SLCSFP EYE md selection exam family medicine

Eye

1. Question 1:

+ A 35-year-old woman presents with a sudden onset of unilateral red eye,
associated with foreign body sensation, photophobia, and watering. She
denies any history of contact lens use, trauma, or recent upper respiratory
tract infection. On examination, her vision is 6/6 in both eyes. There is
conjunctival injection localized to the bulbar conjunctiva and mild corneal
epithelial defect with minimal circumcorneal congestion. Intraocular
pressure (IOP) is normal in both eyes.

+ Based on the clinical presentation, what is the most likely diagnosis?
+ A. Acute bacterial conjunctivitis

+ B. Episcleritis

+ C. Herpes simplex keratitis y
+ D. Anterior uveitis

+ E. Angle-closure glaucoma Ñ ©

2. Answer 01

° C. Herpes simplex keratitis

7. Bun Choroid

Uvea Ciliary body

8. Vision

Pain
Photophobla
Discharge
Injection

Appearance ot
comes

Pupil size

Norma

Nore

None
Punsent with crusting

Oftuse, spares limbus

ES

Blurred

Moderate
Moderae
None
Pertimbic
Chee

Corsinmed

Biyred
Severe
Moderate
None to some

Pentmbio
Clear 10 Cloudy

Normal

Mario blurring
Severe
Moceraro

None

Dittuse

Cloudy

Dilated

9. Normal Uveitis

PTT

limbic sparing

scleral injection

Conjunctival injection

Acute Conjunctivitis Acute lritis

10. Conjuntivitis

healthy eyes

> early-stage infection

oD <>

late-stage infection

11. KERATITIS

ow

a A

oF
OB

HEALTHY EYE KERATITIS

12. Healthy Bacterial Keratitis

Fungal Aspergillus Keratitis Fungal Fusarium Keratitis Fungal Candida Keratitis

13. AACG

Dulated pupil, Hazy cornea, Diffuse

redness

18. Question 2:

+ A 62-year-old man with a history of poorly controlled diabetes presents
with a 2-day history of gradual onset of painless vision loss in his right eye.
He denies any redness, pain, or photophobia. On examination, his vision is
counting fingers at 2 feet in the right eye and 6/6 in the left eye. Intraocular
pressure is 28mmHg in the right eye and 18mmHg in the left eye. The .
anterior chamber is deep and clear in both eyes. Funduscopic examination
of the right eye reveals multiple flame-shaped hemorrhages and scattered
cotton wool spots.

+ What is the most likely cause of the vision loss in this patient?
» A. Acute retinal detachment

+ B. Central retinal vein occlusion

+ C. Neovascular glaucoma

+» D. Diabetic retinopathy with macular edema

+ E. Age-related macular degeneration

19. Question 2:

» A 62-year-old man with a history of poorly controlled diabetes presents
with a 2-day history of gradual onset of painless vision loss in his right eye.
He denies any redness, pain, or photophobia, Onexamination, his-vision’is
counting fingers at 2 feet in the right eye aná 6/6 in the left eye. Intraocular
pressure is 28mmHg in the right eye and 18mmHg in the left eye. The
anterior chamber is deep and clear in both eyes. Funduscopic examination
of theTight eye’reveals multiple flame-shaped hemorrhages and scattered
cotton weet spots. u

+ What is the most likely cause of the vision loss in this patient?
* A. Acute retinal detachment

» B. Central retinal vein occlusion á f
in glucoma ant chamber is not so deep, it

+ C. Neovascular glaucoma will be swallow
* D. Diabetic retinopathy with macular edema
* E. Age-related macular degeneration

20. Answer 02

+ D. Diabetic retinopathy with macular edema

21. Question 3:

+ A 45-year-old man with a history of poorly controlled diabetes presents
with sudden, painless vision loss in his right eye. He denies any recent
headaches, eye pain, or trauma. On examination, his visual acuity is
counting fingers at 1 foot in the right eye and 6/6 in the left eye. Intraocular
pressure is normal in both eyes. Funduscopic examination of the right eye
reveals multiple dot hemorrhages and scattered cotton wool spots
throughout the retina.

+ What is the most likely cause of the sudden vision loss in this patient?
* A. Optic neuritis

+ B. Central retinal vein occlusion

+ C. Giant cell arteritis

{D} Diabetic retinopathy with vitreous hemorrhage

+ E. Migraine with aura

22. Answer 03

+ D. Diabetic retinopathy with vitreous hemorrhage

23. Question 4:

+ A 45-year-old man with a history of migraines presents with a sudden onset
of flickering lights and scintillating scotoma (blind spot) in his right eye,

followed by a gradual decrease in vision over 30 minutes. He denies any
headache eye paper redness. On examination, his visual acuity is 6/12 in —
the right eye and 6/6 in the left eye. There is a relative afferent pupillary/ RA’)
defect in the right eye. Funduscopic examination is unremarkable. \ ‘i E

