Q Q1 \C3 O

A 15-year -old boy presents to the GP surgery with some skin changes of
the neck. The mother reports that she first noticed a small area of skin
changes 3 months ago. Initially, she didn't think too much about it but
recently noticed that it has been getting bigger and more obvious, now
involving the skin covering almost half of the right side of the neck . On
examination, there is a large area of Small, yellow papules of 1- 5 mm in
diameter in a reticular pattern and coalescing at places into plaques.
The skin has a 'plucked-chicken' appearance. The boy reports no
problem with his vision.

What would you be the likely finding on fundoscopy?

Angioid retinal streaks

Lisch nodules

Cotton wool spots

Neovascularisation

Bone spicules

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 T U U T ^ • ••

large area of Small, yellow papules of 1-5 mm in

examination, there is a .
pattern and coalescing at places into plaques
diameter in a reticular no
a 'plucked -chicken ' appearance. The boy reports
The skin has
problem with his vision.

finding on fundoscopy?
What would you be the likely

Angioid retinal streaks

Lisch nodules

Cotton wool spots

Neovascularisation

Bone spicules

Angioid retinal streaks are a feature of pseudoxanthoma

elasticum
Importance: 50

Angioid streaks are small breaks in Bruch's membrane, an elastic tissue

containing membrane of the retina. It is a feature of pseudoxanthoma
elasticum. The earliest sign in pseudoxanthoma elasticum is the skin
changes. This patient likely has pseudoxanthoma elasticum.

Lisch nodules are features of neurofibromatosis.

Cotton wool spots and neovascularisation are both features of diabetic

retinopathy.

Bone spicules are seen in retinitis pigmentosa.

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Angioid retinal streaks

Angioid retinal streaks are seen on fundoscopy as irregular dark red

streaks radiating from the optic nerve head. They are caused by
degeneration, calcification and breaks in Bruch's membrane .

Causes
• pseudoxanthoma elasticum
• Ehler-Danlos syndrome
• Paget's disease
• sickle-cell anaemia
• acromegaly

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 Q2 p

Each one of the following is a cause of a mydriatic pupil, except:

Third nerve palsy

Atropine

Holmes-Adie pupil

Argyll-Robertson pupil

Traumatic iridoplegia

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Each one of the following is a cause of a mydriatic pupil, except:

Third nerve palsy

Atropine

Holmes-Adie pupil

Argyll-Robertson pupil

Traumatic iridoplegia

Argyll-Robertson pupil is one of the classic pupillary syndrome. It is

sometimes seen in neurosyphilis and is often said to be the prostitute's
pupil - accommodates but doesn't react. Another mnemonic used for
the Argyll-Robertson Pupil ( ARP) is Accommodation Reflex Present
( ARP) but Pupillary Reflex Absent (PRA)

Features
• small, irregular pupils
• no response to light but there is a response to accommodate

Causes
• diabetes mellitus
• syphilis

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Mydriasis

Causes of mydriasis (large pupil)

• third nerve palsy
• Holmes-Adie pupil
• traumatic iridoplegia
• phaeochromocytoma
• congenital

Drug causes of mydriasis

• topical mydriatics: tropicamide, atropine
• sympathomimetic drugs: amphetamines, cocaine
• anticholinergic drugs: tricyclic antidepressants

Anisocoria may result in apparent mydriasis, due to the difference with

the other pupil.

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G Q3 P ©
A 71-year -old man who has recently been diagnosed with macular
degeneration asks for advice regarding antioxidant dietary
supplements. Which one of the following may contraindicate the
prescription of such supplements?

Current smoker

Pernicious anaemia

Treated hypertension

History of depression

Previous episodes of tendonitis

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 Current smoker

Pernicious anaemia

Treated hypertension

History of depression

Previous episodes of tendonitis

Beta- carotene has been found to increase the risk of lung cancer and
hence antioxidant dietary supplements are not recommended for
smokers.

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Age related macular degeneration

Age- related macular degeneration is the most common cause of

blindness in the UK . Degeneration of the central retina (macula ) is the
key feature with changes usually bilateral . ARMD is characterised by
degeneration of retinal photoreceptors that results in the formation of
drusen which can be seen on fundoscopy and retinal photography.

Traditionally two forms of macular degeneration are seen:

• dry (90% of cases, geographic atrophy) macular degeneration:
characterised by drusen - yellow round spots in Bruch's membrane
• wet (10 % of cases, exudative, neovascular) macular degeneration:
characterised by choroidal neovascularisation . Leakage of serous
fluid and blood can subsequently result in a rapid loss of vision.
Carries worst prognosis

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Recently there has been a move to a more updated classification:
• early age-related macular degeneration (non-exudative, age-
related maculopathy): drusen and alterations to the retinal
pigment epithelium (RPE)
• late age-related macular degeneration (neovascularisation,
exudative)

Age-related macular degeneration (ARMD) is the commonest cause of

visual loss in elderly persons in the developed world. It affects 30- 50
million people worldwide.

Epidemiology
• population estimates suggest a male to female ratio of 1:2
• the average age of presentation is greater than 70 years of age

Risk factors
• Advancing age itself is the greatest risk factor for ARMD. The risk
of ARMD increases 3 fold for patients aged older than 75 years,
versus those aged 65-74.
• Smoking is another key risk factor in the development of ARMD,
current smokers are twice as likely as non-smokers to have ARMD
related visual loss, and ex- smokers have a slightly increased risk
of developing the condition, (OR 1.13).
• Family history is also a strong risk factor for developing ARMD.
First degree relatives of a sufferer of ARMD are thought to be four
times more likely to inherit the condition.
• Other risk factors for developing the condition include those
associated with increased risk of ischaemic cardiovascular
disease, such as hypertension, dyslipidaemia and diabetes
mellitus.

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Patients typically present with a subacute onset of visual loss with:
• a reduction in visual acuity particularly for near field objects
• difficulties in dark adaptation with an overall deterioration in vision
at night
• fluctuations in visual disturbance which may vary significantly
from day to day
• they may also suffer from photopsia, (a perception of flickering or
flashing lights), and glare around objects

Signs:
• distortion of line perception may be noted on Amsler grid testing
• fundoscopy reveals the presence of drusen, yellow areas of
pigment deposition in the macular area, which may become
confluent in late disease to form a macular scar.
• in wet ARMD well demarcated red patches may be seen which
represent intra-retinal or sub-retinal fluid leakage or haemorrhage.

Investigations:
• slit-lamp microscopy is the initial investigation of choice, to
identify any pigmentary, exudative or haemorrhagic changes
affecting the retina which may identify the presence of ARMD.
This is usually accompanied by colour fundus photography to
provide a baseline against which changes can be identified over
time.
• fluorescein angiography is utilised if neovascular ARMD is
suspected, as this can guide intervention with anti- VEGF therapy.
This may be complemented with indocyanine green angiography
to visualise any changes in the choroidal circulation.
• ocular coherence tomography is used to visualise the retina in
three dimensions, because it can reveal areas of disease which
aren't visible using microscopy alone.

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Treatment:
• the AREDS trial examined the treatment of dry ARMD in 3640
subjects. It showed that a combination of zinc with anti-oxidant
vitamins A,C and E reduced progression of the disease by around
one third. Patients with more extensive drusen seemed to benefit
most from the intervention. Treatment is therefore recommended
in patients with at least moderate category dry ARMD.
• Vascular endothelial growth factor, (VEGF) is a potent mitogen
and drives increased vascular permeability in patients with wet
ARMD. A number of trials have shown that use of anti-VEGF
agents can limit progression of wet ARMD and stabilise or reverse
visual loss. Evidence suggests that they should be instituted
within the first two months of diagnosis of wet ARMD if possible.
Examples of anti-VEGF agents include ranibizumab, bevacizumab
and pegaptanib,. The agents are usually administered by 4 weekly
injection.
• Laser photocoagulation does slow progression of ARMD where
there is new vessel formation, although there is a risk of acute
visual loss after treatment, which may be increased in patients
with sub-foveal ARMD. For this reason anti-VEGF therapies are
usually preferred.

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G Q4 O
A 67-year-old man who is known to have raised intraocular pressure is
prescribed dorzolamide eye drops. What is the mechanism of action of
this drug?

Prostaglandin analogue

Alpha 2-adrenoceptor agonist

Carbonic anhydrase inhibitor

Muscarinic receptor agonist

Beta -blocker

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 Carbonic anhydrase inhibitor

Muscarinic receptor agonist

Beta-blocker

Dorzolamide - carbonic anhydrase inhibitor

Importance: 50

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Primary open- angle glaucoma: management

Glaucomas are optic neuropathies associated with raised intraocular

pressure (IOP). They can be classified based on whether the peripheral
iris is covering the trabecular meshwork, which is important in the
drainage of aqueous humour from the anterior chamber of the eye. In
open-angle glaucoma, the iris is clear of the meshwork. The trabecular
network functionally offers an increased resistance to aqueous outflow,
causing increased IOP.

Epidemiology
• affects 0.5% of people over the age of 40
• the prevalence increases with age up to 10% over the age of 80
years
• affects males and females equally

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Causes
• increasing age
• genetics: first degree relatives of an open-angle glaucoma patient
have a 16% chance of developing the disease

Symptoms:
• characterised by a slow rise in intraocular pressure: symptomless
for a long period
• typically present following an ocular pressure measurement
during a routine examination by an optometrist

Signs:
• increased intraocular pressure
• visual field defect
• pathological cupping of the optic disc i

Case finding:
• optic nerve head damage visible under the slit lamp
• visual field defect
• IOP > 24 mmHg as measured by Goldmann-type applanation
tonometry
• if suspected full investigations are performed

Diagnosis:
• Case finding and provisional diagnosis is done by an optometrist
• Referral to the ophthalmologist is done via the GP
• Final diagnosis is done by investigations as below

Investigations:
• automated perimetry to assess visual field
• slit lamp examination with pupil dilatation to assess optic neve
and fundus for a baseline
• applanation tonometry to measure IOP
• central corneal thickness measurement
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Investigations:
• automated perimetry to assess visual field
• slit lamp examination with pupil dilatation to assess optic neve
and fundus for a baseline
• applanation tonometry to measure IOP
• central corneal thickness measurement
• gonioscopy to assess peripheral anterior chamber configuration
and depth
• Assess risk of future visual impairment, using risk factors such as
IOF! central corneal thickness (CCT ), family history life expectancy

The majority of patients with primary open-angle glaucoma are

managed with eye drops. These aim to lower intra-ocular pressure
which in turn has been shown to prevent progressive loss of visual field.

