Opthalmology
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Opthalmology Opthalmology Document Transcript

  • Opthalmology1. A 22-year-old female presents with an eight weeks history of headaches, which havedeteriorated over the last week. She is aware of a frontal headache, which is constant innature and unrelieved by paracetamol. These headaches have tended to be present whenshe wakes in the morning and lately have been present all day. Over the last six monthsshe also explains that she has gained more than 7 kg in weight.On examination, she is rather tearful, has a BMI of 32 kg/m2 but has no nuchal rigidityand neurological examination is normal except for bilateral optic disc swelling on fundalexamination. Her blood pressure is noted to be 122/88 mmHg and her temperature is37oC.Which of the following is the single best investigation for this patient?(Please select 1 option) Lumbar puncture MRI brain Correct CT brain EEG Fluorescin angiogramThe history suggests BIH. However, brain imaging is needed to exclude a spaceoccupying lesion, hydrocephalus and cerebral venous thrombosis. MRI brain is betterthan CT brain to look for cerebral venous thrombosis where a ‘pyramidal’ defect invenous flow is noted.2. The patient, whose fundus is shown, is likely to demonstrate which of the followingphysical signs?click and drag to move the ophthalmoscope(Please select 1 option) absent red reflex nystagmus Correct
  • ptosis rubeosis iridis xanthelasmaThis is an albino fundus - there is no retinal pigmentation and all the blood vessels can beclearly seen. Nystagmus and photophobia are common findings in albinos.3. These are ophthalmoscopic appearances of a 62-year-old male who has recently beendiagnosed with diabetes mellitus. He has been referred by his optician after noting thevisual acuity in his left eye is 6/36 and 6/12 in his right. There is no correction with pinhole. What is the likely cause of his fundal appearance?(Please select 1 option) Glaucoma Correct Hypertensive retinopathy Macular degeneration Proliferative diabetic retinopathy Retinitis pigmentosaThis patient has optic atrophy as revealed by a particularly pale disc. Causes includeGlaucoma, external compression of the optic nerves eg pituitary tumour and Multiplesclerosis.4. This 74-year-old man presents with poor vision.click and drag to move the ophthalmoscopeWhat is the diagnosis?(Please select 1 option) diabetic retinopathy
  • glaucoma hypertensive retinopathy macular degeneration Correct pan-retinal photocoagulationThe fundus shows small pale dots over the macular area typical of Drusen. This ismacular degneration and one of the commonest causes of blindness.5. With what diseases is this appearance associated?
  • (Please select 3 options) Acromegaly Correct Poorly controlled diabetes mellitus Pseudoxanthoma elasticum Correct Chronic lymphocytic leukaemia Hypertriglyceridaemia Pagets disease of bone Correct Acquired Immune Deficiency Syndrome Retinitis pigmentosa Cytomegalovirus infection
  • Closed angle glaucomaThe slide shows angioid streaks, caused by breaks in Bruchs membrane. Angioid streaksmay be associated with pseudoxanthoma elasticum, Ehlers-Danlos syndrome, sickle celldisease, Acromegaly (and other pituitary disorders), and Pagets disease.6. These are the ophthalmoscopic appearances of a 74-year-old female who presents witha long history of deterioration in her vision. Her vision is 6/36 in both eyes anduncorrected with a pinhole.What is the most likely diagnosis?(Please select 1 option) Glaucoma Correct Macular degeneration Optic atrophy Papilloedema Retinitis pigmentosaThis fundus shows cupping of the optic disc which is typical of glaucoma. Almostinvariably there is an increase in pressure which is sufficient to cause damage to the opticnerve head and causes changes in the visual field. The mean value for intraocularpressure is 15-16 mm Hg with a standard deviation of +/- 2.5. The upper limit of normalis considered to be 21 mm Hg.7. A 35 year-old woman with sickle cell disease was admitted to hospital with abdominalpain. This appearance was noted on fundoscopy.
  • What is the diagnosis?(Please select 1 option) Branch retinal artery occlusion Angioid streaks Correct Papilloedema Central retinal vein occlusion Lipaemia reinalisThe slide shows angioid streaks, caused by breaks in Bruchs membrane.