+ What is the most likely cause of the vision loss in this patient? _

+ A. Amaurosis fugax +4

. (BD Posterior vitreous detachment yn,

, + C. Migraine with aura A
«DJoptic neuritis
* E. Hemianopia ~~» €

24. Optic Neuritis

\+Demyelinating inflammation of the optic nerve

Optic neuritis

Inflammation of the optic nerve

causes pain, vision loss and other Cinieal
+ Sudden loss of monocular partial or complete vision
Pi “ith it of affected
symptoms. : Penh moment of ce pe

+ Loss of color (red) vision
+ Uhthoff's phenomenon
Transient worsening of vision with increased body temperature

Etiologies
+ Multiple sclerosis (most common)

+ Infection (Lyme, Herpes, Syphilis)

+ Autoimmune (Lupus, Neurosarcoidosis)
+ Methanol poisoning

+ B12 deficiency
+ Diabetes a
Management 2

+ Corticosteroids (intravenous)

25. Question 5:

« A65-year-old woman with a history of poorly controlled diabetes
presents with a sudden onset of severe, throbbing pain in her right eye,
associated with photophobia, blurred vision, and redness. She denies
any recent trauma or contact lens use. On examination, her visual
acuity is 6/12 in the right eye and 6/6 in the left eye. Intraocular
pressure is significantly elevated in the right eye (35mmHg) compared
to the left eye (16mmHg). The cornea is clear, but the anterior chamber
appears shallow in the right eye.

* What is the most likely cause of the patient's presentation?
+ A. Acute bacterial conjunctivitis

«B) Acute angle-closure glaucoma

+ C. Iridocyclitis (anterior uveitis)

+ D. Herpes zoster ophthalmicus

+ E. Orbital cellulitis

26. A
Answer 05

« (B) Acute angle-closure glaucoma.

27. druser

ma

ashing light

fl
ual field

exacerbated by exe

al nerve pal

28. Painful

e Trauma (foreign body)

© Orbital cellulitis

e Endophthalmitis

© Anterior uveitis

e Acute angle-closure glaucoma
e Keratitis

+ Giant cell arterit

+ Optic neuritis

+ Migraine with aura

Acute

Unilateral

Painless

e Vitereous haemorrhage
e Central retinal artery occlusion

© Central retinal vein occlusion

+ Age related macular degenration
e Retinal detachment

+ Amaurosis fugax

+ Giant cell arteritis

+ Papilloedema

Visual Loss

Painless

+ Papilloedema
© Cerebrovascular event/ Stroke
e Anticholinergic drugs

e Antipsychotic drugs

Chronic

Painless

+ Refractive error
+ Chronic open angle glaucoma

e Cataract

+ Age related macular degeneration
+ Diabetic maculopathy

e Drug toxicity (hydroxychloroquine)
e Chronic eye strain

29. Question 6:

» A 40-year-old man presents with a 3-day history of progressively
worsening pain in his left eye, associated with redness,
photophobia, and watering. He denies any recent trauma or
contact lens use. On examination, his visual acuity is slightly
reduced (6/9 in the left eye compared to the right (6/6). There is
conjunctival injection localized to the episclera with some scleral
thickening. He experiences significant tenderness on palpation of
the invölved area. en

+ What is the most likely cause of the patient's presentation?

A) Acute bacterial conjunctivitis \y
B./Episcleritis A
Scleritis ~~
* D. Iridocyclitis (anterior uveitis) a»
» E. Corneal ulcer ~~~

30. 1. A 47-year-old female comes to see you in the Clinic with a red eye. She reports
gradual onset of unilateral red eye with associated severe pain, which she describes
as a 'boring' pain and waking her at night time. There is associated watering of the
eye and photophobia. Vision is not affected. She has had no previous episodes and is
normally fit and well. On examination visual acuity is normal. There is diffuse
redness in the left eye and a tender globe. The pupils react normally bilaterally.
What is the most likely diagnosis?

1. Keratitis

. Episclertis

2

3. Anterior uveitis
4. Scleritis
5

. Acute Angle Closure Glaucoma

31. Causes of Red Eye

+ Conjunctivitis

+ Subconjunctival haemorrhage
* Keratitis

+ Corneal ulcer

+ Corneal foreign body

+ Episcleritis

* Scleritis

+ Uveitis

» Acute angle closure glaucoma

32. Anatomy of Eye

Eye lid
Lacrimal caruncle

Ten Lateral rectus muscle

Retina

Macula lutea

Fovea centralis

(central depression)
Anterior chamber ——as
(filled with
aqueous humor)

Posterior chamber 4
Optic nerve and
Suspensory ligaments retinal blood vessels

Ciliary body and muscle

Medial rectus muscle
Right Eye (viewed from above)

33. Keratitis

* Follows adenoviral conjunctivitis

+ Inflammation of cornea

* Clinical features
+ Reduced vision, irritation and photophobia
+ Perilimbal injection , corneal opacities

+ Treatment
* Topical steroids

34. Episcleritis

Common, benign ,self limiting, recurrent disorder
affecting young adults
Inflammation of the episclera
Sectorial redness
Mild discomfort and tearing, Vision normal
Treated with

