• Advise pt to take CLs to clinic as these are also
sent for culture
Marginal keratitis (ulcer)
• Local hypersensitivity to conjunctival infection,
usually staph aureus
• Vascular congestion at the limbus
• Round or elongated ulcer at corneal margin
• Treat any blepharitis with lid hygiene and a topical
antibiotic
• In rosacea also oxytetracycline 250mg bd or
doxycycline 500mg bd x 3/12
• After exclusion of any dendritic ulcer treat with
topical steroids eg. Predsol N qds x 1/52, then bd x
1/52
Herpes Zoster Ophthalmicus
• Headache, fever, general malaise
• Severe burning pain over dermatome
• Vesicular skin rash, involves upper eyelid
only
• Corneal involvement including dendrites
• Complications - uveitis and raised IOP
• Occaisionally scleritis, optic neuritis,
cranial nerve palsy
HZO treatment
• Pain relief
• Oral acyclovir 800mg 5x/day if rash present
<3-5 days
• Acyclovir ointment 5x/day
• Refer to eye clinic 10/7 after onset
• Topical steroids with antiviral treatment if
significant uveitis
• Topical anti-glaucoma treatment as required
Herpes simplex Keratitis
• Mild malaise and fever with initial infection
• Pre-auricular lymphadenopathy+/- skin
lesions on face
• Usually unilateral, pain, redness,
photophobia and blurred vision
• Decreased corneal sensation is an early sign
• In recurrences skin lesions not normally
seen
HSK
• Examination reveals dendritic ulcers or discform
keratitis
• If uncertain of diagnosis can use Rose Bengal
which is taken up by cells at the margins
• Discform keratitis presents as a disc shaped zone
of epithelial oedema and KPs
• Treat dendritic ulcers with Oc Acyclovir 5x/day
for 2/52
• Treat discform keratitis in addition with G Predsol
qds and G.Cyclopentolate 1% tds
Anterior Uveitis (Iritis)
Mainly seen in young people. Sometimes associated
with ankylosing spondylitis or sarcoidosis
• Presentation
– Painful red photophobic eye with reduced VA
– Acute onset, like being “punched in the eye”
– May have been treated for conjunctivitis
• Examination
– Ciliary injection
– Pupil constricted/ irregular, poor light reaction
– Keratic precipitates in severe cases
• Refer within 24 hours
Anterior Uveitis (Iritis)
• 50% no cause found
• 50% have HLA B27 antigen
• Associated with seronegative arthritis,
sarcoidosis, ankylosing spondylitis and
Reiter’s disease
• Treat with Cyclopentolate 1% to dilate
pupil and 2 hourly topical steroids
(Maxidex)
CATARACT
ACQUIRED
• Age
• Diabetes
• Inflammation
• Trauma
• Steroids
Symptoms
• Reduced VA, glare, reduced red reflex
Management
• Surgery: Phacoemulsification/ extracapsular extraction
Congenital cataract
GLAUCOMA
 Optic disc cupping
 Visual field loss
 Raised intraocular pressure enough to damage eye
PHYSIOLOGY
Ciliary body secretes aqueous
Flows through pupil into
anterior chamber
Leaves eye through trabecular
meshwork and into canal of
Schlemm and then episcleral
veins
Types glaucoma
• Primary open angle
• Acute closed angle
• Others
Primary Open Angle Glaucoma
• Commonest form
• 3rd commonest form of blindness in UK
• Resistance through trabecular network
increases- cause not understood. Intraocular
pressure damages nerve- likely ischaemia to
optic nerve head causes damage as well
• Clinical signs of raised IOP depend on rate
and degree of pressure rise
Symptoms
of Primary open angle glaucoma
• Usually and initially – NONE
• Gradual visual loss-peripheral and late
presentation with symptoms
• Screening most common Dx-opticians
• Risk groups: AGE [prevalence 0.02% 4049yr and 10% > 80yrs], 1st degree relatives,
diabetics, short-sighted, Afro-Caribbeans
Signs of Primary Open Angle
Glaucoma
• Eye quiet
• Field loss difficult to pick up clinically until
significant damage has occurred (nasal first)
• Best signs- disc changes = cup:disc ratio
increases as nerve fibres atrophy, also
asymmetry of disc cupping as one eye often
more advanced than other, haemorrhages
poor prognostic sign
Altered disc-cup ratio
Normal intraocular
pressure is usually in the
range of 10 to 21 mmHg
Air pressure
measurements may
overestimate the
intraocular pressure
Applanation tonometry
better
Medical treatment of Glaucoma
• Topical treatment with a beta-blocker or prostaglandin
analogue drop is usually first choice
• Beta Blocker drops eg.Timolol (Timoptol) and Carteolol
(Teoptic). Reduce aqueous secretion, applied twice daily
• Prostaglandin analogues eg.Latanoprost (Xalatan),
Bimatoprost (Lumigan) and Travoprost (Travatan).
