Stage 5 Wear Base Unit Ophthalmology 2017

Welcome to this e-learning module which will provide some core content from the Newcastle University curriculum for Ophthalmology.

 

By the end of the tutorial you should be familiar with the following:

 

Complete this e-learning module and the quiz prior to the teaching session on 31st January 2017. You may access the module and re-attempt the questions as many times as you wish before your finals.

 

Designed and created by Dr. Sunil Mamtora, Sunderland Eye Infirmary (FY2)

The Ophthalmic History

Introduction

Why eye?

Examination of the eye and adnexa is an important part of the general examination of a patient. The eye may reveal a wide variety of systemic diseases and eye pathology is ever more common in the ageing population for whom we need to provide care. 

An understanding of the effects of eye disease is critical to holistic patient care. Reduced visual function can have wide spread implications on the mobility, independence and psychological wellbeing of all patients. 

Ophthalmic complaints are common and past estimates suggest that 6% of casualty attendances and 1.5% of GP consultations are ophthalmic. A number of acute ophthalmological conditions can be readily treated if recognised in their early stages and all doctors should be able to recognise these. 

In addition, sight loss is an increasing health concern in the UK with an ageing population. An essential part of clinical work is to effectively diagnose, treat and refer people with an eye condition. 


Royal College of Ophthalmologists 2015

What do you need to know?

Curriculum requirements:

Ophthalmic history: 

Taking with emphasis on being able to elicit an accurate history of visual loss.

  • Pain 
  • Duration
  • Degree of vision loss
  • Permanent or transient - periodicity
  • Central or peripheral loss
  • Progression – getting better or worse
  • One or both eyes
  • Associated symptoms (flashes and floaters, pain, redness)

History

The history, as with all specialties, is the most important part of the examination in Ophthalmology.

History taking should focus on attempting to identify which part of the eye is causing the patient's presenting complaint - for example a painful, watering eye could indicate that there is a problem with the cornea, the front part of the eye whereas a painless change in vision associated with flashes and floaters could suggest a problem with the retina, the light sensing component at the back of the eye.

The format of the history is generally the same as the medical history but with the addition of Past Ocular History in addition to past medical history - you would want to ask specifically about whether they have had any eye problems in the past, any eye trauma, any surgery to either eyes and when was the last time they saw their optician.




What questions should you be asking?

The format of the history should be as with all other histories but we will list the most important and specific questions that should be enquired about here:

Try to find out roughly what their baseline visual acuity is - most patients won't know their exact visual acuity but you can get a rough idea by asking questions like whether or not they read or drive etc.


Blurred vision?

A lot of patients present with 'blurred vision' - this could mean anything, from complete loss of vision to a watering eye. It is very important to ask specifically what is meant by this term and ask exactly how their vision has changed. You can use some examples when asking patients about this - e.g. could you read the newspaper before and now you can only read large signs. 

Flashes and floaters

Floaters and flashing lights: These are the classic symptoms of a retinal detachment and retinal tears so ask EVERY patient about these symptoms. Most patients complain of some floaters – see if they’re actually new or have worsened recently.

Red eye

 Red, painful eyes:  A common complaint.  Be sure to ask about the nature of the pain (is this a scratchy pain, aching pain, or only pain with bright light). Is there discharge that might indicate an infection?


There is a huge differential for red eye - it is usually conjunctivitis though.

Transient loss of vision - Migraine or something more serious?

Think of migraine vessel spasm in the young and micro-emboli in the elderly. Curtains of darkness might indicate an ischemic event or a retinal detachment, so explore these symptoms in detail.

Migraine may be recurrent and may still warrant further investigation.

Retinal artery occlusion requires urgent treatment as even though vision may be lost in one eye, the other eye is at a high risk. Vascular risk factors should be treated aggressively.

Picture shows the classical cherry red spot with pale fundus in central retinal artery occlusion (CRAO).

Other questions worth asking?

There's so much you could potentially ask and you should all be fairly experienced at history taking.

Some questions that you might want to bare in mind - particularly if you get an Ophthalmology mosler:

If the patient has diabetic retinopathy, ask about how their diabetes control is - ask about their HbA1C, do they use insulin, how well is their blood pressure control, how is their cholesterol, what medication do they take? Is there diabetes managed by their GP or a diabetes specialist. Also think about potential treatments they might have had for their retinopathy - laser? injections? (you will learn more about these at the teaching session)

If the patient has Age related macular degeneration (AMD) you could also ask about vascular risk factors - e.g. smoking which is known to be a risk factor for progression of the wet form of AMD.

