A patient with tunnel vision

AChoroidal melanoma
BCytomegalovirus retinitis
CDiabetic retinopathy
DGlaucoma
EHypertensive retinopathy
FLaser photocoagulation scars
GLipaemic retina
HMacular degeneration
IPre-retinal haemorrhage
JPapilloedema
KRetinal artery occlusion
LRetinal detachment
MRetinal vein occlusion
NRetinitis Pigmentosa
Choose the correct option

This is the retina of a 70-year-old man

with tunnel vision. What is the
diagnosis?

Correct
There are clumps of pigmentation in the
retina in a pattern of 'bone spicules'
typical of retinitis pigmentosa.

Eye examination
AColour vision
BCorneal reflex
CEye movements
DOcular tonometry
EOphthalmoscopic examination
FPupil reaction to light
GPupil reaction to accommodation
HSchirmers test
ISlit lamp examination
JVisual acuity
KVisual field assessment
Select one of the above examinations
that would be most likely to reveal an
abnormality in the following cases:
A 52-year-old female presents with a 2
month history of giddiness. Examination
reveals a nystagmus to both extremes of
gaze and a tendency to fall to the right.
She has deafness of the right ear.

Correct
The presence of nystagmus with
deafness would suggest the presence of
an acoustic neuroma and hence loss of
the corneal reflex may be present.

A 63-year-old female presents with

grittiness of the eyes. She has a 10 year
history of rheumatoid arthritis for which
she has taken disease modifying agents.
She also complains of a dry mouth.

Correct
The second case with rheumatoid and
dry eyes, dry mouth suggest Sjogrens
syndrome which could be confirmed
with a Schirmers test.

An 18-year-old male presents with poor

sexual development. He is noted to have
poorly developed secondary sexual
characteristics and has an absent sense of
smell. Results of investigations reveal a
low testosterone concentration with low
LH and FSH.

Correct
The diagnosis in the third case is
Kallmanns syndrome with
hypogonadotrophic hypogonadism and
anosmia. Colour blindness is often
associated.

A 73-year-old female presents acutely

with nausea, vomiting and giddiness. She
has recently been treated for heart failure
with atrial fibrillation and receives
Digoxin, furosemide and Ramipril.

Correct
The fourth case has digoxin toxicity and
colour blindness is again a noted effect.

A 46-year-old female complains of

headaches, galactorrhoea and
amenorrhoea of 9 months duration.
Examination reveals galactorrhoea to
expression and a pregnancy test is
negative.

Correct

The fifth case has a prolactinoma and

visual fields should be carefully
examined to assess for chiasmal
compression.
Visual problems
AAnalgesics alone
BB complex vitamins
CCorticosteroids
DPan retinal photo coagulation
EPeripheral Iridectomy
FPhysiotherapy
GPilocarpine eyedrops
HPressure over eyeball
IScleral buckling
JSpectacles
KSurgery to retina
Select the most appropriate treatment for
the clinical scenarios:
A 38-year-old female presents with
sudden loss of vision but fundoscopy is
normal. She had a similar episode about
1 year back, which resolved completely
within 3 months. On examination, she
has mild weakness of right upper limb
and the reflexes are exaggerated.

Incorrect - The correct answer is

Corticosteroids

A 54-year-old male with myopia

develops flashes of light, floaters
preceding loss of vision.

Incorrect - The correct answer is

Surgery to retina
These symptoms of floaters and falshes
of light preceding visual loss suggest

retinal detachment. Surgical treatment is

often required.

A 65-year-old female presents with head

ache and loss of vision. Her ESR is
markedly elevated

Correct

A 55-year-old male hypertensive

suddenly lost his vision. The retina is
pale and the fovea appears as a bright
cherry red spot.

Correct
This is central retinal artery occlusion
and occassionally, pressure over the
eyeball or aspiration of vitreous may be
effective in dislodging the clot.