* Topical NSAIDS

. u Topical Steroid

> == + Systemic NSAIDS in resistant cases

SSA

35. Uveitis

+ Inflammation of uveal tract
+ Symptoms
» Pain, photophobia, redness, tearing, reduced
vision
+» Signs
» Circumcorneal injection
* Small pupil / Irregular pupil
* Aqueous cells and flare
* Posterior synechiae
+ MANAGEMENT
+ Basic investigations to exclude a systemic disorder
or a causative agent

36. Uveitis

* Systemic diseases (Ankylosing spondylitis, Reiter's syndromes, Psoriatic arthritis,
Inflammatory Bowel Diseases, Sarcoidosis, Bechet's disease)

+ Treatment
* Topical steroids
* Topical mydriatics and cycloplegics
* Specific treatment for the causative factor

37. Scleritis

+ Inflammation of sclera
+ Sever boring type of pain which may disturb sleep
+ Sometimes the eye is tender to touch

May be a manifestation of Systemic discasc.( RA. SLE.
Wagener granulomatosis, Polyarteritiss nodosa))

M + Treatment
+ Oral NSAIDs
+ Oral prednisolone

+ Immunosuppressive drugs in resistant cases

38. Scleritis

Inflammation of sclera
Sever boring type of pain which may disturb sleep
Sometimes the eye is tender to touch

May be a manifestation of Systemic disease.( RA. SLE.
Wagener granulomatosis, Polyarteritiss nodosa))

Treatment
Oral NSAIDs
Oral prednisolone

Immunosuppressive drugs in resistant cases

39. Acute angle closure glaucoma

Elevation of intra-ocular pressure due to obstruction of
aqueous outflow by partial or complete closure of the
anterior chamber angle by the peripheral iris
Risk factors

* Shallow anterior chamber

+ Hypermetropia(long sighted)

* Small eye

«F>M

+ Age 50-60

* Anti cholinic drugs (TCA, Antihistamine, muscle

relaxant}

40. Acute angle closure glaucoma

+ Symptoms

* Rapidly progressive impairment of vision
+ Periocular pain and severe headache

+ Nausea and vomiting in severe cases

+ Signs

* Circumlimbal injection

* Corneal oedema

+ Severe elevation of IOP (50-100mmHg)
* Shallow anterior chamber depth

+ Mid dilating pupil poorly responding to light and accommodation

41. Angle Closure Glaucoma: The angle
formed by the cornea and the iris
narrows, preventing the aqueous

MANAGEMENT humor from draining out of the eye.

This can lead to a rapid increase in

A : intraocular pressure. Source: The

* Urgent lowering of intraocular Mayo Clinic (www.mayöclinic.com)
pressure needed O:

* Patient should be admitted

+ Hyper osmotic agents — IV
mannitol

* Topical pilocarpine and beta
blockers

* Topical steroids

+ Peripheral iridectomy done to re-
establish the communication
between anterior and posterior
chambers

42. Organism

Signs + Symptoms

Management

Advice

Adenovirus

Highly contagious
Oedema of lids
Watery discharge
Sub conj. H’rrage
Tender
periauricular LN

Symptomatic &
supportive
Spontaneous
resolution in 2/52

Blurred vision,
Keratitis

Staph. aureus,
Strep. epidermidis,
Strep. pneumonia,
H. influensae

Pain+

Purulent discharge
Sticky eye lids

Antibiotic drops
-Tobra
-Cipro
-Oflox
-Genta

Air borne allergens
IgE

Itchy
Commonest form of
eye allergy
Associated with
nasal symptoms,
sneezing, etc

Topical mast cell
stabilizers or topical
antihistamines

In severe cases oral
antihistamines
Steroids

Steroid nasal drops

Chlamydia
Gonococcus

Thick creamy pus
Oedematous tender
lids

Prominent
preauricular LN
Swollen conjunctiva
Very red corneal
ulcers+

Admit to hospital
Culture & ABST
Topical antibiotics
Systemic antibiotics

Sexually
transmitted

43. Viral Conjunctivitis

44. acterial Conductivities

45. Allergic Conjunctivitis

a 7

can see papille

46. Differential diagnosis according to vision

Conjunctivitis Keratitis

Subconjunctival haemorrhage Corneal ulcer

Corneal foreign body Uveitis

Episcleritis Acute angle closure glaucoma
Scleritis

47. Differential diagnosis according to the
presence of pain

Corneal ulcer Conjunctivitis

Uveitis Corneal foreign body

Acute angle closure glaucoma Keratitis

Scleritis Subconjunctival haemorrhage
Episcleritis

48. Differential diagnosis according to the
distribution of redness

Conjuctivitis Subconjunctival haemorrhage Keratitis
Episcleritis Corneal ulcer
Scleritis Corneal foreign body
Uveitis

Acute angle closure glaucoma

49. 1. A 47-year-old female comes to see you in the Clinic with a red eye. She reports
gradual onset of unilateral red eye with associated severe pain, which she describes
as a 'boring' pain and waking her at night time. There is associated watering of the
eye and photophobia. Vision is not affected. She has had no previous episodes and is
normally fit and well. On examination visual acuity is normal. There is diffuse
redness in the left eye and a tender globe. The pupils react normally bilaterally.
What is the most likely diagnosis?

