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A 70-year-old man comes to the emergency department 2 hours after losing vision in his left eye.

He states that the vision in his left eye suddenly blacked out but that other ise he feels fine. !uch episodes have occurred in the past" but have never lasted more than seconds to minutes. His past medical history includes hypertension" diabetes" a cerebrovascular event 2 years ago" and coronary artery disease. #ye e$amination is markedly abnormal. %he left eye reacts to light consensually but not directly" hereas the right eye reacts to light directly but not consensually. &unduscopic e$amination of the right eye is normal. #$amination of the left eye" ho ever" reveals a pale" opacified retina ith a cherry-red macula. Auscultation of the carotids reveals a left carotid bruit. 'isual acuity is 20()0 *+ and no light perception *!. ,nhaled o$ygen is administered. ,n addition to a stat ophthalmology consultation" hich of the follo ing is the most appropriate course of action-

A. .orticosteroids and determination of erythrocyte sedimentation rate

/. +irect application of pressure on affected eye ith heel of hand

.. Heparin bolus and drip0 consider thrombolytic therapy

+. !tat carotid ultrasound or magnetic resonance angiography

#. !urgical consultation for emergent carotid endarterectomy

%he correct ans er is /. %his patient has retinal artery occlusion" an embolic event that results in sudden" painless visual loss and a cherry-red macula. /ecause the neural tissue cannot tolerate prolonged hypo$ia" this is an ophthalmologic emergency. 1ermanent visual loss occurs ithin hours. %he first approach is to press firmly on the eye ith the heel of the hand multiple times. %he rise and fall of multiple compressions results in alternating intraocular pressures that may serve to dislodge the embolus and restore blood flo . ,f this does not ork and ophthalmologic intervention is available" retrobulbar in2ections and anterior chamber paracentesis may be attempted. Administering corticosteroids and checking an erythrocyte sedimentation rate 3choice A4 ould be an appropriate strategy for temporal 3giant cell4 arteritis. %his patient" ho ever" has an arteriolar occlusion" hich ill not be improved ith corticosteroids. Anticoagulation and thrombolytics 3choice .4 are not proven to help ith these small embolic events. %he first procedure that should be used is direct compression of the affected eye. %he source of this patient5s embolic event may ell be his carotids" given his previous .'A and his current bruit. A orkup in the future" including a carotid ultrasound or magnetic resonance angiography 3choice +4" and possibly a carotid endarterectomy 3choice #4" may ell be appropriate. 6one of these steps" ho ever" ill help restore this patient5s vision" hich is his immediate problem" and they are not appropriate emergent interventions.

A 78-year-old African American man returns to the clinic for routine follo -up. At his last visit you noted that he had mildly decreased peripheral vision" confirmed by confrontational testing. 9iven his ethnicity" a family history of glaucoma" and a history of diabetes and hypertension" you referred him to a local ophthalmologist for further evaluation. %he ophthalmologist concurred ith your concerns" and noted that the patient had an elevated intraocular pressure" reduced peripheral vision" and arcuate-shaped scotomas. %he patient as diagnosed ith open-angle glaucoma and started on topical beta-blockers. %oday" on funduscopic e$am" multiple abnormalities are noted. %here are numerous dots and blots" cotton- ool spots" drusen" a large optic cup" and copper ire changes of the arterioles" ith prominent atrioventricular nicking. *f these funduscopic findings" hich is the one most consistent ith glaucoma-

A. Atrioventricular nicking

/. .opper ire changes

.. .otton- ool spots

+. +rusen

#. :arge optic cup

%he correct ans er is #. 9laucomatous cupping" here the optic cup is greater than half the si;e of the optic disc" is a finding almost pathognomonic for glaucoma. %he gro th of the optic cup" the central area of pallor in the optic disc" is due to optic nerve damage from elevated intraocular pressure 3though the intraocular pressure may be measured as ithin normal limits4" and the cupto-disc ratio is one measurement used to diagnose glaucoma. Atrioventricular nicking 3choice A4 and copper ire changes 3choice /4 are ocular manifestations of long-standing systemic hypertension. ,n response to elevated pressures" the small vessels in the eye ill hypertrophy and sclerose. %he thickened alls change the refraction of light and create the appearance of copper or silver ires. As the thickened vessels cross each other" the vie of the thickened arteriole is obscured" creating the appearance of a nick in the thickened blood vessel all. .otton- ool spots 3choice .4 are nonspecific findings often associated ith diabetes and hypertension. <icroinfarctions of the nerve fiber layer produce the lesions" hich are opa=ue and hite and have feathery margins. +rusen 3choice +4 is a nonspecific degenerative change that results in the creation of small hyaline nodules. +rusen often appears as multiple small" distinct" yello - hite lesions" though they may be large and have irregular margins.

A 72-year-old oman seeks help because of diminishing vision for the past year. !he is an immigrant from central Africa" ho 2 years ago had undergone cataract surgery ith intraocular lens implants" in her home country. !he learned hen she arrived in the >nited !tates that her intraocular implant as of an early model" no longer used in this country. !he first noticed ha;y"

blurred vision that as orse on a akening and cleared up during the day. As the months ent by" her condition deteriorated and no her visual impairment is constant. %he most striking finding on physical e$amination is significant" full thickness corneal clouding. <anagement of this problem ill re=uire hich of the follo ing therapies-

A. Aggressive immunosuppressant therapy

/. Antimicrobial therapy

.. .orneal transplantation and replacement of the lens implant

+. ?adial keratotomy

#. ?eplacement of the lens implant ith a more modern design

%he correct ans er is .. %he problem described in this vignette is the most common indication for corneal transplant in this country. #arly models of intraocular lens implants damaged the cornea" leading to permanent corneal clouding. <ore modern devices are less likely to do so0 therefore" hen these corneal transplants are done" the implants are also replaced. ,mmunosuppressants 3choice A4 are not needed for lens implants 3 hich are mechanical devices4 or for corneal transplants 3 hich are protected by their avascular status4.

%he problem described in this vignette is mechanical damage to the cornea" rather than an infectious process. %hus" antimicrobial therapy 3choice /4 is not hat ill resolve it. ?adial keratotomy 3choice +4 is used to treat refraction problems. ?eplacement of the lens implant alone 3choice #4 ould have sufficed if performed before the cornea became permanently ha;y. *nce that occurs" the cornea also has to be replaced.

A 8@-year-old schoolteacher comes to the emergency department after the sudden onset of eye pain earlier that afternoon. !he had been outside and upon entering her darkened classroom began to have a dull" throbbing pain that she feels is located behind her left eye" e$tending to the occiput. !ince then the pain has steadily gro n orse" and she no describes it as the orst headache of my life. !he has had several episodes of nausea and vomiting" her visual acuity in the left eye has diminished markedly" and she avoids looking at bright lights. !he is no sitting on a gurney in obvious discomfort but appears other ise ell. Her left eye is diffusely red" especially in the area ad2acent to the iris. %he cornea appears cloudy" but no foreign body is visible. Attempts at direct ophthalmoscopy are th arted by the patient5s inability to tolerate the light. %he rest of her physical e$amination is unremarkable. Ahich of the follo ing is the most appropriate ne$t step in management-

