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Opthalmology

1. A 22-year-old female presents with an eight weeks history of headaches, which have deteriorated over the last week. She is aware of a frontal headache, which is constant in nature and unrelieved by paracetamol. hese headaches have tended to be present when she wakes in the morning and lately have been present all day. Over the last si! months she also e!plains that she has gained more than " kg in weight. On e!amination, she is rather tearful, has a #$% of &2 kg'm2 but has no nuchal rigidity and neurological e!amination is normal e!cept for bilateral optic disc swelling on fundal e!amination. (er blood pressure is noted to be 122')) mm(g and her temperature is &"o*. +hich of the following is the single best investigation for this patient, -.lease select 1 option/

0umbar puncture $1% brain Correct * brain 223 4luorescin angiogram
he history suggests #%(. (owever, brain imaging is needed to e!clude a space occupying lesion, hydrocephalus and cerebral venous thrombosis. $1% brain is better than * brain to look for cerebral venous thrombosis where a 5pyramidal6 defect in venous flow is noted.

2. he patient, whose fundus is shown, is likely to demonstrate which of the following physical signs,
click and drag to move the ophthalmoscope

-.lease select 1 option/

absent red refle! nystagmus Correct

ptosis rubeosis iridis !anthelasma
his is an albino fundus - there is no retinal pigmentation and all the blood vessels can be clearly seen. 7ystagmus and photophobia are common findings in albinos.

&. hese are ophthalmoscopic appearances of a 82-year-old male who has recently been diagnosed with diabetes mellitus. (e has been referred by his optician after noting the visual acuity in his left eye is 8'&8 and 8'12 in his right. here is no correction with pin hole. +hat is the likely cause of his fundal appearance, -.lease select 1 option/

3laucoma Correct (ypertensive retinopathy $acular degeneration .roliferative diabetic retinopathy 1etinitis pigmentosa
his patient has optic atrophy as revealed by a particularly pale disc. *auses include 3laucoma, e!ternal compression of the optic nerves eg pituitary tumour and $ultiple sclerosis.

9. his "9-year-old man presents with poor vision.
click and drag to move the ophthalmoscope

+hat is the diagnosis, -.lease select 1 option/

diabetic retinopathy

.glaucoma hypertensive retinopathy macular degeneration Correct pan-retinal photocoagulation he fundus shows small pale dots over the macular area typical of :rusen. +ith what diseases is this appearance associated. .. his is macular degneration and one of the commonest causes of blindness.

aget<s disease of bone Correct Ac=uired %mmune :eficiency Syndrome 1etinitis pigmentosa *ytomegalovirus infection .-.seudo!anthoma elasticum Correct *hronic lymphocytic leukaemia (ypertriglyceridaemia .lease select & options/ Acromegaly Correct .oorly controlled diabetes mellitus .

sickle cell disease. hese are the ophthalmoscopic appearances of a "9-year-old female who presents with a long history of deterioration in her vision..-18 mm (g with a standard deviation of >'. year-old woman with sickle cell disease was admitted to hospital with abdominal pain. he upper limit of normal is considered to be 21 mm (g. 8. he mean value for intraocular pressure is 1.lease select 1 option/ 3laucoma Correct $acular degeneration Optic atrophy . his appearance was noted on fundoscopy. 2hlers-:anlos syndrome. Angioid streaks may be associated with pseudo!anthoma elasticum.aget<s disease. and . Almost invariably there is an increase in pressure which is sufficient to cause damage to the optic nerve head and causes changes in the visual field. Acromegaly -and other pituitary disorders/. (er vision is 8'&8 in both eyes and uncorrected with a pinhole.apilloedema 1etinitis pigmentosa his fundus shows cupping of the optic disc which is typical of glaucoma. A &. -.*losed angle glaucoma he slide shows angioid streaks.. ". +hat is the most likely diagnosis. caused by breaks in #ruch<s membrane. .2.

lease select 1 option/ #ranch retinal artery occlusion Angioid streaks Correct . caused by breaks in #ruch<s membrane.+hat is the diagnosis. . -.apilloedema *entral retinal vein occlusion 0ipaemia reinalis he slide shows angioid streaks.