Increase uveoscleral drainage, applied once daily. Side
effects of increased iris pigmentation and longer, darker
eyelashes
Medical treatment of Glaucoma
• Carbonic anhydrase inhibitors eg Dorzolamide (Trusopt),
Brinzolamide (Azopt). Reduce aqueous production,
applied 2-3x daily
• Parasympathomimetic agents eg. Pilocarpine constrict
pupil-small pupil can cause visual problems. Apply
tds/qds. Now less commonly used
• Alpha-2 agonists eg brimonidine (Alphagan). Reduce
aqueous production and facilitate outflow. High allergy
rate (approx 10% local stinging and redness)
Medical treatment of glaucoma
• Combination drops – usually Timolol with one other eg.
+Bimatoprost = Ganfort
+Latanoprost = Xalacom
+Brimonidine = Combigan
+Dorzolamide = Cosopt
• Systemic carbonic anhydrase inhibitor – Acetazolamide
(Diamox) given IV or orally. Lowers IOP very effectively
but numerous side effects so usually used in emergency
treatment of very high IOPs
Surgical Treatment
• Laser iridotomy – YAG laser cuts holes in the peripheral
iris under LA, performed without opening eye surgically.
• Iridectomy – operation to remove a piece of the iris
periphery – most now treated with laser instead.
• Laser trabeculoplasty – Argon laser burns to the trabecular
meshwork in POAG. Only approx 60% patients respond
and effect usually wears off after about 3 years.
• Trabeculectomy – channel created through the sclera and
cornea allowing a new outflow for the aquous humour
under the conjunctiva – the “bleb” is seen under upper lid.
(Treat conjunctivitis early to prevent endophthalmitis).
Acute Closed Angle Glaucoma
• Best known type - dramatic
• Acute presentation - affected eye red and
painful
• Apposition of lens to back of iris prevents
aqueous flow from post chamber to anterior
chamber – most likely when semi-dilated in
dark- this pushes iris onto trabecular
meshwork preventing flow-rapid rise IOP
Symptoms of Acute Closed
Angle Glaucoma
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Pain
Redness
Vomiting
Blurred vision (oedematous cornea) –haloes
around lights (may give Hx of similar
attacks previously but settled when sleptdue to pupil constriction)
Risk groups
• Longsighted people - narrow anterior
chamber
• Elderly (larger lens)
• Commoner in women than men
Signs of Acute Closed Angle
Glaucoma
• VA impaired dependent on degree of corneal
oedema
• Eye red and tender to touch
• Hazy cornea
• Pupil semidilated and fixed to light (attack begins
like this then ischaemia fixes pupil)
• On gentle palpation - pressure asymmetry
• Hx important because all these signs subside after
attack
Management
• EMERGENCY to preserve sight
• Specialist treatment - hospital
• Diamox 500mg IV and Pilocarpine 4% drops if
not possible to get to hospital quickly
• Medical treatment first then surgical - hole made
in iris by surgery (iridectomy) or laser (iridotomy)
to restore flow
• Prevent anterior synechiae (between iris and
cornea)
Other types Glaucoma
• Post inflammation: Anterior uveitis-posterior synechiae
may block flow-ballooning iris and block trabecular
meshwork. Steroid drops may cause raised IOP-monitor
• Rubeotic: new vessel growth on iris - diabetes/ central
retinal vein occlusion. Vessels block trabecular meshworkdifficult to treat.