A. .% scan of the head

/. +ilated indirect slit-lamp evaluation

.. &luorescein stain

+. *cular tonometry

#. 1eripheral iridotomy

%he correct ans er is +. ,n this case" ocular tonometry reveals an intraocular pressure of BC mm Hg 3normal D0E2) mm Hg4" confirming the diagnosis of acute angle-closure glaucoma. Acute angle-closure glaucoma is a relatively uncommon but vision-threatening condition. %he incidence increases ith age and usually occurs hile in a darkened room. 6ormally" a=ueous humor is produced by the ciliary body and flo s through the pupil to the anterior chamber. ,t then drains out of the eye at the periphery" through the canal of !chlemm. ,n acute angle closure" the dilated iris compresses the trabecular mesh ork at the edge of the anterior chamber of the a=ueous humor. %his causes a decrease in the rate at hich a=ueous can drain from the eye. %he position of the lens can also block the pupil" keeping a=ueous from flo ing through it. A=ueous humor production continues" though" causing an increase in intraocular pressure. As intraocular pressure rises" perfusion of the vessels of the iris and retina decrease" causing ischemia. ,f left untreated" it can lead to retinal infarction. %he ischemia to the iris also makes it unable to constrict" causing a fi$ed and dilated unilateral pupil. %he elevated pressure also causes corneal edema" leading to clouding. <anagement consists of =uickly recogni;ing the important history and physical e$am findings and measuring intraocular pressure. %his is performed ith either a %ono-pen 3found in most emergency rooms4 or more sophisticated tonometers used by ophthalmologists. %opical drops such as pilocarpine are then used to constrict the pupil" beta-antagonists such as timolol and beta$olol are used to decrease a=ueous humor production" and osmotic agents such as mannitol are used to dra fluid out of the eye. All of these ork to decrease intraocular pressure until definitive surgical treatment can be achieved. .% scan of the head 3choice A4 is incorrect because it ill not add further diagnostic information and ill only delay treatment. ,t may be useful in ruling out other acute processes" such as subarachnoid hemorrhage" but the nature of this patient5s symptoms and the physical finding of a red eye should lead you to consider acute angle-closure glaucoma. A dilated indirect slit-lamp e$amination 3choice /4 ould also delay the correct diagnosis and appropriate treatment. &urther" dilating the patient5s eye ith mydriatic 3dilating4 drops ould only orsen the blockage to drainage and e$acerbate the elevated intraocular pressure. ,n fact" many cases of acute angle-closure are precipitated by application of mydriatic drops to people ith a predisposition for that condition. &luorescein stain 3choice .4 is used to detect a foreign body in the cornea. !ignificant foreign bodies are often difficult to detect on simple visuali;ation of the cornea" and the presence of eye pain and limbic redness are suggestive of this. Ho ever" the dull aching character of the pain and the findings of a fi$ed pupil and a cloudy cornea should suggest an alternate diagnosis. 1eripheral iridotomy 3choice #4 is the definitive procedure for treatment of acute angle-closure glaucoma. ,n this procedure" a laser or tiny scalpel is used to make a small hole in the edge of the iris. %his creates an alternate ay for a=ueous humor to reach the anterior chamber if the pupil is

blocked by the lens. >ltimately" this patient ill re=uire bilateral iridotomy" because the opposite side ill have the same predisposition to angle closure. Ho ever" it ould be clinically un ise to perform this procedure ithout first confirming the diagnosis ith the simple" noninvasive" and rapid test of ocular tonometry.

A ))-year-old man comes to see you for a painful FbumpF in his right upper eyelid. %he pain started 2 days ago" as did the s elling. A small area of his lid progressively e$panded to become a circumscribed" s ollen" and tender bump on his eyelid. /efore this" he has not had much difficulty ith his eyes" but reports he does occasionally get dry" itchy eyes" for hich he uses normal saline drops and an oral antihistamine. His revie of symptoms and past medical history are unremarkable. 'ital signs areG blood pressure D2C(CC mm Hg" pulse 72(min" respirations 20(min" and temperature )7 . 3@C.7 &4. #$amination of his eyelids reveals a 0.8-cm" tender" s ollen cystic structure on his right upper lid. /oth lids reveal small amounts of dried secretions on the lid margins. His face has some diffuse telangiectasias on both cheeks" and his nose is some hat red and bulbous. *ther ise" his e$amination is unremarkable. Ahich of the follo ing is the most appropriate first line of therapy for this patientHs s ollen eyelid-

A. /iopsy of lesion" send to pathology

/. Hot compresses and lid hygiene

.. ,ncision and drainage of lesion

+. *ral minocycline

#. !teroid ointment

%he correct ans er is /. %his patient has a chala;ion" an inflammatory granuloma of a meibomian gland that occurs hen the gland outlet becomes obstructed" often by dried secretions. /lepharitis" in hich the lid margin becomes inflamed" is often a precursor to this condition. 9iven this patientHs history of dry" itchy eyes" he likely has chronic blepharitis" a common condition. Acne rosacea" hich can present as telangiectasias of the face and rhinophyma" is often associated ith chronic blepharitis. %he first-line treatment for a chala;ion is t ice-a-day hot compresses as ell as good lid hygiene" hich includes daily rinses ith baby shampoo. /iopsy of the lesion 3choice A4 is a reasonable choice in older patients ho do not respond to treatment. ?arely" a meibomian gland tumor can mimic the common chala;ion. ,ncision and drainage 3choice .4 are reasonable if the lesion does not respond to hot compresses. %his should be done by an ophthalmologist" as care needs to be taken to minimi;e scarring" hich can be disfiguring and can increase the likelihood of the lesion recurring. *ral antibiotics 3choice +4 can be used for both rosacea and blepharitis. Ho ever" antibiotics are not the first-line treatment and should be used only for patients ith recurrent problems. !teroid ointment 3choice #4 can be combined ith an antibiotic ointment if the patient does not respond to hot compresses. Ho ever" it should not be given ithout a coadministered antibiotic.

A 8D-year-old homeless man comes to the emergency department complaining of burning red eyes. %he problem began last night and has progressed since. Ahen he a oke this morning his eyes ere glued shut from a yello ish" mucous-like discharge. He has tried to clean his eyes but the eyelid discharge =uickly reaccumulates. Aside from his eyes" he also is orried that he caught something from his ne girlfriend at the homeless shelter. He reports burning ith urination and has seen a green discharge in his bo$er briefs. 1hysical e$amination confirms a purulent" bilateral con2unctivitis ith discharge present along the lid margins. %here is bilateral chemosis" markedly in2ected con2unctivae" eyelid s elling" and tender preauricular lymphadenopathy. %he rest of the physical e$amination" including genitourinary e$amination" is ithin normal limits. A 9ram stain of the con2unctival discharge reveals multiple polymorphonuclear cells ith numerous intracellular gram-negative diplococci. Ahich of the follo ing is the most appropriate management-

A. Admit for systemic and topical antibiotics" emergent ophthalmology consultation

/. Advise use of arm compresses to eyes three times daily" follo up in D-2 eeks

.. .heck urethral s ab for 9ram stain and culture" treat based on culture results

+. 1rescribe a combination of ceftria$one and a;ithromycin for gonococcal infection

#. 1rescribe topical ciproflo$acin eye drops" give cefi$ime and a;ithromycin no

%he correct ans er is A. %his patient has a hyperacute bacterial con2unctivitis" likely caused by 6eisseria gonorrhoeae. %he eye infection is characteri;ed by a profuse purulent con2unctivitis that often progresses ithin hours of inoculation. .hemosis" lid s elling" lymphadenopathy" and irritation are common. A coe$isting or recent history of urethritis usually is present. %his infection is severe and sight threatening and re=uires admission and emergent ophthalmologic consultation" as keratitis and perforation can occur. !ystemic and topical antibiotic therapy is necessary. Aarm compresses 3choice /4 can help relieve the symptoms of most forms of con2unctivitis. %his patient has a severe" hyperacute bacterial con2unctivitis" ho ever" that re=uires aggressive treatment. >rethral s ab and culture 3choice .4 results ill not change the management of this patient. ?egardless of the results of the urethral s ab" this patient has a severe eye infection that needs treatment. .eftria$one and a;ithromycin 3choice +4 are one treatment strategy for uncomplicated urethritis" as this regimen treats both chlamydia and neisseria. %his patient needs admission and more aggressive" longer-term treatment for hyperacute bacterial con2unctivitis. :ike ise" other outpatient regimens" such as topical drops combined ith cefi$ime and a;ithromycin 3choice #4 are inappropriate. %his patient is at risk for losing his sight and needs

inpatient monitoring.

