OPHTHALMOLOGY # Question 1 A 34-year-old woman presents complaining of headaches. Examination of her pupils using a light shone alternately in each eye reveals the right eye constricts to light but the left eye dilates. What is the most likely diagnosis? A. Right optic neuritis B. Left sided Horner's syndrome C. Craniopharyngioma D. Left optic neuritis E. Right Holmes-Adie pupil This is the 'swinging light test' and reveals a relative afferent pupillary defect. Given her age, multiple sclerosis causing optic neuritis is the likely underlying diagnosis. Optic neuritis typically causes a dull ache in the region of the eye which is aggravated by movement Relative afferent pupillary defect Also known as the Marcus-Gunn pupil, a relative afferent pupillary defect is found by the 'swinging light test'. It is caused by a lesion anterior to the optic chiasm i.e. optic nerve or retina Causes Retina: detachment Optic nerve: optic neuritis e.g. multiple sclerosis Pathway of pupillary light reflex Afferent: retina --> optic nerve --> lateral geniculate body --> midbrain Efferent: Edinger-Westphal nucleus (midbrain) --> oculomotor nerve # Question 2 A 65-year-old man with a 16 year history of type 2 diabetes mellitus presents complaining of poor eye sight and blurred vision. Visual acuity measured using a Snellen chart is reduced to 6/12 in the right eye and 6/18 in the left eye. Fundoscopy reveals a number of yellow deposits in the left eye consistent with drusen formation. Similar changes but to a lesser extent are seen in the right eye. What is the most likely diagnosis? A. Wet age-related macular degeneration B. Pre-proliferative diabetic retinopathy C. Chronic open angle glaucoma D. Proliferative diabetic retinopathy E. Dry age-related macular degeneration Drusen = Dry macular degeneration Macular degeneration is the most common cause of blindness in the UK. Degeneration of the central retina (macula) is the key feature with changes usually bilateral. Two forms of macular degeneration are seen:

Dry macular degeneration: characterised by drusen - yellow round spots in Bruch's membrane Wet (exudative, neovascular) macular degeneration: characterised by choroidal neovascularisation. Leakage of serous fluid and blood can subsequently result in a rapid loss of vision. Carries worst prognosis Risk factors Age: most patients are over 60 years of age Family history Smoking More common in Caucasians Female sex Features Reduced visual acuity: 'blurred', 'distorted' vision, central vision is affected first Central scotomas Fundoscopy: drusen, pigmentary changes General management Stopping smoking High does of beta-carotene, vitamins C and E, and zinc may help to slow down visual loss for patients with established macular degeneration Dry macular degeneration - no current medical treatments Wet macular degeneration Photocoagulation Photodynamic therapy Anti-vascular endothelial growth factor (anti-VEGF) treatments: intravitreal ranibizumab # Question 3 Each one of the following is a cause of a mydriatic pupil, except: A. Third nerve palsy B. Atropine C. Holmes-Adie pupil D. Argyll-Robertson pupil E. Traumatic iridoplegia Causes of mydriasis (large pupil) Third nerve palsy Holmes-Adie pupil Traumatic iridoplegia Phaeochromocytoma Congenital Drug causes of mydriasis Topical mydriatics: tropicamide, atropine Sympathomimetic drugs: amphetamines Anticholinergic drugs: tricyclic antidepressants

# Question 4 Which one of the following statements regarding the Holmes-Adie pupil is incorrect? A. May be associated with absent ankle/knee reflexes B. Bilateral in 80% of cases C. It is a benign condition D. Slowly reactive to accommodation but very poorly (if at all) to light E. Causes a dilated pupil The Holmes-Adie pupil is unilateral, rather than bilateral, in 80% of patients Holmes-Adie pupil is a benign condition most commonly seen in women. It is one of the differentials of a dilated pupil Overview Unilateral in 80% of cases Dilated pupil Once the pupil has constricted it remains small for an abnormally long time Slowly reactive to accommodation but very poorly (if at all) to light Holmes-Adie syndrome Association of Holmes-Adie pupil with absent ankle/knee reflexes #Question 5 Which one of the following is least associated with the development of optic atrophy? A. Ataxic telangiectasia B. Longstanding papilloedema C. Multiple sclerosis D. Glaucoma E. Retinitis pigmentosa Optic atrophy is seen as pale, well demarcated disc on fundoscopy. It is usually bilateral and causes a gradual loss of vision. Causes may be acquired or congenital Acquired causes Multiple sclerosis Papilloedema (longstanding) Raised intraocular pressure (e.g. glaucoma, tumour) Retinal damage (e.g. choroiditis, retinitis pigmentosa) Ischaemia Toxins: tobacco amblyopia, quinine, methanol, arsenic, lead Nutritional: vitamin B1, B2, B6 and B12 deficiency Congenital causes Friedreich's ataxia Mitochondrial disorders e.g. Leber's optic atrophy DIDMOAD - the association of cranial Diabetes Insipidus, Diabetes Mellitus, Optic Atrophy and Deafness (also known as Wolfram's syndrome)