  • 8. This 42-year-old lady has a history of repeated bone fractures.What is the diagnosis?(Please select 1 option) Familial hypercholesterolaemia Gaucher disease Correct Sarcoidosis Phenylketonuria Wilsons diseaseThe slide shows yellow papules (pingeculae) in the cornea; these are characteristic ofGaucher disease. Gaucher disease is inherited as an autosomal recessive disease. Diseaseis caused by a deficiency of the enzyme glucocerbrosidase, essentail for the metabolismof glycolipids. There are three types of Gaucher disease: 1. Type 1 (chronic non-neuropathic; adult Gaucher disease) 2. Type 2 (acute neuropathic; infentile Gaucher disease) 3. Type 3 (subacute neuropathic; juvenile Gaucher disease)Patients with all types of disease have hepatosplenomegaly and large glucocerebroside-rich cells (Gaucher cells) infiltrating the bone marrow. Type 2 (infentile Gaucher disease)carries the worst prognosis, with children seldom surviving beyond 2 years. Type 1disease is the commonest, usually presenting in childhood with hepatosplenomegaly, butnot uncommonly in middle- or old-age. Bone marrow replacement and hypersplenismresult in anaemia and thrombocytopoenia. Pathological bone fractures and avascularnecrosis of the femoral heads are not uncommon. Bony disease may be confined to thedistal ends of the femurs, with formation of characteristic Erlenmeyer flask shaped cysts.The skin may show a grey-brown discolouration, especially around the forehead, handsand pre-tibial regions. Characteristic yellow or yellow-brown papules (pingeculae)develop at the sclerocorneal junctions.
  • 9. A 76-year-old male presents with visual loss. Examination reveals a blood pressure of168/102 mmHg and fundoscopy shows an embolus to right superior temporal branch ofthe retinal artery. Carotid dopplers are arranged and these show normal left sidedcarotids, but 90% Right External Carotid Artery stenosis with approximately 50% RightInternal Carotid Artery stenosis. What would be the most appropriate treatment?(Please select 1 option) Aspirin Correct Dipyridamole Right External Carotid Artery endarterectomy Right Internal Carotid Artery endarterectomy WarfarinEndarterectomy is only beneficial if internal carotid artery stenosis is greater than 70%. Ifless than that aspirin and control of vascular risk factors is the treatment of choice. In thiscase hypertensive control is advised.10. A 24-year-old female presents with an eight weeks history of headaches, which havedeteriorated over the last week. She is aware of a frontal headache, which is constant innature and unrelieved by paracetamol. These headaches have tended to be present whenshe wakes in the morning and lately have been present all day. Over the last six monthsshe also explains that she has gained more than 7 kg in weight.On examination, she is rather tearful, has a BMI of 32 kg/m2 but has no nuchal rigidityand neurological examination is normal except for bilateral optic disc swelling on fundalexamination. Her blood pressure is noted to be 122/88 mmHg and her temperature is37oC. An MRI scan of her brain is normal and LP reveals an opening pressure of 30 cmH2O but normal CSF analysis.What treatment would you offer this patient if her vision were threatened?(Please select 1 option) IV dexamethasone Acetazolamide Lumbo-peritoneal shunt Correct
  • IV mannitol FurosemideVisual loss is the single threatening complication of BIH. Urgent LP shunt is thetreatment of choice Optic nerve fenestration is an alternative. There are no comparativestudies between the two interventions.11. A 64-year-old lady presented to the Accident and Emergency Unit with orbital painand swelling (shown below). She had been under review in the endocrinology clinic andhad been started on some new treatment four weeks previously.Thyroid function four weeks ago showed:T4 99 µg/dL (5-12)TSH <0.04 mU/L (0.4-6.0)Thyroid function in A&E shows:T4 2 µg/dL (5-12)TSH 28 mU/L (0.4-6.0)
  • What treatment has she received?(Please select 1 option) Carbimazole Prednisolone Propranolol Propylthiouracil Radioiodine CorrectThe slide shows malignant exophthalmos: malignant refers to the rapidity of onset andthreat to eyesight rather than association with malignancy. Radioiodine therapy canworsen thyroid-associated ophthalmopathy patients with thyroid eye disease are generallytreated with steroids for 1-2 weeks prior to starting radioiodine therapy. Treatment formalignant exophthalmos is rapid administration of steroids. Where sight is threatened,orbital decompression may be necessary.