If the patient presents with uveitis (inflammation in the iris, choroid or ciliary body - you will learn more about this) you should ask about other possible systemic diseases which are associated with uveitis - most notably ankylosing spondylitis, inflammatory bowel disease and sarcoidosis but there are many more!

If the patient presents with flashes and floaters you should ask about their glasses - retinal detachment is much more common in patients who are short sighted because the eye is much longer. 

When asking about what medication they take - DON'T FORGET ABOUT THE DROPS!

If a patient has severe sight impairment then you should always ask about how the patient manages at home? What kind of support do they need? Do they need any low vision aids? Think about how their sight impairment affects their activities of daily living and the impact it may have.

Eye examination

Introduction

This module will briefly cover the aspects of the eye examination that will be expected of you in a MOSLER.

It will NOT cover other aspects of eye examination e.g. pressure measurements and slit lamp examination. These are not in the MBBS curriculum but you are free to read yourself or contact us if you have any questions.

Visual acuity

Traditionally visual acuity is measured with the snellen chart. However, some centres (including Sunderland Eye Infirmary) now use the LOGMAR scale to measure visual acuity as it is thought of as being more sensitive and accurate.

We will only talk about snellen.

It is important that you measure from 6 metres as this is what the chart was designed for. If you use it at 3 metres then you have to use a half sized chart. If the patient cannot read anything on the chart then you have to see if they can count fingers (documented as CF) and if they cannot count fingers then if they have perception of light (documented as PL).

Some places have small rooms and use the normal size chart with a mirror but don't get too stressed about this point.


The important thing to understand is this:

6 / 6 is a person can see at 6 metres what a normal person can see at 6 metres

6/12 is a person can see at 12 metres what a normal person can see at 6 metres

The first number is the normal person (statistically) and the second number is the patient. Some people can be 6/5 which means their visual acuity is better than most!

Acuity should be measured in each eye INDEPENDENTLY!

Visual fields

You will be expected to perform visual fields to confrontation (as with acuity).

Always perform them on one eye at a time. See the below video on how to perform visual fields.

You may be expected in an exam to interpret visual fields e.g. bitemporal hemianopia (an exam favourite). 

It is worthwhile being aware of the origin of the various types of field defects as shown in the image on the left e.g. optic chiasm etc.

This will be covered in your session.


 

Eye movements

Eye movements should be checked routinely as part of every eye examination.

You are mainly looking for any classic cranial nerve palsies and a fantastic video which goes over all the different cranial nerve palsies and how to spot them is below (warning: it is nearly 30 minutes long but it is well worth it and you will won't need to watch anything else!)

As an initial screen you can check them however you like - union jack etc. but you need to make sure there is a complete range of eye movements, there is no pain on eye movement and no double vision. You should also check for nystagmus.

Further evaluation on eye movements e.g. cover/uncover test is beyond the scope of MBBS.


 

Pupils

Pupils can give you a tonne of information.

There are lots of weird and wonderful pupillary defects that may show up specific diseases e.g. syphilis but we won't go into that here.

The main thing you want to see is if the pupils are equal and reactive to light.

You also want to see if there is a relative afferent pupillary defect (RAPD). This indicates damage to the optic nerve. It's worthwhile noting that the patient could be completely blind and not have an RAPD if the visual pathway is intact and they are cortically blind (e.g. after head injury/stroke)

Watch the video below on how to assess the pupils.

IMPORTANT - NEVER DILATE THE PUPILS BEFORE YOU EXAMINE THEM!!!!!!

 

Fundus examination

Direct ophthalmoscopy will require the pupil to be dilated to perform properly.

This should only be done AFTER the pupils have been examined.

Usually Tropicamide 1% , 1 drop in each eye is used. You should generally examine both eyes as it is important to compare them in case you identify suspicious findings.

Watch the video below for a comprehensive explanation on how to perform ophthalmoscopy.

You have some great teaching planned for you to get to grips with ophthalmoscopy. We will revisit this content on the day!

 

Systemic disease and the eye

Optic disc swelling

Disc swelling - is it papilloedema?

Terminology related to disc swelling is important. Disc swelling is commonly referred to as 'papilloedema' - this is not necessarily correct.