A 70-year-old farm orker comes to the clinic complaining of difficulty seeing out of his right eye. His vision has gotten gradually orse over the years" hich the patient believes is caused by e$cess skin on his right eye. Aside from his visual complaints" he has no medical complaints. He feels healthy and still orks in the fields daily" not having missed a day of ork because of illness in more than 8 years. #$amination of the patient5s eyes reveals a edge-shaped gro th of superficial tissue on the right eye. %he tissue is semiopa=ue" heavily vasculari;ed" and e$tends from the nasal side of the eye to ard the pupil" here it crosses the limbus and partially blocks the pupil. 'isual acuity is 20(C0 *+ and 20(28 *!. Ahich of the follo ing is the most appropriate management-

A. .orticosteroid eye drops

/. :aser photocoagulation

.. ?eassurance ithout intervention

+. !urgical resection of tissue

#. %opical antibiotic ointment

%he correct ans er is +. %his patient has a pterygium" a benign gro th of vasculari;ed con2unctiva that e$tends onto the cornea. ,t commonly occurs in the tropics or among patients e$posed to repeated con2unctival irritation" such as ind" sun" and dust. %reatment usually is not re=uired. ,f the pterygium is large and encroaches on the visual access" ho ever" it needs to be removed surgically. ,f it does not encroach on the visual access" reassurance ithout intervention 3choice .4 is an appropriate choice. :aser photocoagulation 3choice /4 is used to treat retinal neovasculari;ation from a variety of causes. ,t is not a techni=ue used to treat pterygiums. .orticosteroid eye drops 3choice A4 do not reduce the vasculari;ed tissue gro th that is impairing this patient5s vision. ,n general" primary care physicians should use corticosteroid eye drops only after consultation ith an ophthalmologist" as they have a variety of severe ocular side effects. %opical antibiotic ointment 3choice #4 ill not improve this patient5s noninfectious condition. %he e$cess tissue" a pterygium" is not believed caused by topical infection.

A )C-year-old man comes to the clinic complaining of a painful red eye. He orks grinding industrial metal parts and is orried that he may have some metal in his right eye. Iesterday afternoon at ork the patient began to suffer pain in his right eye. %he pain progressed throughout the afternoon and evening and as severe enough to cause the patient difficulty sleeping. %he pain is described currently as e$cruciating and he is no too uncomfortable to ork" drive" or read. He has ashed his eye numerous times" but has difficulty keeping the affected eye open. #$amination reveals an in2ected red eye ith mild ciliary flush" but ithout any discharge or corneal opacity. %he red refle$ appears normal and the chamber is ell formed and the pupil round. %he pupil is small and minimally reactive on the right" making the funduscopic e$amination difficult" but it appears grossly normal" though the patient is photophobic in the affected eye. #ye motility is normal. %here are no lid abnormalities or obvious foreign bodies present. 'isual acuity is 20()0 *+ and 20(20 *!. Ahich of the follo ing is the most appropriate ne$t diagnostic test-

A. .% scan ith orbital vie s

/. +ilatation and repeat funduscopy


&luorescein slit-lamp e$amination

+. 6o further evaluation necessary

#. %onometry measurement

%he correct ans er is .. %his patient likely has a corneal abrasion" hich presents ith foreign body sensation and a painful" red eye. *ften the foreign body is dislodged by the time of e$amination" and the defect is too small to visuali;e ith penlight e$amination. &luorescein collects in epithelial defects and is visuali;ed easily using a slit-lamp ith a cobalt blue filter. &luorescein also picks up herpes simple$ virus infections" hich can mimic corneal abrasions. .% scan 3choice A4 is sometimes useful for large foreign bodies that have penetrated the orbit. ,t ould not be helpful in this patient" ho ever" ho has a likely subtle defect of the corneal epithelium. &unduscopic e$amination 3choice /4 should be attempted at least once" to confirm a red refle$. %he fundus is almost certainly normal in this patient" ho ever" and repeating this portion of the e$amination is unlikely to provide further information. Although this patient5s diagnosis is fairly certain before fluorescein e$amination" further evaluation is necessary 3choice +4. !lit-lamp e$amination can locate some foreign bodies not visible on penlight e$amination and can confirm and demarcate the e$tent of corneal involvement. %onometry 3choice #4 is useful for measuring intraocular pressure" hich is elevated in glaucoma. ,t is not necessary in the evaluation of a presumed corneal abrasion.

A 72-year-old man comes to the urgent care alk-in clinic for evaluation of a painful red eye. *ver the past 2 eeks he has had three episodes of blurring and pain in his left eye" but never as severe as this current episode. ,n the past" his pain has resolved spontaneously and as al ays relieved by sleep. Ho ever" a couple of hours ago his symptoms returned and have become progressively orse. He is no nauseous" has vomited t ice" has blurred vision ith halos around lights" and has a pounding headache. 1hysical e$amination reveals a mid-dilated pupil" a shallo

anterior chamber noted on penlight e$am" and a ha;y left cornea. .iliary flush and photophobia are both present. 'isual acuity is 20(D00 *! and 20(20 *+. %onometry reveals an intraocular pressure of 2@ mm Hg in the left eye and DC mm Hg in the right eye. Ahich of the follo ing is the most appropriate course of action-

A. Admission for intravenous antifungal therapy and fre=uent ocular e$aminations

/. /egin corticosteroid eyedrops0 close follo -up ith ophthalmologist tomorro

.. 1atch the eye0 cycloplegic eyedrops and topical antibiotic ointment0 close follo -up

+. !tat ophthalmology consultation0 carbonic anhydrase inhibitor and beta-blocker

#. !upportive treatment0 reassurance0 pain control0 and close follo -up

%he correct ans er is +. %he presence of halos 3indicative of corneal edema from increased intraocular pressure4" nausea and vomiting" and a shallo anterior chamber in the setting of a painful red eye are reasons for concern. %his patient has acute angle closure glaucoma" a condition that re=uires immediate ophthalmologic consultation. %his condition results from an acute increase in intraocular pressure" usually from obstruction of the anterior chamber angle and canal of !chlemm by iris tissue. %he elevated pressures can result in permanent optic nerve damage and

loss of sight if not treated immediately. %opical beta-blockers can rela$ the iris" reduce the acuity of the angle" and increase vitreous fluid outflo " thus lo ering intraocular pressure. !ystemic carbonic anhydrase inhibitors ill reduce the production of vitreous fluid" also reducing intraocular pressure. %here is no indication for antifungal therapy 3choice A4 in this patient. !everely ill patients ith invasive fungal disease may have ocular involvement" hich can necessitate prolonged antifungal therapy. %here is no indication for corticosteroid eyedrops 3choice /4 in this patient" ho needs to see an ophthalmologist today. !teroid eyedrops should be used under the guidance of an ophthalmologist" inasmuch as they can delay healing" promote scar tissue formation" and allo undiagnosed viral infections to spread rapidly. .ycloplegics and topical antibiotic ointment 3choice .4 ith close follo -up are the usual treatments for mild corneal abrasions. Jeep in mind that patching the eye after corneal abrasions is no longer routinely recommended. 1atching" cycloplegics" and topical antibiotic ointment ill not help a patient ith acute angle closure glaucoma. %his patient is at risk of losing his vision if not treated promptly. %he strategy of supportive treatment" reassurance" pain control" and close follo -up 3choice #4 ithout definitive intervention is medical malpractice.