ype 1 disease is the commonest.henylketonuria +ilson<s disease he slide shows yellow papules -pingeculae/ in the cornea? these are characteristic of 3aucher disease. &. ype 2 -infentile 3aucher disease/ carries the worst prognosis.or old-age. ype 1 -chronic non-neuropathic? adult 3aucher disease/ ype 2 -acute neuropathic? infentile 3aucher disease/ ype & -subacute neuropathic? Buvenile 3aucher disease/ . :isease is caused by a deficiency of the en@yme glucocerbrosidase. . +hat is the diagnosis. especially around the forehead. but not uncommonly in middle. .lease select 1 option/ 4amilial hypercholesterolaemia 3aucher disease Correct Sarcoidosis . his 92-year-old lady has a history of repeated bone fractures. 2. usually presenting in childhood with hepatosplenomegaly.atients with all types of disease have hepatosplenomegaly and large glucocerebrosiderich cells -3aucher cells/ infiltrating the bone marrow. -. #one marrow replacement and hypersplenism result in anaemia and thrombocytopoenia. with formation of characteristic <2rlenmeyer flask< shaped cysts. here are three types of 3aucher diseaseA 1. he skin may show a grey-brown discolouration. 3aucher disease is inherited as an autosomal recessive disease. hands and pre-tibial regions.athological bone fractures and avascular necrosis of the femoral heads are not uncommon. #ony disease may be confined to the distal ends of the femurs.). with children seldom surviving beyond 2 years. essentail for the metabolism of glycolipids. *haracteristic yellow or yellow-brown papules -pingeculae/ develop at the sclerocorneal Bunctions.

+hat would be the most appropriate treatment. hese headaches have tended to be present when she wakes in the morning and lately have been present all day. %f less than that aspirin and control of vascular risk factors is the treatment of choice. (er blood pressure is noted to be 122')) mm(g and her temperature is &"o*. she is rather tearful. A "8-year-old male presents with visual loss. has a #$% of &2 kg'm2 but has no nuchal rigidity and neurological e!amination is normal e!cept for bilateral optic disc swelling on fundal e!amination. 2!amination reveals a blood pressure of 18)'1D2 mm(g and fundoscopy shows an embolus to right superior temporal branch of the retinal artery. An $1% scan of her brain is normal and 0. which have deteriorated over the last week. +hat treatment would you offer this patient if her vision were threatened.C. which is constant in nature and unrelieved by paracetamol.lease select 1 option/ %F de!amethasone Aceta@olamide 0umbo-peritoneal shunt Correct . 1D. %n this case hypertensive control is advised. -. but CDE 1ight 2!ternal *arotid Artery stenosis with appro!imately . Over the last si! months she also e!plains that she has gained more than " kg in weight.lease select 1 option/ Aspirin Correct :ipyridamole 1ight 2!ternal *arotid Artery endarterectomy 1ight %nternal *arotid Artery endarterectomy +arfarin 2ndarterectomy is only beneficial if internal carotid artery stenosis is greater than "DE. She is aware of a frontal headache. On e!amination.DE 1ight %nternal *arotid Artery stenosis. A 29-year-old female presents with an eight weeks history of headaches. *arotid dopplers are arranged and these show normal left sided carotids. -. reveals an opening pressure of &D cm (2O but normal *S4 analysis.

D/ TSH ID.D/ TSH 2) mG'0 . Grgent 0.9-8. 11.-12/ -D.9-8.D9 mG'0 hyroid function in AJ2 showsA T4 2 Hg'd0 -.%F mannitol 4urosemide Fisual loss is the single threatening complication of #%(. hyroid function four weeks ago showedA T4 CC Hg'd0 -. shunt is the treatment of choice Optic nerve fenestration is an alternative.-12/ -D. here are no comparative studies between the two interventions. She had been under review in the endocrinology clinic and had been started on some new treatment four weeks previously. A 89-year-old lady presented to the Accident and 2mergency Gnit with orbital pain and swelling -shown below/.

ropranolol . -. +here sight is threatened. orbital decompression may be necessary. reatment for malignant e!ophthalmos is rapid administration of steroids.+hat treatment has she received. . 1adioiodine therapy can worsen thyroid-associated ophthalmopathy patients with thyroid eye disease are generally treated with steroids for 1-2 weeks prior to starting radioiodine therapy.ropylthiouracil 1adioiodine Correct he slide shows malignant e!ophthalmosA malignant refers to the rapidity of onset and threat to eyesight rather than association with malignancy.lease select 1 option/ *arbima@ole .rednisolone .