A 55-year-old man presents with mild

headache. He has changed his spectacles
thrice in one year. There is mild cupping
present in the disc and sickle shaped
scotoma present in both eyes

Incorrect - The correct answer is

Pilocarpine eyedrops
Pilocarpine, a drug that promotes
pupillary constriction, miotic, is a
treatment for glaucoma.

Periodic visual loss in a young female

suggests relapsing and remitting multiple
sclerosis presenting as optic neuritis. Of
patients with multiple sclerosis, 15-20%
initially present with an episode of optic
neuritis, and approximately 70% have an
optic neuritis episode at some point
during the illness. Flashes of light and
sudden loss of vision suggests retinal
detachment which is more common in
myopic patients. There is usually no pain
associated with retinal detachment.
Extremely nearsighted (myopic) subjects
have longer eyeballs with thinner retinas
that are more prone to detaching. Scleral
buckling bends the wall of the eye to
meet the hole in the retina.
The third patient presents with Giant cell
arteritis (GCA), and should be treated
with high dose steroids. When GCA
involves the arteries that supply blood to
the eyes, blindness in one or both eyes
may develop suddenly. Strokes may
rarely occur. Some of the more common
symptoms in GCA include headaches,
pain in the jaw or tongue muscles when
eating or talking, and tenderness of the
scalp over the temples. GCA and
Polymyalgia Rheumatica (PMR) seem to
be related, as they often occur together.
Over 10 percent of people with PMR
also have GCA; approximately 50
percent of people with GCA also have
PMR.
The fourth patient is older and has
hypertension, and sudden loss of vision
with a pale disc and a cherry red spot
suggests central retinal artery occlusion.
photo. In chronic simple glaucoma a
sickle-shaped scotoma called Seidels
sign may be seen as a significant field
defect. Pilocarpine 1 - 4% is a direct
cholinergic agonist which will cause
miosis and accommodative spasm. It is
used to reverse the action of mydriatics
but its greatest therapeutic use is in
lowering ocular pressure in both acute
and chronic glaucoma by acting through

the ciliary muscle to increase aqueous

outflow. Pilocarpine may cause
parasympathetic actions eg. salivation,
sweating, hypertension, tachycardia,
diarrhoea and vomiting, and pulmonary
oedema. Ciliary spasm may cause
browache which may be more severe in
he initial 2-4 weeks of treatment

tDiplopia
AAbducent nerve palsy
BAstigmatism
CCavernous Sinus Syndrome
DGuillian-Barre Syndrome
EMitochondrial myopathy
FMotor neurone disease
GMyasthenia Gravis
HOculomotor nerve palsy
IThyrotoxicosis
JTrochlear nerve palsy
For each of the clinical conditions
described below, choose the most
appropriate diagnosis from the above list
of options. Each option may be used
once or not at all.
A 35-year lady was complaining of
double vision over the last few weeks. It
is on and off and she has particularly
noted that it is worse in the evening.
During that time she also feels weak in
her limbs and goes to bed. She feels well
the following morning. Clinical
examination was normal.

Correct
This has a classical history of symptoms
getting worse by the end of the day (due
to fatigability). Associated symptoms
include weakness, dysphagia and
breathlessness. Clinical examination can

be normal when they don't have any

symptoms. Tensilon test clinches the
diagnosis (Administration of intravenous
edrophonium rapidly reverses the
symptoms).

A 65-year-old diabetic man suddenly

developed pain in his right eye and
double vision. On examination he had
ptosis on the right eye which was
pointing down and out.

Correct
Oculomotor nerve (III rd nerve) palsy.
Presence of ptosis and down and out
deviation of the eye (due to the
unopposed action of lateral rectus and
superior oblique) is the hallmark of third
nerve lesion. Presence of pain indicates
infarction of the nerve, which occurs in
diabetics.