#Question 6 A 65-year-old man with a known history of Paget's disease is noted to have irregular dark red lines radiating from the optic nerve. What is the likely diagnosis? A. Retinitis pigmentosa B. Optic neuritis C. Angioid retinal streaks D. Choroidoretinitis E. Malignant hypertension This is a typical description of angioid retinal streaks which are associated with Paget's disease Angioid retinal streaks are seen on fundoscopy as irregular dark red streaks radiating from the optic nerve head. The elastic layer of Bruch's membrane is characteristically thickened and calcified Causes Pseudoxanthoma elasticum Ehler-Danlos syndrome Paget's disease Sickle-cell anaemia Acromegaly #Question 7 A 62-year-old man presents with sudden visual loss in his right eye. He is otherwise asymptomatic. Which one of the following conditions is least likely to be responsible? A. Ischaemic optic neuropathy B. Occlusion of central retinal vein C. Occlusion of central retinal artery D. Optic neuritis E. Vitreous haemorrhage Whilst optic neuritis can present with sudden loss, in this 62-year-old man it is the least likely option. Typically there is a unilateral decrease in visual acuity over hours or days. There may be poor discrimination of colours and eye pain on movement Sudden painless loss of vision The most common causes of a sudden painless loss of vision are as follows: Ischaemic optic neuropathy (e.g. temporal arteritis or atherosclerosis) Occlusion of central retinal vein Occlusion of central retinal artery Vitreous haemorrhage Retinal detachment Ischaemic optic neuropathy May be due to arteritis (e.g. temporal arteritis) or atherosclerosis (e.g. hypertensive, diabetic older patient) due to occlusion of the short posterior ciliary arteries, causing damage to the optic nerve Altitudinal field defects are seen

Central retinal vein occlusion Incidence increases with age, more common than arterial occlusion Causes: glaucoma, polycythaemia, hypertension Severe retinal haemorrhages are usually seen on fundoscopy Central retinal artery occlusion Due to thromboembolism (from atherosclerosis) or arteritis (e.g. temporal arteritis) Features include afferent pupillary defect, 'cherry red' spot on a pale retina Vitreous haemorrhage Causes: diabetes, bleeding disorders Features may include sudden visual loss, dark spots Retinal detachment Features of vitreous detachment, which may precede retinal detachment, include flashes of light or floaters (see below) Differentiating posterior vitreous detachment, retinal detachment and vitreous haemorrhage Posterior vitreous detachment Central visual loss Retinal detachment that starts peripherally progresses towards the central vision A veil or curtain over the field of vision Straight lines appear curved (positive Amsler grid test) Vitreous haemorrhage Flashes of light (photopsia) - in the peripheral field of vision Floaters, often on the temporal side of the central vision Dense shadow

Large bleeds cause sudden visual loss Moderate bleeds may be described as numerous dark spots Small bleeds may cause floaters

# Question 8 A 71-year-old man presents with severe pain around his right eye and vomiting. On examination the right eye is red and decreased visual acuity is noted. Which one of the following options is the most appropriate initial treatment? A. Topical pilocarpine + oral prednisolone B. Topical pilocarpine + topical steroids C. Topical steroids D. Topical pilocarpine + intravenous acetazolamide E. Topical steroids + intravenous acetazolamide Treatment of acute glaucoma - acetazolamide + pilocarpine

Acute angle closure glaucoma Glaucoma is a group disorders characterised by optic neuropathy due, in the majority of patients, to raised intraocular pressure (IOP). It is now recognized that a minority of patients with raised IOP do not have glaucoma and vice versa In acute angle closure glaucoma (AACG) there is a rise in IOP secondary to an impairment of aqueous outflow. Factors predisposing to AACG include: Hypermetropia (long-sightedness) Pupillary dilatation Lens growth associated with age Features Severe pain: may be ocular or headache Decreased visual acuity Symptoms worse with mydriasis (e.g. watching TV in a dark room) Hard, red eye Haloes around lights Semi-dilated non-reacting pupil Corneal oedema results in dull or hazy cornea Systemic upset may be seen, such as nausea and vomiting and even abdominal pain Management Urgent referral to an ophthalmologist Management options include reducing aqueous secretion with acetazolamide and pupillary constriction with topical pilocarpine #Question 9 A 63-year-old man presents to his GP complaining of pain in his right eye. On examination the sclera is red and the pupil is dilated with a hazy cornea. What is the most likely diagnosis? A. Scleritis B. Conjunctivitis C. Acute angle closure glaucoma D. Anterior uveitis E. Subconjunctival haemorrhage Red eye - glaucoma or uveitis? Glaucoma: severe pain, haloes, 'semi-dilated' pupil Uveitis: small, fixed oval pupil, ciliary flush Red eye There are many possible causes of a red eye. It is important to be able to recognise the causes which require urgent referral to an ophthalmologist. Below is a brief summary of the key distinguishing features

Acute angle closure glaucoma Severe pain (may be ocular or headache) Decreased visual acuity, patient sees haloes Semi-dilated pupil Hazy cornea Anterior uveitis Acute onset Pain Blurred vision and photophobia Small, fixed oval pupil, ciliary flush Scleritis Severe pain (may be worse on movement) and tenderness May be underlying autoimmune disease e.g. rheumatoid arthritis Conjunctivitis Purulent discharge if bacterial, clear discharge if viral Subconjunctival haemorrhage History of trauma or coughing bouts #Question 10 A 67-year-old woman presents for review. She has recently been diagnosed with dry age-related macular degeneration. Which one of the following is the strongest risk factor for developing this condition? A. Hypertension B. Poor diet C. Smoking D. Diabetes mellitus E. Alcohol excess Macular degeneration - smoking is risk factor Having a balanced diet, with plenty of fresh fruits and vegetables may also slow the progression of macular degeneration. There is still ongoing research looking at the role of supplementary antioxidants Macular degeneration is the most common cause of blindness in the UK. Degeneration of the central retina (macula) is the key feature with changes usually bilateral. Two forms of macular degeneration are seen: Dry macular degeneration: characterised by drusen - yellow round spots in Bruch's membrane Wet (exudative, neovascular) macular degeneration: characterised by choroidal neovascularisation. Leakage of serous fluid and blood can subsequently result in a rapid loss of vision. Carries worst prognosis