The characteristic fundus appearance is of blurred disc margins, tortuous vessels and pallor.

The term papilloedema is only used when disc swelling is specifically secondary to RAISED INTRACRANIAL PRESSURE (ICP).

The causes of raised ICP are beyond the scope of this e-learning but are worth reading about.


A cause worth knowing about from an Ophthalmology point of view is Idiopathic Intracranial Hypertension (IIH) also referred to as pseudotumour cerebri.This condition is a raised intracranial pressure, that can be associated with sight loss in up to 25% of patients.It is most commonly found in obese, young, women and has an association with some medication - most notably the COCP.

Treatment is multidisciplinary between Neuro-ophthalmology and Neurology and generally consists of weight loss advice and acetazolamide (treatment to reduce ICP) if required.

An LP is required to identify a raised opening pressure and imaging is required (usually MRI/contrast CT) to exclude an organic cause (e.g. tumour) for the raised intracranial pressure. If one is identified then it is not Idiopathic!

Giant cell arteritis (GCA)

Giant cell arteritis (GCA) is an ESSENTIAL condition to be aware of and should always be excluded.

It is classed as an arteritic anterior ischemic optic neuropathy (AAION).

The condition is closely linked with polymyalgia rheumatica (PMR) which usually presents with girdle tenderness, myalgia and malaise.

Other features are:- 

  • Scalp tenderness and headache 
  • Jaw claudication
  • Polymyalgias of the arms and shoulders 
  • Fevers, night sweats, weight loss.

GCA is an inflammatory vasculitis and if progresses can lead to occlusion of the artery supplying the optic nerve. This can cause permanent, irreversible blindness which may affect both eyes - it is therefore a sight threatening emergency!

ESR is checked initially and will usually be significantly raised with GCA. Gold standard diagnosis is with temporal artery biopsy but may be negative as may demonstrate skip lesions. If in doubt the diagnosis is clinical and should be treated with a low threshold due to the potential for loss of sight.

Treatment is with high dose steroids - IV methylprenisolone which is then converted to a long course of high dose prednisolone.

Optic Neuritis

Classical exam question and associated with Multiple sclerosis (MS)

Presentation is classically with sudden onset reduction in vision with painful eye movements and colour desaturation - classically red desaturation.Optic neuritis may be the first presentation of MS and these patients should be fully worked up accordingly with MDT involvement and neuro-imaging.

Fundus appearance is with a pale disc.


Patients with optic neuritis are treated with IV steroids, which will speed recovery, but won’t ultimately affect the outcome of the disease. WARNING: You treat with IV steroids only, as oral steroids may actually increase the reoccurrence of MS! If enhancing lesions are found in the brain, then you can get neurology involved to discuss possible treatment with interferons which may slow progression.

Thyroid eye disease

Thyroid eye disease is associated with Grave's disease, one of the auto-immune thyroid diseases, mostly associated with hyperthyroidism.

Symptoms most associated are:

  • Proptosis/Exophthalmos
  • Lagophthalmos
  • Restriction of eye movements
  • Peri-orbital swelling
  • Reduced visual acuity (multiple causes)

One important point to note is that the control of thyroid state (e.g. hyper/hypo/euthyroid) is unrelated to the progression of the eye disease. Thyroidectomy can acutely worsen thyroid eye disease!

The underlying cause is inflammatory with inflammation behind the eye causing the eye to be pushed forwards - proptosis. Additionally, inflammation within the extraocular muscles can cause a restriction in the eye movements.

How can this cause sight loss? Sight loss can affect multiple parts of the eye. 

Cornea - with the eye pushed forwards the lids may not be able to close properly and lagophthalmos may be evident. With the eyelids not closed properly, the front, clear window of the eye is very vulnerable to damage and drying. This can be permanent.

Optic nerve - inflammation behind the eye can lead to pressure on the optic nerve and optic nerve atrophy (different kind of pressure to glaucoma!)


Treatment:

To reduce the risk of corneal damage - topic eye lubricants!

For optic nerve pressure - surgery to reduce the pressure - decompressive surgery.

Stopping smoking helps a lotThere are other treatments for eye movement problems e.g. irradiation.

Systemic steroids can aid with generalised inflammation.