A 72-year-old man complains of gradual deterioration of vision. He orks as a 2e eler" performing fine handi ork ith small ob2ects" and recently his vision has interfered ith this ork. He uses reading glasses" and recently ent to an optometrist ho gave him a ne eyeglass prescription that provided ma$imal correction of his vision. %he patient doesn5t think the ne eyeglasses helped very much. He has also noticed halos around streetlights hen he drives at night" though this has not been a big problem for him. He is other ise healthy and has no medical problems. 1ast medical history is positive for an appendectomy at age 2@ and occasional mild asthma in the past for hich he formerly used inhaled steroids and albuterol. He is a nonsmoker and takes no chronic medications. %he patient is afebrile" ith a blood pressure of D)2(CD mm Hg and pulse of C@(min. 9eneral physical e$am is normal. #$amination of the eyes ith an ophthalmoscope reveals a clear cornea" normal retina" and mild cataracts in both eyes. %he cataracts appear minimal in comparison ith others you have seen hen e$amining patients in this age group" and his visual acuity 3 earing reading glasses4 is 20(B0 in both eyes. Ahich of the follo ing is the best approach to the care of this patient-

A. .heck color vision


.heck perimetry 3visual fields4

.. <onitor vision daily ith an Amsler grid

+. ?echeck visual acuity in 2 to ) months

#. ?efer for evaluation for cataract surgery

%he correct ans er is #. %his patient has cataracts and he probably needs cataract surgery to improve his vision. %he main indication for cataract surgery is impairment of vision that interferes ith a patient5s daily functionKregardless of the patient5s measured visual acuity. !ome patients can have relatively severe cataracts ith a notable decline in visual acuity but no important effect on their daily activities. !uch patients do not necessarily re=uire cataract surgery. *ther patients" ho ever" such as the man in this case" ho orks as a 2e eler" re=uire high-acuity vision" and even a relatively minor decline in acuity might interfere ith their ork or daily activities. !o" despite the fact that this patient has only a relatively minor impairment of visual acuity 320(B04" his activity is impaired and further" he has symptoms of cataracts 3halos around lights4. He is therefore" a potential candidate for cataract surgery. %here are also t o other indications for cataract surgeryG *ne is hen a cataract is so dense that it prevents visuali;ation of the retina in a patient ho has retinal disease that re=uires monitoring 3e.g." diabetic retinopathy4. %he second is hen a cataract is impeding the flo of intraocular fluids and thus causing or contributing to glaucoma. &inally" note that this patient formerly used inhaled steroids for treatment of asthma. !teroid therapy predisposes to development of cataracts. Ahile the association bet een steroids and cataracts is strongest for systemic 3oral4 steroids" cataracts have also been linked to the use of chronic inhaled steroids. <easuring color vision 3choice A4 is incorrect. %he patient has no impairment of color vision. ,mpairments of color vision occur in patients taking certain medications" such as ethambutol" but

this patient is not taking any medications.. 1erimetry 3choice /4 is used to test for visual field defects such as might occur in glaucoma or macular degeneration. %his patient" ho ever" has cataracts" hich do not cause visual field defects. <onitoring vision ith an Amsler grid 3choice .4 is helpful in the management of patients ith macular degeneration. %his patient5s ophthalmoscopic e$am" ho ever" is normal and does not sho findings of macular degeneration 3e.g." drusen4. ?echecking the patient5s visual acuity in 2 to ) months 3choice +4 ill result in an unnecessary delay in his treatment. He already has visual impairment that interferes ith daily activity. %here is no point in aiting to see if his vision becomes even orse.

A 2D-year-old oman comes to the emergency department after a day of hiking. !he reports that about 2 hours ago" to ard the end of the hike" a branch brushed across her face and scratched her in the left eye. !he immediately began to e$perience pain and no has a persistent sensation of having something in her eye. !he also complains of tearing and photophobia. !he has no medical problems and takes no medication other than oral contraceptives. 'ital signs are normal and her visual acuity is 20(20 in the right eye and 20()0 in the left. .on2unctival in2ection is noted in the left eye but careful inspection reveals no foreign bodies" even after everting the upper and lo er eyelids. &urther eye e$amination after applying local anesthetic reveals that the cornea is clear and intact and the pupils are e=ually round and reactive to light. ,nspection of the cornea ith a Aood light after application of fluorescein stain reveals a )-mm linear abrasion across the center of the left cornea. Ahich of the follo ing is the most appropriate management-

A. Apply a metal protective eye guard until the patient can be e$amined by an ophthalmologist

/. Apply antibiotic ointment" patch the eye" and instruct the patient to return for a recheck in 2 days.

.. 1rescribe antibiotic drops and instruct the patient to return if symptoms do not resolve hours ithin BC


1rescribe corticosteroid drops until symptoms resolve0 recheck if symptoms do not resolve in 2B to BC hours

#. ?efer to an ophthalmologist for debridement of the corneal abrasion under slit lamp visuali;ation

%he correct ans er is .. %his patient has a corneal abrasion" a superficial in2ury that almost al ays heals spontaneously over D or 2 days. !ymptoms include pain" tearing" and often a foreignbody sensation and photophobia. %he patient in this =uestion has all of these symptoms. %he diagnosis is made by demonstrating a corneal lesion that can be seen ith a Aood light after application of fluorescein stain to the cornea. ,n the past" management of corneal abrasion involved patching the eye after application of antibiotic ointment. ?esearch has sho n" ho ever" that the best outcomes are achieved ithout patching. .urrent recommendations for management of corneal abrasion are to leave the eye unpatched and apply antibiotic drops. !ymptoms should resolve ithin D or 2 days and if they do" it is not necessary to ree$amine the patient. 1atients hose symptoms do not resolve ithin 2 days generally re=uire e$amination by an ophthalmologist. Application of a metal eye guard 3choice A4 is indicated hen there is concern that a patient has e$perienced perforation of the eyeball. ,n this case e are told that the cornea is intact and there is no indication that the integrity of the eyeball has been compromised. Application of antibiotic ointment and patching 3choice /4 as recommended in the past but is no longer considered optimal therapy. %he occlusion created by patching increases the likelihood that the patient ill develop an eye infection" and it does not improve the rate of corneal healing. .orticosteroid drops 3choice +4 are not indicated for corneal abrasion. ,n general" steroid drops should not be prescribed for eye problems ithout the patient first undergoing a full ophthalmologic e$amination to e$clude conditions for hich steroids are contraindicated" such as herpes simple$ keratitis. ?eferring the patient for debridement of the corneal abrasion 3choice #4 is inappropriate. .orneal abrasions do not re=uire debridement because debridement ould cause additional in2ury to the cornea that ould delay healing and perhaps increase the risk of infection.