Risk factors Age: most patients are over 60 years of age Family history Smoking More common in Caucasians Female sex Features Reduced visual acuity: 'blurred', 'distorted' vision, central vision is affected first Central scotomas Fundoscopy: drusen, pigmentary changes General management Stopping smoking High does of beta-carotene, vitamins C and E, and zinc may help to slow down visual loss for patients with established macular degeneration Dry macular degeneration - no current medical treatments Wet macular degeneration Photocoagulation Photodynamic therapy Anti-vascular endothelial growth factor (anti-VEGF) treatments: intravitreal ranibizumab # Question 11 Each one of the following is associated with retinitis pigmentosa, except: A. Usher syndrome B. Refsum disease C. Kearns-Sayre syndrome D. Tuberose sclerosis E. Abetalipoproteinaemia Ocular manifestations of tuberose sclerosis includes retinal hamartomas Retinitis pigmentosa Retinitis pigmentosa primarily affects the peripheral retina resulting in tunnel vision Features Night blindness is often the initial sign Funnel vision (the preferred term for tunnel vision) Associated diseases Refsum disease: cerebellar ataxia, peripheral neuropathy, deafness, ichthyosis Usher syndrome Abetalipoproteinemia Lawrence-Moon-Biedl syndrome Kearns-Sayre syndrome Alport's syndrome

#Question 12 A 64-year-old woman presents with bilateral sore eyelids. She also complains of her eyes being dry all the time. On examination her eyelid margins are erythematous at the margins but are not swollen. Of the given options, what is the most appropriate initial management? A. Topical chloramphenicol + mechanical removal of lid debris B. Hot compresses + topical steroids C. Topical chloramphenicol + topical steroids D. Hot compresses + mechanical removal of lid debris E. Topical chloramphenicol + hot compresses Artificial tears may also be given for symptom relief of blepharitis Blepharitis is inflammation of the eyelid margins. It may due to meibomian gland dysfunction (common, posterior blepharitis) or seborrhoeic dermatitis/staphylococcal infection (less common, anterior blepharitis). Blepharitis is also more common in patients with rosacea The meibomian glands secrete oil on to the eye surface to prevent rapid evaporation of the tear film. Any problem affecting the meibomian glands (as in blepharitis) can hence cause drying of the eyes which in turns leads to irritation Features Symptoms are usually bilateral Grittiness and discomfort, particularly around the eyelid margins Eyes may be sticky in the morning Eyelid margins may be red. Swollen eyelids may be seen in staphylococcal blepharitis Styes and chalazions are more common in patients with blepharitis Secondary conjunctivitis may occur Management Softening of the lid margin using hot compresses twice a day mechanical removal of the debris from lid margins - cotton wool buds dipped in a mixture of cooled boiled water and baby shampoo is often used* Artificial tears may be given for symptom relief in people with dry eyes or an abnormal tear film *an alternative is sodium bicarbonate, a teaspoonful in a cup of cooled water that has recently been boiled #Question 13 A 71-year-old with a history of type 2 diabetes mellitus and hypertension presents due to the sensation of light flashes in his right eye. These symptoms have been present for the past 2 days and seem to occur more at the peripheral part of vision. There is no redness or pain in the affected eye. Corrected visual acuity is measured as 6/9 in both eyes. What is the most likely diagnosis? A. Change in shape of eye secondary to variations in blood sugar B. Primary open angle glaucoma C. Vitreous detachment D. Normal phenomenon in diabetic retinopathy E. Normal phenomenon in healthy eyes

Flashes and floaters - vitreous/retinal detachment Flashes and floaters are symptoms of vitreous detachment. The patient is at risk of retinal detachment and should be referred urgently to an ophthalmologist Sudden painless loss of vision The most common causes of a sudden painless loss of vision are as follows: Ischaemic optic neuropathy (e.g. temporal arteritis or atherosclerosis) Occlusion of central retinal vein Occlusion of central retinal artery Vitreous haemorrhage Retinal detachment Ischaemic optic neuropathy May be due to arteritis (e.g. temporal arteritis) or atherosclerosis (e.g. hypertensive, diabetic older patient) due to occlusion of the short posterior ciliary arteries, causing damage to the optic nerve Altitudinal field defects are seen Central retinal vein occlusion Incidence increases with age, more common than arterial occlusion Causes: glaucoma, polycythaemia, hypertension Severe retinal haemorrhages are usually seen on fundoscopy Central retinal artery occlusion Due to thromboembolism (from atherosclerosis) or arteritis (e.g. temporal arteritis) Features include afferent pupillary defect, 'cherry red' spot on a pale retina Vitreous haemorrhage Causes: diabetes, bleeding disorders Features may include sudden visual loss, dark spots Retinal detachment Features of vitreous detachment, which may precede retinal detachment, include flashes of light or floaters (see below) Differentiating posterior vitreous detachment, retinal detachment and vitreous haemorrhage Posterior vitreous Retinal detachment Vitreous haemorrhage detachment Central visual loss that starts peripherally Flashes of light progresses towards the (photopsia) - in the central vision peripheral field of vision Large bleeds cause sudden visual loss Moderate bleeds may be described as numerous dark spots Small bleeds may cause floaters A veil or curtain over the field of vision Straight lines appear curved (positive Amsler grid test) Floaters, often on the temporal side of the central vision Dense shadow