1. Keratitis
2. Episclertis

3. Anterior uveitis

5. Acute Angle Closure Glaucoma

50. Normal corneal light reflex (Hirschberg test)

The child is placed on their parent’s lap. The
doctor stands at a distance of 1 m in front of
the child, holding a small light. The child’s
attention is directed to the light. The position
of the light’s reflection in each of the child’s
eyes is noted and compared. Normal ocular
alignment will generate an identical light
reflection in each eye.

51. Amblyopia

DEFINITION

° Amblyopia is defined as poor vision caused by abnormal
visual stimulation during early visual development and is the
most common cause of unilaterally reduced vision in
childhood

+ Permanent loss of best corrected visual acuity in a
structurally healthy eye

°2-5% of the population

52. 2. Squint in children:(T or F)

l.Referral should be delayed until the cooperation of the child is
possible.

2 Squint can lead to double vision if left untreated.
3.Hypermetropia is a characteristic finding.

4.The structures of an amblyopic eye are normal.

5. Occlusion of normal eye is a management option.

53. 3.When considering the Diabetic Retinopathy:

1. The finding of persistent albuminuria is typically associated with
retinopathy.

2. Retinopathy has been shown to progress more rapidly during
pregnancy.
3. Type 1 diabetics eye should be screened at the time of diagnosis.

4. In NPDR, new blood vessels can be seen.

5. Laser photocoagulation requires a general anaesthetic.

54. RISK FACTORS

* Duration of DM
* Diagnosis < 30 years — DR after 10 years in 50% , DR after 30 years in
90%
» After 20 years of diabetes, nearly 99% of patients with type 1 DM and
60% with type 11 have some degree of diabetic retinopathy.

* Poor glycaemic control
* Tight control is beneficial

* Tight blood glucose control particularly early of the disease, can prevent or
delay the development or progression of DR

* Raised HbA lc increases the risk of PDR

55. RISK FACTORS

Pregnancy
Sometime associated with rapid progression of DR
+ Greater pre pregnancy severity of retinopathy
* Poor pre pregnancy DM control
« Too rapid control during 1* trimester
* Development of pre-eclampsia

Hypertension

+ Very common in type 2 DM

+ Should be rigorously controlled ( <140/80 mmHg)
* Particularly beneficial in type 2 + DME

* CVD & stroke are predictive

56. RISK FACTORS

Nephropathy
* Associated with worsening of DR
* Treatment of renal disease improves DR

Other
* Hyperlipidemia (TG , LDL )
* Smoking
+ Cataract surgery
+ Obesity
+ Anaemia

57. When to start screening

» Screening in children and adolescents: - Annual screening to
start 3 - 5 years after diagnosis, and once the patient is 10
years old.

* Type 1 diabetics - Generally do not develop retinopathy
within 5 years of the diagnosis.

+ Type 2 diabetics - May have retinopathy before diabetes is
diagnosed. eye should be screened at the time of diagnosis.

58. How often to screen

+ Annual screening is recommended.

* Pregnant diabetics should preferably be screened before
pregnancy, early in the first trimester, in each trimester as
well as 6 weeks postpartum.

59. Mild NPDR

60. Moderate NPDR

61. EEE eee
Severe NPDR

E23

62. PDR

63. CLASSIFICATION

No DR
Very mild NPDR

* Micro-aneurysms only

Review in 12 months

Review (most) in 12 months

Mild NPDR

+ Any /all of: microaneurysms, retinal haemorrhages,
exudates, CWS, up to the level of moderate NPDR
+ No IRMA, No beading

Review 6-12 months

Moderate NPDR

* Severe retinal haemorrhages (20) in 1-3 quadrants /

mild IRMA
* Venous beading in 1 quadrant
+ cws

Review in 6 months
Within 1 year,

- PDRin 26%

- High risk PDR in 8%

Severe NPDR

+ The 4-2-1 rule; one or more of:

+ Severe haemorrahges in ALL 4 quadrants
+ Venous beading in > 2 quadrants

* Moderate IRMA in 2 1 quadrant

Review in 4 months
Within 1 year,
- PDRin 50%

High risk PDR in 15%

Very severe NPDR

* Two or more from above

Review in 2— 3 months
Within 1 year, high risk PDR in 45%

64. POR

Early (mild-mod) PDR

+ NVD/NVE insufficient to meet high
risk

Consider PRP
If not, can review in 2 months

High risk PDR

+ NVD > 1/3 dics area
+ Any NVD +VH
+ NVE>% disc area + VH

PRP asap

Advanced diabetic eye disease

* Vision threatening preretinal / VH
+ TRD
+ NVI

PPV

65. Macula oedema

66. Vitreous Hemorrhage

ABNORMAL BLOOD VESSELS
a a

a

Fang WE

A,
yr VITREOUS HEMORRHAGE
t

67. Laser treatment

68. Laser treatment

A

69. 3.When considering the Diabetic Retinopathy:

1. The finding of persistent albuminuria is typically associated with
retinopathy

2. Retinopathy has been shown to progress more rapidly during
pregnancy

3. Type 1 diabetics eye should be screened at the time of diagnosis.

4. In NPDR, new blood vessels can be seen

5. Laser photocoagulation requires a general anaesthetic

70. 3.When considering the Diabetic Retinopathy:

1. The finding of persistent albuminuria is typically associated with
retinopathy

2. Retinopathy has been shown to progress more rapidly during
pregnancy

3. Type 1 diabetics eye should be screened at the time of diagnosis.
4. In NPDR, new blood vessels can be seen

5. Laser photocoagulation requires a general anaesthetic

71. 4. A 47-year-old lady presents with a very watery left eye. She tells you her visi
normal. On examination, she has a red swelling over the medial edge of the left eye.
This is tender on palpation and tense. Fundoscopy is normal. What is the likely
diagnosis?

1.Orbital cellulitis

2. Pterygium

3.Dacryocystitis
4. Meibomian cyst
5.Stye

72. Orbital cellulitis

+ Red and swollen eyelid; diffusely ri
painful eye mo

73. Pterygium

77
Pterygium is a raised, fleshy, triangular-shaped a PZ
growth on conjunctive. In most cases, a ; a

pterygium grows from the inner corner of the
eye (nearest the nose)Long-term exposure to
UV light is the main cause.

it can block visual axix
after sx can develop astgmatism

74. Dacryocystitis

Presentation is with the subacute onset of pain in the

medial canthal area, associated with epiphora. A very

tender, tense red swelling develops at the medial canthus , Ka
commonly progressing to abscess formation. There may

be associated preseptal cellulitis.

1st give oral ab, if not settle admit & give
iv ab

75. Anatomy of Eye Lid

Y Superio

conjunctival

Orbicularis oculi muscle
Superior tarsus
Meibomian

conjunctiva Sebaceous
A \ glands
Palpebral
conjunctiva
Li (lashes)
Palpebral
commissure

Inferior tarsus

Accessory lacrimal glands

76. Meibomian cyst / Chalazion

Chronic granulomatous inflammatory
lesion (lipogranuloma) of the
meibomian glands caused by retained

sebaceous secretions. non-tender, in
eyelid centre

77. tye

An external hordeolum (stye)
is an acute staphylococcal
abscess of a lash follicle.
Common in young adults and
children.

Red tender swelling of lid
margin

78. 4. A 47-year-old lady presents with a very watery left eye. She tells you her vision is
normal. On examination, she has a red swelling over the medial edge of the left eye.
This is tender on palpation and tense. Fundoscopy is normal. What is the likely
diagnosis?

1.Orbital cellulitis
2.Pterygium
3.Dacryocystitis

4.Meibomian cyst
5.Stye

79. 4. A 47-year-old lady presents with a very watery left eye. She tells you her vision is
normal. On examination, she has a red swelling over the medial edge of the left eye.
This is tender on palpation and tense. Fundoscopy is normal. What is the likely
diagnosis?

1.Orbital cellulitis
2.Pterygium

4.Meibomian cyst
5.Stye

80. 5. Tor F regarding ophthalmoscope examinations

1. During an ophthalmoscope exam, the red reflex is an abnormal
finding.

2. The optic disc is normally located nasally in the retina.
3. Green light use to visualise blood vessels.
4. Drusen are deposits found in the retina that are indicative of diabetic

retinopathy.

5. The ophthalmoscope can be used to detect retinal detachment.

81. Direct ophthalmoscopy

Patient Side Practitioner Side — Brow Rest
Viewing Window

___— viepler Power Display

On/Off Switch

82. Light Settings

Large light Medium light Small light Half light

Red free light Blue light Slit Grid

83. Examination Technique

æ Wash your hands.

® Introduce yourself to the patient.

æ Explain what you are going to do.

® Position the patient so that ophthalmoscope is held directly at the level of
patient’s eye.

® Turn on ophthalmoscope and set the light.

æ Dim lights in the examination room.

84. Examination Technique

Instruct the patient to focus on an object straight ahead on the wall.

To exam patient’s RIGHT eye, hold ophthalmoscope in your RIGHT

hand and use your RIGHT eye to look through the instrument.

Place your left hand on the patient’s head and place your thumb on

their eyebrow.

85. Examination Technique

Hold the ophthalmoscope about 50cm from the eye and 15 degrees to

the right of the patient.
Find the red reflex.

Move in closer, staying nasally until you see the optic nerve.

Rotate diopter lens until optic nerve comes into focus.

86. Examination Technique

™ Farsighted eye requires more plus/green number lenses.
æ Nearsighted eye requires more minus/red number lenses.
æ Measure the cup to disc ratio.

æ Scan slightly up, down, right and left to look at vessels.
æ Move out temporally to find macula and fovea.