A &. he rest of the cranial nerves appeared normal . but *$F is disseminated at this stage of A%:S and the implant does not address systemic infection. (e is not curently taking antiretroviral therapy. Available forms of ganciclovir include intravenous and oral preparations as well as an ocular implant. %nitiation of (AA1 has been shown to worsen active *$F eye disease and should be witheld until *$F is in remission."o*. She had been reading at the time and suddenly noticed that she could not see the print. pulse was )C'min and irregular and temperature was &8. She denied any headache preceding the symptoms and had not noticed any weakness in her arms or legs.'). 1&. She was a smoker of 2D cigarettes per day and did not drink any alcohol. On e!amination she was an!ious and distressed. mm(g. Fisual field analysis revealed a defect in the right inferior nasal field. On auscultation of the heart there was a mitral regurgitation murmur. +hat is the most appropriate therapy to initiate. A recent *:9 count was measured at 2D cells'mm&.yrimethamine > sulfadia@ine are used to treat to!oplams retinitis? @idovudine > lamivudine > nelfinavir constitutes highly active antiretrovral -<combination</ therapy -(AA1 / for (%F disease. A 82-year-old woman presented acutely to *asualty :epartment with sudden visual loss of the right eye. On e!amination of the eyes the pupils were e=ual and reactive to light and ocular movements were full. (er blood pressure was 19. -. . he principal disadvantages of the latter two areA the poor bioavailability of the oral preparation? the implant is effective at clearing ocular disease. She had a past medical history of hypertension and took regular atenolol. year-old man with (%F disease presents with sudden loss of vision in his right eye. %ntravenous ganciclovir is currently the treatment of choice.lease select 1 option/ (igh-dose intravenous aciclovir %ntravenous ganciclovir Correct Kidovudine > lamivudine > nevirapine Sulfadia@ine > pyrimethamine Amphotericin # > flucytosine he slide shows the typical <cottage cheese and tomato ketchup< or <pi@@a< appearance of *$F retinitis in a patient with (%F disease.12.

-. which would e!plain the clinical findings..D L 9DD ! 1DC'0/ -D L &D mm'1st hour/ -1&" L 199 mmol'0/ -&.8 mmol'0 8. %G'0/ -I . 4undoscopy shows an embolus to the right superior temporal branch of the retinal artery.. ! 1DC'0 &D mm'1st hour 1&9 mmol'0 9.and no abnormalities could be found in the peripheral nervous system. mmol'0/ 8D L 11D umol'0/ -I... his places the lesion from the retina to the optic tract.8 mmol'0 -1&.& g'dl "." mmol'0 12D umol'0 ). emporal arteritis presents with a history of a curtain descending over the eye and.D L 1). L ".2 mmol'0/ Serum C-reactive protein C %G'0 he electrocardiogram showed atrial fibrillation with a ventricular rate of )) beats per minute. L 9. %nvestigations revealedA Haemoglobin White cell count Platelets ESR (Westergren) Serum sodium Serum potassium Serum urea Serum creatinine Serum cholesterol 12. he appearance of the retina on fundoscopy is shown belowA +hat is the most likely diagnosis in this patient.arietal lobe infarct emporal arteritis his patient presents with a monocular visual disturbance.lease select 1 option/ *holesterol embolus of the retinal artery Correct 4actitious disorder %nfective endocarditis . She had bilateral non-tender pulsatile temporal arteries. She has a very specific visual disturbance affecting the inferior nasal portion of the right visual field.) ! 1DC'0 &9.D g'd0/ -9 L 11 ! 1DC'0/ -1.C mmol'0/ -2. given a normal .