Eye disease

Cataract

Cataract surgery is one of the most commonly performed operations in the NHS. In terms of quality of life improvement it arguably provides some of the best results. We will cover some of basic principles here. For those who are interested, a video can be found at the bottom of this page which covers in detail, the steps involved to successfully extract a cataract (the video is in animated form!).

The vast majority of cataract surgeries are done as day cases, with the patient having the procedure under a local anaesthetic and being able to go home on the same day! They are discharged with a few days worth of antibiotic and steroid eye drops to prevent infection and reduce inflammation. Patients have an artificial lens - termed an IOL (intraocular lens) inserted to replace their own lens which is removed. The prescription of the lens that is inserted is selected based on the prescription that the patient possesses and allows them to not need any glasses after the operation (except for reading!)

Simply put, a cataract is a clouding of the lens within the eye. There are various types of cataract which form in different parts of the lens - the location of the cataract can provide some clues about the cause of the cataract but specific detail here is beyond the scope of the curriculum.

Cataracts may not necessarily impair visual acuity - they can cause very distressing glare, particularly when driving at night! A patient with completely normal visual acuity may still have great benefit from a cataract operation.

The human lens has multiple roles. Not only does it act as a clear medium to refract light such that you can see clearly, it also adapts and changes shape to allow you to see close up.

When you look at a near object, accommodation occurs. Here, the zonules which hold the lens in place relax, allowing it to 'lean forward' and expand. This leads to a thickening effect of the lens, increasing it's 'refractive power' and allows the individual to see clearly up close!

Some Cataract Terminology

Phakic: When you have your natural lens

Pseudophakic eye: When a cataract is replaced with an artificial lens

Aphakic eye: When a cataract is removed but isn’t replaced.


Other useful points:

People with Marfan's syndrome are at risk of lens dislocation. Their inherent collagen metabolism disorder means that the zonular fibres that hold the lens in place are weaker and can rupture.

Patients with diabetes can get transient lens clouding due to fluid shifts. We will cover this in more detail at your teaching session.

 

 

Glaucoma

Glaucoma is a disease where the optic nerve dies. We are not sure why or how this happens (there are many mechanical, vascular, and biochemical theories) but high intraocular pressure certainly seems to be associated, if not entirely the cause, of optic nerve death.

It is important to remember that glaucoma is not simply 'raised intraocular pressure' - it is a form of characteristic optic nerve damage whose most commonly associated risk factor is raised intraocular pressure.

There are a number of risk factors for the development of glaucoma but we will discuss these more in the teaching session.

There are 2 forms of glaucoma - open and closed (the acute form - angle closed glaucoma) we will first discuss open angle glaucoma.


This picture shows how increased pressure can damage the optic nerve.

Checking the pressure of the eye with the tonopen.

The normal intraocular pressure is quoted as 12-22mmhg.

The majority of glaucoma patients (about 80% ) have chronic open angle glaucoma. Most patients are over the age of 40. This condition is more common in African people, and has a strong familial inheritance. The major risk factors are family history, age, race and high eye pressure.

The most commonly associated factor is intraocular pressure. Pressure in the eye is regulated by aqueous humour production within the eye and how it is produced/drained. The specifics of this are probably beyond the scope - what you do need to remember is that intraocular pressure is modifiable - actually the only modifiable aspect of glaucoma and as such, treatment is based on modifying the intraocular pressure (IOP). 

The classical fundus appearance of a patient with glaucoma is usually with an 'increased cup to disc ratio'.

Here we can see this in the picture on the right - a normal cup disc ratio is usually around less than 0.6.

Here we can see some actual photos of discs.

On the left we have a normal disc and on the right a pathological disc.

The cup disc ratio is measured vertically.

Angle closure glaucoma

This is possibly the only medical emergency that may not require the ABCDE approach - although patients can be in so much discomfort that they do appear to be generally unwell and may present with abdominal pain/nausea and vomiting.

In this condition the pressure within the eye suddenly becomes very high. This can cause damage to the eye. The cornea also swells up. Due to this, patients may complain of seeing halos around lights.


Classically, a patient has a red eye with a fixed, mid-dilated pupil that is sluggish to react and a cloudy cornea.

Treatment is with IV Acetazolamide and eye drops that will reduce the pressure. Laser treatment is used to prevent angle closure from occurring again.

Diabetic Retinopathy

Diabetic retinopathy occurs when prolonged diabetes damages the small bloodvessels and nerves in the retina.