# Question 14 Which one of the following statements regarding macular degeneration is true? A. Drusen is characteristic of wet macular degeneration B. Photodynamic therapy is useful in dry macular degeneration C. Asian ethnicity is a risk factor D. Male sex is a risk factor E. Wet macular degeneration carries the worst prognosis Macular degeneration is the most common cause of blindness in the UK. Degeneration of the central retina (macula) is the key feature with changes usually bilateral. Two forms of macular degeneration are seen: Dry macular degeneration: characterised by drusen - yellow round spots in Bruch's membrane Wet (exudative, neovascular) macular degeneration: characterised by choroidal neovascularisation. Leakage of serous fluid and blood can subsequently result in a rapid loss of vision. Carries worst prognosis Risk factors Age: most patients are over 60 years of age Family history Smoking More common in Caucasians Female sex Features Reduced visual acuity: 'blurred', 'distorted' vision, central vision is affected first Central scotomas Fundoscopy: drusen, pigmentary changes General management Stopping smoking High does of beta-carotene, vitamins C and E, and zinc may help to slow down visual loss for patients with established macular degeneration Dry macular degeneration - no current medical treatments Wet macular degeneration Photocoagulation Photodynamic therapy Anti-vascular endothelial growth factor (anti-VEGF) treatments: intravitreal ranibizumab # Question 15 Which one of the following is not a risk factor for primary open-angle glaucoma? A. Diabetes mellitus B. Family history C. Hypertension D. Afro-Caribbean ethnicity E. Hypermetropia Acute angle closure glaucoma is associated with hypermetropia, where as primary open-angle glaucoma is associated with myopia

Primary open-angle glaucoma Glaucoma is a group disorders characterised by optic neuropathy due, in the majority of patients, to raised intraocular pressure (IOP). It is now recognized that a minority of patients with raised IOP do not have glaucoma and vice versa Primary open-angle glaucoma (POAG, also referred to as chronic simple glaucoma) is present in around 2% of people older than 40 years. Other than age, risk factors include: Family history Black patients Myopia Hypertension Diabetes mellitus POAG may present insidiously and for this reason is often detected during routine optometry appointments. Features may include Peripheral visual field loss - nasal scotomas progressing to 'tunnel vision' Decreased visual acuity Optic disc cupping #Question 16 A 23-year-old female presents with recurrent headaches. Examination of her cranial nerves reveals the right pupil is 3 mm whilst the left pupil is 5 mm. The right pupil constricts to light but the left pupil is sluggish. Peripheral neurological examination is unremarkable apart from difficult to elicit knee and ankle reflexes. What is the most likely diagnosis? A. Acute angle closure glaucoma B. Migraine C. Multiple sclerosis D. Holmes-Adie syndrome E. Argyll-Roberson syndrome Holmes ADIe = DIlated pupil, females, absent leg reflexes Holmes-Adie pupil is a benign condition most commonly seen in women. It is one of the differentials of a dilated pupil Overview Unilateral in 80% of cases Dilated pupil Once the pupil has constricted it remains small for an abnormally long time Slowly reactive to accommodation but very poorly (if at all) to light Holmes-Adie syndrome Association of Holmes-Adie pupil with absent ankle/knee reflexes # Question 17 Which one of the following is least associated with the development of optic atrophy? A. Tobacco B. Methanol C. Vitamin B12 deficiency D. Lead E. Zinc deficiency

Optic atrophy is seen as pale, well demarcated disc on fundoscopy. It is usually bilateral and causes a gradual loss of vision. Causes may be acquired or congenital Acquired causes Multiple sclerosis Papilloedema (longstanding) Raised intraocular pressure (e.g. glaucoma, tumour) Retinal damage (e.g. choroiditis, retinitis pigmentosa) Ischaemia Toxins: tobacco amblyopia, quinine, methanol, arsenic, lead Nutritional: vitamin B1, B2, B6 and B12 deficiency Congenital causes Friedreich's ataxia Mitochondrial disorders e.g. Leber's optic atrophy DIDMOAD - the association of cranial Diabetes Insipidus, Diabetes Mellitus, Optic Atrophy and Deafness (also known as Wolfram's syndrome) #Question 18 Which one of the following causes of Horner's syndrome is due to a central lesion? A. Cavernous sinus thrombosis B. Internal carotid aneurysm C. Syringomyelia D. Pancoast's tumour E. Cervical rib Horner's syndrome - anhydrosis determines site of lesion: Head, arm, trunk = central lesion: stroke, syringomyelia Just face = pre-ganglionic lesion: Pancoast's, cervical rib Absent = post-ganglionic lesion: carotid artery Horner's syndrome Features Miosis (small pupil) Ptosis Enophthalmos (sunken eye) Anhydrosis (loss of sweating one side) Heterochromia (difference in iris colour) is seen in congenital Horner's Distinguishing between causes of anhydrosis: see below Central lesions Anhydrosis of the face, arm and trunk Stroke Syringomyelia Multiple sclerosis Encephalitis Pre-ganglionic lesions Anhydrosis of the face Pancoast's tumour Thyroidectomy Trauma Tumour Cervical rib Post-ganglionic lesions No anhydrosis Carotid artery dissection Carotid aneurysm

# Question 19 Each one of the following are associated with angioid retinal streaks, except: A. Paget's disease B. Pseudoxanthoma elasticum C. Acromegaly D. Kearns-Sayre syndrome E. Ehler-Danlos syndrome Kearns-Sayre syndrome is a mitochondrial disorder associated with retinitis pigmentosa Angioid retinal streaks are seen on fundoscopy as irregular dark red streaks radiating from the optic nerve head. The elastic layer of Bruch's membrane is characteristically thickened and calcified Causes Pseudoxanthoma elasticum Ehler-Danlos syndrome Paget's disease Sickle-cell anaemia Acromegaly #Question 20 A 54-year-old woman presents with a persistent watery left eye for the past 4 days. On examination there is erythema and swelling of the inner canthus of the left eye. What is the most likely diagnosis? A. Blepharitis B. Acute angle closure glaucoma C. Meibomian cyst D. Dacryocystitis E. Pinguecula Dacryocystitis is infection of the lacrimal sac Features Watering eye (epiphora) Swelling and erythema at the inner canthus of the eye Management is with systemic antibiotics. Intravenous antibiotics are indicated if there is associated periorbital cellulitis Congenital lacrimal duct obstruction affects around 5-10% of newborns. It is bilateral in around 20% of cases Features Watering eye (even if not crying) Secondary infection may occur Symptoms resolve in 99% of cases by 12 months of age #Question 21 Which one of the following features is not present in diabetic background retinopathy? A. Microaneurysms B. Blot haemorrhages C. Cotton wool spots D. Seen in both type 1 and type 2 diabetes mellitus E. Hard exudates