  • 12. A 35 year-old man with HIV disease presents with sudden loss of vision in his righteye. He is not curently taking antiretroviral therapy. A recent CD4 count was measured at20 cells/mm3.What is the most appropriate therapy to initiate?(Please select 1 option) High-dose intravenous aciclovir Intravenous ganciclovir Correct Zidovudine + lamivudine + nevirapine Sulfadiazine + pyrimethamine Amphotericin B + flucytosineThe slide shows the typical cottage cheese and tomato ketchup or pizza appearance ofCMV retinitis in a patient with HIV disease. Intravenous ganciclovir is currently thetreatment of choice. Available forms of ganciclovir include intravenous and oralpreparations as well as an ocular implant. The principal disadvantages of the latter twoare: the poor bioavailability of the oral preparation; the implant is effective at clearingocular disease, but CMV is disseminated at this stage of AIDS and the implant does notaddress systemic infection. Pyrimethamine + sulfadiazine are used to treat toxoplamsretinitis; zidovudine + lamivudine + nelfinavir constitutes highly active antiretrovral(combination) therapy (HAART) for HIV disease. Initiation of HAART has been shownto worsen active CMV eye disease and should be witheld until CMV is in remission.13. A 62-year-old woman presented acutely to Casualty Department with sudden visualloss of the right eye. She had been reading at the time and suddenly noticed that she couldnot see the print. She denied any headache preceding the symptoms and had not noticedany weakness in her arms or legs. She had a past medical history of hypertension andtook regular atenolol. She was a smoker of 20 cigarettes per day and did not drink anyalcohol.On examination she was anxious and distressed. Her blood pressure was 145/85 mmHg,pulse was 89/min and irregular and temperature was 36.7oC. On auscultation of the heartthere was a mitral regurgitation murmur. On examination of the eyes the pupils wereequal and reactive to light and ocular movements were full. Visual field analysis revealeda defect in the right inferior nasal field. The rest of the cranial nerves appeared normal
  • and no abnormalities could be found in the peripheral nervous system. She had bilateralnon-tender pulsatile temporal arteries.Investigations revealed: Haemoglobin 12.3 g/dl (13.0 – 18.0 g/dL) White cell count 7.8 x 109/L (4 – 11 x 109/L) Platelets 345 x 109/L (150 – 400 x 109/L) ESR (Westergren) 30 mm/1st hour (0 – 30 mm/1st hour) Serum sodium 134 mmol/L (137 – 144 mmol/L) Serum potassium 4.6 mmol/L (3.5 – 4.9 mmol/L) Serum urea 6.7 mmol/L (2.5 – 7.5 mmol/L) Serum creatinine 120 umol/L ( 60 – 110 umol/L)Serum C-reactive protein 9 IU/L (<5 IU/L) Serum cholesterol 8.6 mmol/L (< 5.2 mmol/L)The electrocardiogram showed atrial fibrillation with a ventricular rate of 88 beats perminute.The appearance of the retina on fundoscopy is shown below:What is the most likely diagnosis in this patient?(Please select 1 option) Cholesterol embolus of the retinal artery Correct Factitious disorder Infective endocarditis Parietal lobe infarct Temporal arteritisThis patient presents with a monocular visual disturbance. This places the lesion from theretina to the optic tract. She has a very specific visual disturbance affecting the inferiornasal portion of the right visual field. Fundoscopy shows an embolus to the right superiortemporal branch of the retinal artery, which would explain the clinical findings. Temporalarteritis presents with a history of a curtain descending over the eye and, given a normal