æ Repeat the same technique on the other eye.

87. Normal fundus

Vein
Macula
Optic Nerve
Fovea
Artery

88. Narrow Field of view through an
ophthalmoscope

89. Red reflex test

red reflex is nl finding
white reflex is ab nl

* Retinoblastoma

=

|

90. Glaucoma Disc

e a

Normal optic nerve head Glaucomatous cupping

91. Disc Swelling

® Blurred Disc Margin,
Hyperaemic Disc,

engorgement of vessels,

haemorrhages around
disc, elevation of disc

93. Age related Macular
degeneration

® Age-related macular
degeneration (AMD)
r sented the principal cause
of blindness.

® AMD is broadly divide
two types: dry AMD and wet
AMD

94. Tractional retinal detachment

LJ Bascom Palmer
Eye Institutes
Umwenst svete

95. 5. T or F regarding ophthalmoscope examinations
1.

During an ophthalmoscope exam, the red reflex is an abnormal
finding.

The optic disc is normally located nasally in the retina
Green light use to visualise blood vessels.

Drusen are deposits found in the retina that are indicative of diabetic
retinopathy.

The ophthalmoscope can be used to detect retinal detachment.

96. 6. T or F regarding cataract

1.Cataracts can only be caused by aging.
2.Wearing sunglasses can help prevent cataracts.
3. Cataracts can be treated with medication.

4. Everyone with cataracts needs surgery.

5. Cataracts can lead to the development of angle-closure glaucoma

97. Cataract

Opacity of the crystalline lens

May be congenital or acquired

Congenital - Metabolic (Galactosaemia, Galactokinase deficiency,
neonatal hypocalcaemia, perinatal hypoglycaemia ), Intra uterine
infections (Rubella and other TORCH diseases ), Systemic
syndromes (Down’s)

Acquired — Age, Metabolic disorders, Trauma, Drugs, Secondary
to ocular disorders, Associated with systemic disorders, UV light,
Smoking

98. Cataract

Symptoms of age related cataracts
* Reduced near and distance vision
* Glare

° Uniocular diplopia

* Haloes around lights

* Improvement of near vision

* Impaired colour vision

99. Cataract - Management

* Early cataracts can be managed with spectacle correction

* Conventional Extra capsular extraction or
phacoemulsification with implantation of Intra Ocular Lens is
done

* Short simple procedure done under LA

* Sometimes done as a Day surgery without hospital stay

100. Cataract

101. Type of cataract

A B C

Anterior Anterior Anterior

Mi posterior A

peripheral Posterior nuclear Posterior subcapsular posterior
opacity Opacity opacity

Anterior lens!

7 Anterior lens

>

.
N Posterior lens “Posterior lens

102. mature catract push the iris & cornea lead
Lens Induced to closure of angle

Glaucoma

Phycomorphic glaucoma
Phycollytic glaucoma

+ Both types are associated with
hypermature cataracts

+ Symptoms occur in an eye
with progressive deterioration
of vision

+ Both are painful causes of red
eye

+ Both need cataract surgery
after control of inflammation
and IOP phycolitic - particals break & block -

cause angle closure

103. 6. T or F regarding cataract
1.Cataracts can only be caused by aging.

2.Wearing sunglasses can help prevent cataracts.
3. Cataracts can be treated with medication.

4. Everyone with cataracts needs surgery.

5. Cataracts can lead to the development of angle-closure glaucoma

104. 7. Tor F regarding Chronic simple glaucoma
Chronic simple glaucoma is always symptomatic in its early stages.

Chronic simple glaucoma can be cured if detected early.

The primary treatment for chronic simple glaucoma is surgery.

Myopia is a risk factor in chronic simple glaucoma

Lifelong treatment and follow up is necessary.

105. CHRONIC OPEN ANGLE GLAUCOMA

* Painless progressive blindness

* May be hereditary

+» At the time of presentation one eye may have severe visual loss

* Characterized by high IOP, cupping of optic discs and visual field loss
* Patients who are at risk

* Increased age

+ High IOP

* First degree relative with COAG

+ Myopia

* Diabetes mellitus

106. pora cup Enlarged cup

Normal Optic nerve

fluid drains optic nerve with glaucoma
here

Retina

Fluid forms

here

(=) Normal Vision Advanced Glaucoma

107. Glaucoma

* Assessment of a patient with glaucoma

+ Tonometry -Goldmann applanation tonometry
* Gonioscopy

+ Examination of the optic nerve head

+ Perimetry —analysis of the visual fields

108. Measuring IOP

7 Pneumotonometer
ù

109. Visual field testing looks for defects and charts
their locations by having the patient stare at a light
while other lights are flashed in the periphery

110. Management

Most patients can be treated with medication (beta blockers,
alpha agonists,carbonic anhydrase inhibitors and
prostaglandin analogues)

Surgery is indicated for resistant cases
Life long treatment and follow up is necessary

111. 7. Tor F regarding Chronic simple glaucoma
L.

Chronic simple glaucoma is always symptomatic in its early stages.