A 7B-year-old African American man complains of blurry vision that has been orsening over several months. His ife insisted that he see you to have his vision checked. *ther than some agerelated farsightedness for hich he ears glasses" the patient reports no other problems ith his

eyes or vision. His medical history is positive only for hypertension" hich is ell controlled on a diuretic and an angiotensin-converting en;yme 3A.#4Einhibitor. His family history is positive for hypertension" glaucoma" and coronary artery disease in his father" ho died at age 72. His younger brother also has glaucoma. His mother died years ago from complications of diabetes. %he patient5s blood pressure is DB2(CC mm Hg" and the remainder of the general physical e$amination is normal e$cept for a bruise on his right shoulder. %he patient5s corrected visual acuity is 20()0 in the left eye and 20(B0 in the right. *n e$amination of the eyes" you find that the corneas are clear and you do not see any evidence of cataract. %he optic fundi vie ed through an ophthalmoscope appear normal e$cept you note that the optic cup in the right eye is much larger than the optic cup in the left eye. ,n the right eye" the optic cup takes up nearly three-=uarters of the surface of the optic disk" hereas it takes up only about half the optic disk in the left eye. Iou ask your colleague do n the hall" an optometrist" to do a =uick check of the patient5s intraocular pressures" and they are normal. Ahich of the follo ing is the most appropriate ne$t step in management-

A. +iscontinue the A.#-inhibitor

/. Have the patient monitor his vision daily ith an Amsler grid

.. *rder perimetry 3visual field evaluation4

+. ?efraction for a ne eyeglass prescription

#. !tart therapy ith beta-blocker eyedrops

%he correct ans er is .. +espite the normal intraocular pressures 3,*1s4" this patient likely has glaucomaKfor several reasons. &irst" he has three important risk factors for glaucomaG he has a strong family history of glaucoma" he is 72 years old 3the prevalence of glaucoma increases ith age4" and he is African American. %he latter is a key risk factor because the rate of glaucoma in African Americans is four times the rate in hites. !econd" the patient has physical e$amination findings of glaucoma. !pecifically" the si;e of his optic cups 3the depression in the center of the optic disks4 is unusually large in relation to the overall si;e of the optic disks. A normal cup-todisk ratio is less than 0.). ,n glaucoma the ratio typically e$ceeds 0.7" probably representing atrophy of optic nerve fibers in the central 3cup4 portion of the optic disk. ,n this patient the ratios are 0.8 and 0.78 rather than the normal value of 0.). &urther" the cup-to-disk ratio is asymmetrical" being larger in one eye than the otherKyet another physical e$am finding of glaucoma. &inally" the bruise on the patient5s shoulder may represent a problem ith peripheral visionKhe is bumping into thingsKand peripheral vision is lost first in glaucoma" often long before central visual acuity is impaired. 1utting all of this together" there is a high likelihood that the patient has glaucoma" despite the normal ,*1s. ,ndeed" perhaps the most important point of this =uestion is to emphasi;e that the primary defect in glaucoma is not elevated ,*1s. ?ather" the primary defect is degeneration of the optic nerve" and this degeneration may or may not be accompanied by ,*1. %hus" although glaucoma is classically associated ith increased ,*1" this is not al ays the case. *ptic nerve damage may occur even in the presence of normal ,*1Kso-called normal-pressure glaucoma. 9iven this patient5s risk factors for glaucoma" his abnormal cup-to-disk ratios" and the bruise suggesting loss of peripheral vision" his normal ,*1 should not preclude further consideration of glaucoma as the cause of his visual problems. /ecause the earliest optic nerve damage and visual loss in glaucoma occur in the peripheral visual fields" the best and most sensitive ay to detect optic nerve damage in this patient is assessment of visual fields ith perimetry. +iscontinuing the A.#-inhibitor 3choice A4 is illogical because A.#-inhibitors do not have ocular side effects and therefore ould not cause this patient5s visual problems. +aily vision checks ith an Amsler grid 3choice /4 are useful for monitoring vision hen patients have age-related macular degeneration. %his patient5s retinal e$amination" ho ever" does not sho the typical findings 3drusen4 of macular degeneration. ?efraction for ne eyeglasses 3choice +4 is not needed because the patient5s visual acuity 320()0 left eye" 20(B0 right eye4 is already in the acceptable range for correction ith eyeglasses. /eta-blocker eyedrops 3choice #4 are an appropriate treatment for glaucoma because they decrease production of intraocular fluids and" therefore" lo er the ,*1. /eta-blocker drops should not be started" ho ever" until the diagnosis of glaucoma is confirmed 3in this case" ith visual field testing4.

A )C-year-old man comes to the office complaining of difficulty ith his vision at night and dryness of the eyes. %hese symptoms began after developing chronic constipation of unkno n etiology for hich he has been using mineral oil la$atives to facilitate bo el movements. He has

no other medical problems and denies any substance use or abuse. 'itals signs are unremarkable. 'isual e$amination is only significant for difficulty visuali;ing letters or structures hen the lights are turned off. #$amination of the eye is only significant for con2unctival dryness and the appearance of small hite patches on the sclera. .orneal e$amination is ithout abnormalities. !upplementation ith hich of the follo ing vitamins most likely ould have prevented this condition-

A. 'itamin A

/. 'itamin /7

.. 'itamin /D2

+. 'itamin .

#. 'itamin #

%he correct ans er is A. +eficiencies of fat-soluble vitamins often occur primarily in underdeveloped countries secondary to malnutrition. ,n more developed countries" ho ever" patients ho have malabsorption syndromes or ho abuse la$atives 3secondary malabsorption4 also can e$perience vitamin deficiencies. ,n this case" the patient has symptoms of vitamin A

deficiency. %he earliest symptoms are night blindness. :ater" patients develop $erosis 3dry eyes4. *cular e$amination sho s hite patchy areas on the sclera. <ore serious corneal in2ury can occur ithout vitamin repletion. %reatment in this patient includes removal of the offending agent 3la$ative4" or if not possible" an initial intramuscular in2ection of vitamin A follo ed by vitamin A supplementation. 'itamin /7 3pyrido$ine4 3choice /4 deficiency causes glossitis" cheilosis" and later peripheral neuropathy and sei;ures not seen in this patient. 'itamin /D2 3cobalamin4 3choice .4 deficiency causes pernicious anemia and also can cause neurologic abnormalities not present in this patient. 'itamin . 3ascorbic acid4 3choice +4 primarily affects the skin and connective tissues" and is characteri;ed by hemorrhages at various sites including the gums and 2oints. 'itamin # 3alpha-tocopherol4 3choice #4 deficiency causes arefle$ia and gait disturbances not present in this patient. ,t can cause paralysis of the ocular muscles" another symptom not consistent ith the current patient.