NICE guidelines:
• first line: prostaglandin analogue (PGA) eyedrop
• second line: beta-blocker, carbonic anhydrase inhibitor, or
sympathomimetic eyedrop
• if more advanced: surgery or laser treatment can be tried2

Reassessment
• important to exclude progression and visual field loss
• needs to be done more frequently if: IOP uncontrolled, the patient
is high risk, or there is progression

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 Mode of
Medication action Notes

Prostaglandin Increases Once daily

analogues (e.g. uveoscleral administration
latanoprost) outflow
Adverse effects include
brown pigmentation of
the iris, increased
eyelash length

Beta-blockers (e.g. Reduces Should be avoided in

timolol, betaxolol) aqueous asthmatics and patients
production with heart block

Sympathomimetics Reduces Avoid if taking MAOI or

(e.g. brimonidine, an aqueous tricyclic antidepressants
alpha 2-adrenoceptor production and
agonist) increases Adverse effects include
outflow hyperaemia

Carbonic anhydrase Reduces Systemic absorption

inhibitors (e.g. aqueous may cause
Dorzolamide) production sulphonamide-like
reactions

Miotics (e.g. Increases Adverse effects

pilocarpine, a uveoscleral included a constricted
muscarinic receptor outflow pupil, headache and
agonist) blurred vision

Surgery in the form of a trabeculectomy may be considered in refractory

cases.

Ala
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Q Q5 |a ©
A 35-year -old man presents with visual problems. He has had very poor
vision in the dark for a long time but is now worried as he is developing
'tunnel vision'. He states his grandfather had a similar problem and was
registered blind in his 50's. What is the most likely diagnosis?

Leber 's congenital amaurosis

Vitelliform macular dystrophy

Central serous retinopathy

Primary open angle glaucoma

Retinitis pigmentosa

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 Retinitis pigmentosa

Retinitis pigmentosa - night blindness + tunnel vision

Importance: 50

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Retinitis pigmentosa

Retinitis pigmentosa primarily affects the peripheral retina resulting in

tunnel vision

Features
• night blindness is often the initial sign
• tunnel vision due to loss of the peripheral retina (occasionally
referred to as funnel vision)
• fundoscopy: black bone spicule- shaped pigmentation in the
peripheral retina, mottling of the retinal pigment epithelium

Associated diseases
• Refsum disease: cerebellar ataxia, peripheral neuropathy,
deafness, ichthyosis
• Usher syndrome
• abetalipoproteinemia
• Lawrence- Moon-Biedl syndrome
• Kearns-Sayre syndrome
• Alport 's syndrome

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G Q6 G
A 62-year-old man presents with sudden visual loss in his right eye. He
is otherwise asymptomatic. Which one of the following conditions is
least likely to be responsible?

Ischaemic optic neuropathy

Occlusion of the central retinal vein

Occlusion of the central retinal artery

Optic neuritis

Vitreous haemorrhage

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 Occlusion of the central retinal vein

Occlusion of the central retinal artery

Optic neuritis

Vitreous haemorrhage

Whilst optic neuritis can present with sudden loss, in this 62-year-old
man it is the least likely option. Typically there is a unilateral decrease in
visual acuity over hours or days. There may be poor discrimination of
colours and eye pain on movement

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Sudden loss of vision

Sudden loss is a frightening symptom for patients. It may represent an

ongoing issue or only be temporary. The term transient monocular
visual loss (TVML) describes a sudden, transient loss of vision that
lasts less than 24 hours.

The most common causes of a sudden painless loss of vision are as

follows:
• ischaemic / vascular (e.g. thrombosis, embolism, temporal arteritis
etc). This includes recognised syndromes e. g. occlusion of central
retinal vein and occlusion of central retinal artery
• vitreous haemorrhage
• retinal detachment
• retinal migraine

Ischaemic / vascular
• often referred to as 'amaurosis fugax '
• wide differential including large artery disease (atherothrombosis,
embolus, dissection), small artery occlusive disease (anterior
ischemic optic neuropathy, vasculitis e. g. temporal arteritis),
venous disease and hypoperfusion
• may represent a form of transient ischaemic attack (TIA). It
should therefore be treated in a similar fashion, with aspirin
300mg being given
• altitudinal field defects are often seen: 'curtain coming down'
• ischaemic optic neuropathy is due to occlusion of the short
posterior ciliary arteries, causing damage to the optic nerve

Central retinal vein occlusion

• incidence increases with age, more common than arterial
occlusion
• causes: glaucoma, polycythaemia, hypertension
• severe retinal haemorrhages are usually seen on fundoscopy
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Central retinal artery occlusion
• due to thromboembolism (from atherosclerosis) or arteritis (e.g.
temporal arteritis)
• features include afferent pupillary defect, 'cherry red' spot on a
pale retina

Vitreous haemorrhage
• causes: diabetes, bleeding disorders, anticoagulants
• features may include sudden visual loss, dark spots

Retinal detachment
• features of vitreous detachment, which may precede retinal
detachment, include flashes of light or floaters ( see below)

Differentiating posterior vitreous detachment, retinal detachment and

vitreous haemorrhage

Posterior
vitreous Vitreous
detachment Retinal detachment haemorrhage

Flashes of light Dense shadow that Large bleeds

(photopsia) - in starts peripherally cause sudden
the peripheral progresses towards the visual loss
field of vision central vision Moderate bleeds
Floaters, often on A veil or curtain over the may be described
the temporal side field of vision as numerous dark
of the central Straight lines appear spots
vision curved Small bleeds may
Central visual loss cause floaters

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Q Q7 P ©
A 68-year - old man with a history of type 2 diabetes mellitus presents
with worsening eye sight . Mydriatic drops are applied and fundoscopy
reveals pre-proliferative diabetic retinopathy. A referral to
ophthalmology is made. Later in the evening whilst driving home he
develops pain in his left eye associated with decreased visual acuity.
What is the most likely diagnosis?

Keratitis secondary to mydriatic drops

Proliferative diabetic retinopathy

Acute angle closure glaucoma

Central retinal artery occlusion

Vitreous haemorrhage

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 Proliferative diabetic retinopathy

Acute angle closure glaucoma

Central retinal artery occlusion

Vitreous haemorrhage

Mydriatic drops are a known precipitant of acute angle closure

glaucoma. This scenario is more common in exams than clinical
practice.

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Acute angle closure glaucoma

Glaucoma is a group of disorders characterised by optic neuropathy

due, in the majority of patients, to raised intraocular pressure (IOP). It is
now recognised that a minority of patients with raised IOP do not have
glaucoma and vice versa.

In acute angle-closure glaucoma ( AACG) there is a rise in IOP

secondary to an impairment of aqueous outflow. Factors predisposing
to AACG include:
• hypermetropia (long-sightedness)
• pupillary dilatation
• lens growth associated with age

Features
severe pain: may be ocular or headache
decreased visual acuity
symptoms worse with mydriasis (e. g. watching TV in a dark room)
hard, red-eye
haloes around lights
semi-dilated non-reacting pupil
corneal oedema results in dull or hazy cornea
systemic upset may be seen, such as nausea and vomiting and
even abdominal pain

Management
• urgent referral to an ophthalmologist
• management options include reducing aqueous secretions with
acetazolamide and inducing pupillary constriction with topical
pilocarpine

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© Q8 ©
A 47-year -old female with a history of rheumatoid arthritis presents with
a painful and red left eye. Visual acuity is normal. Fundoscopy is also
unremarkable. What is the most likely diagnosis?

Scleritis

Episcleritis

Glaucoma

Anterior uveitis

Keratoconjunctivitis sicca

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 Episcleritis

Glaucoma

Anterior uveitis

Keratoconjunctivitis sicca

Scleritis is painful, episcleritis is not painful

Importance: 50

A key way to discriminate between scleritis and episcleritis is the

presence of pain. Keratoconjunctivitis sicca is usually bilateral and
associated more with dryness, burning and itch

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Rheumatoid arthritis: ocular manifestations

Ocular manifestations of rheumatoid arthritis are common, with 25% of

patients having eye problems

Ocular manifestations
• keratoconjunctivitis sicca (most common)
• episcleritis (erythema)
• scleritis (erythema and pain)
• corneal ulceration
• keratitis

Iatrogenic
• steroid-induced cataracts
• chloroauine retinopathy
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G Q9 pa O
A 70-year -old man is investigated for blurred vision. Fundoscopy reveals
drusen, retinal epithelial and macular neovascularisation. A diagnosis of
age related macular degeneration is suspected. What is the most
appropriate next investigation?

Vitreous fluid sampling

MRI orbits

Ocular tonometry

Fluorescein angiography

Kinetic perimetry

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Reference ranges v

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MRI orbits

Ocular tonometry

Fluorescein angiography

Kinetic perimetry

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Q Q10 P ©
A 49-year - old male patient presents with acute onset loss of vision in
the right eye preceded by a 2-hour history of progressively enlarging
dark spots in his vision. He has type-1 diabetes mellitus for over 15
years and has been poorly controlled.

What is the most likely diagnosis

Ocular migraine

Retinal detachment

Vitreous haemorrhage

Ischaemic optic neuropathy

Retinal artery occlusion

Submit answer

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 Retinal detachment

Vitreous haemorrhage

Ischaemic optic neuropathy

Retinal artery occlusion

Vitreous haemorrhage is a cause of sudden painless loss of

vision in the context of diabetic retinopathy
Importance: 50

Vitreous haemorrhage is a cause of sudden painless loss of vision in

the context of diabetic retinopathy. It usually presents with dark spots
(scotoma) in the vision initially. This man is likely to have diabetic
retinopathy.

Ocular migraine does not usually cause visual loss.

Retinal detachment usually presents with dense shadow over vision

progressing centrally.

Even though this man has ischaemic risk factors, ischaemic optic
neuropathy does not usually present with dark spots.

Retinal artery occlusion does not usually present with dark spots.

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o Q11 pj ©
Which one of the following best describes the action of latanoprost in
the management of primary open-angle glaucoma?

Carbonic anhydrase inhibitor

Reduces aqueous production + increases outflow

Opens up drainage pores

Increases uveoscleral outflow

Reduces aqueous production

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Reduces aqueous production + increases outflow

Opens up drainage pores

Increases uveoscleral outflow

Reduces aqueous production

Latanoprost is a prostaglandin analog used in glaucoma. It works

by increasing uveoscleral outflow
Important for me Less important

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Q Q12 P ©
A 67-year - old male patient presents to the ophthalmology emergency
department with sudden onset painless loss of vision in the right eye.
He describes it as having a dense shadow over the vision, progressing
from periphery to the centre. He has no past medical history of note.

What is the most likely diagnosis?

