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Ophthalmology Conditions For Years 3-5 Medical Students By Dr Arthur Green FY2 3 April 2023 BRITISH INDIAN MEDICAL @BRITISHINDIANMEDICASSOCIATION @BINDIANMEDICS @BIMA ASSOCIATION BIMA Clinical Series FY2 Doctor at West Herts Teaching Hospitals Trust Graduated with MBBS from King’s College London 2021 Specialist interest in Ophthalmology Dr Arthur Green MBBS BSc (Hons) Runner up in 2021 Duke Elder National Ophthalmology prize Currently on FY2 ophthalmology rotation at Watford General Hospital BIMA Clinical Crash CourseStructure of talk • 60-75 minutes • Introduction • 13 MCQs with discussion and details on important ophthalmological conditions to know for medical school clinical examinations • Plenty of time for questions – don’t be shy! BIMA Clinical Crash CourseQuestion 1 • 65F referred by optician with bilateral raised intraocular pressure of 25mmHg. PMH: Asthma. A diagnosis of Primary Open Angle Glaucoma is suspected. What is the most appropriate topical ocular treatment for this patient? 1. Timolol (B-Blocker) 2. Prednisolone Acetate 3. Latanoprost (prostaglandin analogue) 4. Brinzolamide (Carbonic anhydrase inhibitor) BIMA Clinical Crash CourseQuestion 1 • 65F referred by optician with bilateral raised intraocular pressure of 25mmHg. PMH: Asthma. A diagnosis of Primary Open Angle Glaucoma is suspected. What is the most appropriate topical ocular treatment for this patient? 1. Timolol (B-Blocker) 2. Prednisolone Acetate 3. Latanoprost (prostaglandin analogue) 4. Brinzolamide (Carbonic anhydrase inhibitor) BIMA Clinical Crash CoursePrimary Open Angle Glaucoma • Usually caused by raised IOP (ocular hypertension) – usually idiopathic. • ‘Normal’ range <21mmHg • Treatment typically initiated if evidence of glaucomatous damage or IOP>24mmhg • Risk Factors: Age, FH, Race (Black), steroid use • Progressive irreversible loss of ganglion cells of neuroretina • May be asymptomatic in early stages • Hx: visual field defect – Textbook “arcuate scotoma”. • Examination and investigation findings: Visual field defect, optic disc “cupping”, Retinal nerve fibre layer thinning on OCT BIMA Clinical Crash CoursePrimary Open Angle Glaucoma • Tx: Updated NICE guidelines 2022 – First line treatment is now selective laser trabeculoplasty (SLT). • Second line is IOP reducing eye drops – first line of these is prostaglandin analogue. Other options include B Blocker, Alpha agonists and carbonic anhydrase inhibitors (CAI) • Prostaglandin analogues side effects include hypertrichosis (long eyelashes), iris and periorbital skin hyperpigmentation, ocular irritation and blepharitis • B-Blocker contra-indicated in asthma • CAI contraindicated in sulfonamide allergy e.g. sulfasalazine • Gold standard treatment is surgical trabeculectomy BIMA Clinical Crash CourseGlaucoma: other • Acute Angle Closure Glaucoma • Acute rise in IOP due to closure of iridocorneal angles, occluding trabecular meshwork • Presentation: Eye pain/headache – unilateral. Blurred vision. Haloes around lights, fixed oval pupil, N+V • Treatment: Ophthalmological emergency!! Acetazolamide to decrease aqueous production, pilocarpine to constrict pupil. Bilateral YAG laser peripheral iridotomy – provides alternative pathway from posterior to anterior chamber • Secondary Glaucoma • Secondary to another disease • Blockage of Trabecular meshwork - e.g. pseudoexfoliative glaucoma and pigmentary glaucoma • Increased pressure of drainage vessels e.g. Sturge-weber syndrome, cavernous sinus thrombosis BIMA Clinical Crash CourseAcute angle closure glaucoma BIMA Clinical Crash CourseQuestion 2 • 82F presents to A+E with painful loss of vision in left eye. On examination left RAPD, swollen pale optic disc on direct ophthalmoscopy and pain across shoulder girdle. What is the most likely diagnosis? 