A B8-year-old African American oman arrives at your office complaining of intermittent blurry vision. *n =uestioning she describes a recent history of increased thirst and reports craving high sodium beverages" such as soda and sports drinks. !he also reports increased fre=uency of urination. !he has a family history of diabetes in both of her parents" but has never been tested herself. *n e$amination she is an obese oman in no apparent distress or pain. 'ital signs and physical e$amination are unremarkable. A finger-stick blood glucose level is obtained that sho s a level of BD7 mg(d:. >rinalysis reveals )L glucose" DL protein" and no ketones. An elevation of hich of the follo ing substances is hypothesi;ed to be the most likely e$planation for her blurry vision-

A. &ructose

/. 9lucagon

.. <annitol



#. !orbitol

%he correct ans er is #. Acute visual changes in diabetes are related to hyperglycemia. 9lucose freely diffuses into the eye and lens" here it is converted to sorbitol. !orbitol is unable to diffuse freely across cell membranes and becomes an effective intraocular osmole. Aater flo s in" distorting the shape of the lens and creating blurry vision from a change in lens refraction. %his is distinct from other causes of long-term vision loss from diabetes that often are related to vascular complications. &ructose 3choice A4 and mannitol 3choice .4 are other sugars not directly implicated in diabetic visual disease. 9lucagon 3choice /4 is elevated in diabetes and may play a role in the pathogenesis of diabetes and the long-term maintenance of hyperinsulinemia. ,t is not directly involved" ho ever" in hyperglycemic refractile changes. !odium 3choice +4 is not directly implicated in the pathogenesis of diabetes. +iabetics often crave high sodium beverages" like this patient" in an attempt to maintain volume in the face of an osmotic diuresis from glucosuria.

A 80-year-old oman comes to the emergency department because of a rash on her face. !he states it started 2.8 days ago on her forehead and no is involving her nose. !he complains of facial pain and a red left eye. Her past medical history includes hypertension that has been ell controlled ith atenolol for the past B years. *n e$amination you find a ell appearing oman ith a vesicular rash in different stages of healing over the left side of her forehead and including the tip of her nose. Iou find that her vision is intact and there is evidence of chemosis of her left con2unctiva. *ther ise her eye e$amination is normal. Ahich of the follo ing is the most appropriate management-

A. Admit her to the hospital for a course of intravenous antivirals

/. 1rescribe an antiviral agent and discharge the patient home

.. 1rescribe an antiviral agent and obtain an ophthalmology consult to rule out involvement of the ophthalmic nerve

+. 1rescribe an antiviral agent and a corticosteroid taper

#. !tart a course of ,g9 gamma globulin and prescribe an antiviral agent

%he correct ans er is .. Herpes ;oster 3shingles4 is the reactivation of the latent herpes ;oster virus infection. %he lesions of shingles are identical to those of chickenpo$" but are limited to a single dermatome in distribution. ,n this case cranial nerve ' has been involved" hich potentially can lead to the vision-threatening condition of herpes ;oster ophthalmicus 3HM*4. !uspected HM* mandates an ophthalmologic consultation. Ahen the cutaneous lesions include the tip of the nose 3Hutchinson sign4" the nasociliary nerve is involved and the eye fre=uently becomes inflamed. %here may be concominant anterior uveitis" retinitis" optic neuritis" scleritis" glaucoma" or ocular motor nerve palsies. ,f HM* is diagnosed" admission and ,' antivirals should be considered 3choice A4. ,f there ere no evidence of HM* it ould be appropriate to prescribe an antiviral such as valacyclovir 3choice /4 for a 7-day course and discharge the patient ith follo up. A short course of topical or oral corticosteroids 3choice +4 may also be considered to treat the keratitis and(or uveitis and to try to reduce the possibility of postherpetic neuralgia. /ecause of the increased chance of systemic 'M' dissemination ith the use of oral corticosteriods" antiviral therapy should be administered concomitnantly.

%here is no role for ,g9 3choice #4 in the treatment of shingles 3complicated or not4.

A 2)-year-old college student comes to the student health clinic complaining of burning" itchy red eyes. Appro$imately ) days ago" he noticed that one of his eyes appeared pink. !ince then" his other eye also has become involved. He has noticed morning crusting of his eyelids and a atery discharge throughout the day. A revie of symptoms reveals additional complaints of lo -grade fever" malaise" diffuse myalgias" and a sore throat" lasting appro$imately a day. He is concerned" as he had pink eye as a child" and is orried about spreading an eye infection. He is hoping you ill prescribe an appropriate antibiotic" as he does not ant to infect friends and family. #$amination of his eyes reveals bilateral in2ected con2unctivae and a scant amount of thin" mucoid discharge in the corner of the eyes" though there is profuse tearing. #$amination of the tarsal con2unctivae reveals a bumpy appearing epithelium by gross e$amination. %here is bilateral" tender preauricular adenopathy. #$amination of the oropharyn$ reveals mild erythema. %he rest of the physical e$amination is unremarkable. Ahich of the follo ing is the most appropriate ne$t step in the management-

A. Admit for further orkup and intravenous antibiotics

/. 9ive prescription for topical antibiotic ointment

.. 1erform slit-lamp e$amination ith fluorescein dye

+. ?ecommend hand- ashing and supportive care

#. !uggest over-the-counter antihistamines and decongestants

%he correct ans er is +. %his patient has a viral con2unctivitis" often seen as a prodromal viral illness" follo ed by adenopathy" fever" pharyngitis" or an upper respiratory infection. 'iral con2unctivitis is benign and self-limited but highly contagious" and is spread by direct contact. %he patient should be advised that this condition is similar to the common cold and ill likely respond similarly. !upportive measures" such as arm compresses and hand ashing" help relieve symptoms and reduce the spread of the condition. %here is no need for admission and further orkup 3choice A4. ,n cases of hyperacute con2unctivitis" characteri;ed by large =uantities of markedly purulent discharge" admission and intravenous antibiotics may be arranted. %opical antibiotic ointment 3choice /4" such as erythromycin" often is given. %his patient has such a classic presentation of an acute viral con2unctivitis ith scant discharge and associated viral symptoms" ho ever" suggesting that antibiotics are of no value. !lit-lamp e$amination 3choice .4 is useful to evaluate for corneal disease. %here is no reason to suspect corneal abnormalities and most patients ith con2unctivitis" a common condition" do not need a slit lamp e$amination. *ver-the-counter antihistamines and decongestants 3choice #4 are of little help. &urther" they often dry the ocular surface" orsening the irritation.

A 88-year-old man ith mild hypertension comes to the emergency department complaining of increasing visual loss in his left eye. He e$plains that he had been orking in his garden hen he noted that his visual field in his left eye became smaller and smaller over an hour. He states it as as if someone as dra ing the blinds do n over my left eye. He denies any headache or recent trauma to the eye. He is nearsighted and ears glasses. His blood pressure is D28(C8 mm Hg and pulse is 70(min. *n physical e$amination of the eye there is no noted in2ection of the sclera or cornea. *phthalmoscopic e$amination sho s a small gray ob2ect floating in the vitreous humor0 there is also an orange crescent-shaped area on the posterior portion of the eye. Ahich of the follo ing is the most appropriate ne$t step in management to prevent morbidity-

A. /iopsy of temporal artery


!urgical intervention

.. %reatment ith aceta;olamide

+. %reatment ith ocular steroids

#. Aorkup for vasculitis

%he correct ans er is /. %he patient is e$periencing an acute retinal detachment" characteri;ed by rapid" progressive visual loss in one or both eyes. 1atients classically describe the loss of vision as a curtain coming do n over the affected eye. 1redisposing risk factors for retinal detachment include trauma and age greater than 80 years. %reatment involves immediate consultation ith an ophthalmologist and immediate surgical intervention. Ahile aiting for surgery" the patient should remain ith the head at less than B8 degrees to facilitate favorable gravitational forces on the retina and to prevent traction related e$acerbation of the detachment. /iopsy of temporal artery 3choice A4 ould be indicated if the patient had a more classic presentation of giant cell arteritis" such as the presence of headache" scalp tenderness" and visual changes. /lindness can occur but it is usually sudden 3ischemic optic neuropathy4. Aceta;olamide 3choice .4 is used for ad2unctive treatment of chronic simple 3open-angle4 glaucoma and secondary glaucoma0 it is used preoperatively in acute angle-closure glaucoma hen delay of surgery is desired to lo er intraocular pressure. %reatment ith ocular steroids 3choice +4 is used primarily in the treatment of inflammatory conditions of the anterior eye and is not indicated in the treatment of a physical detachment of the retina. Aorkup for vasculitis 3choice #4 ould be indicated only if there ere clinical suspicion of an ischemic neuropathy in con2unction ith the retinal detachment. %he primary condition of the detachment must be treated" ho ever" and should not be delayed hile aiting for results of a vasculitis orkup that could take more than 2B hours to complete.