Retinal detachment

Vitreous haemorrhage

Central retinal artery occlusion

Central retinal vein occlusion

Ischaemic optic neuropathy

Submit answer

Reference ranges v

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 Retinal detachment

Vitreous haemorrhage

Central retinal artery occlusion

Central retinal vein occlusion

Ischaemic optic neuropathy

Retinal detachment is a cause of sudden painless loss of vision. It

is characterised by a dense shadow starting peripherally and
progressing centrally
Importance: 50

Retinal detachment is a cause of sudden painless loss of vision. It is

characterised by a dense shadow starting peripherally and progressing
centrally.

Vitreous haemorrhage usually presents with dark spots.

Central retinal artery occlusion and central retinal vein occlusion does
not usually present with progressing dense shadow.

This man's lack of ischaemic risk factors makes ischaemic optic

neuropathy less likely.

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© Q13 ©
A 65-year -old man with a known history of Paget 's disease is noted to
have irregular dark red lines radiating from the optic nerve. What is the
likely diagnosis?

Retinitis pigmentosa

Optic neuritis

Angioid retinal streaks

Choroidoretinitis

Malignant hypertension

Submit answer

Reference ranges v

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 Optic neuritis

Angioid retinal streaks

Choroidoretinitis

Malignant hypertension

This is a typical description of angioid retinal streaks which are

associated with Paget's disease

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G Q14 |a ©
A 24-year -old man who has a family history of retinitis pigmentosa is
reviewed in the ophthalmology clinic. He reports worsening vision over
the past few months. During fundoscopy, which of the following
findings with most support a diagnosis of retinitis pigmentosa ?

Pigmented scrambled egg appearance concentrated around the

macula

Central irregular pigmentation with bull's eye maculopathy

Black bone spicule-shaped pigmentation in the peripheral retina

Drusen with haemorrhagic atrophic changes concentrated at the

periphery of the retina

Pigmented choroidal neovascularisation throughout the retina

Submit answer

Reference ranges v

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Central irregular pigmentation with bull's eye maculopathy

Black bone spicule-shaped pigmentation in the peripheral retina

Drusen with haemorrhagic atrophic changes concentrated at the

periphery of the retina

Pigmented choroidal neovascularisation throughout the retina

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© Q15 P O
A 34-year - old female presents with fatigue and frequent headaches. On
examination of her eyes, you notice an abnormality during the swinging
light test. As the light is moved from the left to the right eye both pupils
appear to dilate. The pupillary response to accommodation is normal
bilaterally. Fundoscopy is also normal bilaterally. Her past medical
history includes type one diabetes and hypertension. What is the most
likely explanation for this patients ' signs ?

Raised intracranial pressure

Diabetic eye disease

Holmes- Adie's pupil on the right

Marcus-Gunn Pupil (relative afferent pupillary defect) on the right

Argyll Robertson pupil on the right

Submit answer

Reference ranges v

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 Marcus-Gunn Pupil (relative afferent pupillary defect) on the right

Argyll Robertson pupil on the right

Marcus Gunn pupil (relative afferent pupillary defect) is diagnosed

during the swinging light test. If there is damage to the afferent pathway
(retina or optic nerve) of one eye, the pupil of that affected eye will
abnormally dilate when a light is shone into it. This is because the
consensual pupillary relaxation response from the healthy eye will
dominate. Marcus Gunn pupil can be found in patients with multiple
sclerosis. Therefore, given the history, this should be ruled out in this
patient.

The history and examination findings in the question are not typical of
raised intracranial pressure. Raised intracranial pressure may present
with symptoms such as a headache, vomiting, bilateral blurred vision
and seizures. Patients with increased intracranial pressure often have
bilateral papilloedema on fundoscopy.

Although the history states the female is diabetic, there are typically
normal pupillary light responses in patients with diabetic eye disease.
Furthermore, with diabetic eye disease, you would expect to see some
abnormality on fundoscopy.

Holmes-Aide's pupil is a dilated pupil which poorly (if at all) reacts to

direct light, however, slowly reacts to accommodation. This does not
correlate to the history.

The information given in the question above does not suggest Argyll
Robertson pupil. This is characterised by a constricted pupil that does
not respond to light but responds to accommodation. It is usually
bilateral and is often associated with neurosyphilis.

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Relative afferent pupillary defect

Also known as the Marcus-Gunn pupil, a relative afferent pupillary

defect is found by the 'swinging light test'. It is caused by a lesion
anterior to the optic chiasm i.e. optic nerve or retina

Finding
• the affected and normal eye appears to dilate when light is shone
on the affected

Causes
• retina: detachment
• optic nerve: optic neuritis e.g. multiple sclerosis

Pathway of pupillary light reflex

-
• afferent: retina optic nerve
midbrain
- lateral geniculate body -
• efferent: Edinger-Westphal nucleus (midbrain)
nerve
- oculomotor

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Q Q16 P C
A 65-year -old male who has a new diagnosis of giant ceil arteritis has
had a positive relative afferent pupillary defect (RAPD) in his left eye on
examination.

Which of the following describes the finding of RAPD in this man?

The right eye appears to dilate when light is shone on the right
eye

The left eye appears to dilate when light is shone on the left eye

The left and right eye appears to dilate when light is shone on the
left eye

The left and right eye appears to dilate when light is shone on the
right eye

The left and right eye appears to constrict when light is shone on
the left eye

Submit answer

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 The left eye appears to dilate when light is shone on the left eye

The left and right eye appears to dilate when light is shone on the
left eye

The left and right eye appears to dilate when light is shone on the
right eye

The left and right eye appears to constrict when light is shone on the
left eye

A relative afferent pupillary defect is when the affected and

normal eye appears to dilate when light is shone on the affected
eye
Importance: 50

A RAPD is caused by differences between the two eyes in the afferent

pathway due to retinal or optic nerve disease. This leads to reduced
constriction, hence appears as dilation, of both pupils when light is
shone from the unaffected eye to the affected eye.

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© Q17 P O
An 84-year -old man presents with loss of vision in his left eye since the
morning. He is otherwise asymptomatic and of note has had no
associated eye pain or headaches. His past medical history includes
ischaemic heart disease but he is otherwise well. On examination he
has no vision in his left eye. The left pupil responds poorly to light but
the consensual light reaction is normal. Fundoscopy reveals a red spot
over a pale and opaque retina. What is the most likely diagnosis?

Vitreous haemorrhage

Retinal detachment

Ischaemic optic neuropathy

Central retinal vein occlusion

Central retinal artery occlusion

Submit answer

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 Ischaemic optic neuropathy

Central retinal vein occlusion

Central retinal artery occlusion

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Central retinal artery occlusion

Central retinal artery occlusion

• causes sudden unilateral visual loss
• due to thromboembolism (from atherosclerosis) or arteritis (e.g.
temporal arteritis)
• features include afferent pupillary defect, 'cherry red' spot on a
pale retina

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o Q18 |a o
A 71-year -old female with dry age-related macular degeneration is
reviewed. Unfortunately her eyesight has deteriorated over the past six
months. She has never smoked and is taking antioxidant supplements.
What is the most appropriate next step?

Retinal transplant

Intravitreal ranibizumab

Explain no other medical therapies currently available

Photodynamic therapy

Photocoagulation

Submit answer

Reference ranges v

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Intravitreal ranibizumab

Explain no other medical therapies currently available

Photodynamic therapy

Photocoagulation

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 Q19

Which one of the following is associated with heterochromia in

congenital disease?

Holmes- Adie pupil

Third nerve palsy

Sixth nerve palsy

Argyll-Robertson pupil

Horner 's syndrome

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-
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Third nerve palsy

Sixth nerve palsy

Argyll -Robertson pupil

Horner 's syndrome

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 Next question >
Horner 's syndrome

Features
• miosis (small pupil)
• ptosis
• enophthalmos* (sunken eye)
• anhidrosis (loss of sweating one side)

Distinguishing between causes

• heterochromia (difference in iris colour) is seen in congenital
Horner 's
• anhidrosis: see below

Pre- ganglionic Post - ganglionic

Central lesions lesions lesions

Anhidrosis of the face, Anhidrosis of No anhidrosis

arm and trunk the face

Stroke Pancoast 's Carotid artery

Syringomyelia tumour dissection
Multiple sclerosis Thyroidectomy Carotid aneurysm
Tumour Trauma Cavernous sinus
Encephalitis Cervical rib thrombosis
Cluster headache

*in reality the appearance is due to a narrow palpebral aperture rather

than true enophthalmos

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Q Q 20 P

A 73-year - old lady presents with visual loss. She describes sudden
onset flashes and floaters in her right eye.

She is short-sighted and has worn glasses since her early teens. She
has a background of hypertension, recurrent DVTs and osteoporosis.

Medication history includes amlodipine 5mg OD, apixaban 2.5mg BD

and alendronic acid 70mg once weekly.

On examination, visual acuity is 6 / 12 in the right eye. Fundoscopy is

unremarkable with a normal optic disc and retinal vessels.

What is the most likely diagnosis?

Acute angle closure glaucoma

Central retinal vein occlusion

Giant cell arteritis

Posterior vitreous detachment

Vitreous haemorrhage

Submit answer

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 Giant cell arteritis

Posterior vitreous detachment

Vitreous haemorrhage

Flashes + floaters are most commonly caused by a posterior

vitreous detachment
Importance : 50

Flashes and floaters are commonly caused by a posterior vitreous

detachment (PVD), where the vitreous shrinks and pulls away from the
retina. About 10% of patients with PVD develop a retinal tear, which is
an important risk factor for a retinal detachment. These patients should
therefore be seen by an ophthalmologist within 24 hours.

Vitreous haemorrhage can be associated with floaters but diffuse

haemorrhage in the vitreous cavity is likely to obscure the view of the
retina on fundoscopy.

Central retinal vein occlusion does not typically present with flashes or
floaters and vessels on fundoscopy are likely to appear tortuous with
flame-shaped haemorrhages, meaning a PVD is more likely in this
scenario.

Giant cell arteritis does not cause flashes or floaters. On fundoscopy,

you would expect to see signs of papilloedema.

Acute angle closure glaucoma does not cause flashes or floaters. It is

more likely to present in hypermetropic (long-sighted) patients.

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Posterior vitreous detachment

Posterior vitreous detachment is the separation of the vitreous

membrane from the retina. This occurs due to natural changes to the
vitreous fluid of the eye with ageing. Posterior vitreous detachment is a
common condition that does not cause any pain or loss of vision.
However, rarely the separation of the vitreous membrane can lead to
tears and detachment of the retina. It is important to rule out retinal
tears or retinal detachment in anyone with suspected posterior vitreous
detachment, as they may result in permanent loss of vision.

Epidemiology:
• Occur in over 75% of people over the age of 65
• More common in females

Risk factors:
• As people age, the vitreous fluid in the eye becomes less viscous,
and thus, does not hold its shape as well. Therefore, it pulls the
vitreous membrane away from the retina towards the centre of the
eye.
• Highly myopic (near-sighted) patients are also at increased risk of
developing posterior vitreous detachment earlier in life. This is
because the myopic eye has a longer axial length than an
emmetropic eye.