1. Central retinal artery occlusion (CRAO) 2. Central retinal vein occlusion (CRVO) 3. Non-arteritic anterior ischaemic optic neuropathy (NAION) 4. Arteritic anterior ischaemic optic neuropathy (AION) BIMA Clinical Crash CourseQuestion 2 • 84F presents to A+E with painful loss of vision in left eye and pain across shoulder girdle. On examination left RAPD, swollen pale optic disc on direct ophthalmoscopy. What is the most likely diagnosis? 1. Central retinal artery occlusion (CRAO) 2. Central retinal vein occlusion (CRVO) 3. Non-arteritic anterior ischaemic optic neuropathy (NAION) 4. Arteritic anterior ischaemic optic neuropathy (AION) BIMA Clinical Crash CourseGiant Cell Arteritis (GCA) • Generalized granulomatous inflammation of medium- to large-sized vessels • Occurs in the elderly • Strong association with polymyalgia rheumatica • Ocular manifestations are common – Most common of which is AAION • Presentation: Headache, jaw claudication, myalgia, constitutional features e.g. fevers and fatigue • Treatment: Urgent high dose oral steroids • Diagnosis: BOTH ESR and CRP, temporal artery biopsy. N.B. none of these tests are 100% sensitive so cannot be used to rule out BIMA Clinical Crash CourseAnterior ischaemic optic neuropathy • Can be differentiated into arteritic and non-arteritic • Patient will present with RAPD and decreased VA • Arteritic • Almost always associated with GCA • Signs: Pale swollen disc +/- adjacent cotton wool spots or haemorrhages • Non-arteritic • Painless loss of vision due to vascular insufficiency • Textbook patient will have small “crowded” optic discs • Ganglion cell death follows disc oedema • No effective treatment BIMA Clinical Crash CourseQuestion 3 • 82M presents with reduction in visual acuity over the past 18 months to 6/18. Fundoscopy shows macular drusen and geographic atrophy. PMH: Hypertension, Hypermetropia. What is the most likely diagnosis? 1. Central retinal artery occlusion 2. Age-related macular degeneration 3. Retinal detachment 4. Optic neuritis BIMA Clinical Crash CourseQuestion 3 • 82M presents with reduction in visual acuity over the past 18 months to 6/18. Fundoscopy shows macular drusen and geographic atrophy. PMH: Hypertension, Hypermetropia. What is the most likely diagnosis? 1. Central retinal artery occlusion 2. Age-related macular degeneration 3. Retinal detachment 4. Optic neuritis BIMA Clinical Crash CourseAge-related Macular Degeneration • Elderly • Painless insidious reduction in visual acuity • Metamorphopsia • Dry AMD • Deposition of drusen in Bruch’s membrane behind retina • Advanced dry AMD can progress to geographic atrophy of retina • Wet AMD • Subretinal or intraretinal fluid/macular oedema • Treatment: Dry AMD changes are irreversible. Smoking cessation and supplementation with specific vitamins (Vitamins C, E, Zinc Copper, Lutein and Zeaxanthin) can slow progression • Wet AMD treated with intravitreal Anti-VEGF injections • Self monitor progression with Amsler grid BIMA Clinical Crash CourseQuestion 4 • 32F diabetic patient presents to GP with the following lesion, which has been gradually enlarging over the past 2 months. What is the most likely diagnosis? 1. Chalazion 2. Hordeolum 3. Squamous cell carcinoma 4. HPV papilloma BIMA Clinical Crash CourseQuestion 4 • 32F diabetic patient presents to GP with the following lesion, which has been gradually enlarging over the past 2 months. What is the most likely diagnosis? 