Chronic simple glaucoma can be cured if detected early.

2
3. The primary treatment for chronic simple glaucoma is surgery.
4.
5

Myopia is a risk factor in chronic simple glaucoma

Lifelong treatment and follow up is necessary.

112. Question 1
Dolli Couper, a 62-year-old warehouse packer, presents with acute onset of vision loss in the last 40
minutes. Dolli reports she was at the shops when the symptoms came on all of a sudden. Initially, she did
not know what was going on and thought it would go away by itself however her vision has not returned.
This has not happened before. Dolli says her right eye seems fine, but the left eye has gone completely
black as though a curtain in her eye has been closed. Dolli wears glasses for reading but not for driving.
Putting on her

asses has not helped at all. Dolli insists she feels completely well in herself - there is no
eye pain, headache, nausea or vomiting. On examination, you note that she has a relative afferent
pupillary defect on the left with a Marcus Gunn pupil. Fundoscopy of her left eye is as shown below. Her
blood pressure is 152/98mmHg. She has a history of hypertension, hypercholesterolaemia and type 2
diabetes for which she takes perindopril/ amlodipine 10/10mg PO OD, atorvastatin/ ezetimibe 80/10mg
PO OD and metformin XR 500mg PO OD.

What is the MOST likely diagnosis?
A. Uveitis
B. Acute angle-closure glaucoma
C. Central retinal artery occlusion
D. Central retinal vein occlusion
E. Keratoconus
F. Optic neuritis

113. Question 1

Dolli Couper, a 62-year-old warehouse packer, presents with acute onset of vision loss in the last 40
minutes. Dolli reports she was at the shops when the symptoms came on all of a sudden. Initially, she did
not know what was going on and thought it would go away by itself however her vision has not returned
This has not happened before. Dolli says her right eye seems fine, but the left eye has gone completely
black as though a curtain in her eye has been closed. Dolli wears glasses for reading but not for driving.
Putting on her glasses has not helped at all. Dolli insists she feels completely well in herself - there is no
eye pain, headache, nausea or vomiting. On examination, you note that she has a relative afferent
pupillary defect on the left with a Marcus Gunn pupil. Fundoscopy of her left eye is as shown below. Her
blood pressure is 152/98mmHg. She has a history of hypertension, hypercholesterolaemia and type 2
diabetes for which she takes perindopril/ amlodipine 10/10mg PO OD, atorvastatin/ ezetimibe 80/10mg
PO OD and metformin XR 500mg PO OD.

What is the MOST likely diagnosis?
Uveitis

Acute angle-closure glaucoma
Central retinal artery occlusion
. Central retinal vein occlusion
Keratoconus

TMPAD>

Optic neuritis

FIGURE 39-8 Central retinal vein occlusion ca
al hemorthage ("blood and

114. Figure 5. a) In retrobulbar ON the appearance of the optic nerve

is normal at onset; b) Optic nerve pallor (arrows) is usually seen 8
weeks after the episode of retrobulbar ON with the neuroretinal rim
losing the orange appearance and appearing pale

Normal Cornea

“WA sae

Cornea with Keratoconus

115. FÄSTLANE Loss of vision DDx

Causes

Nontraumatic causes of transient (<24h) monocular vision loss

Nontraumatic causes of acute persistent monocular vision loss

Le ODA

116. 9 Stanford Whatisthe Marcus Gunn Pupil?

MEDICINE
The Marcus Gunn pupil can be detected by swineing flashlight between both eves, Of course,

normally, if you flash light in one eye, both pupils will constrict. However, ifone eve has a problem with
1ally from a problem with the retina or optic nerve), there will be less constriction

detecting light (u:
when light is shown on that eye. Sometimes

e may be no constriction or even paradoxical dilation

in one or both eyes!

This can be seen in disease of the retina or optic nerve such as in retinal detachment, retinal ischemia or

optic neuritis, among other causes.

Normal Right relative afferent
pupillary defect

ET

> <@

à
RCE
6

117. Question 2

Mortimer Tath, a 48-year-old shower glass installer, presents with increasing left lower eyelid discomfort.
He first noted the discomfort 2 days ago as he was going to bed. When he woke up the next morning,
he noticed swelling of his lower eyelid. Mortimer denies any change in vision, discharge or pain on eye
movement. He usually wears protective eyewear in the course of his work and has reading glasses for
computer and phone use. Mortimer has a family history of rheumatoid arthritis in his mother and his
sister, but he has no current joint issues. He is not on any regular medications and has no medication
allergies.

What is the MOST appropriate next step?

Chloramphenicol drops 0.05% TOP 1 drop QID for 5 to 7 days
Urgent referral to an ophthalmologist for incision and drainage
Check intraocular eye pressures

Warm compress for 5 -10 minutes frequently throughout the day
Referral to a rheumatologist for workup of rheumatoid arthritis
CT scan of orbits for penetrating foreign body

ame op >

118. Question 2

Mortimer Tath, a 48-year-old shower glass installer, presents with increasing left lower eyelid discomfort.
He first noted the discomfort 2 days ago as he was going to bed. When he woke up the next morning,
he noticed swelling of his lower eyelid. Mortimer denies any change in vision, discharge or pain on eye
movement. He usually wears protective eyewear in the course of his work and has reading glasses for
computer and phone use. Mortimer has a family history of rheumatoid arthritis in his mother and his
sister, but he has no current joint issues. He is not on any regular medications and has no medication
allergies.