Symptoms:
• The sudden appearance of floaters (occasionally a ring of floaters
temporal to central vision)
• Flashes of light in vision
• Blurred vision
• Cobweb across vision
• The appearance of a dark curtain descending down vision (means
that there is also retinal detachment)

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Signs:
• Weiss ring on ophthalmoscopy (the detachment of the vitreous
membrane around the optic nerve to form a ring-shaped floater).

Investigations:
• All patients with suspected vitreous detachment should be
examined by an ophthalmologist within 24hours to rule out retinal
tears or detachment.

Management :
• Posterior vitreous detachment alone does not cause any
permanent loss of vision. Symptoms gradually improve over a
period of around 6 months and therefore no treatment is
necessary.
• If there is an associated retinal tear or detachment the patient will
require surgery to fix this.

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Q Q 21 c
A 67-year -old man presents as he has developed a painful blistering
rash around his right eye. On examination a vesicular rash covering the
right trigeminal nerve dermatome is seen. Currently he has no eye
symptoms or signs. Which one of the following is most likely to predict
future eye involvement ?

Presence of the rash on the tip of his nose

Smoking history

Increasing age

Previous courses of corticosteroids

Presence of the rash in the ear canal

Submit answer

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A 67-year -old man presents as he has developed a painful blistering
rash around his right eye. On examination a vesicular rash covering the
right trigeminal nerve dermatome is seen. Currently he has no eye
symptoms or signs. Which one of the following is most likely to predict
future eye involvement ?

Presence of the rash on the tip of his nose

Smoking history

Increasing age

Previous courses of corticosteroids

Presence of the rash in the ear canal

This is Hutchinson's sign which is strongly predictive for ocular

involvement .

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 Next question

Herpes zoster ophthalmicus

Herpes zoster ophthalmicus (HZO) describes the reactivation of the

varicella-zoster virus in the area supplied by the ophthalmic division of
the trigeminal nerve. It accounts for around 10% of case of shingles.

Features
• vesicular rash around the eye, which may or may not involve the
actual eye itself
• Hutchinson's sign: rash on the tip or side of the nose. Indicates
nasociliary involvement and is a strong risk factor for ocular
involvement

Management
• oral antiviral treatment for 7-10 days
o ideally started within 72 hours
o intravenous antivirals may be given for very severe infection
or if the patient is immunocompromised
° topical antiviral treatment is not given in HZO
• topical corticosteroids may be used to treat any secondary
inflammation of the eye
• ocular involvement requires urgent ophthalmology review

Complications
• ocular: conjunctivitis, keratitis, episcleritis, anterior uveitis
• ptosis
• post-herpetic neuralgia

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 Q 22 P

Which one of the following features is not characteristic of optic

neuritis?

Eye pain worse on movement

Relative afferent pupillary defect

Poor discrimination of colours, 'red desaturation'

Sudden onset of visual loss

Central scotoma

Submit answer

Reference ranges >

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^ .
- , .nJI
4a $, a
 Sudden onset of visual loss

Central scotoma

Visual loss typically occurs over days rather than hours. Sudden visual
loss due to optic neuritis is very unusual.

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Optic neuritis

Causes
• multiple sclerosis
• diabetes
• syphilis

Features
• unilateral decrease in visual acuity over hours or days
• poor discrimination of colours, 'red desaturation'
• pain worse on eye movement
• relative afferent pupillary defect
• central scotoma

Management
• high-dose steroids
• recovery usually takes 4- 6 weeks

Prognosis
• MRI: if > 3 white-matter lesions, 5-year risk of developing multiple
sclerosis is c. 50%

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G Q 23 ©
Which one of the following causes of Horner 's syndrome is due to a
lesion in the post - ganglionic part of the nerve supply?

Internal carotid aneurysm

Stroke

Syringomyelia

Pancoast 's tumour

Thyroidectomy

Submit answer

Reference ranges >/

CamScanner -j
Which one of the following causes of Horner 's syndrome is due to a
lesion in the post-ganglionic part of the nerve supply?

Internal carotid aneurysm

Stroke

Syringomyelia

Pancoast 's tumour

Thyroidectomy

Horner 's syndrome - anhydrosis determines site of lesion:

• head, arm, trunk = central lesion: stroke, syringomyelia
• just face = pre-ganglionic lesion: Pancoast's, cervical rib
• absent = post-ganglionic lesion: carotid artery
Importance: 50

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 Next question >

Horner's syndrome

Features
• miosis (small pupil)
• ptosis
• enophthalmos* (sunken eye)
• anhidrosis (loss of sweating one side)

Distinguishing between causes

• heterochromia (difference in iris colour) is seen in congenital
Horner 's
• anhidrosis: see below

Pre- ganglionic Post- ganglionic

Central lesions lesions lesions

Anhidrosis of the face, Anhidrosis of No anhidrosis

arm and trunk the face

Stroke Pancoast 's Carotid artery

Syringomyelia tumour dissection
Multiple sclerosis Thyroidectomy Carotid aneurysm
Tumour Trauma Cavernous sinus
Encephalitis Cervical rib thrombosis
Cluster headache

*in reality the appearance is due to a narrow palpebral aperture rather

than true enophthalmos

Next question >

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Q Q 24 P3 ©
A 64-year-old woman with type 2 diabetes mellitus presents as she has
started to bump into things since the morning. Over the previous two
days she had noticed some ' floating spots in her eyes'. Examination
reveals she has no vision in her right eye. The red reflex on the right side
is difficult to elicit and you are unable to visualise the retina on the right
side during fundoscopy. Examination of the left fundus reveals changes
consistent with pre-proliferative diabetic retinopathy. What is the most
likely diagnosis?

Occlusion of central retinal vein

Vitreous haemorrhage

Proliferative retinopathy

Cataract

Retinal detachment

Submit answer

Reference ranges v

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 Vitreous haemorrhage

Proliferative retinopathy

Cataract

Retinal detachment

The history of diabetes, complete loss of vision in the affected eye and
inability to visualise the retina point towards a diagnosis of vitreous
haemorrhage. Please see the table below for help in differentiating
retinal detachment from vitreous haemorrhage.

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© Q 25 p ©
Which one of the following statements regarding the Holmes- Adie pupil
is incorrect?

May be associated with absent ankle/ knee reflexes

Bilateral in 80% of cases

It is a benign condition

Slowly reactive to accommodation but very poorly (if at all) to

light

Causes a dilated pupil

Submit answer

Reference ranges v

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 Bilateral in 80% of cases

It is a benign condition

Slowly reactive to accommodation but very poorly (if at all) to light

Causes a dilated pupil

The Holmes-Adie pupil is unilateral, rather than bilateral, in 80% of

patients

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Holmes- Adie pupil

Holmes- Adie pupil is a benign condition most commonly seen in

women. It is one of the differentials of a dilated pupil.

Overview
• unilateral in 80% of cases
• dilated pupil
• once the pupil has constricted it remains small for an abnormally
long time
• slowly reactive to accommodation but very poorly (if at all) to light

Holmes- Adie syndrome

• association of Holmes-Adie pupil with absent ankle/knee reflexes

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o Q 26 ©
A 64-year-old woman presents with bilateral sore eyelids. She also
complains of her eyes being dry all the time. On examination her eyelid
margins are erythematous at the margins but are not swollen. Of the
given options, what is the most appropriate initial management ?

Topical chloramphenicol + mechanical removal of lid debris

Hot compresses + topical steroids

Topical chloramphenicol + topical steroids

Hot compresses + mechanical removal of lid debris

Topical chloramphenicol + hot compresses

Submit answer

Reference ranges v

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 Hot compresses + topical steroids

Topical chloramphenicol + topical steroids

Hot compresses + mechanical removal of lid debris

Topical chloramphenicol + hot compresses

1 st line of treatment for blepharitis is hot compresses

Importance: 50

Artificial tears may also be given for symptom relief of blepharitis

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 Next question >
Blepharitis

Blepharitis is inflammation of the eyelid margins. It may due to either

meibomian gland dysfunction (common, posterior blepharitis) or
seborrhoeic dermatitis/ staphylococcal infection (less common, anterior
blepharitis). Blepharitis is also more common in patients with rosacea

The meibomian glands secrete oil on to the eye surface to prevent rapid
evaporation of the tear film. Any problem affecting the meibomian
glands (as in blepharitis) can hence cause drying of the eyes which in
turns leads to irritation

Features
• symptoms are usually bilateral
• grittiness and discomfort, particularly around the eyelid margins
• eyes may be sticky in the morning
• eyelid margins may be red. Swollen eyelids may be seen in
staphylococcal blepharitis
• styes and chalazions are more common in patients with
blepharitis
• secondary conjunctivitis may occur

Management
• softening of the lid margin using hot compresses twice a day
• 'lid hygiene' - mechanical removal of the debris from lid margins
o cotton wool buds dipped in a mixture of cooled boiled water
and baby shampoo is often used
° an alternative is sodium bicarbonate, a teaspoonful in a cup
of cooled water that has recently been boiled
• artificial tears may be given for symptom relief in people with dry
eyes or an abnormal tear film

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Q Q 27 P ©
A 54-year -old man with type 2 diabetes mellitus is found on annual
review to have new vessel formation at the optic disc. Visual acuity in
both eyes is not affected (6 / 9). Blood pressure isl 55 / 84 mmHg.

HbA 1 c 68 mmol/ mol (8.4%)

What is the most important intervention in this patient ?