1. Chalazion 2. Hordeolum 3. Squamous cell carcinoma 4. HPV papilloma BIMA Clinical Crash CourseChalazion and Hordeolum • Hordeolum (or Stye) is a Staph. infection of one of the glands of the lid margin • Painful • Advised not to pop these as can spread infection. Treat with warm compress • Lash follicle = external hordeolum • Meibomian gland = internal hordeolum • Chalazion is a chronic sterile lipogranuloma caused by obstructed meibomian gland within tarsal plate. • Painless • Again, treated with warm compress and gentle massage. • Surgically incised if affecting vision or persistent • Risk factors include diabetes, rosacea, blepharitis BIMA Clinical Crash CourseQuestion 5 A patient has had a stroke which has affected the right optic tract. Which of the following is the most likely clinical findings? 1. Left homonymous hemianopia and left RAPD 2. Blindness of right eye with right RAPD 3. left homonymous hemianopia and no RAPD 4. Left homonymous hemianopia and right RAPD BIMA Clinical Crash CourseQuestion 5 A patient has had a stroke which has affected the right optic tract. Which of the following is the most likely clinical findings? 1. Left homonymous hemianopia and left RAPD 2. Blindness of right eye with right RAPD 3. left homonymous hemianopia and no RAPD 4. Left homonymous hemianopia and right RAPD BIMA Clinical Crash CourseLesions of optic pathwayQuestion 6 30M presents to GP complaining of bilateral red eye. He describes a 2 week history of itchy watery eyes that are crusty in the morning. Nil PMH. O/E hyperaemia and excess lacrimation. Visual acuity and pupil reflexes NAD Which is the most likely diagnosis? 1. Anterior uveitis 2. Episcleritis 3. Scleritis 4. Conjunctivitis BIMA Clinical Crash CourseQuestion 6 30M presents to GP complaining of bilateral red eye. He describes a 2 week history of itchy watery eyes that are crusty in the morning. Nil PMH. O/E hyperaemia and excess lacrimation. Visual acuity and pupil reflexes NAD Which is the most likely diagnosis? 1. Anterior uveitis 2. Episcleritis 3. Scleritis 4. Conjunctivitis BIMA Clinical Crash Courseconjunctivitis • Inflammation of conjunctiva • Causes: infectious (usually bacterial or viral), Allergic atopic conjunctivitis • Sx: itchy/painful, foreign body sensation, discharge or lacrimation • Treatment: lid and hand hygiene. Topical chloramphenicol if bacterial cause suspected BIMA Clinical Crash CourseViral conjunctivitis • Highly contagious • Thin watery discharge • Hand hygiene important including not sharing towels – particularly contagious • Usually spreads to bilateral in a few days BIMA Clinical Crash CourseScleritis and Episcleritis • Inflammation of inner ocular linings Episcleritis Scleritis Disease course Benign Associated with underlying connective tissue diseases – classically Wegner's Redness Prominent redness Usually less prominent – often deeper purple Pain Less painful Deep boring pain Treatment NSAIDs Oral steroids/immunosuppression BIMA Clinical Crash CourseQuestion 7 22M has a painful right eye for 1 day. He had similar symptoms 1 year ago. He has had episodic back pain and stiffness for 4 years which is relieved by exercise and ibuprofen. His right eye is red and photophobic. Which is the most likely cause of his red eye? 1. Chorioretinitis 2. Conjunctivitis 3. Episcleritis 4. Keratitis 5. Uveitis BIMA Clinical Crash CourseQuestion 7 22M has a painful right eye for 1 day. He had similar symptoms 1 year ago. He has had episodic back pain and stiffness for 4 years which is relieved by exercise and ibuprofen. His right eye is red and his vision is blurred. Which is the most likely cause of his red eye? 1. Chorioretinitis 2. Conjunctivitis 3. Episcleritis 4. Keratitis 5. Uveitis BIMA Clinical Crash CourseAnterior Uveitis • Inflammation in the anterior part of the uvea. The uvea involves the iris, ciliary body and choroid. • Anterior chamber infiltrated by immune cells • Usually autoimmune. Also traumatic, infective or malignant • Associated with HLA-B27 seronegative spondyloarthropathies