People with Type 1 or Type 2 diabetes are at risk of developing diabetic retinopathy. The longer a person has diabetes, the higher chance s/he has ofgetting the disease. Pregnant women, especially those who have gestational diabetes, also face a higher risk. High blood pressure and high cholesterol may worsen diabetic retinopathy, as well.

Diabetic retinopathy may progress over time. There are two main stages of the disease that can both lead to vision loss.

A. Non-proliferative diabetic retinopathy (NPDR)

Most patients (95%) have NPDR. This is the earliest stage of retinopathy and it progresses slowly. Because so many diabetic patients have NPDR, this stage is commonly described as “background retinopathy.” The earliest signs of retinal damage arise from capillary wall breakdown, seen on the fundus exam as vessel microaneurysms. Injured capillaries can leak fluid into the retina and the aneurysms themselves can burst, forming “dot-and-blot hemorrhages.”

B. Proliferative Retinopathy

With ongoing injury to the retinal vasculature, there eventually comes a time when the vessels occlude entirely, shutting down all blood supply to areas of the retina. In response, the ischemic retina sends out chemicals that stimulate growth of new vessels. This new vessel growth is called neovascularisation, and is the defining characteristic of proliferative retinopathy. Far fewer patients have proliferative retinopathy, which is fortunate as this stage can advance rapidly with half of these patients going blind within five years if left untreated. The mechanism and complications of neovascularization merit study, so let’s take a closer look.

Macular Edema

Despite the neovascularization phenomenon and its potential for detachments and hemorrhage, the most common cause of blindness in diabetic patients is from macular edema. This occurs when diffuse capillary and microaneurysm leakage at the macula causes the macular retina to swell with fluid.

Here we see proliferative retinopathy - note the appearance of many small wispy vessels throughout the fundus.

Note this is a right eye fundus - imagine a person's head behind the photo looking at you. The disc is always nearer to the nose.

Diabetic retinopathy - background.

Here we see a labelled photograph of typical findings that may often be seen in the fundus of diabetic patients.

Treatment of DR (diabetic retinopathy) Preventative medicine with tighter control of glucose is the ideal treatment, but for worsening symptoms, surgical treatment is necessary. The two main surgeries are laser treatment and vitrectomy. 

Laser Treatment 

In cases of macular edema, an argon laser can be used to seal off leaking vessels and microaneurysm in the retina by burning them. If the leakage or microaneurysm is small and well-defined, it can be selectively sealed off. With larger areas of leaking capillaries, such as diffuse macular edema, the laser can lay down a “grid photocoagulation” pattern over the entire area. 

With advanced retinopathy and neovascularization, a different approach is taken. Instead of individually targeting vessels, PRP (pan-retinal photocoagulation) is performed. With PRP, the ophthalmologist burns thousands of spots around the peripheral retina. This destroys the ischemic retina, decreasing the angiogenic stimulus, and commonly leads to regression and even the complete disappearance of the new vessels. This treatment may seem drastic, but it has proven to be effective. Naturally, there are side effects, with peripheral vision loss and decreased night vision (from the rod photoreceptor loss), but this is acceptable if the central vision is saved. I’ve never seen anyone actually complain of decreased vision, but it’s possible and should be stressed during consent.

Age related macular degeneration (AMD)

AMD

AMD stands for Age related Macular Degeneration and is a common retinal finding in older patients. AMD is actually the leading cause of blindness in the elderly, at least in developed countries like the UK. 

On exam you see localized retinal atrophy and pigmentary changes in the macula that correlate with poor central vision. The visual loss occurs slowly, however, and takes many years to progress.

Neovascular “wet” AMD

Vessels can grow up out of the deep choroidal circulation directly up into the retina! This is dangerous, as this neovascularization can bleed, create edema, and rapidly destroy vision. 

Treating this macular neovascularization is tricky – we would love to burn it away with a laser, but those bad blood vessels are often right at the fovea, and you don’t want to burn away central vision! Instead, we can use a few other techniques with variable success: 

Lucentis: 

You can also inject anti-VEGF drugs like Avastin or Lucentis into the eye to stop angiogenesis. These anti-neovascular drugs also decrease vessel wall leakage and can help with other causes of macular edema. Lucentis is a very expensive drug but is currently the only licensed anti-VEGF agent used in the treatment of wet AMD.