• Congenital: Abnormal trabecular meshwork development
• Post eye injury - red blood cells may block trabecular
meshwork
• Pseudoexfoliation syndrome (deposits of abnormal
proteins on the anterior lens capsule and inside the
trabecular meshwork) and pigment dispersion syndrome
(melanin deposits on the posterior surface of the cornea
and on the trabecular meshwork).
Retinal blood vessel blockage
Retinal artery obstruction,
- Blindness if >1hr
- amaurosis fugax < 1hr
- the cherry spot is the fovea pigment
Retinal vein obstruction
- commoner
- vascular disease e.g. hypertension
- glaucoma
Central Retinal Artery Occlusion
• Sudden painless visual loss
– May be complete
– HT/ IHD
• RAPD
• Cherry red spot, white infarcted retina
• Immediate referral to lower IOP
– Inx of underlying causes
– Longterm aspirin
Retinal artery occlusion
Central Retinal Vein Occlusion
• Sudden painless blurred vision
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VA reduced
BRVO VA may be OK but have field loss
May have RAPD
Haemorrhage and distended veins
• Refer within 24 hours
– ? hypertension/ glaucoma
– May develop rubeotic glaucoma
Retinal vein occlusion
Retinal Detachment
• Hx of floaters or flashes
• Curtain coming across vision
• Vision dependant on state of macula
• Field defect
• Greyish retina
• Refer same day for surgery
Diagrammatic retinal detachment
Maybe
- floaters
- no loss in acuity
- visual field change
What is the diagnosis?
Diabetic retinopathy
Normal Retina
Background retinopathy
Classifying diabetic eye disease
• Background diabetic retinopathy
– Blot haemorrhages, microaneurysms (dots), hard exudates
• Preproliferative retinopathy
– Cotton wool spots (swollen nerve fibres), >3 blots, beading
• Proliferative diabetic retinopathy
– New weak blood vessels that can grow into the vitreous gel + leak
• Maculopathy
– Macula area may become involved, peripheral vision preserved
Proliferative diabetic retinopathy
Post laser treatment
N.B.
Laser treatment
is generally not
painful other
than the
treatment of
new vessels.
S/E
Loss of
peripheral vision
Altered night
and colour
vision
Must inform
DVLA who may
require fields
test
Vitreous Haemorrhage
• Sudden onset black floaters impairing
vision
• Refer same day
• Need assessment for RD (B scan US if
visibility poor)
Giant Cell Arteritis
• Sudden visual loss with persistent headache or jaw
claudication
• RAPD
• Tender temporal artery, no pulsation
• Pale swollen disc if diagnosis late
• Refer immediately
– ESR/ CRP
– Biopsy
– Systemic steroids
Hypertensive Retinopathy
Grade 1 - Mild generalised retinal
arteriolar narrowing
Grade 2 – more severe arteriolar
narrowing and AV nipping
Grade 3 - Add cotton wool spots
(ischaemia distal to narrowing),
exudates (proximal to narrowing),
and haemorrhages
Grade 4 Add swollen optic disc
resembling papilloedema and macular
oedema
Grade 4 – Hypertensive retinopathy
Papilloedema
CAUSES
Blockage of ventricular system/ CSF absorption
Venous sinus thrombosis
S.O.L
Choroid plexus tumour
Idiopathic (B.I.H)
CRVO
Hypertension/ ischaemic optic neuropathy
Optic neuritis
Drugs (ethambutol, isoniazid, streptomycin)
Infiltrative (sarcoid, lymphoma, leukaemia)
Thyroid
Papilloedema
AMD Classification
• Characterised by deposition of small colloid
bodies (drusen) between the retinal pigment
epithelium and the underlying Bruch’s membrane
• Early AMD
– Few medium sized drusen
– Pigmentary abnormalities
• Intermediate AMD
>1 large drusen/numerous medium drusen
geographic atrophy (GA) that doses not extend
to the macular centre
Macular degeneration
Dry
Wet
•
AMD classification
• Advanced Dry AMD
– Non exudative/atrophic
– Drusen and GA extend
to the macular centre
– 20% of AMD related
severe vision loss
– Gradual vision loss
• Advanced Wet AMD
– Exudative /neovascular
– Choroidal
neovascularisation
– 10-15% overall
prevalence but 80% of
AMD related severe
visual loss
– Rapid vision loss over
days/weeks
Treatment of advanced wet AMD
• Referral for anti-VEGF (vascular endothelial
growth factor) treatment ie. intravitreal
ranibizumab (Lucentis - NICE approved June
2008)
• Assessed by slit lamp examination, fluorescein
angiography and OCT
• Minimum of 3 injections per eye one month apart
• Promising results particularly if referred early
with symptoms for <8/52
ANY QUESTIONS??