e.g. ankylosing spondylarthritis, IBD, reactive arthritis, Juvenile idiopathic arthritis • Presentation: Typically unilateral red eye (perilimbal conjunctival injection), photophobia, sluggish or irregular pupil. • More severe: posterior synechiae (adhesions of iris to lens), hypopyon • Management: Steroids and cycloplegic-mydriatics • Investigation: HLA-B27 serotype in bilateral or recurrence BIMA Clinical Crash CourseQuestion 8 A 72 year old diabetic lady presents to A+E with painful red left eye and reduced visual acuity 4 days following uncomplicated cataract surgery. On examination, she has hypopyon, corneal haze, and vitreous opacities. Her visual acuity is perception of light only. What is the most likely diagnosis? 1. Post-surgical traumatic anterior uveitis 2. Endophthalmitis 3. Episcleritis 4. Scleritis BIMA Clinical Crash CourseQuestion 8 A 72 year old diabetic lady presents to A+E with painful red left eye and reduced visual acuity 4 days following uncomplicated cataract surgery. On examination, she has hypopyon, corneal haze, and vitreous opacities. Her visual acuity is perception of light only. What is the most likely diagnosis? 1. Post-surgical traumatic anterior uveitis 2. Endophthalmitis 3. Episcleritis 4. Scleritis BIMA Clinical Crash CourseEndophthalmitis • Sight threatening inflammation of the intraocular fluids, typically due to infection • Typically postoperative or after intravitreal injections • Acute post-op endophthalmitis • Presents within 2 weeks – usually 3-5 days • rapidly progressive, including pain, red eye, ocular discharge, and worsening vision • Lid swelling, marked conjunctival and corneal oedema, hypopyon, AC inflammation, vitritis and panretinitis • Poor visual outcomes if not treated early • 70% due to Staph. epidermidis • Chronic post-op endophthalmitis • Occurs >6 weeks after surgery • May be painless and hypopyon may be absent • 70% due to P. acnes • Ix: Sampling of both AC and vitreous for MC+S • Management: High dose broad spectrum intravitreal antibiotics e.g. Vancomycin or ceftazidime BIMA Clinical Crash CourseQuestion 9 A 72 year old gentleman complains of sudden loss of vision in his right eye. PMH: Hypertension, AF, Diabetes. O/E pale fundus with “cherry red spot”. What is the most likely diagnosis? 1. Branch retinal artery occlusion 2. Central retinal artery occlusion 3. Branch retinal vein occlusion 4. Central retinal vein occlusion BIMA Clinical Crash CourseQuestion 9 A 72 year old gentleman complains of sudden loss of vision in his right eye. PMH: Hypertension, AF, Diabetes. O/E pale fundus with “cherry red spot”. What is the most likely diagnosis? 1. Branch retinal artery occlusion 2. Central retinal artery occlusion 3. Branch retinal vein occlusion 4. Central retinal vein occlusion BIMA Clinical Crash CourseRetinal artery occlusions • Equivalent of a stroke in the retinal vessels – usually thromboembolic disease • Central or branch retinal artery occlusion • Cardiovascular risk factors + carotid artery stenosis • Presentation: Sudden painless loss of vision • Important to rule out arteritic causes e.g. GCA • Management: URGENT ocular massage and IOP lowering treatment e.g. oral acetazolamide • Refer to stroke team • Manage underlying risk factors • In CRAO, 1 in 5 will retain central vision due to cilioretinal artery providing alternative blood supply to fovea from choroid BIMA Clinical Crash CourseRetinal vein occlusions • Classified into branch or central, and into ischaemic or non- ischaemic • Ischaemia associated with worse prognosis • Pathophysiology: Atherosclerotic changes in arteries/arterioles compress and occlude neighbouring vein/venule • Presentation: sudden painless vision loss • Signs: Retinal haemorrhage, cotton wool spots. CRVO “stormy