A 76-year-old man was complaining of

double vision over the four weeks. He
was also slightly unsteady on his feet. He
was on warfarin for AF, and had a fall
about a month ago. On examination he
was unable to abduct the right eye and
had diplopia on lateral gaze.

Correct
Unable to abduct the eye and diplopia on
the horizontal gaze is typical of sixth
nerve palsy (due to the paralysis of
lateral rectus). Sixth nerve has the
longest intracranial course and so the
first one to be involved in any condition
leading to raised intracranial tension.
This patient probably has a subdural

haematoma, which also leads to unsteady

gait.

A 45-year-old diabetic was complaining

of pain in the left eye and double vision
gradually worsening over a week. On
examination, his left eye was bulging out
of the orbit. He had ptosis, prominent
scleral vessels and ophthalmoplegia.

Correct
The sings of ophthalmoplegia, pain,
proptosis and prominent vessels is
typical of this syndrome.
ophthalmoplegia is due to the
involvement of third, fourth and sixth
nerve cranial nerve in the cavernous
sinus. Pathologies include thrombosis,
infiltrative lesions (in
immunocompromised patients) and
carotid artery aneurysm (which can
cause pulsatile proptosis).

A 60-year-old man was complaining of

double vision and difficulty in walking
over the last three days. On examination
he had weakness (power 4/5), absent
deep tendon reflexes and bilateral
ophthalmoplegia.

Correct
Sudden onset weakness and absent
tendon reflexes are classical of this
syndrome. Ophthalmoplegia occurs in
the Miller-Fisher variant of this disease
(also includes ataxia).

Astigmatism - Typically causes monoocular diplopia due to refractory error.

Mitochondrial myopathy - A rare group
syndromes due to abnormal
mitochondria. Causes progressive ptosis,
external ophthalmoplegia and proximal
muscle weakness.
Motor neurone disease - Various
syndromes of upper and lower motor
neurone signs.
Thyrotoxicosis - Also called Grave's
disease. Exophthalmos and
ophthalmoplegia leads to diplopia.
Trochlear nerve palsy - Fourth cranial
nerve palsy rarely occurs alone.
Diplopia...
. Eye Investigations
ACarotid angiography
BCarotid doppler
CCT head
DErythrocyte Sedimentation Rate
EFluorescein angiography
FMRI
Select the most appropriate investigation
from the list above for the following
patients:

A 73-year-old female presents with

monocular visual loss in the left eye,
headache, associated with shoulder
muscle weakness and tenderness.

Incorrect - The correct answer is

Erythrocyte Sedimentation Rate
The first patient displays symptoms and
signs of temporal arteritis.

A 57-year-old male with a history of

hypertension presents with a two month
hiatory of episodic visual loss in the right
eye which resolves over brief but
variable periods.

Correct
Amaurosis fugax is ideally investigated
with carotid dopplers as the initial
investigation. Other investigations to be
considered would include ECG (atrial
fibrillation) and possible ECHO to
elucidate any source of embolism.
Thrombus development occurs via
cholesterol deposition and atheroma
formation within vessel lumens. Patients
experiencing uncomplicated AF have an
85 percent likelihood of full recovery
while 10 to 15 percent will eventually
develop a central retinal artery occlusion.

A 24-year-old female presents with

deteriorating vision. Clinical
examination reveals a right upper
quadrant hemianopia.

Incorrect - The correct answer is

MRI
A quadrantopia suggests a lesion in the
temporal or parietal lobe affecting the
optic radiation.

A 51-year-old male being investigated

for hypertension is found to display
overbiting, prognathism, excessive
sweating, mild diabetes and bitemporal
hemianopia.

Correct
Bitemporal hemianopia with the
associated findings suggests Acromegaly,
which may be confirmed by MRI of the
pituitary. Compression of the optic
chiasm by the pituitary causes the typical
bitemporal hemianopia.