Cotton wool spots are seen in pre-proliferative retinopathy Diabetic retinopathy is the most common cause of blindness in adults aged 35-65 years-old. Hyperglycaemia is thought to cause increased retinal blood flow and abnormal metabolism in the retinal vessel walls. This precipitates damage to endothelial cells and pericytes Endothelial dysfunction leads to increased vascular permeability which causes the characteristic exudates seen on fundoscopy. Pericyte dysfunction predisposes to the formation of microaneurysms. Neovasculization is thought to be caused by the production of growth factors in response to retinal ischaemia In postgraduate exams you are most likely to be asked about the characteristic features of the various stages/types of diabetic retinopathy Background retinopathy Microaneurysms (dots) Blot haemorrhages ( 3 blot haemorrhages Venous beading/looping Deep/dark cluster haemorrhages More common in Type I DM, treat with laser photocoagulation Proliferative retinopathy Retinal neovascularisation - may lead to vitrous haemorrhage Fibrous tissue forming anterior to retinal disc More common in Type I DM, 50% blind in 5 years Maculopathy Based on location rather than severity, anything is potentially serious Hard exudates and other 'background' changes on macula Check visual acuity More common in Type II DM #Question 22 Which one of the following is least recognized as a cause of tunnel vision? A. Papilloedema B. Choroidoretinitis C. Angioid retinal streaks D. Glaucoma E. Retinitis pigmentosa Tunnel vision is the concentric diminution of the visual fields Causes Papilloedema Glaucoma Retinitis pigmentosa Choroidoretinitis Optic atrophy secondary to tabes dorsalis Hysteria

# Question 23 An 84-year-old man presents with loss of vision in his left eye since the morning. He is otherwise asymptomatic and of note has had no associated eye pain or headaches. His past medical history includes ischaemic heart disease but he is otherwise well. On examination he has no vision in his left eye. The left pupil responds poorly to light but the consensual light reaction is normal. Fundoscopy reveals a red spot over a pale and opaque retina. What is the most likely diagnosis? A. Vitreous haemorrhage B. Retinal detachment C. Ischaemic optic neuropathy D. Central retinal vein occlusion E. Central retinal artery occlusion Sudden painless loss of vision The most common causes of a sudden painless loss of vision are as follows: Ischaemic optic neuropathy (e.g. temporal arteritis or atherosclerosis) Occlusion of central retinal vein Occlusion of central retinal artery Vitreous haemorrhage Retinal detachment Ischaemic optic neuropathy May be due to arteritis (e.g. temporal arteritis) or atherosclerosis (e.g. hypertensive, diabetic older patient) due to occlusion of the short posterior ciliary arteries, causing damage to the optic nerve Altitudinal field defects are seen Central retinal vein occlusion Incidence increases with age, more common than arterial occlusion Causes: glaucoma, polycythaemia, hypertension Severe retinal haemorrhages are usually seen on fundoscopy Central retinal artery occlusion Due to thromboembolism (from atherosclerosis) or arteritis (e.g. temporal arteritis) Features include afferent pupillary defect, 'cherry red' spot on a pale retina Vitreous haemorrhage Causes: diabetes, bleeding disorders Features may include sudden visual loss, dark spots Retinal detachment Features of vitreous detachment, which may precede retinal detachment, include flashes of light or floaters (see below) Differentiating posterior vitreous detachment, retinal detachment and vitreous haemorrhage

Posterior vitreous detachment Central visual loss

Retinal detachment that starts peripherally progresses towards the central vision A veil or curtain over the field of vision Straight lines appear curved (positive Amsler grid test)

Vitreous haemorrhage Flashes of light (photopsia) - in the peripheral field of vision Floaters, often on the temporal side of the central vision Dense shadow

Large bleeds cause sudden visual loss Moderate bleeds may be described as numerous dark spots Small bleeds may cause floaters

# Question 24 During routine follow-up at renal clinic a man is noted to have corpuscular pigmentation of the left retina. Which one of the following conditions is associated with retinitis pigmentosa? A. Autosomal dominant polycystic kidney disease B. Tuberous sclerosis C. Von Hippel-Lindau syndrome D. Alport's syndrome E. Medullary sponge kidney Retinitis pigmentosa primarily affects the peripheral retina resulting in tunnel vision Features Night blindness is often the initial sign Funnel vision (the preferred term for tunnel vision) Associated diseases Refsum disease: cerebellar ataxia, peripheral neuropathy, deafness, ichthyosis Usher syndrome Abetalipoproteinemia Lawrence-Moon-Biedl syndrome Kearns-Sayre syndrome Alport's syndrome # Question 25 Each one of the following predisposes to cataract formation, except: A. Down's syndrome B. Hypercalcaemia C. Diabetes mellitus D. Long-term steroid use E. Uveitis