sunset” • Management: Optimisation of vascular risk factors • Complications: Macular oedema, retinal neovascularisation • Treatment of complications: Intravitreal anti-VEGF for oedema, panretinal photocoagulation for neovascularisation BIMA Clinical Crash CourseQuestion 10 A 24 year old male patient attends A+E complaining of visual loss in his right eye after hitting his head on a night out. He reports seeing bright flashing lights and a curtain in his right visual field. Visual acuity is markedly reduced. He wears glasses with prescription of -11 in his right eye and -9 in his left eye. What is the most likely diagnosis? 1. Retinal detachment 2. Ocular migraine 3. Posterior circulation stroke 4. Posterior vitreous haemorrhage 5. Acute angle closure glaucoma BIMA Clinical Crash CourseQuestion 10 A 24 year old male patient attends A+E complaining of visual loss in his right eye after hitting his head on a night out. He reports seeing bright flashing lights and a curtain in his right visual field. Visual acuity is markedly reduced. He wears glasses with prescription of -11 in his right eye and -9 in his left eye. What is the most likely diagnosis? 1. Retinal detachment 2. Ocular migraine 3. Posterior circulation stroke 4. Posterior vitreous haemorrhage 5. Acute angle closure glaucoma BIMA Clinical Crash CourseRetinal detachment (RD) • Key symptoms: New floaters, flashes, a ‘curtain’ defect over part of visual field or reduced visual acuity. • Examination: ballooning of retina forward off posterior pole. • May be preceded by posterior vitreous detachment • Risk factors: High myope (short sighted, large eye), eye injury, FHx or personal Hx, recent eye surgery, diabetes • 3 types: Rhegmatogenous (following a retinal break or tear), Tractional (due to pulling forces), exudative (due to accumulation of fluid behind retina) • Management: Vitrectomy and tamponade of detached retina with gas or silicone BIMA Clinical Crash CourseQuestion 11 55M referred to ophthalmology by GP as his friends have recently noticed his pupils are not the same size. O/E the left pupil is larger than the right. Right eye constricts to light but the left does not. Both eyes constrict and converge to light upon testing of accommodation reflex. It was noticed that the left eye remains smaller than the right for the following few minutes. What is the most appropriate next step for this patient? 1. Instillation of cocaine eye drops 2. IV benzylpenicillin 3. CT aortogram 4. CT chest 5. Reassure and discharge BIMA Clinical Crash CourseQuestion 11 55M referred to ophthalmology by GP as his friends have recently noticed his pupils are not the same size. O/E the left pupil is larger than the right. Right eye constricts to light but the left does not. Both eyes constrict and converge to light upon testing of accommodation reflex. It was noticed that the left eye remains smaller than the right for the following few minutes. What is the most appropriate next step for this patient? 1. Instillation of cocaine eye drops 2. IV benzylpenicillin 3. CT aortogram 4. CT chest 5. Reassure and discharge BIMA Clinical Crash CourseNear-Light dissociation • Adie Tonic Pupil • Benign phenomenon. • Dilated pupil • Constricts well to accommodation but not to light due to parasympathetic denervation. • Delayed dilatation following accommodation • Diagnosed with topical pilocarpine drops to both eyes, affected eye will overreact due to denervation sensitivity • Argyll-Robertson pupil • Tertiary syphilis • Constricted pupil • Does not maintain increased tone as described in this MCQ BIMA Clinical Crash CourseAnisocoria Mydriasis – Dilated Miosis – Constricted (parasympathetic disruption) (Sympathetic disruption) Surgical CNIII palsy Horner Syndrome Adie tonic pupil Argyll-Robertson pupil BIMA Clinical Crash CourseCNIII palsy • Complete ptosis and down and out eye • Vital questions: 1. pupil involvement? 