  • ESR and non-tender arteries, this diagnosis is unlikely. Infective endocarditis is unlikelygiven normal inflammatory markers and haematology.14. A 60-year-old man was seen in Casualty Department having developed transientpainless loss of vision in the right eye lasting several minutes. The loss of vision had beensudden in onset and appeared to descend affecting the entire field of vision. He had noassociated symptoms of headache or any weakness of the face or limbs. He had had anepisode 2 months ago of left facial weakness, which had lasted approximately 20minutes. He had a history of migraines and had also recently attended his GP withworsening dyspnoea and occasional palpitations. He took Pizotifen and Imigran asrequired. He was a non smoker and did not drink any alcohol.On examination there were some purpuric skin lesions over the arms and his faceappeared flushed. His blood pressure was 138/76 mmHg, pulse was 88 beats per minuteand irregular and temperature was 36.7oC. Auscultation of the heart revealed a mid-diastolic murmur heard at the left sternal edge and there were bilateral basal cracklesheard in the chest. There were no carotid bruits. Fundoscopy did not reveal anyabnormalities, pupils were intact and peripheral nervous system examination did notreveal any abnormalities.Investigations revealed: Haemoglobin 13.4 g/dL (13.0-18.0 g/dL) White cell count 8.0 x109/L (4-11 x109/L) Platelets 285 x109/L (150-400 x109/L) ESR (Westergren) 5 mm/1st hour (0-15 mm/1st hour) Serum sodium 136 mmol/L (137-144 mmol/L) Serum potassium 3.8 mmol/L (3.5-4.9 mmol/L) Serum urea 4.5 mmol/L (2.5-7.5 mmol/L) Serum creatinine 88 µmol/L (60-110)Serum C-reactive protein 4 U/L (<5 U/L) Fasting plasma glucose 5.7 mmol/L (3-6 mmol/L) Serum cholesterol 4.7 mmol/L (< 5.2 mmol/L)A lumbar puncture was performed and yielded the following data: Opening pressure 14 cmH2O (6-18 cm H2O) CSF protein 0.35 g/L (0.15-0.45 g/L)CSF white cell count 4 cells per mL (<5 per mL) CSF red cell count 1 cell per mL (<5 per mL)What is the most likely diagnosis?
  • (Please select 1 option) Cardiac embolus Correct Carotid artery embolus Cerebral vasculitis Complex migraine Temporal arteritisThe patient is describing amaurosis fugax, which is unilateral transient loss of vision thatdevelops over seconds, remains for maximal for up to 5 minutes and resolves over 10 -20 minutes. The only feature that differentiates the middle cerebral artery syndrome fromthe carotid artery syndrome is amaurosis fugax. The most likely cause in this patient is acardiac embolus secondary to mitral stenosis as evidenced by malar flush, purpuricembolic skin lesions, signs of left heart failure and a mid-diastolic murmur.Emboli secondary to atheroma is less likely, given the lack of additional risk factors.There are no features in the history suggestive of temporal arteritis and there was nohistory of headache at the onset of symptoms. Cerebral vasculitis can present with amyriad of symptoms, but is unlikely given the normal inflammatory markers and normalcerebro-spinal fluid analysis.15.
  • What is the diagnosis?(Please select 1 option) Anterior uveitis Dislocation of the lens Hyphaema Correct Hypopyon Malignant melanoma of the irisThe slide shows hyphaema, blood in the anterior chamber. Usually caused by trauma –often small objects (champagne corks, squash balls) hitting the eye. Aspiration may berequired to prevent loss of vision.16.
  • What is the most likely visual field defect?(Please select 1 option) Arcuate Central Correct Concentric Lower quadrantic TemporalThe slide shows the typical appearance of toxocara retinitis with a lesion at the macula. Inretinitis due to Toxocara canis, there is usually only a single, well demarcated lesion.17. A 44-year-old woman complains of gradual loss of night vision. She has hadincreasing difficulty driving in the dark and recently stumbled on steps when leaving a
  • restaurant. Clinical examination revealed loss of peripheral visual fields. Her fundoscopyis shown below. What is the diagnosis?click and drag to move the ophthalmoscope(Please select 1 option) Angioid streaks Branch retinal vein occlusion Central retinal artery occlusion Panretinal photocoagulation scarring Retinitis pigmentosa CorrectLoss of night vision and peripheral vision are classic features of Retinitis Pigmentosa.The fundi shows the characteristic bone spicule areas of pigmentation in the periphery ofthe retina.18. A 29-year-old man presents with a 6 months history of nasal congestion. He was seenby an ENT consultant who diagnosed sinusitis. He presents now with a two day history ofright periorbital swelling and diplopia.