(e had a history of migraines and had also recently attended his 3.-9.9 g'd0 -1&.2 mmol'0/ A lumbar puncture was performed and yielded the following dataA !pening pressure 19 cm(2O -8-1) cm (2O/ CS protein D. here were no carotid bruits.D !1DC'0 -9-11 !1DC'0/ Platelets 2). mmol'0 -2. this diagnosis is unlikely..&.C mmol'0/ Serum urea 9." mmol'0 -I . !1DC'0 -1. 19. g'0/ CS "hite cell count 9 cells per m0 -I. pulse was )) beats per minute and irregular and temperature was &8.. mmol'0/ Serum creatinine )) Hmol'0 -8D-11D/ Serum C-reactive protein 9 G'0 -I.D-1). %nfective endocarditis is unlikely given normal inflammatory markers and haematology. G'0/ asting plasma glucose . Auscultation of the heart revealed a middiastolic murmur heard at the left sternal edge and there were bilateral basal crackles heard in the chest. per m0/ +hat is the most likely diagnosis.D-9DD !1DC'0/ ESR (Westergren) .-D.2S1 and non-tender arteries.) mmol'0 -&. (is blood pressure was 1&)'"8 mm(g. A 8D-year-old man was seen in *asualty :epartment having developed transient painless loss of vision in the right eye lasting several minutes.." mmol'0 -&-8 mmol'0/ Serum cholesterol 9.. he loss of vision had been sudden in onset and appeared to descend affecting the entire field of vision. g'0 -D. per m0/ CS red cell count 1 cell per m0 -I. (e had no associated symptoms of headache or any weakness of the face or limbs.-". mm'1st hour -D-1. . %nvestigations revealedA Haemoglobin 1&.1. On e!amination there were some purpuric skin lesions over the arms and his face appeared flushed."o*. (e had had an episode 2 months ago of left facial weakness.9. with worsening dyspnoea and occasional palpitations.D g'd0/ White cell count ).i@otifen and %migran as re=uired. pupils were intact and peripheral nervous system e!amination did not reveal any abnormalities. (e took . mm'1st hour/ Serum sodium 1&8 mmol'0 -1&"-199 mmol'0/ Serum potassium &. (e was a non smoker and did not drink any alcohol.. 4undoscopy did not reveal any abnormalities. which had lasted appro!imately 2D minutes..

but is unlikely given the normal inflammatory markers and normal cerebro-spinal fluid analysis.. here are no features in the history suggestive of temporal arteritis and there was no history of headache at the onset of symptoms.lease select 1 option/ *ardiac embolus *orrect *arotid artery embolus *erebral vasculitis *omple! migraine emporal arteritis he patient is describing amaurosis fuga!. *erebral vasculitis can present with a myriad of symptoms. he most likely cause in this patient is a cardiac embolus secondary to mitral stenosis as evidenced by malar flush. . minutes and resolves over 1D 2D minutes. which is unilateral transient loss of vision that develops over seconds.-. given the lack of additional risk factors. purpuric embolic skin lesions. he only feature that differentiates the middle cerebral artery syndrome from the carotid artery syndrome is amaurosis fuga!. 1. remains for ma!imal for up to . signs of left heart failure and a mid-diastolic murmur. 2mboli secondary to atheroma is less likely.

-.+hat is the diagnosis. blood in the anterior chamber. Gsually caused by trauma L often small obBects -champagne corks.lease select 1 option/ Anterior uveitis :islocation of the lens (yphaema *orrect (ypopyon $alignant melanoma of the iris he slide shows hyphaema. . 18. s=uash balls/ hitting the eye. Aspiration may be re=uired to prevent loss of vision.

there is usually only a single. %n retinitis due to o!ocara canis. She has had increasing difficulty driving in the dark and recently stumbled on steps when leaving a . 1". well demarcated lesion. A 99-year-old woman complains of gradual loss of night vision.lease select 1 option/ Arcuate *entral *orrect *oncentric 0ower =uadrantic emporal he slide shows the typical appearance of to!ocara retinitis with a lesion at the macula.+hat is the most likely visual field defect. -.

lease select 1 option/ Angioid streaks #ranch retinal vein occlusion *entral retinal artery occlusion . 1).anretinal photocoagulation scarring 1etinitis pigmentosa *orrect 0oss of night vision and peripheral vision are classic features of 1etinitis . . (e was seen by an 27 consultant who diagnosed sinusitis.restaurant. (er fundoscopy is shown below.igmentosa. click and drag to move the ophthalmoscope -. (e presents now with a two day history of right periorbital swelling and diplopia. A 2C-year-old man presents with a 8 months history of nasal congestion. he fundi shows the characteristic <bone spicule< areas of pigmentation in the periphery of the retina. *linical e!amination revealed loss of peripheral visual fields. +hat is the diagnosis.