Follow-up ophthalmoscopy in 3 months

Add aspirin

Blood pressure control

Tight glycaemic control

Laser therapy

Submit answer

Reference ranges v

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 Tight glycaemic control

Laser therapy

This patient has proliferative diabetic retinopathy and urgent referral to

an ophthalmologist for panretinal photocoagulation is indicated

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Diabetic retinopathy

Diabetic retinopathy is the most common cause of blindness in adults

aged 35- 65 years-old. Hyperglycaemia is thought to cause increased
retinal blood flow and abnormal metabolism in the retinal vessel walls.
This precipitates damage to endothelial cells and pericytes

Endothelial dysfunction leads to increased vascular permeability which

causes the characteristic exudates seen on fundoscopy. Pericyte
dysfunction predisposes to the formation of microaneurysms.
Neovasculization is thought to be caused by the production of growth
factors in response to retinal ischaemia

In exams you are most likely to be asked about the characteristic

features of the various stages /types of diabetic retinopathy. Recently a
new classification system has been proposed, dividing patients into
those with non-proliferative diabetic retinopathy (NPDR) and those with
proliferative retinopathy (PDR):

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Traditional
classification New classification

Background Mild NPDR

retinopathy • 1 or more microaneurysm
• microaneurysms
(dots)
Moderate NPDR
• blot
haemorrhages • microaneurysms
(< = 3) • blot haemorrhages
• hard exudates • hard exudates
• cotton wool spots, venous
beading / looping and intraretinal
Pre-proliferative microvascular abnormalities
retinopathy (IRMA) less severe than in severe
• cotton wool NPDR
spots (soft
exudates;
Severe NPDR
ischaemic nerve
fibres) • blot haemorrhages and
microaneurysms in 4 quadrants
• blot
>3
haemorrhages • venous beading in at least 2
quadrants
• venous
beading/ looping • IRMA in at least 1 quadrant
• deep / dark
cluster
haemorrhages
• more common in
Type I DM, treat
with laser
photocoagulation

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j
- ©
Proliferative retinopathy
• retinal neovascularisation - may lead to vitrous haemorrhage
• fibrous tissue forming anterior to retinal disc
• more common in Type I DM, 50% blind in 5 years

Maculopathy
• based on location rather than severity, anything is potentially
serious
• hard exudates and other 'background' changes on macula
• check visual acuity
• more common in Type II DM

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© Q 28 P3 ©
A 34-year -old woman presents complaining of headaches. Examination
of her pupils using a light shone alternately in each eye reveals that
when the light is shone in the right eye both pupils constrict but when
the light source immediately moves to the left eye both eyes appear to
dilate.

What is the most likely diagnosis?

Right optic neuritis

Left sided Horner 's syndrome

Craniopharyngioma

Left optic neuritis

Right Holmes-Adie pupil

Submit answer

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 Left sided Horner 's syndrome

Craniopharyngioma

Left optic neuritis

Right Holmes-Adie pupil

This is the 'swinging light test ' and reveals a relative afferent pupillary
defect. As there is a defect in the afferent nerve on the left side the
pupils constrict less than normal, giving the impression of dilation.

Given her age, multiple sclerosis causing optic neuritis is the likely
underlying diagnosis. Optic neuritis typically causes a dull ache in the
region of the eye which is aggravated by movement

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Q Q 29 P3 ©
A 24-year-old man presents to the emergency department complaining
of left eye pain. He has not been able to wear his contact lenses for the
past 24 hours due to the pain. He describes the pain as severe and
wonders whether he has 'got something stuck in his eye'. On
examination there is diffuse hyperaemia of the left eye. The left cornea
appears hazy and pupillary reaction is normal. Visual acuity is reduced
on the left side and a degree of photophobia is noted. A hypopyon is
also seen. What is the most likely diagnosis?

Acute angle closure glaucoma

Viral conjunctivitis

Keratitis

Episcleritis

Anterior uveitis

Submit answer

Reference ranges v

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 Viral conjunctivitis

Keratitis

Episcleritis

Anterior uveitis

Whilst a hypopyon can of course be seen in anterior uveitis the

combination of a normal pupillary reaction and contact lens use make a
diagnosis of keratitis more likely.

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Keratitis

Keratitis describes inflammation of the cornea. Microbial keratitis is not

like conjunctivitis - it is potentially sight threatening and should
therefore be urgently evaluated and treated.

Aetiology

Causes
• bacterial
o typically Staphylococcus aureus
Pseudomonas aeruginosa is seen in contact lens wearers
o

• fungal
• amoebic
o acanthamoebic keratitis
o accounts for around 5% of cases
o increased incidence if eye exposure to soil or contaminated
water
• parasitic: onchocercal keratitis ('river blindness')

Remember, other factors may causes keratitis:

• viral: herpes simplex keratitis
• environmental
o photokeratitis: e. g. welder 's arc eye
o exposure keratitis
o contact lens acute red eye (CLARE)

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Clinical features

Features
• red eye: pain and erythema
• photophobia
• foreign body, gritty sensation
• hypopyon may be seen

Evaluation and management

Referral
• contact lens wearers
o assessing contact lens wearers who present with a painful
red eye is difficult
o an accurate diagnosis can only usually be made with a slit -
lamp, meaning same-day referral to an eye specialist is
usually required to rule out microbial keratitis

Management
• stop using contact lens until the symptoms have fully resolved
• topical antibiotics
° typically quinolones are used first-line
• cycloplegic for pain relief
o e.g. cyclopentolate

Complications may include:

• corneal scarring
• perforation
• endophthalmitis
• visual loss

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G Q 30 la Q
A 34-year -old female patient is brought into the emergency department
by her husband. Husband reports that she has been confused in the last
3 days. She has a long-standing history of severe psoriasis but no other
past medical history. Basic observations are all within normal range and
a CT head is unremarkable. A fundoscopy reveals bilateral
papilloedema.

What is the likely cause?

Encephalitis

Brain abscess

Primary brain tumour

Vitamin A toxicity

Hydrocephalus

Submit answer

Reference ranges >/

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 Brain abscess

Primary brain tumour

Vitamin A toxicity

Hydrocephalus

Vitamin A toxicity is a rare cause of papilloedema

Importance: 50

Vitamin A toxicity is a rare cause of papilloedema. In this case, she is

likely to have been taking retinoids for psoriasis.

Encephalitis does not usually present with papilloedema.

Brain abscess, brain tumour and hydrocephalus are all less likely with a
normal CT head.

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 Next question >
Papilloedema

Papilloedema describes optic disc swelling that is caused by increased

intracranial pressure. It is almost always bilateral.

The following features may be observed during fundoscopy:

• venous engorgement: usually the first sign
• loss of venous pulsation: although many normal patients do not
have normal pulsation
• blurring of the optic disc margin
• elevation of optic disc
• loss of the optic cup
• Paton's lines: concentric / radial retinal lines cascading from the
optic disc

Causes of papilloedema
• space-occupying lesion: neoplastic, vascular
• malignant hypertension
• idiopathic intracranial hypertension
• hydrocephalus
• hypercapnia

Rare causes include

• hypoparathyroidism and hypocalcaemia
• vitamin A toxicity

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G Q 31 ©
A 65-year -old man with a 16 year history of type 2 diabetes mellitus
presents complaining of poor eye sight and blurred vision. Visual acuity
measured using a Snellen chart is reduced to 6 /12 in the right eye and
6 /18 in the left eye. Fundoscopy reveals a number of yellow deposits in
the left eye consistent with drusen formation. Similar changes but to a
lesser extent are seen in the right eye. What is the most likely
diagnosis?

Wet age-related macular degeneration

Pre-proliferative diabetic retinopathy

Chronic open angle glaucoma

Proliferative diabetic retinopathy

Dry age-related macular degeneration

Submit answer

Reference ranges v

CamScanner
Pre-proliferative diabetic retinopathy

Chronic open angle glaucoma

Proliferative diabetic retinopathy

Dry age-related macular degeneration

Drusen = Dry macular degeneration

Importance: 50

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*
 Q32

Which one of the following is the most common ocular manifestation of

rheumatoid arthritis?

Scleritis

Episcleritis

Keratoconjunctivitis sicca

Corneal ulceration

Keratitis

Submit answer

Reference ranges v

CamScanner -i
 Keratoconjunctivitis sicca

Corneal ulceration

Keratitis

Keratoconjunctivitis sicca is characterised by dry, burning and gritty

eyes caused by decreased tear production

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Rheumatoid arthritis: ocular manifestations

Ocular manifestations of rheumatoid arthritis are common, with 25 % of

patients having eye problems

Ocular manifestations
• keratoconjunctivitis sicca (most common)
• episcleritis (erythema )
• scleritis (erythema and pain)
• corneal ulceration
• keratitis

Iatrogenic
• steroid-induced cataracts
• chloroquine retinopathy

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 Q33

Which one of the following causes of Horner 's syndrome is due to a

central lesion?

Cavernous sinus thrombosis

Internal carotid aneurysm

Syringomyelia

Pancoast 's tumour

Cervical rib

Submit answer

Reference ranges >/

CamScanner -;
Internal carotid aneurysm

Syringomyelia

Pancoast 's tumour

Cervical rib

Horner 's syndrome - anhydrosis determines site of lesion:

• head, arm, trunk = central lesion: stroke, syringomyelia
• just face = pre-ganglionic lesion: Pancoast 's, cervical rib
• absent = post-ganglionic lesion: carotid artery
Importance: 50

6
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Q Q 34 P ©
A 54-year -old woman presents with a persistent watery left eye for the
past 4 days. On examination there is erythema and swelling of the inner
canthus of the left eye. What is the most likely diagnosis?

Blepharitis

Acute angle closure glaucoma

Meibomian cyst

Dacryocystitis

Pinguecula

Submit answer

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 Dacryocystitis

Pinguecula

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Lacrimal duct problems

Dacryocystitis is infection of the lacrimal sac

Features
• watering eye (epiphora)
• swelling and erythema at the inner canthus of the eye

Management is with systemic antibiotics. Intravenous antibiotics are

indicated if there is associated periorbital cellulitis

Congenital lacrimal duct obstruction affects around 5-10% of

newborns. It is bilateral in around 20% of cases

Features
• watering eye (even if not crying)
• secondary infection may occur

Symptoms resolve in 99% of cases by 12 months of age

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G Q 35 P ©
An 80-year -old male presents to the Neurology clinic with double vision
and unsteadiness whilst walking. He has a past medical history of
hypertension, hypercholesterolaemia and type 2 diabetes.

On examination, you notice a right partial ptosis and miosis. The patient
also has notable right facial loss of pain and temperature sensation
with left sided truncal sensory loss contralateral to the face.

In the clinic, apraclonidine eye drops are added to the affected eye,
which causes a dilatation, whilst in the opposite eye, a pupil constriction
occurs. After the eye drops have been eliminated from the body, 1%
hydroxyamphetamine eye drops are then instilled. One hour after
instillation, both pupils dilate.

What neurone order is likely affected in the sympathetic pathway?

First order

Second order

Third order

Fourth order

Fifth order

Submit answer

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 First order

Second order

Third order

Fourth order

Fifth order

The answer is the first order neurone.

Apraclonidine eye drops are initially used to confirm a Horner 's pupil.
Apraclonidine stimulates both alpha-1 and alpha-2 receptors. When
added to the affected eye, it causes pupil dilation by >2mm because of
the relative supersensitivity of this pupil to alpha-1 receptor activity. In a
normal pupil, however, it causes constriction due to the more potent
activity at the alpha-2 receptor which triggers reuptake of noradrenaline
in the synaptic cleft.

Hydroxyamphetamine is then used to distinguish between first / second

or third order neurones. In other words, it will distinguish either a lesion
in the brainstem, cervical cord, chest or neck and one affecting above
the superior cervical ganglion at the carotid bifurcation. In a normal
pupil or a first / second order Homer 's, the pupil will dilate secondary to
increased levels of noradrenaline released from the post -synaptic
neurones. In a third order neurone, this will not occur.