A 7C-year-old man comes to clinic for a routine health care visit. Although he states that overall he has been feeling ell" he is a little concerned about diminished vision in his left eye. He is not certain hen his vision first started orsening" though he believes it as sometime in the last month. Ahen =uestioned" he denies any floaters" abrupt episodes of vision loss" headaches" or eye pain. His other medical issues include hypertension and a history of coronary artery disease" ith a myocardial infarction 2 years ago. #$ternal eye e$amination and pupillary light refle$es are normal. &unduscopic e$amination of his right eye is normal but reveals dramatic abnormalities of his left eye. *ptic disc s elling" venous engorgement" cotton- ool spots" and diffuse retinal hemorrhages are present. 'isual acuity is 20(20 *+ and 20(200 *!. Ahich of the follo ing is the most likely cause of this patient5s abnormal funduscopic e$amination-

A. .entral retinal artery occlusion

/. .entral retinal vein occlusion

.. ?etinal tear and partial detachment

+. ?etrobulbar optic neuritis

#. %emporal arteritis

%he correct ans er is /. ?etinal vein occlusions can cause a significant" though often subacute" visual loss ith dramatic funduscopic findings. +espite the intimidating funduscopic e$am" there are no firm recommendations for management and this is not a true ophthalmologic emergency. *phthalmologic follo -up is arranted" ho ever" because neovasculari;ation" hich may re=uire photocoagulation" can occur. ?etinal artery occlusion 3choice A4 presents ith a less dramatic funduscopic e$am. %he fundus appears pale" ith a cherry-red macula. 'isual loss is often abrupt and" if not treated ithin hours" permanent. ?etinal tears and detachment 3choice .4 can cause acute visual loss and may be seen on funduscopic e$am" though the e$am may be normal. %he classic presentation of a retinal tear and detachment is the complaint of flashing lights follo ed by large numbers of floaters and then a shade over the vision in one eye. ?etrobulbar optic neuritis 3choice +4 can cause acute unilateral vision loss" but the funduscopic e$am is normal. %he classic presentation is a young adult ith monocular vision loss and pain on movement of the affected eye. %emporal arteritis 3choice #4 is often associated ith headaches" 2a claudication" and the systemic manifestations of polymyalgia rheumatica. %his vasculitis can result in acute ischemic optic neuropathy and is an emergency re=uiring a stat erythrocyte sedimentation rate" intravenous corticosteroids" and an ophthalmologic consultation.

A 70-year-old man comes to the clinic complaining of difficulty reading that has developed gradually over the last DC months. He has never orn glasses in the past and is surprised that he is having trouble no ith his vision. %he problem is that the center of his vision appears particularly ha;y. He tells you that overall his vision has diminished" but that it is much orse hen he tries to look at one particular ob2ect" hen driving at night" or hen trying to read even large print items" such as street signs. &unduscopic e$amination is remarkable for some ell defined areas of pigment loss" large amounts of drusen" and numerous other small areas of scarring and abnormal pigmentation. 'isual e$amination reveals visual acuity of 20(B0 *+ and 20(70 *!. After a more detailed visual e$amination" ho ever" including Amsler grid and peripheral visual field confrontation" he is found to have central scotomata and line distortion. %hese visual field defects are most consistent ith hich of the follo ing-

A. /ilateral cataracts


.entral mass lesion

.. <acular degeneration

+. *pen-angle glaucoma

#. 'itreous bleeding

%he correct ans er is .. %his patient has a classic presentation of age-related macular degeneration" the leading cause of legal blindness in patients 78 years of age and older in the >nited !tates. +rusen" pigment loss" and areas of scarring or hemorrhage may be seen on funduscopic e$amination. %he entire visual field usually is diminished" ith orse vision centrally. %his is in contrast to glaucoma 3choice +4" hich" in severe cases" results in peripheral visual defects and tunnel vision. 1atients may complain of difficulty reading" focusing on ob2ects" or having difficulty driving. 1atients ith cataracts 3choice A4 may have a focal scotoma and may complain of blurred vision" glare" or difficulty ith reading. :ine distortion and this patient5s funduscopic findings" ho ever" are consistent ith macular degeneration. A central mass lesion 3choice /4 rarely results in central scotomas and line distortion. <ore common are discrete visual field cuts. A vitreous bleed 3choice #4 usually presents acutely" ith a curtain falling or ith floaters. ,t is unlikely to e$plain this patient5s gradual course or funduscopic findings.

A 7C-year-old oman complains of a )-day history of a red" tender nodule in her right eyelid. !he has had numerous nodules in this same area over the last 8 years that have partially resolved spontaneously" though she has been able to palpate a residual bump in her eyelid. Aside from her painful eyelid" she has no medical problems and has been in good health. #$amination of the

right lo er eyelid reveals a tender" discrete nodule ith minimal con2unctival in2ection. A small amount of pus can be e$pressed and the nodule is e$tremely tender and seems to involve a hair follicle. 'isual acuity and pupillary e$amination are normal" as is the rest of the physical e$amination. Ahich of the follo ing is the most appropriate management-

A. #mergent referral to ophthalmologist

/. Hot compresses

.. Hot compresses and topical antibiotics

+. Hot compresses" topical antibiotics" and a biopsy of nodule

#. ,ncision and drainage of nodule" topical antibiotics

%he correct ans er is +. %his patient should be treated for a likely stye" an acute infection involving hair follicles or associated glands of Meis or <oll. Hot compresses and topical antibiotics are the usual treatment for a stye" hich is more likely to be infectious than an upperlid chala;ion 3a nontender chronic granulomatous inflammation of a meibomian gland4. ,t is concerning" ho ever" that this patient has had multiple nodules that have never resolved fully. A persistent or recurring lid mass arrants biopsy to rule out the rare eyelid tumor. As such" this

patient should be treated for a stye and scheduled for an eyelid biopsy" though this does not need to be done emergently 3choice A4. Hot compresses 3choice /4 can help reduce pain and speed drainage. 9iven the frank pus" ho ever" topical antibiotics also should be added. Hot compresses and topical antibiotics 3choice .4 are probably ade=uate for this patient5s acute event. %he recurrent nature of her styes" ho ever" and her description of a mass that never resolved fully" arrants biopsy. ,ncision and drainage of a stye or chala;ion 3choice #4" combined ith topical antibiotics" is a treatment reserved for lesions that have been present several eeks. ,f this lesion does not resolve ith more conservative therapy" then incision and drainage is appropriate.