She had started to feel nauseated particularly early in the morning and on the . 0eft eye appears normal. year-old man with (%F disease presents with sudden loss of vision in his right eye. +hat is the likely diagnosis. (e has marked drooping of the right eyelid with the right eye congested and deviated right with an enlarged right pupil. with no neck stiffness or photophobia and his temperature is &".ituitary adenoma olosa (unt syndrome he history is typical for cavernous sinus thrombosis possibly secondary to sinusitis. -. Grgent * brain and antibiotics are needed.lease select 1 option/ *avernous sinus thrombosis *orrect 2pidural abscess $eningitis . 1C. here is also loss of sensation of the right forehead. (e is not curently taking antiretroviral therapy. 2D. A &. -.lease select 1 option/ *ytomegalovirus *orrect o!ocara canis Toxoplasma gondii Cryptococcus neoformans (uman immundeficiency virus he slide shows the typical <cottage cheese and tomato ketchup< or <pi@@a< appearance of *$F retinitis in a patient with (%F disease. his is a life threatening condition. %n the last few days she had noticed some blurring of her vision and reduction in her visual field. A 2&-year-old obese woman presented to *asualty :epartment with a 9 day history of progressively worsening generalised headache associated with a bu@@ing in her ears. 4undoscopy is normal.2!amination reveals him to be unwell.9M*. +hat is the most likely causative agent. A recent *:9 count was measured at 2D cells'mm&.

lease select 1 option/ #enign intracranial hypertension *orrect *entral retinal vein occlusion Optic nerve meningioma Optic papillitis . which has deteriorated markedly over the last two days and has resulted in her admission. g'0/ CS "hite cell count 2 cells per m0 -I. it is crucial to distinguish between papilloedema and the many other forms of optic disc oedema. per m0/ CS oligoclonal bands 7egative 3iven the above clinical account. $anagement of optic disc oedema begins with a correct diagnosis.. (owever. the headache has deteriorated =uite markedly . here was reduction in temporal visual fields bilaterally and enlargement of the blind spot bilaterally. A 29-year-old woman presents with an eight weeks history of headaches. Fisual acuity was recorded as 8'1) in both eyes. what is the likely cause for this patient6s visual disturbance.morning of admission had vomited several times.9. L D. per m0/ CS red cell count 2 cells per m0 -I. $ost importantly. On e!amination she was orientated with a 3lasgow coma scale of 1. She had a history of severe acne which was treated with long-term oral do!ycycline and smoked &. he fundoscopic appearance is shown belowA An $1% scan of the brain was normal. hese headaches are distressing her have been problematical in the morning but she has found some relief from paracetamol. -. visual fields. including <mas=ueraders< such as buried optic disc drusen.seudopapilloedema he slide shows papilloedema.1. ophthalmoscopy findings and especially the laterality of presentation carefully in the initial work-up. cigarettes a day. A lumbar puncture was performed and yielded the following dataA !pening pressure && cm (2O -8 L 1) cm (2O/ CS protein D. he rest of the neurological e!amination was entirely normal.92 g'0 -D. *onsider the acuity.N 21.'1.

-. he other possible differential diagnosis would be cerebral'sagittal vein thrombosis but one might e!pect to pick up evidence for this on the $1%. +hat is the most likely diagnosis.lease select 1 option/ #enign %ntracranial (ypertension *orrect Subarachnoid (emorrhage $igraine ension type headache $ultiple sclerosis his is a typical history of #%(. he only other information is that she has gained 8 kg in weight the last 8 months. On e!amination she is noted to be obese with a #$% of &2 kg'm2 and a blood pressure of 122'"8 mm(g. 4undoscopy reveals bilateral swelling of both optic discs with loss of venous pulsation but otherwise neurological e!amination is normal. . *S4 analysis and high pressure. %nvestigations reveal normal $1% appearances of the brain and a lumbar puncture reveals an opening pressure of &D cm (2O but *S4 analysis is normal. An obese female patient with headaches and papilloedema. normal #rain imaging.over the last two days being constant and intolerable.