There is no fourth or fifth order neurone.

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 Q 36 P3

Each one of the following predisposes to cataract formation, except:

Down's syndrome

Hypercalcaemia

Diabetes mellitus

Long-term steroid use

Uveitis

Submit answer

Reference ranges v

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 Hypercalcaemia

Diabetes mellitus

Long-term steroid use

Uveitis

Hypocalcaemia is a cause of cataracts

Importance: 50

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Cataracts

A cataract is a common eye condition where the lens of the eye

gradually opacifies i . e. becomes cloudy. This cloudiness makes it more
difficult for light to reach the back of the eye (retina ), thus causing
reduced / blurred vision . Cataracts are the leading cause of curable
blindness worldwide.

Epidemiology
• Cataracts are more common in women than in men
• The incidence of cataracts increases with age. One study found
that 30% of individuals aged 65 and over had a visually-impairing
cataract in either one or both eyes

Causes
• Normal ageing process: most common cause

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Other possible causes
• Smoking
• Increased alcohol consumption
• Trauma
• Diabetes mellitus
• Long-term corticosteroids
• Radiation exposure
• Myotonic dystrophy
• Metabolic disorders: hypocalcaemia

Patients typically present with a gradual onset of:

• Reduced vision
• Faded colour vision: making it more difficult to distinguish
different colours
• Glare: lights appear brighter than usual
• Halos around lights

Signs:
• A Defect in the red reflex: the red reflex is essentially the reddish-
orange reflection seen through an ophthalmoscope when a light is
shone on the retina. Cataracts will prevent light from getting to the
retina, hence you see a defect in the red reflex .

Investigations:
• Ophthalmoscopy: done after pupil dilation. Findings: normal
fundus and optic nerve
• Slit-lamp examination. Findings: visible cataract

Classification
• Nuclear: change lens refractive index, common in old age
• Polar: localized, commonly inherited, lie in the visual axis
• Subcapsular: due to steroid use, just deep to the lens capsule, in
the visual axis
• Dot opacities: common in normal lenses, also seen in diabetes
and myotonic dystrophy
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Management
• Non-surgical: In the early stages, age-related cataracts can be
managed conservatively by prescribing stronger glasses/ contact
lens, or by encouraging the use of brighter lighting. These options
help optimise vision but do not actually slow down the
progression of cataracts, therefore surgery will eventually be
needed.
• Surgery: Surgery is the only effective treatment for cataracts. This
involves removing the cloudy lens and replacing this with an
artificial one. NICE suggests that referral for surgery should be
dependent upon whether a visual impairment is present, impact
on quality of life, and patient choice. Also whether both eyes are
affected and the possible risks and benefits of surgery should be
taken into account. Prior to cataract surgery, patients should be
provided with information on the refractive implications of various
types of intraocular lenses. After cataract surgery, patients should
be advised on the use of eye drops and eyewear, what to do if
vision changes and the management of other ocular problems.
Cataract surgery has a high success rate with 85-90% of patients
achieving 6 /12 corrected vision (on a Snellen chart)
postoperatively.

Complications following surgery

• Posterior capsule opacification: thickening of the lens capsule
• Retinal detachment
• Posterior capsule rupture
• Endophthalmitis: inflammation of aqueous and/ or vitreous
humour

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o Q 37 P3 ©
Which one of the following is associated with the Holmes- Adie pupil ?

Decreased ankle reflexes

Pupillary constriction

Ptosis in 10- 20% of cases

An increased of developing multiple sclerosis

Neurosyphilis

Submit answer

Reference ranges v

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 Decreased ankle reflexes

Pupillary constriction

Ptosis in 10-20% of cases

An increased of developing multiple sclerosis

Neurosyphilis

Holmes ADIe = Dilated pupil, females, absent leg reflexes

Importance: 50

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Holmes- Adie pupil

Holmes-Adie pupil is a benign condition most commonly seen in

women. It is one of the differentials of a dilated pupil.

Overview
• unilateral in 80% of cases
• dilated pupil
• once the pupil has constricted it remains small for an abnormally
long time
• slowly reactive to accommodation but very poorly (if at all) to light

Holmes-Adie syndrome
• association of Holmes-Adie pupil with absent ankle/ knee reflexes
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G Q 38 la Q
A 55-year -old male presents to the emergency department with left
sided vision loss, headache and scalp tenderness. On examination, he
has a temperature of 38.5°C, jaw claudication and a relative afferent
pupillary defect. A diagnosis of giant cell arteritis is suspected and he is
started on high dose prednisone.

Which of the following structural deficits has lead to the relative

afferent pupillary defect ?

Ischaemic optic neuropathy

Blindness

Optic neuritis

Photophobia

Corneal opacity

Submit answer

Reference ranges v

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d 11 fcMtM 11 pupuidiy ueieuir

Ischaemic optic neuropathy

Blindness

Optic neuritis

Photophobia

Corneal opacity

Relative afferent pupillary defect indicates an optic nerve lesion or

severe retinal disease
Importance: 50

Ischaemic optic neuropathy occurs in giant cell arteritis (GCA) as a

result of an inflammatory process of the blood vessels in the head. This
optic nerve lesion may manifest in a relative afferent pupillary defect
(RAPD).

Blindness, corneal opacity and photophobia by itself won't necessarily

lead to a RAPD.

While optic neuritis may give rise to a RAPD, this won't occur in GCA and
may be suggestive of a first presentation of multiple sclerosis.

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0.0
Q Q 39 P C
An 83-year -old female presented to her GP with complete loss of vision
in her right eye which occurred suddenly. The episode lasted for 10
minutes and she denies any pain in her eye. Her past medical history
includes hypercholesterolaemia, diet controlled, and hypertension for
which she takes amlodipine.

Eye examination and fundoscopy are normal. Her blood pressure is

145/ 80 mmHg.

What medication are you going to give first ?

Aspirin 300mg

Aspirin 75mg

Simvastatin 20mg

Apixaban 5mg BD

Enoxaparin 40mg

Submit answer

Reference ranges v

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What medication are you going to give first?

Aspirin 300mg

Aspirin 75mg

Simvastatin 20mg

Apixaban 5mg BD

Enoxaparin 40mg

Monocular transient painless loss of vision (amaurosis fugax)

should be treated as a TIA
Importance: 50

Sudden painless loss of vision with a normal fundoscopy examination

is an amaurosis fugax and thus treated as a transient ischaemic attack
(TIA) . NICE guidance states that 300mg of aspirin should be given
immediately and admission if ABCD 2 score >3 or crescendo TIA,
otherwise an immediate TIA clinic referral is required.

Option 2 is the correct medication but incorrect dose.

Option 3 is likely to be added later but aspirin is the first initial plan.

Apixaban is usually given for cardiovascular disease and enoxaparin

40mg is the dose given for deep vein thrombosis prophylaxis with
normal renal function.

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Q Q 40 P3 ©
A 74-year-old man presents to ophthalmology clinic after seeing his
optician. They have noticed raised intra-ocular pressure and decreased
peripheral vision. His past medical history includes asthma and type 2
diabetes mellitus. What is the most appropriate treatment given the
likely diagnosis?

Latanoprost

Pilocarpine

Timolol

Dorzolamide

Brimonidine

Submit answer

Reference ranges v

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G Q 40 P ©
A 74-year-old man presents to ophthalmology clinic after seeing his
optician. They have noticed raised intra-ocular pressure and decreased
peripheral vision. His past medical history includes asthma and type 2
diabetes mellitus. What is the most appropriate treatment given the
likely diagnosis?

Latanoprost

Pilocarpine

Timolol

Dorzolamide

Brimonidine

A prostaglandin analogue should be used first -line in patients with a

history of asthma.

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G Q 41 P

During routine follow-up at renal clinic a man is noted to have

corpuscular pigmentation of the left retina. Which one of the following
conditions is associated with retinitis pigmentosa ?

Autosomal dominant polycystic kidney disease

Tuberous sclerosis

Von Hippel-Lindau syndrome

Alport 's syndrome

Medullary sponge kidney

Submit answer

Reference ranges v

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Tuberous sclerosis

Von Hippel-Lindau syndrome

Alport 's syndrome

Medullary sponge kidney

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G Q 42 ©
A 72-year -old woman presents with a vesicular rash around her left eye.
The left eye is red and there is a degree of photophobia. A presumptive
diagnosis of herpes zoster ophthalmicus is made and an urgent referral
to ophthalmology is made.

What treatment is she most likely to be given?

Topical aciclovir + topical chloramphenicol

Topical aciclovir + topical corticosteroids

Oral prednisolone + topical aciclovir

Topical aciclovir

Oral aciclovir

Submit answer

Reference ranges v

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 Topical aciclovir + topical corticosteroids

Oral prednisolone + topical aciclovir

Topical aciclovir

Oral aciclovir

There is no role for topical antivirals if systemic therapy is given. Topical

corticosteroids are sometimes given to treat secondary inflammation.

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Herpes zoster ophthalmicus

Herpes zoster ophthalmicus (HZO) describes the reactivation of the

varicella- zoster virus in the area supplied by the ophthalmic division of
the trigeminal nerve. It accounts for around 10% of case of shingles.

Features
• vesicular rash around the eye, which may or may not involve the
actual eye itself
• Hutchinson's sign: rash on the tip or side of the nose. Indicates
nasociliary involvement and is a strong risk factor for ocular
involvement

Management
• oral antiviral treatment for 7-10 days
ideally started within 72 hours
°
o intravenous antivirals may be given for very severe infection
or if the patient is immunocompromised
topical antiviral treatment is not given in HZO
o

• topical corticosteroids may be used to treat any secondary

inflammation of the eye
• ocular involvement requires urgent ophthalmology review

Complications
• ocular: conjunctivitis, keratitis, episcleritis, anterior uveitis
• ptosis
• post -herpetic neuralgia

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© Q 43 P O
A 78-year-old gentleman presents to the emergency department
complaining of a severe headache. His only medical condition is
hypertension, for which he take Ramipril 10 mg and Amlodipine 10 mg.
As part of the full work up fundoscopy is performed, with the following
results bilaterally: Scattered cotton wool spots, tortuous vessels
throughout, and AV nipping.

What stage of hypertensive retinopathy according the Keith-Wagener

classification does this patient have?

Stage 1

Stage 2

Stage 3

Stage 4

No retinopathy present

Submit answer

Reference ranges v

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 Stage 4

No retinopathy present

Fundoscopy reveals end organ damage in hypertension

Importance: 50

This describes stage 3 hypertensive retinopathy, as there are features of

stages 1 to 3 described.