2. painful? • Mydriatic pupil  Surgical 3 nerve palsy ?posterior communicating artery aneurysm rd • Normal pupil  medical 3 nerve palsy ?HTN or DM BIMA Clinical Crash CourseHorner Syndrome • Disrupted ocular sympathetic pathway • Miosis, anhidrosis, partial ptosis (MAP) BIMA Clinical Crash CourseQuestion 12 55M attends annual diabetic eye screen. He reports no visual symptoms but admits worsened diabetic control over recent months. Fundoscopy shows dot and blot haemorrhages, engorged tortuous veins and cotton wool spots. Which is the most likely diagnosis? 1. Mild non-proliferative diabetic retinopathy 2. Severe non-proliferative diabetic retinopathy 3. Central retinal vein occlusion 4. Diabetic maculopathy 5. Central retinal artery occlusion BIMA Clinical Crash CourseQuestion 12 55M attends annual diabetic eye screen. He reports no visual symptoms but admits worsened diabetic control over recent months. Fundoscopy shows dot and blot haemorrhages, engorged tortuous veins and cotton wool spots. Which is the most likely diagnosis? 1. Mild non-proliferative diabetic retinopathy 2. Severe non-proliferative diabetic retinopathy 3. Central retinal vein occlusion 4. Diabetic maculopathy 5. Central retinal artery occlusion BIMA Clinical Crash CourseDiabetic retinopathy • Preproliferative changes: • Background changes are microaneurysms and dots/blots in early disease • Cotton wool spots and venous beading in more advanced disease • Cotton wool spots caused by ischaemia in retinal nerve fibre • Proliferative changes: • NVD/NVE/NVI – new vessels at disc, elsewhere on retina or on iris respectively • Treated with panretinal photocoagulation • Maculopathy: • Occurs alongside retinopathy. • Hard exudates and diabetic macular oedema (DMO) • Oedema treated with anti-VEGF intravitreally BIMA Clinical Crash CourseHypertensive retinopathy • HTN: • 1. Silver wiring • 2. AV nipping • 3. Dots/blots • 4. ‘papilloedema’ (blurred disc margins) BIMA Clinical Crash CourseQuestion 13 but first… Feedback BIMA Clinical SeriesQuestion 13 26F presents to urgent eye clinic with 1 week of severe pain on movement of her left eye. Over the first 4 days her vision was significantly reduced in that eye but has somewhat improved over the last 3 days. Acute optic neuropathy is suspected. Which of the following sings/symptoms is most specific for acute optic neuropathy? 1. Optic disc pallor 2. Photopsia and floaters 3. Reduced Ishihara plate score 4. Redness of eye 5. Arcuate visual field defect BIMA Clinical Crash CourseQuestion 13 26F presents to urgent eye clinic with 1 week of severe pain on movement of her left eye. Over the first 4 days her vision was significantly reduced in that eye but has somewhat improved over the last 3 days. Acute optic neuropathy is suspected. Which of the following sings/symptoms is most specific for acute optic neuropathy? 1. Optic disc pallor 2. Photopsia and floaters 3. Reduced Ishihara plate score 4. Redness of eye 5. Arcuate visual field defect BIMA Clinical Crash CourseOptic neuritis • Typically rapid onset • Retrobulbar pain – worse on eye movement • Followed by decreased visual acuity • RAPD • Optic disc swelling (papillitis) N.B. not 100% sensitive Differential diagnosis: 1. Demyelinating optic neuritis (MS associated) 2. Ischaemic optic neuropathy (e.g. GCA) 3. Compressive (e.g. optic nerve glioma, metastasis) 4. Nutritional (B12/folate deficiency) – usually bilateral BIMA Clinical Crash THANK YOU FOR LISTENING ANY QUESTIONS? Join me for my next ophthalmology talk focussed on Ophthalmology history taking and examination for OSCEs on Thursday 6 April 18:00 GMT BIMA Clinical Series