Cataracts Majority Age related UV light Systemic DM Steroids Infection (congenital rubella) Metabolic (hypocalcaemia, galactosaemia) Myotonic dystrophy, Down's syndrome Ocular Trauma Uveitis High myopia Topical steroids Classification Nuclear: change lens refractive index, common in old age Polar: localized, commonly inherited, lie in the visual axis Subcapsular: due to steroid use, just deep to the lens capsule, in the visual axis Dot opacities: common in normal lenses, also seen in diabetes and myotonic dystrophy # Question 26 A 65-year-old woman presents to the Emergency Department with visual problems. She has rheumatoid arthritis and takes medication to control her blood pressure. Over the past few days she has been getting troublesome headaches and blurred vision but today has noted a marked reduction in vision in the right eye. On examination her right eye is red, has a sluggish pupil and a corrected visual acuity 6/30. Her medication has recently been changed. Which one of the following drugs is most to have precipitated this event? A. Methotrexate B. Doxazosin C. Amitriptyline D. Atenolol E. Bendroflumethiazide Drugs which may precipitate acute glaucoma include anticholinergics and tricyclic antidepressants Glaucoma is a group disorders characterised by optic neuropathy due, in the majority of patients, to raised intraocular pressure (IOP). It is now recognised that a minority of patients with raised IOP do not have glaucoma and vice versa In acute angle closure glaucoma (AACG) there is a rise in IOP secondary to an impairment of aqueous outflow. Factors predisposing to AACG include: Hypermetropia (long-sightedness) Pupillary dilatation Lens growth associated with age

Features Severe pain: may be ocular or headache Decreased visual acuity Symptoms worse with mydriasis (e.g. watching TV in a dark room) Hard, red eye Haloes around lights Semi-dilated non-reacting pupil Corneal oedema results in dull or hazy cornea Systemic upset may be seen, such as nausea and vomiting and even abdominal pain Management Urgent referral to an ophthalmologist Management options include reducing aqueous secretion with acetazolamide and pupillary constriction with topical pilocarpine #Question 27 Which one of the following features is not characteristic of optic neuritis? A. Eye pain worse on movement B. Relative afferent pupillary defect C. Poor discrimination of colours, 'red desaturation' D. Sudden onset E. Central scotomaia Optic neuritis Causes Multiple sclerosis Diabetes Syphilis Features Unilateral decrease in visual acuity over hours or days Poor discrimination of colours, 'red desaturation' Pain worse on eye movement Relative afferent pupillary defect Central scotoma Management MRI: if > 3 white-matter lesions, 5-year risk of developing multiple sclerosis are c. 50% # Question 28 A 43-year-old who is noted to have a high-arched palate, arachnodactyly and a latesystolic murmur presents with visual problems. Which one of the following eye disorders is most associated with his underlying condition? A. Superotemporal ectopia lentis B. Inferonasal ectopia lentis C. Retinitis pigmentosa D. Acute glaucoma E. Retinal detachment This patient has features consistent with Marfan's syndrome. Whilst glaucoma and retinal detachment are seen they are not as common as superotemporal ectopia lentis (upwards lens dislocation), which is seen in around 50% of patients.

Inferonasal ectopia lentis is characteristic of homocystinuria Mitral valve prolapse may cause a late-systolic murmur. This feature helps distinguish the above description from that of a patient with homocystinuria Marfan's syndrome is an autosomal dominant connective tissue disorder. It is caused by a defect in the fibrillin-1 gene on chromosome 15 Features Tall stature with arm span > height ratio > 1.05 High-arched palate Arachnodactyly Pectus excavatum Pes planus Scoliosis of > 20 degrees Heart: dilation of the aortic sinuses (seen in 90%) which may lead to aortic regurgitation, mitral valve prolapse (75%), aortic dissection Lungs: repeated pneumothoraces Eyes: upwards lens dislocation (superotemporal ectopia lentis), blue sclera #Question 29 A 25-year-old woman presents with a one-day history of a painful and red left eye. She describes how her eye is continually streaming tears. On examination she exhibits a degree of photophobia in the affected eye and application of fluorescein demonstrates a dendritic pattern of staining. Visual acuity is 6/6 in both eyes. What is the most appropriate management? A. Topical steroid B. Perform a lumbar puncture C. Treat with subcutaneous sumatriptan D. Topical aciclovir E. Topical chloramphenicol This patient has a dendritic corneal ulcer. Topical aciclovir and ophthalmology review is required Herpes simplex keratitis most commonly presents with a dendritic corneal ulcer Features Red, painful eye Photophobia Epiphora Visual acuity may be decreased Fluorescein staining may show an epithelial ulcer Management Immediate referral to an ophthalmologists + Topical aciclovir # Question 30 A 69-year-old man presents to the Emergency Department with blurred vision. The examining doctor suspects a diagnosis of primary open-angle glaucoma (POAG). Which one of the following features would be most consistent with a diagnosis of POAG? A. Symptoms worse with mydriasis B. Eye pain C. Semi-dilated non-reacting pupil D. Nasal visual field loss E. Red eye