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QUESTION 1
A 78 YEAR OLD MALE PRESENTS WITH A
GRITTY, WATERY, RED, RIGHT EYE. YOU
NOTICE HIS LOWER EYELASHES ARE TURNED
IN. WHAT IS THE DIAGNOSIS?
a.
b.
c.
d.
e.
Viral conjunctivitis
Entropion
Iritis
Exotropia
Allergic conjunctivitis
QUESTION 1
Answer b = Entropion
Senile entropion affects the lower eyelid only
Treatment includes lubrication, surgery, botox
Learning point:
What is exotropia/ esotropia?
What is exophoria/ esophoria?
QUESTION 2
a.
b.
c.
d.
e.
A 60 YEAR OLD MALE SUDDENLY LOSES VISION
IN ONE EYE. THE RETINA LOOKS LIKE A
‘STORMY SUNSET’. WHAT IS THE DIAGNOSIS?
Occlusion of the central retinal artery
Occlusion of the central retinal vein
Vitreous haemorrhage
Retinal detachment
Branch occlusion of the central retinal vein
QUESTION 2
Answer b = central retinal vein occlusion
Sudden painless visual loss
Elderly
Hypertension/ chronic glaucoma
Stormy sunset because of haemorrhage and engorgement
QUESTION 3
A 63 YEAR OLD FEMALE PRESENTS WITH SUDDEN LOSS
OF VISION IN HER LEFT EYE. ON FURTHER QUESTIONING,
SHE STATES SHE ALSO HAS BEEN SUFFERING FROM A
‘HEADACHE’ OVER THAT EYE, AND TENDERNESS WHILE
COMBING HER HAIR. ON EXAMINATION YOU NOTICE A
TENDER HARD LEFT TEMPORAL ARTERY AND PALE
OPTIC DISCS. WHAT IS THE DIAGNOSIS?
a.
b.
c.
d.
e.
Migraine
Subdural bleed
Arterial embolism
Temporal arteritis
Transient ischaemic attack
QUESTION 3
Answer d = temporal arteritis
Oral prednisolone 40-60mg
If visual loss IV steroids are used
QUESTION 4
A 60 YEAR OLD MALE SUDDENLY LOSES HIS
VISION. ON EXAMINATION, THE RETINA
APPEARS PALE WITH A CHERRY RED SPOT AT
THE MACULA. WHAT IS THE DIAGNOSIS?
a.
b.
c.
d.
e.
Occlusion of the central retinal artery
Occlusion of the central retinal vein
Vitreous haemorrhage
Retinal detachment
Branch occlusion of the central retinal vein
QUESTION 4
Answer a = central retinal artery occlusion
Optic atrophy will cause permanent visual loss if occlusion
lasts for more than 1 hour
QUESTION 5
CONCERNING BLEPHARITIS, WHICH ONE OF THE
FOLLOWING IS TRUE?
a.
b.
c.
d.
e.
Topical chloramphenicol is the treatment of choice
Eyelid hygiene is first line treatment
It is an acute painful condition
Contact lenses may not be worn
Visual acuity is impaired
QUESTION 5
Answer b = eyelid hygiene
Warm wet compresses to soften crusts then cotton buds clean
and remove debris
Solution of baby shampoo/ bicarbonate of soda
Sometimes topical antibiotics
Extended course (6/52) oral antibiotics eg. doxycycline
QUESTION 6
WHICH ONE OF THE FOLLOWING FEATURES IS
NOT PRESENT IN DIABETIC PREPROLIFERATIVE DIABETIC RETINOPATHY?
a.
b.
c.
d.
e.