An 18-year-old female with a 10 year

history of type 1 diabetes and an HbA1c
of 14% presents with gradual visual
deterioration over the previous 2 years.
Fundal ophthalmoscopic examination
reveals occassional dot haemorrhages but
nil else.

Correct
Diabetic retinopathy and retinal vascular
occlusive disease affect primarily the
retinal circulation and are usually imaged
with fluorescein dye. Macular oedema as
is suggested by the absence of any
obvious sight threatening new vessels,
exudates or haemorrhages, is often not
seen on direct ophthalmoscopy but is
best detected with fluorescein
angiography.

Description of different types of visual

defects...
Ophthalmological diagnosis
ABehcets disease
BCavernous sinus thrombosis
CGraves disease
DGlaucoma
EMultiple Sclerosis
FOphthalmic herpes zoster
GPancoast tumour
HReiters syndrome
ISjogrens syndrome

JSyphilis
KWegeners granulomatosis
Select one of the above diagnoses for
each of the following cases:
A 72-year-old female presents with
severe pain in the face and right eye.
Examination reveals a temperature of
36.7C and two small red eruptions on
the right lower forehead which are
exquisitely tender.

Correct
The presence of severe forehead and eye
pain with few features suggest herpes
zoster in the ophthalmic division of the
trigeminal nerve.

A 27-year-old female presents with gritty

eyes. Examination reveals that she has a
tremor of the outstretched hands, a pulse
of 110 beats per minute and has redness
and swelling of the conjunctiva.

Incorrect - The correct answer is

Graves disease
The salient features are tremor of
outstretched hands and the chemosis of
eyes suggesting thyrotoxic Graves'
disease with ophthalmopathy.

A 62-year-old male presents with a

weight loss. Examination reveals a thin
individual with clubbing of the fingers, a
slight drooping of the left eyelid and a
smaller pupil on the left compared with
the right.

Correct
This patient has a bronchogenic
carcinoma - clubbing, weight loss and
has a Horners syndrome and is therefore
likely to have a Pancoasts tumour

A 24-year-old male presents acutely with

pain in the left eye. Examination reveals
a temperature of 39C, redness and
swelling of a completely closed left eye.
On raising the eye ocular movements are
universally impaired.

Correct
This patient has a fever with orbital
cellulitis. The loss of eye movements
suggest a cavernous sinus thrombosis.

A 50-year-old male presents with general

lethargy, weight loss, eye discomfort and
nasal stuffiness. Examination reveals a
pulse of 70 beats per minute, mild
proptosis of the left eye with diplopia on
left lateral gaze and a tenderness over the
nasal bridge.

Correct
This case has typical features of with the
nasal involvement and retro-orbital
granulomas frequently produce
proptosis.

Question 7 of 15
Score: 81%

Theme:Acute painful eye conditions

AAcute angle closure glaucoma
BAcute dacrocystitis
CAnterior uveitis
DBlepharitis
EConjunctivitis
FCorneal ulceration
GEpiscleritis
HScleritis
IUlcerative keratitis
For each of the following clinical
scenarios select the SINGLE most likely
diagnosis from the option list:
A 56-year-old woman presents to the GP
with severe pain in her left eye. She is a
known sufferer of rheumatoid arthritis.
External examination of the eye reveals a
tender, erythematous eye with purplishred engorged vessels. The patient also
complains of photophobia.

Incorrect - The correct answer is

Scleritis
This lady is suffering with Scleritis
which can be either anterior or posterior
in origin although the latter is much less
common and associated with more visual
disturbance. The sclera is the tissue that
provides the tough protective layer
around the eye and is composed of
collagen and elastic and is normally
white in appearance. However it can
become inflamed and this is often
associated with systemic/connective
tissue disorders as is the case with this
woman. This condition always requires
referral to a specialist and will often need
to be treated with oral corticosteroids or
immunosuppressives.