The other listed symptoms are seen with acute angle closure glaucoma Glaucoma is a group disorders characterised by optic neuropathy due, in the majority of patients, to raised intraocular pressure (IOP). It is now recognized that a minority of patients with raised IOP do not have glaucoma and vice versa Primary open-angle glaucoma (POAG, also referred to as chronic simple glaucoma) is present in around 2% of people older than 40 years. Other than age, risk factors include: Family history Black patients Myopia Hypertension Diabetes mellitus POAG may present insidiously and for this reason is often detected during routine optometry appointments. Features may include Peripheral visual field loss - nasal scotoma progressing to 'tunnel vision' Decreased visual acuity Optic disc cupping # Question 31 A 40-year-old man presents with bilateral dry, gritty eyes. A diagnosis of blepharitis is considered. Which one of the following is least likely to be associated with blepharitis? A. Meibomian gland dysfunction B. Seborrhoeic dermatitis C. Staphylococcal infection D. Acne rosacea E. Viral upper respiratory tract infection Blepharitis is inflammation of the eyelid margins. It may due to meibomian gland dysfunction (common, posterior blepharitis) or seborrhoeic dermatitis/staphylococcal infection (less common, anterior blepharitis). Blepharitis is also more common in patients with rosacea The meibomian glands secrete oil on to the eye surface to prevent rapid evaporation of the tear film. Any problem affecting the meibomian glands (as in blepharitis) can hence cause drying of the eyes which in turns leads to irritation Features Symptoms are usually bilateral Grittiness and discomfort, particularly around the eyelid margins Eyes may be sticky in the morning Eyelid margins may be red. Swollen eyelids may be seen in staphylococcal blepharitis Styes and chalazions are more common in patients with blepharitis Secondary conjunctivitis may occur

Management Softening of the lid margin using hot compresses twice a day Mechanical removal of the debris from lid margins - cotton wool buds dipped in a mixture of cooled boiled water and baby shampoo is often used* Artificial tears may be given for symptom relief in people with dry eyes or an abnormal tear film *an alternative is sodium bicarbonate, a teaspoonful in a cup of cooled water that has recently been boiled #Question 32 Which one of the following is associated with heterochromia in congenital disease? A. Holmes-Adie pupil B. Third nerve palsy C. Sixth nerve palsy D. Argyll-Robertson pupil E. Horner's syndrome Horner's syndrome Features Miosis (small pupil) Ptosis Enophthalmos (sunken eye) Anhydrosis (loss of sweating one side) Heterochromia (difference in iris colour) is seen in congenital Horner's Distinguishing between causes of anhydrosis: see below Central lesions Anhydrosis of the face, arm and trunk Stroke Syringomyelia Multiple sclerosis Encephalitis Pre-ganglionic lesions Anhydrosis of the face Pancoast's tumour Thyroidectomy Trauma Tumour Cervical rib Post-ganglionic lesions No anhydrosis Carotid artery dissection Carotid aneurysm

#Question 33 A 71-year-old female with dry age-related macular degeneration is reviewed. Unfortunately her eyesight has deteriorated over the past six months. She has never smoked and is taking antioxidant supplements. What is the most appropriate next step? A. Retinal transplant B. Intravitreal ranibizumab C. Explain no other medical therapies currently available D. Photodynamic therapy E. Photocoagulation

Macular degeneration is the most common cause of blindness in the UK. Degeneration of the central retina (macula) is the key feature with changes usually bilateral. Two forms of macular degeneration are seen: Dry macular degeneration: characterised by drusen - yellow round spots in Bruch's membrane Wet (exudative, neovascular) macular degeneration: characterised by choroidal neovascularisation. Leakage of serous fluid and blood can subsequently result in a rapid loss of vision. Carries worst prognosis Risk factors Age: most patients are over 60 years of age Family history Smoking More common in Caucasians Female sex Features Reduced visual acuity: 'blurred', 'distorted' vision, central vision is Affected first Central scotomas Fundoscopy: drusen, pigmentary changes General management Stopping smoking High does of beta-carotene, vitamins C and E, and zinc may help to slow down visual loss for patients with established macular degeneration Dry macular degeneration - no current medical treatments Wet macular degeneration Photocoagulation Photodynamic therapy Anti-vascular endothelial growth factor (anti-VEGF) treatments: intravitreal ranibizumab # Question 34 A 64-year-old woman with type 2 diabetes mellitus presents as she has started to bump into things since the morning. Over the previous two days she had noticed some 'floating spots in her eyes'. Examination reveals she has no vision in her right eye. The red reflex on the right side is difficult to elicit and you are unable to visualize the retina on the right side during fundoscopy. Examination of the left fundus reveals changes consistent with pre-proliferative diabetic retinopathy. What is the most likely diagnosis? A. Occlusion of central retinal vein B. Vitreous haemorrhage C. Proliferative retinopathy D. Cataract E. Retinal detachment Sudden painless loss of vision The most common causes of a sudden painless loss of vision are as follows: Ischaemic optic neuropathy (e.g. temporal arteritis or atherosclerosis) Occlusion of central retinal vein

Occlusion of central retinal artery Vitreous haemorrhage Retinal detachment Ischaemic optic neuropathy May be due to arteritis (e.g. temporal arteritis) or atherosclerosis (e.g. hypertensive, diabetic older patient) due to occlusion of the short posterior ciliary arteries, causing damage to the optic nerve Altitudinal field defects are seen Central retinal vein occlusion Incidence increases with age, more common than arterial occlusion Causes: glaucoma, polycythaemia, hypertension Severe retinal haemorrhages are usually seen on fundoscopy Central retinal artery occlusion Due to thromboembolism (from atherosclerosis) or arteritis (e.g. temporal arteritis) Features include afferent pupillary defect, 'cherry red' spot on a pale retina Vitreous haemorrhage Causes: diabetes, bleeding disorders Features may include sudden visual loss, dark spots Retinal detachment Features of vitreous detachment, which may precede retinal detachment, include flashes of light or floaters (see below) Differentiating posterior vitreous detachment, retinal detachment and vitreous haemorrhage Posterior vitreous detachment Central visual loss Large bleeds cause sudden visual loss Moderate bleeds may be described as numerous dark spots Small bleeds may cause floaters Retinal detachment that starts peripherally progresses towards the central vision A veil or curtain over the field of vision Straight lines appear curved (positive Amsler grid test) Vitreous haemorrhage Flashes of light (photopsia) - in the peripheral field of vision Floaters, often on the temporal side of the central vision Dense shadow