Monitoring progression

Early, dry AMD is very common and requires no treatment (other than possibly antioxidant vitamins), but we want to monitor these patients for progression to wet-AMD. Patients can monitor themselves with an Amsler grid — a sheet of straight lines they can look at weekly for new metamorphopsia (distorted lines that might indicate macular edema). 

Risk Factors?

So who gets AMD? This disease occurs most often in elderly Caucasians with a positive family history for the condition. It’s almost always bilateral. Disease progression is also highly associated with smoking. 

An Amsler grid - if macular disease is present the lines above may look distorted instead of appearing to be straight.

Here we can see the fundus of a left eye (you can tell because the disc is on the left, next to the nose). You can see the dry AMD changes over the macula.

Red eye

Conjunctivitis

We are going to be really brief here because there is not a great deal to say - this can come up in the medical schools finals and will be a really basic question where you simply have to differentiate between the different types of conjunctivitis.

The cause of conjunctivitis is not always apparent and it’s sometimes impossible to determine the cause. Typically, you treat with cool compresses, lubricating drops, and vigorous hand-washing. If you suspect bacteria, you treat with an antibiotic like chloramphenicol. Pathognomonic symptoms include:

1. Viral: watering, follicles, swollen lymph nodes - there may be a history of a recent flu like illness

2. Bacterial: creamy discharge, unilateral

3. Allergy: bilateral itching and swelling

Subconjunctival Haemorrhage

Sub-conjunctival haemorrhage has a classical appearance. It spares the cornea completely and therefore has no impact on the vision itself.

The most common cause is spontaneous that has no real underlying cause. If a patient presents with a sub-conjunctival haemorrhage (SCH) then it is worthwhile asking about potential risk factors - these are primarily blood pressure and coagulopathies (e.g. if the patient is on warfarin or other anti-coagulant).

Classical appearance of a SCH, sparing the cornea and not affecting the vision.

Uveitis

Uveitis is a broad disease and it is hard to give a complete summary of this condition here - it will be covered further in your sessions.

Essentially the 'uvea' covers the iris, ciliary body and choroid. Uveitis is simply an inflammation of one of these parts of the eye. Inflammation may involve the iris, which is termed anterior uveitis and is the most common type of uveitis. Intermediate, Posterior and Pan-uveitis forms also exist.

Systemic disease may be associated with uveitis, here are some examples:

  • Ankylosing spondylitis
  • Juvenile idiopathic arthritis
  • Sarcoidosis
  • Infectious diseases such as HIV and TB
  • There are many more

Patients may classically present with a red, painful eye with a constricted pupil. The pupil may be seen to be irregular.

There may be a history of previous similar 'attacks'

A careful history should be sought to identify any possible systemic assocations.


How can we help people with low vision?

Who is in the MDT?

As with all specialties, there are many members of the ophthalmic MDT. These include:

Ophthalmic nurses

Nurse practitioners

Visual support officers

Opticians

Ophthalmologists

Orthoptists

And many more...

Sight impairment registration

Registered Blind

Generally, to be certified as severely sight impaired (blind), your sight has to fall into one of the following categories, while wearing any glasses or contact lenses that you may need:

• Visual acuity of less than 3 / 60 with a full visual field

• Visual acuity between 3 / 60 and 6 / 60 with a severe reduction of field of vision, suchas tunnel vision

• visual acuity of 6 / 60 or above but with a very reduced field of vision, especially if alot of sight is missing in the lower part of the field.

To be certified as sight impaired (partially sighted) your sight has to fall into one ofthe following categories, while wearing any glasses or contact lenses that you mayneed:

• Visual acuity of 3 / 60 to 6 / 60 with a full field of vision

• Visual acuity of up to 6 / 24 with a moderate reduction of field of vision or with acentral part of vision that is cloudy or blurry

• Visual acuity of 6 / 18 or even better if a large part of your field of vision, for examplea whole half of your vision, is missing or a lot of your peripheral vision is missing.

Driving restrictions

DVLA

Acuity- 6/12 on Snellen scale, or 6/7.5 if lorry driver

Visual field- total field width of 120 degrees, needs to be a field of at least 50 degrees on eachside

Diplopia- ceases driving immediately

Conditions:

• Diabetes- must meet all of the above plus no more than 1 episode of hypoglycaemicattack in last 12months, regular monitoring of BMs and regular medical follow up

• Epilepsy- free from attack for 1 year

Quiz

Quiz

This quiz may include topics which are not included in this e-learning.