A 2B-year-old man comes to the emergency department complaining of pain" tearing" blurred vision" and sensitivity to light in his left eye. He is an industrial machine parts orker and thinks that earlier in the day a piece of metal fle into his eye hile he as grinding a large bolt. /efore this event" he has had no visual problems. #$amination of his eye reveals moderate con2unctival hyperemia and a distorted pupillary margin. %he pupil seems peaked and pointing to ard the inferior-medial aspect of the eye" at hich point there is a small" dark" slightly elevated body. %he patient has seen this body in the mirror and believes this may be a piece of metal from the bolt. %he rest of the physical e$amination is normal. Ahich of the follo ing is the most appropriate first step in the management-

A. Application of a pressure patch

/. #version and e$amination of the lids

.. 1lacement of a protective eye shield

+. ?emoval of the suspected foreign body

#. !tat .% scan to identify foreign body

%he correct ans er is .. %his patient has a penetrating ocular in2ury. %he body at the point of the distorted pupil is likely prolapsed iris. %his is an urgent situation and re=uires immediate intervention. %he first concern is to protect the eye from further damage or manipulation" hich can increase prolapse. An eye shield is shaped so that it is supported by the rim of the orbit" rather than by placing pressure on the eye itself. ,f an eye shield is not available" a trimmed do n !tyrofoam cup can perform the same 2ob. Applying pressure to the eye can further e$trude the prolapsed iris. >nderstandably" pressure patches 3choice A4 and eyelid manipulation or eversion 3choice /4 should be avoided initially. ,n this case" the suspected foreign body is likely prolapsed iris. ?emoval of this suspected foreign body 3choice +4 ould only cause further damage. A tear-drop shaped pupil" a pointed pupil ith a raised mass at the tip" or any pupil ith markedly distorted margins is a givea ay description of a penetrating ocular in2ury. A .% scan 3choice #4 ould be helpful in the near-term management of this patient" as it is a good method to e$amine the orbits and eyes for retained foreign bodies. /efore sending this patient to the .% scanner" ho ever" a protective eye shield needs to be placed to limit further in2ury.

A 72-year-old black man is visiting his optometrist to obtain a prescription for reading glasses. A routine funduscopic e$amination is performed that sho s cupping of the disks. %he cup-to-disk ratio is 0.7 on the left eye and 0.C on the right eye. %he intraocular pressure by applanation tonometry is read as D@ mm Hg in the left eye and 20 mm Hg in the right eye. *ther than the need for reading glasses" the patient does not complain of any visual symptoms. He comes to your office and hands you a report ith these findings. After e$amining him and confirming these finding" hich of the follo ing is the most appropriate ne$t step in management-

A. Administer osmotic diuretic agents


<ap visual fields

.. *rder a .% scan of the brain

+. *rder a glucose tolerance test

#. ?eevaluate in D year

%he correct ans er is /. %his man has glaucoma" even though his pressure readings are borderline. Ahen properly studied" he ill be found to have e$tensive visual field defects" hich patients are often una are of. %hat finding ill confirm the diagnosis and lead to appropriate treatment. *smotic diuretic agents 3choice A4 are used only for acute angle closure glaucoma. %his man does not have that acute problem. .upping is not a sign of brain tumor" thus a .% scan of the brain 3choice .4 ould not be helpful. 1apilledema and a history of severe headaches ould have been good indications for the study. .upping is not a sign of diabetic retinopathy either. 1ursuing that line of investigation 3choice +4 ould be fruitless. ?eevaluation 3choice #4 ithout treatment ould allo continued deterioration of the patient5s vision.

A 7C-year-old obese oman is found at a health fair screening to have type 2 diabetes mellitus. Her random blood sugar determination is )70 mg(d:. !ubse=uent tests sho fasting levels bet een 2D0 and 2B0 mg(d:" and her glycosylated hemoglobin 3Hb A D.4 level as D2N. *phthalmologic evaluation sho s proliferative diabetic retinopathy" ith neovasculari;ation" microaneurysms" and macular edema. Ahich of the follo ing is the most appropriate management

of these ophthalmologic complications-

A. .ontrol of blood-sugar levels

/. .ryotherapy

.. :aser photocoagulation

+. 'itreous surgery

%he correct ans er is .. %he advent of laser photocoagulation has provided an effective eapon to reduce the risk of severe visual loss in diabetic retinopathy. %he e$act mechanism of action is unkno n" but laser treatments induce regression of proliferative diabetic retinopathy and reduce or eliminate the macular edema. .ontrolling blood-sugar levels 3choice A4 is key for the prevention of diabetic complications" but it cannot reverse e$isting retinal damage. .ryotherapy 3choice /4 is an option" along ith laser treatments" for the management of retinal detachments. 'itreous surgery 3choice +4 is used in diabetic retinopathy hen there is vitreous hemorrhage or retinal detachment.

A B@-year-old nurse comes to the clinic complaining of a painful" red eye. *ver the last fe days" he has developed blurred vision and increasing pain in his left eye" particularly hen looking at

lights. %he pain has progressed to the point that he has difficulty keeping his eye open. His eye feels itchy and burns. He cannot think of any precipitating events or episodes in hich he may have gotten a foreign body in his eye" though he does note that he orks as an intensive care nurse" taking care of many critically ill patients. /efore these last fe days" he has been feeling ell. #$amination of his left eye reveals obvious chemosis" eyelid tearing" and edema of the eyelids. %here is moderate con2unctival in2ection. %he cornea appears mildly ha;y" but pupillary e$amination and funduscopic e$amination" ith the e$ception of marked photophobia" are normal. A slit-lamp e$amination ith fluorescein dye reveals dye uptake in multiple branching patterns in the left eye. %he right eye is normal. 'isual acuity is 20(28 *+ and 20(D00 *!. Ahich of the follo ing is the most appropriate management-

A. Admission to hospital for intravenous acyclovir and fre=uent ocular e$aminations

/. Application of corticosteroid eye drops" ith close ophthalmologic consultation

.. .ycloplegic eye drops and topical antibiotics" ith close follo up

+. Hot compresses and topical antibiotic ointment" return to the clinic in D eek

#. %opical antiviral nucleoside treatment" ith ophthalmologic consultation

%he correct ans er is #. %his patient has herpetic keratitis" a herpes simple$ virus-D 3H!'-D4 infection of the cornea. %he hallmark of this disease" the most common cause of blindness orld ide 3and also more fre=uent in hospital orkers and immunocompromised patients4" is an irregular" dendritic lesion of the corneal epithelium seen on slit-lamp e$amination. %reatment involves topical nucleoside antivirals" such as trifluorothymidine eye drops" vidarabine ointment" or acyclovir or ganciclovir gels. >ntreated" this condition can cause corneal ulceration and scarring. %his is a topical infection of the cornea" and re=uires topical treatment. ,ntravenous acyclovir 3choice A4 is not appropriate. .orticosteroid eye drops 3choice /4 are absolutely contraindicated. %hey orsen the infection and increase the risk for corneal ulceration. .orticosteroid eye drops" in general" should never be used ithout ophthalmologic recommendation" partly because of concern for undiagnosed H!'-D infection. .ycloplegics and topical antibiotics 3choice .4 are appropriate treatments for a corneal abrasion. .orneal abrasions are seen as discrete" linear areas of dye uptake. A branched 3dendritic4 pattern can be seen in corneal abrasions but are more consistent ith infection" particularly herpetic. Hot compresses and topical antibiotics 3choice +4 can be used to treat primary eyelid disease" such as hordeolums 3styes4 or chala;ions" but ill not help ith primary ocular disease" as indicated by the findings on slit-lamp e$amination.