# Question 35 A 65-year-old man with a history of primary open-angle glaucoma presents with sudden painless loss of vision in his right eye. On examination of the right eye the optic disc is swollen with multiple flame-shaped and blot haemorrhages. What is the most likely diagnosis? A. Diabetic retinopathy B. Vitreous haemorrhage C. Ischaemic optic neuropathy D. Occlusion of central retinal vein E. Occlusion of central retinal artery Sudden painless loss of vision The most common causes of a sudden painless loss of vision are as follows: Ischaemic optic neuropathy (e.g. temporal arteritis or atherosclerosis) Occlusion of central retinal vein Occlusion of central retinal artery Vitreous haemorrhage Retinal detachment Ischaemic optic neuropathy May be due to arteritis (e.g. temporal arteritis) or atherosclerosis (e.g. hypertensive, diabetic older patient) due to occlusion of the short posterior ciliary arteries, causing damage to the optic nerve Altitudinal field defects are seen Central retinal vein occlusion Incidence increases with age, more common than arterial occlusion Causes: glaucoma, polycythaemia, hypertension Severe retinal haemorrhage are usually seen on fundoscopy Central retinal artery occlusion Due to thromboembolism (from atherosclerosis) or arteritis (e.g. temporal arteritis) Features include afferent pupillary defect, 'cherry red' spot on a pale retina Vitreous haemorrhage Causes: diabetes, bleeding disorders Features may include sudden visual loss, dark spots Retinal detachment Features of vitreous detachment, which may precede retinal detachment, include flashes of light or floaters (see below) Differentiating posterior vitreous detachment, retinal detachment and vitreous haemorrhage Posterior vitreous Retinal detachment Vitreous haemorrhage detachment Central visual loss that starts peripherally Flashes of light progresses towards the (photopsia) - in the central vision peripheral field of vision Large bleeds cause A veil or curtain over the Floaters, often on the sudden visual loss field of vision temporal side of the central vision Moderate bleeds may be Straight lines appear Dense shadow described as numerous curved (positive Amsler dark spots grid test) Small bleeds may cause floaters

#Question 36 Which one of the following is least associated with lens dislocation? A. Ehlers-Danlos syndrome B. Marfan's syndrome C. Cystinosis D. Trauma E. Autosomal recessive ectopia lentis Lens dislocation Causes Marfan's syndrome: upwards Homocystinuria: downwards Ehlers-Danlos syndrome Trauma Uveal tumours Autosomal recessive ectopia lentis # Question 37 A 43-year-old man with a history of chronic back pain presents complaining of pain in his left eye and photophobia. On examination the pupil is small, oval shaped and associated with ciliary congestion. What is the most likely diagnosis? A. Anterior uveitis B. Conjunctivitis C. Scleritis D. Meningitis E. Acute angle closure glaucoma Red eye - glaucoma or uveitis? Glaucoma: severe pain, haloes, 'semi-dilated' pupil Uveitis: small, fixed oval pupil, ciliary flush His chronic back pain may be HLA-B27 related, which is associated with anterior uveitis Red eye There are many possible causes of a red eye. It is important to be able to recognize the causes which require urgent referral to an ophthalmologist. Below is a brief summary of the key distinguishing features Acute angle closure glaucoma Severe pain (may be ocular or headache) Decreased visual acuity, patient sees haloes Semi-dilated pupil Hazy cornea Anterior uveitis Acute onset Pain Blurred vision and photophobia Small, fixed oval pupil, ciliary flush

Scleritis Severe pain (may be worse on movement) and tenderness May be underlying autoimmune disease e.g. rheumatoid arthritis Conjunctivitis Purulent discharge if bacterial, clear discharge if viral Subconjunctival haemorrhage History of trauma or coughing bouts # Question 38 Which one of the following is least associated with choroidoretinitis? A. Syphilis B. Toxoplasmosis C. Sarcoidosis D. Malaria E. Cytomegalovirus Choroidoretinitis Causes Syphilis Cytomegalovirus Toxoplasmosis Sarcoidosis Tuberculosis #Question 39 A 68-year-old man with a type 2 diabetes mellitus present with worsening eye sight. Mydriatic drops are applied and fundoscopy reveals pre-proliferative diabetic retinopathy. A referral to ophthalmology is made. Later in the evening whilst driving home he develops pain in his left eye associated with decreased visual acuity. What is the most likely diagnosis? A. Keratitis secondary to mydriatic drops B. Proliferative diabetic retinopathy C. Acute angle closure glaucoma D. Central retinal artery occlusion E. Vitreous haemorrhage Mydriatic drops area a known precipitant of acute angle closure glaucoma Glaucoma is a group disorders characterised by optic neuropathy due, in the majority of patients, to raised intraocular pressure (IOP). It is now recognized that a minority of patients with raised IOP do not have glaucoma and vice versa In acute angle closure glaucoma (AACG) there is a rise in IOP secondary to an impairment of aqueous outflow. Factors predisposing to AACG include: Hypermetropia (long-sightedness) Pupillary dilatation Lens growth associated with age

Features Severe pain: may be ocular or headache Decreased visual acuity Symptoms worse with mydriasis (e.g. watching TV in a dark room) Hard, red eye Haloes around lights Semi-dilated non-reacting pupil Corneal oedema results in dull or hazy cornea Systemic upset may be seen, such as nausea and vomiting and even abdominal pain Management Urgent referral to an ophthalmologist Management options include reducing aqueous secretion with acetazolamide and pupillary constriction with topical pilocarpine