You are welcome to re-attempt the quiz as many times as you like before finals.

Good luck!


Which of the following structures is most anterior?

  • Sclera
  • Cornea
  • Anterior Chamber
  • Choroid

Which is the most common cause of blindness in working age adults?

  • Glaucoma
  • Trauma
  • Diabetic Retinopathy
  • Age Related Macular Degeneration

A 70 year old patient has sudden loss of vision, painful jaw and tender shoulders. He has an elevated ESR. What is the most likely diagnosis?

  • Polymyalgia Rheumatica
  • Giant Cell Arteritis
  • Acute Angle Closure Glaucoma
  • Central Retinal Artery Occlusion

A 10 year old girl has had a recent flu-like illness. She presents with red eyes and watery discharge from both eyes. What is the most appropriate management?

  • Supportive management with lubricants
  • Chloramphenicol
  • Fusidic acid
  • Refer to opthalmology

A 5 year old girl wakes up with a red eye and green discharge from that eye. Her eye feels ‘gritty’. What is the most likely diagnosis?

  • Foreign body
  • Bacterial conjunctivitis
  • Viral conjunctivitis
  • Corneal abrasion

A patient has sudden onset eye pain with nausea and vomiting. They describe seeing ‘haloes’ around lights. What is the most likely diagnosis?

  • Acute glaucoma
  • Secondary glaucoma
  • Primary glaucoma
  • Open angle glaucoma

A 40 year old with a past medical history of ankylosing spondylitis presents with a painful red eye, photophobia and neck stiffness. What is the most likely diagnosis?

  • Meningitis
  • Uveitis
  • Reactive arthritis
  • Acute glaucoma

A 83 year old man presents with complete ptosis of his left eye. On examination his eye is deviated downward and laterally. His pupils are normal. What cranial nerve is affected?

  • Left 3rd cranial nerve
  • Right 3rd cranial nerve
  • Left 4th cranial nerve
  • Right 4th cranial nerve

A 35 year old female boxer who wears contact lenses presents with flashing lights and floaters in her right eye. What is the most likely diagnosis?

  • Acute glaucoma
  • Retinal detachment
  • Migrane
  • Contact lens keratitis

Which of the following is NOT a sign of diabetic retinopathy?

  • Cotton wool spots
  • Exudate
  • New vessels
  • AV nipping

You perform direct ophthalmoscopy on a 54 year old lady from India with past medical history of T2DM. Her BP is 180/63 You see cotton wool spots, new vessels at the optic disc and dot blot haemorrhages. What is the most cause for these findings?

  • Hypertensive Retinopathy
  • Diabetic Maculopathy
  • Pre-proliferative Diabetic Retinopathy
  • Proliferative Diabetic Retinopathy

A young woman presents with a painful eye. Examination with fluroscein stain reveals a branch like stain. What is the most likely diagnosis?

  • Foreign body
  • Trichiasis
  • Dendritic corneal ulcer
  • Marginal keratitis

What is normal intra-ocular pressure?

  • 6
  • 16
  • 26
  • 36

Short sightedness is also known as?

  • Hypermetropia
  • Presbyopia
  • Myopia
  • Pseudometropia

What is the most common cause of unilateral proptosis?

  • Orbital cellulitis
  • Intracranial mass
  • Intraorbital mass
  • Thyroid eye disease

A 35 year old female presents with sudden onset painful eye movement with reduced colour vision. What is the most likely diagnosis?

  • Cluster headache
  • Optic neuritis
  • Migrane
  • Temporal arteritis

A 66 year old man with heart failure complains of green/yellow tinge to his vision. What medication is causing this?

  • Digoxin
  • Ivabradine
  • Metoprolol
  • Ramipril

A 67 year old man with lung cancer presents with shortness of breath, droopy left eyelid and constricted left pupil. What is most likely to be causing this cluster of symptoms?

  • Renal adenocarcinoma
  • Carotid dissection
  • Pancoast tumour
  • Cavernous sinus thrombosis

A 60 year old lady comes to you because she keeps bumping into things. You notice she has large hands, is sweating and appears agitated. What visual field defect is she likely to have?

  • Bitemporal hemianopia
  • Left homonymous hemianopia
  • Right homonymous hemianopia
  • Arcuate scotoma

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Pick the best answer

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