Figure 1. Lower lid chalazion

What is the MOST appropriate next step?
Chloramphenicol drops 0.05% TOP 1 drop QID for 5 to 7 days
Urgent referral to an ophthalmologist for incision and drainage
Check intraocular eye pressures

Warm compress for 5 -10 minutes frequently throughout the day
Referral to a rheumatologist for workup of rheumatoid arthritis

CT scan of orbits for penetrating foreign body

RA

119. | eyeandear Chalazion

hospital

A chalazion is an inflammatory lump or cyst on the eyelid caused by the blockage of an
oil gland in the eyelid, Both your upper and lower eyelid may be affected and you can
have more than one lesion. They are more common if you have an eye condition called

blepharitis or if you have eczema.

A chalazion is not a stye, which is an infection at the base of an eyelash.

Chalazion in an oil gland.

Normal où gland

What are the symptoms?
oA o evelid

® Mild redness, tenderness or swelling of the lid can occur

* Vision may be slightly distorted if the lesion is large enough to press on the eye

120. eyeandear Chalazion

hospital
What is the treatment for chalazion?

a face-washer or disposable makeup pad as a ho!

jer hot compresses may improve di
your blocked gland. Glan

E towards your lid

elids twice a day with warm wa

te baby shampoo.

sia. Children usually

121. Therapeutic
Guidelines

A chalazion (meiborr
meibomian gland
ated with blepharitis. The

discharge spontaneo

pical antibiot

War

indicated.

presses are the mainst

Chalazion (meibomian cyst) and hordeolum (stye)

on of Un

hich are sebace

generally

arm compre

ail. Internal

ly follow

s are not indicated fo

otics are not

or chalazion and hordeolum; top!

122. GP | =

Acute red eye in children: A practical approach

Table 1. Differential diagnosis list of acute red eye in children, with key features and management. Rows with red
shading denote sight-threatening conditions that require urgent referral to ophthalmology for confirmation of diagnosis

and management.

Key

symptom Discharge Key features Diagnosis

Nil

Purulent

Eyelid nodule; mild Chalazion
discomfort; single

or multiple in

upper or lower lids

Note that eTG,

warm com

Localised tender Stye
swelling on eyelid

Management

Conservative management with warm
compresses and gentle massage

for five minutes, twice a day, Refer
to ophthalmology for incision and
curettage, if not resolving after three
months or showing signs of cellulitis.

Topical broad-spectrum antibiotic
such as chloramphenicol 0,5% eye
drops four times per day for seven
days, Epilate infected follicle if
possible. Conservative management
with warm compresses, gentle
massage and careful eyelid cleaning
with proprietary eyelid wipes, Refer to
ophthalmology if signs of cellulitis.

123. Question 3

Maria Nguyen, a 62-year-old lawyer, presents with a one-day history of right eye pain. There is associated
blurred vision and photosensitivity with watery discharge. Maria reports she has been feeling unwell with
coryzal symptoms for the last week and has been using an over-the-counter oral decongestant for the
last 5 days with good relief of her coryzal symptoms. Since the onset of her eye symptoms, she has tried
over the counter chloramphenicol but this has not helped. Your examination is as shown below (refer to
image).

What is the MOST likely diagnosis?
Bacterial conjunctivitis
Allergic conjunctivitis

Viral conjunctivitis

Acute angle closure glaucoma
Open angle glaucoma

Retinal detachment

Anterior uveitis

Posterior uveitis

Herpes simplex keratitis
Episcleritis

Subconjunctival haemorrhage
Orbital cellulitis

FROEO-TAMMION D>

124. Question 3
Maria Nguyen, a 62-year-old lawyer, presents with a one-day history of right eye pain. There is associated

blurred vision and photosensitivity with watery discharge. Maria reports she has been feeling unwell with
coryzal symptoms for the last week and has been using an over-the-counter oral decongestant for the
last 5 days with good relief of her coryzal symptoms. Since the onset of her eye symptoms, she has tried
over the counter chloramphenicol but this has not helped. Your examination is as shown below (refer to
image).

What is the MOST likely diagnosis? |
A. Bacterial conjunctivitis
B. Allergic conjunctivitis
C. Viral conjunctivitis
D. Acute angle closure glaucoma ‚
E. Open angle glaucoma
F. Retinal detachment |
G. Anterior uveitis u
H. Posterior uveitis

|. Herpes simplex keratitis hr

J. Episcleritis

Figure 1 - Conjunctival hyperemia, comenl edema. iris atrophy, and Red moderately dRated pup

K. Subconjunctival haemorrha

L. Orbital cellulitis