Hypertensive and diabetic retinopathy are both common finals

questions.

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Hypertensive retinopathy

The table below shows the Keith-Wagener classification of hypertensive

retinopathy

Stage Features

I Arteriolar narrowing and tortuosity

Increased light reflex - silver wiring

II Arteriovenous nipping

III Cotton-wool exudates

Flame and blot haemorrhages

IV Papilloedema
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© Q 44 P ©
A 67-year -old woman presents for review. She has recently been
diagnosed with dry age-related macular degeneration. Which one of the
following is the strongest risk factor for developing this condition?

Hypertension

Poor diet

Smoking

Diabetes mellitus

Alcohol excess

Submit answer

Reference ranges v

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 Poor diet

Smoking

Diabetes mellitus

Alcohol excess

Macular degeneration - smoking is risk factor

Importance: 50

Having a balanced diet, with plenty of fresh fruits and vegetables may
also slow the progression of macular degeneration. There is still
ongoing research looking at the role of supplementary antioxidants

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Q Q 45 P3 ©
A 53-year-old male who presents to the emergency department with a
painful red eye. He has vomited once since the pain started. He reports
seeing haloes around lights.

His immediate management includes latanoprost and pilocarpine, and

he requires an urgent ophthalmology referral.

What is the mode of the action of pilocarpine?

Muscarinic receptor agonist

Muscarinic receptor antagonist

Nicotinic receptor agonist

Nicotinic receptor antagonist

Adrenergic receptor agonist

Submit answer

Reference ranges v

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 Muscarinic receptor agonist

Muscarinic receptor antagonist

Nicotinic receptor agonist

Nicotinic receptor antagonist

Adrenergic receptor agonist

Pilocarpine is a muscarinic receptor agonist

Importance: 50

Pilocarpine is a muscarinic receptor agonist - it increases uveoscleral

outflow by constricting the pupil.

Examples of muscarinic receptor antagonists include atropine and

hyoscine (scopolamine) - these are not used in the management of
glaucoma.

Nicotinic receptor agonists include nicotine and acetylcholine, therefore

this answer is incorrect .

Nicotinic receptor antagonists include succinylcholine, atracurium,

vecuronium and bupropion.

Adrenergic receptor agonists include norepinephrine and epinephrine.

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 Next question >
Acute angle closure glaucoma

Glaucoma is a group of disorders characterised by optic neuropathy

due, in the majority of patients, to raised intraocular pressure (IOP). It is
now recognised that a minority of patients with raised IOP do not have
glaucoma and vice versa.

In acute angle-closure glaucoma ( AACG) there is a rise in IOP

secondary to an impairment of aqueous outflow. Factors predisposing
to AACG include:
• hypermetropia (long-sightedness)
• pupillary dilatation
• lens growth associated with age

Features
severe pain: may be ocular or headache
decreased visual acuity
symptoms worse with mydriasis (e. g. watching TV in a dark room)
hard, red-eye
haloes around lights
semi-dilated non-reacting pupil
corneal oedema results in dull or hazy cornea
systemic upset may be seen, such as nausea and vomiting and
even abdominal pain

Management
• urgent referral to an ophthalmologist
• management options include reducing aqueous secretions with
acetazolamide and inducing pupillary constriction with topical
pilocarpine

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Q Q 46 ©
A 19-year -old male presents to the emergency department with a 1-day
history of redness around the left eye associated with puffiness of the
eye and pain on eye movement. Overnight he reports feeling feverish.
His vision is restricted due to an inability to open the eye. On
examination, there is oedema surrounding upper and lower eyelids with
erythema and proptosis. The eye itself appears normal with normal
pupil reflexes but pain on eye movements. There is mildly raised
intraocular pressure. He is normally fit and well but has recently been
taking intranasal corticosteroid for sinusitis.

What is the most appropriate management ?

Refer for urgent (within 1 week) ophthalmology appointment

Admit for intravenous antibiotics

Refer for emergency (within 24 hours) ophthalmology

appointment

Discharge home with oral antibiotics

Discharge home with topical antibiotics

Submit answer

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 Admit for intravenous antibiotics

Refer for emergency (within 24 hours) ophthalmology appointment

Discharge home with oral antibiotics

Discharge home with topical antibiotics

Patients with orbital cellulitis require admission to hospital for IV

antibiotics due to the risk of cavernous sinus thrombosis and
intracranial spread
Importance: 50

The correct answer here is to admit for intravenous antibiotics. This

patient has orbital cellulitis which is a medical emergency due to risk or
optic nerve damage, cavernous sinus thrombosis and intracranial
spread. The systemic upset and pain on eye movements are clues
pointing towards orbital as opposed to periorbital cellulitis. As the
condition progresses patient can develop proptosis, relative afferent
pupillary defect and raised intraocular pressure. There may also be
globe displacement with resistance to retropulsion. Recent sinus
infection or sinusitis is a risk factor for orbital cellulitis and points
towards the diagnosis. In some hospitals, suitable patients may be
ambulated with intravenous antibiotics as an alternative to admission.

Referring to an urgent (within 1 week) ophthalmology appointment

would not be appropriate as this is a medical emergency.

Referring for an emergency (same day) ophthalmology appointment

would be more appropriate than referring for an appointment within 1
week as it highlights the urgency of the situation, however, this patient
should be admitted under the general medical take for intravenous
antibiotics and should not be left without treatment for a period up to
24 hours. As such an outpatient appointment is not appropriate.

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Discharging home with oral antibiotics may be appropriate if periorbital
cellulitis was suspected. The inability to open the eye, pain on eye
movements and history of fever point towards orbital cellulitis as
opposed to periorbital cellulitis and so admission is required.

Topical antibiotics could be used in conjunctivitis but would not be

appropriate in this case.

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Orbital cellulitis

Orbital cellulitis is the result of an infection affecting the fat and

muscles posterior to the orbital septum, within the orbit but not
involving the globe. It is usually caused by a spreading upper respiratory
tract infection from the sinuses and carries a high mortality rate. Orbital
cellulitis is a medical emergency requiring hospital admission and
urgent senior review. Periorbital (preseptal) cellulitis is a less serious
superficial infection anterior to the orbital septum, resulting from a
superficial tissue injury (chalazion, insect bite etc...). Periorbital cellulitis
can progress to orbital cellulitis.

Epidemiology
• Mean age of hospitalisation 7-12 years.

Risk factors
• Childhood
• Previous sinus infection
• Lack of Haemophilus influenzae type b (Hib) vaccination
• Recent eyelid infection/ insect bite on eyelid (Peri-orbital cellulitis)
• Ear or facial infection

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Presentation
• Redness and swelling around the eye
• Severe ocular pain
• Visual disturbance
• Proptosis
• Ophthalmoplegia / pain with eye movements
• Eyelid oedema and ptosis
• Drowsiness +/- Nausea/ vomiting in meningeal involvement (Rare)

Differentiating orbital from preseptal cellulitis

• reduced visual acuity, proptosis, ophthalmoplegia / pain with eye
movements are NOT consistent with preseptal cellulitis

Investigations
• Full blood count - WBC elevated, raised inflammatory markers.
• Clinical examination involving complete ophthalmological
assessment - Decreased vision, afferent pupillary defect,
proptosis, dysmotility, oedema, erythema.
• CT with contrast - Inflammation of the orbital tissues deep to the
septum, sinusitis.
• Blood culture and microbiological swab to determine the
organism. Most common bacterial causes - Streptococcus ,
Staphylococcus aureus , Haemophilus influenzae B.

Management
• admission to hospital for IV antibiotics

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a =L ^ TI" E C-D

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Q Q 47 P3 ©
A 45-year-old man presents to the Emergency Department following the
sudden onset of pain in the right side of his face whilst hammering a
nail into the wall. The pain is described as severe and constant. On
examination he has a mild right ptosis and small right pupil. What is the
most likely diagnosis ?

Trigeminal neuralgia

Glaucoma

Carotid artery dissection

Syringomyelia

Migraine

Submit answer

Reference ranges v

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 Glaucoma

Carotid artery dissection

Syringomyelia

Migraine

This patient has Horner 's syndrome caused by a carotid artery

dissection. This may be caused by relatively benign trauma to the neck
such as hyperextension whilst doing DIY. Cluster headache would be a
differential diagnosis

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o Q 48 p ©
A 71-year-old with a history of type 2 diabetes mellitus and
hypertension presents due to the sensation of light flashes in his right
eye. These symptoms have been present for the past 2 days and seem
to occur more at the peripheral part of vision. There is no redness or
pain in the affected eye. Corrected visual acuity is measured as 6 / 9 in
both eyes. What is the most likely diagnosis?

Change in shape of eye secondary to variations in blood sugar

Primary open angle glaucoma

Vitreous detachment

Normal phenomenon in diabetic retinopathy

Normal phenomenon in healthy eyes

Submit answer

Reference ranges v

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 Primary open angle glaucoma

Vitreous detachment

Normal phenomenon in diabetic retinopathy

Normal phenomenon in healthy eyes

Flashes and floaters - vitreous / retinal detachment

Importance: 50

Flashes and floaters are symptoms of vitreous detachment. The patient

is at risk of retinal detachment and should be referred urgently to an
ophthalmologist

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o Q49 p ©
A 71-year -old man presents with severe pain around his right eye and
vomiting. On examination the right eye is red and decreased visual
acuity is noted. Which one of the following options is the most
appropriate initial treatment?

Topical pilocarpine + oral prednisolone

Topical pilocarpine + topical steroids

Topical steroids

Topical pilocarpine + intravenous acetazolamide

Topical steroids + intravenous acetazolamide

Submit answer

Reference ranges v

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Topical pilocarpine + topical steroids

Topical steroids

Topical pilocarpine + intravenous acetazolamide

Topical steroids + intravenous acetazolamide

Treatment of acute glaucoma - acetazolamide + pilocarpine

Importance: 50

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Q Q 50 P ©
Which one of the following is not a feature of background diabetic
retinopathy?