A 36-year-old woman presents with an

acute onset of severe right eye pain. She

also comments that her vision has

become blurred and that she finds it very
difficult to look at bright lights. External
examination of the eye reveals
circumcorneal redness and a small pupil.
Talbots test is noted to be positive.

Correct
This woman is suffering with anterior
uveitis. The uvea is the pigmented part of
the eye including the iris, ciliary body
and choroids. This again is a condition
that is often associated with systemic
disease and it is therefore worthwhile
looking for relevant conditions in the
history e.g. Ankylosing Spondylitis.
Talbots test is positive when pain
increases as the eyes converge i.e. as
patients watch their finger approach their
nose. A slit lamp would reveal white
deposits on the back of the cornea and
cells in the anterior chamber. Referral to
an ophthalmologist is always necessary
and it is often treated with steroids.

A 59-year-old man presents with a

painful left eye, he also claims to have
vomited since the pain began twice. Prior
to the pain the patient describes that his
vision had become a bit blurry and that
he could see haloes around lights.
External examination reveals corneal
oedema and a fixed dilated pupil.

Incorrect - The correct answer is

Acute angle closure glaucoma
This describes a typical presentation of
acute angle closure glaucoma which is
caused by blockage of drainage of the
aqueous from the anterior chamber via
the canal of schlemm. Dilation of the

pupil at night exacerbates drainage

block. Intraocular pressure then rises
from the normal 15-20mmHg to 60 or
70mmHg. Treatment is with Pilocarpine
drops hourly because miosis opens the
blocked, 'closed' drainage triangle and
Acetazolamide which reduces the
formation of the aqueous humour.

A 22-year-old man presents with a

painful left eye. He has worn contact
lenses for the past 5 years and admits to
occasionally wearing them for prolonged
periods of time. He describes blurred
vision and photophobia. External eye
examination reveals a very red eye
swollen eye that feels warm on
palpation. Flourescein drops
demonstrates a small patch of green
staining.

Incorrect - The correct answer is

Ulcerative keratitis
Due to the fact that in this case the eye is
very red swollen and warm to touch it is
likely that this case has become infected
and therefore ulcerative keratitis is the
most likely diagnosis. It is the infection
here that differentiates this case from
simple corneal ulceration which is often
associated with contact lense wearers. It
is a breach of the epithelium and can
sometimes occur without keratitis in
which case treatment with prophylactic
antibiotic ointment may be used (e.g.
chloramphenicol). Again it is important
here to refer to a specialist as it is
possible that scarring and visual loss can
occur.

A 50-year-old man attends casualty

complaining of deteriorating vision.

Exposure to which of the following

drugs is unlikely to be relevant?
(Please select 1 option)

Ethambutol
Vincristine
Quinine
Irinotecan Correct
Chloroquine
Chloroquine (classically the Bulls eye
retinopathy) and quinine cause visual
disturbance. Ethambutol may lead to loss
of visual acuity, colour blindness, and
restriction of visual fields. Irinotecan is a
Topoisomerase I inhibitor used in
colorectal cancer. Vincristine may cause
a toxic optic neuropathy.
A 61-year-old security guard has had
type 2 diabetes for 10 years. He is seen at
the diabetic follow up clinic yearly. He
has his fundi examined at these visits.
Which of the following features would
require urgent referral to an
opthalmologist?
(Please select 1 option)

Hard exudates
Microaneurysms
Blot haemorrhages
Cotton wool spots Correct
Dot Haemorrhages
Background Retinopathy
microaneurysms, dot and blot
haemorrhages, hard exudates
Maculopathy hard exudates or oedema
in the region of the fundus Proliferative
cotton wool spots, venous beading and
loops, arterial sheathing, flame-shaped
haemorrhages, neovascularisation.
Maculopthy, Neovascularisation and
pre-proliferative retinopathy requires
urgent ophthalmological assessment for
early signs of proliferative retinopathy.
Proliferative retinopathy should be

treated with laser therapy to preserve

sight.