Microaneurysms
Blot haemorrhages
Cotton wool spots
Venous beading
Neovascularisation
QUESTION 6
Answer e = neovascularisation
BDR:
microaneurysms (dots), blot haemorrhages, hard exudate
Pre-proliferative: CWS, more than 3 blots, venous beading
Proliferative:
neovascularisation
Maculopathy: location not severity, hard exudates and other
‘background’ changes at the macula
QUESTION 7
A 25 YEAR OLD WOMAN PRESENTS WITH A ONE DAY HISTORY
OF A PAINFUL, RED LEFT EYE WHICH IS CONTINUALLY
STREAMING. ON EXAMINATION SHE IS PHOTOPHOBIC
AND FLUORESCEIN DEMONSTRATES A DENDRITIC
PATTERN OF STAINING. VISUAL ACUITY IS 6/6
BILATERALLY. WHAT IS THE MOST APPROPRIATE
MANAGEMENT?
a.
Topical steroids
b.
Lumbar puncture
c.
Subcutaneous sumatriptan
d.
Topical aciclovir
e.
Topical chloramphenicol
QUESTION 7
Answer d = topical aciclovir
Herpes simplex keratitis
Dendritic ulcer
Refer to ophthalmology
No topical steroids
QUESTION 8
A 47 YEAR OLD FEMALE WITH A HISTORY OF
RHEUMATOID ARTHRITIS PRESENTS WITH A
PAINFUL, RED LEFT EYE. VISUAL ACUITY IS
NORMAL. WHAT IS THE MOST LIKELY
DIAGNOSIS?
a. Scleritis
b. Episcleritis
c. Glaucoma
d. Anterior uveitis
e. Keratoconjunctivitis sicca
QUESTION 8
Answer a = scleritis
Scleritis is painful, episcleritis is not
Keratoconjunctivitis sicca is usually bilateral, itchy, dry
25% of rheumatoid patients will have eye manifestations:
Keratoconjunctivitis sicca
Episcleritis
Scleritis
Corneal ulceration
Keratitis
Steroid-induced cataracts
Chloroquine retinopathy
QUESTION 9
A 71 YEAR OLD FEMALE WITH DRY ARMD IS
REVIEWED. UNFORTUNATELY HER EYESIGHT
HAS DETERIORATED OVER THE PAST 6
MONTHS. SHE HAS NEVER SMOKED AND IS
TAKING ANTIOXIDANT SUPPLEMENTS. WHAT
IS THE MOST APPROPRIATE NEXT STEP?
a. Retinal transplants
b. Intravitreal ranibizumab
c. Explain no other medical therapies available
d. Photodynamic therapy
e. Photocoagulation
QUESTION 9
Answer c = no other medical therapies
Commonest form of blindness in UK
Most are over 60
Fhx
Smoking
Commoner in Caucasians
Female
QUESTION 10
A 20 YEAR OLD WOMAN NOTICES BRIGHT LINES OF LIGHT IN
BOTH VISUAL FIELDS FOLLOWED SHORTLY
AFTERWARDS BY PARTIAL LOSS OF HER VISION. HER
VISUAL SYMPTOMS RESOLVE AFTER ONE HOUR BUT SHE
HAS SLIGHT NAUSEA. WHAT IS THE MOST LIKELY
DIAGNOSIS?
a.
Acute glaucoma
b.
Migraine
c.
Optic neuritis
d.
Retinal detachment
e.
Vitreous detachment
QUESTION 10
Answer b = migraine
Typical picture of optic/ visual/ ophthalmic migraine
NB No headache
QUESTION 11
A 55 YEAR OLD WOMAN PRESENTS WITH
ERYTHEMA AND SWELLING OF THE MEDIAL
CANTHUS OF HER LEFT EYE WHICH HAS ALSO
BEEN WATERY. WHAT IS THE MOST LIKELY
DIAGNOSIS?
a. Blepharitis
b. Acute angle closure glaucoma
c. Meibomian cyst
d. Pinguecula
e. Dacrocystitis
QUESTION 11
Answer d = dacrocystitis
Infection of lacrimal sac
Systemic antibiotics (IV if associated periorbital cellulitis)
If recurrent may need dacrocystorrhinostomy (DCR)
Congenital lacrimal duct obstruction occurs in 5-10%
newborns and is bilateral in 20% of cases. The majority
resolve within the first year.