Microaneurysms

Blot haemorrhages

Cotton wool spots

Seen in both type 1 and type 2 diabetes mellitus

Hard exudates

Submit answer

Reference ranges >

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-u t u O l
L d j- s
 Cotton wool spots

Seen in both type 1 and type 2 diabetes mellitus

Hard exudates

Cotton wool spots are seen in pre-proliferative retinopathy

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Diabetic retinopathy

Diabetic retinopathy is the most common cause of blindness in adults

aged 35-65 years-old. Hyperglycaemia is thought to cause increased
retinal blood flow and abnormal metabolism in the retinal vessel walls.
This precipitates damage to endothelial cells and pericytes

Endothelial dysfunction leads to increased vascular permeability which

causes the characteristic exudates seen on fundoscopy. Pericyte
dysfunction predisposes to the formation of microaneurysms.
Neovasculization is thought to be caused by the production of growth
factors in response to retinal ischaemia

In exams you are most likely to be asked about the characteristic

features of the various stages / types of diabetic retinopathy. Recently a
new classification system has been proposed, dividing patients into
those with non-proliferative diabetic retinopathy (NPDR) and those with
proliferative retinopathy (PDR):

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Traditional
classification New classification

Background Mild NPDR

retinopathy • 1 or more microaneurysm
• microaneurysms
(dots)
Moderate NPDR
• blot
haemorrhages • microaneurysms
(<=3) • blot haemorrhages
• hard exudates • hard exudates
• cotton wool spots, venous
beading / looping and intraretinal
Pre-proliferative microvascular abnormalities
retinopathy (IRMA) less severe than in severe
• cotton wool NPDR
spots (soft
exudates;
Severe NPDR
ischaemic nerve
fibres) • blot haemorrhages and
microaneurysms in 4 quadrants
• > 3 blot
haemorrhages • venous beading in at least 2
quadrants
• venous
beading/ looping • IRMA in at least 1 quadrant
• deep/ dark
cluster
haemorrhages
• more common in
Type I DM, treat
with laser
photocoagulation

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Proliferative retinopathy
• retinal neovascularisation - may lead to vitrous haemorrhage
• fibrous tissue forming anterior to retinal disc
• more common in Type I DM, 50% blind in 5 years

Maculopathy
• based on location rather than severity, anything is potentially
serious
• hard exudates and other 'background' changes on macula
• check visual acuity
• more common in Type II DM

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Q Google search on "Diabetic retinopathy"

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o Q1 P3 ©
A 40-year-old man presents with bilateral dry, gritty eyes. A diagnosis of
blepharitis is considered. Which one of the following is least likely to be
associated with blepharitis ?

Meibomian gland dysfunction

Seborrhoeic dermatitis

Staphylococcal infection

Acne rosacea

Viral upper respiratory tract infection

Submit answer

Reference ranges v

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Seborrhoeic dermatitis

Staphylococcal infection

Acne rosacea

Viral upper respiratory tract infection

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G Q2 P3 ©
A 71-year-old man presents with a burning sensation around his right
eye. On examination an erythematous blistering rash can be seen in the
right trigeminal distribution. What is the most likely diagnosis?

Ramsay Hunt syndrome

Cluster headache

Fungal keratitis

Herpes zoster ophthalmicus

Trigeminal neuralgia

Submit answer

Reference ranges v

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Cluster headache

Fungal keratitis

Herpes zoster ophthalmicus

Trigeminal neuralgia

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«

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 Q3 P

Which one of the following is not a risk factor for primary open-angle
glaucoma?

Diabetes mellitus

Family history

Hypertension

Afro-Caribbean ethnicity

Hypermetropia

Submit answer

Reference ranges v

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Family history

Hypertension

Afro- Caribbean ethnicity

Hypermetropia

Acute angle closure glaucoma is associated with hypermetropia,

where as primary open- angle glaucoma is associated with myopia
Importance: 50

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o Q4 P ©
An 80-year- old woman presents with ' funny spots' affecting her vision.
Over the past week she has noticed a number of flashes and floaters in
the visual field of the right eye. What is the most likely diagnosis?

Retinal detachment

Posterior vitreous detachment

Optic neuritis

Depression

Vitreous haemorrhage

Submit answer

Reference ranges v

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^=-3 ^ 11
 Posterior vitreous detachment

Optic neuritis

Depression

Vitreous haemorrhage

Posterior vitreous detachment is thought to occur in up to 50-75% of

the population over 65 years and is the most likely diagnosis here. Such
patients are normally reviewed by an ophthalmologist to assess the risk
of progressing to retinal detachment.

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G Q5 ©
Which one of the following statements regarding macular degeneration
is true?

Drusen are characteristic of wet macular degeneration

Photodynamic therapy is useful in dry macular degeneration

Asian ethnicity is a risk factor

Male sex is a risk factor

Wet macular degeneration carries the worst prognosis

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Photodynamic therapy is useful in dry macular degeneration

Asian ethnicity is a risk factor

Male sex is a risk factor

Wet macular degeneration carries the worst prognosis

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G Q6 ©
Which one of the following is least associated with the development of
optic atrophy?

Tobacco

Methanol

Vitamin B12 deficiency

Lead

Zinc deficiency

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 Zinc deficiency

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Optic atrophy

Optic atrophy is seen as pale, well demarcated disc on fundoscopy. It is

usually bilateral and causes a gradual loss of vision*. Causes may be
acquired or congenital

Acquired causes
• multiple sclerosis
• papilloedema (longstanding)
• raised intraocular pressure (e.g. glaucoma, tumour)
• retinal damage (e.g. choroiditis, retinitis pigmentosa)
• ischaemia
• toxins: tobacco amblyopia, quinine, methanol, arsenic, lead
• nutritional: vitamin B1, B 2, B 6 and B12 deficiency

Congenital causes
• Friedreich's ataxia
• mitochondrial disorders e.g. Leber 's optic atrophy
• DIDMOAD - the association of cranial Diabetes Insipidus, Diabetes
Mellitus, Optic Atrophy and Deafness (also known as Wolfram's
syndrome)

*strictly speaking optic atrophy is a descriptive term, it is the optic

neuropathy that results in visual loss

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 Q7

Which one of the following is least recognised as a cause of tunnel

vision?

Papilloedema

Choroidoretinitis

Angioid retinal streaks

Glaucoma

Retinitis pigmentosa

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 Choroidoretinitis

Angioid retinal streaks

Glaucoma

Retinitis pigmentosa

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Tunnel vision

Tunnel vision is the concentric diminution of the visual fields

Causes
• papilloedema
• glaucoma
• retinitis pigmentosa
• choroidoretinitis
• optic atrophy secondary to tabes dorsalis
• hysteria

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Q Q8 ©
A 63-year-old man presents to his GP complaining of pain in his right
eye. On examination the sclera is red and the pupil is dilated with a hazy
cornea. What is the most likely diagnosis?

Scleritis

Conjunctivitis

Acute angle closure glaucoma

Anterior uveitis

Subconjunctival haemorrhage

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Conjunctivitis

Acute angle closure glaucoma

Anterior uveitis

Subconjunctival haemorrhage

Red eye - glaucoma or uveitis?

• glaucoma: severe pain, haloes, 'semi-dilated' pupil
• uveitis: small, fixed oval pupil, ciliary flush
Importance: 50

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G Q9 P ©
A 39-year -old woman with a history of rheumatoid arthritis presents
with a two day history of a red right eye. There is no itch or pain. Pupils
are 3mm, equal and reactive to light. Visual acuity is 6 / 5 in both eyes.
What is the most likely diagnosis?

Keratoconjunctivitis sicca

Scleritis

Glaucoma

Episcleritis

Anterior uveitis

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 Scleritis

Glaucoma

Episcleritis

Anterior uveitis

Scleritis is painful, episcleritis is not painful

Importance: 50

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Rheumatoid arthritis: ocular manifestations

Ocular manifestations of rheumatoid arthritis are common, with 25% of

patients having eye problems

Ocular manifestations
• keratoconjunctivitis sicca (most common)
• episcleritis (erythema)
• scleritis (erythema and pain)
• corneal ulceration
• keratitis

Iatrogenic
• steroid-induced cataracts
• chloroquine retinopathy

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Q Q10 P ©
A 65-year -old woman presents to the Emergency Department with
visual problems. She has rheumatoid arthritis, depression and takes
medication to control her blood pressure. Over the past few days she
has been getting troublesome headaches and blurred vision but today
has noted a marked reduction in vision in the right eye. On examination
her right eye is red, has a sluggish pupil and a corrected visual acuity
6 / 30. Her medication has recently been changed. Which one of the
following drugs is most likely to have precipitated this event ?

Methotrexate

Doxazosin

Amitriptyline

Atenolol

Bendroflumethiazide

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© Q1 p ©
A 65-year -old woman presents to the Emergency Department with
visual problems. She has rheumatoid arthritis, depression and takes
medication to control her blood pressure. Over the past few days she
has been getting troublesome headaches and blurred vision but today
has noted a marked reduction in vision in the right eye. On examination
her right eye is red, has a sluggish pupil and a corrected visual acuity
6 / 30. Her medication has recently been changed. Which one of the
following drugs is most likely to have precipitated this event ?

Methotrexate

Doxazosin

Amitriptyline

Atenolol

Bendroflumethiazide

Submit answer

Reference ranges v

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 Doxazosin

Amitriptyline

Atenolol

Bendroflumethiazide

Drugs which may precipitate acute glaucoma include anticholinergics

and tricyclic antidepressants

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A 65-year-old man with a history of primary open-angle glaucoma
presents with sudden painless loss of vision in his right eye. On
examination of the right eye the optic disc is swollen with multiple
flame-shaped and blot haemorrhages. What is the most likely
diagnosis ?

Diabetic retinopathy

Vitreous haemorrhage

Ischaemic optic neuropathy

Occlusion of central retinal vein

Occlusion of central retinal artery

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^9-^ 1
 Ischaemic optic neuropathy

Occlusion of central retinal vein

Occlusion of central retinal artery

Central retinal vein occlusion - sudden painless loss of vision,

severe retinal haemorrhages on fundoscopy
Importance: 50

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Central retinal vein occlusion

Central retinal vein occlusion (CRVO) is a differential for sudden

painless loss of vision.

Risk factors
• increasing age
• glaucoma
• polycythaemia

Features
• sudden, painless reduction or loss of visual acuity, usually
unilaterally
• severe retinal haemorrhages are usually seen on fundoscopy

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G Q3 P O
A 25-year-old woman presents with a one-day history of a painful and
red left eye. She describes how her eye is continually streaming tears.
On examination she exhibits a degree of photophobia in the affected
eye and application of fluorescein demonstrates a dendritic pattern of
staining. Visual acuity is 6 / 6 in both eyes. What is the most appropriate
management ?

Topical steroid

Perform a lumbar puncture

Treat with subcutaneous sumatriptan

Topical aciclovir

Topical chloramphenicol

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 Topical aciclovir

Topical chloramphenicol

This patient has a dendritic corneal ulcer. Topical aciclovir and

ophthalmology review is required. Giving a topical steroid in this
situation could be disastrous as it may worsen the infection.

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Herpes simplex keratitis

Herpes simplex keratitis most commonly presents with a dendritic

corneal ulcer.

Features
• red, painful eye
• photophobia
• epiphora
• visual acuity may be decreased
• fluorescein staining may show an epithelial ulcer

Management
• immediate referral to an ophthalmologist
• topical aciclovir

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