  • Examination reveals him to be unwell, with no neck stiffness or photophobia and histemperature is 37.4°C. He has marked drooping of the right eyelid with the right eyecongested and deviated right with an enlarged right pupil. Left eye appears normal.Fundoscopy is normal. There is also loss of sensation of the right forehead.What is the likely diagnosis?(Please select 1 option) Cavernous sinus thrombosis Correct Epidural abscess Meningitis Pituitary adenoma Tolosa Hunt syndromeThe history is typical for cavernous sinus thrombosis possibly secondary to sinusitis. Thisis a life threatening condition. Urgent CT brain and antibiotics are needed.19. A 35 year-old man with HIV disease presents with sudden loss of vision in his righteye. He is not curently taking antiretroviral therapy. A recent CD4 count was measured at20 cells/mm3. What is the most likely causative agent?(Please select 1 option) Cytomegalovirus Correct Toxocara canis Toxoplasma gondii Cryptococcus neoformans Human immundeficiency virusThe slide shows the typical cottage cheese and tomato ketchup or pizza appearance ofCMV retinitis in a patient with HIV disease.20. A 23-year-old obese woman presented to Casualty Department with a 4 day history ofprogressively worsening generalised headache associated with a buzzing in her ears. Inthe last few days she had noticed some blurring of her vision and reduction in her visualfield. She had started to feel nauseated particularly early in the morning and on the
  • morning of admission had vomited several times. She had a history of severe acne whichwas treated with long-term oral doxycycline and smoked 35 cigarettes a day.On examination she was orientated with a Glasgow coma scale of 15/15. Visual acuitywas recorded as 6/18 in both eyes. There was reduction in temporal visual fieldsbilaterally and enlargement of the blind spot bilaterally. The rest of the neurologicalexamination was entirely normal.The fundoscopic appearance is shown below: An MRI scan of the brain was normal.A lumbar puncture was performed and yielded the following data: Opening pressure 33 cm H2O (6 – 18 cm H2O) CSF protein 0.42 g/L (0.15 – 0.45 g/L) CSF white cell count 2 cells per mL (<5 per mL) CSF red cell count 2 cells per mL (<5 per mL)CSF oligoclonal bands NegativeGiven the above clinical account, what is the likely cause for this patient’s visualdisturbance?(Please select 1 option) Benign intracranial hypertension Correct Central retinal vein occlusion Optic nerve meningioma Optic papillitis PseudopapilloedemaThe slide shows papilloedema. Management of optic disc oedema begins with a correctdiagnosis. Most importantly, it is crucial to distinguish between papilloedema and themany other forms of optic disc oedema, including masqueraders such as buried opticdisc drusen. Consider the acuity, visual fields, ophthalmoscopy findings and especiallythe laterality of presentation carefully in the initial work-up."21. A 24-year-old woman presents with an eight weeks history of headaches, which hasdeteriorated markedly over the last two days and has resulted in her admission. Theseheadaches are distressing her have been problematical in the morning but she has foundsome relief from paracetamol. However, the headache has deteriorated quite markedly
  • over the last two days being constant and intolerable. The only other information is thatshe has gained 6 kg in weight the last 6 months.On examination she is noted to be obese with a BMI of 32 kg/m2 and a blood pressure of122/76 mmHg. Fundoscopy reveals bilateral swelling of both optic discs with loss ofvenous pulsation but otherwise neurological examination is normal. Investigations revealnormal MRI appearances of the brain and a lumbar puncture reveals an opening pressureof 30 cm H2O but CSF analysis is normal.What is the most likely diagnosis?(Please select 1 option) Benign Intracranial Hypertension Correct Subarachnoid Hemorrhage Migraine Tension type headache Multiple sclerosisThis is a typical history of BIH. An obese female patient with headaches andpapilloedema, normal Brain imaging, CSF analysis and high pressure. The other possibledifferential diagnosis would be cerebral/sagittal vein thrombosis but one might expect topick up evidence for this on the MRI.